Female genital mutilation and cutting: a survey of child abuse pediatricians.

BACKGROUND: As global immigration from countries with a high prevalence of female genital mutilation and cutting (FGM/C) has grown in the United States (US), there is need for pediatricians to have adequate training to care for these patients. The objective of this study is to determine the level of knowledge and attitudes of child abuse pediatricians (CAPs) towards FGM/C in the US. METHODS: This cross-sectional study distributed a peer-reviewed survey to US CAPs-members of the Helfer Society-to assess their attitudes, knowledge, clinical practice, and education about FGM/C. Data was analyzed using descriptive statistics, Kruskal-Wallis tests, and Fisher's exact test. RESULTS: Most of the 65 respondents were aware that FGM/C is illegal (92%) and agreed that it violated human rights (99%). Individuals reporting previous training related to FGM/C were significantly more likely to correctly identify World Health Organization types of FGM/C (p < 0.05) and report confidence in doing so (p < 0.05). Only 21% of respondents felt comfortable discussing FGM/C with parents from countries with a high prevalence of FGM/C. Sixty-three percent were not aware of the federal law, and 74% were not aware of their own state's laws about FGM/C. CONCLUSIONS: US CAPs have high rates of training related to FGM/C; however, they need additional training to increase confidence and ability to identify FGM/C. FGM/C remains a topic that CAPs find difficult to discuss with families. With culturally sensitive training, CAPs have the opportunity to help manage and prevent the practice by serving as educators and experts for general pediatricians.

Addressing Racial Capitalism's Impact on Black Essential Workers During the COVID-19 Pandemic: Policy Recommendations.

Black Americans are more likely to be essential workers due to racial capitalism. Because of the COVID-19 pandemic, essential workers are less able to adhere to social distancing and stay-at-home guidelines due to the nature of their work, because they are more likely to occupy crowded households, and are more likely to possess pre-existing health conditions. To assist Black essential workers in preventing infection or reducing the intensity of symptoms if contracted, vaccination against the virus is essential. Unfortunately, Black essential workers face considerable barriers to accessing vaccinations and are hesitant to receive the vaccine due to widespread misinformation and justified historical mistrust of the American medical system. The purpose of this work is to (1) describe the disproportionate impact of COVID-19 on Black essential workers due to racial capitalism, (2) outline the socioeconomic and racial barriers related to vaccination within this population, and (3) to suggest policy-related approaches to facilitate vaccination such as access to on-site vaccination opportunities, the funding of community outreach efforts, and the mandating of increased employee benefits.

Emerging Trends in Smartphone Photo Documentation of Child Physical Abuse.

ABSTRACT: Photo documentation of injuries on children is universally recommended in cases of suspected child physical abuse. As technology improves, the ability to document physical examination findings through smartphone photography is increasingly accessible and practical. The quality of images captured on smartphones now rivals traditional photography and the integration of photo capture within the electronic medical record has led to a variety of fields adopting smartphone photo documentation for diagnosis, consult, and follow-up. However, in cases of child physical abuse, practitioners have been hesitant to adopt smartphones as a primary means of photo documentation because of concerns around image quality, privacy, and security. In this article, we discuss the technology of available smartphone cameras and current evidence regarding their use for photo documentation, use existing guidelines to propose a workflow to improve the yield of smartphone photo documentation in child physical abuse, and discuss common medicolegal concerns.

Using Voice and Touchscreen Controlled Smart Speakers to Protect Vulnerable Clients in Long-Term Care Facilities.

Background and Objectives: The Centers for Medicare and Medicaid Services restricted long-term care facility visitation to only essential personnel during the coronavirus disease 2019 pandemic. The Maryland Department of Human Services distributed Amazon Echoshow 8 voice and touchscreen controlled smart speakers (VTCSS) to a sample of their institutionalized guardianship clients to enhance caseworker access during the pandemic. Research Design and Methods: This pilot study focused on understanding VTCSS use challenges and the effects on clients' safety and well-being. Two focus groups were conducted with caseworkers (N = 16) who piloted the devices. The interviews were recorded, transcribed, and analyzed using open and axial coding. Results: Four themes were identified, including challenges to providing casework during the pandemic (e.g., facility technology gaps), challenges to device installation and use (e.g., privacy concerns), strategies for overcoming challenges (e.g., alert features), and benefits (e.g., stimulation, care monitoring) and uses (e.g., enhanced access, entertainment). Discussion and Implications: VTCSS show great promise to engage the client, maintain visual access, and monitor quality of care. However, facilitating access to such technology requires planning and training before installation.

National Trends in Emergency Department Visits for Child Maltreatment, 2007-2014.

OBJECTIVE: To understand the prevalence of child maltreatment-related emergency department (ED) visits in the United States, we examined data from the 2007 to 2014 Nationwide Emergency Department Sample. METHODS: Based on existing literature, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) ED discharge codes for children less than 10 years of age were characterized as specified child maltreatment, defined as visits with an explicit maltreatment ICD-9 CM or external causes of injury codes. The prevalence of child maltreatment visits per 100,000 children in the United States (based on Center for Disease Control Wide-ranging ONline Data for Epidemiologic Research estimates) overall and by sociodemographic factors was examined, and tests for trends over time were evaluated with Cochran-Armitage tests. Analyses were conducted in 2019. RESULTS: The prevalence of child maltreatment based in ICD-9 CM discharge codes ED visits dropped from 69.2 visits per 100,000 in 2007 to 65.9 visits per 100,000 in 2014; this trend was statistically significant. The prevalence was lowest in 2010 (60.1 visits per 100,000 children). There were increases observed for some demographic groups in this period. Throughout the 8-year period examined, the prevalence of child maltreatment visits was highest for physical abuse compared with other forms of maltreatment, higher for boys compared with girls; highest for children younger than 1 year, and higher for children living in neighborhoods with the lowest median income compared with children in higher-income neighborhoods. CONCLUSIONS: The Nationwide Emergency Department Sample data set is a valuable surveillance tool for examining trends in child maltreatment. Future studies should explore what factors may explain variations in child maltreatment over time to best develop prevention strategies.

Guiding the Clinical Nurse Specialist role in oncology within Princess Margaret Cancer Centre.

In 2019, the Canadian Nurses Association (CNA) published the Advanced Practice Nursing: A Pan-Canadian Framework, defining and highlighting the competencies of the clinical nurse specialist role (CNS). In response to the CNA publication, the CNS Community of Practice (CoP) at Princess Margaret Cancer Centre (PM) reviewed how the oncology CNS roles at PM aligned with the CNA competencies. The primary goal was to utilize the CNA (2019) document to guide the development of a PM CNS role-clarity document and new-hire CNS pathway to assist the onboarding process for new CNS hires at PM. The secondary goal was to raise awareness of the diverse CNS oncology roles at a local and national level through developing, implementing, and disseminating the PM CNS role-clarity document and new-hire CNS pathway.

Managing Opioids and Mitigating Risk: A Survey of Attitudes, Confidence and Practices of Oncology Health Care Professionals.

In response to Canada's opioid crisis, national strategies and guidelines have been developed but primarily focus on opioid use for chronic noncancer pain. Despite the well-established utility of opioids in cancer care, and the growing emphasis on early palliative care, little attention has been paid to opioid risk in this population, where evidence increasingly shows a higher risk of opioid-related harms than was previously thought. The primary objective of this study was to assess oncology clinicians' attitudes, confidence, and practices in managing opioids in outpatients with cancer. This was explored using pilot-tested, profession-specific surveys for physicians/nurse practitioners, nurses and pharmacists. Descriptive analyses were conducted in aggregate and separately based on discipline. Univariate and multiple linear regression analyses were performed to explore relationships between confidence and practices within and across disciplines. The survey was distributed to approximately 400 clinicians in January 2019. Sixty-five responses (27 physicians/nurse practitioners, 31 nurses, 7 pharmacists) were received. Participants endorsed low confidence, differing attitudes, and limited and varied practice in managing and mitigating opioid risks in the cancer population. This study provides valuable insights into knowledge gaps and clinical practices of oncology healthcare professionals in managing opioids and mitigating associated risks for patients with cancer.

Addictive behaviors across the menstrual cycle: a systematic review.

Research examining relations between menstrual cycle phase and female addictive behaviors is accumulating. Theories suggest addictive behaviors may increase during specific phases of the menstrual cycle resulting from cyclical fluctuations in hormones and affect. In line with self-medication theory, we predicted that addictive behaviors would increase premenstrually and menstrually, phases marked by elevations in negative affect, relative to the follicular and luteal phases. We also hypothesized, coinciding with reward-sensitivity theory, that addictive behaviors may increase during ovulation, a phase characterized by increased positive affect, compared to the same phases. This systematic review summarizes extant literature examining the menstrual cycle phase-addictive behavior relationship and underlying motivations. Articles pertaining to menstrual cycle phase and addictive behaviors within the PsycINFO, CINAL, and PubMED databases were screened to determine eligibility following PRISMA guidelines (n = 1568). Thirty-four articles examining alcohol use, cannabis use, nicotine use, caffeine use, and gambling behavior across menstrual cycle phase met inclusion criteria. Consistent with self-medication theory, strong evidence indicated that nicotine use increased premenstrually and menstrually. Other factors increasing both nicotine and alcohol use premenstrually and menstrually include having a premenstrual dysphoric disorder diagnosis or having premenstrual syndrome. Motivations for using alcohol and nicotine may too vary by menstrual cycle phase. Results were less consistent or understudied for other addictive behaviors and thus conclusions cannot be drawn. Menstrual cycle phase appears to be a female-specific factor affecting some addictive behaviors, particularly nicotine use, and should be considered when conducting addictive behavior research or clinical interventions for reproductive-aged females with addictive disorders.

Prepubescent Female Genital Examination Images: Evidence-Informed Learning Opportunities.

OBJECTIVES: To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. DESIGN AND SETTING: This was a mixed-methods study conducted at a tertiary care pediatric center using images from a previously developed education platform. PARTICIPANTS: Participants comprised 107 medical students, residents, fellows, and attendings who interpreted 158 cases to derive case difficulty estimates. INTERVENTIONS: This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. MAIN OUTCOME MEASURES: We derived the proportion of participants who interpreted an image correctly, and features that were common in images with the most frequent diagnostic errors. RESULTS: We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% confidence interval [CI] 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis (P < .001). The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (eg, diaper cream) in the genital area, and nonspecific erythema were common features in images with lower accuracy scores. CONCLUSIONS: A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

Bone Fractures in Children With Cholestatic Liver Disease May Mimic Those Seen in Child Abuse.

ABSTRACT: Certain fractures in children are highly specific for child abuse. Metabolic bone disease frequently develops in patients with cholestatic liver disease (CLD); this can result in weakened bones and a predisposition to pathologic fractures. Fractures that occur in patients with rickets and osteopenia may mimic a bone response to inflicted injury, which in children raise the concern of child abuse. Here we report a series of 15 patients with CLD who developed pathologic fractures in the setting of metabolic bone disease. During initial evaluation, the caretakers of 5 of these 15 patients were reported to child protective services and investigated for child abuse. Pediatricians should be aware that children with CLD have an increased incidence of pathologic fractures, even after the cholestasis has resolved.

Mobile Host mRNAs Are Translated to Protein in the Associated Parasitic Plant Cuscuta campestris.

Cuscuta spp. are obligate parasites that connect to host vascular tissue using a haustorium. In addition to water, nutrients, and metabolites, a large number of mRNAs are bidirectionally exchanged between Cuscuta spp. and their hosts. This trans-specific movement of mRNAs raises questions about whether these molecules function in the recipient species. To address the possibility that mobile mRNAs are ultimately translated, we built upon recent studies that demonstrate a role for transfer RNA (tRNA)-like structures (TLSs) in enhancing mRNA systemic movement. C. campestris was grown on Arabidopsis that expressed a ß-glucuronidase (GUS) reporter transgene either alone or in GUS-tRNA fusions. Histochemical staining revealed localization in tissue of C. campestris grown on Arabidopsis with GUS-tRNA fusions, but not in C. campestris grown on Arabidopsis with GUS alone. This corresponded with detection of GUS transcripts in Cuscuta on Arabidopsis with GUS-tRNA, but not in C. campestris on Arabidopsis with GUS alone. Similar results were obtained with Arabidopsis host plants expressing the same constructs containing an endoplasmic reticulum localization signal. In C. campestris, GUS activity was localized in the companion cells or phloem parenchyma cells adjacent to sieve tubes. We conclude that host-derived GUS mRNAs are translated in C. campestris and that the TLS fusion enhances RNA mobility in the host-parasite interactions.

Translating Screening into Action: Risk Assessment and Intervention for Bullying in Pediatric Settings.

The prevalence and consequences of childhood bullying demand routine screening and intervention in all pediatric health care settings. Although there are many validated screening tools available, there is little guidance on how to assess children at risk and provide interventions based on risk level. Guided by the Screening, Brief Intervention, and Referral to Treatment model for adolescent substance use, we reviewed the literature to identify factors that raise a child's risk level from bullying. In this article, we discuss the five factors identified and propose interventions for differential risk among children. Beyond screening questions and general guidance, a framework for identifying children most at risk of negative outcomes owing to bullying and practical next steps for care is essential. This article outlines such a framework for use by pediatric nurse practitioners and in pediatric care settings at large.

Childhood adversities and prior involvement with child protective services.

OBJECTIVES: We aimed to determine the relation between childhood adversities and prior involvement with Child Protective Services (CPS) history among children presenting for evaluation at a Child Advocacy Center. STUDY DESIGN: The study evaluated children presenting to a Child Advocacy Center (CAC) from 2009 to 2014. A five-item child adversity measure, based on mother's report, was characterized into a scale of none, one, or two or more adversities. Caseworkers at the CAC assessed whether families had a prior history of involvement with CPS. RESULTS: Among the 727 children included in the analyses, 43% had a prior history of involvement with CPS. Twenty-six percent of the children experienced one childhood adversity while 29% experienced two or more. In regression analyses adjusting for socio-demographics, experiencing one (Prevalence Ratio (PR) 1.25 95%CI 1.0-1.5) or two or more adversities (PR1.67 95%CI 1.4, 2.0) was associated with higher prevalence of CPS history compared to those who reported none. CONCLUSIONS: Childhood adversities are associated with prior contact with CPS, suggesting there are missed opportunities to provide services to high-risk families. CACs may be in a unique position to advocate for families and prevent further victimization of children.

Transforming Triplet Vinylnitrene into Triplet Alkylnitrene at Cryogenic Temperatures.

Photolysis of 2,3-diazidonaphthalene-1,4-dione (1) in methyltetrahydrofuran matrices forms 2-(λ1-azaneyl)-3-azidonaphthalene-1,4-dione (vinylnitrene 32), as confirmed by electron paramagnetic resonance spectroscopy. The zero-field splitting (zfs) parameters for 32 (D/hc = 0.5338 cm-1, and E/hc = 0.0038 cm-1) reveal significant 1,3-biradical character. Irradiating 32 yields 2-(λ1-azaneyl)-1,3-dioxo-2,3-dihydro-1H-indene-2-carbonitrile (alkylnitrene 33), which has zfs parameters typical of a cycloalkylnitrene (D/hc = 1.57 cm-1, and E/hc = 0.00071 cm-1). Photolysis of 1 in argon matrices verifies that 32 forms 33.

Use of Health Services by Maltreated Children in Two Different Sociocultural Contexts: Where Can Doors for Interventions Be Opened?

Among maltreated children, elevated use of non-routine (for illness or injury) services may coexist with underutilization of preventive services. Besides physical health problems, lack of contact with primary care may preclude the identification and delivery of appropriate interventions. We examined health service utilization in the longitudinal Boricua Youth Study of Puerto Rican children residing in the South Bronx (SBx), New York City ( n = 901), and San Juan metropolitan area, Puerto Rico ( n = 1,163). Parents and children ( Mage = 9 years) reported on child physical abuse, sexual abuse, and neglect. Parents reported if their child had been to illness, injury, and well-child visits in the past year. In the SBx site, caretakers were more likely to report the children seeing a doctor for a well-child visit (90%) compared with children in Puerto Rico (71%). Children in Puerto Rico were more likely to visit a doctor for an injury in the past year compared with children in the SBx (39% vs. 24%). Twenty-one percent of children in the SBx reported maltreatment versus 16% in Puerto Rico. Adjusting for sociodemographic factors, compared with non-maltreated children, those who experienced two or more types of maltreatment were more likely to have an illness visit in Puerto Rico (prevalence ratio [PR] = 1.5, 95% confidence interval [CI] = [1.1, 2.2]) and the SBx (PR = 1.8, 95% CI = [1.1, 3.0]), or an injury visit (PR = 4.1, 95% CI = [1.9, 8.9]) in Puerto Rico only. Children in the SBx who reported only one type of maltreatment were less likely to use services for injuries than non-maltreated children (PR = 0.42, 95% CI = [0.2, 0.9]). No relation between maltreatment and well-child visits was noted. Children who experience maltreatment may frequently come in contact with health care providers, presenting opportunities for intervention and the prevention of further maltreatment.

Efficacy of a low-cost bubble CPAP system in treatment of respiratory distress in a neonatal ward in Malawi.

BACKGROUND: Respiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care. METHODS: We conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups. FINDINGS: 87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived. INTERPRETATION: Use of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.

Persistent Diarrhea after Celiac Plexus Block in a Pancreatic Cancer Patient: Case Report and Literature Review.

BACKGROUND: Neurolytic celiac plexus block is increasingly used to treat refractory pain associated with abdominal malignancies, especially pancreatic cancer. While self-limiting diarrhea can occur commonly in patients post procedure, a very rare risk of persistent diarrhea exists. OBJECTIVE: We present a case of a 70 year old female with locally advanced pancreatic adenocarcinoma who was hospitalized for persistent severe diarrhea post celiac plexus block and discuss management options for this adverse effect. DESIGN: A review of the current literature within the past 20 years (PubMed and Ovid databases) was conducted to discuss alternatives of management. MEASUREMENTS/RESULTS: Ninety-three entries were found in total including duplicates and only two were included for relevance. Management options that were discussed included anti-motility agents, alpha-adrenergic agonists, and somastatin analog (octreotide). Our patient was initially treated with loperamide, hyoscine, psyllium, and cholestyramine before responding to octreotide. The patient was discharged on long-acting octreotide after her bowel routine stabilized. CONCLUSIONS: Persistent diarrhea is a very rare complication of celiac plexus block and current literature regarding proper management is based largely on anecdotal evidence. For this patient octreotide was an effective agent for the management of this complication.

Outcomes of Patients with Respiratory Distress Treated with Bubble CPAP on a Pediatric Ward in Malawi.

OBJECTIVE: To describe the outcomes of infants and young children with respiratory distress when treated with a novel, low-cost, stand-alone bubble Continuous Positive Airway Pressure (bCPAP) system in a resource-limited setting. METHODS: A non-randomized, convenience sample study in a pediatric unit in Blantyre, Malawi, 2013. Patients weighing ≤10 kg with respiratory distress were eligible. We compared outcomes for patients with bronchiolitis, pneumonia and Pneumocystis jiroveci pneumonia (PJP) after treatment with bCPAP. RESULTS: Seventy percent of patients treated with bCPAP survived. Outcomes were best for patients with bronchiolitis and worst for those with PJP. Most survivors (80%) showed improvement within 24 h. All treating physicians found bCPAP useful, leading to a change in practice. CONCLUSIONS: Bubble CPAP was most beneficial to patients with bronchiolitis. Children, who were going to get well, tended to get well quickly. Physicians believed the bCPAP system provided a higher level of care than nasal oxygen.