Financing Policy Considerations From Texas to Optimize Care for Children With Medical Complexity.

Texas has a tremendous opportunity and momentum to build a more effective system of care for children with medical complexity (CMC) and their families. This is evidenced by growing collaboration among many committed partners since implementation of the Medicaid STAR Kids managed care program in 2016 and Texas' participation in a US Health Resources and Services Administration-funded, 10-state Collaborative Improvement and Innovation Network to Advance Care for CMC from 2017 to 2022. Texas has several comprehensive health homes for CMC that position the state to serve as a national model of integrated, family-centered care for CMC and ensure high-quality care to an exceedingly vulnerable population. Further, Texas' elected leaders demonstrated their interest in system innovation in 2019 and 2021 by enacting state legislation to explore alternative care models and conduct a health home pilot for CMC. Much more must be done to sustain the work underway and bring the promise of care transformation to reality. To this point, we recommend that care planning and coordination be delegated to provider-led, integrated health homes for CMC with alternative payment structures that appropriately reimburse and align incentives with optimal care delivery. To realize the policy aspirations of an effective system of care for CMC, regulatory oversight, payment models, and outcome measures need to be improved to align with the vision articulated in Texas legislation and agency guidance. Although each state's Medicaid program is different, we believe each state can take away policy lessons from those learned by Texas.

Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma.

Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(ß) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.

Downregulation of testicular function in the goat by altrenogest.

BACKGROUND: The present study investigated whether the administration of the progestin altrenogest provides noninvasive, temporary, and reversible suppression of gonadal function in the goat as a potential alternative to chirurgical castration, which is related with irreversibility, risks of complications till death of the animal and welfare issues. Eight sexually mature Peacock goats were randomly divided into two groups. The experimental group was administered altrenogest (0.088 mg/kg) orally once daily for 7 weeks. The remaining four goats received an oral glucose solution and served as the control group. After completing the administration period, the reversibility of the medication was evaluated for another 7 weeks (observation phase). The treatment effects were assessed by clinical examination; ultrasound examination of the testes, including one-dimensional grayscale analysis, blood testosterone levels, analysis of semen parameters and libido. At the end of the observation period, the animals were castrated and the testicles were examined histologically. RESULTS: Altrenogest treatment had no significant effect on the physical development of the goats, the sonographic appearance of the testes, the gray values measured in the ultrasound images, or the blood testosterone levels. The effects of treatment on the testicular and semen parameters varied widely in the experimental animals; the testicle volume was significantly lower and the number of pathologically altered sperm in the ejaculate was significantly higher in treated animals. CONCLUSION: These findings indicate that daily altrenogest administration at a dose of 0.088 mg/kg does not reliably suppress gonadal function in the goat.

Interocular Grouping in Perceptual Rivalry Localized with fMRI.

Bistable perception refers to a broad class of dynamically alternating visual illusions that result from ambiguous images. These illusions provide a powerful method to study the mechanisms that determine how visual input is integrated over space and time. Binocular rivalry occurs when subjects view different images in each eye, and a similar experience called stimulus rivalry occurs even when the left and right images are exchanged at a fast rate. Many previous studies have identified with fMRI a network of cortical regions that are recruited during binocular rivalry, relative to non-rivalrous control conditions (termed replay) that use physically changing stimuli to mimic rivalry. However, we show here for the first time that additional cortical areas are activated when subjects experience rivalry with interocular grouping. When interocular grouping occurs, activation levels broadly increase, with a slight shift towards right hemisphere lateralization. Moreover, direct comparison of binocular rivalry with and without grouping highlights strong focused activity in the intraparietal sulcus and lateral occipital areas, such as right-sided retinotopic visual areas LO1 and IP2, as well as activity in left-sided visual areas LO1, and IP0-IP2. The equivalent analyses for comparable stimulus (eye-swap) rivalry showed very similar results; the main difference is greater recruitment of the right superior parietal cortex for binocular rivalry, as previously reported. Thus, we found minimal interaction between the novel networks isolated here for interocular grouping, and those previously attributed to stimulus and binocular rivalry. We conclude that spatial integration (i.e,. image grouping/segmentation) is a key function of lateral occipital/intraparietal cortex that acts similarly on competing binocular stimulus representations, regardless of fast monocular changes.

Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history.

BACKGROUND: Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS: A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS: Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(ß) = 9.9[p = 0.001]), bruising (Expß = 5.7[p < 0.001]), subdural blood (Exp(ß) = 5.3[p = 0.001]), seizures (Exp(ß) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(ß) = 2.24[p = 0.02]), loss of consciousness (Exp(ß) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(ß) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(ß) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(ß) = 5.9[p = 0.001]), substance abuse (Exp(ß) = 5.7[p = .001]), unknown number of adults in the home (Exp(ß) = 4.1[p = 0.001]) and intimate partner violence (Exp(ß) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity. CONCLUSIONS: To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE: Prognostic, Level III.

Inflicted versus unintentional injury: towards improved detection and surveillance of supervisory neglect.

BACKGROUND: Many children evaluated for child abuse have non-inflicted injuries due to supervisory neglect. Despite its prevalence, supervisory neglect has received minimal attention. METHODS: We performed a retrospective review of patients maintained in a hospital forensic registry. Text analytics software was used to classify types of supervisory neglect from reported mechanism of injury (MOI). Logistic regression was used to assess risks associated with supervisory neglect. RESULTS: For 1185 eligible patients, 553 were classified as having unintentional injuries. Text analysis identified four types of supervisory neglect for falls (N = 376): interrupted supervision (53.4%); failure to adapt the home (26.7%); safety equipment non-compliance (12.8%); inadequate substitute care (7.0%); a fifth category was identified for non-falls (N = 54): rough handling (32.0%). Supervisory neglect was associated with MOI consistent with the injury (AOR = 15.5[p < 0.001]), no loss of consciousness (AOR = 6.8(p < 0.001]), no bruising away from the injury site (AOR = 3.7[p < 0.001]), and direct hospital presentation (AOR = 1.8[p < 0.05]). Of the 553 with unintentional injury, 62% had isolated head injuries; 20%, however, had evidence of prior head trauma. CONCLUSIONS: Interrupted supervision was the most common form of supervisory neglect. Twenty percent of forensics patients with head injury found to have non-inflicted injuries had evidence of prior head injury. Supervisory neglect suggests a high-risk population. LEVEL OF EVIDENCE: Level II, Prognosis.

Comparison of stimulus rivalry to binocular rivalry with functional magnetic resonance imaging.

When incompatible images are presented to each eye, a phenomenon known as binocular rivalry occurs in which the viewer's conscious visual perception alternates between the two images. In stimulus rivalry, similar perceptual alternations between rival images can occur even in the midst of fast image swapping between the eyes. Here, we used functional magnetic resonance imaging to directly compare brain activity underlying the two types of perceptual rivalry. Overall, we found that activity for binocular rivalry was always stronger and more widespread than that for stimulus rivalry-even more so during passive viewing conditions. In particular, the right superior parietal cortex and the right temporoparietal junction were prominently engaged for passive binocular rivalry. While both types of rivalry engaged higher tier visual regions such as the ventral temporal cortex during an active task, activity for stimulus rivalry was comparatively weak in early visual areas V1 to V3, presumably due to a weaker feed-forward signal due to both intraocular and interocular inhibition that may reduce effective contrast. In sum, only binocular rivalry produced perceptually vivid alternations, increased activation of the early visual cortex, and the coordinated engagement of dorsal stream regions, even when a task was not performed. These findings help characterize how stimulus rivalry fits within hierarchical models of binocular rivalry.