Disparities in Child Welfare Referrals for Patients Seen in a Pediatric Emergency Department for Unintentional Ingestions

OBJECTIVE

To examine the characteristics of patients visiting the pediatric emergency department (PED) for unintentional ingestions and associations between patient race and ethnicity in referrals to Child Protective Services (CPS) for supervisory neglect.

METHODS

We conducted a cross-sectional analysis of children <12 years old who presented to the PED between October 2015 and December 2020 for an unintentional ingestion. Patients were identified by searching the electronic health record for diagnosis codes corresponding to unintentional ingestions. Patient demographics, ingestion type, disposition, and referrals to CPS were abstracted by manual chart review. Logistic regression models were used to evaluate associations between patient demographics and visit characteristics with referral to CPS.

RESULTS

We identified 129 PED encounters for unintentional ingestions that were included for analysis. Overall, 22 patients (17.1%) were referred to CPS for neglect. In the univariate analysis, both ingestion of an illicit drug and arrival to the PED by ambulance were associated with a higher odds of referral to CPS. In the multivariable model adjusted for parent language, ingestion type, and mode of arrival to the PED, Hispanic patients had higher odds of referral to CPS than White patients (adjusted odds ratio (aOR) = 17.2, 95% confidence intervals [1.8-162.3], P = .03). There was not a statistically significant association between Black race and referral to CPS.

CONCLUSIONS

Referrals to CPS from the PED after unintentional ingestions are common and disproportionally involve Hispanic patients. More research is needed to promote equitable child maltreatment reporting for children presenting to the PED following unintentional ingestions.

Substrate-dependent metabolomic signatures of myeloperoxidase activity in airway epithelial cells: Implications for early cystic fibrosis lung disease

Myeloperoxidase (MPO) is released by neutrophils in inflamed tissues. MPO oxidizes chloride, bromide, and thiocyanate to produce hypochlorous acid (HOCl), hypobromous acid (HOBr), and hypothiocyanous acid (HOSCN), respectively. These oxidants are toxic to pathogens, but may also react with host cells to elicit biological activity and potential toxicity. In cystic fibrosis (CF) and related diseases, increased neutrophil inflammation leads to increased airway MPO and airway epithelial cell (AEC) exposure to its oxidants. In this study, we investigated how equal dose-rate exposures of MPO-derived oxidants differentially impact the metabolome of human AECs (BEAS-2B cells). We utilized enzymatic oxidant production with rate-limiting glucose oxidase (GOX) coupled to MPO, and chloride, bromide (Br-), or thiocyanate (SCN-) as substrates. AECs exposed to GOX/MPO/SCN- (favoring HOSCN) were viable after 24 h, while exposure to GOX/MPO (favoring HOCl) or GOX/MPO/Br- (favoring HOBr) developed cytotoxicity after 6 h. Cell glutathione and peroxiredoxin-3 oxidation were insufficient to explain these differences. However, untargeted metabolomics revealed GOX/MPO and GOX/MPO/Br- diverged significantly from GOX/MPO/SCN- for dozens of metabolites. We noted methionine sulfoxide and dehydromethionine were significantly increased in GOX/MPO- or GOX/MPO/Br--treated cells, and analyzed them as potential biomarkers of lung damage in bronchoalveolar lavage fluid from 5-year-olds with CF (n = 27). Both metabolites were associated with increasing bronchiectasis, neutrophils, and MPO activity. This suggests MPO production of HOCl and/or HOBr may contribute to inflammatory lung damage in early CF. In summary, our in vitro model enabled unbiased identification of exposure-specific metabolite products which may serve as biomarkers of lung damage in vivo. Continued research with this exposure model may yield additional oxidant-specific biomarkers and reveal explicit mechanisms of oxidant byproduct formation and cellular redox signaling.

Disposition Decisions in Cases of Medical Complexity and Health Inequity

The question of optimal disposition for children with complex medical and social circumstances has long challenged the well-intentioned clinician. The coronavirus disease 2019 pandemic created unique difficulties for patients, families, and health care providers, in addition to highlighting long-standing racial and socioeconomic inequities in health care. In pediatric hospitals, necessary public health measures such as visitor restrictions shifted many shared decision-making processes such as discharge planning from complicated to impossible. Here, we present the case of a medically complex adult (with a long-standing pediatric condition) whose surrogate decision-maker objected to discharge to a long-term care facility because of restrictions and risks associated with the coronavirus disease 2019 pandemic. We offer the commentary of experts in clinical ethics, intensive care, inpatient subacute care, and palliative care. Our discussion includes analysis of the ethical considerations involved in the case, concrete guidance on steps toward an ethically permissible discharge, and suggestions for how a health equity lens can improve communication and decision-making for families who are victims of systemic racism and economic discrimination.

Long-acting progestin-only contraceptives enhance human endometrial stromal cell expressed neuronal pentraxin-1 and reactive oxygen species to promote endothelial cell apoptosis

CONTEXT

Despite the absence of progesterone receptor protein in human endometrial endothelial cells (HEECs), endometria of women receiving long-acting progestin-only contraceptives (LAPCs) display reduced uterine blood flow, elevated reactive oxygen species generation, increased angiogenesis, and irregularly distributed, enlarged, fragile microvessels resulting in abnormal uterine bleeding.

OBJECTIVE

We propose that paracrine factors from LAPC-treated human endometrial stromal cells (HESCs) impair HEEC functions by shifting the balance between HEEC viability and death in favor of the latter.

DESIGN AND SETTING

Proliferation, apoptosis, and transcriptome analyses were performed in HEECs treated with conditioned medium supernatant (CMS) derived from HESCs treated with estradiol (E2) ± medroxyprogesterone acetate or etonogestrel under normoxia or hypoxia. Mass spectrometry interrogated the CMS secretome while immunostaining for neuronal pentraxin-1 (NPTX1), cleaved caspase-3, and cytochrome c was performed in cultured HEECs and paired endometria from women using LAPCs.

MAIN OUTCOME

HEEC apoptosis and its underlying mechanism.

RESULTS

HESC CMS from E2 + medroxyprogesterone acetate or E2 + etonogestrel incubations under hypoxia induced HEEC apoptosis (P < .05), whereas mass spectrometry of the CMS revealed increased NPTX1 secretion (P < .05). Endothelial cleaved caspase-3 and stromal NPTX1 immunoreactivity were significantly higher in LAPC-treated endometria (P < .001). Transcriptomics revealed AKT signaling inhibition and mitochondrial dysfunction in HEECs incubated with HESC CMS. In vitro analyses proved that CMS decreased HEEC AKT phosphorylation (P < .05) and that recombinant NPTX1 (P < .05) or NPTX1 + H2O2 (P < .001) increase HEEC apoptosis and cytosolic cytochrome c levels.

CONCLUSIONS

LAPC-enhanced NPTX1 secretion and reactive oxygen species generation in HESCs impair HEEC survival resulting in a loss in vascular integrity, demonstrating a novel paracrine mechanism to explain LAPC-induced abnormal uterine bleeding.

Characterization of glomerular diseases using proteomic analysis of laser capture microdissected glomeruli

The application of molecular techniques to characterize clinical kidney biopsies has the potential to provide insights into glomerular diseases that cannot be revealed by traditional renal pathology. The present work is a proof-of-concept approach to test whether proteomic analysis of glomeruli isolated from clinical biopsies by laser capture microdissection can provide unique information regarding differentially expressed proteins relevant to disease pathogenesis. The proteomes of glomeruli isolated by laser capture microdissection from biopsies of normal kidneys (living-related donor kidneys) were compared with those from patients with diabetic nephropathy, lupus nephritis, and fibronectin glomerulopathy. Glomerular proteins were extracted, trypsin digested, and subjected to liquid chromatography-tandem mass spectrometry for identification and quantitation. Relative to normal glomeruli, all disease-associated glomeruli showed an increased presence of complement components, a marked decline in podocyte-associated proteins, and a decrease in proteins associated with cellular metabolism. Additionally, fibronectin glomerulopathy glomeruli differed from all the other glomeruli because of a significant accumulation of fibronectin and fibulin. This study demonstrates that our method acquires reproducible and quantitative proteomic information from laser capture microdissection isolates that can be used to characterize the molecular features of glomerular diseases.

'Fear of Success' Imagery as a Reaction to Sex-role Inappropriate Behavior

Cue effects on TAT imagery, often considered evidence of fear of success, were examined. The cue generally used to assess this motive (Horner, 1968) was modified to depict success in an occupation traditionally considered appropriate for females (ballet). This new cue and Horner's original "medical student"cue produced very different results in fear of success imagery, the modified cue eliciting significantly less of this imagery from females and more from males. A substantial portion of what has been interpreted as "fear of success" imagery appears to involve anxiety about engaging in achievement activities that have traditionally been considered inappropriate to one's sex-role. The implications of this finding for female achievement conflict are discussed.

Prevention of rat neonatal cardiomyocyte apoptosis induced by simulated in vitro ischemia and reperfusion

Apoptosis, or programmed cell death, is an active metabolic response to physiological signals or exposure to cytotoxic agents. Recent evidence has shown that the cell death response can be modified by agents presumed to be unrelated to the initial signal, but capable of interfering with the molecular mechanisms of the apoptotic pathway progression. Here we show the results of investigations on the use of a phospholipid-based pharmaceutical preparation for suppression of myocardial damage. First, we show that serum or serum/glucose deprivation, in vitro ischemia with subsequent simulated reperfusion, inhibition of protein synthesis, and treatment with ceramide, staurosporine, adriamycin, cis-platinum and menadione induce apoptotic death in a primary culture of rat neonatal cardiomyocytes. Then we demonstrate that a mixture of specific phospholipids, which has been originally purified from soy flour on the basis of its anti-apoptotic activity, prevents cardiomyocyte death induced by serum or serum/glucose deprivation, by ischemia with subsequent simulated reperfusion, and by ceramide, but not by other cytotoxic treatments. This suggests that ceramide, a lipid secondary messenger which triggers apoptosis induced by some cytotoxic agents, may be involved in the process of signaling ischemia/reperfusion induced apoptotic death of cardiomyocytes. These results further demonstrate that an active pharmaceutical preparation for the suppression of cardiomyocyte death can be formulated based upon a novel strategy of apoptosis modification.

Reanimation of the paralyzed eyelid with the enhanced palpebral spring or the gold weight: modern replacements for tarsorrhaphy

The enhanced palpebral spring and the gold weight are the modern devices that should nearly completely replace tarsorrhaphy in the management of ocular problems secondary to facial paralysis. They actually reanimate the lid, rather than merely hold the lids closed in a disfigured position, as does tarsorrhaphy. The surgical techniques of each procedure, results, and pros and cons of each are compared. Personal experience with over 1400 spring implantations is discussed, as is experience with the use of bandage contact lenses in lieu of lid surgery. The gold weight implantation is simpler to learn and perform than the enhanced spring procedure, in which the levator is tightened in addition to implanting the spring. However, when it is really important to close the eye well, the spring is the superior procedure. Unlike the weight, the spring closes the eye well in the supine position, such as when the patient sleeps.

An evaluation of residential treatment for sexually aggressive youth

This longitudinal study investigated the effectiveness of a one and one-half year long residential treatment program for 26 boys aged 11-15 with histories of sexually aggressive behavior. The clients were assessed with self-report and staff-report measures at the beginning and end of treatment and at several time points in between; also, aggressive acts were tabulated during a one-year follow-up period. There was evidence of improved functioning on 10 of the 12 measures. During the follow-up, 27% of the sample committed an aggressive act, and 8% committed a sexually aggressive act. On most of the measures, improvement occurred gradually over the course of treatment, and on some measures most of the improvement occurred late in the placement.

Dehydrothalebanin: a source of resistance from Glycosmis pentaphylla against the citrus root weevil Diaprepes abbreviatus

Roots of a citrus relative, Glycosmis pentaphylla (orangeberry), were shown to inhibit the growth and survival of larvae of the citrus root weevil Diaprepes abbreviatus. Roots of G. pentaphyllaincorporated into the diet of D. abbreviatus increasingly inhibited the growth of neonate larvae with increased concentration of roots, while roots from citrus rootstocks produced little inhibition. The diet-incorporation assay was used to guide fractionation of an active acetone extract of G.pentaphylla roots. Three major fractions from silica open-column liquid chromatography were active, and these were purified using semipreparative normal-phase HPLC. A single active HPLC subfraction was isolated from each of the three liquid chromatography fractions, and two active compounds were isolated and identified by GC-MSD. GC-MSD and NMR identified one compound as the amide dehydrothalebanin B, and the other was identified by GC-MSD as dieldrin, a chlorinated hydrocarbon insecticide whose origin in our samples is uncertain.

Vitellin and vitellogenin in the soldier bug, Podisus maculiventris: identification with monoclonal antibodies and reproductive response to diet

A 171,000 M(r )polypeptide of Podisus maculiventris (Say) (Heteroptera: Pentatomidae) that constituted 16% of the protein in eggs also constituted up to 25% of the protein in hemolymph of fed females. It was identified as the major or sole apoprotein of vitellogenin. Eggs contained major polypeptides of 171, 106, and 51 kDa. The hemolymph polypeptide was identified with a polypeptide (vitellin) in egg extracts by comparing molecular weights, specificity of occurrence in fed females, and immunological reactivities. Females, starved for 5 days after eclosion to assure complete previtellogenic development, produced vitellogenin within a day after feeding on larval Galleria mellonella, and within 4 days after feeding on an artificial diet. Appearance of vitellogenin preceded ovarian growth by 2-3 days. Two monoclonal antibodies raised against egg proteins of P. maculiventris were selected for their strong reaction against egg extract and female hemolymph and null reaction against male hemolymph. Only one 170-kDa band in egg and hemolymph reacted with the antibodies on denaturing Western blots. These monoclonal antibodies are being used to develop an enzyme-linked immunosorbent assay (ELISA) to quantitate reproductive response of females to diets of differing quality.

Identification of sources of plant resistance to Diaprepes abbreviatus (Coleoptera: Curculionidae) by three bioassays

Host plant resistance to the root weevil Diaprepes abbreviatus (L.) was assessed for 3 citrus rootstock cultivars, 5 promising hybrid rootstocks, and 3 citroid fruit trees using 3 bioassay methods: a pot bioassay with 1-yr seedlings; a new, 21-cm plastic cell bioassay with 5-mo seedlings; and a diet incorporation bioassay. The plastic cell bioassay is a more rapid screening method and is capable of evaluating a larger number of entries in a shorter period compared with current methods. The 3 bioassays yielded similar results. Larval growth was inhibited by 2 of the remote citroid fruit trees, Murraya koenigii (L.) Sprengel and Glycosmis pentaphylla (Retzius) Correa, compared with growth on commercial rootstock cultivars. Specifically, larvae allowed to feed on roots of M. koenigii or G. pentaphylla gained less weight compared with larvae fed on the commercial rootstock cultivar 'Swingle' [Citrus paradisi Macfayden x Poncirus trifoliata (L.) Rafinesque-Schmaltz]. The resistance of G. pentaphylla confirms previous reports. M. koenigii is a new source of resistance to D. abbreviatus.

Youth attitudes toward guns and violence: relations with sex, age, ethnic group, and firearm exposure

Investigated relations between young people's scores on the Attitudes Toward Guns and Violence Questionnaire (AGVQ; Shapiro, Dorman, Burkey, Welker, & Clough, 1997), demographic variables, and exposure to firearms and violence. 1,164 students, Grades 3 to 12, from an urban, suburban, parochial, and private school system completed anonymous self-report questionnaires in their classrooms. Boys produced higher AGVQ scores than did girls. Scores were similar in Grades 3 and 5, were much higher in Grade 6 than in Grade 5, and were similar in Grades 6 and above. This pattern was found across sex, race, and school system. African Americans obtained higher scores than Caucasians on the AGVQ and on 2 of its 4 factors. Students in the urban public schools produced higher scores than did youth in the other school systems. Both traumatic and nontraumatic exposure to firearms were associated with high AGVQ scores. Sex, grade, and firearm exposure were associated with relatively large differences, while ethnic group and school system were associated with relatively small differences.

SARPs: a family of secreted apoptosis-related proteins

Quiescent mouse embryonic C3H/10T1/2 cells are more resistant to different proapoptotic stimuli than are these cells in the exponential phase of growth. However, the exponentially growing 10T1/2 cells are resistant to inhibitors of RNA or protein synthesis, whereas quiescent cells die upon these treatments. Conditioned medium from quiescent 10T1/2 cells possesses anti-apoptotic activity, suggesting the presence of protein(s) that function as an inhibitor of the apoptotic program. Using differential display technique, we identified and cloned a cDNA designated sarp1 (secreted apoptosis-related protein) that is expressed in quiescent but not in exponentially growing 10T1/2 cells. Hybridization studies with sarp1 revealed two additional family members. Cloning and sequencing of sarp2 and sarp3 revealed 38% and 40% sequence identity to sarp1, respectively. Human breast adenocarcinoma MCF7 cells stably transfected with sarp1 or infected with SARP1-expressing adenovirus became more resistant, whereas cells transfected with sarp2 displayed increased sensitivity to different proapoptotic stimuli. Expression of sarp family members is tissue specific. sarp mRNAs encode secreted proteins that possess a cysteine-rich domain (CRD) homologous to the CRD of frizzled proteins but lack putative membrane-spanning segments. Expression of SARPs modifies the intracellular levels of beta-catenin, suggesting that SARPs interfere with the Wnt-frizzled proteins signaling pathway.

A naturalistic study of psychotherapeutic methods and client in-therapy functioning in a child community setting

Utilized a naturalistic methodology to examine treatment responses associated with major psychotherapeutic methods in 150 youth aged 11 to 17 years old in a community mental health center. Treatment methods were not experimentally controlled but were measured retrospectively by therapist report. Treatment response was assessed by a composite of 6 measures completed by clients, parents, and therapists. Pretest/posttest comparisons indicated improved functioning in the sample as a whole. Treatment response was not related to the proportion of therapy using individual, family, or group modalities. Therapy response was positively associated with extent of use of cognitive therapy. Social skills training, behavior therapy, and family systems therapy were associated with more positive treatment response in some subgroups of clients. The number of approaches used in an individual case (technical eclecticism) was positively related to client response. Treatment response was more consistently related to level of client and parent functioning in therapy than to treatment method.

Ceramide is involved in triggering of cardiomyocyte apoptosis induced by ischemia and reperfusion

Involvement of ceramide signaling in the initiation of apoptosis induction in myocardial cells by in vitro and in vivo ischemia and reperfusion was analyzed. Synthetic cell permeable C2-ceramide induced apoptotic death of rat neonatal cardiomyocytes in vitro. In vitro ischemia (oxygen/serum/glucose deprivation) led to a progressive accumulation of ceramide in cardiomyocytes. After 16 hours of simulated in vitro reperfusion (readdition of oxygen, serum and glucose), the level of ceramide in surviving cells was found to have returned to baseline, whereas, levels in nonadherent dead cells remained high. In the rat heart left coronary artery occlusion model, ischemia with the subsequent reperfusion, but not ischemia alone, induced apoptosis in myocardial cells as demonstrated by DNA electrophoresis and measurement of soluble chromatin degradation products. The content of ceramide in ischemic area was elevated to 155% baseline levels at 30 minutes, and to 330% after 210 minutes of ischemia. Ischemia (30 minutes) followed by reperfusion (180 minutes) increased the ceramide level to 250% in the ischemic area. The combination of results obtained in both in vitro and animal models demonstrate for the first time that ceramide signaling can be involved in ischemia/reperfusion death of myocardial cells.

Development and factor analysis of a measure of youth attitudes toward guns and violence

Administered the Attitudes Toward Guns and Violence Questionnaire (AGVQ) to 1,619 students in Grades 3, 5, 6, 7, 9, 11, and 12 from four demographically diverse school systems. Fifty-two of the 61 items exhibited satisfactory part-whole correlation and correlation with a validity criterion. Factor analysis revealed four main factors: Aggressive Response to Shame, Comfort With Aggression, Excitement, and Power/Safety. The instrument was reduced to 23 items by deleting items with high cross-loadings. Construct validity was similar for the longer and shorter versions. Youth who self-reported owning a gun produced scores 1.5 SD higher than nonowners. Low scores were associated with a 1 in 125 chance of gun ownership, and high scores were associated with a 1 in 3 chance. Congruency coefficients indicated similar factor structure for the present sample and a separate sample of 5th-, 7th- and 9th-grade students. These results indicate that the AGVQ is a reliable and valid measure of violence-related attitudes in young people.

Development and factor analysis of a measure of youth attitudes toward guns and violence

Administered the Attitudes Toward Guns and Violence Questionnaire (AGVQ) to 1,619 students in Grades 3, 5, 6, 7, 9, 11, and 12 from four demographically diverse school systems. Fifty-two of the 61 items exhibited satisfactory part-whole correlation and correlation with a validity criterion. Factor analysis revealed four main factors: Aggressive Response to Shame, Comfort With Aggression, Excitement, and Power/Safety. The instrument was reduced to 23 items by deleting items with high cross-loadings. Construct validity was similar for the longer and shorter versions. Youth who self-reported owning a gun produced scores 1.5 SD higher than nonowners. Low scores were associated with a 1 in 125 chance of gun ownership, and high scores were associated with a 1 in 3 chance. Congruency coefficients indicated similar factor structure for the present sample and a separate sample of 5th-, 7th- and 9th-grade students. These results indicate that the AGVQ is a reliable and valid measure of violence-related attitudes in young people.

The Youth Client Satisfaction Questionnaire: development, construct validation, and factor structure

Developed and pilot-tested a measure of satisfaction with mental health services for young clients. One hundred fifty youth from 11 to 17 years of age who had completed services received the measure as a telephone interview. Fourteen of 17 candidate items met criteria for test-retest reliability, part-whole correlation, and correlation with a validation item, and they were retained in the instrument. Total score test-retest reliability and internal consistency were highly satisfactory. Principal components analysis revealed two factors, labeled Relationship With Therapist and Benefits of Therapy. Unexpectedly, satisfaction scores were not related to change in youth self-reported behavior problems. However, convergent validity was indicated by significant relationships with change in parent-reported behavior problems, parent satisfaction, parent ratings of treatment progress, therapist ratings of progress, and Global Assessment of Functioning change scores. These results indicate that the Youth Client Satisfaction Questionnaire is a reliable and valid measure of consumer evaluations of their treatment.

Identification and characterization of acidic hydrolases with chitinase and chitosanase activities from sweet orange callus tissue

Acidic chitinases (EC 3.2.1.14) were isolated and characterized from 4-week-old nonembryogenic Citrus sinensis L. Osbeck cv 'Valencia' callus tissue. The enzymes were purified using size exclusion, anion exchange, and chromatofocusing HPLC techniques. Eleven isoforms were isolated with M(r)s between 26,000 and 37,400. Eight of the isoforms were purified to homogeneity, and all but one cross-reacted with a polyclonal antibody raised against a basic class I potato leaf chitinase. The isoelectric points (determined by chromatofocusing) were from pH 4.5 to 5.4. All hydrolases degraded chitin and four were capable of hydrolyzing solubilized shrimp shell chitosan suggesting they may be chitosanases (EC 3.2.1.99). Apparent chitosanase activity generally decreased with decreasing acetylation of the chitosan (i.e. from 20% to 0% acetylation). The chitinases and chitinases/chitosanases are predominantly endochitinases. Chitosanase activity was optimal at pH 5 while the pH optimum for chitinase activity ranged between pH 3.5 and 5.5. The chitinases and chitinases/chitosanases were stable up to 60 degrees C and showed their highest enzyme activity at that temperature. N-terminal sequences were obtained on three of the isoforms. One of the isoforms was identified as a class II chitinase and the other two as class III chitinases.