Importance: Alcohol use disorder (AUD) is a major public health concern; medications for AUD (MAUD) are an effective form of treatment but remain underused. Identifying MAUD access trends and the characteristics of counties with limited availability can inform targeted efforts to expand treatment capacity.
Objective: To examine trends in geographic availability of MAUD at US substance use disorder treatment facilities (SUDTFs) from 2017 to 2023 and assess county characteristics associated with SUDTFs offering MAUD.
Design, setting, and participants: This nationwide cross-sectional study used data from the Mental Health and Addiction Treatment Tracking Repository, which includes longitudinal data on licensed SUDTFs and whether they offer MAUD (acamprosate, disulfiram, or naltrexone), to quantify trends in MAUD availability at SUDTFs from January 2017 to December 2023.
Main outcomes and measures: The primary outcome was a county-year indicator for whether at least 1 SUDTF in the county offered MAUD. Explanatory county variables included rurality, percentage of traffic fatalities involving alcohol, percentage of the population that drank excessively, percentage of uninsured individuals, poverty rate, percentage of individuals over age 65 years, and percentage of non-Hispanic White individuals. Univariate logistic regressions with state and year fixed effects were used to explore associations between county characteristics and the probability that a county had any SUDTFs offering MAUD.
Results: Across 22 000 county-years in a total of 3153 counties, the mean (SD) percentage of counties with at least 1 SUDTF offering MAUD increased from 34.12% (47.42%) in 2017 to 43.88% (49.63%) in 2021, but growth plateaued after 2021. Lower MAUD presence in a county was associated with rural-adjacent (difference, -22.40 percentage points [pp]; 95% CI, -24.43 to -20.38 pp) and rural-remote (-23.64 pp; 95% CI, -25.72 to -21.56 pp) relative to metropolitan county status as well as with a higher poverty rate (-0.66 pp; 95% CI, -0.93 to -0.38 pp), greater percentage of individuals aged 65 years or older (-2.33 pp; 95% CI, -3.02 to -1.65 pp), and higher proportion of non-Hispanic White individuals (-0.58 pp; 95% CI, -0.71 to -0.46 pp), whereas greater prevalence of binge drinking (difference, 1.90 pp; 95% CI, 1.26-2.54 pp) and a higher percentage of college-educated individuals (1.28 pp; 95% CI, 1.13-1.43) were associated with higher MAUD presence.
Conclusions and relevance: In this cross-sectional study, the proportion of SUDTFs offering MAUD increased from 2017 to 2021, but growth then plateaued. Policies supporting the expansion of MAUD-providing facilities, particularly in underserved counties, may be needed to address persistent gaps in access.
Importance: Delays in patient care and occupational burnout are potential consequences of difficulty in managing rising volumes of patient portal messages. The Smart Messaging Tool (SMT) was a custom-built natural language processing tool developed to address 4 key criteria: alignment with care pathways, adaptation to evolving conditions, demonstration of high accuracy, and accommodation of large volumes of messages.
Objective: To assess the viability of SMT in classifying patient messages in a large, integrated, value-based health care system.
Design, setting, and participants: This quality improvement study compared the first 2 years of SMT implementation (March 28, 2023, to March 27, 2025) with the legacy system it replaced. Patient messages sent via the Southern California Permanente Medical Group's (SCPMG's) patient portal were processed by SMT, which generated a label that populated the topic column in the receiving clinician's inbox. Deployed broadly to primary care departments across SCPMG, SMT reached the inboxes of more than 1000 clinicians. Messages could come from any of SCPMG's 4.9 million patients who opted to send secure messages.
Main outcomes and measures: Median time to first read by a clinician of high-acuity messages and SMT classification performance metrics were assessed.
Results: The SMT processed 3 030 247 messages sent by 1 042 418 unique patients (the majority [31.9%] aged 30-49 years; 60.5% female). Median time-to-first read by a clinician for high-acuity messages fell from 22.03 hours (95% CI, 21.47-22.48 hours) to 5.02 hours (95% CI, 4.50-5.77 hours). The SMT achieved 81.0% (95% CI, 77.8%-83.6%) accuracy, which is higher than the 44.0% accuracy of the legacy system. The SMT achieved a top-3 accuracy of 88.5% (95% CI, 86.0%-90.8%) and a top-5 accuracy of 90.7% (95% CI, 88.5%-92.7%).
Conclusions and relevance: This quality improvement study found that SMT reliably categorized patient messages to support improvements in the timely processing of high-acuity messages. The findings suggest that the SMT's practical applicability underscores its relevance to organizations aiming to leverage natural language processing to address message management challenges.
Importance: The improvement of childhood cancer outcomes has relied on clinical trials, primarily from high-income countries (HICs). Inconsistent access to clinical trials, especially in low-income countries (LICs) and middle-income countries, contributes to disparate care and limits the generalizability of conclusions from trials conducted in HICs.
Objective: To describe the global availability of clinical trials for children and adolescents with cancer in different economic settings.
Design, setting, and participants: In this cross-sectional study, the World Health Organization's International Clinical Trials Registry Platform was used to search for clinical trials on May 8, 2024. Trials were included if they were interventional studies for pediatric patients (<18 years old) with an active cancer diagnosis.
Main outcomes and measures: Clinical trials were analyzed based on geographic location, World Bank country income classification, and trial characteristics, including study phase, sponsor type, intervention type, and inclusion criteria. The main outcome was differences between HICs and low- and middle-income countries in the availability, design, and results of clinical trials for children and adolescents with cancer.
Results: Of 138 595 oncology trials, 5645 met the inclusion criteria. Of these, 3149 (55.8%) were pediatrics-only trials. Most pediatrics-only trials (2558 of 3149 [81.2%]) were conducted by sponsors in HICs. Among identified trials, 12.5% (394 of 3149) were open for accrual in upper-middle-income countries (UMICs), 8.9% (281 of 3149) in lower-middle-income countries (LMICs), and 0.2% (7 of 3149) in LICs. Compared with HICs, LMICs or LICs registered fewer early-phase trials (28.8% [42 of 146] vs 81.4% [1709 of 2100]; P < .001), trials with cancer-directed treatments (17.6% [46 of 262] vs 76.8% [1964 of 2558]; P < .001), and multi-institutional trials (6.5% [17 of 262] vs 54.2% [1386 of 2558]; P < .001). LMICs or LICs registered more supportive care-based trials (81.7% [214 of 262] vs 19.9% [509 or 2558]; P < .001). Supportive care trials, later-phase trials, and trials from UMICs, LMICs, and LICs were more likely to publish clinical trial results within 10 years.
Conclusions and relevance: In this cross-sectional study of global pediatric oncology clinical trials, low- and middle-income countries were underrepresented. These data illustrate the need to improve the clinical research infrastructure in low- and middle-income countries and foster inclusive collaborations to promote equity in global pediatric cancer clinical trials.
Importance: There has been a rise in state policies targeting the rights of lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minority (LGBTQIA+) people in the United States. Although large-scale studies have quantified associations between these policies and LGBTQIA+ people's mental health, less research has centered the first-hand accounts of LGBTQIA+ people.
Objective: To examine LGBTQIA+ people's accounts of how they perceive these policies to be impacting their mental health.
Design, setting, and participants: From July to October 2024, 1-hour, semistructured, virtual interviews were conducted with LGBTQIA+ adults living in states that had recently proposed or enacted state LGBTQIA+-targeted policies. The state policies included: (1) gender-affirming care restrictions; (2) sports bans for transgender and nonbinary (TNB) people; (3) public bathroom bans for TNB people; (4) school restrictions of sexual orientation and/or gender identity discussions; and (5) religious exemptions, which permit individuals and service organizations to withhold services from LGBTQIA+ people for religious reasons.
Main outcomes and measures: Transcripts were analyzed using thematic analysis, focusing on participants' perceptions of the mental health impacts of these policies.
Results: Interviews with the 61 adult participants in the sample (median [IQR] age, 35 [30-48] years; 13 cisgender men [21.3%], 19 cisgender women [31.1%], 16 nonbinary people [26.2%], 8 transgender men [13.1%], 2 transgender women [3.3%], and 3 people with another gender identity [4.9%]) revealed that LGBTQIA+ people perceive these policies to negatively impact their mental health. These perceived impacts were organized into 3 themes: (1) chronic worry and hypervigilance, (2) social isolation, and (3) hopelessness and powerlessness. A fourth cross-cutting theme was also identified: participants perceived these policies' mental health impacts to be unequal and more pronounced for those most frequently targeted by these policies (eg, youths, TNB people), racially and ethnically minoritized people, those without social and financial resources, and those living in rural areas.
Conclusions and relevance: In this qualitative study, LGBTQIA+ adults in the United States perceived LGBTQIA+-targeted policies to have profound and unequal impacts on their mental health. As LGBTQIA+-targeted policies increase in number, multilevel resources and supports are necessary to support LGBTQIA+ people's well-being.
Importance: Melatonin is the leading cause of unsupervised medication exposure and overdose in emergency departments for young children (aged 0-6 years). Existing literature has documented the benefits of melatonin in older children (aged 7-18 years) with neurologic conditions but has yet to examine young children.
Objective: To examine the long-term outcomes (safety and effectiveness) associated with melatonin use in young children.
Evidence review: Nine databases, including Ovid MEDLINE, Embase, and Web of Science; 2 clinical trial registries; existing subject matter systematic reviews; and forward and backward citation of included articles were reviewed from inception to February 26, 2025, to identify observational and interventional studies that investigated the safety and effectiveness of exogenous melatonin on sleep in young children. Methodological quality was assessed using the Downs and Black Checklist.
Findings: Nineteen articles representing 12 observational studies, 6 experimental studies (hereafter, trials), and 1 protocol published between 2000 and 2025 were included. The observational studies reported on 9 years (range, 3-21 years) of data from Nordic or Australian registries or poisoning data from the US and Portugal. The trials included 167 young children with neurologic conditions and lasted a mean of 12.7 weeks (range, 2 weeks to 2 years). For safety, observational studies documented rises in prescribing practices, extended use, and overdoses, especially in the past decade. For effectiveness, trials provided evidence for improved sleep onset in young children with neurologic conditions (eg, autism spectrum disorder), with few adverse events. However, data regarding long-term outcomes for other behaviors and health outcomes were absent, and efficacy data were not available for children with typical development. The methodological quality of included studies was poor for 3 studies, fair for 9, and good for 6.
Conclusions and relevance: These findings suggest a global rise in prescriptions without efficacy data on use in children with typical development, underscoring the need to identify strategies to prevent and reduce melatonin use in young children, as well as to improve adherence by pediatricians to evidence-based practice standards.
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