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Process evaluations provide insight into the implementation of complex interventions. This study is a process evaluation for the implementation of a parent-led physical activity intervention at home with youth with a rare neurodevelopmental disorder (Prader-Willi syndrome, PWS) and youth with non-syndromal obesity (NSO). Participants included 42 youth with PWS (10.9 ± 2.5 y; 24M: 18F) and 65 youth with NSO (9.8 ± 1.1 y; 34M: 31F), assigned to an intervention or a delayed intervention group. The 24-week intervention included parent training, receiving equipment and a pre-planned curriculum with playground games and interactive console-based games. We evaluated intervention implementation fidelity, dose (reported physical activity minutes), acceptability (perceived difficulty and enjoyment of the planned activities) and contextual factors (facilitators and barriers). Overall, 68.2% of participants (immediate and delayed intervention groups) completed = 70% of the planned physical activity sessions. The average length of the sessions was 44 ± 23 and = 49 ± 22 min for playground and console-based games, respectively. Most activities were more difficult for those with PWS than those with NSO. Common barriers to implementation included scheduling and the child's motivation, and facilitators included features of the curriculum and social support. This intervention modality (home-based, delivered by parents) appears suitable for families with children with and without neurodevelopmental disorders.

Bone mineral density (BMD) is of concern in Prader-Willi syndrome (PWS). This study compared responses to a physical activity intervention in bone parameters and remodeling markers in youth with PWS ( n = 45) and youth with non-syndromic obesity (NSO; n = 66). Measurements occurred at baseline (PRE) and after 24 weeks (POST) of a home-based active games intervention with strengthening and jumping exercises (intervention group = I) or after a no-intervention period (control group = C). Dual x-ray absorptiometry scans of the hip and lumbar spine (L1-L4) determined BMD and bone mineral content (BMC). Bone markers included fasting bone-specific alkaline phosphatase (BAP) and C-terminal telopeptide of type I collagen (CTx). Both I and C groups increased their hip BMD and BMC ( p < 0.001). Youth with PWS-I increased their spine BMC from PRE to POST ( p < 0.001) but not youth with PWS-C ( p = 1.000). Youth with NSO (I and C) increased their spine BMC between PRE and POST (all p < 0.001). Youth with PWS showed lower BAP (108.28 ± 9.19 vs. 139.07 ± 6.41 U/L; p = 0.006) and similar CTx (2.07 ± 0.11 vs.1.84 ± 0.14 ng/dL; p = 0.193) than those with NSO regardless of time. Likely, the novelty of the intervention exercises for those with PWS contributed to gains in spine BMC beyond growth. Bone remodeling markers were unaltered by the intervention.

Objective: To assess the effectiveness of behavioral parent-only (PO) and family-based (FB) interventions on child weight, dietary intake, glycated hemoglobin, and quality of life in rural settings., Methods: This study was a three-armed, randomized controlled trial. Participants were children (age 8-12 years) with overweight or obesity and their parents. A FB (n = 88), a PO (n = 78) and a health education condition (HEC) (n = 83) each included 20 group contacts over 1 year. Assessment and treatment contacts occurred at Cooperative Extension Service offices. The main outcome was change in child body mass index z-score (BMIz) from baseline to year 2., Results: Parents in all conditions reported high treatment satisfaction (mean of 3.5 or higher on a 4-point scale). A linear mixed model analysis of change in child BMIz from baseline to year 1 and year 2 found that there were no significant group by time differences in child BMIz (year 2 change in BMIz for FB = -0.03 [-0.1, 0.04], PO = -0.01 [-0.08, 0.06], and HEC = -0.09 [-0.15, -0.02]). While mean attendance across conditions was satisfactory during months 1-4 (69%), it dropped during the maintenance phase (42%). High attendance for the PO intervention was related to greater changes in child BMIz (p < .02). Numerous barriers to participation were reported., Conclusion: Many barriers exist that inhibit regular attendance at in-person contacts for many families. Innovative delivery strategies are needed that balance treatment intensity with feasibility and acceptability to families and providers to facilitate broad dissemination in underserved rural settings.ClinicalTrials.gov Identifier: NCT01820338., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Prader-Willi syndrome (PWS) is a complex, rare neurobehavioral syndrome characterized by excessive fat, hypotonia, poor motor skills, and behavioral and cognitive disabilities. We tested the effectiveness of a home-based physical activity (PA) intervention led by parents in youth with obesity with and without PWS to increase moderate-to-vigorous PA (MVPA) and gross motor proficiency., Methods: Participants were 111 youth age 8 to 16 yr (45 with PWS and 66 without PWS, but categorized as obese). A parallel design was used with the control group (C) receiving the intervention after serving as control. Intervention participants (I) completed a PA curriculum 4 d·wk for 24 wk including warm-up exercises, strengthening exercises, and playground games 2 d·wk and interactive console games 2 d·wk guided by their parents. Pre-post outcomes (baseline to 24 wk) included MVPA (7-d accelerometry) and motor proficiency including upper limb coordination, bilateral coordination, balance, running speed and agility, and muscle strength (Bruininks-Oseretsky Test of Motor Proficiency)., Results: The intervention led to no change in MVPA (I group, 39.6 vs 38.9 min·d; C group, 40.6 vs 38.3 min·d). The intervention led to improvements in body coordination (22.3%; P < 0.05), as well as strength and agility (13.7%; P < 0.05). Specifically, the I group showed increases in upper limb coordination (19.1%), bilateral coordination (27.8%), and muscle strength (12.9%; P < 0.05 for all) not observed in the C group: -0.2%, 2.5%, and -3.2%, respectively., Conclusions: This parent-guided PA intervention did not increase PA. However, the intervention led to improvements in gross motor skill competency. Providing families with tools and support can lead to implementation of PA routines that contribute to motor skill proficiency in youth with and without PWS.

Adverse pregnancy outcomes, including preterm delivery, short gestational age, and abnormal birth weight, remain a public health concern. The evidence on the association of the most common phthalate, di-2-ethylhexyl phthalate (DEHP) with adverse pregnancy outcomes remains equivocal. This systematic review summarizes published studies that investigated the association of DEHP with preterm delivery, gestational age, and birthweight. A comprehensive literature search found 15 relevant studies, most of which evaluated more than one outcome (four studies for preterm delivery, nine studies for gestational age, and ten studies for birthweight). Studies varied greatly with respect to study design, exposure assessment, analytical methods, and direction of the associations. We identified important methodological concerns which could have resulted in selection bias and exposure misclassification and contributed to null findings and biased associations. Given limitations of the previous studies discussed in this review, more thorough investigation of these associations is warranted to advance our scientific knowledge., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Examine relations between depressive symptoms, ethnic identity, and health-related quality of life (HRQOL) in overweight or obese (OV/OB) children., Methods: A total of 166 OV/OB 8- to 17-year-olds (M = 12.94 years; 86.7% obese; 50.6% racial/ethnic minority) attending an outpatient pediatric obesity medical clinic participated. Children completed the Children's Depression Inventory-Short Form, Multigroup Ethnic Identity Measure (MEIM), and Pediatric Quality of Life Inventory., Results: Increased depressive symptoms significantly predicted reduced total, physical, and psychosocial HRQOL. For minority OV/OB youth only, MEIM Affirmation/Belonging moderated depressive symptoms and total HRQOL (effect = -2.59, t = -2.24, p = .027; R(2) overall model = 0.315) and depressive symptoms and psychosocial HRQOL (effect = -3.01, t = -2.47, p = .015; R(2) overall model = 0.331)., Conclusions: Depressive symptoms are negatively associated with HRQOL. In minority OV/OB youth, high ethnic identity may be protective when depressive symptoms are minimal. Ethnic identity and other cultural factors are important to consider in psychosocial treatments for pediatric obesity., (© The Author 2015. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Youth engage in a variety of methods to manage their weight, including unhealthy weight control behaviors (UWCBs). The purpose of this study was to examine factors associated with youth's engagement in UWCBs, including media influence, youth's BMI z-score and self-esteem., Methods: Participants were 179 youth, aged 10-17, attending a primary care clinic appointment. Youth completed questionnaires assessing frequency of UWCBs, global self-worth, and perception of media influence to lose weight. BMI z-score was calculated based on height and weight measurements obtained from medical charts. The SPSS macro, PROCESS, was used to conduct moderation analyses., Results: Over 40% of youth endorsed using at least one UWCB in the past year. Girls reported using more UWCBs and engaging in UWCBs more frequently than boys. For boys, media influence to lose weight was only related to UWCB frequency for those with a BMI z-score of 1.23 and above. For girls, media influence was only related to UWCB frequency for those with low to average levels of global self-worth., Conclusions: Girls' and boys' use of UWCBs is impacted by different factors. Prevention efforts should consider targeting factors, such as weight status and self-esteem, which are uniquely associated with gender., (Copyright © 2015. Published by Elsevier Ltd.)

Objective: Although caregiver restriction of child food intake is a common weight control strategy, factors that make a caregiver more likely to engage in restriction have not been fully explored. This study examined the relations between child weight, peer victimization, and restriction. Peer victimization was expected to serve as a mechanism through which child weight was associated with restriction., Method: Two hundred fourteen youth (6-17 yr) were recruited from pediatric primary care clinics in the South. Youth reported their levels of peer victimization, and caregivers reported on their use of restriction of child food intake. Child height and weight were obtained from medical records., Results: Ethnic minority adolescent females were more likely to be obese than nonethnic minority adolescents/children. Greater child body mass index (BMI)-z was associated with increased caregiver restriction (B = 0.86, p < .05) and peer victimization (B = 0.66, p < .05). When peer victimization was entered into the model of BMI-z predicting caregiver restriction of child food intake, the relationship between these 2 variables decreased from 74% to 46% and was no longer significant (B = 0.68, p = .08). However, the test of the indirect effect was not significant., Conclusions: Greater degree of overweight was associated with increased peer victimization, which in turn related to caregiver restriction of food intake. Children's social relationships may serve as an impetus for caregivers to engage in child weight control practices. Clinicians should regularly screen for weight-related peer difficulties and provide caregivers with guidance on healthy versus unhealthy weight control practices to promote overall child health.

Objective: To determine the variability of the institutional review board (IRB) process for a minimal risk multicenter study., Methods: Participants included 24 Continuity Research Network (CORNET) sites of the Academic Pediatric Association that participated in a cross-sectional study. Each site obtained individual institutional IRB approval. An anonymous questionnaire went to site investigators about the IRB process at their institution., Results: Twenty-two of 24 sites (92%) responded. Preparation time ranged from 1 to 20 hours, mean of 7.1 hours. Individuals submitting ≤3 IRB applications/year required more time for completion than those submitting >3/year (P < .05). Thirteen of 22 (59%) study sites received approval with "exempt" status, and 6 (27%) approved as "expedited" studies., Conclusions: IRB experiences were highly variable across study sites. These findings indicate that multicenter research projects should anticipate barriers to timely study implementation. Improved IRB standardization or centralization for multicenter clinical studies would facilitate this type of practice-based clinical research.

The Extension Family Lifestyle Intervention Project (E-FLIP for Kids) is a three-arm, randomized controlled trial assessing the effectiveness of two behavioral weight management interventions in an important and at-risk population, overweight and obese children and their parents in rural counties. Participants will include 240 parent-child dyads from nine rural counties in north central Florida. Dyads will be randomized to one of three conditions: (a) a Family-Based Behavioral Group Intervention, (b) a Parent-Only Behavioral Group Intervention, and (c) an Education Control Condition. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 12) and follow-up (month 24). Assessment and intervention sessions will be held at Cooperative Extension Service offices within each participating county. The primary outcome measure is change in child BMI z-score. Additional key outcome measures include child body fat, waist circumference, dietary intake, physical activity, blood lipids, blood glucose, blood pressure, physical fitness, quality of life, and program and participants costs. Parent BMI, dietary intake, and physical activity also will be assessed. Randomized controlled trials testing the effectiveness of childhood obesity interventions in real-world community-based settings are extremely valuable, but much too rare. The E-FLIP for Kids trial will evaluate the impact of a community-based intervention delivered to families in rural settings utilizing the existing Cooperative Extension Service network on long-term child behavior, weight status and biological markers of diabetes and early cardiovascular disease. If successful, a Parent-Only intervention program may provide a cost-effective and practical intervention for families in underserved rural communities., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Objectives: To examine the association between weight status and health service use, while considering the influence of psychosocial functioning and demographic variables., Methods: Two hundred child-parent dyads were recruited from pediatric primary care clinics and completed measures of height, weight, and questionnaires assessing psychosocial functioning. Claims and expenditure data over a 12-month retrospective period were extracted from the Medicaid claims database., Results: Children who were obese incurred greater health service use and expenditures than children who were of a healthy weight, even after controlling for psychosocial functioning and other demographic variables. Children who were overweight (but not obese) did not have differing levels of claims or expenditures than their healthy weight peers., Conclusions: Understanding the impact of pediatric obesity on long-term expenditures is critical. These results provide some indication of the financial savings that might be achieved if obese children were supported to achieve a healthier weight status.

Objective: To identify factors associated with resident satisfaction concerning residents' continuity experience., Design and Methods: Continuity directors distributed questionnaires to residents at their respective institutions. Resident satisfaction was defined as satisfied or very satisfied on a Likert scale. The independent variables included 60 characteristics of the continuity experience from 7 domains: 1) patient attributes, 2) continuity and longitudinal issues, 3) responsibility as primary care provider, 4) preceptor characteristics, 5) educational opportunities, 6) exposure to practice management, and 7) interaction with other clinic and practice staff. A stepwise logistic regression model and the Generalized Estimating Equations approach were used., Results: Thirty-six programs participated. Of 1155 residents (71%) who provided complete data, 67% (n = 775) stated satisfaction with their continuity experience. The following characteristics (adjusted odds ratio [OR] and 95% confidence interval [CI]) were found to be most significant: preceptor as good role model, OR = 7.28 ( CI = 4.2, 12.5); appropriate amount of teaching, OR = 3.25 (CI = 2.1, 5.1); involvement during hospitalization, OR = 2.61 (CI = 1.3, 5.2); exposure to practice management, OR = 2.39 (CI = 1.5, 3.8); good balance of general pediatric patients, OR = 2.34 (CI = 1.5, 3.6); resident as patient advocate, OR = 1.74 (CI = 1.2, 2.4); and appropriate amount of nursing support, OR = 1.65 (CI = 1.1, 2.6). Future career choice, type of continuity site, and level of training were not found to be statistically significant., Conclusions: Pediatric resident satisfaction was significantly associated with 7 variables, the most important of which were the ability of the preceptor to serve as a role model and teacher. The type of continuity site was not significant. Residency programs may use these data to develop interventions to enhance resident satisfaction, which may lead to enhanced work performance and patient satisfaction.

Objective: To compare the use of alternative therapy (AT) in families of children with cancer with its use in those with routine pediatric conditions., Background and Rationale: AT refers to healing practices such as therapeutic massage, acupuncture, and use of medicinal herbs that have become increasingly popular with the general public, but are not widely accepted by the medical profession. Although studies have investigated the use of AT in the families of both healthy children and children with cancer, no comparison of the incidence of its use between these two populations has been published. We hypothesized that AT was used more frequently among the families of children with cancer., Methods: Using a prevalence survey design, we interviewed 81 parents of children with cancer attending a pediatric hematology/oncology clinic and 80 parents of children attending a continuity care clinic for routine check-ups and acute care. We explored the types of AT being used, the reasons for its use, and the frequency with which it was discussed with the patient's physician., Results: 1) Overall, 65% of the cancer group were using AT, compared with 51% of the control group. This was not statistically significant. 2) Prayer, exercise, and spiritual healing were three AT practices most often used by the cancer group, and prayer, massage, and spiritual healing by the control group. 3) Discussion of AT with the physician varied according to group, with 53% of the cancer patients discussing its use; income level, with 59% of parents in the higher income group discussing its use; and ethnicity, with 47% of whites discussing its use., Conclusion: Use of AT is not limited to the families of children with life-challenging illnesses, but is commonly used by those of children with routine pediatric problems. Pediatricians need to be aware that their patients may not tell them about AT practices they are using in addition to prescribed treatment.

The Accreditation Council for Graduate Medical Education (ACGME) established guidelines in 1989 requiring pediatric residents to attend a continuity clinic (CC) one half-day per week. OBJECTIVE. To assess pediatric residents' CCs, with an emphasis on those factors potentially affecting house staff education and patient care. DESIGN AND PARTICIPANTS. A multi-item questionnaire designed to assess the educational, administrative, and clinical components of CCs was distributed to all US CC directors. RESULTS. Responses were received from 164 programs (74.9%), which represented more than 90% of all house staff in accredited US pediatric programs. Fifty-five percent of programs acknowledged non-ACGME-approved exemptions from attendance, and 64% changed CC schedules dependent on in-patient rotation assignment. Less than half of the programs had core curricula or didactic conferences. Most programs (76%) were located in hospital clinics. Clinic resources and equipment were often limited; faculty preceptors and nursing and clerical support staff were frequently insufficient in number. On average, PL1s saw four patients per session, whereas PL2s and PL3s saw five. Continuity of care for the patient for phone calls, acute and after-hours visits, and hospitalization was limited. Directors' perceived support for CCs' educational programs ranged from a high of 87% by generalists to a low of 33% by intensivists. CONCLUSIONS. Despite the ACGME directives, many residency programs have not provided the required priority, protected time, or adequate resources for CCs. The recent emphasis on health care reform and primary care medical education highlights the prominent role the CC should play as an important site in our teaching of longitudinal and ambulatory medicine. Departmental support and committed resources necessary to enhance the experience and to meet the educational challenge successfully will be required.

This study assessed primary care physicians' familiarity and attitudes toward oral rehydration therapy in the management of mild, moderate or severe diarrheal dehydration in children. An anonymous questionnaire was distributed to a cross-sectional representation of pediatricians, family practitioners and pediatric residents in North Central Florida. All were familiar with this type of therapy. Fewer were familiar with the Florida Oral Rehydration Therapy Program. Pediatricians reported significantly higher self-assessment scores than family practitioners or residents, and more of them were familiar with the American Academy of Pediatrics' recommendations for treatment of dehydration. Pediatric residents used intravenous therapy more frequently than pediatricians or family practitioners. The major obstacles to oral rehydration therapy use were identified as parental acceptance, compliance, and lack of a specific treatment area. The findings of this study suggest that pediatricians are more confident in their assessment, management and use of this type of therapy in children. Efforts to increase its use should focus on educational programs for physicians and parents. Dissemination of information to parents and pediatric providers may promote early treatment which should prevent more severe degrees of dehydration, decrease hospitalization and possibly prevent unnecessary deaths.

The effector mechanisms responsible for autoimmune beta cell destruction in insulin dependent (type 1) diabetes (IDD) remain elusive. In order to investigate whether T lymphocytes bearing the gamma-delta T cell receptor (gamma delta+ T cells) could be involved in this process, we measured percentages of peripheral blood gamma delta+ T cells in IDD patients, relatives of IDD probands and controls. High levels of gamma delta+ T cells strongly differentiated 23 relatives at high risk for IDD on the basis of positive islet cell autoantibodies (ICA positive relatives) from 59 controls (P = 0.0013), whereas 26 ICA negative relatives, 14 recent-onset and nine long term IDD patients could not be distinguished from controls on the basis of percentages of gamma delta+ T cells. These data suggest that increased levels of circulating gamma delta+ T cells correlate with the ongoing autoimmune process in pancreatic islets of subjects at high risk for IDD and may thus represent an additional marker for the development of the disease.

Linkage analysis of Kell:PTC loci demonstration close linkage, theta = 0.045 with a lod score of 10.78. The results, which include the Sutter blood group, support the hypothesis that Sutter is a part of the Kell system.