Caregiver perspectives on a water safety toolkit for child supervision.

ISSUE ADDRESSED: Drowning is one of the leading causes of unintentional deaths among children and adolescents globally. Adult supervision is one method to decrease the risk of drowning among youth. METHODS: We sought to assess the acceptability of a Water Watcher toolkit among children's caregivers. The toolkit consists of a badge-to designate the adult(s) responsible for supervision during water activities-and a smartphone application. When activated, the application blocks incoming calls, text messages and other applications, for example, mobile games and social media, as well as providing a button to quickly dial 911 and information for guided cardiopulmonary resuscitation. We conducted online and in-person semi-structured interviews of 16 adults residing in Washington State, United States and providing supervision to a child under 18 years of age for at least 20 h per week. Interview guides were developed based on the Health Belief Model and we performed content analysis on interview transcripts using an inductive approach. RESULTS: When asked about Water Watcher tools, respondents generally reacted favourably towards the intervention, citing benefits of formally delegating a responsible party during group activities and elimination of distractions. Primary challenges to using the toolkit were social acceptability, competence with technology, and the independence of older children (i.e., those 13- to 17-years-old). CONCLUSIONS: Caregivers recognized the importance of minimizing distractions, and many liked the strategy to formally designate responsibility for child supervision during aquatic recreation. SO WHAT?: Interventions such as the Water Watcher toolkit are generally considered acceptable and expanding access to these resources could reduce the burden of unintentional drownings.

Prevalence of a loaded firearm in the home among birth parents experiencing symptoms of postpartum depression.

Firearm access increases the risk of suicide among all household members. The prevalence of loaded firearms in the home among those experiencing symptoms of postpartum depression (PPD) is unknown. We conducted a cross-sectional study using Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2012 to 2019. We included participants from the nine jurisdictions that asked about loaded firearms in the home and who screened positive for PPD. We excluded participants whose infants were not alive at time of survey completion and who did not respond to the firearm question, resulting in an analytic sample of 4986 participants. Using PRAMS analytic weights, we estimated the prevalence of a loaded firearm in the home and the prevalence of screening for PPD based on having a loaded firearm in the home. Among PRAMS participants experiencing symptoms of PPD, 8.8% (95% CI: 7.6%, 10.1%) reported there was a loaded firearm in their home. Participants with a loaded firearm in their home were more likely to be White (81.3% vs. 60.6%) and live in a rural area (57.9% vs. 27.5%) than those without. Among participants who reported attending a postpartum checkup, 78.6% (95% CI: 67.0%, 90.2%) of those with a loaded firearm in their home reported having been asked by a provider if they were feeling depressed, compared to 88.7% (95% CI: 85.3%, 92.0%) of those without. About 1 in 11 birth parents experiencing symptoms of PPD report a loaded firearm in their home. Further screening for firearm access in this population may need to be considered.

State earned income tax credits and suicidal behavior: A repeated cross-sectional study.

Suicide is an increasingly common cause of death in the United States and recent increases in suicide rates disproportionately impact low income individuals. We sought to assess the impact of income support in the form of state earned income tax credit policies on suicide-related behaviors. This state-level study used repeated cross-sectional data from vital records and the National Survey of Drug Use and Health data representative at the state-level. The population included adults who either died by suicide or were selected for in-person NSDUH interviews between 2008 and 2018. Exposure was measured as the generosity of a refundable state earned income tax credit policy measured as a percentage of the federal policy. Outcomes assessed were suicidal ideation, suicidal planning, non-fatal suicide attempt, suicide deaths, and combined fatal and non-fatal suicide attempts. Analyses were performed between April and June 2020. A 10 percentage-point increase in the generosity of state earned income tax credit was associated with lower frequency of non-fatal suicide attempts (prevalence ratio [PR] = 0.96; 95% CI: 0.93-0.99), combined fatal and non-fatal suicide attempts (PR = 0.96; 95% CI: 0.93-0.99), and suicide deaths (PR = 0.99; 95% CI: 0.99-1.00). This translates to 4 fewer suicide attempts per 10,000 population each year. Generous state earned income tax credit policies are associated with reductions in the frequency of most severe suicidal behavior. Income support policies may be one way to reduce suicide attempts and death, especially among low-income adults.

Income inequality and firearm homicide in the US: a county-level cohort study.

OBJECTIVE: Income inequality has been rising in the US and thought to be associated with violence especially homicide. About 75% of homicides involve firearms. We quantified the association between county-level income inequality and all-race/ethnicity and race/ethnicity-specific firearm homicide rates among individuals aged 14-39 years. METHODS: We conducted a cohort study of US counties to examine the association of Gini Index (ranging from 0 [perfect income equality] to 1.0 [perfect income inequality]) separately measured in 1990 and 2000 with all-race/ethnicity and race/ethnicity-specific firearm homicide rates in 2005-2015. Generalised linear mixed models with Poisson distribution including a random intercept for state provided IRRs and 95% CIs. Bayesian Poisson-lognormal hierarchical modelling with integrated nested Laplace approximations was used in exploratory spatial analyses. Models accounted for county-level age, sex and race/ethnicity composition, crime rate, deprivation, social capital, urbanicity, and firearm ownership. FINDINGS: The Gini Index was associated with firearm homicide rates among all races/ethnicities. After accounting for contextual determinants of firearm homicide, the association persisted among African-Americans. In this group, a 1 SD greater Gini Index in 1990 (IRR=1.09; 95% CI 1.02 to 1.16) and 2000 (IRR=1.09; 95% CI 1.01 to 1.17) was associated with greater firearm homicide rates in 2005-2015. Exploratory spatial analyses did not materially change the results. CONCLUSION: Policies addressing the gap between the rich and the poor deserve further considerations for reducing firearm homicide rates. Incorporating income inequality to refine measures of socioeconomic position may advance public health and clinical research and practice for firearm violence prevention.

Management and Outcomes in the Oldest-Old Population with Glioblastoma.

OBJECTIVES: Glioblastoma is a lethal disease in the elderly population. We aimed to evaluate disease and treatment outcomes in the oldest-old patients. METHODS: Patients >80 years old with histologically confirmed glioblastoma treated between 2004 and 2009 were identified. We included patients managed with best supportive care (BSC), temozolomide (TMZ) alone, radiotherapy (RT) alone, or concomitantly with TMZ (CRT). Survival outcomes were analyzed using the Kaplan-Meier method. RESULTS: Ultimately, 48 patients were analyzed. Median age and Eastern Cooperative Oncology Group (ECOG) Performance Status were 82 years and 2, respectively. The median Age-Adjusted Charlson Index (AAC) was 6. Gross total and subtotal resections were performed in 16.7% and 18.8% of patients, respectively. Biopsy followed by RT alone was the treatment modality for 23/48 (47.9%), while 17/48 (35.4%) received surgery followed by RT alone or CRT. A total of 8 (16.7%) were managed with BSC after biopsy. Median overall survival (OS) and progression-free survival (PFS) were 4.1 (95% confidence interval [95% CI] 3.3-4.9) and 2.7 (95% CI 1.5-3.9) months, respectively. Improved median OS was observed in those treated with surgical resection followed by RT alone or CRT (7.1 months), compared to biopsy followed by RT alone (4.2 months) or BSC (2.0 months; p=0.002). Surgical resection, age≤85, and AAC<6 were associated with better OS (p=0.032, p=0.031, and p=0.02, respectively). Cause of death was neurological progression in 56% of cases. RT was well-tolerated. CONCLUSIONS: PFS and OS outcomes remain poor in the oldest-old patients (>80 years old). Younger age, lower AAC, surgical resection, and adjuvant treatment were associated with improved OS.

Moana: Alternate surveillance for COVID-19 in a Unique Population (MASC-UP).

Objective: Create a longitudinal, multi-modal and multi-level surveillance cohort that targets early detection of symptomatic and asymptomatic COVID-19 cases among Native Hawaiian and Pacific Islander adults in the Continental US and identify effective modalities for participatory disease surveillance and sustainably integrate them into ongoing COVID-19 and other public health surveillance efforts. Materials and methods: We recruited cohorts from three sites: Federal Way, WA; Springdale, AR; and remotely. Participants received a survey that included demographic characteristics and questions regarding COVID-19. Participants completed symptom checks via text message every month and recorded their temperature daily using a Kinsa smart thermometer. Results: Recruitment and data collection is ongoing. Presently, 441 adults have consented to participate. One-third of participants were classified as essential workers during the pandemic. Discussion: Over the past 18 months, we have improved our strategies to elicit better data from participants and have learned from some of the weaknesses in our initial deployment of this type of surveillance system. Other limitations stem from historic inequities and barriers which limited Native Hawaiian and Pacific Island representation in academic and clinical environments. One manifestation of this was the limited ability to provide study materials and support in multiple languages. We hope that continued partnership with the community will allow further opportunities to help restore trust in academic and medical institutions, thus generating knowledge to advance health equity. Conclusion: This participatory disease surveillance mechanism complements traditional surveillance systems by engaging underserved communities. We may also gain insights generalizable to other pathogens of concern.

Mental Health Comorbidities, Household Firearm Ownership, and Firearm Access Among Children.

OBJECTIVES: To examine how youth and their caregivers' mental health risk factors for suicide are associated with youth firearm access inside and outside the home. METHODS: This study examines a cross-section of the Adolescent Brain and Cognitive Development Social Development study data collected from 2016 to 2021. The sample included 2277 children aged 10 to 15 years from 5 study sites across the United States. We estimated multilevel generalized linear models of household firearm ownership and the child's reported firearm access (hard access or easy access). The primary exposures were the child's and their caregivers' mental health risk factors for suicide. RESULTS: In the Adolescent Brain and Cognitive Development Social Development study sample, approximately 20% of children lived in a firearm-owning household and 5% of all children reported easy firearm access. In non-firearm-owning households, children with diagnosed lifetime suicidality were 2.48 times more likely (95% confidence interval [CI], 1.50-4.10) than their counterparts to report easy firearm access. In firearm-owning households, children of caregivers who self-reported any mental health history or externalizing problems were 1.67 times (95% CI, 1.10-2.54) and 2.28 times (95% CI, 1.55-3.37) more likely than their counterparts to report easy firearm access. CONCLUSIONS: Youths with mental health risk factors for suicide may be just as likely or more likely to report firearm access as those without such risk factors. Youth suicide prevention efforts should address youths' firearm access outside the home and caregiver mental health.

Characterizing Female Firearm Suicide Circumstances: A Natural Language Processing and Machine Learning Approach.

INTRODUCTION: Since 2005, female firearm suicide rates increased by 34%, outpacing the rise in male firearm suicide rates over the same period. The objective of this study was to develop and evaluate a natural language processing pipeline to identify a select set of common and important circumstances preceding female firearm suicide from coroner/medical examiner and law enforcement narratives. METHODS: Unstructured information from coroner/medical examiner and law enforcement narratives were manually coded for 1,462 randomly selected cases from the National Violent Death Reporting System. Decedents were included from 40 states and Puerto Rico from 2014 to 2018. Naive Bayes, Random Forest, Support Vector Machine, and Gradient Boosting classifier models were tuned using 5-fold cross-validation. Model performance was assessed using sensitivity, specificity, positive predictive value, F1, and other metrics. Analyses were conducted from February to November 2022. RESULTS: The natural language processing pipeline performed well in identifying recent interpersonal disputes, problems with intimate partners, acute/chronic pain, and intimate partners and immediate family at the scene. For example, the Support Vector Machine model had a mean of 98.1% specificity and 90.5% positive predictive value in classifying a recent interpersonal dispute before suicide. The Gradient Boosting model had a mean of 98.7% specificity and 93.2% positive predictive value in classifying a recent interpersonal dispute before suicide. CONCLUSIONS: This study developed a natural language processing pipeline to classify 5 female firearm suicide antecedents using narrative reports from the National Violent Death Reporting System, which may improve the examination of these circumstances. Practitioners and researchers should weigh the efficiency of natural language processing pipeline development against conventional text mining and manual review.

Disparities in Adolescent Reported Drowning Prevention Strategies.

PURPOSE: Describe use of drowning prevention strategies among diverse adolescents. METHODS: We analyzed 47,051 responses to 2012-2018 Washington statewide surveys of 8th-12th grade students, regarding formal swimming lessons, comfort in deep water (a measure of perceived water competency), and life jacket use in small watercraft. Using survey-weighted Poisson regression, we measured these strategies in relation to race/ethnicity, primary language, maternal education, and urbanicity. RESULTS: 78.6% of students spoke English at home. Most students reported having had formal swimming lessons (62.2%), being comfortable in deep water (65.8%), and wearing life jackets (58.5%). Students primarily speaking Spanish (11.2%) reported formal swimming lessons (PR: 0.72; 95%CI: 0.67-0.78) and perceived water competency (PR: 0.75; 95%CI: 0.70-0.80) less often than primarily English-speaking. All prevention strategies were associated with higher maternal education. DISCUSSION: Drowning prevention strategies, access to swimming lessons, life jackets, and water competency should be promoted among low-income children and those whose primary language is not English.

State earned income tax credits and depression and alcohol misuse among women with children.

About 30% of single mothers in the US live at or below the poverty line. Poverty is associated with higher risk of depression and substance use. We investigated associations between state earned income tax credit (EITC) policies and reported depressive symptoms and alcohol misuse among birthing parents who responded to Pregnancy Risk Assessment Monitoring Survey spanning 1990-2017. Nearly half of birthing parents reported no more than a high school education (45.4%; 95% CI: 45.3%-45.6%). An estimated 28.5% of birthing parents reported binge drinking in the three months prior to conception (95% CI: 28.3-28.8%). Among birthing parents, each 10 percentage-point increase in the generosity of state EITC relative to the federal EITC was associated with a lower prevalence of binge drinking (prevalence ratio = 0.96; 95% CI: 0.93-0.99) prior to conception. This association was more pronounced among birthing parents with no more than high school education (prevalence ratio = 0.92; 95% CI: 0.88-0.97). There was no association between state EITC and number of reported depressive symptoms prior to conception or after birth, except among those with lower educational attainment (prevalence ratio = 0.94; 95% CI: 0.89-0.99). Anti-poverty policies such as EITC may reduce the burden of alcohol misuse, especially among people with children.

Association of State-Level Earned Income Tax Credits With Rates of Reported Child Maltreatment, 2004-2017.

Poverty is an important predictor of child maltreatment. Social policies that strengthen the economic security of low-income families, such as the Earned Income Tax Credit (EITC), may reduce child maltreatment by impeding the pathways through which poverty leads to it. We used variations in the presence and generosity of supplementary EITCs offered at the state level and administrative child maltreatment data from the National Child Abuse and Neglect Data System (NCANDS) to examine the effect of EITC policies on state-level rates of child maltreatment from 2004 through 2017. Two-way fixed effects models indicated that a 10-percentage point increase in the generosity of refundable state EITC benefits was associated with 241 fewer reports of neglect per 100,000 children (95% Confidence Interval [CI] [-449, -33]). An increase in EITC generosity was associated with fewer reports of neglect both among children ages 0-5 (-324 per 100,000; 95% CI [-582, -65]) and children ages 6-17 (-201 per 100,000; 95% CI [-387, -15]). Findings also suggested associations between the EITC and reductions in other types of maltreatment (physical abuse, emotional abuse); however, those did not gain statistical significance. Economic support policies may reduce the risk of child maltreatment, especially neglect, and improve child wellbeing.

State earned income tax credits and general health indicators: A quasi-experimental national study 1993-2016.

OBJECTIVE: To assess the relationship between the presence and generosity of state-level Earned Income Tax Credits (EITC) and multiple self-reported measures of general health. DATA SOURCES: Data on state-level tax credits and covariates were obtained from the National Bureau of Economic Research and University of Kentucky Center for Poverty Research, respectively. These data were merged with Behavioral Risk Factor Surveillance System survey records from 1993-2016. STUDY DESIGN: Using difference-in-differences approaches and survey-weighted Poisson regression that accounted for clustering of observations and included state and year fixed-effects, we assessed relationships between EITC and self-reported overall health, frequent mental distress, and frequent poor physical health in the prior 30 days. Covariates included state minimum wage, state GDP, and adoption of Medicaid expansion. Sensitivity analyses revealed that parallel trends were plausible; there were no significant lead and lag effects. DATA EXTRACTION METHODS: Analyses were restricted to respondents with no more than a high school diploma or equivalent because less-educated adults are more likely to be low-wage earners and therefore qualify for EITC. PRINCIPAL FINDINGS: Among adults with no education beyond high school (n = 2 884 790), each additional 10-percentage-point increase in the generosity of state EITC-relative to the federal credit-was associated with fewer reports of frequent mental distress (-97.3 per 100 000; 95% CI: -237.2, 42.6) and frequent poor physical health (-149.6 per 100 000; 95% CI: -284.4, -14.9). When restricted to individuals interviewed during the three months when tax rebates are commonly disbursed, the magnitude of the association between EITC and prevalence of reported frequent mental distress was greater (-329.7 per 100 000; 95% CI: -636.0, -23.5). CONCLUSIONS: The generosity of state EITC policies is positively associated with significant reductions in frequent mental distress and poor physical health, especially during months when the credit is received. Interventions to reduce poverty may positively impact health by reducing material hardship and stress.

Firearm Storage and Adult Alcohol Misuse Among Washington State Households With Children.

Importance: Firearm injuries and fatalities among children are an important public health problem. Children living with an adult misusing alcohol may be at a heightened risk for self-harm or unintentional injury, highlighting the need to investigate the association between household firearm storage and adult alcohol misuse. Objectives: To characterize household firearm presence among children by various sociodemographic characteristics, and to assess the association between children living in a home with an unsafely stored firearm and an adult reporting alcohol misuse. Design, Setting, and Participants: This cross-sectional investigation uses data from the 2013 and 2016 Behavioral Risk Factor Surveillance System in the state of Washington, a program that administers a telephone survey statewide to randomly selected noninstitutionalized adults at least 18 years of age about their health-related risk behaviors, chronic health conditions, and use of preventive services. The 2013 and 2016 data included 5241 responses to the firearm ownership and storage module and the Random Child Selection module (intended for a randomly selected child younger than age 18 years and reported by an adult living in the same household). Data for this study were collected from January 1 through December 31, 2013, and January 1 through December 31, 2016. Data were analyzed from March through May 2018. Main Outcomes and Measures: The primary outcomes were a child's residence in a firearm-owning home, the manner in which household firearms were stored, and the adult respondent's alcohol consumption. Results: Among the 3443 children living in a non-firearm-owning household, 50.7% were male (all values given as a percentage only are weighted); among those reporting specific age, the weighted mean age was 9.3 years (unweighted mean [SD], 10.1 [5.2] years). In the 1756 children living in a firearm-owning household, 52.5% were male; among those reporting specific age, the weighted mean age was 9.1 years (unweighted mean [SD], 9.8 [5.4] years). An estimated 470 000 children (29.4%; 95% CI, 27.3%-31.7%) in the state resided in a firearm-owning household. Among them, 258 000 children (54.6%; 95% CI, 51.5%-57.6%) lived with at least 1 firearm that was not stored safely (ie, not locked and unloaded). Firearms were more likely to be stored unsafely in homes in which an adult reported alcohol misuse (prevalence ratio: 1.20; 95% CI, 1.07-1.35). Conclusions and Relevance: Children living in a household with an adult who misuses alcohol may be more likely to live with an unsafely stored firearm, which is concerning given the association between adult alcohol misuse and children's risk for sustaining injury.

Predictors of a successful external cephalic version: A population-based study of Washington state births.

BACKGROUND: Breech presentation affects approximately 3% of women with singleton pregnancies. External cephalic version is a manual procedure that reorients a foetus to cephalic position in preparation for birth, reducing indications for caesarean birth. However, unsuccessful attempts are associated with some adverse health outcomes. Versions are successful in 17-86% of attempts. Temporal trends in version success and association between maternal height or prenatal care and version success are unknown. Few population-based studies and no recent investigations in the United States have evaluated predictive factors for version success. OBJECTIVES: This study aimed to estimate the proportion of successful version procedures in the United States and to evaluate factors associated with version success. METHODS: We used birth certificate and hospital administrative data. The study included all women who had a singleton birth in Washington State between 2003-2014 following a version procedure (total n=4981). Prevalence ratios and 95% confidence intervals were calculated using Poisson regression. FINDINGS: 57.2% of version attempts were successful. Primiparity (Prevalence Ratio:1.43; 95% Confidence Interval:1.29-1.60) and multiparity (Prevalence Ratio:1.68; 95% Confidence Interval:1.50-1.88) were associated with procedure success. Oligohydramnios was associated with lower version success (Prevalence Ratio:0.75; 95% Confidence Interval:0.57-1.00). Maternal height, pre-pregnancy weight, polyhydramnios, frequency of prenatal care, smoking, infant sex, and year of birth were not significantly associated with version outcome. CONCLUSION: We found that most version procedures are successful. This reinforces that procedures may be able to reduce the frequency of caesarean birth. These contemporary results can help women and clinicians make decisions with realistic estimates of success.

Contemporary management of high-grade gliomas.

High-grade gliomas, including glioblastoma, are the most common malignant brain tumors in adults. Despite intensive efforts to develop new therapies for these diseases, treatment options remain limited and prognosis is poor. Recently, there have been important advances in our understanding of the molecular basis of glioma, leading to refinements in our diagnostic and management approach. There is new evidence to guide the treatment of elderly patients. A multitude of new agents have been investigated, including targeted therapies, immunotherapeutics and tumor-treating fields. This review summarizes the key findings from this research, and presents a perspective on future opportunities to advance the field.

A critical balance: managing coagulation in patients with glioma.

Cancer-associated thrombosis, including both arterial and venous thromboembolism (VTE), is a significant source of morbidity and mortality in patients with glioma. This risk is highest in the immediate postoperative period and is increased by chemotherapy, radiation, and corticosteroids. Systemic anticoagulation with low molecular weight heparin is the treatment of choice in both the therapeutic and prophylactic settings. However, these patients are also at risk of intracranial hemorrhage, a potentially catastrophic complication of anticoagulation, and this risk must be carefully balanced against the risk of VTE. In this review we outline the incidence, pathophysiology and management of thrombosis in patients with glioma, with a focus on clinical considerations including perioperative management, chemotherapy-induced thrombocytopenia, and end-of-life management.