Search

Abstract Background Scandium-47 is the therapeutic counterpart to the diagnostic radionuclides, 43Sc and 44Sc. Together, these form elementally matched theranostic nuclide pairs, but their incorporation into radiopharmaceuticals requires developing production techniques leading to radioscandium isotopes with high chemical and radionuclidic purity. Previous 47Sc production methods involved expensive, enriched titanium targets that require additional procedures for target recovery. This work investigates the irradiation of natural vanadium targets and the development of purification methods for high-purity 47Sc. Natural vanadium foils were used in cyclotron target configurations. Targets were irradiated with 24 MeV protons at currents of up to 80 µA. A purification method was developed by determining the Kd values of Sc, Cr, and V using MP-50 resin. The final purification method used MP-50 and CM resin columns to isolate the 47Sc from natV and co-produced 51Cr. Inductively Coupled Plasma Mass Spectrometry (ICP-MS), gamma-ray spectroscopy, and a DOTA titration were used to characterize the 47Sc product. Results Two cyclotron targets were designed, a small-scale target for developing a purification procedure and a high-power target for scaled-up production. The high-power target maximum current was 80 µA of 24 MeV protons. The yield for an 8 h irradiation at 80 µA of 24 MeV protons, was 128.02 ± 11.1 MBq of 47Sc at End of Bombardment. The radionuclidic purity of 47Sc was 99.5 ± 0.2%. The purification using MP-50 and CM columns resulted in the removal of natV target and 51Cr contaminate in the final 47Sc product, with an average recovery of 72 ± 2.1% and a DOTA apparent molar activity of 7733 ± 155 MBq/µmol. ICP-MS results showed that all top-row transition metals were below the limit of detection (

ABSTRACT The spore-forming bacterial pathogen Clostridium difficile is a leading cause of health care-associated infections in the United States. In order for this obligate anaerobe to transmit infection, it must form metabolically dormant spores prior to exiting the host. A key step during this process is the assembly of a protective, multilayered proteinaceous coat around the spore. Coat assembly depends on coat morphogenetic proteins recruiting distinct subsets of coat proteins to the developing spore. While 10 coat morphogenetic proteins have been identified in Bacillus subtilis, only two of these morphogenetic proteins have homologs in the Clostridia: SpoIVA and SpoVM. C. difficile SpoIVA is critical for proper coat assembly and functional spore formation, but the requirement for SpoVM during this process was unknown. Here, we show that SpoVM is largely dispensable for C. difficile spore formation, in contrast with B. subtilis. Loss of C. difficile SpoVM resulted in modest decreases (~3-fold) in heat- and chloroform-resistant spore formation, while morphological defects such as coat detachment from the forespore and abnormal cortex thickness were observed in ~30% of spoVM mutant cells. Biochemical analyses revealed that C. difficile SpoIVA and SpoVM directly interact, similarly to their B. subtilis counterparts. However, in contrast with B. subtilis, C. difficile SpoVM was not essential for SpoIVA to encase the forespore. Since C. difficile coat morphogenesis requires SpoIVA-interacting protein L (SipL), which is conserved exclusively in the Clostridia, but not the more broadly conserved SpoVM, our results reveal another key difference between C. difficile and B. subtilis spore assembly pathways. IMPORTANCE The spore-forming obligate anaerobe Clostridium difficile is the leading cause of antibiotic-associated diarrheal disease in the United States. When C. difficile spores are ingested by susceptible individuals, they germinate within the gut and transform into vegetative, toxin-secreting cells. During infection, C. difficile must also induce spore formation to survive exit from the host. Since spore formation is essential for transmission, understanding the basic mechanisms underlying sporulation in C. difficile could inform the development of therapeutic strategies targeting spores. In this study, we determine the requirement of the C. difficile homolog of SpoVM, a protein that is essential for spore formation in Bacillus subtilis due to its regulation of coat and cortex formation. We observed that SpoVM plays a minor role in C. difficile spore formation, in contrast with B. subtilis, indicating that this protein would not be a good target for inhibiting spore formation.

The Gram-positive, spore-forming pathogen Clostridium difficile is the leading definable cause of healthcare-associated diarrhea worldwide. C. difficile infections are difficult to treat because of their frequent recurrence, which can cause life-threatening complications such as pseudomembranous colitis. The spores of C. difficile are responsible for these high rates of recurrence, since they are the major transmissive form of the organism and resistant to antibiotics and many disinfectants. Despite the importance of spores to the pathogenesis of C. difficile, little is known about their composition or formation. Based on studies in Bacillus subtilis and other Clostridium spp., the sigma factors σ(F), σ(E), σ(G), and σ(K) are predicted to control the transcription of genes required for sporulation, although their specific functions vary depending on the organism. In order to determine the roles of σ(F), σ(E), σ(G), and σ(K) in regulating C. difficile sporulation, we generated loss-of-function mutations in genes encoding these sporulation sigma factors and performed RNA-Sequencing to identify specific sigma factor-dependent genes. This analysis identified 224 genes whose expression was collectively activated by sporulation sigma factors: 183 were σ(F)-dependent, 169 were σ(E)-dependent, 34 were σ(G)-dependent, and 31 were σ(K)-dependent. In contrast with B. subtilis, C. difficile σ(E) was dispensable for σ(G) activation, σ(G) was dispensable for σ(K) activation, and σ(F) was required for post-translationally activating σ(G). Collectively, these results provide the first genome-wide transcriptional analysis of genes induced by specific sporulation sigma factors in the Clostridia and highlight that diverse mechanisms regulate sporulation sigma factor activity in the Firmicutes.

Scandium-47 is a promising radionuclide for targeted radiotherapy and is also an elementally matched therapeutic partner to 43 Sc and 44 Sc, which are suitable for Positron Emission Tomography. The predominantly reported routes for the production of 47 Sc employ expensive enriched titanium or calcium targets to achieve high radionuclidic purity. This study reports measurements of the excitation function of the nat V(p,x) 47 Sc reaction at proton energies of 18-24 MeV to optimize bombardment parameters for the production of 47 Sc using this promising approach. The cross-sections reported here demonstrate that irradiation of vanadium targets can produce >99% radionuclidically pure 47 Sc with a proton energy of 24 MeV, albeit at modest yields., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Child maltreatment can affect multiple children in a family, yet its occurrence and chronicity has been often assessed by focusing on a single child. Although this approach provides valuable insights, considering the experiences of all children in a family may provide a more complete understanding of maltreatment dynamics. Using linked birth and child protection system (CPS) records from California, we analyzed 20 years of data on 194,514 first-time mothers to document the prevalence, timing, and chronicity of maternal CPS reporting across multiple children. Mothers were categorized by the number of live childbirths: one (25.7%), two (36.2%), three (20.9%), and four or more (17.2%). Overall, 33.0% of mothers were reported to CPS, increasing from 18.5% for mothers with one child to 63.1% for those with four or more children. For mothers with two or more children, more than 70% experienced an initial CPS report only after the second child's birth. Our findings have implications for understanding the dynamics of maternal reports to CPS, emphasizing the need for lasting and family-focused interventions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Child protection systems often intervene after substance-exposed births but are not designed to address the postpartum needs of the delivering parent. In this retrospective cohort study, we aimed to estimate the association between early child protection system removal and high-risk subsequent birth trajectories among a cohort of mothers with substance-exposed births in California. Of 6,893 births in 2015 with documented prenatal drug and alcohol exposure, 20.4% of mothers experienced child protection system removal within 30 days after birth. First-month child protection system removal was associated with short-interval birth (adjusted hazard ratio [HR] 1.61, 95% CI, 1.09-2.36) and short-interval birth with documentation of substance exposure (adjusted HR 3.17, 95% CI, 1.65-6.08). We found that child separation was associated with an increase, not a reduction, in subsequent substance-exposed births. These findings indicate the need for focused public health and supportive services to address the treatment, health care, family-building, and psychological needs of parents with substance use during pregnancy., Competing Interests: Financial Disclosure Davida Schiff reports that money was paid to their institution from the NIDA (K23DA048169). They have received funding for presentations from the AAP, UMass, and Dartmouth Hitchcock. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive., Objective: To document the child protection system involvement and the characteristics of children who test positive for illicit substances., Design, Setting, and Participants: This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024., Exposure: Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine., Main Measures and Outcomes: CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements., Results: A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children., Conclusions and Relevance: In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.

Most child protective services (CPS) investigations involve allegations of neglect. Broad and vague definitions have led to concerns that CPS-investigated neglect is driven by poverty-based material hardship. In a representative sample of 295 neglect investigations in California in 2017, structured data and narrative text fields were used to characterize the types of neglect and concurrent parental risk factors investigated by CPS and to assess the rate and nature of investigated physical neglect, defined as inadequate food, housing, or hygiene. The most common types of neglect were inadequate supervision (44%) and failure to protect (29%), followed by physical neglect (14%). Common risk factors identified in neglect investigations were parental substance use (41%), domestic violence (21%), mental illness (18%), and co-reported physical or sexual abuse (29%). Nearly all investigations of physical neglect (99%) included concerns related to substance use, domestic violence, mental illness, co-reported abuse or an additional neglect allegation (i.e., abandonment). Given concerns identified in neglect investigations, economic supports are likely insufficient without an array of behavioral-health supports., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The purpose of this study is to estimate the rate of emotional disturbance (ED) among children in foster care and assess the validity of the national foster care census data (AFCARS) measure of ED. This study used linked child protection and Medicaid records from 2014 and 2015, for the states of California and Wisconsin, as well as data from AFCARS, a federal population census of children in foster care which states are mandated to contribute to. ED is defined by AFCARS and includes an array of mental and behavioral health diagnoses. According to AFCARS, 13% of CA children in foster care and 15% of WI children in foster care had an ED, whereas Medicaid claims produce rates of 45% and 48%, respectively. Rates of ED among children in congregate care were underestimated by 43-46 percentage points, with substantial proportions having diagnoses of disruptive behavioral disorders. Despite the AFCARS ED measure being cited in congressional testimonies and its wide use in research, results from this study suggest that the AFCARS ED estimates are an unreliable metric for use in research, policy, or practice., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate whether maltreatment investigated during infancy affects high-acuity health care utilization patterns during early childhood., Methods: Retrospective case-control study based on linked data between child protection and hospital encounter records conducted to review health records of infants investigated for abuse and/or neglect. Cases and controls were followed longitudinally through the Rady Children's Hospital electronic health records for 4 years starting at the age of 1 year., Results: A total of 3692 children were investigated for maltreatment within the first year of life. When comparisons were made between children reported for maltreatment and matched controls, children with infancy maltreatment reports had significantly more high-acuity health care encounters than matched controls (average treatment effect = 1.53, 95% Confidence Interval 1.08-1.99, P < .001)., Conclusions: Infants investigated for maltreatment have greater high-acuity health care utilization in early childhood. These findings highlight this population's need for well-defined medical homes to ensure appropriate health care. Further understanding of the underlying reasons for this increased health care burden will help inform these efforts., Competing Interests: Declaration of Competing Interest Each author confirms that they have no conflicts of interest related to this publication., (Published by Elsevier Inc.)

Objective: Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE)., Method: We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record., Results: In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3., Discussion: PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population., (© 2023. The Author(s).)

Background: Mechanisms for reporting child maltreatment (CM) were affected by changes in service provision immediately following the onset of the COVID-19 pandemic., Objective: To examine changes in counts and CPS reporting of CM medical encounters before and after the onset of COVID-19., Participants and Setting: All emergency department and inpatient medical encounters with at least one CM diagnosis during the study period at Rady Children's Hospital San Diego, the largest pediatric hospital in California between 2016 and November 2021., Methods: Using linked medical record and CPS administrative data, interrupted time series models tested for changes in monthly counts and percentages of CM medical encounters reported to CPS with the onset of COVID-19. Logistic regression tested for the likelihood of a CPS report being associated with a CM encounter., Results: CM medical encounters totaled 2528, including 793 after the onset of COVID-19. Interrupted time series models indicated with the onset of the pandemic, the counts of CM encounters increased 18 % (RR: 1.18, 95 % CI 1.03-1.34) and the percentages reported to CPS increased 10 % (RR: 1.10, 95 % CI: 1.05-1.17). CM encounters that occurred after the onset of the COVID-19 pandemic had increased odds of a CPS report (fully adjusted model: OR: 1.08; 95 % CI: 1.05-1.12)., Conclusions: This study found increases in monthly counts and a higher percentage of CM medical encounters with CPS reports after the pandemic onset., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

We used National Child Abuse and Neglect Data System and Census data to examine Black-White and Hispanic-White disparities in reporting, substantiation, and out-of-home placement both descriptively from 2005-2019 and in multivariate models from 2007-2017. We also tracked contemporaneous social risk (e.g., child poverty) and child harm (e.g., infant mortality) disparities using non-child protective services (CPS) sources and compared them to CPS reporting rate disparities. Black-White CPS reporting disparities were lower than found in non-CPS risk and harm benchmarks. Consistent with the Hispanic paradox, Hispanic-White CPS reporting disparities were lower than risk disparities but similar to harm disparities. Descriptive and multivariate analyses of data from the past several years indicated that Black children were less likely to be substantiated or placed into out-of-home care following a report than White children. Hispanic children were slightly more likely to be substantiated or placed in out-of-home care than White children overall, but this difference disappeared in multivariate models. Available data provide no evidence that Black children were overreported relative to observed risks and harms reflected in non-CPS data. Reducing reporting rates among Black children will require addressing broader conditions associated with maltreatment.

Objective: To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic., Methods: Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters., Results: Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed that the count of maltreatment encounters increased 64% with the onset of COVID-19., Conclusions: We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment., Competing Interests: Declaration of Competing Interest Funding for this project came from NICHD R21HD105907. The Children's Data Network also receives essential infrastructure funding from First 5 LA, the Conrad N. Hilton Foundation, The Reissa Foundation, and the Heising-Simons Foundation. The authors do not have conflicts of interest to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or any other funder or data partner., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Research with administrative records involves the challenge of limited information in any single data source to answer policy-related questions. Record linkage provides researchers with a tool to supplement administrative datasets with other information about the same people when identified in separate sources as matched pairs. Several solutions are available for undertaking record linkage, producing linkage keys for merging data sources for positively matched pairs of records. In the current manuscript, we demonstrate a new application of the Python RecordLinkage package to family-based record linkages with machine learning algorithms for probability scoring, which we call probabilistic record linkage for families (PRLF). First, a simulation of administrative records identifies PRLF accuracy with variations in match and data degradation percentages. Accuracy is largely influenced by degradation (e.g., missing data fields, mismatched values) compared to the percentage of simulated matches. Second, an application of data linkage is presented to compare regression model estimate performance across three record linkage solutions (PRLF, ChoiceMaker, and Link Plus). Our findings indicate that all three solutions, when optimized, provide similar results for researchers. Strengths of our process, such as the use of ensemble methods, to improve match accuracy are discussed. We then identify caveats of record linkage in the context of administrative data., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Prindle et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The health services literature indicates that the day and time of a medical encounter is often significant factor in patient outcomes, yet little is known about the role of temporal dimensions in child maltreatment reporting or substantiation., Objective: We examined time-specific dynamics of screened-in reports of alleged maltreatment from different reporter sources, including their relationship to the likelihood of substantiation., Participants and Setting: We used a population-based dataset of administrative records for 119,758 child protection investigations involving 193,300 unique children in Los Angeles County, California, between 2016 and 2017., Methods: For each report, we coded three categorical temporal dimensions of the maltreatment report: season, day of the week, and time of day. We descriptively examined how temporal characteristics varied by reporting source. Finally, we ran generalized linear models to estimate the likelihood of substantiation., Results: We observed variability overall and by reporter type for all three measures of time. Reports were less likely during summer months (22.2 %), during the weekend (13.6 %), and after midnight (10.4 %). Counts of reports from law enforcement were more common after midnight and contributed to a greater proportion of substantiations over the weekend than other reporter types. Weekend and morning reports were nearly 10 % more likely than weekday and afternoon to be substantiated, respectively. Reporter type was the most prominent factor for substantiation regardless of temporal dimensions., Conclusions: Screened-in reports varied by season and other classifications of time, but temporal dimensions exhibited only a modest influence on the likelihood of substantiation., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Child maltreatment recidivism is typically measured and studied at the individual level. Conditions that give rise to child abuse and neglect, however, typically affect multiple children in a given family. In the current study, we estimated maltreatment recidivism at the maternal level and examined its risk as a function of maternal sociodemographic characteristics that may change over time. Using linked administrative records, we identified a subset of first-time mothers in California whose first child was reported to the child protection system (CPS) between birth and age 5 and who then gave birth to another child ( n = 14,715). Following the firstborn child's CPS reporting, nearly half of these mothers (43.3%) were re-reported concerning the non-firstborn children during the first 5 years of the child's life. Risk factors consistently documented across births were associated with a heightened risk of maternal CPS recidivism. Our study advances an understanding of the full extent of maltreatment recidivism by broadening the focus from individual children.

An estimated 1 in 3 U.S. children will be the subject of a child protective services (CPS) investigation during their lifetime, typically for allegations of neglect. Whether and how an initial report of neglect is addressed may place children on divergent trajectories for safety and stability throughout childhood. The purpose of this study is to track subsequent CPS contact among children born in California in 2000 who were first investigated by CPS for neglect allegations alone (no co-occurring abuse) and not permanently separated from their families of origin (i.e., not removed or reunified if removed). We estimated the rates of subsequent CPS referrals, substantiated maltreatment, placement in foster care, and allegations of physical and sexual abuse by age 18. We assessed how rates of subsequent contact varied by initial CPS response and age at first investigation. Supplemental analyses disaggregated data by race and ethnicity. Results indicate that 64% of children initially investigated for neglect alone were re-referred to CPS by age 18 and 16% experienced a subsequent removal; however, these estimates varied greatly by age. Four out of five (79% to 83%) of children initially investigated as infants had one or more subsequent CPS referrals during childhood. Children were not only re-referred for allegations of neglect; more than half of children re-referred were reported for allegations of physical or sexual abuse, indicating that abuse risk was either missed during the initial CPS investigation or escalated afterward. The failure to address maltreatment risks when children first present to the system is a complex problem with no easy solution. Our findings document that a majority of children initially referred for neglect experience future CPS involvement, often for allegations of physical or sexual abuse., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Palmer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

With the transition to the International Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10-CM), additional research is needed to understand which diagnostic codes for intimate partner violence (IPV) are being used. The current study examined characteristics of IPV visits and frequency of diagnostic codes to identify IPV in all emergency department (ED) and inpatient hospital visits for adults in California from 2016-2018, after ICD-10-CM implementation. Five ICD-10-CM codes outlined in the Uniform Data System Reporting Instructions were used to identify IPV. Fewer than 0.1% of visits (17,347 ED visits and 1,430 hospitalizations) included documentation of IPV. Visits with documented IPV were more common among patients who were younger, female, Black, primarily English-speaking, and publicly insured compared to visits with no documented IPV. There were fairly consistent patterns over time in the specific ICD-10-CM codes used for IPV between 2016 and 2018. Physical and sexual abuse were the most common codes for types of abuse. Among the 15 EDs and 15 hospitals in California with the highest volume of IPV visits, there was variability in the use of ICD-10-CM codes for IPV visits. Accurate documentation of IPV in administrative data may improve patient care and increase understanding of the burden and effects of IPV on individuals and communities.

Objective: To determine the population prevalence of diagnosed mental health disorders among Medicaid-insured children <18 years old in California based on levels of current and past child protection system (CPS) involvement., Study Design: In this retrospective, population-based study, we examined the full population of children enrolled in California's Medicaid program for at least 1 month between 2014 and 2015 and who had at least 1 claim during that period (n = 3 352 886). Records for Medicaid-insured children were probabilistically linked to statewide CPS records of maltreatment and foster care placements since 1998. A primary or secondary mental health diagnosis was classified using International Classification of Diseases codes., Results: Overall, 14% (n = 470 513) of all children insured through Medicaid in 2014-2015 had a documented mental health diagnosis. Among children with a diagnosis, the percentage with CPS involvement (ie, any report for maltreatment) was nearly twice that of the Medicaid population overall (50.4% vs 26.9%). This finding held across all diagnostic groups but with notable variations in magnitude. A graded relationship emerged between the level of CPS involvement and the likelihood of a mental health diagnosis. Diagnoses among children reported for maltreatment were common, regardless of placement in foster care., Conclusions: Findings document high rates of both mental health diagnoses and past child protection involvement in a population of Medicaid-insured children. Most children reported for maltreatment will never be placed in foster care, underscoring the importance of ensuring that the children who remain at home receive the proper array and coordination of services., (Copyright © 2022. Published by Elsevier Inc.)

The federal Child Abuse Prevention and Treatment Act (CAPTA) requires that a plan of safe care, called a family care plan (FCP) in Connecticut, be developed for all newborns identified as being affected by substance abuse and their caregivers. In Connecticut, FCPs are developed in treatment or hospital settings, not by child protective services. Analyzing data from Connecticut from 2019-2021, we found robust yet uneven implementation of FCPs that may have resulted in inadequate support for some affected caregiver-infant dyads. Additional implementation strategies may be needed to ensure that all dyads receive comprehensive FCPs., Competing Interests: Conflict of Interest: Lloyd Sieger was a sub-award recipient from the Connecticut Department of Children and Families.

Background: Child protective services (CPS) agencies use risk assessment tools to augment decision making about alleged child maltreatment. Under the Family First Prevention Services Act, states and tribes are permitted to claim federal reimbursement for prevention services for children at imminent risk of entering foster care based on assessment tools and protocols. In this context, existing tools are being repurposed. It is critical to reassess the evidence supporting their use., Objective: We aimed to synthesize the evidence pertaining to validity and reliability of specific risk assessment tools designed for CPS agencies, summarize how this work has been carried out, and review the conceptual dimensions of risk included in each tool., Participants and Setting: We included United States-based, quantitative evaluations of risk assessment tools published between 1990 and May 2021., Methods: We carried out a scoping review using a protocol in alignment with PRISMA-ScR. We used a multiphase selective screening approach with at least two screeners., Results: In total, 25 studies met inclusion criteria. Overall, research about the validity and reliability of risk assessment tools is dated and heterogeneous in methodology. The conceptualizations of risk assessment and the operationalization of risk also varied widely. There was a general dearth of evidence that supported the use of tools across demographic subgroups., Conclusions: Heterogeneity of studies assessing tool validity and reliability suggests a lack of agreement about how to assess tools and makes it difficult to interpret findings across studies. Agencies should be cautious about overreliance on tools for which evidence is limited., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Childhood maltreatment involves dynamics between the type of maltreatment experienced and the context of maltreatment. Reports of alleged maltreatment to child protective services may overlap and shift over time, complicating understanding of their independent and interacting nature, including how child protection systems respond. Latent class analysis (LCA) and latent transition analysis (LTA) were used to construct data-based models of longitudinal dynamics of alleged maltreatment throughout childhood. We sought to identify patterns leading to system decisions to substantiate allegations of maltreatment and place children in foster care. Using linked birth and child protection records, we defined a cohort of children born in California in 1999, 29.4% of whom had at least one referral for alleged maltreatment before their 18th birthday. Maltreatment and perpetrator indicators were coded, and LCA identified five alleged maltreatment classes and one class of children without referrals. LTA determined consistency of classifications and estimated transitions between classes over age periods. Children with multitype maltreatment patterns or experiences of neglect were most likely to experience future maltreatment allegations. Estimated probabilities of placement indicated children with Multitype Maltreatment allegations were more likely to experience substantiated maltreatment allegations and out-of-home placements. Findings identify a repeatable method for better understanding complex systems.

Background: Children are reported for maltreatment during infancy at elevated rates; research has established persistent racial/ethnic differences in the likelihood of reporting to the child protection system (CPS)., Objective: To model the influence of race/ethnicity and community disadvantage in CPS reporting during infancy., Participants/setting: A population-based dataset consisting of more than 1.2 million children born in California between 2012 and 2014. Vital birth records were probabilistically linked to administrative CPS records. American Community Survey data were used to measure community disadvantage., Methods: For each child, we coded sociodemographic information from the birth record, assigned the child to a community using their residential address at birth, and captured maltreatment reports from child protection records. We employed a modified Poisson regression model to examine an infant's likelihood of being reported to CPS by race/ethnicity across levels of community disadvantage and after adjusting for individual-level covariates., Results: Infants born in neighborhoods with the most concentrated disadvantage were reported to CPS at 7 times the rate of children born in the most advantaged neighborhoods (12.3% vs. 1.8%). After adjusting for individual-level covariates, we found that both Black and Hispanic infants born on public insurance were significantly less likely than White infants to be reported for maltreatment overall - and Black and Hispanic infants had a statistically equivalent or lower likelihood of reporting at the two extremes of neighborhood disadvantage. Among privately insured families, Hispanic infants continued to have a lower likelihood of reporting, but Black infants were reported at higher rates than White infants. This Black-White difference persisted in the most advantaged neighborhoods, but disappeared in the most disadvantaged neighborhoods., Conclusions: Capturing individual-level differences in socioeconomic status and associated risk factors is critical to understanding sources of racial/ethnic differences in CPS reporting, including when there is unwarranted variation or disparate treatment. Our findings suggest an elevated likelihood of maltreatment reporting among privately insured Black infants not explained by differences in observed risk or neighborhood, but no such differences were documented for Black or Hispanic infants on public insurance., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Calls continue for staff training as an instrumental response to racially based differences in rates of child protection system interactions and outcomes. These recommendations echo a reliance on implicit bias and diversity training (referred to broadly as "anti-bias and racial sensitivity training") across disciplines of social and human services in the United States as a feasible and politically expedient solution to racial disparities. But focusing on anti-bias training to address racial disparities in child protection systems will almost certainly fail to achieve desired objectives for at least three reasons: (a) there is no evidence that implicit bias or racial sensitivity trainings change behavior; (b) personnel training initiatives misapply an individual behavioral solution to an institutional and structural problem; and (c) an emphasis on internal training initiatives distracts and reduces the accountability of other systems of care better positioned to produce change. We conclude that if the goal is to reduce racial disparities, systemic innovations and broader policy reforms both internal and external to the child protection system are needed. Training will not meaningfully shift the downstream effects of structural racism., (Copyright © 2022. Published by Elsevier Ltd.)

The Children's Data Network (CDN) is a data and research collaborative focused on the linkage and analysis of administrative records. In partnership with public agencies, philanthropic funders, affiliated researchers, and community stakeholders, we seek to generate knowledge and advance evidence-rich policies that improve the health, safety, and well-being of the children of California. Given our experience negotiating access to and working with existing administrative data (and importantly, data stewards), the CDN has demonstrated its ability to perform cost-effective and rigorous record linkage, answer time-sensitive policy- and program-related questions, and build the public sector's capacity to do the same. Owing to steadfast and generous infrastructure and project support, close collaboration with public partners, and strategic analyses and engagements, the CDN has promoted a person-level and longitudinal understanding of children and families in California and in so doing, informed policy and program development nationwide. We sincerely hope that our experience-and lessons learned-can advance and inform work in other fields and jurisdictions., Competing Interests: Statement on conflicts of interest: The authors do not have any conflicts of interest to report.

Living in a neighborhood with high levels of intergenerational mobility is associated with better childhood cognition and behavior as well as adult health. Nevertheless, it is unclear if such differences originate earlier, and thus if neighborhood intergenerational mobility is associated with health differences at birth. To address this question, we examined whether neighborhood intergenerational mobility, independent of neighborhood poverty, was associated with low birth weight (LBW) in a population-based cohort of singleton children born in California in 2017 (n = 426,873). Although increased neighborhood mobility was associated with a decreased likelihood of LBW, it was no longer associated with LBW (OR = 0.98, CI = 0.96, 1.00) after adjusting for neighborhood poverty. Meanwhile, neighborhood poverty was associated with LBW (OR = 1.04, CI = 1.02, 1.05) after accounting for mobility, with the odds of LBW 9.4% higher among children born where neighborhood poverty was in the 90th percentile compared with children born where neighborhood poverty was in the 10th percentile. Findings indicate that neighborhood poverty, but not intergenerational mobility, is a robust and independent correlate of increased LBW births, and thus early developmental health. These findings also suggest that the role of neighborhood intergenerational mobility in child and adult health outcomes may emerge later in development, independent of LBW, or that the role of neighborhood intergenerational mobility in LBW may be indirectly mediated through exposure to neighborhood poverty., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

During the COVID-19 pandemic, reports to child abuse and neglect hotlines have dropped significantly across the United States. Yet, during this same period, calls to domestic violence hotlines have increased. The purpose of this study was to examine if there have been measurable changes in domestic violence-related reports to child abuse and neglect hotlines. Using administrative child protection records from California, we plotted counts and proportions of child maltreatment reports with and without domestic violence allegations before and through the onset of school closures associated with the COVID-19 pandemic. We used an interrupted time series analysis to evaluate whether or not there was a change in domestic violence allegations in child protection reports corresponding to the COVID-19 pandemic. We document that during the first two quarters of 2020 there was a 14.3% drop in the overall number of child protection reports. Despite a decline in maltreatment reporting overall, there was a 25% increase in the proportion of reports with allegations of domestic violence. Our findings suggest both the count and composition of reports to child protection agencies were affected by the COVID-19 pandemic. The current analyses also showcase the seasonality of CPS reports generally, and reports with DV allegations, specifically., Competing Interests: Conflict of interestThe authors declare they have no conflict of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021.)

Background: In 2011, California enacted its public safety realignment initiative (realignment) motivated by a U.S. Supreme Court ruling to reduce state prison overcrowding and in effort to reduce recidivism. Realignment transferred authority for lower-level felony offenders from the state to the counties, leading to a rapid reduction in state prison incarceration levels., Objective: This study drew on a unique dataset to assess the effects of California's efforts to downsize the prison system on maternal incarceration levels and to better understand the characteristics of incarcerated mothers and their children., Methods: Incarceration records concerning all women in California state prisons between 2010 and 2012 (N = 16,917) were linked to 7.5 million vital birth records dating to 1999 to identify incarcerated women who had given birth. Multinomial logistic regression models were specified to better understand offense type differences among incarcerated mothers versus nonmothers., Results: Findings indicate that realignment disproportionately affected women. The number of men entering prison decreased 67.8% between 2010 and 2012. In comparison, the number of women entering prison decreased 78.5%. Further, more than half of incarcerated women had given birth. Mothers were more likely than nonmothers to be convicted of nonviolent crimes., Discussion: This study underscores how prison downsizing can disproportionately reduce incarceration levels for women. Given that such large proportion of incarcerated women were mothers, this policy change may have potential spillover next-generation benefits. Finally, this work reinforces the potential to use linked administrative records to study incarcerated populations., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Intimate partner violence (IPV) negatively affects children. Although IPV-related reports frequently come to the attention of child protective services (CPS), there is neither a unified standard for how CPS systems should respond, nor sufficient research documenting that reaction. The current study used population-based administrative records from California to assess how CPS responds to reported allegations of IPV, with and without physical abuse and/or neglect allegations. We used multinomial regression to model the likelihood of investigation outcomes. Results indicate that 20.7% of CPS reports had IPV alleged during hotline screening, and of those, just 3.2% were screened out compared to 20.2% for reports where IPV was not alleged. Almost half (45.5%) of IPV-alleged reports came from law enforcement, in contrast to 15.2% of reports that did not allege IPV. IPV-alleged reports were more likely to have allegations substantiated without a case opened for services, but less likely to result in foster care placements. Several statistically significant differences were identified by the type of alleged maltreatment co-reported with IPV. This study contributes to an understanding of how CPS responds to IPV-alleged reports.

Research on secondary prevention is mixed as to whether referrals to evidence-based practices and other community interventions reduce maltreatment recidivism. This evaluation sought to rigorously assess whether a community service-linkage model to evidence-based programs decreased subsequent reports of abuse and neglect among families reported to the child protection system (CPS). Between 2016 and 2018, administrative CPS records were used to identify families with at least one child under 5 years of age recently reported for maltreatment in Orange County, California, but where no follow-up services were mandated. Families were randomized to one of two community outreach and engagement conditions (i.e., targeted provider outreach vs. treatment-as-usual). Re-reporting outcomes were tracked in administrative records for a period of 12 months. A total of 4873 families met eligibility criteria, with 2231 (45.0%) randomized to the intervention arm and 2642 (54.0%) families to the control group. Among families in the intervention group, 811 (36.4%) were successfully contacted by a community provider. Of those families contacted, 145 (18.0%) agreed to participate in voluntary services. Overall, we did not detect any significant difference in re-reporting between our treatment and control groups (P = .433). Likewise, no significant differences in re-reporting were observed when we stratified the treatment group by levels of outreach and service engagement. Findings indicate low levels of successful engagement of families in voluntary services. Notwithstanding the absence of significant findings, this study demonstrates the potential for using community-based RCTs and administrative records to rigorously evaluate secondary prevention programs in the child protection system., (© 2021. Society for Prevention Research.)

Purpose: The purpose of this study was to provide a population-based analysis of child protection system (CPS) involvement among children and adolescents who died by suicide., Methods: We performed a case-control study of child and adolescent suicide and CPS involvement. Using linked birth, death, and CPS records, we longitudinally followed all children born in California in 1999 and 2000 (N = 1,052,333) in CPS and death records through 2017. Cases were defined as children who died in California and had a manner of death coded as suicide using the International Classification of Diseases, 10th revision (n = 170). Each suicide case was matched to four living controls, and children were classified based on CPS exposure: no history, reported for alleged child maltreatment, substantiated for child maltreatment, and placed in foster care. Crude suicide rates were documented, and conditional logistic regression models were used to estimate the adjusted odds of suicide., Results: Among children and adolescents who died by suicide, 56.5% had a history of past allegations of abuse or neglect. Children with any CPS history had three times the odds of suicide compared to children with no history. No additional risk was found for children substantiated or placed in foster care compared to children with only an allegation., Conclusions: Suicide risk is not isolated to the relatively small group of children and youth placed in foster care. Findings reinforce the importance of increased attention to the experiences of the larger universe of children who remain at home after alleged or substantiated maltreatment., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine whether postneonatal infants reported for maltreatment face a heightened risk of deaths attributable to medical causes., Methods: Birth and death records for all children born in California between 2010 and 2016 ( N = 3 455 985) were linked to administrative child protection system records. Infants were prospectively followed from birth through death or age 1 year. Reports of maltreatment and foster care placement episodes were modeled as time-varying covariates; sociodemographic characteristics at birth were modeled as baseline covariates. Stratified, multivariable competing risk models were used to estimate the adjusted relative hazard of postneonatal infant death attributed to a medical cause ( n = 1051)., Results: After adjusting for baseline risk factors, and compared with infants never reported for maltreatment, the medical-related mortality risk was almost twice as great among infants reported once for maltreatment (hazard ratio: 1.77; 95% confidence interval: 1.36-2.30) and 3 times greater if there was >1 maltreatment report (hazard ratio: 3.27; 95% confidence interval: 2.48, 4.30). Among infants reported for maltreatment, periods of foster care placement reduced the risk of death by roughly half., Conclusion: Infants reported for alleged maltreatment had a higher risk of death from medical causes, with foster care emerging as protective. Targeted support services for parents and improved communication between the child protection system and the pediatric health care community is needed, especially when infants who may be medically fragile remain at home after an allegation of abuse or neglect., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: The estimated number of youth who come into contact with both the child welfare and juvenile justice systems, or "dual system" youth, varies widely because studies use different methodologies. Recent work using linked administrative data shows promise for identifying a stable range of dual system rates, generalizable to other jurisdictions and useful for understanding the nature and timing of system involvement., Objective: This study replicates the U.S. Department of Justice, Office of Juvenile Justice and Delinquency Prevention (OJJDP) Dual System Youth Design Study methodology to explore dual system overlap and six distinct dual system pathways defined by the type (i.e., nonconcurrent or concurrent) and timing (i.e., first contact with child welfare or juvenile justice) of dual system contact in Los Angeles County., Participants and Setting: Using data from the Los Angeles Probation Department, a cohort of youth born in/after 1998 with a first juvenile justice petition between 2014 and 2016 was identified (N = 6877) and matched to statewide child welfare records between 1998 and 2017., Method: Descriptive statistics were produced for dual system youth and pathways, and differences across groups were tested using chi-square and t-tests., Results: Two-thirds of youth with a first juvenile justice petition interacted with the child welfare system. The majority of dual system youth did not have contact with both systems at the same time and nearly all dual system youth were involved with the child welfare system before the juvenile justice system. Female and Black youth were more likely to be dual system youth and to have more extensive involvement with the child welfare system. Probation experiences and outcomes were associated with the nature and chronicity of child welfare involvement., Conclusion: Implementing a delinquency prevention continuum that starts with community-based supports and continues throughout all levels of child welfare and juvenile justice involvement is essential to disrupting dual system involvement., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Research has indicated an association between child abuse and adolescent suicide. Little population-based information exists, however, about the nature of maltreatment experiences or interactions with the child protection system (CPS)., Objective: To examine child maltreatment characteristics and system-level responses associated with risk of adolescent suicide., Participants and Setting: Linked vital death records and CPS records were used to identify the population of adolescents who died by suicide in California between 2010 and 2017 and who had a history of at least one report to CPS prior to death., Method: A case control design was used, with cases defined as a suicide of an adolescent with a history of CPS involvement. Using CPS records, living controls were then matched to cases based on year of birth, sex, race and ethnicity, and age of first child maltreatment allegation. A conditional logistic regression model was used to estimate the adjusted odds of adolescent suicide across various CPS and maltreatment characteristics., Results: Recent CPS involvement, allegations of physical abuse, and allegations of sexual abuse emerged as significant risk factors for death by suicide. No differences in suicide risk were observed between youth with unsubstantiated or substantiated allegations., Conclusions: Suicide risk appears to be more closely tied to specific maltreatment experiences than to substantiation or placement into foster care. As adolescent suicide rates rise, better a understanding of risk factors among already vulnerable populations of youth is critical., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Youth who exit the nation's foster care system without permanency are at high risk of experiencing difficulties during the transition to adulthood., Objective: To present an illustrative test of whether an algorithmic decision aid could be used to identify youth at risk of existing foster care without permanency., Methods: For youth placed in foster care between ages 12 and 14, we assessed the risk of exiting care without permanency by age 18 based on their child welfare service involvement history. To develop predictive risk models, 28 years (1991-2018) of child welfare service records from California were used. Performances were evaluated using F1, AUC, and precision and recall scores at k %. Algorithmic racial bias and fairness was also examined., Results: The gradient boosting decision tree and random forest showed the best performance (F1 score = .54-.55, precision score = .62, recall score = .49). Among the top 30 % of youth the model identified as high risk, half of all youth who exited care without permanency were accurately identified four to six years prior to their exit, with a 39 % error rate. Although racial disparities between Black and White youth were observed in imbalanced error rates, calibration and predictive parity were satisfied., Conclusions: Our study illustrates the manner in which potential applications of predictive analytics, including those designed to achieve universal goals of permanency through more targeted allocations of resources, can be tested. It also assesses the model using metrics of fairness., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objectives. To document the cumulative childhood risk of different levels of involvement with the child protection system (CPS), including terminations of parental rights (TPRs). Methods. We linked vital records for California's 1999 birth cohort (n = 519 248) to CPS records from 1999 to 2017. We used sociodemographic information captured at birth to estimate differences in the cumulative percentage of children investigated, substantiated, placed in foster care, and with a TPR. Results. Overall, 26.3% of children were investigated for maltreatment, 10.5% were substantiated, 4.3% were placed in foster care, and 1.1% experienced a TPR. Roughly 1 in 2 Black and Native American children were investigated during childhood. Children receiving public insurance experienced CPS involvement at more than twice the rate of children with private insurance. Conclusions. Findings provide a lower-bound estimate of CPS involvement and extend previous research by documenting demographic differences, including in TPRs. Public Health Implications. Conservatively, CPS investigates more than a quarter of children born in California for abuse or neglect. These data reinforce policy questions about the current scope and reach of our modern CPS.

Importance: Nearly 6 million children are reported as allegedly experiencing abuse or neglect in the US annually. Child protection agencies are increasingly turning to automated predictive risk models (PRMs) that mine information found in routinely collected administrative data and estimate a likelihood that an individual will experience some future adverse outcome., Objective: To test if a PRM used at the time of referral for alleged maltreatment, which automatically generates a risk stratification score indicating the relative likelihood of future foster care placement, is also predictive of injury hospitalization data., Design, Setting, and Participants: This retrospective cohort study based on a probabilistic association between child protection and hospital encounter data was conducted in Allegheny County, Pennsylvania, and at Children's Hospital of Pittsburgh (Pittsburgh, Pennsylvania). Participants included children referred for alleged neglect or abuse in Allegheny County between April 1, 2010, and May 4, 2016., Exposures: Risk score generated from the PRM., Main Outcomes and Measures: Medical encounters (emergency department and inpatient hospitalizations) for any-cause injuries, suicide or self-inflicted harm injuries, and abuse injuries between 2002 and 2015 for children classified by the PRM to different risk levels at the time of a maltreatment referral. Cancer encounters were used as a placebo test., Results: Of 47 305 participants, 23 601 (49.9%) were girls, the mean (SD) age at referral was 8 (5.7) years, 28 211 (59.6%) were black, and 19 094 (40.4%) were nonblack. Children who scored in the highest 5% risk group by the PRM were more likely to have a medical encounter for an injury during the follow-up period than low-risk children (ie, those in the bottom 50% of risk). Specifically, among children referred for maltreatment and classified as highest risk, the rate of experiencing an any-cause injury encounter was 14.5 (95% CI, 13.1-15.9) per 100 compared with children who scored as low risk who had an any-cause injury encounter rate of 4.9 (95% CI, 4.7-5.2) per 100. For abuse-associated injury encounters, the rate for high-risk children was 2.0 (95% CI, 1.5-2.6) per 100 and that of low-risk children was 0.2 (95% CI, 0.2-0.3) per 100; for suicide and self-harm, the high-risk encounter rate was 1.0 (95% CI, 0.6-1.4) per 100 and that of low-risk children was 0.1 (95% CI, 0.1-0.1) per 100. There was no association between risk scores and cancer encounters., Conclusions and Relevance: Findings confirm that children reported for having experienced alleged maltreatment and classified by a PRM tool to be at high risk of foster care placement are also at increased risk of emergency department and in-patient hospitalizations for injuries.

Breast cancer patients presenting with symptomatic brain metastases have poor prognosis, and current chemotherapeutic agents are largely ineffective. In this study, we evaluated the hypomethylating agent azacitidine (AZA) for its potential as a novel therapeutic in preclinical models of brain metastasis of breast cancer. We used the parental triple-negative breast cancer MDA-MB-231 (231) cells and their brain colonizing counterpart (231Br) to ascertain phenotypic differences in response to AZA. We observed that 231Br cells have higher metastatic potential compared to 231 cells. With regard to therapeutic value, the AZA IC 50 value in 231Br cells is significantly lower than that in parental cells (P < .01). AZA treatment increased apoptosis and inhibited the Wnt signaling transduction pathway, angiogenesis, and cell metastatic capacity to a significantly higher extent in the 231Br line. AZA treatment in mice with experimental brain metastases significantly reduced tumor burden (P = .0112) and increased survival (P = .0026) compared to vehicle. Lastly, we observed a decreased expression of keratin 18 (an epithelial maker) in 231Br cells due to hypermethylation, elucidating a potential mechanism of action of AZA in treating brain metastases from breast cancer., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

The value of using administrative records for operational and evaluation purposes has been well established in health and human services. However, these records typically reflect the reach of a single government agency or program and fail to capture the experiences of individuals as they engage with different agencies or programs over time. Thus, the potential for these data to improve everyday operations, coordinate services, develop targeted interventions, and advance the science behind broader social policies has yet to be fully realized. A first step toward realizing that potential is to transition from an agency-centered to a client- or person-centered organization of data. We systematically linked tens of millions of records across California's largest health and human services programs. Our results underscore how the integration of records can help shift discussions from the programs that administer services to the people who are served.