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Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers.Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles.Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage.In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

Purpose: The aim of this study was to provide insight for the feasibility and outcomes of hybrid (combination of in-person office and Internet-based appointments) audiology services. Method: This pilot included two phases. First, we surveyed audiologists regarding what elements of a best-practice, in-person delivery of a hearing intervention could be delivered via Internet-based appointments. Next, we piloted the feasibility and assessed outcomes of the procedures identified. Ten first-time hearing aid users aged 70 years and older were fit with Phonak Audeo M90-312T hearing aids. Two Internet-based follow-up appointments were completed using the myPhonak app. We administered the Hearing Handicap Inventory for the Elderly–Screening Version (HHIE-S), the Client Oriented Scale of Improvement (COSI), the Quick Speech-in-Noise Test (QuickSIN), and real-ear aided responses (REARs) to determine whether participants experienced improvements on hearing-related outcomes. The Telehealth Acceptance Questionnaire (TAQ) and the Visit-Specific Satisfaction Questionnaire (VSQ-9) were administered to gauge comfort with telehealth and satisfaction with Internet-based appointments. Results: Survey results revealed that after an initial in-person appointment, nearly all follow-up hearing intervention components could be delivered remotely. We performed Wilcoxon signed-ranks tests to determine if the baseline and outcome results differed for outcomes. Baseline scores improved after 6 weeks ( p s = .02 and. 005 for QuickSIN and HHIE-S) for speech-in-noise performance and self-perceived hearing difficulties. REARs from 500 to 4000 Hz measured after 6 weeks did not differ from baseline ( p s = .612 and .398 for the right and left ears), suggesting no significant deviation from prescriptive targets because of remote fitting adjustments. All participants reported improvement in COSI goals after the intervention. TAQ results suggested that comfort with telehealth improved after attending Internet-based appointments ( p = .005). VSQ-9 results revealed no differences in reported patient satisfaction between in-person and Internet-based appointments. Conclusions: We were able to develop a feasible hybrid audiology service delivery model for older adults. Our results enhance the evidence base for the implementation of telehealth audiology services.

Guidelines recommend lifelong follow-up with transthoracic echocardiograms (TTE) for patients who had a patent ductus arteriosus (PDA) device closure via catheterization. The goal of this study was to determine the utility of follow-up TTE in patients who underwent an uncomplicated PDA device closure during infancy.Chart review was performed on patients who had a PDA closure at not more than 1 year of age between January 1, 2002 and June 1, 2020. Patients were excluded if they had other congenital heart disease, did not have a follow-up TTE at least 3 months after procedure, or had a velocity greater than 2.0 m/s in the left pulmonary artery (LPA) or descending aorta (DAo) on the first TTE at least 3 months after device placement. Time points included the first TTE after the procedure, first TTE at least 3 months after procedure, and the most recent TTE.Total of 147 infants met the inclusion criteria. Age and weight at initial procedure were 141 ± 217 days and 4.2 ± 2.8 kg. There was no significant difference in DAo velocity between initial and most recent TTE. LPA velocity and left ventricular diastolic Z score significantly decreased between initial and most recent TTE. Seventy-eight patients had repeat echocardiograms more than 1 year after PDA procedure with no change in clinical management. No patient underwent an intervention on the LPA or DAo for stenosis.In patients who underwent an uncomplicated PDA closure during infancy, TTE parameters either stayed stable or improved over time. These findings need to be corroborated in larger studies with longer follow-up. If verified, the long-term TTE guidelines may need to be simplified for this patient population.

Guidelines recommend lifelong follow-up with transthoracic echocardiograms (TTE) for patients who had a patent ductus arteriosus (PDA) device closure via catheterization. The goal of this study was to determine the utility of follow-up TTE in patients who underwent an uncomplicated PDA device closure after infancy.Chart review was performed on patients who had a PDA closure ≥ 1 year of age between 1/1/2002 and 6/1/2020. Patients were excluded if they had other congenital heart disease, did not have a follow-up TTE ≥ 6 months after procedure, had a residual PDA or velocity 2.0 m/s in the left pulmonary artery (LPA) or descending aorta (DAo) on the first TTE ≥ 6 months after device placement. Time points included the initial TTE after the procedure, first TTE ≥ 6 months after procedure, and the most recent TTE.A total of 189 patients met the study criteria. The median age and weight at initial procedure were 2.7 (1.0-64.7) years and 12.5 (3.4-69.2) kg. Most recent TTE was performed 2.0 (0.4-17.0) years after PDA closure. There were no significant differences in fractional shortening (36.4 ± 5.0% vs. 36.9 ± 5.6%) or LPA velocity (1.1 ± 0.4 m/s vs. 1.1 ± 0.4 m/s) from initial to most recent TTE, respectively. Left ventricular internal diastolic diameter Z-score significantly decreased (1.4 ± 1.8 vs. - 0.01 ± 1.2, p 0.01) and DAo peak velocity significantly increased (1.2 ± 0.3 m/s vs. 1.3 ± 0.3 m/s, p = 0.02) from initial to most recent TTE, respectively. No patient died or underwent an intervention on the LPA or DAo for stenosis. Seventy-five patients had a total of 208 repeat TTE 1 year after PDA procedure with no change in clinical management.In patients who underwent an uncomplicated PDA closure after infancy, TTE parameters improved or stayed within normal limits on the most recent TTE. Repeat lifetime TTEs after 1-year post-device placement in this population may not necessarily be needed if there are no clinical concerns.

Treating chronic pruritus is challenging for dermatologists due to the lack of therapeutic options. We review the effects of κ-opioid receptor (KOR) and μ-opioid receptor (MOR) in the modulation of itch, summarize evidence supporting the efficacy and safety of opioid receptor-targeting agents in chronic pruritus, and address clinical considerations.Preclinical studies have found neural pathways underlying detection, transmission, and modulation of itch signaling and spotlighted the importance of neuronal KOR and MOR in itch perception. Clinical reports suggest that opioid axis modulation may be the basis for the successful treatment of chronic itch. Several agents (MOR antagonist naltrexone; KOR agonists nalfurafine and difelikefalin; dual-acting KOR agonists/MOR antagonists butorphanol and nalbuphine) have been evaluated for treating chronic pruritus in case series, small studies, and clinical trials; nalbuphine has progressed through preliminary (phase II/III) studies in uremic pruritus and prurigo nodularis. The antipruritic efficacy of these agents has been observed across multiple disorders with disparate etiologies, suggesting the potential utility of this class to provide a unified approach to chronic pruritus treatment.The relative safety of these agents, including a reduced potential for dependence versus MOR-agonist analgesics, should help overcome resistance to the use of opioid receptor-targeting agents in chronic pruritus treatment.

BACKGROUND: Bladder cancer treatments may variably impact health-related quality of life (QOL). OBJECTIVE: To characterize the quality of life of patients with bladder cancer at various time points across the continuum of bladder cancer care from non-muscle-invasive disease to metastatic bladder cancer and develop utility scores to inform cost-effective analyses. METHODS: We performed a cross-sectional survey of bladder cancer patients in the Bladder Cancer Advocacy Network Patient Survey Network. Participants were classified into mutually exclusive health states based upon non-muscle invasive (NMIBC), muscle-invasive (MIBC), or metastatic bladder cancer and completed surveys of generic cancer and bladder cancer-specific quality of life, financial toxicity, and work impairment. We constructed generalized linear mixed models to identify patient, clinical, and treatment factors associated with quality of life over time and derived health state utilities. RESULTS: Among 911 self-identified patients with bladder cancer, overall QOL scores and function domains were worse among those with advanced cancer. Financial toxicity was similar among non-metastatic disease states. Work and activity impairment increased with advancing disease (13%and 12%among non-recurrent NMIBC to 63%and 31%for metastatic disease respectively; p

Introduction: Treatment for adolescents and young adults with mood and anxiety disorders typically focuses on recovery of symptoms and improvement in functioning. Measuring positive states of health—using self-report surveys such as the Flourishing Measure—may help to promote holistic treatment. We piloted the Flourishing Measure—Adolescent Version in a clinical sample of adolescents and young adults with mood and/or anxiety disorders to determine appropriateness and acceptability in this population. Methods: We recruited adolescents (age 12–18) and young adults (age 19–25) with mood and/or anxiety disorders from an outpatient psychiatry clinic associated with an academic hospital. We used cognitive interviewing, a method used in survey development that determines whether respondents’ understanding aligns with instrument intention. Participants completed the Flourishing Measure and answered questions about their impressions of items. Results: Sixteen participants (10 adolescents and 6 young adults) participated in the study. Participants generally understood the concept of flourishing and the intention of individual items. The items were generally considered clear and participants offered minor suggestions for improvement in wording of the items. Discussion: Participants in our study understood the meaning of flourishing, as well as individual items in the measure. The Flourishing Measure may be suitable for use in clinical and research settings for adolescents and young adults, though piloting with larger, more diverse samples is needed.

BackgroundResearch demonstrates that SARS-CoV-2 infection (COVID-19) among adults disproportionately impacts racial and ethnic minorities and those living in lower-income communities. Similar research in children is limited due, in part, to the relatively low COVID-19 incidence in children compared to adults. This analysis, conducted as part of the RECOVER Initiative, explores this question.MethodsElectronic health record (EHR) data from PEDSnet, a multi-institutional research network of pediatric healthcare organizations, were geocoded and linked to two indices of contextual social deprivation: the Area Deprivation Index and the Child Opportunity Index. Univariate statistics were employed to test the association between each index and COVID19 positivity among children ages 0-20 tested at one of six Children’s hospitals. Multivariate logistic regression was used to explore the relationship between these social context indices and racial disparities in positivity, controlling co-variates.ResultsBoth ADI and COI were significantly associated with COVID-19 positivity in univariate and adjusted models, particularly in the pre-delta and delta variant waves. ADI showed a stronger association. Higher rates of positivity were found for non-Hispanic Black, Hispanic, and multi-racial children compared to non-Hispanic White children. These racial disparities remained significant after control for either index and for other variables.ConclusionADI and COI are significantly associated with COVID-19 test positivity in a population of children and adolescents tested in children’s hospital settings. These social contextual variables do not fully explain racial disparities, arguing that racial disparities are not solely a reflection of socioeconomic status. Future disparities research should consider both race and social context.

Minimal data exist about the incidence and risk factors for arch intervention after comprehensive stage II (CSII). Goal of this study was to document incidence of arch interventions after CSII and determine if any differences existed between those who underwent an arch intervention (aiCSII) versus those did not have an intervention. Single-center retrospective chart review of all hypoplastic left heart syndrome patients who underwent a CSII between 6/1/2005 and 2/1/2020 was performed. Univariate analysis was conducted in addition to principal components analysis (PCA). One hundred patients were evaluated. Sixteen patients underwent 24 arch interventions. Age at initial arch reintervention was 1.3 ± 1.2 years (median 1.0 years, range 0.5-2.2 years). Univariate analysis showed that the aiCSII group were more likely to be female, to have had a retrograde arch intervention post-hybrid procedure, and to be younger at time of CSII. On echocardiograms, aiCSII group had significantly higher pre-CSII patent ductus arteriosus velocities, arch velocities on their 1st post-operative and discharge study post-CSII, and arch velocities pre-Fontan. Gradients were higher in the aiCSII via pre-Fontan catheterization. With PCA, echocardiographic and catheterization data remained significantly associated with aiCSII versus those who did not undergo an arch intervention (OR = 4.5 (1.9, 19.8), p = 0.008). Incidence of arch intervention post-CSII was 16%. Echocardiographic arch velocities during the CSII hospitalization were the strongest predictors for subsequent aortic arch interventions. Further studies are needed to determine any modifiable variables that may reduce the incidence of arch interventions.

Human trafficking is the recruitment, harboring, transportation, provision, and/or obtaining of a person by the use of force, fraud, and/or coercion, for the purposes of labor and/or sexual exploitation. Trafficked individuals span all ages, genders, races, economic backgrounds, and national origins. People with a trafficking experience present to healthcare settings, especially emergency departments (ED).

The success of the use of novel therapies in the treatment of advanced urothelial carcinoma has contributed to growing interest in evaluating these therapies at earlier stages of the disease. However, trials evaluating these therapies in the neoadjuvant setting must have clearly defined study elements and appropriately selected end points to ensure the applicability of the trial and enable interpretation of the study results. To advance the development of rational trial design, a public workshop jointly sponsored by the US Food and Drug Administration and the Bladder Cancer Advocacy Network convened in August 2019. Clinicians, clinical trialists, radiologists, biostatisticians, patients, advocates and other stakeholders discussed key elements and end points when designing trials of neoadjuvant therapy for muscle-invasive bladder cancer (MIBC), identifying opportunities to refine eligibility, design and end points for neoadjuvant trials in MIBC. Although pathological complete response (pCR) is already being used as a co-primary end point, both individual-level and trial-level surrogacy for time-to-event end points, such as event-free survival or overall survival, remain incompletely characterized in MIBC. Additionally, use of pCR is limited by heterogeneity in pathological evaluation and the fact that the magnitude of pCR improvement that might translate into a meaningful clinical benefit remains unclear. Given existing knowledge gaps, capture of highly granular patient-related, tumour-related and treatment-related characteristics in the current generation of neoadjuvant MIBC trials will be critical to informing the design of future trials.

Professional identity formation is an important aspect of medical education that can be difficult to translate into formal curricula. The role of arts and humanities programs in fostering professional identity formation remains understudied. Analyzing learners' written reflections, we explore the relationship between an arts-based course and themes of professional identity formation.Two cohorts of learners participated in a 5-day online course featuring visual arts-based group activities. Both cohorts responded to a prompt with written reflections at the beginning and end of the course. Using a thematic analysis method, we qualitatively analyzed one set of reflections from each cohort.Themes included the nature of the good life; fulfilling, purposeful work; entering the physician role; exploration of emotional experience; and personal growth. Reflections written at the end of the course engaged significantly with art - including literature, poetry, lyrics, and film. One student disclosed a mental illness in their reflection.Our qualitative analysis of reflections written during a visual arts-based course found several themes related to professional identity formation. Such arts-based courses can also enrich learners' reflections and provide a space for learners to be vulnerable.(five short bullets conveying the main points) Arts-based courses can support learners' professional identity formationReflection themes related to professional identity formation included entering the physician role, fulfilling clinical work, and personal growthAt the end of the course, learners' reflections included significant engagement with artReflective writing in small, arts-based learning communities can provide space for learners to be vulnerableThe Role of Arts-Based Curricula in Professional Identity Formation: Results of A Qualitative Analysis of Learner's Written Reflections.

While public and medical perceptions of HIV and those living with HIV have shifted to be more accepting, many individuals still report stigmatizing experiences in clinical and non-clinical settings. Interviews with 40 people living with HIV, homelessness, substance use, and mental illness participating in a patient-centered medical home (PCMH) were conducted in seven sites across the U.S. to assess experiences with stigma in social and clinical spheres. The most salient themes of the study were: 1) how current and past experiences of stigma-in interactions with friends, family, and providers-informed clients' relationships with disclosure, and 2) how, through coordinated and confidential systems of care, the PCMH minimized the necessity to disclose HIV status, thereby reducing the anxiety associated with it.

Alloreactivity can drive autoimmune syndromes. After allogeneic hematopoietic stem cell transplantation (allo-HCT) chronic graft-versus-host disease (cGVHD), a B cell-mediated autoimmune-like syndrome, commonly occurs. Because donor-derived B cells continually develop under selective pressure from host alloantigens, aberrant B Cell Receptor (BCR)-activation and IgG production can emerge and contribute to cGVHD pathobiology. To better understand molecular programing of B cells under selective pressure of alloantigens, we performed scRNA-Seq analysis on high numbers of purified B cells from allo-HCT patients. An unsupervised analysis revealed 10 clusters, distinguishable by signature genes for maturation, activation and memory. We found striking transcriptional differences in the memory B cell compartment after allo-HCT compared to healthy or infected individuals. To identify intrinsic properties when B-cell tolerance is lost after allo-HCT, we then assessed clusters for differentially expressed genes (DEGs) between patients with vs. without autoimmune-like manifestations (Active cGVHD vs. No cGVHD, respectively). DEGs were found in Active cGVHD in both naive and BCR-activated clusters, suggesting functional diversity. Some DEGs were also differentially expressed across most clusters, suggesting common molecular programs that may promote B cell plasticity. Our study of human allo-HCT and cGVHD provides new understanding of B-cell memory in the face of chronic alloantigen stimulation.

Objectives: Long-standing racial disparities, particularly between White and Black women, in maternal and birth outcomes necessitate an examination of the factors influencing these disparities. This study aimed to understand the experiences of women of color as they relate to pregnancy and/or birth complications to inform policy and strategy to decrease racial and ethnic health disparities. Methods: Six focus groups were conducted with women ( n = 31) who were identified as a woman of color, were 18 years or older, self-identified as having experienced pregnancy or birth complications after 2016, and who spoke English. A focus group guide co-created with the research team, community partners, and peer researchers from the local community was utilized to elicit discussions related to barriers, successes, and existing opportunities to provide equitable care and services to families throughout the perinatal period. An inductive and iterative approach to qualitative analyses of the focus group transcripts was used to identify key themes. Results: The seven themes identified include: lack of knowledge, mental health, communication with providers, support systems, representation, social determinants of health, and discrimination and stigma. Women shared a variety of experiences related to their health care from before pregnancy into their post-partum period, revealing many areas for improvement to extant systems. Conclusion: The inclusion of voices of the populations most deeply affected by health disparities is crucial to understanding how care and services provided can be improved. This analysis suggests the need for change at multiple levels of the health care and social services systems. These experiences provide valuable insight into some of the many struggles and barriers that women of color face during pregnancy and beyond.

Medical education comprises intense periods of transition, which can significantly impact student well-being, as well as personal and professional development. In 2020, medical students navigating transitions from pre-clinical to clinical roles were also experiencing the historic forces of the COVID-19 pandemic and ongoing societal reckoning with systemic injustice and racism, likely heightening the usual challenges associated with these transitions. Reflection has been suggested as a tool for facilitating such transitions, and arts-mediated approaches hold promise in inspiring authentic reflection, yet they are rarely used to prompt medical student reflection. This article describes common themes in medical students' reflections on a specific period of transition during a unique moment in history, via qualitative analysis of their narrative responses to visual arts-mediated reflective prompts. The authors used a visual arts-based activity to explore medical students' hopes and concerns as they transitioned to clinical clerkships between the 2019-2020 and 2020-2021 academic years at one academic institution. Qualitative analysis using an exploratory constructivist approach revealed that students' reflections often focused on identity within three main themes: the personal self, the professional self, and the social self. Within these categories, subthemes included uncertainty and concerns focusing on medical training and knowledge, the sense of hope and value inherent to their social connections, critiques of the culture of medical education, and reflections on complicity and responsibility in racial injustice. This article not only provides a cross-sectional snapshot of the experiences of medical students during a historic moment, but also provides themes to guide discussions on training transitions and describes a low-cost, adaptable approach to facilitating deep exploration and reflection on tumultuous moments in training.

Post-operative analgesic management is challenging in infants and opioids have been the standard of care. However, they are associated with adverse effects which may negatively impact infants. In this retrospective cohort study, we sought to explore the postoperative analgesic efficacy of quadratus lumborum (QL) block in the infant population undergoing dorsal lumbotomy pyeloplasty. Chart review of 34 infants (≤12 months) who underwent dorsal lumbotomy pyeloplasty between 2016–2020 was performed. Post-operative pain was assessed using externally validated pain scales (CRIES &amp, FLACC) and monitored hemodynamics (pulse and blood pressure). Opioid doses were standardized by using morphine milligram equivalency (MME). The Prescription Database Monitoring Program (PDMP) was utilized to determine if discharge opioid prescriptions were filled. Of 34 patients, 13 received the QL block. Mean age at the time of surgery was 6.2 months ± 3.2 months. The QL group received 0.8 MME postoperatively, whereas the non-QL group received 0.9 MME (p = 0.82). The QL group (20%) filled their discharge opioid prescription less frequently compared to non-QL group (100%) (p = 0.002). There were no observed differences between pain scale or hemodynamic variables. Further studies are warranted to explore QL block’s efficacy for post-operative infant pain management.

Allergic conjunctivitis is highly prevalent and affects up to one third of the general population. The current understanding of the pathophysiology and therapeutic strategies center around the type 2 inflammatory pathway. However, there is an increasing body of evidence that suggests neurogenic mechanisms also play a role in allergic inflammation, with a substantial proportion of allergic conjunctivitis patients experiencing both ocular itch and pain.Unmyelinated C fibres on the ocular surface transmit histaminergic itch and can be directly activated by mast cell mediators. The conjunctival mucosa also contains TRPV1+ (histamine-dependent) and TRPA1+ (histamine-independent) neurons that enhance ocular pain and itch in allergic conjunctivitis. Allergen-complexed IgE also binds directly to FcεRI expressed on peripheral neurons. Environmental aeroallergens can also directly stimulate neuronal nociceptors to release inflammatory substances. Allergic inflammation thus stimulates nerve terminals to release vasoactive and inflammatory neuropeptides, leading to a cyclical neuronal dysregulation that augments mast cell activity. These repetitive cycles lead to both peripheral and central sensitization and neuronal plasticity, resulting in decreased itch/pain thresholds and a heightened itch/pain response.Neurogenic mechanisms including peripheral and central sensitization may drive chronic ocular itch and pain secondary to allergic inflammation. Research into these pathways may help to identify therapeutic targets in allergic conjunctivitis patients with refractory symptoms.

Nearly 1 in every 14 youth have had a parent incarcerated at some point. In any given year, over 9 million adults from jail and 700,000 adults from prison return to their families and communities. However, few studies have explored the family experiences during re-entry or have provided suggestions on how to best support children during this time. The goal of this qualitative study was to describe family experiences and provide their considerations on how to better support children during the period of parent's re-entry. Qualitative data was gathered from 26 participants using semi-structured, in-depth phone interviews from March to August 2020. The sample included 10 youth (12-18 years) who have had a parent incarcerated, 10 custodial caregivers of youth who have had incarcerated parents, and 6 parents released from incarceration. Qualitative content analysis and open-coding procedures were used to determine themes across raters. Experiences centred on the challenges of assimilating to new family roles upon the parent returning home and to the community. Families also shared the difficulty in navigating parole restrictions and managing fears surrounding the recidivism of the parent. Three primary themes were deduced as relationship-building obstacles, unaligned family expectations and parole-related family burdens. Results from this study revealed suggestions that may address youth, caregiver and returning parent's needs during the re-entry phase. Family counselling and peer support groups may improve the process of mending or forming relationships. Access to re-entry programs, mental health services, and parental education may better align family expectations. Transparent wrap-around social services and decreasing legal challenges may reduce the parole-related burdens on the family.

Several instruments and outcomes measures have been reported in pediatric patients undergoing epilepsy surgery. The objective of this systematic review is to summarize, evaluate, and quantify outcome metrics for the surgical treatment of pediatric epilepsy that address seizure frequency, neuropsychological, and health-related quality of life (HRQL). We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify publications between 2010 and June 2021 from PubMed, Embase, and the Cochrane Database of Systematic Reviews that report clinical outcomes in pediatric epilepsy surgery. Eighty-one articles were included for review. Overall, rates of postoperative seizure frequency were the most common metric reported (n = 78 studies, 96%). Among the seizure frequency metrics, the Engel Epilepsy Surgery Outcome Scale (n = 48 studies, 59%) was most commonly reported. Neuropsychological outcomes, performed in 32 studies (40%) were assessed using 36 different named metrics. HRQL outcomes were performed in 16 studies (20%) using 13 different metrics. Forty-six studies (57%) reported postoperative changes in antiepileptic drug (AED) regimen, and time-to-event analysis was performed in 15 (19%) studies. Only 13 outcomes metrics (1/5 seizure frequency, 6/13 HRQL, 6/36 neuropsychological) have been validated for use in pediatric patients with epilepsy and only 13 have been assessed through reliability studies (4/5 seizure frequency, 6/13 HRQL, and 3/36 neuropsychological). Of the 81 included studies, 17 (21%) used at least one validated metric. Outcome variable metrics in pediatric epilepsy surgery are highly variable. Although nearly all studies report seizure frequency, there is considerable variation in reporting. HRQL and neuropsychological outcomes are less frequently and much more heterogeneously reported. Reliable and validated outcomes metrics should be used to increase standardization and accuracy of reporting outcomes in pediatric patients undergoing epilepsy surgery.

To understand experiences of patients with genitourinary cancer who experienced delayed cancer care due to the COVID-19 pandemic.We conducted a mixed methods study with an explanatory sequential design. Qualitative findings are reported here. Patients with muscle invasive bladder, advanced prostate or kidney cancer were eligible. Participants were selected for interviews if they self-reported low (0-3/10) or high (6-10/10) levels of distress on a previous survey. Participants were interviewed about their experiences. Interviews were transcribed, coded and categorised using thematic data analysis methodology.Eighteen patients were interviewed. Seven had prostate cancer, six bladder cancer and five kidney cancer. Six themes were derived from the interviews: (1) arriving at cancer diagnosis was hard enough, (2) response to treatment delay, (3) labelling cancer surgery as elective, (4) fear of COVID-19 infection, (5) quality of patient-provider relationship and communication and (6) what could have been done differently.These findings offer insight into the concerns of patients with genitourinary cancers who experienced treatment delays due to COVID-19. This information can be applied to support patients with cancers more broadly, should treatment delays occur in the future.

Objectives: This study aimed to understand the experiences of youth who had been prescribed antipsychotics but did not have psychosis, mania, autism spectrum disorder, or developmental disability. Methods: Twenty-three qualitative telephone interviews were conducted with youth aged 11–18 who had been prescribed an antipsychotic medication but did not have a diagnosis of psychotic disorder, bipolar disorder, autism spectrum disorder, or developmental disability. Participants were recruited from four U.S. healthcare systems participating in the pragmatic trial Safer Use of Antipsychotics in Youth (SUAY). Interviews were recorded, transcribed and analyzed using template analysis techniques. Results: Prior to initiating an antipsychotic medication, most participants experienced behavioral health crises; many felt that they had no options other than to start the medication. Other core themes included: (1) antipsychotics had both positive psychosocial outcomes, such as improvement of family life, and adverse effects, such as drowsiness or weight gain, (2) antipsychotics were only one part of a broader treatment plan, (3) efforts were made to maximize benefits and minimize side effects through careful titration, (4) feedback from friends and family was important in the decision to continue. Conclusions: The findings provide valuable insights into how to engage youth in conversations around the use of antipsychotics.

The 2020-2021 residency application cycle was subject to major alterations following the COVID-19 global pandemic. This study determined the online presence of US-based residency training programs during this time period.An official list of accredited US residency programs for 24 medical specialties was obtained through the Electronic Residency Application Service Programs' online presence and was evaluated for website ownership in addition to Twitter, Instagram, and Facebook account ownership. Date of social media account foundation and virtual opportunities offered were recorded. Doximity Residency Navigator for 2020-2021 was used to determine program rank, and programs were stratified by location using Association of American Medical Colleges regions. Program rank and geographic location were used to determine potential trends in online presence. This study was performed during the residency application cycle from September 2, 2020, to November 29, 2020, during which applications were submitted and the interview cycle began.Fifty-seven percent of the 4,562 programs had a presence on social media. One-third of all accounts were created after March 1, 2020, and most (58%) were residency program-associated. A total of 1,315 programs offered virtual open houses through Twitter (829), Instagram (792), and Facebook (295). First-quartile programs had significantly more social media accounts per program on average (1.8) than those in subsequent quartiles, and Western region programs had significantly more accounts per program on average (1.3) than the Central (1.0), Northeastern (1.0), and Southern (1.1) regions.US residency programs created social media accounts and online opportunities for applicants following March 1, 2020. Online interactions may serve as substitutes at a time when in-person interaction is not possible. Future studies may examine the influence and impact of virtual interactions.

Patients with chronic graft-versus-host disease (cGVHD) have increased B cell–activating factor (BAFF) levels, but whether BAFF promotes disease after allogeneic bone marrow transplantation (allo-BMT) remains unknown. In a major histocompatibility complex–mismatched model with cGVHD-like manifestations, we first examined B-lymphopenic μMT allo-BMT recipients and found that increased BAFF levels in cGVHD mice were not merely a reflection of B-cell number. Mice that later developed cGVHD had significantly increased numbers of recipient fibroblastic reticular cells with higher BAFF transcript levels. Increased BAFF production by donor cells also likely contributed to cGVHD, because BAFF transcript in CD4+ T cells from diseased mice and patients was increased. cGVHD manifestations in mice were associated with high BAFF/B-cell ratios and persistence of B-cell receptor (BCR)–activated B cells in peripheral blood and lesional tissue. By employing BAFF transgenic (Tg) mice donor cells, we addressed whether high BAFF contributed to BCR activation in cGVHD. BAFF increased NOTCH2 expression on B cells, augmenting BCR responsiveness to surrogate antigen and NOTCH ligand. BAFF Tg B cells had significantly increased protein levels of the proximal BCR signaling molecule SYK, and high SYK protein was maintained by BAFF after in vitro BCR activation or when alloantigen was present in vivo. Using T cell–depleted (BM only) BAFF Tg donors, we found that BAFF promoted cGVHD manifestations, circulating GL7+ B cells, and alloantibody production. We demonstrate that pathologic production of BAFF promotes an altered B-cell compartment and augments BCR responsiveness. Our findings compel studies of therapeutic targeting of BAFF and BCR pathways in patients with cGVHD.

Neighbourhood environments are a known social determinant of health. Vacant and abandoned buildings and lots and poor or hazardous housing conditions, combined with crime and violence, can affect residents’ health and wellbeing. Nationwide Children’s Hospital and its partners launched the Healthy Homes initiative in 2008, which sought to improve nearby residents’ health and wellbeing by rejuvenating vacant and abandoned properties and increasing homeownership in the South Side neighbourhood of Columbus, Ohio. Between 2008 and mid-2019 the initiative funded 273 repairs or renovations in this neighbourhood. We conducted a ZIP-code-level comparative case study of the Healthy Homes housing interventions using synthetic control methodology to evaluate changes in crime rate in the intervention area compared with those in a synthetic control area. While findings were mixed, we found some evidence of reduced thefts in the Healthy Homes area, relative to its synthetic control. This initiative to repair, rebuild and increase ownership of housing has the potential to reduce crime rates for neighbours of the Nationwide Children’s Hospital.

Purpose To examine receipt of formal sexual health education on Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) and receipt of HIV testing in adolescents and young adults (AYAs) residing in nonmetropolitan versus metropolitan areas. Methods A secondary data analysis of the 2015–2017 National Survey of Family Growth of AYAs ages 15–24 years (N = 3,114). Logistic regression models predicted associations between nonmetropolitan versus metropolitan status and outcomes of interest (formal sexual health education on HIV/AIDS and HIV testing). Results Most AYAs (85.3%) reported receiving formal sexual health education on HIV/AIDS, while less than half (46.9%) indicated receiving HIV testing. Residing in a nonmetropolitan area was associated with a lower odds of reporting formal sexual health education on HIV/AIDS (OR = .47, CI = [.29, .77]) but not with HIV testing (OR = 1.33, CI = [.89, 2.01]). Conclusions AYAs living in nonmetropolitan areas are less likely to receive formal sexual health education on HIV/AIDS.

BACKGROUND: The unique burden of treatment and survivorship of patients with bladder cancer can negatively impact caregiver experience and their use of supportive care resources. OBJECTIVE: To assess caregivers’ well-being and their perception of potential supportive resources. METHODS: In this cross-sectional survey, caregivers of patients with bladder cancer (N = 630) were recruited through the nationwide Bladder Cancer Advocacy Network Patient Survey Network. We used stakeholder-developed questionnaires to examine caregiver well-being (i.e., physical well-being, tiredness, fear, worry, sadness), the perceived helpfulness of potential resources (i.e., web-based and print-based information, specialized support, personal stories of other caregivers, phone-call and online chat with other caregivers), and influencing factors. RESULTS: Caregivers more frequently reported emotional well-being as a moderate to serious problem (67% for fear, 78% for worry, 66% for sadness) compared with physical well-being (30%) and tiredness (47%). Decreased well-being was associated with female gender of the caregiver, higher than high school education, or caring for a patient with advanced (versus non-invasive) bladder cancer. Of six potential resources, “web-based information” was perceived as “very helpful” among 79% of respondents, followed by “personal stories from other caregivers” (62%). Caregiver preferences for “web-based information” was not associated with any specific demographic or clinical factors. CONCLUSIONS: Caregivers reported moderate to serious problems with emotional and physical well-being. Web-based platforms were perceived as beneficial supportive resources for bladder cancer caregivers. Future intervention research should target the influencing factors identified in this study to optimize the health outcomes of caregivers and enhance the supportive care resources for improving their well-being.

The novel coronavirus (COVID-19) and physical distancing guidelines around the world have resulted in unprecedented changes to normal routine and increased smartphone use to maintain social relationships and support. Reports of depressive and anxiety symptom are on the rise, contributing to suffering among people-especially adolescents and young adults-with pre-existing mental health conditions. Psychiatric care has shifted primarily to telehealth limiting the important patient nonverbal communication that has been part of in-person clinical sessions. Supplementing clinical care with patient electronic communication (EC) data may provide valuable information and influence treatment decision making. Research in the impact of patient EC data on managing psychiatric symptoms is in its infancy. This review aims to identify how patient EC has been used in clinical care and its benefits in psychiatry and research. We discuss smartphone applications used to gather different types of EC data, how data have been integrated into clinical care, and implications for clinical care and research.

Background Prolonged wear of facial protective equipment can lead to occupational dermatoses. Objective To identify important causes of occupational dermatoses from facial protective equipment. Methods A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using PubMed and Embase databases. Articles were included if they reported occupational dermatoses caused by surgical/procedure masks or N95 respirators, or both. Results We identified 344 articles, and 16 were suitable for inclusion in this review. Selected articles focused on facial occupational dermatoses in health care workers. Allergic contact dermatitis to the elastic straps, glue, and formaldehyde released from the mask fabric was reported. Irritant contact dermatitis was common on the cheeks and nasal bridge due to pressure and friction. Irritant dermatitis was associated with personal history of atopic dermatitis and prolonged mask wear (>6 hours). Acneiform eruption was reported due to prolonged wear and occlusion. Contact urticaria was rare. Limitations Only publications listed in PubMed or Embase were included. Most publications were case reports and retrospective studies. Conclusion This systematic review from members of the American Contact Dermatitis Society highlights cases of occupational dermatitis to facial protective equipment, including potential offending allergens. This work may help in the diagnosis and treatment of health care workers with facial occupational dermatitis.

Background The coronavirus infectious disease 2019 pandemic has resulted in health care workers donning personal protective equipment (PPE) for extended periods. Objectives The aims of the study were to review facial PPE (surgical masks and N95 respirators) ingredients, to identify facial PPE resterilization techniques, and to recommend strategies for prevention and management of facial PPE-related dermatoses. Methods Twenty-one facial PPE (11 N95 respirators, 10 surgical masks) were reviewed. Resterilization techniques were identified. Personal protective equipment-induced occupational dermatoses and management strategies were explored. Results Polypropylene is the most common chemical identified in facial PPE. Most masks contain aluminum at the nosepiece. Two surgical masks released nickel. Facial PPE dermatoses include irritant contact dermatitis, allergic contact dermatitis, acne, and contact urticaria. Strategies for prevention and management of facial PPE occupational dermatoses are discussed. Conclusions There are increasing reports of occupational dermatoses associated with facial PPE. This review discusses the components of facial PPE, mask resterilization methods, and strategies for prevention and management of facial PPE dermatoses.

Background Racially disparate pain management affects both adult and pediatric patients, but is not well studied among pediatric surgical patients after discharge. The objectives were to evaluate racial disparities in pediatric postoperative opioid prescription filling. Methods This retrospective cohort study included black or white pediatric Medicaid patients who underwent tonsillectomy, supracondylar humeral fracture fixation, or appendectomy (2/2012–7/2016). Patients were followed for 14 days post-surgery to identify opioid prescription fills. Logistic regression models evaluated the association between race and the probability of filling an opioid prescription. Results Among 39,316 surgical patients, the proportions of patients with post-surgical opioid prescriptions were 66.0%, 83.9%, and 68.5%, among tonsillectomy, supracondylar fracture, and appendectomy patients, respectively. The proportion of black appendectomy patients with a postoperative opioid prescription was significantly lower compared to white patients (65.0% vs. 69.2% respectively, p = 0.03), but was no longer significant after adjusting for other patient and provider characteristics. There were no differences by race in opioid prescription filling among other surgical patient groups. Conclusions The present study did not identify racial disparities in opioid prescription filling in adjusted analyses. Racial differences in unadjusted postoperative opioid prescription filling among appendectomy patients may be explained in part by longer postoperative length-of-stay among black children. Type of Study Prognosis Study Level of Evidence Level II

This annotated bibliography provides an overview of sentinel and influential literature about human trafficking for general mental health practitioners.A modified participatory ranking methodology was used to create the list of articles.We identified 25 articles relevant to trafficking and mental health which covered the topics of epidemiology, treatment, identification, policy, and research methodology.The articles presented cover a broad range of trafficking types and topics. However, there is a dearth of literature about labor trafficking and the trafficking of men, boys, transgender, and nonbinary people.

BACKGROUND Public health programs are tasked with educating the community on pertinent public health topics, but it is unclear how effective these programs are and if they are acceptable for learners. Currently, these programs are delivered via a variety of platforms including in-person, virtually, and over the telephone. Sickle cell trait (SCT) education for parents of children with this trait is one of many education programs provided by the Ohio Department of Health. The novel SCTaware videoconference education program was developed by a research team after central Ohio’s standard program transitioned from in-person to telephone-only during the COVID-19 pandemic. OBJECTIVE Our objective was to investigate acceptability of format and engagement with the SCTaware education, and to assess parental worry about having a child with SCT before and after receiving SCTaware. METHODS This was a single center, prospective study of English-speaking parents of children RESULTS Fifty-five participants completed follow-up surveys after receiving standard SCT telephone education and then completing SCTaware. Most (n=51) participants reported that the SCTaware content and visuals were very easy to understand (n=47) and facilitated conversation with the Educator (n=42). All said the visuals were respectful and trustworthy, helped them understand content better, and that their questions were addressed. Nearly two-thirds (62%) reported that the pictures appeared very personal and applied to them. The Educator noted most participants (n=45) were engaged and asked questions (n=45), despite having to manage distractions during their education sessions. Many participants (n=33) reported some level of worry following telephone-only education; this was significantly reduced after receiving SCTaware (p < 0.0001). CONCLUSIONS Our results suggest that SCTaware is acceptable and engaging to parents. While telephone education may make SCT education more accessible, these findings suggest that many parents experience significant worry about their child with SCT after these sessions. A study to evaluate SCTaware’s effectiveness at closing parents’ SCT knowledge gaps is ongoing.

Pediatricians are uniquely and well positioned to recognize risk factors for and experiences of labor and sex trafficking in children. While clinical and social interventions are well discussed in the literature, the underlying mechanisms that cause and contribute to trafficking are poorly addressed among healthcare professionals. A "colorblind" or otherwise "apolitical" approach to trafficking prevention is ineffective and may be detrimental to the patient-practitioner relationship. Pediatricians must be historico-socially aware of the contexts in which they practice to improve the health of pediatric populations. This article addresses the relevant trafficking legal terminology that may be unfamiliar to most pediatricians and focuses on a few "ism"-schisms (capitalism, racism, sexism, cis-heteronormativity, nativism, and classism) that create vulnerability to trafficking in pediatric populations. The article closes with some intervention recommendations and many more prevention-measure recommendations.

Labor and sex trafficking impact children of all ages, genders, and nationalities. Trafficked patients present to the emergency department for illnesses and injuries both related and unrelated to their trafficking experiences. Emergency clinicians are not meant to be experts in labor and sex trafficking, but they must know enough to be able to identify patients at risk for trafficking and ensure that these patients have the opportunity to be connected to relevant services and support. This issue reviews the ways in which youth are trafficked, the indicators of trafficking, and the evidence-based and best-practice recommendations for addressing suspected or confirmed trafficking in the pediatric and adolescent patient populations.

Purpose of this study was to observe if there was any increase in epistaxis admissions to hospital after the introduction of routine population wide nasal swabbing. This study looked at difference in epistaxis admissions from 2020 and 2021 across the 9 NHS Trusts in the Southwest.This study found that there were less hospital admissions in 2021 due to epistaxis. This could be due to the widespread fear amongst the populace at the time of attending hospital due risk of COVID-19 and of overburdening the hospital. Patient’s that did present to ED may have received more effective epistaxis management with biodegradable nasal pacs and topical haemostatic matrices. However there are many confounding factors, thus it is important to avoid over interpretation of the data.

The discovery of JAKs and STATs and their roles in cytokine and IFN action represented a significant basic advance and a new paradigm in cell signaling. This was quickly followed by discoveries pointing to their essential functions, including identification of JAK3 mutations as a cause of SCID. This and other findings predicted the use of therapeutically targeting JAKs as a new strategy for treating immune and inflammatory diseases. This now is a reality with seven approved jakinibs being used to treat multiple forms of arthritis, inflammatory bowel disease and myeloproliferative neoplasms, and numerous ongoing clinical trials in other settings. This story provides interesting insights into the process of translating basic discoveries and also reveals the need to return to basic work to fill gaps that now become apparent.