Sex is a natural part of human development and ensuring that young people are getting quality sex education is crucial,” said principal investigator Laura Lindberg, PhD, a principal research scientist at the Guttmacher Institute, a New York City research and policy organization pursuing sexual and reproductive health and rights.

The study culled nationally representative data from the National Survey of Family Growth, in youth aged 15 to 19 years, for 2 time periods: 2011 to 2015 and 2015 to 2019.

Between the 2 time periods, there were only a few significant changes in adolescents’ receipt of formal sex education.

Instruction on waiting until marriage to have sex declined from 73% to 67% among females (

In addition, in both time periods, only about half of adolescents received sex education that meets the federal minimum standard.

In the later time period, there were significant gender differences in the instruction to wait until marriage to have sex: 67% of females received instruction vs 58% of males (

Condom skills were taught to 55% of females and 60% of males (

However, non-Hispanic Black and Hispanic males were significantly less likely than non-Hispanic White males to receive formal instruction before the first sex on sexually transmitted infection/HIV, birth control or where to get birth control in the later time period.

Data from the later time period also found that many adolescents reported religious settings as the sources of instruction about waiting until marriage to have sex: 56% of females and 49% of males. But nearly none received instruction about birth control from such settings.

“Evidence shows that adolescents in the United States are clearly not getting the quality sex education they need,” Lindberg told 

. “In fact, it is shocking that our research shows that young people are less likely to receive information about birth control now than they were 25 years ago.”

Moreover, there are concerning inequities between who has access to sex education by race, gender, and sexual orientation that leaves young people vulnerable, according to Lindberg. “For example, queer young men are significantly less likely than their straight counterparts to receive information on essential sex ed topics,” she said.

Withholding critical information about sexual health violates adolescents’ right to accurate, timely information, says Lindberg, who noted that health care providers can and must help address this gap by furnishing teens with the information and services they need for their health and wellbeing.

“Our schools and communities also need to expand their provision of sex education, with support from federal, state, and local policies,” Lindberg said. “Policymakers should create links to sexual health services for young people who face the greatest barriers to care.”

To begin, Lindberg urges policymakers to fully fund the Teen Pregnancy Prevention Program and Personal Responsibility Education Program. “These are federally funded grant programs that support evidence-based, medically accurate programs to reduce adolescent pregnancy and STIs,” she said.

Lindberg also advocates passage of the Real Education and Access for Healthy Youth Act, “which would eliminate funding for abstinence-only programs and establish the country’s first federal grant program for comprehensive sex education,” she said.

Furthermore, Lindberg would like the federal government to eliminate all funding for 

misleading and incomplete abstinence-only-until-marriage programs

, “which harm young people. Instead, this money should be used to fund sex education programs that offer informative and inclusive curricula.”

This article was originally published by sister publication Contemporary OB/GYN.

Lindberg LD, Kantor LM. Adolescents’ receipt of sex education in a nationally representative sample, 2011 – 2019. 

. Published online November 4, 2021. doi:org/10.1016/j.jadohealth.2021.08.027

Articles

Many adolescents across the United States lack quality sex education, a trend that has worsened in recent years. Moreover, national statistics mask significant inequities in the receipt of formal sex education by gender, race and ethnicity, sexual orientation, and the location of instruction.

Quality sex education lacking for many teens in the United States

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

In the past several years, governments have attempted to control advertising for foods and beverages with poor nutritional quality on television and other forms of traditional media. Although this has been met with some success, there aren’t any rulesthat regulate food and drinks on social media, which is an extremely common source of information and entertainment for children and teenagers. Many celebrities include mentions, images and videos of foods and beverages in their posts, both sponsored and unsponsored. A 

 examines the nutritional quality of the food and drinks featured in celebrity posts.

The investigators performed a cross-sectional study that looked at the content of posts on Instagram that included food and beverages. The pool of celebrities included athletes, actors, and musicians. The Nutrient Profile Index was used to rate the nutritional quality of the posted food and beverages and was based on the sugar, sodium, energy, saturated fat, fiber, protein, and fruit and/or vegetable content per 100-g sample (a score of 0 indicated least healthy and 100, healthiest). A score of less than 64 for foods and less than 70 for drinks was considered “less healthy.” A secondary outcome was if a link existed between the nutritional quality of items in a post and the sponsorship status.

A total of 181 celebrity accounts with a combined follower count of 5.7 billion, were included in the sample. There were 3065 social media posts examined with 5180 foods and beverages included. In these posts, snacks and sweets (920 [37.3%] of the foods) and alcoholic beverages (1375 [50.7%] of the beverages) were the most commonly seen. Nearly 90% of the celebrity profiles were given a less healthy overall food nutrition score and a less healthy overall beverage nutrition score. These scores were deemed unhealthy enough to fail the advertising laws for children in the United Kingdom. Posts that featured foods with higher nutrition scores had significantly fewer likes (b, –0.003; 95% CI, –0.006 to 0.000; 

 = .04) and comments (b, –0.006; 95% CI, –0.009 to –0.003; 

 < .001) from followers, but beverage nutrition scores had no significant links to (b, –0.010; 95% CI, –0.025 to 0.005; 

 = .18) or comments (b, –0.003; 95% CI, –0.022 to 0.016; 

 = .73). Just 147 of the posts had been sponsored by a food or beverage company, such as Red Bull, Aviation American Gin, and Wheaties. Drinks in a sponsored post were found to have more than twice as much alcohol as those in nonsponsored posts (10.8 g [95% CI, 9.3 g to 12.3 g] per 100 g of beverage vs 5.3 g [95% CI, 4.7 g to 5.9 g] per 100 g of beverage).

The investigators concluded that many celebrities with extensive followings on Instagram feature a variety of food that is generally unhealthy and that the vast majority of those posts are not sponsored. This indicates that unhealthy food and beverage depictions are found beyond advertising and likely requires a more hands-on approach to combat.

1. Turnwald B, Anderson K, Markus H, Crum A. Nutritional analysis of foods and beverages posted in social media accounts of highly followed celebrities. 

. 2022;5(1):e2143087. doi:10.1001/jamanetworkopen.2021.43087

Regulations ensure that the advertising of unhealthy foods is limited to children in traditional media. An investigations looks into how celebrity social media may be showing children and adolescents a variety of unhealthy foods and drinks.

How social media may be getting around measures to restrict depictions of unhealthy food and drinks

Ellen Hight, M.D., a family medicine physician in East Greenwich, Rhode Island, says the electronic health record (EHR) completely changed her practice, and not necessarily in a good way. “When our practice started using an EHR, I began to feel a distance between myself and my patients because I was constantly staring at the computer,” she says. Her work-life balance also took a hit as she began to spend Saturday mornings finishing her notes from the previous week.

When the Rhode Island Primary Care Physicians Corporation (RIPCPC), an independent practice association to which her practice belongs, approached her about piloting a virtual scribe program — and said it would pay for the first two months of participation — she jumped at the opportunity. “When I heard about virtual scribes, I thought, ‘Well that’s a good idea,’ ” she recalls.

Scribes are someone who works offsite or in a different area of the practice (i.e., not in the exam room) to document important aspects of the encounter so the physician or other provider can focus on providing patient care and working more efficiently.

RIPCPC partnered with an outsourced virtual scribe vendor to launch the two-month pilot program that included Hight, one other physician, and one nurse practitioner. Hight says the pilot was a huge success, prompting her to continue working with the scribe, a dentist in India. “My hands are not on the keyboard and I’m looking directly at the patient,” says Hight. “It’s more personal. I just feel so much more relaxed.”

Greater efficiencies enable Hight to see six or seven additional patients a day without putting in extra hours. She also usually does not take work home at night or on weekends.

The other physician who participated in the pilot continues to use a virtual scribe. Hight’s still assessing whether it makes financial sense for the nurse practitioner (who bills under her own national provider identifier rather than incident-to a physician) to continue.

Jonathan Weiss, MD, internist in Monticello, New York, has used a domestic virtual scribe for the last four years and says his scribe does just about everything except take vital signs, draw blood, perform electrocardiograms and administer vaccines. For example, in addition to completing all relevant documentation, the scribe listens to the doctor’s verbal instructions and then orders tests, initiates referrals, messages relevant office staff to obtain prior authorizations and checks off boxes in the EHR for quality measures. She even navigates to different parts of the record to retrieve information for Weiss upon request.

“To me, virtual scribing is one of the holy grails of making medicine tolerable again,” says Weiss. “During a 15-minute established patient visit, I can produce an incredibly well-documented note, get all the tests ordered and stay on schedule. In the majority of cases, I can legitimately obtain a higher E/M (evaluation and management) level because my notes are so robust. Ten minutes after my last patient, I’m in the car and headed home.”

Weiss is also able to see an additional three or four patients per day without extending his hours. Previously, he would have stayed until 8 p.m. and paid his staff overtime. In addition, his medical assistant is not tied to the computer and can engage patients more directly.

“Working with a remote scribe has been the single most work-changing thing I’ve done in 15 years,” he says. “If it was taken away from me, I would quit my job. I could not go back to the way I was doing things before.”

At UW Health, an integrated health system of the University of Wisconsin-Madison serving more than 700,000 patients each year in the Upper Midwest, working with virtual scribes was part of a deliberate effort to reduce physician burnout, says Christine Williams, director of health information management.

“Providers didn’t go to school to document. They went to school to practice medicine and make a difference,” says Williams. “With virtual scribes, physicians can stay connected to the patient. This is true whether it’s a small practice or a large academic medical center.”

Physicians at UW Health have the option of working with a virtual scribe. If they opt in, they are required to see one additional patient per session (i.e., every four hours). This additional revenue covers most of the cost of the scribe, says Williams.

UW Health began its scribe offering with a pilot program in 2019 that subsequently converted into a permanent program focused on ambulatory providers. Williams says she eventually wants to include emergency department physicians and hospitalists. Approximately 150 ambulatory providers currently use virtual scribes with an additional 10 providers joining each month.

Why offer a virtual scribe program? Preventing burnout ultimately reduces costly physician turnover, says Williams. “Physician resignation and needing to fill vacancies is a very large cost, especially for small practices,” she adds.

Matthew Malek, M.D., M.P.H., family medicine physician and medical director of provider experience at Thundermist Health Center, a federally qualified health center in Rhode Island, agrees. “If you can prevent one physician from leaving, this is an incredible savings on the order of $300,000 to $500,000,” he says.

Why are the costs so high? First, it takes time to find and hire a new provider. “When you consider the lack of billing during this time, that’s a big chunk of change,” says Malek.

It also takes time for physicians to build a patient panel and maximize efficiency. “At our organization, it takes about a year for a new physician to get to their eventual baseline productivity,” he adds.

Using virtual scribes at Thundermist Health Center was a data-driven decision, says Malek, who was instrumental in launching the program. The health center partnered with the American Medical Association to assess physician well-being using the Mini Z 2.0 burnout survey. It also used a set of validated questions about efficiency of practice and teamwork as well as community self-reported data. Finally, the health center tracked an EHR-based metric called the WOW8 to objectively measure work outside of office hours. This metric is defined by time on the EHR outside of scheduled patient hours per eight hours of patient scheduled time.

“We realized that our clinicians were spending a lot of time outside of the clinical work doing clinical documentation,” he says. “We had the data to bring to leadership to justify the virtual scribes.”

The pandemic was the perfect backdrop for a virtual program. “We also use remote scribes in our COVID(-19) evaluation and treatment clinics,” he says. “It’s nearly impossible to fit three people in an exam room and maintain appropriate distance.”

Now that the program is up and running, physicians choose whether to participate. If they do, they also decide how many hours they would like to work with the scribe. However, the vendor requires a minimum of four continuous hours and 50 total hours per month. Thundermist requires physicians using scribes to add roughly two visits per day to cover the cost, says Malek.

“The maturation of the scribe market makes it a much more understandable value proposition,” he adds. “I think remote scribing is a very scalable intervention to improve physician well-being.”

Think a virtual scribe may be what you’re looking for? Industry experts provide six tips to help you succeed.

 Are you exploring a virtual scribe program to address burnout concerns and prevent attrition? See additional patients and generate more revenue? See the same number of patients in the same or fewer hours? Improve patient satisfaction?

Knowing the why helps physicians gauge impact and return on investment, says Sean M. Weiss, chief compliance officer at DoctorsManagement, LLC, adding that some physicians work with virtual scribes simply to ensure timely, accurate documentation that establishes medical necessity for services rendered. Your why will determine the key performance indicators necessary to measure the success of the program. Examples might include physician and staff turnover rates, physician self-reported data related to well-being, or patients seen per hour.

Experts recommend asking these questions:

What type of training or credentials do the virtual scribes have? For example, are they an RN, LPN, or have some other medical training?

What type of ongoing education for medical specialties, terminology, anatomy, physiology and pharmacology do they receive?

What is their knowledge of medical coding and clinical documentation requirements (including CPT modifiers and quality measures)?

What is the vendor’s plan if a virtual scribe is suddenly unavailable (e.g., due to sickness, vacation or turnover)? Can it provide immediate backup coverage?

 “There’s a significant risk of using remote scribes and really any third-party vendor, and it’s not getting the attention it should,” says Sean Weiss. “That risk is the risk of cyberattack.” He says most breaches occur through third-party vendors such as outsourced billing/coding companies, outsourced release of information vendors, virtual scribes and others.

Sean Weiss points to a recent case in Florida in which a hacker fraudulently billed $10 million to Medicare by gaining access to patients’ protected financial information, demographics, diagnostic information and the provider’s UPIN (unique physician identification number). “The group practice actually had a strong cybersecurity protocol, but this individual was able to hack into the system through the third-party vendor,” he says.

Experts agree that practices intending to work with a virtual scribe should ask these questions of the vendor employing the scribe:

What is the risk management plan in place to test the system, and how often do these tests occur?

What were the results of the most recent risk assessment?

What corrective action plan, if any, was implemented?

Has the vendor ever experienced a cyberattack?

What is the vendor’s plan for business continuity during downtime due to a cyberattack?

What is the risk management strategy going forward? For example, does each virtual scribe have their own login information? Do they receive ongoing HIPAA (Health Insurance Portability and Accountability Act of 1996) training?

 “A scribe can be trained by someone else on how to navigate the EMR (electronic medical record), but the provider really needs to train the scribe on their specific dictation style and workflow,” says Williams. This process could take a few weeks and physicians need to be on board with the upfront work that’s required, she adds.

 “This ensures it fits within the autonomy of that practice specifically,” says Williams. “It ensures you’re not interrupting five or 10 clinicians at a time. You have one or two who are really committed to working out some of the kinks. It’s not just plug and play.” For example, practices will need to ensure processes for patient notification and reviewing documentation for billing and compliance purposes.

 “If physicians are only asking for documentation, they’re missing half the boat,” says Jonathan Weiss. “They should be pushing scribes to be a virtual medical assistant. You get much more value for your dollar.”

This article was originally published by sister publication Medical Economics.

Scribes are someone who works offsite or in a different area of the practice (ie, not in the exam room) to document important aspects of the encounter so the physician or other provider can focus on providing patient care and working more efficiently.

Reducing EHR headaches with ‘virtual’ scribes

Neurodevelopmental disorders have been linked to poor social and health outcomes. An understanding of population data on age at time of diagnosis, demographic variations, and incidence are incredibly helpful in the identification of risk factors that are modifiable and can impact the planning of services and intervention. A

 new population-based cohort investigation

Investigators used nationwide data using birth cohorts from the 2000-2014 Medicaid Analytic eXtract and the 2003-2015 IBM MarketScan Research Database to find children who were publicly and privately insured at the time of their birth. Identified conditions included attention-deficit/hyperactivity disorder, learning disabilities, speech or language disorders, developmental coordination disorders, intellectual disabilities, neurodevelopmental disorders, autism spectrum disorders, and behavioral disorders. Analyses estimated the incidence and timing of diagnosis, which was stratified by child’s sex, birth year, maternal age at delivery, and race and ethnicity.

The sample included 2,070,541 children who were publicly insured and 1,309,900 children insured privately at the time of birth. By their 8th birth, 23.9% of publicly insured children and 11.0% of privately insured children had been given a diagnosis of at least 1 neurodevelopmental disorder:

attention-deficit/hyperactivity disorder, 14.5% and 5.8%;

speech or language disorder, 8.4% and 4.5%;

developmental coordination disorder, 0.9% and 0.7%;

intellectual disability, 0.7% and 0.1%; and

The risk of diagnosis was found to be much higher among boys (incidence of ≥1 neurodevelopmental disorder by age 8 years for boys vs girls: 30.7% vs 16.7% among publicly insured children and 15.0% vs 6.7% among privately insured children) and White children (30.2% vs 9.1% among Asian children, 23.0% among Black children, 15.4% among Hispanic children, and 22.7% among children of unknown race or ethnicity; information on race and ethnicity was available only for publicly insured children). With the exception of attention-deficit/hyperactivity disorder, diagnosis occurred slightly earlier for children with private insurance. Co-occurring disorders were common, particularly in children who had intellectual disability and autism spectrum disorder (>70% had ≥1 other disorder).

The investigators concluded that there was a fairly high incidence of and co-occurrence of neurodevelopmental disorders, but a disparity in incidence and timing of diagnosis by insurance type and race and ethnicity existed. They believe the results show the importance of timely, accessible developmental assessments and educational services.

1. Straub L, Bateman B, Hernandez-Diaz S, et al. Neurodevelopmental disorders among publicly or privately insured children in the United States. 

. Epub ahead of print. January 5, 2022. doi:10.1001/jamapsychiatry.2021.3815

Understanding the population characteristics of neurodevelopmental disorders is an important way to find modifiable risk factors and help determine needed services.

Examining the population characteristics of neurodevelopmental disorders in pediatrics

The move to remote learning during the COVID-19 pandemic led to many potential issues including lack of access to support programs and lack of access to food programs as well as a lack of socialization. However, is it possible that there may have been some positives from the move to remote learning, such as more sleep? A 

 whether teenagers had increased sleep as a result of distance learning and if this sleep improvement led to better health characteristics.

The investigators performed a survey study that sent cross-sectional online surveys to students attending 21 public high school in Zurich, Switzerland. They compared a control sample who completed the survey from May to July 2017 and a sample during the lockdown from May to June 2020. The survey asked questions about sleep-wake patterns, health-related quality of life, substance use including caffeine, and depressive symptoms. Surveys were included in the study as long as they provided sex, age, and school.

A total of 8972 students were included in the sample, with 5308 in the control sample and 3664 were in the lockdown sample. Both subcohorts had a median age of 16 years and skewed female. The investigators found that during the lockdown, the sleep period on school days was 75 minutes longer (semipartial R2 statistic [R2β*], 0.238; 95% CI, 0.222-0.254; 

 < .001). Students reported less consumption of alcohol (R2β*, 0.014; 95% CI, 0.008-0.022; 

 < .001) and caffeine (R2β*, 0.010; 95% CI, 0.006-0.015; 

 < .001). They also reported better health-related quality of life. Overall, longer sleep duration was tied to less consumption of caffeine (R2β*, 0.013; 95% CI, 0.009-0.019; 

 < .001) as well as better health-related quality of life (R2β*, 0.027; 95% CI, 0.020-0.034; 

 < .001). The investigators also looked at depressive symptoms and its link to health-related quality of life in the lockdown subcohort and found an inverse association (R2β*, 0.285; 95% CI, 0.260-.0311; 

 < .001) as well as a positive association with caffeine consumption (R2β*, 0.003; 95% CI, 0.000-0.008; 

The investigators concluded that there were 2 effects of school closures and adolescent health and both were in opposition: a negative impact on psychological health and a positive impact as a result of increased sleep duration. Not only should the findings be considered when determining the need for and starting school closures, but they provide further support for delaying the school start time for teenagers.

1. Albrecht J, Warner H, Rieger N, et al. Association between homeschooling and adolescent sleep duration and health during COVID-19 pandemic high school closures. 

. 2022;5(1):e2142100. doi:10.1001/jamanetworkopen.2021.42100

The move to distance learning as a result of the pandemic led to may negative impacts on the lives of children, but a new report indicates that there may have been at least one positive: better sleep duration for teenagers.

Finding the positive in distance learning

 on menstrual health have led to much vaccine hesitancy. While its effects weren’t studied in the initial Pfizer/BioNTech, Moderna, and Johnson & Johnson clinical trials, recent research delivers reassuring results.

A retrospective cohort analysis found that slight, temporary changes in menstrual cycles may occur after COVID-19 vaccination but return to normal after 2 postvaccine cycles.1

Investigators conducted a retrospective cohort analysis of nearly 4000 vaccinated and unvaccinated women, examining 6 cycles of menstrual data using the US Food and Drug Administration-approved fertility app 

Data were used from women in the United States aged 18 to 45. All women reported normal cycle lengths (24 to 38 days), and investigators included data of the vaccinated group for 3 consecutive cycles before the first vaccine dose, followed by vaccine dose cycles (cycles 4-6). Data for the unvaccinated group included 6 cycles in a similar period. They included women in the United States aged 18 to 45 with normal cycle lengths of 24 to 38 days over the course of 3 consecutive cycles.

Of the 3959 women, 2403 were vaccinated and 1556 were not. Most of the vaccinated women received the Pfizer/BioNTech vaccine (55%), followed by Moderna (35%) and Johnson & Johnson/Janssen (7%).

After adjusting for confounders, investigators reported that all women experienced small variations in cycle length, regardless of vaccination status. As for the vaccinated group, the difference in cycle length was less than 1 day when compared with the unvaccinated group. A small group of women who received both vaccine doses in the same cycle had their period for an average of 2 days longer than the unvaccinated group, but this alteration diminished after 2 postvaccine cycles.

Investigators found no change in menses length between or within the 2 groups.

These results are useful for ob-gyns because, even though a 1-day change is not clinically significant, a cycle change of any kind may cause concern or raise hopes of patients avoiding or planning for pregnancy.

Edelman A, Boniface ER, Benhar E, et al. Association between menstrual cycle length and coronavirus disease 2019 (COVID-19) vaccination: a U.S. cohort. 

 Published online January 5, 2022. doi:10.1097/AOG.0000000000004695

A new study showed that COVID-19 vaccinations may temporarily cause changes to the timing of menstruation. 

What does the COVID-19 vaccine do to the menstrual cycle?

Gun violence is an ongoing epidemic in the United States. Firearms-related deaths are the second leading cause of death among children and young adults, with nearly a quarter of all deaths among people aged 15 to 24 years resulting from firearms.

 Ninety-one percent of firearm deaths around the world in children aged 0 to 14 years occur in the United States.

 The risk of death linked to unintentional injury is higher in counties with a higher level of poverty. An investigation examines whether living in a county with a higher poverty concentration was linked to a child or teenager’s risk of death related to a firearm.

The investigators ran a cross-section study that analyzed US firearm fatalities among children and young adults aged 5 to 24 years from January 2007 to December 2016. They used data from the Compressed Mortality File from the Centers for Disease Control and Prevention as well as annual intercensal population data from the US Census Bureau. Firearm-related deaths included homicides, suicides, unintentional deaths, and deaths that had undetermined intent. Poverty concentration was defined as population that was living below the federal poverty level, which was #21,027 in 2007 and $24,339 in 2016 for a family of 4, and divided into 5 groups: 0% to 4.9%, 5% to 9.9%, 10% to 14.9%, 15% to 19.9%, and ≥20%).

There were 67,905 firearm-related deaths from 2007 to 2016 included in the cohort, which was mainly comprised of 60,164 males. Among these deaths, 42,512 were homicides; 23,034 were suicides; and 1627 were considered unintentional. The investigators found that there was a stepwise increase in firearm-related mortality risk due tied to increasing county poverty concentration. When compared with counties that had the lowest poverty concentration, those with the highest poverty concentration saw an increased rate of total deaths related to firearms (adjusted incidence rate ratio [IRR], 2.29; 95% CI, 1.96-2.67), homicides (adjusted IRR, 3.55; 95% CI, 2.80-4.51), suicides (adjusted IRR, 1.45; 95% CI, 1.20-1.75), and unintentional deaths (adjusted IRR, 9.32; 95% CI, 2.32-37.4). The population-attributable fraction was .51 (95% CI, 0.43-0.57) for all firearm-related deaths, 0.66 (95% CI, 0.57-0.73) for homicides, 0.30 (95% CI, 0.17-0.42) for suicides, and 0.86 (95% CI, 0.46-0.97) for unintentional deaths. This means that 34,292 deaths from firearms would not have occurred if all counties had the same level of risk as the ones with the lowest concentration of poverty. Overall, a total of 3,833,105 years of potential life were lost.

Investigators did note that there were limitations to their study. The first was that they could only report association and not causations. The demographic variables as well as causes of death noted in the Compressed Mortality File may have been misclassified. The heterogenous nature of counties, where neighborhoods may have varying levels of poverty, along with the inability to determined income data for the teenagers and young adults themselves meant the investigators were not able to determine the implications of individual-level poverty versus county-level poverty. Additionally, the investigators were not able to account for illicit firearm ownership.

The investigators concluded that counties with a higher level of poverty concentration were linked to increased rates of total firearm deaths, homicides, suicides, and unintentional deaths. Particularly troubling was the fact that over 50% of the fire-arm related deaths as well as over two-thirds of all homicides tied to firearms in the age group could be linked to living in a county with a higher poverty concentration. With the trend of increasing income inequality, this data could indicate the potential likelihood for increasing risk of firearm-related death because of county-level poverty.

This important article shows the dramatic impact of poverty on firearm-related deaths in the United States.It is no surprise that deaths from gun violence are related to poverty, but the numbers reported here and the strong association with higher county poverty concentration is staggering.

It is well known that school shootings have increased in the United States in recent years, and these tragic events understandably capture national attention. This article makes us look closely at the more subtle epidemic of gun-related deaths that occur daily on the streets of our country.

The authors briefly describe the impact of children living in high poverty concentration neighborhoods.Children in these communities often have inadequate housing, limited access to high quality schools, and increased toxic stress.It is no surprise they also have a disproportionate number of firearm-related deaths. 

 reported that Chicago had 101 gun-related homicides in residents under age 20 in 2021, up for 76 in 2019.In my own city of Philadelphia, 2021 brought a new record for homicides (562) and the large majority of these deaths was by firearms.More than 200 teens were caught in the cross fire with the rising gun violence in Philadelphia and at least 36 were killed in 2021. The large majority of these shootings also occurred in sections of the city with increased concentration of poverty.

In 2016 the American Academy of Pediatrics (AAP) noted that almost half of children in the United States live in poverty or near poverty. They issued a Policy Statement indicating the AAP is “committed to reducing and ultimately eliminating poverty in the United States”.This is a daunting task, as is ending the crisis of gun violence in our country.The authors of this study in 

 mention some helpful interventions such as the Child Tax Credit, Head Start, the Special Supplementation Nutrition Program for Women, Infants and Children.They also note the importance of firearm regulation legislation.Our country seems to be a long way off from this.

We need data to make any progress in reducing gun-related violence.This study provides very valuable data that will at least help us target our efforts

1. Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER). Accessed March 31, 2021. https://wonder.cdc.gov/

2. LeeLK﻿, MannixR﻿.Increasing fatality rates from preventable deaths in teenagers and young adults. 

. 2018;320(6):543-544. doi:10.1001/jama.2018.6566

3. Centers for Disease Control and Prevention. WISQARS (Web-Based Injury Statistics Query and Reporting System). 

4. Centers for Disease Control and Prevention. Leading causes of injury death highlighting violence. WISQARS. Accessed March 31, 2021. 

https://webappa.cdc.gov/sasweb/ncipc/mortrate.html

5. GrinshteynE﻿, HemenwayD. Chapter 6: Firearm violence in the pediatric population: an international perspective. In: LeeLK﻿, FleeglerEW﻿, eds.

Pediatric Firearm Injuries and Fatalities: The Clinician’s Guide to Policies and Approaches to Firearm Harm Preventio

n. Springer International Publishing; 2021:75-85. doi:10.1007/978-3-030-62245-9_6

6. Barrett J, Lee L, Monuteaux M, Farrell C, Hoffmann J, Fleegler E. Association of county-level poverty and inequities with firearm-related mortality in US youth. 

. Epub ahed of print. November 22, 2021. doi:10.1001/jamapediatrics.2021.4822

NAPNAP urges the government to address gun violence

The day after the November 30, 2021 shooting in Oxford Township, Michigan, the National Association of Pediatric Nurse Practitioners released a statement

 calling for the leaders of state and federal government to immediately start addressing the gun violence issue facing the United States. The organization advocated for several congressional reforms including:

Increasing funding to programs that research and track gun violence

Institute 72-hour waiting periods to allow for thorough background checks

Set the federal minimum age for firearm purchase to 21 years, with exemptions for people in the military or law enforcement

Bolster background check and remove loopholes that prevent background checks from occurring

Constrain the sale and import of high-capacity magazines

1. NAPNAP urges government to address gun violence. NAPNAP.org. December 1, 2021. Accessed January 10, 2022. https://www.napnap.org/napnap-urges-government-to-address-gun-violence/

Steven Selbst, MD, comments on a new study showing the devastation of gun violence in low-income communities.

A sobering look at children and gun violence in the United States

The move to distance learning led to a lot of negative outcomes for students, such as lack of socialization with peers, reduced access to food sources, and difficulty in providing programs for children who required additional help. However, most children were able to sleep for longer periods of time. What are the benefits of this in teenagers?

The patchwork legalization of marijuana in the United States has led to worries that it may lead to accidental ingestion in children as well as other concerns. A recent investigation examines what happened when Canada legalized the substance for the entire country.

A look at what to expect from Contemporary Pediatrics this week

What's new on Contemporary Pediatrics: January 10 to 14

The US Food and Drug Administration recently expanded the emergency use authorization for COVID-19 Pfizer/BioNTech booster to include pediatric patients aged 12 years and older, the Centers for Disease Control and Prevention (CDC) 

 the Advisory Committee on Immunization Practices’ recommendation to expand boosters to include children aged 12 to 15 years.

 The organization recommends that people aged 12 to 17 years receive a booster dose 5 months after undergoing the primary vaccine series.

In support of this expansion, CDC director, Rochelle Walensky, MD, MPH, said, “it is critical that we protect our children and teens from COVID-19 infection and the complications of severe disease. We now recommend that all adolescents aged 12-17 years should receive a booster shot 5 months after their primary series. This booster dose will provide optimized protection against COVID-19 and the Omicron variant. I encourage all parents to keep their children up to date with CDC’s COVID-19 vaccine recommendations.”

1. Centers for Disease Control and Prevention. CDC expands booster shot eligibility and strengthens recommendations for 12-17 year olds. Published January 5, 2022. Accessed January 10, 2022. 

https://www.cdc.gov/media/releases/2022/s0105-Booster-Shot.html

The Centers for Disease and Control and Prevention (CDC) has given their support for giving a COVID-19 booster to children aged 12 to 15 years.

CDC expands COVID-19 booster recommendations to kids 12-15

The use of supplemental oxygen is a key component when providing critical care in the hospital. Evidence has shown that overusing it can lead to hyperoxia, which may lead to worse outcomes than those with a normal oxygen level. A 

 examined whether this was true in the pediatric population.

Investigators performed a systematic research of EMBASE, MEDLINE, Cochrane Library, and ClinicalTrials.gov. There were no language restrictions applied to the search. They included clinical trials or observational studies of children who were admitted to a pediatric intensive care unit that examined for hyperoxia and included at least 1 outcome of interest. Primary outcome was 28-day mortality and secondary outcomes included ventilator-related outcomes, extracorporeal organ support, functional performance, and length of stay.

A total of 16 studies, which involved 27,555 patient, were included in the meta-analysis. Fifteen were observational cohort studies and 1 was a randomized clinical pilot trial. The study populations included post–cardiac arrest (n = 6), traumatic brain injury (n = 1), extracorporeal membrane oxygenation (n = 2), and general critical care (n = 7). Both the definition and assessment used for hyperoxia was different among the included studies. The most frequently used measure to define hyperoxia was partial pressure of arterial oxygen, which was determined mainly by categorical cutoff. By any definition, hyperoxia had an odds ratio for mortality of 1.59 (95% CI, 1.00-2.51; after Hartung-Knapp adjustment, 95% CI, 1.05-2.38). Signal of harm was seen at higher thresholds of arterial oxygen levels when clustered using the definition of hyperoxia. There were inadequate data to include the secondary outcomes in the meta-analysis.

The investigators determined that the results indicate the hyperoxia is linked to mortality in critically ill children, even with the methodological limitations they noted for the included studies. They urged for further prospective observational studies to better study the connection as well as the need to address the implications of hyperoxia in children who are critically ill.

1. Lilien T, Groeneveld N, van Etten-Jamaludin F, et al. Association of arterial hyperoxia with outcomes in critically ill children: a systematic review and meta-analysis. 

. 2022;5(1):e2142105. doi:10.1001/jamanetworkopen.2021.42105

Supplemental oxygen is a major element of critical care, but is there such a thing as too much of good thing? A meta-analysis examines the impact of hyperoxia on mortality in critically ill children.

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What's new on Contemporary Pediatrics: January 10 to 14

CDC expands COVID-19 booster recommendations to kids 12-15

What hyperoxia means for critically ill children