Nien-Chen Li

Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis

Objective To investigate whether angiotensin receptor blockers protect against Alzheimer’s disease and dementia or reduce the progression of both diseases. Design Prospective cohort analysis. Setting Administrative database of the US Veteran Affairs, 2002-6. Population 819 491 predominantly male participants (98%) aged 65 or more with cardiovascular disease. Main outcome measures Time to incident Alzheimer’s disease or dementia in three cohorts (angiotensin receptor blockers, lisinopril, and other cardiovascular drugs, the “cardiovascular comparator”) over a four year period (fiscal years 2003-6) using Cox proportional hazard models with adjustments for age, diabetes, stroke, and cardiovascular disease. Disease progression was the time to admission to a nursing home or death among participants with pre-existing Alzheimer’s disease or dementia. Results Hazard rates for incident dementia in the angiotensin receptor blocker group were 0.76 (95% confidence interval 0.69 to 0.84) compared with the cardiovascular comparator and 0.81 (0.73 to 0.90) compared with the lisinopril group. Compared with the cardiovascular comparator, angiotensin receptor blockers in patients with pre-existing Alzheimer’s disease were associated with a significantly lower risk of admission to a nursing home (0.51, 0.36 to 0.72) and death (0.83, 0.71 to 0.97). Angiotensin receptor blockers exhibited a dose-response as well as additive effects in combination with angiotensin converting enzyme inhibitors. This combination compared with angiotensin converting enzyme inhibitors alone was associated with a reduced risk of incident dementia (0.54, 0.51 to 0.57) and admission to a nursing home (0.33, 0.22 to 0.49). Minor differences were shown in mean systolic and diastolic blood pressures between the groups. Similar results were observed for Alzheimer’s disease. Conclusions Angiotensin receptor blockers are associated with a significant reduction in the incidence and progression of Alzheimer’s disease and dementia compared with angiotensin converting enzyme inhibitors or other cardiovascular drugs in a predominantly male population.

Long-term posttraumatic stress symptoms vary inversely with early opiate dosing in children recovering from serious burns: effects durable at 4 years.

BACKGROUND Children surviving serious burns are at risk for developing posttraumatic stress disorder (PTSD) as a function both of the injury and of its treatment. Short-term studies in such children have demonstrated reduced PTSD symptoms with intensive early pain control. However, the long-term impact of early pain control strategies on posttraumatic stress symptoms in children recovering from serious burn injuries has not been examined. METHODS This was a retrospective review of a multiple time point data collection involving a cohort of 147 infants, children, and teenagers with 4 years of follow-up after serious burns conducted at 4 pediatric burn centers to examine the impact of early opiate dosing on long-term posttraumatic stress symptoms. The main outcome measure was the nine-item Short Form Child Stress Disorders Checklist, which is an established and validated assessment. The impact of total opiate dosing during the first 7 days on these scores was assessed. RESULTS Subjects had an average age of 11 years and average injury size of 22% total body surface area burned (%TBS). The correlation between opiate units (OUs) and %TBS was 0.46 at baseline, OU increasing with increasing %TBS. OUs were strongly predictive of Child Stress Disorders Checklist scores up to 4 years, with higher OU (10 units vs. 6 and 2 units) remaining constantly different up to 4 years in predicting lower stress scores for both smaller and larger burns. CONCLUSION Early opiate management of pain associated with acute burn wounds and burn treatment predicts the development and resolution rate of PTSD symptoms in a large multicenter sample of children hospitalized for serious burns. The effect seems to be dose related and durable at least up to 4 years in a range of burn sizes. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level II.

Assessing risk of sexually abusive behavior among youth in a child welfare sample

Statutory management of juvenile sexual offenders demands reliable, valid methods for assessing the risk posed by these youth. This study examined the predictive validity of the J-SOAP-II using samples of adolescent and pre-adolescent boys who were wards of the Massachusetts Department of Social Services. The base rate for sexual recidivism among the adolescents (14-16%) is generally in line with what has been reported. The equivalent base rate for the pre-adolescents (25-28%), however, was notably higher. Although the J-SOAP-II was developed for adolescents, the scale also worked with the pre-adolescents in predicting sexual recidivism over 7 years, with AUC values of 0.77, 0.74, 0.77, and 0.80 for Scales 1, 3, 4, and Total among the pre-adolescents and AUC values of 0.80, 0.82, and 0.83 for Scales 1, 4, and Total among the adolescents. Discussion focuses on extant J-SOAP research and sample dependent variability, as well as social policy implications.

The effect of family characteristics on the recovery of burn injuries in children.

BACKGROUND Interactions between family members and characteristics of family life and function may affect a child’s recovery from burn injury. We prospectively examined the relationship between family characteristics and physical and psychosocial recovery from burns. METHODS The families of 399 burned children aged 5 years to 18 years admitted to one of four Shriners Hospitals for Children for management of acute burns completed the Family Environment Scale within 7 days of admission and then the American Burn Association/Shriners Hospitals for Children Burn Outcome Questionnaire (BOQ) at baseline, 3, 6, 12, 18, 24, 36, and 48 months. Generalized estimating equations with random effects for the time since burn were used to track recovery of the BOQ patient-centered domains associated with baseline family characteristics during the course of the study. RESULTS The children had a mean age of 11 years and burn size of 32% total body surface area burned. Higher Family Environment Scale scores in cohesion, independence, organization, and active recreational orientation were associated with significantly better rates of recovery in multiple BOQ domains of health-related quality of life. Higher scores in conflict and achievement orientation predicted statistically significant impaired recovery. Higher expressiveness predicted greater difficulty with school reentry. CONCLUSION Family characteristics affect the recovery of children after serious burns. Some of these may be amenable to focused anticipatory family interventions to help optimize outcomes. In particular, those characteristics that impair school reentry should be targeted. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Measuring the cost of care for children with acute burn injury.

BACKGROUND There have been few studies on costs of burn treatment. Furthermore, quantifying the actual cost of care at the patient level is hindered by anomalies of our insurance system. This article presents a practical method for determining the cost of caring for pediatric burn patients, using a cohort of patients from the Multi-Center Benchmarking Study at the Shriners Hospitals for Children-Boston and allows an estimate of resource use that may be linked to need or to best practices, without the confounding variable of inconsistent billing practices. METHODS We estimated the cost of hospitalization for a cohort of 230 pediatric patients who sustained burn injuries. In a simulation of billing patterns of all US hospitals between 2001 and 2009, we applied Shriners Hospitals for Children use data to two external sources of cost information. For the hospital component of costs, we used the Healthcare Cost and Utilization Project Kid’s Inpatient Database, and for the physician component of costs, we used the Medicare fee schedule. RESULTS Patients had a mean of 1.9 hospitalizations over 3 to 4 years. The mean total cost of hospitalization was

Recovery curves for pediatric burn survivors advances in patient-oriented outcomes

83,535 per patient, and the median total cost was

Impact of hand burns on health-related quality of life in children younger than 5 years

16,331 in 2006 dollars. CONCLUSION This is the first effort to estimate the early hospital costs of caring for children and young adults with burns in specialty hospitals and to establish a referent for quantifying the cost of caring for patients with acute burns. It lays the groundwork for studies relating costs of specific interventions to their effects on patient-centered outcomes. LEVEL OF EVIDENCE Economic analysis, level III.

Test performance characteristics of a case-finding psychosocial questionnaire for children with burn injuries and their families

IMPORTANCE Patient-reported outcomes serving as benchmarks for recovery of pediatric burn survivors are lacking, and new approaches using longitudinal cohorts for monitoring their expected recovery based on statistical models are needed for patient management during the early years following the burn. OBJECTIVE To describe multidimensional patient-reported outcomes among pediatric burn survivors younger than 5 years to establish benchmarks using recovery curve methods. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of pediatric burn survivors younger than 5 years at 12 burn centers. Age-matched nonburned reference groups were studied to define expected results in normal growth and development. The Burn Outcomes Questionnaire for children aged 0 to 5 years (BOQ0-5) was administered to parents of children who had burns and were younger than 5 years. Mixed models were used to generate 48-month recovery curves for each of the 10 BOQ0-5 domains. The study was conducted between January 1999 and December 2008. MAIN OUTCOMES AND MEASURES The 10 BOQ0-5 domains including play, language, fine motor skills, gross motor skills, emotional behavior, family functioning, pain/itching, appearance, satisfaction with care, and worry/concern up to 48 months after burn injury. RESULTS A total of 336 pediatric burn survivors younger than 5 years (mean [SD] age, 2.0 [1.2] years; 58.4% male; 60.2% white, 18.6% black, and 12.0% Hispanic) and 285 age-matched nonburned controls (mean [SD] age, 2.4 [1.3] years; 51.1% male; 67.1% white, 8.9% black, and 15.0% Hispanic) completed the study. Predicted scores improved exponentially over time for 5 of the BOQ0-5 domains (predicted scores at 1 month vs 24 months: play, 48.6 vs 52.1 [P = .03]; language, 49.2 vs 54.4 [P < .001]; gross motor skills, 48.7 vs 53.0 [P = .002]; pain/itching, 15.8 vs 33.5 [P < .001]; and worry/concern, 31.6 vs 44.9 [P < .001]). Pediatric burn survivors had higher scores in language, emotional behavior, and family functioning domains compared with healthy children in later months. CONCLUSIONS AND RELEVANCE This study demonstrates significant deficits in multiple functional domains across pediatric burn survivors compared with controls. Recovery curves can be used to recognize deviation from the expected course and tailor care to patient needs.

Pharmacoepidemiological Studies Using the Veterans Affairs Decision Support System

BACKGROUND The purpose of this multicenter study was to evaluate the impact of hand burn injury in preschool children younger than 5 years on health-related quality of life, including both physical and psychosocial function, in the 5 years after burn injury. METHODS This prospective case series assessed children younger than 5 years admitted to four pediatric burn centers. Each child’s family completed the American Burn Association/Shriners Hospitals for Children Burn Outcome Questionnaire (BOQ), a validated and reliable assessment tool, which measures the physical and psychosocial functioning of the child with burn injury ages 0 year to 5 years, at baseline, 3, 6, 12, 18, 24, 36, and 48 months after discharge. Multivariate models controlling for sociodemographic and clinical characteristics were developed, and recovery curves were generated for the time since burn using generalized estimating equations with random effects. RESULTS A cohort of 438 patients was followed up prospectively. Mean (SD) patient age was 2.2 (1.2) years, mean (SD) total body surface area (TBSA) was 28% (22.4%), and 19% had inhalation injury. Children with hand burns had lower scores in most of the areas tested, with the most pronounced and significant differences were in fine motor function, gross motor function, and appearance. These findings applied to both small (<20% TBSA) and large (≥20% TBSA) burns. The most profound impact of hand burns was noted in fine and gross motor function during the 4 years of follow-up. CONCLUSION Children with hand burns have significantly worse outcomes than do children with burns in other areas. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

PREDICTING HANDS-ON CHILD SEXUAL OFFENSES AMONG POSSESSORS OF INTERNET CHILD PORNOGRAPHY

BACKGROUND The Long-Form Psychosocial Questionnaire (LFPQ) includes full versions of the Child Stress Reaction Checklist, the Family Environment Scale, and the Parenting Stress Index. Condensed versions of these measures were used to create a Short-Form Psychosocial Questionnaire (SFPQ) that could be used as an indicator of child well-being and specific areas of child, parent, and family functioning in children aged 0 years to 18 years with burn injury. METHODS Parents of 830 children aged 0 years to 18 years with acute burn injury from the Shriners Hospitals for Children Multi-Center Benchmarking Study completed the LFPQ at baseline and follow-up visits up to 48 months at four major burn centers. The internal consistency reliability and variability of the LFPQ explained by the SFPQ for each of the measures were calculated. The construct validity of the SFPQ measures was determined by factor analysis. The magnitude of the change for the SFPQ measures during 48 months of follow-up was examined. RESULTS The internal consistency reliability of the short-form measures ranged from 0.62 to 0.90. The variability of the long-form measures explained by the short-form measures was 61% for the Child Stress Reaction Checklist (average of six long-form scales), 60% for the Family Environment Scale (conflict), and 90% for the Parenting Stress Index (average of 13 scales). Factor analysis supported the construct validity of the model for the short-form measures. The magnitude of change for the short-form measures showed clinical improvement for 48 months. CONCLUSION The SFPQ is both a reliable and valid assessment for evaluating the psychosocial functioning of children following burn injuries.