Canadian Consensus Statements on the Transition of Adolescents and Young Adults with Inflammatory Bowel Disease from Pediatric to Adult Care: A Collaborative Initiative Between the Canadian IBD Transition Network and Crohn’s and Colitis Canada

Objectives

With the increased prevalence of childhood-onset inflammatory bowel disease (IBD), there is a greater need for a planned transition process for adolescents and young adults (AYA). The Canadian IBD Transition Network and Crohn’s and Colitis Canada joined in collaborative efforts to describe a set of care consensus statements to provide a framework for transitioning AYA from pediatric to adult care.

Methods

Consensus statements were drafted after focus group meetings and literature reviews. An expert panel consisting of 20 IBD physicians, nurses, surgeon, adolescent medicine physician, as well as patient and caregiver representatives met, discussed and systematically voted. The consensus was reached when greater than 75% of members voted in agreement. When greater than 75% of members rated strong support, the statement was rendered a strong recommendation, suggesting that a clinician should implement the statement for all or most of their clinical practice.

Results

The Canadian expert panel generated 15 consensus statements (9 strong and 6 weak recommendations). Areas of focus of the statements included: transition program implementation, key stakeholders, areas of potential need and gaps in the research.

Conclusions

These consensus statements provide a framework for the transition process. The quality of evidence for these statements was generally low, highlighting the need for further controlled studies to investigate and better define effective strategies for transition in pediatric to adult IBD care.

OUP accepted manuscript

Background

Rural dwellers with inflammatory bowel disease (IBD) face barriers to accessing specialized health services. We aimed to contrast health care utilization between rural and urban residents diagnosed with IBD in Saskatchewan, Canada.

Methods

We completed a population-based retrospective study from 1998/1999 to 2017/2018 using administrative health databases. A validated algorithm was used to identify incident IBD cases aged 18+. Rural/urban residence was assigned at IBD diagnosis. Outpatient (gastroenterology visits, lower endoscopies, and IBD medications claims) and inpatient (IBD-specific and IBD-related hospitalizations, and surgeries for IBD) outcomes were measured after IBD diagnosis. Cox proportional hazard, negative binomial, and logistic models were used to evaluate associations adjusting by sex, age, neighbourhood income quintile, and disease type. Hazard ratios (HR), incidence rate ratios (IRR), odds ratios (OR), and 95% confidence intervals (95% CI) were reported.

Results

From 5,173 incident IBD cases, 1,544 (29.8%) were living in rural Saskatchewan at IBD diagnosis. Compared to urban dwellers, rural residents had fewer gastroenterology visits (HR = 0.82, 95% CI: 0.77-0.88), were less likely to have a gastroenterologist as primary IBD care provider (OR = 0.60, 95% CI: 0.51-0.70), and had lower endoscopies rates (IRR = 0.92, 95% CI: 0.87-0.98) and more 5-aminosalicylic acid claims (HR = 1.10, 95% CI: 1.02-1.18). Rural residents had a higher risk and rates of IBD-specific (HR = 1.23, 95% CI: 1.13-1.34; IRR = 1.22, 95% CI: 1.09-1.37) and IBD-related (HR = 1.20, 95% CI: 1.11-1.31; IRR = 1.23, 95% CI: 1.10-1.37) hospitalizations than their urban counterparts.

Conclusion

We identified rural-urban disparities in IBD health care utilization that reflect rural-urban inequities in the access to IBD care. These inequities require attention to promote health care innovation and equitable management of patients with IBD living in rural areas.

Increasing Prevalence and Direct Health Care Cost of Inflammatory Bowel Disease Among Adults: A Population-Based Study From a Western Canadian Province

Objectives

Our study aimed to calculate the prevalence and estimate the direct health care costs of inflammatory bowel disease (IBD), and test if trends in the prevalence and direct health care costs of IBD increased over two decades in the province of Saskatchewan, Canada.

Methods

We conducted a retrospective population-based cohort study using administrative health data of Saskatchewan between 1999/2000 and 2016/2017 fiscal years. A validated case definition was used to identify prevalent IBD cases. Direct health care costs were estimated in 2013/2014 Canadian dollars. Generalized linear models with generalized estimating equations tested the trend. Annual prevalence rates and direct health care costs were estimated along with their 95% confidence intervals (95%CI).

Results

In 2016/2017, 6468 IBD cases were observed in our cohort; Crohn’s disease: 3663 (56.6%), ulcerative colitis: 2805 (43.4%). The prevalence of IBD increased from 341/100,000 (95%CI 340 to 341) in 1999/2000 to 664/100,000 (95%CI 663 to 665) population in 2016/2017, resulting in a 3.3% (95%CI 2.4 to 4.3) average annual increase. The estimated average health care cost for each IBD patient increased from $1879 (95%CI 1686 to 2093) in 1999/2000 to $7185 (95%CI 6733 to 7668) in 2016/2017, corresponding to an average annual increase of 9.5% (95%CI 8.9 to 10.1).

Conclusions

Our results provide relevant information and analysis on the burden of IBD in Saskatchewan. The evidence of the constant increasing prevalence and health care cost trends of IBD needs to be recognized by health care decision-makers to promote cost-effective health care policies at provincial and national levels and respond to the needs of patients living with IBD.

Population-Based Evidence From a Western Canadian Province of the Decreasing Incidence Rates and Trends of Inflammatory Bowel Disease Among Adults

Background and Aims

Canada has one of the highest inflammatory bowel disease (IBD) incidence rates worldwide. Higher IBD incidence rates have been identified among urban regions compared to rural regions. The study objectives were to (i) estimate IBD incidence rates in Saskatchewan from 1999 to 2016 and (ii) test for differences in IBD incidence rates for rural and urban regions of Saskatchewan.

Methods

A population-based study was conducted using provincial administrative health databases. Individuals aged 18+ years with newly diagnosed Crohn's disease or ulcerative colitis were identified using a validated case definition. Generalized linear models with a negative binomial distribution were used to estimate incidence rates and incidence rate ratios (IRRs) adjusted for age group, sex and rurality with 95% confidence intervals (CIs).

Results

The average annual incidence rate of IBD among adults in Saskatchewan decreased from 75/100,000 (95% CI 67 to 84) in 1999 to 15/100,000 (95% CI 12 to 18) population in 2016. The average annual incidence of IBD declined significantly by 6.9% (95% CI -7.6 to -6.2) per year. Urban residents had a greater overall risk of IBD (IRR = 1.19, 95% CI 1.11 to 1.27) than rural residents. This risk difference was statistically significant for Crohn's disease (IRR = 1.25, 95% CI 1.14 to 1.36), but not for ulcerative colitis (IRR = 1.08, 95% CI 0.97 to 1.19).

Conclusions

The incidence of IBD in Saskatchewan dropped significantly from 1999 to 2016 with urban dwellers having a 19% higher risk of IBD onset compared to their rural counterparts. Health care providers and decision-makers should plan IBD-specific health care programs considering these specific IBD rates.

Development of a screening tool to detect nutrition risk in patients with inflammatory bowel disease

BACKGROUND AND OBJECTIVES

Malnutrition is a known complication of Inflammatory Bowel Disease (IBD). We assessed a known screening tool, as well as developed and validated a novel screening tool, to detect nutrition risk in outpatients with IBD.

METHODS AND STUDY DESIGN

The Saskatchewan IBD-Nutrition Risk (SaskIBD-NR Tool) was developed and administered alongside the Malnutrition Universal Screening Tool (MUST). Nutrition risk was confirmed by the IBD dietitian (RD) and gastroenterologist (GI). Agreement between screening tools and RD/GI assessment was computed using Cohen's kappa.

RESULTS

Of the 110 patients screened, 75 (68.2%) patients had Crohn's Disease and 35 (31.8%) ulcerative colitis. Mean BMI was 26.4 kg/m2 (SD=5.8). RD/GI assessment identified 23 patients (20.9%) at nutrition risk. The SaskIBD-NR tool classified 21 (19.1%) at some nutrition risk, while MUST classified 17 (15.5%). The SaskIBD-NR tool had significant agreement with the RD/GI assessment (k 0.83, p<0.001), while MUST showed a lack of agreement (k 0.15, p=0.12). The SaskIBD-NR had better sensitivity (82.6% vs 26.1%), specificity (97.7% vs 87.4%), positive predictive value (90.5% vs 35.3%), and negative predictive value (95.5% vs 81.7%) than the MUST.

CONCLUSION

The SaskIBD-NR, which assesses GI symptoms, food restriction, and weight loss, adequately detects nutrition risk in IBD patients. Broader validation is required.

Biomarker-Based Models Outperform Patient-Reported Scores in Predicting Endoscopic Inflammatory Disease Activity

BACKGROUND

The Crohn's Disease Activity Index (CDAI), a scoring index including patient-reported outcomes (PROs), has known limitations for measuring intestinal inflammatory disease burden. Noninvasive markers of inflammation could prove more accurate than PROs; thus, regulatory authorities are exploring the use of PROs and endoscopic data as coprimary end points in clinical trials. The aim of this study was to assess the predictive ability of individual components of the CDAI, along with biomarker concentrations, to create models for predicting endoscopic disease activity.

METHODS

Between 2004 and 2006, 164 patients with established Crohn's disease (CD) undergoing clinically indicated ileocolonoscopy were recruited. Individual CDAI variables and fecal calprotectin (FC) were selected to explore their predictive accuracy for endoscopic disease activity, with the Simple Endoscopic Score-Crohn's Disease (SES-CD) as the outcome variable. Simple Poisson regression was performed on each variable, and 2 multivariate models were created (PRO-exclusive and PRO+FC [PRO+]). Additional analyses explored the patient-level agreement between models.

RESULTS

Number of liquid stools, abdominal pain, hematocrit (Hct), FC, and high-sensitivity C-reactive protein (hsCRP) correlated significantly with the SES-CD. For the prediction of SES-CD (>7 vs ≤6), the area under the curve (AUC) was 0.81, with 63% and 88% sensitivity and specificity, for the PRO+ model, compared with a 0.56 AUC, with 61% and 55%, respectively, for the PRO model. Intra-individual comparison revealed the PRO+ model to be superior in the prediction of endoscopically active disease.

CONCLUSIONS

The inclusion of biomarkers significantly improved predictive accuracy for endoscopic disease activity compared with PRO-exclusive models.

Impact of an Integrated Model of Care on Outcomes of Patients With Inflammatory Bowel Diseases: Evidence From a Population-Based Study

BACKGROUND AND AIMS

Studies evaluating the impact of integrated models of care [IMC] for inflammatory bowel disease [IBD] on disease-related outcomes are needed. We compared the risk of IBD-related outcomes and prescription medication claims between patients exposed and non-exposed to an IMC.

METHODS

A retrospective population-based matched cohort study was conducted between 2009 and 2015, using administrative health data of Saskatchewan, Canada. Patients aged 18+ years with a diagnosis of IBD were identified with a validated administrative definition. Cases were classified as exposed and non-exposed to the IMC for IBD and matched based on propensity scores and disease duration. IBD-related hospitalisations, surgeries, prescription medication claims, and corticosteroid dependency [CsDep] were measured. Cox and logistic regression models evaluated differences between the groups, estimating hazard [HRs] and odds [ORs] ratios with corresponding confidence intervals [CIs].

RESULTS

In total, 2312 matched patients were included; 24.3% were exposed individuals. Compared with non-exposed, exposed patients had a lower risk of IBD-related surgeries [HR = 0.78, 95% CI 0.61-0.99], higher risk of prescriptions of immune modulators [HR = 1.68, 95% CI 1.42-1.99], and biologics [HR = 1.85, 95% CI 1.52-2.27], and a lower risk of 5-aminosalicylic acid prescriptions [HR = 0.81, 95% CI 0.69-0.95]. A lower risk of IBD-related hospitalisations among exposed ulcerative colitis [UC] patients [HR = 0.66, 95% CI 0.49-0.89] was identified in stratified analyses. The odds of CsDep among exposed UC patients was 0.39 [95% CI 0.15-0.98].

CONCLUSIONS

The observed differences in disease-related outcomes and use of steroid-sparing maintenance therapies between exposed and non-exposed individuals support the concept that enhanced quality of care can be achieved within IMC for IBD.

Inverse relationship between body mass index and mortality in older nursing home residents: a meta-analysis of 19,538 elderly subjects

Body mass index (BMI) and mortality in old adults from the general population have been related in a U-shaped or J-shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m(2)), the most adjusted hazard ratios (HRs) according to a pre-defined list of covariates were obtained from authors and pooled by random-effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow-up were meta-analysed. Compared with normal weight, all-cause mortality HRs were 1.41 (95% CI = 1.26-1.58) for underweight, 0.85 (95% CI = 0.73-0.99) for overweight and 0.74 (95% CI = 0.57-0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13-2.40]). RR results corroborated primary HR results, with additionally lower infection-related mortality in overweight and obese than in normal-weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.

SMAD3 gene variant is a risk factor for recurrent surgery in patients with Crohn's disease

BACKGROUND AND AIMS

More than 80% of Crohn's disease (CD) patients will require surgery. Surgery is not curative and rates of re-operation are high. Identification of genetic variants associated with repeat surgery would allow risk stratification of patients who may benefit from early aggressive therapy and/or post-operative prophylactic treatment.

METHODS

CD patients who had at least one CD-related bowel resection were identified from the Prospective Registry in IBD Study at Massachusetts General Hospital (PRISM). The primary outcome was surgical recurrence. Covariates and potential interactions were assessed using the Cox proportional hazard model. Kaplan-Meier curves for time to surgical recurrence were developed for each genetic variant and analyzed with the log-rank test.

RESULTS

194 patients were identified who had at least 1 resection. Of these, 69 had two or more resections. Clinical predictors for repeat surgery were stricturing (HR 4.18, p=0.022) and penetrating behavior (HR 3.97, p=0.024). Smoking cessation was protective for repeat surgery (HR 0.45, p=0.018). SMAD3 homozygosity for the risk allele was also independently associated with increased risk of repeat surgery (HR 4.04, p=0.001). NOD2 was not associated with increased risk of surgical recurrence.

CONCLUSION

Stricturing and penetrating behavior were associated with increased risk of surgical recurrence, while smoking cessation was associated with a decreased risk. A novel association between SMAD3 and increased risk of repeat operation and shorter time to repeat surgery was observed. This finding is of particular interest as SMAD3 may represent a new therapeutic target specifically for prevention of post-surgical disease recurrence.

IVF outcomes in obese donor oocyte recipients: a systematic review and meta-analysis

STUDY QUESTION

Does obesity influence the chance of pregnancy after IVF in donor oocyte recipients?

SUMMARY ANSWER

The chance of pregnancy after IVF is no different in obese donor oocyte recipients versus those in the normal BMI range.

WHAT IS KNOWN ALREADY

Obesity is associated with decreased chances of pregnancy in women undergoing IVF with autologous oocytes. Prior studies have investigated the impact of obesity on IVF outcomes in donor oocyte recipients, with disparate results. This is the first systematic review and meta-analysis to address this topic.

STUDY DESIGN, SIZE, DURATION

A systematic review and meta-analysis of published literature identified in Medline, EMBASE and Scopus through December of 2011 were performed to address the association between BMI and outcomes for donor oocyte recipients. The primary outcome of this study was implantation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two authors conducted the searches independently, selected the studies and abstracted the data. Studies in English of first donor oocyte cycles with reported recipient BMI were included. Primary data collected from the IVF program at Washington University were also included as one study (n = 123 donor oocyte recipients). Studies limited to frozen embryo transfer were excluded. Data were synthesized using DerSimonian-Laird random effects models for implantation, clinical pregnancy, miscarriage and live birth.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 475 screened articles, 7 were reviewed and 5 were included together with primary data from Washington University, giving a total of 4758 women who were included for the assessment of the primary outcome. No associations between obesity (BMI ≥ 30 kg/m(2)) and chance of pregnancy after IVF were noted in women using donor oocytes [risk ratio (RR): 0.98, 95% confidence intervals (CI): 0.83-1.15, I(2): 61.6%]. Additional analyses assessing associations between recipient obesity and embryo implantation (RR: 0.93, 95% CI: 0.80-1.07, I(2): 0%), miscarriage (RR: 1.12, 95% CI: 0.83-1.50, I(2): 0%) and live birth (RR: 0.91, 95% CI: 0.65-1.27, I(2) 47.9%) also failed to show a negative effect.

LIMITATIONS, REASONS FOR CAUTION

Included studies were small and they were performed in a variety of locations and practice settings where stimulation and laboratory protocols may differ, and extremes of BMI may also differ. Furthermore, included studies had different inclusion and exclusion criteria. These factors could not be controlled for in this meta-analysis and statistical heterogeneity was noted for some outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

These data suggest obesity does not affect IVF outcomes in women using donor oocytes. Oocyte quality rather than endometrial receptivity may be the overriding factor influencing IVF outcomes in obese women using autologous oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

E.S.J. and M.G.T receive support from the Women's Reproductive Health Research Program sponsored by the National Institutes of Health (K12 HD063086). The authors do not have any competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Effects of cancer treatment on inflammatory bowel disease remission and reactivation

BACKGROUND & AIMS

Little is known about the effects of cancer therapy for extraintestinal malignancy in patients with inflammatory bowel diseases (IBDs).

METHODS

We analyzed data from the Massachusetts General Hospital and the Brigham and Women's Hospital on 84 patients diagnosed with Crohn's disease, ulcerative colitis, or indeterminate colitis found to have a solid malignant extraintestinal neoplasm between January 15, 1993, and December 15, 2011. We investigated the incidence of remission with cancer treatment (cytotoxic chemotherapy, hormone therapy, or both) among patients with active IBD (n = 15) and time to disease activation after cancer treatment of those with inactive disease (n = 69). Cox proportional hazards models and survival curves were constructed to identify independent predictors of these outcomes.

RESULTS

Among patients with active IBD at cancer diagnosis, 66.7% (n = 10/15) achieved remission during cancer treatment; the median duration of remission was 27 months. Ninety percent of these patients had received cytotoxic chemotherapy. For patients with IBD in remission at cancer diagnosis, 17.4% (n = 12/69) developed active IBD; the type of treatment was the strongest predictor of IBD reactivation. The risk of IBD reactivation was greatest among patients who received a combination of cytotoxic chemotherapy and adjuvant hormone therapy (hazard ratio, 12.25; 95% confidence interval, 1.51-99.06) or only hormone therapy (hazard ratio, 11.56; 95% confidence interval, 1.39-96.43). Ninety percent of patients who received cytotoxic chemotherapy remained in remission at 5 years compared with 64% of those who received only hormone therapy or the combination of cytotoxic chemotherapy and adjuvant hormone therapy (log rank, P = .02).

CONCLUSIONS

IBD is more likely to remit among patients who receive cytotoxic chemotherapy for solid malignancies than those who receive only hormone therapy or the combination of cytotoxic chemotherapy and adjuvant hormone therapy. Among patients with inactive IBD at the time of cancer diagnosis, hormonal therapy, alone or in combination with cytotoxic chemotherapy, increases the risk of IBD reactivation.

Prolongation of the intravascular retention of hemoglobin modified with a long-chain fatty acid derivative

To develop hemoglobin (Hb) derivatives with an increased circulatory half-life, Hb was chemically modified with long chain fatty acid analogs. One compound, sodium 1-hexadecyl 6-(2-iodoacetamido)hexyl phosphate, specifically modified the Cys-93 beta residues of human hemoglobin (HbA) as determined by sulfhydryl titration analysis. The resulting modified Hb derivative, FAHbA, was isolated and was shown to have a two-fold longer circulatory half-life than native HbA in a rat low-dose acute transfusion model.

Allosteric kinetics and equilibria of triligated, cross-linked hemoglobin

Using modulated excitation, we have measured the forward and reverse rates of the allosteric transition between relaxed (R) and tense (T) quaternary structures for triply ligated hemoglobin (Hb), cross-linked between the alpha chains at Lys 99. Oxygen, carbon monoxide, and water were used as ligands and were studied in phosphate and low Cl- bis-Tris buffers at neutral pH. Since the cross-link prohibits disproportionation, triply ligated aquomet Hb species with ferrous beta chains were specifically isolated by isoelectric focusing. Modulated excitation provides rate pairs and therefore gives equilibrium constants between quaternary structures. To coordinate with that information, oxygen binding curves of fully ferrous and tri-aquomet Hb were also measured. L3, the equilibrium constant between three liganded R and T structures, is determined by modulated excitation to be of order unity for O2 or CO (1.1 to 1.5 for 3O2 and 0.7 for 3CO bound), while with three aquomet subunits it is much greater (> or = 23). R-->T conversion rates are similar to those found for HbA, with weak sensitivity to changes in L3. The L3 values from HbXL O2 were used to obtain a unique allosteric decomposition of the ferrous O2 binding curve in terms of KT, KR, and L3. From these values and the O2 binding curve of tri-aquomet HbXL, L3 was calculated to be 2.7 for the tri-aquomet derivative. Consistency in L3 values between equilibrium and modulated excitation data for tri-aquomet-HbXL can be achieved if the equilibrium constant for O2 binding to the alpha chains is six times lower than that for binding to the beta chains in the R state, while the cooperative properties remain homogeneous. The results are in quantitative agreement with other studies, and suggest that the principal effect of the cross-link is to decrease the R state and T state affinity of the alpha subunits with almost no change in the affinity of the beta subunits, leaving the allosteric parameters L and c unchanged.

Isolation and characterization of the triply oxidized derivative of a cross-linked hemoglobin

Hemoglobin A, cross-linked between Lys 99 alpha 1 and Lys 99 alpha 2, was used to obtain a partially oxidized tetramer in which only one of the four hemes remains reduced. Because of the absence of dimerization, asymmetric, partially oxidized derivatives are stable. This is evidenced by the fact that eight of the ten possible oxidation states could be resolved by analytical isoelectric focusing. A triply oxidized hemoglobin population HbXL+3 was isolated whose predominant component was (alpha + alpha +, beta + beta 0). This triferric preparation was examined as a possible model for the triliganded state of ferrous HbA. The aquomet and cyanomet derivatives were characterized by their CD spectra and their kinetic reactions with carbon monoxide. CD spectra in the region of 287 nm showed no apparent change in quaternary structure upon binding ligand to the fourth, ferrous heme. The spectra of the oxy and deoxy forms of the cyanomet and aquomet derivatives of HbXL+3 differed insignificantly and were characteristic of the normal liganded state. Upon addition of inositol hexaphosphate (IHP), both the oxy and deoxy derivatives of the high-spin triaquomet species converted to the native deoxy conformation. In contrast, IHP had no such effect on the conformation of the low-spin cyanomet derivatives of HbXL+3. The kinetics of CO combination as measured by stopped-flow and flash photolysis techniques present a more complex picture. In the presence of IHP the triaquomet derivative does bind CO with rate constants indicative of the T state whether these are measured by the stopped-flow technique or by flash photolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

An analysis of the effects of multiple setting events on the social behavior of preschool children with special needs

We examined the effects of four combinations of setting events on the social interactions of 7 preschool children with social delays. In Study 1, the status of the teacher, activity materials, and peer varied across conditions. In Study 2, the status of the teacher and materials varied across conditions. Within the combinations of setting events, we also examined teacher behavior. Teacher presence and absence was varied in both studies. The type and rate of teacher prompting were varied in Study 2. The four combinations of setting events produced different rates of social behavior by the children with social delays. The optimal combination of setting events for promoting peer interaction and reducing teacher-child interaction included teacher absence from the activity, a limited number and form of materials, and children paired with a socially skilled partner.

Generalization and maintenance of preschool children's social skills: a critical review and analysis

This paper summarizes the results of a retrospective review of generalization in the context of social skills research with preschool children. A review of studies from 22 journals (1976 to 1990) that assessed generalization as part of social interaction research provided information concerning the prevalence of studies that have assessed generalization, common practices concerning the production and assessment of generalization, and the overall success of obtaining generalization and maintenance of social behaviors. A comparison of the most and least successful studies, with respect to generalization, revealed some differences concerning the practices employed by studies within each group. Differences differentially related to the production of generalization are discussed and recommendations are provided to guide and support future research efforts.

Reactivity in self-recording: obtrusiveness of recording procedure and peer comments

Reactivity refers to behavior change that occurs during self-recording without specific programming of consequences. We analyzed the effects of obtrusiveness of recording procedure and peer comments on reactivity to self-recording. Three first-grade students in Experiment 1 completed math questions during a 5-min work period. When we gave the children recording devices and told them to try to complete more questions than the highest number they had previously completed, math performance increased, as did the number of verbalizations about it. Two children showed more reactivity when they used the more obtrusive recording device. Because the increase in math performance corresponded closely to increases in peer comments, we manipulated peer comments directly in Experiment 2. Four second-grade students completed a math task and an alphabet task. Three of the students showed increased math performance during periods when peer comments occurred compared to periods when peer comments did not occur. Although the data from the math task suggested that peer comments can enhance reactivity, we did not observe this relationship with the alphabet task. These results suggest that the conditions necessary to produce desirable results through self-recording are complex and contextually specific.

Scanning electron microscopy of deposits remaining in soft contact lens polishing marks after cleaning

Deposits are a complication of contact lens wear that have been associated with ocular diseases, including keratitis and giant papillary conjunctivitis. The purpose of this morphologic study was to describe the deposits on soft contact lenses fabricated by different surface manufacturing methods and to evaluate the ease of removal of deposits by surfactant cleaning. We studied the anterior surfaces of 30 soft contact lenses (10 lathe cut [polished]; 10 spin cast [unpolished], and 10 cast molded [unpolished]) of the same polymer and water content. All lenses were worn for 8 hours by two asymptomatic persons who did not routinely wear contact lenses. Lenses from one eye were immersed in glutaraldehyde, while lenses from the other eye were cleaned before immersion in glutaraldehyde. All lenses were then dehydrated in graded alcohols, critical-point-dried, and observed by scanning electron microscopy. The amount of deposit on the lens surface was judged by an individual who did not know the identity of the lens. All lenses showed similar types of deposits. At the end of 8 hours wear, all types of lens surfaces were covered with deposits. Cleaning removed some but not all deposits. The lens surfaces manufactured in such a way as to leave polishing or lathe marks showed deposits "heaped-up" on the marks before cleaning and remaining in the mark after cleaning. Polishing marks from lens fabrication may represent an increased risk for conjunctival insult from deposits remaining in the marks after cleaning.

A comparison of two intervention roles: peer monitor and point earner

Two fifth-grade students' high levels of off-task and disruptive behavior decreased rapidly during an intervention in which they were appointed peer monitors or point earners. The children worked in dyads in which one child served as a peer monitor and the other child earned points from his or her monitor for good behavior. Points were accumulated as part of a group contingency. We introduced the two appointments in an independent math period and alternated the appointments across days. The peer monitor and point earner roles, when alternated on an every-other-day basis, were equally effective in reducing the students' inappropriate behavior. Furthermore, their behavior during intervention fell well within the range of inappropriate behavior levels exhibited by classmates. The speed with which both students completed their math problems increased during both appointments. The accuracy of their academic work, however, varied; one student improved slightly and the other student decreased slightly in accuracy.

Binding of iron by factor IX. Possible role for beta-hydroxyaspartic acid

In concentrations exceeding 1 mg/ml, bovine factor IX exhibits a pink color that arises from a broad absorption band with a lambda max = 500 nm. Analysis by x-ray fluorescence reveals the presence of iron but no other transition metals in the factor IX preparation. Quantitative analysis by atomic absorption spectroscopy indicates that 1 g atom of iron is bound tightly to 1 mol of factor IX. The iron is removed slowly (t1/2 = 3 h) by EDTA. In contrast, prothrombin binds no detectable iron, and factor X binds less than 0.2 g atom/mol. alpha-Hydroxybutyrate chelates Fe3+ with sufficient stability to preclude formation of [Fe(OH)3]n. It is proposed that factor IX binds iron with physiologically significant affinity and that the beta-hydroxyaspartate residue in factor IX is a chelator for the bound metal.

Role reversals: an analysis of therapeutic effects achieved with disruptive boys during their appointments as peer monitors

Three 7-year-old boys with histories of negative interactions were appointed to monitor individual classmates during daily noon recess. As monitors, the boys awarded points to their classmates for playing appropriately and, on rare occasions, withdrew a point for negative interactions. The three boys immediately decreased their own rates of negative interactions during the sessions in which they were appointed as monitors. Two of the boys concomitantly increased their rates of positive interactions. Their reductions in negative interactions were not maintained during reversals and did not clearly generalize to the morning or afternoon recess periods. Subsequent appointment of the boys as peer monitors during the morning recess produced similar improvements in their behavior. Results suggest that appointment to the role of peer monitor may itself function as an intervention.

Identification of proteins in contact lens surface deposits by immunofluorescence microscopy

Worn soft contact lenses from five asymptomatic subjects were examined by immunofluorescence microscopy for type of protein on the lens surface. Lysozyme was the predominant protein component identified by this technique. IgA was also identified in deposits on all five lenses, but the staining was less intense than that for lysozyme. Lactoferrin was identified on the surface of four lenses, one of which stained intensely for this protein and three less intensely. IgG was identified on two contact lenses; the staining was less intense than that for lysozyme. New, never-worn soft contact lenses did not stain for any of the proteins examined in this study. We conclude that several normal tear proteins are capable of contributing to surface deposits on soft contact lenses, and all worn soft contact lenses have protein adherent to their surface as a result of normal wear.

The use of peer monitors to reduce negative interaction during recess

The negative interactions of a midly retarded child, Dennis, were reduced in three daily recess periods, with the use of a point system. Adult monitors initiated the intervention in the morning recess; reductions achieved during adult monitoring were maintained in that recess during two subsequent conditions: peer monitoring and self-monitoring. Dennis' negative interactions were reduced next in the afternoon recess by peer monitors. Again, reductions were maintained during a subsequent self-monitoring condition. Finally, during the noon recess, Dennis was trained to serve as a peer monitor for Ed, a moderately retarded classmate. Dennis' rate of negative interactions quickly decreased following his appointment as a peer monitor. The results show that a point system, originally designed for adult monitoring, can be adapted without loss of program effectiveness for peer monitoring or self-monitoring. The results also suggest that classmates who serve as peer monitors may benefit significantly from their role. The conditions under which these therapeutic effects occur and the role that treatment order effects may play in this process require further investigation.

Training prosocial behaviors to young children: an analysis of reciprocity with untrained peers

We examined the effects of a social skills training package on the play behaviors of three young girls. Two children were taught to invite their peers to play and to use social amenities during their conversations with other children. A combined reversal and multiple baseline across responses design demonstrated that both children directed more social behaviors to their classroom peers after training and that these two children's play invitations were maintained in the later absence of experimental contingencies. In addition, both target children received a greater number of play invitations from their peers during the free play periods. In contrast, a third child's play invitations were not reciprocated by peers; her invitations subsequently decreased in rate after training was discontinued. An interdependent group contingency produced a reciprocal exchange of invitations between this child and her classroom peers. A reversal design demonstrated partial maintenance of subject-peer exchanges after the group intervention was discontinued. The results obtained with the three target children suggest that peer reciprocity may facilitate the maintenance of children's play invitations over time.

Surface deposits on worn hard contact lenses

Giant papillary conjunctivitis (GPC) is associated with deposits on contact lenses. We used scanning electron microscopy to study the anterior surface of 30 hard contact lenses, both cleaned and not cleaned, worn by patients with GPC and with keratoconus and by asymptomatic subjects. Uncleaned lenses worn by asymptomatic subjects for one day had deposits on about 5% of the surface. In most cases, the deposits were removed completely by one cleaning. Uncleaned lenses worn by patients with GPC or keratoconus had deposits on about 90% of the surface. Most of these deposits were removed by one cleaning. However, residual deposits after cleaning were greater on lenses from patients with keratoconus than on those from patients with GPC. Lenses from asymptomatic subjects rarely had residual deposits after cleaning. We found that the types of deposits on worn soft and hard contact lenses are similar, that there are fewer deposits on hard lenses than on soft lenses, and that deposits on hard lenses, unlike those on soft lenses, generally can be removed by one cleaning.

"Read me a story, mom". A home-tutoring program to teach prereading skills to language-delayed children

Four mildly delayed children, aged four to six years, were taught to identify either letters of the alphabet or sets of basic sight words during story-reading times conducted by their mothers at home. The sets of letters or words were trained in a multiple baseline design. Acquisition of the trained letters or words was assessed by their teacher at school through weekly pretests and posttests. Results demonstrated that preliminary reading skills could be taught successfully at home during a story-reading time; posttest data indicated that children generalized their new skills to school and maintained them through a two-month follow-up period. Furthermore, substantial gains by two of the children on the Peabody Picture Vocabulary Test suggest that additional benefits, such as increases in receptive vocabulary, may result from the daily story reading.

Positive peer pressure: the effects of peer monitoring on children's disruptive behavior

Classroom peers can serve as powerful sources of reinforcement in increasing or maintaining both the positive and negative behaviors of their classmates. In two experiments, we examined the effectiveness of a peer-monitored token system on reducing disruption and nonparticipation during a transition period of a kindergarten class for behaviorally impaired children. Additionally, the effect of providing and subsequently withholding corrective feedback to peer mediators on the accuracy of their point awards was evaluated. Results in Experiment 1 suggest that both teacher- and peer-monitored interventions were successful in decreasing disruption and increasing participation of monitored peers. Experiment 2 further demonstrated that peer monitors could successfully initiate the token system without prior adult implementation. Analysis of the point awards in both experiments indicates that peer monitors consistently awarded points that were earned. However, when corrective feedback was withdrawn the peer monitors frequently awarded points that were not earned, i.e., they rarely withheld points for undesirable behavior. Even so, the monitored peers' disruptive behavior was maintained at low rates.

Cell surface variations of the human upper tarsal conjunctiva

Fifteen specimens of the upper tarsal conjunctiva were obtained from subjects with biomicroscopically normal conjunctivae. Ten specimens were examined by scanning electron microscopy and five by transmission electron microscopy. This examination was performed to examine cells with variant surface morphologic appearance that may be signs of the initial changes typical of those seen in the diseased conjunctiva. Although most specimens had cells with a characteristic uniform distribution of microvilli, seven specimens had cells with nonuniform microvillar patterns. In these seven specimens, less than 5% of the cells showed these changes. Cell surface variations marked by reduced cell diameters and alterations in the microvillar distribution were categorized into two groups: cells with microvilli that were grouped together to form tufts of varying height and number, and cells with a single, centralized group of microvilli. These variations were seen with increased frequency in disease, and it is postulated that the microvillar changes described in this study represent a continuum of adaptive responses of cells to insult and disease.

The effect of cleaning soft contact lenses. A scanning electron microscopic study

Scanning electron microscopy was used to investigate the effectiveness of surfactant and enzyme cleaners in removing coatings from soft contact lenses. We examined ten continuously worn lenses and 15 lenses worn and cleaned regularly for at six months. About 30% of the surface of continuously worn lenses cleaned with surfactant or enzyme was uncoated; smooth, matted coating covered the remainder. Continuously worn lenses cleaned with the combination surfactant and enzyme cleaner had similar deposits covering 50% of the surface. Lenses worn and cleaned regularly had more deposits after cleaning with surfactant or enzyme cleaner than after cleaning with combination cleaner. Approximately 25% of the surface of lenses cleaned with the combination was coated with deposits. The deposits on both types of lenses were about 30% less thick after use of the combination cleaner than with either single cleaner. The coating on worn contact lenses is not completely removed by any method we tested.

"Do I have to be good all day? The timing of delayed reinforcement as a factor in generalization

Delayed reinforcement, sometimes delivered just after the setting in which the critical behavior had occurred (Early), and sometimes delivered only after several further settings had been encountered (Late), was used to improve a variety of behaviors in seven preschool children, and to control their generalization. Performance of those behaviors was measured in two classroom settings: the Contingent setting, within which performance of the specified behavior determined the latter (Early or Late) reinforcement, and the Generalization setting, in which there were no experimental contingencies, immediate or delayed, for the performance of the same behavior. Performances by all children in the Contingent setting were controlled by delayed reinforcement, whether Early or late. All children showed consistent generalization from the Contingent setting to the Generalization setting during the Late condition, when reinforcement was delivered at the end of the school day. Generalization did not occur during the Early condition, when reinforcement was provided immediately after the Contingent setting (prior to the Generalization setting), unless that condition had been preceded by a Late condition (as it was for S6 and S7). The results suggest that the Late timing of delayed reinforcement was an effective and efficient generalization-promotion technique for performances that did not generalize spontaneously.

The surface of the continuously worn contact lens

The anterior surfaces of continuously worn therapeutic contact lenses and routinely cleaned cosmetic lenses were compared by scanning electron microscopy. The continuously worn lenses were uniformly and completely coated with material thicker and smoother that that on the incompletely coated cosmetic lenses. It is concluded that continuously worn lenses build up coatings steadily, whereas routinely cleaned lenses have at least part of the coating removed with each cleaning.

Evolution of soft contact lens coatings

To investigate further the reported possibility that surface deposits on soft contact lenses contribute to giant papillary conjunctivitis, we performed scanning electron microscopy on 22 lenses worn for varying durations by a group including persons who had never worn contact lenses and asymptomatic persons who had, and on five never-worn lenses. Thirty minutes' wear resulted in covering of about 50% of the anterior surface with scattered cell-membrane-like and mucus-like material, with mucus-like material on top of cells in places. Eight hours' wear produced about 90% covering with more complex coatings. Routinely worn and cleaned lenses had still more complex coatings on more than 90% of the surface. Deposits were found on routinely worn lenses even after professional cleaning. We conclude that all worn soft contact lenses have coatings that become more complex with time and may never be removed completely.

Soft contact lenses from patients with giant papillary conjunctivitis

We used scanning electron microscopy to study the surfaces of five coated soft contact lenses from subjects with giant papillary conjunctivitis. Findings were compared to the surfaces of five coated lenses from normal, asymptomatic wearers and five new, nerver-worn lenses. Lenses were from various manufacturers. All worn contact lenses differed strikingly from new, never-worn lenses. The anterior surface of worn lenses was covered with apparently adherent deposits. In only a few areas was the surface similar to new, never-worn lenses. Thick coatings on lenses from patients with giant papillary conjunctivitis and asymptomatic wearers were similar. High magnification of the coatings revealed a trabeculated morphology. Also seen was debris that resembled mucus-like material in both strand and particulate forms. On some lenses bacterial-shaped structures were scattered randomly over the surface. Smooth structures resembling cells were also seen. The posterior lens surface of all worn lenses was smoother than the anterior lens surface. The findings support our idea that the capacity to develop giant papillary conjunctivitis is influenced by individual differences more than by differences in lens deposits.

Attachment of bacteria to soft contact lenses

A total of 25 soft contact lenses from 17 asymptomatic contact lens wearers and eight patients with contact lens-associated giant papillary conjunctivitis were examined by scanning electron microscopy. Structures that resembled bacteria were present on the anterior surface of seven lenses. All lenses showed a coating of granular mucus-like deposits. Some bacteria were seen scattered randomly over the surface, with no apparent attachment to the lens, whereas others were attached to the coated surface by thin, flagella-like foot processes, the distal ends of which were unattached. These attached bacteria were cylindrical in shape. Several bacteria showed a constriction centrally. Some bacteria were covered by the surface coating, while others, which were round to ovoid in shape, appeared partially embedded in the coating itself. Aggregations of bacteria were seen around clumps of mucus-like debris.

Calcium and 25-hydroxyvitamin D3 binding proteins in human placenta

The placental translocation of calcium is a well-known process, but the underlying mechanisms remain unknown. Placental cytoplasmic proteins capable of binding calcium and the active metabolites of vitamin D3 were sought in these studies. Cytosol from full-term human placenta was prepared by ultracentrifugation of homogenates and tested for binding. Partial purification by column chromatography revealed the presence of two discrete proteins which bound specifically 45Ca and 3H-25-hydroxyvitamin D3 and having approximate molecular weights of 12,000 and 67,000, respectively. These placental proteins may be intermediaries in the process of placental calcium translocation.

Training preschool children to recruit natural communities of reinforcement

Four normal and four deviant children aged four-to-six years were taught to judge the quality of their academic work in a preschool classroom, and to prompt or cue their teachers to comment about the quality of that work. When these skills did not generalize spontaneously to other teachers in concurrent natural situations, generalized responding was taught by the experimenter, in multiple-baseline design across subjects. This generalization programming enabled the children to contact a sometimes dormant, but readily available natural community of teacher praise and reinforcement, i.e., to recruit an increase in cued praise and schedules of praise for their good work. These behaviors may be important to young children who find themselves bereft of attention in classrooms.

Color-matching technique to train children in the correct use of stairs

Color cues were used to train four severely retarded children and two learning disabled children to move in a left foot-right foot alteration pattern when using stairs. The occurrence of left-right alterations and marking time behavior was recorded throughout baseline and training conditions. The color-cue procedure effectively produced a consistent pattern of alteration of four of the children and eliminated marking time in three of the children. Physical prompts were used to train alteration in two children for whom color-cue training was not sufficient. At the termination of training, observations of the children's performances in new settings and to new adults were conducted. Results indicated that the children continued to alternate correctly. In addition, follow-up investigations conducted between two weeks to 16 months after training indicated that the children were maintaining the stair alteration pattern. Future research should determine whether a visual-cue procedure could be used in training other forms of locomotion or motor behavior.