Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations.

This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.

Early Childhood Obesity Prevention: Challenges and Barriers of Implementing Child and Adult Care Food.

INTRODUCTION: The Child and Adult Care Food Program requirements promote healthy eating behaviors and increased physical activity in the daycare setting to help prevent childhood obesity. Some of these standards can be difficult to meet for early childhood education centers. This study examines the challenges and barriers daycare centers face when implementing these guidelines. METHODS: Focus groups consisting of participants from early childhood education centers within our community were conducted in April and May of 2018. RESULTS: Three focus groups were conducted, with a total of 7 childcare center directors. Eight themes that affect nutrition and physical activity curriculums at early childhood education centers arose: teacher philosophy and involvement, training/expertise of staff, parental involvement, financial constraints, children's interests, food availability, physical environment, and regulations/guidelines. Overall, participants expressed their sense that child care facilities are undervalued. They agreed that healthy, fresh food choices are expensive, difficult to obtain due to the volume needed, and require additional training to prepare. Emphasis on gross motor development has a varied level of support from families and teachers. Challenges and barriers to providing adequate gross motor activities include limited financial support, lack of physical space, lack of teacher willingness to engage in outdoor activity, and parental resistance. CONCLUSIONS: Financial constraints and the "undervaluing" of childcare contribute greatly to many of the challenges and barriers early childhood education centers face in meeting nutrition and physical activity standards. Findings from this study shed light on the significant role early childcare centers play in nurturing child development and the efforts these centers undertake in the interest of children.

Monocyte Distribution Width: A Novel Indicator of Sepsis-2 and Sepsis-3 in High-Risk Emergency Department Patients.

OBJECTIVES: Most septic patients are initially encountered in the emergency department where sepsis recognition is often delayed, in part due to the lack of effective biomarkers. This study evaluated the diagnostic accuracy of peripheral blood monocyte distribution width alone and in combination with WBC count for early sepsis detection in the emergency department. DESIGN: An Institutional Review Board approved, blinded, observational, prospective cohort study conducted between April 2017 and January 2018. SETTING: Subjects were enrolled from emergency departments at three U.S. academic centers. PATIENTS: Adult patients, 18-89 years, with complete blood count performed upon presentation to the emergency department, and who remained hospitalized for at least 12 hours. A total of 2,212 patients were screened, of whom 2,158 subjects were enrolled and categorized per Sepsis-2 criteria, such as controls (n = 1,088), systemic inflammatory response syndrome (n = 441), infection (n = 244), and sepsis (n = 385), and Sepsis-3 criteria, such as control (n = 1,529), infection (n = 386), and sepsis (n = 243). INTERVENTIONS: The primary outcome determined whether an monocyte distribution width of greater than 20.0 U, alone or in combination with WBC, improves early sepsis detection by Sepsis-2 criteria. Secondary endpoints determined monocyte distribution width performance for Sepsis-3 detection. MEASUREMENTS AND MAIN RESULTS: Monocyte distribution width greater than 20.0 U distinguished sepsis from all other conditions based on either Sepsis-2 criteria (area under the curve, 0.79; 95% CI, 0.76-0.82) or Sepsis-3 criteria (area under the curve, 0.73; 95% CI, 0.69-0.76). The negative predictive values for monocyte distribution width less than or equal to 20 U for Sepsis-2 and Sepsis-3 were 93% and 94%, respectively. Monocyte distribution width greater than 20.0 U combined with an abnormal WBC further improved Sepsis-2 detection (area under the curve, 0.85; 95% CI, 0.83-0.88) and as reflected by likelihood ratio and added value analyses. Normal WBC and monocyte distribution width inferred a six-fold lower sepsis probability. CONCLUSIONS: An monocyte distribution width value of greater than 20.0 U is effective for sepsis detection, based on either Sepsis-2 criteria or Sepsis-3 criteria, during the initial emergency department encounter. In tandem with WBC, monocyte distribution width is further predicted to enhance medical decision making during early sepsis management in the emergency department.