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To evaluate the impact of the series 13Reasons Why on depression and suicidal behaviors in children and adolescents.Data from the 2016 to 2018 Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) of the Healthcare Cost and Utilization Project (HCUP) from 2016 to 2018 was used to determine the presentation in both settings for depression and suicidal thoughts and behavior. This was compared to predictive modeling for presentations in the same time frame.Following the release of 13 Reasons Why both hospital admissions and presentations to the Emergency Department (ED) increased for complaints of worsening depression or suicidal thoughts and behavior. This was more pronounced for youth aged 10-17 years, Black race, and female sex. There were no significant findings, overall, for females 6-9 years, but in-patient visits for depression increased in May 2017 for Black females 6-9 years. Males 6-9 years had higher rates of ED visits for depression and both ED and in-patient visits for suicidal behaviors.Secondary data analyses have known limitations including inability to track over time, inclusion of only visit-level data, and failure to collect variables of interest.The series 13 Reasons Why was likely associated with exacerbations of both depressive illnesses and suicidal behavior in youth, particularly for female and Black youth from 10 to 17 years. This study adds to known concerns regarding the role of media in influencing suicidal behavioral in vulnerable children and has important implications for youth monitoring and parent and youth education. More research is needed to identify specific targets for prevention.

SUMMARY STATEMENT Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

Objectives: The National Survey of Children's Health reported a concerning increase in children 2–5 years being diagnosed with attention-deficit/hyperactivity disorder (ADHD) in 2016. Concerns incl...

Objective : Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5. Method : Kentucky Medicaid claims from 2012–2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015–2017 for a sub-sample (n = 5,071). Results : The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015–2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010). Conclusions : DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

Simulation-based education is a particularly germane strategy for addressing the difficult topic of racism and implicit bias due to its immersive nature and the paradigm of structured debriefing. Researchers have proposed actionable frameworks for implicit bias education, particularly outlining the need to shift from recognition to transformation, with the goal of changing discriminatory behaviors and policies. As simulation educators tasked with training health care professionals, we have an opportunity to meet this need for transformation. Simulation can shift behaviors, but missteps in design and implementation when used to address implicit bias can also lead to negative outcomes. The focus of this article is to provide recommendations to consider when designing simulation-based education to specifically address racism and implicit bias.

Background The use of antipsychotic medication and psychotropic polypharmacy has increased in the United States over the last two decades especially for children from low-income families and those in foster care. Although attention has been paid to providing greater insight, prescribing patterns remain concerning since there is a lack of evidence related to safety and efficacy. High-level psychotropic polypharmacy has not been described. We aim to compare the use of HLPP for children receiving Medicaid services and those in foster care and identify factors associated with the duration of use of high-level psychotropic polypharmacy. Additionally, we will examine the frequency of laboratory metabolic screening and emergency department, inpatient, and outpatient visits. Methods A cross-sectional, secondary analysis of statewide data describes trends in high-level psychotropic polypharmacy from 2012 to 2017 and the prevalence and predictors of high-level psychotropic polypharmacy duration and resource use in 2017 for all children on Medicaid and those in foster care. High-level psychotropic polypharmacy included concurrent use, at least four classes of medications including an antipsychotic, and at least 30 days duration. Results High-level psychotropic polypharmacy increased from 2012 to 2014 for both groups but stabilized in 2015–2016. Children in foster care showed a slight increase compared to their peers in 2017. There was no association between duration and demographic characteristics or foster care status. Diagnoses predicted duration. Neither group received metabolic monitoring at an acceptable rate. Conclusions Concerning patterns of high-level psychotropic polypharmacy and metabolic monitoring were identified. Cautious use of high-level psychotropic polypharmacy and greater oversight to ensure that these children are receiving comprehensive services like behavioral health, primary care, and primary prevention.

Background: Kentucky has among the highest rate of attention deficit/hyperactivity disorder (ADHD) and stimulant use in the United States. Little is known about this use by race/ethnicity and geography. This article describes patterns of diagnosis of ADHD and receipt of stimulants and psychosocial interventions for children aged 6-17 years receiving Kentucky Medicaid in 2017 and identifies factors associated with diagnosis and treatment. Methods: Using Medicaid claims, children with and without ADHD (ICD-10 codes F90.0, F90.1, F90.2, F90.8, and F90.9) were compared and predictors of diag­nosis and treatment type were examined. Psychosocial interventions were defined as having at least one relevant CPT code. Chi-squared tests and logistic regression models were used for univariate and multivariable analysis, respectively. Results: The rates of ADHD, stimulant use, and psychosocial interventions in our study population exceeded the national aver­age (14% vs 9%; 75% vs 65.5%; and 51% vs 46.5%, respectively). The distributions varied by sex, race/ethnicity, sex among race/ethnicities, and population density. In general, race/ethnicity predicted ADHD diagnosis, stimulant use, and receipt of psy­chosocial interventions with non-Hispanic White children being more likely to receive diagnosis and medication, but less likely to receive psychosocial therapy than other children. Differences were also shown for rural compared with urban residence, sex, and sex within racial/ethnic groups. Conclusions: Diagnosis and treatment modalities differed for children by race/ ethnicity, population density, and sex. More data are needed to better understand whether differences are due to provider bias, child characteristics, or cultural varia­tions impacting the utilization of different treatment options. Ethn Dis. 2021;31(1):67- 76; doi:10.18865/ed.31.1.67

This study assessed the extent to which a community-based intervention developed for children impacted parent perceptions and behaviors toward physical activity in a rural community. Focus groups and individual interviews were conducted with parents of children who participated in physical activity programs. Analysis revealed an increased community awareness surrounding physical activity following program implementation. Parents and children encouraged each other to be physically active. Ecological barriers and enabling factors to adult physical activity were identified. These findings indicate a bidirectional influence between parent and child physical activity and the need for communityfacilities where families can be active together.

A qualitative study was conducted to better understand the factors that contribute to psychotropic medication (PM) overuse among children in the child welfare system in Kentucky, including barriers...

This study assessed the: (1) effect of an LGBTQI + health equity curriculum (eQuality) on implicit attitudes among first (M1) and second year (M2) medical students and (2) utility of dedicated time to explore implicit bias.Implicit biases were assessed at baseline using implicit association tests (IAT) for all M2s and a random sample of first years (M1A). These students were then debriefed on strategies to mitigate bias. Following eQuality, all M1 and M2s completed post-intervention IATs. The remaining first years (M1B) were then debriefed. Paired sample t-tests assessed differences between pre/post. Independent sample t-tests assessed differences in post-IATs between M1 groups.IATs indicated preferences for "Straight," "White," and "Thin" at both pre and post. M2s demonstrated statistically significant improvements pre to post for sexuality (p = 0.01) and race (p = 0.03). There were significant differences in post-intervention IAT scores between M1As who received the IAT and debriefing prior to eQuality and M1Bs for sexuality (p = 0.002) and race (p = 0.046). There were no significant changes for weight.eQuality reduced implicit preference for "Straight" and "White." Differences in M1 post-intervention IAT scores between groups suggest dedicating time to debrief implicit attitudes enhances bias mitigation.

Patients who are lesbian, gay, bisexual, transgender (LGBT), gender nonconforming (GNC), or born with differences of sex development (DSD) face significant health disparities. Many of these disparities originate from discrimination and systemic biases that decrease access to care and from inadequate provider knowledge that contributes to unmet medical needs. Provider training to deliver equitable care for these populations is thus critical, but such training is deficient at most medical institutions. The authors developed an integrated educational model, eQuality, that sought to drive educational and system innovation by teaching and assessing the acquisition of attitudes, knowledge, and skills needed to provide competent care for LGBT/GNC/DSD individuals. This paper outlines the process of its implementation for other programs to model. With input from an LGBT/GNC community advisory panel, eQuality incorporated new teaching sessions and revised existing content in 50.5 h of required curriculum. This curriculum involved 23 teaching faculty and included direct student-LGBT/GNC/DSD patient interactions for 320 students. The program was piloted in the first and second years of medical school and is being expanded into medical school years 3 and 4 with clinical assessments to ensure that curriculum translates into improved patient care. eQuality demonstrates that promoting healthcare equity for LGBT/GNC/DSD populations through medical education is feasible. Forthcoming baseline data will also enable future longitudinal comparisons as eQuality cultivates exceptional insight into the evolution of LGBT/GNC/DSD health knowledge and awareness among both students and faculty.

Background Although Latinos, African-Americans, and American Indians/Alaska Natives comprise 34% of Americans, these under-represented minorities (URMs) account for only 7% of US medical-school faculty. Even when URMs become faculty, they face many substantial challenges to success. Little has been published, however, on keys to academic success for URM young faculty investigators. Methods The Research in Academic Pediatrics Initiative on Diversity (RAPID) goal is to enhance the professional advancement of URM junior faculty pursuing research careers in general academic pediatrics. One important RAPID component is the annual mentoring/career-development conference, which targets URM residents, fellows, and junior faculty, and has included 62 URM participants since its 2013 inception. A conference highlight is the panel discussion on keys to academic success for URM young investigators, conducted by the RAPID National Advisory Committee, a diverse group of leading senior researchers. The article aim was to provide a guide to academic success for URM young investigators using the 2018 RAPID Conference panel discussion. A modified Delphi technique was used to provide a systematic approach to obtaining answers to six key questions using an expert panel: the single most important key to success for URM young investigators; ensuring optimal mentorship; how to respond when patients/families say, “I don’t want you to see my child because you are ____”; best strategies for maximizing funding success; how to balance serving on time-consuming committees with enough time to advance research/career objectives; and the single thing you wish someone had told you which would have substantially enhanced your success early on. Results/Conclusions This is the first published practical guide on keys to academic success for URM young investigators. Identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you, dealing with families who do not want you to care for their child because of your race/ethnicity by seeking to understand the reasons and debriefing with colleagues, seeking non-traditional funding streams, balancing committee work with having enough time to advance one’s research and career by using these opportunities to generate scholarly products, and asking for all needed resources when negotiating for new jobs.

Introduction The eQuality project at the University of Louisville aims to train future physicians to deliver equitable quality care for all people by creating an integrated educational model utilizing the competencies identified in the AAMC's Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born With DSD. This foundational interprofessional health equity session for early learners addresses knowledge and attitude milestones relating to interprofessional collaboration, professionalism, and systems-based practice competencies for lesbian, gay, bisexual, and transgender (LGBT) populations. Methods First-year medical students were assigned to interprofessional teams of approximately 10 health sciences students each. Students participated in a 75-minute session utilizing a group case study activity, including a systems lecture exploring social determinants and community resources related to LGBT health. Students collaboratively discussed the case and recorded strategies for optimal patient care. The Readiness for Interprofessional Learning Scale and health disparities attitudes and knowledge scales were administered pre-/postsession. Results One hundred fifty-eight first-year medical students participated in the session. Posttest scores reflected an improvement for all disparities knowledge items (p < .001), and an increased interest in working with other health professions students on future projects (p < .001). Changes in attitudes toward systemic and social factors affecting health were also observed. However, content analysis of worksheets revealed that only 36% of teams identified specific action steps for the case scenarios. Discussion This session was effective in improving knowledge and attitudes related to LGBT health equity and interprofessional education.

Introduction Within health sciences education literature, the majority of reported student experiences with refugee populations are limited to traditional, professionally independent, elective courses and extracurricular volunteer opportunities. A simulated patient exercise is a learning opportunity that helps participants engage with material in real time in a realistic environment, demanding higher levels of learning. This session utilized a simulated patient facilitator in interprofessional small groups to explore common health needs and barriers to care among refugee populations. Methods Health professions students from nine degree programs participated in a refugee health session in interprofessional teams of nine to 10 students to explore patient cases. The session concluded with a debriefing discussing the outcomes of the student-patient interaction, best practices, and exemplary practice models as takeaways. The simulated patient facilitators completed an Observation Checklist to assess students' grasp of learning objectives. Results Five hundred twenty-four students participated in the refugee session, divided into 61 groups. Observation Checklists were completed for 58 groups (95%). Assessment of student engagement focused on general health needs common to refugee populations: barriers to health care, team and individual roles, bias, consequences of nontreatment, and social determinants of health. Most of the groups (95%) reported engagement between the simulated patient facilitator and the group of student providers. Qualitative data indicated student groups were knowledgeable in each of the overarching learning objectives. Discussion This session allowed health sciences students to focus on culturally effective patient care for refugee populations as a part of an interprofessional team.

Phenomenon: Transgender patients experience discrimination, limited access to care, and inadequate provider knowledge in healthcare settings. Medical education to address transgender-specific disparities is lacking. Research that engages transgender community members may help address health disparities by empowering patients, increasing trust, and informing medical curricula to increase competence.A 2015 Community Forum on Transgender Health Care was hosted at the University of Louisville School of Medicine, which included healthcare professionals and transgender community members to facilitate dialogue among mixed-participant groups using a World Café model. Fifty-nine participants discussed the status of transgender healthcare and made recommendations for local improvements. A follow-up survey was administered to 100 individuals, including forum participants and their referrals. The forum discussion and survey responses were analyzed to determine common perceptions of transgender healthcare, priorities for improvement interventions, and themes to inform curriculum.The community forum discussion showed that local transgender care is overwhelmingly underdeveloped and unresponsive to the needs of the transgender community. The follow-up survey revealed that priorities to improve transgender care included a multidisciplinary clinic for lesbian, gay, bisexual, and transgender (LGBT) patients, an LGBT-friendly network of physicians, and more training for providers and support staff. This mutually constructive engagement experience influenced reform in undergraduate curricula and continuing education opportunities. Insights: Community engagement in healthcare disparities research can cultivate improbable discussions, yield innovative insight from marginalized populations, and build relationships with community members for future collaborations and interventions. Societal acceptance of transgender identities, which could be promoted through healthcare providers, could stimulate significant progress in transgender healthcare. Supplemental educational interventions for practicing physicians will improve the current conditions of transgender healthcare, but a comprehensive medical school curriculum specifically for transgender health that includes interactions between the transgender community and medical students could be particularly impactful.

Objective: Children from low-income families are often not well-prepared for kindergarten entry, especially in mathematical skills. Caregivers may lack the knowledge and confidence to teach early mathematical skills. The purpose of this study was to develop a parent–child activities-based mathematics learning programme and test its acceptability and initial efficacy. Method: The evidence-based Reach Out and Read (ROR) programme was adapted to incorporate mathematics content. ROR plus Mathematics (ROR+M) was developed and introduced during well-child visits. Descriptive and repeated-measures analysis of variance analyses were used to evaluate pre- and three weekly post-intervention assessments. Results: Parents self-reported acceptability and initial efficacy of the ROR+M programme was demonstrated. No change was reported in non-mathematical reading behaviour. Discussion: ROR+M was developed and implemented in a primary care paediatric setting serving primarily low-income families. Acceptability and initia...

Health literacy has been shown to predict health behaviors and outcomes above the effects of education or socioeconomic status. Much remains unknown about the health literacy of parents and the role it plays in children’s health outcomes or in health disparities. The current study explored the health communication needs and health literacy indicators in a diverse sample of parents (n = 75) to identify potential areas for future interventions. The sample consisted of parents of children 18 to 36 months old who were visiting 3 different pediatric medical offices, 2 of which served low-income families and 1 located in an affluent suburb. When comparisons were made between 2 educational attainment groups, there were variations in indicators of health literacy and health communication needs. These data can be used to guide the development of interventions by primary care providers to improve parent education.

Child sexual abuse poses a serious threat to public health and is often unreported, unrecognized, and untreated. Prevention, early recognition, and treatment are critically important to reduce long-term effects. Little data are available on effective methods of preventing child sexual abuse. The current research demonstrates a unique approach to promoting awareness and stimulating discussion about child sexual abuse. Qualitative methods have rarely been used to study child sexual abuse prevention. Qualitative inductive analyses of interviews from 20 key informants identified both positive and negative assessments with six emergent themes. The themes revealed inherent tensions in using narrative accounts to represent the complex cultural context within which child sexual abuse occurs. More research is needed, but the program shows potential as a methodology to raise awareness of child sexual abuse.

Children in foster care have exceptional needs due to their histories of abuse, neglect, and increased exposure to violence. The rates of psychiatric symptoms and disorders, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, and reactive attachment disorder, are much higher in children in foster care; furthermore, the rate of these children receiving psychotropic medications is 3 times that of children who are not in foster care. Pediatricians, in their role of providing a medical home, play a central role in safeguarding the physical and mental health of these children. By taking a trauma-informed approach to understanding the unique needs and gaps in their health care, pediatricians can improve the mental health and maximize outcome for children in foster care. [ Pediatr Ann . 2016;45(10):e342–e348.]

Practitioner attitudes about low-income patients may impact clinical care and outcomes. Poverty simulation, employing low-income community volunteers, is an effective teaching tool in improving attitudes toward poverty among health professions students. This study explores the experiences of these essential simulation volunteers who share their stories with student participants. Focus groups were conducted with low-income community members who staff resource tables during poverty simulations. Data were audio-recorded, transcribed, and analyzed using a grounded theoretical approach. Participants spoke of the systemic nature of poverty and identified multiple barriers to healthcare access. Perceived lower quality of care, mistrust in health professionals, and a lack of continuity of care were discussed. In regards to the simulation, participants were empowered through sharing their stories with students, and offered suggestions for program improvement. Simulation provides a forum for community members to educate the future healthcare workforce on systemic barriers faced by low-income populations.

This study describes the experiences of and barriers for pediatricians in Kentucky in providing behavioral/mental health (B-MH) services in primary care settings. These data will serve as a foundation for improving service delivery. An online survey was completed by 70 pediatricians. Descriptive data are presented. More than 90% of the respondents said that they saw at least one patient a month with 1 of 10 specific B-MH diagnoses. Physicians' comfort with diagnosing and treating disorders varied widely by diagnosis, age-group, and drug classification. Major barriers to providing optimal care were inaccessibility of mental health professionals for consultation and referral, lack of communication, and lack of knowledge. Respondents were more likely to favor consultation and co-location models over an integration model of care delivery. Overall, the authors found that pediatricians are dealing with patients with B-MH problems for which they may not have been adequately trained. Communication and collaboration needs were identified.

* Abbreviation: AOM — : acute otitis media Acute otitis media (AOM) is an almost universal occurrence during childhood, with at least 90% experiencing ≥1 episode by age 7 years.1 Multiple studies through the early 2000s noted a lower frequency of AOM among black children compared with white children.2,3 Other studies suggested that rates of middle ear effusion4,5 and clinical diagnoses of AOM3 did not differ between black and white children. The apparent rate difference in many studies more likely reflected differences in access to care and possibly differences in diagnosis and management by health care providers, rather than differences in genetic predisposition. In a recent study in the Philadelphia area, primary care physicians were less likely to diagnose AOM in black children versus non-black children; they were more likely, however, to prescribe recommended narrow-spectrum amoxicillin than broader-spectrum antimicrobial agents when they diagnosed AOM in black children versus non-black children.6 In this issue of Pediatrics , Fleming-Dutra et al7 present their results on this topic from analyses of the National Ambulatory Care Survey and National Hospital Ambulatory Care Survey databases from 2008–2010. AOM diagnoses in these databases were assigned by the treating physician, although not necessarily confirmed with the level of rigor required of a prospective clinical trial. The sample size … Address correspondence to Charles R. Woods, MD, MS, Pediatric Infectious Diseases, 571 S. Floyd St, Suite 321, Louisville, KY 40202. E-mail: charles.woods{at}louisville.edu

Purpose: The racial and ethnic composition of the U.S. population has undergone significant changes with Asian Pacific Islanders being the fastest growing population. Furthermore, the number of immigrant children has doubled in the past two decades, and a quarter of U.S. children are estimated to have at least one foreign-born parent. Despite such increases in immigrant populations and ethnic diversity, the current literature focuses primarily on African Americans and Hispanics/Latinos, with analyses of health inequalities among recent ethnic and immigrant groups from Asia relatively uncommon. Compared to their white …

Significant numbers of children have diagnosable mental health problems, but only a small proportion of them receive appropriate services. Stigma has been associated with help-seeking for adult mental health problems and for Caucasian parents. The current study aims to understand factors, including stigma, associated with African American parents’ help-seeking behavior related to perceived child behavior problems. Participants were a community sample of African American parents and/or legal guardians of children ages 3–8 years recruited from an urban primary care setting (N = 101). Variables included child behavior, stigma (self, friends/family, and public), object of stigma (parent or child), obstacles for engagement, intention to attend parenting classes, and demographics. Self-stigma was the strongest predictor of help-seeking among African American parents. The impact of self-stigma on parents’ ratings of the likelihood of attending parenting classes increased when parents considered a situation in which their child’s behavior was concerning to them. Findings support the need to consider parent stigma in the design of care models to ensure that children receive needed preventative and treatment services for behavioral/mental health problems in African American families.

Introduction The aim of this study is to understand low-income parents' preferences for and barriers to receiving child health promotion information. Methods A mixed-methods approach was used. Data were collected in an urban pediatric primary care setting serving predominantly low-income African American families. Parents ( n = 190) of 3- to 8-year-old children completed a survey; a randomly selected subset participated in focus groups. Results The quantitative and qualitative samples differed with regard to whether they would like to get parenting information from their doctors. The most commonly cited obstacles to attending parenting classes were time (50.6%), work schedule (40.6%), transportation (37.7%), and own health (22.4%). Discussion New and creative methods are needed to promote child health and development that do not increase the burden associated with raising children in the context of limited resources.

Background and purpose This study was designed to assess potential relationships of race and socioeconomic status (SES) to bedtime behavior from a community sample of 2- to 7-year-old children. Patients and methods A previously validated sleep questionnaire was administered to parents of children enrolled in the Jefferson County, Kentucky school system. The sleep behavior of African-American (n=973) and Caucasian (n=2398) children was analyzed. Median annual income of residential zip codes was used as a proxy for SES. Results Mean age was 4.8±1.1 years. Two composite ‘sleep behavior scores’ were generated related to excessive daytime sleepiness and sleep-related behavior. Children in the lower SES group had significantly more impaired ‘sleep behavior scores’ than those in the higher SES group, regardless of race or age. African-American children had later bedtimes than Caucasian children with similar rise times, resulting in significantly shorter sleep duration and more excessive daytime sleepiness, independent of SES and age. Conclusions Cultural variables impact sleep-related behavior in children. Race and SES have independent relationships with sleep behavior. Independent of SES, African-American children sleep less due to later bedtimes. SES does play a role, however, in parentally reported sleep-related behavior problems. Thus, cultural variables such as race and SES are important modifiers of sleep behaviors in children and should be addressed in sleep education programs.

Spatial epidemiological methods were used to identify relationships between pediatric asthma hospitalizations and specific demographic factors. A cross-sectional analysis of pediatric asthma hospital discharge data was linked to demographic, sociodemographic, and zip code-based information. Five hundred thirty-seven admissions were reported from 32 zip code areas. The mean crude rate of asthma discharges was 138.76/100,000, with 13 of these zip code areas exceeding this rate; 10 were adjacent (p < 0.002). Asthma rates organized by zip code found that the distribution of poverty (p < 0.0001), proportion of African-American residents (p < .0001), and educational attainment (p < 0.0001) in Jefferson County had similar aggregation patterns. Physician location was inversely correlated. Spatial epidemiology is a useful tool to demonstrate relationships between demographic information and disease rates, thus permitting intervention that is focused on high-risk communities.

A term Caucasian male infant, born to a healthy non-related couple, was noted at birth to have bilateral edema and bluish discoloration of the lower eyelids. On physical examination, the eye globes were not visualized and hypertelorism was noted. Radiological imaging revealed large bilateral orbital cysts, microphthalmos, and severe optic nerve hypoplasia. Histological study of the excised orbital masses showed cysts lined by primitive, immature retinal tissue which contained neuroglial elements and scattered dysplastic rosettes. Chromosome analysis revealed an apparent balanced reciprocal translocation between the long arm of chromosome 3 and 5, i.e. 46, XY, t (3; 5) (q27; q11.2). Chromosome studies in parents were normal. To our knowledge, the association of this balanced translocation and microphthalmos with cyst has not been previously described in the English literature.

The purpose of this study was to determine whether anticipatory guidance at well-child visits (WCV) that included early literacy development and the provision of books by the examining physician changed family literacy practices. It was conducted in an inner-city pediatric clinic that serves as the continuity practice site for pediatric and pediatric/internal medicine residents. There were 352 children (181 treatment: 171 control), aged 2 to 24 months, enrolled in this prospective, controlled study. The health care providers underwent training on literacy and on how to incorporate this information during WCV. Anticipatory guidance on safety, development, and early literacy was given to all parents. Additionally, the treatment group received an age-appropriate book at each WCV. There were 1,263 visits made (686 treatment, 577 control). Questionnaires were completed by parents on physician helpfulness and by physicians on parental receptiveness. Parental ratings on physician helpfulness were higher in the treatment group than in the control group (p

OBJECTIVE To examine the relationships between 2 parenting styles and family nutrition and physical activity. METHODS Parents of elementary/primary school children in the southeastern United States (N = 145) completed surveys regarding family relationships and health behaviors. RESULTS Parents exhibiting a laissez-faire parenting style reported lower levels of family nutrition and physical activity. In addition, parent BMI moderated the relationship between laissez-faire parenting and these health behaviors. CONCLUSIONS This study indicates that family-oriented nutrition and physical activity programs may benefit from including a focus on decreasing laissez-faire parenting, as well as helping overweight parents reduce their BMIs.

core mission of health professions schools is to educate and train a workforce that will be optimally prepared to provide health care and public health services for the diverse communities that they serve. It is important to create and develop a health care workforce who can understand and assist in the battle against health care disparities. For health care workers and health profession schools, cultural competence education and training has been identified as one solution to the problem. However to educate and properly train a culturally competent health care workforce is not an easy task. The literature on cultural competency is growing, with numerous studies that have focused on specific traits of cultural competency but unfortunately, a consensus on the best approach to achieve the desired outcomes has not been reached. A review of the literature on cultural competency reveals some common concerns regarding cultural competency, especially about how cultural competence education is incorporated in the classroom/clinical setting. What training and preparation does the instructor possess to qualify him or her to teach cultural competency? Was the instructor chosen because of gender or because he/she is from a racial or ethnic minority group which somehow makes him/her an expert? How much time should be devoted to cultural competency training in health professions? How do we accurately assess student learning of cultural competency? And finally, how do we as faculty committed to cultural competency get our colleagues to also participate in cultural training/education? These are key ques- tions, concerns, and problems that many who teach cultural competency training have encountered. Therefore, a variety of approaches to cultural competency education and training have been developed within our schools. Earlier this year, a joint expert panel convened by the Association of American Medical Colleges and the Association of Schools of Public Health released a report with recommendations for Schools of medicine and public health defining a set of

Epidemiological studies have suggested that ethnicity is a risk factor for sleep-disordered breathing (SDB) and that African-American children are three times more likely than Caucasian children to have SDB. Ethnic differences in sleep architecture and other routinely assessed sleep parameters have not been critically assessed, thus the aim of this study was to compare sleep characteristics in African-American and Caucasian children.A total of 41,363 sleep questionnaires were mailed to parents of children aged 5-7 years in Jefferson County, KY. Parents of snoring and non-snoring children were invited to have their child undergo overnight polysomnography.Complete questionnaires were returned by 9872 families (23% response rate). Of these, 689 agreed to undergo polysomnography, and 542 complete polysomnograms were obtained (5.7% of questionnaire respondents). There were 391 Caucasian and 151 African-American children with a mean age of 6.7+/-0.5 years who underwent overnight polysomnographic evaluation. No differences between groups were observed for sleep latency, total sleep time, sleep efficiency, or rapid eye movement (REM) latency. African-American children had slightly increased stage 3 sleep (6.0+/-2.8% vs. 5.4+/-2.8%; p=0.01), although the total proportion of slow wave sleep was similar. Higher respiratory arousal index (3.6+/-6.5/h vs. 1.4+/-2.7/h; p0.001) and total arousal index (11.5+/-5.2/h vs. 9.8+/-4.8/h; p0.001) emerged in African-American children, who were more likely to have mild SDB (AHI1:34% in African-American vs. 24% in Caucasian; p=0.017) and SDB (AHI5: 22.5% vs. 7%; p0.001). However, Caucasian children were more likely to have periodic leg movements during sleep (PLMS; 16.5% vs. 7% in AA; p=0.004). The odds ratio for a Caucasian child to have PLMS was 2.6 (95% confidence interval (CI) 1.3-5.3; p=0.006). Furthermore, in the absence of SDB, the odds ratio for a Caucasian child to have PLMS was 9.5 (95% CI: 2.2-39.9; p=0.002).African-American and Caucasian children have similar sleep architecture. African-American children are more likely to display respiratory disturbances during sleep, while PLMS are significantly more prevalent among Caucasian children.

"Saving a life" is a credible definition of heroism in the United States. However, the pervasive societal impression of immediate gratification has led to a widespread recognition of "life saving" only in circumstances of immediate danger. The lengthening national life expectancy is not accorded respect as an accomplishment in and of itself. Families of dying, elderly persons still mistake the "loss" by failing to appreciate the many times this life has been saved and esteeming the accomplishment that death at a later age poses. Public health and preventive medicine both suffer general disregard for this shortsighted perspective, from the public and those who determine federal funding priorities. This narrative expounds on this frustration and describes its implication for the future of public health as it is currently practiced in this nation.

Sleep-disordered breathing (SDB) in children is associated with poor school performance, with minority children being at increased risk for both conditions. The latter have been attributable to low socio-economic status (SES). To further study these relationships, the contribution of SES to SDB and learning was examined in 1,010 validated questionnaires collected from parents of both white and African-Arnerican low-SES preschoolers. Twenty-two percent of disadvantaged preschoolers were reported to be at risk for SDB. These children were more likely to be African American, and had a higher incidence of daytime sleepiness, lower academic performance, and hyperactivity. Maternal education level did not account for these differences.

Objective: To evaluate fine needle aspiration of enlarged lymph nodes in children. Design: Retrospective study of children who were referred for fine needle aspiration of a palpable lymph node that was of concern to their clinicians. Setting: Large, urban, tertiary care pediatric hospital. Subjects: One hundred nineteen patients (123 cases) aged 10 months through 21 years during the 30-month period from January 1990 to June 1992. Results: Aspirated material in 13 cases (10.6%) was deemed inadequate for cytologic diagnosis. In the remaining 110 cases, five aspirates revealed malignancy: two patients had Hodgkin's disease, one had non-Hodgkin's lymphoma, one had a leukemic infiltrate, and one had rhabdomyosarcoma. The findings in two cases were suspicious for malignancy, but the lymph nodes were found to be benign on excisional biopsy. No false-negative findings for malignancy were detected. The conditions of patients in the remaining 103 cases were diagnosed as a benign process, most commonly reactive lymphadenitis. Of 57 aspirates cultured, eight (14%) were positive for a microorganism. No significant complications were encountered in any of the 123 cases. Conclusion: Fine needle aspiration of enlarged lymph nodes in children is a safe, reliable (accuracy, 98%) procedure that often obviates the need for an excisional biopsy. (Arch Pediatr Adolesc Med. 1994;148:1327-1330)

We describe two patients in whom bacterial tracheitis developed shortly after elective tonsillectomy and adenoidectomy. Bacterial tracheitis has not previously been reported in this clinical setting. Prompt recognition is essential if a fatal outcome is to be avoided. The cause remains uncertain, but the outcome is good if timely treatment is instituted.