Faculty Bibliography

AIM/OBJECTIVE:A randomized controlled trial (RCT) was conducted to test the null hypothesis that there is no difference in complication rates and length of stay (LOS) between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps of the right colon. METHOD/METHODS:A single-centre RCT (NCT01986699) was conducted on patients with polyps of the right colon deemed by the gastroenterologist to be unresectable. Patients underwent a repeat colonoscopy with biopsy by an interventional endoscopist and were allocated to LRC or LACP. Patients with a nonlift sign, dysplasia, adenocarcinoma, inflammatory bowel disease or familial adenomatous polyposis were excluded from the trial. The study was powered to detect a 73% difference in the LOS which required 17 patients in each arm with an α error of 0.05 and a power of 95%. RESULTS:Thirty-four patients were comparable for age (P = 0.919), gender (P = 0.364), body mass index (P = 0.634), American Society of Anesthesiologists class (P = 0.388) and previous abdominal surgery (P = 0.366). There was no significant difference in the preoperative morphology (P = 0.485), location (P = 0.297), size (P = 0.690) or histology of the polyps (P = 0.779). LRC patients experienced a longer operating time (180 vs 90 min; P = 0.001), required more intravenous infusion (3.1 vs 2.0 l; P = 0.025), took significantly longer to pass flatus (2.88 vs 1.44 days; P < 0.001), resumed solid food later (3.94 vs 1.69 days; P < 0.001) and had a longer postoperative LOS (4.94 vs 2.63 days; P < 0.001). Postoperative complications (P = 0.656), readmissions (P = 0.5) and reoperations (P = 0.5) did not differ. Final size (P = 0.339) and histology (P = 0.104) of the polyps did not differ. There were four cancers in the LRC arm. At follow-up colonoscopy with biopsy of the scar in 10 patients at 15.3 months, one patient had recurrence of the polyp at the site of the previous LACP. CONCLUSION/CONCLUSIONS:LACP and LRC had similar complication rates, but LOS was shorter after LACP.

A randomized experiment was conducted in two outpatient clinics evaluating a measurement feedback system called contextualized feedback systems. The clinicians of 257 Youth 11-18 received feedback on progress in mental health symptoms and functioning either every 6 months or as soon as the youth's, clinician's or caregiver's data were entered into the system. The ITT analysis showed that only one of the two participating clinics (Clinic R) had an enhanced outcome because of feedback, and only for the clinicians' ratings of youth symptom severity on the SFSS. A dose-response effect was found only for Clinic R for both the client and clinician ratings. Implementation analyses showed that Clinic R had better implementation of the feedback intervention. Clinicians' questionnaire completion rate and feedback viewing at Clinic R were 50 % higher than clinicians at Clinic U. The discussion focused on the differences in implementation at each site and how these differences may have contributed to the different outcomes of the experiment.

The experience of parents in helping their children access and use mental health services is linked to service outcomes. Parent peer support service, based on the principles of family-centered care, is one model to improve parent experience and engagement in services. Yet, little is known about how best to integrate this service into the existing array of mental health services. Integration is challenged by philosophical differences between family-centered services and traditional children's treatment services, and is influenced by the organizational social contexts in which these services are embedded. We describe an organizational and frontline team intervention that draws on research in behavior change, technology transfer, and organizational social context for youth with serious emotional disturbance. The two-pronged intervention, called FAMILY (FCC and ARC Model to Improve the Lives of Youth) is guided by the evidence-based Availability, Responsiveness, and Continuity (ARC) organizational intervention, targeted primarily at program and upper management leadership and includes a family-centered care (FCC) intervention, targeted at frontline providers. The approach employs multilevel implementation strategies to promote the uptake, implementation and sustainability of new practices. We include examples of exercises and tools, and highlight implementation challenges and lessons learned in facilitating program and staff level changes in family-centered service delivery.

OBJECTIVE:Research on adults with cyclothymic disorder (CycD) suggests that irritability and impulsive aggression (IA) are highly prevalent among this population. Less is known about whether these behaviors might also distinguish youth with CycD from youth without CycD. Additionally, little is known about how irritability and IA relate to one another, and whether they are associated with different outcomes. This study aimed to compare irritability and IA across diagnostic subtypes to determine whether CycD is uniquely associated with these behaviors, and to assess how irritability and IA relate to youth social and general functioning. METHODS:Participants (n = 459), 11-18 years of age, were recruited from an urban community mental health center and an academic outpatient clinic; 25 had a diagnosis of CycD. Youth and caregivers completed measures of IA and irritability. Youth and caregivers also completed an assessment of youth friendship quality. Clinical interviewers assessed youth social, family, and school functioning. RESULTS:Youth with CycD had higher scores on measures of irritability and IA than youth with nonbipolar disorders, but scores were not different from other youth with bipolar spectrum disorders. Measures of irritability and IA were correlated, but represented distinct constructs. Regression analyses indicated that irritability was related to friendship quality (p < 0.005). Both IA and irritability were related to social impairment (ps < 0.05-0.0005) and Child Global Assessment Scale (C-GAS) scores (ps = 0.05-0.005). CycD diagnosis was associated with poorer caregiver-rated friendship quality and social functioning (ps < 0.05). CONCLUSIONS:We found that irritability and aggression were more severe among youth with CycD than among youth with nonbipolar diagnoses, but did not differ across bipolar disorder subtypes. Among youth seeking treatment for mental illness, irritability and IA are prevalent and nonspecific. Irritability and IA were uniquely related to our outcomes of social and general functioning, suggesting that it is worthwhile to assess each separately, in order to broaden our understanding of the characteristics and correlates of each.

OBJECTIVE:Depression and bipolar disorder (negative mood disorders, NMD) are associated with dysregulated hypothalamic-pituitary-adrenal (HPA)-axis function and disrupted emotion processing. The neural networks involved in attenuation of HPA-axis reactivity overlap with the circuitry involved in perception and modulation of emotion; however, direct links between these systems are understudied. This study investigated whether cortisol activity prior to undergoing fMRI was related to neural processing of emotional information in participants with NMD. METHODS:=36.43, SD=17.33) provided salivary cortisol samples prior to completing a facial emotion perception test during 3-Tesla fMRI. RESULTS:Overall, pre-scan cortisol level was positively associated with greater engagement of the dorsal anterior cingulate (dACC), inferior parietal lobule, insula, putamen, precuneus, middle and medial frontal and postcentral gyri, posterior cingulate, and inferior temporal gyrus during emotion processing of all faces. NMD status moderated this effect; in NMD participants' pre-scan cortisol was associated with attenuated activation of the insula, postcentral gyrus, precuneus, and putamen for fearful faces and the medial frontal gyrus for angry faces relative to HCs. Cortisol-related attenuation of activation among NMD participants was also observed for facial identification in the dACC, putamen, middle temporal gyrus, precuneus, and caudate. CONCLUSIONS:Across all participants, cortisol was associated with greater activation in several regions involved in the perception and control of emotion. However, cortisol responsivity was associated with hypoactivation of several of these regions in the NMD group, suggesting that HPA-axis activity may selectively interfere with the potentially adaptive recruitment of circuits supporting emotion perception, processing and/or regulation in mood disorders.

OBJECTIVES/OBJECTIVE:The phenomenology and diagnosis of pediatric bipolar disorder has been controversial. We aimed to update a 2005 meta analysis of the prevalence of manic symptoms in youth, in order to determine whether the picture of pediatric mania has changed as research on pediatric bipolar disorder has grown. METHODS:We conducted literature reviews in PsycINFO and PubMed; studies with the prevalence of manic symptoms in youth were included. Two raters coded each study; kappa was 0.86-1.0. RESULTS:Twenty studies were meta-analyzed (N = 2,226 youths). The most common symptoms across bipolar subtypes, using a random-effects model, were: increased energy 79%, irritability 77%, mood lability 76%, distractibility 74%, goal-directed activity 72%, euphoric/elated mood 64%, pressured speech 63%, hyperactive 62%, racing thoughts 61%, poor judgment 61%, grandiosity 57%, inappropriate laughter 57%, decreased need for sleep 56%, and flight of ideas 54%. Symptom rates were heterogeneous across samples; potential predictors were explored but no clear patterns were found. CONCLUSIONS:Debate continues about the definitions of pediatric bipolar disorder; the results of this meta-analysis suggest that there is significant heterogeneity of symptom prevalence between studies, and that symptoms vary widely across individuals. Understanding the roots of this heterogeneity could broaden understanding of the complex clinical presentation of pediatric mania, and aid in diagnosis.

Obtaining quantitative measures from biomedical images often requires segmentation, i.e., finding and outlining the structures of interest. Multi-modality imaging datasets, in which multiple imaging measures are available at each spatial location, are increasingly common, particularly in MRI. In applications where fully automatic segmentation algorithms are unavailable or fail to perform at desired levels of accuracy, semi-automatic segmentation can be a time-saving alternative to manual segmentation, allowing the human expert to guide segmentation, while minimizing the effort expended by the expert on repetitive tasks that can be automated. However, few existing 3D image analysis tools support semi-automatic segmentation of multi-modality imaging data. This paper describes new extensions to the ITK-SNAP interactive image visualization and segmentation tool that support semi-automatic segmentation of multi-modality imaging datasets in a way that utilizes information from all available modalities simultaneously. The approach combines Random Forest classifiers, trained by the user by placing several brushstrokes in the image, with the active contour segmentation algorithm. The new multi-modality semi-automatic segmentation approach is evaluated in the context of high-grade glioblastoma segmentation.

PURPOSE OF THE STUDY:Communication contributes to increased stress, mortality, and decreased quality of life (QOL) for persons with dementia (PWD) and caregivers. PWD use communicative coping behaviors (CCBs) to manage the demands of the disease. However, most assessments neither look for nor give credit to communication behaviors. This is the first study to examine CCBs in the home environment as measured by the Communicative Coping Behavior Checklist (CCBC). DESIGN AND METHODS:This cross-sectional quantitative study included 26 dementia and 18 cognitively normal control dyads. Raters observed their partners' CCBs at home, over several weeks and completed the CCBC. We analyzed the endorsement rates (how often behaviors were observed by a rater) of emotion and activity-focused CCBs in dementia and control dyads. RESULTS:The primary outcome was rate of CCB endorsement. Secondary outcomes included dementia diagnosis, cognitive status, depressive mood, life satisfaction (SWL) and QOL. Dementia dyads endorsed 11 of 23 CCBs significantly more than control dyads. Action-focused CCBs (p < .001) were more frequent than emotion-focused CCBs (p = .004) in dementia dyads. Specific CCBs such as humor correlated with higher caregiver QOL (p = .019) and PWD's SWL (p = .003). Another CCB, general humor, correlated with lower PWD's SWL (p = .024). IMPLICATIONS:This was the first study to examine CCBs in the home environment comparing dementia and control dyads. Higher endorsement rates of action-focused than emotion-focused CCBs were seen in dementia dyads. We conclude that attention to CCBs during treatment and care will improve QOL and SWL of PWD and caregivers.