Asking the difficult questions: Building the capacity of community paediatricians to routinely enquire and respond to family violence.

AIM: To enhance the confidence and capacity of community paediatricians and paediatric trainees to identify and respond to family violence, through a series of education sessions and evidence-based recommendations. METHODS: The action research methodology included a literature search to review the data on family violence education programmes and evidence-based family violence screening tools. Six education sessions were then developed and held for physicians at the Community Paediatric and Child Health Service (CPCHS). An audit was performed on the charts of all new referrals to the CPCHS for a period of 18 months prior to the education sessions and 5 months following the education sessions. A questionnaire was distributed at the first and final education sessions to gauge physician comfort with enquiry into family violence. RESULTS: The documented rate of enquiry into family violence at CPCHS was 24% in the retrospective chart audit. Following the series of education sessions, the documented rate of enquiry increased to 60% (P < 0.05, odds ratio 4.7, confidence interval 2.7-8.4). The documented rate of disclosure of family violence also increased from 13% of all new patients in the retrospective chart audit to 24% in the prospective arm of the study (P < 0.05, odds ratio 2.1, confidence interval 1.0-4.0). Following the education sessions, all participants agreed that they routinely enquired about family violence and were comfortable enquiring about family violence. CONCLUSION: This study demonstrates that clinician education about family violence supports routine enquiry about family violence in community paediatric consultations.

An analysis of patient self-reported COVID-19 symptoms during the first wave of the pandemic in Ireland.

BACKGROUND: Since the outbreak of COVID-19 in December 2019, there have been more than 115 million cases worldwide (1). Symptoms of COVID-19 vary widely and the spectrum of clinical presentation has yet to be fully characterised (2). Many countries have detailed their early experience with COVID-19, with a focus on the clinical characteristics of the disease. However, to our knowledge, there has been no such study detailing symptoms in the Irish population. AIM: Our aim is to describe COVID-19 symptoms in the Irish population at the beginning of the COVID-19 pandemic and compare symptoms between those reporting positive and negative test results. METHOD: A Web page MyCovidSymptoms.ie was created by researchers at the National University of Ireland, Galway, in April 2020 to investigate COVID-19 symptoms in Ireland. The Web page invited participants to self-report RT-PCR test outcome data (positive, negative, untested), temperature and a range of symptoms (cough, shortness of breath, fatigue, loss of taste, loss of smell). RESULTS: One hundred and twenty-three Irish participants who had a RT-PCR test for COVID-19 logged their symptoms. Eighty-four patients reported that they tested positive for COVID-19, and 39 patients reported a negative COVID-19 test. In our cohort of respondents with a positive COVID-19 test, 49/84 (58%) respondents reported a cough. Of the 39 respondents with a negative COVID-19 test, 17 (44%) reported having a cough. The distribution of temperature was similar in both those with and without COVID-19. Levels of self-reported fatigue were high in both groups with 65/84 (77%) of COVID-19-positive patients reporting fatigue and 30/39 (77%) of those who were COVID-19-negative reporting fatigue. New symptoms emerging at the time of data collection included loss of taste and smell. We demonstrated a higher proportion of loss of smell (p = 0.02) and taste (p = 0.01) in those reporting a positive result, compared to those reporting a negative result. CONCLUSION: These data represents an early picture of the clinical characteristics of COVID-19 in an Irish population. It also highlights the potential use of self-reported data globally as a powerful tool in helping with the pandemic.

Artificial Intelligence for Detecting COVID-19 With the Aid of Human Cough, Breathing and Speech Signals: Scoping Review.

Goal: Official tests for COVID-19 are time consuming, costly, can produce high false negatives, use up vital chemicals and may violate social distancing laws. Therefore, a fast and reliable additional solution using recordings of cough, breathing and speech data for preliminary screening may help alleviate these issues. Objective: This scoping review explores how Artificial Intelligence (AI) technology aims to detect COVID-19 disease by using cough, breathing and speech recordings, as reported in the literature. Here, we describe and summarize attributes of the identified AI techniques and datasets used for their implementation. Methods: A scoping review was conducted following the guidelines of PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). Electronic databases (Google Scholar, Science Direct, and IEEE Xplore) were searched between 1st April 2020 and 15th August 2021. Terms were selected based on the target intervention (i.e., AI), the target disease (i.e., COVID-19) and acoustic correlates of the disease (i.e., speech, breathing and cough). A narrative approach was used to summarize the extracted data. Results: 24 studies and 8 Apps out of the 86 retrieved studies met the inclusion criteria. Half of the publications and Apps were from the USA. The most prominent AI architecture used was a convolutional neural network, followed by a recurrent neural network. AI models were mainly trained, tested and run-on websites and personal computers, rather than on phone apps. More than half of the included studies reported area-under-the-curve performance of greater than 0.90 on symptomatic and negative datasets while one study achieved 100% sensitivity in predicting asymptomatic COVID-19 from cough-, breathing- or speech-based acoustic features. Conclusions: The included studies show that AI has the potential to help detect COVID-19 using cough, breathing and speech samples. The proposed methods (with some time and appropriate clinical testing) could prove to be an effective method in detecting various diseases related to respiratory and neurophysiological changes in the human body.

Calcium-sensing receptor antagonism or lithium treatment ameliorates aminoglycoside-induced cell death in renal epithelial cells.

The aminoglycoside antibiotic gentamicin elicits proximal tubular toxicity and cell death. In calcium-sensing receptor (CaR)-transfected HEK-293 (CaR-HEK) cells and CaR-expressing proximal tubule-derived opossum kidney (OK) cells, chronic gentamicin treatment elicits dose-dependent, caspase-mediated apoptotic cell death. Here we investigated whether the renal cell toxicity of the CaR agonist gentamicin could be prevented by CaR antagonism or by lithium cotreatment which may interfere with receptor-mediated signalling. Chronic treatment of OK and CaR-HEK cells with low concentrations of gentamicin elicited cell death, an effect that was ameliorated by cotreatment with the CaR negative allosteric modulator (calcilytic) NPS-89636. This calcilytic also attenuated CaR agonist-induced ERK activation in these cells. In addition, 1 mM LiCl, equivalent to its therapeutic plasma concentration, also inhibited gentamicin-induced toxicity in both cell types. This protective effect of lithium was not due to the disruption of phosphatidylinositol-mediated gentamicin uptake as the cellular entry of Texas red-conjugated gentamicin into OK and CaR-HEK cells was unchanged by lithium treatment. However, the protective effect of lithium was mimicked by glycogen synthase 3beta inhibition. Together, these data implicate CaR activation and a lithium-inhibitable signalling pathway in the induction of cell death by gentamicin in renal epithelial cells in culture.

Extracellular calcium- and magnesium-mediated regulation of passive calcium transport across Caco-2 monolayers.

The calcium-sensing receptor (CaR) is expressed on intestinal epithelial serosal membrane and in Caco-2 cells. In renal epithelium, CaR expressed on the basolateral membrane acts to limit excess tubular Ca2+ reabsorption. Therefore, here we investigated whether extracellular calcium (Ca(o)2+) can regulate active or passive 45Ca2+ transport across differentiated Caco-2 monolayers via CaR-dependent or CaR-independent mechanisms. Raising the Ca(o)2+ concentration from 0.8 to 1.6 mM increased transepithelial electrical resistance (TER) and decreased passive Ca2+ permeability but failed to alter active Ca2+ transport. The Ca(o)2+ effect on TER was rapid, sustained and concentration-dependent. Increasing basolateral Mg2+ concentration increased TER and inhibited both passive and active Ca2+ transport, whereas spermine and the CaR-selective calcimimetic NPS R-467 were without effect. We conclude that small increases in divalent cation concentration elicit CaR-independent increases in TER and inhibit passive Ca2+ transport across Caco-2 monolayers, most probably through a direct effect on tight junction permeability. Whilst it is known that the complete removal of Ca(o)2+ lowers TER, here we show that Ca(o)2+ addition actually increases TER in a concentration-dependent manner. Therefore, such Ca(o)2+-sensitivity could modulate intestinal solute transport including the limiting of excess Ca2+ absorption.

Characteristics of out-of-home caregiving environments provided under child welfare services.

A national probability sample of children who have been in child welfare supervised placements for about one year identifies the characteristics (e.g., age, training, education, health, and home) of the foster parents, kinship foster parents, and group home caregivers. Caregiving respondents provided information about their backgrounds. Interviewers also used the HOME-SF to assess the caregiving environments of foster care and kinship care. Comparisons are made to other nationally representative samples, including the U.S. Census and the National Survey of America's Families. Kinship care, foster care, and group care providers are significantly different from each other--and the general population--in age and education. Findings on the numbers of children cared for, understimulating environments, use of punitive punishment, and low educational levels of caregivers generate suggestions for practice with foster families.

Substance abuse treatment and the recurrence of maltreatment among caregivers with children living at home: a propensity score analysis.

Policy and programmatic initiatives of the last decade have focused on increased coordination of services and expansion of prompt substance abuse treatment for mothers initially involved with child welfare services (CWS). Yet, little evidence has been amassed concerning the implications of this approach on the recurrent need for CWS. Data are from a large national probability sample of children and their caregivers involved with CWS following an allegation of maltreatment. Data include the recurrence of maltreatment reports for this group of children who remain at home. Selected from 1,101 caregivers with an indicated substance abuse problem, a group of 224 clients who did not receive services were compared with 224 treated clients. Event history analyses showed that clients who received substance abuse treatment were nearly twice as likely to have another child abuse report within 18 months. Reasons why participation in substance abuse treatment may result in greater involvement with CWS are posited.

Complexity of ambulatory care visits of patients with diabetes as reflected by diagnoses per visit.

AIMS: As the proportion of people with multiple chronic conditions grows, so does the complexity of patient care. Although office-based visits to subspecialists are expected to be intense, due to the focused nature of the visit, the complexity of office-based visits to primary care physicians has yet to be explored in depth. To explore complexity, we looked at diabetes as a case study to determine whether and how the complexity of office-based visits varies by physician specialty type, as measured by the number of diagnoses reported per visits. METHODS: The Medical Expenditure Panel Survey data is used to create a nationally-representative sample of adults who self-report a diabetes diagnosis, the specialty of the treating physician for their care, and the number of diagnoses for each visit. Using cross tabulations, the distribution of office-based visits are analyzed based on a categorization of patients by number of visit diagnoses, number of conditions reported, and type of physician seen. RESULTS: Almost 80 percent of visits made by adults with diabetes to subspecialist involved care for that single diagnosis; while 55 percent of visits to primary care involved care for at least one additional diagnosis. Almost 70 percent of visits in which only one diagnosis was reported were to subspecialist physicians. Almost 90 percent of visits in which four diagnoses were reported were to primary care physicians. CONCLUSIONS: Office-based visits to primary care physicians are made increasingly complex by growing population morbidity. Adults with diabetes report more conditions being cared for per visit with primary care physicians than with subspecialty physicians. Future studies into where our results hold for other chronic conditions would be beneficial. As recent United States legislation moves health care payment toward paying for value and population health, encounter complexity should be accommodated.

Family medicine graduate proximity to their site of training: policy options for improving the distribution of primary care access.

BACKGROUND AND OBJECTIVES: The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location. METHODS: Using the 2012 American Medical Association Masterfile and American Academy of Family Physicians membership file, we obtained the percentage of family physicians in direct patient care located within 5, 25, 75, and 100 miles and within the state of their family medicine residency program (FMRP). We also analyzed the effect of time on family physician distance from training site. RESULTS: More than half of family physicians practice within 100 miles of their FMRP (55%) and within the same state (57%). State retention varies from 15% to 75%; the District of Columbia only retains 15% of family physician graduates, while Texas and California retain 75%. A higher percentage of recent graduates stay within 100 miles of their FMRP (63%), but this relationship degrades over time to about 51%. CONCLUSIONS: The majority of practicing family physicians remained proximal to their GME training site and within state. This suggests that decentralized training may be a part of the solution to uneven distribution among primary care physicians. State and federal policy-makers should prioritize funding training in or near areas with poor access to primary care services.

Parental views of in-home services: what predicts satisfaction with child welfare workers?

Evidence on client satisfaction deserves consideration in the design of child welfare policies, programs, and practices. Data in this study come from the National Survey of Child and Adolescent Well-Being. Clients receiving in-home services reported moderate levels of satisfaction with their child welfare workers. Caregiver reports of having less than two child welfare workers, having more recent contact, and receiving timely, responsive services were associated with higher perceived quality of relationships with child welfare workers. The child welfare workers' reports of cooperativeness by the caregiver were also associated with higher caregiver-reported relationship quality.

A report on eight early-stage state and regional projects testing value-based payment.

To help contain health care spending and improve the quality of care, practitioners and policy makers are trying to move away from fee-for-service toward value-based payment, which links providers' reimbursement to the value, rather than the volume, of services delivered. With funding from the Robert Wood Johnson Foundation, eight grantees across the country are designing and implementing value-based payment reform projects. For example, in Salem, Oregon, the Physicians Choice Foundation is testing "Program Oriented Payments," which include incentives for providers who follow a condition-specific program of care designed to meet goals set jointly by patient and provider. In this article we describe the funding rationale and the specific objectives, strategies, progress, and early stages of implementation of the eight projects. We also share some early lessons and identify prerequisites for success, such as ensuring that providers have broad and timely access to data so they can meet patients' needs in cost-effective ways.

Raising low 'patient activation' rates among Hispanic immigrants may equal expanded coverage in reducing access disparities.

There is a growing consensus that activating consumers to become better managers of their health is an essential component of US health care reform. We measured how activated blacks, whites, and Hispanics are-that is, how confident, skillful, and knowledgeable they are about taking an active role in improving their health and health care. We found that patient activation among blacks and Hispanics was low, relative to that of whites. For example, 24.8 percent of Hispanics were at the highest level of patient activation, compared to 39.5 percent of blacks and 45.3 percent of whites. Among Hispanic immigrants, low acculturation and lack of familiarity with the US health care system contribute to low activation. The findings indicate that increasing activation levels among Hispanic immigrants may be as important as expanding insurance coverage in reducing disparities in unmet medical need.

Ca2+-sensing receptor induces Rho kinase-mediated actin stress fiber assembly and altered cell morphology, but not in response to aromatic amino acids.

The Ca2+-sensing receptor (CaR) is a pleiotropic, type III G protein-coupled receptor (GPCR) that associates functionally with the cytoskeletal protein filamin. To investigate the effect of CaR signaling on the cytoskeleton, human embryonic kidney (HEK)-293 cells stably transfected with CaR (CaR-HEK) were incubated with CaR agonists in serum-free medium for up to 3 h. Addition of the calcimimetic NPS R-467 or exposure to high extracellular Ca2+ or Mg2+ levels elicited actin stress fiber assembly and process retraction in otherwise stellate cells. These responses were ablated by cotreatment with the calcilytic NPS 89636 and were absent in vector-transfected HEK-293 cells. Cotreatment with the Rho kinase inhibitors Y-27632 and H1152 attenuated the CaR-induced morphological change but not intracellular Ca2+ (Ca2+(i)) mobilization or ERK activation, although transfection with a dominant-negative RhoA-binding protein also inhibited calcimimetic-induced actin stress fiber assembly. CaR effects on morphology were unaffected by inhibition of G(q/11) or G(i/o) signaling, epidermal growth factor receptor, or the metalloproteinases. In contrast, CaR-induced cytoskeletal changes were not induced by the aromatic amino acids, treatments that also failed to potentiate CaR-induced ERK activation despite inducing Ca2+(i) mobilization. Together, these data establish that CaR can elicit Rho-mediated changes in stress fiber assembly and cell morphology, which could contribute to the receptor's physiological actions. In addition, this study provides further evidence that aromatic amino acids elicit differential signaling from other CaR agonists.