The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children.

BACKGROUND: There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses. METHOD: This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP). RESULTS: The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers. CONCLUSIONS: Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

A prospective cohort study on the intersectionality of obesity, chronic disease, social factors, and incident risk of COVID-19 in US low-income minority middle-age mothers.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has disproportionally affected communities of color. We aimed to determine what factors are associated with COVID-19 testing and test positivity in an underrepresented, understudied, and underreported (U3) population of mothers. METHODS: This study included 2996 middle-aged mothers of the Boston Birth Cohort (a sample of predominantly urban, low-income, Black and Hispanic mothers) who were enrolled shortly after they gave birth and followed onward at the Boston Medical Center. COVID-19 testing and test positivity were defined by the SARS-CoV-2 nucleic acid test. Two-probit Heckman selection models were performed to identify factors associated with test positivity while accounting for potential selection associated with COVID testing. RESULTS: The mean (SD) age of study mothers was 41.9 (±7.7) years. In the sample, 1741 (58.1%) and 667 (22.3%) mothers were self-identified as Black and Hispanic, respectively. A total of 396 mothers had COVID-19 testing and of those, 95 mothers tested positive from March 2020 to February 2021. Among a multitude of factors examined, factors associated with the probability of being tested were obesity (RR = 1.27; 95% confidence interval (CI): 1.08-1.49); and presence of preexisting chronic medical conditions including hypertension, asthma, stroke, and other comorbidities (coronary heart disease, chronic kidney disease, and sickle cell disease) with a corresponding RR = 1.40 (95% CI: 1.23-1.60); 1.29 (95% CI: 1.11-1.50); 1.44 (95% CI: 1.23-1.68); and 1.37 (95% CI: 1.12-1.67), respectively. Factors associated with higher incident risk of a positive COVID-19 test were body mass index, birthplace outside of the USA, and being without a college-level education. CONCLUSIONS: This study demonstrated the intersectionality of obesity and social factors in modulating incident risk of COVID-19 in this sample of US Black and Hispanic middle-aged mothers. Methodologically, our findings underscore the importance of accounting for potential selection bias in COVID-19 testing in order to obtain unbiased estimates of COVID-19 infection.

A Nonlinear Relation Between Maternal Red Blood Cell Manganese Concentrations and Child Blood Pressure at Age 6-12 y: A Prospective Birth Cohort Study.

BACKGROUND: Although manganese (Mn) is an essential trace element and a common component of most multivitamins on the market, an adverse effect on blood pressure (BP) has been reported in adults. In addition, the longitudinal relation between prenatal Mn status and childhood BP is still unknown. OBJECTIVE: This study investigated the association between prenatal Mn concentrations and risk of elevated BP at ages 3-12 y. METHOD: The analyses included 1268 mother-child dyads who were enrolled at birth and followed prospectively at the Boston Medical Center. Maternal RBC Mn concentrations were measured by inductively coupled plasma mass spectrometry, using RBCs collected within 1-3 d after delivery (reflecting late-pregnancy Mn exposure). Child elevated BP was defined as systolic or diastolic BP ≥90th percentile for a given age, sex and height. Multivariate logistic regression models were conducted. Path analysis was applied to mediation estimation. RESULTS: The median (IQR) maternal RBC Mn concentration was 37.5 (29.2-48.5) µg/L. The rate of child elevated BP at ages 3-12 y was 25%. Both the lowest and highest quartiles of maternal RBC Mn concentrations were associated with higher risk of elevated BP among children aged 6-12 y (OR: 1.52; 95% CI: 1.04, 2.21 and OR: 1.65; 95% CI: 1.13, 2.40, respectively) compared with those in the second and third quartiles. Gestational age and fetal growth mediated the association between low maternal RBC Mn (first quartile) and child elevated BP, explaining 25% of the association, but not for high (fourth quartile) maternal RBC Mn concentrations. No association was found between maternal RBC Mn concentrations and BP among children aged 3-5 y. CONCLUSION: We found a nonlinear association between maternal RBC Mn concentrations and elevated BP among children aged 6-12 y from a high-risk, predominantly minority population. Our findings warrant further investigation.

The scope and severity of white-nose syndrome on hibernating bats in North America.

Assessing the scope and severity of threats is necessary for evaluating impacts on populations to inform conservation planning. Quantitative threat assessment often requires monitoring programs that provide reliable data over relevant spatial and temporal scales, yet such programs can be difficult to justify until there is an apparent stressor. Leveraging efforts of wildlife management agencies to record winter counts of hibernating bats, we collated data for 5 species from over 200 sites across 27 U.S. states and 2 Canadian provinces from 1995 to 2018 to determine the impact of white-nose syndrome (WNS), a deadly disease of hibernating bats. We estimated declines of winter counts of bat colonies at sites where the invasive fungus that causes WNS (Pseudogymnoascus destructans) had been detected to assess the threat impact of WNS. Three species undergoing species status assessment by the U.S. Fish and Wildlife Service (Myotis septentrionalis, Myotis lucifugus, and Perimyotis subflavus) declined by more than 90%, which warrants classifying the severity of the WNS threat as extreme based on criteria used by NatureServe. The scope of the WNS threat as defined by NatureServe criteria was large (36% of Myotis lucifugus range) to pervasive (79% of Myotis septentrionalis range) for these species. Declines for 2 other species (Myotis sodalis and Eptesicus fuscus) were less severe but still qualified as moderate to serious based on NatureServe criteria. Data-sharing across jurisdictions provided a comprehensive evaluation of scope and severity of the threat of WNS and indicated regional differences that can inform response efforts at international, national, and state or provincial jurisdictions. We assessed the threat impact of an emerging infectious disease by uniting monitoring efforts across jurisdictional boundaries and demonstrated the importance of coordinated monitoring programs, such as the North American Bat Monitoring Program (NABat), for data-driven conservation assessments and planning.

Alcance y Severidad del Síndrome de Nariz Blanca en los Murciélagos Hibernando en América del Norte Resumen La evaluación del alcance y la severidad de las amenazas es necesaria para los análisis de impacto sobre las poblaciones que se usan para orientar a la planeación de la conservación. La evaluación cuantitativa de amenazas con frecuencia requiere de programas de monitoreo que proporcionen datos confiables en escalas espaciales y temporales, aunque dichos programas pueden ser difíciles de justificar hasta que exista un estresante aparente. Gracias a una movilización de esfuerzos de las agencias de manejo de fauna para registrar los conteos invernales de murciélagos hibernadores, recopilamos datos para cinco especies en más de 200 sitios a lo largos de 27 estados de EUA y dos provincias canadienses entre 1995 y 2018 para determinar el impacto del síndrome de nariz blanca (SNB), una enfermedad mortal de los murciélagos hibernadores. Estimamos declinaciones en los conteos invernales de las colonias de murciélagos en sitios en donde el hongo invasivo que ocasiona el SNB (Pseudogymnoascus destructans) había sido detectado para evaluar el impacto de amenaza del SNB. Tres especies que se encuentran bajo valoración por parte del Servicio de Pesca y Vida Silvestre de los EUA (Myotis septentrionalis, Myotis lucifugus y Perimyotis subflavus) tuvieron una declinación de más del 90%, lo que justifica la clasificación de la severidad de la amenaza del SNB como extrema con base en el criterio usado por NatureServe. El alcance de la amenaza del SNB definido por el criterio de NatureServe fue desde amplio (36% de la distribución de Myotis lucifugus) hasta dominante (79% de la distribución de Myotis septentrionalis) para estas especies. Las declinaciones de otras dos especies (Myotis sodalis y Eptesicus fuscus) fueron menos severas, pero de igual manera quedaron clasificadas desde moderada hasta seria con base en los criterios de NatureServe. El intercambio de datos entre las jurisdicciones proporcionó una evaluación completa del alcance y la severidad de la amenaza del SNB e indicó las diferencias regionales que pueden guiar a los esfuerzos de respuesta realizados en las jurisdicciones internacionales, nacionales, estatales o provinciales. Evaluamos el impacto de amenaza de una enfermedad infecciosa emergente mediante la combinación de los esfuerzos de monitoreo que sobrepasan fronteras jurisdiccionales y demostramos la importancia que tienen para la planeación y la evaluación basadas en datos de la conservación los programas de monitoreo coordinados, como el Programa de Monitoreo de los Murciélagos Norteamericanos (NABat).

Birth outcomes across the spectrum of maternal age: dissecting aging effect versus confounding by social and medical determinants.

BACKGROUND: Given the trend of increasing maternal age and associated adverse reproductive outcomes in the US, this study aimed to assess whether this association is due to an independent aging or confounded by sociodemographic, biomedical, or behavioral determinants in a predominantly Black US population. METHODS: Data was from 8509 women enrolled in the Boston Birth Cohort. Adverse reproductive outcomes included spontaneous preterm delivery, cesarean delivery, and low birth weight. Covariates included sociodemographic (parity, race/ethnicity, education, marital status, income, receipt of public assistance, nativity); biomedical (obesity, hypertensive disorders, diabetes mellitus); and behavioral (consistent intake of multivitamin supplements, support from father of baby, support from family, major stress in pregnancy, cigarette smoking, alcohol intake). Analysis included Lowess and marginal probability plots, crude and adjusted sequential logistic regression models to examine age-outcome associations and to what degree the association can be explained by the above covariables. RESULT: Overall, the study sample had high levels of spontaneous preterm birth (18%), cesarean delivery (33%) and low birth weight (26%). Unadjusted models showed no significant difference odds of spontaneous preterm birth by maternal age but higher odds of cesarean section (aOR: 1.77, 95% CI: 1.60, 1.95) and low birth weight (aOR: 1.15, 95% CI: 1.04, 1.28) among women 30 years or older. Adjustment for sociodemographic factors, biomedical conditions and behavioral factors revealed higher odds of spontaneous preterm birth: (aOR: 1.30, 95% CI: 1.14, 1.49), cesarean section deliveries (aOR: 1.68, 95% CI: 1.51, 1.87) and low birth weight (aOR: 1.36, 95% CI: 1.21, 1.53). Across all ages, optimal BMI status and consistent multivitamin supplement intake were protective of spontaneous preterm birth and low birth weight. CONCLUSION: In this high-risk minority population, we demonstrated that the association between increasing maternal age and adverse pregnancy outcomes was due to an independent aging effect and the presence of confounding by sociodemographic, biomedical, and behavioral factors. Some modifiable risk factors to counteract aging effect, include optimizing BMI and consistent intake of multivitamin supplement. A fundamental change in how care is provided to women, particularly low income Black women, is needed with emphasis on the protective role of optimal nutritional status. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03228875.

Enabling Factors Associated with Receipt of Interconception Health Care.

OBJECTIVES: Preventive health care between pregnancies may benefit future pregnancies and women's long-term health, yet such care is frequently incomplete. We used Andersen's Model of Health Services Use to identify factors associated with receipt of interconception care. METHODS: This secondary analysis uses data from a trial that recruited women from four health centers in the Baltimore metropolitan area. We used data on factors associated with Andersen's model reported up to 15 months postpartum. Factors included health history (diabetes, hypertension, prematurity), self-rated health, demographics (age, race/ethnicity, education, marital status, employment, income, parity), predisposing factors (depression, stress, social support), and enabling factors (usual place of care, personal doctor or nurse, insurance). Relative risk regression modeled the relationship between these factors and a dependent variable defined as completing both a postpartum visit and one subsequent health care visit. Models also accounted for time since birth, clustering by site, and trial arm. RESULTS: We included 376 women followed a mean of 272 days postpartum (SD 57), of whom 226 (60%) completed a postpartum and subsequent visit. Women were predominantly non-Hispanic Black (84%) and low income (50% household income < $20,000/year). In regression, two enabling factors were associated with increased receipt of care: having a personal doctor or nurse (RR 1.38, 95% CI 1.11-1.70) and non-Medicaid insurance (RR 1.64, 95% CI 1.09-2.56). CONCLUSIONS FOR PRACTICE: Enabling factors were associated with receipt of recommended care following birth. These factors may be modifiable components of efforts to improve care during this critical life course period.

The association between organizational cultural competence and teamwork climate in a network of primary care practices.

BACKGROUND: A health system's commitment to delivering culturally competent care is essential in creating a culture of respect for patients, clinicians, and administrative staff. As the diversity of the health care workforce grows, gaining an understanding of the perspectives among different health care personnel and the value that they place on organizational cultural competence is a first step in developing more effective team environments. PURPOSE: The aim of the study was to determine whether an association exists between perceptions of organizational cultural competence and teamwork climate among employees in a health system. METHODOLOGY/APPROACH: One thousand eighty employees in a primary care network consisting of 49 ambulatory practices were surveyed on their perceptions of senior management's efforts in organizational cultural competence and teamwork climate in their own work setting using 5-point Likert scales. Linear regression models were used to evaluate the association between organizational cultural competence and teamwork climate. RESULTS: The overall organizational response rate for the survey was 84%. Higher perception of organizational cultural competence was associated with better teamwork climate (coef. = 0.4, p <0.001) after adjusting for gender, age, years in specialty, race, and position type. The association was stronger in magnitude for support staff compared to administrators and clinicians and stronger for younger compared to older age groups. CONCLUSIONS: Higher employee perceptions of organizational cultural competence are associated with better self-reported teamwork climate, and this relationship is magnified for support staff and younger employees. PRACTICE IMPLICATIONS: Senior leaders of health systems should consider investment in cultural competence as a contributor toward team effectiveness. Specifically, organizations may help support cultural competence by committing resources to the following: developing a comprehensive plan that addresses patients' cultural needs, recruiting and retaining a diverse staff and leadership, collaborating with the community, recognizing and rewarding care that meets patients' cultural needs, and providing adequate diversity training.

In utero exposure to mercury and childhood overweight or obesity: counteracting effect of maternal folate status.

BACKGROUND: Low-dose mercury (Hg) exposure has been associated with cardiovascular diseases, diabetes, and obesity in adults, but it is unknown the metabolic consequence of in utero Hg exposure. This study aimed to investigate the association between in utero Hg exposure and child overweight or obesity (OWO) and to explore if adequate maternal folate can mitigate Hg toxicity. METHODS: This prospective study included 1442 mother-child pairs recruited at birth and followed up to age 15 years. Maternal Hg in red blood cells and plasma folate levels were measured in samples collected 1-3 days after delivery (a proxy for third trimester exposure). Adequate folate was defined as plasma folate ≥ 20.4 nmol/L. Childhood OWO was defined as body mass index ≥ 85% percentile for age and sex. RESULTS: The median (interquartile range) of maternal Hg levels were 2.11 (1.04-3.70) µg/L. Geometric mean (95% CI) of maternal folate levels were 31.1 (30.1-32.1) nmol/L. Maternal Hg levels were positively associated with child OWO from age 2-15 years, independent of maternal pre-pregnancy OWO, diabetes, and other covariates. The relative risk (RR = 1.24, 95% CI 1.05-1.47) of child OWO associated with the highest quartile of Hg exposure was 24% higher than those with the lowest quartile. Maternal pre-pregnancy OWO and/or diabetes additively enhanced Hg toxicity. The highest risk of child OWO was found among children of OWO and diabetic mothers in the top Hg quartile (RR = 2.06; 95% CI 1.56-2.71) compared to their counterparts. Furthermore, adequate maternal folate status mitigated Hg toxicity. Given top quartile Hg exposure, adequate maternal folate was associated with a 34% reduction in child OWO risk (RR = 0.66, 95% CI 0.51-0.85) as compared with insufficient maternal folate. There was a suggestive interaction between maternal Hg and folate levels on child OWO risk (p for interaction = 0.086). CONCLUSIONS: In this US urban, multi-ethnic population, elevated in utero Hg exposure was associated with a higher risk of OWO in childhood, and such risk was enhanced by maternal OWO and/or diabetes and reduced by adequate maternal folate. These findings underscore the need to screen for Hg and to optimize maternal folate status, especially among mothers with OWO and/or diabetes.

Inter-generational link of obesity in term and preterm births: role of maternal plasma acylcarnitines.

BACKGROUND/OBJECTIVES: Acylcarnitines, intermediates of fatty acid oxidation, are known to be involved in obesity and insulin resistance. Since maternal prepregnancy overweight or obesity (OWO) is a recognized major risk factor for offspring OWO, we hypothesized that maternal plasma acylcarnitines may play a role in inter-generational OWO. SUBJECTS/METHODS: This study included 1402 mother-child pairs (1043 term, 359 preterm) recruited at birth from 1998-2013 and followed prospectively up to age 18 years at the Boston Medical Center. The primary outcomes were child OWO defined as BMI ≥ 85th percentile for age and sex. The primary exposures were maternal prepregnancy OWO defined as BMI ≥ 25 kg/m2 and maternal acylcarnitine levels measured in plasma samples collected soon after delivery using liquid chromatography-tandem mass spectrometry (LC-MS) in a targeted manner. RESULTS: Approximately 40% of the children in this study were OWO by age 5. Maternal OWO had a significant association with childhood OWO, both in term and preterm births. ß-hydroxybutyryl-carnitine (C4-OH) levels were significantly and positively associated with child OWO among term births after adjustment for potential confounders and multiple-comparisons. Children born to OWO mothers in the top tertile C4-OH levels were at the highest risk of OWO: OR = 3.78 (95%CI: 2.47, 5.79) as compared with those born to non-OWO mothers in the lowest tertile (P for interaction of maternal OWO and C4-OH = 0.035). In a four-way decomposition of mediation/interaction analysis, we estimated that C4-OH levels explained about 27% (se = 0.08) of inter-generational OWO risk (P = 0.001). In contrast, these associations were not observed in preterm births. CONCLUSIONS: In this U.S. urban low-income birth cohort, we provide further evidence of the inter-generational link of OWO and reveal the differential role of C4-OH in explaining the inter-generational obesity between term and preterm births. Further investigations are warranted to better understand and prevent the inter-generational transmission of OWO.

The Uniqueness and Importance of Children in Addressing Health Disparities Across the Life Course: Implications for Research.

As the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Division of Intramural Population Health Research celebrates its 50th Anniversary, it is appropriate to recognize great achievements in reducing child morbidity and mortality and increasing life expectancy. Unfortunately large racial/ethnic and socioeconomic health and healthcare disparities persist. This commentary suggests a framework to clarify the research and interventions needed to eliminate health disparities starting early in the life course.

Life Course Approaches to the Causes of Health Disparities.

Reducing health disparities requires an understanding of the mechanisms that generate disparities. Life course approaches to health disparities leverage theories that explain how socially patterned physical, environmental, and socioeconomic exposures at different stages of human development shape health within and across generations and can therefore offer substantial insight into the etiology of health disparities. Life course approaches are informed by developmental and structural perspectives. Developmental perspectives emphasize how socially patterned exposures to risk factors during sensitive life stages shift health trajectories, whereas structural perspectives emphasize how social identity and position within socially patterned environments disproportionately allocate risk factors and resources, resulting in altered health trajectories. We conclude that the science of health disparities will be advanced by integrating life course approaches into etiologic and intervention research on health disparities. The following 4 strategies are offered to guide in this process: (1) advance the understanding of multiple exposures and their interactions, (2) integrate life course approaches into the understanding of biological mechanisms, (3) explore transgenerational transmission of health disparities, and (4) integrate life course approaches into health disparities interventions.

Higher fat stores contribute to persistence of little brown bat populations with white-nose syndrome.

The persistence of populations declining from novel stressors depends, in part, on their ability to respond by trait change via evolution or plasticity. White-nose syndrome (WNS) has caused rapid declines in several North America bat species by disrupting hibernation behaviour, leading to body fat depletion and starvation. However, some populations of Myotis lucifugus now persist with WNS by unknown mechanisms. We examined whether persistence of M. lucifigus with WNS could be explained by increased body fat in early winter, which would allow bats to tolerate the increased energetic costs associated with WNS. We also investigated whether bats were escaping infection or resistant to infection as an alternative mechanism explaining persistence. We measured body fat in early and late winter during initial WNS invasion and 8 years later at six sites where bats are now persisting. We also measured infection prevalence and intensity in persisting populations. Infection prevalence was not significantly lower than observed in declining populations. However, at two sites, infection loads were lower than observed in declining populations. Body fat in early winter was significantly higher in four of the six persisting populations than during WNS invasion. Physiological models of energy use indicated that these higher fat stores could reduce WNS mortality by 58%-70%. These results suggest that differences in fat storage and infection dynamics have reduced the impacts of WNS in many populations. Increases in body fat provide a potential mechanism for management intervention to help conserve bat populations.

Maternal postpartum plasma folate status and preterm birth in a high-risk US population.

OBJECTIVE: While maternal folate deficiency has been linked to poor pregnancy outcomes such as neural tube defects, anaemia and low birth weight, the relationship between folate and preterm birth (PTB) in the context of the US post-folic acid fortification era is inconclusive. We sought to explore the relationship between maternal folate status and PTB and its subtypes, i.e. spontaneous and medically indicated PTB. DESIGN: Observational study. SETTING: Boston Birth Cohort, a predominantly urban, low-income, race/ethnic minority population at a high risk for PTB.ParticipantsMother-infant dyads (n 7675) enrolled in the Boston Birth Cohort. A sub-sample (n 2313) of these dyads had maternal plasma folate samples collected 24-72 h after delivery. RESULTS: Unadjusted and adjusted logistic regressions revealed an inverse relationship between the frequency of multivitamin supplement intake and PTB. Compared with less frequent use, multivitamin supplement intake 3-5 times/week (adjusted OR (aOR) = 0·78; 95 % CI 0·64, 0·96) or >5 times/week (aOR = 0·77; 95 % CI 0·64, 0·93) throughout pregnancy was associated with reduced risk of PTB. Consistently, higher plasma folate levels (highest v. lowest quartile) were associated with lower risk of PTB (aOR = 0·74; 95 % CI 0·56, 0·97). The above associations were similar among spontaneous and medically indicated PTB. CONCLUSIONS: If confirmed by future studies, our findings raise the possibility that optimizing maternal folate levels across pregnancy may help to reduce the risk of PTB among the most vulnerable US population in the post-folic acid fortification era.

Asthma and Attendance in Urban Schools.

INTRODUCTION: Asthma is linked to student absenteeism, a risk factor for poor achievement and school dropout. Studies of asthma and absenteeism have common limitations, including relying on parent-reported asthma, which may be unreliable and prone to selection, and inadequately accounting for confounding health and social risks. Therefore, the rate of absenteeism attributable to asthma and the extent to which better asthma control would translate into better attendance remain unclear. METHODS: Participants were 1,194 students in 2 large urban US schools (1 elementary, 1 middle) in 2016-2018. Student asthma was assessed based on parent report on health forms, student-reported asthma-related emergency department/hospitalization or medication use, and school health center record of asthma. Multiple imputation was used to reduce selection from missing asthma reports. The relationship between asthma and school district-reported days absent was estimated using Poisson random intercept regression, accounting for health and demographic covariates. RESULTS: Parent-reported ever asthma (27%) was not associated with absenteeism in adjusted models. Student-reported asthma health care or medication use (16%) and school health center record of asthma (17%) were associated with higher absenteeism (incidence rate ratio [IRR], 1.16; 95% confidence interval [CI], 1.01-1.35 and IRR, 1.21; 95% CI, 1.09-1.34, respectively). Student-reported asthma and school health center record of asthma were associated with 1.9 and 1.5 absences per year, respectively. CONCLUSION: Student-reported and school health center record of asthma explained 14% to 18% of student absenteeism, even after accounting for other health and social risks. When possible, student reports should supplement parent reports to ensure that students with asthma are identified and obtain access to care.

Profiles of Future Orientation among Assault-injured Adolescents: Correlates and Concurrent Outcomes.

Future orientation has been established as having positive associations with health and educational outcomes for adolescents exposed to violence. However, conceptualizations of future orientation have been inconsistent. This study uses latent profile analysis to understand the interrelationships between measures of future orientation (e.g., commitment to learning, goal orientation, hope, expectancies, fatalism). Participants were 188 primarily African American male early adolescents ranging from 10 to 15 years old (60.6% male; Mage = 12.87, SDage = 1.52). Adolescents in the high- and low-future orientation profiles differed on academic behaviors and aggressive behavior. A discordant profile emerged with adolescents moderate on all measures of future orientation except expectancies. Relational aspects of parenting were associated with higher likelihood of adolescents being assigned to the high- and low-future orientation profiles. These findings suggest the importance of parental warmth in promoting future orientation for adolescents in risky environments, as improving future orientation might mitigate risk for future negative academic comes or engagement in violent behavior.

Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the impact of provision of folate vitamins and a preconception health intervention on folate use among mothers bringing infants to pediatric primary care. STUDY DESIGN: We conducted a cluster randomized trial in mothers presenting with their infants (<12 months) at 4 urban pediatric practices in the Baltimore, Maryland, metropolitan area. There were 45 clinicians randomized into an intervention group (15-item preconception health screening and counseling and 90-day multivitamin supply) and control group (preconception health and community resource handouts and 90-day multivitamin supply). Participating mothers were enrolled in the study group assigned to their child's clinician. Baseline and 6-month follow-up interviews were performed. The outcome was daily use of folate, multivitamin, and a prenatal vitamin containing folate. Primary independent variables were time of assessment and mother's study group (intervention or control groups). Covariates investigated were mother's and child's age, race/ethnicity, education, marital status, income, insurance status, previous live births, and intention to have a pregnancy in the next 6 months. RESULTS: We enrolled 415 mothers at baseline who were majority African American and low income. Of the 415 enrolled participants, 352 (85%) completed follow-up interviews. Among all participants, daily vitamin intake increased from baseline to 6-month follow-up (33.8% vs 42.6%; P = .016). After adjustment for covariates and clustered design, there was an augmented effect in the intervention vs control group (aOR, 2.04; 95% CI, 1.04-3.98). CONCLUSIONS: Offering vitamins and recommending folate intake to mothers within pediatric practice can increase use. Pediatric practice is an important contact point and context for improving maternal folate use. TRIAL REGISTRATION: ClinicalTrials.govNCT02049554.