Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections.

OBJECTIVE: The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. DESIGN, SETTING AND PARTICIPANTS: We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. MAIN OUTCOME AND MEASURES: We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. RESULTS: We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

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.

Spending on public benefit programs and exposure to adverse childhood experiences.

BACKGROUND: Adverse childhood experiences are associated with poverty, and public benefit programs are increasingly used as primary prevention for negative child outcomes. OBJECTIVE: To estimate the association between spending on benefit programs and cumulative exposure to ACEs among children. PARTICIPANTS AND SETTING: Children aged 0-17 years in the United States during 2016-17 as reported in National Survey of Children's Health. METHODS: We examined the sum of state and federal spending on 5 categories of public benefit programs at the state-level. The primary exposure was mean annual spending per person living below the Federal poverty limit across 2010-2017 Federal fiscal years. The primary outcome was children <18 years old having ever been exposed to ≥ 4 ACEs. RESULTS: Nationally, 5.7 % (95 % confidence interval [CI] 5.3 % - 6.0 %) of children had exposure to ≥ 4 ACEs. After adjustment for children's race and ethnicity, total spending on benefit programs was associated with lower exposure to ≥ 4 ACEs (odds 0.96 [95 % CI: 0.95, 0.97]; p < 0.001). Increased spending in each individual benefit category was also associated with decreased cumulative ACEs exposure (all p < 0.05). Inverse associations were largely consistent when children were stratified by race and ethnicity and income strata. CONCLUSIONS: Investments in public benefit programs may not only decrease poverty but also have broad positive effects on near- and long-term child well-being beyond the programs' stated objectives. Findings support federal and state efforts to prioritize families' economic stability as part of a public health model to prevent ACEs.

An Analysis of Solicitations From Predatory Journals in Ophthalmology.

PURPOSE: To evaluate trends associated with email communication from potentially predatory publishers to faculty in ophthalmology. DESIGN: Cross-sectional study METHODS: Ophthalmologists (n = 14) from various subspecialties and institutions were recruited to participate. Participants identified unsolicited emails that they had received originating from publishers in May 2021. Information collected included details on email contents and publisher organizations. Trends in communications from predatory publishers were evaluated. RESULTS: Over a 30-day study period, a total of 1813 emails were received from 383 unique publishers and 696 unique journals, with a mean (SD) of 4.73 (2.46) emails received per day per participant. Of the 1813 emails identified, 242 (13%) emails were invitations to conferences, whereas 1440 (80%) were solicitations for article submissions to open-access, pay-to-publish journals. A total of 522 (29.0%) emails were related to ophthalmology, and reference to a prior publication of the participant occurred in 262 emails (14%). Of the 696 unique journals identified, 174 (25%) journals were indexed on PubMed and 426 (61%) were listed on Beall's list. When comparing journals that were listed on PubMed vs those that were not, PubMed indexed journals had a higher impact factor (2.1 vs 1.5, P = .002), were less likely to use "greetings" (76% vs 91%, P < .001), had fewer spelling/grammar errors (40% vs 51%, P = .01), and were less likely to offer rapid publication (16% vs 25%, P = .02). CONCLUSIONS: Unsolicited requests to publish occur frequently and may diminish the quality of the scientific literature. We encourage individuals in ophthalmology to be aware of these trends in predatory publishing.

Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes.

BACKGROUND: Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE: To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES: We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS: We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.

Effect of cognitive load on time spent offline during wakefulness.

Humans continuously alternate between online attention to the current environment and offline attention to internally generated thought and imagery. This may be a fundamental feature of the waking brain, but remains poorly understood. Here, we took a data-driven approach to defining online and offline states of wakefulness, using machine learning methods applied to measures of sensory responsiveness, subjective report, electroencephalogram (EEG), and pupil diameter. We tested the effect of cognitive load on the structure and prevalence of online and offline states, hypothesizing that time spent offline would increase as cognitive load of an ongoing task decreased. We also expected that alternation between online and offline states would persist even in the absence of a cognitive task. As in prior studies, we arrived at a three-state model comprised of one online state and two offline states. As predicted, when cognitive load was high, more time was spent online. Also as predicted, the same three states were present even when participants were not performing a task. These observations confirm our method is successful at isolating seconds-long periods of offline time. Varying cognitive load may be a useful way to manipulate time spent in at least one of these offline states in future experimental studies.

Association of Sociodemographic Characteristics with Pediatric Vision Screening and Eye Care: An Analysis of the 2021 National Survey of Children's Health.

PURPOSE: Vision screening and regular eye care can help detect and treat potentially irreversible vision impairment. This study aims to investigate the associations between sociodemographic and health characteristics and the receipt of eye care among children aged 17 years and younger in the United States. DESIGN: This cross-sectional study used data from the National Survey of Children's Health (NSCH), a nationally representative and population-based survey of randomly sampled households. PARTICIPANTS: Participants were children aged 0 to 17 years, residing in all 50 states and the District of Columbia, whose caregivers or parents answered an address-based survey by mail or online. METHODS: Weighted prevalence calculations were applied to analyze the data, and logistic regression was performed to explore associations between reported eye care and demographic, health, and parent-related variables. MAIN OUTCOME MEASURES: Caregiver-reported vision screenings, referral to an eye doctor after vision screening, eye doctor visits, and prescription of corrective lenses. RESULTS: Caregivers reported that 53.2% of children had a vision screening at least once (if child ≤ 5 years) or within the past 2 years (if child > 5 years). Of those screened, 26.9% were referred to an eye doctor. Overall, 38.6% of all children had a previous eye doctor visit, and among them, 55.4% were prescribed corrective lenses during the visit. Factors associated with decreased odds of vision screening included younger age, lack of health care visits, no insurance coverage, parent education high school or less, and lower household income. Non-White ethnicities, households with a non-English primary language, and lower incomes were more likely to be referred to an eye doctor after vision screening. Lower rates of eye doctor visits were associated with younger age, lack of insurance coverage, and primary household languages other than English. CONCLUSIONS: Children from disadvantaged backgrounds are less likely to receive vision screening and eye care. Targeted strategies are needed to increase vision screening and access to eye care services in these vulnerable groups. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Leveraging a Peer-to-Peer Approach to Mitigate Vaccine Misinformation and Improve Vaccine Communication During a Pandemic: Experiences From the Development of a Massive Open Online Course.

The COVID-19 pandemic has not only led to massive global mortality and morbidity, but it has also fueled an infodemic of false and misleading information about COVID-19 and vaccines. The spread of misinformation and disinformation on vaccine safety and efficacy has contributed to vaccine hesitancy and distrust of public health institutions and has undermined the public health response to the COVID-19 pandemic. Because communication plays a monumental role in pandemic preparedness, a promising approach to countering the COVID-19 infodemic is empowering peers to serve as trusted messengers to provide accurate information using evidence-based communication approaches. With this in mind, we developed a massive open online course (MOOC) to provide the general public with the knowledge, skills, and resources to effectively navigate potentially contentious vaccine conversations with their peers, with a specific focus on parents. Within the first year of the course launch, 29,000 people had enrolled. Learners appreciated the information related to vaccine development, communication tips and techniques, and identifying and responding to vaccine misinformation. Over 1,000 learners who completed the course participated in an online evaluation survey. To address public distrust in healthcare providers, government, and science, our survey results indicate that peer-to-peer approaches to addressing vaccine hesitancy can empower community members to educate others and promote vaccine acceptance at scale.

Addressing Health Disparities in Pediatric Eye Care for School-Age Children: A Call to Action.

Disparities in access to pediatric eye care among school-age children pose significant challenges to their health and well-being; addressing these disparities will necessitate coordination across multiple systems. Although vision screenings are mandated in most US states, differences persist in terms of who receives screenings and subsequent follow-up care. Racial, ethnic, and socioeconomic factors exacerbate the issue, with potential ramifications of unaddressed eye problems on learning performance and the risk of widening preexisting educational disparities. To address these challenges, various initiatives and strategic plans have emphasized the need to improve access, enhance diversity in the workforce, and promote health literacy. School-based vision programs (SBVPs) have shown promise in improving access to care and academic outcomes, but issues with integration into the health care system exist. This article explores opportunities to address structural barriers, establish resilient and equitable systems for delivering pediatric eye care to school-age children, and leverage the success of SBVPs to build stronger connections with community providers. Proposed strategies include developing standardized guidelines; establishing referral mechanisms; fostering communication with parents, teachers, and community providers; and promoting eye health literacy across the school community. Collectively, these measures aim to improve health outcomes, address social determinants of health, and reduce disparities in access to care.

Development of a community-informed communication toolkit to prevent spread of viral illness in schools, including SARS-COV-2.

Introduction: Schools were uniquely impacted during the COVID-19 (SARS-COV-2) pandemic. We sought to elucidate how parents/guardians of elementary and middle school students in Maryland navigated the return to in-person school following remote instruction. We also sought to understand how they perceived communication about school-based COVID-19 mitigation strategies and their preferences for the content and format of public health communication about COVID-19 mitigation in schools. Methods: We engaged a community advisory board comprised of key partners and implemented a survey and focus groups. Results: Results indicated that parents/guardians wanted clearer communication about COVID-19 mitigation policies in schools and were experiencing fatigue and confusion. These insights informed the development of a tailorable communication toolkit. The toolkit was designed to (1) inform parents/guardians about the importance and effectiveness of mitigation strategies for preventing viral spread to keep children in school, (2) promote a sense of community and support, and (3) help school communication teams effectively communicate information about mitigation strategies being implemented. Discussion: We describe a process for leveraging schools as a trusted messenger, engaging school communities in the development of communication messages, and utilizing a tailorable communication toolkit in the context of shifting public health guidance and local needs. The toolkit development and dissemination process offers a model for targeting public health messaging to parents/guardians in school settings.

Predictors of student mask mandate policies in United States school districts during the COVID-19 pandemic.

Introduction: Although factors such as urbanicity, population demographics, and political affiliation have been linked with COVID-19 masking behavior and policy in community settings, little work has investigated factors associated with school mask policies. We sought to characterize United States state and school district student COVID-19 masking policies during the 2021-22 school year and determine predictors of these mandates at four time points, including before and after federal guidance relaxed school mask recommendations in February 2022. Methods: Student mask policies for US states and the District of Columbia, as well as a sample of 56 districts were categorized as prohibited, recommended, or required in September 2021, November 2021, January 2022, and March 2022 based on the Johns Hopkins eSchool+ Initiative School Reopening Tracker. Changes in policies over time were characterized. Generalized estimating equations and logistic regression were used to evaluate whether political affiliation of governor, urbanicity, economic disadvantage, and race/ethnic composition of district students, and county-level COVID-19 incidence predicted the presence of a district mask mandate at any time point and at all four time points. Results: State and district policies changed over time. Districts that implemented student mandates at any point were more likely to be in states with Democratic governors (AOR: 5.52; 95% CI: 2.23, 13.64) or in non-rural areas (AOR: 8.20; 95% CI: 2.63, 25.51). Districts that retained mask mandates at all four time points were more likely to have Democratic governors (AOR: 5.39; 95% CI: 2.69, 10.82) and serve a smaller proportion of economically disadvantaged students (AOR: 0.97; 95% CI: 0.95, 0.99). Districts serving a larger proportion of students from minoritized racial/ethnic groups were more likely to have mask mandates at any or all timepoints. Notably, county-level COVID-19 prevalence was not related to the presence of a mask mandate at any or all time points. By March 2022, no factors were significantly associated with district mask policy. Discussion: Political, geographic, and demographic characteristics predicted the likelihood of student mask mandates in the 2021-22 school year. Public health promotion messages and policy must account for variation in these factors, potentially through centralized and consistent messaging and unbiased, trustworthy communication.

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.

Consistency between Household and County Measures of Onsite Schooling during the COVID-19 Pandemic.

The academic, socioemotional, and health impacts of school policies throughout the COVID-19 pandemic have been a source of many questions that require accurate information about the extent of onsite schooling occurring. This article investigates school operational status datasets during the pandemic, comparing (1) self-report data collected nationally on the household level through a Facebook-based survey, (2) county-level school policy data, and (3) a school-level closure status dataset based on phone GPS tracking. The percentage of any onsite instruction within states and counties are compared across datasets from December 2020 to May 2021. Sources were relatively consistent at the state level and for large counties, but key differences were revealed between units of measurement, showing differences between policy and household decisions surrounding children's schooling experiences. The consistency levels across sources support the usage of each of the school policy sources to answer questions about the educational experiences, factors, and impacts related to K-12 education across the nation during the pandemic, but it remains vital to think critically as to which unit of measurement is most relevant to targeted research questions.

Memory Consolidation during Ultra-short Offline States.

Traditionally, neuroscience and psychology have studied the human brain during periods of "online" attention to the environment, while participants actively engage in processing sensory stimuli. However, emerging evidence shows that the waking brain also intermittently enters an "offline" state, during which sensory processing is inhibited and our attention shifts inward. In fact, humans may spend up to half of their waking hours offline [Wamsley, E. J., & Summer, T. Spontaneous entry into an "offline" state during wakefulness: A mechanism of memory consolidation? Journal of Cognitive Neuroscience, 32, 1714-1734, 2020; Killingsworth, M. A., & Gilbert, D. T. A wandering mind is an unhappy mind. Science, 330, 932, 2010]. The function of alternating between online and offline forms of wakefulness remains unknown. We hypothesized that rapidly switching between online and offline states enables the brain to alternate between the competing demands of encoding new information and consolidating already-encoded information. A total of 46 participants (34 female) trained on a memory task just before a 30-min retention interval, during which they completed a simple attention task while undergoing simultaneous high-density EEG and pupillometry recording. We used a data-driven method to parse this retention interval into a sequence of discrete online and offline states, with a 5-sec temporal resolution. We found evidence for three distinct states, one of which was an offline state with features well-suited to support memory consolidation, including increased EEG slow oscillation power, reduced attention to the external environment, and increased pupil diameter (a proxy for increased norepinephrine). Participants who spent more time in this offline state following encoding showed improved memory at delayed test. These observations are consistent with the hypothesis that even brief, seconds-long entry into an offline state may support the early stages of memory consolidation.

Variation in stool testing for children with acute gastrointestinal infections.

BACKGROUND AND OBJECTIVE: Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections. MAIN OUTCOME AND MEASURES: We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates. RESULTS: We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models. CONCLUSIONS: Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship.

Pediatric and School-Age Vision Screening in the United States: Rationale, Components, and Future Directions.

Pediatric vision screening detects children at risk for visual conditions with the goal of connecting those in need with an eye care provider for evaluation and treatment. The primary aim for vision screening in younger children is the detection of those at risk for amblyopia, which can result in irreversible vision loss if left untreated. In older children, screening goals broaden to include the detection of risk for uncorrected refractive error. In the United States, professional organization guidelines and state-mandated requirements for vision screening vary widely across both the timing and components of screening. In this article, we describe the goals and components of pediatric vision screenings, current challenges, novel approaches to providing follow-up services through school-based vision programs, and future directions.

Considerations in Building a School-Based Vision Program.

The burden of childhood visual impairment and disparities in access to pediatric vision care remain pressing issues in the United States. School-based vision programs (SBVPs) serve as one approach to advancing health equity. Operating at the intersection of schools and healthcare, SBVPs can increase access to pediatric vision services, improve academic performance, and facilitate referrals to community vision care providers. To maximize their impact, SBVPs must tailor their services to the individual needs and resources of local school communities. School nurses, who have strong ties to school health care services and the school community, are trusted partners in building SBVPs. This article aims to facilitate SBVP development, implementation, and sustainability processes by offering guidance for school nurses and other stakeholders who aim to build a SBVP, support local programs, or learn more about how SBVPs operate.

Advancing health equity in pediatric eye care: the role of school-based vision programs, research, advocacy, community engagement, and medical education.

Disparities in access to pediatric vision care for school-age children remain a pressing issue in the United States. School-based vision programs (SBVPs) are regarded as a means to advance health equity, especially for disadvantaged students. While SBVPs can be beneficial, these programs are only part of the solution. Interdisciplinary collaborations are needed to strengthen the pediatric eye care delivery system and advocate for broader access to needed eye services. This discussion will frame the role of SBVPs in conjunction with research, advocacy, community engagement, and medical education to advance health equity in pediatric eye care.

The Health Education and Training (HEAT) Corps: A Medical-Community Collaboration Response during the COVID-19 Pandemic.

With the declaration of the COVID-19 pandemic by the World Health Organization in March 2020, many elements of society were faced with attempting to assimilate public health recommendations for infectious control. Vital social organizations had to balance delivering their social services while attempting to stay up to date with COVID-19 information and comply with evolving regulations. In the realm of schools and school systems, guidance on how to best adapt to COVID-19 was often limited. School officials and staff had to assist with multiple public health crises as a consequence of the pandemic, from the pandemic's transmission prevention strategies (e.g., face masks and physical distancing) to the recognition that students would have personal tragedies related to COVID-19. In this review, we highlight the process and feasibility of implementing an international COVID-19 school-based initiative over two years of the pandemic, the Health Education and Training (HEAT) Corps program.