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The legal and medical rights of lesbian, gay, bisexual, transgender, queer (LGBTQ+) and other gender and sexual minority (GSM) youth are under attack in the United States. Approximately 160 anti-LGBTQ+ bills were proposed across the United States during the 2021 legislative session, with 70% of states considering at least one anti-LGBTQ+ bill. Over one hundred of the proposed bills specifically target transgender youth and have already resulted in the prohibition of nearly 85,000 13-17-year-old trans youth from participating in sports as their affirmed gender. Such legislation directly impacts the health of youth including in Arkansas and Tennessee which passed bills that limit youth access to evidenced-based, gender-affirming care; in February 2022, the governor of Texas directed state agencies to investigate gender-affirming care for trans youths as 'child abuse'. Despite these anti-LGBTQ+ proposed and passed laws, 22 states have full non-discrimination protections for LQBTQ+ individuals, and 24 states have laws that protect LGBTQ+ students from bullying on the basis of their sexual orientation and/or gender identity. Civil rights policies have the power to grant protections to LGBTQ+ youth under the law. Conversely, the rollback of those liberties may lead to irreparable harm and preventable deaths. The consequences of anti-LGBTQ+ legislation can additionally deleteriously affect local and state economies as companies and organizations move to supportive communities. Clinicians can, and should, play an important role to engage stakeholders and advocate for LGBTQ+ inclusive policies at the institutional, local, state, and national policy level.
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Homosexualidad Femenina , Minorías Sexuales y de Género , Personas Transgénero , Adolescente , Femenino , Humanos , Masculino , Identidad de Género , Políticas , Conducta Sexual , Estados UnidosRESUMEN
OBJECTIVE: To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US. STUDY DESIGN: This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics. RESULTS: In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81). CONCLUSIONS: Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.
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Salud Infantil , Características de la Residencia , Niño , Estudios Transversales , Servicio de Urgencia en Hospital , Vivienda , Humanos , Estados UnidosRESUMEN
Emergency departments frequently serve marginalized populations. Spanish-speaking families who come to the ED often have high rates of unmet social needs. Our study investigated how to efficiently screen families for unmet social needs in an emergency department. Participants who screened positive for needs were referred to geographically convenient, community-based resources. It became clear that barriers related to language discordance existed for recruiting Spanish-speaking participants that were not present for English-speaking participants, which we believe exacerbate existing inequities and must be addressed. We advocate for the extension of the Affordable Care Act Section 1557 to mandate expanded teams of interpreters to meet both clinical and research demands in conjunction with purposeful hiring of multilingual research assistants, along with concerted effort to standardize the certification process for multilingual staff. Prohibitive costs for the translation of written research materials need to be decreased and journals should evaluate submitted research with a language equity lens, which will help the field of clinical research prioritize inclusivity and diversity in research populations. Currently, systemic barriers complicate enrolling research participants who speak a language other than English, and we believe the proposed changes are feasible solutions to overcome these obstacles. Equitable representation in research is a critical part of addressing the legacy of oppression and exclusion within healthcare systems. Language equity is not a panacea for the distrust and systemic racism patients of color experience within our healthcare system that often prevent participation in clinical research, but it is a key first step.
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Lenguaje , Multilingüismo , Barreras de Comunicación , Humanos , Patient Protection and Affordable Care Act , Atención Dirigida al Paciente , Estados UnidosRESUMEN
INTRODUCTION AND HYPOTHESIS: Obstetrical external anal sphincter (EAS) injury and subsequent dysfunction are leading risk factors for female fecal incontinence (FI). Limited knowledge of the EAS structure-function relationship hinders treatment optimization. We directly measured functionally relevant intrinsic parameters of human EAS and tested whether vaginal delivery alters the EAS structure-function relationship. METHODS: Major predictors of in vivo EAS function were compared between specimens procured from vaginally nulliparous (VN, n = 5) and vaginally parous (VP, n = 7) cadaveric donors: operational sarcomere length (Ls), which dictates force-length relationship; physiological cross-sectional area (PCSA), which determines isometric force-generating capacity; fiber length (Lfn), responsible for muscle excursion and contractile velocity; and muscle stiffness. Data were analyzed using unpaired and paired t tests, α < 0.05. Results are presented as mean ± SEM. RESULTS: The VN and VP (median parity 3) groups were similar in age and BMI. No gross anatomical defects were identified. EAS Ls (2.36 ± 0.05 µm) was shorter than the optimal Lso (2.7 µm), at which contractile force is maximal, P = 0.0001. Stiffness was lower at Ls than Lso (5.4 ± 14 kPa/µm vs 35.3 ± 12 kPa/µm, P < 0.0001). This structural design allows active and passive tension to increase with EAS stretching. EAS relatively long Lfn (106 ± 24.8 mm) permits rapid contraction without decreased force, whereas intermediate PCSA (1.3 ± 0.3 cm2) is conducive to maintaining resting tone. All parameters were similar between groups. CONCLUSIONS: This first direct examination of human EAS underscores how EAS intrinsic design matches its intended function. Knowledge of the EAS structure-function relationship is important for understanding the pathogenesis of FI and the optimization of treatments for EAS dysfunction.
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Canal Anal/anatomía & histología , Canal Anal/fisiología , Incontinencia Fecal/fisiopatología , Sarcómeros/patología , Sarcómeros/fisiología , Canal Anal/patología , Incontinencia Fecal/etiología , Femenino , Humanos , Contracción Muscular/fisiología , EmbarazoRESUMEN
INTRODUCTION AND HYPOTHESIS: Animal models are essential to further our understanding of the independent and combined function of human pelvic floor muscles (PFMs), as direct studies in women are limited. To assure suitability of the rhesus macaque (RM), we compared RM and human PFM architecture, the strongest predictor of muscle function. We hypothesized that relative to other models, RM best resembles human PFM. METHODS: Major architectural parameters of cadaveric human coccygeus, iliococcygeus, and pubovisceralis (pubococcygeus + puborectalis) and corresponding RM coccygeus, iliocaudalis, and pubovisceralis (pubovaginalis + pubocaudalis) were compared using 1- and 2-way analysis of variance (ANOVA) with post hoc testing. Architectural difference index (ADI), a combined measure of functionally relevant structural parameters predictive of length-tension, force-generation, and excursional muscle properties was used to compare PFMs across RM, rabbit, rat, and mouse. RESULTS: RM and human PFMs were similar with respect to architecture. However, the magnitude of similarity varied between individual muscles, with the architecture of the most distinct RM PFM, iliocaudalis, being well suited for quadrupedal locomotion. Except for the pubovaginalis, RM PFMs inserted onto caudal vertebrae, analogous to all tailed animals. Comparison of the PFM complex architecture across species revealed the lowest, thus closest to human, ADI for RM (1.9), followed by rat (2.0), mouse (2.6), and rabbit (4.7). CONCLUSIONS: Overall, RM provides the closest architectural representation of human PFM complex among species examined; however, differences between individual PFMs should be taken into consideration. As RM is closely followed by rat with respect to PFM similarity with humans, this less-sentient and substantially cheaper model is a good alternative for PFM studies.
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Macaca mulatta/anatomía & histología , Diafragma Pélvico/anatomía & histología , Adulto , Animales , Colágeno/análisis , Femenino , Humanos , Persona de Mediana Edad , Músculo Esquelético/químicaRESUMEN
OBJECTIVE: The aim of this study is to describe the changes in term fetal heart tracings after magnesium exposure. MATERIALS AND METHODS: This was a retrospective cohort study of consecutive women delivering at a gestational age of ≥ 37 weeks with severe preeclampsia, receiving magnesium for seizure prophylaxis. Overall 90 minutes of electronic fetal monitoring (30 before magnesium, 30 during magnesium bolus, and 30 during steady state infusion) was prospectively interpreted by formally trained and blinded research nurses using American Congress of Obstetricians and Gynecologists guidelines. Multivariable analyses were performed using generalized estimating equations, comparing preexposure patterns to bolus, and steady state. RESULTS: Out of the 238 women evaluated, an average decrease of 2.4 beats per minute (p = 0.02) was found after magnesium bolus. This persisted into the steady state (p < 0.01). Minimal/absent variability increased during bolus infusion (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.10-5.62) but corrected by steady state (OR 1.44, 95% CI 0.76-2.80). There were no significant changes in the fetal heart rate (FHR) baseline < 120, tachycardia, or presence of accelerations or decelerations. CONCLUSION: Exposure to magnesium is associated with a transient decrease in variability and a clinically insignificant decrease in FHR baseline without an increased incidence in bradycardia or category change.
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Anticonvulsivantes/farmacología , Frecuencia Cardíaca Fetal/efectos de los fármacos , Sulfato de Magnesio/farmacología , Adolescente , Adulto , Cardiotocografía , Femenino , Humanos , Preeclampsia/tratamiento farmacológico , Embarazo , Estudios Retrospectivos , Convulsiones/prevención & control , Adulto JovenRESUMEN
INTRODUCTION: Health-related social problems may be conceptualized as the presence of either a social risk (i.e., food insecurity as defined by a screening tool) or a social need (i.e., desire for referral to a food program). Identification of social risks may not correlate with patients' desire to receive help. This study aimed to identify and compare patients and families with social risks versus social needs in a pediatric emergency department. METHODS: This was a planned secondary analysis conducted in 2023 of a previously published prospective intervention study, which screened and referred caregivers and adult patients for health-related social problems in an urban tertiary pediatric emergency department between May 2019 and October 2020. Participants completed a screening tool for social risks and self-identified social needs by selecting desired assistance from a list of social service categories. Participants' social risk screening results were compared with their selection of resources for social needs across demographic and socioeconomic characteristics and the number of positive social risks using chi-squared or Fisher's exact tests. RESULTS: Of 258 participants, 42.2% (109) screened positive for any social risk, and 38.0% (98) self-selected a social need. Of those, only 59.2% (77/130) both screened positive and self-selected a need. Among those who screened positive for a social risk, several demographic and socioeconomic factors including race, ethnicity, and income were significantly different between those interested versus not interested in assistance. CONCLUSIONS: Both social risks and self-identified social needs should be considered within social care interventions in the pediatric healthcare setting.
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Servicio de Urgencia en Hospital , Inseguridad Alimentaria , Humanos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Masculino , Niño , Estudios Prospectivos , Adolescente , Adulto , Preescolar , Evaluación de Necesidades , Factores SocioeconómicosRESUMEN
Importance: Many US children and adolescents with mental and behavioral health (MBH) conditions do not access MBH services. One contributing factor is limited insurance coverage, which is influenced by state MBH insurance parity legislation. Objective: To investigate the association of patient-level factors and the comprehensiveness of state MBH insurance legislation with perceived poor access to MBH care and perceived inadequate MBH insurance coverage for US children and adolescents. Design, Setting, and Participants: This retrospective cross-sectional study was conducted using responses by caregivers of children and adolescents aged 6 to 17 years with MBH conditions in the National Survey of Children's Health and State Mental Health Insurance Laws Dataset from 2016 to 2019. Data analyses were conducted from May 2022 to January 2024. Exposure: MBH insurance legislation comprehensiveness defined by State Mental Health Insurance Laws Dataset (SMHILD) scores (range, 0-7). Main Outcomes and Measures: Perceived poor access to MBH care and perceived inadequacy of MBH insurance were assessed. Multivariable regression models adjusted for individual-level characteristics. Results: There were 29â¯876 caregivers of children and adolescents with MBH conditions during the study period representing 14â¯292â¯300 youths nationally (7â¯816â¯727 aged 12-17 years [54.7%]; 8â¯455â¯171 male [59.2%]; 292â¯543 Asian [2.0%], 2â¯076â¯442 Black [14.5%], and 9â¯942â¯088 White [69.6%%]; 3â¯202â¯525 Hispanic [22.4%]). A total of 3193 caregivers representing 1â¯770â¯492 children and adolescents (12.4%) perceived poor access to MBH care, and 3517 caregivers representing 1â¯643â¯260 of 13â¯175â¯295 children and adolescents (12.5%) perceived inadequate MBH insurance coverage. In multivariable models, there were higher odds of perceived poor access to MBH care among caregivers of Black (adjusted odds ratio [aOR], 1.35; 95% CI, 1.04-1.75) and Asian (aOR, 1.69; 95% CI, 1.01-2.84) compared with White children and adolescents. As exposures to adverse childhood experiences (ACEs) increased, the odds of perceived poor access to MBH care increased (aORs ranged from 1.68; 95%, CI 1.32-2.13 for 1 ACE to 4.28; 95% CI, 3.17-5.77 for ≥4 ACEs compared with no ACEs). Compared with living in states with the least comprehensive MBH insurance legislation (SMHILD score, 0-2), living in states with the most comprehensive legislation (SMHILD score, 5-7) was associated with lower odds of perceived poor access to MBH care (aOR, 0.79; 95% CI, 0.63-0.99), while living in states with moderately comprehensive legislation (score, 4) was associated with higher odds of perceived inadequate MBH insurance coverage (aOR, 1.23; 95% CI, 1.01-1.49). Conclusions and Relevance: In this study, living in states with the most comprehensive MBH insurance legislation was associated with lower odds of perceived poor access to MBH care among caregivers for children and adolescents with MBH conditions. This finding suggests that advocacy for comprehensive mental health parity legislation may promote improved child and adolescent access to MBH services.
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Accesibilidad a los Servicios de Salud , Cobertura del Seguro , Servicios de Salud Mental , Humanos , Niño , Adolescente , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Estudios Transversales , Masculino , Femenino , Estados Unidos , Cobertura del Seguro/estadística & datos numéricos , Cobertura del Seguro/legislación & jurisprudencia , Estudios Retrospectivos , Servicios de Salud Mental/legislación & jurisprudencia , Servicios de Salud Mental/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Seguro de Salud/legislación & jurisprudencia , Trastornos MentalesRESUMEN
Mixed lineage kinase 3 (MLK3) is a mitogen-activated protein kinase kinase kinase (MAP3K) that activates MAPK signaling pathways and regulates cellular responses such as proliferation, migration and apoptosis. Here we report high levels of total and phospho-MLK3 in ovarian cancer cell lines in comparison to immortalized nontumorigenic ovarian epithelial cell lines. Using small interfering RNA (siRNA)-mediated gene silencing, we determined that MLK3 is required for the invasion of SKOV3 and HEY1B ovarian cancer cells. Furthermore, mlk3 silencing substantially reduced matrix metalloproteinase (MMP)-1, -2, -9 and -12 gene expression and MMP-2 and -9 activities in SKOV3 and HEY1B ovarian cancer cells. MMP-1, -2, -9 and-12 expression, and MLK3-induced activation of MMP-2 and MMP-9 requires both extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK) activities. In addition, inhibition of activator protein-1 (AP-1) reduced MMP-1, MMP-9 and MMP-12 gene expression. Collectively, these findings establish MLK3 as an important regulator of MMP expression and invasion in ovarian cancer cells.
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Quinasas Quinasa Quinasa PAM/metabolismo , Metaloproteinasas de la Matriz/genética , Neoplasias Ováricas/enzimología , Neoplasias Ováricas/patología , Femenino , Perfilación de la Expresión Génica , Humanos , Quinasas Quinasa Quinasa PAM/genética , Metaloproteinasas de la Matriz/metabolismo , Invasividad Neoplásica/genética , Invasividad Neoplásica/patología , Neoplasias Ováricas/metabolismo , Fosforilación , Reacción en Cadena en Tiempo Real de la Polimerasa , Factor de Transcripción AP-1/metabolismo , Células Tumorales Cultivadas , Proteina Quinasa Quinasa Quinasa 11 Activada por MitógenoRESUMEN
ABSTRACT: A 2012 Massachusetts shelter eligibility regulation required many families to spend a night in a location "not meant for human habitation" before qualifying for the state-run shelter system, and many families experiencing homelessness stayed in pediatric emergency departments (EDs) overnight to meet this requirement. ED clinicians initially recognized an increase in ED visits for homelessness after this regulation and began compiling and sharing stories with key institutional and community partners and stakeholders. To bolster advocacy efforts, the authors collected data on the magnitude of the problem and its associated health care costs. Guided by the policy knowledge of community partners, the authors leveraged the expertise and advocacy power of clinicians to share these data and stories with legislators via written and oral testimony, community events, and the media. Academic publication lent additional credibility and exposure to their research. In 2019, the Massachusetts Legislature passed budget language to overturn the 2012 shelter eligibility regulation. However, despite this policy victory, some families continue to present to EDs for homelessness. Therefore, current advocacy efforts have shifted focus toward implementation and enforcement of the new policy, monitoring issues, and developing new programmatic responses. In this advocacy case study, we illustrate how clinicians have unique abilities to serve as effective advocates for social policy change using a framework of strategies including storytelling, coalition building, tailored communication, and data sharing. Partnering with existing advocacy networks within their institution and community enhances the advocacy efforts of all stakeholders to influence social and health outcomes for children and families.
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Personas con Mala Vivienda , Niño , Humanos , Problemas Sociales , Vivienda , Costos de la Atención en Salud , Agencias GubernamentalesRESUMEN
Importance: Infant mortality in the United States is highest among peer nations; it is also inequitable, with the highest rates among Black infants. The association between tax policy and infant mortality is not well understood. Objective: To examine the association between state-level tax policy and state-level infant mortality in the US. Design, Setting, and Participants: This state-level, population-based cross-sectional study investigated the association between tax policy and infant mortality in the US from 1996 through 2019. All US infant births and deaths were included, with data obtained from the National Center for Health Statistics. Data were analyzed from November 28, 2021, to July 9, 2022. Exposures: State-level tax policy was operationalized as tax revenue per capita and tax progressivity. The Suits index was used to measure tax progressivity, with higher progressivity indicating increased tax rates for wealthier individuals. Main Outcomes and Measures: The association between tax policy and infant mortality rates was analyzed using a multivariable, negative binomial, generalized estimating equations model. Since 6 years of tax progressivity data were available (1995, 2002, 2009, 2012, 2014, and 2018), 300 state-years were included. Adjusted incidence rate ratios (aIRRs) were calculated controlling for year, state-level demographic variables, federal transfer revenue, and other revenue. Secondary analyses were conducted for racial and ethnic subgroups. Results: There were 148â¯336 infant deaths in the US from 1996 through 2019, including 27â¯861 Hispanic infants, 1882 non-Hispanic American Indian or Alaska Native infants, 5792 non-Hispanic Asian or Pacific Islander infants, 41â¯560 non-Hispanic Black infants, and 68â¯666 non-Hispanic White infants. The overall infant mortality rate was 6.29 deaths per 1000 live births. Each $1000 increase in tax revenue per capita was associated with a 2.6% decrease in the infant mortality rate (aIRR, 0.97; 95% CI, 0.95-0.99). An increase of 0.10 in the Suits index (ie, increased tax progressivity) was associated with a 4.6% decrease in the infant mortality rate (aIRR, 0.95; 95% CI, 0.91-0.99). Increased tax progressivity was associated with decreased non-Hispanic White infant mortality (aIRR, 0.95; 95% CI, 0.91-0.99), and increased tax revenue was associated with increased non-Hispanic Black infant mortality (aIRR, 1.04; 95% CI, 1.01-1.08). Conclusions and Relevance: In this cross-sectional study, an increase in tax revenue and the Suits index of tax progressivity were both associated with decreased infant mortality. These associations varied by race and ethnicity. Tax policy is an important, modifiable social determinant of health that may influence state-level infant mortality.
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Etnicidad , Mortalidad Infantil , Impuestos , Humanos , Lactante , Estudios Transversales , Hispánicos o Latinos , Políticas , Estados Unidos , Indio Americano o Nativo de Alaska , Blanco , Negro o AfroamericanoRESUMEN
Research suggests that increased voting among adults is associated with improved child health. Despite the benefits of voting, the United States has low voter turnout compared with peer nations. Turnout is especially low among marginalized people in the United States. Voter registration is essential for increasing voter turnout, and registration efforts have been successfully carried out in clinical settings. Working with a nonprofit called Vot-ER, we advocated for nonpartisan voter registration efforts in pediatric settings nationwide preceding the November 2020 US elections. We describe lessons learned from these efforts. Using data obtained from Vot-ER, we also provide the first estimates of participation in a national voter registration campaign in pediatric settings. There was widespread engagement in voter registration efforts among pediatricians in 2020. Many lessons were learned from these efforts, including the benefits of advanced planning because registration deadlines can be up to 1 month in advance of Election Day. Obtaining buy-in from numerous stakeholders (e.g., health center leadership, public relations teams) supports widespread staff participation. Also important is to consider the tradeoffs between active voter registration (in which staff can broach the topic of voting with patients and families) and passive efforts (in which voting is discussed only if patients or families inquire about it). These and other lessons can inform future voter registration efforts in diverse pediatric settings across the country.
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Política , Adulto , Humanos , Estados UnidosRESUMEN
OBJECTIVE: To explore barriers, facilitators, and benefits of collaboration between academic pediatricians and institutional offices of government relations (OGR) to enhance policy advocacy efforts. METHODS: The Academic Pediatric Associations' Health Policy Scholars met with the government relations team in their affiliated institutions as part of their experiential learning curriculum. Afterward, they submitted written reflections, which were coded and analyzed using inductive qualitative content analysis to identify key themes. RESULTS: Reflections were completed by 21 of 23 (91.3%) participants. Most participants (76.2%) were faculty at free-standing children's hospitals and had been at their institutions <5 years (52.3%) or 5 to 10 years (33.3%). Institutional OGR structure varied widely and not all institutions had well-defined priorities. Key themes of the reflections included that OGRs often had dynamic priorities and fiscal considerations frequently took precedence. Barriers to physician involvement with OGR are often related to difficulty identifying the correct staff contact and not having the time and support for advocacy work. Facilitators included leveraging existing relationships and collaborations, including those of peer or mentor connections to the OGR staff. Anticipated benefits to both OGR and physicians included improved knowledge of advocacy opportunities, enhanced advocacy efforts leveraging physicians' expertise and patient stories, and message alignment and amplification of physician and institutional advocacy work. CONCLUSIONS: Collaboration between physician-advocates and institutional OGR is feasible and, with orientation and mentorship, may facilitate improved physician and institutional policy advocacy efforts. Supporting this type of collaboration may enhance physician and institutional advocacy on behalf of their shared patients and communities.
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OBJECTIVE: Many families in pediatric emergency departments (PED) have unmet social needs, which may be detected and addressed with the use of a digital social needs intervention. Our objective was to characterize the feasibility and effectiveness of utilizing personal phones or a PED tablet for screening and referral to social services. METHODS: We conducted a prospective single-arm intervention study using a convenience sample of caregivers and adult patients in an urban PED between May 2019 and October 2020. Participants chose either their personal phone or a PED-provided tablet to use an app, "HelpSteps." Participants self-selected need(s) then referrals to service agencies. Participants completed a 1-month follow-up. Clinicians were surveyed about screening and impact on visit. RESULTS: Of 266 participants enrolled, 55% of participants elected to use their personal phone. Of all participants, 67% self-selected at least 1 health-related social need; 34% selected 3 or more. The top 3 "most important" needs were housing (14%), education (12%), and fitness (12%). At one month follow-up, 44% of participants reported their top need was "completely" or "somewhat" solved. For 95% of encounters, clinicians reported the intervention did not increase length of stay. CONCLUSIONS: A mobile social needs intervention was feasible and effective at identifying and referring participants in the PED setting. While more than half of participants used their personal phones, several smartphone owners cited barriers and elected to use a tablet. Overall, participants found the app easy to use, appropriate for the PED, and the intervention had minimal impact on clinical flow.
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Servicio de Urgencia en Hospital , Teléfono , Niño , Adulto , Humanos , Estudios Prospectivos , Encuestas y Cuestionarios , Derivación y ConsultaRESUMEN
INTRODUCTION: The objective of this study was to determine the rates and trends in the reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity in published pediatric clinical trials. METHODS: A cross-sectional study of pediatric clinical trials conducted in the U.S. published from January 1, 2011 through December 31, 2020 in 5 general pediatric and 5 general medical journals with the highest impact factor in their respective fields was performed. Outcomes were reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity. In late 2021, descriptive statistics and logistic regression to understand how reporting of preferred language and socioeconomic factors changed over time were performed. RESULTS: Of 612 trials, 29.6% (n=181) reported preferred language. Among these, 64.6% (n=117 of 181) exclusively enrolled participants whose preferred language was English. From 2011 to 2020, there was a relative increase in the reporting of preferred language (8.6% per year, 95% CI=1.8, 16.0). Socioeconomic factors were reported in 47.9% (n=293) of trials. There was no significant change in the reporting of socioeconomic factors (8.2% per year, 95% CI= -1.9, 15.1). Only 5.1% (9 of 179) of published trial results among adolescent participants reported any measure of sexual orientation, and 1.1% (2 of 179) reported gender identity. CONCLUSIONS: Preferred language, socioeconomic factors, sexual orientation, and gender identity were infrequently reported in pediatric clinical trial results despite these characteristics being increasingly recognized as social determinants of health. To achieve more inclusiveness and to reduce unmeasured disparities, these characteristics should be incorporated into routine trial registration, design, funding decisions, and reporting.
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Identidad de Género , Determinantes Sociales de la Salud , Adolescente , Humanos , Masculino , Femenino , Niño , Estudios Transversales , Conducta Sexual , Factores SocioeconómicosRESUMEN
Indigenous Peoples suffer environmental violence related to pesticide exposure, including imported pesticides that are banned in the exporting countries (including the U.S.) due to their known detrimental health impacts and used in or near their traditional territories. The Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) is a U.S. statue that allows "pesticides that are not approved - or registered - for use in the U.S." to be manufactured in the U.S. and exported elsewhere. The UN Rotterdam Convention also allows the global exportation of "banned pesticides." The ongoing exportation of banned pesticides leads to disproportionately high rates of morbidity and mortality, most notably in Indigenous women and children. In this paper, we present evidence describing the documented harms of banned pesticides with a focus on the Yaqui Nation in Sonora, Mexico, give background on the problematic laws allowing these harms, and highlight concrete solutions.
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Importance: Equitable representation of participants who are members of racial and ethnic minority groups in clinical trials enhances inclusivity in the scientific process and generalizability of results. Objective: To assess participant race and ethnicity in pediatric clinical trials published from 2011 to 2020. Design, Setting, and Participants: This cross-sectional study examined articles reporting pediatric clinical trials conducted in the US published in 5 leading general pediatric and 5 leading general medical journals from January 1, 2011, to December 31, 2020. Main Outcomes and Measures: Reporting of participant race and ethnicity and comparison of enrolled participants vs US census populations of pediatric racial and ethnic groups in published clinical trials. Results: The study included 612 articles reporting pediatric clinical trials during the study period, with 565â¯618 total participants (median per trial, 200 participants [IQR, 90-571 participants]). Of the 612 articles, 486 (79.4%) reported participant race and 338 (55.2%) reported participant ethnicity. From 2011 to 2020, relative rates of reporting of participant race increased by 7.9% per year (95% CI, 0.2%-16.3% per year) and reporting of ethnicity increased by 11.4% per year (95% CI, 4.8%-18.4% per year). Among articles reporting race and ethnicity, the method of assignment was not reported in 261 of 511 articles (51.1%) and 207 of 359 articles (57.7%), respectively. Black/African American children were enrolled proportionally more than the US population of Black/African American children (odds ratio [OR], 1.88; 95% CI, 1.87-1.89). Hispanic/Latino children were enrolled commensurately with the US population of Hispanic/Latino children (OR, 1.02; 95% CI, 1.01-1.03). American Indian/Alaska Native (OR, 0.82; 95% CI, 0.79-0.85), Asian (OR, 0.56; 95% CI, 0.55-0.57), and Native Hawaiian/Pacific Islander (OR, 0.66; 95% CI, 0.61-0.72) children were enrolled significantly less compared with the respective US populations of these groups. White children were enrolled less than expected (OR, 0.84; 95% CI, 0.84-0.85) but represented 188â¯156 (46.0%) of participants in trials reporting race or ethnicity. Conclusions and Relevance: This cross-sectional study revealed that the proportion of published pediatric clinical trials that reported participant race and ethnicity increased from 2011 to 2020, but participant race and ethnicity were still underreported. Disparities existed in pediatric clinical trial enrollment of American Indian/Alaska Native, Asian, and Native Hawaiian/Pacific Islander children. The greater representation of Black/African American children compared with the US population suggests inclusive research practices that could be extended to other historically disenfranchised racial and ethnic groups.
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Etnicidad , Grupos Minoritarios , Niño , Estudios Transversales , Minorías Étnicas y Raciales , Humanos , Grupos Raciales , Estados UnidosRESUMEN
BACKGROUND AND OBJECTIVES: High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk. METHODS: Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk. RESULTS: Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children's toys and only 6.9% knew high-powered magnets were previously removed from the United States market. CONCLUSIONS: Over 90% of subjects from the IMPACT study didn't know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children's toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.
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Cuerpos Extraños , Imanes , Niño , Adulto , Humanos , Estados Unidos , Estudios Retrospectivos , Juego e Implementos de Juego , MorbilidadRESUMEN
BACKGROUND AND OBJECTIVES: High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market. METHODS: This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019. RESULTS: Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality. CONCLUSIONS: Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.
Asunto(s)
Cuerpos Extraños , Imanes , Adolescente , Niño , Ingestión de Alimentos , Endoscopía Gastrointestinal , Femenino , Cuerpos Extraños/epidemiología , Cuerpos Extraños/cirugía , Hospitales Pediátricos , Humanos , Imanes/efectos adversos , Masculino , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
Objective: Psychotic disorders are serious illnesses that are most amenable to early intervention. Though inpatient units are typically the first care setting for young people with psychosis, almost all early intervention work has been limited to outpatient settings. Social difficulties are a core feature of psychotic illnesses, and despite need for empirically supported social-skills treatments there are few interventions intended specifically for the developmental phase during which psychosis manifests (i.e., late teenage to early adult years). Method: Our group implemented an adapted social-skills training intervention (SST) designed for young adults on a psychiatric inpatient unit. Nineteen young adult inpatients (aged 18-35) with psychosis participated. Psychiatric symptoms and aspects of social functioning, including reported social self-efficacy and performance on social skills role-plays, were assessed before and after SST participation. Results: Preliminary data demonstrate improvements in both self-report and performance-based measures of social functioning after SST participation. Conclusions and Implications for Practice: These findings, though preliminary, support additional, larger-scale investigations of this SST among young adults with psychosis. Further, multidisciplinary collaborations are valuable in providing specialized care for young adults with psychosis who are receiving inpatient psychiatric care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).