Conceptualizations of health, ability to act upon those definitions and desire for supports among families from historically marginalized communities.

Respect for parents' values and clinician-parent collaboration is less common among families from historically marginalized communities. We investigated how parents from marginalized communities operationalize health and their preferences for paediatric primary care. We recruited families who spoke English, Haitian Creole or Spanish with at least one child younger than 6 years old. Staff queried families' values and life experiences, perspectives on health and healthcare, social supports and resources. Fourteen interviews with the parents of 26 children were thematically analysed. Interviews revealed the following four themes: (1) parents' definitions of 'health' extend beyond physical health; (2) families' ability to actuate health definitions is complicated by poverty's impact on agency; (3) parents engage in ongoing problem recognition and identify solutions, but enacting solutions can be derailed by barriers and (4) parents want support from professionals and peers who acknowledged the hard work of parenting. Eliciting parents' multidimensional conceptualizations of health can support families' goal achievement and concern identification in the context of isolation, limited agency and few resources. Efforts to improve family centred care and reduce disparities in paediatric primary care must be responsive to the strengths, challenges, resources and priorities of marginalized families.

Hospital Parenting Support for Adults with Incurable End-Stage Cancer: Multidisciplinary Health Professional Perspectives.

Patients with incurable end-stage cancer (IESC) who are parenting minor-age children often experience parenting-related distress. Parenting concerns are not always addressed as part of routine hospital-based psychosocial care. Currently, there is a lack multidisciplinary health professional (HP) perspectives in this area. An exploratory study of hospital-based HP perspectives of adult patients' and coparents' parenting experiences, support needs, and parenting supportive care practice was conducted. Twelve multidisciplinary HPs from one Australian tertiary hospital participated in a semistructured focus group and interviews. Data were audio recorded, transcribed, and analyzed using thematic analysis. Results showed HPs were cognizant of patients' and coparents' diverse parenting support needs and experiences and other aspects that comprise best practice. However, multilevel organization, HP, and patient/coparent barriers impeded optimal practice. Barriers included a nonsystemized approach to screening patients' parenting status and parenting support needs, inadequate resources, limited professional support, hospital environment, and parent psychosocial factors. This article provides feasible options for addressing practice barriers. Reviewing what factors influence optimal parenting focus from interdisciplinary HP perspectives helped identify potential strategies that could influence a shift from medical-focused care to more holistic family-focused patient care.

High-protein rice flour in the development of gluten-free pasta.

Cahokia Rice, a new biofortified high-protein (10%-12%) variety of rice, was used to develop and analyze a gluten-free pasta. Different pastas were made with high-protein white rice flour (HPWRP), high-protein brown rice flour (HPBRP), commercial white rice flour (CWRP), commercial brown rice flour (CBRP), and wheat flour (WP). Cooking quality of the pasta was evaluated by measuring pasting properties, cooking time, water absorption capacity, and cooking loss. Proximate analysis, color, and texture were done on dry and cooked pasta. Sensory testing was done to determine consumer acceptability and purchase intent of HPWRP and HPBRP in comparison to WP. HPWRP and HPBRP had higher pasting temperatures and lower peak viscosity than commercial rice flour pastas, which was related to the higher protein content. HPWRP and HPBRP had less cooking loss than CWRP and CBRP; all treatments had similar water absorption capacity (∼130%) except for WP that was higher (140%). White rice pastas along with WP took more time to cook than brown rice pastas. HPWRP and HPBRP had higher protein (around 7.5%) and fat content, creating a firmer cooked pasta (138.23 g HPBRP, 179.82 g HPWRP) than commercial rice pastas. Consumers' overall liking of HPBRP (5.37), HPWRP (6.00), and WP (6.81) was acceptable. Color, firmness, and stickiness attributes negatively affected the overall liking of HPWRP and HPBRP. Cooked high-protein rice flour pastas had improved firmness and cooking loss closer to wheat resulting in an acceptable product in overall liking. It is recommended to further improve the color, firmness, and stickiness of the pasta to reach higher sensory acceptability. PRACTICAL APPLICATION: This research provides a possible use for a new high-protein rice flour that can be used in gluten-free products. This will help the rice industry by adding value to the product. Those persons who are Celiac or who desire more nutritional gluten-free products will have a healthier gluten-free pasta option.

Pediatric Provider and Staff Burnout in Federally Qualified Community Health Centers.

This study examined changes in provider and staff burnout in 4 Boston-area federally qualified community health centers (FQHCs) participating in a pediatric behavioral health integration project. Utilizing the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSSMP), the study found that emotional exhaustion among primary care providers ( M = 20.5; confidence interval [CI], 17.8-23.2) was higher ( P = .001) than that among behavioral health clinicians ( M = 13.6; CI, 10.4-16.8) and ( P = .00005) community health workers ( M = 10.8; CI, 7.3-14.2). Emotional exhaustion among staff increased ( P = .04) from baseline ( M = 16.8; CI, 15.0-18.6) to follow-up ( M = 20.8; CI, 17.5-24.2), but burnout at follow-up was lower than national averages. FQHCs are integral in caring for marginalized patients; therefore, supporting a stable workforce by minimizing burnout is essential.

Implementation of a Novel Pediatric Behavioral Health Integration Initiative.

This study explores healthcare professionals' perspectives about the impact of behavioral health integration (BHI) on pediatric primary care delivery in community health centers (CHCs). A concurrent, qualitative-dominant mixed methods empirical study design was utilized, applying semi-structured interviews with healthcare professionals at the end of the implementation phase of a 3-year co-development, implementation, and evaluation process. Surveys were also administered at three time points. Via thematic analysis, emergent qualitative themes were mapped onto the Relational Coordination (RC) conceptual framework to triangulate and complement final qualitative results with quantitative results. Interview findings reveal five emergent themes aligning with RC domains. Survey results show that healthcare professionals reported increased behavioral healthcare integration into clinic practice (p = 0.0002) and increased clinic readiness to address behavioral health needs (p = 0.0010). Effective pediatric BHI and care delivery at CHCs may rely on strong professional relationships and communication. Additional research from the patient/caregiver perspective is needed.

Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care.

Importance: More than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers. Objective: To examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs. Design, Setting, and Participants: This retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022. Exposures: Receipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016. Main Outcomes and Measures: Utilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined. Results: Among the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, -0.4%; 95% CI -0.7% to -0.01%) and polypharmacy (DID, -0.3%; 95% CI, -0.4% to -0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations. Conclusions and Relevance: The first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers.

OBJECTIVE: The purpose of this study is to understand change in parent-reported outcomes of mental health symptoms, health-related quality of life (QoL), and school-related functioning among children receiving mental health care at 3 federally qualified health centers engaging in a comprehensive pediatric mental health integration model. METHODS: Trained personnel enrolled English- or Spanish-speaking families of 6- to 12-year-old children who had recently started receiving integrated mental health care and surveyed their parent/caregiver at 3 time points: entry into the cohort, 6-month follow-up, and 12-month follow-up (unique N = 51). Primary outcomes included validated measures of child symptoms, child health-related QoL, and child school-related functioning. Secondary outcomes focused on parental functioning and included validated measures of parental stress and depressive and internalizing symptoms. A multilevel mixed-effects generalized linear model was used to estimate the change in parent-reported outcomes over time, with inverse probability weights used to address attrition. Additional analyses were conducted to determine the degree to which changes in symptoms over time were associated with improvements in school-related functioning. RESULTS: Over 12 months, children's mental health symptoms, health-related QoL, and school-related functional outcomes significantly improved. No changes in parental functioning were observed. In addition, improvements in mental health symptoms and health-related QoL were associated with improvements in school-related functional outcomes over time. CONCLUSION: Findings demonstrate that outcomes of children who received integrated mental health care improved over time, both in regard to mental health and school functioning.

Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers.

BACKGROUND: Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). METHODS: FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. RESULTS: Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state's long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5-12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, "warm hand-off") were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). CONCLUSIONS: Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Diagnosis of insulinoma in a Maine Coon cat.

CASE SUMMARY: A 14-year-old male neutered Maine Coon cat presented with a 6-month history of polyphagia and one recent episode of tremors and weakness. Blood work revealed profound hypoglycemia and results of a paired insulin glucose test were consistent with an insulinoma. Abdominal ultrasound revealed a solitary pancreatic mass, and results of a fine-needle aspirate (FNA) gave further support for the location of the neuroendocrine tumor. After unsuccessful medical management of the hypoglycemia, the mass was surgically removed. Immunohistochemistry confirmed that it was an insulinoma. At the time of writing, the patient had been in clinical remission for 9 months. RELEVANCE AND NOVEL INFORMATION: Feline insulinomas are rare and there is very little information on their behavior, clinical course and histologic characteristics. This is the first reported case of an insulinoma in a Maine Coon cat and the first to describe results of an ultrasound-guided FNA of the mass. In addition, the progression of disease, histopathology and immunohistochemistry results add to the currently minimal database for feline insulinomas.

Reconnecting mothers and children after violence (RECOVER): a feasibility study protocol of child-parent psychotherapy in Australia.

INTRODUCTION: Intimate partner violence detrimentally affects the social and emotional well-being of children and mothers. These two populations are impacted both individually and within the context of their relationship with one another. Child mental health, maternal mental health and the mother-child relationship may be impaired as a consequence. Early intervention to prevent or arrest impaired mother-child attachment and child development is needed. Dyadic or relational mental health interventions that include mothers with their children, such as child-parent psychotherapy, are effective in improving the mental health of both children and mothers and also strengthening their relationship. While child-parent psychotherapy has been trialled overseas in several populations, Australian research on relational interventions for children and women recovering from violence is limited. This study aims to assess the acceptability and feasibility of implementing child-parent psychotherapy in Australian families. METHODS AND ANALYSIS: Using a mixed methods, prepost design this feasibility study will examine the acceptability of the intervention to women with preschool aged children (3-5 years, n=15 dyads) and providers, and identify process issues including recruitment, retention and barriers to implementation and sustainability. In addition, intervention efficacy will be assessed using maternal and child health outcomes and functioning, and mother-child attachment measures. Young children's mental health needs are underserviced in Australia. More research is needed to fully understand parenting in the context of intimate partner violence and what works to help women and children recover. If the intervention is found to be feasible, findings will inform future trials and expansion of child-parent psychotherapy in Australia. ETHICS AND DISSEMINATION: Ethics approval obtained from clinical sites and the La Trobe University Human Research Ethics Committee (ID: HEC17-108). Results will be disseminated through conference proceedings and academic publications.

Perceptions of the Implementation of Pediatric Behavioral Health Integration in 3 Community Health Centers.

Pediatric behavioral health integration (BHI) represents a promising approach to address unmet child mental health need but little research exists to guide BHI implementation. Through in-depth interviews with 38 professionals involved in a comprehensive pediatric BHI initiative at 3 community health centers, we explored perceptions of the impact of BHI on clinical practice, and facilitators and barriers to BHI implementation. Professionals identified 2 overarching themes about the impact of BHI on clinical practice (greater interdisciplinary collaboration/communication and enhanced provider wellness); 5 themes about facilitators of BHI (staff buy-in for BHI, leadership support, staff belonging to the same team culturally and/or structurally, co-location with close physical proximity, and data-driven quality improvement); and 5 themes about barriers to BHI (inadequate clinician staffing, insufficient space, limited provider time, billing/reimbursement issues, and care coordination challenges). Future pediatric BHI efforts may consider these findings to develop strategies to promote facilitators and reduce barriers during implementation.