Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data.

Background: Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed. Methods: We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use. Results: Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%. Discussion: Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

State-Level Variation in the Cumulative Prevalence of Child Welfare System Contact, 2015-2019.

Background: Prior estimates of the cumulative risks of child welfare system contact illustrate the prominence of this system in the lives of children in the United States (U.S.). However, these estimates report national data on a system administered at the state and local levels and are unable to detail potential simultaneous geographic and racial/ethnic variation in the prevalence of these events. Methods: Using 2015-2019 data from the National Child Abuse and Neglect Data System and Adoption and Foster Care Analysis and Reporting System, we use synthetic cohort life tables to estimate cumulative state- and race/ethnicity-specific risks by age 18 of experiencing: (1) a child protective services investigation, (2) confirmed maltreatment, (3) foster care placement, and (4) termination of parental rights for children in the U.S. Results: In the U.S., state-level investigation risks ranged from 14% to 63%, confirmed maltreatment risks from 3% to 27%, foster care placement risks from 2% to 18%, and risks of parental rights termination from 0% to 8%. Racial/ethnic disparities in these risks varied greatly across states, with larger disparities at higher levels of involvement. Whereas Black children had higher risks of all events than white children in nearly all states, Asian children had consistently lower risks. Finally, ratios comparing risks of child welfare events show these prevalences did not move in parallel, across states or racial/ethnic groups. Contribution: This study provides new estimates of spatial and racial/ethnic variation in children's lifetime risks of maltreatment investigation, confirmed maltreatment, foster care placement, and termination of parental rights in the U.S., as well as relative risks of these events.

Contact with Child Protective Services is pervasive but unequally distributed by race and ethnicity in large US counties.

This article provides county-level estimates of the cumulative prevalence of four levels of Child Protective Services (CPS) contact using administrative data from the 20 most populous counties in the United States. Rates of CPS investigation are extremely high in almost every county. Racial and ethnic inequality in case outcomes is large in some counties. The total median investigation rate was 41.3%; the risk for Black, Hispanic, and White children exceeded 20% in all counties. Risks of having a CPS investigation were highest for Black children (43.2 to 72.0%). Black children also experienced high rates of later-stage CPS contact, with rates often above 20% for confirmed maltreatment, 10% for foster care placement, and 2% for termination of parental rights (TPR). The only other children who experienced such extreme rates of later-stage CPS interventions were American Indian/Alaska Native children in Middlesex, MA; Hispanic children in Bexar, TX; and all children except Asian/Pacific Islander children in Maricopa, AZ. The latter has uniquely high rates of late-stage CPS interventions. In some jurisdictions, such as New York, NY, (0.2%) and Cook, IL (0.2%), very few children experienced TPR. These results show that early CPS interventions are ubiquitous in large counties but with marked variation in how CPS systems respond to these investigations.

Cumulative Prevalence of Confirmed Maltreatment and Foster Care Placement for US Children by Race/Ethnicity, 2011-2016.

Objectives. To estimate the cumulative prevalence of confirmed child maltreatment and foster care placement for US children and changes in prevalence between 2011 and 2016.Methods. We used synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System and the National Child Abuse and Neglect Data System and population counts from the Centers for Disease Control and Prevention.Results. US children's cumulative prevalence of confirmed maltreatment remained stable between 2011 and 2016 at about 11.7% (95% confidence interval [CI] = 11.6%, 11.7%) of the population and increased by roughly 11% for foster care placement from 4.8% (95% CI = 4.8%, 4.8%) to 5.3% (95% CI = 5.3%, 5.4%). American Indian/Alaska Native children experienced the largest change, an 18.0% increase in confirmed maltreatment risk from 13.4% (95% CI = 13.1%, 13.6%) to 15.8% (95% CI = 15.6%, 16.1%) and a 21% increase in foster care placement risk from 9.4% (95% CI = 9.2%, 9.6%) to 11.4% (95% CI = 11.2%, 11.6%).Conclusions. Confirmed child maltreatment and foster care placement continued to be experienced at high rates in the United States in 2012 through 2016, with especially high risks for American Indian/Alaska Native children. Rates of foster care have increased, whereas rates of confirmed maltreatment have remained stable.

FISCAL PRESSURES, THE GREAT RECESSION, AND MONETARY SANCTIONS IN WASHINGTON COURTS OF LIMITED JURISDICTION.

Many municipal governments have come to depend heavily on fines and fees generated by the criminal justice system. This essay uses data from all courts of limited jurisdiction (municipal and district courts) in Washington State between 2000 and 2014 to evaluate the relationships between local government finances, the Great Recession, and the imposition of debt through the criminal justice system. I find that municipalities issued more criminal justice debt during and after the recession across Washington, but that government finances as measured by tax receipts and expenditures per capita were weakly related to sentencing practices. These findings suggest that macroeconomic fiscal pressures may be drivers of enforcement and prosecutorial practices through increasing case volumes, but that macroeconomic pressures and local fiscal pressures did not appear to shift court sentencing practices in Washington during the Great Recession.

The Cumulative Prevalence of Termination of Parental Rights for U.S. Children, 2000-2016.

Recent research has used synthetic cohort life tables to show that having a Child Protective Services investigation, experiencing confirmed maltreatment, and being placed in foster care are more common for American children than would be expected based on daily or annual rates for these events. In this article, we extend this literature by using synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System to generate the first cumulative prevalence estimates of termination of parental rights. The results provide support for four conclusions. First, according to the 2016 estimate, 1 in 100 U.S. children will experience the termination of parental rights by age 18. Second, the risk of experiencing this event is highest in the first few years of life. Third, risks are highest for Native American and African American children. Nearly 3.0% of Native American children and around 1.5% of African American children will ever experience this event. Finally, there is dramatic variation across states in the risk of experiencing this event and in racial/ethnic inequality in this risk. Taken together, these findings suggest that parental rights termination, which involves the permanent loss of access to children for parents, is far more common than often thought.

Treating Opioid Withdrawal With Buprenorphine in a Community Hospital Emergency Department: An Outreach Program.

STUDY OBJECTIVE: We assess the feasibility of using our community hospital emergency department (ED) as an immediate portal to medication-assisted treatment for patients in opioid withdrawal. METHODS: This was a prospective observational cohort study. In collaboration with an outpatient substance abuse treatment center, we alerted the public through media outlets that individuals could receive immediate buprenorphine treatment for opioid withdrawal in the ED, with rapid referral for medication-assisted treatment. If medication-assisted treatment intake was delayed, patients could return for up to 2 more days for buprenorphine administration to treat their withdrawal symptoms. We measured compliance with initial follow-up and continued treatment engagement at 30 and 90 days. RESULTS: The study was conducted during 12 months. A total of 62 patients were enrolled, evaluated for buprenorphine criteria, and referred for medication-assisted treatment. Fifty subjects were compliant with their first medication-assisted treatment follow-up visit (81% [95% confidence interval 71% to 91%]), and 43 of these 50 patients were still engaged in medication-assisted treatment at 30 days (86% [95% confidence interval 76% to 96%]), with 33 of the 50 still engaged at 90 days (66% [95% confidence interval 53% to 79%]). We observed no instances of precipitated withdrawal or other adverse reactions in the ED. CONCLUSION: A substantial number of patients responded to this program and received accelerated engagement in medication-assisted treatment. Such a program is feasible in the community hospital ED and may prevent some individuals from relapsing into high-risk illicit drug use when immediate medication-assisted treatment is not otherwise available.

The Diagnosis and Management of Toxic Alcohol Poisoning in the Emergency Department: A Review Article.

CONTEXT: This review discusses the range of clinical presentations seen with poisonings by the major toxic alcohols--methanol, ethylene glycol, and isopropyl alcohol. It outlines a straightforward diagnostic strategy and discusses in detail the current treatment recommendations. EVIDENCE ACQUISITION: The authors conducted a literature search of primary and secondary sources related to the topic. For treatment recommendations, search restrictions included articles published between 2008 and 2019. For background information, search restrictions included articles written from 1990 - present. RESULTS: This review discusses in detail how the diagnosis can be made via clinical signs, symptoms, and laboratory values as well as the most recent treatment recommendations. This paper will also discuss the limitations of the emergency department workup and how the absence of particular laboratory findings does not necessarily rule out the diagnosis. CONCLUSION: Poisoning with methanol, ethylene glycol, and isopropanol present diagnostic and therapeutic challenges to emergency physicians. Toxic alcohol poisonings lead to an elevated osmolar gap and, with the exception of Isopropanol, a metabolic acidosis. In order for the timely initiation of life-saving treatment, emergency physicians need a solid understanding of the pathophysiology, clinical presentation, laboratory workup, and treatment.

Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex.

We use data on police-involved deaths to estimate how the risk of being killed by police use of force in the United States varies across social groups. We estimate the lifetime and age-specific risks of being killed by police by race and sex. We also provide estimates of the proportion of all deaths accounted for by police use of force. We find that African American men and women, American Indian/Alaska Native men and women, and Latino men face higher lifetime risk of being killed by police than do their white peers. We find that Latina women and Asian/Pacific Islander men and women face lower risk of being killed by police than do their white peers. Risk is highest for black men, who (at current levels of risk) face about a 1 in 1,000 chance of being killed by police over the life course. The average lifetime odds of being killed by police are about 1 in 2,000 for men and about 1 in 33,000 for women. Risk peaks between the ages of 20 y and 35 y for all groups. For young men of color, police use of force is among the leading causes of death.

Monetary Sanctions: A Review of Revenue Generation, Legal Challenges, and Reform.

The Ferguson Report became a watershed moment for understanding the costs and consequences of the monetary sanctions system for communities of color. Since that time, myriad reports, studies, and commissions have uncovered evidence that suggests that Ferguson, Missouri, was not an outlier but rather part of a broader set of systems throughout the country that relied on increasingly punitive assessment and collection strategies for revenue. The growth and expansion of these systems continue to have detrimental and widespread consequences. In this article, we aim to shed light on the current state of monetary sanctions as the full scope and damage of the monetary sanctions system come better into focus on the national, state, and local level. We explore the legal challenges and legislative reforms that are attempting to reshape the landscape of monetary sanctions and lessen the burden on economically disadvantaged individuals and communities of color.

Risk of Police-Involved Death by Race/Ethnicity and Place, United States, 2012-2018.

OBJECTIVES: To estimate the risk of mortality from police homicide by race/ethnicity and place in the United States. METHODS: We used novel data on police-involved fatalities and Bayesian models to estimate mortality risk for Black, Latino, and White men for all US counties by Census division and metropolitan area type. RESULTS: Police kill, on average, 2.8 men per day. Police were responsible for about 8% of all homicides with adult male victims between 2012 and 2018. Black men's mortality risk is between 1.9 and 2.4 deaths per 100 000 per year, Latino risk is between 0.8 and 1.2, and White risk is between 0.6 and 0.7. CONCLUSIONS: Police homicide risk is higher than suggested by official data. Black and Latino men are at higher risk for death than are White men, and these disparities vary markedly across place. Public Health Implications. Homicide reduction efforts should consider interventions to reduce the use of lethal force by police. Efforts to address unequal police violence should target places with high mortality risk.

Monetary Sanctions: Legal Financial Obligations in US Systems of Justice.

This review assesses the current state of knowledge about monetary sanctions, e.g., fines, fees, surcharges, restitution, and any other financial liability related to contact with systems of justice, which are used more widely than prison, jail, probation, or parole in the United States. The review describes the most important consequences of the punishment of monetary sanctions in the United States, which include a significant capacity for exacerbating economic inequality by race, prolonged contact and involvement with the criminal justice system, driver's license suspension, voting restrictions, damaged credit, and incarceration. Given the lack of consistent laws and policies that govern monetary sanctions, jurisdictions vary greatly in their imposition, enforcement, and collection practices of fines, fees, court costs, and restitution. A review of federally collected data on monetary sanctions reveals that a lack of consistent and exhaustive measures of monetary sanctions presents a unique problem for tracking both the prevalence and amount of legal financial obligations (LFOs) over time. We conclude with promising directions for future research and policy on monetary sanctions.

Ultrasound assisted evaluation of chest pain in the emergency department.

Chest pain is a commonly encountered emergency department complaint, with a broad differential including several life-threatening possible conditions. Ultrasound-assisted evaluation can potentially be used to rapidly and accurately arrive at the correct diagnosis. We propose an organized, ultrasound assisted evaluation of the patient with chest pain using a combination of ultrasound, echocardiography and clinical parameters. Basic echo techniques which can be mastered by residents in a short time are used plus standardized clinical questions and examination. Information is kept on a checklist. We hypothesize that this will result in a quicker, more accurate evaluation of chest pain in the ED leading to timely treatment and disposition of the patient, less provider anxiety, a reduction in the number of diagnostic errors, and the removal of false assumptions from the diagnostic process.

Spreading vasodilatation in the murine microcirculation: attenuation by oxidative stress-induced change in electromechanical coupling.

Regulation of blood flow in microcirculatory networks depends on spread of local vasodilatation to encompass upstream arteries; a process mediated by endothelial conduction of hyperpolarization. Given that endothelial coupling is reduced in hypertension, we used hypertensive Cx40ko mice, in which endothelial coupling is attenuated, to investigate the contribution of the renin-angiotensin system and reduced endothelial cell coupling to conducted vasodilatation of cremaster arterioles in vivo. When the endothelium was disrupted by light dye treatment, conducted vasodilatation, following ionophoresis of acetylcholine, was abolished beyond the site of endothelial damage. In the absence of Cx40, sparse immunohistochemical staining was found for Cx37 in the endothelium, and endothelial, myoendothelial and smooth muscle gap junctions were identified by electron microscopy. Hyperpolarization decayed more rapidly in arterioles from Cx40ko than wild-type mice. This was accompanied by a shift in the threshold potential defining the linear relationship between voltage and diameter, increased T-type calcium channel expression and increased contribution of T-type (3 µmol l(-1) NNC 55-0396), relative to L-type (1 µmol l(-1) nifedipine), channels to vascular tone. The change in electromechanical coupling was reversed by inhibition of the renin-angiotensin system (candesartan, 1.0 mg kg(-1) day(-1) for 2 weeks) or by acute treatment with the superoxide scavenger tempol (1 mmol l(-1)). Candesartan and tempol treatments also significantly improved conducted vasodilatation. We conclude that conducted vasodilatation in Cx40ko mice requires the endothelium, and attenuation results from both a reduction in endothelial coupling and an angiotensin II-induced increase in oxidative stress. We suggest that during cardiovascular disease, the ability of microvascular networks to maintain tissue integrity may be compromised due to oxidative stress-induced changes in electromechanical coupling.

Non-linear relationship between hyperpolarisation and relaxation enables long distance propagation of vasodilatation.

Blood flow is adjusted to tissue demand through rapidly ascending vasodilatations resulting from conduction of hyperpolarisation through vascular gap junctions. We investigated how these dilatations can spread without attenuation if mediated by an electrical signal. Cremaster muscle arterioles were studied in vivo by simultaneously measuring membrane potential and vessel diameter. Focal application of acetylcholine elicited hyperpolarisations which decayed passively with distance from the local site,while dilatation spread upstream without attenuation. Analysis of simultaneous recordings at the local site revealed that hyperpolarisation and dilatation were only linearly related over a restricted voltage range to a threshold potential, beyond which dilatation was maximal. Experimental data could be simulated in a computational model with electrotonic decay of hyperpolarisation but imposition of this threshold. The model was tested by reducing the amplitude of the local hyperpolarisation which led to entry into the linear range closer to the local site and decay of dilatation. Serial section electron microscopy and light dye treatment confirmed that the spread of dilatation occurred through the endothelium and that the two cell layers were tightly coupled. Generality of the mechanism was demonstrated by applying the model to the attenuated propagation of dilatation found in larger arteries.We conclude that long distance spread of locally initiated dilatations is not due to a regenerative electrical phenomenon, but rather a restricted linear relationship between voltage and vessel tone, which minimises the impact of electrotonic decay of voltage. Disease-related alterations in endothelial coupling or ion channel expression could therefore decrease the ability to adjust blood flow to meet metabolic demand.

Depolarization evoked by acetylcholine in mesenteric arteries of hypertensive rats attenuates endothelium-dependent hyperpolarizing factor.

OBJECTIVE: During blockade of endothelium-dependent hyperpolarizing factor (EDHF), acetylcholine evoked larger and faster depolarization in mesenteric arteries of spontaneously hypertensive rats (SHR) than normotensive Wistar-Kyoto (WKY) rats. We studied the mechanism underlying this response and its role in the attenuation of EDHF. METHODS: Electrophysiology, computational modelling and myography were used to study changes in membrane potential and effects on contractility. RESULTS: The large acetylcholine-evoked depolarization in SHR was accompanied by contraction, but this was not seen in WKY rats. The depolarization depended on release of intracellular Ca2+ but was unaffected by nonselective cation channel inhibitors, gadolinium, lanthanum or amiloride. The depolarization was significantly reduced by the Ca2+-dependent Cl- channel inhibitors, niflumic acid or flufenamic acid, or alterations in Cl- gradients using bumetanide (Na/K/Cl transporter inhibitor) or external Cl- replacement with isethionate. These drugs altered the time course of EDHF-evoked hyperpolarizations in SHR, making them indistinguishable from those in WKY rats. EDHF-induced relaxation was less sensitive to acetylcholine in SHR than in WKY rats, but this difference was eliminated following artery pretreatment with bumetanide. Computational modelling in which the SHR fast depolarizing response was selectively modulated mimicked physiologically acquired results obtained in SHR and WKY rats during Cl- -channel blockade. CONCLUSIONS: Acetylcholine evokes a fast depolarization in SHR but not in WKY rats, mediated by the opening of Ca2+-dependent Cl- channels. The depolarization is responsible for a constriction that reduces EDHF-mediated relaxation. Data suggest that Ca2+-dependent Cl- channels may provide a novel therapeutic target for improvement of endothelial dysfunction during hypertension.