Assessment of Pediatric Primary Care Providers Behaviors and Procedures Regarding Pediatric Overweight and Obesity

CAPSTONE INTRODUCTION Childhood overweight/obesity is a critical public health problem with devastating consequences. Many factors have combined to create the epidemic, and primary care providers can play an important role in addressing the problem by identifying overweight/obese children and encouraging them to engage in healthy behaviors. However, providers face a number of competing priorities making it difficult for them to provide these services effectively without outside support. Obesity has reached an epidemic proportion in the nation’s youth. The Data Resource Center for Child and Adolescent Health (2011) found that 35.7% of children age 10 – 17 in Kentucky are overweight or obese. This is higher than the United States’ (U.S.) national average of 31.3%. Kentucky also ranks seventh of the most obese states in the U.S. (Robert Wood Johnson Foundation, 2010). According to Flower, Perrin, Viadro, and Ammerman (2007) the obesity epidemic is one of the most predominant health conditions pediatric primary care providers face. Childhood obesity can lead to many other chronic health problems including hypertension, diabetes, hyperlipidemia, and psychosocial problems. These health conditions can lead to increased morbidity and mortality for the nations’ pediatric population. It has been estimated that one in three children born in 2000 will develop diabetes (McConnaughey, 2003). The primary care setting provides a unique opportunity to identify concerns and potential problems and educate children and parents. Well child or preventative visits have many components, which can be time consuming and leave little time for education and preventative screening. Although the statistics are alarming and guidelines related to pediatric overweight and obesity have been clearly established, many providers are not meeting the standards for screening, diagnosis, treatment, and education related to this epidemic. Prior to beginning the capstone project three goals were established. The first goal was to determine the current practices in relation to practice guidelines for the screening, diagnosis, and treatment of pediatric overweight or obesity. The second goal was to examine reports and opinions from primary care providers regarding current practice and barriers to following practice guidelines. The final goal was to develop a reference tool for providers to utilize in practice toensure they are following practice guidelines. Each of the three manuscripts addressed one of the three goals. The first capstone manuscript is an integrative literature review regarding pediatric provider knowledge of the current practice guidelines of pediatric overweight/obesity management in the primary care setting. The review begins with current practice guidelines and recommendations for pediatric overweight/obesity and outlines evidence based practice research on this topic from 2008 to 2014. The manuscript also discusses the current reported practices of primary care providers and knowledge gaps identified regarding pediatric overweight/obesity management. Gaps in the literature pertaining to pediatric overweight/obesity andrecommendations for future research are included. The second capstone manuscript summarizes a 2014 investigation: “Assessment of Pediatric Primary Care Providers Behaviors and Procedures Regarding Pediatric Overweight and Obesity,” a survey administered to pediatric primary care providers in the state of Kentucky belonging to the Kentucky Coalition of Nurse Practitioners and Nurse Midwives and/or the Kentucky Chapter of the American Academy of Pediatrics.The survey results indicated that there is a knowledge deficit in relation to the current practice guidelines for identification, management, and treatment of pediatric overweight/obesity and a lack of community and referral resources available to primary care providers. The final manuscript is an educational reference resource for providers, developed in response to the findings of the literature review and survey results. The need for additional education regarding, screening, identification, diagnosis, and treatment, in the primary care setting, was identified in the pediatric obesity survey. “Pediatric Obesity Management in the Primary Care Setting: Reference Guide for Providers” includes an algorithm for providers outlining the steps to successful management of pediatric overweight/obesity in the primary care setting

Polypyrrole nanoparticles for tunable, pH-sensitive and sustained drug release

We report the development of a generalized pH-sensitive drug delivery system that can release any charged drug preferentially at the pH range of interest. Our system is based on polypyrrole nanoparticles (PPy NPs), synthesized via a simple one-step microemulsion technique. These nanoparticles are highly monodisperse, stable in solution over the period of a month, and have good drug loading capacity (∼15 wt%). We show that PPy NPs can be tuned to release drugs at both acidic and basic pH by varying the pH, the charge of the drug, as well as by adding small amounts of charged amphiphiles. Moreover, these NPs may be delivered locally by immobilizing them in a hydrogel. Our studies show encapsulation within a calcium alginate hydrogel results in sustained release of the incorporated drug for more than 21 days. Such a nanoparticle-hydrogel composite drug delivery system is promising for treatment of long-lasting conditions such as cancer and chronic pain which require controlled, localized, and sustained drug release.DAA

Trauma memory characteristics and the development of acute stress disorder and post-traumatic stress disorder in youth

Background & objectives: The present study addresses gaps in knowledge regarding the association between trauma memory processes and posttraumatic stress responses in youth. Our primary goal was to explore the relative contribution of perceptions of trauma memory quality versus narrative trauma memory characteristics to explain overall adjustment.  Methods: Children (N = 67) were interviewed within four weeks (T1) of an injury leading to hospital treatment and then again eight weeks later (T2). In each interview, the child told a trauma narrative (which were later coded), and answered the Trauma Memory Quality Questionnaire (Meiser-Stedman, Smith, Yule, & Dalgleish, 2007a), a self-report measure indexing the sensory, fragmented, and disorganised characteristics of trauma memory. They then completed measures of Acute Stress Disorder (ASD) symptoms and associated psychopathology at T1 and measures of Posttraumatic Stress (PTS) symptoms and associated psychopathology at T2.  Results: Self-reported trauma memory characteristics predicted ASD symptoms cross-sectionally at T1 and PTS symptoms prospectively over time. At both time points, self-reported trauma memory characteristics accounted for all of the unique variance in symptoms initially explained by narrative characteristics. A reduction in self-report ratings, but not the hypothesised narrative features (e.g., disorganised or lexical elements of the narrative), significantly predicted a reduction in PTS symptoms over time.  Limitations: The small sample size and the absence of a within-subjects narrative control were the main limitations of the study.  Conclusions: These findings underscore the importance of self-reported trauma memory characteristics to the aetiology of PTSD

Novel Collective Effects in Integrated Photonics

Superradiance, the enhanced collective emission of energy from a coherent ensemble of quantum systems, has been typically studied in atomic ensembles. In this work we study theoretically the enhanced emission of energy from coherent ensembles of harmonic oscillators. We show that it should be possible to observe harmonic oscillator superradiance for the first time in waveguide arrays in integrated photonics. Furthermore, we describe how pairwise correlations within the ensemble can be measured with this architecture. These pairwise correlations are an integral part of the phenomenon of superradiance and have never been observed in experiments to date.Comment: 7 pages, 3 figure

Psychological impact of comprehensive tumor genomic profiling results for advances cancer patients

Objective Comprehensive tumor genomic profiling (CTGP) is increasingly used to personalize treatments, providing hope, but potentially disappointment, for patients. We explored psychological outcomes in patients with advanced, incurable cancer, after receiving CTGP results. Methods Participants with advanced, incurable cancer (n = 560, mean age 56, 43% university educated) in this longitudinal substudy of the Molecular Screening and Therapeutics Program (MoST), completed questionnaires before and after receiving CGP results. MoST participants, recruited from Australian oncology clinics, undergo CTGP, and if there are actionable findings, are offered treatment in a related therapeutic trial if available. Results Patients who received actionable results, (n = 356, 64%) had lower gene-related distress (MICRA) (p \u3c 0.001) and Impact of Events scores (p = 0.039) than patients with non-actionable results. Those with actionable results offered ensured access to tailored treatment (n = 151) reported lower anxiety (p = 0.002) and depressive symptoms (p = 0.01) and greater hope (p = 0.002) than those not offered. Positive attitudes towards uncertainty and higher self-efficacy for coping with results were associated with lower psychological distress and uncertainty, and higher hope and satisfaction with the decision to have CTGP (ps=0.001–0.047). Those with higher knowledge reported greater anxiety (p = 0.034). Conclusion Receiving a non-actionable CTGP result, or an actionable result without ensured access to treatment, may cause increased distress in advanced cancer patients. Coping style was also associated with distress. Practice implications Pre-testing assessment and counseling addressing attitudes toward uncertainty and self-efficacy, and post-CTGP result support for patients receiving a non-actionable result or who receive an actionable results without ensured access to treatment, may benefit patients

Impact of BRCA1/2 cascade testing on anxiety, depression, and cancer worry levels among unaffected relatives in a multiethnic Asian cohort

Cascade testing for families with BRCA pathogenic variants is important to identify relatives who are carriers. These relatives can benefit from appropriate risk management and preventative strategies arising from an inherited increased risk of breast, ovarian, prostate, melanoma, and pancreatic cancers. Cascade testing has the potential to enable cost-effective cancer control even in low- and middle-income settings, but few studies have hitherto evaluated the psychosocial impact of cascade testing in an Asian population, where the cultural and religious beliefs around inheritance and destiny have previously been shown to influence perception and attitudes toward screening. In this study, we evaluated the short- and long-term psychosocial impact of genetic testing among unaffected relatives of probands identified through the Malaysian Breast Cancer Genetics Study and the Malaysian Ovarian Cancer Study, using validated questionnaires (Hospital Anxiety and Depression Scale and Cancer Worry Scale) administered at baseline, and 1-month and 2-year post-disclosure of results. Of the 305 unaffected relatives from 98 independent families who were offered cascade testing, 256 (84%) completed predictive testing and family history of cancers was the only factor significantly associated with uptake of predictive testing. We found that the levels of anxiety, depression, and cancer worry among unaffected relatives decreased significantly after result disclosure and remained low 2-year post-result disclosure. Younger relatives and relatives of Malay descent had higher cancer worry at both baseline and after result disclosure compared to those of Chinese and Indian descent, whereas relatives of Indian descent and those with family history of cancers had higher anxiety and depression levels post-result disclosure. Taken together, the results from this Asian cohort highlight the differences in psychosocial needs in different communities and inform the development of culture-specific genetic counseling strategies

A longitudinal examination of the relationship between trauma-related cognitive factors and internalising and externalising psychopathology in physically injured children

Cognitive models of posttraumatic stress disorder (PTSD) highlight maladaptive posttrauma appraisals, trauma memory qualities, and coping strategies, such as rumination or thought suppression, as key processes that maintain PTSD symptoms. Anxiety, depression and externalising symptoms can also present in children in the aftermath of trauma, yet there has been little empirical investigation of the potential relevance of posttrauma cognitive processes for such difficulties. Here, we examined whether: a) acute maladaptive cognitive processes (specifically, maladaptive appraisals, memory qualities, and cognitive coping) were associated with symptoms of PTSD, internalising, and externalising at 1-month posttrauma (T1); and b) changes in these cognitive processes predicted symptom change at a follow-up assessment 6 months later (T2). We recruited 132 6–13 year old children and their parents from emergency departments following the child’s experience of an acute trauma. Children self-reported on their maladaptive appraisals, trauma-memory and cognitive coping strategies, along with symptoms of PTSD, anxiety and depression. Parents also rated children’s internalising and externalising symptoms. We found each cognitive process to be robustly associated with PTSD and non-PTSD internalising symptoms at T1, and change in each predicted change in symptoms to T2. Maladaptive appraisals and cognitive coping were unique predictors of children’s posttrauma internalising. Effects were partially retained even controlling for co-occurring PTSD symptoms. There was less evidence that trauma-specific cognitive processes were associated with externalising symptoms. Findings suggest aspects of cognitive models of PTSD are applicable to broader posttrauma psychopathology, and have implications for how we understand and target children’s posttrauma psychological adjustment

Parent and child agreement for acute stress disorder, post-traumatic stress disorder and other psychopathology in a prospective study of children and adolescents exposed to single-event trauma

Examining parent-child agreement for Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) in children and adolescents is essential for informing the assessment of trauma-exposed children, yet no studies have examined this relationship using appropriate statistical techniques. Parent-child agreement for these disorders was examined by structured interview in a prospective study of assault and motor vehicle accident (MVA) child survivors, assessed at 2-4 weeks and 6 months post-trauma. Children were significantly more likely to meet criteria for ASD, as well as other ASD and PTSD symptom clusters, based on their own report than on their parent's report. Parent-child agreement for ASD was poor (Cohen's κ = -.04), but fair for PTSD (Cohen's κ = .21). Agreement ranged widely for other emotional disorders (Cohen's κ = -.07-.64), with generalised anxiety disorder found to have superior parent-child agreement (when assessed by phi coefficients) relative to ASD and PTSD. The findings support the need to directly interview children and adolescents, particularly for the early screening of posttraumatic stress, and suggest that other anxiety disorders may have a clearer presentation post-trauma

What is the effect of a low literacy talking book on patient knowledge, anxiety and communication before radiation therapy starts? A pilot study

Introduction: Radiation therapy is a common cancer treatment, requiring timely information to help patients prepare for treatment. We pilot tested a low literacy, psycho-educational talking book (written booklet, with accompanying audio recording) to examine (i) the effect of the tool on knowledge, anxiety and communication; (ii) acceptability, and (iii) how it was used in appointments. Methods: A pre-post design was employed. Patients scheduled to receive radiation therapy for any cancer were recruited from two hospitals in Sydney, Australia. Participants were sent the talking book before treatment planning and completed baseline and follow-up surveys, before and after the intervention. Results: Forty participants were recruited, and 39 completed all study assessments. Overall, knowledge increased after receiving the talking book by 3.8 points from 13.9 to 17.7/20 (95% confidence interval (CI) 2.7, 4.8, P < 0.001). Anxiety and concerns were significantly lower after receiving the talking book (P = 0.015 and P = 0.004, respectively). Nearly half of participants (s = 17, 48%) reported using the book during appointments. Most reported finding it easier to communicate (n = 31, 89%) and to ask more questions (n = 21, 62%). Conclusion: The talking book shows promise in improving knowledge, reducing anxiety and enhancing communication. Strategies to support the implementation of the talking book are required. Further studies to translate the book into different languages are also planned