WHAT'S KNOWN ON THIS SUBJECT:Family-based, behavioral weight management programs are associated with moderate weight losses and health benefits for school-aged children, but few studies have focused on severely obese children. WHAT THIS STUDY ADDS:Intervention was associated with short-term reductions in obesity and improvements in medical parameters. Sustained decreases in overweight were observed only among children with better session attendance. Chronic care models are indicated to optimize health outcomes for severely obese children.abstract OBJECTIVE: We evaluated the efficacy of family-based, behavioral weight control in the management of severe pediatric obesity. METHODS:Participants were 192 children 8.0 to 12.0 years of age (mean Ϯ SD: 10.2 Ϯ 1.2 years). The average BMI percentile for age and gender was 99.18 (SD: 0.72). Families were assigned randomly to the intervention or usual care. Assessments were conducted at baseline, 6 months, 12 months, and 18 months. The primary outcome was percent overweight (percent over the median BMI for age and gender). Changes in blood pressure, body composition, waist circumference, and health-related quality of life also were evaluated. Finally, we examined factors associated with changes in child percent overweight, particularly session attendance. RESULTS:Intervention was associated with significant decreases in child percent overweight, relative to usual care, at 6 months. Intent-totreat analyses documented that intervention was associated with a 7.58% decrease in child percent overweight at 6 months, compared with a 0.66% decrease with usual care, but differences were not significant at 12 or 18 months. Small significant improvements in medical outcomes were observed at 6 and 12 months. Children who attended Ն75% of intervention sessions maintained decreases in percent overweight through 18 months. Lower baseline percent overweight, better attendance, higher income, and greater parent BMI reduction were associated with significantly greater reductions in child percent overweight at 6 months among intervention participants. CONCLUSIONS:Intervention was associated with significant shortterm reductions in obesity and improvements in medical parameters and conferred longer-term weight change benefits for children who attended Ն75% of sessions.

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Objective-To determine the effectiveness of an on-site modular intervention in improving access to mental health services and outcomes for children with behavioral problems in primary care relative to enhanced usual care.Setting-Boys and girls from six primary care offices in metropolitan Pittsburgh, PA.Participants-One-hundred and sixty three clinically referred children who met a modest clinical cutoff (75 th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention (PONI) or to enhanced usual care (EUC). PONI applied treatment modules from an evidence based specialty mental health treatment for children with disruptive behavior disorders that were adapted for delivery in the primary care setting; EUC offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community.Main Outcome Measures-Standardized rating scales, including the PSC-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected.Results-PONI cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at one-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time.Conclusions-A psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.Reprints may be obtained from Dr. Kolko, U. of Pittsburgh School of Medicine, WPIC, 3811 O'Hara St., Pittsburgh, PA 15213, Phone: 412-246-5888, Fax: 412-246-5341, kolkodj@upmc The pediatric primary care setting is a critical venue for the identification and management of mental health problems, 1 including behavior problems (BP) such as oppositional and aggressive behaviors. BPs are relevant to primary care clinicians (PCCs) 2, 3 given their prevalence in pediatric practice (10%-17%), associated physical 4 and psychosocial impairments, 5 and relationship to excessive health and emergency services use. 6,7 Access to specialty mental health services is limited for children with BP and other common mental disorders such as ADHD. 8,9 Consequently, PCCs are increasingly being called on to address such problems, 10 but report unease, inadequate training, limited tools, 11 time pressures, 5, 11 and minimal access to specialty mental health support 9, 12 as serious barriers to care delivery. 13 It is, thus, important to determine if on-site mental health service delivery in primary care is feasible and improves access to care and clinical outcomes for chi...

Objective-Depressed mothers of children with psychiatric illness struggle with both their own psychiatric disorder and the demands of caring for ill children. When maternal depression remains untreated, mothers suffer, and psychiatric illness in their offspring is less likely to improve. This randomized, controlled trial compared the interpersonal psychotherapy for depressed mothers (IPT-MOMS), a nine-session intervention based on standard interpersonal psychotherapy, to treatment as usual for depressed mothers with psychiatrically ill offspring.Method-Forty-seven mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment and randomly assigned to IPT-MOMS (N=26) or treatment as usual (N=21). Mother-child pairs were assessed at three time points: baseline, 3-month follow-up, and 9-month follow-up. Child treatment was not determined by the study.Results-Compared to subjects assigned to treatment as usual, subjects assigned to IPT-MOMS showed significantly lower levels of depression symptoms, as measured by the Hamilton Depression Rating Scale, and higher levels of functioning, as measured by the Global Assessment of Functioning, at 3-month and 9-month follow-ups. Compared to the offspring of mothers receiving treatment as usual, the offspring of mothers assigned to IPT-MOMS showed significantly lower levels of depression as measured by the Children's Depressive Inventory at the 9-month follow-up.Conclusions-Assignment to IPT-MOMS was associated with reduced levels of maternal symptoms and improved functioning at the 3-and 9-month follow-ups compared to treatment as usual. Maternal improvement preceded improvement in offspring, suggesting that maternal changes may mediate child outcomes.Major depressive disorder is a common, debilitating illness, affecting one of five women in their lifetime (1). Many women who suffer from depression are mothers. Because of shared genetic and environmental risk factors, the offspring of depressed mothers have a two-to fivefold increased risk of experiencing a psychiatric illness relative to the offspring of unaffected parents (2,3). In a negatively reinforcing cycle, depressed mothers whose children develop psychiatric illness find it difficult to juggle the mental health treatment needs of multiple affected family members, often putting their own care behind that of their children (4). Consequently, maternal depression remains untreated (5), with attendant impairment in a range of functions that have been implicated in both poor maternal and child outcomes, including maternal interpersonal functioning (6,7) and parenting skills (8). Even when children receive psychiatric treatment, the likelihood of favorable responses decreases in the face of persistent maternal depressive symptoms (9).Depressed mothers with psychiatrically ill children present both challenges and opportunities. On one hand, if maternal illness is untreated, it is likely to have a negative e...

This US study was conducted to determine whether mode of diagnosis and initial disease presentation influence lung disease and survival in patients with cystic fibrosis. The study population included 27,703 patients reported to the 1986-2000 Cystic Fibrosis Foundation Registry. Patients were segregated into four diagnostic categories: meconium ileus (MI), prenatal/neonatal screening (SCREEN), positive family history (FH), and symptoms other than meconium ileus (SYMPTOM). When compared with patients in the SCREEN group, those in the MI or SYMPTOM group were found to have significantly greater risks of shortened survival, Pseudomonas aeruginosa acquisition, and forced expiratory volume in 1 second (FEV(1)) below 70% of predicted. In the SYMPTOM group, the greatest risks of shortened survival, P. aeruginosa acquisition, and FEV(1) <70% occurred for patients presenting with combined respiratory and gastrointestinal symptoms, followed by respiratory or gastrointestinal symptoms alone; the best outcomes were in patients with other presenting features. Additionally, patients with presumably "severe" genotypes (DeltaF508 plus other class I, II, III mutations in both alleles) had greater risks of shortened survival and P. aeruginosa acquisition compared with patients with presumably "mild" genotypes (class IV or V mutations in one or both alleles).

Background Studies of the impact of pre-surgery weight loss and lifestyle preparation on outcomes following bariatric surgery are needed. Objective To evaluate whether a pre-surgery behavioral lifestyle intervention improves weight loss through 24-months post-surgery. Setting Bariatric Center of Excellence at a large, urban medical center. Methods Candidates for bariatric surgery were randomized to a 6-month behavioral lifestyle intervention or to 6 months of usual pre-surgical care. The lifestyle intervention consisted of 8 weekly face-to-face sessions followed by 16 weeks of face-to-face and telephone sessions prior to surgery; the intervention also included 3 monthly telephone contacts after surgery. Assessments were conducted at 6-, 12- and 24-months post-surgery. Results Participants who underwent surgery (n = 143) were 90.2% female and 86.7% White. Average age was 44.9 years, and average BMI was 47.5 kg/m2 at study enrollment. At follow-up, 131 (91.6%), 126 (88.1%), 117 (81.8%) patients participated in the 6-, 12- and 24 month assessments, respectively. Percent weight loss from study enrollment to 6- and 12-months post-surgery was comparable for both groups, but at 24-months post-surgery, the lifestyle group had significantly smaller percent weight loss than the usual care group (26.5% vs. 29.5%, respectively, p = 0.02). Conclusions Pre-surgery lifestyle intervention did not improve weight loss at 24 months post-surgery. Findings raise questions about the utility and timing of adjunctive lifestyle interventions for bariatric surgery patients.

In this initial report, we document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery. Participants (N = 240) were 86.7% female, 82.9% white, 52.3% married, and 85.8% had ≥ high school education. Mean BMI was 47.9 ± 6.7 kg/m2 and age was 45.2 ± 11 years. After completing a baseline assessment, patients were randomized to a 6-month, evidence-informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses. Results indicated that LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,182) = 23.6, p < 0.0001], with an effect size of 0.72. LIFESTYLE patients were more likely to lose at least 5% of initial body weight than those in USUAL CARE (OR = 4.98, p < 0.0001), as were participants who were older (OR = 1.04, p = 0.01 for every year increase in age) or heavier (OR = 1.06, p = 0.02 for each unit increase in BMI). A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.

Judicious use of SAE for patients with blunt splenic injury avoids unnecessary surgery and expands the number of patients who can retain their spleen.