INTRODUCTION:Few studies have examined county-level hotspots of veteran suicide and associated place-based contributors, limiting development of targeted community-level prevention strategies. The objectives of this national spatial analysis of all veteran suicides were to identify areas of the United States with higher-than-expected veteran suicide rates and determine county-level social and economic characteristics associated with areas of higher risk. METHODS:Using Bayesian hierarchical modeling, county-level standardized mortality ratios for veteran suicide deaths were estimated for time periods 2011-2018, 2011-2014, and 2015-2018. Adjusted relative risk, accounting for community characteristics, for each county was then estimated and associations between community characteristics and veteran suicide risk were examined. Analyses were conducted in 2023-2024. RESULTS:Risk of veteran suicide is predominantly concentrated in the Mountain West and West. Significant predictors of risk across all time periods were per capita number of firearm retailers (2011-2018 relative risk [RR]=1.065 [95% credible interval [CI] 1.030-1.102]), the proportion of residents who moved in the past year (2011-2018 RR=1.060 [95% CI 1.039-1.081]), the proportion of residents who live alone (2011-2018 RR=1.067 [95% CI 1.046-1.089]), the proportion of residents in rental housing (2011-2018 RR=1.041 [95% CI 1.018-1.065]), and the proportion of married residents (2011-2018 RR=0.915 [95% CI 0.890-0.941]). CONCLUSIONS:This study contributes to a comprehensive public health approach to veteran suicide prevention by identifying where resources are needed most, and which place-based intervention targets have the largest potential for impact. Findings suggest that public health efforts to address suicide among veterans should address community-level firearm access and identify ways to alleviate deleterious effects of social fragmentation.

Developing a public health approach to suicide prevention among United States (US) military veterans requires additional data and guidance on where, when, for whom, and what prevention resources should be deployed. This study examines veteran suicide mortality across one US state (Oregon) to identify county-level "hotspots" for veteran suicide, identify community characteristics associated with increased suicide among veterans, and examine excess spatial risk after accounting for space, time, and community characteristics. We linked Oregon mortality data with VA databases to identify veterans who had resided in Oregon and died by suicide between January 1, 2009 and December 31, 2018 (n = 1727). Community characteristic data were gathered at the county level from publicly available datasets on social determinants of health known to be associated with poor health outcomes, including suicide risk. We estimated spatial generalized linear mixed models for the full 10-year period and for each 5-year period using integrated nested Laplace approximation with county as the higher hierarchy. Smoothed standardized mortality ratios were used to identify counties with higher risk of veteran suicide. We found a small clustering of counties in the southwestern corner of Oregon that held the highest risk for veteran suicide across the ten years studied. In multivariable models, higher prevalence of unmarried persons was the only community measure significantly associated with increased veteran suicide risk. However, social contextual factors as a group, along with geographic space, explained most risk for suicide among veterans at the population level.

Infections with unusual organisms are frequently found in patients with primary and acquired immunodeficiency. It is estimated that 1 in 1200 individuals in the United States have a diagnosis of primary immunodeficiency, with common variable immunodeficiency (CVID) accounting for approximately 35% of the cases.1 CVID is a heterogeneous disorder that is primarily a defect of the humoral immune system, although approximately 50% of patients have T cell defects as well. Patients with CVID have increased susceptibility to infections, particularly of the upper and lower respiratory tract, and increased incidence of autoimmune diseases and neoplasms.

Background In the USA, deaths due to suicide, alcohol, or drug-related causes (e.g., alcohol-related liver disease, overdose) have doubled since 2002. Veterans appear disproportionately impacted by growing trends. Limited research has been conducted regarding the relationship between community-level factors (e.g., rurality, community distress resulting from economic conditions) and the presence of spatial clustering of suicide, alcohol-related, or drug-related deaths. We explored community-level relationships in Colorado Veterans and compared suicide, alcohol-, and drug-related death rates between the Colorado adult population and Veterans. Methods 2009–2020 suicide, alcohol-related, and/or drug-related deaths were identified using qualifying multiple cause-of-death International Classification of Disease (ICD)-10 codes in CDC WONDER for the general adult population and Colorado death data for Veteran populations. Age and race adjusted rates were calculated to compare risk overall and by mortality type (i.e., suicide, alcohol-related, drug-related). In Veteran decedents, age-adjusted rates were stratified by rurality and community distress, measured by the Distressed Communities Index. Standardized mortality ratios were calculated to measure spatial autocorrelation and identify clusters using global and local Moran’s I , respectively. Results 6.4% of Colorado Veteran deaths ( n = 6948) were identified as being related to suicide, alcohol, or drugs. Compared to rates in the general population of Colorado adults, Veterans had 1.8 times higher rates of such deaths overall (2.1 times higher for suicide, 1.8 times higher for alcohol-related, 1.3 times higher for drug-related). Among Veterans, community distress was associated with an increased risk of alcohol-related [age-adjusted rate per 100,000 (95% CI) = 129.6 (89.9–193.1)] and drug-related deaths [95.0 (48.6–172.0)]. This same significant association was not identified among those that died by suicide. Rurality was not associated with risk for any of the deaths of interest. There was significant spatial clustering for alcohol-related deaths in southeast Colorado. Conclusions Colorado Veterans have higher rates of deaths due to suicide, alcohol-related, and drug-related causes compared to members of the general adult population. Upstream prevention efforts, such as community-based interventions targeting alcohol-use and community economic distress, are warranted. More research is also needed to understand how community distress and other social determinants of health impact the community burden of suicide, alcohol-related, and drug-related mortality.

Background: Opioids accounted for 75% of drug overdoses in the United States in 2020, with rural states particularly impacted by the opioid crisis. While medication assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD; and (2) evaluate the role of specific OpitMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention. Methods: We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence. Discussion: This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone appbased interventions. Trial registration: ClinicalTrials.gov identifier: NCT05336188, registered March 21, 2022, https://clinicaltrials.gov/ct2/show/NCT05336188.

Introduction: The purpose of this study was to identify risk factors for primary medication nonadherence among low-income minority children with persistent asthma. Method: Data were from an environmental control and educational intervention for children with uncontrolled asthma who were treated in the emergency department for an asthma exacerbation. Presence or absence of pharmacy records for child asthma medications was the outcome of interest. A range of sociodemographic, health, and psychosocial measures were included in the binary logistic regression. Results: Of the 222 youths (mean age 6.3 years; 93.7% Black), 25 (11.3%) lacked pharmacy records of asthma medications. For every 1-point increase in caregiver depressive symptoms, the odds of the child having a pharmacy record declined by 5% (odds ratio = 0.95; p = .012). Discussion: Providers should systematically assess and monitor caregiver depressive symptoms as a potential contributing factor for primary medication nonadherence in low-income minority children with persistent, uncontrolled asthma.

BACKGROUND: Whether concomitant home exposures modify the effectiveness of mouse allergen reduction among mouse-sensitized children with asthma is unknown. OBJECTIVE: To determine whether a lower baseline home mouse allergen level, lower particulate matter 10 mu or less (PM10), and the absence of sensitization and exposure to other indoor allergens are associated with greater improvements in asthma associated with mouse allergen reduction. METHODS: A secondary analysis of a randomized clinical trial of a home mouse allergen intervention was performed to examine the effect of 3 indoor factors on the relationship between mouse allergen reduction and a range of asthma outcomes. RESULTS: Participants (N = 297) were predominantly minority (78% African American, 22% Hispanic) and publicly insured (88%). Higher baseline mouse allergen levels were associated with a greater response to mouse allergen reduction for several symptom and exacerbation outcomes. Lower indoor PM10 levels were associated with a greater response to mouse allergen reduction for several symptom outcomes, but not exacerbation outcomes. Overall, sensitization and exposure to other indoor allergens did not appear to modify the effect of mouse allergen reduction. CONCLUSIONS: In this population of predominantly low-income children with persistent asthma and mouse sensitization, mouse allergen reduction was associated with improvements in asthma, especially among those with high baseline mouse allergen exposure. Lower indoor PM10 was associated with greater improvements in asthma symptoms. (C) 2021 American Academy of Allergy, Asthma & Immunology

The purpose of this study was to examine relationships among caregiver social support, caregiver depressive symptoms, medication adherence, and asthma control in a sample of low-income, urban, Black children aged 3–12 years with uncontrolled asthma and their caregivers. Using longitudinal data from a randomized controlled trial (RCT) assessing the efficacy of an environmental control educational intervention, we used generalized estimating equations and ordered logistic regression models to evaluate the relationship between caregiver social support (Medical Outcomes Study Social Support Survey), depressive symptoms (Center for Epidemiologic Studies Depression scale), and two child asthma outcomes: (a) medication adherence (Asthma Medication Ratio) and (b) asthma control. At baseline, 45.7% of the 208 children had very poorly controlled asthma. Nearly a third of caregivers (97% female) had clinically significant depressive symptoms at each data collection point. Social support was not associated with either asthma outcome nor did it moderate the relationship between depressive symptoms and child asthma outcomes. Higher caregiver depressive symptoms predicted decreased medication adherence (b=−0.003, SE 0.002). Moderate asthma at baseline (OR: 0.305, SE: 0.251), severe asthma at baseline (OR: 0.142, SE: 0.299), household income < $20,000 per year (OR: 0.505, SE: 0.333), and fall season (OR: 0.643, SE: 0.215) were associated with poorer asthma control. Attending to the social context of low-income, urban, Black children with asthma is critical to reduce asthma morbidity. Maternal depressive symptoms are modifiable and should be targeted in interventions to improve child asthma outcomes in this vulnerable population. The RCT was registered with ClinicalTrials.gov (NCT01981564) in October 2013.

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

OBJECTIVE:Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) is an interprofessional team that delivers televideo case conferences to help providers optimize treatment of pain using nonopioid, evidence-based therapies. This article assesses AR-IMPACT using the RE-AIM (reach, efficacy, adoption, implementation, maintenance) framework.DESIGN:A cross-sectional study.SETTING:Large, academic medical center.PARTICIPANTS:Healthcare providers.INTERVENTIONS:Televideo case conferences.MAIN OUTCOME MEASURES:Reach was evaluated by the number of participants, professions represented, and counties/states in which providers resided. Efficacy was assessed via a participant evaluation survey. Adoption was evaluated by calculating the number of repeat participants and soliciting information on barriers to adoption of conference recommendations in clinical practice using the participant evaluation survey. Implementation was evaluated by calculating the time and cost burden of the program.RESULTS:Reach was widespread; continuing education (CE) credits have been claimed by 395 providers in 54 of the 75 counties in Arkansas and 18 states outside Arkansas. For efficacy, the majority of providers noted increases in their knowledge due to AR-IMPACT (89.6 percent). Like reach, adoption was also extensive; approximately 42 percent of AR-IMPACT participants attended more than one conference, and close to 56 percent of participants noted no barriers to adopting the changes discussed in the conferences. With implementation, the time requirements for developing a case conference ranged from 2 to 4 hours, and the cost per CE credit was $137, which is on par with other programs.CONCLUSIONS:AR-IMPACT was successful, particularly in reach and efficacy. Entities that implement programs similar to AR-IMPACT will likely experience extensive uptake by providers.

This study explored factors that influence the accuracy of caregivers’ appraisals of the foods their children with food allergy should avoid. Seventy-two caregivers of children with food allergy completed measures of caregiver educational attainment, food allergy knowledge, food allergy worry, and a questionnaire assessing whether or not their child should avoid specific foods (the Foods to Avoid Test). Unnecessary avoidance was indicated when a caregiver reported their child should avoid a food item, even though that item was safe for their child based on their food allergy (i.e., false positive). Lack of appropriate avoidance was represented by caregivers reporting a food did not need to be avoided when it should be avoided based on the child’s food allergy (i.e., false negative). Caregivers with lower educational attainment and less food allergy knowledge and whose children were more recently diagnosed had more false-negative appraisal errors. In contrast, false-positive appraisal errors were most strongly related to parental worry about food allergy. The findings suggest that screening for food allergy general knowledge and food avoidance appraisals may help identify gaps in caregivers’ knowledge and ultimately prevent accidental exposures and/or unnecessary avoidance.

The coronavirus disease 2019 (COVID-19) pandemic profoundly altered the way that society functioned, with resultant shifts in behavior and exposures particularly when the orders for national shelter in place were implemented in mid-March 2020. These changes may have substantially impacted patients with chronic diseases including asthma, which disproportionately affects underserved minority children.1Beck AF Huang B Auger KA Ryan PH Chen C Kahn RS. Explaining racial disparities in child asthma readmission using a causal inference approach.JAMA Pediatr. 2016; 170: 695-703Crossref PubMed Scopus (76) Google Scholar In addition to changes in exposures such as viruses and environmental triggers, changes in health care access and utilization impact asthma morbidity.2Olsen SJ Azziz-baumgartner E Budd AP et al.Decreased influenza activity during the COVID-19 pandemic - United States, Australia, Chile, and South Africa, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1305-1309Crossref PubMed Scopus (201) Google Scholar, 3Partridge E McCleery E Cheema R et al.Evaluation of seasonal respiratory virus activity before and after the statewide COVID-19 shelter-in-place order in northern California.JAMA Netw Open. 2021; 4 (e2035281)Crossref PubMed Scopus (32) Google Scholar, 4Papadopoulos NG Custovic A Deschildre A et al.Impact of COVID-19 on pediatric asthma: practice adjustments and disease burden.J Allergy Clin Immunol Pract. 2020; 8: 2592-2599Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5CDC COVID-19 Response TeamCoronavirus disease 2019 in children - United States, February 12-April 2, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 422-426Crossref PubMed Scopus (14) Google Scholar, 6Chan KH Lee PW Chan CY Lam KBH Ho PL. Monitoring respiratory infections in covid-19 epidemics.BMJ. 2020; 369: m1628Crossref PubMed Scopus (26) Google Scholar, 7Taquechel K Diwadkar AR Sayed S et al.Pediatric asthma health care utilization, viral testing, and air pollution changes during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2020; 8 (e11): 3378-3387Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Initially, it was unclear whether these changes would have a positive or negative impact on children with asthma.5CDC COVID-19 Response TeamCoronavirus disease 2019 in children - United States, February 12-April 2, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 422-426Crossref PubMed Scopus (14) Google Scholar Over the past year, several studies have reported a reduction in emergency department (ED) visits for pediatric asthma throughout the United States.7Taquechel K Diwadkar AR Sayed S et al.Pediatric asthma health care utilization, viral testing, and air pollution changes during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2020; 8 (e11): 3378-3387Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 8DeLaroche AM Rodean J Aronson PL et al.Pediatric emergency department visits at US children's hospitals during the COVID-19 pandemic.Pediatrics. 2021; 147 (e2020039628)Crossref Scopus (58) Google Scholar, 9Kenyon CC Hill DA Henrickson SE Bryant-Stephens TC Zorc JJ. Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization.J Allergy Clin Immunol Pract. 2020; 8 (e1): 2774-2776Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar The current study sought to evaluate the impact of the COVID-19 pandemic on ED visits and hospitalizations in an inner-city pediatric population with specific comparisons of exacerbation severity. This study was deemed exempt by our institutional review board. Retrospective data were collected from our urban academic hospital to include children presenting to the ED with a diagnosis of “asthma exacerbation” (International Classification of Diseases Tenth Revision codes J45.901/2, J45.21-25, J45.22-52) as one of the top 2 diagnoses. Data included patient demographics and final disposition—discharged from the ED, admitted to the general inpatient unit, or admitted to the pediatric intensive care unit (PICU)—as surrogate markers of illness severity. Data were divided into 12-week quarters with quarter 1 covering January to March, quarter 2 covering April to June, quarter 3 covering July to September, and quarter 4 covering October to December. The onset of COVID-19 was defined as April 1, 2020 (quarter 2). Pre-COVID-19 data were collected from 2016 to 2019 and covered 48 weeks on average for each quarter. During COVID-19, data included were on the average of 12 weeks for each 2020 quarter. Data collection ended December 2020 (quarter 4). Quarter 1 during COVID-19 was from January to March 2021, thus, it was not included in our analysis. The number of ED visits for asthma per week and the percentage of patients with each final disposition (ED, inpatient, or PICU) was averaged for each quarter before and during the COVID-19. Unpaired t tests were used to compare the means per week pre- to during COVID-19 for each quarter (2-4). The overall study population consisted of 4664 unique patients. The overall sample had a mean age of 8.2 years with 56.2% boys and 89.3% African American; the remainder self-identified as either White, multiracial, or other. Age, sex, and race did not significantly differ pre- and during COVID-19; although, during COVID-19, health insurance coverage changed, with 87.3% Medicaid insured pre- and 95.1% during-, 10.7% privately insured pre- and 4.9% during and 2.0% uninsured patients pre- and 0% during COVID-19. As illustrated in Figure 1, there was a statistically significant decrease in ED presentations for asthma during COVID-19 vs pre–COVID-19 in quarter 2 (decreased 87.2%), quarter 3 (73.5%), and quarter 4 (77.3%), (P < .001 for all.) There was a significant increase in the percentage of patients who did not require any admission (discharged from the ED) during COVID-19, compared with pre–COVID-19 in quarters 2 (P < .001) and 3 (P < .05), but no difference were found in quarter 4. There were no significant differences in the percentage of patients admitted to the general inpatient unit during vs pre-COVID-19 for any quarter. There was a significant reduction in the percentage of patients admitted to the PICU during COVID-19 in quarter 2 (P < .001), a reduction in quarter 3 that approached significance (P = .05), and no difference in quarter 4. We found a statistically significant reduction in ED visits for asthma during the pandemic (79.3%), which is higher than other studies (range: 45.2%-75%).8DeLaroche AM Rodean J Aronson PL et al.Pediatric emergency department visits at US children's hospitals during the COVID-19 pandemic.Pediatrics. 2021; 147 (e2020039628)Crossref Scopus (58) Google Scholar,9Kenyon CC Hill DA Henrickson SE Bryant-Stephens TC Zorc JJ. Initial effects of the COVID-19 pandemic on pediatric asthma emergency department utilization.J Allergy Clin Immunol Pract. 2020; 8 (e1): 2774-2776Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar We initially hypothesized that the significant reduction in pediatric asthma ED visits was because of reluctance to go to the ED because of concerns of contracting COVID-19. If so, we would expect higher exacerbation severity, resulting in increased PICU admissions and decreased ED discharges. However, we found the opposite. To our knowledge, our study is the first to use final disposition (admitted to PICU vs discharged from the ED) as a marker of asthma exacerbation severity, pre and during COVID-19. Decreased ED visits were sustained 9 months after the onset of the pandemic, suggesting that the ongoing COVID-19 precautions such as social distancing, distance learning, and masks may have contributed to this improvement. Though designed to reduce transmission of severe acute respiratory syndrome coronavirus 2, these measures could also reduce transmission of other respiratory viruses that are the primary cause of asthma exacerbations.7Taquechel K Diwadkar AR Sayed S et al.Pediatric asthma health care utilization, viral testing, and air pollution changes during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2020; 8 (e11): 3378-3387Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar,10Kim CK Callaway Z Gern JE. Viral infections and associated factors that promote acute exacerbations of asthma.Allergy Asthma Immunol Res. 2018; 10: 12-17Crossref PubMed Scopus (38) Google Scholar With children and caregivers spending more time at home, other potential contributing factors include changes in indoor allergen exposure from school to home1Beck AF Huang B Auger KA Ryan PH Chen C Kahn RS. Explaining racial disparities in child asthma readmission using a causal inference approach.JAMA Pediatr. 2016; 170: 695-703Crossref PubMed Scopus (76) Google Scholar and improved asthma medication adherence.7Taquechel K Diwadkar AR Sayed S et al.Pediatric asthma health care utilization, viral testing, and air pollution changes during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2020; 8 (e11): 3378-3387Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar The percent reduction in PICU asthma admissions is both striking and novel. We found a significant impact in quarter 2, but not 3 and 4. Although data were unavailable to investigate this, possible explanations include reduced adherence to COVID-19 precautions later in the pandemic and seasonal fluctuations in viral prevalence. One study limitation is that detailed information, including allergen sensitization, exposure data, receipt of specialty care, and respiratory viral data were unavailable. Unfortunately, fewer respiratory viral panels were obtained during COVID-19, limiting our ability to assess specific pre/during viral triggers. Another factor that could impact our results is a change in the threshold for PICU admissions during COVID-19 because of bed availability. However, we continued to use our standardized asthma pathway admission criteria throughout the pandemic, and there were no PICU bed shortages. Finally, without the availability of comparison data for other diseases, we cannot conclude that COVID-19 measures were specifically only affecting asthma. In conclusion, we found, in our underserved, minority, inner-city pediatric population, that both the frequency and severity of asthma exacerbations decreased immediately after the onset of the COVID-19 pandemic. Changes in behavior, such as sheltering in place, distance learning, and wearing of masks to reduce the spread of severe acute respiratory syndrome coronavirus 2, had a profound impact on asthma morbidity in our population. These may not be reasonable long-term measures and COVID-19 vaccination of children may change the need for some of them. Further studies may elucidate if any of these measures should be recommended for all or select populations of children to prevent viral illnesses that impact asthma morbidity and mortality. The authors thank Marty Reynolds for her assistance in hospital data retrieval.

Highly prevalent in the United States, chronic pain (CP) is associated with depression, anxiety, insomnia, and suicide behavior. Racial and ethnic differences in CP have been documented, but Native Hawaiians and Pacific Islanders (NHPI) are frequently grouped with Asians despite different cultural/social experiences. Using the 2014 NHPI National Health Interview Survey, we examined the prevalence of CP and associations with sociodemographic and health correlates. Descriptive statistics were estimated followed by logistic regression modeling CP and negative binomial regression modeling CP count. Our NHPI cohort consisted of 1,334 adults with pain prevalence similar to all U.S. adults. However, the prevalence of depression and anxiety symptoms was significantly higher among NHPI compared with U.S. adults, particularly for anxiety. In regression models, moderate to severe fatigue ranks above other important factors in predicting both CP and CP count, increasing the odds of CP 4.5 times, 95% confidence interval [2.3, 8.9], and the mean count of pain conditions 1.62 times, 95% confidence interval [1.28, 2.04], for each added condition. Depression symptoms were positively associated with only CP, whereas anxiety symptoms were positively associated with only CP count. This first look at CP among NHPI suggests significant differences between U.S. and NHPI adults in associated risk factors, especially fatigue, depression, and anxiety. Although these results may have clinical implications, additional work is needed to address NHPI heterogeneity to understand fully the NHPI CP experience.

Pediatric asthma affects 8 million US children, and approximately 50% experience an acute asthma exacerbation each year. 1 Akinbami L.J. Moorman J.E. Garbe P.L. Sondik E.J. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 2009; 123: S131-S145 Crossref PubMed Scopus (660) Google Scholar ,2 Zahran H.S. Bailey C.M. Damon S.A. Garge P.L. Breysse P.N. Vital signs: asthma in children-United States, 2001-2016. MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155 Crossref PubMed Scopus (251) Google Scholar Despite national guidelines that recommend daily anti-inflammatory or controller medication to treat persistent and uncontrolled asthma, 3 US Department of Health and human ServicesThe National Asthma Education and Prevention Program. in: Expert Panel Report 3 (EPR): Guidelines for the Diagnosis and management of Asthma. US Dept of Health and Human Services, Washington, DC2007 Google Scholar most inner-city children with persistent asthma do not receive guideline-based therapy. 4 Butz A. Morphew T. Lewis-Land C. Kub J. Bellin M. Ogborn J. et al. Factors associated with poor controller medication use in children with high asthma emergency department use. Ann Allergy Asthma Immunol. 2017; 118: 419-426 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Understanding factors associated with underuse of controller medication may inform clinical interventions to improve asthma control in these high-risk children. We examined sociodemographic and health factors associated with timing of controller medication fills in children with frequent asthma emergency department (ED) visits.

BACKGROUND:Few trials have tested targeted environmental control (EC) interventions based on biomarkers of second hand smoke (SHS) exposure and allergen sensitization in reducing asthma emergency department (ED) visits in children with poorly controlled asthma.METHODS:Overall, 222 children with poorly controlled asthma were randomized into a home-based EC intervention (INT) or control (CON) group and followed for ED visits over 12 months. All children received allergen-specific IgE serologic testing and SHS exposure biomarker testing to inform the EC intervention. Pharmacy data was examined for asthma medication fills. Cox proportional hazards and multivariate regression models were performed to examine factors associated with repeat ED visits.RESULTS:There was no difference in increased risk of >1 ED visit at 12 months between INT and CON groups. Most children (75%) had moderate/severe persistent asthma. Over half (56%) had SHS exposure and 83% tested positive for >1 allergen sensitization. Among children without SHS exposure, the median time to first recurrent ED visit differed by group (CON: 195; INT: >365 days) after adjusting for child age, allergic sensitization, medication fills prior to baseline, controller medication use, and the interaction between group status and SHS exposure. Children who had positive allergic sensitizations, younger, had increased controller medication use and randomized to the CON group and had no SHS exposure had increased risk for a repeat ED visit over 12 months.CONCLUSIONS:In this study, a home-based EC intervention was not successful in reducing asthma ED revisits in children with poorly controlled asthma with SHS exposure. Allergic sensitization, young age, and increased controller medication use were important predictors of asthma ED visits.

Among the 8 million US children with asthma, approximately 50% experience an acute exacerbation each year. 1 Akinbami L.J. Moorman J.E. Garbe P.L. Sondik E.J. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 2009; 123: S131-S145 Crossref PubMed Scopus (672) Google Scholar Recurrent emergency department visits and hospital admissions often result from poorly controlled asthma. National and international guidelines advise that the goal of asthma management is to achieve well-controlled asthma, 2 US Department of Health and Human ServicesThe National Asthma Education and Prevention Program. in: Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. US Dept of Health and Human Services, Washington, DC2007 Google Scholar , 3 Global Initiative for Asthma (GINA)Global Strategy for Asthma Management and prevention. https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/Date: 2018 Date accessed: December 19, 2018 Google Scholar yet asthma remains not well or very poorly controlled in approximately 50% of adult and pediatric patients. 4 Chipps B.E. Zeiger R.S. Dorenbaum A. et al. TENOR Study GroupAssessment of asthma control and asthma exacerbations in the epidemiology and natural history of asthma, outcomes and treatment regimens (TENOR) observation cohort. Curr Respir Care Rep. 2012; 1: 259-269 Google Scholar Achieving well-controlled asthma requires adept use of stepwise therapy and sufficient practitioner time for patient counseling to implement step-up and step-down therapy. 5 Zeiger R.S. Schatz M. Qiaowu L. Zhang F. Purdum A.S. Chen W. Step-up care improves impairment in uncontrolled asthma: an administrative data study. Am J Manag Care. 2010; 16: 897-906 PubMed Google Scholar Missed opportunities to adjust medications and provide appropriate medication instructions in acute care settings may also contribute to very poorly controlled asthma. Furthermore, asthma guidelines recommend specialty care for children with very poorly controlled asthma, yet specialty care is often underused in low-income minority children. 6 Mitchell S.J. Bilderback A.L. Okelo S.O. Racial disparities in asthma morbidity among pediatric patients seeking asthma specialist care. Acad Pediatr. 2016; 16: 64-67 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Our study aims to examine patterns of asthma medication fills in low-income minority children by level of asthma control defined as well controlled, not well controlled, or very poorly controlled and determine factors associated with very poorly controlled asthma.

BACKGROUND: It is unknown whether caregiver perception of a child's asthma control, independent of guideline-based asthma control assessment, is a predictor of future acute visits. OBJECTIVE: To determine whether caregiver-reported asthma control is an indicator of future risk of acute visit. METHODS: Two study populations of low-income, minority 5to 17-year-old children with persistent asthma were included. Questionnaires administered at baseline and at 3, 6, 9, and 12 months captured symptoms, short-acting b-agonist use, acute visits in the previous 3 months, and caregiver-reported asthma control. Well-controlled, not well-controlled, and very poorly controlled asthma were defined using National Asthma Education and Prevention Program guideline-based assessment. Relationships between caregiver-reported control and acute visits in the subsequent 3 months were examined. RESULTS: At baseline, both populations were predominantly black/African American (91% and 79%) with public insurance (85% and 88%) and very poorly controlled asthma (47% and 50%). In both populations, most caregivers reported that their child's asthma was well controlled (73% and 69%). In both populations, participants whose caregivers reported that their child had uncontrolled asthma had greater odds of having an acute visit in the following 3 months as compared with participants whose caregivers reported that their child's asthma was well controlled, independent of guideline-based control, age, sex, race, controller medication, insurance, and atopy (odds ratio [95% CI], 2.4 [1.4-4.2] and 1.6 [1.1-2.4]). CONCLUSIONS: Among predominantly low-income minority children with asthma, caregiver-reported asthma control may provide information about the risk of future acute visit for asthma that is complementary to guideline-based control assessment. (C) 2019 American Academy of Allergy, Asthma & Immunology

The study examined the influence of two dimensions of intolerance of uncertainty (i.e., desire for predictability and uncertainty paralysis) on protective parenting behaviors in mothers of children with food allergy. Sixty-six mothers of 3- to 6-year-old children with food allergy completed the Intolerance of Uncertainty Scale (IUS) and measures of two types of protective parenting - restrictive protectiveness and intrusive/nurturant protectiveness. Restrictive protectiveness was significantly related to both the desire for predictability and uncertainty paralysis dimensions of the IUS among mothers of children over the age of 5 years. Intrusive/nurturant protectiveness was significantly related only to the desire for predictability dimension of the IUS among mothers of children under the age of 4.5 years. The results demonstrate the two dimensions of intolerance of uncertainty predict the type of protective parenting behaviors used by mothers of children with food allergy and that age moderates this association. Taken together, the findings suggest that intolerance of uncertainty may be a risk factor for overly protective parenting in children with food allergy and other health conditions.