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Abstract Background The steadily increasing number of prokaryotic genomes has accelerated the study of genome evolution; in particular, the availability of sets of genomes from closely related bacteria has facilitated the exploration of the mechanisms underlying genome plasticity. The family Vibrionaceae is found in the Gammaproteobacteria and is abundant in aquatic environments. Taxa from the family Vibrionaceae are diversified in their life styles; some species are free living, others are symbiotic, and others are human pathogens. This diversity makes this family a useful set of model organisms for studying bacterial evolution. This evolution is driven by several forces, among them gene duplication and lateral gene transfer, which are believed to provide raw material for functional redundancy and novelty. The resultant gene copy increase in one genome is then detected as lineage-specific expansion (LSE). Results Here we present the results of a detailed comparison of the genomes of eleven Vibrionaceae strains that have distinct life styles and distinct phenotypes. The core genome shared by all eleven strains is composed of 1,882 genes, which make up about 31%–50% of the genome repertoire. We further investigated the distribution and features of genes that have been specifically expanded in one unique lineage of the eleven strains. Abundant duplicate genes have been identified in the eleven Vibrionaceae strains, with 1–11% of the whole genomes composed lineage specific radiations. These LSEs occurred in two distinct patterns: the first type yields one or more copies of a single gene; we call this a single gene expansion. The second pattern has a high evolutionary impact, as the expansion involves two or more gene copies in a block, with the duplicated block located next to the original block (a contiguous block expansion) or at some distance from the original block (a discontiguous block expansion). We showed that LSEs involve genes that are tied to defense and pathogenesis mechanisms as well as in the fundamental life cycle of Vibrionaceae species. Conclusion Our results provide evidence of genome plasticity and rapid evolution within the family Vibrionaceae. The comparisons point to sources of genomic variation and candidates for lineage-specific adaptations of each Vibrionaceae pathogen or nonpathogen strain. Such lineage specific expansions could reveal components in bacterial systems that, by their enhanced genetic variability, can be tied to responses to environmental challenges, interesting phenotypes, or adaptive pathogenic responses to host challenges.

Abstract Background To evaluate effectiveness outcomes in a real-world setting in patients with schizophrenia initiating risperidone long-acting therapy (RLAT). Methods This was a 24-month, multicenter, prospective, longitudinal, observational study in patients with schizophrenia who were initiated on RLAT. Physicians could change treatment during the study as clinically warranted. Data were collected at baseline and subsequently every 3 months up to 24 months. Effectiveness outcomes included changes in illness severity as measured by Clinical Global Impression-Severity (CGI-S) scale; functional scores as measured by Personal and Social Performance (PSP) scale, Global Assessment of Functioning (GAF), and Strauss-Carpenter Levels of Functioning (LOF); and health status (Medical Outcomes Survey Short Form-36 [SF-36]). Life-table methodology was used to estimate the cumulative probability of relapse over time. Adverse events were evaluated for safety. Results 532 patients were enrolled in the study; 209 (39.3%) completed the 24-month study and 305 (57.3%) had at least 12 months of follow-up data. The mean (SD) age of patients was 42.3 (12.8) years. Most patients were male (66.4%) and either Caucasian (60.3%) or African American (23.7%). All changes in CGI-S from baseline at each subsequent 3-month follow-up visit were statistically significant (p < .0001), indicating improvement in disease severity. Improvements were also noted for the PSP, GAF, and total LOF, indicating improvement in daily functioning and health outcome. Conclusions Patients with schizophrenia who were initiated on RLAT demonstrated improvements in measures of effectiveness within 3 months, which persisted over 24 months. Trial Registration ClinicalTrials.gov: NCT00246194

Abstract Background Because wide variations in mental health care utilization exist throughout the world, determining long-term effectiveness of psychotropic medications in a real-world setting would be beneficial to physicians and patients. The purpose of this analysis was to describe the effectiveness of injectable risperidone long-acting therapy (RLAT) for schizophrenia across countries. Methods This was a pragmatic analysis of data from two prospective observational studies conducted in the US (Schizophrenia Outcomes Utilization Relapse and Clinical Evaluation [SOURCE]; ClinicalTrials.gov registration number for the SOURCE study: NCT00246194) and Spain, Australia, and Belgium (electronic Schizophrenia Treatment Adherence Registry [eSTAR]). Two separate analyses were performed to assess clinical improvement during the study and estimate psychiatric hospitalization rates before and after RLAT initiation. Clinical improvement was evaluated using the Clinical Global Impressions-Severity (CGI-S) and Global Assessment of Functioning (GAF) scales, and change from baseline was evaluated using paired t tests. Psychiatric hospitalization rates were analyzed using incidence densities, and the bootstrap resampling method was used to examine differences between the pre-baseline and post-baseline periods. Results The initial sample comprised 3,069 patients (US, n = 532; Spain, n = 1,345; Australia, n = 784; and Belgium, n = 408). In all, 24 months of study participation, completed by 39.3% (n = 209), 62.7% (n = 843), 45.8% (n = 359), and 64.2% (n = 262) of patients from the US, Spain, Australia, and Belgium, respectively, were included in the clinical analysis. Improvements compared with baseline were observed on both clinical assessments across countries (P < 0.001 at all post-baseline visits). The mean improvement was approximately 1 point on the CGI-S and 15 points on the GAF. A total of 435 (81.8%), 1,339 (99.6%), 734 (93.6%), and 393 (96.3%) patients from the US, Spain, Australia, and Belgium, respectively, had ≥1 post-baseline visit and were included in the analysis of psychiatric hospitalization rates. Hospitalization rates decreased significantly in all countries regardless of hospitalization status at RLAT initiation (P < 0.0001) and decreased significantly in the US and Spain (P < 0.0001) when the analysis was limited to outpatients only. Conclusions RLAT in patients with schizophrenia was associated with improvements in clinical and functional outcomes and decreased hospitalization rates in the US, Spain, Australia, and Belgium, despite differences in health care delivery systems.

Background: Hospitalized pediatric patients and their caregivers often experience anxiety and fear, resulting in withdrawal and aggression. Despite virtual reality (VR) being a safe and effective anxiolytic, it is unknown what software design aspects contribute to its effectiveness. This prospective observational study evaluated which VR application elements increased awe, which is correlated with improved behavior and satisfaction. Methods: Patients aged 6 to 25 years and their caregivers at an academic pediatric hospital interacted with a custom VR application that compared design aspects, including environment, graphics fidelity, and presence of a motivational character. Outcomes investigated self-reported awe, vastness, accommodation, and engagement. Data were analyzed using repeated measure ANOVA tests and correlation analyses. Results: A total of 202 participants were enrolled, and 179 (88 pediatric patients, 91 adult caregivers) were included in the final analysis. A fictional environment was more effective at increasing awe in pediatric patients ( P = 0.030) compared with a realistic environment. However, increased graphics fidelity was more effective at increasing awe in caregiver adults ( P = 0.023) compared with low resolution graphics. Presence of a motivational character did not influence awe in either patients or caregivers ( P = 0.432, P = 0.904, respectively). All measures of awe were positively correlated with application engagement ( P < 0.005). Conclusion: In conclusion, when software developers design VR software for pediatric patients and their caregivers, fictional settings and increased graphic fidelity should be considered for pediatric patients and adults, respectively. Future studies will explore other VR elements in gameplay settings.

Objectives: To examine the association of biopsychosocial stress indicators (perceived stress, perceived discrimination, stressful life events, and allostatic load) with sleep outcomes (sleep duration and insomnia symptoms) and to examine sex and age interactions for associations between stress and sleep in older Puerto Rican adults., Methods: Secondary analyses were performed with 830 participants (72% female) from wave 2 (2006-2011) of the Boston Puerto Rican Health Study (BPRHS), a prospective population-based cohort study (45-75years at baseline) and Boston Puerto Rican Osteoporosis Study (BPROS) (2007-2012), an ancillary study of the BPRHS. Recruitment occurred in randomly selected census blocks using door-to-door and community-based activities. In-home data collection visits included a baseline assessment and follow-up interviews. Questionnaires assessed perceived stress, discrimination, stressful life events, and sleep. Allostatic load indicators were measured objectively. Regression models controlled for sociodemographic, behavioral, and health factors, with interaction analyses, followed by sex- and sex-by-age-stratified analyses., Results: In the prior 2years, participants with chronic stress had 50% greater odds of reporting nonoptimal sleep duration (<7 or >9 hours). Life events trajectories were significantly related to insomnia symptoms. Men ≥65years who experienced chronic stress had greater insomnia symptoms than women, or than men with low stress or acute stress., Conclusions: Stressful life events may affect sleep duration and insomnia symptoms among older Puerto Rican adults, particularly men 65 years and older who experienced chronic stress. Given the differences in sleep patterns experienced by older adults and their relationships with health outcomes, identifying methods to support sleep health among those with chronic stress is important., Competing Interests: Declaration of conflicts of interest The authors do not have any conflicts of interest to report., (Copyright © 2024 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Both virtual reality (VR) and exercise reduce pain while avoiding the risks of traditional pharmacotherapy. The aim of this study was to assess how VR-facilitated exercise modulates sympathetic activity and pain perception., Design: Healthy adult volunteers were randomized by hand dominance and then subjected to a standardized cold pressor test while experiencing a VR application. After a 5-minute washout, participants were crossed-over and repeated the test on their other hand while undergoing a VR-facilitated exercise application. Sympathetic activation, pain sensation, and pain tolerance data were collected identically during both conditions., Results: 110 participants were analyzed. Sympathetic activity increased in both conditions but was higher in the VR-facilitated exercise condition (p < 0.0001). Pain sensation scores were initially higher with VR-facilitated exercise but dropped below the VR-only condition by the end of the intervention (p = 0.0175). There were no differences in pain tolerance between conditions (p = 0.18)., Conclusion: The decrease in pain perception with VR-facilitated exercise condition compared to VR alone indicates VR-facilitated exercise can be a useful tool for managing pain. Though this effect did not translate into higher pain tolerance, VR-facilitated exercise may be a useful intervention in the setting of physical therapy or for patients with chronic pain., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objective: HRAD± was developed to quickly assess pediatric perioperative affect and cooperation. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD± as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD± and predictive validity of induction HRAD± with emergence delirium., Design: This was a prospective observational investigation., Setting: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California., Patients: A total of 197 patients were included in this investigation. Children 1-14 years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible., Interventions: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence., Measurements: RAs scored each mask induction using the following scales: HRAD±, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD±. IRR of HRAD± between the RAs as well as predictive validity of HRAD± to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated., Main Results: HRAD± scores strongly correlated with mYPAS (r = 0.840, p < 0.0001) with moderate correlation to OSBD (r = 0.685, p < 0.0001) and ICC (-0.663, p < 0.0001). IRR was moderate for the affect and cooperation portion of the HRAD± scale, respectively (κ = 0.595 [p < 0.0001], κ = 0.478 [p < 0.0001]). A weak correlation was observed with PAED (r = 0.134 [p = 0.0597]) vs HRAD±. No correlations were observed between Watcha (r = 0.013 [p = 0.8559]) and Cravero and HRAD± scales (r = 0.002 [p = 0.9767])., Conclusions: HRAD± is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P  = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC ( P  = .457). Zero percent had ED with AR versus 0.7% with SOC ( P  = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Parent education and language use are associated with child obesity, but the impact of their interaction is less known. This study assessed whether parent education was associated with child adiposity and if this association was moderated by home language use in Latino families., Methods: Participants (n = 415) were Latino families from the Long Beach area. Demographic data were obtained by self-report parent surveys, and children's body size was objectively assessed via bioelectric impedance. Independent t-tests and hierarchical linear regressions were performed on baseline data from a larger intervention study., Results: In the overall sample, parent education and child body mass index (BMI) percentile were not related (p = .050). However, stratification by home language use revealed that parent education was inversely associated with child BMI percentile among those whose primary home language was Spanish (p = .049), but not English/bilingual homes (p = .296). There were no significant associations with child percent body fat., Conclusion: Higher education was associated with a lower BMI percentile only in Spanish-speaking homes. Research to understand how home language influences this relationship is warranted, particularly as it relates to a subset of education and health literacy. Significant results with BMI percentile but not percent body fat highlight the fact that these distinct markers of obesity are not interchangeable., (© 2024. W. Montague Cobb-NMA Health Institute.)

Study Objective: Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain., Design: Within-subject cross-over clinical trial., Setting: The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS)., Patients: Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS., Interventions: Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions., Measurements: Pain sensitivity was scored 0-10 and collected every 30 s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30 s epochs by a biosensor. In all analyses, data were nested by participant., Main Results: Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p < 0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition., Conclusions: The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise., Competing Interests: Declaration of Competing Interest Authors SR, EW, and TC are on the board of a nonprofit (Invincikids, Inc), that seeks to distribute immersive technology to hospitalized children at no cost. The Stanford Chariot Program has received philanthropic donations from Meta Inc., and Magic Leap, Inc. SR received consultation fees from Apple, Inc. All other authors declare no competing interests or conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Evidence on sleep duration or quality and cognitive function in diverse older adults is limited. We examined prospective associations between subjective sleep measures and cognitive function, with modifying effects of sex and age (<65 vs ≥65 years)., Methods: Data are from the longitudinal Boston Puerto Rican Health Study, Waves 2 (n = 943) and 4 (n = 444), with mean follow-up of 10.5 years (range 7.2-12.8). Subjective measures of sleep duration (short <7, ref. 7, or long ≥8 hours) and insomnia symptoms (sum of difficulty falling asleep, waking up at night, and early morning awakening), were assessed at Wave 2. Linear regression models were used to assess changes in global cognition, executive function, memory, and Mini-Mental State Examination, and tested for modifying roles of sex and age., Results: Significant 3-way interaction (sex × age × cognition) in fully adjusted models showed greater decline in global cognitive function in older men with short (β [95% confidence interval]: -0.67 [-1.24, -0.10]) or long sleep duration (-0.92 [-1.55, -0.30]), compared to women, younger men, and older men with 7 hours of sleep. Insomnia symptoms were associated with a greater decline in memory (-0.54, [-0.85, -0.22]) among older men, compared to women and younger men., Conclusion: Sleep duration showed a U-shaped association with cognitive decline, and insomnia symptoms were associated with memory decline in fully adjusted models. Older men, versus women and younger men, were at relatively greater risk for cognitive decline associated with sleep factors. These findings are important for personalizing sleep interventions to support cognitive health., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Fas ligand (FasL) is one ligand that activates extrinsic apoptosis pathway. High expression in lymphocytes of FasL have been found in patients with acute rejection of liver transplantation (LT). No high blood concentrations of soluble FasL (sFasL) have been found in patients with acute LT rejection; however, the samples size of those studies was small., Aim: To determine whether patients with hepatocellular carcinoma (HCC) that dead during the first year of LT have higher blood sFasL concentrations previously to LT that those who that remain alive in a study of higher sample size., Methods: Patients underwent LT due to HCC were included in this retrospective study. Serum sFasL levels prior to LT were measured and one-year LT mortality was registered., Results: Non-surviving patients ( n = 14) showed higher serum sFasL levels [477 (269-496) vs 85 (44-382) pg/mL; P < 0.001] than surviving patients ( n = 113). Serum sFasL levels (pg/mL) were associated with mortality (OR = 1.006; 95%CI = 1.003-1.010; P = 0.001) independently of age of LT donor in the logistic regression analysis., Conclusion: We report for the first time that HCC patients who die within the first year of HT have higher blood sFasL concentrations prior to HT than those who remain alive., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to declare., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Study Objective: Virtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain., Design: Randomized, controlled crossover within-subject clinical trial., Setting: This study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine., Patients: 156 healthy volunteers were included., Interventions: Participants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed., Measurements: Outcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR., Main Results: 153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P < 0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P < 0.001). SCRD increased as time progressed for both VR and control groups (P = 0.047 combined), with no significant mean group differences., Conclusions: Participants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Oxidative damage of DNA and RNA has been associated with mortality of patients with different diseases. However, there is no published data on the potential use of DNA and RNA oxidative damage to predict the prognosis of patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT)., Aim: To determine whether patients with increased DNA and RNA oxidative damage prior to LT for HCC have a poor LT prognosis., Methods: Patients with HCC who underwent LT were included in this observational and retrospective study. Serum levels of all three oxidized guanine species (OGS) were measured prior to LT since guanine is the nucleobase that forms DNA and RNA most prone to oxidation. LT mortality at 1 year was the end-point study., Results: Surviving patients ( n = 101) showed lower serum OGS levels ( P = 0.01) and lower age of the liver donor ( P = 0.03) than non-surviving patients ( n = 13). An association between serum OGS levels prior to LT and 1-year LT (odds ratio = 2.079; 95% confidence interval = 1.356-3.189; P = 0.001) was found in the logistic regression analysis., Conclusion: The main new finding was that high serum OGS concentration prior to LT was associated with the mortality 1 year after LT in HCC patients., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Purpose: Evaluation findings from Comprando Rico y Sano (CRS), a culturally relevant, community-based intervention addressing nutrition knowledge and food access are presented., Design: No-control quasi-experimental intervention with pre, post, and follow-up assessments., Setting: CRS was promotores -led through UnidosUS's Affiliate Network of community-based partners., Sample: Low-income Latino adults (N = 966) receiving services at 25 partner sites., Intervention: CRS was a six-hour intervention focused on nutrition knowledge and consumption of fruits, vegetables, and home-prepared meals. It also provided guidance for health-conscious grocery shopping, Supplemental Nutrition Assistance Program (SNAP) information, and enrollment assistance., Measures: Self-report surveys assessed nutrition knowledge; intention to change; and frequency of fruit, vegetable, and home-prepared meal consumption. Sites reported monthly SNAP enrollment data., Analysis: Paired-samples t-tests and repeated-measures ANOVAs assessed changes in knowledge, intentions, and behavior from pre-to-post (n = 960) and pre-to-follow-up (n = 115)., Results: Pre-to-follow-up increases in nutrition knowledge (P < .001) were observed. Intention to consume more vegetables (P = .027) and home-prepared meals (P < .001) also improved between pre- and follow-up. Increases from pre-to-follow-up were observed for frequency of consuming fruits (P = .007), vegetables (P = .001), and home-prepared meals (P < .001). Across 16 months, 24,359 Latinos enrolled for SNAP., Conclusion: Large-scale community collaborations to deliver culturally relevant nutrition education and SNAP enrollment assistance can increase food access, health literacy, and promote healthful diets for Latinos.

Study Objective: HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales., Design: We conducted an observational study., Setting: Videos of pediatric patients were collected in the perioperative environment., Patients: Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included., Interventions: To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±., Measurements: Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability., Main Results: HRAD± scores strongly correlated with mYPAS (r = 0.846, p < 0.0001) and OSBD scores (r = 0.723, p < 0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r = -0.715, p < 0.0001) and in the PIV group (r = -0.869, p < 0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p < 0.0001) and for PIV assessment was 0.378 (p < 0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p < 0.0001) and PIV assessment was 0.683 (p < 0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765., Conclusions: HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose of Review: Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation., Recent Findings: In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content., Summary: Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays., Summary of Key Points: While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge., Conclusions and Recommendations for Clinical Practice: While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.)

Objective: This study examined whether the frequency of experiences of ethnic microaggressions and the sensitivity to such experiences were associated with cortisol responses to an acute social stressor (Trier Social Stress Test; TSST) among an ethnically diverse sample of young adults ( N = 109, M age = 18.82 years, SD = 1.40 years, 74% female, 44% Latinx). Method: Self-reported experiences of and sensitivity to microaggressions were assessed using the Everyday Microaggressions Scale. Participants' salivary cortisol was collected before, immediately after, and at three 15-min intervals after the TSST (for a total of 5 salivary samples) to assess their cortisol responses to an acute social stressor. Results: Mixed model analyses revealed that experiencing a higher frequency of microaggressions ( p = .005) and being more sensitive to those experiences ( p = .001) were associated with a more blunted cortisol response (i.e., lower cortisol reactivity and recovery) to the TSST, relative to experiencing a lower frequency of microaggressions and being less sensitive to them. Furthermore, this blunted cortisol response to the TSST was more prominent among young adults of Latinx and other ethnic backgrounds (i.e., biracial, African American, and Native American) compared to their Asian American and non-Hispanic White peers ( p = .034). Conclusion: Findings provide insight into the different ways in which experiences of ethnic microaggressions can be associated with biological markers of stress. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Aims: The HTC VIVE virtual reality (VR) system is a potential tool for collecting kinematic data during inpatient and outpatient physical therapy (PT). When validated against research-grade systems, the VIVE has a reported translational error between 1.7 mm-2.0 cm. Our purpose was to portabilize the VIVE for room to room PT and validate the motion tracking software., Methods: The VIVE was configured on a mobile cart. To validate the motion tracking software, the VIVE sensors (motion tracker, controller, headset) were mounted on a rigid linear track and driven through 10, one-meter translations in the X, Y, and Z axes., Results: The mean translational error for all three sensors was below 4.9 cm. While error is greater than that reported for research-grade systems, motion tracking software on the portable VIVE unit appears to be a valid means of tracking aggregate movement., Conclusion: Some therapy may require more precise measurements, however, the advantages of portability and accessibility to patients may outweigh the limitation of reduced precision., (© The Author(s) 2020.)

Background: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation., Aim: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation., Methods: This retrospective cohort study included patients 2-11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed-effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed-effects logistic regression was used to examine the association between preoperative interventions and cooperation., Results: 9692 patients underwent 23 474 procedures during the study period. 3372 patients undergoing 5980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002)., Conclusion: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation., (© 2020 John Wiley & Sons Ltd.)

Background: Inflammation is implicated as one of many factors related to the development of chronic disease; thus, identifying its modifiable risk factors offers potential intervention targets to reduce risk., Purpose: To investigate whether depression and anxiety symptoms may indirectly affect high-sensitivity C-reactive protein (hs-CRP) and plasminogen activator inhibitor-1 (PAI-1) through sleep duration and adiposity (i.e., percentage body fat and waist circumference)., Methods: Multiple regression analyses were performed on Hispanic Community Health Study/Study of Latinos Youth (ages 8-16 years) cross-sectional baseline data, which were weighted to adjust for sampling design. Data were collected at a clinical assessment, including fasting blood samples, self-report surveys, and objectively measured anthropometrics., Results: Adjusting for sociodemographic covariates, depression symptoms were associated with log hs-CRP (β = .011, p = .047) but not PAI-1 (p = .285). Percentage body fat and waist circumference were positively related to depression symptoms (p = .026 and p = .028, respectively) and log hs-CRP (p < .001 for both). When including adiposity in the hs-CRP model, the associations of depression symptoms with hs-CRP were attenuated and became nonsignificant. Monte Carlo confidence intervals (CIs) showed that the indirect effects from depression symptoms to CRP through percentage body fat (95% CI: .0006, .0119) and waist circumference (95% CI: .0004, .0109) were statistically significant., Conclusions: Results indicate that the association between psychological distress and inflammation may occur indirectly through adiposity in Hispanic/Latino children. If findings are replicated in causal designs, reducing depression symptoms and adiposity among Hispanic/Latino children may be avenues for primary prevention of inflammation in later years., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Virtual reality (VR) is an emerging tool for anxiety and fear reduction in pediatric patients. VR use is facilitated by Certified Child Life Specialists (CCLS) at pediatric hospitals. The primary aim of this study was to retrospectively review the safety of VR by analyzing adverse events after the utilization of VR under CCLS supervision. Secondary objectives were to characterize the efficacy of VR in enhancing patient cooperation, describe the integration of VR into Child Life services, and identify interventions that accompanied VR., Methods: The Stanford Chariot Program developed VR applications, customized VR interfaces, and patient head straps, and distributed these to CCLS. Chart review analyzed VR utilization through CCLS patient notes. Inclusion criteria were all patients ages 6 to 18-years-old who received a Child Life intervention., Results: From June 2017 to July 2018, 31 CCLS saw 8,098 patients, 3,696 of which met age criteria with pre- and post-intervention cooperation data. Two hundred thirteen patients received VR with an accompanying intervention, while 34 patients received only VR. Adverse events were rare, and included increased anxiety (3.8%, n=8), dizziness (0.5%, n=1), and nausea (0.5%, n=1). Patients were more likely to be cooperative after receiving VR (99.5%, n=212) compared to pre-intervention (96.7%, n=206, p=0.041). VR use was most common in the perioperative setting (60%, n=128), followed by outpatient clinics (15%, n=32)., Conclusion: VR is safe in pediatric patients with appropriate hardware, software, and patient selection. Side effects were rare and self-limited. VR appears to be associated with improvements in cooperation., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics., Aims: The primary aim was to determine whether pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events., Methods: A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified Induction Compliance Checklist, and satisfaction surveys, respectively. Chi-squared, t tests, and regression models were used to analyze the results., Results: The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in postprocedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, P = .59), postprocedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater), or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96-5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events., Conclusion: This study demonstrates no reduction in pain while using Virtual reality (VR) across a heterogeneous pediatric inpatient population undergoing vascular access., (© 2019 John Wiley & Sons Ltd.)

Background: Physical activity in childhood and adolescence helps support physical and emotional health., Purpose: The study aimed to investigate if age was related to motivation for physical activity in minority girls, and whether the relationship may be potentially mediated by psychological or physiological stress., Methods: This cross-sectional observational study recruited Latino and African American girls ages 8 - 12 years (n = 79) in Tanner stage 1 or 2 via purposive sampling. Intrinsic motivation and perceived stress were measured by self-report survey; morning salivary cortisol samples were taken to calculate cortisol awakening response to estimate biological stress reactivity., Results: Increased age was related to higher intrinsic motivation to engage in physical activity. Lower perceived stress and lower awakening cortisol response were associated with higher intrinsic motivation. Bootstrapped mediation results indicated perceived stress may be a pathway through which age impacts intrinsic motivation for physical activity., Conclusion: While motivation to engage in physical activity may increase with age, perceived stress may dampen this motivation, resulting in decreased physical activity. Interventions to help increase pre-adolescent girls' engagement in active behaviors may benefit from reducing children's perceptions of stress.

Background : Higher liver caspase-3 activity has been found in patients with different liver diseases. However, there is no published data about circulating caspase-3 levels in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT). Therefore, our objective in this study was to determine whether an association between circulating caspase-3 levels in HCC patients prior to LT and one-year mortality after LT exists. Methods : In this observational and retrospective study, we included HCC patients who underwent LT. We measured serum levels of caspase-3 (as the main executor of apoptosis) and caspase-cleaved cytokeratin (CCCK)-18 (to estimate apoptosis degree) before LT. Results : One-year surviving LT patients (n = 129) showed lower serum levels of caspase-3 (p = 0.004) and CCCK-18 (p = 0.001) than non-surviving LT patients (n = 16). Logistic regression analysis showed that serum caspase-3 levels prior to LT were associated with one-year after LT mortality (Odds Ratio = 2.612; 95% CI = 1.519-4.493; p = 0.001). We found a positive association between serum levels of caspase-3 and CCCK-18 (rho = 0.26; p = 0.002). Conclusions : Our study is the first one reporting data of circulating caspase-3 levels prior to LT for HCC, and an association between high serum caspase-3 levels previously to LT and survival at first year after LT.

Background: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behavior. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety., Aims: The primary aim was to determine if a large projection-based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age., Methods: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included (a) induction compliance; (b) child fear; (c) frequency of emergence delirium; and (d) satisfaction., Results: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51) = 13.18, P < 0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) × group (BERT vs Tablet) was not significant, f(2, 51) = 1.96, P = 0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups., Conclusion: In a low-risk population, preoperative anxiety was low and induction compliance was high when pairing screen-based distraction interventions, regardless of size, with parental presence at induction of anesthesia., (© 2019 John Wiley & Sons Ltd.)

Melatonin administration has been associated with different benefits in animals and patients suffering from liver diseases. However, there is no published data about circulating melatonin levels in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT). Thus, the objective of this observational and retrospective study was to determine whether patients with HCC with lower serum melatonin levels prior to LT have a higher risk of one-year mortality after LT. We measured serum levels of melatonin, malondialdehyde (to assess lipid peroxidation), and total antioxidant capacity (to assess antioxidant state) before LT. One-year surviving LT patients ( n = 129) showed higher serum levels of melatonin ( p = 0.001) and total antioxidant capacity ( p = 0.001) and lower serum levels of malondialheyde ( p = 0.01) than non-surviving LT patients ( n = 16). Logistic regression analysis showed that high serum melatonin levels prior to LT were associated with lower one-year LT mortality (odds ratio = 0.525; 95% confidence interval (CI) = 0.331⁻0.834; p = 0.006). We found an association between serum levels of melatonin with serum levels of malondialheyde (rho = -0.22; p = 0.01) and total antioxidant capacity (rho = 0.21; p = 0.01). Thus, the novel findings of our study were the association between high serum melatonin levels prior to LT and survival at first year after LT and the association between serum levels of melatonin with malondialheyde and total antioxidant capacity.

Objective To determine whether there was an association between serum total antioxidant capacity (TAC) levels prior to in liver transplantation (LT) for hepatocellular carcinoma (HCC) and 1-year LT mortality. Methods This observational retrospective single-centre study of patients with LT for HCC measured serum levels of TAC and malondialdehyde (as a biomarker of lipid peroxidation) before LT. The study endpoint was 1-year LT mortality. Results This study included 142 patients who underwent LT for HCC. Patients who survived the first year ( n = 127) had significantly lower aged liver donors, significantly higher serum TAC levels, and significantly lower serum malondialdehyde levels compared with the non-survivors ( n = 15). Logistic regression analysis found that serum TAC levels (odds ratio [OR] 0.275; 95% confidence interval [CI] 0.135, 0.562) and the age of the LT donor (OR 1.050; 95% CI 1.009, 1.094) were associated with 1-year LT mortality. There was an inverse association between serum levels of TAC and malondialdehyde levels (rho = -0.22). Conclusions There was an association between low serum TAC levels prior to LT for HCC and mortality during the first year after LT. There was an inverse association between serum TAC levels and lipid peroxidation as measured by malondialdehyde levels.

Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization., Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time., Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative ( P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" ( P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT ( P = 0.001)., Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."

Purpose: Substance P is a tachykinins family member with inflammatory effects. Higher circulating levels of substance P have been found in patients with liver diseases and in patients with higher severity of liver diseases. The objective of this study was to determine whether serum levels of substance P levels, prior to liver transplantation (LT) for hepatocellular carcinoma (HCC) are associated with one-year LT mortality., Material and Methods: In this observational retrospective unicenter study were included patients with LT for HCC. Serum levels of substance P were measured before LT. The end-point of the study was one-year mortality after LT., Results: We found that one-year survivor patients ( n = 127) showed a lower age in liver donors ( p = 0.03) and lower levels of serum substance P levels ( p = 0.003) than non-survivor patients ( n = 15). Logistic regression analysis showed that serum levels of substance P (levels) were associated with one-year mortality (Odds Ratio = 1.011; 95% CI = 1.004-1.018; p = 0.002) controlling for the age of the LT donor., Conclusions: We believe that our study is the first study reporting data on circulating levels of substance P previously to LT for HCC, and an association between elevated levels of serum substance P before LT and mortality during the first year of LT., Competing Interests: CONFLICTS OF INTEREST None.

Purpose: CD40L and its soluble form (sCD40L) are proteins of the tumor necrosis factor superfamily (TNFSF) that exhibit prothrombotic and proinflammatory properties when binding to CD40, which is a cell surface receptor of the tumor necrosis factor receptor superfamily (TNFRSF). High circulating levels of sCD40L have been associated with poor prognosis in patients with hepatocellular carcinoma (HCC). However, it is unknown whether there is an association between circulating sCD40L levels and survival in patients with HCC underwent to liver transplantation (LT), and this was the objective of that study., Methods: Serum sCD40L levels were measured in a total of 139 patients before LT (124 survivors at 1year of LT and 15 non-survivors). The end-point study was 1year survival after liver LT., Results: We found that 1-year non-surviving patients showed higher serum sCD40L levels than survivor patients (p=0.02). We found in logistic regression analysis that serum sCD40L levels higher than 321pg/mL (Odds Ratio=6.86; 95% confidence interval=2.06-22.76; p=0.002) and age of LT deceased donor were associated with death at 1year., Conclusions: The new finding of our study was that high serum sCD40L levels previously to LT in patients with HCC are associated with higher mortality at one year., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Cytokeratin (CK)-18 is the major intermediate filament protein in the liver and during hepatocyte apoptosis is cleaved by the action of caspases; the resulting fragments are released into the blood as caspase-cleaved cytokeratin (CCCK)-18. Higher circulating levels of CCCK-18 have been found in patients with hepatocellular carcinoma (HCC) than in healthy controls and than in cirrhotic patients. However, it is unknown whether serum CCCK-18 levels before liver transplantation (LT) in patients with HCC could be used as a prognostic biomarker of one-year survival, and this was the objective of our study with 135 patients. At one year after LT, non-survivors showed higher serum CCCK-18 levels than survivors (p = 0.001). On binary logistic regression analysis, serum CCCK-18 levels >384 U/L were associated with death at one year (odds ratio = 19.801; 95% confidence interval = 5.301-73.972; p < 0.001) after controlling for deceased donor age. The area under the receiver operating characteristic (ROC) curve of serum CCCK-18 levels to predict death at one year was 77% (95% CI = 69%-84%; p < 0.001). The new finding of our study was that serum levels of CCCK-18 before LT in patients with HCC could be used as prognostic biomarker of survival., Competing Interests: The authors declare no conflict of interest.

Previous studies have found higher levels of serum malondialdehyde (MDA) in hepatocellular carcinoma (HCC) patients compared to healthy controls and higher MDA concentrations in tumoral tissue of HCC patients than in non-tumoral tissue. However, the association between pre-transplant serum levels of MDA and survival in HCC patients after liver transplantation (LT) has not been described, and the aim of the present study was to determine whether such an association exists. In this observational study we measured serum MDA levels in 127 patients before LT. We found higher pre-LT serum MDA levels in 15 non-surviving than in 112 surviving patients one year after LT (p = 0.02). Exact binary logistic regression analysis revealed that pre-LT serum levels of MDA over 3.37 nmol/mL were associated with mortality after one year of LT (Odds ratio = 5.38; 95% confidence interval (CI) = from 1.580 to infinite; p = 0.007) adjusting for age of the deceased donor. The main finding of our study was that there is an association between serum MDA levels before LT for HCC and 1-year survival after LT.

Background and Objectives: Epidural steroid injections (ESIs) are commonly performed for adults with spinal pain and/or radiculopathy. Previous pediatric ESI case series were not identified by literature review. The primary aim of this study was to examine the safety and provisional outcomes of pediatric ESIs., Methods: With institutional review board approval, medical records were reviewed for patients aged 9 to 20 years receiving a first ESI at Boston Children's Hospital from 2003 through 2013. A subset of patients completed a Web-based follow-up questionnaire. Descriptive statistics included frequencies, medians, interquartile ranges, and Kaplan-Meier methods. Statistical comparisons were made using Wilcoxon rank sum, χ2, Fisher exact, and Cox proportional hazards regression analyses., Results: A total of 224 patients aged 9 to 20 years underwent 428 ESIs. One hundred seventy-four (76.0%) patients had a lumbar disc herniation with radiculopathy; the others had a spectrum of other spinal disorders. There were no serious adverse events, hospitalizations, dural punctures, or nerve injuries. During follow-up, 69 (41.6%) of 166 previously nonoperated lumbar disc plus radiculopathy patients underwent discectomy at a median time of 128 days (interquartile range, 76-235 days) after first injection. Degrees of straight-leg raising at presentation was significantly associated with subsequent discectomy. On follow-up, patients who did and did not undergo discectomy had low pain scores and high function scores., Conclusions: Children and adolescents can receive ESIs under conscious sedation with good safety. Further prospective studies may better define the role for these injections in the comprehensive management of pediatric spinal pain disorders.

Objectives: To explore the relationships of perceived stress and depressive symptoms to sleep problems, testing for mediation by adaptive and maladaptive coping strategies., Methods: Alternative high school students (N = 1676) completed self-report surveys. Cross-sectional data were analyzed via Preacher and Hayes' procedures for multiple mediation., Results: The positive relationship between depressive symptoms and sleep problems was mediated partially by anger coping (positively related to sleep problems). The positive relationship between perceived stress and sleep problems was not mediated by coping strategies., Conclusions: Findings provide information on psychological factors that may lead to poor sleep outcomes, and are useful for developing health promotion interventions to impact lifelong health behaviors.

Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.

The Salud con Hyland's Project: Comienzo Saludable, Familia Sana [Health With Hyland's Project: Healthy Start, Healthy Family],was developed to provide education and support to Latina mothers regarding healthy infant feeding practices and maternal health. The promotora-delivered intervention was comprised of two charlas (educational sessions) and a supplemental, culturally and linguistically relevant infant feeding and care rolling calendar. Results indicate that the intervention increased intention to breastfeed exclusively, as well as to delay infant initiation of solids by 5 to 6 months. Qualitative feedback identified barriers to maternal and child health education as well as highlighted several benefits of the intervention.

While most studies have focused on investigating the preventive effects of physical activity on metabolic risk, the longitudinal impacts of metabolic syndrome (MetS) on activity levels is poorly understood. This study aims to examine the influence of MetS on initial activity levels and the trajectory of activity levels in Latina and African American female children over 12 months (n = 55, 9 ± 1 years). Metabolic measures, including fat and lean tissue mass by BodPod, fasting glucose, lipids, blood pressure, and waist circumference, were collected at baseline. Moderate-to-vigorous physical activity and sedentary behavior by accelerometry were collected on a quarterly basis. There were no significant differences in either initial activity levels by MetS status (Moderate-to-vigorous physical activity: 33 ± 12 mins/day for MetS, 48 ± 28 mins/day for Non-MetS, p = .12; sedentary behavior: 408 ± 57 mins/day for MetS, 421 ± 72 mins/day for Non-MetS, p = .67). Longitudinal declines in moderate-to-vigorous physical activity (p = .038) and increases in sedentary behavior (p = .003) were found. Daily sedentary behavior increased by 82.64 more minutes in youth with MetS than in those without over one year (p = .015). This study yields the first evidence of the adverse effect of MetS on sedentary behavior. Targeted intervention strategies to reduce progressive sedentariness evident in minority youth with MetS are warranted.

Object: Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery., Methods: In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups., Results: Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28)., Conclusions: The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

The effort in hospitals to improve the patient experience has yielded a new impetus to address compassion fatigue (CF), a combination of secondary traumatic stress and burnout. Over the last 3 years, Barnes-Jewish Hospital has developed a systemic program for CF resiliency. An initial evaluation of the extent to which CF was affecting the hospital's oncology staff led to the formal implementation of a resiliency program for oncology registered nurses. The success of that program ultimately led to the implementation of a hospital-wide resiliency program, designed to help professional caregivers understand CF, recognize the physical, mental, and emotional effects of stress, and adopt resiliency strategies. The voluntary program has been very well received by participants, and a formal evaluation shows promising results with a decline in secondary traumatic stress and burnout among participants. Developing an institutional culture of recognition and support for CF is critical for health care organizations. Establishing such a culture may help managers proactively create work environments that provide opportunities for connection and support among staff. Compassion fatigue training allows professional caregivers to reconnect to their personal mission and then truly begin to connect with an organization's values and mission.

Background: Eating breakfast is believed to promote a healthy body weight. Yet, few studies have examined the contribution of energy balance-related behavioral factors to this relation in minority youth., Objective: We assessed the associations between breakfast consumption and dietary intake, physical activity (PA), and adiposity before and after accounting for energy intake and PA in minority girls., Design: Cross-sectional data were obtained on body mass index (BMI), percentage body fat (measured by BodPod), dietary intake (measured with 3-d dietary records), and PA (measured with 7-d accelerometry) from 87 Latina and African American girls 8-17 y of age (75% Latina, 80% overweight). Dietary records were used to categorize girls as more frequent breakfast eaters (MF; 2 or 3 of 3 d; n = 57) or less frequent breakfast eaters (LF; 0 or 1 of 3 d; n = 30). Chi-square tests, ANCOVA, and multiple regression analyses were conducted. Mediation was assessed with a Sobel test., Results: Compared with the MF group, the LF group spent 30% less time (12.6 min/d) in moderate-to-vigorous-intensity PA (MVPA; P = 0.004) and had a higher percentage body fat (P = 0.029). MVPA accounted for 25% (95% CI: -8.8%, 58.1%; P = 0.139) of the relation between breakfast consumption and percentage body fat. We were unable to show that energy intake or MVPA was a significant mediator of the relation between breakfast consumption and adiposity in this sample., Conclusions: Evidence suggests that among predominantly overweight minority girls, MVPA, but not energy intake, was associated with both breakfast consumption and adiposity; however, a lack of power reduced our ability to detect a significant mediation effect. Other unobserved variables likely contribute to this relation.

Unlabelled: What is already known about this subject Physical activity declines as children enter puberty. Leptin is cross-sectionally associated with physical activity, but there are conflicting findings on the magnitude and direction of this association. Leptin concentrations fluctuate during puberty, and may impact energy balance. What this study adds Leptin predicts the decline in physical activity during the start of puberty independent of central adiposity. Based on a median split of leptin, girls with low leptin levels have higher levels of physical activity than girls with high leptin levels at the start of puberty. Leptin levels at the start of puberty may provide a biological basis for the age-related physical activity decline in girls., Background: Leptin may influence moderate to vigorous physical activity (MVPA) at the start of puberty. The direction and magnitude of this association are unclear., Objectives: To determine the effect of baseline leptin on MVPA over 1 year in minority girls at high risk for obesity., Methods: Data came from TRANSITIONS, a longitudinal observational study on the age-related MVPA decline. Fifty peripubertal girls aged 8-11 years at baseline participated. Baseline leptin (ng mL(-1) ) was collected via a duplicated assay using a double antibody radio immune assay. MVPA (min d(-1) ) was measured using accelerometers for at least four 10-h days on a quarterly basis for up to 1 year., Results: Continuous leptin was negatively related to MVPA (P = 0.001) independent of central adiposity at baseline and predicted the MVPA decline over 1 year (P = 0.002). For descriptive purposes, baseline leptin was dichotomized at the sample median into 'high leptin' and 'low leptin' categories to determine whether MVPA trajectories differed between these groups. Girls with 'low leptin' at baseline had significantly higher levels of MPVA at baseline, visit 1 and visit 2 compared to girls with 'high leptin'., Conclusions: High leptin levels predicted nearly a 12.6% decline in MVPA over 1 year. These findings provide support for the biological basis of declining MVPA as girls enter puberty., (© 2012 The Authors. Pediatric Obesity © 2012 International Association for the Study of Obesity.)

Objective: Addressing recruitment challenges faced by researchers when the intended participants are young individuals from minority communities is crucial to prevent increases in study costs, prolonged length of the study, and loss of generalizability that may occur due to the resulting higher attrition rates. This article focuses on understanding the differences in census-tract level income, education, and socioeconomic status of young Latina and African American female participants and non-participants during the first 26 months of recruitment (June 2006-August 2008) in a longitudinal biobehavioral study., Design: The Transitions Study examines the psychological and physiological determinants influencing the decrease in physical activity during puberty among Latina and African American girls aged 8 to 11 years within the greater Los Angeles area. Recruitment and retention through five main steps in the process were examined: telephone contact, telephone screening, consent, clinical screening, and baseline overnight visit., Results: As of August 2008, the recruitment pool consisted of 110 African Americans (17.8%) and 373 Latinas (60.4%); of these, only 40 Latinas and 11 African American girls completed the final step into the study. African Americans were less willing to provide their phone numbers, but more likely to be reached at initial phone contact than Latino families., Conclusions: Understanding the heterogeneity within minority populations, population characteristics, through careful and timely analyses, could be used to adjust recruitment and retention strategies in a study involving minority youth.

The aim of this study is to present the development of the Meanings of Eating Index (MEI) in a diverse sample of children. Exploratory factor analysis was performed on MEI items. Factors with eigenvalues above 1.0 were retained. Items that loaded on multiple factors or with item-total correlations below 0.50 were discarded. A 24-item, 5-factor scale comprised the final MEI. Personal Negative Emotions and Disturbed Eating were positively associated with frequency of high calorie snack food intake (r=0.21, p<0.05; r=0.33, p<0.01), and Personal Well Being was positively associated with eating vegetables more frequently (r=0.20; p<0.05). Eating on Behalf of Others was negatively associated with frequency of vegetable intake (r=-.20; p<0.05). Pleasure Eating was not associated with dietary intake. The MEI shows promise as a tool for understanding the affective determinants of dietary intake in minority youth., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Purpose: To investigate the effect of worries on weight concerns, emotional eating, and body mass index (BMI) percentile in an ethnically diverse sample of female youth., Methods: This study used baseline and follow-up data from a brief school-based physical activity intervention trial involving minority female youth. Partial correlations adjusted for intervention status, age, and ethnicity were used to assess the relationships between emotional eating, weight concerns, and BMI percentile at follow-up. Multilevel modeling was used to analyze the relationships between baseline worries and follow-up emotional eating, weight concerns, and BMI percentile. Additional analysis assessed whether emotional eating mediated and/or moderated the relationship between baseline worries and follow-up BMI. Data were analyzed using SAS version 9.1., Results: The sample consisted of 404 minority females (67.1% Latina; mean age = 12.5 ± .6; 60.6% were of normal weight). Weight concerns were positively correlated with emotional eating and BMI percentile (p < .001 for both). At follow-up, baseline worries significantly predicted emotional eating (p = .027) and weight concerns (p < .001) but not BMI percentile (p = .183). Emotional eating did not mediate the relationship between baseline worries and follow-up BMI percentile; however, it did moderate the relationship between baseline worries and follow-up BMI percentile (p = .003)., Conclusions: In this sample, worries were associated with psychosocial variables but not with BMI percentile. Reducing worries in those with high emotional eating scores may influence future weight gain among Latina females., (Copyright © 2011 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)