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PURPOSE: While the association between income and depression is well established, less explored is the relation between wealth and depression, particularly among low-income adults. We studied the relation between two types of assets—savings and home ownership—and probable depression to understand how access to different assets may shape depression among low-income US adults. METHODS: STUDY SAMPLE: We conducted a serial cross-sectional, observational study with 12,019 adults with low-income in the United States using National Health and Nutrition Examination Survey (NHANES) data from 2007–2016. MEASURES: We measured probable major depressive disorder (MDD) with impairment using the Patient Health Questionnaire-9. Low savings was defined as having $5,000 or less in family savings. STATISTICAL ANALYSIS: We estimated adjusted and unadjusted prevalence, odds ratios, and predicted probability of probable MDD across asset groups. RESULTS: Of low-income US adults, 5.4% had probable MDD with impairment, 85.9% had low savings, and 54.9% rented their home. Persons with low savings had 2.34 (95% CI 1.44–3.79) times the odds of having probable MDD relative to those with high savings. Home owners had 2.14 (95% CI 1.20–3.86) and home renters had 3.65 (95% CI 1.45–9.20) times the odds of having probable MDD if they had low savings relative to high savings. CONCLUSION: Family savings and home ownership are associated with lower burden of depression among low-income adults in the US.

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19–2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.

Background The COVID-19 pandemic and its consequences have been associated with an increase in poor population mental health. We assessed how depressive symptoms changed among U.S. adults over the course of the COVID-19 pandemic and identified the key risk factors for these symptoms. Methods Longitudinal panel study of a nationally representative group of U.S. adults ages 18 years and older surveyed in March-April 2020 (Time 1; N=1441) and March-April 2021 (Time 2; N=1161) in the COVID-19 and Life Stressors Impact on Mental Health and Well-being study (CLIMB). The Patient Health Questionnaire-9 (PHQ-9) was used to define elevated depressive symptoms (cut-off ≥10) and depressive symptoms score (0-27). Findings The prevalence of elevated depressive symptoms persisted from 27.8% in 2020 (95% CI: 24.9, 30.9) to 32.8% in 2021 (95% CI: 29.1, 36.8). Over time, the central drivers of depressive symptoms were low household income, not being married, and experiencing multiple stressors during the COVID-19 pandemic. The odds ratio of elevated depressive symptoms for low income relative to high income persons increased from 2.3 (95% CI: 1.2, 4.2) in 2020 to 7.0 (95% CI: 3.7, 13.3) in 2021. Fewer people reported experiencing 4 or more COVID-19 stressors in 2021 than in 2020 (47.5% in 2020 vs 37.1% in 2021), but the odds ratio of elevated depressive symptoms associated with 4 or more stressors relative to 1 stressor or less increased from 1.9 (95% CI: 1.2, 3.1) in 2020 to 5.4 (95% CI: 3.2, 9.2) in 2021. Interpretation The burden of depressive symptoms in the U.S. adult population increased over the course of the COVID-19 pandemic. Mental health gaps grew between populations with different assets and stressor experiences during the COVID-19 pandemic. Funding CLIMB Time 1 was sponsored by the Rockefeller Foundation-Boston University 3-D Commission. CLIMB Time 2 was sponsored by the de Beaumont Foundation.

OBJECTIVE This research aims to take an in-depth look into the child, housing, and neighborhood characteristics associated with Providence children's likelihood of having elevated blood lead levels (BLLs). DESIGN AND SETTING The 2019 Providence, Rhode Island, Property Tax Assessor's database, containing each property owner's address, was geocoded and spatially joined with the 2017-2019 blood lead tests for children aged 0 to 6 years from the Rhode Island Department of Health. MAIN OUTCOME MEASURES The prevalence of elevated BLLs (≥5 μg/dL) overall, as well as by property type, number of properties owned, owner occupancy, assessed value, and neighborhood rates of old housing and poverty, was computed. We assessed the relationship between having elevated BLLs and these housing and neighborhood characteristics, adjusting for gender, age at test, and test method. RESULTS We found that, compared with children living in properties with landlords who owned only one property, children living in properties with landlords who owned 4 or more properties had lower odds of having elevated BLLs (odds ratio = 0.98; 95% confidence interval, 0.97-0.99). The proportion of houses built pre-1950 in the neighborhood was associated with increased odds of elevated BLLs. There was no significant association between owner-occupancy status and property type with children having elevated BLLs. CONCLUSIONS Children living in properties with landlords who owned 4 or more properties were less likely to have elevated BLLs. This association may suggest that the current lead legislation is having some impact, but public health efforts should address lead exposure in properties that are currently exempt from the law.

Objectives To analyze the distribution of patient-centered medical homes (PCMHs) among US adolescents, and to examine whether disparities exist among subgroups. Study design Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007. Results Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007. Conclusions PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Background. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. Methods. A sample was extracted from the 2011-2012 National Survey of Children’s Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. Results. An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. Conclusions. Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.

Background Falls represent the leading cause of nonfatal unintentional injuries among children in the United States. Although unintentional injury risks have been studied, neighborhood impact on falls remains underexplored. This study examined the association of neighborhood attributes with rates of fall-related injuries. Methods This is a retrospective study of children who presented to emergency departments within a statewide hospital network for fall-related injuries between 2005 and 2014. Patients’ home addresses were geocoded to identify US Census block groups (BGs). Average annual fall rates were computed for each BG. A neighborhood risk index was constructed using 8 socioeconomic BG measures (education, crowding, vacancy, renter occupancy, poverty, family structure, race/ethnicity, and housing age). Public outdoor recreational facilities in each BG were enumerated. Linear regression analysis was used to assess the association of neighborhood risk and recreational facilities with fall rates. Results From 2005 to 2014, there were 139,986 unintentional injury emergency department visits; of these, 42,691 (30%) were for falls. The largest proportion of falls were among males (58%), children ages 1 to 4 years (39%), non-Hispanic whites (59%), and children with public health insurance (53%). Higher quintiles of neighborhood risk were associated with higher annual fall rates compared to the lowest quintile of risk: quintile 2, β = 0.44, 95% confidence interval (CI), 0.20–0.68; quintile 3, β = 0.85, 95% CI, 0.61–1.10; quintile 4, β = 1.11, 95% CI, 0.85–1.37; quintile 5, β = 1.57, 95% CI, 1.29–1.85. The presence of public outdoor recreational facilities was not associated with fall rates (β = 0.01; 95% CI, –0.14 to 0.15). Conclusion Neighborhood-level socioeconomic characteristics are associated with higher fall-related injuries. Injury prevention programs could be tailored to address these neighborhood risks.

Background COVID-19 and related containment policies have caused or heightened financial stressors for many in the USA. We assessed the relation between assets, financial stressors and probable depression during the COVID-19 pandemic. Methods Between 31 March 2020 and 13 April 2020, we surveyed a probability-based, nationally representative sample of US adults ages 18 and older using the COVID-19 and Life stressors Impact on Mental Health and Well-being survey (n=1441). We calculated the prevalence of probable depression using the Patient Health Questionnaire-9 (cut-off ≥10) and exposure to financial stressors by financial, physical and social assets categories (household income, household savings, home ownership, educational attainment and marital status). We estimated adjusted ORs and predicted probabilities of probable depression across assets categories and COVID-19 financial stressor exposure groups. Results We found that (1) 40% of US adults experienced COVID-19-related financial stressors during this time period; (2) low assets (OR: 3.0, 95% CI 2.1 to 4.2) and COVID-19 financial stressor exposure (OR: 2.8, 95% CI 2.1 to 3.9) were each associated with higher odds of probable depression; and (3) among persons with low assets and high COVID-19 financial stressors, 42.7% had probable depression; and among persons with high assets and low COVID-19 financial stressors, 11.1% had probable depression. Persons with high assets and high COVID-19 financial stressors had a similar prevalence of probable depression (33.5%) as persons with low assets and low COVID-19 financial stressors (33.5%). The more assets a person had, the lower the level of probable depression. Conclusion Populations with low assets are bearing a greater burden of mental illness during the COVID-19 pandemic.

Burn injury continues to cause significant morbidity and mortality in the US pediatric population. Many studies using inpatient samples have found a relationship between low socioeconomic status (SES) and burn injury. The purpose of our study was to evaluate the association between SES and the likelihood of admission for Emergency Department (ED) visits for pediatric burn injury.A retrospective database review of pediatric ED visits for burn injury from a statewide hospital system, from January 1, 2005 to December 31, 2014. SES was assigned using an eight factor Neighborhood Risk Index (NRI) created from census block group data, with a higher score indicative of lower SES. The outcome measure was ED visits admitted to inpatient care.We analyzed a sample of 1845 pediatric ED visits for burn injuries. Most visits were discharged from the ED (88.4%) while 10.5% were admitted to inpatient care and 1.0% were transferred to another hospital. In a multivariable logistic regression model, patients from high risk areas (75th percentile NRI) had 1.58 higher odds of inpatient admission compared to patients from low risk areas (75th percentile NRI; 95% CI: 1.08-2.30), after adjusting for age, gender, ethnicity, distance to the hospital, and previous ED visit for burn injury in the past 30 days. In addition, for every 1-mile increase in distance, a child's likelihood of admission increased by 6% (95% CI: 4-9%).Children with a burn injury from the highest risk socioeconomic areas in Rhode Island had a higher likelihood of inpatient admission. Further research is needed to determine what factors associated with socioeconomic status impact this finding.

Objectives To investigate the association of residential mobility with flourishing among school-age children. Methods Data from the 2011/2012 National Survey of Children's Health were used to examine parent/caregiver-reported information on flourishing and residential mobility for children age 6-17 (N = 63,333). Residential mobility was the number of times the child moved categorized as: none, 1-2, and 3+. Children who were reported to show interest/curiosity, finish tasks, stay calm/in control, care about doing well in school, and do all homework were coded as flourishing. Sex-specific multivariable models were used to model the relative risk of mobility on flourishing. Interactions of mobility with age and poverty were tested. Results Among US school-age children, 22% had no moves, 39% had 1-2 moves and 39% had 3+ moves in their lifetime. Nearly half (45%) were flourishing. Both boys and girls who moved 3+ times were less likely to flourish compared to children with no moves. Among poor boys moving 3+ times was associated with less flourishing (aRR 0.83, 95% CI 0.71, 0.98) with no association for non-poor boy. Among girls the pattern was reversed (aRR 0.88, 95% CI 0.81, 0.95 for non-poor girls and no association for poor girls). Conclusions for Practice Residential mobility may lead to lower rates of flourishing. The patterns, when stratified by age or poverty, are different for boys and girls.

Objective To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. Data sources 2011-2016 Medicaid claims from a Northeastern state. Study design Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. Data collection We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. Principal findings Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. Conclusions Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.

Neonatal intensive care unit graduates residing in high-risk neighborhoods were at increased risk of emergency department use and had higher rates of social/environmental risk factors. Distances to primary care provider and emergency department did not contribute to emergency department use. Knowledge of neighborhood risk is important for preventative service reform.

BACKGROUND AND OBJECTIVES:Pediatric surveillance of young children depends on providers’ assessment of developmental milestones, yet normative data are sparse. Our objectives were to develop new norms for common milestones to aid in clinical interpretation of milestone attainment.METHODS:We analyzed responses to the developmental screening form of the Survey of Well-being of Young Children from 41 465 screens across 3 states. Associations between developmental status and a range of child characteristics were analyzed, and norms for individual questions were compared to guidelines regarding attainment of critical milestones from the Centers for Disease Control and Prevention (CDC).RESULTS:A contemporary resource of normative data for developmental milestone attainment was established. Lower developmental status was associated with child age in the presence of positive behavioral screening scores (P < .01), social determinants of health (P < .01), Medicaid (P < .01), male sex (P < .01), and child race (P < .01). Comparisons between Survey of Well-being of Young Children developmental questions and CDC guidelines reveal that a high percentage of children are reported to pass milestones by the age at which the CDC states that “most children pass” and that an even higher percentage of children are reported to pass milestones by the age at which the CDC states that parents should “act early.” An interactive data visualization tool that can assist clinicians in real-time developmental screening and surveillance interpretation is also provided.CONCLUSIONS:Detailed normative data on individual developmental milestones can help clinicians guide caregivers’ expectations for milestone attainment, thereby offering greater specificity to CDC guidelines.

Objectives Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization. Methods The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics. Results Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency. Conclusions Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.

Flame injuries are the primary cause of burns in young adults. Although drug and alcohol intoxication has been associated with other types of trauma, its role in burn injury has not been well described in this population. The purpose of this study was to investigate the association of intoxication and flame burn injuries in young adults in the United States. The 2014 Nationwide Emergency Department Sample was queried for burn injury visits of young adult patients, 13-25 years old. This data is weighted to allow for national estimates. Burn mechanism and intoxication status were determined by International Classification of Diseases, Ninth Revision codes. Multivariable logistic regression analysis was used to assess the association of intoxication and emergency department (ED) visits due to flame burns, adjusting for patient age, gender, zip code median income, zip code rural-urban designation, timing of visit, and hospital region. Further analyses assessed the odds of admission or transfer, as a possible proxy of injury severity, in patients with flame or other burns, with and without intoxication adjusting for patient age, gender, primary insurance, and hospital trauma designation. There were 20,787 visits for patients 13-25 years old with burn injuries and 12.9% (n = 2678) had a codiagnosis of intoxication. There was an increasing proportion of intoxication by age (5.8% 13-17 years old, 25% 18-20 years old, 69% 21-25 years old, P < .001). ED visits for burns with a codiagnosis of intoxication had 1.34 times ([95% confidence interval (CI): 1.18, 1.52], P < .01) higher odds of having flame burns compared to other burn mechanisms. Those with flame burns and intoxication were most likely to be admitted or transferred when compared to nonflame, nonintoxication visits in the adjusted model (odds ratio [OR] 5.49, [95% CI: 4.29, 7.02], P < .01). Furthermore, the odds of admission or transfer in visits with the combined exposure of intoxication and flame mechanism were significantly higher than visits due to nonflame burns and intoxication (OR 2.75, [2.25, 3.36], P < .01) or flame burns without intoxication (OR 3.00, [95% CI: 2.61, 3.42], P < .01). This study identified a significant association between flame-burn-related ED visits and intoxication in the young adult population in the United States. In addition, the combination of flame mechanism and intoxication appears to result in more substantial injury compared with either exposure alone. The relationship seen between intoxication and flame burn injury underscores a major target for burn prevention efforts in the young adult population.

Introduction Studies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use. Methods This retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block-group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child's sociodemographic information, season, and multiple measurements per child. Results From 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06-1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34-0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile. Conclusion Interventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.

OBJECTIVES: To determine the associations of adverse childhood experiences (ACEs) and protective familial and community factors with school performance and attitudes in children ages 6 to 17. METHODS: A cross-sectional analysis of the 2011–2012 National Survey of Children’s Health was performed. All data were demographically weighted and included 65 680 children ages 6 to 17. The survey identified up to 9 ACEs in each child. ACE scores were categorized as 0, 1, 2, 3, and ≥4 ACEs. Children’s protective factors (PFs) included the following: safe neighborhood, supportive neighbors, 4 neighborhood amenities, well-kept neighborhood, no household smoking, ≥5 family meals per week, and a parent who can talk to the child. PFs were categorized into ≤3, 4, 5, 6, and 7 PFs. School outcomes included the following: child repeated ≥1 grade; never, rarely, or sometimes completes homework; and never, rarely, or sometimes cares about school. χ2 tests and logistic regressions assessed the relationships between ACEs and school outcomes, PFs and school outcomes, and both ACEs and PFs and school outcomes, adjusting for sex, age, race, ethnicity, and maternal education. RESULTS: Each negative school outcome is associated with higher ACE scores and lower PF scores. After adding PFs into the same model as ACEs, the negative outcomes are reduced. The strongest PF is a parent who can talk to the child about things that matter and share ideas. CONCLUSIONS: As children’s ACE scores increase, their school performance and attitudes decline. Conversely, as children’s PF scores increase, school outcomes improve. Pediatric providers should consider screening for both ACEs and PFs to identify risks and strengths to guide treatment, referral, and advocacy.

Introduction Burn injuries contribute a considerable burden of disease in variable-resource settings, often resulting in mortality. Despite contributing a substantial burden, outcomes from burn injuries in rural Africa are rarely described. The objective of this study was to examine factors associated with mortality from burn injury in rural Africa. Methods A retrospective chart review was conducted for all patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in eastern Africa. Bivariate analysis was used to compare patients who survived the hospital stay with those who did not. Using total body surface area (TBSA), the LD50 (Lethal Dose 50, burn size with a lethality of 50% of patients), and the modified-Baux score were calculated. Due to small sample size, lasso inference techniques for logistic regression were utilized to avoid overfitting a model and to determine relevant risk factors for mortality, by evaluating burn severity, age, sex, location of residence, payer status, time from injury to arrival, distance from hospital, presence of full thickness burns, inhalational injury, and referral status. Results A total 171 burn injury patients were reviewed for this study; two were excluded due to missing data. Among 169 patients, 14.8% (n=25) experienced mortality prior to hospital discharge. Fifty patients suffered an adverse event (29.6%) including: 17 wound infections, 10 urinary tract infections, 10 with sepsis, and 25 with respiratory complications. The LD50 for TBSA was 42%. The LD50 for the modified-Baux score was 81. Non-survivors had higher average TBSA (31.0±5.0% vs 11.5±0.8%; p< 0.01), more inhalational injury (44% vs 2.8%, p< 0.01), full-thickness burns (56.5% vs 23.9%, p< 0.01), and complications (88% vs 19.4%, p< 0.01). Odds of mortality increased 1.06 times for every percent increase in TBSA burn (95%CI: 1.02, 1.11; p< 0.01) and 13.9 times with inhalational injury (95%CI: 3.4, 56.4; p < 0.01). Conclusions Mortality from burn injury represents a substantial portion of patients at a hospital in rural Africa. Factors of larger TBSA and inhalational injury represent the greatest risk.

Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum.Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission).Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91).This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.

Background Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis. Methods We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes. Results Providers expressed challenges effectively meeting their patients’ needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice. Conclusions Underinvestment in primary care in Medicaid may detract from providers’ professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Introduction: Limited data are available regarding differences in presentation and management of pediatric emergency department (PED) patients based on insurance status. The objective of the study was to assess the difference in management of pediatric facial lacerations based on medical insurance status. Methods: We conducted a retrospective cohort study with universal sampling of patients with facial lacerations who were treated in an urban PED (45K visits/year) over a one-year period. Demographic features and injury characteristics for patients with commercial (private) insurance and those with Medicaid or Medicare (public) insurance were compared. Results: Of 1235 children included in the study, 667 (54%) had private insurance and 485 (39%) had public insurance. The two groups did not differ in age or gender, arrival by ambulance, location of injury occurrence, mechanism of injury, part of face involved, length or depth of laceration, use of local anesthetic, or method of repair but differed in acuity assigned at triage. Patients with public insurance were found less likely to have subspecialty consultation in bivariable (OR=0.41, 95% CI [0.24–0.68]) and multivariable logistic regression analyses (OR=0.45, 95% CI [0.25-0.78]). Patients with public insurance received procedural sedation significantly less often than those with private insurance (OR=0.48, 95% CI [0.29-0.76]). This difference was not substantiated in multivariable models (OR=0.74, 95% CI [0.40-1.31]). Conclusion: Patients with public insurance received less subspecialty consultation compared to privately insured patients despite a similarity in the presentation and characteristics of their facial lacerations. The reasons for these disparities require further investigation. [West J Emerg Med 2015;16(4)-0.]

OBJECTIVE: Many states have passed concussion laws that mandate that players undergo medical clearance before returning to play. Few data have been collected on the impact of such laws on emergency department (ED) visits. This study measures the impact of Rhode Island concussion legislation on sports-related concussion visits to a pediatric ED. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes with injury mechanism-associated E-codes were extracted from hospital databases from 2004 to 2011 for both sports-related concussions and sports-related ankle ligamentous injuries (comparison group). Visit rates for sports-related concussions were compared before and after the passage of the state concussion law.Secondary outcome measures included rates of head imaging per ED visit for concussion before and after passage of the law. Times series analysis was used to analyze season-to-season count and rate changes. RESULTS: Overall rate of sports-related concussion visits more than doubled (2.2-fold increase; 95% confidence interval, 1.3-3.6; adjusted P = 0.01) during the fall sports season following the implementation of legislation (2010) relative to the previous year (3.6% vs 1.4%). Rates of sports-related ankle sprain visits tended to increase during the fall sports season but did not achieve statistical significance. Rates of computed tomography scan imaging of the head did not change over time. CONCLUSIONS: The data from this study revealed an increase in pediatric ED visits for sports-related concussions, without a corresponding increase in head imaging, suggesting that the passage of a state concussion law has led to increased vigilance in evaluation of sports-related concussions, without an increase in diagnostic computed tomography scans. Language: en

Objectives For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care. Methods Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits. Results A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance. Conclusions Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.

Poor neighborhood perceptions among mothers during pregnancy are associated with negative health outcomes such as maternal stress, preterm birth and long-term mental health problems in children. Given the increasing research on neighborhood perceptions, we examined the maternal-, child-, and neighborhood-level correlates of self-reported maternal neighborhood satisfaction at 13 months post-partum. Women were recruited from the post-partum units at Women and Infants Hospital of Rhode Island from January 5, 2009 to March 19, 2009. Unadjusted and adjusted regression coefficients were estimated using linear regression. In the full model, being a mother in excellent or very good health, being Hispanic/Latino, and having a higher or unknown household income were associated with a higher neighborhood satisfaction rating at 13 months, and having a stubborn baby, having more than a high school or GED education, as well as living in a neighborhood with a higher percent of black and Latino residents were significantly associated with a lower neighborhood satisfaction rating. Our results indicate that various aspects of the neighborhood environment, maternal characteristics, and characteristics of the child influence maternal neighborhood satisfaction post-partum. All of these characteristics should be accounted for when assessing the relationship between maternal neighborhood perceptions and both short- and long-term health effects in the offspring. In addition, when assessing neighborhood perception at any point in the life course, it is important to account for neighborhood- and individual-level characteristics, as well as risk factors associated with daily stress at the time of assessment.

We construct a unique individual-level dataset linking preschool blood lead levels with third grade test scores for Rhode Island children born 1997–2005. Using two identification strategies, we show for the first time that reductions of lead from even historically low levels have significant positive effects. A one-unit decrease in average blood lead levels reduces the probability of being substantially below proficient in reading (math) by 0.96 (0.79) percentage points on a baseline of 12 (16) percent. Since disadvantaged children have greater exposure to lead, lead poisoning may be one of the causes of continuing disparities in test scores. (JEL I12, I14, I18, I21, I24, J13)

Purpose: Primary care providers (PCPs) of children with special health care needs (CSHCN) in rural areas face challenges in accessing specialty care to support a patient-centered medical home. This study assessed the practice characteristics and attitudes regarding pediatric specialty care among Montana PCPs of CSHCN. Methods: We surveyed 433 Montana PCPs identified through a statewide registry. Demographic and practice information was collected, including the proportion of time spent on CSHCN care coordination. A 5-point Likert scale was used to calculate mean need scores for each pediatric specialty, access to these specialties, and barriers to care. Results were analyzed separately for pediatricians and family physicians, as well as rural and urban providers, using λ2, t tests, and Mann-Whitney tests. Results: Of the PCPs surveyed, 386 had a valid address and were currently practicing in Montana, 112 (29%) responded, and 91 provided care to CSHCN (averaged 29% of time spent in CSHCN care coordination). Child psychiatry (4.1) and developmental/behavioral pediatrics (3.7) were identified as the most needed specialties, yet they scored lowest in access to care (2.2 and 2.6, respectively). The most important rated specialist characteristics were quality (4.1), availability (3.5), and communication skills (2.8). Among the top barriers to care, lack of appropriate specialists was identified by 82% of PCPs. Conclusions: Specialty care delivery for CSHCN in rural areas such as Montana should focus on matching availability with the identified need for specialty services, and ensuring that systems of communication between PCPs and specialists support the care coordination function of PCPs.

To examine residential mobility (i.e., moving) during pregnancy and in the first year of an infant's life using a large, prospective birth cohort in Rhode Island. Participants were recruited from Women and Infants Hospital of Rhode Island between January 5, 2009 and March 19, 2009. Residential histories were collected from mothers in-person immediately post-partum and by phone at 7 months and at 13 months post-partum. Of 1,040 mothers interviewed at birth, 71% (n = 740) completed the 13 month follow-up interview. Forty-one percent of mothers (n = 300) moved at least once between conception and 1 year post-partum, with the number of moves ranging from 0 to 8. Among movers, 69.0% moved once, 21.0% moved twice, and 10.0% moved three or more times. Mothers who moved tended to be younger, have fewer children, were not White, and had lower household incomes than those who did not move. Mothers who moved during pregnancy had 2.05 (95% CI: 1.40-2.98) times the odds of moving post-partum than mothers who had not moved in the antenatal period. There were statistical differences across socio-demographic groups with regard to when, where, and why mothers moved. Forty percent of movers during pregnancy (n = 61) moved for at least one negative reason, while 32.2% of movers during infancy (n = 64) relocated under negative circumstances. A substantial proportion of mothers moved pre- and post-partum, frequently under negative circumstances. Study findings have important implications for obstetric and pediatric providers who seek to understand, retain, and improve the health of their patient populations.

Treatment for childhood obesity in a research setting has progressed in the past 25 years (1), with family-based behavioral treatment being the most consistently investigated intervention (1). A recent review of eight, family-based, pediatric obesity intervention trials conducted over the past 25 years in research settings describes an intervention that has predominantly targeted children aged 8 to 12 years, and has provided 6 months (16 to 20 sessions) of intensive behavioral treatment to parents and children, using a combined group and individual format for each session (1). Children were asked to reduce energy intake to 800 to 1200 kcals/day, and increase physical activity and/or decrease sedentary behaviors. This type of intervention has significantly improved weight status in participating children (1). Unfortunately, these highly effective, intensive, research interventions are likely not feasible for primary care settings (2). In 1997, a U.S. Expert Committee developed recommendations for pediatric obesity treatment in primary care settings (3). The Committee acknowledged there was no intervention designed for a non-research setting that was known to be efficacious. General guidelines were provided, which included: 1) starting with children as young as 3 years of age; 2) monitoring growth outcomes regularly (i.e., monthly); 3) applying a family-based model; and 4) using behavior modification techniques to change the child’s eating and activity behaviors (3). The Committee also emphasized that two or three energy-balance behaviors should be targeted during treatment (3). Although these recommendations suggest using components from empirically supported treatment, it is unclear whether a less intensive treatment approach will be effective in enhancing weight control. These recommendations were updated in 2007 and were very similar to the previous general guidelines, particularly in regards to the use of a family-based model and behavior modification techniques (4). Determining the efficacy of such an approach, including which energy balance behaviors to target, is imperative. Thus, this investigation examined the efficacy of the 1997 U.S. pediatric obesity treatment recommendations for primary care with two separate randomized trials (RTs) in children aged 4 to 9 years. Since the focus was on efficacy, not effectiveness, these interventions were delivered primarily in research settings to maximize treatment integrity. Both RTs had three interventions: one intervention focused on increasing child growth monitoring and providing feedback to families (GROWTH MONITORING); and two interventions that combined GROWTH MONITORING with a 6-month, behavioral, parent-only intervention that focused on two energy-balance behaviors ( decreasing sugar sweetened beverage and sweet and salty snack food intake [DECREASE] vs. increasing fruit, vegetable, and low-fat dairy intake [INCREASE]) (Trial 1) and decreasing sugar sweetened beverage intake and increasing physical activity [TRADITIONAL] vs. increasing low-fat milk intake and decreasing TV watching [SUBSTITUTE]) (Trial 2). It was hypothesized that the combined interventions would show greater improvements in child weight status.

The High-energy Stereoscopic System (H.E.S.S.) is an array of atmospheric Cherenkov telescopes dedicated to GeV-TeV γ ray astronomy. Four 12 meter diameter telescopes (CT) are currently in operation and a fifth 28 meter diameter telescope (LCT) should be completed by 2011. This will lower the system's energy threshold in stereoscopy down to ≈ 50 GeV. Concurrently, the LCT will also be used to detect monoscopic lower energy showers without a coincident detection on the smaller telescopes. This is made possible thanks to the higher sensitivity and the faster electronics of the LCT. But lowering the L1 trigger conditions on the LCT results in a larger number of spurious background detections the reduction of which motivates the second level trigger system of the LCT. An efficient L2 selection algorithm was designed based on intensive off line simulations of air shower images from different background events and their morphological differences as seen by the LCT. The present contribution reports on the flexible and reconfigurable hardware solution designed for the L2 trigger, and on the real-time implementation of the proposed L2 algorithm.

Toxins and other health threats can cause health problems, whether they are present in the child’s own home, other neighborhood homes where the child spends time, or common areas such as playgrounds. We assess the impact of where a child lives on the burden of lead poisoning. Statewide lead screening data was obtained from the Rhode Island Department of Health. Block group level indicators of old housing and poverty were obtained from the US Census. Of the 204,746 study children, 35,416 (17.3%) had a blood lead level ≥10 μg/ dL. The proportion of study children who were lead poisoned in each block group ranged from 0.0 to 48.6%. The proportion of study children with an elevated blood lead level increased from 8% among children living in block groups in the lowest quintile of poverty to 31% for those in the highest quintile for poverty. Old housing also had an important impact on the risk of lead poisoning. The proportion of children with an elevated blood lead level increased from 7% among children living in block groups in the lowest quintile for pre-1950 housing to 27% for those in the highest quintile for pre-1950 housing. The adjusted odds ratio was 1.64 for the highest quintile of poverty and 1.77 for the highest quintile of pre-1950 housing. The findings of this large, statewide study demonstrate the powerful impact of where children live on the risk of lead poisoning. The findings have important implications for understanding the problem of lead poisoning and for planning primary prevention programs.

Introduction A 10 K run was organized in southwestern France in early April 2017. Several dozens of runners had discomforts, some of them very serious faint. Early health care was provided by first aid workers on site. Fire and emergency Service and the local hospital activated their emergency response plan. The Regional Health Agency called on the local Poison Control Center (PCC) and the Regional office of the French National Agency for Public Health to investigate the outbreak. The purpose of the survey was to describe the event and to determine the causes of these discomforts, and the risk factors of their occurrence. Methods An exploratory survey was set up to describe the event. Telephone interviews were conducted with the race organizer, the first aid station director, paramedics and the local hospital. People transported to the hospital were asked about their consumption (water, food, doping substances, medication, etc.) before and during the race, their risk factors for hyperthermia, as well as their symptoms through an individual questionnaire. A telephone survey was conducted by an epidemiologist. Emergency and hospitalization reports as well as the results of biological and toxicological analyses were evaluated by a toxicologist from the regional PCC. Results The running event gathered 4280 participants, including 70 dropouts. The event started at 6:30 PM. First participants arrived on site at 4:30 PM, which implied a 2-hour-wait under unusual heat for the season (27 °C at 6 PM). The first aid station took care of 31 people during and after the event for severe dehydration and hypoglycemia, especially after the 7th and the 8th km A total of 17 people (2 women and 15 men, between 23 and 52 years old) were transported to the hospital, 15 of them for a medical consultation and 2 were hospitalized in intensive care. They all recovered; no deaths were reported. Individual risk factors could be investigated for 7 men who were transported to hospital, including the 2 admitted to intensive care. Of these, 2 were overweight, 1 reported chronic pathology (asthma). None had used alcohol or other psychoactive substances within 24 hours of the race. It was the first participation to such an event for only one man. However, this man practiced running on a regular basis. Four runners spontaneously reported a lack of water or difficulties to access to the water, particularly at the 7th km. Eight hospitalization reports were sent to regional PCC. The clinical and biological analyses of these patients were consistent with heat stroke. Toxicology tests did not indicate any presence of toxic substances. For one of the patients, the consumption of a prescribed medication (corticoid) may have contributed to the occurrence of the heat stroke. Discussion The investigation was consistent with heat stroke. Relatively hot conditions, prolonged exposure to heat before the race, limited access to water stations and some unclear waypoints may have been aggravating factors. A delay in preventive health care (rehydration–cooling) was also reported. These elements were taken into account by the organizers for the organization of the next races. The organization of a sport's events during a heat wave requires specific precautions to be taken by the organizers and by participants. Prompt medical assistance during the race is needed.

The Benchmark of the Rance beams has been organised in order to evaluate the capabilities of various modelling tools, to predict the residual load carrying capacity of corroded beams. The Rance beams have been corroded in a marine environment for nearly 40 years. Different types of prestressed beams, made of different types of cement, have been subjected to four points bending monotonous and cyclic tests as well as direct traction tests. The tests have been carried on up to failure, in order to evaluate the residual carrying capacity of the beams. Different teams have participated to the blind prediction of the tests results. In this framework, the CEA/DM2S/LM2S team has performed bidimensionnal modellings which are described in details in this paper. The various constitutive elements of the beams are represented: for concrete, the isotropic Mazars' damage model is used, in a non local version, for prestressing and passive steels, an elasto-plastic strain hardening model is adopted. The corrosion effects, taken into account for the longitudinal rebars, are derived on one hand from the measurements performed on the beams after the tests, and on the other hand from the literature. They consist mainly in a reduction of the rebars cross-section, as well as in their ductility. In principle, the properties of the bond between steel and rebars are also modified by the corrosion. Here, because of the unavailability of specific data on the smooth rebars of the Rance beams, the bond has been modelled by means of specific joint finite elements. The load carrying capacity has been calculated for the monotonous as well as the cyclic tests. Moreover, a sensitivity analysis has been performed, by considering variants where either the rebars are sane, or they have only reduced sections, with their original ductility. The results are compared to the experimental database, and discussed.

Objectives: This study examined tuberculosis screening among preschool children enrolled in a statewide Medicaid managed care program. Methods: A random sample of 2,000 was selected from 19 to 35 month old children who were continuously enrolled in Rhode Island's Medicaid managed care program for 1 year. Sociodemographic data were obtained from computerized administrative databases. Medical record audits were performed to obtain the dates and results of tuberculosis tests. Results: Data from the medical record audits were available for 1,988 of the study children. For 1,215 of the study children (1,215/1,988=61%) a tuberculin skin test had been performed, but a reading was only documented for 736 children (60% of children who received a tuberculin skin test) and only one child tested positive (0.1%). Conclusions: A majority of preschool children in this population in which the prevalence of risk factors for tuberculosis is likely to be relatively high did have a tuberculosis test performed. However, in many cases the tuberculin skin test was either not read or the results not documented. The low rate of positivity is consistent with current AAP guidelines for selective tuberculin skin testing.

Purpose of reviewThis article reviews the impact of the Medicaid program, including the proportion of children in America insured by Medicaid; the extent to which Medicaid-enrolled children have access to care; the use of services and the quality of care received by Medicaid enrollees, including evi

Objective: The objective of this study was to examine the relationship between healthcare use and children’s healthcare needs as assessed from the perspectives of children themselves, parents, and healthcare practitioners. Research Design: We conducted a prospective cohort study in which service use was monitored for the 12 months before and after administration of a health survey. Subjects: We studied 384 parents and children aged 6 to 11 years enrolled for 2 years in a northern California health maintenance organization or a Medicaid managed care program in Rhode Island. Measures: Child and parent perspectives on needs were determined using the Child Health and Illness Profile, Child Edition (CHIP-CE). Plan administrative data were used to develop a treated morbidity index, which was based on diagnosis codes recorded by practitioners during the year before the survey and to obtain prospective measures of service use. Results: For both child- and parent-respondents, low satisfaction and comfort scale scores from the CHIP-CE were significant predictors of number of visits. CHIP-CE domain scales unrelated to future use were risk avoidance, resilience, and achievement. Multivariable regression using CHIP-CE information collected from children explained more variation in total physician visits than models that used parent-respondent data. The treated morbidity index was a weaker predictor of physician visits than the CHIP-CE scale scores. None of the domain scales were significant predictors of any emergency department use or any specialist use; however, the treated morbidity index was associated with any specialist use. Conclusions: A child’s sense of well-being and burden of symptoms predict future use. Perceived healthcare needs, as assessed by the CHIP-CE, is a better predictor of children’s service use than evaluated needs as assessed by physician-diagnosed disorders. Our results support the validity of using the responses of children aged 6 to 11 years as a measure of need for future health care.

Objectives: To describe pediatric emergency department (ED) utilization within a Medicaid managed care system and to investigate the association between pediatric ED utilization and the type of medical home. Methods: This was a retrospective cohort study, set at Rhode Island's statewide Medicaid managed care program (RIte Care). The study population was a random sample of 2,000 children aged 19 to 35 months at the conclusion of a period of continuous RIte Care enrollment from July 1, 1996, until June 30, 1997. For description of ED utilization, rates of utilization and percentages were calculated. Bivariate and multivariate analyses were used to determine the effect of type of medical home and individual/family characteristics on ED utilization. Logistic regression models were used to determine odds ratios for types of medical home while controlling for sociodemographic factors and practice level variation. Results: Of the 1,988 children who were eligible for analysis, 791 children utilized the ED during the study year at a rate of 68 ED visits/100 person-years. Thirty-one percent of those visits were for injuries/poisonings. Logistic regression analysis demonstrated decreased ED utilization for patients enrolled in a staff-model health maintenance organization (HMO) (OR 0.34; 95% CI = 0.27 to 0.42) or a health center (OR 0.71; 95% CI = 0.53 to 0.95) compared with hospital-based clinics. There was no significant association between the receipt of preventive services and ED utilization. Conclusions: Despite the presence of a defined medical home, ED use was common among preschool children enrolled in the statewide Medicaid managed care program. The type of medical home was an important determinant of ED use in this population.

Objectives. We examined the effects of changes in Rhode Island’s Lead Hazard Mitigation Law in 2005 on children’s blood lead levels. Methods. We used 2005 to 2009 data from Rhode Island’s Lead Elimination Surveillance System; city tax assessor records in Central Falls, Pawtucket, Providence, and Woonsocket, Rhode Island; and records of conformance to the state’s lead hazard mitigation law, to assess the extent to which legislation changes resulted in minimizing children’s exposure to lead. Results. During the 5-year study, the proportion of properties that complied with the new law increased for properties that housed young children. However, the majority of rental properties did not comply with the law. Children’s lead levels declined by approximately 1 microgram per deciliter on average in properties that did comply, demonstrating that the law could have a protective effect for children. Conclusions. Legislation changes increased the proportion of properties that were certified as nonhazardous, leading to decreased blood lead levels for children living in these properties. However, legislation cannot be a highly effective primary prevention strategy if it does not cover all properties where children live and is not strictly enforced.

This article examines the association between mental health disorders and being identified as a bully among children between the ages of 6 and 17 years. Data from the 2007 National Survey of Children’s Health were examined. A total of 63,997 children had data for both parental reported mental health and bullying status. Bivariate analysis and logistic regression was performed to assess the association between mental health status and being identified as a bully with an age-stratified analysis and sub-analysis by type of mental health disorder. In 2007, 15.2% of U.S. children ages 6 to 17 years were identified as bullies by their parent or guardian. Children with a diagnosis of depression, anxiety, or depression had a threefold increased odds of being a bully. The diagnosis of depression is associated with a 3.31 increased odds (95% CI = [2.7, 4.07]) of being identified as a bully. Children with anxiety and attention deficit and hyperactivity disorder (ADHD) had similar odds. The diagnosis of a mental health disorder is strongly associated with being identified as a bully. In particular, depression, anxiety, and ADHD are strongly associated with being identified as a bully. These findings emphasize the importance of providing psychological support to not only victims of bullying but bullies as well. Understanding the risk profile of childhood bullies is essential in gaining a better grasp of this public health problem and in creating useful and appropriate resources and interventions to decrease bullying.

Objectives The goal of this study was to assess (i) whether preschool children enrolled in a hospital-based, Medicaid managed care practice had received recommended preventive screenings, including blood lead, hematocrit and tuberculosis testing, and (ii) the prevalence of positive results in these screens. Design and methods All children between 12 and 35 months of age who had been continuously enrolled in the practice for the last 6 months of 1996 were included in the study, regardless of their visit frequency. Medical records were reviewed for the study children. The dates and results of all blood lead, hematocrit and tuberculosis tests were abstracted. Results Eight hundred and twelve children met the study inclusion criteria. All but two of these children had a hospital medical record available for review. Six hundred and ninety of the 812 children (85.0%) had a documented blood lead test. Of those screened, more than one-quarter (190 of 690; 27.5%) had at least one result ≥ 10 μg/dL. A hematocrit result was documented for 742 of the study children (91.4%), and 377 of these children (50.8%) were anemic on at least one test (defined as a hematocrit two standard deviations below published norms). Two-thirds of study children (536) had documentation of a tuberculosis screen being performed, with two-thirds of these having a documented reading. None of the 342 children with a documented tuberclin skin test reading had a positive test. Conclusions Screening rates were relatively high in this study group, especially when one considers that the denominator for screening rates was based on enrollment in the practice, regardless of whether or not the child had been seen. The results of these screening tests provide evidence for the high burden of lead poisoning and anemia in this low-income population. Implications for practice This study demonstrates that it is feasible to carry out assessments based on defined primary care responsibilities, allowing for a more population-based approach to health care in hospital-based clinics.

Objectives. To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates. Design and methods. The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment"). Results. With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series. Conclusions. When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.

Background.Reading aloud is an important activity to prepare children to succeed in learning to read. Many Hispanic children have reading difficulties and therefore are at increased risk for school failure.Methods.We conducted a prospective, randomized, controlled study to evaluate the effectiveness of a literacy promoting intervention delivered to low-income Hispanic families with infants. We consecutively enrolled 135 low-income Hispanic parents of healthy 5 to 11 month old infants. Families were randomly assigned to an intervention (n = 65) or control (n = 70) group. At enrollment and at two consecutive well-child visits, pediatricians gave intervention families: 1) an age-appropriate bilingual children's book, 2) a bilingual handout explaining the benefits of reading to children, and 3) literacy-promoting anticipatory guidance. Ten months after enrollment we reinterviewed 130 parents.Results.Both groups were comparable at baseline. At follow-up, intervention parents were more likely to read books with their child at least 3 days/week (intervention = 66% vs control parents = 24%) and to report that reading books was one of their three most favorite things to do with their child (intervention = 43% vs controls = 13%). Intervention families also had a greater number of children's books and total books at home. Using a multiple logistic regression model, controlling for child and parental age, reading habits, and English proficiency, we found that the odds of parents reading to their child at least 3 days/week were 10 times greater in intervention families (OR 10.1, 95% CI 4.0–25.6) compared with control families.Conclusions.This simple, culturally appropriate intervention significantly increased literacy behaviors in low-income Hispanic families.

Objective. To determine the community-wide incidence of missed opportunities to vaccinate, to describe the clinical settings in which they occur, and to estimate the impact of missed opportunities on immunization coverage. Design and Methods. We abstracted outpatient medical records from a random, community-based sample of 2-year-old children whose residence was inner-city Baltimore. The date of each vaccine and the date, diagnoses, and temperature at each visit were collected for 502 children at 98 different provider sites. Main Outcome Measures. Missed opportunities to vaccinate and up-to-date vaccination status. Results. By 24 months of age, 75% of the children had at least one missed opportunity and only 55% were up-to-date for the 4:3:1 series. Missed opportunities occurred at more than one third of eligible visits for each vaccine, including >20% of preventive care visits. Diagnoses commonly associated with missed opportunities were "well child," otitis media, upper respiratory infection, gastroenteritis, skin infection, and resolving illness. If no missed opportunities had occurred, 73% of the children would have been up-to-date by 24 months. Conclusions. Missed opportunities occurred commonly at providers serving inner-city children in Baltimore and represent a major factor in underimmunization. Reduction of missed opportunities by accurate screening at all visits and adherence to the contraindication guidelines is a provider-based, low-cost method to increase immunization coverage.

Because improving health is the ultimate goal of a health care system, the measurement of health outcomes in research is a logical and important goal for the evaluation of the impact of health services. Although health can be defined in various ways, here we employ a conceptualization that has several domains including longevity, disease, comfort, perceived well being, activity, achievement, and resilience. Given that health is such a broad concept, the difficult task for outcomes research is to provide the means of measuring it. As this brief summary of current work indicates, a number of approaches have been used in recent pediatric studies. Most focus on a small subset of health concerns. However, some studies have attempted to broaden the assessment of health outcome either by using multiple health measures or developing multidimensional instruments for measuring health. Care must be taken in evaluating the usefulness of any of the instruments until sufficient data are obtained as to their reliability and validity. Further work in this area is needed, particularly with regards to multidimensional approaches, which are beginning to provide a more sensitive and comprehensive means of assessing the impact of health services.

Refugee children can have significant health problems. Our objective was to describe health status and health care utilization of refugee children after resettlement. A retrospective chart review of refugee children was performed. Initial laboratory data was extracted. Primary care visits, emergency room visits, and subspecialty referrals in the first 15 months from arrival were recorded. The sample included 198 refugees, many with positive initial screening tests. After arrival, 21% had an emergency department visit, 40% had a primary care sick visit, and 71% had a primary care follow-up. Mean number of visits ranged from 0.3 for emergency department to 1.9 for follow-up. Fifty-seven percent were referred to at least one subspecialist. Refugee children had substantial disease burden at arrival. Most had primary care follow-up visits and subspecialty referral after resettlement. These visits were largely for problems identified on initial screening and for general pediatric illnesses.

H.E.S.S is an array of atmospheric Cherenkov telescopes dedicated to GeV-TeV gamma-ray astronomy. The original array has been in operation since the beginning of 2004. It is composed of four 12-meter diameter telescopes. The installation of a fifth 28-meter diameter telescope is being completed. This telescope will operate both in stereoscopic mode and in monoscopic mode i.e. without a coincident detection on the smaller telescopes. A second-level trigger system is needed to supress spurious triggers of the 28-meter telescope when operated in monoscopic mode. This paper gives the motivation and principle of the second-level trigger. The principle of operation is illustrated by an example algorithm. The hardware implementation of the second level trigger system of H.E.S.S. phase 2 is described and its expected performances are then evaluated., Comment: accepted for publication in Astroparticle Physics