Neighborhood Food Access in Early Life and Trajectories of Child Body Mass Index and Obesity.

Importance: Limited access to healthy foods, resulting from residence in neighborhoods with low food access, is a public health concern. The contribution of this exposure in early life to child obesity remains uncertain. Objective: To examine associations of neighborhood food access during pregnancy or early childhood with child body mass index (BMI) and obesity risk. Design, Setting, and Participants: Data from cohorts participating in the US nationwide Environmental Influences on Child Health Outcomes consortium between January 1, 1994, and March 31, 2023, were used. Participant inclusion required a geocoded residential address in pregnancy (mean 32.4 gestational weeks) or early childhood (mean 4.3 years) and information on child BMI. Exposures: Residence in low-income, low-food access neighborhoods, defined as low-income neighborhoods where the nearest supermarket is more than 0.5 miles for urban areas or more than 10 miles for rural areas. Main Outcomes and Measures: BMI z score, obesity (age- and sex-specific BMI ≥95th percentile), and severe obesity (age- and sex-specific BMI ≥120% of the 95th percentile) from age 0 to 15 years. Results: Of 28 359 children (55 cohorts; 14 657 [51.7%] male and 13 702 [48.3%] female; 590 [2.2%] American Indian, Alaska Native, Native Hawaiian, or Other Pacific Islander; 1430 [5.4%] Asian; 4034 [15.3%] Black; 17 730 [67.2%] White; and 2592 [9.8%] other [unspecified] or more than 1 race; 5754 [20.9%] Hispanic and 21 838 [79.1%] non-Hispanic) with neighborhood food access data, 23.2% resided in low-income, low-food access neighborhoods in pregnancy and 24.4% in early childhood. After adjusting for individual sociodemographic characteristics, residence in low-income, low-food access (vs non-low-income, low-food access) neighborhoods in pregnancy was associated with higher BMI z scores at ages 5 years (ß, 0.07; 95% CI, 0.03-0.11), 10 years (ß, 0.11; 95% CI, 0.06-0.17), and 15 years (ß, 0.16; 95% CI, 0.07-0.24); higher obesity risk at 5 years (risk ratio [RR], 1.37; 95% CI, 1.21-1.55), 10 years (RR, 1.71; 95% CI, 1.37-2.12), and 15 years (RR, 2.08; 95% CI, 1.53-2.83); and higher severe obesity risk at 5 years (RR, 1.21; 95% CI, 0.95-1.53), 10 years (RR, 1.54; 95% CI, 1.20-1.99), and 15 years (RR, 1.92; 95% CI, 1.32-2.80). Findings were similar for residence in low-income, low-food access neighborhoods in early childhood. These associations were robust to alternative definitions of low income and low food access and additional adjustment for prenatal characteristics associated with child obesity. Conclusions: Residence in low-income, low-food access neighborhoods in early life was associated with higher subsequent child BMI and higher risk of obesity and severe obesity. We encourage future studies to examine whether investments in neighborhood resources to improve food access in early life would prevent child obesity.

Do small effects matter more in vulnerable populations? an investigation using Environmental influences on Child Health Outcomes (ECHO) cohorts.

BACKGROUND: A major challenge in epidemiology is knowing when an exposure effect is large enough to be clinically important, in particular how to interpret a difference in mean outcome in unexposed/exposed groups. Where it can be calculated, the proportion/percentage beyond a suitable cut-point is useful in defining individuals at high risk to give a more meaningful outcome. In this simulation study we compute differences in outcome means and proportions that arise from hypothetical small effects in vulnerable sub-populations. METHODS: Data from over 28,000 mother/child pairs belonging to the Environmental influences on Child Health Outcomes Program were used to examine the impact of hypothetical environmental exposures on mean birthweight, and low birthweight (LBW) (birthweight < 2500g). We computed mean birthweight in unexposed/exposed groups by sociodemographic categories (maternal education, health insurance, race, ethnicity) using a range of hypothetical exposure effect sizes. We compared the difference in mean birthweight and the percentage LBW, calculated using a distributional approach. RESULTS: When the hypothetical mean exposure effect was fixed (at 50, 125, 167 or 250g), the absolute difference in % LBW (risk difference) was not constant but varied by socioeconomic categories. The risk differences were greater in sub-populations with the highest baseline percentages LBW: ranging from 3.1-5.3 percentage points for exposure effect of 125g. Similar patterns were seen for other mean exposure sizes simulated. CONCLUSIONS: Vulnerable sub-populations with greater baseline percentages at high risk fare worse when exposed to a small insult compared to the general population. This illustrates another facet of health disparity in vulnerable individuals.

Global Challenges After a Global Challenge: Lessons Learned from the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) has affected not only individual lives but also the world and global systems, both natural and human-made. Besides millions of deaths and environmental challenges, the rapid spread of the infection and its very high socioeconomic impact have affected healthcare, economic status and wealth, and mental health across the globe. To better appreciate the pandemic's influence, multidisciplinary and interdisciplinary approaches are needed. In this chapter, world-leading scientists from different backgrounds share collectively their views about the pandemic's footprint and discuss challenges that face the international community.

Means to an end: Characteristics and follow-up of emergency department patients with a history of suicide attempt via medication overdose.

OBJECTIVE: Availability and accessibility of a wide range of medications may be a contributing factor to rising medication-related overdose (OD) rates. Treatment for both suicide attempts (SAs) and ODs often occurs in the emergency department (ED), highlighting its potential as a screening and intervention point. The current study aimed to identify sociodemographic and clinical characteristics of individuals who reported SA via medication OD compared to other methods and to examine how these patients' suicide severity and behaviors differed over 12-month post-ED follow-up. METHODS: Data were analyzed from Phases 1 and 2 of the Emergency Department Safety Assessment and Follow-up Evaluation multicenter study (N = 1376). Participants with a history of SA (n = 987) were categorized based on whether they indicated a past medication-related SA via OD. RESULTS: Of participants with history of SA, 62.7% (n = 619) reported medication OD for either their most serious or their most recent SA. Multivariate analyses indicated female birth sex, diagnosis of bipolar disorder, and having some college education were significantly associated with membership in the medication OD attempt group (p <0.05). Of those who attempted suicide over the 12-month follow-up, nearly 60% of participants in the medication OD attempt group reported a subsequent SA via OD over follow-up. However, nearly half (46.5%) of participants with no medication OD at baseline also reported medication OD at follow-up. CONCLUSIONS: Among patients presenting to the ED, females, individuals with bipolar disorder, and patients with a college education, respectively, may be at highest risk for SAs via medication OD. Prospectively, medication OD appears to be a frequent method, even among individuals with no prior attempt via OD, as demonstrated by the high percentage of patients who did not have a medication OD at baseline, but reported a medication OD during follow-up.

Preventive Health Services Offered in a Sampling of US Emergency Departments, 2022-2023.

Introduction: In the United States, more chronic and preventive healthcare is being delivered in the emergency department (ED) setting. Understanding the availability of preventive health services in the ED setting is crucial. Our goal was to understand the availability of a subset of preventive health services in US EDs and explore how that has changed over time. Methods: In 2022-2023, using the National Emergency Department Inventory (NEDI)-USA, we surveyed a random 20% (1,064) sampling of all 5,613 US EDs. We asked directors of these EDs about the availability of and preference for 12 preventive health services, social worker availability, self-reported percentage of uninsured ED patients, and measures of ED crowding. We also asked about perceptions of barriers to implementing preventive health services in the ED. We used unadjusted and multivariable logistic regression models to compare service frequency in 2022-2023 to prior findings from 2008-2009 that represented a 5.7% random sampling of all EDs. Results: Among 302 responders to the 2022-2023 survey (5.4% random sampling, 28.4% response rate), 94% reported offering at least one preventive health service, with a median of five services. The most common service offered was intimate partner violence screening (83%), while the least common was routine HIV screening (19%). Seven services (eg, intimate partner violence, alcohol risk, and smoking cessation screening) had a higher odds of being offered in 2022-2023 than in 2008-2009; findings were unchanged in sensitivity analyses. A small proportion of directors opposed offering preventive health services. However, many expressed concerns that preventive health services in the ED would lead to longer lengths of stay (56%), increased costs to their ED (58%), a diversion of staff time from providing acute care (50%), or that their patients would not have access to adequate follow-up (49%). Conclusion: Nearly all EDs offer at least one preventive health service. Many offer multiple services; rates were higher than those identified in 2008-2009, in both unadjusted and multivariable models. Although limited by the response rate, this work provides the most recent and comprehensive snapshot of the type and frequency of a subset of preventive health services currently offered in US EDs.

Integrated nasopharyngeal airway metagenome and asthma genetic risk endotyping of severe bronchiolitis in infancy and risk of childhood asthma.

The severe bronchiolitis endotype characterized by a high abundance of H. influenzae, high proportion of RV-A and RV-C infections, and high asthma genetic risk had a significantly higher risk for developing asthma. BACKGROUND: Infants with bronchiolitis are at increased risk for developing asthma. Growing evidence suggests bronchiolitis is a heterogeneous condition. However, little is known about its biologically distinct subgroups based on the integrated metagenome and asthma genetic risk signature and their longitudinal relationships with asthma development. METHODS: In a multi-center prospective cohort study of infants with severe bronchiolitis (i.e., bronchiolitis requiring hospitalization), we profiled nasopharyngeal airway metagenome and virus at hospitalization, and calculated the polygenic risk score of asthma. Using similarity network fusion clustering approach, we identified integrated metagenome-asthma genetic risk endotypes. We also examined their longitudinal association with the risk of developing asthma by age six years. RESULTS: Of 450 infants with bronchiolitis (median age, 3 months), we identified five distinct endotypes-characterized by their nasopharyngeal metagenome, virus, and asthma genetic risk profiles. Compared with endotype A infants (who clinically resembled "classic" bronchiolitis), endotype E infants (characterized by a high abundance of H. influenzae, high proportion of RV-A and RV-C infections, and high asthma genetic risk) had a significantly higher risk for developing asthma (35.9% versus 16.7%; ORadj, 2.24; 95%CI, 1.02-4.97; p=0.046). The pathway analysis showed that endotype E had enriched microbial pathways (e.g., glycolysis, L-lysine, arginine metabolism) and host pathways (e.g., IFNs, IL-6/JAK/STAT3, fatty acids, MHC, and immunoglobin-related) (FDR<0.05). Additionally, endotype E had a significantly higher proportion of neutrophils (FDR<0.05). CONCLUSION: In this multi-center prospective cohort study of infant bronchiolitis, the clustering analysis of integrated-omics data identified biologically distinct endotypes with differential risks for developing asthma.

Teletrauma Use in US Emergency Departments.

Importance: Nearly 30 million predominantly rural US residents lack timely access to trauma care expertise available at level I or II trauma centers. Telehealth is an established approach to improve access to health care expertise using remote consultation; however, the prevalence of use of telehealth in trauma (teletrauma) across the US is not known. Objective: To examine the prevalence of, trends in, and factors associated with teletrauma use and adoption among US emergency departments (EDs). Design, Setting, and Participants: This survey study included data from the National Emergency Department Inventory (NEDI)-USA survey from January 1, 2016, to December 31, 2020. Each year, a 1-page survey was sent to the directors of nonfederal, nonspecialty EDs by mail and email up to 3 times; nonresponders were further contacted via telephone to complete the survey. Data were analyzed from January to March 2023. Main Outcomes and Measures: The primary outcome was self-reported ED use of teletrauma for each year studied. Additional measures included data regarding self-reported use of any other telehealth service and ED characteristics. Multivariable logistic regression analyses were performed to assess ED characteristics associated with teletrauma use in 2020 and teletrauma adoption between 2017 and 2020. Results: Of 5586 EDs in the US in 2020, 4512 had available teletrauma survey data (80.8% response rate); 379 (8.4%) of these EDs reported teletrauma use. In contrast, 2726 (60.4%) reported use of any other telehealth service. Teletrauma use (among EDs with any telehealth use) ranged between 0% in Alabama; Connecticut; Washington, DC; Indiana; New Jersey; Nevada; Oklahoma; Oregon; Rhode Island; and South Carolina to more than 60% in Arkansas (39 of 64 [60.9%]), South Dakota (31 of 41 [75.6%]), and North Dakota (30 of 35 [85.7%]). Factors associated with teletrauma use included rural location (odds ratio [OR], 2.44; 95% CI, 1.77-3.36), critical access hospital (OR, 2.67; 95% CI, 1.83-3.88), and basic stroke hospital vs nonstroke hospital (OR, 1.74; 95% CI, 1.32-2.30) designations. Factors associated with adoption of teletrauma by 2020 included critical access hospital (OR, 1.98; 95% CI, 1.35-2.90) and basic stroke hospital vs nonstroke hospital (OR, 1.42; 95% CI, 1.04-1.94) designation. Conclusion and Relevance: This survey study found that teletrauma use lagged significantly behind use of other telehealth services in US EDs in 2020. While most EDs using teletrauma were located in rural areas, there was significant state-level variation in teletrauma use. Future research is needed on how teletrauma is being used and to identify barriers to its wider implementation.

Weekly Vitamin D Supplementation to Prevent Acute Respiratory Infections in Young Children at Different Latitudes: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of weekly vitamin D supplementation in reducing the number of acute respiratory infections (ARI) in preschool children. STUDY DESIGN: Randomized, double-blind, placebo-controlled trial in 303 children aged 1.5-3.5 years from 2014 to 2105 in 3 Chilean cities at different latitudes: Santiago (33°S, n = 101), Talcahuano (37°S, n = 103), and Punta Arenas (53°S, n = 99). Participants were allocated (1:1:1) to receive placebo, cholecalciferol (vitamin D3 (VD3)) 5600 IU/week (low-dose), or 11 200 IU/week (high-dose) for 6 months. Primary outcome was parent-reported number of ARI; secondary outcomes included number of ARI hospitalizations, change of serum 25-hydroxyvitamin D (25(OH)D) and LL-37/cathelicidin levels, and adverse events. RESULTS: The mean age of participants was 26 ± 6 months; 45% were female. Baseline 25(OH)D was 24.9 ± 6.1 ng/ml, with 23% having 25(OH)D <20 ng/ml. No significant baseline clinical or laboratory differences were observed among groups. Overall, 64% (n = 194) completed study participation, without baseline differences between subjects lost to follow-up vs those completing participation or differences in completion rates across groups. After 6 months, a dose-dependent increase in serum 25(OH)D was observed from the VD3 intervention (P < .001), with a higher proportion of subjects ending the trial with 25(OH)D <20 ng/ml in the placebo group (30.8%) vs the low-dose (7.4%) and high-dose groups (5.1%). However, no group differences were observed in number of ARI (P = .85), ARI hospitalizations (P = .20), LL-37/cathelicidin change (P = .30), or adverse events (P = .41). CONCLUSIONS: While weekly VD3 supplementation, in doses equivalent to 800 IU and 1600 IU daily, was associated with improved 25(OH)D levels in preschoolers, we did not find a reduced number of ARI in this sample.

Integrated-omics analysis with explainable deep networks on pathobiology of infant bronchiolitis.

Bronchiolitis is the leading cause of infant hospitalization. However, the molecular networks driving bronchiolitis pathobiology remain unknown. Integrative molecular networks, including the transcriptome and metabolome, can identify functional and regulatory pathways contributing to disease severity. Here, we integrated nasopharyngeal transcriptome and metabolome data of 397 infants hospitalized with bronchiolitis in a 17-center prospective cohort study. Using an explainable deep network model, we identified an omics-cluster comprising 401 transcripts and 38 metabolites that distinguishes bronchiolitis severity (test-set AUC, 0.828). This omics-cluster derived a molecular network, where innate immunity-related metabolites (e.g., ceramides) centralized and were characterized by toll-like receptor (TLR) and NF-κB signaling pathways (both FDR < 0.001). The network analyses identified eight modules and 50 existing drug candidates for repurposing, including prostaglandin I2 analogs (e.g., iloprost), which promote anti-inflammatory effects through TLR signaling. Our approach facilitates not only the identification of molecular networks underlying infant bronchiolitis but the development of pioneering treatment strategies.

Nasal microRNA signatures for disease severity in infants with respiratory syncytial virus bronchiolitis: a multicentre prospective study.

BACKGROUND: Respiratory syncytial virus (RSV) bronchiolitis contributes to a large morbidity and mortality burden globally. While emerging evidence suggests that airway microRNA (miRNA) is involved in the pathobiology of RSV infection, its role in the disease severity remains unclear. METHODS: In this multicentre prospective study of infants (aged<1 year) hospitalised for RSV bronchiolitis, we sequenced the upper airway miRNA and messenger RNA (mRNA) at hospitalisation. First, we identified differentially expressed miRNAs (DEmiRNAs) associated with higher bronchiolitis severity-defined by respiratory support (eg, positive pressure ventilation, high-flow oxygen therapy) use. We also examined the biological significance of miRNAs through pathway analysis. Second, we identified differentially expressed mRNAs (DEmRNAs) associated with bronchiolitis severity. Last, we constructed miRNA-mRNA coexpression networks and determined hub mRNAs by weighted gene coexpression network analysis (WGCNA). RESULTS: In 493 infants hospitalised with RSV bronchiolitis, 19 DEmiRNAs were associated with bronchiolitis severity (eg, miR-27a-3p, miR-26b-5p; false discovery rate<0.10). The pathway analysis using miRNA data identified 1291 bronchiolitis severity-related pathways-for example, regulation of cell adhesion mediated by integrin. Second, 1298 DEmRNAs were associated with bronchiolitis severity. Last, of these, 190 DEmRNAs were identified as targets of DEmiRNAs and negatively correlated with DEmiRNAs. By applying WGCNA to DEmRNAs, four disease modules were significantly associated with bronchiolitis severity-for example, microtubule anchoring, cell-substrate junction. The hub genes for each of these modules were also identified-for example, PCM1 for the microtubule anchoring module, LIMS1 for the cell-substrate junction module. CONCLUSIONS: In infants hospitalised for RSV bronchiolitis, airway miRNA-mRNA coexpression network contributes to the pathobiology of bronchiolitis severity.

Factors Associated With Potentially Unnecessary Transfers for Children With Asthma: A Retrospective Cohort Study.

OBJECTIVE: Our objective was to identify the hospital- and community-related factors associated with the hospital-level rate of potentially unnecessary interfacility transfers (IFTs) for pediatric patients with asthma exacerbations. METHODS: We analyzed California Emergency Department (ED) data from 2016 to 2019 to capture ED visits where a pediatric patient (age, 2-17 years) presented with an asthma exacerbation and was transferred to another ED or acute care hospital. The primary outcome was hospital-level rate of potentially unnecessary IFTs, defined as a visit where length of stay after transfer was <24 hours and no advanced services (eg, critical care) were used. Hospital- and community-related characteristics included urbanicity, teaching hospital status, availability of pediatric resources in the sending facility and patient's community, pediatric patient volume, and Social Vulnerability Index. We described and compared hospitals in the top quartile of potentially unnecessary IFT rate versus all others and used a multivariable modified Poisson model to identify factors associated with potentially unnecessary IFT. RESULTS: A total of 325 sending hospitals were included, with a median 573 pediatric asthma visits (interquartile range, 183-1309) per hospital annually. Nearly half of the hospitals (145/325, 45%) sent a potentially unnecessary IFT. Most (90%) hospitals were urban, 9% were teaching hospitals, 5% had >500 beds, and 22% had a pediatric ED on-site. Factors associated with higher adjusted prevalence of potentially unnecessary IFT included availability of pediatric telehealth (prevalence ratio [PR], 1.5; 95% confidence interval [CI], 1.2-2.0), increased pediatric volume (eg, <1800 vs ≥10,000 visits: PR, 2.6; 95% CI, 1.4-4.7), and higher community Social Vulnerability Index (PR, 1.5; 95% CI, 1.1-1.9). CONCLUSIONS: Several hospital- and community-related factors were associated with potentially unnecessary IFTs among pediatric patients presenting to the ED with asthma exacerbations. These findings provide insight into disparities in potentially unnecessary IFT across communities and can guide the development of future interventions.

Association of maternal fish consumption and ω-3 supplement use during pregnancy with child autism-related outcomes: results from a cohort consortium analysis.

BACKGROUND: Prenatal fish intake is a key source of omega-3 (ω-3) polyunsaturated fatty acids needed for brain development, yet intake is generally low, and studies addressing associations with autism spectrum disorder (ASD) and related traits are lacking. OBJECTIVE: This study aimed to examine associations of prenatal fish intake and ω-3 supplement use with both autism diagnosis and broader autism-related traits. METHODS: Participants were drawn from 32 cohorts in the Environmental influences on Child Health Outcomes Cohort Consortium. Children were born between 1999 and 2019 and part of ongoing follow-up with data available for analysis by August 2022. Exposures included self-reported maternal fish intake and ω-3/fish oil supplement use during pregnancy. Outcome measures included parent report of clinician-diagnosed ASD and parent-reported autism-related traits measured by the Social Responsiveness Scale (SRS)-second edition (n = 3939 and v3609 for fish intake analyses, respectively; n = 4537 and n = 3925 for supplement intake analyses, respectively). RESULTS: In adjusted regression models, relative to no fish intake, fish intake during pregnancy was associated with reduced odds of autism diagnosis (odds ratio: 0.84; 95% confidence interval [CI]: 0.77, 0.92), and a modest reduction in raw total SRS scores (ß: -1.69; 95% CI: -3.3, -0.08). Estimates were similar across categories of fish consumption from "any" or "less than once per week" to "more than twice per week." For ω-3 supplement use, relative to no use, no significant associations with autism diagnosis were identified, whereas a modest relation with SRS score was suggested (ß: 1.98; 95% CI: 0.33, 3.64). CONCLUSIONS: These results extend previous work by suggesting that prenatal fish intake, but not ω-3 supplement use, may be associated with lower likelihood of both autism diagnosis and related traits. Given the low-fish intake in the United States general population and the rising autism prevalence, these findings suggest the need for better public health messaging regarding guidelines on fish intake for pregnant individuals.

Defining Levels of US Hospitals' Pediatric Capabilities.

Importance: Classifying hospitals across a wide range of pediatric capabilities, including medical, surgical, and specialty services, would improve understanding of access and outcomes. Objective: To develop a classification system for hospitals' pediatric capabilities. Design, Setting, and Participants: This cross-sectional study included data from 2019 on all acute care hospitals with emergency departments in 10 US states that treated at least 1 child per day. Statistical analysis was performed from September 2023 to February 2024. Exposure: Pediatric hospital capability level, defined using latent class analysis. The latent class model parameters were the presence or absence of 26 functional capabilities, which ranged from performing laceration repairs to performing organ transplants. A simplified approach to categorization was derived and externally validated by comparing each hospital's latent class model classification with its simplified classification using data from 3 additional states. Main Outcomes and Measures: Health care utilization and structural characteristics, including inpatient beds, pediatric intensive care unit (PICU) beds, and referral rates (proportion of patients transferred among patients unable to be discharged). Results: Using data from 1061 hospitals (716 metropolitan [67.5%]) with a median of 2934 pediatric ED encounters per year (IQR, 1367-5996), the latent class model revealed 4 pediatric levels, with a median confidence of hospital assignment to level of 100% (IQR, 99%-100%). Of 26 functional capabilities, level 1 hospitals had a median of 24 capabilities (IQR, 21-25), level 2 hospitals had a median of 13 (IQR, 11-15), level 3 hospitals had a median of 8 (IQR, 6-9), and level 4 hospitals had a median of 3 (IQR, 2-3). Pediatric level 1 hospitals had a median of 66 inpatient beds (IQR, 42-86), level 2 hospitals had a median of 16 (IQR, 9-22), level 3 hospitals had a median of 0 (IQR, 0-6), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median of 19 PICU beds (IQR, 10-28), level 2 hospitals had a median of 0 (IQR, 0-5), level 3 hospitals had a median of 0 (IQR, 0-0), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median referral rate of 1% (IQR, 1%-3%), level 2 hospitals had a median of 25% (IQR, 9%-45%), level 3 hospitals had a median of 70% (IQR, 52%-84%), and level 4 hospitals had a median of 100% (IQR, 98%-100%) (P < .001). Conclusions and Relevance: In this cross-sectional study of hospitals from 10 US states, a system to classify hospitals' pediatric capabilities in 4 levels was developed and was associated with structural and health care utilization characteristics. This system can be used to understand and track national pediatric acute care access and outcomes.

Examining the association between prenatal cannabis exposure and child autism traits: A multi-cohort investigation in the environmental influences on child health outcome program.

This study examined the association between prenatal cannabis exposure and autism spectrum disorder (ASD) diagnoses and traits. A total sample of 11,570 children (ages 1-18; 53% male; 25% Hispanic; 60% White) from 34 cohorts of the National Institutes of Health-funded environmental influences on child health outcomes consortium were included in analyses. Results from generalized linear mixed models replicated previous studies showing that associations between prenatal cannabis exposure and ASD traits in children are not significant when controlling for relevant covariates, particularly tobacco exposure. Child biological sex did not moderate the association between prenatal cannabis exposure and ASD. In a large sample and measuring ASD traits continuously, there was no evidence that prenatal cannabis exposure increases the risk for ASD. This work helps to clarify previous mixed findings by addressing concerns about statistical power and ASD measurement.

Development of neffy, an Epinephrine Nasal Spray, for Severe Allergic Reactions.

Epinephrine autoinjectors (EAIs) are used for the treatment of severe allergic reactions in a community setting; however, their utility is limited by low prescription fulfillment rates, failure to carry, and failure to use due to fear of needles. Given that delayed administration of epinephrine is associated with increased morbidity/mortality, there has been a growing interest in developing needle-free, easy-to-use delivery devices. neffy (epinephrine nasal spray) consists of three Food and Drug Administration (FDA)-approved components: epinephrine, Intravail A3 (absorption enhancer), and a Unit Dose Spray (UDS). neffy's development pathway was established in conjunction with the FDA and the European Medicines Agency and included multiple clinical trials to evaluate pharmacokinetic and pharmacodynamic responses under a variety of conditions, such as self-administration and allergic and infectious rhinitis, as well as an animal anaphylaxis model of severe hypotension, where neffy demonstrated a pharmacokinetic profile that is within the range of approved injection products and a pharmacodynamic response that is as good or better than injections. The increased pulse rate (PR) and blood pressure (BP) observed even one minute following the administration of neffy confirm the activation of α and ß adrenergic receptors, which are the key components of epinephrine's mechanism of action. The results suggest that neffy will provide a safe and effective needle-free option for the treatment of severe allergic reactions, including anaphylaxis.

Development and Evaluation of Modified Criteria for Infant and Toddler Anaphylaxis.

BACKGROUND: Current clinical criteria for identifying anaphylaxis do not account for unique aspects of infant anaphylaxis presentation and have not been validated in patients younger than 2 years of age. This may contribute to under recognition and is thus an unmet need. OBJECTIVE: To demonstrate age-specific signs and symptoms that more accurately identify anaphylaxis in young children and to develop and compare modified criteria for "likely anaphylaxis" against the widely used 2006 National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria. METHODS: Retrospective chart review of 337 clinical encounters presenting with suspected allergic or anaphylactic reactions to a pediatric emergency department. Modified criteria for likely anaphylaxis were developed and evaluated against the NIAID/FAAN criteria. RESULTS: The study population included 33% infants (age < 12 mo), 39% toddlers (age 12 mo to < 36 mo), and 29% children (age ≥ 36 mo). The NIAID/FAAN criteria captured 85% of all patient encounters in the study and the modified criteria captured 98% (P < .001). Compared with NIAID/FAAN criteria, modified criteria had 22.8% improved performance among infants (p < .001) and 10.3% improved performance among toddlers (P = .04). CONCLUSIONS: We developed modified anaphylaxis clinical criteria that incorporated symptoms specific to infants and young children. The modified criteria increased identification of anaphylaxis in infants and potentially toddlers. Future research is needed to validate our findings on a larger cohort.

Estimating the size and scope of the academic emergency physician workforce.

BACKGROUND: Academic emergency medicine (EM) is foundational to the EM specialty through the development of new knowledge and clinical training of resident physicians. Despite recent increased attention to the future of the EM workforce, no evaluations have specifically characterized the U.S. academic EM workforce. We sought to estimate the national proportion of emergency physicians (EPs) identified as academic and the proportion of emergency department (ED) visits that take place at academic sites. METHODS: We performed a cross-sectional analysis of EPs and EDs using data from the American Hospital Association, the Centers for Medicare & Medicaid Services, and Doximity's Residency Navigator. EPs were identified as "academic" if they were affiliated with at least one facility determined to be academic, defined as EDs officially designated by the Accreditation Council for Graduate Medical Education (ACGME) as clinical training sites at accredited EM residency programs. Our primary outcomes were to estimate the national proportion of EPs identified as academic and the proportion of ED visits performed at academic sites. RESULTS: Our analytic sample included 26,937 EPs practicing clinically across 4920 EDs and providing care during 130,471,386 ED visits. Among EPs, 11,720 (43.5%) were identified as academic, and among EDs, 635 (12.9%) were identified as academic sites, including 585 adult/general sites, 45 pediatric-specific sites, and 10 sites affiliated with the Department of Veterans Affairs. In 2021, academic EDs provided care for 42,794,106 ED visits or 32.8% of all ED visits nationally. CONCLUSIONS: Approximately four in 10 EPs practice in at least one clinical training site affiliated with an ACGME-accredited EM residency program, and approximately one in three ED visits nationally occur in these academic EDs. We encourage further work using alternative definitions of an academic EPs and EDs, along with longitudinal research to identify trends in the workforce's composition.