Pre-surgical factors related to latent trajectories of 5-year weight loss for a diverse bariatric surgery population.

BACKGROUND: Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery. OBJECTIVES: The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence. SETTING: Large integrated health system in Southern California with 11 surgical practices and 23 surgeons. METHODS: A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey. RESULTS: For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies. CONCLUSIONS: Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Trends in firearm injury in a southern California health care system from 2010 to 2020.

BACKGROUND: Firearm injury is a significant public health concern in the United States. METHODS: Data on fatal and nonfatal firearm injuries were obtained from a cohort of N = 7,473,650 members of Kaiser Permanente Southern California, a large integrated healthcare system between 2010 and 2020. Age-adjusted rates of combined fatal and nonfatal firearm injury per 100,000 members were calculated by year, with the 2010 US census as the reference population. Trends were evaluated using Poisson or negative binomial regression. RESULTS: There was an increasing trend in overall firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system (p < .0001), primarily driven by non-self-inflicted firearm injuries (p < .0001). Self-inflicted injuries decreased during this time (p = .01). Injuries among youth showed no significant change. CONCLUSION: There was an increasing trend in firearm injuries between 2010 and 2020 among adults in this large integrated healthcare system, primarily driven by non-self-inflicted firearm injuries; however, self-inflicted injuries decreased during this time. Injuries among youth showed no significant change.

Factors Associated With Firearm Injury Among Pediatric Members of a Large Integrated Healthcare System.

BACKGROUND AND OBJECTIVES: Few studies have tested multiple socio-ecological risk factors assocated with firearm injury among pediatric populations and distinguished self-inflicted from non-self-inflicted injury. To address this gap, the current study examined demographic, individual psychosocial, and neighborhood variables as risk factors for firearm injury among a large cohort of children and adolescents. METHODS: Retrospective cohort study. Data were obtained from the electronic health records of a large integrated healthcare system. The cohort included children <18 years with at least one clinical encounter between January 1, 2010 and December 31, 2018. Poisson regression was used to examine demographic (age, gender, race and ethnicity, Medicaid status), psychosocial (depression, substance use disorder, medical comorbidities), and neighborhood education variables as potential risk factors for non-self-inflicted and self-inflicted firearm injuries. RESULTS: For non-self-inflicted injury, the highest relative risk was found for children age 12-17 years old compared to 0-5 year olds (RR = 37.57); other risk factors included male gender, Black and Hispanic race and ethnicity (compared to White race), being a Medicaid recipient, lower neighborhood education, and substance use disorder diagnosis. For self-inflicted injury, only age 12-17 years old and male gender were associated with increased risk. CONCLUSIONS: These results reinforce the established higher risk for firearm injury among adolescent males, highlight differences between self-inflicted and non-self-inflicted injuries, and the need to consider demographic, psychosocial, and neighborhood variables as risk factors to inform interventions aimed to reduce firearm injuries among children and adolescents.

Assessment of Screening for Adverse Childhood Experiences and Receipt of Behavioral Health Services Among Children and Adolescents.

Importance: Screening for adverse childhood experiences (ACEs) in primary care settings has been increasing as a response to the overwhelming and consistent evidence of the deleterious associations between ACEs and later physical and mental health. However, there is little empirical guidance on the appropriate implementation of ACEs screening in pediatric primary care. Objective: To test the use of a pilot intervention for ACEs screening and referral on the receipt of behavioral health care for children and adolescents within a large integrated health care delivery system. Design, Setting, and Participants: A retrospective cohort study was conducted in a large integrated health care system serving Southern California. Child and adolescent members of the target health care system younger than 18 years between July 1, 2018, and November 30, 2021, who received a positive screening for ACEs at the pilot clinic were included. This pilot clinic implemented an intervention that included additional screening questions and incorporated social workers into the process of evaluation and referral for behavioral health needs following ACEs screening. Exposures: ACEs screening. Main Outcomes and Measures: Visit to a behavioral health care service within 90 days of a positive ACEs screen determined as a score of 1 or higher and behavioral symptoms. Results: The cohort consisted of 4030 children (mean [SD] age, 9.94 [4.55] years) with positive ACEs screening, 48% adolescents (11-17.99 years), approximately equal gender (51% females), 73% Hispanic, and 33% with Medicaid insurance. After the intervention, children were more likely to have a behavioral health services visit within 90 days of the screening than before the intervention (from 4.33% to 32.48%; incidence rate ratio, 7.50; 95% CI, 1.55-36.2). Conclusions and Relevance: In this cohort study, the implementation of a new ACEs screening and referral process was associated with increased receipt of behavioral health services among children with a positive ACEs screening. This could be useful strategy for other health care systems responding to state and local mandates to screen and provide care for children with ACEs.

Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018.

The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status.

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.

The Implementation of Screening for Adverse Childhood Experiences in Pediatric Primary Care.

OBJECTIVE: To assess the implementation of screening, screening rates, and prevalence of adverse childhood experiences (ACEs) in a large integrated healthcare system. STUDY DESIGN: Kaiser Permanente Southern California is a large integrated healthcare system with 15 medical centers/hospitals and 233 medical office buildings that serve approximately 1.5 million children. Screening for ACEs began in July 2018 at 1 medical center (Downey, Bellflower medical office) for 3- and 5-year-old well-child visits (yearly physical examination). It quickly expanded to 3 other medical centers (6 clinics in total) and now also includes the 10- and 13-year-old well-child visits. RESULTS: Since July 2018 we have screened 3241 3-year-olds (53% of the target population), 2761 5-year-olds (53%), 545 10-year-olds (37%), and 509 13-year-olds (13%). Of the 3-year-olds who were screened, 15% had an ACEs score of 1 or higher. Of the 5-year-olds that were screened, 17.5% had an ACEs score of 1 or higher. Of the 10-year-olds, 30.5% had an ACEs score of 1 or higher and of the 13-year-olds, 33.8% had an ACEs score of 1 or higher. CONCLUSIONS: Although we have encountered some challenges, particularly with follow-up for those screening positive for ACEs, screening was feasible. The data show an increasing trend of ACEs in 3- to 13-year-old children, highlighting the need for early education about ACEs to mitigate the effects of toxic stress.

Childhood Sexual Abuse and Early Timing of Puberty.

PURPOSE: The purpose was to examine whether the timing of puberty, indexed by breast development and pubic hair development, was earlier for sexually abused females compared with a matched comparison group of nonabused females, controlling for key alternative confounds. METHODS: A cohort of sexually abused females and matched comparisons was followed longitudinally at mean ages 11 through 20 years. Sexually abused participants (N = 84) were referred by protective services. Comparison participants (N = 89) were recruited to be comparable in terms of age, ethnicity, income level, family constellation, zip codes, and nonsexual trauma histories. Stage of puberty was indexed at each assessment by nurse and participant ratings of breast and pubic hair development using Tanner staging-the gold standard for assessing pubertal onset and development. Cumulative logit mixed models were used to estimate the association between sexual abuse status and the likelihood of transitioning from earlier to later Tanner stage categories controlling for covariates and potential confounds. RESULTS: Sexual abuse was associated with earlier pubertal onset: 8 months earlier for breasts (odds ratio: 3.06, 95% CI: 1.11-8.49) and 12 months earlier for pubic hair (odds ratio: 3.49, 95% CI: 1.34-9.12). Alternative explanations including ethnicity, obesity, and biological father absence did not eradicate these findings. CONCLUSIONS: This study confirms an association between exposure to childhood sexual abuse and earlier pubertal onset. Results highlight the possibility that, due to this early onset, sexual abuse survivors may be at increased risk for psychosocial difficulties, menstrual and fertility problems, and even reproductive cancers due to prolonged exposure to sex hormones.

Exposure to peer delinquency as a mediator between self-report pubertal timing and delinquency: a longitudinal study of mediation.

This study examined exposure to peer delinquency as a mediator between pubertal timing and self-reported delinquency longitudinally and whether this mediational model was moderated by either gender or maltreatment experience. Data were obtained from Time 1, 2, and 3 of a longitudinal study of maltreatment and development. At Time 1 the sample comprised 454 children aged 9-13 years. Analyses via structural equation modeling supported full mediation. Gender did not moderate this mediational relationship, but maltreatment experience did. The results show that early maturing males and females are both at risk for being exposed to peers that may draw them into delinquent behavior. In addition, the mechanism linking early pubertal timing to delinquency differs depending on maltreatment experience.