Foster Care and Health in Medicaid-Enrolled Children Experiencing Parental Opioid Use Disorder.

Importance: The burden of the US opioid crisis has fallen heavily on children, a vulnerable population increasingly exposed to parental opioid use disorder (POUD) in utero or during childhood. A paucity of studies have investigated foster care involvement among those experiencing parental opioid use during childhood and the associated health and health care outcomes. Objective: To examine the health and health care outcomes of children experiencing POUD with and without foster care involvement. Design, Setting, and Participants: This population-based cohort study used nationwide Medicaid claims data from January 1, 2014, to December 31, 2020. Participants included Medicaid-enrolled children experiencing parental opioid use-related disorder during ages 4 to 18 years. Data were analyzed between January 2023 and February 2024. Exposure: Person-years with (exposed) and without (nonexposed) foster care involvement, identified using Medicaid eligibility, procedure, and diagnostic codes. Main Outcomes and Measures: The main outcomes included physical and mental health conditions, developmental disorders, substance use, and health care utilization. The Pearson χ2 test, the t test, and linear regression were used to compare outcomes in person-years with (exposed) and without (nonexposed) foster care involvement. An event study design was used to examine health care utilization patterns before and after foster care involvement. Results: In a longitudinal sample of 8 939 666 person-years from 1 985 180 Medicaid-enrolled children, 49% of children were females and 51% were males. Their mean (SD) age was 10 (4.2) years. The prevalence of foster care involvement was 3% (276 456 person-years), increasing from 1.5% in 2014 to 4.7% in 2020. Compared with those without foster care involvement (8 663 210 person-years), foster care involvement was associated with a higher prevalence of developmental delays (12% vs 7%), depression (10% vs 4%), trauma and stress (35% vs 7%), and substance use-related disorders (4% vs 1%; P < .001 for all). Foster children had higher rates of health care utilization across a wide array of preventive services, including well-child visits (64% vs 44%) and immunizations (41% vs 31%; P < .001 for all). Health care utilization increased sharply in the first year entering foster care but decreased as children exited care. Conclusions and Relevance: In this cohort study of Medicaid-enrolled children experiencing parental opioid use-related disorder, foster care involvement increased significantly between 2014 and 2020. Involvement was associated with increased rates of adverse health outcomes and health care utilization. These findings underscore the importance of policies that support children and families affected by opioid use disorder, as well as the systems that serve them.

The ion transporter Na+-K+-ATPase enables pathological B cell survival in the kidney microenvironment of lupus nephritis.

The kidney is a comparatively hostile microenvironment characterized by highsodium concentrations; however, lymphocytes infiltrate and survive therein in autoimmune diseases such as lupus. The effects of sodium-lymphocyte interactions on tissue injury in autoimmune diseases and the mechanisms used by infiltrating lymphocytes to survive the highsodium environment of the kidney are not known. Here, we show that kidney-infiltrating B cells in lupus adapt to elevated sodium concentrations and that expression of sodium potassium adenosine triphosphatase (Na+-K+-ATPase) correlates with the ability of infiltrating cells to survive. Pharmacological inhibition of Na+-K+-ATPase and genetic knockout of Na+-K+-ATPase γ subunit resulted in reduced B cell infiltration into kidneys and amelioration of proteinuria. B cells in human lupus nephritis biopsies also had high expression of Na+-K+-ATPase. Our study reveals that kidney-infiltrating B cells in lupus initiate a tissue adaption program in response to sodium stress and identifies Na+-K+-ATPase as an organ-specific therapeutic target.

The association of sex and payer status on management and subsequent survival in acute myocardial infarction.

BACKGROUND: Previous reports have generally shown lower utilization of hospital resources and lower survival in women than men with acute myocardial infarction. However, to our knowledge, no reports have described the influence of payer status on the treatment and outcome of women and men with acute myocardial infarction. METHODS: Baseline and clinical presenting characteristics, utilization of hospital resources, and subsequent clinical outcome were ascertained among 327 040 women and men enrolled in a national registry of myocardial infarction from June 1, 1994, to January 31, 1997. Separate Cox regression analyses were performed for Medicare, Medicaid, health maintenance organizations, and commercial payer groups to ascertain variables that were predictive of mortality in the study population. RESULTS: After adjustment for differences in age and other baseline and presenting characteristics, women were significantly more likely than men to die in the hospital (hazard ratio, 1.13; 95% confidence interval, 1.10-1.16), and this difference was greatest among women with health maintenance organization and commercial insurance (hazard ratios, 1.30 and 1.29, respectively), and least among women with Medicare (hazard ratio, 1.07). However, after adjustment for the additional effect on short-term survival of sex differences in the utilization of both pharmacologic treatments administered within the first 24 hours and invasive cardiac procedures, the mortality difference observed for women and men further diminished (hazard ratio, 1.08; 95% confidence interval, 1.05-1.10). CONCLUSION: In this large registry, we did not observe significant variations among payer classes in management and mortality among women and men after acute myocardial infarction.

Effects of acute hormone therapy on recurrent ischemia in postmenopausal women with unstable angina.

OBJECTIVES: We tested whether acute hormone therapy reduces ambulatory electrocardiographic ischemia in postmenopausal (PMP) women with unstable angina (UA). BACKGROUND: Endothelial dysfunction contributes to the pathophysiology of UA. Acute estrogen administration improves endothelial function in PMP women with coronary artery disease and increases coronary artery blood flow. METHODS: Two hundred ninety-three PMP women with UA (mean age 69.7 years), treated with standard anti-ischemic therapy, were enrolled within 24 h of symptom onset. In a double-blind fashion, subjects were randomized to receive intravenous followed by oral conjugated estrogen for 21 days, intravenous estrogen followed by oral conjugated estrogen plus medroxyprogesterone for 21 days or placebo. The primary end point was the number of ambulatory electrocardiographic ischemic events over the first 48 h. Clinical events were also determined over six months of follow-up. RESULTS: Electrocardiographic ischemia did not differ among the three randomized groups. The mean number of ischemic events per patient over 48 h was 0.74 for estrogen, 0.86 for estrogen plus progesterone and 0.74 for the placebo groups (p = 0.87). The percentage of patients with ischemic events and the mean duration of ischemia did not differ between hormone- and placebo-treated patients. In-hospital and six-month rates of adverse clinical events were also similar among the three randomized groups. CONCLUSIONS: Acute hormone therapy does not reduce ischemia in PMP women with UA when added to standard anti-ischemic therapy.