Designing for caregiving networks: a case study of primary caregivers of children with medical complexity

OBJECTIVE

The study aimed to characterize the experiences of primary caregivers of children with medical complexity (CMC) in engaging with other members of the child's caregiving network, thereby informing the design of health information technology (IT) for the caregiving network. Caregiving networks include friends, family, community members, and other trusted individuals who provide resources, information, health, or childcare.

MATERIALS AND METHODS

We performed a secondary analysis of two qualitative studies. Primary studies conducted semi-structured interviews (n = 50) with family caregivers of CMC. Interviews were held in the Midwest (n = 30) and the mid-Atlantic region (n = 20). Interviews were transcribed verbatim for thematic analysis. Emergent themes were mapped to implications for the design of future health IT.

RESULTS

Thematic analysis identified 8 themes characterizing a wide range of primary caregivers' experiences in constructing, managing, and ensuring high-quality care delivery across the caregiving network.

DISCUSSION

Findings evidence a critical need to create flexible and customizable tools designed to support hiring/training processes, coordinating daily care across the caregiving network, communicating changing needs and care updates across the caregiving network, and creating contingency plans for instances where caregivers are unavailable to provide care to the CMC. Informaticists should additionally design accessible platforms that allow primary caregivers to connect with and learn from other caregivers while minimizing exposure to sensitive or emotional content as indicated by the user.

CONCLUSION

This article contributes to the design of health IT for CMC caregiving networks by uncovering previously underrecognized needs and experiences of CMC primary caregivers and drawing direct connections to design implications.

Adaptive Intervention to Prevent Respiratory Illness in Cerebral Palsy: Protocol for a Feasibility Pilot Randomized Controlled Trial

BACKGROUND

This study will pilot-test an innovative just-in-time adaptive intervention to reduce severe respiratory illness among children with severe cerebral palsy (CP). Our intervention program, Respiratory Exacerbation-Plans for Action and Care Transitions (RE-PACT), delivers timely customized action planning and rapid clinical response when hospitalization risk is elevated.

OBJECTIVE

This study aims to establish RE-PACT's feasibility, acceptability, and fidelity in up to 90 children with severe CP. An additional aim is to preliminarily estimate RE-PACT's effect size.

METHODS

The study will recruit up to 90 caregivers of children with severe CP aged 0 to 17 years who are cared for by a respiratory specialist or are receiving daily respiratory treatments. Participants will be recruited from pediatric complex care programs at the University of Wisconsin-Madison (UW) and the University of California, Los Angeles (UCLA). Study participants will be randomly assigned to receive usual care through the complex care clinical program at UW or UCLA or the study intervention, RE-PACT. The intervention involves action planning, rapid clinical response to prevent and manage respiratory illness, and weekly SMS text messaging surveillance of caregiver confidence for their child to avoid hospitalization. RE-PACT will be run through 3 successively larger 6-month trial waves, allowing ongoing protocol refinement according to prespecified definitions of success for measures of feasibility, acceptability, and fidelity. The feasibility measures include recruitment and intervention time. The acceptability measures include recruitment and completion rates as well as intervention satisfaction. The fidelity measures include observed versus expected rates of intervention and data collection activities. The primary clinical outcome is a severe respiratory illness, defined as a respiratory diagnosis requiring hospitalization. The secondary clinical outcomes include hospital days and emergency department visits, systemic steroid courses, systemic antibiotic courses, and death from severe respiratory illness.

RESULTS

The recruitment of the first wave began on April 27, 2022. To date, we have enrolled 30 (33%) out of 90 participants, as projected. The final wave of recruitment will end by October 31, 2023, and the final participant will complete the study by April 30, 2024. We will start analyzing the complete responses by April 30, 2024, and the publication of results is expected at the end of 2024.

CONCLUSIONS

This pilot intervention, using adaptive just-in-time strategies, represents a novel approach to reducing the incidence of significant respiratory illness for children with severe CP. This protocol may be helpful to other researchers and health care providers caring for patients at high risk for acute severe illness exacerbations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05292365; https://clinicaltrials.gov/study/NCT05292365.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49705.

An mHealth Design to Promote Medication Safety in Children with Medical Complexity

BACKGROUND

Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks.

OBJECTIVES

The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home.

METHODS

Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured.

RESULTS

A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented.

CONCLUSION

This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.

Feasibility of social network analysis to study outcomes of children with medical complexity

Since most care for children with medical complexity (CMC) is delivered daily in communities by multiple caregiving individuals, that is, caregiving networks, tools to assess and intervene across these networks are needed. This study evaluated the feasibility of applying social network analysis (SNA) to describe caregiving networks. Because hospitalization is among the most frequently used outcomes for CMC, exploratory correlations between network characteristics and CMC hospital use were evaluated. Within 3 weeks, the goal network enrollment was achieved, and all feasibility measures were favorable. Network characteristics correlated with hospital use, that is, smaller, denser networks, with more closed-loop communication correlated with fewer hospital days. Networks with more professional caregivers also correlated with fewer hospital days. SNA is a feasible tool to study CMC caregiving networks. Preliminary data support rigorous hypothesis testing using SNA methods. Network-based interventions to improve CMC health may be an important future direction.

Barriers to and facilitators of a just-in-time adaptive intervention for respiratory illness in cerebral palsy: a qualitative study

OBJECTIVE

To understand caregiver, healthcare professional and national expert perspectives on implementation of a just-in-time adaptive intervention, RE-PACT (Respiratory Exacerbation-Plans for Action and Care Transitions) to prevent respiratory crises in severe cerebral palsy.

DESIGN

Qualitative research study.

SETTING

Paediatric complex care programmes at two academic medical institutions.

PARTICIPANTS

A total of n=4 focus groups were conducted with caregivers of children with severe cerebral palsy and chronic respiratory illness, n=4 with healthcare professionals, and n=1 with national experts.

METHODS

Participants viewed a video summarising RE-PACT, which includes action planning, mobile health surveillance of parent confidence to avoid hospitalisation and rapid clinical response at times of low confidence. Moderated discussion elicited challenges and benefits of RE-PACT's design, and inductive thematic analysis elicited implementation barriers and facilitators.

RESULTS

Of the 19 caregivers recruited, nearly half reported at least one hospitalisation for their child in the prior year. Healthcare professionals and national experts (n=26) included physicians, nurses, respiratory therapists, social workers and researchers. Four overarching themes and their barriers/facilitators emphasised the importance of design and interpersonal relationships balanced against health system infrastructure constraints. Intervention usefulness in crisis scenarios relies on designing action plans for intuitiveness and accuracy, and mobile health surveillance tools for integration into daily life. Trust, knowledge, empathy and adequate clinician capacity are essential components of clinical responder-caregiver relationships.

CONCLUSIONS

RE-PACT's identified barriers are addressable. Just-in-time adaptive interventions for cerebral palsy appear well-suited to address families' need to tailor intervention content to levels of experience, preference and competing demands.

School Attendance Decisions for Children With Medical Complexity During COVID-19

OBJECTIVE

School attendance by children with medical complexity (CMC) may be influenced by parent perceptions of their child's risk for coronavirus disease 2019 (COVID-19). The authors of this study aimed to quantify in-person school attendance and identify attendance predictors.

METHODS

From June to August 2021, surveys were collected from English- and Spanish-speaking parents of children aged 5 to 17 years with ≥1 complex chronic condition who received care at an academic tertiary children's hospital in the Midwestern United States and who attended school prepandemic. The outcome, in-person attendance, was defined dichotomously as any in-person attendance versus none. We evaluated parent-perceived school attendance benefits, barriers, motivation, and cues, COVID-19 severity and susceptibility using survey items derived from the health belief model (HBM). Latent HBM constructs were estimated with exploratory factor analysis. Associations between the outcome and the HBM were evaluated with multivariable logistic regression and structural equation models.

RESULTS

Among 1330 families (response rate 45%), 19% of CMC were not attending in-person school. Few demographic and clinical variables predicted school attendance. In adjusted models, family-perceived barriers, motivation, and cues predicted in-person attendance, whereas benefits, susceptibility, and severity did not. The predicted probability (95% confidence interval) of attendance ranged from 80% (70% to 87%) for high perceived barriers to 99% (95% to 99%) for low perceived barriers. Younger age (P <.01) and previous COVID-19 infection (P = .02) also predicted school attendance.

CONCLUSIONS

Overall, 1 in 5 CMC did not attend school at the end of the 2020 to 2021 academic year. Family perceptions of schools' mitigation policies and encouragement of attendance may be promising avenues to address this disparity.

Interventions in the Home and Community for Medically Complex Children: A Systematic Review

CONTEXT

Most care occurs in home and community settings; however, the best approaches to improve CMC health are poorly understood.

OBJECTIVE

We sought to summarize evidence from interventions in the home and community to improve health for children with medical complexity (CMC) using comprehensive conceptions of CMC health.

DATA SOURCES

PubMed, CINAHL, Scopus, and Cochrane databases.

STUDY SELECTION

Included studies evaluated interventions for CMC caregivers in home or community settings and evaluated at least 1 outcome in 10 domains of CMC health.

DATA EXTRACTION

Data were extracted on participant characteristics, intervention activities, and outcomes. Interventions were categorized thematically into strategies, with results summarized by effects on outcomes within each health domain.

RESULTS

The 25 included interventions used 5 strategies: intensive caregiver education (n = 18), support groups (n = 3), crisis simulation (n = 2), mobile health tracking (n = 1), and general education (n = 1). Substantial variation existed in the extent to which any outcome domain was studied (range 0-22 studies per domain). Interventions addressing 4 domains showed consistent improvement: support group and mobile health tracking improved long-term child and caregiver self-sufficiency; mobile health tracking improved family-centered care; intensive caregiver education and support groups improved community system supports. Three domains (basic needs, inclusive education, patient-centered medical home) were not studied.

LIMITATIONS

Risk of bias was moderate due primarily to limited controlled experimental designs and heterogeneous population and outcome definitions.

CONCLUSIONS

Interventions that improve CMC health exist; however, current studies focus on limited segments of the 10 domains framework. Consensus outcome measures for CMC health are needed.

In-Home COVID-19 Testing for Children With Medical Complexity: Feasibility and Association With School Attendance and Safety Perceptions

The REstarting Safe Education and Testing program for children with medical complexity was implemented in May 2021 at the University of Wisconsin to evaluate the feasibility of in-home rapid antigen COVID-19 testing among neurocognitively affected children. Parents or guardians administered BinaxNOW rapid antigen self-tests twice weekly for three months and changed to symptom and exposure testing or continued surveillance. In-home testing was feasible: nearly all (92.5%) expected tests were conducted. Symptomatic testing identified seven of nine COVID-19 cases. School safety perceptions were higher among those opting for symptom testing. Clinical Trials.gov identifier: NCT04895085. (Am J Public Health. 2022;112(S9):S878-S882. https://doi.org/10.2105/AJPH.2022.306971).

Trauma support in your pocket

Background

Research indicates that technological approaches to the delivery of trauma-based support can help address structural and perceptual barriers. Yet, there is a lack of research on digital trauma support for children and adolescents. A systematic review of trauma apps identified 2 of 69 were for children, of which neither were evidence based. The aim of this project was to develop a trauma support app, co-designed with and for children and young people, based on a community-based group support program called Teaching Recovery Techniques.

Methods

In a series of workshops utilising the Design Studio method, a team of 7 young people between 14-20 years (3 boys and 4 girls) co-created the app. The team were recruited via youth organisations and self-reported having experienced (undisclosed) trauma. The techniques presented in the manual have been prioritised via stepwise consideration of content session by session. Prototypes were developed based on the generated ideas and shared with the team for feedback.

Results

Contributions of the young people to the design can be considered in three categories: mechanics, dynamics and aesthetics. Mechanics are the rules and interactions that inform the structure of the app. Dynamics refers to what the user can actually see, e.g. the outcome when the user presses a button. Aesthetics relate to the desirable emotional responses evoked in the user when they interact with the app. Beyond influence on basic aesthetics, such as fonts and symbols, the young people actively contributed to the user experience and gave great consideration to the emotional responses that could be evoked.

Conclusions

Young people with personal experience of trauma can actively engage in the development of a digital trauma intervention. Design Studio was an effective method for the co-creation process, enabling the generating and converging of young peoples’ ideas.

Key messages

• Co-creating an app for trauma support with youth with experience of trauma was a feasible process for both researchers and youth.

• Using Design Studio, a collaborative workshop method, facilitated the co-creative process, allowing the youth to contribute to the mechanics, dynamics and aesthetics factors of the app.

Moving a youth trauma support group online: participatory adaption, usability and pilot test

Background

Posttraumatic stress poses a significant threat to a young person’s development. Internet-based delivery could ameliorate barriers to care, but has mostly been tested with adults. This project aimed to (i) adapt the group intervention Teaching Recovery Techniques for online delivery through a participatory process, (ii) investigate the usability of the online format and (iii) pilot the new format.

Methods

Adaption recommendations were generated through participatory workshops with service users and providers, and consultation with an advisory panel with professionals and parents. Usability testing was conducted with intervention leaders (n = 5) and youth (n = 5). The public involvement in the project was assessed through a multi-method approach including behavioural observations, questionnaires and field notes. A pilot study (n = 14) is ongoing.

Results

The workshops focused on safety, participation and learning. Recommendations included an emergency response protocol, communication strategies, and guidance on intervention delivery. Whilst the advisory panel largely agreed, points of disagreement included workshop ideas around personalisation, where the panel conveyed the importance of consistency in manualised interventions. Usability testing highlighted the need for explicit guidance, particularly on safety processes.

Conclusions

Online delivery of trauma group support requires adaptions to ensure positive group dynamics, learning and safety. Yet, some adaptions resulting from the usability testing were also relevant to the original format, pointing to the need for more extensive use of usability testing across intervention manuals. The young people, parents and professionals involved in the project provided rich and varied perspectives, illustrating the value of broad stakeholder engagement. The ongoing pilot study explores the feasibility of online delivery, including youth perceptions of the format.

Key messages

• The varied perspectives in the participatory process highlighted the importance of broad stakeholder engagement for interventions to be equally evidence-based and adapted to the target population.

• The current pilot study explores the feasibility of online delivery, including youth perceptions of the format, in order to assess the potential for scale up.

Parents’ experiences of an antenatal visit being part of a home visiting program in deprived areas

Background

There are considerable health divides between residential areas in many Swedish cities. In more disadvantaged areas children grow up with poorer health outcomes than the country average. To meet the greater needs of children growing up in these areas through proportionate universalism, an extended home visiting program has been delivered. A novel part of this program has been the social worker and nurse later conducting home visits meeting the parents at the maternity care clinic before childbirth. The aim of this study was to explore parents’ experiences of that antenatal visit.

Methods

Semi-structured interviews were carried out with nine mothers and three fathers around 3 months postpartum. Nine of the participants were foreign-born and a translator was used for four of the interviews. The interviews were recorded and transcribed verbatim and the data was analyzed with thematic analysis with an inductive approach.

Results

The parents’ overall experiences are comprised in the main theme: ‘A feeling of security and care for the whole family'. This main theme is derived from the three following themes: 1) ‘Staff - a trustworthy source of information'. Parents perceived the staff as experienced and knowledgeable and appreciated obtaining information about practical things and about the Swedish system; 2) ‘Access to emotional support'. Several parents expressed the need for emotional support and valued that by meeting the staff they knew they had someone to turn to; 3) ‘Becoming familiar with the staff'. It was appreciated to know who will come to your home as this gave parents an increased sense of security.

Conclusions

Initiating the program through introducing home visiting staff at a scheduled antenatal visit benefited parents, by giving them useful information and social support. The visit also seems to be indirectly beneficial as it contributes to building trust for the staff and the rest of the program.

Key messages

• Initiating an extended home visiting program at a scheduled antenatal visit benefited parents, by giving them useful information and social support.

• Initiating an extended home visiting program at a scheduled antenatal visit contributed to building parents’ sense of trust for the staff and the rest of the program.

Ethical perspectives of the involvement of vulnerable populations in health research

Background

Public involvement in research has potential to transform public health research processes and outcomes, as well as contribute to sustainable collaborations between academia and the civil society. However, this all relies on public involvement being conducted in an ethical and inclusive way, especially when involving representatives from vulnerable populations.

Methods

In this empirically informed theoretical reflection, ethical perspectives on involvement of vulnerable populations in health research were explored using data collected within a public involvement evaluation project. By analysing observational and longitudinal qualitative data from research projects involving public representatives from vulnerable groups, ethical aspects were identified.

Results

Responsibility and decision-making appeared as important ethical aspects, where laws and regulations conflicted with involvement ideals. Similarly, reimbursement and recognition for public contributors became an ethical issue when facing legislation and bureaucracy, especially when involving children or refugees. Another ethical aspect concerned researchers’ concerns in balancing involvement and protection of vulnerable groups, especially when involving contributors living under unstable circumstances. Finally, effectively communicating around research and involvement in an accessible way, for contributors to be involved but not burdened, was a challenge for researchers.

Conclusions

Public involvement of vulnerable populations led to ethical challenges related to conflicting ideals and practical realities, including balancing involvement and protection of contributors. This highlighted a need for ethical guidance to support ethical decision-making and practice. The findings are used to guide the development of an ethical framework for decision-making in public involvement.

Key messages

• Researchers involving public contributors from vulnerable groups face ethical challenges which causes barriers to involvement.

• There is need for guidance on ethical decision-making for researchers involving representatives from vulnerable groups in research.

Navigating to support: experiences of forced migrant survivors of sexual and gender-based violence

Background

Sexual and gender-based violence (SGBV) is a severe human rights violation as well as a widespread global health problem with several negative consequences for emotional-psychological, sexual-reproductive and physical health. People who have experienced forced migration have a heightened exposure to SGBV, yet face several challenges to access support. Increased understanding of the help seeking processes of forced migrants who have experienced SGBV can help improve access to adequate support.

Methods

Interviews with thirty forced migrants in Sweden who have experienced SGBV have been analyzed using thematic analysis to generate an understanding of their help-seeking processes. The participants were recruited through a broad range of service providers, nongovernmental organizations and community sites.

Results

The disempowerment experienced after arrival to Sweden exacerbated health needs, increased the risk of violence, and prevented help seeking. Increased independency and more stable circumstances ameliorated the anticipated risks of seeking help and improved well-being. Activities and places providing a platform for social interactions as well as opportunities to acquire needed knowledge, such as language, were highlighted as valuable and could become a pathway to specialized services through a process of increased trust.

Conclusions

Help-seeking processes for SGBV can be promoted by early access to support services and social networks, as well as language classes and information about the society. Access to support can be facilitated by increased collaboration between non-violence-related service providers working close to forced migrants, such as language schools, and specialized services. The societal factors influencing help seeking processes are being further explored in an ongoing analysis of interviews with 29 service providers. The findings will inform the co-development of a new service model.

Key messages

Caregiver perceptions of in-home COVID-19 testing for children with medical complexity: a qualitative study

BACKGROUND

In-home direct antigen rapid testing (DART) plays a major role in COVID-19 mitigation and policy. However, perceptions of DART within high-risk, intellectually impaired child populations are unknown. This lack of research could negatively influence DART uptake and utility among those who stand to benefit most from DART. The purpose of this study was to describe caregivers' perceptions of an in-home COVID-19 DART regimen in children with medical complexity, including the benefits and limitations of DART use.

METHODS

This qualitative study was a subproject of the NIH Rapid Acceleration of Diagnostics Underserved Populations research program at the University of Wisconsin. We combined survey data and the thematic analysis of semi-structured interview data to understand caregivers' perceptions of in-home COVID-19 testing and motivators to perform testing. Caregivers of children with medical complexity were recruited from the Pediatric Complex Care Program at the University of Wisconsin (PCCP). Data were collected between May and August 2021.

RESULTS

Among n = 20 caregivers, 16/20 (80%) of their children had neurologic conditions and 12/20 (60%) used home oxygen. Survey data revealed that the largest caregiver motivators to test their child were to get early treatment if positive (18/20 [90%] of respondents agreed) and to let the child's school know if the child was safe to attend (17/20 [85%] agreed). Demotivators to testing included that the child could still get COVID-19 later (7/20 [35%] agreed), and the need for officials to reach out to close contacts (6/20 [30%] agreed). From interview data, four overarching themes described perceptions of in-home COVID-19 testing: Caregivers perceived DART on a spectrum of 1) benign to traumatic and 2) simple to complex. Caregivers varied in the 3) extent to which DART contributed to their peace of mind and 4) implications of test results for their child.

CONCLUSIONS

Although participants often described DART as easy to administer and contributing to peace of mind, they also faced critical challenges and limitations using DART. Future research should investigate how to minimize the complexity of DART within high-risk populations, while leveraging DART to facilitate safe school attendance for children with medical complexity and reduce caregiver burden.

COVID-19 Vaccination Intentions for Children With Medical Complexity

OBJECTIVES

The chronic conditions and functional limitations experienced by children with medical complexity (CMC) place them at disproportionate risk for COVID-19 transmission and poor outcomes. To promote robust vaccination uptake, specific constructs associated with vaccine hesitancy must be understood. Our objective was to describe demographic, clinical, and vaccine perception variables associated with CMC parents' intention to vaccinate their child against COVID-19.

METHODS

We conducted a cross-sectional survey (June-August 2021) for primary caregivers of CMC between ages 5 to 17 at an academic medical center in the Midwest. Multivariable logistic regression examined associations between vaccination intent and selected covariates.

RESULTS

Among 1330 families, 65.8% indicated vaccination intent. In multivariable models, demographics had minimal associations with vaccination intent; however, parents of younger children (<12 years) had significantly lower adjusted odds of vaccination intent (adjusted odds ratio [95% confidence interval]: 0.26 [0.17-0.3]) compared to parents of older children (≥12 years). CMC with higher severity of illness, ie, those with ≥1 hospitalization in the previous year (versus none) or >1 complex chronic condition (vs 1), had higher adjusted odds of vaccination intent (1.82 [1.14-2.92] and 1.77 [1.16-2.71], respectively). Vaccine perceptions associated with vaccine intention included "My doctor told me to get my child a COVID-19 vaccine" (2.82 [1.74-4.55]); and "I'm concerned about my child's side effects from the vaccine" (0.18 [0.12-0.26]).

CONCLUSIONS

One-third of CMC families expressed vaccine hesitation; however, constructs strongly associated with vaccination intent are potentially modifiable. Pediatrician endorsement of COVID-19 vaccination and careful counseling on side effects might be promising strategies to encourage uptake.

Feasibility Testing of Tubes@HOME: A Mobile Application to Support Family-Delivered Enteral Care

BACKGROUND

Assistance from medical devices is common for children with medical complexity (CMC) but introduces caregiving challenges. We tested the feasibility of "Tubes@HOME," a mobile application supporting CMC family-delivered care using enteral care as a model.

METHODS

Caregivers of CMC with enteral tubes participated in a 30-day feasibility study of Tubes@HOME November 2020 through January 2021. Tubes@HOME was available on mobile devices and designed to support collaborative care and tracking over time. Key features include child profile, caregiving network management, care routines, feedback loop, and action plans. Care routines delineated nutrition, medication, and procedural tasks needed for the child: frequencies, completions, and reminders. Metadata summarized feature use among users. Feasibility was evaluated with postuse questionnaires and interviews. Measures of Tubes@HOME's usability and usefulness included the NASA Task Load Index (TLX), System Usability Scale (SUS), and Acceptability and Use of Technology Questionnaire (AUTQ).

RESULTS

Among n = 30 children, there were 30 primary (eg, parent) and n = 22 nonprimary caregivers using Tubes@HOME. Children had a median (IQR) 10 (5.5-13) care routines created. For care routines created, 93% were marked complete at least once during the study period, with participants engaging with routines throughout study weeks 2 to 4. Results (mean [SD]) indicated low mental workload (TLX) 30.9 (12.2), good usability (SUS) 75.4 (14.7), and above-average usefulness (AUTQ) 4.0 (0.7) associated with Tubes@HOME, respectively. Interviews contextualized usefulness and suggested improvements.

CONCLUSIONS

Longitudinal use of Tubes@HOME among caregiving networks appeared feasible. Efficacy testing is needed, and outcomes could include reliability of care delivered in home and community.

Priorities for Safer In-Person School for Children With Medical Complexity During COVID-19

OBJECTIVES

To establish statewide consensus priorities for safer in-person school for children with medical complexity (CMC) during the coronavirus disease 2019 (COVID-19) pandemic using a rapid, replicable, and transparent priority-setting method.

METHODS

We adapted the Child Health and Nutrition Research Initiative Method, which allows for crowdsourcing ideas from diverse stakeholders and engages technical experts in prioritizing these ideas using predefined scoring criteria. Crowdsourcing surveys solicited ideas from CMC families, school staff, clinicians and administrators through statewide distribution groups/listservs using the prompt: "It is safe for children with complex health issues and those around them (families, teachers, classmates, etc.) to go to school in-person during the COVID-19 pandemic if/when…" Ideas were aggregated and synthesized into a unique list of candidate priorities. Thirty-four experts then scored each candidate priority against 5 criteria (equity, impact on COVID-19, practicality, sustainability, and cost) using a 5-point Likert scale. Scores were weighted and predefined thresholds applied to identify consensus priorities.

RESULTS

From May to June 2021, 460 stakeholders contributed 1166 ideas resulting in 87 candidate priorities. After applying weighted expert scores, 10 consensus CMC-specific priorities exceeded predetermined thresholds. These priorities centered on integrating COVID-19 safety and respiratory action planning into individualized education plans, educating school communities about CMC's unique COVID-19 risks, using medical equipment safely, maintaining curricular flexibility, ensuring masking and vaccination, assigning seats during transportation, and availability of testing and medical staff at school.

CONCLUSIONS

Priorities for CMC, identified by statewide stakeholders, complement and extend existing recommendations. These priorities can guide implementation efforts to support safer in-person education for CMC.

Medical Device Workarounds in Providing Care for Children With Medical Complexity in the Home

OBJECTIVES

Children with medical complexity (CMC) are commonly assisted by medical devices, which family caregivers are responsible for managing and troubleshooting in the home. Optimizing device use by maximizing the benefits and minimizing the complications is a critical goal for CMC but is relatively unexplored. In this study, we sought to identify and describe workarounds families have developed to optimize medical device use for their needs.

METHODS

We conducted 30 contextual inquiry interviews with families of CMC in homes. Interviews were recorded, transcribed, and analyzed for barriers and workarounds specific to medical device usage through a directed content analysis. We used observation notes and photographs to confirm and elaborate on interview findings.

RESULTS

We identified 4 barriers to using medical devices in the home: (1) the quantity and type of devices allotted do not meet family needs, (2) the device is not designed to be used in locations families require, (3) device use is physically or organizationally disruptive to the home, and (4) the device is not designed to fit the user. We also identified 11 categories of workarounds to the barriers.

CONCLUSIONS

Families face many barriers in using medical devices to care for CMC. Our findings offer rich narrative and photographic data revealing the ways in which caregivers work around these barriers. Future researchers should explore the downstream effects of these ubiquitous, necessary workarounds on CMC outcomes toward developing interventions that optimize device use for families.

Linking Parent Confidence and Hospitalization through Mobile Health: A Multisite Pilot Study

OBJECTIVE

To evaluate the associations between parent confidence in avoiding hospitalization and subsequent hospitalization in children with medical complexity (CMC); and feasibility/acceptability of a texting platform, Assessing Confidence at Times of Increased Vulnerability (ACTIV), to collect repeated measures of parent confidence.

STUDY DESIGN

This prospective cohort study purposively sampled parent-child dyads (n = 75) in 1 of 3 complex care programs for demographic diversity to pilot test ACTIV for 3 months. At random days/times every 2 weeks, parents received text messages asking them to rate confidence in their child avoiding hospitalization in the next month, from 1 (not confident) to 10 (fully confident). Unadjusted and adjusted generalized estimating equations with repeated measures evaluated associations between confidence and hospitalization in the next 14 days. Post-study questionnaires and focus groups assessed ACTIV's feasibility/acceptability.

RESULTS

Parents were 77.3% mothers and 20% Spanish-speaking. Texting response rate was 95.6%. Eighteen hospitalizations occurred within 14 days after texting, median (IQR) 8 (2-10) days. When confidence was <5 vs ≥5, adjusted odds (95% CI) of hospitalization within 2 weeks were 4.02 (1.20-13.51) times greater. Almost all (96.8%) reported no burden texting, one-third desired more frequent texts, and 93.7% were very likely to continue texting. Focus groups explored the meaning of responses and suggested ACTIV improvements.

CONCLUSIONS

In this demographically diverse multicenter pilot, low parent confidence predicted impending CMC hospitalization. Text messaging was feasible and acceptable. Future work will test efficacy of real-time interventions triggered by parent-reported low confidence.

'I felt like a human being' – An exploratory, multi-method study of refugee involvement in the development of mental health intervention research

The purpose of this study was to pilot and methodologically appraise innovative patient and public involvement (PPI) evaluation tools and to describe a case study of refugee involvement in the development of mental health intervention research. 'Refugee Advisors' were involved in the development of a randomised controlled trial protocol evaluating a brief group intervention for refugee children experiencing symptoms of post-traumatic stress in Sweden. During an 8-hour research meeting, observation and questionnaire data were collected using the Active Involvement of Users in Research Observation Schedule and Questionnaire, followed by a focus group discussion. The multi-method approach demonstrated good feasibility. There were clear examples of how the advisors influenced research development e.g. recruitment strategy, cultural brokerage among study group participants, outcome measure validation. The advisors described a perceived impact on the research, equality and acceptance, and knowledge gain. A sense of appreciation and empowerment was also interpreted. However, potential issues relating to the relevance of contributions and use of an interpreter were identified.

Implementation and maintenance of a community intervention for refugee youth with symptoms of PTSD

Background

Transferring effective health and wellbeing interventions into community-based settings is challenging, with many only ever implemented in the academic settings in which they were developed. Over the last few years, Teaching Recovery Techniques (TRT), a community-based intervention for refugee youth reporting symptoms of post-traumatic stress, has been scaled up across Sweden using the model of a distribution network pathway. This means the lead organisation works with a distribution organisation using the latter's existing network of implementing organisations. Often the distribution partner is a national organisation with many local member agencies. The model offers possibility for quick spread, but only allows for a low level of control at the local site level. Therefore, it is important to understand the factors and agents that have facilitated the implementation and maintenance of TRT from successful sites, in order to inform ongoing efforts to scale up the intervention.

Methods

Semi-structured interviews were conducted with personnel from 'successful' TRT sites, defined as having conducted at least two TRT groups and maintaining full delivery of the programme. Interview data were analysed using content analysis.

Results

Our results indicated that active networking and collaboration were key to successful maintenance of TRT delivery. Active recruitment strategies, resource availability and management, and careful integration of the interpreter were also raised as important factors.

Conclusions

Although the interviewed professionals represented successful sites, they remained dependent on informal networks and collaboration for programme delivery. The possibility of integrating TRT into a local stepped-care model for post-traumatic stress in refugee children and adolescents will be presented.

Key messages

Transferring effective health and wellbeing interventions into community-based settings is challenging, with many only ever implemented in the academic settings in which they were developed. Active networking and collaboration are key to successful maintenance of community interventions.

“Sometimes you need to go beyond the manual” – TRT facilitators’ experiences when refugee youth disclose suicidal ideation

Community-based mental health interventions offer a way to reach lots of people when there is a high level of need. However, it is important to consider safety aspects when pushing interventions out to community settings. Teaching Recovery Techniques (TRT) is a manualised intervention based on trauma-focused cognitive behavioural therapy for children and adolescents reporting symptoms of post-traumatic stress. Facilitators with no previous therapeutic experience or specialist training in psychiatry are eligible to deliver the intervention after a three-day training workshop. Although TRT was not developed for a specialist health care setting, a substantial number of refugee minors who receive the TRT programme in Sweden report severe high-risk psychiatric symptoms. The objective of this study was to examine how facilitators, without extensive psychological training, experience the intervention including the inbuilt safety protocol when participating refugee minors are in an unstable setting and disclose suicidal ideation. Semi-structured interviews were conducted with TRT facilitators. Data were analysed using systemic text condensation. Findings will be presented at the workshop.

Assessment tools for screening the mental health of refugee minors: from preschool to adolescence

The high number of asylum seekers in Sweden highlighted the need to develop and evaluate structured assessment tools for children and adolescents. In a series of studies, we aimed to explore the utility of (i) the Strengths and Difficulties Questionnaire with a trauma supplement of six items (SDQ-T) for preschool children; (ii) the Children's Revised Impact of Events Scale (CRIES-8) with unaccompanied refugee adolescents; and (iii) the Refugee Health Screener (RHS-13) with refugee adolescents. Parents of two- to six-year-olds (N = 61) were asked to complete the SDQ-T, and refugee adolescents were asked to complete the CRIES-8 (N = 208) and, in a separate study, the RHS-13 (N = 29) during the routine health checks. Focus-group interviews were conducted with the nurses who used the SDQ-T. The nurses felt the SDQ-T contributed to a more structured and informative conversation about the child's mental health. The SDQ total difficulties showed good internal consistency (α=.82). A significant proportion of children scored above the clinical cut-off and SDQ scores correlated with the number of post-traumatic stress symptoms measured using the trauma supplement (rho=.29). The findings suggest the SDQ-T is a useful tool in this clinical setting. The CRIES-8 was feasible to use, showed good internal consistency and its factor structure was confirmed. However, an independent assessment of test-retest reliability (N = 48) and longitudinal invariance (N = 284) indicated potential instability. It could be the CRIES-8 does not perform well when used with the unaccompanied refugee adolescent population over time, or that PTSD symptoms are less stable within this group given the multiple stressors in everyday life related to acculturation stress, family separation and living arrangements. The RHS showed excellent internal consistency (α=.96) and correlated with symptoms of post-traumatic stress disorder (r=.41).

Meaningful patient and public involvement to advance healthcare equity, quality and accessibility

Background

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. It can lead to a richer understanding of public health research topics, improve data quality and analysis, increase trust in and dissemination of research findings, and ultimately achieve health services that are useful, useable and desirable. However, this all relies on PPI being conducted in a meaningful, respectful and inclusive way. Guidance is available on how to conduct, report and evaluate PPI activities. However, evaluative data are often brief, narrative descriptions, which reflects the lack of robust tools specifically developed to assess PPI. The purpose of this study was to develop and pilot tools to objectively assess PPI in the context of research project meetings.

Methods

PPI and group dynamics literature was used to guide the construction of an observation protocol and questionnaire. The research tools were piloted within a randomised trial of a community intervention for refugee children reporting symptoms of posttraumatic stress.

Results

The Active Involvement of Users in Research Observation Schedule is a semi-structured observation protocol, which consists of 12 observable behaviours relating to the interpersonal relations between researchers and PPI advisors; the nature of advisor contributions; and how the advisors guide research development. Each category consists of positive and negative behaviours. There is an accompanying paper-based assessment form that allows attendees to independently and anonymously grade the meeting on a list of items that correspond to those on the observation pro-forma. Preliminary inter-rater reliability for the observation protocol is good (ICC=0.833; 95% CI: 0.569-0.947).

Conclusions

Although the research tools require further refinement and validation, the methodological approach offers a promising, rigorous way to evaluate PPI.

Key messages

A large part of public health is promoting healthcare equity, quality and accessibility. Patient and public involvement (PPI) is a powerful tool to support this goal. The Active Involvement of Users in Research Observation Schedule and Questionnaire offer a promising, rigorous way to evaluate PPI and promote meaningful involvement to advance public health research.

Codesign and Usability Testing of a Mobile Application to Support Family-Delivered Enteral Tube Care

BACKGROUND

Enteral tubes are prevalent among children with medical complexity (CMC), and complications can lead to costly health care use. Our objective was to design and test the usability of a mobile application (app) to support family-delivered enteral tube care.

METHODS

Human-centered design methods (affinity diagramming, persona development, and software development) were applied with family caregivers of CMC to develop a prototype. During 3 waves of usability testing with design refinement between waves, screen capture software collected user-app interactions and inductive content analysis of narrative feedback identified areas for design improvement. The National Aeronautics and Space Administration Task Load Index and the System Usability Scale quantified mental workload and ease of use.

RESULTS

Design participants identified core app functions, including displaying care routines, reminders, tracking inventory and health data, caregiver communication, and troubleshooting. Usability testing participants were 80% non-Hispanic white, 28% lived in rural settings, and 20% had not completed high school. Median years providing enteral care was 2 (range 1-14). Design iterations improved app function, simplification, and user experience. The mean System Usability Scale score was 76, indicating above-average usability. National Aeronautics and Space Administration Task Load Index revealed low mental demand, frustration, and effort. All 14 participants reported that they would recommend the app, and that the app would help with organization, communication, and caregiver transitions.

CONCLUSIONS

Using a human-centered codesign process, we created a highly usable mobile application to support enteral tube caregiving at home. Future work involves evaluating the feasibility of longitudinal use and effectiveness in improving self-efficacy and reduce device complications.

Health System Research Priorities for Children and Youth With Special Health Care Needs

OBJECTIVES

In this study, we sought to establish priorities for a national research agenda for children and youth with special health care needs (CYSHCN) through a structured, multistakeholder, mixed-methods approach.

METHODS

Using surveys, we solicited responses from >800 members of expert-nominated stakeholder organizations, including CYSHCN families, health care providers, researchers, and policymakers, to identify what research with or about CYSHCN they would like to see in a national research agenda. From 2835 individual free-text responses, 96 research topics were synthesized and combined. Using an adapted RAND/UCLA Appropriateness Method (a modified Delphi approach), an expert panel rated research topics across 3 domains: need and urgency, research impact, and family centeredness. Domains were rated on 9-point Likert scales. Panelist ratings were used to sort research topics into 4 relative-priority ranks. Rank 1 (highest priority) research topics had a median of ≥7 in all domains.

RESULTS

The RAND/UCLA Appropriateness Method was used to prioritize CYSHCN research topics and depict their varying levels of stakeholder-perceived need and urgency, research impact, and family centeredness. In the 15 topics that achieved rank 1, social determinants of health (disparities and rurality), caregiving (family resilience and care at home), clinical-model refinement (effective model elements, labor divisions, telemedicine, and system integration), value (stakeholder-centered value outcomes, return on investment, and alternative payment models), and youth-adult transitions (planning, insurance, and community supports) were emphasized.

CONCLUSIONS

High-priority research topics identified by CYSHCN experts and family leaders underscore CYSHCN research trends and guide important directions. This study is the first step toward an efficient and cohesive research blueprint to achieve highly-effective CYSHCN health systems.

Acute Myocardial Injury Caused by Sydney Funnel-web Spider (Atrax robustus) Envenoming

A 67-year-old female suffered envenoming by a Sydney funnel-web spider (Atrax robustus ), complicated by ST elevation and elevated troponin levels consistent with an acute myocardial injury. She was treated primarily with funnel-web spider antivenom, admission to intensive care and initial respiratory support for acute pulmonary oedema. The mechanism by which funnel-web spider envenomation caused myocardial injury is unclear but follow-up nuclear studies in the patient demonstrated that she had minimal atherosclerotic disease.

Encounters From Device Complications Among Children With Medical Complexity

OBJECTIVES

Children with medical complexity (CMC) are commonly assisted by medical devices to support essential body functions, although complications may lead to preventable emergency department (ED) and hospital use. Our objective was to identify predictors of device-complicated ED visits and hospitalizations.

METHODS

This single-center retrospective cohort study included patients referred to a Pediatric Complex Care Program between April 1, 2014, and April 30, 2016, assisted by at least 1 medical device. Hospitalizations and ED visits in the year before enrollment were rated for likelihood for being due to device complications. Interrater reliability among 3 independent reviewers was assessed. Bivariate followed by multivariate logistic regression clustered by patient helped us identify associations between demographic, clinical, and device characteristics associated with device-complicated ED or hospital encounters.

RESULTS

Interrater reliability was high (κ = 0.92). Among 98 CMC, device-complicated encounters represented 17% of 258 hospitalizations and 31% of 228 ED visits. Complications of 3 devices (central venous catheters, enteral tubes, and tracheostomy tubes) accounted for 13% of overall hospitalizations and 28% of overall ED visits. Central venous catheter presence (adjusted odds ratio [aOR] 3.2 [95% confidence interval (CI) 1.1-9.5]) was associated with device-complicated ED visits. Gastrojejunostomy/jejunostomy tube presence (aOR 3.3 [95% CI 1.5-7.5]) or tracheostomies with (aOR 8.1 [95% CI 2.3-28.5]) or without (aOR 4.5 [95% CI 1.7-7.5]) ventilator use was associated with device-complicated hospitalizations. Clinical variables were poor predictors of device-complicated encounters.

CONCLUSIONS

Device-complicated ED visits and hospitalizations comprised a substantial proportion of total hospital and ED use. Developing interventions to prevent device complications may be a promising strategy to reduce overall CMC use.

Hospitalizations for Ambulatory Care-Sensitive Conditions among Children with Chronic and Complex Diseases

OBJECTIVE

To evaluate ambulatory-care sensitive (ACS) hospitalizations for children with noncomplex chronic diseases (NC-CD) and children with medical complexity (CMC), and identify associations with ambulatory care characteristics. Although ACS hospitalizations are potentially preventable in general populations, the specific ambulatory care predictors and influence of medical complexity on them is poorly understood.

STUDY DESIGN

Retrospective cohort study of NC-CD and CMC hospitalizations at a children's hospital during 2007-2014, excluding labor/delivery and children over 21 years. Pediatric medical complexity algorithm identified NC-CD or CMC. ACS hospitalizations were identified using Agency for Healthcare Research and Quality indicator definitions. Demographic and ambulatory care characteristics were compared between ACS and non-ACS hospitalizations with logistic regression clustered by patient. Measures of ambulatory care during 2 years before admission were explored with 20% random sample of general pediatrics discharges.

RESULTS

Among 4035 children with NC-CD, 14.6% of 4926 hospitalizations were ACS hospitalizations. Among 5084 CMC, 5.3% of 14 390 discharges were ACS hospitalizations. Among NC-CD discharges, ACS hospitalizations were more likely with no prior-year outpatient visits (OR 1.4, 95% CI 1.1-1.7) and less likely with timely well checks (OR 0.8, 95% CI 0.6-0.9) and phone encounters in the month before admission (OR 0.5, 95% CI 0.2-1.0). Among CMC discharges, the only association observed was with provider continuity (OR 0.3, 95% CI 0.1- 1.0).

CONCLUSIONS

Provider continuity may be associated with fewer CMC ACS hospitalizations, however, measures of ambulatory care were more consistently associated with ACS hospitalizations for NC-CD. CMC may need more precise ACS hospitalization definitions.

Age and gender-related differences in emotional and behavioural problems and autistic features in children and adolescents with Down syndrome: a survey-based study of 674 individuals

BACKGROUND

Recent studies have indicated an increased risk of autism, behavioural and emotional problems and attention-deficit/hyperactivity disorder in individuals with Down syndrome.

METHOD

In a large-scale survey-based study, we examined the rates of these problems and their relationship to age and gender, in a sample of 674 individuals (4-18 years) with Down syndrome. The relationship with IQ level was also explored in a subsample (n = 175). The Strengths and Difficulties Questionnaire and the Social Communication Questionnaire were used to assess behavioural and emotional problems and autism traits.

RESULTS

On the Strengths and Difficulties Questionnaire, peer problems were the most frequently reported difficulty (48% > cut-off), followed by hyperactivity/inattention (34% > cut-off). On the Social Communication Questionnaire, 37% scored at or above cut-off (≥15) for autism spectrum disorder; 17% were at or above the suggested cut-off (≥22) for autism. Little association between age and behavioural or emotional problems or with severity of autistic symptomatology was found. However, peer problems were more common in adolescents than in junior school children (P < 0.001); Hyperactivity/inattention was less prevalent among adolescents (P < 0.001).

CONCLUSIONS

High rates of autistic features, emotional and behavioural problems are documented. These problems are related to age, gender and degree of intellectual disability.

Profiles of children with Down syndrome who meet screening criteria for autism spectrum disorder (ASD): a comparison with children diagnosed with ASD attending specialist schools

BACKGROUND

Recent research suggests that around 16% to 18% of children with Down syndrome (DS) also meet diagnostic criteria for autism spectrum disorder (ASD). However, there are indications that profiles of autism symptoms in this group may vary from those typically described in children with ASD.

METHOD

Rates of autism symptoms and emotional and behavioural problems among children with DS who screened positive for ASD on the Social Communication Questionnaire (SCQ) (n = 183) were compared with a group of children with clinical diagnoses of ASD (n = 189) attending specialist schools in the UK. Groups were matched for age and approximate language level (use of phrase speech).

RESULTS

Profiles of autistic symptoms in the two groups were generally similar, but children with DS meeting ASD cut-off on the SCQ tended to show fewer problems in reciprocal social interaction than those in the ASD group. They also showed slightly lower rates of emotional and peer-related problems. The results mostly confirm findings from a previous study in which the original validation sample for the SCQ was used as a comparison group.

CONCLUSION

Findings suggest that children with DS who meet screening criteria for ASD show similar profiles of communication and repetitive behaviours to those typically described in autism. However, they tend to have relatively milder social difficulties. It is important that clinicians are aware of this difference if children with DS and ASD are to be correctly diagnosed and eligible for specialist intervention and education services.

Post-hoc comparison of vitamin D status at three timepoints during pregnancy demonstrates lower risk of preterm birth with higher vitamin D closer to delivery

There have been observational reports that maternal vitamin D status at baseline and not closest to delivery is a better predictor of pregnancy outcomes, suggesting that a cascade of events is set into motion that is not modifiable by vitamin D supplementation during later pregnancy. To address this issue, in this exploratory post-hoc analysis using correlation and logistic regression, we sought to measure the strength of the association between serum 25(OH)D concentrations at 3 timepoints during pregnancy: baseline, 1st trimester (<16 weeks); 2nd trimester (16-26 weeks); and 3rd trimester (≥27 weeks) and preterm birth. It was hypothesized that the 25(OH)D value closest to delivery would be most significantly associated with preterm birth. To accomplish this objective, the datasets from NICHD (n=333) and Thrasher Research Fund (n=154) vitamin D supplementation pregnancy studies were combined. The results of this analysis were that 25(OH)D values closer to delivery were more strongly correlated with gestational age at delivery than earlier values: 1st trimester: r=0.11 (p=0.02); 2nd trimester: r=0.08 (p=0.09); and 3rd trimester: r=0.15 (p=0.001). When logistic regression was performed with preterm birth (<37 weeks) as the outcome and 25(OH)D quartiles as the predictor variable, adjusting for study and participant race/ethnicity, as with the correlation analysis, the measurements closer to delivery were more significantly associated and had a higher magnitude of effect. That is, at baseline, those who had serum concentrations <50nmol/L (20ng/mL) had 3.3 times of odds of a preterm birth compared to those with serum concentrations ≥100nmol/L (40ng/mL; p=0.27). At 2nd trimester, the odds were 2.0 fold (p=0.21) and at the end of pregnancy, the odds were 3.8 fold (p=0.01). The major findings from this exploratory analysis were: (1) maternal vitamin D status closest to delivery date was more significantly associated with preterm birth, suggesting that later intervention as a rescue treatment may positively impact the risk of preterm delivery, and (2) a serum concentration of 100nmol/L (40ng/mL) in the 3rd trimester was associated with a 47% reduction in preterm births. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Yunis-varon syndrome: further delineation of cardiovascular and endocrine outcome

Yunis-Varon syndrome is a rare autosomal recessive condition initially characterized by specific skeletal and ectodermal abnormalities, and a poor prognosis, due to neurological and cardiovascular involvement. We describe the cardiovascular and endocrine complications in a 26-year-old man who had been reported previously, adding dilated cardiomyopathy to the clinical features consistent with Yunis-Varon syndrome. Short stature, successfully treated with growth hormone, and hypertension secondary to bilateral renal artery stenosis expand the phenotype.

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial

OBJECTIVE

To assess the impact of different management strategies in urinary tract infections.

DESIGN

Randomised controlled trial.

SETTING

Primary care.

PARTICIPANTS

309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

INTERVENTION

Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

MAIN OUTCOME MEASURES

Symptom severity (days 2 to 4) and duration, and use of antibiotics.

RESULTS

Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

CONCLUSION

All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

STUDY REGISTRATION

National Research Register N0484094184 ISRCTN: 03525333.

Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study

OBJECTIVE

To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance.

DESIGN

Observational study.

SETTING

Primary care.

PARTICIPANTS

839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection.

MAIN OUTCOME MEASURE

Duration and severity of symptoms.

RESULTS

684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline.

CONCLUSION

Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study

OBJECTIVES

To estimate clinical and dipstick predictors of infection and develop and test clinical scores; to compare management using clinical and dipstick scores with commonly used alternative strategies; to estimate the cost-effectiveness of each strategy; and to understand the natural history of urinary tract infection (UTI) and women's concerns about its presentation and management.

DESIGN

There were six studies: (1) validation development for diagnostic clinical and dipstick scores; (2) validation of the scores developed; (3) observation of the natural history of UTI; (4) randomised controlled trial (RCT) of scores developed in study 1; (5) economic analysis of the RCT; (6) qualitative study of patients in the RCT.

SETTING

Primary care.

PARTICIPANTS

Women aged 17-70 with suspected UTI.

INTERVENTIONS

Patients were randomised to five management approaches: empirical antibiotics; empirical delayed antibiotics; target antibiotics based on a higher symptom score; target antibiotics based on dipstick results; or target antibiotics based on a positive mid-stream specimen of urine (MSU).

MAIN OUTCOME MEASURES

Antibiotic use, use of MSUs, rates of reconsultation and duration, and severity of symptoms.

RESULTS

(1) 62.5% of women had confirmed UTI. Only nitrite, leucocyte esterase and blood independently predicted diagnosis of UTI. A dipstick rule--based on having nitrite or both leucocytes and blood--was moderately sensitive (77%) and specific (70%) [positive predictive value (PPV) 81%, negative predictive value (NPV) 65%]. A clinical rule--based on having two of urine cloudiness, offensive smell, reported moderately severe dysuria, moderately severe nocturia--was less sensitive (65%) (specificity 69%, PPV 77%, NPV 54%). (2) 66% of women had confirmed UTI. The predictive values of nitrite, leucocyte esterase and blood were confirmed. The dipstick rule was moderately sensitive (75%) but less specific (66%) (PPV 81%, NPV 57%). (3) Symptoms rated as moderately bad or worse lasted 3.25 days on average for infections sensitive to antibiotics; resistant infections lasted 56% longer, infections not treated with antibiotics 62% longer and symptoms associated with urethral syndrome 33% longer. Symptom duration was shorter if the doctor was perceived to be positive about prognosis, and longer with frequent somatic symptoms, previous history of cystitis, urinary frequency and more severe symptoms at baseline. (4) 66% of the MSU group had laboratory-confirmed UTI. Women suffered 3.5 days of moderately bad symptoms if they took antibiotics immediately but 4.8 days if they delayed taking antibiotics for 48 hours. Taking bicarbonate or cranberry juice had no effect. (5) The MSU group was more costly over 1 month but not over 1 year. Cost-effectiveness acceptability curves showed that for a value per day of moderately bad symptoms of over 10 pounds, the dipstick strategy is most likely to be cost-effective. (6) Fear of spread to the kidneys, blood in the urine, and the impact of symptoms on vocational and leisure activities were important triggers for seeking help. When patients are asked to delay taking antibiotics the uncomfortable and worrying journey from 'person to patient' needs to be acknowledged and the rationale behind delaying the antibiotics made clear.

CONCLUSIONS

To achieve good symptom control and reduce antibiotic use clinicians should either offer a 48-hour delayed antibiotic prescription to be used at the patient's discretion or target antibiotic treatment by dipsticks (positive nitrite or positive leucocytes and blood) with the offer of a delayed prescription if dipstick results are negative.

Coronary artery fistula in a patient with pulmonary atresia and tricuspid atresia clinical and MRI findings

The MRI findings of a case of coronary artery fistula occurring in a patient with pulmonary atresia and tricuspid atresia is presented.

St John's wort versus placebo in obsessive-compulsive disorder: results from a double-blind study

Although St John's wort (Hypericum perforatum) is one of the most widely used and studied herbal medicines for depression, less is known about its efficacy in anxiety disorders, in spite of the fact that patients with anxiety disorders are among the most likely to self-medicate using alternative treatments. Pharmacokinetic evidence for the serotonergic, domaminergic and GABAminergic activity of hypericum, and a recent successful open-label study, suggests that it may be effective for obsessive-compulsive disorder (OCD). Sixty subjects were randomized to 12 weeks of treatment with St John's wort (LI 160) or matching placebo. Subjects with Hamilton Depression Scale scores of 16 or above were excluded. A flexible-dose schedule was utilized (600-1800 mg/day). The mean change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) with St John's wort (3.43) was not significantly different than the mean change found with placebo (3.60) (P=899). No significant differences were found on any of the Y-BOCS subscales. The percentage of patients rated as 'much' or 'very much' improved at endpoint was not significantly different between St John's wort (17.9%) and placebo (16.7%) (P=0.905). Only one patient from each group discontinued due to adverse events [sinus infection (St John's wort); confusion (placebo)]. The results fail to support the efficacy of St John's wort for OCD.

St. John's wort versus placebo in social phobia: results from a placebo-controlled pilot study

Recognition of social anxiety disorder (social phobia) as a common and disabling condition has led to new advances in its pharmacotherapy. Limitations with selective seroton reuptake inhibitors (side effects) and behavior therapy (scarcity of trained therapists), coupled with the tendency for patients with the disorder to self-medicate with alternative treatments, have led to the interest in Saint John's wort (SJW) (Hypericum perforatum) for this disorder. Although the literature is mixed, SJW has demonstrated efficacy in several double-blind depression trials, and some open-label studies with anxiety disorders. There is pharmacokinetic evidence for the serotonergic, domaminergic, and GABAminergic activity of hypericum, all of which are implicated in social anxiety disorder. This study was designed to generate pilot data to examine the potential efficacy of SJW in generalized social anxiety disorder. Forty subjects were randomized to 12 weeks of treatment with a flexible dose (600-1800 mg) of SJW (n = 20) or placebo (n = 20). Subjects with comorbid depression (clinician HAMD > 16) were excluded. Results found no significant difference between mean change on the Liebowitz Social Anxiety Scale with SJW (11.4) and placebo (13.2), P = 0.27, effect size = -0.09. Post-hoc analyses found larger effects sizes associated with increased baseline severity, omitting patients with variable scores (+/-30%) during the first week, and use of self-report HAMD scores for exclusion. Results of the study fail to provide evidence for the efficacy of SJW in social phobia. The impact of methodologic improvements on signal detection, while suggestive of improvement, remains to be established.

Psychosocial, lifestyle, and health status variables in predicting high attendance among adults

BACKGROUND

Increasing consultation rates have implications for the organisation of health services, the quality of care, and understanding the decision to consult. Most quantitative studies have concentrated on very high attenders--not those attending five or more times a year, who are responsible for most (60%) consultations--and have assessed neither the role of lifestyle nor patients' attitudes.

AIMS

To assess associations with higher than average attendance (five or more times ayear).

DESIGN OF STUDY

Postal questionnaire sent to a random sample.

SETTING

Four thousand adults (one per household) from six general practices.

METHOD

Data were analysed to identify predictors significantly associated with higher than average attendance.

RESULTS

The response rate was 74%. Sef-reported attendance agreed with the notes (r = 0.80, likelihood ratio for a positive test = 9.4). Higher attendance was independently predicted by the severity of ill health (COOP score = 0-7, 8-9, and 10+; adjusted odds ratios= 1, 1.72, 1.91 respectively; test for trend P<0.001) and the number of reported medical problems (COOP score = 0, 1, 2, and 3+ respectively; adjusted ORs = 1, 2.05, 2.31, 4.29; P<0.001). After controlling for sociodemographic variables, medical problems, the severity of physical ill health, and other confounders, high attendance was more likely in those with medically unexplained somatic symptoms (0, 1-2, 3-5, and 6+ symptoms respectively, ORs = 1, 1.15, 1.48, and 1.62; P<0.001); health anxiety (Whitely Index = 0, 1-5, 6-7 and 8+ respectively, ORs = 1, 1.22, 1.77, and 2.78; P<0.001); and poor perceived health ('very good', 'good', 'poor' respectively, ORs = 1, 1.61, and 2.93; P<0.001). Attendance was less likely in those with negative attitudes to repeated surgery use (OR = 0.61, 95% CI = 0.47-0.78), or to doctors (Negdoc scale <18, 18-20, and 21+ respectively; ORs = 1, 0.87, 0.67; P<0.001), in those usually trying the pharmacy first (OR = 0.61, 95% CI 0.48-0.78), and those consuming alcohol (0, 1, 2, 3+ units/day respectively; ORs = 1, 0.62, 0.41, 0.29; P<0.001). Anxiety or depression predicted perceived health, unexplained symptoms, and health anxiety.

CONCLUSION

Strategies to manage somatic symptoms, health anxiety, dealing with the causes of--or treating--anxiety and depression, and encouraging use of the pharmacy have the potential both to help patients manage symptoms and in the decision to consult. Sensitivity to the psychological factors contributing to the decision to consult should help doctors achieve a better shared understanding with their patients and help inform appropriate treatment strategies.

Family influences in a cross-sectional survey of higher child attendance

BACKGROUND

A quarter of all consultations are for children, but there is little quantitative evidence documenting what parental factors are important in the decision to consult.

AIM

To assess parental factors in higher child attendance (three or more times per year)--the 32% responsible for most (69%) general practice consultations with children.

DESIGN OF STUDY

A random sample of 4000 individuals (one per household), including 670 children.

SETTING

Six general practices within a 30-mile radius of the administrative centre.

METHOD

Parents completed a postal questionnaire for themselves and their child. The adult questionnaire documented lifestyle, attitude to doctors and medicine, Kokko's personality types, perceived health, health anxiety, number of medical problems, medically unexplained somatic symptoms, and willingness to tolerate symptoms. The child questionnaire documented perceived health, the number of medical problems, somatic symptom inventory, willingness to tolerate symptoms, and self-reported attendance.

RESULTS

(Adjusted odds ratios, test for trend, 95% confidence intervals.) A response rate of 490/670 (73%) paired adult and child questionnaires was obtained. Reported higher attendance was valid compared with the notes (likelihood ratio positive test = 5.2, negative test = 0.24), and was independently predicted by the child's age, medical problems, council house occupancy, and by the parents' assessment of the severity of the child's ill health. After controlling for these variables, higher attendance was more likely if the parents were higher attenders (adjusted OR = 3.71, 95% CI = 2.31-5.98), and if they perceived their children had medically unexplained physical symptoms (MUPS) (for 0, 1, 2, 3+ symptoms; adjusted ORs (95% CIs) = 1, 3.1 (1.7-5.7), 2.30 (0.97-5.5), 4.2 (1.8-9.6) respectively, P < or = 0.001). Attendance was less likely if they were willing to tolerate symptoms in their children (score for seven normally self-limiting scenarios = 0-17, 18-29 and 30+; adjusted ORs = 1, 0.71, 0.39 respectively, z for trend P = 0.03), willingness to tolerate symptoms and parental perception of child MUPS were associated with council house tenancy and health anxiety. Parents' perception of child MUPS also related to perception of child health and the parents' own MUPS. Parents of higher attenders were more likely to be depressed (HAD depression scale = 0-7, 8-10, 11+ respectively; adjusted ORs (95% CIs) = 1, 2.04 (1.27-3.27), 1.60 (0.75-3.42)) or anxious (anxiety scale 0-7, 8-10, 11+, respectively; adjusted ORs [95% CIs] = 1, 1.60 [0.99-2.58], 1.97 [1.20-3.26]).

CONCLUSION

Important parental factors are council house tenancy, the parents' perception of and willingness to tolerate, somatic symptoms in the child, and the parents' own attendance history, health anxiety, and perception of somatic symptoms Doctors should be sensitive to the parental and family factors that underlie the decision to consult and of the needs of parents of high-attending children.

Association of NRAMP1 polymorphism with leprosy type but not susceptibility to leprosy per se in west Africans

Twin and family studies indicate that host genetic factors influence susceptibility to leprosy and, possibly, leprosy type. Murine studies have suggested a role for the natural resistance-associated macrophage protein 1 (Nramp1) gene, which can influence cellular immune responses to intracellular pathogens. We evaluated a variation in the human homolog, NRAMP1, recently associated with tuberculosis susceptibility in West Africa. A total of 273 patients with leprosy and 201 controls from Mali were genotyped for NRAMP1 polymorphisms previously associated with tuberculosis. No association was found with leprosy per se (P = 0.83), but the NRAMP1 3'-untranslated region 4-bp insertion/deletion polymorphism was associated with leprosy type (P = 0.007). Heterozygotes were more frequent among multibacillary than paucibacillary leprosy cases. Thus, variation in or near the NRAMP1 gene may exert an influence on the clinical presentation of leprosy, possibly by influencing cellular immune response type.