Liver Complications in Untreated Treatment-Ineligible versus Treated Treatment-Eligible Patients with Hepatitis B.

BACKGROUND: A substantial number of patients who do not meet treatment criteria for chronic hepatitis B (CHB) later develop adverse outcomes such as cirrhosis and hepatocellular carcinoma (HCC). Our aim was to determine whether current practice guidelines adequately identify CHB patients who will benefit from antiviral therapy. METHODS: We performed a retrospective cohort study comparing the incidence of adverse liver outcomes (cirrhosis and/or HCC) in untreated treatment-ineligible (at baseline and throughout follow-up) versus treated treatment-eligible patients according to standard American Association for the Study of Liver Diseases (AASLD) 2018 guidance (alanine aminotransferase [ALT] >70/50 U/L for men/women plus hepatitis B virus [HBV] DNA >20,000/2,000 IU/mL for HBeAg+/-) and with a sensitivity analyses using a lower threshold (ALT >40 U/L and HBV DNA >2,000 IU/mL). RESULTS: We reviewed records of 5,840 patients from 5 clinics in California and identified 2,987 treatment-naive non-HCC CHB patients. Of those, 271 patients remained untreated treatment-ineligible, 514 patients were treatment-eligible and initiated treatment, with 5-year cumulative adverse liver incidences of 12.5% versus 7.2%, p = 0.074. On multivariable analysis adjusting for age, sex, diabetes, albumin, platelet count, and HBV DNA, compared to treated treatment-eligible patients, untreated treatment-ineligible patients had a significantly higher risk of adverse liver outcomes (adjusted hazard ratio: 2.38, 95% confidence interval 1.03-5.48, p = 0.04) in main analysis by AASLD 2018 criteria but not in sensitivity analysis using the lower treatment threshold (p = 0.09). CONCLUSION: Patients never meeting standard AASLD 2018 criteria for antiviral therapy and never treated had twice the risk of developing cirrhosis and/or HCC when compared to eligible and treated patients.

Health disparities in pediatric sleep-disordered breathing.

Sleep-disordered breathing reflects a continuum of overnight breathing difficulties, ranging from mild snoring to obstructive sleep apnea syndrome. Sleep-disordered breathing in childhood is associated with significant adverse outcomes in multiple domains of functioning. This review summarizes the evidence of well-described ethnic, racial, and socioeconomic disparities in pediatric sleep-disordered breathing, from its prevalence to its treatment-related outcomes. Research on potential socio-ecological contributors to these disparities is also reviewed. Critical future research directions include the development of interventions that address the modifiable social and environmental determinants of these health disparities.

Racial/Ethnic Differences in Pediatric Emergency Department Wait Times.

OBJECTIVES: Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. METHODS: We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. RESULTS: Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. CONCLUSIONS: In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.

Poor Adherence to Guidelines for Treatment of Chronic Hepatitis B Virus Infection at Primary Care and Referral Practices.

BACKGROUND & AIMS: The American Association for the Study of Liver Diseases (AASLD) guidelines for treatment of chronic hepatitis B virus (HBV) infection have changed with time. We assessed rates of treatment evaluation and initiation in patients with chronic HBV infection from different practice settings in the past 14 years. METHODS: Treatment-naive patients with chronic HBV infection were recruited from different practice settings in California from January 2002 through December 2016. The study population comprised 4130 consecutive, treatment-naive patients with chronic HBV infection seen by community primary care physicians (n = 616), community gastroenterologists (n = 2251), or university hepatologists (n = 1263). Treatment eligibility was assessed using data from the first 6 months after initial presentation based on AASLD criteria adjusted for changes over time. RESULTS: Within the first 6 months of care, the proportions of patients evaluated by all 3 relevant tests (measurements of alanine aminotransferase, hepatitis B virus e antigen, and HBV DNA levels) were as follows: 36.69% in community primary care, 59.80% in gastroenterologist care, and 79.97% in hepatology care (P < .0001 among the 3 groups). Higher proportions of patients were eligible for treatment in specialty practices: 12.76% in community primary care, 24.96% in gastroenterologist care, and 29.43% in hepatology care (P < .0001). Among treatment-eligible patients, there was no significant difference in the proportions of patients who began antiviral therapy between those receiving treatment from a gastroenterologist (55.65%) vs a hepatologist (57.90%; P = .56). Of 243 evaluable patients receiving community primary care, only 31 were eligible for treatment and only 12 of these (38.71%) received treatment. CONCLUSIONS: In an analysis of patients receiving care for chronic HBV infection, we found the proportions evaluated and receiving treatment to be suboptimal, according to AASLD criteria, in all practice settings. However, rates of evaluation and treatment were lowest for patients receiving community primary care.

Hepatitis B and renal function: A matched study comparing non-hepatitis B, untreated, treated and cirrhotic hepatitis patients.

BACKGROUND & AIM: Renal impairment is associated with chronic hepatitis B (CHB). To overcome prior study design differences, we used propensity score matching to balance the non-CHB and CHB cohorts and generalized linear modelling (GLM, models using probit and logit linking functions for complex models) to evaluate the effect of CHB, treatment and cirrhosis on renal function. METHODS: A retrospective cohort (1996-2017) from one U.S. university medical centre. Included patients had ≥12 months of serial creatinine laboratories and a baseline estimated glomerular filtration rate (eGFR, by the Modification of Diet in Renal Disease Study equation) ≥60 mL/min/1.73 m2 . Propensity score matching was performed using age, sex, ethnicity, diabetes, hypertension and baseline eGFR. GLM was performed to generate adjusted mean eGFR over time. RESULTS: Adjusted mean eGFR was significantly higher for non-CHB vs. untreated CHB patients (eGFR 87.4 vs. 85.6, P= 0.004, n = 580, median follow-up = 82 months). A significant difference in adjusted mean eGFR between untreated vs. entecavir (ETV)-treated CHB patients (eGFR 85.1 vs. 83.5, P= 0.02, n = 340, median follow-up = 70 months) was found among non-cirrhotic CHB. Among treated CHB, there was no difference in adjusted mean eGFR between non-cirrhotic vs. cirrhotic patients (eGFR 77.0 vs. 76.5; P= 0.66, n = 112, median follow-up = 58 months). CONCLUSION: After PSM and GLM, the significant predictors for worsening renal function were age, hypertension and diabetes mellitus but not CHB, ETV or cirrhosis. However, given small sample size, data regarding the use of ETV in patients with cirrhosis should be interpreted with caution and requires additional investigation.

Implicit Bias in Pediatric Academic Medicine.

OBJECTIVE: Despite known benefits of diversity, certain racial/ethnic groups remain underrepresented in academic pediatrics. Little research exists regarding unconscious racial attitudes among pediatric faculty responsible for decisions on workforce recruitment and retention in academia. This study sought to describe levels of unconscious racial bias and perceived barriers to minority recruitment and retention among academic pediatric faculty leaders. METHODS: Authors measured unconscious racial bias in a sample of pediatric faculty attending diversity workshops conducted at local and national meetings in 2015. A paper version of the validated Implicit Association Test (IAT) measured unconscious racial bias. Subjects also reported perceptions about minority recruitment and retention. RESULTS: Of 68 eligible subjects approached, 58 (85%) consented and completed the survey with IAT. Of participants, 83% had leadership roles and 93% were involved in recruitment. Participants had slight pro-white/anti-black bias on the IAT (M = 0.28, SD = 0.49). There were similar IAT scores among participants in leadership roles (M = 0.33, SD = 0.47) and involved in recruitment (M = 0.28, SD = 0.43). Results did not differ when comparing participants in local workshops to the national workshop (n = 36, M = 0.29, SD = 0.40 and n = 22, M = 0.27, SD = 0.49 respectively; p = 0.88). Perceived barriers to minority recruitment and retention included lack of minority mentors, poor recruitment efforts, and lack of qualified candidates. CONCLUSIONS: Unconscious pro-white/anti-black racial bias was identified in this sample of academic pediatric faculty and leaders. Further research is needed to examine how unconscious bias impacts decisions in academic pediatric workforce recruitment. Addressing unconscious bias and perceived barriers to minority recruitment and retention represent opportunities to improve diversity efforts.

Characterizing analgesic use during air medical transport of injured children.

BACKGROUND: Pain management is an important aspect of emergency care for children suffering traumatic injuries. OBJECTIVES: The objectives of this study were to characterize analgesic administration to injured children during air medical transport, to describe factors associated with analgesic use, and to examine the effects of patient race on analgesia. METHODS: We used electronic records for patients transported by a regional air medical transport agency. We retrospectively examined data from 2003-2012 for patients ≤ 15 years old suffering traumatic injuries. We used bivariable analyses to identify associations for multivariable logistic regression models to determine factors associated with our outcomes -documentation of pain score and analgesic administration. RESULTS: Of 5,057 patients, the median age was 8 (IQR 3-12) years. The majority of patients were male (66%, 95% CI 64-66%), were white non-Hispanic (83%, 95% CI 82-84%), and had no pain score documented (61%, 95% CI 60-62%). While only 15% of patients received analgesics overall, 70% with an initial pain score ≥ 5 received analgesics. In unadjusted models, non-white race was associated with lower odds of having a pain score documented (OR 0.52, 95% CI 0.44-0.62) and receiving analgesics (OR 0.64, 95% CI 0.50-0.82). After adjusting for confounders, there was no evidence of racial differences in pain management. Multivariable analysis revealed that younger age, lack of intravenous access, higher Glasgow Coma Scale, systolic blood pressure <100, transportation from the scene, initial pain score <5, and not having a pain score documented were associated with lower odds of receiving analgesics. CONCLUSIONS: Few pediatric patients had pain scores documented and fewer received analgesics during air medical transport for injuries. Racial differences in analgesia seen in unadjusted analyses did not persist after controlling for confounders. Resources, training, and appropriate pain management protocols should be made available to facilitate pain assessment in children as a strategy for increasing appropriate analgesic use during transport.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence.

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

An 11-year-old girl with right-sided weakness secondary to cerebral abscesses: a case report.

A previously healthy 11-year-old girl who presented to the emergency department with 8 days of headache and right-sided weakness was found to have 2 cerebral abscesses. Brain abscess is an uncommon finding for children in the emergency department. With this case, we review the clinical presentation, evaluation, and management of this unusual but potentially life-threatening condition.

Going viral: adapting to pediatric surge during the H1N1 pandemic.

OBJECTIVES: The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. METHODS: Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. RESULTS: The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. CONCLUSIONS: Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

Child Health Advocacy: The Journey to Antiracism.

The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.

Research Priorities for Pediatric Emergency Care to Address Disparities by Race, Ethnicity, and Language.

Importance: Health care disparities are well-documented among children based on race, ethnicity, and language for care. An agenda that outlines research priorities for disparities in pediatric emergency care (PEC) is lacking. Objective: To investigate research priorities for disparities in PEC among medical personnel, researchers, and health care-affiliated community organizations. Design, Setting, and Participants: In this survey study, a modified Delphi approach was used to investigate research priorities for disparities in PEC. An initial list of research priorities was developed by a group of experienced PEC investigators in 2021. Partners iteratively assessed the list through 2 rounds of electronic surveys using Likert-type responses in late 2021 and early 2022. Priorities were defined as achieving consensus if they received a score of highest priority or priority by at least 60% of respondents. Asynchronous engagement of participants via online web-conferencing platforms and email correspondence with electronic survey administration was used. Partners were individuals and groups involved in PEC. Participants represented interest groups, research and medical personnel organizations, health care partners, and laypersons with roles in community and family hospital advisory councils. Participants were largely from the US, with input from international PEC research networks. Outcome: Consensus agenda of research priorities to identify and address health care disparities in PEC. Results: PEC investigators generated an initial list of 27 potential priorities. Surveys were completed by 38 of 47 partners (80.6%) and 30 of 38 partners (81.1%) in rounds 1 and 2, respectively. Among 30 respondents who completed both rounds, there were 7 family or community partners and 23 medical or research partners, including 4 international PEC research networks. A total of 12 research priorities achieved the predetermined consensus threshold: (1) systematic efforts to reduce disparities; (2) race, ethnicity, and language data collection and reporting; (3) recognizing and mitigating clinician implicit bias; (4) mental health disparities; (5) social determinants of health; (6) language and literacy; (7) acute pain-management disparities; (8) quality of care equity metrics; (9) shared decision-making; (10) patient experience; (11) triage and acuity score assignment; and (12) inclusive research participation. Conclusions and Relevance: These results suggest a research priority agenda that may be used as a guide for investigators, research networks, organizations, and funding agencies to engage in and support high-priority disparities research topics in PEC.

A Social Media-Based Public Health Campaign to Reduce Indoor Tanning in High-Risk Populations.

Introduction: Indoor tanning beds cause more than 450,000 new skin cancers each year, yet their use remains common, with a global indoor tanning prevalence of 10.4%. Social media provides an opportunity for cost-effective, targeted public health messaging. We sought to direct Instagram users at high risk of indoor tanning to accurate health information about the risks of indoor tanning and to reduce indoor tanning bed use. Methods: We disseminated a public health campaign on Instagram on April 6-27, 2022 with 34 video and still-image advertisements. We had 2 target audiences at high risk of indoor tanning: women aged 18-30 years in Kentucky, Nebraska, Ohio, or Tennessee interested in indoor tanning and men aged 18-45 years in California interested in indoor tanning. To evaluate the impact of the campaign, we tracked online metrics, including website visits, and conducted an interrupted time-series analysis of foot traffic data in our target states for all tanning salons documented on SafeGraph from January 1, 2018 to 3 months after the campaign. Results: Our indoor tanning health information advertisements appeared on Instagram feeds 9.1 million times, reaching 1.06 million individuals. We received 7,004 views of our indoor tanning health information landing page (Average Time on Page of 56 seconds). We did not identify a significant impact on foot traffic data on tanning salons. Conclusions: We show the successful use of social media advertising to direct high-risk groups to online health information about indoor tanning. Future research quantifying tanning visits before and after indoor tanning interventions is needed to guide future public health efforts.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Antiracism, Black Lives Matter, and Critical Race Theory: The ABCs of Promoting Racial Equity in Pediatric Practice.

Police shootings of unarmed Black men, women, and children at the intersection of disparities in the setting of the coronavirus disease 2019 pandemic have resulted in a long overdue national awakening regarding race and racism in society. This article defines some of the key terms, providing a foundation to help promote equity in pediatric practice. Although no single article can result in full competency regarding such complex issues, it is meant to provide a foundation for pediatricians on a journey to deepen their knowledge and understanding toward a path to action. [Pediatr Ann. 2022;51(3):e95-e106.].

"It Makes Me a Better Person and Doctor": A Qualitative Study of Residents' Perceptions of a Curriculum Addressing Racism.

OBJECTIVE: Explore how pediatric residents perceive the impact of a curriculum addressing racism on their knowledge, motivation, skills and behaviors, and investigate the contextual factors that promote or impede the curriculum's effectiveness. METHODS: Open-ended, semistructured interviews were conducted at 2 academic medical centers between August 2019 and 2020 among pediatric residents who participated in the curriculum. Interviews were recorded, transcribed, and analyzed by using inductive content analysis. RESULTS: Pediatric residents (n = 16) were predominantly white (66.7%), female (86.7%) interns (60%) from the Midwest (40%). Six major themes emerged describing the perceived impact of the curriculum on: knowledge - (1) Understanding of race and racism as structural forces in a historical context; motivation - (2) Owning the issue of racism, (3) Having the curriculum makes a statement; skills - (4) Critical self-reflection, (5) Perceived development of skills to mitigate biases; and action-planning - (6) Turning insight into strategies to combat racism and improve patient care. Two additional themes emerged describing contextual factors that promoted or impeded the curriculum such as the content of the curriculum itself, the racial demographics of the participants, the implementation infrastructure and environmental factors such as the culture of the training program. CONCLUSIONS: Medical education addressing racism can facilitate the perceived acquisition of foundational knowledge regarding race and racism; motivation and skill-building to combat racism; and action planning aimed at improving patient care. Contextual factors should be considered when developing and implementing such curricula to not only promote racial equity but avoid unintended harms.

Effects of a Curriculum Addressing Racism on Pediatric Residents' Racial Biases and Empathy.

Background: Racism is a longstanding driver of health inequities. Although medical education is a potential solution to address racism in health care, best practices remain unknown. Objective: We sought to evaluate the impact of participation in a curriculum addressing racism on pediatric residents' racial biases and empathy. Methods: A pre-post survey study was conducted in 2 urban, university-based, midsized pediatric residency programs between July 2019 and June 2020. The curriculum sessions included Self-Reflection on Implicit Bias, Historical Trauma, and Structural Racism. All sessions were paired with empathy and perspective-taking exercises and were conducted in small groups to facilitate reflective discussion. Wilcoxon signed rank tests were used to assess changes in racial bias and empathy. Linear regression was used to assess the effect of resident characteristics on racial bias and empathy. Results: Ninety of 111 residents receiving the curriculum completed pre-surveys (81.1%), and among those, 65 completed post-surveys (72.2%). Among participants with baseline pro-White bias, there was a statistically significant shift (0.46 to 0.36, P=.02) toward no preference. Among participants with a baseline pro-Black bias, there was a statistically significant shift (-0.38 to -0.21, P=.02), toward no preference. Among participants with baseline pro-White explicit bias, there was a statistically significant shift (0.54 to 0.30, P<.001) toward no preference. Among all residents, there was a modest but statistically significant decrease in mean empathy (22.95 to 22.42, P=.03). Conclusions: Participation in a longitudinal discussion-based curriculum addressing racism modestly reduced pediatric residents' racial preferences with minimal effects on empathy scales.

Myopericarditis in a previously healthy adolescent male following COVID-19 vaccination: A case report.

We report the case of a previously healthy 16-year-old male who developed myopericarditis following the second dose of his Pfizer-BioNTech COVID-19 vaccine, with no other identified triggers. Adolescents and young adults experiencing chest pain after COVD-19 vaccination should seek emergent medical care, and emergency providers should have a low threshold to consider and evaluate for myopericarditis. More data are needed to better understand the potential association between COVID-19 vaccines and myopericarditis. If a true causal link is identified, the risk must also be viewed in context with the millions of patients who have been safely vaccinated and the known morbidity and mortality from COVID-19 infection. As we see widespread vaccine rollout, it is important that all potential adverse reactions are reported as we continue to monitor for more rare but potentially serious side effects not identified in vaccination trials.

Executions and Police Conflicts Involving Children, Adolescents and Young Adults.

Police violence in the United States represents a pressing public health crisis impacting youth, particularly youth of color. This article reviews the recent epidemiology of police executions and conflicts involving children, adolescents, and young adults. The roles of social determinants of health and centuries-long history of white supremacy and racism as root causes of adverse policing are emphasized. The article summarizes the evidence as to how direct and vicarious experiences of police violence impact youth academic, behavioral, and health outcomes. Recommendations are provided for pediatricians to address this public health crisis through clinical practice, education, advocacy, and research.