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ObjectivesSchool racial/ethnic segregation in U.S. schoolsDifferences in school racial/ethnic composition may increase health disparities by concentrating educational opportunities that confer long-term health benefits in schools serving predominantly wwhite students. For racial minority students, high concentrations of white students may increase exposure to racismis also associated with psychologicstress, which may ultimately reduceing the long-term health benefits from educational opportunities. Meanwhile associations of racial/ethnic academic tacking within schools and health have been mixed. We sought to test whether: 1) differences in racial/ethnic composition between schools and, 2) racial/ethnic distribution of students in academic tracks within schools are associated with long-term health benefits or risks for white, Black and Latinx students.MethodsWe analyzed the National Longitudinal Study of Adolescent to Adult Health (12,438 participants, collected 1994-2008), to test whether the school-level segregation (percent of non-Latinx white students at participants' school during adolescence) was associated with adult health outcomes at ages 18-26 & 24-32, controlling for contextual factorscomparing Black, Latinx, and white students, and controlling for contextualf factors. A secondary analysis explored whether racial/ethnic cohorting across levels of English courses was associated with each health outcome.ResultsAttending a school with a higher percent of white students was associated with higher adult depression scores, substance abuse, and worse self-rated health for black Black students; lower depression scores, better self-rated health, and alcohol abuse for white students; and no health differences for Latinx students. Greater within school racial/ethnic cohorting across English courses was associated with increased odds of alcohol abuse for white students; decreased odds of alcohol abuse for Black and Latinx students; and decreased odds of drug abuse for Black students.ConclusionAmong Bblack youth, attending a school with a higher percentage of white students is associated with worse behavioral health in adulthood. Understanding the potential impacts of school racial/ethnic composition on health is critical to designing policies that maximize access to opportunity and health.Education policies should comprehensively address school quality and racism to maximize adult health.

Abstract Objective To describe how minority parents help their young children navigate issues of race and racism and discuss implications this racial socialization may have for school readiness. Methods Sixteen focus groups were conducted among 114 African American, English language-primary Latino, Spanish language-primary Latino, and Korean language-primary Korean parents of children ages 0 to 4 years old. Transcripts were coded for major themes and subsequently compared across the 4 language-ethnicity groups. Parents also shared demographic and parenting data by survey, from which group-specific proportions provide context for identified themes. Results In this sample, nearly half of surveyed parents had already talked to their young child about unfair treatment due to race. The proportion of such conversations ranged from one-fifth of Korean parents to two-thirds of Spanish language-primary parents. In focus groups, Korean parents reported fewer experiences with racism than African American and Latino parents. Within each language-ethnicity group, fewer fathers than mothers reported addressing race issues with their young children. All focus groups endorsed messages of cultural pride, preparation for bias, and a strong focus on the individual. The majority of parents viewed racial socialization as an important part of school readiness. Conclusions Racial socialization was believed to be salient for school readiness, primarily practiced by mothers, and focused at the individual level. The smaller role of fathers and systems-based approaches represent opportunities for intervention. These results may inform the development of culturally tailored parenting interventions designed to decrease the race-based achievement gap and associated health disparities.

Established in 1994, Salvadoran Asociación Pro-Búsqueda de Niñas y Niños Desaparecidos (Association for the Search of Disappeared Children) has located 384 children, often with the aid of DNA evidence, of the more than 500 who went missing or were abducted during El Salvador’s civil war. Families in other countries who were unaware of the forced separations adopted many of these children. Between 2005 and 2009, we conducted semi-structured interviews with twenty-six children, now young adults aged twenty-four to thirty-four years, who had been reunited with their biological families. We found that we could conceptually categorize the process of separation and reunifcation into six phases: pre-disappearance, disappearance, separation, searching, reunion, and reunifcation. While these young adults said that reunifcation was extremely important, they often found this stage psychologically challenging, given their new identities and their uncertainty about how they would reintegrate back—if at all—into their biological families. We call this process “ambiguous reunifcation.”.

Context: In 2004, California's Paid Family Leave Insurance Program (PFLI) became the first state program to provide paid leave to care for an ill family member.Objective: To assess awareness and use of the program by employed parents of children with special health care needs, a population likely to need leave.Design, Setting, and Participants: Telephone interviews with successive cohorts of employed parents before (November 21, 2003-January 31, 2004; n = 754) and after (November 18, 2005-January 31, 2006; n = 766) PFLI began, randomly sampled from 2 children's hospitals, one in California (with PFLI) and the other in Illinois (without PFLI). Response rates were 82% before and 81% after (California), and 80% before and 74% after (Illinois).Main Outcome Measures: Taking leave, length of leave, unmet need for leave, and awareness and use of PFLI.Results: Similar percentages of parents at the California site reported taking at least 1 day of leave to care for their ill child before (295 [81%]) and after (327 [79%]) PFLI, taking at least 4 weeks before (64 [21%]) and after (74 [19%]) PFLI, and at least once in the past year not missing work despite believing their child's illness necessitated it before (152 [41%]) and after (156 [41%]) PFLI. Relative to Illinois, parents at the California site reported no change from before to after PFLI in taking at least 1 day of leave (difference of differences, -3%; 95% confidence interval [CI], -13% to 7%); taking at least 4 weeks of leave (1%; 95% CI, -9% to 10%); or not missing work, despite believing their child's illness necessitated it (-1%; 95% CI, -13% to 10%). Only 77 parents (18%) had heard of PFLI approximately 18 months after the program began, and only 20 (5%) had used it. Even among parents without other access to paid leave, awareness and use of PFLI were minimal.Conclusions: Parents of children with special health care needs receiving care at a California hospital were generally unaware of PFLI and rarely used it. Among parents of children with special health care needs, taking leave in California did not increase after PFLI implementation compared with Illinois. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Pregnancy rates among Filipino American adolescents exceed those of other Asian and Pacific Islander adolescents. Strong parent-adolescent communication may promote healthy sexual development and protect against adolescent sexual risk behaviors. We explored communication barriers between Filipino American parents and adolescents. METHODS: Using community-based participatory research (CBPR), we collaborated with Filipino American community leaders, parents, and adolescents to design a focus-group study. Trained bilingual moderators conducted focus groups with 85 Filipino Americans (41 parents and grandparents and 44 adolescents aged 14-18 years) from various neighborhoods in Los Angeles. Sessions were recorded, transcribed, coded, and analyzed for themes. RESULTS: Focus-group participants appeared to divide sex information into 3 categories, which we termed facts, feelings, and values. Adolescents emphasized facts and feelings. Parents and grandparents emphasized facts and values. In general, facts were obtained through school, feelings through friends, and values through parents. The focus groups identified large barriers to value transmission, stemming from adolescent acculturation to the United States. Parents and grandparents felt that values were transmitted best through traditional Filipino respect for parents who often eschewed open discussion. Adolescents believed that open discussion was necessary for value transmission to occur. The result was bilateral withdrawal from family communication about sex. CONCLUSIONS: Our focus groups found that parent-child communication about sex, especially regarding values, was limited. Potential causes included conflicts between Filipino and US beliefs regarding respect for parents and open discussion. Our results raise important questions about the effect of acculturation on sex education for Filipino American adolescents and demonstrate potential advantages of CBPR. [ABSTRACT FROM AUTHOR]

Women may experience a decline in physical function during menopause. Whether this decline is due to aging or to changes in hormonal status is unknown. The authors performed a longitudinal data analysis on data collected between 1996 and 2001 to determine the effects of menopausal status, age, race, and use of hormone replacement therapy (HRT) on 3-year changes in grip and pinch strength. Participants were 563 women from the Chicago, Illinois, site of the Study of Women's Health Across the Nation. According to adjusted analyses, women who became postmenopausal showed a 1.04-kg decline in grip strength (p = 0.10) and a 0.57-kg decline in pinch strength (p = 0.002) relative to women who remained premenopausal. Women who became early perimenopausal showed a 0.20-kg decline in pinch strength (p = 0.04), whereas women who transitioned to late perimenopause showed a 0.93-kg decline in grip strength (p = 0.07). Effects of menopausal status on grip and pinch strength did not vary by race. A significant HRT-by-race interaction for grip strength was found; African-American HRT users had greater grip strength during the study, whereas Caucasian HRT users did not (p = 0.05). Greater physical activity was the strongest predictor of grip and pinch strength (p < 0.0001). Results indicate that transition through menopause is associated with a decline in grip and pinch strength. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Parents of children with special health care needs are especially vulnerable to work-family conflicts that family leave benefits might help resolve. We examined leave-taking among full-time-employed parents of children with special health care needs. METHODS: We identified all children with special health care needs in 2 large inpatient/outpatient systems in Chicago, Illinois, and Los Angeles, California, and randomly selected 800 per site. From November 2003 to January 2004, we conducted telephone interviews with 1105 (87% of eligible and successfully contacted) parents. Among the sample's 574 full-time-employed parents, we examined whether leave benefits predicted missing any work for child illness, missing >4 weeks for child illness, and ability to miss work whenever their child needed them. RESULTS: Forty-eight percent of full-time-employed parents qualified for federal Family and Medical Leave Act benefits; 30% reported employer-provided leave benefits (not including sick leave/vacation). In the previous year, their children averaged 20 missed school/child care days, 12 doctor/emergency department visits, and 1.7 hospitalizations. Although 81% of parents missed work for child illness, 41% reported not always missing work when their child needed them, and 40% of leave-takers reported returning to work too soon. In multivariate regressions, parents who were eligible for Family and Medical Leave Act benefits and aware of their eligibility had 3.0 times greater odds of missing work for child illness than ineligible parents. Parents with >4 weeks of employer-provided leave benefits had 4.7 times greater odds of missing >4 weeks than parents without benefits. Parents with paid leave benefits had 2.8 times greater odds than other parents of missing work whenever their child needed them. CONCLUSIONS: Full-time-employed parents of children with special health care needs experience severe work-family conflicts. Although most have leave benefits, many report unmet need for leave. Access to Family and Medical Leave Act benefits and employer-provided leave may greatly affect leave-taking. [ABSTRACT FROM AUTHOR]

Purpose: Examine the effectiveness of the "Eat Healthy, Stay Active!" pilot program, a multisite, 6-month educational intervention to promote healthy nutrition and physical activity among Head Start staff, parents, and children.Design: Comparison of within-group preintervention and postintervention knowledge and behavior, along with anthropomorphic measurements.Setting: The study was conducted in a convenience sample of six large Head Start agencies in five states.Subjects: Participants included 496 staff, 438 parents, and 112 preschool children.Intervention: The 6-month intervention consisted of core trainings and reinforcing activities for staff and parents that aligned with children's curricula.Measures: Pre-post questionnaires and anthropometric measurements examined changes in body mass index (BMI), knowledge, and behaviors related to nutrition and physical activity.Analysis: Paired t-tests to compare preintervention and postintervention weights and BMI; multiple regression analyses to examine associations between weight changes and other covariates, including knowledge and behavior changes, controlling for sociodemographic variables.Results: Each group of participants demonstrated significant reductions in BMI (mean  =  30.1 to 29.2; p < .001 in adults and 17.0 to 16.6; p < 0.001 in children) and in the proportion of obese children (30% to 21%; p < .001) and adults (45% to 40%; p < .001). Child weight changes correlated with parent weight changes.Conclusion: This intervention showed promising initial results, with potential effectiveness as an intervention to promote healthier behaviors among adults and children in Head Start settings. [ABSTRACT FROM AUTHOR]

Introduction: Lack of knowledge of Early Intervention (EI) is a barrier to developmental delay (DD) management. We aimed to examine the feasibility of measuring pediatricians' knowledge of EI, determine the distribution of EI knowledge, and determine factors associated with increased EI knowledge., Methods: We conducted an exploratory cross-sectional study with a convenience sample from a local American Academy of Pediatrics chapter to administer a survey with 10 multiple-choice questions regarding the EI referral process, evaluation process, eligibility criteria and fee structure. Our outcome variable was a composite score of these 10 multiple-choice questions, Total Knowledge Score (TKS). Our predictor variables included physician characteristics (i.e., years of experience, percentage of patients seen with private insurance, receipt of EI training in the last 5 years) and practice characteristics (i.e., medical home status)., Results: Our sample consisted of a total of 194 pediatric residents/attendings. Multivariable regression demonstrated seeing ≥ 50% patients who were privately insured, increased experience, and receiving training in the last 5 years were associated with higher TKS., Discussion: We were able to quantitatively evaluate physician's knowledge of EI and demonstrated that seeing a majority of privately insured patients, having more experience, and having received formal EI training in the last 5 years were associated with higher EI knowledge. This disproportionate distribution of EI knowledge has the potential to contribute to disparities in the management of DD. This may indicate that medical institutions, where physicians see a small percent of privately insured patients, need to hire more experienced physicians, and provide routine EI training., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Adverse birth outcomes in the US, including preterm birth and low birth weight, are strongly tied to socioeconomic disadvantage and disproportionately impact infants of Black mothers. Increasing investments in social programs represents a potential policy approach to addressing disparities in birth outcomes., Objective: To examine state-level associations of government expenditures on social programs with rates of preterm birth and low birth weight both overall and by race., Design, Setting, and Participants: This cross-sectional, ecological study was conducted among liveborn infants in the 50 US states between January 1, 2011, and December 31, 2019. Data analysis was performed from May 2022 to May 2024., Exposures: Yearly state and local government expenditures per low-income person on social programs in the following categories: state refundable Earned Income Tax Credit; cash assistance; childcare assistance; housing and community development; and public health., Main Outcomes and Measures: Yearly state-level rates of preterm birth (gestational age <37 weeks) and low birth weight (<2500 g)., Results: From January 1, 2011, to December 31, 2019, there were 35.1 million live births in the US, of which 3.4 million (9.8%) were preterm and 2.8 million (8.1%) were low birth weight. Median (IQR) state social expenditures per low-income person were $1546 ($1074-$2323). Greater total state social expenditures were associated with lower overall rates of preterm birth (adjusted prevalence ratio [aPR] for every increase of $1000 per low-income person, 0.99; 95% CI, 0.97-0.999) but not with overall rates of low birth weight. In secondary analyses, greater state social expenditures were associated with lower preterm birth rates for infants of Black mothers (aPR, 0.96; 95% CI, 0.92-0.999). Greater state expenditures specifically on cash assistance (aPR, 0.64; 95% CI, 0.43-0.94) and housing and community development (aPR, 0.91; 95% CI, 0.84-0.98) were associated with lower preterm birth rates for infants of Black mothers., Conclusions and Relevance: In this cross-sectional, ecological study, greater state-level expenditures on social programs were associated with reduced rates of preterm birth, particularly for infants of Black mothers. State and local governments may consider bolstering investments in cash assistance and housing and community development to address maternal and infant health disparities.

Background: A predominate azole-resistant Candida tropicalis clade 4 genotype causing candidemia has been detected in not only Taiwan but also China, Singapore, and Australia. It can also be detected on fruit surfaces. In addition to determining distribution and drug susceptibilities of pathogenic yeasts in environments of intensive care units of 25 hospitals in Taiwan, we would also like to investigate whether the azole-resistant C. tropicalis exists in Taiwan's hospital environment., Methods: The swabs of hospital environments were collected from August to November in 2020 and were cultured for yeasts. The yeasts were identified by rDNA sequence and the antifungal susceptibilities of those isolates were determined by the broth microdilution method., Results: The average yeast-culture rate of hospitals was 9.4% (217/2299). Sinks had the highest yeast-positive culture rate (32.7%), followed by bedside tables (28.9%), floors (26.0%), water-dispenser buttons (23.8%), and TV controller/touch panels (19.0%). Of 262 identified isolates, Candida parapsilosis was the most common species, accounting for 22.1%, followed by Filobasidium uniguttulatum (18.3%), Candida albicans (9.5%), C. tropicalis (8.0%), Candida glabrata (Nakaseomyces glabratus) (6.9%), and 30 other species (35.1%). Of the 21 C. tropicalis isolates from 11 units in 9 hospitals, 15 diploid sequence types (DSTs) were identified. The two DST506 fluconazole-resistant ones belonged to clade 4., Conclusion: We detected not only various pathogenic yeast species but also the predominant clade 4 genotype of azole-resistant C. tropicalis. Our findings highlight and re-emphasize the importance of regular cleaning and disinfection practices., Competing Interests: Declaration of competing interest The authors declare no conflict of interests., (Copyright © 2024. Published by Elsevier B.V.)

Background and Objectives: Early intervention services can improve outcomes for children with developmental delays. Health care providers, however, often struggle to ensure timely referrals and services. We tested the effectiveness of telephone-based early childhood developmental care coordination through 211 LA, a health and human services call center serving Los Angeles County, in increasing referral and enrollment in services., Methods: In partnership with 4 clinic systems, we recruited and randomly assigned children aged 12 to 42 months with upcoming well-child visits and without a known developmental delay, to intervention versus usual care. All children received developmental screening and usual clinic care. Intervention children also received telephone connection to a 211 LA early childhood care coordinator who made referrals and conducted follow-up. Primary outcomes at a 6-month follow-up included parent-reported referral and enrollment in developmental services. Secondary outcomes included referral and enrollment in early care and education (ECE). Logistic regression models were used to estimate the odds of outcomes, adjusted for key covariates., Results: Of 565 families (282 intervention, 283 control), 512 (90.6%) provided follow-up data. Among all participants, more intervention than control children were referred to (25% vs 16%, adjusted odds ratio [AOR] 2.25, P = .003) and enrolled in (15% vs 9%, AOR 2.35, P = .008) ≥1 service, and more intervention than control children were referred to (58% vs 15%, AOR 9.06, P < .001) and enrolled in (26% vs 10%, AOR 3.75, P < .001) ECE., Conclusions: Telephone-based care coordination through 211 LA is effective in connecting young children to developmental services and ECE, offering a potentially scalable solution for gaps and disparities., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: To better understand impacts of the COVID-19 pandemic and resulting economic and social disruptions on families, we analyzed qualitative data capturing perspectives from parents of young children., Methods: This study analyzes interviews of parents of children aged 1-3.5 years at enrollment, recruited from four primary care systems serving mainly lower-income Hispanic families in Los Angeles, California. Interviews were conducted over 15 months beginning September 2020. Analyses focused on the open-ended question: Please describe in your own words how the COVID-19 pandemic has affected you and your family. We used iterative, multi-step processes to identify emergent qualitative themes., Results: A total of 460 parent responses were collected and coded. Key themes and subthemes were tested for interrater reliability, with Kappa ranging from 0.74 to 0.91. Thematic analysis revealed two groups of responses, one emphasizing stress and one emphasizing "silver linings." Parents cited a range of stressors, from fear of COVID-19 to social isolation. Those emphasizing "silver linings" also referenced formal or informal supports - especially government/community assistance programs and childcare access - that enabled stronger family ties and positive lifestyle modifications., Conclusions for Practice: Experiences of families with young children during COVID-19 were not uniform. Economic stability and reliable childcare may be critical mediators of family stress. Results affirm that the pandemic's impacts were distributed through channels largely built on, and possibly exacerbating, existing disparities. For lower-income families with young children, funding for public and private programs that target economic stability and childcare assistance may merit prioritization in future socio-economic disruptions., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Abstract: Health care delivery requires physicians to operate in teams to successfully navigate complexity in caring for patients and communities. The importance of training physicians early in core concepts of working in teams (i.e., "teaming") has long been established. Over the past decade, however, little evidence of team effectiveness training for medical students has been available. The recent introduction of health systems science as a third pillar of medical education provides an opportunity to teach and prepare students to work in teams and achieve related core competencies across the medical education continuum and health care delivery settings. Although educators and health care system leaders have emphasized the teaching and learning of team-based care, conceptual models and evidence that inform effective teaming within all aspects of undergraduate medical education (including classroom, clinical, and community settings) are needed to advance the science regarding learning and working in teams. Anchoring teaming through the core foundational theory of team effectiveness and its operational components could catalyze the empirical study of medical student teams, uncover modifiable factors that lead to the evidence for improved student learning, and improve the link among competency-based assessments between undergraduate medical education and graduate medical education. In this article, authors articulate several implications for medical schools through 5 conceptual areas: admissions, the design and teaching of team effectiveness in health systems science curricula, the related competency-based assessments, and course and program evaluations. The authors then discuss the relevance of the measurable components and intended outcomes to team effectiveness in undergraduate medical education as critical to successfully prepare students for teaming in clerkships and eventually residency and clinical practice., (Copyright © 2024 the Association of American Medical Colleges.)

The axon-initial-segment (AIS) of mature neurons contains microtubule (MT) fascicles (linear bundles) implicated as retrograde diffusion barriers in the retention of MT-associated protein (MAP) tau inside axons. Tau dysfunction and leakage outside of the axon is associated with neurodegeneration. We report on the structure of steady-state MT bundles in varying concentrations of Mg 2+ or Ca 2+ divalent cations in mixtures containing αβ-tubulin, full-length tau, and GTP at 37 °C in a physiological buffer. A concentration-time kinetic phase diagram generated by synchrotron SAXS reveals a wide-spacing MT bundle phase (B ws ), a transient intermediate MT bundle phase (B int ), and a tubulin ring phase. SAXS with TEM of plastic-embedded samples provides evidence of a viscoelastic intervening network (IN) of complexes of tubulin oligomers and tau stabilizing MT bundles. In this model, αβ-tubulin oligomers in the IN are crosslinked by tau's MT binding repeats, which also link αβ-tubulin oligomers to αβ-tubulin within the MT lattice. The model challenges whether the cross-bridging of MTs is attributed entirely to MAPs. Tubulin-tau complexes in the IN or bound to isolated MTs are potential sites for enzymatic modification of tau, promoting nucleation and growth of tau fibrils in tauopathies., (© 2024. The Author(s).)

Background: Adverse childhood experiences are associated with poverty, and public benefit programs are increasingly used as primary prevention for negative child outcomes., Objective: To estimate the association between spending on benefit programs and cumulative exposure to ACEs among children., Participants and Setting: Children aged 0-17 years in the United States during 2016-17 as reported in National Survey of Children's Health., Methods: We examined the sum of state and federal spending on 5 categories of public benefit programs at the state-level. The primary exposure was mean annual spending per person living below the Federal poverty limit across 2010-2017 Federal fiscal years. The primary outcome was children <18 years old having ever been exposed to ≥ 4 ACEs., Results: Nationally, 5.7 % (95 % confidence interval [CI] 5.3 % - 6.0 %) of children had exposure to ≥ 4 ACEs. After adjustment for children's race and ethnicity, total spending on benefit programs was associated with lower exposure to ≥ 4 ACEs (odds 0.96 [95 % CI: 0.95, 0.97]; p < 0.001). Increased spending in each individual benefit category was also associated with decreased cumulative ACEs exposure (all p < 0.05). Inverse associations were largely consistent when children were stratified by race and ethnicity and income strata., Conclusions: Investments in public benefit programs may not only decrease poverty but also have broad positive effects on near- and long-term child well-being beyond the programs' stated objectives. Findings support federal and state efforts to prioritize families' economic stability as part of a public health model to prevent ACEs., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Importance: Public benefit programs, including state spending on local, state, and federal-state partnership programs, have consistently been associated with overall reductions in child protective services (CPS) involvement. Inequities in eligibility and access to benefit programs may contribute to varying associations by race and ethnicity., Objective: To determine whether associations between state spending on benefit programs and rates of CPS investigations differ by race and ethnicity., Design, Setting, and Participants: This cross-sectional ecological study used repeated state-level measures of child maltreatment from the National Child Abuse and Neglect Data System and population estimates from the US Census Bureau for all Black, Hispanic, and White children. All 50 US states from October 1, 2009, through September 30, 2019 (fiscal years 2010-2019), were included. Data were collected and analyzed from May 13, 2022, to March 2, 2023., Exposures: Annual state spending on benefit programs per person living below the federal poverty limit, total and by the following subcategories: (1) cash, housing, and in-kind; (2) housing infrastructure; (3) child care assistance; (4) refundable earned income tax credit; and (5) medical assistance programs., Main Outcomes and Measures: Race- and ethnicity-specific rates of CPS investigations. Generalized estimating equations, with repeated measures of states, an interaction between race and spending, and estimated incidence rate ratios (IRRs) and 95% CIs for incremental changes in spending of US $1000 per person living below the federal poverty limit were calculated after adjustment for federal spending, race- and ethnicity-specific child poverty rate, and year., Results: A total of 493 state-year observations were included in the analysis. The association between total spending and CPS investigations differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children (IRR, 0.94 [95% CI, 0.91-0.98]) but not for Black children (IRR, 0.98 [95% CI, 0.94-1.02]) or Hispanic children (IRR, 0.99 [95% CI, 0.95-1.03]) (P = .02 for interaction). Likewise, inverse associations were present for only White children with respect to all subcategories of state spending and differed significantly from Black and Hispanic children for all subcategories except the refundable earned income tax credit (eg, IRR for medical assistance programs for White children, 0.89 [95% CI, 0.82-0.96]; P = .005 for race and spending interaction term)., Conclusions and Relevance: These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations. States' eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.

Purpose: School-based health centers (SBHCs) may mitigate barriers to health care access and improve students' academic outcomes, but few studies test this hypothesis. We examined whether school attendance improved after students received care at an SBHC., Methods: We conducted a secondary analysis of data from 17 SBHCs affiliated with a single large urban school district and demographic and attendance data from SBHC users (N = 14,030) and nonusers (N = 230,046) from August 2015-February 2020. We examined the percent of full school days present each month for three years before and after students' first SBHC visit and a proxy visit date for SBHC nonusers. Propensity weighted linear regression models tested whether visiting an SBHC was associated with a change in the attendance trajectory compared to a matched sample of SBHC nonusers., Results: Among SBHC users, attendance trajectories declined more steeply prior to their first SBHC visit than after the first visit (preslope -0.71%, postslope -0.05%), whereas SBHC nonusers had a similar attendance trajectory over the entire period (preslope -0.18%, postslope -0.17%), with difference-in-difference 0.65. Changes in trajectories were more pronounced for students with a mental health encounter. Prior to the first SBHC mental health visit, SBHC users displayed a marked decline in monthly attendance (preslope -1.02%). After the first mental health visit, attendance increased (postslope 1.44%), with difference-in-difference 2.33., Discussion: SBHC utilization was associated with improved school attendance over time, particularly for students with a mental health diagnosis. Investing in SBHCs may reduce school absenteeism and support student health., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Adolescents, particularly racial and ethnic minorities, are at increased risk for neighborhood threat and violence exposure, which impacts behavioral and neural outcomes. Caregiver support is associated with healthy socioemotional adjustment and self-regulatory and coping behaviors; however, it remains unclear whether caregiver support, specifically, consolation, can moderate the behavioral and neural impacts of neighborhood threat., Objective: The aim of this study was to examine the role of youth-perceived neighborhood threat on neural and behavioral correlates and to test the moderating potential of caregiver support. Sex differences in associations were examined., Participants and Setting: 11,559 nine- and ten-year old youth enrolled in the multi-site Adolescent Brain Cognitive Development (ABCD) Study at baseline., Methods: Associations were examined via linear regression models employing youth-perceived neighborhood threat and caregiver support. Regression and interaction models controlled for youth age, sex, race and ethnicity, primary caregiver's education, family income, family structure, youth-perceived school threat, and intracranial volume when examining neural outcomes. An ANOVA employing a Chi-square test and simple slopes analysis were used to identify significant interactions in moderation models., Results: Neighborhood threat is associated with structural alterations in the left amygdala (p = .004). Meanwhile, caregiver support interacts in a dose-response fashion with neighborhood threat to attenuate its relationship with left amygdala volume (p = .008). Among youth reporting neighborhood threat, problematic behaviors were more common (p < .0001). While not significant, males reported higher rates of neighborhood threat than females (p = .267). Females reported greater levels of caregiver support (p = .017). Lastly, racial and ethnic differences in neighborhood threat and caregiver support were evident (p < .001)., Conclusions: While youth may not have been exposed to direct or immediate sources of threat and violence, these findings shed light on the impact of neighborhood threat perception on problematic behaviors and amygdala volume among nine- and ten-year olds. Future research should identify other culturally inclusive sources and measures of support and resiliency., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Ltd.)

Objective: To understand caregiver, healthcare professional and national expert perspectives on implementation of a just-in-time adaptive intervention, RE-PACT (Respiratory Exacerbation-Plans for Action and Care Transitions) to prevent respiratory crises in severe cerebral palsy., Design: Qualitative research study., Setting: Paediatric complex care programmes at two academic medical institutions., Participants: A total of n=4 focus groups were conducted with caregivers of children with severe cerebral palsy and chronic respiratory illness, n=4 with healthcare professionals, and n=1 with national experts., Methods: Participants viewed a video summarising RE-PACT, which includes action planning, mobile health surveillance of parent confidence to avoid hospitalisation and rapid clinical response at times of low confidence. Moderated discussion elicited challenges and benefits of RE-PACT's design, and inductive thematic analysis elicited implementation barriers and facilitators., Results: Of the 19 caregivers recruited, nearly half reported at least one hospitalisation for their child in the prior year. Healthcare professionals and national experts (n=26) included physicians, nurses, respiratory therapists, social workers and researchers. Four overarching themes and their barriers/facilitators emphasised the importance of design and interpersonal relationships balanced against health system infrastructure constraints. Intervention usefulness in crisis scenarios relies on designing action plans for intuitiveness and accuracy, and mobile health surveillance tools for integration into daily life. Trust, knowledge, empathy and adequate clinician capacity are essential components of clinical responder-caregiver relationships., Conclusions: RE-PACT's identified barriers are addressable. Just-in-time adaptive interventions for cerebral palsy appear well-suited to address families' need to tailor intervention content to levels of experience, preference and competing demands., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Dengue virus outbreaks are increasing in number and severity worldwide. Viral transmission is assumed to require a minimum time period of viral replication within the mosquito midgut. It is unknown if alternative transmission periods not requiring replication are possible., Methods: We used a mouse model of dengue virus transmission to investigate the potential of mechanical transmission of dengue virus. We investigated minimal viral titres necessary for development of symptoms in bitten mice and used resulting parameters to inform a new model of dengue virus transmission within a susceptible population., Findings: Naïve mice bitten by mosquitoes immediately after they took partial blood meals from dengue infected mice showed symptoms of dengue virus, followed by mortality. Incorporation of mechanical transmission into mathematical models of dengue virus transmission suggest that this supplemental transmission route could result in larger outbreaks which peak sooner., Interpretation: The potential of dengue transmission routes independent of midgut viral replication has implications for vector control strategies that target mosquito lifespan and suggest the possibility of similar mechanical transmission routes in other disease-carrying mosquitoes., Funding: This study was funded by grants from the National Health Research Institutes, Taiwan (04D2-MMMOST02), the Human Frontier Science Program (RGP0033/2021), the National Institutes of Health (1R01AI143698-01A1, R01AI151004 and DP2AI152071) and the Ministry of Science and Technology, Taiwan (MOST104-2321-B-400-016)., Competing Interests: Declaration of interests OSA. is a founder of Agragene, Inc. with equity interest and a founder of Synvect with equity interest. The terms of this arrangement have been reviewed and approved by the University of California, San Diego in accordance with its conflict of interest policies. All remaining authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Adversity occurring during development is associated with detrimental health and quality of life outcomes, not just following exposure but throughout the lifespan. Despite increased research, there exists both overlapping and distinct definitions of early life adversity exposure captured by over 30 different empirically validated tools. A data-driven approach to defining and cataloging exposure is needed to better understand associated outcomes and advance the field., Methods: We utilized baseline data on 11,566 youth enrolled in the ABCD Study to catalog youth and caregiver-reported early life adversity exposure captured across 14 different measures. We employed an exploratory factor analysis to identify the factor domains of early life adversity exposure and conducted a series of regression analyses to examine its association with problematic behavioral outcomes., Results: The exploratory factor analysis yielded a 6-factor solution corresponding to the following distinct domains: 1) physical and sexual violence; 2) parental psychopathology; 3) neighborhood threat; 4) prenatal substance exposure; 5) scarcity; and 6) household dysfunction. The prevalence of exposure among 9-and 10-year-old youth was largely driven by the incidence of parental psychopathology. Sociodemographic characteristics significantly differed between youth with adversity exposure and controls, depicting a higher incidence of exposure among racial and ethnic minoritized youth, and among those identifying with low socioeconomic status. Adversity exposure was significantly associated with greater problematic behaviors and largely driven by the incidence of parental psychopathology, household dysfunction and neighborhood threat. Certain types of early life adversity exposure were more significantly associated with internalizing as opposed to externalizing problematic behaviors., Conclusions: We recommend a data-driven approach to define and catalog early life adversity exposure and suggest the incorporation of more versus less data to capture the nuances of exposure, e.g., type, age of onset, frequency, duration. The broad categorizations of early life adversity exposure into two domains, such as abuse and neglect, or threat and deprivation, fail to account for the routine co-occurrence of exposures and the duality of some forms of adversity. The development and use of a data-driven definition of early life adversity exposure is a crucial step to lessening barriers to evidence-based treatments and interventions for youth., (© 2023. The Author(s).)

Objectives: Adverse childhood experiences (ACEs) can drive poor adult mental and physical health, but the impact of early life protective factors should not be overlooked. Positive childhood experiences (PCEs) measures quantify protective factors, but evidence is lacking on their link to health conditions independent of ACEs in nationally representative studies. This study examines associations between composite PCE score and adult health, adjusting for ACEs., Methods: The most recent 2017 wave of the Panel Study of Income Dynamics, a nationally representative study and its 2014 Childhood Retrospective Circumstances supplement (n = 7496) collected adult health outcomes, PCEs, and ACEs. Multivariable logistic regression assessed associations between PCE score and adult self-rated health or condition diagnosis, with and without ACEs adjustment. Cox proportional hazards models examined relationships between PCEs, ACEs, and annual risk of diagnosis., Results: Adults with 5 to 6 PCEs had 75% (95% confidence interval [CI], 0.58-0.93) of the risk of fair/poor overall health and 74% of the risk of any psychiatric diagnosis (CI, 0.59-0.89) compared with those with 0 to 2 PCEs, independent of ACEs. In survival analysis models accounting for PCEs and ACEs, reporting 5 to 6 PCEs was associated with a 16% lower annual hazard of developing any adult psychiatric or physical condition (hazard ratio, 0.84; CI, 0.75-0.94); reporting 3+ ACEs was associated with a 42% higher annual hazard (CI, 1.27-1.59)., Conclusions: PCEs were independently associated with lower risks of fair or poor adult health, adult mental health problems, and developing any physical or mental health condition at any given age after adjusting for ACEs., (Copyright © 2023 by the American Academy of Pediatrics.)

Intracellular calcium (Ca 2+ ) has been reported to regulate transcription factor activity and cancer development, but how it affects the function of Forkhead box protein M1 (FOXM1), a crucial transcription factor and key oncogene participating in tumorigenesis, remains unclear. Here, we investigated the regulatory role of Ca 2+ on FOXM1 and found that Ca 2+ depletion caused the distribution of FOXM1 to aggregate on the nuclear envelope, which was also observed in many cell lines. Further experiments revealed that sequestrated FOXM1 colocalized with lamin B in the inner nuclear membrane (INM) and was affected by the activity of nuclear export protein exportin 1 (XPO1). To investigate how intracellular Ca 2+ affects FOXM1, we found that among the posttranscriptional modifications, only SUMOylation of FOXM1 showed a pronounced increase under reduced Ca 2+ , and suppressed SUMOylation rescued FOXM1 sequestration. In addition, Ca 2+ -dependent SUMOylated FOXM1 appeared to enhance the G2/M transition of the cell cycle and decrease cell apoptosis. In conclusion, our findings provide a molecular basis for the relationship between Ca 2+ signaling and FOXM1 regulation, and we look to elucidate Ca 2+ -dependent FOXM1 SUMOylation-related biological functions in the future., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Context: Most care occurs in home and community settings; however, the best approaches to improve CMC health are poorly understood., Objective: We sought to summarize evidence from interventions in the home and community to improve health for children with medical complexity (CMC) using comprehensive conceptions of CMC health., Data Sources: PubMed, CINAHL, Scopus, and Cochrane databases., Study Selection: Included studies evaluated interventions for CMC caregivers in home or community settings and evaluated at least 1 outcome in 10 domains of CMC health., Data Extraction: Data were extracted on participant characteristics, intervention activities, and outcomes. Interventions were categorized thematically into strategies, with results summarized by effects on outcomes within each health domain., Results: The 25 included interventions used 5 strategies: intensive caregiver education (n = 18), support groups (n = 3), crisis simulation (n = 2), mobile health tracking (n = 1), and general education (n = 1). Substantial variation existed in the extent to which any outcome domain was studied (range 0-22 studies per domain). Interventions addressing 4 domains showed consistent improvement: support group and mobile health tracking improved long-term child and caregiver self-sufficiency; mobile health tracking improved family-centered care; intensive caregiver education and support groups improved community system supports. Three domains (basic needs, inclusive education, patient-centered medical home) were not studied., Limitations: Risk of bias was moderate due primarily to limited controlled experimental designs and heterogeneous population and outcome definitions., Conclusions: Interventions that improve CMC health exist; however, current studies focus on limited segments of the 10 domains framework. Consensus outcome measures for CMC health are needed., (Copyright © 2023 by the American Academy of Pediatrics.)

Objective: Closely spaced, mistimed, and unwanted pregnancies are common among postpartum women and can lead to adverse maternal and perinatal outcomes. Women inconsistently attend postpartum obstetric visits, though they reliably interface with pediatric providers during the postpartum months, presenting novel opportunities to identify and address unmet family planning needs., Methods: We conducted a qualitative study to explore pediatric provider perspectives on addressing maternal family planning in three settings: a neonatal intensive care unit, a primary care clinic, and a high-risk infant follow-up clinic., Results: Pediatric providers were generally open to incorporating postpartum family planning screening and counseling into a pediatric encounter, if given appropriate training and implementation support. Providers largely agreed that contraceptive provision to women was not feasible in their practices, and they shared ideas for utilizing the pediatric encounter to connect women with comprehensive contraceptive care., Conclusion: Pediatric providers perceived postpartum family planning screening and counseling, and not contraceptive provision, as potentially acceptable and feasible in their practice settings. These exploratory findings justify further investigation to assess their generalizability and to develop postpartum family planning interventions for pediatrics., (Copyright © 2022. Published by Elsevier Inc.)

Background: Prior studies on technical skills use small collections of videos for assessment. However, there is likely heterogeneity of performance among surgeons and likely improvement after training. If technical skill explains these differences, then it should vary among practicing surgeons and improve over time. Materials and Methods: Sleeve gastrectomy cases ( n  = 162) between July 2018 and January 2021 at one health system were included. Global evaluative assessment of robotic skills (GEARS) scores were assigned by crowdsourced evaluators. Videos were manually annotated. Analysis of variance was used to compare continuous variables between surgeons. Tamhane's post hoc test was used to define differences between surgeons with the eta-squared value for effect size. Linear regression was used for temporal changes. A P value <.05 was considered significant. Results: Variations in operative time discriminated between individuals (e.g., between 2 surgeons, means were 91 and 112 minutes, Tamhane's = 0.001). Overall, GEARS scores did not vary significantly (e.g., between those 2 surgeons, means were 20.32 and 20.6, Tamhane's = 0.151). Operative time and total GEARS score did not change over time ( R 2  = 0.0001-0.096). Subcomponent scores showed idiosyncratic temporal changes, although force sensitivity increased among all ( R 2  = 0.172-0.243). For a novice surgeon, phase-adjusted operative time ( R 2  = 0.24), but not overall GEARS scores ( R 2  = 0.04), improved over time. Conclusions: GEARS scores showed less variability and did not improve with time for a novice surgeon. Improved technical skill does not explain the learning curve of a novice surgeon or variation among surgeons. More work could define valid surrogate metrics for performance analysis.

Introduction: The relationship between intraoperative surgical performance scores and patient outcomes has not been demonstrated at a single-case level. The GEARS score is a Likert-based scale that quantifies robotic surgical proficiency in 5 domains. Given that even highly skilled surgeons can have variability in their skill among their cases, we hypothesized that at a patient level, higher surgical skill as determined by the GEARS score will predict individual patient outcomes., Methods: Patients undergoing robotic sleeve gastrectomy between July 2018 and January 2021 at a single-health care system were captured in a prospective database. Bivariate Pearson's correlation was used to compare continuous variables, one-way ANOVA for categorical variables compared with a continuous variable, and chi-square for two categorical variables. Significant variables in the univariable screen were included in a multivariable linear regression model. Two-tailed p-value < 0.05 was considered significant., Results: Of 162 patients included, 9 patients (5.5%) experienced a serious morbidity within 30 days. The average excess weight loss (EWL) was 72 ± 12% at 6 months and 74 ± 15% at 12 months. GEARS score was not significantly correlated with EWL at 6 months (p = 0.349), 12 months (p = 0.468), or serious morbidity (p = 0.848) on unadjusted analysis. After adjusting, total GEARS score was not correlated with serious morbidity (p = 0.914); however, GEARS score did predict EWL at 6 (p < 0.001) and 12 months (p < 0.001). All GEARS subcomponent scores, bimanual dexterity, depth perception, efficiency, force sensitivity, and robotic control were predictive of EWL at 6 months (p < 0.001) and 12 months (p < 0.001) on multivariable analysis., Conclusion: For patients undergoing sleeve gastrectomy, surgical skill as assessed by the GEARS score was correlated with EWL, suggesting that better performance of a sleeve gastrectomy can result in improved postoperative weight loss., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Poverty is a common root cause of poor health and disrupts medical care. Clinically embedded antipoverty programs that address financial stressors may prevent missed visits and improve show rates. This pilot study evaluated the impact of clinic-based financial coaching on adherence to recommended preventive care pediatric visits and vaccinations in the first 6 months of life., Methods: In this community-partnered randomized controlled trial comparing clinic-based financial coaching to usual care among low-income parent-infant dyads attending pediatric preventive care visits, we examined the impact of the longitudinal financial intervention delivered by trained coaches addressing parent-identified, strengths-based financial goals (employment, savings, public benefits enrollment, etc.). We also examined social needs screening and resource referral on rates of missed preventive care pediatric visits and vaccinations through the 6-month well-child visit., Results: Eighty-one parent-infant dyads were randomized (35 intervention, 46 control); nearly all parents were mothers and more than one-half were Latina. The rate of missed visits among those randomized to clinic-based financial coaching was half that of controls (0.46 vs 1.07 missed of 4 recommended visits; mean difference, 0.61 visits missed; P = .01). Intervention participants were more likely to have up-to-date immunizations each visit (relative risk, 1.26; P = .01) with fewer missed vaccinations by the end of the 6-month preventive care visit period (2.52 vs 3.8 missed vaccinations; P = .002)., Conclusions: In this pilot randomized trial, a medical-financial partnership embedding financial coaching within pediatric primary care improved low-income families' adherence to recommended visits and vaccinations. Clinic-based financial coaching may improve care continuity and quality in the medical home., (Copyright © 2023 by the American Academy of Pediatrics.)

Background and Objectives: Academic tracking is a widespread practice, separating students by prior academic performance. Clustering lower performing students together may unintentionally reinforce risky peer social networks, school disengagement, and risky behaviors. If so, mixing lower performing with high performing youth ("untracking") may be protective, leading to better adolescent health., Methods: Advancement via Individual Determination (AVID), a nationally-disseminated college preparatory program, supports placing middle-performing students in rigorous college-preparatory classes alongside high-performing peers. We conducted the first randomized, controlled trial of AVID in the United States, randomizing 270 students within 5 large public high schools to receive AVID (AVID group) versus usual school programming (control group). Participants completed surveys at the transition to high school (end of eighth grade/ beginning of ninth grade) and the end of ninth grade. Intent-to-treat analyses tested whether AVID resulted in healthier social networks (primary outcome), health behaviors, and psychosocial wellbeing., Results: At follow-up, AVID students had lower odds of using any substance (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.48-0.89) and associating with a substance-using peer (OR 0.74, 95% CI 0.45-0.98), and higher odds of associating with a peer engaged in school (OR 1.73, 95% CI 1.11-2.70). Male AVID students had lower stress and higher self-efficacy, grit, and school engagement than control students (P < .05 for all). No adverse health effects among high-performing peers were observed., Conclusions: AVID positively impacts social networks, health behaviors, and psychosocial outcomes suggesting academic untracking may have substantial beneficial spillover effects on adolescent health.

Introduction: We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias., Methods: Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region., Results: 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0 days. Univariate analysis comparing operation <1 day to ≥1 day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure., Conclusion: Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.

Every year, about 700,000 youth arrests occur in the United States, creating significant neurodevelopmental strain; this is especially concerning as most of these youth have early life adversity exposures that may alter brain development. Males, Black, and Latinx youth, and individuals from low socioeconomic status households have disproportionate contact with the juvenile justice system (JJS). Youth confined in the JJS are frequently exposed to threat and abuse, in addition to separation from family and other social supports. Youths' educational and exploratory behaviors and activities are substantially restricted, and youth are confined to sterile environments that often lack sufficient enrichment resources. In addition to their demonstrated ineffectiveness in preventing future delinquent behaviors, high recidivism rates, and costs, juvenile conditions of confinement likely exacerbate youths' adversity burden and neurodevelopmentally harm youth during the temporally sensitive window of adolescence. Developmentally appropriate methods that capitalize on adolescents' unique rehabilitative potential should be instated through interventions that minimize confinement. Such changes would require joint advocacy from the pediatric and behavioral health care communities. "The distinct nature of children, their initial dependent, and developmental state, their unique human potential as well as their vulnerability, all demand the need for more, rather than less, legal and other protection from all forms of violence (United Nations Committee on the Rights of the Child, 2007).", Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Orendain, Galván, Smith, Barnert and Chung.)

Objective: To test associations between parent-reported confidence to avoid hospitalization and caregiving strain, activation, and health-related quality of life (HRQOL)., Study Design: In this prospective cohort study, enrolled parents of children with medical complexity (n = 75) from 3 complex care programs received text messages (at random times every 2 weeks for 3 months) asking them to rate their confidence to avoid hospitalization in the next month. Low confidence, as measured on a 10-point Likert scale (1 = not confident; 10 = fully confident), was defined as a mean rating <5. Caregiving measures included the Caregiver Strain Questionnaire, Family Caregiver Activation in Transition (FCAT), and caregiver HRQOL (Medical Outcomes Study Short Form 12 [SF12]). Relationships between caregiving and confidence were assessed with a hierarchical logistic regression and classification and regression trees (CART) model., Results: The parents were mostly mothers (77%) and were linguistically diverse (20% spoke Spanish as their primary language), and 18% had low confidence on average. Demographic and clinical variables had weaker associations with confidence. In regression models, low confidence was associated with higher caregiver strain (aOR, 3.52; 95% CI, 1.45-8.54). Better mental HRQOL was associated with lower likelihood of low confidence (aOR, 0.89; 95% CI, 0.80-0.97). In the CART model, higher strain similarly identified parents with lower confidence. In all models, low confidence was not associated with caregiver activation (FCAT) or physical HRQOL (SF12) scores., Conclusions: Parents of children with medical complexity with high strain and low mental HRQOL had low confidence in the range in which intervention to avoid hospitalization would be warranted. Future work could determine how adaptive interventions to improve confidence and prevent hospitalizations should account for strain and low mental HRQOL., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: National data on the health of children and adolescents exposed to commercial sexual exploitation (CSE) are lacking, during both adolescence and adulthood. Using nationally representative data, we examined the health of male and female adolescents in grades 7-12 who experienced CSE exposure and subsequent adult health outcomes and access to health care., Methods: Our retrospective cohort study used data from Waves I-IV of the National Longitudinal Study of Adolescent to Adult Health (1994-2008) to characterize relationships between CSE exposure before or during adolescence and health during adolescence and adulthood. The analytic sample included 10 918 adult participants aged 24-34 in Wave IV. We performed bivariate analyses, stratified by sex, to quantify the relationship between CSE exposure before or during adolescence and adolescent and adult health outcomes., Results: Four percent of participants reported having a CSE exposure before or during adolescence (5% of males, 3% of females). Factors associated with CSE exposure among adolescents included race/ethnicity, parental education level, previous abuse, same-sex romantic attractions, history of ever having run away from home, and substance use. During adolescence, exposure to CSE was associated with worse overall health, depressive symptoms, and suicidal thoughts for both males and females. In adulthood, adolescent CSE exposure was associated with depression among males and functional limitations among females. A higher percentage of males with CSE exposure before or during adolescence, compared with their non-CSE-exposed peers, used the emergency department as their usual source of care during adulthood., Conclusions: CSE exposure before or during adolescence was associated with poor adolescent and adult health outcomes and health care access. Observed differences between males and females warrant further exploration.

Background: Evaluation of robotic surgical skill has become increasingly important as robotic approaches to common surgeries become more widely utilized. However, evaluation of these currently lacks standardization. In this paper, we aimed to review the literature on robotic surgical skill evaluation., Methods: A review of literature on robotic surgical skill evaluation was performed and representative literature presented over the past ten years., Results: The study of reliability and validity in robotic surgical evaluation shows two main assessment categories: manual and automatic. Manual assessments have been shown to be valid but typically are time consuming and costly. Automatic evaluation and simulation are similarly valid and simpler to implement. Initial reports on evaluation of skill using artificial intelligence platforms show validity. Few data on evaluation methods of surgical skill connect directly to patient outcomes., Conclusion: As evaluation in surgery begins to incorporate robotic skills, a simultaneous shift from manual to automatic evaluation may occur given the ease of implementation of these technologies. Robotic platforms offer the unique benefit of providing more objective data streams including kinematic data which allows for precise instrument tracking in the operative field. Such data streams will likely incrementally be implemented in performance evaluations. Similarly, with advances in artificial intelligence, machine evaluation of human technical skill will likely form the next wave of surgical evaluation., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The Academic Pediatrics Association has taken multiple steps over the last 2 years to incorporate the lenses of anti-racism and social justice into our mission and work. In this commentary, we discuss the creation and work of the Anti-Racism and Diversity Task Force, which was charged by the Academic Pediatrics Association's Board of Directors with identifying strategies to promote anti-racism and advance the diversity, equity and inclusion agenda., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC., Methods: A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit., Results: Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5])., Conclusions: Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings., Competing Interests: Disclosure: The authors declare no conflict of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)