Home-based Treatment Research Articles

Knee osteoarthritis functional classification scheme – Validation of time dependent treatment effect. One year follow-up of 518 patients

Objective: The purpose of the current study was to validate time dependent changes of a novel functional classification for patients with knee osteoarthritis (KOA), following a home-based biomechanical treatment (HBBT).Methods: A retrospective analysis of 518 patients with KOA was conducted. All patients were classified using a novel knee osteoarthritis functional grade (KOFG) classification for KOA, based on spatio-temporal gait analysis. Patients were re-classified after 3 months and 1 year of HBBT to examine and validate this classification using timedependant changes. The time dependent changes in the classification were compared to gold-standard selfassessment questionnaires, WOMAC and short form 36 (SF-36).Results: The changes in KOFG were demonstrated over time, with most changes occurring after 3 months of treatment with consolidation of the effect at 12 months. For example, of 427 patients that were classified in KOFG 2-4 grade at baseline, 44.9% and 51.5% had lower (better) KOFG grades at 3 and 12 months of treatment, respectively. The changes in KOFG were validated with WOMAC and SF-36 questionnaires showing a significant correlation between KOFG changes and changes in WOMAC and SF-36. SF-36 pain sub-scale showed an improvement of 33.0% and 38.0% following 3 months and 12 months of treatment, respectively (p values <0.0001).Conclusions: The results of the current study validate the knee osteoarthritis functional grade classification scheme as a tool to assess time dependant changes in KOA as well as its sensitivity to assess treatment effect. The KOFG can offer a more robust mode of reporting clinical results in describing the natural history and time-dependent treatment results of patients suffering from knee OA and should be considered as an additional outcome measure in future studies.

False economies in home-based parenteral antibiotic treatment: a health-economic case study of management of lower-limb cellulitis in Australia.

The majority of healthcare costs accrued managing cellulitis can be attributed to the small proportion of patients treated with parenteral antibiotics. Hospital in the home (HITH) instead of or following initial inpatient treatment is a safe and effective alternative, but there are few data evaluating its cost-effectiveness for cellulitis. Our retrospective cohort study included all treatment episodes (by either HITH or an inpatient service for >24 h) with an ICD-10 primary diagnosis code of lower-leg cellulitis at a tertiary-level health service in Melbourne, Australia over 12 months (2012-13). Data included demography, social factors and ICD-10 codes mapped to major comorbidities constituting the Charlson comorbidity index (CCI). Differences in length of stay (LOS) and individual clinical costing (ICC) between HITH- and non-HITH-treated patients were tested with univariable and multivariable (generalized linear model) analyses. For 328 admissions in 294 patients, the average per-day costs were AU$431 for HITH and AU$761 for inpatient care. For 124 patients (38%) treated in HITH, both LOS [mean (95% CI) 7.48 days (6.76-8.20 days) versus 5.82 days (3.45-8.18 days)] and ICC [mean (95% CI) AU$5873 (AU$5212-AU$6534) versus AU$5196 (AU$4567- AU$5824)] were higher than those for patients with solely inpatient care. In multivariable analysis controlling for age, comorbidity, carer support and language, HITH remained associated with significantly longer LOS [1.63-fold (95% CI: 1.24- to 2.13-fold): P < 0.001] and non-significantly with higher cost [1.14-fold (95% CI: 0.97- to 1.34-fold): P = 0.11]. Management of cellulitis represents a substantial cost burden for hospital services. Modest per-day cost savings from HITH can be offset by much longer HITH LOS.

Cost-optimization in the treatment of multidrug resistant tuberculosis in Nigeria.

To compare the cost of facility-based MDR TB care (F) to home-based care (H) from the perspective of the Nigerian national health system. We assessed the expected costs of the two MDR TB treatment approaches using a decision-analytic model with a follow-up of 6 months. MDR TB treatment outcomes were obtained from a systematic review of randomised clinical trials. The outcomes of interest included treatment success, treatment failure, treatment default and mortality and did not vary significantly between the two alternatives. Treatment costs included the cost of the following: drug therapy (F, H), hospital stay (F), nurse care (F, H), physician care (F), nursing facility (F) and transport to the healthcare provider (H). Finally, we estimated the potential cost savings associated with home-based treatment for all patients starting MDR TB treatment in Nigeria. The average expected total treatment cost for a Nigerian patient treated for MDR TB was estimated at US2095 for facility - based care and 1535 for home-based care, a potential saving of 25%. One of the major drivers of this difference is significantly more intensive, and therefore more costly, nursing care in hospitals. In 2013, a total of 426 patients were initiated on facility-based MDR TB treatment in Nigeria. Thus, the potential savings through home-based care are US$ 223 204 per year. In Nigeria, treatment of MDR TB using home-based care is expected to result in similar patient outcomes at markedly reduced public health costs as facility-based care.

Early qualitative analysis to enhance trial processes

The LASER Trial is an RCT of the effectiveness of the use of a Temperature-controlled Laminar Airflow (TLA) device in adults with severe allergic asthma. The trial is funded by the NIHR-HTA. The trial aims to determine whether home-based nocturnal treatment with a TLA device can reduce the frequency of asthma exacerbations over a one year period. In order to inform decisions about implementation of the device should it be shown to be effective, participant's experience of using the TLA device is being assessed by means of qualitative interviews. We conducted telephone interviews with 10 trial participants in the first 4 months of the trial in order to determine participant's thoughts, values and opinions of trial processes and the treatment device. This early qualitative evaluation as part of the larger experimental study has provided us with an opportunity to address different questions (What is happening? How is it happening?) than otherwise would be possible with quantitative data collection alone. We have been able to provide feedback to develop and enhance subsequent trial processes including recruitment and retention of participants. Experience from conducting this early evaluation is that the qualitative interviews and subsequent analysis have provided a useful insight into the difficulties that patients have experienced and what is important to them. As a result we have a better understanding and this has resulted in an informed plan of how to address these learning points with actions to enhance the experience of taking part in the trial for future participants.

Consistency of outcomes of home-based family treatment in The Netherlands as an indicator of effectiveness

Most youth care interventions are not supported by evidence from experimental or quasi-experimental studies. Yet children and families have to be treated and financiers and policy makers are asking value for money. For these reasons, evidence from practice-based studies should not be overlooked. Particularly, strengthening the designs of these studies could yield useful indications of effectiveness. The present study shows how this can be done by analyzing consistency in group and individual outcomes over time and across locations. Pre- and post-measures of behavior problems were collected over nine consecutive years at three locations in The Netherlands from nearly 900 children whose families received Intensive Family Treatment (IFT), a home-based treatment for multi-problem families. Over the years, the overall effect size was 0.66 (range of 0.51–0.80). Further analysis showed that these effects were stable over time and across locations. The reliable change index showed that about 63% of the children improved significantly during treatment (range of 56–68%) and 9% deteriorated or relapsed (range of 6–13%). These changes were also stable over time and partially stable across locations. The consistency of these results serves as an empirical indication of the effectiveness of IFT. Due to the lack of studies using control groups, such consistency might help practitioners choose promising interventions that would support their clients and be accountable to financiers and policy makers.

Assisted Peritoneal Dialysis for Older People with End-Stage Renal Disease: The French and Danish Experience.

Older people are the largest and fastest growing group of patients with end-stage renal disease (ESRD), and, due to advanced age and a heavy burden of comorbidities, they are usually not candidates for renal transplantation or home-based dialysis treatment. Some of the barriers for home treatment are non-modifiable, but the majority of physical disabilities and psychosocial problems can be overcome provided that assistance is offered to the patients at home.In the present review, we describe the programs for assisted peritoneal dialysis (PD) in France and Denmark, respectively. In both nations, assisted PD is totally publicly funded, and the cost of assisted PD is comparable to the cost of in-center HD. Assisted continuous ambulatory PD (aCAPD) is the preferred modality in France whereas assisted automated PD (aAPD) is the preferred modality in Denmark. Assistants are professional nurses or healthcare technicians briefly educated by expert PD nurses from the dialysis unit.The establishment of a program for assisted PD may increase the number of patients actually treated with PD and may reduce the risk of PD technique failure and prolong PD duration. Compared with autonomous PD patients, patients on assisted PD may have shorter patient survival and peritonitis-free survival indicating that, besides advanced age and the burden of comorbidities, dependency on help may be an independent risk factor for poorer outcome.Assisted PD is an evolving dialysis modality, and may in the future prove to be a feasible complementary alternative to in-center hemodialysis (HD) for the growing group of dependent older patients with ESRD.

Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates.

BackgroundDespite healthcare policies and evidence which promote home dialysis, uptake rates have been falling for over 10 years in England. A target introduced by commissioners in the West Midlands provided a unique opportunity to study how hospitals can increase home-based treatment for a group of patients with complex life-threatening conditions.MethodsQuantitative changes in home treatment uptake rates in seven hospitals in the West Midlands were compared with the rest of England for 3 years pre and post the introduction of the target in 2010, using a logistic regression model. Qualitative interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients explored the barriers and facilitators to increasing the uptake of home treatment and the impact of the target.ResultsHome treatment uptake rates increased significantly in the seven study hospitals compared with the 3 years prior to the introduction of the target and compared with the rest of England where rates remained static. The four main factors facilitating increased uptake were as follows: the commissioner’s target, linked to financial penalties; additional funding for specialist staff and equipment; committed, visible clinical champions and good systems for patient training and ongoing healthcare support at home. The three main barriers were as follows: lack of training for non-specialist staff, poorly developed patient education and considerable unrecognised and unmet emotional and psychological patient needs.ConclusionsThis study shows the impact of using targets with financial penalties to achieve change and how hospitals can increase significantly the uptake of home-based self-care for a group of patients with complex medical needs. It provides useful pointers to the main barriers and facilitators, which are likely to be relevant to other groups of patients who could be treated at home. It also highlights two neglected areas which need to improve if patients with life-threatening long-term conditions are to be encouraged to take up home treatment: individualised patient education which allows exploration of the impacts of treatment options and the provision of ongoing emotional support.

Home-based neurologic music therapy for upper limb rehabilitation with stroke patients at community rehabilitation stage-a feasibility study protocol.

Background: Impairment of upper limb function following stroke is more common than lower limb impairment and is also more resistant to treatment. Several lab-based studies with stroke patients have produced statistically significant gains in upper limb function when using musical instrument playing and techniques where rhythm acts as an external time-keeper for the priming and timing of upper limb movements.Methods: For this feasibility study a small sample size of 14 participants (3–60 months post stroke) has been determined through clinical discussion between the researcher and study host in order to test for management, feasibility and effects, before planning a larger trial determined through power analysis. A cross-over design with five repeated measures will be used, whereby participants will be randomized into either a treatment (n = 7) or wait list control (n = 7) group. Intervention will take place twice weekly over 6 weeks. The ARAT and 9HPT will be used to measure for quantitative gains in arm function and finger dexterity, pre/post treatment interviews will serve to investigate treatment compliance and tolerance. A lab based EEG case comparison study will be undertaken to explore audio-motor coupling, brain connectivity and neural reorganization with this intervention, as evidenced in similar studies.Discussion: Before evaluating the effectiveness of a home-based intervention in a larger scale study, it is important to assess whether implementation of the trial methodology is feasible. This study investigates the feasibility, efficacy and patient experience of a music therapy treatment protocol comprising a chart of 12 different instrumental exercises and variations, which aims at promoting measurable changes in upper limb function in hemiparetic stroke patients. The study proposes to examine several new aspects including home-based treatment and dosage, and will provide data on recruitment, adherence and variability of outcomes.

Feedback mechanisms of change: How problem alerts reported by youth clients and their caregivers impact clinician-reported session content

Objective. This study explored how clinician-reported content addressed in treatment sessions was predicted by clinician feedback group and multi-informant cumulative problem alerts that appeared in computerized feedback reports for 299 clients aged 11–18 years receiving home-based community mental health treatment. Method. Measures included a clinician report of content addressed in sessions and additional measures of treatment progress and process (e.g., therapeutic alliance) completed by clinicians, clients, and their caregivers. Item responses in the top 25th percentile in severity from these measures appeared as “problem alerts” on corresponding computerized feedback reports. Clinicians randomized to the feedback group received feedback weekly while the control group did not. Analyses were conducted using the Cox proportional hazards regression for recurrent events. Results. For all content domains, the results of the survival analyses indicated a robust effect of the feedback group on addressing specific content in sessions, with feedback associated with shorter duration to first occurrence and increased likelihood of addressing or focusing on a topic compared to the non-feedback group. Conclusion. There appears to be an important relationship between feedback and cumulative problem alerts reported by multiple informants as they influence session content.

Plasma-derived C1-INH for managing hereditary angioedema in pediatric patients: A systematic review.

Presently, medications approved for children with Hereditary Angioedema (HAE) are extremely limited. This is especially the case for children under 12 years of age. For this reason we reviewed and summarized the data on treatment of children with HAE. Available data indicate that plasma derived C1-inhibitor is a safe, effective treatment option for HAE in pediatric patients, including those below 12 years of age. Other therapies are also appear safe for the under 12 year of age, but less data are available. Importantly, home-based treatment of HAE in this age group appears to be safe and effective and can improve quality of life. These findings support current HAE consensus guidelines which strongly recommend the use of plasma derived C1-inhibitor as a first-line treatment in children and encourage home and self-treatment.

Severe malaria in African children: Still a challenge

Malaria remains one of the leading causes of morbidity and mortality in children from sub-Saharan Africa. Mothers and caretakers should be able to recognize the symptoms of a sick child and, in areas without health workers at hand, even to suspect malaria and start early home-based treatment before seeking help at a health centre or a hospital, thereby hopefully decreasing the risk of the child developing severe malaria. As malaria is a febrile illness with highly nonspecific symptoms, the final diagnosis depends on the identification of parasites by microscopy or by tests identifying the parasite derived proteins like histidinerich protein 2 [1]. At the health centre level a microscopist might or might not be available. If a malaria film cannot be examined or parasitological test results are likely to be delayed, a presumptive clinical diagnosis has to be made for which several algorithms have been suggested [2,3]. It is important not to miss a case of severe or complicated malaria as the consequence may be fatal, and antimalarial treatment should be started based on the clinical diagnosis. Furthermore, false negative test results might occur due to poorly prepared or poorly stained malaria films or due to poor quality microscopes or inexperienced technicians. There-

A Child Develops Drop Foot after Spinal Anaesthesia.

To the Editor, Spinal anesthesia has been used with children since 1909 (1). In 1950, a study reported that a cooperative child is likely to be a good subject for spinal anesthesia in cases where premedication may be inadequate (2). A nine-year-old girl weighing 20 kgs and with a height of 126 cm was diagnosed with acute appendicitis. An emergency operation was planned. Her medical history was normal except for a productive cough and runny nose over the previous three days. In the preoperative physical examination, rales in the lungs, extensive tenderness and distension in the abdomen were found. Thirty minutes before the operation, midazolam 0.05 mg/kg was given for premedication. A non-traumatic lumbar puncture was performed using a 26 G (Atraucan, 50 mm Braun Melsungen AG, Germany) pediatric spinal needle in the sitting position. At first at-tempt a clear cerebrospinal fluid flowed out, then 0.2 mg/kg of heavy bupivacaine was applied into the subarachnoid space between the third and fourth lumbar vertebrae. Sensorial block dermatome was checked using a pinprick test. When the level reached T8, the operation was started. The patient was hemodynamically stable during the operation and was in the recovery room for 30 minutes. In the sixth postoperative hour, she developed weakness in her left ankle, with muscle strength loss in the dorsiflexion (1/5), eversion (1/5), plantar flexion (3/5), toe dorsiflexion (1/5), and plantar flexion (3/5). Accompanying sensory deficit in the dorsum and anterolateral tibial part of the left leg (L5 and S1 dermatomes) was observed. Lumbar magnetic resonance imaging and computed tomography revealed normal findings. Postoperative 1st and 20th day electromyography showed no pathologic findings. A course of 25 mg/kg ga bapentin three times a day and vitamin B complex twice a day were prescribed. Physical therapy, including passive stretching, range of motion, balance, and strengthening exercises were performed. For the left anterior tibialmuscle, electrical stimulation was applied daily for 15 minutes. In neurological examination, improvement in muscle deficit was observed. Muscle strength was 4/5 in all of the muscles involved. Discharged with a home-based treatment program, she was able to walk without support on the 70th day. Although publications about complications of spinal anesthesia in children exist (3), there are few reports indicating safe and effective usage of spinal anesthesia (4,5). Transient neurological damage usually develops without pain or paresthesia during the lumbar puncture, as in our case. In differential diagnosis of neurological damage after spinal anesthesia, possible diagnosis of epidural hematoma, epidural abscess, anterior spinal artery syndrome, adhesivear-achnoiditis, caudaequina syndrome should be excluded. We excluded all these diagnoses with the help of a physical examination and MRI. Since the patient was in a supine position and had no history of any intramuscular injection, neurologic damage due to malpositioning or intramuscular injection were also excluded. In case of complications, a multidisciplinary approach is necessary for prompt and correct diagnosis, as well as to initiate the most appropriate mode of therapy for optimal results in the shortest time.

Home-Based Feeding Tube Weaning

Introduction. Over the past 2 decades a dramatic increase of pediatric feeding via tube has been reported, which has resulted in a higher prevalence of feeding tube dependency (FTD). Several treatment programs for FTD have been established over the past 2 decades, but only a few with detailed outlines and definitions of terms have been published. This article will outline the home-based tube weaning program as well review existing evidence. Program Outline. The home-based treatment program is a new treatment modality that allows children to stay in a home environment during treatment. The underlying condition as well as the treatment in its 5 phases have been outlined: assessment, preparation, hunger induction, intensive treatment, and follow-up. Treatment Outcome. Three articles regarding the treatment outcomes of home-based FTD treatment were reviewed. The results of this review show that the success rate of the treatment program has been consistently 90% of the involved cases, with major improvements in eating behavior and without deceleration of growth. Conclusion. The home-based treatment program is a safe and promising new modality for FTD.

Socio-Demographic and Adherence Factors Associated with Viral Load Suppression in HIV-Infected Adults Initiating Therapy in Northern Nigeria: A Randomized Controlled Trial of a Peer Support Intervention

Virological suppression is the main goal of antiretroviral therapy. To achieve this goal, efficient interventions that promote treatment adherence are needed. This study was aimed at exploring the impact of peer-education on virological outcomes in Northern Nigeria. A randomized controlled trial (RCT) among patients receiving antiretroviral treatment was conducted in 2 phases between August 2006 and January 2008 in the "largely Muslim" Northern Nigeria. Participants were randomized into one of three intervention arms: standard of care arm, a second arm which included daily reminders via alarm and follow-up calls from peer-educators, and adherence support by a home-based treatment partner; and a third arm which included second arm activities, plus home visits by peer-educators. We evaluated sociodemographic factors and adherence levels, measured using self-report and pharmacy (Rx) refill rates, as risk factors for viral load (VL) suppression. Of the 600 participants (43% males), 276 were observed till the end of the study. There were no significant differences in mean log 10 VL between the intervention groups. At the end of entire follow-up period, 83% (229/276) who were not lost to follow-up achieved undetectable VL (< 400 copies/ml). In the multivariable analysis, age between 30-34 years (vs 18-24 years) and both baseline CD4 ranges between 100-199 cells/mm(3) or 200-349 cells/mm(3) (vs CD4 <100 cells/mm(3)) as positively associated with VL suppression while poor self-reported adherence and <95% Rx refill rates were negatively associated with VL suppression. High levels of viral suppression and low prevalence of drug resistance mutations (DRMs) were seen in this cohort participating in an ART adherence study in Northern Nigeria. Self-reported good adherence and optimal Rx refill rates were reported as significant predictors of VL suppression. Our findings indicate that ART adherence will improve significantly regardless of whether HIV-infected adults received peer-education-based medication adherence interventions or standard of care services.

Patients with chronic non-specific low back pain who reported reduction in pain and improvement in function also demonstrated an improvement in gait pattern.

To assess the changes in gait pattern and clinical symptoms of patients with chronic non-specific low back pain (CNSLBP) following a home-based biomechanical treatment (HBBT). This was a retrospective analysis of 60 CNSLBP patients. All patients underwent a gait evaluation and completed self-assessment questionnaires at pre-treatment and after 3 and 6months of a HBBT (AposTherapy). Twenty-four healthy, aged-matched individuals served as a reference group. Significant differences were found in all gait parameters and clinical symptoms between patients with CNSLBP and healthy people before treatment. Significant improvements were found in all gait parameters and clinical measures following 6months of therapy including an increase in gait velocity (10.6%), step length (5.6%), cadence (5%), and quality of life and a decrease in pain (13.3%). There were no significant differences between groups in the gait parameters following 6months of treatment. Significant differences exist between patients with CNSLBP and healthy controls in terms of gait pattern and self-assessed health status. The examined HBBT led to significant improvements in gait pattern, reduction in pain, improved function and increased quality of life. However, future studies should validate these results while comparing this treatment to other treatment modalities.

Evaluation of a home-based transcranial direct current stimulation (tDCS) treatment device for chronic pain: study protocol for a randomised controlled trial.

BackgroundStimulation of the primary motor cortex (M1) has been shown to reduce the pain of neuropathy in multiple studies. There are several methods of stimulation both invasive and non-invasive. Recent work by this laboratory has seen that 40% of a sample of chronic neuropathic pain patients responded positively to non-invasive repetitive transcranial magnetic stimulation (rTMS) to the motor cortex with a reduction in pain levels by at least 20%. The effect however is short lived and multiple return visits are necessary to maintain this response. Transcranial direct current stimulation (tDCS) offers a more mobile method of motor cortex stimulation and is similarly non-invasive. The protocol described is designed to assess the analgesic effect of a home-based tDCS treatment device on chronic neuropathic pain in both responders and non-responders to previous TMS treatment.Methods/designThis article reports the protocol for a randomised, sham-controlled, double-blinded crossover study in which patients with chronic neuropathic pain (n = 24) will receive anodal, cathodal and sham tDCS over M1. All patients will have previously completed a study of rTMS of the motor cortex and have been designated as responders or non-responders to this modality.Patients receive all three tDCS stimulation types by self-administration. We assess the effect on pain scores [numerical rating scale (NRS)], self reported health status (Short Form-36 Health Survey) and anxiety/depression (Hospital Anxiety and Depression Scale). A linear mixed model with fixed effects will analyse changes in pain scores from pre- to post- interventions. Analysis will be carried out on an intention-to-treat basis. A proportion analysis will also be carried out with patients separated into either responders or non-responders to previous TMS.Safety will be assessed throughout the study by monitoring of adverse events.DiscussionThe result of this trial will assess the efficacy of self-administered tDCS of the motor cortex in the treatment of chronic neuropathic pain and also provide insight into whether a potential differential effect is seen in patients that have previously been shown to be either responsive or non-responsive to rTMS over the same area.Trial registrationISRCTN56839387 date 27 January 2014. First patient randomised to trial 30 October 2012.

Innovative healthcare strategies in geriatric psychiatry and psychotherapy

The development of efficacious treatment strategies in older adults with mental illnesses is necessary. The growing number of homebound patients and the incidence of physical comorbidities and impairment of activities of daily living are important factors for interdisciplinary treatment strategies in old age and there is a need for home-based services providing medical and psychosocial interventions. Recent studies have provided information on home-based and collaborative treatment strategies in mentally ill elderly patients. This article provides an overview on selected randomized controlled trials (RCT) conducted with mentally ill older adults. Studies have shown promising effects when applying stepped care interventions, collaborative care and assertive community treatment in old patients suffering from mental diseases when compared to usual care. Long-standing home-based mental health programs have been designed and successfully implemented showing improved identification, treatment and ongoing care of mental health problems. In-home tele-psychotherapy has been shown to be efficacious in homebound older adults with limited access to evidence-based psychotherapy and showed a sustained effect in one study. Collaborative care models, stepped care interventions in primary care settings and an enhanced inter-professional approach to patient care in old age psychiatry is necessary to improve detection, treatment and ongoing care. Tele-mental health services may become important parts of the provision of mental health services and the effectiveness revealed for in-home tele-health problem solving therapy in old age depression may be an approach to make psychotherapy available to a large number of underserved elderly patients with mental illness.

Influencing the Home Food and Activity Environment of Families of Preschool Children Receiving Home-Based Treatment for Obesity.

The prevalence of overweight and obesity remains notably higher for Hispanic preschool children (16.7%) compared with African Americans (11.3%), Asians (3.4%), and non-Hispanic White children (3.5%).1 While socioeconomic status may partially explain some of the risk for obesity between racial and ethnic groups, other behavioral and environmental modifiable factors require further study.2 The home physical environment has recently been identified as a potential target for not only intervention (eg, changing the availability of home foods) but also as a setting for the delivery of clinical intervention.3,4 To date, few treatment studies have been developed and tested to directly improve the home food environment of preschoolers with obesity and its associations with weight outcome. An exception has been the LAUNCH program (Learning about Activity and Understanding Nutrition for Child Health), which was based on behavioral family-based programs for school-aged children and adapted for families of preschoolers.4–6 The LAUNCH program was delivered over 18 sessions that alternated between clinic and home visitations. Feasibility and pilot study results showed promising improvements in weight outcomes for preschoolers with obesity4,6 and comparison of clinic only visits versus clinic plus home visits showed support for the inclusion of home visitations when treating preschool obesity.5 In particular, significant changes in the home food environment were shown for the clinic plus home visit group, including fewer high-calorie foods and more fruits and vegetables at the end of treatment [5]. However, the LAUNCH studies primarily included white families from middle to upper income levels and it remains relatively unknown how families of preschoolers from diverse backgrounds may construct their home food and activity environment and modify them during the course of a home-based obesity intervention. The goal of this study was to characterize the home food and activity environments of overweight and obese preschool-aged children from low socioeconomic status Latino families. Additionally, differences in available key foods and activity devices at the beginning of treatment were compared with end of treatment changes to assess program impact on the home health environment. Characterization of the home food and activity environment for treatment seeking families was considered exploratory. Based on prior studies, participants who completed the program were hypothesized to show increased availability of fruits and vegetables at posttreatment compared with baseline.3,4 In addition, preschool participants who showed a decreased body mass index (BMI) trajectory at posttreatment compared with baseline were hypothesized to have a higher availability of fruits and vegetables and devices that promote physical activity compared with participants who showed smaller change or no change in zBMI.4–6

Sequential Multiple Assignment Randomized Trial (SMART) to Construct Weight Loss Interventions for African American Adolescents

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12–16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Health Seeking Behavior of Caregivers Whose Children (6–60 Months) Presented With Severe Malaria in a Tertiary Health Institution in Nigeria

Early recognition of symptoms of malaria and commencing appropriate home-based treatment or seeking prompt treatment in a health facility are malaria control strategies recommended under the Roll Back Malaria initiative. This initiative aims at reducing malaria morbidity and prevention of mortality in children aged <5 years. The success of this strategic plan for malaria control depends on the health-seeking behavior of caregivers of these children. The goal of …