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Seizures and abnormal periodic or rhythmic patterns are observed on continuous electroencephalography monitoring (cEEG) in up to half of patients hospitalized with moderate to severe traumatic brain injury (TBI). We aimed to determine the impact of seizures and abnormal periodic or rhythmic patterns on cognitive outcome 3 months following moderate to severe TBI. This was a post hoc analysis of the multicenter randomized controlled phase 2 INTREPID2566 clinical trial conducted from 2010 to 2016 across 20 United States Level I trauma centers. Patients with nonpenetrating TBI and postresuscitation Glasgow Coma Scale scores 4–12 were included. Bedside cEEG was initiated per protocol on admission to intensive care, and the burden of ictal-interictal continuum (IIC) patterns, including seizures, was quantified. A summary global cognition score at 3 months following injury was used as the primary outcome. 142 patients (age mean + / − standard deviation 32 + / − 13 years; 131 [92%] men) survived with a mean global cognition score of 81 + / − 15; nearly one third were considered to have poor functional outcome. 89 of 142 (63%) patients underwent cEEG, of whom 13 of 89 (15%) had severe IIC patterns. The quantitative burden of IIC patterns correlated inversely with the global cognition score (r = − 0.57; p = 0.04). In multiple variable analysis, the log-transformed burden of severe IIC patterns was independently associated with the global cognition score after controlling for demographics, premorbid estimated intelligence, injury severity, sedatives, and antiepileptic drugs (odds ratio 0.73, 95% confidence interval 0.60–0.88; p = 0.002). The burden of seizures and abnormal periodic or rhythmic patterns was independently associated with worse cognition at 3 months following TBI. Their impact on longer-term cognitive endpoints and the potential benefits of seizure detection and treatment in this population warrant prospective study.

BACKGROUND Sleep is increasingly recognized as a vital part of health. Screen time has been linked to sleep quality in children. The purpose of this study was to analyze associations between screen time and sleep characteristics among low-income preschoolers. METHODS A total of 1,700 preschool-aged children participated in this study at 50 federally and state-funded preschool centers in Michigan. Baseline measurement for an ongoing longitudinal intervention trial was obtained for cross-sectional use. At baseline, parents reported the number of hours their child spent engaging in screen time on a typical week day and weekend. An aggregate measure of total screen time was created. Parents reported on the quality of their child's sleep, how often they were tired during the day, and whether they had difficulty falling asleep. A mixed model linear regression was created to analyze data. RESULTS Controlling for child's age, race, and parental income, children who engaged in more screen time were significantly more likely to have more trouble falling or staying asleep, be tired during the day, and had worse quality of sleep (P values = .004, .006 and .001, respectively). Spearman correlations of screen time, sleep variables and demographics show parents of Black children reported significantly higher weekly screen time than parents of non-Black children (r = 0.23, P

OBJECTIVE. This study examined whether carrying dopamine-related “risk” genes—either the dopamine transporter (DAT1) 10-repeat allele or dopamine receptor-4 (DRD4) 7-repeat allele—moderated the association of family environment and executive function (EF) following traumatic brain injury in early childhood. METHOD. Caregivers of children with traumatic brain injury (TBI) or orthopedic injury (OI) completed the Behavior Rating Inventory of Executive Function (BRIEF) at post-injury visits. General linear models examined gene-environment interactions as moderators of the effects of TBI on EF at 12 months and 7 years post-injury. RESULTS. At 12 months, we did not find any significant gene by environment interactions. At 7 years, we found a significant 3-way interaction among combined carrier status, level of permissive parenting, and injury type. For children exposed to more optimal parenting, carriers of DAT1 and/or DRD4 risk alleles with TBI showed significantly worse parent-reported EF compared to carriers with OI. In those with less optimal parenting, carriers and non-carriers with TBI, as well as carriers with OI, showed significantly worse parent-reported EF compared to non-carriers with OI, with medium to large effect sizes. CONCLUSIONS. The findings highlight the importance of considering polygenetic and environmental factors in future studies of recovery following TBI and other injuries in childhood.

One of the biggest challenges that face cochlear implant (CI) users is the highly variable hearing outcomes of implantation across patients. Since speech perception requires the detection of various dynamic changes in acoustic features (e.g., frequency, intensity, timing) in speech sounds, it is critical to examine the ability to detect the within-stimulus acoustic changes in CI users. The primary objective of this study was to examine the auditory event-related potential (ERP) evoked by the within-stimulus frequency changes (F-changes), one type of the acoustic change complex (ACC), in adult CI users, and its correlation to speech outcomes. Twenty-one adult CI users (29 individual CI ears) were tested with psychoacoustic frequency change detection tasks, speech tests including the Consonant-Nucleus-Consonant (CNC) word recognition, Arizona Biomedical Sentence Recognition in quiet and noise (AzBio-Q and AzBio-N), and the Digit-in-Noise (DIN) tests, and electroencephalographic (EEG) recordings. The stimuli for the psychoacoustic tests and EEG recordings were pure tones at three different base frequencies (0.25, 1, and 4 kHz) that contained a F-change at the midpoint of the tone. Results showed that the frequency change detection threshold (FCDT), ACC N1′ latency, and P2′ latency did not differ across frequencies (p > 0.05). ACC N1′-P2 amplitude was significantly larger for 0.25 kHz than for other base frequencies (p < 0.05). The mean N1′ latency across three base frequencies was negatively correlated with CNC word recognition (r = −0.40, p < 0.05) and CNC phoneme (r = −0.40, p < 0.05), and positively correlated with mean FCDT (r = 0.46, p < 0.05). The P2′ latency was positively correlated with DIN (r = 0.47, p < 0.05) and mean FCDT (r = 0.47, p < 0.05). There was no statistically significant correlation between N1′-P2′ amplitude and speech outcomes (all ps > 0.05). Results of this study indicated that variability in CI speech outcomes assessed with the CNC, AzBio-Q, and DIN tests can be partially explained (approximately 16–21%) by the variability of cortical sensory encoding of F-changes reflected by the ACC.

Background and Objectives: Adult class II/III obesity (BMI ≥ 35 kg/m2) has significant adverse health outcomes. Early prevention and treatment are critical, but prospective childhood risk estimates are lacking. This study aimed to define the prospective risk of adult class II/III obesity, using childhood BMI. Methods: Children ages 3–19 years enrolled in cohorts of The International Childhood Cardiovascular Cohort (i3C) Consortium with measured BMI assessments in childhood and adulthood were included. Prospective risk of adult class II/III obesity was modeled based on childhood age, sex, race and BMI. Results: 12 142 individuals (44% male, 85% white) were assessed at median age 14 [Interquartile range, IQR: 11, 16] and 33 [28, 39] years. Class II/III adult obesity developed in 6% of children with normal weight; 29% of children with overweight; 56% of children with obesity; and 80% of children with severe obesity. However, 38% of the 1 440 adults with class II/III obesity (553/1440) were normal weight as children. Prospective risk of adult class II/III obesity varied by age, sex and race within childhood weight status classifications, and is notably higher for girls, black participants, and those in the United States. The risk of class II/III obesity increased with older adult age. Conclusions: Children with obesity or severe obesity have a substantial risk of adult class II/III obesity, and observed prospective risk estimates are now presented by age, sex, race and childhood BMI. Clinical monitoring of children’s BMI for adult class II/III obesity risk may be especially important for females and black Americans., Table of Contents Summary This study developed prospective risk estimates of adult class II/III obesity using childhood BMI, childhood age, sex and race, using longitudinal international data.

Objective:We examined parent- and adolescent-reported executive functioning (EF) behaviors following pediatric traumatic brain injury (TBI) in the context of Online Family Problem-Solving Therapy (OFPST) and moderators of change in EF behaviors.Method:In total, 274 families were randomized to OFPST or an internet resource comparison group. Parents and adolescents completed the Behavior Rating Inventory of Executive Function at four time points. Mixed models were used to examine EF behaviors, assessing the effects of visit, treatment group, rater, TBI severity, age, socioeconomic status, and family functioning.Results:Parents rated their adolescents’ EF as poorer (F(3,1156) = 220.15, p < .001; M = 58.11, SE = 0.73) than adolescents rated themselves (M = 51.81, SE = 0.73). Across raters, EF behaviors were poorer for adolescents whose parents had less education (F(3,1156) = 8.60, p = .003; M = 56.76, SE = 0.98) than for those with more education (M = 53.16, SE = 0.88). Age at baseline interacted with visit (F(3,1156) = 5.05, p = .002), such that families of older adolescents reported improvement in EF behaviors over time. Family functioning also interacted with visit (F(3, 1156) = 2.61, p = .049), indicating more improvement in EF behaviors over time in higher functioning families. There were no effects of treatment or TBI severity.Conclusion:We identified a discrepancy between parent- and adolescent-reported EF, suggesting reduced awareness of deficits in adolescents with TBI. We also found that poorer family functioning and younger age were associated with poorer recovery after TBI, whereas adolescents of parents with less education were reported as having greater EF deficits across time points.

In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM ( N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate ( OR = 1.63, p < .01), vicarious HIV stigma ( OR = 2.73, p < .01), and age ( OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC ( OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.

IntroductionThere remain significant knowledge gaps about the management and outcomes of children with anaphylaxis. These gaps have led to practice variation regarding decisions to hospitalise children and length of observation periods following treatment with epinephrine. The objectives of this multicentre study are to (1) determine the prevalence of and risk factors for severe, persistent, refractory and biphasic anaphylaxis, as well as persistent and biphasic non-anaphylactic reactions; (2) derive and validate prediction models for emergency department (ED) discharge; and (3) determine data-driven lengths of ED and inpatient observation prior to discharge to home based on initial reaction severity.Methods and analysisThe study is being conducted through the Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC). Children 6 months to less than 18 years of age presenting to 30 participating EDs for anaphylaxis from October 2015 to December 2019 will be eligible. The primary outcomes for each objective are (1) severe, persistent, refractory or biphasic anaphylaxis, as well as persistent or biphasic non-anaphylactic reactions; (2) safe ED discharge, defined as no receipt of acute anaphylaxis medications or hypotension beyond 4 hours from first administered dose of epinephrine; and (3) time from first to last administered dose of epinephrine and vasopressor cessation. Analyses for each objective include (1) descriptive statistics to estimate prevalence and generalised estimating equations that will be used to investigate risk factors for anaphylaxis outcomes, (2) least absolute shrinkage and selection operator regression and binary recursive partitioning to derive and validate prediction models of children who may be candidates for safe ED discharge, and (3) Kaplan-Meier analyses to assess timing from first to last epinephrine doses and vasopressor cessation based on initial reaction severity.Ethics and disseminationAll sites will obtain institutional review board approval; results will be published in peer-reviewed journals and disseminated via traditional and social media, blogs and online education platforms.

Given sparse literature examining receipt of behavioral health service in children and caregivers following traumatic brain injury (TBI), we sought to identify predictors of unmet need. We performed an individual participant data meta-analysis using generalized linear mixed-effect models to examine predictors of behavioral health service use and unmet need. We included 572 children, ages 3 to 18, who were hospitalized overnight following complicated mild to severe TBI between 2002 and 2015. Caregivers completed ratings of depression and distress, child behavior problems, family functioning, and behavioral health service utilization. For children, unmet behavioral health service need was defined as an elevation on one or more child behavior problem scales without receipt of behavioral health services. For caregivers, unmet need was defined as an elevation on either a depression or distress scale without behavioral health service utilization. Among those with behavioral health needs, rates of unmet need were high for both children (77.8%) and caregivers (71.4%). Poorer family functioning was related to more unmet need in children (F(1, 497) = 6.57, p = 0.01; OR = 1.8) and caregivers (F(1, 492) = 17.54, p

This study examined the feasibility and acceptability of an evidence-based HIV prevention program for men who have sex with men (MSM) in Ghana through a participatory approach. The program involved 57 self-identified adult cisgender MSM and led by a community-based organization in collaboration with local nurses. We used an explanatory mixed-method design to evaluate the program. We computed descriptive statistics, relative frequency and paired t-test for the survey data and subjected the focus groups data to summative content analysis. Five key themes from the qualitative data indicated strong evidence of acceptability and efficacy of the program among MSM. The program contributed to building social support networks, sense of social justice among MSM, and facilitated the development of personalized HIV prevention menus by the participants. There were no statistically significant differences in scores between the baseline and 1-week post-program assessments. Nonetheless, we observed increases in HIV testing (from 4% to 17%) and increases in relative frequency of condom use for anal, oral, and vaginal sex. The program served as an example of a successfully implemented culturally grounded intervention that has a potential to increasing HIV and STI awareness and prevention among MSM in Ghana and other highly stigmatized environments.

Black men bear a disproportionate burden of HIV infection. These HIV inequities are influenced by intersecting social, clinical, and behavioral factors. The purpose of this analysis was to determine the combinations of factors that were most predictive of HIV infection and HIV testing among black men in Toronto. Classification and regression tree analysis was applied to secondary data collected from black men (N = 460) in Toronto, 82% of whom only had sex with women and 18% whom had sex with men at least once. For HIV infection, 10 subgroups were identified and characterized by number of lifetime male partners, age, syphilis history, and perceived stigma. Number of lifetime male partners was the best single predictor of HIV infection. For HIV testing, the analysis identified 8 subgroups characterized by age, condom use, number of sex partners and Chlamydia history. Age (>24 years old) was the best single predictor of HIV testing.

Introduction: The transplant waiting list exceeds the number of organs available. One means of increasing the organ pool is to broaden potential donors to include those with chronic diseases. Research Questions: The study tested the effectiveness of using peer mentors to encourage individuals on dialysis to enroll on an organ donor registry. Design: Dialysis units were pair-matched by size and racial composition and then randomized to one of 2 interventions: meetings with a peer mentor (experimental intervention) or organ donation mailings (control). Peer mentors were trained to discuss organ donation with individuals on dialysis during in-person meetings at dialysis units. The primary outcome was verified registration in the state’s donor registry. Results: After adjusting for age, gender, race, income, and education and accounting for correlation within the dialysis center, there was a significant intervention effect. Among individuals in the intervention group, the odds of enrolling (verified) on the donor registry were 2.52 times higher than those in the control group. Discussion: The use of peer mentors to discuss donating organs after death with individuals on dialysis can increase enrollment on a donor registry. Dispelling myths about chronic illness and donation can counter widely held misconceptions and help persons make an informed choice about end-of-life decisions and present an opportunity to increase the number of organs and tissues available for transplant.

PURPOSE: Adolescents represent over half of the newly diagnosed sexually transmitted infections in the US annually. Emergency departments (ED) may serve as an effective, nontraditional setting to screen for Chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings. METHODS: This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents ages 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED. RESULTS: Both EDs experienced modest but statistically significant increases in CT/GC testing post- vs. pre- intervention (main: 11.5% vs. 7.9%; CI: 2.9, 4.2; p < 0.0001 and satellite: 3.8% vs. 2.6%; 95% CI: 0.7, 1.7; p < 0.0001). Among those tested, the positivity rate at the main ED did not significantly change post- vs. pre-intervention (24.1% vs. 23.2%, 95% CI: −1.9, 3.8; p=0.71) but significantly decreased at the satellite ED (7.6% vs. 14.8%, 95% CI: −12.2, −2.2; p=0.01). CONCLUSION: A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.

Short sleep has been linked to adolescent obesity risk, but questions remain regarding the dietary mechanisms by which this occurs. We tested whether mildly shortening sleep influences how rewarding and appealing healthy adolescents find several kinds of foods. Eighty-eight healthy adolescents completed a within-subjects crossover sleep experiment comparing 5 days of Short Sleep (6.5 hour sleep opportunity) vs. 5 days of Healthy Sleep (9.5 hour sleep opportunity). Following each condition, adolescents completed measures of food appeal and reinforcing value of food across five food types: sweets/desserts, fruits/vegetables, lean meats/eggs, fast food entrees, and processed snacks. Adolescents averaged 2.2 hours/night longer sleep periods in Healthy Sleep vs. Short Sleep. We observed a significant interaction of experimental order with sleep condition on three of four primary outcomes related to the appeal and reinforcing value of foods (p’s.05). This study provides evidence that restricting adolescents’ sleep opportunity to 6.5 hours (compared to sleeping a healthy amount) increases the appeal and reinforcing value of a variety of foods, but this may occur only under protracted short sleep. Increased food reward may be one mechanism linking chronically shortened sleep with obesity risk in adolescence.

Objective To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors. Setting Children's hospitals in the Midwestern/Western United States. Participants 381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago. Design Secondary data analysis of a multistudy cohort. Main measures Child Behavior Checklist (CBCL) administered pretreatment. Results Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys. Conclusions Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.

PURPOSE: The pediatric emergency department (PED) provides care for adolescents at high risk of unintended pregnancy, but little is known regarding the efficacy of PED-based pregnancy prevention interventions. The objectives of this PED-based pilot intervention study were to (1) assess the rate of contraception initiation after contraceptive counseling and appointment facilitation in the PED during the study period (2) identify barriers to successful contraception initiation and (3) determine adolescent acceptability of the intervention. METHODS: This pilot intervention study included females 14–19 years of age at risk for unintended pregnancy. Participants received standardized contraceptive counseling and were offered an appointment with Gynecology. Participants were followed via electronic medical record and phone to assess contraception initiation and barriers. Chi-square tests were used to examine the association between contraception initiation and participant characteristics. RESULTS: One hundred forty-four patients were eligible, and 100 were enrolled. In the PED, 68% (68/100) expressed interest in initiating hormonal contraception, with 70% (48/68) of interested participants, indicating long acting reversible contraception (LARC) was their preferred method. Twenty-five percent (25/100) of participants initiated contraception during the study period, with 19 participants starting LARC. Thirty-nine percent (22/57) of participants that accepted a gynecology appointment, attended that appointment. Barriers to follow-up include transportation and inconvenient follow up times. Participants were accepting of the intervention with 93% agreeing that the PED is an appropriate place for contraceptive counseling. CONCLUSIONS: PED contraceptive counseling is acceptable among adolescents and led to successful contraception initiation in 25% of participants. The main barrier to contraception initiation was participant follow up with the gynecology appointment.

PURPOSE: Examine the impact of traumatic brain injury (TBI) on parenting behavior over time. METHOD: Included 206 children (3–7 years old) with moderate-severe TBI or orthopedic injury, using a prospective longitudinal cohort study design. Assessments completed at baseline, 6-months, 12-months, 18-months, 3.5 years, and 6.8 years after injury. Dependent variables included authoritative, permissive, and authoritarian parenting. RESULTS: Injury characteristics had limited impact on parenting behaviors over time. Levels of authoritative parenting remained stable over time; however, levels of warmth and involvement declined over time for those with TBI. Levels of permissive and authoritarian parenting declined for all participants by 3.5 years post injury. SES and stressors impacted parenting behaviors. CONCLUSIONS: While there was limited effect of TBI on parenting behavior over time, it remains unclear how individuals respond to these parenting behaviors years after injury. Clinicians should monitor family and parenting behaviors to foster an environment to promote positive recovery.

The purpose of this pilot quasi-experimental study was to examine the feasibility and preliminary efficacy of using Facebook in a 10-week lifestyle intervention with Head Start caregiver–preschooler dyads to improve healthy behaviors and reduce body mass index. Sixty-nine dyads participated with 39 in the intervention group. Average preschooler attendance rate for the Head Start center-based program was 77%, and caregiver participation rate was 87%. About 94% of the caregivers were satisfied with the program, and 97% would recommend the program to others and/or participate again. The intervention decreased preschoolers’ body mass index z score (Cohen’s d = –.30) and screen time ( d = –.21), and increased their fruit and vegetable intake ( d = .40) and moderate-to-vigorous physical activity ( d = .42). The intervention increased caregivers’ fruit and vegetable intake ( d = .40). The intervention is feasible, and preliminary efficacy is encouraging, but further investigation using a rigorous study design is warranted.

Objective Adolescent traumatic brain injury (TBI) contributes to deficits in executive functioning and behavior, but few evidence-based treatments exist. We conducted a randomized clinical trial comparing Teen Online Problem Solving with Family (TOPS-Family) with Teen Online Problem Solving with Teen Only (TOPS-TO) or the access to Internet Resources Comparison (IRC) group. Methods Children, aged 11 to 18 years, who sustained a complicated mild-to-severe TBI in the previous 18 months were randomly assigned to the TOPS-Family (49), TOPS-TO (51), or IRC group (52). Parent and self-report measures of externalizing behaviors and executive functioning were completed before treatment and 6 months later. Treatment effects were examined using linear regression models, adjusting for baseline symptom levels. Age, maternal education, and family stresses were examined as moderators. Results The TOPS-Family group had lower levels of parent-reported executive dysfunction at follow-up than the TOPS-TO group, and differences between the TOPS-Family and IRC groups approached significance. Maternal education moderated improvements in parent-reported externalizing behaviors, with less educated parents in the TOPS-Family group reporting fewer symptoms. On the self-report Behavior Rating Inventory of Executive Functions, treatment efficacy varied with the level of parental stresses. The TOPS-Family group reported greater improvements at low stress levels, whereas the TOPS-TO group reported greater improvement at high-stress levels. The TOPS-TO group did not have significantly lower symptoms than the IRC group on any comparison. Conclusion Findings support the efficacy of online family problem solving to address executive dysfunction and improve externalizing behaviors among youth with TBI from less advantaged households. Treatment with the teen alone may be indicated in high-stress families.

Objectives To determine whether participation in a home visiting program increases and expedites utilization of early intervention services for suspected developmental delays. Methods Children participating in Every Child Succeeds (ECS), a large home visiting (HV) program serving greater Cincinnati, between 2006 and 2012, were propensity score matched to a sample of children identified from birth records who did not receive services from ECS. Data were linked to early intervention (EI) data acquired from the Ohio Department of Health. Descriptive statistics were employed to evaluate success of the matching. Chi square and log-rank tests evaluated whether the proportion of children accessing EI and the time to EI services differed for families participating in HV compared to eligible children not participating. Logistic regression and Cox proportional hazards regression modeled the associations. Results Among 3574 HV and 3574 comparison participants, there was no difference in the time to EI service utilization; however a higher percentage of HV participants accessed services. Overall, 6% of the HV group and 4.3% of the comparison group accessed services (p = 0.001). Modeling revealed an odd ratio = 1.43 [95% confidence interval (CI) 1.16-1.78, p value = 0.001] and hazard ratio = 1.42 [95% CI 1.15-1.75, p value = 0.001]. Differences in utilization were greatest directly after birth and between approximately 2 and 3 years. Conclusions for Practise Participation in home visiting was associated with greater utilization of EI services during two important developmental time points, demonstrating that home visiting may serve as an important resource for facilitating access to early intervention services.

Background: Implicit gender bias leads to differences in assessment. Studies examining gender differences in resident milestone assessment data demonstrate variable results. The purpose of this study was to determine if observational entrustment scores differ by resident and assessor gender in a program of assessment based on discrete, observable skills. Methods: We analyzed overall entrustment scores and entrustment scores by Accreditation Council for Graduate Medical Education (ACGME) core competency for 238 residents (49% female) from 396 assessors (38% female) in one internal medicine residency program from July 2012 to June 2019. We conducted analyses at 1-12 months, 1-36 months, 1-6 months, 7-12 months, and 31-36 months. We used linear mixed-effect models to assess the role of resident and assessor gender, with resident-specific and assessor-specific random effect to account for repeated measures. Results: Statistically significant interactions existed between resident and assessor gender for overall entrustment at 1-12 months (p < 0.001), 1-36 months (p< 0.001), 1-6 months (p Conclusions: No significant differences in entrustment scores were found based on resident or assessor gender in our large, robust entrustment-based program of assessment. Determining the reasons for our findings may help identify ways to mitigate gender bias in assessment.

Context With healthy behaviors becoming established in the preschool years, intervening with preschool children to assist them in establishing a healthy lifestyle and maintaining a long-term healthy weight is critical. To optimize future intervention designs, this meta-analysis aimed to estimate the effects of lifestyle interventions on BMI among preschool children and explore potential intervention moderators. Evidence acquisition In October 2015, a search of PubMed, CINAHL, EMBASE, PsycINFO, ERIC, and Cochrane library databases yielded 52 eligible articles with 42 randomized intervention–control comparisons (31 prevention and 11 treatment). In 2016, weighted standardized mean differences for BMI were calculated using random-effects models to estimate effect sizes. Evidence synthesis The effect sizes were –0.19 (95% CI=–0.28, –0.09) and –0.28 (95% CI=–0.48, –0.09) kg/m 2 for prevention and treatment interventions, with sustained effect sizes of –0.21 (95% CI=–0.35, –0.08) and –0.23 (95% CI=–0.43, –0.04) kg/m 2 , respectively. Child mean age, percentage Hispanic, and parental intervention sessions were common significant moderators. School-based or prevention interventions with active parental involvement did not yield better outcomes. Interventions targeting parents with parenting skill training and behavioral change strategies, and children with general health and nutrition education, resulted in greater effects. Conclusions Although publication bias limits the validity of the study findings, the meta-analysis results highlight the promising intervention approaches of parenting skill training and behavioral change strategies to target parents. However, for children, general health and nutrition education should be employed.

Objective To determine the stability and influence of adherence barriers on medication adherence and seizure control in pediatric epilepsy. Methods Caregivers of 118 children aged 2-12 years old with epilepsy completed the Pediatric Epilepsy Medication Self-Management Questionnaire at nine time points over 2 years post diagnosis. Electronically monitored antiepileptic drug adherence and seizure outcome data were collected. Results Hierarchical linear modeling results for overall barriers remained stable over 2 years. Specific item-level barriers were also generally stable over time, with the exception of running out of medication becoming more of a barrier over time. No specific barriers were related to seizure control; however, difficulties swallowing medication, forgetting, and medication refusal were related to electronically monitored adherence over time. Conclusions Assessing for specific adherence barriers over time may lead to identification of interventions that result in improved adherence and care.

The objectives of the study were to characterize long-term neuropsychological outcomes following traumatic brain injury (TBI) sustained during early childhood, and determine whether identified neuropsychological impairments mediated the effect of TBI on long-term adaptive functioning. Participants included 16 children with severe TBI, 42 children with moderate TBI, and 72 children with orthopedic injuries (OI) sustained between ages 3 and 7 years. Children completed neuropsychological tests and caregivers completed a structured interview of child adaptive functioning at 6.9 (±1.10) years post-injury. Profile analysis and multiple mediator modeling were employed. Children with severe TBI demonstrated poorer fluid reasoning and inhibitory control than both children with moderate TBI and OI, as well as slower processing speed than the OI group. Both fluid reasoning and processing speed were significant independent mediators of the effect of severe TBI on adaptive functioning. No neuropsychological measure significantly mediated the effect of moderate TBI on adaptive functioning. Children sustaining early severe TBI demonstrate persisting neuropsychological impairments into adolescence and young adulthood. The impact of severe TBI on children's long-term adaptive functioning is mediated in part by its effects on fluid reasoning and processing speed.

Healthcare disparities exist in pediatric asthma in the United States. Children from minority, low-income families in inner-city areas encounter barriers to healthcare, leading to greater rates of poorly controlled asthma and healthcare utilization. Finding an effective way to deliver high-quality healthcare to this underserved population to improve outcomes, reduce morbidity and mortality, and reduce healthcare utilization is of the utmost importance. The purpose of this study was to assess the feasibility and efficacy of a novel school-based care delivery model that incorporates video-based telehealth (VBT) medical and self-management visits with electronic inhaler monitoring to improve asthma outcomes. Over a 6-month period, children from inner-city, low-income schools with uncontrolled asthma completed seven scheduled medical visits with an asthma specialist and five self-management visits with an adherence psychologist at school using VBT. Composite Asthma Severity Index (CASI) scores and electronic inhaler monitor data were recorded and analyzed. A total of 21 patients were enrolled in the study. Study subjects with higher baseline severity (CASI ≥ 4 at visit 1) demonstrated a greater reduction in their score than those with lower baseline severity (CASI < 4 at visit 1). The CASI domains showed improvement in daytime symptoms, nighttime symptoms, and exacerbations. Adherence results demonstrated a significant improvement in adherence from baseline to postintervention. Study retention was 100%. This study demonstrates that a multicomponent medical and behavioral interventional program delivered by VBT to a school-based setting is feasible and can significantly improve asthma outcomes and care in a challenging population.

Objectives: We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time. Methods: We examined data from 359 children with complicated mild to severe TBI, aged 5–18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent–child conflict). Results: We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = −5.15, p < .001, and t(731) = −3.90, p = .002, respectively, for child outcomes; t(532) = −4.81, p < .001, and t(532) = −3.80, p < .001, respectively, for family outcomes]. Conclusions: The results suggest limited differences in the measures’ responsiveness to treatment while highlighting OFPST’s utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

Introduction Most cochlear implant (CI) users have difficulty in listening tasks that rely strongly on perception of frequency changes (e.g., speech perception in noise, musical melody perception, etc.). Some previous studies using behavioral or subjective assessments have shown that short-term music training can benefit CI users’ perception of music and speech. Electroencephalographic (EEG) recordings may reveal the neural basis for music training benefits in CI users. Objective To examine the effects of short-term music training on CI hearing outcomes using a comprehensive test battery of subjective evaluation, behavioral tests, and EEG measures. Design Twelve adult CI users were recruited for a home-based music training program that focused on attentive listening to music genres and materials that have an emphasis on melody. The participants used a music streaming program (i.e., Pandora) downloaded onto personal electronic devices for training. The participants attentively listened to music through a direct audio cable or through Bluetooth streaming. The training schedule was 40 min/session/day, 5 days/week, for either 4 or 8 weeks. The pre-training and post-training tests included: hearing thresholds, Speech, Spatial and Qualities of Hearing Scale (SSQ12) questionnaire, psychoacoustic tests of frequency change detection threshold (FCDT), speech recognition tests (CNC words, AzBio sentences, and QuickSIN), and EEG responses to tones that contained different magnitudes of frequency changes. Results All participants except one finished the 4- or 8-week training, resulting in a dropout rate of 8.33%. Eleven participants performed all tests except for two who did not participate in EEG tests. Results showed a significant improvement in the FCDTs as well as performance on CNC and QuickSIN after training (p < 0.05), but no significant improvement in SSQ scores (p > 0.05). Results of the EEG tests showed larger post-training cortical auditory evoked potentials (CAEPs) in seven of the nine participants, suggesting a better cortical processing of both stimulus onset and within-stimulus frequency changes. Conclusion These preliminary data suggest that extensive, focused music listening can improve frequency perception and speech perception in CI users. Further studies that include a larger sample size and control groups are warranted to determine the efficacy of short-term music training in CI users.

PURPOSE: To examine the long-term consequences of early childhood traumatic brain injury (TBI), approximately 7 years post-injury, on cognitive communication competency within a complex interplay of individual, contextual, and psychosocial factors. Additionally, we were interested in looking at the association of communication competence with social competence and overall functioning. METHODS: 64 children with orthopedic injury, 40 children with moderate traumatic brain injury, and 14 children with severe traumatic brain injury who were between 3 years and 6 years 11 months at injury completed a narrative discourse task and clinical measures in a single visit at a longer term follow up in early adolescence, an average of 6.8 years post injury. Analyses of covariance were conducted to compare groups on the discourse task, and hierarchical linear regressions were conducted to examine the association of discourse measures with clinical measures of cognitive and psychosocial functioning. RESULTS: Children with severe traumatic brain injury performed worse than children with moderate traumatic brain injury and orthopedic injury on all discourse indices and clinical measures. Injury severity, pragmatic skills, and socioeconomic status were associated with discourse gist. Discourse gist was the most sensitive measure of communication competence, and it was significantly associated with psychosocial outcomes independent of group. CONCLUSION: Children who sustain a severe traumatic brain injury in early childhood are at risk for long-term cognitive communication impairments that may be related to a complex interplay of injury, individual, and social factors.

A series of five randomized controlled clinical trials (RCTs) conducted between 2002 and 2015 support the potential efficacy of online family problem-solving treatment (OFPST) in improving both child and parent/family outcomes after pediatric traumatic brain injury (TBI). However, small sample sizes and heterogeneity across individual studies have precluded examination of potentially important moderators. We jointly analyzed individual participant data (IPD) from these five RCTs, involving 359 children and adolescents between the ages of 5 and 18 years, to confirm the role of previously identified moderators (child's age and pre-treatment symptom levels, parental education) and to examine other potential moderators (race, sex, IQ), using IPD meta-analysis. This reanalysis revealed statistically strong evidence that parental education, child age at baseline, IQ, sex, and parental depression level pre-treatment moderated the effect of OFPST on various outcomes. In particular, children of parents with a less than high school education exhibited fewer internalizing problems and better social competence. Children injured at an older age exhibited fewer externalizing behaviors and less executive dysfunction following OFPST. Child IQ moderated the effect of OFPST on social competence, with significantly better competence for children with lower IQ who received OFPST. Lower levels of parental depression followed OFPST among subgroups with lower IQ, boys, and higher parental depression scores at baseline. Our findings indicate that the optimal application of OFPST is likely to involve older children, those with lower IQ scores, or those from families with lower socioeconomic status (SES).

Background African, Caribbean, and Black (Black) men account for 16.5% of new HIV diagnoses among men in Ontario. There is substantial evidence that sexually transmitted infections (STIs) are associated with increased likelihood of HIV infection; however, little is known regarding the prevalence of HIV/STI co-infections among Black men in Toronto. Progress has been made in understanding factors contributing to racial/ethnic disparities in HIV between among men who have sex with men (MSM). In this study, we investigate within-racial group patterns of HIV/STI infection between Black MSM and Black men who only have sex with women (MSW). Methods A cross-sectional descriptive epidemiological study was conducted with a non-probability sample of Black men recruited from Toronto, Ontario. Audio Computer Assisted Self-Interviews (ACASI) surveys were used to collect demographic and behavioral data. Biological specimens were collected to screen for HIV and other STIs. Chi-Square tests were used to compare the prevalence of (1) HIV and current STIs between MSM and MSW and (2) current STIs between people living with HIV and people not living with HIV. Logistic regression models were constructed to assess whether or not history of STIs were associated with current HIV infection. Results The prevalence of HIV (9.2%), syphilis (7.2%), hepatitis B (2.7%), and high-risk anal HPV (8.4%) and penile HPV (21.3%) infections were high in Black men (N = 487) and were significantly increased in Black MSM compared with MSW; the prevalence of syphilis and high-risk HPV were also increased in men living with HIV. Men with a history of syphilis (OR = 6.48, 95% CI: 2.68,15.71), genital warts (OR = 4.32, 95% CI: 1.79,10.43) or genital ulcers (OR = 21.3, 95% CI: 1.89,239.51) had an increased odds of HIV infection. Conclusions The HIV/STI prevalence was high among this sample of Black men, although the study design may have led to oversampling of men living with HIV. The associations between STIs and current HIV infection highlight the need for integrated of HIV/STI screening and treatment programs for Black men. Public health strategies are also needed to reduce disproportionate HIV/STI burden among Black MSM—including improving HPV vaccine coverage.

BACKGROUND AND OBJECTIVES: To determine whether online family problem-solving treatment (OFPST) is more effective in improving behavioral outcomes after pediatric traumatic brain injury with increasing time since injury. METHODS: This was an individual participant data meta-analysis of outcome data from 5 randomized controlled trials of OFPST conducted between 2003 and 2016. We included 359 children ages 5 to 18 years who were hospitalized for moderate-to-severe traumatic brain injury 1 to 24 months earlier. Outcomes, assessed pre- and posttreatment, included parent-reported measures of externalizing, internalizing, and executive function behaviors and social competence. RESULTS: Participants included 231 boys and 128 girls with an average age at injury of 13.6 years. Time since injury and age at injury moderated OFPST efficacy. For earlier ages and short time since injury, control participants demonstrated better externalizing problem scores than those receiving OFPST (Cohen’s d = 0.44; P = .008; n = 295), whereas at older ages and longer time since injury, children receiving OFPST had better scores (Cohen’s d = −0.60; P = .002). Children receiving OFPST were rated as having better executive functioning relative to control participants at a later age at injury, with greater effects seen at longer (Cohen’s d = −0.66; P = .009; n = 298) than shorter (Cohen’s d = −0. 28; P = .028) time since injury. CONCLUSIONS: OFPST may be more beneficial for older children and when begun after the initial months postinjury. With these findings, we shed light on the optimal application of family problem-solving treatments within the first 2 years after injury.

The objective of this study is to identify the demographic and payer factors that are associated with lumbar fusion surgery.A case-control study was conducted utilizing a population of 38,092 patients from the 2010 Florida Agency for Health Care Administration (AHCA), USA hospital discharge data. The case population included 16,236 records with any of five ICD-9-CM principal procedure codes for initial lumbar fusion. The control group was comprised of 21,856 patients who were admitted for the same principal diagnoses as the cases, but who did not have initial fusion surgery. Logistic regression was used to analyze the association of age, gender, race and principal payer type with initial lumbar fusions. The interaction between age and payer was also examined, as payer type may moderate the association between age and lumbar fusion surgery.Gender, race, principal payer and age were all found to be significantly associated with lumbar fusion surgery. The interaction of payer and age was also found to be significant. Being female was significantly associated with having a fusion (OR = 1.11, 95 % CI 1.07-1.16). The association between age and receiving surgery was greatest for the less than 20 age group (OR = 10.43, 95 % CI 8.74-12.45). Employees and dependents of Federal government agencies (Tricare, etc.) and patients with commercial insurance were significantly associated with surgery (OR = 1.48, 95 % CI 1.29-1.70 and OR = 1.12, 95 % CI 1.04-1.20, respectively). Patients insured through Medicaid (a social health care program for those with low incomes and limited resources), and the uninsured were negatively associated with surgery (OR = 0.53, 95 % CI 0.47-0.60 and OR = 0.52, 95 % CI 0.46-0.58, respectively).Lumbar fusion surgery is not recommended in clinical practice guidelines for the top four principal diagnoses in this study. Yet, patients covered by certain types of insurance were found to be significantly associated with fusion surgery.

Exposure to childhood religious affiliations where the majority of members discourage homosexuality may have negative psychological impacts for Black men who have sex with men. This study tested the hypothesis that exposures to these environments during childhood were associated with adulthood human immunodeficiency virus (HIV)/sexually transmitted infection (STI) behavioral risk and HIV infection, because these exposures influenced HIV/STI risk by undermining race/sexual identity congruence and increasing internalized homophobia and interpersonal anxiety. Structural equation modeling as well as logistic and Poisson regressions were performed using baseline data from HIV Prevention Trials Network 061 ( N = 1,553). Childhood religion affiliations that were more discouraging of homosexuality were associated with increased likelihood of HIV infection; however, the association was no longer significant after adjusting for age, income, and education. Having a childhood religion affiliation with high prevalence of beliefs discouraging homosexuality was associated with increased numbers of sexual partners (adjusted odds ratio = 4.31; 95% confidence interval [3.76, 4.94], p < .01). The hypothesized path model was largely supported and accounted for 37% of the variance in HIV infection; however, interpersonal anxiety was not associated with HIV/STI risk behaviors. Structural interventions are needed that focus on developing affirming theologies in religious institutions with Black men who have sex with men congregants.

This study reports the psychometric properties and correlates of a measure of organ donation attitudes and practices for African Americans. Methods. We surveyed 736 members from 14 alumni chapters of historically African American sororities and fraternities in Michigan. We constructed subscales and compared subscale values with two variables related to donation status: 1) enrollment status in the state donor registry, and 2) intentions for future enrollment. Results. Psychometric analyses indicated our measure tapped four distinct domains of attitudes concerning donation. The four subscales identified—General Benefits, Race Benefits, General Barriers, and Disparity Barriers—had good psychometric properties. For all four scales the more positive the attitudes toward donation held by the respondent, the more likely they were to report having signed up to be an organ donor. Discussion. An understanding of attitudes toward donation may help development of effective culturally sensitive intervention messages targeting the African American community.

Background Last-minute surgery cancellation represents a major wastage of resources and can cause significant inconvenience to patients. Our objectives in this study were: 1) To develop predictive models of last-minute surgery cancellation, utilizing machine learning technologies, from patient-specific and contextual data from two distinct pediatric surgical sites of a single institution; and 2) to identify specific key predictors that impact children’s risk of day-of-surgery cancellation. Methods and findings We extracted five-year datasets (2012–2017) from the Electronic Health Record at Cincinnati Children’s Hospital Medical Center. By leveraging patient-specific information and contextual data, machine learning classifiers were developed to predict all patient-related cancellations and the most frequent four cancellation causes individually (patient illness, “no show,” NPO violation and refusal to undergo surgery by either patient or family). Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) using ten-fold cross-validation. The best performance for predicting all-cause surgery cancellation was generated by gradient-boosted logistic regression models, with AUC 0.781 (95% CI: [0.764,0.797]) and 0.740 (95% CI: [0.726,0.771]) for the two campuses. Of the four most frequent individual causes of cancellation, “no show” and NPO violation were predicted better than patient illness or patient/family refusal. Models showed good cross-campus generalizability (AUC: 0.725/0.735, when training on one site and testing on the other). To synthesize a human-oriented conceptualization of pediatric surgery cancellation, an iterative step-forward approach was applied to identify key predictors which may inform the design of future preventive interventions. Conclusions Our study demonstrated the capacity of machine learning models for predicting pediatric patients at risk of last-minute surgery cancellation and providing useful insight into root causes of cancellation. The approach offers the promise of targeted interventions to significantly decrease both healthcare costs and also families’ negative experiences.

This study examined whether the ankyrin repeat and kinase domain containing 1 gene (ANKK1) C/T single-nucleotide polymorphism (SNP) rs1800497 moderated the association of family environment with long-term executive function (EF) following traumatic injury in early childhood. Caregivers of children with traumatic brain injury (TBI) and children with orthopedic injury completed the Behavior Rating Inventory of Executive Function (BRIEF) at post-injury visits. DNA was collected to identify the rs1800497 genotype in the ANKK1 gene. General linear models examined gene-environment interactions as moderators of the effects of TBI on EF at two times post-injury (12 months and 7 years). At 12 months post-injury, analyses revealed a significant three-way interaction of genotype with level of permissive parenting and injury type. Post hoc analyses showed genetic effects were more pronounced for children with TBI from more positive family environments, such that children with TBI who were carriers of the risk allele (T-allele) had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. At 7 years post-injury, analyses revealed a significant two-way interaction of genotype with level of authoritarian parenting. Post hoc analyses found that carriers of the risk allele had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. These results suggest a gene-environment interaction involving the ANKK1 gene as a predictor of EF in a pediatric injury population. The findings highlight the importance of considering environmental influences in future genetic studies on recovery following TBI and other traumatic injuries in childhood.

Importance After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment. Objective To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD. Design, Setting, and Participants Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children’s hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group. Main Outcomes and Measures Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device–Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning. Results The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio [HR], 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91). Conclusions and Relevance Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.