Need For Multidisciplinary Interventions Research Articles

The quality of life among women with breast cancer: a qualitative study in the environment of healthcare in Morocco

ABSTRACT Breast cancer is a real Moroccan public health problem, deeply affecting the quality of life of patients. This qualitative study aimed to explore the quality of life among breast cancer patients in Morocco. Twenty-three patients were interviewed during November-December 2023. The data was analysed using Interpretative Phenomenological Analysis. The results showed that patients confirmed the feeling of great depression and anxiety after the announcement of the diagnosis. Side effects of treatment are the most difficult challenge for patients. Married participants reported alteration of sex life and salaried patients abandon their professions. Yet, the patients maintained good self-esteem. These results indicate the need for multidisciplinary interventions to maintain a good quality of life in breast cancer patients.

Prevalence of potentially inappropriate medications and prescription dynamics in elderly hospitalized patients in Spain

PurposeIn recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75.Patients and methodsThis was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria.ResultsA total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed.ConclusionIn this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge.These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.

Implementation of a geriatric oncology service at the Royal Marsden Hospital

IntroductionDespite significant evidence supporting the benefits of comprehensive oncogeriatric assessment in the management of older patients with cancer, the adoption of specialised geriatric oncology programs in the United Kingdom remains limited. Descriptions of clinic structure and models, patient demographics and baseline characteristics, resource utilisation, and predictors of resource utilisation are lacking in this population, which may complicate or impede the planning, resourcing, and development of further services in this subspecialty on a national and regional basis. Materials and MethodsBetween November 2021 and April 2023, 244 patients commencing systemic anticancer treatment at the Royal Marsden Hospital, London underwent geriatric screening using the Senior Adult Oncology Programme-3 (SAOP3) screening tool. Baseline clinical factors (sex, age, Charlson Comorbidity Index score, Cumulative Illness Rating Scale-Geriatric [CIRS-G] score, Katz Index score, Barthel Index score, treatment intent, and Eastern Cooperative Oncology Group Performance Status [ECOG-PS]) were assessed as predictors of geriatric impairments and need for multidisciplinary referral and intervention using a negative binomial regression analysis. Referral rates to multidisciplinary teams were assessed against ECOG-PS score using point-biserial correlation, as well as against a historical control using descriptive statistics. ResultsThe median age of participants was 77; 75.8% were female. Breast cancer was the most prevalent diagnosis (61.9%). Most patients (67.6%) were undergoing treatment in the palliative setting. Two hundred eleven (86.5%) patients were identified as having at least one geriatric impairment. Six hundred forty-nine multidisciplinary referrals were made, of which 583 (86.7%) were accepted by the referred patient. Higher ECOG PS was positively associated with geriatric impairments in physiotherapy, occupational therapy, dietetics, pharmacy, and welfare rights domains, as well as with the overall number of geriatric impairments. DiscussionThe Royal Marsden Senior Adult Oncology Programme represents the first geriatric oncology service in a tertiary cancer centre in the United Kingdom. Following implementation of SAOP3 screening, we observed a substantial increase in referrals to all multidisciplinary teams, suggestive of previously underrecognized needs among this population. The need for multidisciplinary intervention was strongly correlated with baseline ECOG-PS score, but not with other measured clinical variables, including comorbidity or functional indices.

Pesticide Application in Trinidadian Food Supply Chain: Food Safety and Sustainability Implications

The use of pesticides, although ensures crop protection and enables to achieve food security, often causes negative externalities for both human and the environment. This study sought to identify the factors that influence pesticide application in Trinidad, a major CARICOM nation, by conducting structured interviews with 174 farmers in eight municipal counties. The data were analysed using Ordered Probit Model. While gender and age showed no significant impact on pesticide use frequency, farm size and experience influenced application behaviours. Larger farms and experienced farmers displayed distinct patterns, calling for customized interventions. Notably, secondary and collegiate education was linked to reduced pesticide use, aligning with sustainability goals. Crop-specific trends were seen with an increase in the use of pesticides in the Solanaceae crop and leafy vegetables, underscoring the need for tailored approaches. Insect and weed issues had a limited impact, however, management of crop diseases was essential in reducing pesticide use. This study emphasizes the need for multi-disciplinary interventions that take into account the size of the farm, the level of experience, the level of education, and the types of crops grown in Trinidad, to promote the sustainable use of pesticides in agriculture. Such comprehensive strategies are essential for enhancing food safety and long-term sustainability of the Trinidad food supply chain, while also mitigating the negative externalities of pesticide application.

The moderating effect of mental health and health insurance ownership on the relationships between physical multimorbidity and healthcare utilisation and catastrophic health expenditure in India

BackgroundThe current demographic transition has resulted in the growth of the older population in India, a population group which has a higher chance of being affected by multimorbidity and its subsequent healthcare and economic consequences. However, little attention has been paid to the dual effect of mental health conditions and physical multimorbidity in India. The present study, therefore, aimed to analyse the moderating effects of mental health and health insurance ownership in the association between physical multimorbidity and healthcare utilisation and catastrophic health expenditure (CHE).MethodsWe analysed the Longitudinal Aging Study in India, wave 1 (2017–2018). We determined physical multimorbidity by assessing the number of physical conditions. We built multivariable logistic regression models to determine the moderating effect of mental health and health insurance ownership in the association between the number of physical conditions and healthcare utilisation and CHE. Wald tests were used to evaluate if the estimated effects differ across groups defined by the moderating variables.ResultsOverall, around one-quarter of adults aged 45 and above had physical multimorbidity, one-third had a mental health condition and 20.5% owned health insurance. Irrespective of having a mental condition and health insurance, physical multimorbidity was associated with increased utilisation of healthcare and CHE. Having an additional mental condition strengthened the adverse effect of physical multimorbidity on increased inpatient service use and experience of CHE. Having health insurance, on the other hand, attenuated the effect of experiencing CHE, indicating a protective effect.ConclusionsThe coexistence of mental health conditions in people with physical multimorbidity increases the demands of healthcare service utilisation and can lead to CHE. The findings point to the need for multidisciplinary interventions for individuals with physical multimorbidity, ensuring their mental health needs are also addressed. Our results urge enhancing health insurance schemes for individuals with mental and physical multimorbidity.

An Exploration of Occupational Therapy Practices with Children and Adolescents Experiencing Complex Trauma: An Irish Perspective

Complex trauma has considerable impact on children and frequently results in the need for multidisciplinary intervention including occupational therapy. This study aimed to explore occupational therapy practice with children experiencing complex trauma in Ireland. Sixty occupational therapists participated in an anonymous online survey. School-based activities and sensory processing were identified as most frequently addressed in occupational therapy. Sensory-based therapy and parent-coaching are the most frequently used interventions in practice. There is an identified need for further trauma-specific training and resources to advance occupational therapy practice with this population. The results from this study are limited to therapists practicing in Ireland.

Racial and ethnic differences in colon cancer surgery type performed and delayed treatment among people 45 years old and older in the USA between 2007 and 2017: Mediating effect on survival

BackgroundThis study examined the associations of socioeconomic status (SES), race/ethnicity, surgery type, and treatment delays with mortality among colon cancer patients. In addition, the study also quantifies the extent to which clinical and SES factors’ variations explain the racial/ethnic differences in overall survival. Patients and methodsWe studied 111,789 adult patients ≥45 years old who were diagnosed with colon cancer between 2010 and 2017, identified from the Surveillance, Epidemiology, and End Results (SEER) database. We performed logistic regression models to examine the association of SES and race/ethnicity with surgery type and first course of treatment delays. We also performed mediation analysis to quantify the extent to which treatment, sociodemographic and clinicopathologic factors mediated racial/ethnic differences in survival. ResultsNon-Hispanic (NH) Blacks [adjusted Odds Ratio (aOR) = 1.19, 95% CI:1.13–1.25] were significantly more likely to undergo subtotal colectomy and to experience treatment delays [aOR = 1.39, 95% CI: 1.31–1.48] compared to NH Whites. Hispanics [aOR = 1.59, 95% CI: 1.49–1.69] were more likely to experience treatment delays than NH Whites. Delayed first course of treatment explained 23.56% and 56.73% of the lower survival among NH Blacks and Hispanics, respectively, compared to their NH White counterparts. ConclusionsRace/ethnicity is significantly associated with the surgery type performed and the first course of treatment delays. Variations in treatment, SES, and clinicopathological factors significantly explained racial disparities in overall mortality. These disparities highlight the need for multidisciplinary interventions to address the treatment and social factors perpetuating racial disparities in colon cancer mortality.

PSUN316 Racial Disparities in Diabetes Control and Use of Technology in a High Risk Cohort of Youth with Diabetes

Abstract Background Racial and ethnic minority children experience significant disparities in achieving the American Diabetes Association-recommended hemoglobin A1c (HbA1c) levels when compared to non-Hispanic Whites (NHW). Continuous glucose monitoring (CGM) and insulin pump (IP) use are associated with improved glycemic control. Racial and ethnic disparities exist in the use of these technologies in youth with Type 1 diabetes (T1D), which may contribute to the observed poor glycemic outcomes in this population. However, racial and ethnic differences in CGM and IP use have not been examined in children and adolescents with diabetes. Objective We describe the differences in glycemic control, CGM and IP use in an ethnically diverse cohort of children and adolescents seen in a multidisciplinary diabetes clinic designed to provide support (i.e., diabetes education, psychology, social work, nutrition) to youth with poorly controlled diabetes. Methods Demographic data, HbA1c levels, CGM and IP use were collected from a cohort of high-risk youth with T1D and T2D attending a multidisciplinary diabetes clinic from January to December of 2021. Results A total of 125 children and adolescents (age: 4-20 years) diagnosed with diabetes were included. Twenty (16%) were African Americans (AA), 81 (65%) Hispanic (H), 23 (15%) non-Hispanic White (NHW), and 1 (0.8%) Asian (A). The mean HbA1c in the cohort was 9.07%. HbA1c in AA patients was 12.9% (SD + 3.11), in Hispanics 8.64% (SD + 2.28), and 9.00% (SD + 1.84) in NHW. Seventy percent of AA patients had an A1c> 9%, compared to 36% of Hispanics and 48% of NHW. Use of CGM and IP was 40% and 10% in AA, 79% and 36% in Hispanics, and 82% and 57% in NHW, respectively. Conclusions Our study describes recent data on glycemic control and use of diabetes technology among a racially diverse cohort of children and adolescents seen in a multidisciplinary diabetes clinic. Consistent with literature on adults, HbA1c was highest and CGM and IP use were lowest in AA as compared to H and NHW youth. Data was collected during the COVID-19 pandemic, which may have disproportionately impacted AA patients’ economic, social, and personal behaviors that may contribute to diabetes care. These data support the need for multidisciplinary interventions using systems-based and culturally tailored approaches to improve access and use of technology for diabetes management. The current multidisciplinary diabetes clinic is designed to identify high-risk factors and reduce barriers to optimal management of diabetes. Future research will focus on the impact of multidisciplinary intervention on diabetes control through the use of technology, especially for African Americans. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Mealtime challenges and food selectivity in children with autism spectrum disorder in South Africa

Background: Children with autism spectrum disorder (ASD) have a number of associated feeding difficulties and problematic mealtime behaviours. These problems can have a negative impact on the child’s nutritional intake and little is known about the food preferences and characteristics of food choices. In addition, these difficulties can be exacerbated for children and caregivers living in low- and middle-income countries such as South Africa due to limited access to food, resources and health care. Objectives: The purpose of this study was to determine (1) types of feeding difficulties prevalent in children with ASD, (2) food items that children in South Africa prefer, (3) the relationship between age and ASD severity on food preferences. Method: A cross-sectional quantitative research design was employed using an online questionnaire. There was a total of 40 respondents from different provinces in South Africa. The data were analysed using descriptive statistics as well as multiple linear correlation analysis. Results: The study has identified common feeding difficulties in children with ASD and those being diagnosed as picky eaters in South Africa and compared them with difficulties that were found in the international literature. The study also highlighted the food groups that were preferred by children with ASD, showing a preference for starches and snack items compared with fruits and vegetables. In addition, there were significant correlations between ASD severity and ASD age on food preferences, suggesting that both age and severity may be predictors of food choices made by children with ASD, and highlighted a need for multidisciplinary intervention. Conclusions: This study adds to the existing literature on feeding difficulties in children with ASD but provides additional insights into children living in low- and middle-income countries and can be used to improve appropriate and responsive interventions. This study provides evidence that supports the influence of context and family environment regarding feeding in children with ASD.

The management of displaced femoral neck fractures: a narrative review.

This article serves to review the existing clinical guidelines, and highlight the most recent medical and surgical recommendations, for the management of displaced femoral neck fractures (FNFs). It stresses the need for multi-disciplinary intervention to potentially improve mortality rates, limit adverse events and prevent further economic liability.Globally, the incidence of FNFs continues to rise as the general population ages and becomes more active. The annual number of FNFs is expected to exceed six million by 2050. The increased burden of FNFs exacerbates the demand on all services associated with treating these injuries.The management of FNFs may serve as an indicator of the quality of care of the geriatric population. However, despite escalating health costs, a significant 30-day and one-year mortality rate, increased rate of peri-operative adverse events and sub-optimal functional clinical outcomes, continued controversy exists over optimal patient care.Much debate exists over the type of surgery, implant selection and peri-operative clinical care and rehabilitation. FNF care models, systematized clinical pathways, formal geriatrics consultation and specialized wards within an established interdisciplinary care framework may improve outcomes, mitigate adverse events and limit unnecessary costs.Cite this article: EFORT Open Rev 2021;6:139-144. DOI: 10.1302/2058-5241.6.200036

High prevalence of malnutrition in Internal Medicine wards – a multicentre ANUMEDI study

BackgroundDisease-related malnutrition is a significant problem in hospitalized patients, with high prevalence rates depending on the studied population. Internal Medicine wards are the backbone of the hospital setting. However, prevalence and determinants of malnutrition in these patients remain unclear. We aimed to determine the prevalence of malnutrition in Internal Medicine wards and to identify and characterize malnourished patients. MethodsA cross-sectional observational multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Demographics, hospital admissions during the previous year, type of admission, primary diagnosis, Charlson comorbidity index, and education level were registered. Malnutrition at admission was assessed using Patient-Generated Subjective Global Assessment (PG-SGA). Demographic characteristics were compared between well-nourished and malnourished patients. Logistic regression analysis was used to identify determinants of malnutrition. Results729 participants were included (mean age 74 years, 51% male). Main reason for admission was respiratory disease (32%). Mean Charlson comorbidity index was 5.8 ± 2.8. Prevalence of malnutrition was 73% (56% moderate/suspected malnutrition and 17% severe malnutrition), and 54% had a critical need for multidisciplinary intervention (PG-SGA score ≥9). No education (odds ratio [OR] 1.88, 95% confidence interval [CI]: 1.16–3.04), hospital admissions during previous year (OR 1.53, 95%CI: 1.05–2.26), and multiple comorbidities (OR 1.22, 95%CI: 1.14–1.32) significantly increased the odds of being malnourished. ConclusionsPrevalence of malnutrition in the Internal Medicine population is very high, with the majority of patients having critical need for multidisciplinary intervention. Low education level, admissions during previous year, and multiple comorbidities increase the odds of being malnourished.

Financial hardship among individuals with serious mental illness

This study explored financial hardship, defined as difficulty in obtaining food, shelter, or medicine in the past 12 months and its personal and clinical correlates in individuals with serious mental illness (SMI) in a sample of 271 adults with SMI newly admitted to two inner city community mental health centers. The study found that 59 percent (n = 161) reported experiencing financial hardship in the past 12 months. Patients with financial hardship were more likely to be female, to experience self-stigma, to experience medical care delays, and to use emergency services. Patients who experienced financial hardship typically had more severe psychiatric symptoms, including depressive symptoms, emotional lability, and interpersonal problems. Financial hardship persisted in nearly half of those with hardship interviewed a year later. The findings highlight the role of multiple social and economic challenges that the SMI patients face in recovery from serious mental illness and the importance of awareness of such challenges by providers treating this population. Though mental health treatment may help alleviate the psychiatric symptoms it alone is not sufficient in addressing persistent hardship. These findings highlight the need for multidisciplinary interventions in order to better serve this vulnerable population.

Tobacco use among adolescents in Qatar: Findings from Global Youth Tobacco Surveys 2004-2013.

INTRODUCTIONTobacco use has become a global health concern. Almost a third of the adolescents of the Eastern Mediterranean Region (EMR) have reported tobacco use and the percentage is expected to rise in the future, making tobacco consumption a main public health issue among students, 13–15 years old, in the region’s countries. We aimed to conduct an analysis of the previous Global Youth Tobacco Surveys (GYTS) in Qatar to detect any significant changes that might inform decision makers on planning policies and interventions accordingly.METHODSThis study presents a retrospective data analysis, based on three GYTS conducted in Qatar during 2004, 2007, and 2013. All analyses were weighted to account for the complex survey design and for differential non-response at school, class and student levels, with the exception of the analysis of sociodemographic characteristics. The differences between the proportions were tested by Pearson’s chi-squared test. Data were analyzed using the statistical software SPSS (Statistical Package for Social Sciences), version 21.0 (Chicago, IL). A p-value <0.05 was considered to be significant.RESULTSThere was an overall increase in the prevalence of smoking, the accessibility, and the availability of cigarettes. Additionally, the percentage of participants who desired to stop smoking decreased between 2004 and 2013, while that of students who reported ‘exposure to free tobacco promotion’ was highest in 2013.CONCLUSIONSDespite the effort made by the local authorities in Qatar to reverse the spread or limit the growing tobacco epidemic, there is a need for multidisciplinary interventions through tobacco prevention and control programs targeting youths.

Pregnancy and Childbirth Experiences of Women with Epilepsy: A Phenomenological Approach

PurposeThis study sought to understand and describe the pregnancy and childbirth experiences of women with epilepsy (WWE). MethodsData were collected from 2016–2017 through in-depth individual interviews with 12 WWE who experienced childbirth within 36 months. Verbatim transcripts were analyzed following Colaizzi’s phenomenological analysis to uncover the meaning of the experiences of the participants. ResultsThe pregnancy and childbirth experiences of WWE were clustered into four theme clusters and 8 themes from 20 meaning units: 1) Feeling anxious due to unplanned pregnancy and unexpected changes; 2) Standing at crossroads that never guarantee satisfaction; 3) Carrying a burden of fearful expectation and daily routines; 4) Enjoying rewards of pregnancy and childbirth as a woman with epilepsy. ConclusionWWE had strong anxiety about the possible abnormality of their babies during pregnancy. They had mixed feelings about delivery and had to make a tough decision about breastfeeding because of antiepileptic drugs use. After childbirth, they had increased fear about the possible inheritance of the illness and had a hard time managing the burden of childcare and seizure control. However, pregnancy allows these women to gain disease awareness and further appreciate the importance of their health. The study results indicate the need for multidisciplinary intervention for WWE, before, during, and after pregnancy to increase communication with health professionals. Especially, preconception counselling and education led by nurses are required.

The Correlation of the Tinnitus Handicap Inventory with Depression and Anxiety in Veterans with Tinnitus.

Objective. The mechanisms of tinnitus are known to alter neuronal circuits in the brainstem and cortex, which are common to several comorbid conditions. This study examines the relationship between tinnitus and anxiety/depression. Subjects and Methods. Ninety-one male veterans with subjective tinnitus were enrolled in a Veterans Affairs Tinnitus Clinic. The Tinnitus Handicap Inventory (THI) was used to assess tinnitus severity. ICD-9 codes for anxiety/depression were used to determine their prevalence. Pure tone averages (PTA) were used to assess hearing status. Results. Descriptive analyses revealed that 79.1% of the 91 tinnitus sufferers had a diagnosis of anxiety, 59.3% had depression, and 58.2% suffered from both anxiety/depression. Patients with anxiety had elevated total THI scores as compared to patients without anxiety (p < 0.05). Patients with anxiety or depression had significantly increased Functional and Emotional THI scores, but not Catastrophic THI score. Significant positive correlations were illustrated between the degree of tinnitus and anxiety/depression (p < 0.05). There were no differences in PTA among groups. Conclusions. A majority of patients with tinnitus exhibited anxiety and depression. These patients suffered more severe tinnitus than did patients without anxiety and depression. The data support the need for multidisciplinary intervention of veterans with tinnitus.

Manutenção do aleitamento materno de recém-nascidos pré-termo: revisão integrativa da literatur

This integrative review was performed with the objective to evaluate the available evidence regarding the factors associated with maintaining the breastfeeding of preterm newborns. The search was performed on the MEDLINE and LILACS databases using the descriptors “breast feeding” and “infant, premature”. The sample included twenty studies with an evidence level of 2 and 4, which pointed out facilitating and hindering aspects associated with maintaining breastfeeding. There is a need for multidisciplinary interventions in the health follow-up program, including educational strategies that promote mother-baby attachment and family welcoming. Special care should be given to the social, economical and cultural conditions of the family, as well as the clinical demands of the preterm newborns to maintain breastfeeding. Descriptors: Breast Feeding; Nursing; Infant, Premature; Weaning.

Limits on quality of life in communication after total laryngectomy.

Summary Introduction: Among people affected by cancer, the impairment of quality of life of people affected by cancer can cause have devastating effects. The self-image of patients after post-laryngectomyzed patients may be find themselves compromised, affecting the quality of life in this population. Objective: To characterize quality of life in related to communication in people who have undergone went total laryngectomy surgery. Methods: This is an observational study, with a cross-sectional and descriptive series. Design of series study. The sample were comprised 15 patients interviewed the period from January to February of 2011. We used the Quality Protocol for Life Communication in Post-laryngectomy adapted from Bertocello (2004); which this questionnaire contains 55 questions. The protocol was organized from the nature of using responses classified as positive and negative aspects, proposals in with respect to five 5 communication domains: family relationships, social relationships, personal analysis; morphofunctional aspect, and use of writing. To promote and guarantee the autonomy of the respondents, was examiners made use of used assistive technology with the Visual Response Scale. Results: The responses that total laryngectomy compromises the quality of life in communication amounted to 463 occurrences (65.7%), and that who responses suggesting good quality of life were represented with amounted to 242 occurrences (34.3%), from a total of 705 occurrencesresponses. From Among the five 5 Communication domains, four 4 had percentages of above 63% for occurrences of negative content for impact on communication. Appearance Morphofunctional appearance gave the had the highest percentage of negative content, amounting to 77.3% of cases. Conclusions: The results showed important limitations of a personal and social nature due to poor communication with their peers. Thus, there is a need for multidisciplinary interventions that aim to minimize the entrapment of negative impact on these people communication among these patients.

Predictors of health status in women with fibromyalgia: A prospective study

Although cross-sectional studies have identified correlates of dysfunction in fibromyalgia (FM) patients (e.g., psychological distress and pain), predictors of health status have not been previously investigated using a longitudinal research design. We gathered data from 156 women who met American College of Rheumatology criteria for primary FM recruited from both tertiary care and community settings. Stepwise multiple linear regression analysis indicated that poorer health status (p < .0001) and more comorbidity (p = .0089) at baseline were predictors of poorer health status 6 months later. After controlling for these covariates, psychological distress contributed significantly to the model (p = .01). There was a trend indicating that palliative coping styles (i.e., self-care, energy conservation) altered the impact of pain on 6-month health status (p = .06). These findings highlight the need for multidisciplinary interventions that target psychological distress, coping, and comorbidity in patients with FM.

Maltreatment of children and adolescents with multiple handicaps: Five case examples

Little attention has been directed toward abuse and neglect in children and adolescents with multiple handicaps. This population, however, may be at especially high risk for maltreatment. Factors contributing to added risk include: (a) disruption in mother-infant attachment, (b) greater stress related to care needs and difficult to manage behavior problems, and (c) increased vulnerability due to communication and/or cognitive limitations. Five cases are presented involving abuse and neglect in psychiatrically referred children with multiple handicaps. Cases are discussed in terms of: (a) difficulties in identifying maltreatment in those with multiple handicaps, (b) the need for multidisciplinary intervention with families who engage in maltreatment, and (c) suggestions for future directions that research might take.