Racial Inequities in Adolescent Contraceptive Care Delivery: A Reproductive Justice Issue.

STUDY OBJECTIVE: The objective of this study was to examine racial/ethnic disparities in contraceptive delivery for adolescent patients within an adolescent medicine subspecialty clinical system before and during the COVID-19 pandemic. Secondarily, we aimed to assess the relationship between race and contraceptive delivery by telehealth. DESIGN: Retrospective cohort study using electronic health record data SETTING: Three adolescent medicine subspecialty clinics in a large academic hospital system, including an urban location and 2 suburban locations PARTICIPANTS: Patients assigned female sex at birth prescribed hormonal contraception between January 1st, 2018, and May 31st, 2021. MAIN OUTCOME MEASURES: Method and type of contraceptive prescribed (short-acting, medium-acting, long-acting reversible contraception [LARC]) RESULTS: There were 2453 patients in the study; 47.5% were White, 36.0% were Black, and 8.1% identified as Hispanic. After controlling for insurance and age, Black patients, compared with non-Black patients, had twofold higher odds of receiving LARC compared with a short-acting method across the study period (aOR = 2.0; 95% CI, 1.52-2.62). We identified effect modification with significant interaction between Black race and the pandemic period, with evidence of a higher marginal probability of Black patients receiving LARCs during the pandemic. Additionally, during the pandemic, patients receiving new contraceptive prescriptions via telehealth were less likely to be Black (aOR = 0.63; 95% CI, 0.41-0.94) or publicly insured (aOR = 0.56; 95% CI, 0.38-0.81). CONCLUSION: Our data show significantly higher prescribing of LARCs to Black adolescents by clinicians, which could suggest differences in physician contraceptive counseling with a bias toward preferentially counseling Black patients toward LARCs. Our data also show that Black and publicly insured patients had decreased utilization of contraceptive care by telehealth during the pandemic.

A Microbial Signature for Paediatric Perianal Crohn's Disease.

BACKGROUND AND AIMS: Perianal fistulising disease can affect up to 25% of patients with Crohn's disease [CD] and lead to significant morbidity. Although the role of the gut microbiota in inflammatory bowel disease [IBD] has been increasingly recognised, its role in fistula development has scarcely been studied. Here, we aimed to define the microbial signature associated with perianal fistulising CD in children. METHODS: A prospective observational study including children age 6-18 years with a diagnosis of perianal fistulising CD was conducted. Stool samples and rectal and perianal fistula swabs were collected. Stool samples and rectal swabs from children with CD without perianal disease and healthy children were included as comparison. Whole shotgun metagenomic sequencing was performed. RESULTS: A total of 31 children [mean age 15.5 ± 3.5 years] with perianal CD were prospectively enrolled. The fistula-associated microbiome showed an increase in alpha diversity and alteration in the abundance of several taxa compared with the rectal- and faecal-associated microbiome with key taxa belonging to the Proteobacteria phylum. Genes conferring resistance to the clinically used antibiotic regimen ciprofloxacin and metronidazole were found in the three sample types. In comparison with children without the perianal phenotype [N = 36] and healthy controls [N = 41], the mucosally-associated microbiome of children with perianal CD harboured a reduced butyrogenic potential. Linear discriminant analysis identified key taxa distinguishing the rectal mucosally-associated microbiome of children with perianal CD from children without this phenotype. CONCLUSIONS: The microbial community within CD-related anorectal fistula is compositionally and functionally unique. Taken together, these findings emphasise the need to better understand the ecosystem of the fistula milieu to guide development of novel microbiome-based strategies in this CD phenotype.

Implementation of an adapted Sepsis Risk Calculator algorithm to reduce antibiotic usage in the management of early onset neonatal sepsis: a multicentre initiative in Wales, UK.

OBJECTIVE: Assess the impact of introducing a consensus guideline incorporating an adapted Sepsis Risk Calculator (SRC) algorithm, in the management of early onset neonatal sepsis (EONS), on antibiotic usage and patient safety. DESIGN: Multicentre prospective study SETTING: Ten perinatal hospitals in Wales, UK. PATIENTS: All live births ≥34 weeks' gestation over a 12-month period (April 2019-March 2020) compared with infants in the preceding 15-month period (January 2018-March 2019) as a baseline. METHODS: The consensus guideline was introduced in clinical practice on 1 April 2019. It incorporated a modified SRC algorithm, enhanced in-hospital surveillance, ongoing quality assurance, standardised staff training and parent education. The main outcome measure was antibiotic usage/1000 live births, balancing this with analysis of harm from delayed diagnosis and treatment, disease severity and readmissions from true sepsis. Outcome measures were analysed using statistical process control charts. MAIN OUTCOME MEASURES: Proportion of antibiotic use in infants ≥34 weeks' gestation. RESULTS: 4304 (14.3%) of the 30 105 live-born infants received antibiotics in the baseline period compared with 1917 (7.7%) of 24 749 infants in the intervention period (45.5% mean reduction). All 19 infants with culture-positive sepsis in the postimplementation phase were identified and treated appropriately. There were no increases in sepsis-related neonatal unit admissions, disease morbidity and late readmissions. CONCLUSIONS: This multicentre study provides evidence that a judicious adaptation of the SRC incorporating enhanced surveillance can be safely introduced in the National Health Service and is effective in reducing antibiotic use for EONS without increasing morbidity and mortality.

Private health insurance reforms: impact of the psychiatric care waiting period exemption policy.

Younger people are more likely to experience incident mental health conditions and hold lower levels of private health insurance coverage. Government reforms introduced in 2018 enabled customers to avoid 2-month waiting periods to access mental health hospital care. Effectiveness in reducing time to admission is assessed.

Spinal deformity following selective dorsal rhizotomy.

The authors performed a review of 79 patients treated by selective dorsal rhizotomy with laminoplasty, 78 of whom were ambulatory, to determine the prevalence of spinal deformities. The mean radiographic follow-up was 4.2 years, the mean clinical follow-up 5.8 years. Scoliosis (11 degrees -24 degrees ) was identified in 13 children, none of whom had a preexisting deformity. There were no significant differences between preoperative and follow-up thoracic kyphosis or lumbar lordosis, although there was a significant difference in lumbar lordosis between sitting and standing radiographs. No progressive or rigid hyperlordotic deformities were observed in the lumbar spine. Spondylolisthesis was identified in nine children (12%) (8/9 grade I), and one patient required an arthrodesis for pain. Spondylolisthesis was correlated with greater lumbar lordosis, stronger hip abductors, and increased popliteal femoral angles preoperatively, and with stronger hip flexors postoperatively. Back pain was identified in 4 of the 79 patients at last follow-up, 2 of whom had spondylolisthesis. As some cases of spondylolisthesis will remain asymptomatic, periodic radiographic follow-up is recommended.