Effect of recipient age on prioritisation for liver transplantation in the UK: a population-based modelling study.

BACKGROUND: Following the introduction of an algorithm aiming to maximise life-years gained from liver transplantation in the UK (the transplant benefit score [TBS]), donor livers were redirected from younger to older patients, mortality rate equalised across the age range and short-term waiting list mortality reduced. Understanding age-related prioritisation has been challenging, especially for younger patients and clinicians allocating non-TBS-directed livers. We aimed to assess age-related prioritisation within the TBS algorithm by modelling liver transplantation prioritisation based on data from a UK transplant unit and comparing these data with other regions. METHODS: In this population-based modelling study, serum parameters and age at liver transplantation assessment of patients attending the Scottish Liver Transplant Unit, Edinburgh, UK, between December, 2002, and November, 2023, were combined with representative synthetic data to model TBS survival predictions, which were compared according to age group (25-49 years vs ≥60 years), chronic liver disease severity, and disease cause. Models for end-stage liver disease (UKELD [UK], MELD [Eurotransplant region], and MELD 3.0 [USA]) were used as validated comparators of liver disease severity. FINDINGS: Of 2093 patients with chronic liver disease, 1808 (86%) had complete datasets and liver disease parameters consistent with eligibility for the liver transplant waiting list in the UK (UKELD ≥49). Disease severity as assessed by UKELD, MELD, and MELD 3.0 did not differ by age (median UKELD scores of 56 for patients aged ≥60 years vs 56 for patients aged 25-49 years; MELD scores of 16 vs 16; and MELD 3.0 scores of 18 vs 18). TBS increased with advancing age (R=0·45, p<0·0001). TBS predicted that transplantation in patients aged 60 years or older would provide a two-fold greater net benefit at 5 years than in patients aged 25-49 years (median TBS 1317 [IQR 1116-1436] in older patients vs 706 [411-1095] in younger patients; p<0·0001). Older patients were predicted to have shorter survival without transplantation than younger patients (263 days [IQR 144-473] in older patients vs 861 days [448-1164] in younger patients; p<0·0001) but similar survival after transplantation (1599 days [1563-1628] vs 1573 days [1525-1614]; p<0·0001). Older patients could reach a TBS for which a liver offer was likely below minimum criteria for transplantation (UKELD <49), whereas many younger patients were required to have high-urgent disease (UKELD >60). US and Eurotransplant programmes did not prioritise according to age. INTERPRETATION: The UK liver allocation algorithm prioritises older patients for transplantation by predicting that advancing age increases the benefit from liver transplantation. Restricted follow-up and biases in waiting list data might limit the accuracy of these benefit predictions. Measures beyond overall waiting list mortality are required to fully capture the benefits of liver transplantation. FUNDING: None.

Effect of a Comprehensive School-Based Health Center on Academic Growth in K-8th Grade Students.

OBJECTIVE: School-based health centers (SBHCs) improve health care access, but associations with educational outcomes are mixed and limited for elementary and middle school students. We investigated whether students enrolled in a comprehensive SBHC demonstrated more growth in standardized math and reading assessments over 4 school years versus nonenrolled students. We also explored changes in absenteeism. METHODS: Participants were students enrolled in 2 co-located Title I schools from 2015-19 (1 elementary, 1 middle, n = 2480). Analysis of math and reading was limited to students with baseline and postbaseline scores (math n = 1622; reading n = 1607). Longitudinal regression models accounting for within-subject clustering were used to estimate the association of SBHC enrollment with academic scores and daily absenteeism, adjusting for grade, sex, body mass index category, health conditions, baseline outcomes (scores or absenteeism), and outcome pretrends. RESULTS: More than 70% of SBHC-enrolled students had math (1194 [73.6%]) and reading 1186 [73.8%]) scores. Enrollees were more likely than nonenrollees to have asthma (39.7% vs 19.6%) and overweight/obesity (42.4% vs 33.6%). Adjusted baseline scores were significantly lower in math and reading for enrollees. Mean change from baseline for enrollees exceeded nonenrollees by 3.5 points (95% confidence interval [CI]: 2.2, 4.8) in math and 2.1 points (95% CI: 0.9, 3.3) in reading. The adjusted rate of decrease in daily absenteeism was 10.8% greater for enrollees (incident rate ratio 0.772 [95% CI: 0.623, 0.956]) than nonenrollees (incident rate ratio 0.865 [95% CI: 0.696, 1.076]). CONCLUSIONS: SBHC enrollees had greater health and educational risk but demonstrated more growth in math and reading and less absenteeism than nonenrollees.

Maryland School Health partners' Perspectives on the Impact of COVID-19 on School Health Services for Grades K-12.

BACKGROUND: The COVID-19 pandemic disrupted routine school operations, including school health programs. This study aims to describe the pandemic's impact on school health service delivery from the perspective of Maryland school health partners. METHODS: We conducted semi-structured interviews with health service representatives from public schools (K-12) between July and December 2021. Interviews were recorded, transcribed, and coded through an iterative process to develop analytic themes. RESULTS: Twenty school health partners from 15 Maryland school districts participated. Participants identified key impacts of COVID-19 on school health: (1) COVID-19 disrupted delivery of services such as dental, mental health, and preventative care, (2) COVID-19 necessitated changes in service delivery platforms, (3) COVID-19 affected school health staff through increased responsibilities and staffing shortages, and (4) COVID-19 prompted schools to become hubs for community outreach and health education. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Consideration of school health service disruptions and the increased demands on service providers may inform future priorities for school administrators, health departments, and policymakers. CONCLUSIONS: COVID-19 impacted the timing and method of service delivery as well as the roles of school health staff and schools themselves in public health and education.

Trial Participants' Perceptions of the Impact of Ecological Momentary Assessment on Smoking Behaviors: Qualitative Analysis.

Background: Ecological momentary assessment (EMA) is an increasingly used tool for data collection in behavioral research, including smoking cessation studies. As previous addiction research suggests, EMA has the potential to elicit cue reactivity by triggering craving and increasing behavioral awareness. However, there has been limited evaluation of its potential influence on behavior. Objective: By examining the perspectives of research participants enrolled in a tobacco treatment intervention trial, this qualitative analysis aims to understand the potential impact that EMA use may have had on smoking behaviors that may not have otherwise been captured through other study measures. Methods: We performed a qualitative analysis of in-depth interviews with participants enrolled in a pilot randomized controlled trial of a tobacco treatment intervention that used SMS text messaging to collect EMA data on smoking behaviors. In the pilot randomized controlled trial, combustible cigarette and e-cigarette use and smoking-related cravings were measured as part of an EMA protocol, in which SMS text messaging served as a smoking diary. SMS text messaging was intended for data collection only and not designed to serve as part of the intervention. After a baseline assessment, participants were asked to record daily nicotine use for 12 weeks by responding to text message prompts that they received 4 times per day. Participants were prompted to share their experiences with the EMA text messaging component of the trial but were not directly asked about the influence of EMA on their behaviors. Transcripts were coded according to the principles of the framework for applied research. The codes were then examined, summarized, and grouped into themes based on the principles of grounded theory. Results: Interviews were analyzed for 26 participants. The themes developed from the analysis suggested the potential for EMA, in the form of an SMS text messaging smoking diary, to influence participants' smoking behaviors. The perceived impacts of EMA text messaging on smoking behaviors were polarized; some participants emphasized the positive impacts of text messages on their efforts to reduce smoking, while others stressed the ways that text messaging negatively impacted their smoking reduction efforts. These contrasting experiences were captured by themes reflecting the positive impacts on smoking behaviors, including increased awareness of smoking behaviors and a sense of accountability, and the negative impacts on emotions and smoking behaviors, including provoking a sense of guilt and triggering smoking behaviors. Conclusions: The collection of EMA smoking behavior data via SMS text messaging may influence the behaviors and perceptions of participants in tobacco treatment interventions. More research is needed to determine the magnitude of impact and mechanisms, to account for the potential effects of EMA. A broader discussion of the unintended effects introduced by EMA use is warranted among the research community.

Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

BACKGROUND: Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. METHODS: A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. RESULTS: We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. CONCLUSION: Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Parents' Trust in COVID-19 Messengers and Implications for Vaccination.

PURPOSE: To characterize factors associated with parents' trust in messengers of COVID-19 guidance and determine whether trust in their doctors is associated with COVID-19 vaccination. DESIGN: Web-based and mailed survey (January-June 2022). SETTING: Maryland, USA. SUBJECTS: 567 parents/caregivers of public elementary and middle school students. MEASURES: Parents rated trust in 9 messengers on a 4-point scale ["not at all" (0) to "a great deal" (3)], dichotomized into low (0-1) vs high (2-3). They reported on health insurance, income, race, ethnicity, education, sex, urbanicity, political affiliation, and COVID-19 vaccination. ANALYSIS: ANOVA and t-tests were computed to compare overall trust by parent characteristics. Multivariable logistic regression was run to evaluate factors associated with high trust for each messenger. Multivariable logistic regression was used to evaluate the relationship between trust in doctors and odds of COVID-19 vaccination. RESULTS: Most trusted messengers were doctors (M = 2.65), family members (M = 1.87), and schools (M = 1.81). Parents' trust varied by racial identity, sex, urbanicity, health insurance, and political affiliation. Greater trust in their or their child's doctor was associated with greater odds of child (aOR: 2.97; 95% CI: 1.10, 7.98) and parent (aOR: 3.30; 95% CI: 1.23, 1.47) vaccination. CONCLUSION: Parent characteristics were associated with trust, and trust was linked to vaccination. Public health professionals should anticipate variability in trusted messengers to optimize uptake of public health guidance.

Patient preferences for physical therapy programs after a lower extremity fracture: a discrete choice experiment.

OBJECTIVE: To quantify patients' preferences for physical therapy programmes after a lower extremity fracture and determine patient factors associated with preference variation. DESIGN: Discrete choice experiment. SETTING: Level I trauma centre. PARTICIPANTS: One hundred fifty-one adult (≥18 years old) patients with lower extremity fractures treated operatively. INTERVENTION: Patients were given hypothetical scenarios and asked to select their preferred therapy course when comparing cost, mobility, long-term pain, session duration, and treatment setting. MAIN OUTCOME MEASURES: A multinomial logit model was used to determine the relative importance and willingness to pay for each attribute. RESULTS: Mobility was of greatest relative importance (45%, 95% CI: 40% to 49%), more than cost (23%, 95% CI: 19% to 27%), long-term pain (19%, 95% CI: 16% to 23%), therapy session duration (12%, 95% CI: 9% to 5%) or setting (1%, 95% CI: 0.2% to 2%). Patients were willing to pay US$142 more per session to return to their preinjury mobility level (95% CI: US$103 to US$182). Willingness to pay for improved mobility was higher for women, patients aged 70 years and older, those with bachelor's degrees or higher and those living in less-deprived areas. Patients were willing to pay US$72 (95% CI: US$50 to US$93) more per session to reduce pain from severe to mild. Patients were indifferent between formal and independent home therapy (willingness to pay: -US$12, 95% CI: -US$33 to US$9). CONCLUSIONS: Patients with lower extremity fractures highly value recovering mobility and are willing to pay more for postoperative physical therapy programmes that facilitate returning to their pre-injury mobility level. These patient preferences might be useful when prescribing and designing new techniques for postoperative therapy.

Defining and Promoting Pediatric Pulmonary Health: Equitable Family and Community Partnerships.

Optimizing pulmonary health across the lifespan begins from the earliest stages of childhood and requires a partnership between the family, pulmonologist, and pediatrician to achieve equitable outcomes. The Community Pediatrics session of the Defining and Promoting Pediatric Pulmonary Health workshop weaved together 4 community-based pillars with 4 research principles to set an agenda for future pediatric pulmonary research in optimizing lung and sleep health for children and adolescents. To address diversity, equity, and inclusion, both research proposals and workforce must purposefully include a diverse set of participants that reflects the community served, in addition to embracing nontraditional, community-based sites of care and social determinants of health. To foster inclusive, exploratory, and innovative research, studies must be centered on community priorities, with findings applied to all members of the community, particularly those in historically marginalized and minoritized groups. Research teams should also foster meaningful partnerships with community primary care and family members from study conceptualization. To achieve these goals, implementation and dissemination science should be expanded in pediatric pulmonary research, along with the development of rapid mechanisms to disseminate best practices to community-based clinicians. To build cross-disciplinary collaboration and training, community-academic partnerships, family research partnerships, and integrated research networks are necessary. With research supported by community pillars built on authentic partnerships and guided by inclusive principles, pediatric lung and sleep health can be optimized for all children and adolescents across the full lifespan in the community in which they live and thrive.

Identifying and preventing fraudulent responses in online public health surveys: Lessons learned during the COVID-19 pandemic.

Web-based survey data collection has become increasingly popular, and limitations on in-person data collection during the COVID-19 pandemic have fueled this growth. However, the anonymity of the online environment increases the risk of fraudulent responses provided by bots or those who complete surveys to receive incentives, a major risk to data integrity. As part of a study of COVID-19 and the return to in-person school, we implemented a web-based survey of parents in Maryland between December 2021 and July 2022. Recruitment relied, in part, on social media advertisements. Despite implementing many existing best practices, we found the survey challenged by sophisticated fraudsters. In response, we iteratively improved survey security. In this paper, we describe efforts to identify and prevent fraudulent online survey responses. Informed by this experience, we provide specific, actionable recommendations for identifying and preventing online survey fraud in future research. Some strategies can be deployed within the data collection platform such as careful crafting of survey links, Internet Protocol address logging to identify duplicate responses, and comparison of client-side and server-side time stamps to identify responses that may have been completed by respondents outside of the survey's target geography. Other strategies can be implemented during the survey design phase. These approaches include the use of a 2-stage design in which respondents must be eligible on a preliminary screener before receiving a personalized link. Other design-based strategies include within-survey and cross-survey validation questions, the addition of "speed bump" questions to thwart careless or computerized responders, and the use of optional open-ended survey questions to identify fraudsters. We describe best practices for ongoing monitoring and post-completion survey data review and verification, including algorithms to expedite some aspects of data review and quality assurance. Such strategies are increasingly critical to safeguarding survey-based public health research.

A deep surgical site infection risk score for patients with open tibial shaft fractures treated with intramedullary nail.

OBJECTIVES: To identify deep infection risk factors in patients with open tibial shaft fractures and to develop a scoring algorithm to predict the baseline deep infection risk in this patient population. METHODS: A retrospective cohort study conducted at a single academic trauma center identified patients with open tibial shaft fractures treated with intramedullary nail fixation from December 2006 to October 2020. The primary outcome was a deep surgical site infection requiring surgical debridement. The outcome was identified by Current Procedural Terminology codes and confirmed with a medical chart review documenting evidence of a tibial draining wound or sinus tract. RESULTS: Deep surgical site infection occurred in 13% of patients (97/769). Factors that predicted deep surgical site infection were identified. Gustilo-Anderson type IIIB or IIIC was the strongest predictor with a 12-fold increase in the odds of deep infection (OR 11.8, p < 0.001). Additional factors included age >40 years (OR 1.7, p = 0.03), American Society of Anesthesiologists score ≥3 (OR 1.9, p < 0.01), Gustilo-Anderson type IIIA vs. type I or II (OR 2.8, p = 0.004), and gunshot wounds (OR 2.9, p = 0.02). The risk scoring model predicted patients who would develop an infection with an acceptable level of accuracy (AUC 0.79). The risk score categorized patients from a low probability of deep infection 2%-6% with <10 points to high risk (58%-69%) with >40 points. CONCLUSIONS: This risk score model predicts deep postoperative infection in patients with open tibial shaft fractures treated with intramedullary nails. The ability to accurately estimate deep infection risk at the time of presentation might aid patient expectation management and allow clinicians to focus infection prevention strategies on the high-risk subset of this population.

Parent Engagement with a School-Based Health Center Consent Process Predicts Student Attendance and School Transition.

BACKGROUND: School-based health centers (SBHCs) fill critical pediatric health care access gaps but typically require parental consent for enrollment. Families' responses to SBHC consent form outreach efforts may reflect broader school engagement. This study investigated whether SBHC consent form return predicted subsequent chronic absenteeism and school transition, indicators of student and family school engagement. METHODS: Multivariable logistic regression was used to compare the odds of being chronically absent or transitioning out of a US elementary/middle school (n = 1917) during 2015-2016 and 2016-2017 for those who declined SBHC enrollment or did not return a consent form, compared to those who enrolled. RESULTS: Compared to enrolled students, those who declined had 78% lower odds of chronic absenteeism [95% CI: 0.09, 0.54]. Families who did not respond had 2.8 times greater odds of their student transitioning out of school [95% CI: 2.15, 3.58] but were no more likely to be chronically absent. CONCLUSIONS: Consent form return may predict aspects of broader students and family school engagement.

Patients value their own pain over braking safety when deciding when to return to driving: a discrete choice experiment on lower extremity injuries.

Objective: To quantify patient preferences towards time to return to driving relative to compromised reaction time and potential complication risks. Design: Cross-sectional discrete choice experiment. Setting: Academic trauma center. Patients: Ninety-six adult patients with an operative lower extremity fracture from December 2019 through December 2020. Intervention: None. Main Outcome Measurement: Patient completed a discrete choice experiment survey consisting of 12 hypothetical return to driving scenarios with varied attributes: time to return to driving (range: 1 to 6 months), risk of implant failure (range: 1% to 12%), pain upon driving return (range: none to severe), and driving safety measured by braking distance (range: 0 to 40 feet at 60 mph). The relative importance of each attribute is reported on a scale of 0% to 100%. Results: Patients most valued a reduced pain level when resuming driving (62%), followed by the risk of implant failure (17%), time to return to driving (13%), and braking safety (8%). Patients were indifferent to returning to driving at 1 month (median utility: 28, interquartile range [IQR] -31 to 80) or 2 months (median utility: 59, IQR: 41 to 91) postinjury. Conclusion: Patients with lower extremity injuries demonstrated a willingness to forego earlier return to driving if it might mean a decrease in their pain level. Patients are least concerned about their driving safety, instead placing higher value on their own pain level and chance of implant failure. The findings of this study are the first to rigorously quantify patient preferences toward a return to driving and heterogeneity in patient preferences. Level of Evidence: V.

High-Resolution Spinal Motor Mapping Using Thoracic Spinal Cord Stimulation in Patients With Chronic Pain.

BACKGROUND: High-resolution spinal cord stimulation (HR-SCS) paddle can stimulate medial-dorsal columns and extend stimulation coverage to the laterally positioned spinal targets. OBJECTIVE: To investigate the medio-lateral selectivity of an HR-SCS paddle in patients with chronic pain. METHODS: During standard-of-care spinal cord stimulation (SCS) placement, epidurally evoked electromyography and antidromic dorsal column-evoked potentials were recorded in 12 subjects using an HR-SCS paddle with 8 medio-lateral sites spanning the full epidural width at thoracic T9-12 and a commercial paddle consecutively. RESULTS: Recruitment maps were aligned with respect to physiological midline which was overlapping with anatomic midline in 10 of 11 cases. Overlapping contacts between the HR-SCS and commercial paddles exhibited similar patterns while HR-SCS demonstrated higher precision targeting of certain dermatomes. Spinal motor maps showed that the lateral contacts triggered stronger responses in medial gastrocnemius, adductor magnus, and tibialis anterior while the medial contacts triggered stronger responses in gluteus maximus and adductor hallucis. The time-locked popliteal fossa responses indicated ipsilateral activation by HR-SCS at the lateral contacts and bilateral activation at the medial contacts with stronger ipsilateral responses. CONCLUSION: This study is the first to perform high-resolution medio-lateral SCS mapping in patients with chronic pain. These results show promise that HR-SCS may provide additional ipsilateral recruitment within the extremities which improve targeting of focal pain in the lower extremities. Furthermore, this study supports the functional use of intraoperative neuromonitoring as a decision tool to determine physiological midline in thoracic SCS surgeries and provides a full methodological framework.

Surgical factors associated with symptomatic implant removal after patella fracture.

OBJECTIVES: To determine whether certain types of fixation and other factors associated with the fixation could be identified that predict an increased risk of symptomatic implant removal. METHODS: We conducted a retrospective cohort study at our urban academic level 1 trauma center. Patients aged ≥18 years who underwent operative fixation for patella fracture were included. The primary outcome was symptomatic implant removal after operative fixation. RESULTS: Of the 186 study patients (mean age, 44 [SD 17] years, 65% male), 53 patients (28.5%) underwent symptomatic implant removal. Modifiable risk factors for symptomatic implant removal included the use of Kirschner (k)-wires (OR: 4.93; 95% CI, 1.89-14.10; p < 0.001), and a trend towards significance for implant prominence >5 mm (OR: 2.57; 95% CI, 0.93-7.93; p = 0.07). Symptomatic implant removal was also less likely in patients >45 years of age (OR: 0.14; 95% CI, 0.06-0.34; p < 0.01), of a racial minority (OR: 0.40; 95% CI, 0.17-0.88; p = 0.03), and a body mass index >25 kg/m2 (OR: 0.39; 95% CI, 0.18-0.84; p = 0.02). The final model demonstrated excellent prognostic performance, with an AUC of 0.83 (0.76-0.90). CONCLUSION: We identified both modifiable and non-modifiable factors associated with symptomatic implant removal in patients with patella fractures. Surgeons should be aware that the use of k-wires and any implant prominence exceeding 5 mm might be associated with increased odds of symptomatic implant removal in patients with patella fractures.

A Parent Survey Assessing Association of Exposure to Gun Violence, Beliefs, and Physician Counseling.

OBJECTIVES: The study objectives are to assess associations between hospitalized children's parental exposure to gun violence (GV) and parental beliefs about guns and gun safety; secondarily, the authors aim to describe parental views on the pediatrician's role in firearm injury prevention (FIP) counseling. METHODS: Parents residing with children <20 years old hospitalized at a quaternary care hospital in a large city were eligible. Researchers administered verbal surveys between March 2017 and July 2019. We analyzed data (Wilcoxon rank-sum, χ2, or Fisher's exact tests, as appropriate) to compare the characteristics of those with exposure to GV and those without, and to assess associations of those with and without GV exposure with various beliefs. RESULTS: Enrollment included 225 parents or guardians. Although 75.5% agreed pediatricians should talk to parents about safe gun storage, 8.9% reported FIP counseling by their child's doctor. There were no substantial differences in characteristics between those with GV exposure versus those without. The study revealed that 60.0% of participants reported hearing gunshots, and 41.8% had a friend/relative who had been shot; only 29.8% reported neither. There were no differences between groups in gun-related beliefs regardless of exposure. CONCLUSIONS: In this population, there was no association between exposure to GV and gun-related beliefs. Most parents are receptive to FIP counseling, yet few have discussed FIP with their pediatrician despite high exposure to GV in this community. Nearly all parents agreed with the use of gunlocks and stricter laws for background checks. Regardless of exposure to GV, parents agreed with safe gun storage and support strengthening gun safety laws.

SARS-CoV-2 Gastrointestinal Shedding in Hospitalized Children.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that can cause gastrointestinal (GI) symptoms, with studies demonstrating detection of stool viral RNA weeks after respiratory tract clearance. It is unknown if children who test negative for SARS-CoV-2 on a nasopharyngeal (NP) swab may be shedding the virus in their stool. OBJECTIVE: To measure the prevalence of SARS-CoV-2 stool shedding in children with positive and negative SARS-CoV-2 NP polymerase chain reactions (PCR) tests, and to determine clinical factors associated with GI shedding. METHODS: In this cross-sectional study, we enrolled hospitalized patients 0 to 21 years old with a positive or a negative SARS-CoV-2 NP PCR test who had respiratory and/or GI symptoms. Participants were surveyed, and stool samples were sent for viral PCR testing. Fisher's exact test was used to evaluate bivariate associations of stool PCR test positivity with categorical variables. RESULTS: Sixty-seven patients were consented; 34 patients did not provide stool samples so 33 patients were included: 17 NP-positive and 16 NP-negative for SARS-CoV-2. Eight of the 17 NP-positive patients had a positive stool PCR test for SARS-CoV-2, while none of the 16 SARS-CoV-2 NP-negative patients had a positive result (P < .01). For the 17 SARS-CoV-2 NP-positive patients, GI symptoms were associated with a positive stool PCR test (P = .05) for SARS-CoV-2, but this association was not found for all 33 patients (P = .11). No associations were found with patients in an immunocompromised state or those with a comorbid condition, fever and/or chills, respiratory symptoms, headache and/or myalgias, or anosmia and/or ageusia. CONCLUSIONS: SARS-CoV-2 GI shedding is common and associated with GI symptoms in NP-positive children, with 47% having positive stool PCRs for SARS-CoV-2. GI shedding was not demonstrated in SARS-CoV-2 NP-negative children.

An Intervention to Promote Adherence to Glasses Wearing Among Urban Public Elementary School Students: Associations With Classroom Behavior.

Glasses wearing at school remains low even when glasses are provided. This study investigated whether a classroom intervention to promote glasses wearing was associated with increased glasses wearing and improved classroom behavior. A pretest, posttest design was implemented with 44 students in Grades 1-4 at an urban public elementary school. Over 5 weeks, teachers encouraged eyeglass wearing through a classroom tracker, verbal reminders, and incentives. Glasses wearing and student behavior were monitored using the Direct Behavior Rating Scale of academic engagement and behavior for 13 weeks, including 4 weeks before and after the intervention. Glasses wearing increased from 56% to 73% (95% confidence interval [CI] = [0.08, 0.26]) in the first 2 weeks of the intervention, but not after a spring recess. The intervention was associated with significantly improved academic engagement (4.31%, 95% CI [2.17, 6.45]), respect (3.55%, 95% CI [1.77, 5.34]), and disruption (-4.28%, 95% CI [-6.51, -2.06]) compared to baseline. Higher academic engagement and disruption persisted 4 weeks after the intervention ended. A classroom-based glasses tracking and incentive system is associated with improved eyeglass wearing and classroom behavior among elementary students. A longer term randomized trial is needed to confirm these promising results.

Classroom Temperatures and Asthma-Related School-Based Health Care Utilization: An Exploratory Study.

OBJECTIVE: Schools with aging infrastructure may expose students to extreme temperatures. Extreme outdoor temperatures have previously been linked to more asthma-related health care utilization. Explore the relationship between classroom temperatures and school-based health care visits for asthma in an urban school building with an outdated heating and cooling system. METHODS: Participants were students in grades K-8 who received health care from a school-based health center (SBHC) (n = 647) or school nurse (n = 1244) in 2 co-located urban public schools between 2016 and 2018. The probability of an asthma visit to the SBHC or school nurse was modeled as a function of indoor temperature exposure using generalized estimating equations with covariates accounting for grade, sex, outdoor temperature, days at risk of asthma visit, nonasthma visits, month, and year fixed effects. RESULTS: Classroom temperatures ranged from 48.0˚F to 100.6°F. Higher mean grade-level indoor temperatures from a baseline of approximately 70˚F to 76˚F were associated with increased rates of asthma-related visits to the SBHC or school nurse on same day of exposure. Model-generated estimates suggest that an increase of 10˚F in indoor temperature relative to a baseline of 75˚F was associated with a 53% increase in the rate of asthma-related SBHC visits. CONCLUSIONS: Elevated classroom temperatures may be associated with more school-based health care utilization for asthma. Low-income and students from racial and ethnic minority groups have disproportionately higher rates of asthma and are also more likely to attend schools with poor infrastructure. The potential benefits of school infrastructure investments for student health, health care costs, and health equity merit further investigation.

Developing an Outpatient Pediatric Pre-Procedure COVID-19 Testing Model.

PURPOSE: The purpose of this project was to design, develop, implement, and manage a sustainable process for pediatric preoperative COVD-19 testing and use the test results to determine the level of personal protective equipment and infection control required for each patient for optimal surgical scheduling and preservation of resources. DESIGN: This quality improvement project used the Plan-Do-Study-Act methodology. Multiple cycles of re-evaluation refined this process which was standardized across the enterprise. METHODS: A process for preoperative testing for all patients undergoing procedures requiring anesthesia was developed and implemented. FINDINGS: A safe, feasible, timely process was developed and piloted to obtain COVID-19 test results to guide individualized interventions. During the pilot, 1,707 patients were screened, and five tested positive for COVID-19, eliminating the need to manage 1702 patients as COVID-19 positive. CONCLUSION: To continue to safely re-open, knowledge of the patient's COVID-19 status is imperative to ensure a safe journey through the perioperative area.

Displacement, Violence, and Mental Health: Evidence from Rohingya Adolescents in Cox's Bazar, Bangladesh.

The Rohingya have endured generations of trauma through displacement and targeted violence in Myanmar. Hundreds of thousands have been forced out of the country, with a large proportion settling in refugee camps in Cox's Bazar, Bangladesh. This study examines the impacts of exposure to trauma on mental health outcomes among Rohingya adolescents living in Bangladesh. Post-traumatic stress disorder (PTSD) and depression are examined as outcomes. The main explanatory variable is a measure of exposure to trauma at two levels of proximity (experiencing and witnessing). Resilience is investigated as a potential effect modifier. Experiencing and witnessing traumatic events are positively and significantly associated with PTSD and depression. However, this effect is only seen for PTSD as a continuous measure, reflecting high rates of low-level PTSD in this population. Resilience is found to reduce the effects of trauma on depression, indicating an effect modification of this relationship.