Pandemic Planning, Response, and Recovery for Pediatricians: A Focus on Health Equity and Social Determinants of Health.

This article summarizes how pediatricians may be uniquely positioned to mitigate the long-term trajectory of COVID-19 on the health and wellness of pediatric patients especially with regard to screening for social determinants of health that are recognized drivers of disparate health outcomes. Health inequities, that is, disproportionately deleterious health outcomes that affect marginalized populations, have been a major source of vulnerability in past public health emergencies and natural disasters. Recommendations are provided for pediatricians to collaborate with disaster planning networks and lead strategies for public health communication and community engagement in pediatric pandemic and disaster planning, response, and recovery efforts.

Health Care Utilization among Homeless-Experienced Adults Who Were Seen by a Mobile Addiction Health Clinic in Boston, Massachusetts: A Quasi-Experimental Study.

Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; pdiff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; pdiff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; pdiff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.

The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status.

BACKGROUND: Although socioeconomic disparities in outcomes of peripheral artery disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. METHODS: Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005-2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. RESULTS: There were 765,175 patients identified; 34% in the first MHI quartile and 18% in the fourth MHI quartile. Compared to patients in the first quartile, those in the fourth quartile were more likely White (69% vs. 42%, P < 0.001), more likely ≥65 years old (75% vs. 62%, P < 0.001), and were less likely to undergo amputations (25% vs. 34%, P < 0.001). After adjusting for patient characteristics, the fourth quartile was associated with more severe disease [Odds ratio: 1.19, 95% confidence interval (CI): 1.11-1.27] compared to the first quartile. CONCLUSIONS: While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

Child Health Advocacy: The Journey to Antiracism.

The last several years have seen accelerated activity and discourse directed at antiracism. Specifically following the 2020 murder of George Floyd, institutions across the country engaged in a range of introspective exercises and transparent reckonings examining their practices, policies, and history insofar as equity and racism is concerned. The authors of this article, both active protagonists in this domain, have been, and continue to be, part of ongoing national efforts and have learned much about the strategies and tactics necessary to initiate, engage, and sustain traction on the path to antiracism.

Reimagining Children's Rights in the US.

Importance: The US faces a pivotal moment of opportunity and risk regarding issues affecting children (aged 0-17 years). Although the US remains the only United Nations member state to not have ratified the Convention on the Rights of the Child (CRC), a child rights framework is essential for child health professionals seeking to advance many issues affecting children in the US. The Reimagining Children's Rights project (2020-2021) conducted an in-depth environmental scan of relevant literature and policy analysis using the Three Horizons design process to assess strategies that could advance the rights and well-being of children in the US. The project was overseen by a steering committee and informed by an advisory committee composed of youth leaders and experts in children's rights, advocacy, health, law, and a range of child-specific issues (eg, youth justice, early childhood development), who provided expert input on strategic considerations for advancing children's rights. Observations: Seven findings about advancing children's rights in the US are notable, all reflecting current gaps and opportunities for using a whole-child rights framework in the US, even without formal adoption of the CRC. Actionable strategies, tactics, and tools to leverage sustainable change in the multitude of issue areas can advance the current state of children's rights. High-potential strategies for catalyzing advancement of children's rights include youth activism, innovations in governance and accountability, legislative action, impact litigation, place-based initiatives, education and public awareness, alignment with other children's movements, and research. The child rights framework is unifying and adaptive to future unforeseen challenges. Conclusions and Relevance: Children's rights provide a powerful, synergistic framework for child health professionals-in partnership with youth and other leaders-to increase equity and protect the rights and well-being of all children in the US.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018.

Importance: Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. Objective: To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. Design, Setting, and Participants: This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Main Outcomes and Measures: Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. Results: In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). Conclusions and Relevance: In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction.

OBJECTIVE: Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction. METHODS: Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses. RESULTS: Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups. CONCLUSIONS: Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.

X-ray Crystal Structure of Thorium Tetrahydroborate, Th(BH4)4, and Computational Studies of An(BH4)4 (An = Th, U).

The crystal structure of Th(BH4)4 is described. Two of the four BH4- ions are terminal and tridentate (κ3), whereas the other two bridge between neighboring ThIV centers in a κ2,κ2 (i.e., bis-bidentate) fashion. Thus, each thorium center is bound to six BH4- groups by 14 Th-H bonds. The six boron atoms describe a distorted octahedron in which the κ3-BH4- ions are mutually cis; the 14 ligating hydrogen atoms define a highly distorted bicapped hexagonal antiprism. The thorium centers are linked into a polymer consisting of interconnected helical chains wound about 4-fold screw axes. The structures of An(BH4)4 (An = Th, U) were also investigated by DFT. The geometries of [An(BH4)6]2-, [An3(BH4)16]4-, and [An5(BH4)26]6- fragments of the polymeric structures were optimized at the B3LYP and/or PBE levels. Most calculated geometries are 14-coordinate and agree with the experimental structures, but isolated [Th(BH4)6]2- units are predicted to feature 16-coordinate ThIV centers.

Experience with a Mobile Addiction Program among People Experiencing Homelessness.

A mobile addiction-focused outreach program designed to improve access to care for people experiencing homelessness was implemented in response to the opioid overdose crisis. This innovative program was readily accepted among participants and can inform the development of similar programs delivering addiction-focused care to people experiencing homelessness elsewhere.

Synthesis and Characterization of Divalent Samarium and Thulium N,N-Dimethylaminodiboranates.

The syntheses and molecular structures of new SmII and TmII N,N-dimethylaminodiboranate (DMADB) complexes are described. Treating SmI2(THF)2 with Na(H3BNMe2BH3) in THF results in the formation of Sm(H3BNMe2BH3)2(THF)3 (1), which can be readily converted to Sm(H3BNMe2BH3)2(DME)2 (DME = 1,2-dimethoxyethane) or Sm(H3BNMe2BH3)2(diglyme) by exchange with the corresponding ether. We also show that Sm(H3BNMe2BH3)2(THF)3 can be prepared by reduction of the SmIII compound Sm(H3BNMe2BH3)3(THF) with KC8 and that addition of 18-crown-6 to this reaction mixture results in the formation of the SmII compound Sm(H3BNMe2BH3)2(18-crown-6). In a similar fashion, two new TmII complexes have been synthesized: treatment of TmI2 in THF with Na(H3BNMe2BH3) results in the formation of Tm(H3BNMe2BH3)2(THF)2 and Tm(H3BNMe2BH3)2(THF)3, which form a cocrystal. IR data and elemental analyses are reported for all the new compounds, as are their crystal structures. 1H and 11B NMR data are provided where available.

Executions and Police Conflicts Involving Children, Adolescents and Young Adults.

Police violence in the United States represents a pressing public health crisis impacting youth, particularly youth of color. This article reviews the recent epidemiology of police executions and conflicts involving children, adolescents, and young adults. The roles of social determinants of health and centuries-long history of white supremacy and racism as root causes of adverse policing are emphasized. The article summarizes the evidence as to how direct and vicarious experiences of police violence impact youth academic, behavioral, and health outcomes. Recommendations are provided for pediatricians to address this public health crisis through clinical practice, education, advocacy, and research.

Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness.

Importance: People experiencing homelessness have been disproportionately affected by the opioid overdose crisis. To mitigate morbidity and mortality, several office-based addiction treatment (OBAT) programs designed for this population have been established across the US, but studies have not yet evaluated their outcomes. Objective: To evaluate treatment retention and mortality in an OBAT program designed specifically for individuals experiencing homelessness with opioid use disorder (OUD). Design, Setting, and Participants: A retrospective cohort study was conducted in the Boston Health Care for the Homeless Program (BHCHP). Participants included all adult patients (N = 1467) who had 1 or more OBAT program encounter at BHCHP from January 1 through December 31, 2018. Data analysis was conducted from January 13 to December 14, 2020. Exposures: Sociodemographic, clinical, and addiction treatment-related characteristics were abstracted from the BHCHP electronic health record. Main Outcomes and Measures: The primary outcome was all-cause mortality, identified by linkage to the Massachusetts Department of Public Health vital records. Multivariable Cox proportional hazards regression analyses were performed to evaluate baseline and time-varying variables associated with all-cause mortality. Secondary addiction treatment-related outcomes were abstracted from the electronic health record and included (1) BHCHP OBAT program retention, (2) buprenorphine continuation and adherence verified by toxicology testing, and (3) opioid abstinence verified by toxicology testing. Results: Of 1467 patients in the cohort, 1046 were men (71.3%) and 731 (49.8%) were non-Hispanic White; mean (SD) age was 42.2 (10.6) years. Continuous retention in the OBAT program was 45.2% at 1 month, 21.7% at 6 months, and 11.3% at 12 months. Continuous buprenorphine adherence was 41.5% at 1 month, 17.6% at 6 months, and 10.2% at 12 months, and continuous opioid abstinence was 28.3% at 1 month, 6.1% at 6 months, and 2.9% at 12 months. The all-cause mortality rate was 29.0 deaths per 1000 person-years, with 51.8% dying from drug overdose. Past-month OBAT program attendance was associated with lower mortality risk (adjusted hazard ratio, 0.34; 95% CI, 0.21-0.55). Conclusions and Relevance: Mortality rates were high in this cohort of addiction treatment-seeking homeless and unstably housed individuals with OUD. Although continuous OBAT program retention was low, past-month attendance in care was associated with reduced mortality risk. Future work should examine interventions to promote increased OBAT attendance to mitigate morbidity and mortality in this vulnerable population.

Emergency Medical Services (EMS) 2050: A Vision for the Future of Pediatric Prehospital Care.

The National Highway Traffic Safety Administration (NHTSA) released EMS Agenda 2050 in 2019. It places into context the problems of prehospital care of children today and projects where we want to be in 2050. It does not provide a list of solutions but provides a vision for EMS as a people-centered EMS system that meets the goals of the six guiding principles. This vision for EMS in 2050 can be applied by leaders in pediatrics, emergency medicine, emergency medical services (EMS), and local, state and federal governments, and proposed actions help to frame how the emergency medicine and EMS communities can optimize the care of children in future EMS systems.