Understanding Health Risks for Adolescents in Protective Custody

Children in child welfare protective custody (e.g., foster care) are known to have increased health concerns compared to children not in protective custody. The poor health documented for children in protective custody persists well into adulthood; young adults who emancipate from protective custody report poorer health, lower quality of life, and increased health risk behaviors compared to young adults in the general population. This includes increased mental health concerns, substance use, sexually transmitted infections, unintended pregnancy, and HIV diagnosis. Identifying youth in protective custody with mental health concerns, chronic medical conditions, and increased health risk behaviors while they remain in custody would provide the opportunity to target prevention and intervention efforts to curtail poor health outcomes while youth are still connected to health and social services. This study leveraged linked electronic health records and child welfare administrative records for 351 youth ages 15 and older to identify young people in custody who were experiencing mental health conditions, chronic medical conditions, and health risk behaviors (e.g., substance use, sexual risk). Results indicate that 41.6% of youth have a mental health diagnosis, with depression and behavior disorders most common. Additionally, 41.3% of youth experience chronic medical conditions, primarily allergies, obesity, and vision and hearing concerns. Finally, 39.6% of youth use substances and 37.0% engage in risky sexual behaviors. Predictors of health risks were examined. Those findings indicate that women, those with longer lengths of stay and more times in custody, and those in independent living and conjugate care settings are at greatest risk for mental health conditions, chronic medical conditions, and health risk behaviors. Results suggest a need to ensure that youth remain connected to health and mental health safety nets, with particular attention needed for adolescents in care for longer and/or those placed in non-family style settings. Understanding who is at risk is critical for developing interventions and policies to target youth who are most vulnerable for increased health concerns that can be implemented while they are in custody and are available to receive services

Who Speaks for Me?: Addressing Variability in Informed Consent Practices for Minimal Risk Research Involving Foster Youth

Background: Youth in protective custody (i.e., foster care) are at higher risk for poorer physical and mental health outcomes compared with those who are not. These differences may be due in part to the lack of research on the population to create evidence-based recommendations for health care delivery. A potential contributor to this lack of research is difficulties in obtaining informed consent for empirical studies in this population. The objective of this study was to describe the approaches to obtaining informed consent in minimal risk studies of foster youth and provide recommendations for future requirements. Methods: We conducted a systematic review of the literature to characterize the informed consent approaches in published minimal risk research involving youth in foster care. We searched PubMed, CINAHL, PsychINFO, Embase, ERIC, Scopus, and EBMR. Inclusion criteria were: studies conducted in the United States, included current foster youth, minimal risk, peer reviewed, and published in English. Full text was reviewed, and individuals required to consent and assent were extracted. Results: Forty-nine publications from 33 studies were identified. Studies required 0 to 3 individuals to consent. Individuals required to give consent included case workers (16, 48%), foster caregivers (12, 36%), biological parents (7, 21%), judges (5, 15%), and guardian ad litems (2, 6%). Twenty-nine (88%) studies required the youth’s assent. The studies used 14 different combinations of individuals. One (3%) study utilized a waiver of consent. Conclusions: There is no consistent approach for obtaining informed consent for foster youth to participate in minimal risk research. Consent should ideally involve individuals with legal authority and knowledge of the individual youth’s interests and should not be burdensome. Consensus regarding consent requirements may facilitate research involving foster youth

The Role of Information Sharing to Improve Case Management in Child Welfare

Congress enacted the Adoption and Safe Families Act to improve outcomes concerning the permanency, safety, and wellbeing of children in the care of child welfare agencies. However, achieving its goals for the more than 700,000 children who spend time in the custody of child protective services (CPS) every year in the United States is made more difficult by their poorer health compared to the general population.1 Common health concerns among children in CPS custody include developmental delay (e.g., intellectual delay or disability, gross or fine motor delay, speech delay), infections diseases, mental and behavioral health concerns, and medical concerns. Higher levels of healthcare compared to other children who live in poverty are often required.2 While health concerns may have been identified before children entered CPS custody, connections to healthcare providers and services are disrupted when children are removed from their families of origin and placed in out-of-home care. Efforts to collect a child’s complete medical history upon entering care may be difficult, and incomplete histories negatively impact health and disease management. Moreover, disruptions in healthcare can continue even after children enter CPS custody and out-of-home care—for example, when children change placements or caseworkers—leading to additional challenges managing children’s health needs and increasing healthcare use.

Putting Families First: How the Opioid Epidemic is Affecting Children and Families, and the Child Welfare Policy Options to Address It

Abstract: Opioids and Child Welfare Across the country, placements in foster care are rising. In 2016, the U.S. Department of Health and Human Services reported that 273,539 children in the U.S. entered foster care. In 34 percent of those cases, parental drug abuse was one of the factors leading to the child’s removal from their family. Additionally, the U.S. Substance Abuse and Mental Health Services Administration estimates that 400,000 births nationally are affected by prenatal exposure to alcohol and illicit drugs, which represents 10 percent of all live births. As the opioid epidemic continues, increasing numbers of children are at high risk for developmental and behavioral disorders because of their prenatal substance and alcohol exposure. In addition, children who remain at home may endure the challenges and trauma resulting from impaired caregiving due to parental substance use disorders (SUDs). This article explores the intersection of the opioid epidemic and child welfare, examining current research and publicly available data to discuss policy opportunities for better serving families affected by parental SUDs, including: ensuring health and safety for infants prenatally exposed to substances; appropriate identification, diagnosis, and treatment of developmental and behavioral needs; ensuring parents have access to outpatient treatment and services that can allow families to stay together when safe and appropriate; and ensuring sufficient access to inpatient treatment options that can serve parents and children together

Global urban environmental change drives adaptation in white clover

Urbanization transforms environments in ways that alter biological evolution. We examined whether urban environmental change drives parallel evolution by sampling 110,019 white clover plants from 6169 populations in 160 cities globally. Plants were assayed for a Mendelian antiherbivore defense that also affects tolerance to abiotic stressors. Urban-rural gradients were associated with the evolution of clines in defense in 47% of cities throughout the world. Variation in the strength of clines was explained by environmental changes in drought stress and vegetation cover that varied among cities. Sequencing 2074 genomes from 26 cities revealed that the evolution of urban-rural clines was best explained by adaptive evolution, but the degree of parallel adaptation varied among cities. Our results demonstrate that urbanization leads to adaptation at a global scale

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Dedicated Retinal Examination in Children Evaluated for Physical Abuse without Radiographically Identified Traumatic Brain Injury

Objective To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. Study design This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. Results The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. Conclusions Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination

Dedicated Retinal Examination in Children Evaluated for Physical Abuse without Radiographically Identified Traumatic Brain Injury

Objective To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. Study design This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. Results The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. Conclusions Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination