Effects of child trauma screening on trauma-informed multidisciplinary evaluation and service planning in the child welfare system.

Despite the prevalence of exposure to potentially traumatic events (PTEs) among children involved with the child welfare system (CWS), trauma screening is not yet a common practice. The purpose of this study was to assess the impact of embedding a formal trauma screening process in statewide multidisciplinary evaluations for CWS-involved youth. A retrospective record review was conducted with two random samples of cases reflecting both pre- and postimplementation of formal screening procedures (n = 70 preimplementation, n = 100 postimplementation). Findings from the record review indicate statistically significant improvements in the documentation of general, χ2(1, N = 170) = 18.8, p < .001, and specific, χ2(1, N = 170) = 10.7, p = .001, details of children's reactions associated with PTE exposure, as well as increases in providers' recommendations, χ2(1, N = 170) = 18.1, p < .001, and referrals, χ2(1, N = 170) = 4.5, p = .034, for trauma-focused services. The early identification of trauma-related symptoms may help connect children more promptly to trauma-informed evidence-based interventions, which may avert or mitigate the long-term sequelae of child maltreatment and CWS involvement.

The feasibility and utility of trauma screening for children involved in the juvenile justice system.

Childhood exposure to potentially traumatic events and adversity is highly prevalent and linked to adverse outcomes. Many children suffering from symptoms related to traumatic stress are not identified or do not receive appropriate trauma-focused treatment, including evidence-based treatments. Trauma screening is a promising strategy to improve identification, but many child-serving staff members have concerns about asking youth and caregivers about trauma. This study aimed to describe staff perceptions about the feasibility, utility, and potential for distress associated with trauma screening. Between 2014 and 2019, the Child Trauma Screen was used in 1,272 trauma screenings completed by juvenile probation officers or mental health clinicians as part of routine practice with youth in the juvenile justice system. Further, 1,190 caregiver reports about youth trauma were completed for youth in the juvenile justice system. Staff completed a brief postscreening survey about the feasibility and utility of the screening and the perceived level of child or caregiver distress. Across staff roles, trauma screening was deemed to be feasible and worthwhile to practice, with very few staff members reporting that children or caregivers appeared very uncomfortable as a result of screening, although some differences in feasibility and utility by staff role did occur. Trauma screening measures appear to be useful and practical in juvenile justice settings when appropriate support is provided, including when administered by nonclinical staff. Nonclinical staff may benefit from additional training, consultation, or support with trauma screening.

Step-Up Therapy in Black Children and Adults with Poorly Controlled Asthma.

BACKGROUND: Morbidity from asthma is disproportionately higher among black patients than among white patients, and black patients constitute the minority of participants in trials informing treatment. Data indicate that patients with inadequately controlled asthma benefit more from addition of a long-acting beta-agonist (LABA) than from increased glucocorticoids; however, these data may not be informative for treatment in black patients. METHODS: We conducted two prospective, randomized, double-blind trials: one involving children and the other involving adolescents and adults. In both trials, the patients had at least one grandparent who identified as black and had asthma that was inadequately controlled with low-dose inhaled glucocorticoids. We compared combinations of therapy, which included the addition of a LABA (salmeterol) to an inhaled glucocorticoid (fluticasone propionate), a step-up to double to quintuple the dose of fluticasone, or both. The treatments were compared with the use of a composite measure that evaluated asthma exacerbations, asthma-control days, and lung function; data were stratified according to genotypic African ancestry. RESULTS: When quintupling the dose of fluticasone (to 250 µg twice a day) was compared with adding salmeterol (50 µg twice a day) and doubling the fluticasone (to 100 µg twice a day), a superior response occurred in 46% of the children with quintupling the fluticasone and in 46% of the children with doubling the fluticasone and adding salmeterol (P = 0.99). In contrast, more adolescents and adults had a superior response to added salmeterol than to an increase in fluticasone (salmeterol-low-dose fluticasone vs. medium-dose fluticasone, 49% vs. 28% [P = 0.003]; salmeterol-medium-dose fluticasone vs. high-dose fluticasone, 49% vs. 31% [P = 0.02]). Neither the degree of African ancestry nor baseline biomarkers predicted a superior response to specific treatments. The increased dose of inhaled glucocorticoids was associated with a decrease in the ratio of urinary cortisol to creatinine in children younger than 8 years of age. CONCLUSIONS: In contrast to black adolescents and adults, almost half the black children with poorly controlled asthma had a superior response to an increase in the dose of an inhaled glucocorticoid and almost half had a superior response to the addition of a LABA. (Funded by the National Heart, Lung, and Blood Institute; BARD ClinicalTrials.gov number, NCT01967173.).

Mometasone or Tiotropium in Mild Asthma with a Low Sputum Eosinophil Level.

BACKGROUND: In many patients with mild, persistent asthma, the percentage of eosinophils in sputum is less than 2% (low eosinophil level). The appropriate treatment for these patients is unknown. METHODS: In this 42-week, double-blind, crossover trial, we assigned 295 patients who were at least 12 years of age and who had mild, persistent asthma to receive mometasone (an inhaled glucocorticoid), tiotropium (a long-acting muscarinic antagonist), or placebo. The patients were categorized according to the sputum eosinophil level (<2% or ≥2%). The primary outcome was the response to mometasone as compared with placebo and to tiotropium as compared with placebo among patients with a low sputum eosinophil level who had a prespecified differential response to one of the trial agents. The response was determined according to a hierarchical composite outcome that incorporated treatment failure, asthma control days, and the forced expiratory volume in 1 second; a two-sided P value of less than 0.025 denoted statistical significance. A secondary outcome was a comparison of results in patients with a high sputum eosinophil level and those with a low level. RESULTS: A total of 73% of the patients had a low eosinophil level; of these patients, 59% had a differential response to a trial agent. However, there was no significant difference in the response to mometasone or tiotropium, as compared with placebo. Among the patients with a low eosinophil level who had a differential treatment response, 57% (95% confidence interval [CI], 48 to 66) had a better response to mometasone, and 43% (95% CI, 34 to 52) had a better response to placebo (P = 0.14). In contrast 60% (95% CI, 51 to 68) had a better response to tiotropium, whereas 40% (95% CI, 32 to 49) had a better response to placebo (P = 0.029). Among patients with a high eosinophil level, the response to mometasone was significantly better than the response to placebo (74% vs. 26%) but the response to tiotropium was not (57% vs. 43%). CONCLUSIONS: The majority of patients with mild, persistent asthma had a low sputum eosinophil level and had no significant difference in their response to either mometasone or tiotropium as compared with placebo. These data provide equipoise for a clinically directive trial to compare an inhaled glucocorticoid with other treatments in patients with a low eosinophil level. (Funded by the National Heart, Lung, and Blood Institute; SIENA ClinicalTrials.gov number, NCT02066298.).

The CDC Worksite Health ScoreCard: A Tool to Advance Workplace Health Promotion Programs and Practices.

INTRODUCTION: The CDC Worksite Health ScoreCard (ScoreCard) is a free, publicly available survey tool designed to help employers assess the extent to which they have implemented evidence-based interventions or strategies at their worksites to improve the health and well-being of employees. We examined how, how broadly, and to what effect the ScoreCard has been applied. METHODS: We analyzed peer-reviewed and grey literature along with the ScoreCard database of online submissions from January 2012 through January 2021. Our inclusion criteria were workplace settings, adult working populations, and explicit use of the ScoreCard. RESULTS: We found that the ScoreCard had been used in 1) surveillance efforts by states, 2) health promotion training and technical assistance, 3) research on workplace health promotion program effectiveness, and 4) employer efforts to improve program design, implementation, and evaluation. CONCLUSION: The ScoreCard has been used as intended to support the development, planning, monitoring, and continuous improvement of workplace health promotion programs. Our review revealed gaps in the tool and opportunities to improve it by 1) enhancing surveillance efforts, 2) engaging employers in low-wage industries, 3) adding new questions or topic areas, and 4) conducting quantitative studies on the relationship between improvements in the ScoreCard and employee health and well-being outcomes.

Environmental and clinical data utility in pediatric asthma exacerbation risk prediction models.

BACKGROUND: Asthma exacerbations are triggered by a variety of clinical and environmental factors, but their relative impacts on exacerbation risk are unclear. There is a critical need to develop methods to identify children at high-risk for future exacerbation to allow targeted prevention measures. We sought to evaluate the utility of models using spatiotemporally resolved climatic data and individual electronic health records (EHR) in predicting pediatric asthma exacerbations. METHODS: We extracted retrospective EHR data for 5982 children with asthma who had an encounter within the Duke University Health System between January 1, 2014 and December 31, 2019. EHR data were linked to spatially resolved environmental data, and temporally resolved climate, pollution, allergen, and influenza case data. We used xgBoost to build predictive models of asthma exacerbation over 30-180 day time horizons, and evaluated the contributions of different data types to model performance. RESULTS: Models using readily available EHR data performed moderately well, as measured by the area under the receiver operating characteristic curve (AUC 0.730-0.742) over all three time horizons. Inclusion of spatial and temporal data did not significantly improve model performance. Generating a decision rule with a sensitivity of 70% produced a positive predictive value of 13.8% for 180 day outcomes but only 2.9% for 30 day outcomes. CONCLUSIONS: EHR data-based models perform moderately wellover a 30-180 day time horizon to identify children who would benefit from asthma exacerbation prevention measures. Due to the low rate of exacerbations, longer-term models are likely to be most clinically useful. TRIAL REGISTRATION: Not applicable.

Emergency Department Use by Children and Youth with Mental Health Conditions: A Health Equity Agenda.

There are growing concerns regarding the referral of children and youth with mental health conditions to emergency departments (EDs). These focus on upward trends in utilization, uncertainty about benefits and negative effects of ED visits, and inequities surrounding this form of care. A review was conducted to identify and describe available types of data on ED use. The authors' interpretation of the literature is that it offers compelling evidence that children and youth in the U.S. are being sent to EDs for mental health conditions at increasing rates for reasons frequently judged as clinically inappropriate. As a major health inequity, it is infrequent that such children and youth are seen in EDs by a behavioral health professional or receive evidence-based assessment or treatment, even though they are kept in EDs far longer than those seen for reasons unrelated to mental health. The rate of increase in these referrals to EDs appears much greater for African American and Latinx children and youth than White children and is increasing for the publicly insured and uninsured while decreasing for the privately insured. A comprehensive set of strategies are recommended for improving healthcare quality and health equity. A fact sheet is provided for use by advocates in pressing this agenda.

Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.

BACKGROUND: Asthma exacerbations occur frequently despite the regular use of asthma-controller therapies, such as inhaled glucocorticoids. Clinicians commonly increase the doses of inhaled glucocorticoids at early signs of loss of asthma control. However, data on the safety and efficacy of this strategy in children are limited. METHODS: We studied 254 children, 5 to 11 years of age, who had mild-to-moderate persistent asthma and had had at least one asthma exacerbation treated with systemic glucocorticoids in the previous year. Children were treated for 48 weeks with maintenance low-dose inhaled glucocorticoids (fluticasone propionate at a dose of 44 µg per inhalation, two inhalations twice daily) and were randomly assigned to either continue the same dose (low-dose group) or use a quintupled dose (high-dose group; fluticasone at a dose of 220 µg per inhalation, two inhalations twice daily) for 7 days at the early signs of loss of asthma control ("yellow zone"). Treatment was provided in a double-blind fashion. The primary outcome was the rate of severe asthma exacerbations treated with systemic glucocorticoids. RESULTS: The rate of severe asthma exacerbations treated with systemic glucocorticoids did not differ significantly between groups (0.48 exacerbations per year in the high-dose group and 0.37 exacerbations per year in the low-dose group; relative rate, 1.3; 95% confidence interval, 0.8 to 2.1; P=0.30). The time to the first exacerbation, the rate of treatment failure, symptom scores, and albuterol use during yellow-zone episodes did not differ significantly between groups. The total glucocorticoid exposure was 16% higher in the high-dose group than in the low-dose group. The difference in linear growth between the high-dose group and the low-dose group was -0.23 cm per year (P=0.06). CONCLUSIONS: In children with mild-to-moderate persistent asthma treated with daily inhaled glucocorticoids, quintupling the dose at the early signs of loss of asthma control did not reduce the rate of severe asthma exacerbations or improve other asthma outcomes and may be associated with diminished linear growth. (Funded by the National Heart, Lung, and Blood Institute; STICS ClinicalTrials.gov number, NCT02066129 .).

Interviews with caregivers during acute asthma hospitalisations.

Objective: Childhood asthma is complex and poor management of childhood asthma is the leading health reason for pediatric emergency department visits, hospitalizations and missed school days for school-aged children. The purpose of this study was to explore caregiver perceptions of home management of childhood asthma in school-aged children who have been hospitalized for asthma. Methods: Using qualitative descriptive design with in-depth interviews, we aimed to explore family caregiver perceptions of managing asthma in school-aged children between 5 and 12 years of age. Results: Data were collected from 17 participants; however, two transcripts were incomplete due to interruption in interview from medical team. The sample consisted of 15 families with child age mean of 8 years, and diagnosed with asthma at 2 years and 8 months. Four experts with asthma and research design analyzed all transcripts and six clear themes emerged. These themes included family or caregiver burden, care coordination, certainty or uncertainty continuum, effort to control, sign or symptom recognition, and trigger recognition. In this article, we defined each theme and identify specific statements from families on daily life when affected by childhood asthma. Conclusions: The findings of this study confirm and extend results from other studies of caregivers who have school-aged children diagnosed with asthma. This study found that families play a vital role in management of asthma on a daily basis and families often assess the overall management of asthma by all child relations throughout the day. Clinical implications are highlighted within each theme.

Evaluation of associations between asthma exacerbations and distance to roadways using geocoded electronic health records data.

BACKGROUND: Asthma exacerbations in children often require medications, urgent care, and hospitalization. Multiple environmental triggers have been associated with asthma exacerbations, including particulate matter 2.5 (PM2.5) and ozone, which are primarily generated by motor vehicle exhaust. There is mixed evidence as to whether proximity to highways increases risk of asthma exacerbations. METHODS: To evaluate the impact of highway proximity, we assessed the association between asthma exacerbations and the distance of child's primary residence to two types of roadways in Durham County, North Carolina, accounting for other patient-level factors. We abstracted data from the Duke University Health System electronic health record (EHR), identifying 6208 children with asthma between 2014 and 2019. We geocoded each child's distance to roadways (both 35 MPH+ and 55 MPH+). We classified asthma exacerbation severity into four tiers and fitted a recurrent event survival model to account for multiple exacerbations. RESULTS: There was a no observed effect of residential distance from 55+ MPH highway (Hazard Ratio: 0.98 (95% confidence interval: 0.94, 1.01)) and distance to 35+ MPH roadway (Hazard Ratio: 0.98 (95% confidence interval: 0.83, 1.15)) and any asthma exacerbation. Even those children living closest to highways (less 0.25 miles) had no increased risk of exacerbation. These results were consistent across different demographic strata. CONCLUSIONS: While the results were non-significant, the characteristics of the study sample - namely farther distance to roadways and generally good ambient environmental pollution may contribute to the lack of effect. Compared to previous studies, which often relied on self-reported measures, we were able to obtain a more objective assessment of outcomes. Overall, this work highlights the opportunity to use EHR data to study environmental impacts on disease.

Adverse childhood experiences, epigenetics and telomere length variation in childhood and beyond: a systematic review of the literature.

A systematic review following PRISMA guidelines was conducted to answer the question: What epigenetic, telomeric and associated biological changes are associated with exposure to adverse childhood experiences (ACEs) in the under 12s? Using PRISMA guidelines, appropriate databases were searched. 190 papers were returned with 38 articles fully reviewed. Articles were each independently quality rated by two authors using the Crowe Critical Appraisal Tool and data were extracted. Of the 38 articles, 23 were rated as very high quality. Most study participants were adults (n = 7769) with n = 727 child participants. Only seven of the very/high-quality studies were prospective and involved children. Methylation was the most studied method of epigenetic modification. There is some evidence supporting epigenetic modification of certain markers in participants exposed to ACEs measured in adulthood. Research is lacking on non-coding aspects of the epigenome and on coding aspects other than DNA methylation. There is some evidence of a more powerful effect on telomere length if physical neglect was involved. Much further work is required to model biological and psychological effects of epigenetic changes during childhood using prospective study designs. The effect of ACEs on the cellular ageing process during childhood is inadequately investigated and relies solely on measure of telomere length. Future research suggestions are proposed.

Acetaminophen versus Ibuprofen in Young Children with Mild Persistent Asthma.

BACKGROUND: Studies have suggested an association between frequent acetaminophen use and asthma-related complications among children, leading some physicians to recommend that acetaminophen be avoided in children with asthma; however, appropriately designed trials evaluating this association in children are lacking. METHODS: In a multicenter, prospective, randomized, double-blind, parallel-group trial, we enrolled 300 children (age range, 12 to 59 months) with mild persistent asthma and assigned them to receive either acetaminophen or ibuprofen when needed for the alleviation of fever or pain over the course of 48 weeks. The primary outcome was the number of asthma exacerbations that led to treatment with systemic glucocorticoids. Children in both groups received standardized asthma-controller therapies that were used in a simultaneous, factorially linked trial. RESULTS: Participants received a median of 5.5 doses (interquartile range, 1.0 to 15.0) of trial medication; there was no significant between-group difference in the median number of doses received (P=0.47). The number of asthma exacerbations did not differ significantly between the two groups, with a mean of 0.81 per participant with acetaminophen and 0.87 per participant with ibuprofen over 46 weeks of follow-up (relative rate of asthma exacerbations in the acetaminophen group vs. the ibuprofen group, 0.94; 95% confidence interval, 0.69 to 1.28; P=0.67). In the acetaminophen group, 49% of participants had at least one asthma exacerbation and 21% had at least two, as compared with 47% and 24%, respectively, in the ibuprofen group. Similarly, no significant differences were detected between acetaminophen and ibuprofen with respect to the percentage of asthma-control days (85.8% and 86.8%, respectively; P=0.50), use of an albuterol rescue inhaler (2.8 and 3.0 inhalations per week, respectively; P=0.69), unscheduled health care utilization for asthma (0.75 and 0.76 episodes per participant, respectively; P=0.94), or adverse events. CONCLUSIONS: Among young children with mild persistent asthma, as-needed use of acetaminophen was not shown to be associated with a higher incidence of asthma exacerbations or worse asthma control than was as-needed use of ibuprofen. (Funded by the National Institutes of Health; AVICA ClinicalTrials.gov number, NCT01606319.).

Obesity and childhood asthma.

PURPOSE OF REVIEW: Asthma is a common chronic disease of the airways characterized by recurrent respiratory symptoms, bronchoreactivity, and airway inflammation. The high toll on quality of life has led to sustained efforts to understand the factors leading to asthma inception and poor disease control. Obesity is another increasingly common pediatric disease, which appears to increase the risk for incident asthma and worsened disease severity. Currently, our understanding of how obesity affects asthma risk and affects its phenotypic characteristics remains incomplete. The current review describes our current understanding of the epidemiology, clinical characteristics, and management considerations of obesity-related asthma in children. RECENT FINDINGS: The epidemiologic relationship between obesity in children and incident asthma remains confusing despite numerous longitudinal cohort studies, and appears to be influenced by early life exposures, patterns of somatic growth and underlying familial risks of allergic disease. Children with comorbid obesity and asthma demonstrate diverse phenotypic characteristics which are still becoming clear. SUMMARY: Like any child with asthma, a child with comorbid obesity requires an individualized approach adhering to current best-practice guidelines and an understanding of how obesity and asthma may interact.

A Dried Blood Spot Analysis for Solithromycin in Adolescents, Children, and Infants: A Short Communication.

BACKGROUND: Solithromycin is a fourth-generation macrolide antibiotic with potential efficacy in pediatric community-acquired bacterial pneumonia. Pharmacokinetic (PK) studies of solithromycin in pediatric subjects are limited, therefore application of minimally invasive drug sampling techniques, such as dried blood spots (DBS), may enhance the enrollment of children in PK studies. The objectives of this study were to compare solithromycin concentrations in DBS with those in liquid plasma samples (LPS) and to quantify the effects of modeling DBS concentrations on the results of a population PK model. METHODS: Comparability analysis was performed on matched DBS and LPS solithromycin concentrations collected from two different phase 1 clinical trials of solithromycin treatment in children (clinicaltrials.gov #NCT01966055 and #NCT02268279). Comparability of solithromycin concentrations was evaluated based on DBS:LPS ratio, median percentage prediction error, and median absolute percentage prediction error. The effect of correcting DBS concentrations for both hematocrit and protein binding was investigated. In addition, a previously published population PK model (NONMEM) was leveraged to compare parameter estimates resulting from either DBS or LPS concentrations. RESULTS: A total of 672 paired DBS-LPS concentrations were available from 95 subjects (age: 0-17 years of age). The median (range) LPS and DBS solithromycin concentrations were 0.3 (0.01-12) mcg/mL and 0.32 (0.01-14) mcg/mL, respectively. Median percentage prediction error and median absolute percentage prediction error of raw DBS to LPS solithromycin concentrations were 5.26% and 22.95%, respectively. In addition, the majority of population PK parameter estimates resulting from modeling DBS concentrations were within 15% of those obtained from modeling LPS concentrations. CONCLUSIONS: Solithromycin concentrations in DBS were similar to those measured in LPS and did not require correction for hematocrit or protein binding.

Clinical characterization of children with resistant airflow obstruction, a multicenter study.

OBJECTIVE: To characterize a cohort of children with airflow limitation resistant to bronchodilator (BD) therapy. METHODS: Pulmonary function tests performed in children 6-17 years of age at 15 centers in a clinical research consortium were screened for resistant airflow limitation, defined as a post-BD FEV1 and/or an FEV1/FVC less than the lower limits of normal. Demographic and clinical data were analyzed for associations with pulmonary function. RESULTS: 582 children were identified. Median age was 13 years (IQR: 11, 16), 60% were males; 62% were Caucasian, 28% were African-American; 19% were obese; 32% were born prematurely and 21% exposed to second hand smoke. Pulmonary diagnoses included asthma (93%), prior significant pneumonia (28%), and bronchiectasis (5%). 65% reported allergic rhinitis, and 11% chronic sinusitis. Subjects without a history of asthma had significantly lower post-BD FEV1% predicted (p = 0.008). Subjects without allergic rhinitis had lower post-BD FEV1% predicted (p = 0.003). Children with allergic rhinitis, male sex, obesity and Black race had better pulmonary function post-BD. There was lower pulmonary function in children after age 11 years without a history of allergic rhinitis, as compared to those with a history of allergic rhinitis. CONCLUSIONS: The most prevalent diagnosis in children with BD-resistant airflow limitation is asthma. Allergic rhinitis and premature birth are common co-morbidities. Children without a history of asthma, as well as those with asthma but no allergic rhinitis, had lower pulmonary function. Children with BD-resistant airflow limitation may represent a sub-group of children with persistent obstruction and high risk for life-long airway disease.

Overweight/obesity status in preschool children associates with worse asthma but robust improvement on inhaled corticosteroids.

BACKGROUND: Overweight/obesity (OW) is linked to worse asthma and poorer inhaled corticosteroid (ICS) response in older children and adults. OBJECTIVE: We sought to describe the relationships between OW and asthma severity and response to ICS in preschool children. METHODS: This post hoc study of 3 large multicenter trials involving 2- to 5-year-old children compared annualized asthma symptom days and exacerbations among normal weight (NW) (body mass index: 10th-84th percentiles) versus OW (body mass index: ≥85th percentile) participants. Participants had been randomized to daily ICS, intermittent ICS, or daily placebo. Simple and multivariable linear regression was used to compare body mass index groups. RESULTS: Within the group not treated with a daily controller, OW children had more asthma symptom days (90.7 vs 53.2, P = .020) and exacerbations (1.4 vs 0.8, P = .009) thanNW children did. Within the ICS-treated groups, OW and NW children had similar asthma symptom days (daily ICS: 47.2 vs 44.0 days, P = .44; short-term ICS: 61.8 vs 52.9 days, P = .46; as-needed ICS: 53.3 vs 47.3 days, P = .53), and similar exacerbations (daily ICS: 0.6 vs 0.8, P = .10; short-term ICS: 1.1 vs 0.8 days, P = .25; as-needed ICS: 1.0 vs 1.1, P = .72). Compared with placebo, daily ICS in OW led to fewer annualized asthma symptom days (90.7 vs 41.2, P = .004) and exacerbations (1.4 vs 0.6, P = .006), while similar protective ICS effects were less apparent among NW. CONCLUSIONS: In preschool children off controller therapy, OW is associated with greater asthma impairment and exacerbations. However, unlike older asthmatic patients, OW preschool children do not demonstrate reduced responsiveness to ICS therapy.

Enhancing Capacity for Trauma-informed Care in Child Welfare: Impact of a Statewide Systems Change Initiative.

Youth involved in the child welfare system (CWS) are disproportionally impacted by the negative effects of exposure to trauma. While efforts to develop trauma-informed CWSs are accelerating, little research is available about the effects of these efforts on system capacity to respond to the needs of youth exposed to trauma. No studies evaluate longer-term effects of these efforts. In 2011, Connecticut implemented CONCEPT, a multi-year initiative to enhance capacity of the state's CWS to provide trauma-informed care. CONCEPT used a multi-component approach including workforce development, deployment of trauma screening procedures, policy change, improved access to evidence-based trauma-focused treatments, and focused evaluation of program effects. Changes in system capacity to deliver trauma-informed care were assessed using statewide stratified random samples of child welfare staff at three time points (Year 1: N = 223, Year 3: N = 231, Year 5: N = 188). Significant improvements across nearly all child welfare domains were observed during the first 3 years of implementation, demonstrating system-wide improvements in capacity to provide trauma-informed care. These gains were maintained through the final year of implementation, with continued improvements in ratings of collaboration between child welfare and behavioral health settings on trauma-related issues observed. Responses documented familiarity with and involvement in many of the CONCEPT activities and initiatives. Staff reported greater familiarity with efforts to increase access to specific evidence-based services (e.g., TF-CBT) or to enhance trauma-related policy and practice guidelines, but less familiarity with efforts to implement new practices (e.g., trauma screening) in various sectors. Staff also reflected on the contribution of these components to enhance system capacity for trauma-informed care.

Systems Measures of a Trauma-Informed Approach: A Systematic Review.

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

Gait and Functional Outcomes Between Cruciate-Retaining and Cruciate-Substituting Implants in Total Knee Arthroplasty: A Prospective, Randomized Study.

Significant debate persists about posterior cruciate-retaining (CR) versus posterior cruciate-substituting (PS) implant design for total knee arthroplasty (TKA). This study sought to test the hypothesis that CR TKA will facilitate improved early functional outcomes in gait compared with PS TKA. Patients were randomized to either the CR or PS implant. Various patient-reported and surgeon-reported outcomes as well as gait analyses were obtained pre- and postoperatively. Patients undergoing PS TKA had higher University of California, Los Angeles activity scores at 12 months. No significant difference in spatiotemporal, kinematic, or kinetic parameters between groups was detected, but there was a trend toward quadriceps overuse gait pattern in the CR group. Patients undergoing TKA with a PS implant were more willing to engage in regular higher level physical activity. The CR implant may be a risk factor for quadriceps overuse gait pattern, while the PS implant may be protective against quadriceps overuse. (Journal of Surgical Orthopaedic Advances 28(3):215-223, 2019).

Association of free vitamin D3 concentrations and asthma treatment failures in the VIDA Trial.

BACKGROUND: Use of vitamin D3 serum concentrations as a biomarker of vitamin D status is questionable because of variation in vitamin D binding protein. OBJECTIVE: To determine associations between free vitamin D3 concentrations and rates of treatment failure and exacerbations in patients with asthma participating in the Vitamin D Add-on Therapy Enhances Corticosteroid Responsiveness in Asthma (VIDA) trial. METHODS: Free concentrations were directly measured by enzyme-linked immunosorbent assay and stratified into low, medium, and high groups: less than 5pg/mL (n = 65), 5 to 9pg/mL (n = 84), and greater than 9pg/mL (n = 48) after 12 weeks of supplementation with oral vitamin D3 and associated with outcomes. RESULTS: Outcomes did not associate with free concentrations: overall treatment failure rates were 0.60 (95% confidence interval [CI] 0.46-0.78), 0.53 (95%CI 0.40- 0.70), and 0.69 (95%CI 0.54-0.90)/person-year (P = .51), respectively; overall exacerbation rates were 0.28 (95%CI 0.17-0.48), 0.15 (95%CI 0.08-0.30) and 0.42 (95%CI 0.27-0.66)/person-year (P = .22). Mean (standard deviation) baseline free concentrations were lower in non-Hispanic blacks and Hispanics compared with non-Hispanic whites: 4.10 (1.33) and 4.38 (1.11) pg/mL vs 5.16 (1.65) pg/ml, (P < .001 and P = 0.038), respectively. Mean (standard deviation) baseline free concentrations differed between females and males: 4.57 (1.58) and 5.08 (1.41) (P = .026); and between non-overweight (body mass index [BMI] < 25) and overweight (BMI > 25): 5.45 (1.86) vs 4.54 (1.39) (P < .001). The free fraction differed by race and sex but not by BMI. CONCLUSION: The use of free concentrations was inferior to total concentrations as a biomarker of efficacy of vitamin D3 supplementation in VIDA trial participants. Future studies of vitamin D status in patients with asthma should measure both free and total concentrations to better understand which marker of vitamin D function is most informative.