Drivers of Variation in Diagnosis and Management of Eosinophilic Esophagitis: A Survey of Pediatric Gastroenterologists.

BACKGROUND: Widespread variation in the diagnosis and treatment of eosinophilic esophagitis (EoE) has previously been reported among adult gastroenterologists; however, variation in EoE practice in among pediatric populations is poorly characterized. The study objectives were to describe guideline adherence and understand reasons for variation in EoE practice among pediatric gastroenterologists following publication of the updated 2018 international EoE guidelines. METHODS: We developed and administered a 28-item survey to pediatric gastroenterologists via an email listserv using the PEDGI Bulletin Board from 03/2019 to 04/2019. The survey was developed using evidence-based review, expert validation, and cognitive interviews. Survey domains included respondent knowledge of and adherence to published guidelines, diagnostic and management approach and rationale, and participant demographics. Analysis included descriptive statistics and tests for association. RESULTS: A total of 288 pediatric gastroenterologists completed the survey, most of whom practiced in an academic center (73%). More than half (63%) reported knowledge of the 2018 updated guidelines; however, only 52% agreed with them and 50% reported adherence. Respondents who reported not agreeing with updated guidelines cited concerns regarding increasing number of endoscopies (72%), misdiagnosing eosinophilia from reflux (56%), and insufficient data (23%). The most common drivers of decision making with respect to therapy choice were patient/family preference, evidence/guidelines, and symptom burden. CONCLUSIONS: Many physicians are not adherent to current guidelines for reasons which include lack of knowledge of updated guidelines and concern regarding the strength of the supporting evidence. This study elucidates several areas to enhance education regarding these guidelines to promote widespread adherence.

Strengthening policy coding methodologies to improve COVID-19 disease modeling and policy responses: a proposed coding framework and recommendations.

BACKGROUND: In recent months, multiple efforts have sought to characterize COVID-19 social distancing policy responses. These efforts have used various coding frameworks, but many have relied on coding methodologies that may not adequately describe the gradient in social distancing policies as states "re-open." METHODS: We developed a COVID-19 social distancing intensity framework that is sufficiently specific and sensitive to capture this gradient. Based on a review of policies from a 12 U.S. state sample, we developed a social distancing intensity framework consisting of 16 domains and intensity scales of 0-5 for each domain. RESULTS: We found that the states with the highest average daily intensity from our sample were Pennsylvania, Washington, Colorado, California, and New Jersey, with Georgia, Florida, Massachusetts, and Texas having the lowest. While some domains (such as restaurants and movie theaters) showed bimodal policy intensity distributions compatible with binary (yes/no) coding, others (such as childcare and religious gatherings) showed broader variability that would be missed without more granular coding. CONCLUSION: This detailed intensity framework reveals the granularity and nuance between social distancing policy responses. Developing standardized approaches for constructing policy taxonomies and coding processes may facilitate more rigorous policy analysis and improve disease modeling efforts.

Reopening schools safely and educating youth (ROSSEY) study: Protocol for a community-based, cluster randomized controlled trial.

INTRODUCTION: ROSSEY is a community-academic partnership aiming to develop and test a COVID-19 risk communication intervention for elementary school students and families in Yakima County, Washington. We describe the ROSSEY study protocol that will be implemented in the Yakima School District. METHODS: Aim 1 is to identify the community's social, ethical, and behavioral needs and resources for students to return to school and maintain onsite learning. We will conduct semi-structured interviews with students and school employees and focus groups with parents. Aim 2 is to evaluate the effectiveness of risk communication on students' school attendance. We will conduct a cluster randomized control trial. We will enroll 14 Yakima School District elementary schools with 900 student participants and randomize the schools into the COVID-19 risk communication intervention or control group. Aim 3 will assess implementation of the risk communication intervention and schools' COVID-19 mitigation strategies. We will use the RE-AIM framework to guide this work, which will entail conducting semi-structured interviews with students and school employees and focus groups with parents. DISCUSSION: Implementation of science-based risk communication can educate the community on the benefits and safety of COVID-19 testing and vaccination. Risk communication may also inform families about the role of COVID-19 testing and vaccines as part of mitigation strategies to allow for safe in-person learning. Schools have extraordinary influence to promote children's health through policy and practice change. Study findings will provide evidence to facilitate policy decisions and best practices at schools that facilitate adoption of COVID-19 risk communication. TRIAL REGISTRATION: ClinicalTrials.govNCT04859699. Registered on April 26, 2021.

Factors contributing to U.S. parents' decisions to administer melatonin to children.

OBJECTIVE: Pediatric melatonin use is increasingly prevalent in the U.S. despite limited research on its efficacy and long-term safety. The current study investigated factors contributing to parents' decisions whether to give children melatonin. METHODS: Parents of children 1.0-13.9 years completed an online questionnaire on children's health, sleep, and melatonin use. Parents who reported giving melatonin to their child were asked open-ended follow-up questions on why their child takes melatonin and why they stopped (if applicable). Responses were assigned to categories through thematic coding. RESULTS: Data were analyzed on 212 children who either consumed melatonin in the past 30 days (n = 131) or took melatonin previously (n = 81). Among children who recently took melatonin, 51.1 % exhibited bedtime resistance and 46.2 % had trouble falling asleep. Parents most commonly gave children melatonin to: help them fall asleep (49.3 %), wind down before bedtime (22.7 %), facilitate changes in their sleep routine (17.5 %), and/or change their circadian rhythm (11.4 %). Parents stopped giving melatonin because their child did not need it anymore (32.0 %), experienced negative side effects (9.3 %), and/or concerns about health and safety (13.3 %). Finally, parents initiated melatonin use on their own (50.0 %), were encouraged by a friend or family member (27.4 %), and/or followed the recommendation of a health provider (48.1 %). CONCLUSIONS: Parents administered melatonin to children for a number of reasons and discontinued melatonin based on their own observations of a variety of effects. Parents frequently initiated use without the recommendation of a medical professional. Further research on indications and efficacy of melatonin and wider dissemination of guidelines are needed to help parents make informed decisions regarding children's sleep health.

Infant video viewing and salivary cortisol responses: a randomized experiment.

OBJECTIVE: To test the hypothesis that salivary cortisol levels respond differently when infants play with blocks compared with watching a digital video disk (DVD). STUDY DESIGN: We conducted a randomized experiment in which 8- to 14-month-old infants either watched a DVD or played with blocks for 30 minutes. Serial salivary cortisol measurements were obtained and analyzed, and parental and infant responses and activities were recorded. Results were converted to standardized effect sizes (ESs) for clarity of presentation. RESULTS: A total of 49 infants (49% female, mean age 10.6 months) participated in the study. In linear regression analyses, there was a trend toward higher cortisol levels in the block group at the 35-minute collection point (ES = 0.47, P = .08) and significantly higher levels at 45 minutes (ES = 0.56, P = .04); these salivary cortisol levels reflect serum levels approximately 10 and 20 minutes into the activity period, respectively. The results were substantially the same in sensitivity analyses excluding the outliers. CONCLUSION: Viewing by infants of a DVD leads to different neuroendocrine responses than block play in a laboratory setting. The implications of these differences are currently unknown, but may suggest different means of cognitive engagement between interactive play and DVD viewing.

A multi-institutional analysis of inpatient treatment for supraventricular tachycardia in newborns and infants.

This study aimed to examine practice patterns in the inpatient medical treatment of newborns and infants with supraventricular tachycardia (SVT) using the Pediatric Health Information System (PHIS) database, a large, multi-institutional administrative database. A retrospective examination of pediatric hospital discharge data was performed during the study period from January 2003 to September 2008. Data were extracted from the index hospitalization of all individuals younger than 1 year with the principal discharge diagnosis of SVT. Those with coexisting congenital or acquired structural heart disease were excluded from the study. The analysis included 171 patients. No deaths occurred, and 95 % of the infants were discharged to home. More than half (53 %) of the patients spent a portion of their hospital stay in an intensive care unit (ICU) setting. Multidrug therapy was common, with 45 % of the patients receiving two or more antiarrhythmic agents on the day of discharge. The five most commonly used antiarrhythmic drugs, in order of decreasing frequency of use, were propranolol, digoxin, amiodarone, flecainide, and sotalol. The median hospital stay for the group was 4 days, and this value increased as a function of the number of antiarrhythmic drugs used (median, 7 days for three or more agents) and the need for intensive care (median, 6 days). The information provided in this study helps to define common practice patterns and should allow caregivers to provide meaningful expectations to families regarding their potential treatment course and to anticipate the hospital length of stay.

Outcomes in pediatric surgery by hospital volume: a population-based comparison.

PURPOSE: The volume-outcome relationship has not been well-defined in pediatric surgery. Our aim was to determine the association between hospital-volume and outcomes for common procedures in children. METHODS: Retrospective population-based cohort study of patients <18 years of age hospitalized between 1989 and 2009 for common surgical procedures in Washington State. The association between annual hospital case volume and post-operative outcomes (readmission and reoperation within 30-days, post-operative complications) was assessed using multivariate logistic regression. RESULTS: The three most common procedures over the study period were appendectomy (n = 36,525), skin and soft tissue debridement (n = 9,813), and pyloromyotomy (n = 3,323). A greater proportion of patients with comorbidities were treated at higher-volume hospitals. After adjustment, outcomes did not differ significantly across hospital-volume quartiles except that debridement patients had lower odds of readmission (OR = 0.63, 95 % CI 0.46-0.88) and re-operation (OR = 0.53, 95 % CI 0.35-0.81) at medium-high-volume compared with high-volume centers. CONCLUSIONS: This work suggests that risks of readmission and post-operative complications for common procedures may be similar across hospital-volume categories, but appropriate risk-stratification is essential. In order to optimize safety, we must identify the resources required for low-, medium-, and high-risk surgical patients, and implement these standards into practice.

Racial disparities in youth pretrial detention: a retrospective cohort study grounded in critical race theory.

BACKGROUND AND METHOD: Pretrial detention makes up 75% of juvenile detention admissions and contributes to the disproportionate contact of minoritized youth in the juvenile carceral system. Given that prior evidence largely examines differences between Black and white youth, this study expands research on disproportionate contact in the pretrial detention setting to Hispanic/Latinx, Indigenous, and Asian youth. With a sample of over 44,000 juvenile cases in a northwest state, we used a generalized linear mixed model to estimate the effect of individual level characteristics while accounting for the random effect of differences at the county level. Additionally, we utilized Critical Race Theory (CRT) in formulating our theoretical model and predictions and apply CRT in our analysis and discussion of our results. In doing so we hope to build upon its application in public health discourse for naming and deconstructing processes that lead to unjust social and health stratification. RESULTS: After factoring in gender, age, crime severity, previous offenses, and variation between counties, our analyses show that Black, Hispanic/Latinx, and American Indian/Alaskan Native youth are more likely to experience pretrial detention than white youth. The likelihood of pretrial detention for Asian youth and for youth identified as "Other" or "Unknown" was not significantly different from white youth. CONCLUSIONS: As the iatrogenic effects of detention are disproportionately imposed upon youth of color-particularly Black, Indigenous, and Hispanic/Latinx youth-the disparities present in our study reveal further evidence of institutional racism. In this way, we can see how this carceral process operates as a mechanism of racialized social stratification as put forth by CRT. Considering implications for policy or further research, persistent disparity highlights an enduring need for building or strengthening diversion programs and alternatives to the carceral system, with emphasis on those that are culturally responsive.

A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents.

OBJECTIVE: We longitudinally explored frequency of disordered eating among transgender and nonbinary (TGNB) adolescents and explored trends by gender identity and gender-affirming care. METHODS: Participants completed an abbreviated version of the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, 3, 6, and 12 months after establishing care in a gender clinic. We analyzed descriptive statistics and multivariate linear regression analyses. RESULTS: Of the 91 TGNB adolescent participants, 61% were transmasculine, 30% transfeminine, and 7% nonbinary/gender-fluid. Among TGNB adolescents, disordered eating thoughts/behaviors were frequently endorsed with 26% of participants engaging in any occurrence of binge eating, 27% limiting the amount of food they ate, and 30% excluding foods from their diet. Forty percent of participants reported any occurrence of at least 1 disordered eating behavior and 17% at least 3 behaviors. Abbreviated EDE-Q responses did not differ significantly by sex assigned at birth, gender identity, gender-affirming medications, or time spent receiving gender-affirming care. There was a significant effect of age (P value = .003) on abbreviated EDE-Q scores. CONCLUSIONS: There were no significant changes in disordered eating after initiating gender-affirming medical care, possibly due to the limited study time frame of 12 months. Given the high prevalence of disordered eating behaviors, clinicians should consider screening all TGNB adolescents for disordered eating thoughts/behaviors throughout gender-affirming care. Future longitudinal research should recruit larger samples with a diverse range of gender identities and survey disordered eating thoughts/behaviors at least one year after starting gender-affirming medications.

Associations Between Sleep Duration and Positive Mental Health Screens During Adolescent Preventive Visits in Primary Care.

OBJECTIVE: The purpose of this paper was to understand associations between low sleep duration (<8.ßhours) and positive mental health screens among adolescents (ages 13...18) seen for preventive visits in primary care. METHODS: Data were from two randomized controlled trials testing the efficacy of an electronic health risk behavior screening and feedback tool for adolescent preventive visits. Participants (n.ß=.ß601) completed screeners at baseline, 3 months, and 6 months which included sleep duration in hours and the Patient Health Questionnaire 9 and Generalized Anxiety Disorder 7 screeners for depression and anxiety, respectively. Main analyses included adjusted logistic regressions testing associations between low sleep duration and positive mental health screens. RESULTS: Adjusted models showed that low sleep duration was associated with significantly greater odds of a positive depression screen (OR.ß=.ß1.58, 95% CI: 1.06...2.37) but not with a positive anxiety screen or co-occurring positive depression and anxiety screens. However, follow-up analyses indicated an interaction between sleep duration and anxiety in the association with a positive depression screen, such that the association between low sleep and a positive depression screen was driven by those who did not screen positive for anxiety. CONCLUSIONS: As pediatric primary care guidelines for sleep continue to evolve, further research, training, and support for sleep screening are warranted to ensure effective early intervention for sleep and mental health problems during adolescence.

Co-designing mind-body technologies for sleep with adolescents.

Sleep is critical for well-being, yet adolescents do not get enough sleep. Mind-body approaches can help. Despite the potential of technology to support mind-body approaches for sleep, there is a lack of research on adolescent preferences for digital mind-body technology. We use co-design to examine adolescent perspectives on mind-body technologies for sleep. From our analysis of design sessions with 16 adolescents, four major themes emerged: system behavior, modality, content, and context. In light of these key findings, we recommend that technology-based mind-body approaches to sleep for adolescents be designed to 1) serve multiple functions while avoiding distractions, 2) provide intelligent content while maintaining privacy and trust, 3) provide a variety of content with the ability to customize and personalize, 4) offer multiple modalities for interaction with technology, and 5) consider the context of adolescent and their families. Findings provide a foundation for designing mind-body technologies for adolescent sleep.

An agricultural community's perspectives on COVID-19 testing to support safe school reopening.

Introduction: School-based COVID-19 testing may be an effective strategy for reducing transmission in schools and keeping schools open. The study objective was to examine community perspectives on school-based COVID-19 testing as a mitigation strategy to support safe school reopening. Methods: We conducted a qualitative study in Yakima County, an agricultural region of Washington state, where over half of residents are Hispanic/Latino. From June to July 2021, we interviewed 18 students (13 years old, on average) and 19 school employees, and conducted four focus groups (2 in Spanish, 2 in English) with 26 parents. We audio-recorded the semi-structured interviews and focus group discussions which were then transcribed. We used an inductive, constant comparison approach to code the transcripts and conducted a thematic analysis to generate themes. Results: We identified four main themes. Students, parents, and school employees desired a return to in-person learning (Theme 1). Schools implemented numerous COVID-19 mitigation strategies (e.g., masking) to facilitate a safe return to school but felt that adding testing would not be feasible due to a lack of resources and overworked staff (Theme 2). Parents and school employees' familiarity with COVID-19 testing procedures influenced their support for testing (Theme 3). Parents and school employees felt there were inadequate resources for individuals who test positive for COVID-19 (Theme 4). Discussion: Schools require adequate resources and medical personnel to implement COVID-19 testing. Individuals also need resources after testing positive, including physical space to isolate, financial resources for those without paid time off, and delivery of food and other necessities to households in rural communities.

Evaluation of an experiential training program in patient-centered outcomes and comparative effectiveness research for diverse researcher communities and health care organizations.

Background/Objective: The goal of the Patient-Centered Outcomes Research Partnership was to prepare health care professionals and researchers to conduct patient-centered outcomes and comparative effectiveness research (CER). Substantial evidence gaps, heterogeneous health care systems, and decision-making challenges in the USA underscore the need for evidence-based strategies. Methods: We engaged five community-based health care organizations that serve diverse and underrepresented patient populations from Hawai'i to Minnesota. Each partner nominated two in-house scholars to participate in the 2-year program. The program focused on seven competencies pertinent to patient-centered outcomes and CER. It combined in-person and experiential learning with asynchronous, online education, and created adaptive, pragmatic learning opportunities and a Summer Institute. Metrics included the Clinical Research Appraisal Inventory (CRAI), a tool designed to assess research self-efficacy and clinical research skills across 10 domains. Results: We trained 31 scholars in 3 cohorts. Mean scores in nine domains of the CRAI improved; greater improvement was observed from the beginning to the midpoint than from the midpoint to conclusion of the program. Across all three cohorts, mean scores on 52 items (100%) increased (p ≤ 0.01), and 91% of scholars reported the program improved their skills moderately/significantly. Satisfaction with the program was high (91%). Conclusions: Investigators that conduct patient-centered outcomes and CER must know how to collaborate with regional health care systems to identify priorities; pose questions; design, conduct, and disseminate observational and experimental research; and transform knowledge into practical clinical applications. Training programs such as ours can facilitate such collaborations.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents.

BACKGROUND AND OBJECTIVES: Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses. METHODS: This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis. RESULTS: Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth. CONCLUSIONS: Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

BACKGROUND AND OBJECTIVES: Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. METHODS: This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. RESULTS: Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. CONCLUSIONS: Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Racial and ethnic disparities in the timing of orchiopexy for cryptorchidism.

INTRODUCTION: Many children do not undergo surgery for cryptorchidism in a timely fashion, increasing risk of infertility and malignancy. Racial and ethnic disparities in surgery timing has been suggested in other specialties, but has not been well-explored in Pediatric Urology. OBJECTIVES: Our aim was to investigate the association of race and ethnicity with age at orchiopexy. MATERIALS AND METHODS: We performed a retrospective cohort study of individuals <18 years of age as captured in the NSQIPP PUF from 2012 to 2016. Those with cancer were excluded. The primary outcome of interest was age at time of surgery. Secondary outcome was the proportion of individuals undergoing surgery by recommended age. Generalized linear models and logistic regression models were created for the outcomes of interest. RESULTS: The median age at orchiopexy was 17.4 months (10.7, 43.0) and overall, 51% of subjects underwent orchiopexy by 18 months of age. Non-Hispanic white individuals were most likely to have undergone orchiopexy by 18 months of age, at 56%, compared with only 44% of non-Hispanic black individuals (p < 0.001). When adjusting for co-morbidities and developmental delay, Hispanic patients underwent orchiopexy 5 months later than white patients, on average, and black patients had a delay of 7 months compared to white patients. DISCUSSION: These data suggest that orchiopexy is happening at younger ages compared to prior large-scale studies. However, minority patients are on average older at time of orchiopexy, potentially increasing future risk of infertility or malignancy. While an estimated average delay of 5-7 months may not seem high, studies suggest there is an appreciable change in risk with a 6-month delay. Patient, provider, and system-level factors likely all contribute, and these need to be further elucidated. CONCLUSIONS: Many racial and ethnic minorities with cryptorchidism have later orchiopexies, and are more likely to have surgery outside the recommended timeframe. Further investigation is warranted to determine the factors contributing to these disparities.

Exploring needs, interests and preferences for digital mind-body tools for adolescents.

Sleep problems are common among adolescents and research on mind-body interventions for sleep is promising. Although technology-based mind-body interventions have been shown to help early adolescents with practicing mind-body approaches, engagement and adherence has been a challenge. Using a Human-Centered Design framework with semi-structured interviews with parent-adolescent dyads, we describe exposure to, interest in, and preferences for digital mind-body technology for sleep. Identified challenges (e.g., 'establish routine', 'busy schedule) and preferences (e.g., age-appropriate content) reflect mind-body technology needs that impact engagement. Based on these findings, we recommend that a technology-based mind-body approach for early adolescents be designed to 1) provide content customized for adolescents 2) include functionalities that engage adolescents like games and rewards, and 3) allow for granular sharing controls. These recommendations provide a foundation for designing digital mind-body tools for adolescents.

Non-COVID-19 vaccine hesitancy among migrant populations worldwide: a scoping review of the literature, 2000-2020.

INTRODUCTION: Migration can be linked to the transmission of vaccine-preventable diseases. Hence, monitoring migrants' vaccination-related concerns can inform needed interventions to support vaccine acceptance. AREAS COVERED: Along with Google and Google Scholar, we searched 13 bibliographic databases between 1 January 2000 and 10 October 2020, to identify published studies of vaccine hesitancy among migrant populations. From a total of 8,915 records, we screened 745 abstracts and included 112 eligible articles. We summarized extracted data using figures, tables, and narrations. Of the 112 articles, 109 were original quantitative (48%), qualitative (45%), and mixed-methods (7%) research, originating mainly from the United States (US) (68%), the United Kingdom (UK) (12%), and Scandinavia (6%). Most articles addressed human papillomavirus (63%), measles (13%), and influenzas (9%) vaccinations, and the leading sponsor of funded research was the US National Institutes of Health (50%). Discernable migrant groups with vaccine-specific concerns included Somali diasporas, UK-based Poles and Romanians, and US-based Haitians and Koreans. Among US-based Latina/Latino immigrants, lower vaccine uptake frequency was mostly associated with awareness levels, knowledge gaps, and uninsured status. EXPERT OPINION: Migrants' vaccine-related apprehensions may cascade well beyond their proximate social connections and influence vaccine attitudes and behaviors in their countries-of-origin.

Novel and modifiable factors associated with adherence to continuous positive airway pressure therapy initiated during stroke rehabilitation: An exploratory analysis of a prospective cohort study.

OBJECTIVE/BACKGROUND: Continuous positive airway pressure (CPAP) for the treatment of sleep apnea may improve stroke recovery but is limited by poor adherence. We evaluated baseline features and psychosocial factors associated with CPAP adherence among stroke patients enrolled in a pilot study of an intensive CPAP adherence protocol initiated during inpatient rehabilitation. PATIENTS/METHODS: In a retrospective analysis of a prospective cohort study, we compared participants adherent to CPAP (≥4 h for ≥70% of nights over 3 months) to non-adherent participants. Using mixed methods, we quantitatively compared baseline demographic and stroke-related factors associated with adherence and qualitatively compared facilitators and barriers to adherence. RESULTS: There were 32 adherent and 20 non-adherent participants. Quantitative analysis revealed more severe stroke, aphasia and white race were associated with adherence. Adherent compared to non-adherent participants also had fewer early CPAP complaints, especially claustrophobia. In a thematic qualitative analysis, facilitators of adherence included improvement in sleep and stroke symptoms, confidence in CPAP use, and positive treatment expectations. Conversely, barriers to adherence included both potentially modifiable factors (lack of confidence in CPAP use, discomfort with a new health technology, and common CPAP-related complaints), and less modifiable factors (social stressors, sleep disturbance, and lack of home social support). DISCUSSION: Adherence programs for CPAP use after stroke should address modifiable barriers, with early desensitization to improve CPAP-related complaints and claustrophobia, and training to address perceived self-efficacy with CPAP. Future studies should explore individual goals and barriers associated with CPAP use among stroke survivors to improve long-term CPAP adherence. CLINICAL TRIAL REGISTRATION NUMBER: NCT02809430.

Case fatality in children with supraventricular tachycardia in the United States.

BACKGROUND: The prognosis for most patients with supraventricular tachycardia (SVT) is thought to be excellent. However, the fatality rate in children with SVT is poorly defined and there are no large-scale, multicenter studies to support this commonly held belief. METHODS: We reviewed an administrative database containing inpatient records from 41 stand-alone children's hospitals and identified all hospitalized patients younger than 25 years with a discharge diagnosis of SVT between January 2003 and September 2008. RESULTS: We analyzed the index hospitalization of 1,755 patients with the discharge diagnosis of SVT, of whom 58% were male and 52% had comorbid structural heart disease (SHD). There were a total of 68 patient deaths (4%) with 56 of 68 (82%) of the deaths occurring in patients with SHD. In total, 6% of the patients with SHD died, whereas only 1% of the patients without SHD died. Regression analysis revealed that case fatality is increased in patients less than 1 month of age (OR 2.41, 95% CI 1.35 to 4.32), in patients with SHD (OR 2.67, 95% CI 1.22 to 5.80), and in those having cardiomyopathy with (OR 6.72, 95% CI 1.79 to 25.28) and without SHD (OR 6.74, 95% CI 1.67 to 27.26). CONCLUSIONS: The case fatality in patients who have SVT without SHD is low. It is increased in the very young and in those with comorbid cardiovascular disease. Case fatality is highest in patients with a cardiomyopathy regardless of SHD.