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Judith D Schaechter,1,2 Richard Goldstein,1 Ross D Zafonte,1– 4 Julie K Silver1– 4 1Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; 2Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA; 3Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Boston, MA, USA; 4Department of Physical Medicine and Rehabilitation, Brigham and Women’s Hospital, Boston, MA, USACorrespondence: Julie K Silver, Spaulding Rehabilitation Hospital, 300 1st Ave, Charlestown, MA, 02129, USA, Tel +1 617-952-5000, Fax +1 508-718-4036, Email julie_silver@hms.harvard.eduPurpose: There is a high rate of attrition of professionals from healthcare institutions, which threatens the economic viability of these institutions and the quality of care they provide to patients. Women professionals face particular challenges that may lower their sense of belonging in the healthcare workplace. We sought to test the hypothesis that workplace belonging of women healthcare professionals relates to the likelihood that they expect to leave their institution.Methods: Participants of a continuing education course on women’s leadership skills in health care completed a survey about their experiences of belonging in workplace and their likelihood of leaving that institution within the next 2 years. An association between workplace belonging (measured by the cumulative number of belonging factors experienced, scale 0– 10) and likelihood of leaving (measured on a 5-point Likert scale) was evaluated using ordinal logistic regression. The relative importance of workplace belonging factors in predicting the likelihood of leaving was assessed using dominance analysis.Results: Ninety-nine percent of survey participants were women, and 63% were clinicians. Sixty-one percent of participants reported at least a slight likelihood of leaving their healthcare institution within the next 2 years. Greater workplace belonging was found to be associated with a significant reduction in the reported likelihood of leaving their institution after accounting for the number of years having worked in their current institution, underrepresented minority status, and the interaction between the latter two covariates. The workplace belonging factor found to be most important in predicting the likelihood of leaving was the belief that there was an opportunity to thrive professionally in the institution. Belonging factors involving feeling able to freely share thoughts and opinions were also found to be of relatively high importance in predicting the likelihood of leaving.Conclusion: Greater workplace belonging was found to relate significantly to a reduced likelihood of leaving their institution within the next 2 years. Our findings suggest that leaders of healthcare organizations might reduce attrition of women by fostering workplace belonging with particular attention to empowering professional thriving and creating a culture that values open communication.Keywords: gender equity, diversity, turnover, retention, healthcare workforce, thriving

What right does a teenager have to confidential health care? What influence does HIPAA have on that right? How you apply the answers in your practice could determine whether an adolescent seeks health services -- or forgoes necessary care. [ABSTRACT FROM AUTHOR]

Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists., (Copyright © 2024 by the American Academy of Pediatrics.)

The American Academy of Pediatrics and its members recognize the importance of improving the physician's ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify IPV survivors in pediatric settings, to evaluate and treat children exposed to IPV, and to connect families with available local and national resources. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Pediatricians should be aware of these profound effects of exposure to IPV on children and how best to support and advocate for IPV survivors and their children., (Copyright © 2023 by the American Academy of Pediatrics.)

Since all-terrain vehicles (ATVs) were introduced in the mid-1970s, regulatory agencies, injury prevention researchers, and pediatricians have documented their dangers to youth. Major risk factors, crash mechanisms, and injury patterns for children and adolescents have been well characterized. Despite this knowledge, preventing pediatric ATV-related deaths and injuries has proven difficult and has had limited success. This policy statement broadly summarizes key background information and provides detailed recommendations based on best practices. These recommendations are designed to provide all stakeholders with strategies that can be used to reduce the number of pediatric deaths and injuries resulting from youth riding on ATVs., (Copyright © 2022 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Firearm injury is a leading cause of death and injury for children and adolescents, able to cause disability and interfere with normal development. Child developmental stages, variance of behavior, and mental health may all put children at risk for firearm injury or lead to increased morbidity after experiencing firearm violence. Family, community, and contextual factors can accentuate the risk of violence. Adults and social structures have the responsibility to protect children and adolescents from firearm violence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Gun injury is a leading cause of death among US children and adolescents. Unintentional firearm death disproportionately affects youth. Reports have shown that at least a third of US homes with children have firearms. When children are fatally injured by guns, the location is most often a home, the shooter is family, the gun owner is a relative, and the gun most often originates from the home, where it was left unlocked., Methods: We conducted an Internet search of pediatric (0-18 years old) fatal and nonfatal firearm injuries from January 1 to August 31, 2014, in the United States, querying the terms shot, gun, accident, and year-old for media reports. Cases were screened for intent and coded for demographics, location, gun specifics, circumstances, relationship between the victim, shooter, gun owner, and any resultant charges., Results: A total of 277 unintentional pediatric gun injury events were reviewed, two-thirds were nonfatal. Half of the victims were younger than 13 years; 25.3% were younger than 7 years, 80% of the victims and 85.6% of the shooters were male. Of shooters, 84.3% were the child victim themselves, a family member, or a friend/acquaintance. Seventy-seven percent of the events took place in a residence. When gun ownership was reported, 68% were owned by a family member. When charges were reported, a third were against minors., Conclusion: This study reinforced previous studies that unintentional child firearm injuries predominantly involve the home, family guns, young children, and males, and most could be prevented through adult responsibility for minimizing child access and securing storage of firearms. We further learned that media accounts frequently did not report on gun ownership or charges, details which might increase community awareness or inform policies useful to prevention. Shooters, not owners, were more often charged in unintentional child injuries, and minors were charged even when Child Access Prevention laws could be applied., Level of Evidence: Epidemiologic study, level 4.

The National Heart, Lung, and Blood Institute (NHLBI) Expert Panel in the United States (US) recently published its report, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. The Panel's goals were to develop comprehensive, evidence-based strategies for use by general practitioners in the primary and primordial prevention of cardiovascular disease (CVD). These Guidelines have been endorsed by the American Academy of Pediatrics. Many of the recommendations restate existing lifestyle guidance similar to those proposed by the Committee on Nutrition in 2008. However a debate has emerged because for the first time, universal and comprehensive childhood dyslipidemia screening and treatment is now recommended by these new Guidelines. Because of universal screening, dyslipidemia attributed to both lifestyle and genetic factors could potentially be ascertained. The recommendations to screen for serum lipids and glucose have stimulated heated discussions among pediatricians, subspecialists, and policy-makers. This commentary discusses the medical, psychosocial and economic benefits and risks of universal cholesterol screening in children.

Background: Motor vehicle crashes are the leading cause of death for U.S. Latinos aged 1 to 35 years. Restraint use is an effective means of prevention of motor vehicle crash injury. Effective interventions to raise restraint use include the following: legislation, law enforcement, education, and equipment distribution. The effects of law enforcement interventions in Latino immigrant communities are understudied. We measured the community-level effect of a combined intervention that included warnings and citations phase enforcement in Latino communities., Methods: We designed and implemented in two of three Latino-majority communities a multicomponent intervention consisting of a community awareness campaign, restraint use education with equipment distribution, and a two-staged law enforcement intervention. Restraint use observations were conducted in all three communities at baseline, after the warnings phase and again after the citations phase of the intervention were completed., Results: The combined intervention of community awareness, education, child passenger restraint distribution, and law enforcement focused on educational traffic stops with incentives and warnings was associated with a significant increase in both driver and child passenger restraint use in one intervention community, but only driver restraint increased to a level of significance in the other intervention community; significant increase was also noted among nonintervention drivers. The citations phase of the intervention did not result in a significant increase in restraint use and was complicated by interruptions due to unlicensed drivers., Conclusion: The combined effort of community awareness, education, equipment distribution and law enforcement intervention that included incentives and warnings may be effective at increasing seat belt use in Latino communities without the need for citations.

Objective: The purpose of this study was to describe homicides of infants (children <2 years of age) in the U.S., Methods: Cases were derived from the National Violent Injury Statistics System; 71 incidents involving 72 infant homicides were in the data set. Type 1 involved beating/shaking injuries inflicted by a caretaker; type 2 involved all other homicides (including neonaticide, intimate partner problem-related homicide, crime-related death, and other types)., Results: Seventy-five percent of the incidents were type 1 incidents, perpetrated mainly by men (83%; typically the infant's father or the boyfriend of the infant's mother). In 85% of the type 1 incidents, the infant was transported to the hospital, usually at the initiative of the perpetrator or another household member. In almost one half of the type 1 incidents, a false story was offered initially to explain the injuries. In contrast, the type 2 incidents (16 cases) were perpetrated mainly by women (11 of 16 cases) and involved methods such as poisoning, drowning, sharp instruments, or withdrawal of food and water; most infants were not taken to the hospital. Although 93% of incidents were perpetrated by caretakers, the large differences between the 2 incident types suggest different avenues for prevention., Conclusions: The circumstances involved in the type 1 homicides (beatings by caretakers) suggested that those attacks occurred impulsively, death was unintended, and emergency care was summoned, often with a false story. Previous abuse was suspected in more than one half of those incidents.

The Miami-Dade County Injury Surveillance System was created as part of a hospital-based injury prevention program associated with the Injury Free Coalition for Kids. Initially the program utilized trauma center and mortality data to describe injury. However, as community programming and coalition-building developed, so did the demands on the surveillance system. Coalition partners and potential partners desired a more comprehensive and population-based system. As a result of the county-wide approach and open access to results, the surveillance system has engaged new partners and leveraged additional resources to injury prevention.

Objectives: Unintentional firearm death is often considered a nearly negligible proportion of overall gun death. These rates are based on medical examiner (ME) and coroner death classifications, which affect derived epidemiologic data and subsequent prevention measures. The aim of this study was to compare the proportion of pediatric unintentional gun deaths in Miami-Dade County based on manner of death coding by the ME with an intent-based classification of child gun deaths., Methods: ME and police records for all pediatric firearm fatalities in Miami-Dade County from 1994 to 1998 were reviewed. The ME's assignment of manner of death as homicide, suicide, or accident was compared with an intent-based classification of intentional homicide, intentional suicide, and unintentional firearm death based on expressed or implied evidence of intent to harm., Results: There were 123 pediatric firearm deaths in Miami-Dade County from 1994 to 1998. A significant difference between ME coding and the intent-based classification was found for homicide (94 vs 78) but not for suicide. A significant difference was also found between the ME's coding for "accident" and the investigator's classification of "unintentional" firearm death (4 vs 26)., Conclusions: The incidence of unintentional pediatric firearm deaths is significantly underreported by the Miami-Dade County ME when the classification of "accidental" firearm death is used. Reviewing the manner of death classification criteria or establishing an intent code on official death documentation is recommended. Furthermore, clinicians should be aware that the true incidence of unintentional gun death may be higher than that reported as accidental.

Functional brain imaging studies have provided insights into the processes related to motor recovery after stroke. The comparative value of different motor activation tasks for probing these processes has received limited study. We hypothesized that different hand motor tasks would activate the brain differently in controls, and that this would affect control-patient comparisons. Functional magnetic resonance imaging (MRI) was used to evaluate nine control subjects and seven patients with good recovery after a left hemisphere hemiparetic stroke. The volume of activated brain in bilateral sensorimotor cortex and four other motor regions was compared during each of three tasks performed by the right hand: index-finger tapping, four-finger tapping, and squeezing. In control subjects, activation in left sensorimotor cortex was found to be significantly larger during squeezing as compared with index-finger tapping. When comparing control subjects with stroke patients, patients showed a larger volume of activation in right sensorimotor cortex during index-finger tapping but not with four-finger tapping or squeezing. In addition, patients also showed a trend toward larger activation volume than controls within left supplementary motor area during index-finger tapping but not during the other tasks. Motion artifact was more common with squeezing than with the tapping tasks. The choice of hand motor tasks used during brain mapping can influence findings in control subjects as well as the differences identified between controls and stroke patients. The results may be useful for future studies of motor recovery after stroke.

Previous studies have shown that unilateral finger movements are normally accompanied by a small activation in ipsilateral motor cortex. The magnitude of this activation has been shown to be altered in a number of conditions, particularly in association with stroke recovery. The site of this activation, however, has received limited attention. To address this question, functional magnetic resonance imaging (MRI) was used to study precentral gyrus activation in six control and three stroke patients during right index finger tapping, then during left index finger tapping. In each hemisphere, the most significantly activated site (P < 0.001 required) was identified during ipsilateral and during contralateral finger tapping. In the motor cortex of each hemisphere, the site activated during use of the ipsilateral hand differed from that found during use of the contralateral hand. Among the 11 control hemispheres showing significant activation during both motor tasks, the site for ipsilateral hand representation (relative to contralateral hand site in the same hemisphere) was significantly shifted ventrally in all 11 hemispheres (mean, 11 mm), laterally in 10/11 hemispheres (mean, 12 mm), and anteriorly in 8/11 hemispheres (mean, 10 mm). In 6 of 11 hemispheres, tapping of the contralateral finger simultaneously activated both the ipsilateral and the contralateral finger sites, suggesting bilateral motor control by the ipsilateral finger site. The sites activated during ipsilateral and contralateral hand movement showed similar differences in the unaffected hemisphere of stroke patients. The region of motor cortex activated during ipsilateral hand movements is spatially distinct from that identified during contralateral hand movements.

We designed a public service and educational program to aid children and families coping with chronic illness and to augment medical student education. Medical students developed relationships with chronically ill children and families based on the Big Brother-Big Sister program model. In addition, students attended bimonthly seminars on childhood chronic illness and family dynamics. Medical students learned about the psychosocial aspects of illness through these relationships and reported that the program contributed to their sense of worth as caregivers. By fostering students' innate altruism, medical schools may succeed in cultivating caring and humanism in their student physicians. We propose a model that encourages medical students to relate personally with patients and their families. A program such as this has the potential to nurture compassion in medical students, contribute to medical education, and provide support to patients and families.

Arachidonic acid (AA), a cis-unsaturated fatty acid that activates certain subspecies of protein kinase C (PKC), has been proposed to act as a retrograde messenger in modifying the efficacy of synapses during long-term potentiation (LTP). One prominent PKC substrate of the nerve terminal membrane, GAP-43 (F1, B-50, neuromodulin), shows an increase in phosphorylation that correlates with the persistence of LTP. The present study investigated whether AA might exert its effects on presynaptic endings by modulating the phosphorylation of GAP-43 and other membrane-bound proteins. Using synaptosomal membranes from the rat cerebrocortex, in which in vivo relationships between protein kinases and their native substrates are likely to be preserved, we found that in the absence of Ca2+, AA exerted a modest effect on the phosphorylation of GAP-43 and several other proteins; however, when AA was applied in conjunction with Ca2+, GAP-43 showed a particularly striking response: at Ca2+ levels likely to exist at the nerve terminal membrane during synaptic activity (10(-7) to 10(-5) M), AA (50 microM) increased the sensitivity of GAP-43 phosphorylation to Ca2+ by an order of magnitude, and increased its maximal level of phosphorylation by 50%. At resting Ca2+ levels, AA potentiated the stimulation in GAP-43 phosphorylation produced by 4 beta-phorbol 12,13-dibutyrate, a diacylglycerol (DAG) analog. The stimulatory effect of AA and its synergistic interaction with Ca2+ were found to be mediated by PKC, since they were blocked by a specific peptide inhibitor of PKC, [Ala25]PKC(19-31), but were unaffected by an inhibitor of protein phosphatase activity or by scavengers of free radicals. Since GAP-43 has been implicated in the development and plasticity of synaptic relationships, the synergistic effects of AA and the intracellular signals Ca2+ and DAG on the phosphorylation of GAP-43 may serve as an AND gate to modify presynaptic function and/or structure in response to coincident pre- and postsynaptic activity.

This study examines directly the effects on serotonin release of varying brain tryptophan levels within the physiologic range. It also addresses possible interactions between tryptophan availability and frequency of membrane depolarization in controlling serotonin release. We demonstrate that reducing tryptophan levels in rat hypothalamic slices (by superfusing them with medium supplemented with 100 microM leucine) decreases tissue serotonin levels as well as both spontaneous and electrically-evoked serotonin release. Conversely, elevating tissue tryptophan levels (by superfusing slices with medium supplemented with 2 microM tryptophan) increases both tissue serotonin levels and serotonin release. Serotonin release was found to be affected independently by tryptophan availability and frequency of electrical field-stimulation (1-5 Hz), since increasing both variables produced nearly additive increases in release. These observations demonstrate for the first time that both precursor-dependent elevations and reductions in brain serotonin levels produce proportionate changes in serotonin release, and that the magnitude of the tryptophan effect is unrelated to neuronal firing frequency. The data support the hypothesis that serotonin release is proportionate to intracellular serotonin levels.

An elderly woman was admitted to the hospital with a presumptive diagnosis of optic neuritis following abrupt loss of vision in her left eye. Noninvasive studies were unrevealing, and she was put on a course of prednisone. Further visual loss 2 weeks later prompted a second course of prednisone therapy. Six years later the patient died from cardiac arrest. The autopsy revealed an aneurysm arising from the origin of the left ophthalmic artery. Selected brain specimens were histologically examined by application of a newly developed staining technique capable of identifying degenerated axons in human brain tissue even after long survival periods. We traced degeneration from the site of compression at the left optic nerve to five primary visual nuclei. Furthermore, transsynaptic cellular changes were observed in the lateral geniculate nucleus.

Application of a novel in vitro experimental system has allowed us to describe the relationship between tryptophan availability and serotonin release from rat hypothalamic slices. Superfusing hypothalamic slices with a physiologic medium containing l-tryptophan (1, 2, 5, or 10 microM) caused dose-dependent elevations in tissue tryptophan levels; the magnitude of the elevations produced by supplementing the medium with less than 5 microM tryptophan was within the physiologic range for rat brain tryptophan levels. Slice serotonin levels rose biphasically as the tryptophan concentration in the medium was increased. Superfusing the slices with medium supplemented with a low tryptophan concentration (1 or 2 microM) caused proportionally greater incremental changes in serotonin levels than the increases caused by further elevating the tryptophan concentration (5 or 10 microM). The spontaneous release of serotonin from the slices exhibited a dose-dependent relationship with the tryptophan concentration of the superfusion medium. Electrically evoked serotonin release, which was calcium-dependent and tetrodotoxin-sensitive, also increased in proportion to the medium tryptophan concentration. These data suggest that the rate at which serotonin is released from hypothalamic nerve terminals is coupled to brain tryptophan levels. Accelerations in hypothalamic serotonin synthesis, caused by elevating brain tryptophan levels, result in proportionate increases in the rates of serotonin release during rest and with membrane depolarization.

It has been proposed that, in animals, a retinohypothalamic pathway exists which mediates the synchronization of the diurnal light-dark cycle with the central neural components regulating endogenous rhythms. There have been numerous anatomic, physiologic and behavioral investigations to substantiate this proposed connection in experimental animals. Morphologic investigation of a retinohypothalamic tract in man has awaited the development of a technique capable of axonal tracing in the human brain. The paraphenylenediamine method was applied to 7 post-mortem human brains. Degenerated axons were found in the suprachiasmatic nuclei of the hypothalamus in each of the 4 patients who had incurred prior optic nerve damage. The retinosuprachiasmatic pathway may be the anatomical substrate for the integration of retinal light information with endogenous rhythms in man.

D-fenfluramine, an anorectic agent in rats and man, was administered daily at doses 1.25, 2.5, 5 or 10 mg/kg/day for 10 days, and sacrificed 6 days later. Hypothalamic serotonin (5-HT) levels were unchanged in rats receiving 1.25-5 mg/kg/day of d-fenfluramine but reduced by 22% (p less than 0.01) at the highest drug dose (10 mg/kg/day); hypothalamic 5-hydroxyindole acetic acid (5-HIAA) levels were reduced by 15% (p less than 0.05) or 28% (p less than 0.01) in rats receiving 5 or 10 mg/kg/day of the drug, respectively. Hypothalamic slices prepared from rats which were previously treated with any of the drug doses spontaneously released endogenous 5-HT at rates that did not differ from those of vehicle-treated rats. 5-HT released with electrical field-stimulation was unaffected by prior d-fenfluramine treatment at doses of 1.25-5 mg/kg/day, and was reduced by 20% (p less than 0.05) from slices prepared from rats which received 10 mg/kg/day. 5-HIAA efflux was also attenuated by the highest drug dose. These data indicate that chronic administration to rats of customary anorectic doses of d-fenfluramine (i.e. 0.06-1.25 mg/kg) fail to cause long-lasting reductions in brain 5-HT release.

A retinofugal projection to the suprachiasmatic nucleus of the hypothalamus has been described in man by means of a newly developed staining technique (PPD) for tracing degenerated fibers in the human brain. We applied the PPD method to the chiasmal/hypothalamic area of human autopsy brains from patients who had incurred prior optic nerve damage. We followed degenerated fibers from the optic nerve through the optic chiasm and the optic tract. At the optic chiasm/tract junction, some fibers were seen to diverge and to form an optic fascicle which traversed the lateral preoptic-anterior hypothalamic area towards the third ventricle. These degenerated fibers terminated in the paraventricular nucleus of the hypothalamus. We suggest that there are at least two retinohypothalamic pathways in man. Some of the neuroendocrine imbalances in blind persons may be attributed to the disruption of the retinal input to the paraventricular and suprachiasmatic nuclei of the hypothalamus. These retinohypothalamic pathways may be the anatomical substrates for light/dark entrainment of human neuroendocrine and autonomic regulatory processes.