Background:Neonatal abstinence syndrome (NAS) has been associated with increased risks for adverse developmental, cognitive, and behavioral outcomes in childhood. However, there are limited data on academic achievement. We aimed to compare longitudinal academic achievement test scores in school-aged children with and without a history of NAS while controlling for relevant biologic and socioenvironmental variables. Methods:This retrospective, observational cohort study used a large, comprehensive, linked dataset from the South Carolina Integrated Data System to evaluate standardized English/Language Arts (ELA) and math achievement scores from grades 3-8 for children with and without a history of NAS. Linear mixed effects modeling assessed test scores by NAS group and grade, with random effects to account for correlation within school districts, schools, students, and mothers. Thirteen bio-socio-environmental variables were also included in the models. Findings:The analysis sample included 3494 students: 814 (23%) children with a history of NAS and 2680 (77%) without, frequency matched in a 1:3 ratio according to birth year, sex, mother's education level, and insurance payer at birth. 30.5% had a mother with less than a high school education and 85.1% were insured by Medicaid/uninsured. Mean test scores between students with and without a history of NAS were similar for ELA (-6.3 points, [95% confidence interval (CI): -15.1 to 2.5], p = 0.16) and math (-8.9 points, [95% CI: -16.9 to -0.9], p = 0.030). Interpretation:In a sample of children matched on bio-socio-environmental factors and for whom potential confounders were controlled, we found similar academic achievement scores between children with and without a history of NAS. These results emphasize the importance of socioenvironmental factors on childhood outcomes and suggest prenatal opioid exposure and NAS contribute minimally to academic achievement. Funding:This work was supported by funding from the National Institute on Drug Abuse 5K23DA055096 award to Dr. Tammy Corr.

Background: Nirsevimab, a monoclonal antibody for respiratory syncytial virus (RSV), reduces medically attended RSV infections. It was introduced in the 2023–24 RSV season. This study examined the association between caregiver vaccination (seasonal influenza vaccine (SIV), COVID-19, and boosters) and intent to immunize infants against RSV. Methods: Data from 118 caregivers with infants ≤ 8 months were analyzed. Chi-squared tests and logistic regression assessed the relationship between caregiver vaccination and intent to immunize against RSV. Results: In total, 74.6% of caregivers intended to immunize their infants against RSV. Intent was positively associated with caregiver receipt of a seasonal influenza vaccine (p < 0.001), COVID-19 vaccine (p < 0.001), and COVID-19 booster (p < 0.001). Intent was also associated with older child seasonal vaccination. Caregiver receipt of both COVID-19 vaccinations and boosters had a strong relationship with RSV immunization intent (OR 7.91 (1.90–33.0, p = 0.004)). Conclusions: Caregiver vaccination behaviors are linked to RSV immunization intent, helping physicians identify hesitant families and prepare for immunization conversations.

Objectives New respiratory syncytial virus (RSV) immunizations for infants and pregnant mothers recently became available to prevent severe RSV disease in infants. We aimed to determine the primary reasons for parental RSV immunization decisions. We further sought to evaluate the associations between vaccine receipt and source of health care information and trust in one's health care provider. Study design A convenience sample of parents and guardians of infants were surveyed during the 2023-2024 RSV season in one newborn nursery and three affiliated clinics that are part of an academic health system. Results Among the 118 respondents, 79 (66.9%) chose to receive an RSV vaccine themselves (n = 42) or consented for infant immunization (n = 37). Thirty-nine (92.9%) parents who consented to maternal vaccination and 35 (87.5%) who consented to infant immunization stated a primary reason was protection for their infant. Among those that did not receive the maternal vaccine, the most common reasons were nonavailability (39.7%) or no provider immunization offer (22.2%). Infant immunoprophylaxis was most commonly refused due to the immunization being too new (66.7%). There were no significant associations between vaccine receipt and reported source of health information or between vaccine receipt and degree of trust in the health care provider. Conclusions The desire to protect their infant from illness was the primary reason for parental RSV immunization intent, while the primary reasons for not immunizing were lack of availability, lack of provider recommendation, and the perception that the immunizations are too new. Ensuring availability and strong recommendations may improve immunization uptake.

Optimal antibiotic duration for diverticulitis managed without procedural source control is unknown. While antibiotic-sparing approaches in select patients are supported by high quality data, up to 24

BACKGROUND:Management of primary spontaneous pneumothorax varies widely. We aimed to assess national trends in PSP management in the last decade. METHODS:We conducted a 10-year retrospective analysis of the MarketScan claims database to identify adolescents and young adults (aged 10-24 years) diagnosed with primary spontaneous pneumothorax (2012-2021). Outcomes during index admission and recurrence included imaging, drainage procedures (aspiration or tube thoracostomy), surgery, and length of stay. Thirty-day postoperative outcomes included emergency department visits, readmission, and return to the operating room. RESULTS:Among 2,480 patients (mean age 18.9 years; 83.7% male), 41.5% underwent a computed tomography scan of the chest. During index admission, 60.9% underwent a drainage procedure. Surgeries were performed in 32.3% (n = 801) of patients after a mean of 4.1 (standard deviation, 2.7) days. Over the 10-year period, the use of cross-sectional imaging utilization increased (odds ratio, 1.04; 95% confidence interval, 1.01-1.07, P = .008) but time to surgical intervention remained unchanged. Median length of stay was 4 days (interquartile range, 2-6). Those who underwent surgery were less likely to experience readmission (4.9% vs 19.8%, P < .001) or have an visit to the emergency department (12.6% vs. 21.7%, P < .001) within 30 days compared with those with no surgery. At 1 year, approximately 9.5% of patients experienced a recurrence that resulted in an admission, with nearly 75% undergoing surgery. CONCLUSION:Management of primary spontaneous pneumothorax in adolescents and young adults varies based on clinical presentation and patient factors. Reducing the use of computed tomography and expediting decision-making process for proceeding to the operating room may serve as potential targets for optimizing health care resource use.

While advancements in therapeutic options for inflammatory bowel disease reduced rates of surgical resection, some patients still require surgery despite multiple lines of medical therapies. This study investigates the relationship between the number, class, and progression rate of different advanced therapies (AT) and risk of surgical resection and postoperative complications in patients with Crohn’s Disease (CD). This study is a retrospective cohort study utilizing the MarketScan database, including adult patients with CD on AT from 2005 to 2020. The number of AT, class of AT, and comorbidities were assessed for all patients. The primary endpoint was surgical resection. A time-varying Cox proportional hazards regression model was used to assess risk of surgical resection. Logistic regression was used to assess secondary outcomes, including postoperative complications, readmissions, and emergency department (ED) visits. The sample included 15,547 patients of whom 10.6

Objective: To determine the financial impact of Ehlers-Danlos syndromes (EDS) on patients in the United States by examining the medical expenses incurred by patients. Patients and Methods: We used a convenience sample approach and disseminated a self-reported survey questionnaire to individuals with EDS via patient advocacy organizations and support groups across the country, social media, and health professionals from April 1, 2023, to December 31, 2023. The survey focused on the out-of-pocket medical expenses incurred by patients. Results: The final analytic data set included 884 responses. Responses were received from individuals in all 50 states and the District of Columbia. More than 50% reported individual income less than $25,000, and more than 30% reported household income less than $50,000. More than 80% of respondents had some type of commercial insurance and 29% reported receiving Medicaid. Respondents received more financial assistance from their family and friends than from government sources. The total median out-of-pocket financial cost by our analysis was $13,450 (IQR: $6500-$25,800). Of the 838 who responded to the question, “Did the affected person receive the health care they needed?”, 19% answered “no”, 51% answered “yes, sometimes”, and 30% answered “yes, most of the time”. Conclusion: The factors contributing to financial impact include both direct and indirect costs of accessing and receiving medical care. Our study findings highlight the magnitude of the burden of health care spending on patients with EDS.

Background/Objectives: Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and infant hospitalization in the US. RSV prevention evolved in 2023 as nirsevimab and maternal RSV pre-fusion vaccine became available for healthy newborns and infants. This study investigates sociodemographic characteristics associated with RSV immunoprophylaxis. Methods: A cross-sectional survey was conducted from November 2023 through March 2024 among a convenience sample of parents of infants aged <8 months who received newborn care or pediatric ambulatory care at a single academic institution in Central Pennsylvania, USA. Logistic regression examined sociodemographic factors associated with RSV immunoprophylaxis uptake. Given the nirsevimab shortage during the 2023–2024 RSV season, a sensitivity analysis was completed for intended immunoprophylaxis. Results: Among 118 participants, 66.9% received RSV immunoprophylaxis while 74.5% intended to receive nirsevimab. Higher income, private insurance, out-of-home childcare, and an adult/partner working in healthcare were associated with intended nirsevimab receipt. Participation in the Women, Infants and Children program was associated with lower rates of intended nirsevimab receipt. Out-of-home childcare was associated with both RSV immunoprophylaxis uptake and intended nirsevimab receipt. Conclusions: Sociodemographic factors significantly influence the intent to receive nirsevimab and RSV immunoprophylaxis uptake. Having an adult/partner in healthcare was the most significant predictor for intent, suggesting that greater health literacy drives immunization intention. Enrollment in out-of-home childcare was the sole predictor of RSV immunoprophylaxis uptake. These findings highlight the importance of policy initiatives that promote equitable access to RSV immunoprophylaxis, including strategies to address socioeconomic barriers, improve health literacy, and ensure consistent availability of preventive agents for all infants.

OBJECTIVE: This study introduces the SEEK Teen Questionnaire, expanding the Safe Environment for Every Kid (SEEK) approach to include adolescent perspectives alongside caregiver responses for dual psychosocial screening. The objective of this study was to triangulate adolescent responses with those of their caregivers to demonstrate the benefits of dual psychosocial screening. METHODS: The SEEK Teen Questionnaire was developed by integrating input from primary care and adolescent medicine professionals, national experts, and adolescent stakeholders. The resulting 32-item psychosocial screening tool was administered to adolescent patients aged 11-18 during well visits simultaneously with caregiver completion of the SEEK Parent Questionnaire from August to October, 2022 with interventions offered for identified problems. Responses were compared using McNemar's and RESULTS: Four hundred and eighty caregivers and adolescents consented to the study. Participants were generally white (64%), non-Hispanic (81%), and privately insured (62%). Adolescents had a high completion rate (97%) with concordant responses among matched caregivers between 83% and 96%. Among discordant dyads, adolescents disclosed concerns for their caregivers more commonly than caregivers expressed for themselves: discipline (83% vs. 17%, P < 0.001), food insecurity (71% vs. 29%, P = 0.09), intimate partner violence (78% vs. 22%, P < 0.018), stress (81% vs. 19%, P < 0.001), depression (64% vs. 36%, P = 0.12), and substance misuse (91% vs. 9%, P < 0.001). CONCLUSIONS: This study demonstrates adolescents' willingness to provide insights into their caregivers' well-being and their high awareness of stressors affecting them. Incorporating adolescent perspectives enhances the identification of issues that may otherwise go unnoticed, underscoring the importance of dual psycho- social screening during adolescence.

OBJECTIVE:Patients with features of systemic lupus erythematosus (SLE) who do not fulfill classification criteria can be designated as incomplete lupus erythematosus (ILE). This condition includes individuals with a high risk of progression to SLE. Treatment of ILE may reduce symptoms, severity, and incidence of SLE. METHODS:Hydroxychloroquine (HCQ) was chosen as an ILE intervention for a randomized, double-blind trial to determine whether the rate of accumulation of SLE features defined by the 2012 Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) criteria could be reduced. ILE was defined as antinuclear antibody positivity with one to two additional criteria. Patients 15 to 49 years old were eligible. Randomization was 1:1 HCQ to placebo. Evaluations were at 3-month intervals over 24 months. Meeting SLICC classification sooner required exit. RESULTS:Participants (N = 187) were randomized at seven sites. After excluding 7 patients who met SLE classification at baseline when screening laboratory data were completed, 180 patients were analyzed: 92 receiving HCQ and 88 receiving placebo. Considering all these enrollees, 55 developed additional criteria. Of the 118 participants who exited early with SLE or who completed 24 months of evaluation, SLE classification developed in 24 (13.3%); another 24 developed additional criteria but did not meet classification. The rates of acquisition of SLICC criteria and progression to SLE were similar in the two groups (P = 0.72 and P = 0.98, respectively). Development of SLE was associated with new malar rash, oral ulcers, joint tenderness, or pleurisy (P < 0.04). CONCLUSION:Although the Study of Antimalarials in Incomplete Lupus Erythematosus (SMILE) did not show effects of HCQ on ILE progression, the results offer insights into SLE risk in the ILE population.

BACKGROUND:Disease-modifying anti-inflammatory bowel disease drugs (DMAIDs) revolutionized the management of ulcerative colitis (UC). This study assessed the relationship between the number and timing of drugs used to treat UC and the risk of colectomy and postoperative complications. METHODS:This was a retrospective review of adult patients with UC treated with disease-modifying drugs between 2005 and 2020 in the MarketScan database. Landmark and time-varying regression analyses were used to analyze risk of surgical resection. Multivariable Cox regression analysis was used to determine risk of postoperative complications, emergency room visits, and readmissions. RESULTS:A total of 12,193 patients with UC and treated with disease-modifying drugs were identified. With a median follow-up time of 1.7 years, 23.8% used >1 drug, and 8.3% of patients required surgical resection. In landmark analyses, using 2 and ≥3 drugs before the landmark date was associated with higher incidence of surgery for each landmark than 1 drug. Multivariable Cox regression showed hazard ratio (95% CIs) of 4.22 (3.59-4.97), 11.7 (9.01-15.3), and 22.9 (15.0-34.9) for using 2, 3, and ≥4 drugs, respectively, compared with using 1 DMAID. That risk was constant overtime. The number of drugs used preoperatively was not associated with an increased postoperative risk of any complication, emergency room visits, or readmission. CONCLUSION:The use of multiple disease-modifying drugs in UC is associated with an increased risk of surgical resection with each additional drug. This provides important prognostic data and highlights the importance of patient counseling with minimal concern regarding risk of postoperative morbidity for additional drugs.

Objective:Standing desks present a novel approach to reduce sedentary time in the classroom and address cardiovascular risk factors at an early age. In the context of designing a standing desk study, parents and children were surveyed regarding their perceptions and current use of standing desks and other flexible seating. Methods:Survey administered from January 31st to February 26th, 2024 to a convenience cohort of 50 parent-child pairs presenting for well or acute care at a pediatrics clinic affiliated with an academic institution (Hershey, Pennsylvania, United States). Logistic regression examined parent support of and child willingness to use a standing desk in the classroom. Results:Parents were primarily non-Hispanic, white females above 40 years of age. Child participants mean age and grade level were 10.5 years and 5th grade respectively. Among parents, 85 % (39/46) were supportive of their child's use of a standing desk in the classroom, with 4 declining to answer. For children, almost half, 48 % (24/50), were willing to use a standing desk. Acceptability decreased for child body mass index (BMI) ≥85th percentile versus BMI <85th percentile (parent acceptability OR = 0.07 [95 % CI: 0.01-0.63; p = 0.018]; child acceptability: OR = 0.13 [95 % CI 0.03-0.51, p = 0.003]). Conclusions:Most parents and children are amenable to use of a standing desk in the classroom. Additional information for children with elevated BMI and their parents may be required to address reservations about standing. This study was limited by its small sample size, which may not generalize to other populations.

ObjectiveTo examine the multimorbidity burden of clinical trial participants and assess its association with treatment response.MethodsReanalysis of patient level data. There were 29,954 participants from 8 clinical trials containing 11 comparisons between an intervention and control condition. Patients were classified by Charlson Comorbidity Index (CCI) score. The primary outcomes were the primary study endpoints as originally specified for each trial. A Cox model that included the CCI score groups, the randomized group and their interaction was used to compare the primary outcome between randomized groups. The interaction term between randomized group and comorbidity index allowed the treatment effect to differ by level of comorbidity index and comprised the primary effect of interest. Hazard ratios (HR) and risk differences (RD) were reported for all comparisons.ResultsThe mean CCI scores of trial populations ranged from 2.1 to 3.9 pointsand the percentage of patients with scores ≥5 from 3% to 39%. Tests of interaction terms in models yielded p values ≤ 0.10 for 4/11 comparisons and ≤ 0.05 for 2/11 comparisons. In 3 additional comparisons, potentially important treatment variation on an absolute scale was observed despite interaction tests with p values > 0.10 on the relative scale.ConclusionsThese trials were mainly composed of patient populations with CCI scores ≤4. Despite this, biologically plausible treatment interactions were commonly suggested. These results are hypothesis generating; confirmation of results would require larger studies or studies targeted specifically toward patients with higher levels of multimorbidity.

Background: This study examined the trends and patterns of opioid and non-opioid pharmacotherapy use among a large national sample of privately insured pediatric patients with cancer in the United States. Materials and Methods: We identified pediatric (aged < 21) patients diagnosed with central nervous system (CNS), lymphoma, gonadal, leukemia, or bone cancer from MarketScan data 2005-2019. We examined the proportion of patients who filled a prescription for the following 5 types of pharmacotherapy: opioid, anticonvulsant, non-steroidal anti-inflammatory drug (NSAID), antidepressant, and muscle relaxant during active cancer treatment. We assessed the trends and patterns in pharmacotherapy using multivariable logistic regressions. Results: Among 4174 patients included, 2979 (71%) had an opioid prescription; 746 (18%), 384 (9%), 202 (5%), and 169 (4%) had anticonvulsant, NSAID, antidepressant and muscle relaxant prescriptions, respectively. Multivariable logistic regression showed a nonlinear trend in the use of opioids among pediatric patients with cancer over time such that use slightly increased until 2012 (OR of 1.40 [95% CI, 1.12-1.73] for 2012 vs. 2006) but then decreased thereafter (OR of 0.51 [0.37-0.68] for 2018 vs. 2012). The use of anticonvulsants, NSAIDs, and muscle relaxants increased significantly linearly over time (all P < .005). Conclusion: There has been a downward trend in the use of opioids in recent years among pediatric patients with cancer and an upward trend in the use of non-opioid pharmacotherapy for pain management potentially as an alternative to opioids.

Introduction:Food insecurity is a common problem with many associated negative downstream health impacts. Despite government sponsored and private supports, many individuals struggle with making healthy, nutritious meals. Penn State's Cooking with the Community program was constructed with the objective of providing cooking equipment and instructions to increase knowledge of healthy cooking techniques and consumption of under-utilized food pantry ingredients.Methods:Four cooking demonstrations were held over an 8-month study period in 2021 designed to educate participants on under-utilized and seasonally available ingredients. Each demonstration was professionally led by a chef who taught cooking skills and the use of different equipment, which were subsequently gifted to the participants. Participants were surveyed before and after each demonstration to assess cooking perceptions and comfort using Likert scales. Final analysis was completed in 2022 using mixed effects models to analyze changes between pre- and post-demonstration.Results:There were 34 total participants. Statistically significant improvements were seen in confidence in cooking (mean increase=0.5; SD=0.2; p=0.031; 95% CI=0.1, 1.0), preparation of a simple recipe (mean increase=0.6; SD=0.2; p=0.013; 95% CI=0.1, 1.0), and cooking new foods (mean increase=0.6; SD=0.3; p=0.026; 95% CI=0.1, 1.1).Conclusions:Cooking with the Community provides valuable information on how cooking confidence may be boosted within vulnerable populations by providing cooking equipment and professional instructions on its use.

IntroductionPatients with Ehlers-Danlos syndromes (EDS) and hypermobility spectrum disorders (HSD) have significant health challenges that are well-documented, however their impact in terms of cost is not known. Our research objective was to examine the cost burden of EDS and HSD in the United States. We focused this analysis on those with commercial insurance plans.MethodsWe queried the MarketScan® database for year 2021 for claims that contained an ICD-10 diagnosis code for EDS or hypermobility. Excess costs for patients in the EDS and HSD cohorts were determined by matching each patient to one patient in the database that did not have a claim for EDS or HSD and comparing total costs for the calendar year. We determined whether patients had claims for selected comorbid conditions likely to impact costs during the calendar year.ResultsSample sizes were 5,113 for adult (age ≥ 18) patients with EDS, 4,880 for adult patients with HSD, 1,059 for child (age 5–17) patients with EDS, and 2,427 for child patients with HSD. The mean excess costs were $21,100 for adult EDS patients, $11,600 for adult HSD patients, $17,000 for child EDS patients, and $11,000 for child HSD patients. EDS and HSD cohorts, both adults and children, with any of the comorbidities had greater healthcare costs. The largest difference was found in the EDS cohort with gastrointestinal comorbid conditions, with more than double the costs for adults.DiscussionWe found that patients in the MarketScan database, adults and children, who had EDS or HSD had substantially higher associated excess healthcare costs than patients without EDS or HSD when considering age, sex, geographic location, and comorbidities. These disproportionate healthcare costs in this population have health policy and economic implications, including the need for rapid diagnosis, access to treatment, and accelerated research to advance treatments.

Objective: As youth spend the majority of their time in school, school personnel suicide prevention training has gained support as an approach to mitigate rising youth suicide rates. This study examined associations between state school personnel suicide prevention training requirements (i.e., mandatory/non-mandatory and annual/not annual), year of legislation enactment (2013 or earlier/2014 or later), and changes in youth suicide rates by state from 2007-09 to 2016-18. Methods: School personnel suicide prevention training requirement data were collected through state-specific Department of Education websites while state-specific youth suicide rates were collected from the Center for Disease Control and Prevention's 2020 National Vital Statistics Report. Data were analyzed using a mixed effects linear regression model. Results: Training is mandated in 40/50 (80 %) states; 19/50 (38 %) require annual training. All states demonstrated increases in youth suicide rates from 2007-09 to 2016-18 (mean increase 3.9/100,000 [sd = 1.8]), but the change did not differ significantly by state requirements for mandatory (p = 0.44) or annual (p = 0.70) training, nor for year of enactment of legislation (p = 0.45). Conclusions: School personnel suicide prevention training requirements were not associated with changes in the youth suicide rate, though study results are limited in that data was not available on how successfully schools implemented the required trainings.

Introduction Human papillomavirus (HPV) vaccination rates are lower than other recommended adolescent vaccines. Cancer survivor narratives are used to promote cancer prevention and control, but little is known about their impact on adolescent HPV vaccination. Objective This pilot study explored the feasibility and effects of a video education intervention using a cancer survivor narrative to improve parents’ attitudes toward and intentions to get the HPV vaccine. Methods This study utilized a one-group design; participants completed a pre-intervention survey, watched the video before attending their sons’ wellness visits, and completed a post-intervention survey within one week of their appointment. Using the narrative persuasion framework, we developed a 4-minute video of a local HPV-related cancer survivor to promote the HPV vaccine as cancer prevention. We recruited 37 participants between June and October 2020. Participants were parents of males ages 9-17 who had not yet initiated HPV vaccination. Results After the video, more parents agreed that HPV vaccination is safe (pre: 66% vs. post: 82%; P = .045) and that their child’s chances of getting HPV-related cancer in the future are high (pre: 24% vs. post: 46%; P = .014). Overall, 91% of parents felt the cancer survivor story helped them understand the risks of HPV cancers, and 52% said the story influenced their decision to start HPV vaccination for their child. Conclusions Our findings suggest that cancer survivor narratives influence parents’ vaccine opinions and understanding of their child’s risk of HPV infection, leading to increased parental intent to get the HPV vaccine for their adolescent males.