Evidence From the USPSTF and New Approaches to Evaluate Interventions to Prevent Child Maltreatment.

Importance: The United States Preventive Services Task Force (USPSTF) has considered the topic of prevention of child maltreatment multiple times over its nearly 40-year history, each time reaching the conclusion that the evidence is insufficient to recommend for or against interventions aimed at preventing this important health problem with significant negative sequelae before it occurs. In the most recent evidence review, which was conducted from August 2021 to November 2023 and published in March 2024, the USPSTF considered contextual questions on the evidence for bias in reporting and diagnosis of maltreatment in addition to key questions regarding effectiveness of interventions to prevent child maltreatment. Observations: A comprehensive literature review found evidence of inaccuracies in risk assessment and racial and ethnic bias in the reporting of child maltreatment and in the evaluation of injuries concerning for maltreatment, such as skull fractures. When children are incorrectly identified as being maltreated, harms, such as unnecessary family separation, may occur. Conversely, when children who are being maltreated are missed, harms, such as ongoing injury to the child, continue. Interventions focusing primarily on preventing child maltreatment did not demonstrate consistent benefit or information was insufficient. Additionally, the interventions may expose children to the risk of harm as a result of these inaccuracies and biases in reporting and evaluation. These inaccuracies and biases also complicate assessment of the evidence for making clinical prevention guidelines. Conclusions and Relevance: There are several potential strategies for consideration in future efforts to evaluate interventions aimed at the prevention of child maltreatment while minimizing the risk of exposing children to known biases in reporting and diagnosis. Promising strategies to explore might include a broader array of outcome measures for addressing child well-being, using population-level metrics for child maltreatment, and assessments of policy-level interventions aimed at improving child and family well-being. These future considerations for research in addressing child maltreatment complement the USPSTF's research considerations on this topic. Both can serve as guides to researchers seeking to study the ways in which we can help all children thrive.

Computationally derived transition points across phases of clinical care.

The objective of this study is to use statistical techniques for the identification of transition points along the life course, aiming to identify fundamental changes in patient multimorbidity burden across phases of clinical care. This retrospective cohort analysis utilized 5.2 million patient encounters from 2013 to 2022, collected from a large academic institution and its affiliated hospitals. Structured information was systematically gathered for each encounter and three methodologies - clustering analysis, False Nearest Neighbor, and transitivity analysis - were employed to pinpoint transitions in patients' clinical phase. Clustering analysis identified transition points at age 2, 17, 41, and 66, FNN at 4.27, 5.83, 5.85, 14.12, 20.62, 24.30, 25.10, 29.08, 33.12, 35.7, 38.69, 55.66, 70.03, and transitivity analysis at 7.27, 23.58, 29.04, 35.00, 61.29, 67.03, 77.11. Clustering analysis identified transition points that align with the current clinical gestalt of pediatric, adult, and geriatric phases of care. Notably, over half of the transition points identified by FNN and transitivity analysis were between ages 20 and 40, a population that is traditionally considered to be clinically homogeneous. Few transition points were identified between ages 3 and 17. Despite large social and developmental transition at those ages, the burden of multimorbidities may be consistent across the age range. Transition points derived through unsupervised machine learning approaches identify changes in the clinical phase that align with true differences in underlying multimorbidity burden. These transitions may be different from conventional pediatric and geriatric phases, which are often influenced by policy rather than clinical changes.

Addressing the Transition to Adult Health Care for Adolescents and Young Adults with Pancreatic Disorders.

INTRODUCTION:  The transition from pediatric to adult health care is a vulnerable time period for adolescents and young adults (AYA). Guidance on how to effectively implement transition support for AYA with recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) is lacking. METHODS:  To address this gap, we formed a consortium of pancreatic centers that would work in coordination to test interventions to improve the transition for AYA with RAP and CP. We then performed a baseline assessment of consortium resources and patient transition readiness and developed an educational toolkit for AYA with RAP and CP.  Results: Our consortium consists of three National Pancreatic Centers of Excellence, each with a multidisciplinary team to work with AYA with RAP and CP. While our patients ages 18 to 23 were generally seen at the pediatric centers, the baseline assessment of transition readiness suggests that our patients may have higher transition readiness scores than other populations. The educational toolkit contains both pancreas-specific and general guidance to support AYA with RAP and CP during their transition, including guidance on nutrition, pain management, and finding an adult gastroenterologist.  Conclusions: We have formed a consortium to test interventions to improve the transition to adult health care for AYA with RAP and CP. We have completed a baseline assessment and developed our first intervention: an educational tool kit. Future work planned includes tests of the tool kit and efforts to improve rates of transfer to an adult provider for YA with RAP and CP.

The Scope of Multimorbidity in Family Medicine: Identifying Age Patterns Across the Lifespan.

INTRODUCTION: Multimorbidity rates are both increasing in prevalence across age ranges, and also increasing in diagnostic importance within and outside the family medicine clinic. Here we aim to describe the course of multimorbidity across the lifespan. METHODS: This was a retrospective cohort study across 211,953 patients from a large northeastern health care system. Past medical histories were collected in the form of ICD-10 diagnostic codes. Rates of multimorbidity were calculated from comorbid diagnoses defined from the ICD10 codes identified in the past medical histories. RESULTS: We identify 4 main age groups of diagnosis and multimorbidity. Ages 0 to 10 contain diagnoses which are infectious or respiratory, whereas ages 10 to 40 are related to mental health. From ages 40 to 70 there is an emergence of alcohol use disorders and cardiometabolic disorders. And ages 70 to 90 are predominantly long-term sequelae of the most common cardiometabolic disorders. The mortality of the whole population over the study period was 5.7%, whereas the multimorbidity with the highest mortality across the study period was Circulatory Disorders-Circulatory Disorders at 23.1%. CONCLUSION: The results from this study provide a comparison for the presence of multimorbidity within age cohorts longitudinally across the population. These patterns of comorbidity can assist in the allocation to practice resources that will best support the common conditions that patients need assistance with, especially as the patients transition between pediatric, adult, and geriatric care. Future work examining and comparing multimorbidity indices is warranted.

Continuation of Pediatric Care after Transfer to Adult Care Among Autistic Youth Overlap of Pediatric and Adult Care.

The transition from pediatric to adult health care is a vulnerable time period for autistic adolescents and young adults (AYA) and for some autistic AYA may include a period of receiving care in both the pediatric and adult health systems. We sought to assess the proportion of autistic AYA who continued to use pediatric health services after their first adult primary care appointment and to identify factors associated with continued pediatric contact. We analyzed electronic medical record (EMR) data from a cohort of autistic AYA seen in a primary-care-based program for autistic people. Using logistic and linear regression, we assessed the relationship between eight patient characteristics and (1) the odds of a patient having ANY pediatric visits after their first adult appointment and (2) the number of pediatric visits among those with at least one pediatric visit. The cohort included 230 autistic AYA, who were mostly white (68%), mostly male (82%), with a mean age of 19.4 years at the time of their last pediatric visit before entering adult care. The majority (n = 149; 65%) had pediatric contact after the first adult visit. Younger age at the time of the first adult visit and more pediatric visits prior to the first adult visit were associated with continued pediatric contact. In this cohort of autistic AYA, most patients had contact with the pediatric system after their first adult primary care appointment.

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Promoting mental well-being in Western Australia: Act Belong Commit® mental health promotion campaign partners' perspectives.

The Act Belong Commit® mental health promotion campaign aims to improve population mental well-being. Based on a social-franchising model, partnerships are sought with organizations offering 'mentally healthy activities' that foster social connectedness and mental well-being. There are four categories of partner organizations sought: Site (government agencies and health services), Associate (organizations with state-wide or national services), Community (local, grass-roots community groups) and Schools. This research explored organizational perceptions of the Act Belong Commit® Partnership Program. A purposive sample of 14 organizational representatives across all four partner categories participated in semi-structured interviews online or face-to-face between July and September 2021. Reflexive thematic analysis was used to identify three main themes: (a) A passion for promoting mental health; (b) Implementation, innovation, adaption and creation (e.g. the ability to adapt, create and deliver activities aligned with the campaign message; and (c) Future sustainability (e.g. recommendations for the sustainability of the programme). The use of reflexive thematic analysis enabled deeper insights into the complexity of the partnerships. Findings describe how the Act Belong Commit® Partnership Program supports mutually desirable objectives and extends the campaign reach. Embedded in a shared belief system that incorporates a passion for good mental health, the model supports the flexibility to adapt, create and deliver fit-for-purpose activities that promote mental well-being in the places where people live, work and play.

Primary care use and depression screening among young adults with sickle cell disease during their final year of pediatric hematology care.

Depression may contribute to transition risk among young adults with sickle cell disease (SCD). It is unclear if they receive depression screening because primary care providers (PCPs) routinely perform this screening, but PCP use declines with age. This retrospective study of young adults with SCD during their final year of pediatric hematology care identified 51 (91%) had PCPs. Among those with hospital system PCPs, 20% saw their PCP and 50% of those were screened for depression by the PCP. This suggests young adults with SCD may not receive depression screening or see PCPs, leading to potential missed opportunities for intervention.

Born This Way: Integrating LGBTQIA+ Identities as Pharmacy Practitioners.

Progression through the profession of pharmacy is filled with many milestones that can contribute to feelings of stress, rejection, and isolation. For Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual+(LGBTQIA+) students and practitioners, these feelings can be compounded by similar issues experienced by their sexual orientation or gender identity. Historically, LGBTQIA+ students, new practitioners, and seasoned professionals alike have lacked visible role models for how to intersect personal and professional identity in the pharmacy profession. In this paper, the authors describe experiences of intersecting personal queer identities with professional pharmacy identities; exploring barriers to integration and developing solutions to overcome these barriers. The authors also share how the formation of a collective of LGBTQIA+ practitioners and educators has led to a unified voice to advocate for the advancement of LGBTQIA+ healthcare in pharmacy education and practice. This manuscript will provide readers with a guide to navigate and address issues with the integration of personal and professional identity to lead to practice that validates personal identity as important, valuable, and affirmed.

Predicting timely transfer to adult care in a cohort of autistic adolescents and young adults.

BACKGROUND: The transition from pediatric to adult care is a challenge for autistic adolescents and young adults. Data on patient features associated with timely transfer between pediatric and adult health care are limited. Our objective was to describe the patient features associated with timely transfer to adult health care (defined as

Balancing ring and stopper group size to control the stability of doubly threaded [3]rotaxanes.

Synthesizing doubly threaded [3]rotaxanes requires the use of larger rings than more traditional singly threaded [2]rotaxanes. A key challenge in accessing stable doubly threaded [3]rotaxanes with large rings is finding the right combination of ring to stopper size. In this study, a series of doubly threaded [3]rotaxanes derived from five different sized macrocycles in the size range of 40-48 atoms and two different stopper groups, which contain 1 or 2 tris(p-t-butylbiphenyl)methyl moieties, were prepared and their kinetic stability examined. These interlocked compounds were synthesized using a metal-templated approach and fully characterized utilizing a combination of mass spectrometry, NMR spectroscopy, and size-exclusion chromatography techniques. The effect of ring size on the stability of the doubly threaded [3]rotaxane was investigated via kinetic stability tests monitored using 1H-NMR spectroscopy. By tightening the macrocycle systematically every 2 atoms from 48 to 40 atoms, a wide range of doubly threaded interlocked molecules could be accessed in which the rate of room temperature slippage of the macrocycle from the dumbbells could be tuned. Using the larger stopper group with a 48-atom ring results in no observable rotaxane, 46-44 atom macrocycles result in metastable rotaxane species with a slippage half-life of ∼5 weeks and ∼9 weeks, respectively, while macrocycles of 42 atoms or smaller yield a stable rotaxane. The smaller sized stopper is not able to fully stabilize any of the [3]rotaxane structures but metastable [3]rotaxanes are obtained with slippage half-lives of 25 ± 2 hours and 13 ± 1 days using macrocycles with 42 or 40 atoms, respectively. These results highlight the dramatic effect that relatively small ring size changes can have on the structure of doubly threaded [3]rotaxanes and lay the synthetic groundwork for a range of higher order doubly threaded interlocked architectures.

Effectiveness of teen Mental Health First Aid in Improving Teen-to-Teen Support Among American Adolescents.

BACKGROUND: teen Mental Health First Aid (tMHFA) is an Australian school-based universal program for grade 10 to 12 students. tMHFA teaches teens how to recognize and respond to a peer in crisis or experiencing mental health concerns. METHODS: Schools implementing tMHFA in 2019 and 2020 were propensity score matched, yielding a sample of instructors (n = 130) and students (n = 1915) in 44 high schools in 24 American states. Effectiveness and acceptability were assessed with student surveys at baseline and after implementation. RESULTS: There were significant findings for primary outcomes, including improved helpful first aid intentions (Cohen ds = 0.57 to 0.58), confidence supporting a peer (ds = 0.19 to 0.31); the number of adults rated as helpful (ds = 0.37 to 0.44); and reductions in stigmatizing beliefs (ds = 0.21 to 0.40) and "harmful first aid intentions" (ds = 0.11 to 0.42). Instructors and students rated the program favorably with students sharing improvements on their recognition and responses to mental health problems and crises. CONCLUSION: tMHFA is an effective, feasible, and scalable training program for increasing mental health literacy and decreasing mental health stigma in adolescents in the short term, consistent with trials of tMHFA in Australian adolescents.

Using Fume Hood to Reduce Nurses' Exposure to Particulate Matters Dispersed Into the Air During Pill Crushing.

BACKGROUND: Pill crushing is a common practice in patient care settings. Crushing pills can disperse particulate matter (PM) into indoor air. The PM is a widespread air pollutant composed of microscopic particles and droplets of various sizes and may carry active and/or inactive ingredients nurses can inhale. This study aimed to quantify PM sizes and concentration in indoor air when pills are crushed and examine the role of a fume hood in reducing particulate pollution. METHODS: Two scenarios (with and without a fume hood) representing nurses' pill-crushing behaviors were set up in a positive-pressure cleanroom. Two acetaminophen tablets (325 mg/tablet) were crushed into powder and mixed with unsweetened applesauce. The PM sizes and concentrations were measured before and during crushing. RESULTS: Different sizes of PM, including inhalable, respirable, and thoracic particles, were emitted during medication crushing. The total count of all particle sizes and mass concentrations of particles were significantly lower during crushing when a fume hood was used (p = .00). CONCLUSION: Pill crushing increases PM and should be considered a workplace safety health hazard for nurses. Healthcare professionals should work under a fume hood when crushing pills and wear proper protective equipment. The findings of significant particulate pollution related to pill crushing suggest that further research is warranted.

Adolescent peer support for mental health problems: evaluation of the validity and reliability of the Mental Health Support Scale for Adolescents.

BACKGROUND: The Mental Health Support Scale for Adolescents (MHSSA) is a criterion-referenced measure of adolescents' supportive intentions towards peers with mental health problems, which was developed for use in evaluations of adolescent mental health interventions, such as the teen Mental Health First Aid (tMHFA) program. The present study aimed to examine the validity and reliability of the MHSSA. METHODS: A sample of 3092 school students (Mean ± SD: 15.9 ± 0.4 years old) and 65 tMHFA Instructors (the adult group with known expertise in tMHFA) completed the 12 items of the MHSSA. A sub-sample of 1201 students repeated the scale after a 3-4-week interval. Item concordance rates with the tMHFA Action Plan across helpful and harmful intentions scales were calculated. Scale reliabilities were assessed using agreement coefficients from a single test administration and test-retest reliability measured by intraclass correlation coefficients. The mean differences of MHSSA scores of students and Instructors were compared using independent samples t-tests, while convergent validity was tested via correlations of the scale with validated measures of confidence in providing help, social distance and personal stigma. RESULTS: The average score of Instructors was significantly higher than that of students. The scale was positively associated with confidence in providing help, whilst negatively associated with social distance and dimensions of personal stigma. All scales of MHSSA had high agreement coefficients (all > 0.80) and fair to good test-retest reliability over 3-4 weeks. CONCLUSIONS: The MHSSA shows evidence of validity and reliability for use among adolescents for evaluating the quality of intentions to help peers with mental health problems.

Diagnosis of Pulmonary Embolism in Pregnancy.

Pulmonary embolism (PE) is a significant cause of obstetric morbidity and mortality. However, overdiagnosis related to excessive use of diagnostic testing is also associated with long-term major health issues, including impact on future pregnancies and subsequent health care. Accurate diagnosis of PE depends on the knowledge of prevalence of PE in the pregnant population, the a priori probability of a PE based on specific findings in a given patient, and understanding of the accuracy of computed tomography pulmonary angiography (CTPA), the dominant diagnostic modality employed for this diagnosis. Venous thromboembolism is widely considered to be more common in pregnancy. However, this term includes both deep venous thrombosis as well as PE. While the former appears to be more common, published data on the prevalence of PE in pregnancy show little or no increase relative to the general population. Given the published data on the sensitivity and specificity of CTPA, a positive reading is more likely to be a false positive unless the probability of a PE in a given patient is at least 5% (a 200-fold increase from baseline). Doubling the probability to 10% (a 400-fold increase) only improves the positive predictive value to approximately 67%. Strategies to refine the a priori probability of a PE in a given patient are detailed, including scoring systems and D-dimer measurements. A careful history and physical examination and thoughtful development of a differential diagnosis are key elements of clinical practice and should include both the likelihood of each possible diagnosis and the accuracy of diagnostic modalities. This approach should precede the application of a given algorithm. Such a structured approach can decrease utilization and limit false positive diagnoses without increasing morbidity or mortality. KEY POINTS: · Incidence of PE is lower than assumed.. · Incidence is critical for assessing predictive value of a test.. · Computed tomography angiography is likely overused in pregnancy.. · Clinical scoring and D-dimer have a role in PE diagnosis..

Body image profiles combining body shame, body appreciation and body mass index differentiate dietary restraint and exercise amount in women.

This project aimed to establish whether meaningful body image profiles (BIPs) could be identified across measures of body shame, body appreciation, and body mass index (BMI), and whether these profiles could differentiate key health behaviours. Data came from 1200 adult women who responded to an online body image survey. Latent profile analysis was used to identify BIPs based on relative levels of body shame, body appreciation and BMI. Differences in dietary restraint and weekly exercise amount were investigated according to BIP membership. Latent profile analysis revealed four unique BIPs; 1. Appreciative BIP (AP-BIP); 2. Medium Shame BIP (MS-BIP); 3. High Shame BIP (HS-BIP) and 4. Average BIP (AV-BIP). Dietary restraint and exercise amount differed significantly according to BIP in most comparisons. Women in the High Shame BIP exhibited the highest dietary restraint and lowest exercise. Women in the Appreciative BIP exhibited the lowest dietary restraint and highest exercise. Body shame and body appreciation intersect with BMI to form unique profiles (BIPs) that differentiate dietary restraint and exercise. Using BIPs to tailor interventions designed to promote healthful diet and exercise should be considered in public health initiatives.