Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid.

PURPOSE: Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation. METHODS: This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018. RESULTS: Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001). DISCUSSION: We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.

Characterizing continuous positive airway pressure (CPAP) Belly Syndrome in preterm infants in the neonatal intensive care unit (NICU).

OBJECTIVE: Reproducibly define CPAP Belly Syndrome (CBS) in preterm infants and describe associated demographics, mechanical factors, and outcomes. STUDY DESIGN: A retrospective case-control study was conducted in infants <32 weeks gestation in the Stanford Children's NICU from January 1, 2020 to December 31, 2021. CBS was radiographically defined by a pediatric radiologist. Data analysis included descriptive statistics and comparator tests. RESULTS: Analysis included 41 infants with CBS and 69 infants without. CBS was associated with younger gestational age (median 27.7 vs 30 weeks, p < 0.001) and lower birthweight (median 1.00 vs 1.31 kg, p < 0.001). Infants with CBS were more likely to receive bilevel respiratory support and higher positive end expiratory pressure. Infants with CBS took longer to advance enteral feeds (median 10 vs 7 days, p = 0.003) and were exposed to more abdominal radiographs. CONCLUSIONS: Future CBS therapies should target small infants, prevent air entry from above, and aim to reduce time to full enteral feeds and radiographic exposure.

Language Disparities in Caregiver Satisfaction with Physician Communication at Well Visits from 0-2 Years.

OBJECTIVE: This study aimed to describe caregiver satisfaction with physician communication over the first two years of life and examine differences by preferred language and the relationship to physician continuity. METHODS: Longitudinal data were collected at well visits (2 months to 2 years) from participants in a randomized controlled trial to prevent childhood obesity. Satisfaction with communication was assessed using the validated Communication Assessment Tool (CAT) questionnaire. Changes in the odds of optimal scores were estimated in mixed-effects logistic regression models to evaluate the associations between satisfaction over time and language, interpreter use, and physician continuity. RESULTS: Of 865 caregivers, 35% were Spanish-speaking. Spanish-speaking caregivers without interpreters had lower odds of an optimal satisfaction score compared with English speakers during the first 2 years, beginning at 2 months [OR 0.64 (95% CI: 0.43, 0.95)]. There was no significant difference in satisfaction between English-speaking caregivers and Spanish-speaking caregivers with an interpreter. The odds of optimal satisfaction scores increased over time for both language groups. For both language groups, odds of an optimal satisfaction score decreased each time a new physician was seen for a visit [OR 0.82 (95% CI: 0.69, 0.97)]. CONCLUSION: Caregiver satisfaction with physician communication improves over the first two years of well-child visits for both English- and Spanish-speakers. A loss of physician continuity over time was also associated with lower satisfaction. Future interventions to ameliorate communication disparities should ensure adequate interpreter use for primarily Spanish-speaking patients and address continuity issues to improve communication satisfaction.

Younger age at initiation of subcutaneous treprostinil is associated with better response in pediatric Group 1 pulmonary arterial hypertension.

Children with severe Group 1 pulmonary arterial hypertension (PAH) have an unpredictable response to subcutaneous treprostinil (TRE) therapy, which may be influenced by age, disease severity, or other unknown variables at time of initiation. In this retrospective single-center cohort study, we hypothesized that younger age at TRE initiation, early hemodynamic response (a decrease in pulmonary vascular resistance by ≥30% at follow-up catheterization), and less severe baseline hemodynamics (Rp:Rs < 1.1) would each be associated with better clinical outcomes. In 40 pediatric patients with Group I PAH aged 17 days-18 years treated with subcutaneous TRE, younger age (cut-off of 6-years of age, AUC 0.824) at TRE initiation was associated with superior 5-year freedom from adverse events (94% vs. 39%, p = 0.002), better WHO functional class (I or II: 88% vs. 39% p = 0.003), and better echocardiographic indices of right ventricular function at most recent follow-up. Neither early hemodynamic response nor less severe baseline hemodynamics were associated with better outcomes. Patients who did not have a significant early hemodynamic response to TRE by first follow-up catheterization were unlikely to show subsequent improvement in PVRi (1/8, 13%). These findings may help clinicians counsel families and guide clinical decision making regarding the timing of advanced therapies.

Long-Acting Reversible Contraception Initiation Among Adolescents After an American Academy of Pediatrics Policy Statement.

This cross-sectional study compares monthly rates of long-acting reversible contraception (LARC) insertions among adolescents before and after an American Academy of Pediatrics (AAP) policy statement recommending LARC for this age group.

"It changed everything we do": A mixed methods study of youth and parent experiences with a pilot exercise education intervention following new diagnosis of type 1 diabetes.

AIMS: This pilot study delivered a comprehensive exercise education intervention to youth with new-onset type 1 diabetes (T1D) and their parents to increase knowledge and confidence with physical activity (PA) shortly after diagnosis. METHODS: Youth initiated continuous glucose monitoring (CGM) and PA trackers within 1 month of diagnosis. Youth and their parents received the 4-session intervention over 12 months. Participants completed self-report questionnaires at baseline, 6- and 12-months. Surveys were analyzed using linear mixed effects models. Semi-structured interviews and focus groups explored experiences with the exercise education intervention. Groups and interviews were audio-recorded, transcribed, and analyzed using content analysis. RESULTS: A total of 16 parents (aged 46 ± 7 years; 88 % female; 67 % non-Hispanic White) and 17 youth (aged 14 ± 2 years; 41 % female; 65 % non-Hispanic White) participated. Worry about hypoglycemia did not worsen throughout the study duration. Parents and youth reported increased knowledge and confidence in managing T1D safely and preventing hypoglycemia during PA following receiving the tailored exercise education intervention. CONCLUSION: This study assessed a novel structured exercise education program for youth and their parents shortly following T1D diagnosis. These results support the broad translation and acceptability of a structured exercise education program in new-onset T1D.

In focus: perplexing increase of urinary stone disease in children, adolescent and young adult women and its economic impact.

Background: Urinary stone disease (USD) historically has affected older men, but studies suggest recent increases in women, leading to a near identical sex incidence ratio. USD incidence has doubled every 10 years, with disproportionate increases amongst children, adolescent, and young adult (AYA) women. USD stone composition in women is frequently apatite (calcium phosphate), which forms in a higher urine pH, low urinary citrate, and an abundance of urinary uric acid, while men produce more calcium oxalate stones. The reasons for this epidemiological trend are unknown. Methods: This perspective presents the extent of USD with data from a Canadian Province and a North American institution, explanations for these findings and offers potential solutions to decrease this trend. We describe the economic impact of USD. Findings: There was a significant increase of 46% in overall surgical interventions for USD in Ontario. The incidence rose from 47.0/100,000 in 2002 to 68.7/100,000 population in 2016. In a single United States institution, the overall USD annual unique patient count rose from 10,612 to 17,706 from 2015 to 2019, and the proportion of women with USD was much higher than expected. In the 10-17-year-old patients, 50.1% were girls; with 57.5% in the 18-34 age group and 53.6% in the 35-44 age group. The roles of obesity, diet, hormones, environmental factors, infections, and antibiotics, as well as the economic impact, are discussed. Interpretation: We confirm the significant increase in USD among women. We offer potential explanations for this sex disparity, including microbiological and pathophysiological aspects. We also outline innovative solutions - that may require steps beyond typical preventive and treatment recommendations.

The Performance of Flash Replenishment Contrast-Enhanced Ultrasound for the Qualitative Assessment of Kidney Lesions in Patients with Chronic Kidney Disease.

We investigated the accuracy of CEUS for characterizing cystic and solid kidney lesions in patients with chronic kidney disease (CKD). Cystic lesions are assessed using Bosniak criteria for computed tomography (CT) and magnetic resonance imaging (MRI); however, in patients with moderate to severe kidney disease, CT and MRI contrast agents may be contraindicated. Contrast-enhanced ultrasound (CEUS) is a safe alternative for characterizing these lesions, but data on its performance among CKD patients are limited. We performed flash replenishment CEUS in 60 CKD patients (73 lesions). Final analysis included 53 patients (63 lesions). Four readers, blinded to true diagnosis, interpreted each lesion. Reader evaluations were compared to true lesion classifications. Performance metrics were calculated to assess malignant and benign diagnoses. Reader agreement was evaluated using Bowker's symmetry test. Combined reader sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing malignant lesions were 71%, 75%, 45%, and 90%, respectively. Sensitivity (81%) and specificity (83%) were highest in CKD IV/V patients when grouped by CKD stage. Combined reader sensitivity, specificity, PPV, and NPV for diagnosing benign lesions were 70%, 86%, 91%, and 61%, respectively. Again, in CKD IV/V patients, sensitivity (81%), specificity (95%), and PPV (98%) were highest. Inter-reader diagnostic agreement varied from 72% to 90%. In CKD patients, CEUS is a potential low-risk option for screening kidney lesions. CEUS may be particularly beneficial for CKD IV/V patients, where kidney preservation techniques are highly relevant.

Antimicrobial exposure is associated with decreased survival in triple-negative breast cancer.

Antimicrobial exposure during curative-intent treatment of triple-negative breast cancer (TNBC) may lead to gut microbiome dysbiosis, decreased circulating and tumor-infiltrating lymphocytes, and inferior outcomes. Here, we investigate the association of antimicrobial exposure and peripheral lymphocyte count during TNBC treatment with survival, using integrated electronic medical record and California Cancer Registry data in the Oncoshare database. Of 772 women with stage I-III TNBC treated with and without standard cytotoxic chemotherapy - prior to the immune checkpoint inhibitor era - most (654, 85%) used antimicrobials. Applying multivariate analyses, we show that each additional total or unique monthly antimicrobial prescription is associated with inferior overall and breast cancer-specific survival. This antimicrobial-mortality association is independent of changes in neutrophil count, is unrelated to disease severity, and is sustained through year three following diagnosis, suggesting antimicrobial exposure negatively impacts TNBC survival. These results may inform mechanistic studies and antimicrobial prescribing decisions in TNBC and other hormone receptor-independent cancers.

Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic.

Importance: Information about the trend in illicit substance ingestions among young children during the pandemic is limited. Objectives: To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies. Design, Setting, and Participants: Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023. Exposure: Absence or presence of the COVID-19 pandemic. Main Outcome(s) and Measure(s): The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances. Results: Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters. Conclusions and Relevance: In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Breast Cancer Diagnosis, Treatment, and Outcomes of Patients From Sex and Gender Minority Groups.

Importance: Sexual orientation and gender identity data are not collected by most hospitals or cancer registries; thus, little is known about the quality of breast cancer treatment for patients from sex and gender minority (SGM) groups. Objective: To evaluate the quality of breast cancer treatment and recurrence outcomes for patients from SGM groups compared with cisgender heterosexual patients. Design, Setting, and Participants: Exposure-matched retrospective case-control study of 92 patients from SGM groups treated at an academic medical center from January 1, 2008, to January 1, 2022, matched to cisgender heterosexual patients with breast cancer by year of diagnosis, age, tumor stage, estrogen receptor status, and ERBB2 (HER2) status. Main Outcomes and Measures: Patient demographic and clinical characteristics, as well as treatment quality, as measured by missed guideline-based breast cancer screening, appropriate referral for genetic counseling and testing, mastectomy vs lumpectomy, receipt of chest reconstruction, adjuvant radiation therapy after lumpectomy, neoadjuvant chemotherapy for stage III disease, antiestrogen therapy for at least 5 years for estrogen receptor-positive disease, ERBB2-directed therapy for ERBB2-positive disease, patient refusal of an oncologist-recommended treatment, time from symptom onset to tissue diagnosis, time from diagnosis to first treatment, and time from breast cancer diagnosis to first recurrence. Results were adjusted for multiple hypothesis testing. Compared with cisgender heterosexual patients, those from SGM groups were hypothesized to have disparities in 1 or more of these quality metrics. Results: Ninety-two patients from SGM groups were matched to 92 cisgender heterosexual patients (n = 184). The median age at diagnosis for all patients was 49 years (IQR, 43-56 years); 74 were lesbian (80%), 12 were bisexual (13%), and 6 were transgender (6%). Compared with cisgender heterosexual patients, those from SGM groups experienced a delay in time from symptom onset to diagnosis (median time to diagnosis, 34 vs 64 days; multivariable adjusted hazard ratio, 0.65; 95% CI, 0.42-0.99; P = .04), were more likely to decline an oncologist-recommended treatment modality (35 [38%] vs 18 [20%]; multivariable adjusted odds ratio, 2.27; 95% CI, 1.09-4.74; P = .03), and were more likely to experience a breast cancer recurrence (multivariable adjusted hazard ratio, 3.07; 95% CI, 1.56-6.03; P = .001). Conclusions and Relevance: This study found that among patients with breast cancer, those from SGM groups experienced delayed diagnosis, with faster recurrence at a 3-fold higher rate compared with cisgender heterosexual patients. These results suggest disparities in the care of patients from SGM groups and warrant further study to inform interventions.

Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes.

BACKGROUND: Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients. METHODS: Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 - PT with nonoperative humeral shaft fracture, Group 2 - PT with humeral fixation on Day 1, and Group 3 - PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups. RESULTS: There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001]. CONCLUSIONS: This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.

Pursuing a Career in Pediatrics: Intersection of Educational Debt and Race/Ethnicity.

OBJECTIVES: To examine the associations among pediatric trainees' self-reported race/ethnicity, educational debt, and other factors for pursuing a pediatrics career. STUDY DESIGN: Cross-sectional study using data from the American Board of Pediatrics In-training Examination Post-examination Survey years 2018-2020 of categorical pediatric interns. Independent variable of interest was race/ethnicity. Classifications used were White, Hispanic/Latinx, Black/African American, Asian, and other/multiracial. The primary dependent variable was educational debt; secondary dependent variables included the importance of personal, professional, and financial factors in selecting a pediatric career. Means with 95% CIs were computed to summarize scores regarding a factor's importance. Chi-square tests of homogeneity and one-way ANOVA F tests were used to compare proportions and means of dependent variables across levels of self-reported race/ethnicity. RESULTS: A total of 11 150 (91.5%) completed the survey. Of the final analytical sample (7 943), approximately 6.3% self-identified as Black/African American, 8.2% as Hispanic/Latinx, 22% as Asian, and 55% as White; 44% reported >$200 000 of debt. Overall, 33% of those identifying as Black/African American had >$300 000 in educational debt. The highest ranked career factor was interest in a specific disease/patient population. The importance of educational debt in career choices was highest among those identifying as Black/African American, followed by Asians and Hispanic/Latinx. Among all races/ethnicities, the importance of mentorship decreased with higher educational debt. CONCLUSION: Among individuals pursuing pediatrics, the intersection of race/ethnicity and debt may influence trainees' pursuit of pediatric careers. Educational debt negatively impacts the importance of mentorship.

The Association Between Routine Car Seat Screening and Subsequent Health Care Utilization.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends preterm newborns undergo car seat tolerance screening (CSTS) before discharge despite limited evidence supporting the practice. We examined subsequent health care utilization in screened and unscreened late preterm and low birth weight newborns. METHODS: This observational study included late preterm (34-36 weeks) and term low birth weight (<2268 g) newborns born between 2014 and 2018 at 4 hospitals with policies recommending CSTS for these infants. Birth hospitalization length of stay (LOS) in addition to 30-day hospital revisits and brief resolving unexplained events were examined. Unadjusted and adjusted rates were compared among 3 groups: not screened, pass, and fail. RESULTS: Of 5222 newborns, 3163 (61%) were discharged from the nursery and 2059 (39%) from the NICU or floor. Screening adherence was 91%, and 379 of 4728 (8%) screened newborns failed the initial screen. Compared with unscreened newborns, adjusted LOS was similar for newborns who passed the CSTS (+5.1 hours; -2.2-12.3) but significantly longer for those who failed (+16.1; 5.6-26.7). This differed by screening location: nursery = +12.6 (9.1-16.2) versus NICU/floor = +71.2 (28.3-114.1) hours. Hospital revisits did not significantly differ by group: not screened = 7.3% (reference), pass = 5.2% (aOR 0.79; 0.44-1.42), fail = 4.4% (aOR 0.65; 0.28-1.51). CONCLUSIONS: Hospital adherence to CSTS recommendations was high, and failed screens were relatively common. Routine CSTS was not associated with reduced health care utilization and may prolong hospital LOS, particularly in the NICU/floor. Prospective trials are needed to evaluate this routine practice for otherwise low-risk infants.

Semiparametric analysis of a generalized linear model with multiple covariates subject to detection limits.

Studies on the health effects of environmental mixtures face the challenge of limit of detection (LOD) in multiple correlated exposure measurements. Conventional approaches to deal with covariates subject to LOD, including complete-case analysis, substitution methods, and parametric modeling of covariate distribution, are feasible but may result in efficiency loss or bias. With a single covariate subject to LOD, a flexible semiparametric accelerated failure time (AFT) model to accommodate censored measurements has been proposed. We generalize this approach by considering a multivariate AFT model for the multiple correlated covariates subject to LOD and a generalized linear model for the outcome. A two-stage procedure based on semiparametric pseudo-likelihood is proposed for estimating the effects of these covariates on health outcome. Consistency and asymptotic normality of the estimators are derived for an arbitrary fixed dimension of covariates. Simulations studies demonstrate good large sample performance of the proposed methods vs conventional methods in realistic scenarios. We illustrate the practical utility of the proposed method with the LIFECODES birth cohort data, where we compare our approach to existing approaches in an analysis of multiple urinary trace metals in association with oxidative stress in pregnant women.

Time-Varying Associations between Food Insecurity and Infant and Maternal Health Outcomes.

BACKGROUND: Food insecurity (FI) is dynamic for families and adversely affects infant and maternal health. However, few studies have examined the longitudinal impact of FI on infant and maternal health. OBJECTIVES: We aimed to examine the relation between food insecurity in the first year of life and infant and maternal health outcomes. We hypothesized FI would be associated with poorer infant and maternal health outcomes. METHODS: We conducted a retrospective cohort study of 364 infants 12-15 months and their caregivers receiving care at a single primary care clinic. The exposure of interest was food insecurity measured during well-child checks using a validated 2-item screening tool. The primary outcome was infant weight-for-length z score. Secondary outcomes included infant log-transformed ferritin, infant hemoglobin, infant lead concentrations, and maternal depression, assessed by the Edinburgh Postnatal Depression Scale. Unadjusted and adjusted effects were estimated using generalized mixed linear models, and the linear effect of visit time was tested using likelihood ratios. RESULTS: In adjusted models, no overall association between FI and infant weight-for-length z score was observed; however, FI male infants had lower weight-for-length z scores than female infants (P = 0.05). FI infants had 14% lower log ferritin concentrations per month of exposure to FI. FI was positively associated with maternal depression (IRR 5.01 [95% CI 2.21-11.3]). CONCLUSIONS: Food insecurity can have longitudinal and demographically-varied associations with infant and maternal outcomes that warrant further exploration.