ILC2-derived LIF licences progress from tissue to systemic immunity.

Migration and homing of immune cells are critical for immune surveillance. Trafficking is mediated by combinations of adhesion and chemokine receptors that guide immune cells, in response to chemokine signals, to specific locations within tissues and the lymphatic system to support tissue-localized immune reactions and systemic immunity1,2. Here we show that disruption of leukaemia inhibitory factor (LIF) production from group 2 innate lymphoid cells (ILC2s) prevents immune cells leaving the lungs to migrate to the lymph nodes (LNs). In the absence of LIF, viral infection leads to plasmacytoid dendritic cells (pDCs) becoming retained in the lungs where they improve tissue-localized, antiviral immunity, whereas chronic pulmonary allergen challenge leads to marked immune cell accumulation and the formation of tertiary lymphoid structures in the lung. In both cases immune cells fail to migrate to the lymphatics, leading to highly compromised LN reactions. Mechanistically, ILC2-derived LIF induces the production of the chemokine CCL21 from lymphatic endothelial cells lining the pulmonary lymphatic vessels, thus licensing the homing of CCR7+ immune cells (including dendritic cells) to LNs. Consequently, ILC2-derived LIF dictates the egress of immune cells from the lungs to regulate tissue-localized versus systemic immunity and the balance between allergen and viral responsiveness in the lungs.

Race, community disadvantage, and cognitive decline: Findings from KHANDLE and STAR.

INTRODUCTION: Community disadvantage is associated with late-life cognition. Few studies examine its contribution to racial disparities in cognition/cognitive change. METHODS: Inverse probability weighted models estimated expected mean differences in cognition/cognitive change attributed to residing in less advantaged communities, defined as cohort top quintile of Area Deprivation Indices (ADI): childhood 66-100; adulthood ADI 5-99). Interactions by race tested. RESULTS: More Black participants resided in less advantaged communities. Semantic memory would be lower if all participants had resided in less advantaged childhood (b = -0.16, 95% confidence interval [CI] = -0.30, -0.03) or adulthood (b = -0.14, 95% CI = -0.22, -0.04) communities. Race interactions indicated that, among Black participants, less advantaged childhood communities were associated with higher verbal episodic memory (interaction p-value = 0.007) and less advantaged adulthood communities were associated with lower semantic memory (interaction p-value = 0.002). DISCUSSION: Examining racial differences in levels of community advantage and late-life cognitive decline is a critical step toward unpacking community effects on cognitive disparities.

Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018.

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes. CONTEXT: The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care. METHODS: To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models. FINDINGS: We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital. CONCLUSIONS: Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

A real-life comparison of hypoglycaemia symptomatology between insulin-treated type 2 diabetes participants with and without impaired awareness of hypoglycaemia.

AIMS: We aim to compare and correlate Gold and Clarke questionnaire scores with hypoglycaemic symptomatic responses between insulin-treated type 2 diabetes participants with and without IAH in a real-life study. METHODS: Insulin-treated type 2 diabetes participants attending an outpatient diabetes clinic in Singapore were asked to complete the Gold and Clarke questionnaires, record capillary blood glucose (CBG) and hypoglycaemic symptoms for 4 weeks. RESULTS: Data were collected from 153 participants (M:F = 98:55) with mean age 61.0 ± 9.4 years, duration of diabetes 19.5 ± 8.8 years and HbA1c 68 ± 17 mmol/mol (8.4 ± 1.5%). Gold and Clarke methods classified 19.6% and 26.8% of participants with IAH, respectively. Using CBG threshold of <3 mmol/L, significantly greater proportion of participants with intact awareness were experiencing autonomic symptoms than those with IAH with either method (Gold: 69% vs. 18%, p = 0.006; Clarke: 85% vs. 46%, p = 0.010). Significantly greater proportion of participants with IAH experienced no hypoglycaemia symptoms than those with intact awareness (Gold: 3.4% vs. 36%, p = 0.015; Clarke: 3.7% vs. 31%, p = 0.031). Participants with IAH had significantly higher rates of severe hypoglycaemia in the preceding year compared to those without (Gold: 17% vs. 3.3%; Clarke: 15% vs. 2.7%, p = 0.012). CONCLUSIONS: Gold and Clarke questionnaires are appropriate tools in ascertaining IAH status in insulin-treated type 2 diabetes participants. This is the first time whereby the hypoglycaemia symptomology has robustly validated the Gold and Clarke questionnaire in insulin-treated type 2 diabetes participants.

Generation and age of immigration on later life cognitive performance in KHANDLE.

OBJECTIVES: We examined the association of generational status and age at immigration with later life cognitive outcomes in a diverse sample of Latinos and Asian Americans. DESIGN: Baseline data were obtained from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study, and a prospective cohort is initiated in 2017. SETTING: Older adults in Northern California. PARTICIPANTS: Our cohort consisted of Asians (n = 411) and Latinos (n = 340) who were on average 76 years old (SD = 6.8). MEASUREMENTS: We used multivariable linear regression models to estimate associations between generational status and age at immigration (collapsed into one five-level variable) with measures of verbal episodic memory, semantic memory, and executive function, adjusting for age, gender, race and ethnicity, and own- and parental education. RESULTS: Generational status and age at immigration were associated with cognitive outcomes in a graded manner. Compared to third-generation or higher immigrants, first-generation immigration in adulthood was associated with lower semantic memory (ß = -0.96; 95% CI: -1.12, -0.81) than immigration in adolescence (ß = -0.68; 95% CI: -0.96, -0.41) or childhood (ß = -0.28; 95% CI: -0.49, -0.06). Moreover, immigration in adulthood was associated with lower executive function (ß = -0.63; 95% CI: -0.78, -0.48) than immigration in adolescence (ß = -0.49; 95% CI: -0.75, -0.23). Similarly, compared to third-generation individuals, first-generation immigrants had lower executive functioning scores. CONCLUSIONS: Our study supports the notion that sociocontextual influences in early life impact later life cognitive scores. Longitudinal studies are needed to further clarify how immigration characteristics affect cognitive decline.

Wearable Sensor System to Monitor Physical Activity and the Physiological Effects of Heat Exposure.

Mobile health monitoring via non-invasive wearable sensors is poised to advance telehealth for older adults and other vulnerable populations. Extreme heat and other environmental conditions raise serious health challenges that warrant monitoring of real-time physiological data as people go about their normal activities. Mobile systems could be beneficial for many communities, including elite athletes, military special forces, and at-home geriatric monitoring. While some commercial monitors exist, they are bulky, require reconfiguration, and do not fit seamlessly as a simple wearable device. We designed, prototyped and tested an integrated sensor platform that records heart rate, oxygen saturation, physical activity levels, skin temperature, and galvanic skin response. The device uses a small microcontroller to integrate the measurements and store data directly on the device for up to 48+ h. continuously. The device was compared to clinical standards for calibration and performance benchmarking. We found that our system compared favorably with clinical measures, such as fingertip pulse oximetry and infrared thermometry, with high accuracy and correlation. Our novel platform would facilitate an individualized approach to care, particularly those whose access to healthcare facilities is limited. The platform also can be used as a research tool to study physiological responses to a variety of environmental conditions, such as extreme heat, and can be customized to incorporate new sensors to explore other lines of inquiry.

Changing home care aides: Differences between family and non-family care in California Medicaid home and community-based services.

In California Medicaid home-and-community-based services (HCBS), recipients' family members receive payment as home care aides (HCAs). We analyzed data on first-time HCBS recipients to examine factors associated with the likelihood of switching HCAs within the first year of services. Those with family HCAs were less than half as likely to change than those with non-family HCAs and racial/ethnic minorities with non-family HCAs had the highest switching rates. Lower wages and local unemployment were associated with switching of non-family HCAs but not family HCAs. Policymakers can foster continuity of home care by paying family members for home care and raising worker wages.

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training.

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.

Predictors of Nursing Facility Entry by Medicaid-Only Older Adults and Persons With Disabilities in California.

Nearly one-third of adult Medicaid beneficiaries who receive long-term services and supports (LTSS) consist of older adults and persons with disabilities who are not eligible for Medicare. Beneficiaries, advocates, and policymakers have all sought to shift LTSS to home and community settings as an alternative to institutional care. We conducted a retrospective cohort study of Medicaid-only adults in California with new use of LTSS in 2006-2007 (N = 31 849) to identify unique predictors of entering nursing facilities versus receiving Medicaid home and community-based services (HCBS). Among new users, 18.3% entered into nursing facilities, whereas 81.7% initiated HCBS. In addition to chronic conditions, functional and cognitive limitations, substance abuse disorders (odds ratio [OR] 1.35; 95% confidence interval [CI]: 1.23, 1.48), and homelessness (OR: 4.35, 9% CI: 3.72, 5.08) were associated with higher odds of nursing facility entry. For older adults and persons with disabilities covered by Medicaid only, integration with housing and behavioral health services may be key to enabling beneficiaries to receive LTSS in noninstitutional settings.

Health Care Expenditures After Initiating Long-term Services and Supports in the Community Versus in a Nursing Facility.

BACKGROUND: Individuals who receive long-term services and supports (LTSS) are among the most costly participants in the Medicare and Medicaid programs. OBJECTIVES: To compare health care expenditures among users of Medicaid home and community-based services (HCBS) versus those using extended nursing facility care. RESEARCH DESIGN: Retrospective cohort analysis of California dually eligible adult Medicaid and Medicare beneficiaries who initiated Medicaid LTSS, identified as HCBS or extended nursing facility care, in 2006 or 2007. SUBJECTS: Propensity score matching for demographic, health, and functional characteristics resulted in a subsample of 34,660 users who initiated Medicaid HCBS versus extended nursing facility use. Those with developmental disabilities or in managed care plans were excluded. MEASURES: Average monthly adjusted acute, postacute, long-term, and total Medicare and Medicaid expenditures for the 12 months following initiation of either HCBS or extended nursing facility care. RESULTS: Those initiating extended nursing facility care had, on average, $2919 higher adjusted total health care expenditures per month compared with those who initiated HCBS. The difference was primarily attributable to spending on LTSS $2855. On average, the monthly LTSS expenditures were higher for Medicare $1501 and for Medicaid $1344 when LTSS was provided in a nursing facility rather than in the community. CONCLUSIONS: The higher cost of delivering LTSS in a nursing facility rather than in the community was not offset by lower acute and postacute spending. Medicare and Medicaid contribute similar amounts to the LTSS cost difference and both could benefit financially by redirecting care from institutions to the community.

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review.

STUDY OBJECTIVE: Previous reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events. METHODS: We identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate- to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations. RESULTS: We evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations. CONCLUSION: High-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation.

Integrating Health Care for the Most Vulnerable: Bridging the Differences in Organizational Cultures Between US Hospitals and Community Health Centers.

Policymakers have increasingly promoted health services integration to improve quality and efficiency. The US health care safety net, which comprises providers of health care to uninsured, Medicaid, and other vulnerable patients, remains a largely fragmented collection of providers. We interviewed leadership from safety net hospitals and community health centers in 5 US cities (Boston, MA; Denver, CO; Los Angeles, CA; Minneapolis, MN; and San Francisco, CA) throughout 2013 on their experiences with service integration. We identify conflicts in organizational mission, identity, and consumer orientation that have fostered reluctance to enter into collaborative arrangements. We describe how smaller scale initiatives, such as capitated model for targeted populations, health information exchange, and quality improvements led by health plans, can help bridge cultural differences to lay the groundwork for developing integrated care programs.

Safety net integration: a shared strategy for becoming providers of choice.

With the expansion of coverage as a result of federal health care reform, safety net providers are confronting a challenge to care for the underserved while also competing as a provider of choice for the newly insured. Safety net institutions may be able to achieve these goals by pursuing greater delivery system integration. We interviewed safety net hospital and community health center (CHCs) leaders in five US cities to determine what strategies these organizations are employing to promote care integration in the safety net. Although there is some experimentation with payment reform and health information exchange, safety net providers identify significant policy and structural barriers to integrating service delivery. The enhanced Medicaid payments for CHCs and the federal requirement that CHCs retain independent boards discourage these organizations from integrating with other safety net providers. Current policies are not mobilizing safety net providers to pursue integration as a way to deliver more efficient and effective care. Medicaid and other policies at the federal and state level could be revised to overcome known fragmentation in the health care safety net. This includes addressing the conflicts in financing and governance arrangements that are encouraging providers to resist integration to preserve their independence.

Viral genome methylation differentially affects the ability of BZLF1 versus BRLF1 to activate Epstein-Barr virus lytic gene expression and viral replication.

The Epstein-Barr virus (EBV) immediate-early proteins BZLF1 and BRLF1 can both induce lytic EBV reactivation when overexpressed in latently infected cells. Although EBV genome methylation is required for BZLF1-mediated activation of lytic gene expression, the effect of viral genome methylation on BRLF1-mediated viral reactivation has not been well studied. Here, we have compared the effect of viral DNA methylation on BZLF1- versus BRLF1-mediated activation of lytic EBV gene transcription and viral genome replication. We show that most early lytic viral promoters are preferentially activated by BZLF1 in the methylated form, while methylation decreases the ability of BRLF1 to activate most early lytic promoters, as well as the BLRF2 late viral promoter. Moreover, methylation of bacmid constructs containing the EBV genome enhances BZLF1-mediated, but decreases BRLF1-mediated, early lytic gene expression. Methylation of viral promoter DNA does not affect BRLF1 binding to a variety of different CpG-containing BRLF1 binding motifs (RREs) in vitro or in vivo. However, BRLF1 preferentially induces H3K9 histone acetylation of unmethylated promoters in vivo. The methylated and unmethylated forms of an oriLyt-containing plasmid replicate with similar efficiency when transfected into EBV-positive cells that express the essential viral replication proteins in trans. Most importantly, we demonstrate that lytic viral gene expression and replication can be induced by BRLF1, but not BZLF1, expression in an EBV-positive telomerase-immortalized epithelial cell line (NOKs-Akata) in which lytic viral gene promoters remain largely unmethylated. These results suggest that the unmethylated form of the EBV genome can undergo viral reactivation and replication in a BRLF1-dependent manner.

Asian American Diversity and Representation in the Health Care Workforce, 2007 to 2022.

Importance: Asian American individuals comprise over 40 ethnoracial groups but are regularly aggregated into 1 category within health workforce analysis, thus obscuring substantial inequities in representation. Objectives: To describe trends in Asian American diversity across the 4 most populous US health professions (physicians, registered nurses, nursing assistants, and home health aides) and to characterize subgroup representation within professions. Design, Setting, and Participants: Serial cross-sectional study from American Community Survey (ACS) population estimates of people reporting health profession occupations from 2007 to 2022. The ACS samples US residents every day, with approximately 3.5 million surveyed each year. Based on their sampling methods, the ACS then produces estimates of the entire US population for 1-year, 3-year, and 5-year periods. Data were analyzed from April to August 2024. Main Outcomes and Measures: For each year and subgroup, the proportions of the US population, the profession, and Asian American individuals within the profession were calculated. The representation quotient (RQ) of each subgroup was then calculated, defined as the proportion of the subgroup within the profession of interest divided by the proportion of the subgroup within the US population. Trends were examined over the 15-year period. Results: Over the 15-year period, Indian Americans composed the largest percentage of Asian American physicians (mean [SD], 40.6% [1.6%]), followed by Chinese Americans (mean [SD], 18.9% [1.4%]). Pakistani and Indian Americans had the highest relative representation (mean [SD] RQ, 8.9 [0.9] and 7.8 [0.9], respectively). Conversely, Cambodian and Hmong Americans remained largely underrepresented (mean [SD] RQ, 0.2 [0.2] for both). Filipinx Americans accounted for more than half of Asian American registered nurses and nursing assistants, with high relative representation (mean [SD] RQ, 5.6 (0.3) and 2.9 [0.4], respectively). Bangladeshi and Chinese American relative representation were high among home health aides (mean [SD] RQ, 4.1 [1.5] and 2.7 [0.5], respectively). Asian American individuals accounted for an estimated 22% of physicians (approximately 260 693 respondents), 10% of registered nurses (approximately 420 418 respondents), 4.8% of nursing assistants (approximately 93 913 respondents), and 8.3% of home health aides (approximately 60 968 respondents) in 2022. Conclusions and Relevance: By examining disaggregated data, this study found persistent inequities among Asian American subgroups in the health workforce. Reducing Asian American populations to a single racialized group erases subgroup differences rooted in histories of racism, colonialism, and xenophobia; enables false narratives of Asian American overrepresentation and success; and hampers progress in advancing health justice.

The health implications of neighborhood networks based on daily mobility in US cities.

A large body of research has been dedicated to understanding the neighborhood conditions that impact health, which outcomes are affected, and how these associations vary by demographic and socioeconomic neighborhood and individual characteristics. This literature has focused mostly on the neighborhoods in which individuals reside, thus failing to recognize that residents across race/ethnicity and class spend a non-trivial amount of their time in neighborhoods far from their residential settings. To address this gap, we use mobile phone data from the company SafeGraph to compare racial inequality in neighborhood socioeconomic advantage exposure across three scales: the neighborhoods that residents live in, their adjacent neighborhoods, and the neighborhoods that they regularly visit. We found that the socioeconomic advantage levels in neighborhood networks differ from the levels at the residential and adjacent scales across all ethnoracial neighborhoods. Furthermore, socioeconomic advantage at the network level is associated with diabetes and hypertension prevalence above and beyond its impact at the residential and adjacent levels. We also find ethnoracial differences in these associations, with greater beneficial consequences of network socioeconomic advantage exposure on hypertension and diabetes for white neighborhoods. Future social determinants of health research needs to reconceptualize exposure to include the larger neighborhood network that a community is embedded in based on where their residents travel to and from.

Experiences of Leaders in Diversity, Equity, and Inclusion in US Academic Health Centers.

Importance: The murder of George Floyd in 2020 spurred an outpouring of calls for racial justice in the United States, including within academic medicine. In response, academic health centers announced new antiracism initiatives and expanded their administrative positions related to diversity, equity, and/or inclusion (DEI). Objective: To understand the experiences of DEI leaders at US allopathic medical schools and academic health centers, ie, the structure of their role, official and unofficial responsibilities, access to resources, institutional support, and challenges. Design, Setting, and Participants: This qualitative study used key informant interviews with participants who held formal DEI positions in their school of medicine, health system, or department. Interviews were conducted from December 2020 to September 2021. Transcripts were coded using a phenomenographic approach, with iterative concurrent analysis to identify thematic categories across participants. Data were analyzed from January to December 2021. Exposure: Formal DEI role. Main Outcomes and Measures: Questions elicited reflection on the responsibilities of the role and the strengths and challenges of the unit or office. Results: A total of 32 participants (18 of 30 [56%] cisgender women; 16 [50%] Black or African American, 6 [19%] Latinx or Hispanic, and 8 [25%] White) from 27 institutions with a mean (range) of 14 (3-43) years of experience in medical education were interviewed. More than half held a dean position (17 [53%]), and multiple participants held 2 or more titled DEI roles (4 [13%]). Two-thirds self-identified as underrepresented in medicine (20 [63%]) and one-third as first generation to attend college (11 [34%]). Key themes reflected ongoing challenges for DEI leaders, including (1) variability in roles, responsibilities, and access to resources, both across participants and institutions as well as within the same position over time; (2) mismatch between institutional investments and directives, including insufficient authority, support staff, and/or funding, and reduced efficacy due to lack of integration with other units within the school or health system; (3) lack of evidence-based practices, theories of change, or standards to guide their work; and (4) work experiences that drive and exhaust leaders. Multiple participants described burnout due to increasing demands that are not met with equivalent increase in institutional support. Conclusions and Relevance: In this qualitative study, DEI leaders described multiple institutional challenges to their work. To effectively address stated goals of DEI, medical schools and academic centers need to provide leaders with concomitant resources and authority that facilitate change. Institutions need to acknowledge and implement strategies that integrate across units, beyond one leader and office. Policymakers, including professional organizations and accrediting bodies, should provide guidance, accountability mechanisms, and support for research to identify and disseminate evidence for best practices. Creating statements and positions, without mechanisms for change, perpetuates stagnation and injustice.

Psychological Outcomes in Families of PICU Survivors: A Meta-Analysis.

BACKGROUND: Pediatric critical illness exposes family members to stressful experiences that may lead to subsequent psychological repercussions. OBJECTIVE: To systematically review psychological outcomes among PICU survivors' family members. DATA SOURCES: Four medical databases (PubMed, Embase, CINAHL and PsycInfo) were searched from inception till October 2023. STUDY SELECTION: Studies reporting psychological disorders in family members of PICU patients with at least 3 months follow-up were included. Family members of nonsurvivors and palliative care patients were excluded. DATA EXTRACTION: Screening and data extraction was performed according to PRISMA guidelines. Data were pooled using a random-effects model. RESULTS: Of 5360 articles identified, 4 randomized controlled trials, 16 cohort studies, and 2 cross-sectional studies were included (total patients = 55 597; total family members = 97 506). Psychological distress was reported in 35.2% to 64.3% and 40.9% to 53% of family members 3 to 6 months and 1 year after their child's PICU admission, respectively. Post-traumatic stress disorder was diagnosed in 10% to 48% of parents 3 to 9 months later. Parents that experienced moderate to severe anxiety and depression 3 to 6 months later was 20.9% to 42% and 6.1% to 42.6%, respectively. Uptake of mental counseling among parents was disproportionately low at 0.7% to 29%. Risk factors for psychiatric morbidity include mothers, parents of younger children, and longer duration of PICU stay. LIMITATIONS: The majority of studies were on parents with limited data on siblings and second degree relatives. CONCLUSIONS: There is a high burden of psychological sequelae in family members of PICU survivors. Risk stratification to identify high-risk groups and early interventions are needed.

Experiences of low-income college students in selection of health insurance, access, and quality of care.

OBJECTIVE: To understand the experiences and perspectives of low-income University of California undergraduates related to their health insurance options, access to and quality of care. PARTICIPANTS: 14 undergraduate students across five UC campuses who identified as socioeconomically disadvantaged or low-income. METHODS: We conducted 4 focus groups organized by type of insurance coverage in April 2022. RESULTS: (1) the insurance selection process for low-income students is complicated by multiple, sometimes competing factors; (2) the lack of clear information confuses students' selection of insurance and health care options; and (3) students experiences challenges in access and quality of care, irrespective of insurance type. CONCLUSIONS: Ensuring access to high quality care, information and coverage is critical to the university mission to support a diverse, equitable and inclusive environment, for a student body that reflects the needs of the population of California.