Impact of the COVID-19 pandemic on pediatric faculty: a report from nine academic institutions.

BACKGROUND: The COVID-19 pandemic affected home and work routines, which may exacerbate existing academic professional disparities. Objectives were to describe the impact of the pandemic on pediatric faculty's work productivity, identify groups at risk for widening inequities, and explore mitigation strategies. METHODS: A cross-sectional study of faculty members was conducted at nine U.S. pediatric departments. Responses were analyzed by demographics, academic rank, and change in home caregiving responsibility. RESULTS: Of 5791 pediatric faculty members eligible, 1504 (26%) completed the survey. The majority were female (64%), over 40 years old (60%), and assistant professors (47%). Only 7% faculty identified as underrepresented in medicine. Overall 41% reported an increase in caregiving during the pandemic. When comparing clinical, administrative, research, and teaching activities, faculty reported worse 1-year outlook for research activities. Faculty with increased caregiving responsibilities were more likely to report concerns over delayed promotion and less likely to have a favorable outlook regarding clinical and research efforts. Participants identified preferred strategies to mitigate challenges. CONCLUSIONS: The COVID-19 pandemic negatively impacted pediatric faculty productivity with the greatest effects on those with increased caregiving responsibilities. COVID-19 was particularly disruptive to research outlook. Mitigation strategies are needed to minimize the long-term impacts on academic pediatric careers. IMPACT: The COVID-19 pandemic most negatively impacted work productivity of academic pediatric faculty with caregiving responsibilities. COVID-19 was particularly disruptive to short-term (1-year) research outlook among pediatric faculty. Faculty identified mitigation strategies to minimize the long-term impacts of the pandemic on academic pediatric career pathways.

Change in Functional Status During Hospital Admission and Long-Term Health-Related Quality of Life Among Pediatric Septic Shock Survivors.

OBJECTIVES: To investigate whether change in functional status from pre-hospitalization baseline to hospital discharge is associated with long-term health-related quality of life (HRQL) among children surviving septic shock. DESIGN: Secondary analysis of Life After Pediatric Sepsis Evaluation (LAPSE), a prospective cohort study of children with community-acquired septic shock, enrolled from January 2014 to June 2017. SETTING: Twelve U.S. academic PICUs. PATIENTS: Children, 1 month to 18 years, who survived to hospital discharge and had follow-up data for HRQL at 3 and/or 12 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Functional Status Scale (FSS) was assessed around enrollment to ascertain baseline status (pre-hospitalization) and at 28 days or hospital discharge. Two measures of HRQL were utilized: children with significant development delay were measured with the Functional Status II-R (FSII-R); typically, developing children were measured with the Pediatric Quality of Life Inventory (PedsQL). Each group was analyzed separately with multivariable regression modeling to determine the association between change in FSS from baseline to day 28 and HRQL at 3 and 12 months from PICU admission. Of the original 389 LAPSE participants, 224 (58%) are included. Among children with developmental delay ( n = 88), worsened FSS was associated with lower FSII-R at 3 months from PICU admission (-2.02; 95% CI, -3.34 to -0.0.71; p = 0.003), but not 12 months. Among developmentally typical children ( n = 136), worsened FSS was associated with lower PedsQL at both 3 and 12 months. Developmentally typical children with a neurologic insult during the PICU stay had the largest decrement in PedsQL at 12 months (-14.04 mo; 95% CI, -22.15 to -5.94 mo; p < 0.001). However, worsened FSS remained associated with poor HRQL-PedsQL at 3 and 12 months, after controlling for neurologic events (both p < 0.001). CONCLUSIONS: Change in FSS during hospitalization for septic shock is associated with long-term reductions in HRQL and could serve as a useful tool for identifying children at risk for this sequela.

Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really Make it Work.

OBJECTIVES: Many academic pediatric emergency departments (PEDs) have successfully implemented pediatric septic shock care pathways. However, many general emergency departments (GEDs), who see the majority of pediatric ED visits, have not. This study aims to compare the workflow, resources, communication, and decision making across these 2 settings to inform the future implementation of a standardized care pathway for children with septic shock in the GED. METHODS: We used the critical incident technique to conduct semistructured interviews with 24 ED physicians, nurses, and technicians at one PED and 2 GEDs regarding pediatric septic shock care. We performed a thematic analysis using the Framework Method to develop our coding schema through inductive and deductive analyses. We continued an iterative process of revising the schema until we reached consensus agreement and thematic saturation. RESULTS: We identified the following 6 themes: (1) functioning like a "well-oiled machine" may be key to high performance; (2) experiencing the sequence of care for children with sepsis as invariant and predictable may be essential to high-quality performance; (3) resilience and flexibility are characteristic of high levels of performance; (4) believing that "the buck stops here" may contribute to more accountability; (5) continuous system learning is essential; and (6) computerized clinical decision support may not be optimized to drive decision-making at the point of care. Commentary from GED and PED participants differed across the 6 themes, providing insight into the approach for standardized care pathway implementation in GEDs. CONCLUSIONS: Pediatric septic shock workflow, decision making, and system performance differ between the PED and GEDs. Implementation of a standardized care pathway in GEDs will require a tailored approach. Specific recommendations include (1) improving shared situation awareness; (2) simulation for knowledge, skill, and team-based training; and (3) promoting a culture of continuous learning.

The Pediatric Critical Care Trauma Scientist Development: Building a Community of Scientists for the Fields of Pediatric Critical Care and Trauma Surgery.

OBJECTIVES: To assess the National Institute of Child Health and Human Development's Pediatric Critical Care Trauma Scientist Development Program national K12 program. DESIGN: Mixed-methods study. SETTING: Pediatric Critical Care Trauma Scientist Development Program participants from 2005 to 2018. SUBJECTS: Past participants in the Pediatric Critical Care Trauma Scientist Development Program, including those who received funding (scholars), those who did not receive funding (applicants), and those who participated as diversity fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty-four past scholars, participants, and fellows in the Pediatric Critical Care Trauma Scientist Development were interviewed, including 19 women (56%) and 15 men (44%) via Skype. Interviews were audio recorded and transcribed, with permission. Codes were developed, using qualitative methods, that included the following: Community Building and Mentorship, Career and Research Development, and Tensions and Growth Opportunities. Quantitative data about physician-scholar grant success were retrieved from the National Institutes of Health system to search for funded grants, RePORT, physician-scholar curriculum vitae, and university websites. Since inception of the program, 46 scholars have been appointed. Scholars are equally split between women and men. Four members of the total cohort (9%) are from under-represented minority groups in medicine. Among the total past 46 participants, 72% of those who completed the K12 achieved an National Institutes of Health K-award and 36% of those not on K-level funding achieved at least one Research Program Grant-level award. All scholars, except one, remain academically active, as noted by recent publications in the peer reviewed literature; scholars from 2005 to 2013 are progressing in their careers, with 60% promoted to associate or full professor. CONCLUSIONS: The Pediatric Critical Care Trauma Scientist Development Program is reaching its programmatic goals of buildin g a community of scientists in pediatric critical care and trauma surgery as shown by the qualitative analysis. Key challenges include increasing the diversity of applicants, encouraging applicants who are not funded, increasing the rate of K- to R-conversion, and preserving National Institute of Child Health and Human Development Program priorities for national K12 programs and individual K-awards.

Changing Healthcare and School Needs in the First Year After Traumatic Brain Injury.

OBJECTIVE: To examine children's unmet and unrecognized healthcare and school needs following traumatic brain injury (TBI). SETTING: Two pediatric trauma centers. PARTICIPANTS: Children with all severity of TBI aged 4 to 15 years. DESIGN: Prospective cohort. MAIN MEASURES: Caregivers provided child health and school service use 3 and 12 months postinjury. Unmet and unrecognized needs were categorized compared with norms on standardized physical, cognitive, socioemotional health, or academic competence measures in conjunction with caregiver report of needs and services. Modified Poisson models examined child and family predictors of unmet and unrecognized needs. RESULTS: Of 322 children, 28% had unmet or unrecognized healthcare or school needs at 3 months, decreasing to 24% at 12 months. Unmet healthcare needs changed from primarily physical (79%) at 3 months to cognitive (47%) and/or socioemotional needs (68%) at 12 months. At 3 months, low social capital, preexisting psychological diagnoses, and 6 to 11 years of age predicted higher healthcare needs and severe TBI predicted higher school needs. Twelve months postinjury, prior inpatient rehabilitation, low income, and preexisting psychological diagnoses were associated with higher healthcare needs; family function was important for school and healthcare needs. CONCLUSIONS: Targeted interventions to provide family supports may increase children's access to services.

Development and Prospective Validation of Tools to Accurately Identify Neurosurgical and Critical Care Events in Children With Traumatic Brain Injury.

OBJECTIVE: To develop and validate case definitions (computable phenotypes) to accurately identify neurosurgical and critical care events in children with traumatic brain injury. DESIGN: Prospective observational cohort study, May 2013 to September 2015. SETTING: Two large U.S. children's hospitals with level 1 Pediatric Trauma Centers. PATIENTS: One hundred seventy-four children less than 18 years old admitted to an ICU after traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Prospective data were linked to database codes for each patient. The outcomes were prospectively identified acute traumatic brain injury, intracranial pressure monitor placement, craniotomy or craniectomy, vascular catheter placement, invasive mechanical ventilation, and new gastrostomy tube or tracheostomy placement. Candidate predictors were database codes present in administrative, billing, or trauma registry data. For each clinical event, we developed and validated penalized regression and Boolean classifiers (models to identify clinical events that take database codes as predictors). We externally validated the best model for each clinical event. The primary model performance measure was accuracy, the percent of test patients correctly classified. The cohort included 174 children who required ICU admission after traumatic brain injury. Simple Boolean classifiers were greater than or equal to 94% accurate for seven of nine clinical diagnoses and events. For central venous catheter placement, no classifier achieved 90% accuracy. Classifier accuracy was dependent on available data fields. Five of nine classifiers were acceptably accurate using only administrative data but three required trauma registry fields and two required billing data. CONCLUSIONS: In children with traumatic brain injury, computable phenotypes based on simple Boolean classifiers were highly accurate for most neurosurgical and critical care diagnoses and events. The computable phenotypes we developed and validated can be used in any observational study of children with traumatic brain injury and can reasonably be applied in studies of these interventions in other patient populations.

Pediatricians' Knowledge, Attitudes, and Behaviors to Screening Children After Complicated Mild TBI: A Survey.

OBJECTIVE: To understand pediatricians' attitudes, knowledge, and behaviors about the care of children with complicated mild traumatic brain injury (TBI). PARTICIPANTS: A total of 3500 pediatricians randomly selected from the American Medical Association Master File. DESIGN: It was a cross-sectional survey. MAIN MEASURES: A survey developed to assess pediatricians' attitudes toward following children with complicated mild TBI for cognitive and behavioral sequelae; their knowledge of TBI sequelae; and their usual evaluation and management of children after TBI. RESULTS: There were 576 (16.5%) completed responses. Most pediatricians (51%) see 1 or 2 patients with complicated mild TBI annually. Most do not think that pediatricians are the correct clinician group to be primarily responsible for following children with complicated mild TBI for cognitive (74%) or behavioral sequelae (54%). Pediatricians report difficulty referring children for cognitive (56%) and behavioral (48%) specialty services. Pediatricians have good knowledge of short-term complications of complicated mild TBI. CONCLUSION: Pediatricians do not think they are the clinicians that should primarily care for children after hospitalization for complicated mild TBI; however, other clinicians are frequently not accessible. Pediatricians need educational and referral support to provide surveillance for injury sequelae in this group of children.

Perceived social risk in medical decision-making for physical child abuse: a mixed-methods study.

BACKGROUND: The medical literature reports differential decision-making for children with suspected physical abuse based on race and socioeconomic status. Differential evaluation may be related to differences of risk indicators in these populations or differences in physicians' perceptions of abuse risk. Our objective was to understand the contribution of the child's social ecology to child abuse pediatricians' perception of abuse risk and to test whether risk perception influences diagnostic decision-making. METHODS: Thirty-two child abuse pediatrician participants prospectively contributed 746 consultations from for children referred for physical abuse evaluation (2009-2013). Participants entered consultations to a web-based interface. Participants noted their perception of child race, family SES, abuse diagnosis. Participants rated their perception of social risk for abuse and diagnostic certainty on a 1-100 scale. Consultations (n = 730) meeting inclusion criteria were qualitatively analyzed for social risk indicators, social and non-social cues. Using a linear mixed-effects model, we examined the associations of social risk indicators with participant social risk perception. We reversed social risk indicators in 102 cases whilst leaving all injury mechanism and medical information unchanged. Participants reviewed these reversed cases and recorded their social risk perception, diagnosis and diagnostic certainty. RESULTS: After adjustment for physician characteristics and social risk indicators, social risk perception was highest in the poorest non-minority families (24.9 points, 95%CI: 19.2, 30.6) and minority families (17.9 points, 95%CI, 12.8, 23.0). Diagnostic certainty and perceived social risk were associated: certainty increased as social risk perception increased (Spearman correlation 0.21, p < 0.001) in probable abuse cases; certainty decreased as risk perception increased (Spearman correlation (-)0.19, p = 0.003) in probable not abuse cases. Diagnostic decisions changed in 40% of cases when social risk indicators were reversed. CONCLUSIONS: CAP risk perception that poverty is associated with higher abuse risk may explain documented race and class disparities in the medical evaluation and diagnosis of suspected child physical abuse. Social risk perception may act by influencing CAP certainty in their diagnosis.

What Happened Next: Interviews With Mothers After a Finding of Child Maltreatment in the Household.

Child Protective Services (CPS) identifies over 700,000 victims of child maltreatment in the United States annually. Research shows that risk factors for these children may persist despite CPS intervention. Mothers have unique and often untapped perspectives on the experiences and consequences of CPS intervention that may inform future practice. We explored these perspectives through interviews with 24 mothers after a first-time CPS finding of maltreatment not resulting in out-of-home placement. Male partners were primary perpetrators in 21 cases, with mothers or sitters identified as perpetrators in remaining cases. Data were analyzed using grounded theory. Mothers described risk factors or Roots of maltreatment prior to CPS involvement and reported variable experiences with Recognition of and Response to maltreatment. Divergent Outcomes emerged: I Feel Stronger and We're No Better These findings provide an understanding of household experiences around child maltreatment that may support practice and policy changes to improve outcomes for vulnerable children.

Intracranial Pressure Monitoring in Infants and Young Children With Traumatic Brain Injury.

OBJECTIVE: To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001. DESIGN: Prospective, observational cohort study. SETTING: Twelve PICUs in North Carolina. PATIENTS: All children 24 months old or younger with traumatic brain injury, admitted to an included PICU. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies. CONCLUSION: Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Functional Status Scale in Children With Traumatic Brain Injury: A Prospective Cohort Study.

OBJECTIVES: In children with traumatic brain injury, 1) to describe the hospital discharge functional outcome and change from baseline function using the Functional Status Scale and 2) to determine any associations between discharge Functional Status Scale and age, injury mechanism, neurologic examination, imaging, and other predictors of outcome. DESIGN: Prospective observational cohort study, May 2013 to November 2015. SETTING: Two U.S. children's hospitals designated as American College of Surgeons level 1 pediatric trauma centers. PATIENTS: Children less than 18 years old admitted to an ICU with acute traumatic brain injury and either a surgical or critical care intervention within the first 24 hours or in-hospital mortality. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital discharge Functional Status Scale. Most, 133 of 196 (68%), had severe traumatic brain injury (admission Glasgow Coma Scale, 3-8). Overall hospital mortality was 14%; 20% among those with severe traumatic brain injury. Hospital discharge Functional Status Scale had an inverse relationship with Glasgow Coma Scale: for each increase in admission Glasgow Coma Scale by 1, the discharge Functional Status Scale decreased by 0.5 (95% CI, 0.7-0.3). Baseline Functional Status Scale was collected at one site (n = 75). At that site, nearly all (61/62) of the survivors had normal or near-normal (≤ 7) preinjury Functional Status Scale. More than one-third, 23 of 62 (37%), of survivors had new morbidity at hospital discharge (increase in Functional Status Scale, ≥ 3). Among children with severe traumatic brain injury who had baseline Functional Status Scale collected, 21 of 41 survivors (51%) had new morbidity at hospital discharge. The mean change in Functional Status Scale from baseline to hospital discharge was 3.9 ± 4.9 overall and 5.2 ± 5.4 in children with severe traumatic brain injury. CONCLUSIONS: More than one-third of survivors, and approximately half of survivors with severe traumatic brain injury, will have new morbidity. Hospital discharge Functional Status Scale, change from baseline Functional Status Scale, and new morbidity acquisition can be used as outcome measures for hospital-based care process improvement initiatives and interventional studies of children with traumatic brain injury.

Cervical spine imaging in hospitalized children with traumatic brain injury.

OBJECTIVES: The purposes of this study, in children with traumatic brain injury (TBI), to describe cervical spine imaging practice, to assess for recent changes in imaging practice, and to determine whether cervical spine computed tomography (CT) is being used in children at low risk for cervical spine injury. METHODS: The setting was children's hospitals participating in the Pediatric Health Information System database, from January 2001 to June 2011. Participants were children (younger than 18 y) with TBI who were evaluated in the emergency department, admitted to the hospital, and received a head CT scan on the day of admission. The primary outcome measures were cervical spine imaging studies. This study was exempted from institutional review board assessment. RESULTS: A total of 30,112 children met study criteria. Overall, 52% (15,687/30,112) received cervical spine imaging. The use of cervical spine radiographs alone decreased between 2001 (47%) and 2011 (23%), with an annual decrease of 2.2% (95% confidence interval [CI], 1.1%-3.3%), and was largely replaced by an increased use of CT, with or without radiographs (8.6% in 2001 and 19.5% in 2011, with an annual increase of 0.9%; 95% CI, 0.1%-1.8%). A total of 2545 children received cervical spine CT despite being discharged alive from the hospital in less than 72 hours, and 1655 of those had a low-risk mechanism of injury. CONCLUSIONS: The adoption of CT clearance of the cervical spine in adults seems to have influenced the care of children with TBI, despite concerns about radiation exposure.

Probabilistic Linkage Creates a Novel Database to Study Bronchiolitis Care in the PICU.

OBJECTIVES: Lack of a comprehensive database containing diagnosis, patient and clinical characteristics, diagnostics, treatments, and outcomes limits needed comparative effectiveness research (CER) to improve care in the PICU. Combined, the Pediatric Hospital Information System (PHIS) and Virtual Pediatric Systems (VPS) databases contain the needed data for CER, but limits on the use of patient identifiers have thus far prevented linkage of these databases with traditional linkage methods. Focusing on the subgroup of patients with bronchiolitis, we aim to show that probabilistic linkage methods accurately link data from PHIS and VPS without the need for patient identifiers to create the database needed for CER. METHODS: We used probabilistic linkage to link PHIS and VPS records for patients admitted to a tertiary children's hospital between July 1, 2017 to June 30, 2019. We calculated the percentage of matched records, rate of false-positive matches, and compared demographics between matched and unmatched subjects with bronchiolitis. RESULTS: We linked 839 of 920 (91%) records with 4 (0.5%) false-positive matches. We found no differences in age (P = .76), presence of comorbidities (P = .16), admission illness severity (P = .44), intubation rate (P = .41), or PICU stay length (P = .36) between linked and unlinked subjects. CONCLUSIONS: Probabilistic linkage creates an accurate and representative combined VPS-PHIS database of patients with bronchiolitis. Our methods are scalable to join data from the 38 hospitals that jointly contribute to PHIS and VPS, creating a national database of diagnostics, treatment, outcome, and patient and clinical data to enable CER for bronchiolitis and other conditions cared for in the PICU.

Healthcare utilization in the first year after pediatric traumatic brain injury in an insured population.

OBJECTIVE: To compare the healthcare use by children with and without a traumatic brain injury (TBI) in the year following injury to understand whether children access primary care. PARTICIPANTS: Children 0 to 15 years with a TBI (N = 545) and (N = 2310) uninjured age and sex-matched comparisons. SETTING: A full benefits healthcare plan from 2000 to 2007. MAIN MEASURES: Mean annual healthcare utilization. RESULTS: Children with TBI had higher mean annual outpatient visits (4.2 vs. 3.5, P = .001), but similar mean annual general pediatric visits (2.7 vs. 2.8, P = .3) than comparison children. More cases than comparisons attended a general pediatric visit (80.0% vs. 73.3%, risk ratio = 1.1, 95% CI: 1.0-1.1). However, approximately 50% of children older than 7 years who had an intracranial injury did not attend a general pediatric visit and those were slightly more likely to receive specialty care (adjusted risk ratio = 1.1, 95% CI: 1.0-1.2). These children did not appear to be substituting specialty for primary care. CONCLUSIONS: Children with a full benefits insurance plan do not access primary care routinely after TBI. These findings present a challenge for designing a system to screen children after TBI.

Longitudinal Developmental Outcomes of Infants and Toddlers With Traumatic Brain Injury.

Importance: Among children, infants and toddlers have some of the highest rates of traumatic brain injury (TBI), but longitudinal information on their developmental outcomes to guide postinjury surveillance is sparse. Objective: To evaluate infants' and toddlers' development over 3 years following TBI compared with those with orthopedic injury (OI). Design, Setting, and Participants: A longitudinal observational cohort study was conducted at 2 level 1 pediatric trauma centers from January 20, 2013, to September 30, 2015; data analysis was performed from May 12 to October 20, 2021. Participants included children injured when younger than 31 months with TBI or OI who received emergency department care. Exposures: Mild, moderate, or severe TBI or OI. Main Outcomes and Measures: Parents completed baseline measures representing preinjury status and 3-, 12-, 24-, and 36-month postinjury status, using the Ages & Stages Questionnaire-3 (ASQ-3), with a mean reference value of 50 and higher scores indicating more advanced development. Linear mixed models characterized children's outcomes for each ASQ-3 domain after adjustment for baseline ASQ-3, injury severity and group, age, injury mechanism (abuse or not), sex, prematurity, family function, social capital, and time. Interactions with time were evaluated. Results: Consent for participation was provided for 195 children; 184 parents (94%) completed a baseline survey. The cohort included 168 children who completed at least 1 follow-up survey: 48 (29%) mild; 54 (32%) complicated mild/moderate; 21 (13%) severe TBI; and 45 (27%) orthopedic injury. The cohort included 95 boys (57%), 49% injured before age 1 year; and 13% injured by abuse. Mean (SD) age at the time of injury was 13.9 (9.4) months. At 36 months, children with mild or complicated mild/moderate TBI performed similarly to children with OI across ASQ-3 domains. Children with severe TBI performed poorly as shown by negative mean differences in communication (-8.8; 95% CI, -13.8 to -3.8); gross motor (-10.1; 95% CI, -15.1 to -5.1); problem solving (-6.6; 95% CI, -11.2 to -1.9), and personal social (-6.3; 95% CI, -10.4 to -2.1) domains with little recovery over time. Children with abusive injury experienced decrements in ability over time in fine motor and personal social skills. Social capital was protective in communication (mean, 1.5; 95% CI, 0.3-2.7) and problem solving (mean, 1.2; 95% CI, 0.1-2.3) domains. Conclusions and Relevance: In this cohort study of children with TBI, children with severe injury showed little recovery. These findings suggest that early childhood intervention is needed, while children with milder injury remained on their developmental track and should continue routine developmental surveillance.

Developing a clinical research infrastructure embedded in an academic medicine center that equitably supports future clinician scientists.

Clinical research in academic medical centers can be difficult to conduct and meet enrollment goals. Students under-represented in medicine (URiM) are also under-represented in academic leadership positions and as physician-scientists but are critical to help solve health disparities. Barriers in pursuing medicine as a career may be high for URiM students, therefore it is important to create pre-medicine opportunities accessible to all students interested in healthcare careers. We describe an undergraduate clinical research platform, the Academic Associate (AcA) program, embedded in the medical system that supports clinical research for academic physician scientists and provides students equitable access to experiences and mentoring opportunities. Students have the opportunity of completing a Pediatric Clinical Research Minor (PCRM) degree. This program satisfies many pre-medicine opportunities for undergraduate students, including those URiM, and allows access to physician mentors and unique educational experiences for graduate school or employment. Since 2009, 820 students participated in the AcA program (17.5% URiM) and 235 students (18% URiM) completed the PCRM. Of the 820 students, 126 (10% URiM) students matriculated to medical school, 128 (11%URiM) to graduate school, and 85 (16.5% URiM) gained employment in biomedical research fields. Students in our program supported 57 publications and were top-enrollers for several multicentered studies. The AcA program is cost-effective and achieves a high level of success enrolling patients into clinical research. Additionally, the AcA program provides equitable access for students URiM to physician mentorship, pre-medical experiences, and an avenue to early immersion in academic medicine.

Reducing Stress after Trauma (ReSeT): study protocol for a randomized, controlled trial of an online psychoeducational program and video therapy sessions for children hospitalized after trauma.

BACKGROUND: Post-traumatic stress symptoms develop in a quarter to half of injured children affecting their longer-term psychologic and physical health. Evidence-based care exists for post-traumatic stress; however, it is not readily available in some communities. We have developed an eHealth program consisting of online, interactive educational modules and telehealth therapist support based in trauma-focused cognitive behavioral therapy, the Reducing Stress after Trauma (ReSeT) program. We hypothesize that children with post-traumatic stress who participate in ReSeT will have fewer symptoms compared to the usual care control group. METHODS: This is a randomized controlled trial to test the effectiveness of the ReSeT intervention in reducing symptoms of post-traumatic stress compared to a usual care control group. One hundred and six children ages 8-17 years, who were admitted to hospital following an injury, with post-traumatic stress symptoms at 4 weeks post-injury, will be recruited and randomized from the four participating trauma centers. The outcomes compared across groups will be post-traumatic stress symptoms at 10 weeks (primary outcome) controlling for baseline symptoms and at 6 months post-randomization (secondary outcome). DISCUSSION: ReSeT is an evidence-based program designed to reduce post-traumatic stress symptoms among injured children using an eHealth platform. Currently, the American College of Surgeons standards suggest that trauma programs identify and treat patients at high risk for mental health needs in the trauma system. If effectiveness is demonstrated, ReSeT could help increase access to evidence-based care for children with post-traumatic stress within the trauma system. TRIAL REGISTRATION: ClinicalTrials.gov NCT04838977. 8 April 2021.

Longitudinal experiences of children remaining at home after a first-time investigation for suspected maltreatment.

OBJECTIVE: To describe longitudinal change in risk for children remaining at home following a first-time investigation for suspected maltreatment. STUDY DESIGN: A retrospective cohort study of children remaining at home following first-time investigation for maltreatment using a nationally representative sample of households involved with Child Protective Services. Outcomes include poverty, social support, caregiver depression, intimate partner violence (IPV), drug/alcohol dependence, corporal punishment, and child behavior problems at baseline, 18, and 36 months following first-time Child Protective Services investigation. We present longitudinal models to (1) estimate prevalence of risk factors at each timepoint; and (2) examine associations between risk-specific service referrals and longitudinal change in risk factor prevalence. RESULTS: Our sample represented 1057056 US children remaining at home following first-time investigation for maltreatment. Almost 100000 (9.2%) children experienced out-of-home placement within 36 months. The prevalence of poverty (44.3%), poor social support (36.3%), caregiver depression (24.4%), IPV (22.1%), and internalizing (30.0%) and externalizing (35.8%) child behavior problems was above general population prevalence at baseline and remained high over the next 36 months. Referral to risk-specific services occurred in a minority of cases, but was associated with significant longitudinal reductions in IPV, drug/alcohol dependence, and externalizing child behavior problems. CONCLUSIONS: Children remaining at home following a first-time investigation for maltreatment live with persistent risk factors for repeat maltreatment. Appropriate service referrals are uncommon, but may be associated with meaningful reduction in risk over time. Pediatricians and policy makers may be able to improve outcomes in these families with appropriate service provision and referrals.

A qualitative analysis of physician decision making in the use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest.

Aim of Study: To prepare for the design of future randomized clinical trials of extracorporeal cardioupulmonary resuscitation (ECPR), we sought to understand physician beliefs regarding the use of ECPR and subsequent management, among physicians who already perform ECPR, as these physicians would be likely to be involved in many planned ECPR trials. Methods: We performed 12 semi-structured interviews of physicians who already perform ECPR across a variety of medical specialties, centers and geographic regions, but all with 10-50+ cases of ECPR experience. We qualitatively analyzed these interview to identify key characteristics of their experience using ECPR, the tensions involved in patient identification, the complications of subsequent management, and their willingness to enroll potential ECPR patients in randomized trials of ECPR. Results: Physicians who routinely perform ECPR have strong beliefs regarding the use of ECPR, and typically have protocols they follow, though they are willing to break these protocols to cannulate young or healthy patients, or patients with immediate pre-hospital CPR and shockable rhythms. We found that physicians lacked equipoise to randomize these types of patients to continued conventional CPR. Future RCTs might be successful in enrolling older patients, younger patients without immediate pre-hospital care/bystander CPR, or patients with obvious comorbidities. Conclusions: RCTs for ECPR will need to avoid targeting patients in whom physicians feel strongly compelled to do ECPR or not do ECPR, instead identifying the middle range of patients in whom the physicians consider ECPR reasonable, but not required or contraindicated.