COVID-19 Pandemic Exacerbates Childhood Immunization Disparities.

BACKGROUND: The objective of this study was to measure the recovery of routine pediatric immunization after a period of reduced vaccine administrations in the early weeks of the COVID-19 pandemic. METHODS: We recorded data on vaccines administered in Children's Wisconsin primary care or urgent care clinics from January 2019 through December 2020 and aggregated data by date and insurance type. RESULTS: During the gradual reopening period after week 21 in 2020, vaccine administration returned to prepandemic levels for children with commercial insurance but remained below baseline rates until the end of 2020 for children with Medicaid insurance. DISCUSSION: The decline in pediatric vaccination in 2020 disproportionately affected children with Medicaid insurance.

Improving Child Development Screening: Implications for Professional Practice and Patient Equity.

INTRODUCTION AND OBJECTIVES: A pediatric group with 25 clinics and 150 providers used multifaceted approaches to implement workflow processes and an electronic health record (EHR) flowsheet to improve child developmental screening. The key outcome was developmental screening done for every patient during 3 periods between ages 8 and 36 months. Identification of developmental concerns was the secondary study outcome. Screening rates and referrals were hypothesized to be optimized for children regardless of demographic backgrounds. METHODS: During preventive visits, developmental screens targeted patients in age groups 8 to 12, 13 to 24, and 25 to 36 months. EHRs were analyzed for screening documentation, results, and referrals by patient demographics. Fifteen pediatric professionals were interviewed about their qualitative experiences. Quality improvement interventions included appointing clinic champions, training staff about the screening process and responsibilities, using a standardized tool, employing plan-do-study-act cycles, posting EHR prompts, providing financial incentives, and monitoring screening rates using control charts. RESULTS: Within 25 months, screening rates improved from 60% to >95% within the 3 preventive visit age groups for a total of more than 30 000 children. Professionals valued the team process improvements. Children enrolled in Medicaid, black children, and those living in lower income zip codes had lower screening rates than privately insured, white children, and those living in higher income areas. Ages and Stages Questionnaire 3rd edition results were significantly different by gender, race/ethnicity, insurance, and income categories across all groups. Referral rates varied by race/ethnicity and zip code of residence. CONCLUSIONS: This project resulted in an effective and efficient process to improve child developmental screening that was valued by pediatric professionals. Analyses of patient demographics revealed disparities in services for the most vulnerable families. Ongoing quality improvement, health services research, and advocacy offer hope to improve health equity.

Regional entropy of functional imaging signals varies differently in sensory and cognitive systems during propofol-modulated loss and return of behavioral responsiveness.

The level and richness of consciousness depend on information integration in the brain. Altered interregional functional interactions may indicate disrupted information integration during anesthetic-induced unconsciousness. How anesthetics modulate the amount of information in various brain regions has received less attention. Here, we propose a novel approach to quantify regional information content in the brain by the entropy of the principal components of regional blood oxygen-dependent imaging signals during graded propofol sedation. Fifteen healthy individuals underwent resting-state scans in wakeful baseline, light sedation (conscious), deep sedation (unconscious), and recovery (conscious). Light sedation characterized by lethargic behavioral responses was associated with global reduction of entropy in the brain. Deep sedation with completely suppressed overt responsiveness was associated with further reductions of entropy in sensory (primary and higher sensory plus orbital prefrontal cortices) but not high-order cognitive (dorsal and medial prefrontal, cingulate, parietotemporal cortices and hippocampal areas) systems. Upon recovery of responsiveness, entropy was restored in the sensory but not in high-order cognitive systems. These findings provide novel evidence for a reduction of information content of the brain as a potential systems-level mechanism of reduced consciousness during propofol anesthesia. The differential changes of entropy in the sensory and high-order cognitive systems associated with losing and regaining overt responsiveness are consistent with the notion of "disconnected consciousness", in which a complete sensory-motor disconnection from the environment occurs with preserved internal mentation.

Fine-Grained Parcellation of Brain Connectivity Improves Differentiation of States of Consciousness During Graded Propofol Sedation.

Conscious perception relies on interactions between spatially and functionally distinct modules of the brain at various spatiotemporal scales. These interactions are altered by anesthesia, an intervention that leads to fading consciousness. Relatively little is known about brain functional connectivity and its anesthetic modulation at a fine spatial scale. Here, we used functional imaging to examine propofol-induced changes in functional connectivity in brain networks defined at a fine-grained parcellation based on a combination of anatomical and functional features. Fifteen healthy volunteers underwent resting-state functional imaging in wakeful baseline, mild sedation, deep sedation, and recovery of consciousness. Compared with wakeful baseline, propofol produced widespread, dose-dependent functional connectivity changes that scaled with the extent to which consciousness was altered. The dominant changes in connectivity were associated with the frontal lobes. By examining node pairs that demonstrated a trend of functional connectivity change between wakefulness and deep sedation, quadratic discriminant analysis differentiated the states of consciousness in individual participants more accurately at a fine-grained parcellation (e.g., 2000 nodes) than at a coarse-grained parcellation (e.g., 116 anatomical nodes). Our study suggests that defining brain networks at a high granularity may provide a superior imaging-based distinction of the graded effect of anesthesia on consciousness.

Propofol attenuates low-frequency fluctuations of resting-state fMRI BOLD signal in the anterior frontal cortex upon loss of consciousness.

Recent studies indicate that spontaneous low-frequency fluctuations (LFFs) of resting-state functional magnetic resonance imaging (rs-fMRI) blood oxygen level-dependent (BOLD) signals are driven by the slow (<0.1Hz) modulation of ongoing neuronal activity synchronized locally and across remote brain regions. How regional LFFs of the BOLD fMRI signal are altered during anesthetic-induced alteration of consciousness is not well understood. Using rs-fMRI in 15 healthy participants, we show that during administration of propofol to achieve loss of behavioral responsiveness indexing unconsciousness, the fractional amplitude of LFF (fALFF index) was reduced in comparison to wakeful baseline in the anterior frontal regions, temporal pole, hippocampus, parahippocampal gyrus, and amygdala. Such changes were absent in large areas of the motor, parietal, and sensory cortices. During light sedation characterized by the preservation of overt responsiveness and therefore consciousness, fALFF was reduced in the subcortical areas, temporal pole, medial orbital frontal cortex, cingulate cortex, and cerebellum. Between light sedation and deep sedation, fALFF was reduced primarily in the medial and dorsolateral frontal areas. The preferential reduction of LFFs in the anterior frontal regions is consistent with frontal to sensory-motor cortical disconnection and may contribute to the suppression of consciousness during general anesthesia.

Comparison of caregiver otitis media risk factor knowledge in suburban and urban primary care environments.

OBJECTIVE: There are many risk factors for otitis media. Some of these, such as passive tobacco smoke exposure and childcare arrangements; have the potential to be modified. The purpose of this study is to assess caregiver knowledge deficits about risk factors associated with otitis media and their willingness to modify behaviors associated with those risks. RESEARCH DESIGN AND METHODS: This study is a prospective survey study investigating knowledge deficits of parents or guardians of children ages 6-36 months about the risk factors of otitis media. The patients were consecutively drawn from a suburban and an urban pediatric practice. Any difference in survey results between these two groups was also assessed. Participants completed a survey of 21 questions with content including demographic and OM risk factor data. RESULTS: A total of 401 caregivers completed surveys, with 213 from an urban pediatric practice and 188 from a suburban practice. There was a significant difference in the ethnic distributions of the two populations. The suburban population had a significantly greater family history of ear infections, number of ear infections in the past 12 months, and number of previous ventilation tubes placed. The urban population had a significantly greater number of smokers in the household and decreased knowledge about day care as a risk for OM. The urban population's question responses suggested a greater willingness to change day care arrangements to reduce the risk of otitis media. CONCLUSIONS: Both populations demonstrated knowledge deficits regarding risk factors associated with OM and both populations exhibited willingness to modify behaviors to reduce risk. These findings demonstrate that there are opportunities for improving education regarding OM risk factors and that this education could potentially reduce risk for OM and in turn reduce the incidence of OM in children.