<p><strong>AIM: </strong>Cardiopulmonary resuscitation (CPR) in hospitalized infants is a relatively uncommon but high-risk event associated with mortality. The study objective was to identify factors associated with mortality and survival among infants who receive CPR in the neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU).</p>

<p><strong>METHODS: </strong>Retrospective observational study of infants with an index CPR event in the NICU or PICU between 1/1/06 and 12/31/18 in the American Heart Association's Get With The Guidelines-Resuscitation registry. Associations between patient, event, unit, and hospital factors and the primary outcome, mortality prior to discharge, were examined using multivariable logistic regression.</p>

<p><strong>RESULTS: </strong>Among 3,521 infants who received CPR, 2,080 (59%) died before discharge, with 25% mortality during CPR and 40% within 24 hours. Mortality prior to discharge occurred in 65% and 47% of cases in the NICU and PICU, respectively. Factors most strongly independently associated with pre-discharge mortality were vasoactive agent before CPR (adjusted odds ratio (aOR): 2.77, 95% confidence interval (CI) 2.15-3.58), initial pulseless condition (aOR: 2.38, 95% CI 1.46-3.86) or development of pulselessness (aOR: 2.36, 95% CI 1.78-3.12), and NICU location compared with PICU (aOR: 3.85, 95% CI 2.86-5.19). Endotracheal intubation during CPR was associated with decreased odds of pre-discharge mortality (aOR: 0.40, 95% CI 0.33-0.49).</p>

<p><strong>CONCLUSION: </strong>Infants who receive CPR in the intensive care unit experience high mortality rates; identifiable patient, event, and unit factors increase the odds of mortality. Further investigation should explore the association between unit type, resuscitation processes, and mortality.</p>

<p><strong>BACKGROUND: </strong>The goal of regionalized perinatal care, specifically levels of maternal care, is to improve maternal outcomes through risk-appropriate obstetric care. Studies of levels of maternal care are limited by current approaches to identify a hospital's level of care, often relying on hospital self-reported data, which is expensive and challenging to collect and validate. The study objective was to develop an empiric approach to determine a hospital's level of maternal care using administrative data reflective of the patient care provided and apply this approach to describe the levels of maternal care available over time.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of mother-infant dyads who delivered in California, Missouri, and Pennsylvania hospitals from 2000 to 2009. Linked mother-infant administrative records with an infant born at 24-44 weeks' gestation and a birth weight of 400-8000 g were included. Using the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine descriptions of levels of maternal care, four levels were classified based on the appropriate location of care for patients with specific medical or pregnancy conditions. Individual hospitals were assigned a level of maternal care annually based on the volume of patients who delivered reflective of the four classified levels as determined by International Classification of Diseases and Current Procedural Terminology.</p>

<p><strong>RESULTS: </strong>Based on the included 6,895,000 mother-infant dyads, the obstetric hospital levels of maternal care I, II, III and IV were identified. High-risk patients more frequently delivered in hospitals with higher level maternal care, accounting for 8.9, 10.9, 13.8, and 16.9% of deliveries in level I, II, III and IV hospitals, respectively. The total number of obstetric hospitals decreased over the study period, while the proportion of hospitals with high-level (level III or IV) maternal care increased. High-level hospitals were located in more densely populated areas.</p>

<p><strong>CONCLUSION: </strong>Identification of the level of maternal care, independent of hospital self-reported variables, is feasible using administrative data. This empiric approach, which accounts for changes in hospitals over time, is a valuable framework for perinatal researchers and other stakeholders to inexpensively identify measurable benefits of levels of maternal care and characterize where specific patient populations receive care.</p>

<p><strong>INTRODUCTION: </strong>Mental health follow-up after an emergency department (ED) visit for suicide ideation/attempt is a critical component of suicide prevention for young people.</p>

<p><strong>METHODS: </strong>We analyzed 2009-2012 Medicaid Analytic Extract for 62,139 treat-and-release ED visits and 30,312 ED-to-hospital admissions for suicide ideation/attempt among patients ages 6- to 17-years. We used mixed-effects logistic regression models to examine associations between patients' healthcare utilization prior to the ED visit and likelihood of completing a 30-day mental health follow-up visit.</p>

<p><strong>RESULTS: </strong>Overall, for treat-and-release ED visits, 49% had a 30-day follow-up mental health visit, and for ED-to-hospital admissions, 67% had a 30-day follow-up mental health visit. Having a mental health visit in the 30-days preceding the ED visit was the strongest predictor of completing a mental health follow-up visit (ED treat-and-release: adjusted odds ratio [AOR] 11.01; 95% Confidence interval [CI] 9.82-12.35; ED-to-hospital AOR 4.60; 95%CI 3.16-6.68). Among those with no mental health visit in the 30-days preceding the ED visit, only 25% had an ambulatory mental health follow-up visit. Having a general healthcare visit in the 30-days preceding the ED visit had a much smaller association with completing a mental health follow-up visit (ED treat-and-release: AOR 1.17; 95%CI 1.09-1.24; ED-to-hospital AOR 1.25; 95%CI 1.17-1.34).</p>

<p><strong>CONCLUSIONS: </strong>Young people without an existing source of ambulatory mental health care have low rates of mental health follow up after an ED visit for suicide ideation or attempt, and opportunities exist to improve mental health follow up for youth with recent general healthcare visits.</p>

<p><strong>BACKGROUND: </strong>Maternal mortality is higher among Black compared to White people in the United States. Whether Black-White disparities in maternal in-hospital mortality during the delivery hospitalization vary across hospital types (Black-serving vs. non-Black-serving and teaching vs. non-teaching) and whether overall maternal mortality differs across hospital types is not known.</p>

<p><strong>OBJECTIVES: </strong>1) Determine whether risk-adjusted Black-White disparities in maternal mortality during the delivery hospitalization vary by hospital types - this is analysis of disparities in mortality within hospital types. 2) Compare risk-adjusted in-hospital maternal mortality among Black-serving and non-Black-serving teaching and non-teaching hospitals regardless of race - this is an analysis of overall mortality across hospital types.</p>

<p><strong>STUDY DESIGN: </strong>We performed a population-based, retrospective cohort study of 5,679,044 deliveries among Black (14.2%) and White (85.8%) patients in three states (CA, MO, PA) from 1995-2009. A hospital discharge disposition of "death" defined maternal in-hospital mortality. Black-serving hospitals had at least 7% Black obstetric patients (top quartile). We performed risk adjustment by calculating expected death rates using predictions from logistic regression models incorporating sociodemographics, rurality, comorbidities, multiple gestations, gestational age at delivery, year, state, and mode of delivery. We calculated risk-adjusted risk ratios of mortality by comparing observed:expected ratios among Black and White patients within hospital types and then examined mortality across hospital types, regardless of patient race. We quantified the proportion of Black-White disparities in mortality attributable to delivering in Black-serving hospitals using causal mediation analysis.</p>

<p><strong>RESULTS: </strong>There were 330 maternal deaths among 5,679,044 patients (5.8 per 100,000). Black patients died more often (11.5 per 100,000) than White patients (4.8 per 100,000) (RR 2.38, 95% CI: 1.89-2.98). Examination of Black-White disparities revealed that after risk adjustment, Black patients had significantly greater risk of death (adjusted RR 1.44, 95% CI 1.17-1.79) and that the disparity was similar within each of the hospital types. Comparison of mortality, regardless of race, across hospital types, revealed that among teaching hospitals, mortality was similar in Black-serving and non-Black-serving hospitals. However, among non-teaching hospitals, mortality was significantly higher in Black-serving versus non-Black-serving hospitals (adjusted RR 1.47, 95% CI: 1.15-1.87). Notably, 53% of Black patients delivered in non-teaching, Black-serving hospitals, compared with just 19% of White patients. Among non-teaching hospitals, 47% of Black-White disparities in maternal in-hospital mortality attributable to delivering at Black-serving hospitals.</p>

<p><strong>CONCLUSION: </strong>Maternal in-hospital mortality during the delivery hospitalization among Black patients is more than double that of White patients. Our data suggest this disparity is due to both excess mortality among Black patients within each hospital type, in addition to excess mortality in non-teaching, Black-serving hospitals where most Black patients deliver. Addressing downstream effects of racism to achieve equity in maternal in-hospital mortality will require transparent reporting of quality metrics by race to reduce differential care and outcomes within hospital types, improvements in care delivery at Black-serving hospitals, overcoming barriers to accessing high-quality care among Black patients, and eventually desegregation of healthcare.</p>

<p><strong>OBJECTIVES: </strong>To determine incidence and severity of acute kidney injury (AKI) within 7 days of sepsis evaluation and to assess AKI duration and the association between AKI and 30-day mortality.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective, matched cohort study in a single-center level IV NICU. Eligible infants underwent sepsis evaluations at ≥72 hours of age during calendar years 2013-2018. Exposed infants ("cases") were those with culture-proven sepsis and antimicrobial duration ≥5 days. Non-exposed infants ("controls") were matched 1:1 to exposed infants based on gestational and corrected gestational age, and had negative sepsis evaluations with antibiotic durations &lt;48 hours. AKI was defined by modified neonatal Kidney Disease Improving Global Outcomes criteria. Statistical analysis included Mann-Whitney and Chi-square tests, multivariable logistic regression, and Kaplan-Meier time-to-event analysis.</p>

<p><strong>RESULTS: </strong>Among 203 episodes of late-onset sepsis, 40 (20%) developed AKI within 7 days following evaluation, and among 193 episodes with negative cultures, 16 (8%) resulted in AKI (p=0.001). Episodes of sepsis also led to greater AKI severity, compared with non-septic episodes (P = .007). The timing of AKI onset and AKI duration did not differ between groups. Sepsis was associated with increased odds of developing AKI (aOR 3.0, 95% CI 1.5-6.2, p=0.002). AKI was associated with increased 30-day mortality (aOR 4.5, 95% CI 1.3-15.6, p=0.017).</p>

<p><strong>CONCLUSIONS: </strong>Infants with late-onset sepsis had increased odds of AKI and greater AKI severity within 7 days of sepsis evaluation, compared with age-matched infants without sepsis. AKI was independently associated with increased 30-day mortality. Strategies to mitigate AKI in critically ill neonates with sepsis may improve outcomes.</p>

<p><strong>BACKGROUND: </strong>Cohort studies represent rich sources of data that can be used to link components of resilience to a variety of health-related outcomes. The Adolescent to Adult Health (Add Health) cohort study represents one of the largest data sets of the health and social context of adolescents transitioning into adulthood. It did not however use validated resilience scales in its data collection process. This study aimed to retrospectively create and validate a resilience indicator using existing data from the cohort to better understand the resilience of its participants.</p>

<p><strong>METHODS: </strong>Questions asked of participants during one Add Health data collection time period (N = 15,701) were matched to items on a well-known and widely validated resilience scale called the Connor Davidson Resilience Scale. Factor analysis and psychometric analyses were used to refine and validate this novel Adolescent to Adult Health Resilience Instrument. Construct validity utilized participants' answers to the 10 item Center for Epidemiologic Studies Depression Scale, which has been used to validate other resilience scales.</p>

<p><strong>RESULTS: </strong>Factor analysis yielded an instrument with 13 items that showed appropriate internal consistency statistics. Resilience scores in our study were normally distributed with no ceiling or floor effects. Our instrument had appropriate construct validity, negatively correlating to answers on the depression scale (r = -0.64, p&lt;0.001). We also found demographic differences in mean resilience scores: lower resilience scores were seen among women and those who reported lower levels of education and household income.</p>

<p><strong>CONCLUSIONS: </strong>It is possible to retrospectively construct a resilience indicator from existing cohort data and achieve good psychometric properties. The Adolescent to Adult Health Resilience Instrument can be used to better understand the relationship between resilience, social determinants of health and health outcomes among young adults using existing data, much of which is publicly available.</p>

<p><strong>BACKGROUND: </strong>Surface mining has become a significant method of coal mining in the Central Appalachian region of the eastern United States alongside the traditional underground mining. Concerns have been raised about the health effects of this surface mining, particularly mountaintop removal mining where coal is mined upon steep mountaintops by removing the mountaintop through clearcutting forests and explosives.</p>

<p><strong>METHODS: </strong>We used a control group design with a pretest and a posttest to assess the associations of surface mining in Central Appalachia with low birth weight and other adverse birth outcomes. The pretest period is 1977-1989, a period of low surface mining activity. We consider three posttest periods: 1990-1998, 1999-2011 and 2012-2017, with 1999-2011 as the primary analysis and the other periods as secondary analyses. Surface mining in Central Appalachia increased after 1989, partly resulting from the Clean Air Act Amendments of 1990 which made surface mining more financially attractive. For the primary analysis, we fit a logistic regression model of the primary outcome (low birth weight, &lt;2500 grams) on dummy variables for county and year; individual level maternal/infant covariates (maternal race, maternal age, infant sex and whether birth was a multiple birth); and the amount of surface mining during the year of the birth in the maternal county of residence.</p>

<p><strong>RESULTS: </strong>Our analysis sample consisted of 783,328 infants -- 482,284 infants born from 1977-2017 to women residing in substantial surface mining activity counties and 301,044 infants born from 1977-2017 to women residing in matched control counties. Compared to the pre-period of low surface mining from 1977-1989, for the primary analysis post-test period of 1999-2011, there was an estimated relative increase in low birth weight in surface mining counties compared to matched control counties that was not statistically significant (odds ratio for a 5 percentage point increase in area disturbed by surface mining: 1.07, 95% confidence interval (0.96, 1.20), p-value: .22). For the secondary analysis post-test period of 1990-1998, there was no increase (odds ratio: 0.91, 95% confidence interval: (0.74, 1.13), p-value: .41). For the secondary analysis post-test period of 2012-2017, there was a statistically significant relative increase (odds ratio: 1.28, 95% confidence interval: (1.08, 1.50), p-value: .004). Qualitatively similar results were found for the outcomes of very low birth weight, preterm birth and small-for-gestational age.</p>

<p><strong>CONCLUSIONS: </strong>We examined the hypothesis that surface mining activity in Central Appalachia contributes to low birth weight using an observational study. We found evidence in secondary analyses that surface mining was associated with low birth weight in the 2012-2017 time period and potentially beginning in the early to mid 2000's. Evidence for an association was not found prior to 2000. A potential explanation for this pattern of association is that surface mining caused an increase in low birth weight but its onset was delayed. Future research is needed to clarify the findings and if replicated, identify the mechanism necessary to mitigate the impacts of mining on adverse birth outcomes.</p>

<p><strong>OBJECTIVE: </strong>Evaluate racial/ethnic differences in maternal resilience and its associations with low birthweight (LBW).</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study of 3244 women surveyed in the Longitudinal Study of Adolescent to Adult Health. The Add Health Resilience Instrument assessed resilience. Logistic regression models explored associations between women's resilience and risk of LBW.</p>

<p><strong>RESULT: </strong>Resilience scores were lowest in American Indian women. Women with the lowest resilience scores were more likely to deliver a LBW infant than highly resilient women, after adjusting for demographic and health-related factors (aOR 1.58 95% CI 1.05-2.38). The risk-adjusted rate of LBW among highly resilient Black women (15.6%) was significantly higher than the risk-adjusted rate of LBW among highly resilient white women (9.1%, p = 0.01) and highly resilient Hispanic women (8.6%, p = 0.04).</p>

<p><strong>CONCLUSION: </strong>Resilience scores differ significantly among women of different race and ethnicity but do not appear to entirely account for racial/ethnic disparities in LBW.</p>

<p>In US trauma centers, firearms are the second leading cause of trauma-related death in pediatric patients. In children (&lt;18 years), firearms are associated with one of the highest case fatality rates (16.7%) of all injury mechanisms. According to the Gun Violence Archive, in 2019 alone, 3774 children experienced gun violence, including 985 killed and 2789 injured. The US Centers for Disease Control and Prevention reports multiple-victim school homicide rates have increased significantly between 2009 and 2018, following 15 years of decline. Considering the overall burden of gun violence, mass shootings are responsible for a relatively small number of deaths and injuries. However, these events also expose other residents, notably children, in the nearby communities to violence. This study examines the location of mass shootings relative to schools and places frequented by children, highlighting the potential risk of exposure to violence in our communities.</p>

<p><b>BACKGROUND: </b>The prevalence of opioid use during pregnancy is increasing. Two downstream effects are neonatal abstinence syndrome (NAS), a postnatal withdrawal syndrome, and long-term prenatal opioid exposure (LTPOE) without documented withdrawal symptoms in the infant. Mental health characteristics of mothers of infants with NAS and LTPOE have not been described.</p><p><b>METHODS: </b>Using linked maternal and infant Medicaid claims and birth certificate data, we analyzed 15,571 infants born to Medicaid-insured women 15-24 years old in a mid-Atlantic city from 2007 to 2010. Pairwise comparisons with multinomial logistic regression, adjusting for maternal and infant covariates, were performed. We compared four mental health conditions among mothers of infants with NAS, infants with LTPOE without NAS, and controls: depression, anxiety, bipolar disorder, and schizophrenia.</p><p><b>RESULTS: </b>The prevalence of depression among mothers of infants with NAS, infants with LTPOE, and controls was 26, 21.1, and 5.5% respectively. Similar results were found for anxiety. In multivariable analysis, mothers of infants with NAS and LTPOE had approximately twice the depression risk as controls, while mothers of infants with LTPOE had 2.2 times the bipolar disorder risk and 4.6 times the schizophrenia risk as controls. The overall risk of mental health conditions in mothers of infants with NAS and LTPOE was similar.</p><p><b>DISCUSSION: </b>Mothers of infants with LTPOE who did not develop NAS are at similarly high risk for mental health conditions as mothers of infants with NAS, and both are at higher risk than controls. Therefore, those mothers of infants who did not develop symptoms of NAS despite LTPOE may be a vulnerable population that needs additional mental health support in the post-partum period.</p>