OBJECTIVE: To examine the effect of psychiatric diagnoses on healthcare use in youth with systemic lupus erythematosus (SLE) during their first year of SLE care.

METHODS: We conducted a retrospective cohort study using claims from 2000 to 2013 from Clinformatics Data Mart (OptumInsight). Youth aged 10 years to 24 years with an incident diagnosis of SLE (≥ 3 International Classification of Diseases, 9th revision, codes for SLE 710.0, > 30 days apart) were categorized as having: (1) a preceding psychiatric diagnosis in the year before SLE diagnosis, (2) an incident psychiatric diagnosis in the year after SLE diagnosis, or (3) no psychiatric diagnosis. We compared ambulatory, emergency, and inpatient visits in the year after SLE diagnosis, stratified by nonpsychiatric and psychiatric visits. We examined the effect of childhood-onset vs adult-onset SLE by testing for an interaction between age and psychiatric exposure on outcome.

RESULTS: We identified 650 youth with an incident diagnosis of SLE, of which 122 (19%) had a preceding psychiatric diagnosis and 105 (16%) had an incident psychiatric diagnosis. Compared with those without a psychiatric diagnosis, youth with SLE and a preceding or incident psychiatric diagnosis had more healthcare use across both ambulatory and emergency settings for both nonpsychiatric and psychiatric-related care. These associations were minimally affected by age at time of SLE diagnosis.

CONCLUSION: Psychiatric comorbidity is common among youth with newly diagnosed SLE and is associated with greater healthcare use. Interventions to address preceding and incident psychiatric comorbidity may decrease healthcare burden for youth with SLE.

Background Insertable cardiac monitors (ICMs) are effective in the detection of paroxysmal arrhythmias. In 2014, the first miniaturized ICM was introduced with a less invasive implant technique. The impact of this technology on ICM use in pediatric patients has not been evaluated. We hypothesized an increase in annual pediatric ICM implants starting in 2014 attributable to device miniaturization. Methods and Results A retrospective observational study was conducted using administrative claims from MarketScan Medicaid and commercial insurance claims databases. Use of ICM between January 2013 and December 2018 was measured (normalized to the total enrolled population ≤18 years) and compared with balancing measures (Holter ambulatory monitors, cardiac event monitors, encounters with syncope diagnosis, implantation of implantable cardioverter-defibrillator/pacemaker). Secondary analyses included evaluations of subsequent interventions and complications. The study cohort included 33 532 185 individual subjects, of which 769 (0.002%) underwent ICM implantation. Subjects who underwent ICM implantation were 52% male sex, with a median age of 16 years (interquartile range, 10-17 years). A history of syncope was present in 71%, palpitations in 43%, and congenital heart disease in 28%. Following release of the miniaturized ICM, use of ICMs increased from 5 procedures per million enrollees in 2013 to 11 per million between 2015 and 2018 (<0.001), while balancing measures remained static. Of 394 subjects with ≥1 year of follow-up after implantation, interventions included catheter ablation in 24 (6%), pacemaker implantation in 15 (4%), and implantable cardioverter-defibrillator implantation in 7 (2%). Conclusions Introduction of the miniaturized ICM was followed by a rapid increase in pediatric use. The effects on outcomes and value deserve further attention.

Background Insertable cardiac monitors (ICMs) are effective in the detection of paroxysmal arrhythmias. In 2014, the first miniaturized ICM was introduced with a less invasive implant technique. The impact of this technology on ICM use in pediatric patients has not been evaluated. We hypothesized an increase in annual pediatric ICM implants starting in 2014 attributable to device miniaturization. Methods and Results A retrospective observational study was conducted using administrative claims from MarketScan Medicaid and commercial insurance claims databases. Use of ICM between January 2013 and December 2018 was measured (normalized to the total enrolled population ≤18 years) and compared with balancing measures (Holter ambulatory monitors, cardiac event monitors, encounters with syncope diagnosis, implantation of implantable cardioverter-defibrillator/pacemaker). Secondary analyses included evaluations of subsequent interventions and complications. The study cohort included 33 532 185 individual subjects, of which 769 (0.002%) underwent ICM implantation. Subjects who underwent ICM implantation were 52% male sex, with a median age of 16 years (interquartile range, 10-17 years). A history of syncope was present in 71%, palpitations in 43%, and congenital heart disease in 28%. Following release of the miniaturized ICM, use of ICMs increased from 5 procedures per million enrollees in 2013 to 11 per million between 2015 and 2018 (<0.001), while balancing measures remained static. Of 394 subjects with ≥1 year of follow-up after implantation, interventions included catheter ablation in 24 (6%), pacemaker implantation in 15 (4%), and implantable cardioverter-defibrillator implantation in 7 (2%). Conclusions Introduction of the miniaturized ICM was followed by a rapid increase in pediatric use. The effects on outcomes and value deserve further attention.

<p>For infants with shunt-dependent or ductal-dependent single ventricle heart disease, poor growth is common and associated with morbidity and impaired neurodevelopmental outcomes. Although attention has focused on nutrition to promote weight gain, little is known about the relation between heart failure and growth factors. A prospective observational pilot study was performed to assess the relation between heart failure, assessed by brain natriuretic peptide (BNP), and growth factors (insulin-like growth factor 1 [IGF-1] and insulin-like growth factor-binding protein 3) at 3 visits: (1) before discharge from neonatal intervention with the establishment of stable pulmonary blood flow, (2) immediately before superior cavopulmonary connection, and (3) before discharge after superior cavopulmonary connection operation. The relation between BNP and growth factors was analyzed using Spearman pairwise correlations at each visit and modeled over time with a linear mixed-effects model. Correlations were considered worthy of further exploration using a p &lt;0.10, given the exploratory nature of the study. The study included 38 infants (66% male, 68% hypoplastic left heart syndrome). Median BNP was elevated at visit 1 and decreased over time (287&nbsp;pg/dl [interquartile range 147 to 794], 85&nbsp;pg/dl [52 to 183], and 90&nbsp;pg/dl [70 to 138]). Median IGF-1 Z&nbsp;score was &lt;0 at each visit but increased over time (-0.9 [interquartile range -1.1 to 0.1], -0.7 [-1.2 to 0.1], and -0.5 [-1.2 to 0]). Inverse correlations were found between BNP and IGF-1 at visit 1 (r&nbsp;=&nbsp;-0.40, p&nbsp;=&nbsp;0.097), BNP and IGF-1 and insulin-like growth factor-binding protein 3 at visit 2 (r&nbsp;=&nbsp;-0.33, p&nbsp;=&nbsp;0.080 and r&nbsp;=&nbsp;-0.33, p&nbsp;=&nbsp;0.085, respectively) and BNP and IGF-1 Z&nbsp;score at visit 3 (r&nbsp;=&nbsp;-0.42, p&nbsp;=&nbsp;0.049). Significant relations were likewise found between the change in BNP and the change in IGF-1 between visits 1 and 3 (p&nbsp;=&nbsp;0.046) and between visits 2 and 3 (p&nbsp;=&nbsp;0.048). In conclusion, this pilot study demonstrates an inverse correlation between BNP and growth factors, suggesting that the heart failure state associated with this physiology may play a mechanistic role in impaired growth.</p>

<p><strong>OBJECTIVES: </strong>Depression and anxiety are common in children with asthma, and asthma hospitalization is an underused opportunity to identify mental health concerns. We assessed depression and anxiety symptoms during asthma hospitalization and 1 to 2 months post discharge.</p>

<p><strong>METHODS: </strong>This prospective cohort study included children aged 7 to 17 years who were hospitalized for asthma exacerbation. Participants completed the self-report PROMIS (Patient-Reported Outcomes Measurement Information System) depression and anxiety symptom scales (T score mean = 50, SD = 10) during hospitalization and 1 to 2 months after discharge. Higher scores indicate more symptoms and/or greater severity. We compared patients' scores during hospitalization and at follow-up using paired tests and examined individual patients' depression and anxiety symptom trajectories using a Sankey diagram.</p>

<p><strong>RESULTS: </strong>Among 96 participants who completed the study, 53% had elevated symptoms of depression, anxiety, or both either during hospitalization or after discharge. During hospitalization, 38% had elevated depression symptoms and 45% had elevated anxiety symptoms. At postdischarge follow-up, 18% had elevated depression symptoms and 20% had elevated anxiety symptoms. We observed all possible symptom trajectories: symptoms during hospitalization that persisted (especially if both depression and anxiety symptoms were present), symptoms that resolved, and symptoms that were present at follow-up only.</p>

<p><strong>CONCLUSIONS: </strong>Just more than half of youth hospitalized for asthma exacerbation experienced depression and/or anxiety symptoms during hospitalization or at follow-up. Patients who had both depression and anxiety symptoms during hospitalization were the most likely to have persistent symptoms at follow-up. Screening at both time points may be useful to identify mental health symptoms.</p>

<p><strong>OBJECTIVES: </strong>Multiple states have passed legislation permitting marijuana use. The impact of legalization on trends in hospital encounters for marijuana exposures in young children across states remains unknown. We aimed to describe trends in marijuana-related hospital encounters over time in children &lt;6 years and assess the association of state-level marijuana legislation with the rate of marijuana-related hospitalizations.</p>

<p><strong>METHODS: </strong>We identified inpatient, emergency department and observation encounters for children &lt;6 years with marijuana exposures (defined by International Classification of Diseases diagnosis codes) unique on the patient-year level at 52 children's hospitals in the Pediatric Health Information System database from 01/01/2004-12/31/2018. Trends in encounters across the study period were evaluated using negative binomial regression with outcome of marijuana-related hospital encounters and year as the predictor variable accounting for clustering by hospital. We then estimated a negative binomial regression difference-in-differences model to examine the association between the main outcome and state recreational and medical marijuana legalization.</p>

<p><strong>RESULTS: </strong>Of the 1296 included unique patient-year encounters, 50% were female with mean age 2.1 years (SD=1.4). Fifty percent were inpatient (n=645) and 15% required intensive care with 4% requiring mechanical ventilation. There was a 13.3-fold increase in exposures in 2018 compared to 2004 (p &lt;0.001). We did not find an effect of state legalization status for recreational (p=0.24) or medical (p=0.30) marijuana.</p>

<p><strong>CONCLUSIONS: </strong>The observed dramatic increase in marijuana-related hospital encounters highlights the need for prevention strategies aimed at reducing unintentional marijuana exposures in young children, even in states without legislation permitting marijuana use.</p>

<p><strong>STUDY OBJECTIVE: </strong>To describe sexual initiation pattern in female adolescents and examine its association with adolescent characteristics and racial disparities in adverse sexual health across adolescence into early adulthood.</p>

<p><strong>DESIGN: </strong>A prospective, longitudinal, observational study from adolescence to adulthood.</p>

<p><strong>SETTING: </strong>Nationally representative, the National Longitudinal Study of Adolescent to Adult Health data, ranged 24-32 years old at final assessment.</p>

<p><strong>PARTICIPANTS: </strong>43,577 US females in 1994-2008.</p>

<p><strong>INTERVENTIONS AND MAIN OUTCOME MEASURES: </strong>Adolescent sex related characteristics in individual-family-school peer level were accessed, and multiple sex partners, STIs/HIV, and inter-partner violence (IPV) were longitudinally tracked. The sexual initiation pattern and its longitudinal association with sexual health were analyzed using latent class analysis and Mixed-effects Poisson regression models.</p>

<p><strong>RESULTS: </strong>The sexual initiation patterns were determined as normative (65.9%), late (24.8%) and early but unempowered (9.3%). The highest rate of early-unempowered group was shown in Hispanics (14.4%); they were more likely to be depressed, unsatisfied with their bodies and on welfare and have less educated/permissive parents to their sexual initiation than others. The late group had a higher BMI and more satisfaction with their bodies. The highest number of STIs/HIV and IPV victimization was shown in non-Hispanic blacks (NHBs) and Hispanics, respectively. However, NHB females' higher STIs/HIV was shown in late/normative groups, not in early-unempowered group. Among Hispanic females, adolescent sexual initiation patterns were not directly associated with their frequent IPV victimization.</p>

<p><strong>CONCLUSIONS: </strong>NHB females' higher STI/HIV in late/normative groups and Hispanic females' frequent IPV victimization regardless of their sexual initiation patterns may indicate that racial/ethnic disparities in female sexual health was not directly determined by adolescent risk behaviors.</p>

<p><strong>OBJECTIVE: </strong>Message framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents' preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting.</p>

<p><strong>METHODS: </strong>We conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (e.g. general health, cancer, respiratory illnesses, financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership.</p>

<p><strong>RESULTS: </strong>We identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n=92, 51%), Group 2 favored gain-framed messages (n=63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n=25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1.</p>

<p><strong>CONCLUSIONS: </strong>We identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.</p>

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Insights from behavioral economics suggests that the effectiveness of health messages depends on how a message is framed. Parent preferences for smoking cessation messaging has not been studied in pediatrics, warranting further exploration to maximize benefit. We sought to assess parents' perceptions regarding the relative importance of distinct message framings to promote their smoking cessation.</p>

<p><strong>METHODS: </strong>We conducted a cross-sectional discrete choice experiment in which parent smokers rated the relative importance of 26 messages designed to encourage them to begin cessation treatment. Messages varied on who was featured (child, parent, or family), whether the message was gain or loss framed, and what outcome was included (general health, cancer, respiratory illnesses, child becoming a smoker, or financial impact). The participants were 180 parent smokers attending primary care visits with their children at 4 diverse pediatric sites. The main outcome was the importance of smoking cessation messages based on who was featured, gain or loss framing, and the outcome emphasized.</p>

<p><strong>RESULTS: </strong>Parent smokers highly prioritized cessation messages emphasizing the impact of quitting smoking on their child versus parent or family. Messages focusing on respiratory illness, cancer, or general health outcomes consistently ranked highest, whereas messages focused on the financial benefits of quitting ranked lowest. Gain versus loss framing did not meaningfully influence rankings.</p>

<p><strong>CONCLUSIONS: </strong>Parent smokers identified smoking cessation messages that emphasized the impact on their child, with outcomes focused on respiratory health, cancer, or general health, as most important. The clinical impact of these messages should be tested in future research.</p>

<p>Patients with single ventricle (SV) heart defects have two primary surgical options for superior cavopulmonary connection (SCPC): bidirectional Glenn (BDG) and hemi-Fontan (HF). Outcomes based on type of SCPC have not been assessed in a multi-center cohort. This retrospective cohort study uses the Single Ventricle Reconstruction (SVR) Trial public use dataset. Infants who survived to SCPC were evaluated through 1&nbsp;year of age, based on type of SCPC. The primary outcome was transplant-free survival at 1&nbsp;year. The cohort included 343 patients undergoing SCPC across 15 centers in North America; 250 (73%) underwent the BDG. There was no difference between the groups in pre-SCPC clinical characteristics. Cardiopulmonary bypass times were longer [99&nbsp;min (IQR 76, 126) vs 81&nbsp;min (IQR 59, 116), p &lt; 0.001] and use of deep hypothermic circulatory arrest (DHCA) more prevalent (51% vs 19%, p &lt; 0.001) with HF. Patients who underwent HF had a higher likelihood of experiencing more than one post-operative complication (54% vs 41%, p = 0.05). There were no other differences including the rate of post-operative interventional cardiac catheterizations, length of stay, or survival at discharge, and there was no difference in transplant-free survival out to 1&nbsp;year of age. Mortality after SCPC is low and there is no difference in mortality at 1&nbsp;year of age based on type of SCPC. Differences in support time and post-operative complications support the preferential use of the BDG, but additional longitudinal follow-up is necessary to understand whether these differences have implications for long-term outcomes.</p>