Impact of poverty and neighborhood opportunity on outcomes for children treated with CD19-directed CAR T-cell therapy.

Children living in poverty experience excessive relapse and death from newly diagnosed acute lymphoblastic leukemia (ALL). The influence of household poverty and neighborhood social determinants on outcomes from chimeric antigen receptor (CAR) T-cell therapy for relapsed/refractory (r/r) leukemia is poorly described. We identified patients with r/r CD19+ ALL/lymphoblastic lymphoma treated on CD19-directed CAR T-cell clinical trials or with commercial tisagenlecleucel from 2012 to 2020. Socioeconomic status (SES) was proxied at the household level, with poverty exposure defined as Medicaid-only insurance. Low-neighborhood opportunity was defined by the Childhood Opportunity Index. Among 206 patients aged 1 to 29, 35.9% were exposed to household poverty, and 24.9% had low-neighborhood opportunity. Patients unexposed to household poverty or low-opportunity neighborhoods were more likely to receive CAR T-cell therapy with a high disease burden (>25%), a disease characteristic associated with inferior outcomes, as compared with less advantaged patients (38% vs 30%; 37% vs 26%). Complete remission (CR) rate was 93%, with no significant differences by household poverty (P = .334) or neighborhood opportunity (P = .504). In multivariate analysis, patients from low-opportunity neighborhoods experienced an increased hazard of relapse as compared with others (P = .006; adjusted hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.3-4.1). There was no difference in hazard of death (P = .545; adjusted HR, 1.2; 95% CI, 0.6-2.4). Among children who successfully receive CAR T-cell therapy, CR and overall survival are equitable regardless of proxied SES and neighborhood opportunity. Children from more advantaged households and neighborhoods receive CAR T-cell therapy with a higher disease burden. Investigation of multicenter outcomes and access disparities outside of clinical trial settings is warranted.

Association of the social disorganization index with time to first septic shock event in children with acute myeloid leukemia.

BACKGROUND: Pediatric acute myeloid leukemia (AML) chemotherapy increases the risk of life-threatening complications, including septic shock (SS). An area-based measure of social determinants of health, the social disorganization index (SDI), was hypothesized to be associated with SS and SS-associated death (SS-death). METHODS: Children treated for de novo AML on two Children's Oncology Group trials at institutions contributing to the Pediatric Health Information System (PHIS) database were included. The SDI was calculated via residential zip code data from the US Census Bureau. SS was identified via PHIS resource utilization codes. SS-death was defined as death within 2 weeks of an antecedent SS event. Patients were followed from 7 days after the start of chemotherapy until the first of end of front-line therapy, death, relapse, or removal from study. Multivariable-adjusted Cox regressions estimated hazard ratios (HRs) comparing time to first SS by SDI group. RESULTS: The assembled cohort included 700 patients, with 207 (29.6%) sustaining at least one SS event. There were 233 (33%) in the SDI-5 group (highest disorganization). Adjusted time to incident SS did not statistically significantly differ by SDI (reference, SDI-1; SDI-2: HR, 0.84 [95% confidence interval (CI), 0.51-1.41]; SDI-3: HR, 0.70 [95% CI, 0.42-1.16]; SDI-4: HR, 0.97 [95% CI, 0.61-1.53]; SDI-5: HR, 0.72 [95% CI, 0.45-1.14]). Nine patients (4.4%) with SS experienced SS-death; seven of these patients (78%) were in SDI-4 or SDI-5. CONCLUSIONS: In a large, nationally representative cohort of trial-enrolled pediatric patients with AML, there was no significant association between the SDI and time to SS.

Characterizing proximity and transfers of deceased organ donors to donor care units in the United States.

Some United States organ procurement organizations transfer deceased organ donors to donor care units (DCUs) for recovery procedures. We used Organ Procurement and Transplantation Network data, from April 2017 to June 2021, to describe the proximity of adult deceased donors after brain death to DCUs and understand the impact of donor service area (DSA) boundaries on transfer efficiency. Among 19 109 donors (56.1% of the cohort) in 25 DSAs with DCUs, a majority (14 593 [76.4%]) were in hospitals within a 2-hour drive. In areas with DCUs detectable in the study data set, a minority of donors (3582 of 11 532 [31.1%]) were transferred to a DCU; transfer rates varied between DSAs (median, 27.7%, range, 4.0%-96.5%). Median hospital-to-DCU driving times were not meaningfully shorter among transferred donors (50 vs 51 minutes for not transferred, P < .001). When DSA boundaries were ignored, 3241 cohort donors (9.5%) without current DCU access were managed in hospitals within 2 hours of a DCU and thus potentially eligible for transfer. In summary, approximately half of United States deceased donors after brain death are managed in hospitals in DSAs with a DCU. Transfer of donors between DSAs may increase DCU utilization and improve system efficiency.

Pediatric obesity during COVID-19: the role of neighborhood social vulnerability and collective efficacy.

INTRODUCTION: Childhood obesity increased in the first year of COVID-19 with significant disparities across race, ethnicity, and socioeconomic status. Social distancing led to fewer physical activity opportunities but increased screen time and high-calorie food consumption, all co-determined by neighborhood environments. This study aimed to test the moderation effects of neighborhood socioeconomic and built environments on obesity change during COVID-19. METHODS: Using electronic health records from a large pediatric primary care network in 2018-2022, we cross-sectionally examined 163,042 well visits of 2-17-year-olds living in Philadelphia County in order to examine (1) the pandemic's effect on obesity prevalence and (2) moderation by census-tract-level neighborhood socioeconomic disadvantage, crime, food and physical activity-related environments using interrupted-time-series analysis, Poisson regression, and logistic regression. RESULTS: Weekly obesity prevalence increased by 4.9 percent points (pp) during the pandemic (January 2021-August 2022) compared to pre-pandemic (March 2018-March 2020) levels. This increase was pronounced across all age groups, racially/ethnically minoritized groups, and insurance types (ranging from 2.0 to 6.4 pp) except the Non-Hispanic-white group. The increase in obesity among children racially/ethnically minoritized groups was significantly larger in the neighborhoods with high social vulnerability (3.3 pp difference between high and low groups), and low collective efficacy (2.0 pp difference between high and low groups) after adjusting for age, sex, and insurance type. CONCLUSIONS: Racially/ethnically minoritized children experienced larger obesity increases during the pandemic, especially those in socioeconomically disadvantaged neighborhoods. However, the buffering effect of community collective efficacy on the disparities underscores the importance of environments in pediatric health.

Factors Associated with Growth in a Cohort of Children with Complex Biventricular Congenital Heart Disease.

OBJECTIVES: To evaluate patterns and determinants of longitudinal growth among children requiring complex biventricular repair for congenital heart disease, as well as to assess for associations of growth with early feeding modality, comorbidities, postoperative complications, and socioeconomic characteristics. STUDY DESIGN: A single-institution retrospective cohort study was performed in children born February 1999 to March 2009 with complex congenital heart disease who underwent biventricular repair before age 4 years, defined by Risk Adjustment in Congenital Heart Surgery-1 category 3-5. Clinical characteristics, height, weight, and body mass index (BMI) from ages 2-12 years were collected by chart review. Neighborhood-level socioeconomic data were identified using a geographic information system approach. The adjusted association of covariates with growth outcomes was estimated using multivariable linear regression models using generalized estimating equations. RESULTS: Compared with population growth curves, the cohort (n = 150) trended toward early decrease in age-adjusted weight and height. Early tube feeding was significantly associated with decreased BMI before adolescence (-0.539; 95% CI -1.02, -0.054; P = .029). In addition, other clinical and perioperative characteristics had significant associations with growth, including low birth weight, preoperative tube feeds, need for multiple bypass runs, and diagnosis of feeding disorder. CONCLUSIONS: Early childhood growth in children with complex biventricular repair may be impaired. Early tube feeding was associated with decreased BMI over the course of early childhood, which may indicate a need for continued close nutrition follow-up and support even beyond the duration of tube feeds.

Lessons Learned from a Citywide Abandoned Housing Experiment.

Problem research strategy and findings: The negative impact of vacant and abandoned housing in city neighborhoods is extreme, affecting health and quality of life, promoting violence, and leading to further abandonment. One approach to addressing abandoned housing is to intervene with low-cost interventions that provide a visual sense of ownership. We tested whether a low-cost remediation of abandoned and vacant houses or a trash cleanup intervention would make a noticeable difference in the levels of nearby disrepair, disorder, and public safety. The abandoned housing remediation and trash cleanup interventions were a test of compliance with municipal ordinances. We used an experimental design to test the causal effects of the ordinances, and because the scale of abandonment was too large to provide treatment to all abandoned houses in the city. We used systematic social observation methods to rate changes in disrepair, disorder, and litter at housing sites and on the city blocks they were located, and police reported data on gun violence and illegal substance uses. Our experimental design allowed us to see if observed disrepair, disorder, and public safety improved after working windows and doors were installed on abandoned houses compared with a trash cleanup around properties or a no-intervention control condition. Our results showed significant changes in observed disrepair, disorder, and gun violence and illustrate the benefits of experimental evaluations of place-based changes to the built environment. Takeaway for practice: Improving compliance with ordinances to remediate abandoned housing can make a noticeable difference in disrepair in neighborhoods and contribute improved public safety. We illustrate how planners can use field experiments in partnership with city agencies, nonprofit community groups, and local universities to discover novel approaches to advance place-based changes to the built environment that can help economically disadvantaged communities abate problems of physical disorder.

Sociodemographic and Geographic Variation in Access to Neuro-Ophthalmologists in the United States.

BACKGROUND: Neuro-ophthalmologists have expertise in rare and complex disorders, but the ability of patients to access neuro-ophthalmic care has not been examined at a nationwide level. METHODS: Using the 2020 directory of all 502 members of the North American Neuro-Ophthalmology Society as a reference, we found the practice locations of 461 confirmed practicing members and converted each street address to latitude and longitude coordinates. We calculated the travel distance and time from each census tract to the nearest practice location and calculated population-weighted averages by state, region, and other prespecified factors. Choropleth maps were used to visualize the distribution of travel distances and times across the United States. RESULTS: California had the most practicing neuro-ophthalmologists out of any state (50), whereas 4 states (DE, MT, SD, and WY) had none. Washington, DC and MA had the most neuro-ophthalmologists per capita. The average travel distance and time to the nearest neuro-ophthalmologists were found to be 40.90 miles and 46.50 minutes, respectively, although a large portion of western plains and mountain regions had travel times of over 120 minutes. Patients in rural areas had longer travel times than those in urban areas, and Native American patients had the longest travel times of any racial or ethnic group. CONCLUSION: The travel time to see a neuro-ophthalmologist varies widely by state, region, and rurality, with Native American patients and rural patients being disproportionately affected. By identifying the areas with the greatest travel burdens, future policies can work to alleviate these potential barriers to care.

Inequities in Chlamydia trachomatis Screening Between Black and White Adolescents in a Large Pediatric Primary Care Network, 2015-2019.

Objectives. To identify associations between patient race and annual chlamydia screening among adolescent females. Methods. We performed a retrospective cohort study of females aged 15 to 19 years in a 31-clinic pediatric primary care network in Pennsylvania and New Jersey from 2015 through 2019. Using mixed-effect logistic regressions, we estimated associations between annual chlamydia screening and patient (race/ethnicity, age, previous chlamydia screening and infection, insurance type) and clinic (size, setting) characteristics. We decomposed potential effects of clinician's implicit racial bias and screening, using covariates measuring the proportion of Black patients in each clinician's practice. Results. There were 68 935 well visits among 37 817 females, who were 28.8% Black and 25.8% Medicaid insured. The mean annual chlamydia screening rate was 11.1%. Black females had higher odds of screening (adjusted odds ratio [AOR] = 1.67; 95% confidence interval [CI] = 1.51, 1.84) than did White females. In the clinician characteristics model, individual clinicians were more likely to screen their Black versus non-Black patients (AOR = 1.88; 95% CI = 1.65, 2.15). Conclusions. Racial bias may affect screening practices and should be addressed in future interventions, given the critical need to increase population-level chlamydia screening.(Am J Public Health. 2022;112(1):135-143. https://doi.org/10.2105/AJPH.2021.306498).

Neighborhood education status drives racial disparities in clinical outcomes in PPCM.

BACKGROUND: Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry. Additionally, clinical outcomes are worse in this subpopulation compared to White women with PPCM.  The extent to which socioeconomic parameters contribute to these racial disparities is not known. METHODS: We aimed to quantify the association between area-based proxies of socioeconomic status (SES) and clinical outcomes in PPCM, and to determine the potential contribution of these factors to racial disparities in outcomes. A retrospective cohort study was performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of Black individuals. The cohort included 220 women with PPCM, 55% of whom were Black or African American. Available data included clinical and demographic characteristics as well as residential address georeferenced to US Census-derived block group measures of SES. Rates of sustained cardiac dysfunction (defined as persistent LVEF <50%, LVAD placement, transplant, or death) were compared by race and block group-level measures of SES, and a composite neighborhood concentrated disadvantage index (NDI). The contributions of area-based socioeconomic parameters to the association between race and sustained cardiac dysfunction were quantified. RESULTS: Black race and higher NDI were both independently associated with sustained cardiac dysfunction (relative risk [RR] 1.63, confidence interval [CI] 1.13-2.36; and RR 1.29, CI 1.08-1.53, respectively). Following multivariable adjustment, effect size for NDI remained statistically significant, but effect size for Black race did not. The impact of low neighborhood education on racial disparities in outcomes was stronger than that of low neighborhood income (explaining 45% and 0% of the association with black race, respectively). After multivariate adjustment, only low area-based education persisted as significantly correlating with sustained cardiac dysfunction (RR 1.49; CI 1.02-2.17). CONCLUSIONS: Both Black race and NDI independently associate with adverse outcomes in women with PPCM in a single center study. Of the specific components of NDI, neighborhood low education was most strongly associated with clinical outcome and partially explained differences in race. These results suggest interventions targeting social determinants of health in disadvantaged communities may help to mitigate outcome disparities.

Effect of Neighborhood Food Environment and Socioeconomic Status on Serum Phosphorus Level for Patients on Chronic Dialysis.

BACKGROUND: Elevated blood phosphorus levels are common and associated with a greater risk of death for patients receiving chronic dialysis. Phosphorus-rich foods are prevalent in the American diet, and low-phosphorus foods, including fruits and vegetables, are often less available in areas with more poverty. The relative contributions of neighborhood food availability and socioeconomic status to phosphorus control in patients receiving dialysis are unknown. METHODS: Using longitudinal data from a national dialysis provider, we constructed hierarchical, linear mixed-effects models to evaluate the relationships between neighborhood food environment or socioeconomic status and serum phosphorus level among patients receiving incident dialysis. RESULTS: Our cohort included 258,510 patients receiving chronic hemodialysis in 2005-2013. Median age at dialysis initiation was 64 years, 45% were female, 32% were Black, and 15% were Hispanic. Within their residential zip code, patients had a median of 25 "less-healthy" food outlets (interquartile range, 11-40) available to them compared with a median of four "healthy" food outlets (interquartile range, 2-6). Living in a neighborhood with better availability of healthy food was not associated with a lower phosphorus level. Neighborhood income also was not associated with differences in phosphorus. Patient age, race, cause of ESKD, and mean monthly dialysis duration were most closely associated with phosphorus level. CONCLUSIONS: Neither neighborhood availability of healthy food options nor neighborhood income was associated with phosphorus levels in patients receiving chronic dialysis. Modifying factors, such as nutrition literacy, individual-level financial resources, and adherence to diet restrictions and medications, may be more powerful contributors than food environment to elevated phosphorus.

Early Evaluation and the Effect of Socioeconomic Factors on Neurodevelopment in Infants with Tetralogy of Fallot.

Neurodevelopmental sequelae are prevalent among patients with congenital heart defects (CHD). In a study of infants and children with repaired tetralogy of Fallot (TOF), we sought to identify those at risk for abnormal neurodevelopment and to test associations between socioeconomic and medical factors with neurodevelopment deficits. Single-center retrospective observational study of patients with repaired TOF that were evaluated at the institution's Cardiac Kids Developmental Follow-up Program (CKDP) between 2012 and 2018. Main outcomes included neurodevelopmental test scores from the Bayley Infant Neurodevelopmental Screener (BINS), Peabody Developmental Motor Scale (PDMS), and Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Mixed effects linear regression and marginal logistic regression models tested relationships between patient characteristics and outcomes. Sub-analyses were conducted to test correlations between initial and later neurodevelopment tests. In total, 49 patients were included, predominantly male (n = 33) and white (n = 28), first evaluated at a median age of 4.5 months. Forty-three percent of patients (n = 16) had deficits in the BINS, the earliest screening test. Several socioeconomic parameters and measures of disease complexity were associated with neurodevelopment, independently of genetic syndrome. Early BINS and PDMS performed in infancy were associated with Bayley-III scores performed after 1 year of age. Early screening identifies TOF patients at risk for abnormal neurodevelopment. Socioeconomic factors and disease complexity are associated with abnormal neurodevelopment and should be taken into account in the risk stratification and follow-up of these patients. Early evaluation with BINS and PDMS is suggested for detection of early deficits.

Violence in Rural, Suburban, and Urban Schools in Pennsylvania.

School violence is a public health issue with direct and collateral consequences that has academic and social impacts for youth. School violence is often considered a uniquely urban problem, yet more research is needed to understand how violence in rural and suburban schools may be similar or different from urban counterparts. Using school violence data from a state with urban, suburban, and rural counties, we explored the landscape of school violence in Pennsylvania (PA) through mapping, descriptive statistics, and factor analysis. Results show school violence is not solely an urban problem. Schools in all county types and across grade levels deal with violence to varying degrees, and the majority of schools across county types experience low levels of violence. Types of violence experienced by PA schools loaded onto three factors, suggesting that targeted interventions may be better suited to addressing school violence.

An exploratory study on school children's intent attributions for parental structuring behaviors.

This paper begins by proposing a theory-driven, two-dimensional model of children's intent attributions for parental structuring behaviors. The two dimensions are parent-centered intents vs child-centered intents and instrumental goals vs social-emotional goals. These two dimensions imply four categories of intent attribution for parental structuring behaviors. An exploratory study was conducted to examine school children's intent attributions for parental structuring behaviors. Responses in the four proposed categories were observed. Additionally, two new categories emerged from the data: parental structuring behaviors for the sake of the parents' intangible benefits and parental structuring behaviors for the sake of social interests. Research implications of these findings are discussed.

Geospatial Disparities in Youth Sexually Transmitted Infections During COVID-19.

INTRODUCTION: Early in the COVID-19 pandemic, routine sexually transmitted infection (STI) screenings decreased, and test positivity rates increased due to limited screening appointments, national-level STI testing supply shortages, and social distancing mandates. It is unclear if adolescent preventive STI screening has returned to pre-pandemic levels and if pre-existing disparities worsened in late-pandemic. METHODS: This cross-sectional study examined 22,974 primary care visits by 13-19-year-olds in the Philadelphia metropolitan area undergoing screening for gonorrhea and chlamydia in a 31-clinic pediatric primary care network during 2018-2022. Using interrupted-time-series analysis and logistic regression, pandemic-related changes in the asymptomatic STI screening rate and test positivity were tracked across patient demographics. Neighborhood moderation was investigated by census-tract-level Child Opportunity Index in 2023. RESULTS: The asymptomatic STI screening rate dropped by 27.8 percentage points (pp) and 13.5pp when the pandemic and national STI test supply shortage began, respectively, but returned to pre-pandemic levels after supply availability was restored in early 2021. Non-Hispanic-Black adolescents had a significant pandemic drop in STI screening rate, and it did not return to prep-andemic levels (-3.6 pp in the late-pandemic period, p<0.01). This decrease was more pronounced in socioeconomically and educationally disadvantaged neighborhoods (7.5 pp and 9.9 pp lower, respectively) than in advantaged neighborhoods (both p<0.001), controlling for sex, age, insurance type and clinic characteristics. CONCLUSIONS: Neighborhood socioeconomic and educational disadvantage amplified racial-ethnic disparities in STI screening during the pandemic. Future interventions should focus on improving primary care utilization of non-Hispanic-Black adolescents to increase routine STI screening and preventive care utilization.

Disparities in pediatric obesity during COVID-19: The role of neighborhood social vulnerability and collective efficacy.

Introduction: Childhood obesity increased in the first year of Covid-19 with significant disparities across race, ethnicity, and socioeconomic status. Social distancing led to fewer physical activity opportunities but increased screen time and high-calorie food consumption, all co-determined by neighborhood environments. This study aimed to test the moderation effects of neighborhood socioeconomic and built environments on racial/ethnic disparities in obesity change during Covid-19. Methods: Using electronic health records from a large pediatric primary care network in 2018-2022, we cross-sectionally examined 163,042 well visits of 2-17 year-olds living in Philadelphia county in order to examine (1) the pandemic's effect on obesity prevalence and (2) moderation by census-tract-level neighborhood socioeconomic disadvantage, crime, food and physical activity-related environments using interrupted-time-series analysis, Poisson regression, and logistic regression. Results: Weekly obesity prevalence increased by 4.9 percent points (pp) during the pandemic (Jan 2021-Aug 2022) compared to pre-pandemic (Mar 2018-Mar 2020) levels. This increase was pronounced across all age groups, racially/ethnically-minoritized groups, and insurance types (ranging from 2.0 to 6.4 pp) except the Non-Hispanic-white group. The increase in obesity among children racially/ethnically-minoritized groups was significantly larger in the neighborhoods with high social vulnerability (3.3 pp difference between high and low groups), and low collective efficacy (2.0 pp difference between high and low groups) after adjusting for age, sex, and insurance type. Conclusions: Racially/ethnically-minoritized children experienced larger obesity increases during the pandemic, especially those in socioeconomically disadvantaged neighborhoods. However, the buffering effect of community collective efficacy on the disparities underscores the importance of environments in pediatric health.

Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial.

Importance: Structural racism has resulted in long-standing disinvestment and dilapidated environmental conditions in Black neighborhoods. Abandoned houses signal neglect and foster stress and fear for residents, weakening social ties and potentially contributing to poor health and safety. Objective: To determine whether abandoned house remediation reduces gun violence and substance-related outcomes and increases perceptions of safety and use of outdoor space. Design, Setting, and Participants: This cluster randomized trial was conducted from January 2017 to August 2020, with interventions occurring between August 2018 and March 2019. The study included abandoned houses across Philadelphia, Pennsylvania, and surveys completed by participants living nearby preintervention and postintervention. Data analysis was performed from March 2021 to September 2022. Interventions: The study consisted of 3 arms: (1) full remediation (installing working windows and doors, cleaning trash, weeding); (2) trash cleanup and weeding only; and (3) a no-intervention control. Main Outcomes and Measures: Difference-in-differences mixed-effects regression models were used to estimate the effect of the interventions on multiple primary outcomes: gun violence (weapons violations, gun assaults, and shootings), illegal substance trafficking and use, public drunkenness, and perceptions of safety and time outside for nearby residents. Results: A master list of 3265 abandoned houses was randomly sorted. From the top of this randomly sorted list, a total of 63 clusters containing 258 abandoned houses were formed and then randomly allocated to 3 study arms. Of the 301 participants interviewed during the preintervention period, 172 (57.1%) were interviewed during the postintervention period and were included in this analysis; participants were predominantly Black, and most were employed. Study neighborhoods were predominantly Black with high percentages of low-income households. Gun violence outcomes increased in all study arms, but increased the least in the full remediation arm. The full housing remediation arm, compared with the control condition, showed reduced weapons violations by -8.43% (95% CI, -14.68% to -1.19%), reduced gun assaults by -13.12% (95% CI, -21.32% to -3.01%), and reduced shootings by a nonsignificant -6.96% (95% CI, -15.32% to 3.03%). The trash cleanup arm was not associated with a significant differential change in any gun violence outcome. Instances of illegal substance trafficking and use and public drunkenness outcomes were not significantly affected by the housing remediation or trash cleanup treatment. Perceptions of neighborhood safety and time spent outside were unaffected by the intervention. The study arms did differ in a baseline characteristic and some preintervention trends, which raises questions regarding other potential nonmeasured differences between study arms that could have influenced estimates. No evidence of displacement of gun violence outcomes was found. Conclusions and Relevance: In this cluster randomized controlled trial among low-income, predominantly Black neighborhoods, inexpensive, straightforward abandoned housing remediation was directly linked to significant relative reductions in weapons violations and gun assaults, and suggestive reductions in shootings. Trial Registration: isrctn.org Identifier: ISRCTN14973997.

Neighborhood Social Vulnerability and Interstage Weight Gain: Evaluating the Role of a Home Monitoring Program.

Background Poor interstage weight gain is a risk factor for adverse outcomes in infants with hypoplastic left heart syndrome. We sought to examine the association of neighborhood social vulnerability and interstage weight gain and determine if this association is modified by enrollment in our institution's Infant Single Ventricle Management and Monitoring Program (ISVMP). Methods and Results We performed a retrospective single-center study of infants with hypoplastic left heart syndrome before (2007-2010) and after (2011-2020) introduction of the ISVMP. The primary outcome was interstage weight gain, and the secondary outcome was interstage growth failure. Multivariable linear and logistic regression models were used to examine the association between the Social Vulnerability Index and the outcomes. We introduced an interaction term into the models to test for effect modification by the ISVMP. We evaluated 217 ISVMP infants and 111 pre-ISVMP historical controls. The Social Vulnerability Index was associated with interstage growth failure (P=0.001); however, enrollment in the ISVMP strongly attenuated this association (P=0.04). Pre-ISVMP, as well as high- and middle-vulnerability infants gained 4 g/d less and were significantly more likely to experience growth failure than low-vulnerability infants (high versus low: adjusted odds ratio [aOR], 12.5 [95% CI, 2.5-62.2]; middle versus low: aOR, 7.8 [95% CI, 2.0-31.2]). After the introduction of the ISVMP, outcomes did not differ by Social Vulnerability Index tertile. Infants with middle and high Social Vulnerability Index scores who were enrolled in the ISVMP gained 4 g/d and 2 g/d more, respectively, than pre-ISVMP controls. Conclusions In infants with hypoplastic left heart syndrome, high social vulnerability is a risk factor for poor interstage weight gain. However, enrollment in the ISVMP significantly reduces growth disparities.

Feasibility and acceptability of mobile methods to assess home and neighborhood environments related to adolescent sleep.

OBJECTIVE: A growing evidence base suggests home and neighborhood environmental exposures may influence adolescent sleep, but few studies have assessed these relationships using methods that account for time-varying, location-specific exposures, or multiple neighborhood contexts. This study aimed to assess the feasibility and acceptability of using smartphone global positioning system (GPS) tracking and ecological momentary assessment (EMA) to assess time-varying home and neighborhood environmental exposures hypothesized to be associated with adolescent sleep. METHODS: Adolescents aged 15-17 years in Philadelphia completed 7 days of continuous smartphone GPS tracking, which was used to identify daily levels of exposure to geocoded neighborhood factors (eg, crime, green space). Four daily EMA surveys assessed home sleep environment (eg, noise, light), stress, health behaviors, and neighborhood perceptions. Feasibility and acceptability of GPS tracking and EMA were assessed, and distributions of daily environmental exposures were examined. RESULTS: Among 25 teens (mean age 16, 56% male), there was a high level of GPS location data captured (median daily follow-up: 24 hours). Seventy-eight percent of EMA surveys were completed overall. Most participants (96%) reported no privacy concerns related to GPS tracking and minimal burden from EMA surveys. Exposures differed between participants' home neighborhoods and locations visited outside the home neighborhood (eg, higher crime away from home). Sleep environment disruptions were present on 29% of nights (most common: uncomfortable temperature) and were reported by 52% of adolescents. CONCLUSIONS: Results demonstrate the feasibility and acceptability of mobile methods for assessing time-varying home and neighborhood exposures relevant to adolescent sleep for up to 1 week.

Adolescent Access to Federally Funded Clinics Providing Confidential Family Planning Following Changes to Title X Funding Regulations.

Importance: In May 2019, new federal regulations regarding Title X funding were introduced. There has been no formal evaluation of the impact of this regulatory shift as it pertains to minors' access to services. Objective: To explore the geography of federally funded clinics providing confidential reproductive care to adolescents following changes to Title X funding regulations. Design, Setting, and Participants: This retrospective cross-sectional study used a population-based sample of US Census tracts. All clinics participating in the Title X program in August 2018 and August 2020 were included in the analysis. Data were analyzed from January to December 2021. Exposures: Period, defined as before and after the 2019 Title X rule change (August 2018 and August 2020, respectively). Main Outcomes and Measures: US Census tracts were evaluated for the availability of confidential family planning care within a 30-minute drive, according to the presence of a Title X clinic or a permissive state law. Census tracts in which minors lost access to confidential care after the rule change were characterized in terms of demographic characteristics. Univariate logistic regression evaluated associations between Census tract characteristics and the odds of losing vs maintaining access to legally protected confidential minor services. Results: The study included 72 620 Census tracts, accounting for approximately 324 697 728 US residents (99.96% of the population). After the Title X rule change, 1743 clinics in the Title X program left (39.0%) and minors living in 6299 Census tracts (8.7%) lost access to confidential family planning care, corresponding to an estimated 933 649 youth aged 15 to 17 years. Minors living in rural Census tracts (odds ratio [OR], 1.27; 95% CI, 1.18-1.36) and those in the Midwest (OR, 2.41; 95% CI, 2.24-2.60) had higher odds of losing access to care. Minors living in Census tracts with a higher Social Vulnerability Index (OR, 0.51; 95% CI, 0.47-0.55), a larger proportion of Black individuals (OR, 0.34; 95% CI, 0.31-0.37), and/or a larger proportion of Hispanic individuals (OR, 0.45; 95% CI, 0.42-0.49) were less likely to lose access to care. Conclusions and Relevance: These findings suggest that there were losses in access to legally protected confidential reproductive health services for youth after the 2019 Title X rule change. Although evidence-based Title X guidelines have since been reinstated, state laws that ensure adolescent confidentiality in obtaining family planning services may protect youth from future alterations to the Title X program.

The impact of heat on kidney stone presentations in South Carolina under two climate change scenarios.

The risk of kidney stone presentations increases after hot days, likely due to greater insensible water losses resulting in more concentrated urine and altered urinary flow. It is thus expected that higher temperatures from climate change will increase the global prevalence of kidney stones if no adaptation measures are put in place. This study aims to quantify the impact of heat on kidney stone presentations through 2089, using South Carolina as a model state. We used a time series analysis of historical kidney stone presentations (1997-2014) and distributed lag non-linear models to estimate the temperature dependence of kidney stone presentations, and then quantified the projected impact of climate change on future heat-related kidney stone presentations using daily projections of wet-bulb temperatures to 2089, assuming no adaptation or demographic changes. Two climate change models were considered-one assuming aggressive reduction in greenhouse gas emissions (RCP 4.5) and one representing uninibited greenhouse gas emissions (RCP 8.5). The estimated total statewide kidney stone presentations attributable to heat are projected to increase by 2.2% in RCP 4.5 and 3.9% in RCP 8.5 by 2085-89 (vs. 2010-2014), with an associated total excess cost of ~ $57 million and ~ $99 million, respectively.