Management of child maltreatment suspicions in general practice: a mixed methods study.

BACKGROUND: Maltreated children have many long-term consequences throughout their lives, but often maltreated children are not recognised in time by professionals. General practice could be central to the early recognition of child maltreatment due to the long-term relationship with families. OBJECTIVE: How do general practitioners (GPs) and practice nurses (PNs) deal with suspected maltreatment in children below 18 years of age, and which factors influence them to report cases to social authorities. DESIGN AND SETTING: A mixed methods study set in general practice in Denmark. METHOD AND SUBJECTS: We combined data from a nationwide questionnaire with observations from five clinics and 20 interviews with GPs and PNs. We explored our data using the concept of uncertainty as a driver that shapes action and decision-making in general practice. RESULTS: Most GPs (94%) said they would discuss cases of suspected child maltreatment with social services, but in many cases they would prefer to discuss their suspicions with a colleague first (83%) - most likely where there are no clear-cut signs. The qualitative data added nuance to these findings by highlighting the difficulty of communicating across sectors, the importance of maintaining a connection with the child's family, and practicing watchful waiting. CONCLUSION: General practice has an opportunity to act early in cases of suspected child maltreatment if uncertainty is accepted as a critical part of the process of reaching a diagnosis. Communication across sectors is key, as is support for GPs with suspicions and for families in need of help.Key pointsGPs are often thought to underreport child maltreatment but despite low levels of reporting, this does not mean they ignore it.Building on the connection with the family, making follow appointments, and discussing suspicions with colleagues are typical of how GPs manage suspicions of child abuse.Accepting uncertainty as a condition of raising the alarm could help GPs to act quickly to support children at risk of abuse.

Suspicion of child maltreatment: Knowledge and experiences with mandatory reports to social services among general practitioners in Denmark in 2019-20.

BACKGROUND: Child maltreatment has many consequences through the lifespan. The general practitioners (GPs) are in longitudinal contact with the family and can play an important role in identifying children in danger and reporting to the social services. OBJECTIVE: To explore how GPs manage suspicions of child maltreatment and to investigate potential demographic and geographic differences in reporting practices among Danish GPs. PARTICIPANTS AND SETTING: All registered GPs in Denmark retrieved from Medcom, a state-financed non-profit organization. METHODS: We mailed a questionnaire to all registered GPs with demographics, experiences, knowledge, and attitudes in the context of child maltreatment. RESULTS: We received 1252 completed questionnaires (response rate: 38 %). Most of the participants had suspected child maltreatment during their professional life (90 %) and had made a mandatory report (85 %). More than half had received feedback after the report (56 %) and said that their report led to action (56 %). Most GPs reported feeling confident in dealing with child maltreatment (79 %) and being willing to get involved in case of suspicion (8.9 on a 0-10 scale). We observed no geographical differences in reporting neither across the Danish regions nor among rural and urban practices, but GPs working in single practices made fewer reports to the social services. CONCLUSIONS: Participant GPs in this study are aware of their role in child protection, have experiences with mandatory reports, and are willing to get involved. Possible areas for attention include collaboration and support between different settings, especially between GP practice, hospitals, justice sector, and social services.

Advanced Access scheduling in general practice and use of primary care: a Danish population-based matched cohort study.

BACKGROUND: Advanced access scheduling (AAS) allows patients to receive care from their GP at the time chosen by the patient. AAS has shown to increase the accessibility to general practice, but little is known about how AAS implementation affects the use of in-hours and out-of-hours (OOH) services. AIM: To describe the impact of AAS on the use of in-hours and OOH services in primary care. DESIGN & SETTING: A population-based matched cohort study using Danish register data. METHOD: A total of 161 901 patients listed in 33 general practices with AAS were matched with 287 837 reference patients listed in 66 reference practices without AAS. Outcomes of interest were use of daytime face-to-face consultations, and use of OOH face-to-face and phone consultations in a 2-year period preceding and following AAS implementation. RESULTS: No significant differences were seen between AAS practices and reference practices. During the year following AAS implementation, the number of daytime face-to-face consultations was 3% (adjusted incidence rate ratio [aIRR] = 1.03; 95% confidence interval [CI] = 0.99 to 1.07) higher in the AAS practices compared with the number in the reference practices. Patients listed with an AAS practice had 2% (aIRR = 0.98; 95% CI = 0.92 to 1.04) fewer OOH phone consultations and 6% (aIRR = 0.94; 95% CI = 0.86 to 1.02) fewer OOH face-to-face consultations compared with patients listed with a reference practice. CONCLUSION: This study showed no significant differences following AAS implementation. However, a trend was seen towards slightly higher use of daytime primary care and lower use of OOH primary care.

Very regular high-frequency pulsation modes in young intermediate-mass stars.

Asteroseismology probes the internal structures of stars by using their natural pulsation frequencies1. It relies on identifying sequences of pulsation modes that can be compared with theoretical models, which has been done successfully for many classes of pulsators, including low-mass solar-type stars2, red giants3, high-mass stars4 and white dwarfs5. However, a large group of pulsating stars of intermediate mass-the so-called δ Scuti stars-have rich pulsation spectra for which systematic mode identification has not hitherto been possible6,7. This arises because only a seemingly random subset of possible modes are excited and because rapid rotation tends to spoil regular patterns8-10. Here we report the detection of remarkably regular sequences of high-frequency pulsation modes in 60 intermediate-mass main-sequence stars, which enables definitive mode identification. The space motions of some of these stars indicate that they are members of known associations of young stars, as confirmed by modelling of their pulsation spectra.

PLANETARY CANDIDATES OBSERVED BY Kepler. VIII. A FULLY AUTOMATED CATALOG WITH MEASURED COMPLETENESS AND RELIABILITY BASED ON DATA RELEASE 25.

We present the Kepler Object of Interest (KOI) catalog of transiting exoplanets based on searching four years of Kepler time series photometry (Data Release 25, Q1-Q17). The catalog contains 8054 KOIs of which 4034 are planet candidates with periods between 0.25 and 632 days. Of these candidates, 219 are new in this catalog and include two new candidates in multi-planet systems (KOI-82.06 and KOI-2926.05), and ten new high-reliability, terrestrial-size, habitable zone candidates. This catalog was created using a tool called the Robovetter which automatically vets the DR25 Threshold Crossing Events (TCEs) found by the Kepler Pipeline (Twicken et al. 2016). Because of this automation, we were also able to vet simulated data sets and therefore measure how well the Robovetter separates those TCEs caused by noise from those caused by low signal-to-noise transits. Because of these measurements we fully expect that this catalog can be used to accurately calculate the frequency of planets out to Kepler's detection limit, which includes temperate, super-Earth size planets around GK dwarf stars in our Galaxy. This paper discusses the Robovetter and the metrics it uses to decide which TCEs are called planet candidates in the DR25 KOI catalog. We also discuss the simulated transits, simulated systematic noise, and simulated astrophysical false positives created in order to characterize the properties of the final catalog. For orbital periods less than 100 d the Robovetter completeness (the fraction of simulated transits that are determined to be planet candidates) across all observed stars is greater than 85%. For the same period range, the catalog reliability (the fraction of candidates that are not due to instrumental or stellar noise) is greater than 98%. However, for low signal-to-noise candidates found between 200 and 500 days, our measurements indicate that the Robovetter is 73.5% complete and 37.2% reliable across all searched stars (or 76.7% complete and 50.5% reliable when considering just the FGK dwarf stars). We describe how the measured completeness and reliability varies with period, signal-to-noise, number of transits, and stellar type. Also, we discuss a value called the disposition score which provides an easy way to select a more reliable, albeit less complete, sample of candidates. The entire KOI catalog, the transit fits using Markov chain Monte Carlo methods, and all of the simulated data used to characterize this catalog are available at the NASA Exoplanet Archive.

Stellar spin-orbit misalignment in a multiplanet system.

Stars hosting hot Jupiters are often observed to have high obliquities, whereas stars with multiple coplanar planets have been seen to have low obliquities. This has been interpreted as evidence that hot-Jupiter formation is linked to dynamical disruption, as opposed to planet migration through a protoplanetary disk. We used asteroseismology to measure a large obliquity for Kepler-56, a red giant star hosting two transiting coplanar planets. These observations show that spin-orbit misalignments are not confined to hot-Jupiter systems. Misalignments in a broader class of systems had been predicted as a consequence of torques from wide-orbiting companions, and indeed radial velocity measurements revealed a third companion in a wide orbit in the Kepler-56 system.

Kepler-62: a five-planet system with planets of 1.4 and 1.6 Earth radii in the habitable zone.

We present the detection of five planets--Kepler-62b, c, d, e, and f--of size 1.31, 0.54, 1.95, 1.61 and 1.41 Earth radii (R⊕), orbiting a K2V star at periods of 5.7, 12.4, 18.2, 122.4, and 267.3 days, respectively. The outermost planets, Kepler-62e and -62f, are super-Earth-size (1.25 R⊕ < planet radius ≤ 2.0 R⊕) planets in the habitable zone of their host star, respectively receiving 1.2 ± 0.2 times and 0.41 ± 0.05 times the solar flux at Earth's orbit. Theoretical models of Kepler-62e and -62f for a stellar age of ~7 billion years suggest that both planets could be solid, either with a rocky composition or composed of mostly solid water in their bulk.

A sub-Mercury-sized exoplanet.

Since the discovery of the first exoplanets, it has been known that other planetary systems can look quite unlike our own. Until fairly recently, we have been able to probe only the upper range of the planet size distribution, and, since last year, to detect planets that are the size of Earth or somewhat smaller. Hitherto, no planets have been found that are smaller than those we see in the Solar System. Here we report a planet significantly smaller than Mercury. This tiny planet is the innermost of three that orbit the Sun-like host star, which we have designated Kepler-37. Owing to its extremely small size, similar to that of the Moon, and highly irradiated surface, the planet, Kepler-37b, is probably rocky with no atmosphere or water, similar to Mercury.

Kepler-36: a pair of planets with neighboring orbits and dissimilar densities.

In the solar system, the planets' compositions vary with orbital distance, with rocky planets in close orbits and lower-density gas giants in wider orbits. The detection of close-in giant planets around other stars was the first clue that this pattern is not universal and that planets' orbits can change substantially after their formation. Here, we report another violation of the orbit-composition pattern: two planets orbiting the same star with orbital distances differing by only 10% and densities differing by a factor of 8. One planet is likely a rocky "super-Earth," whereas the other is more akin to Neptune. These planets are 20 times more closely spaced and have a larger density contrast than any adjacent pair of planets in the solar system.

Fast core rotation in red-giant stars as revealed by gravity-dominated mixed modes.

When the core hydrogen is exhausted during stellar evolution, the central region of a star contracts and the outer envelope expands and cools, giving rise to a red giant. Convection takes place over much of the star's radius. Conservation of angular momentum requires that the cores of these stars rotate faster than their envelopes; indirect evidence supports this. Information about the angular-momentum distribution is inaccessible to direct observations, but it can be extracted from the effect of rotation on oscillation modes that probe the stellar interior. Here we report an increasing rotation rate from the surface of the star to the stellar core in the interiors of red giants, obtained using the rotational frequency splitting of recently detected 'mixed modes'. By comparison with theoretical stellar models, we conclude that the core must rotate at least ten times faster than the surface. This observational result confirms the theoretical prediction of a steep gradient in the rotation profile towards the deep stellar interior.

Gravity modes as a way to distinguish between hydrogen- and helium-burning red giant stars.

Red giants are evolved stars that have exhausted the supply of hydrogen in their cores and instead burn hydrogen in a surrounding shell. Once a red giant is sufficiently evolved, the helium in the core also undergoes fusion. Outstanding issues in our understanding of red giants include uncertainties in the amount of mass lost at the surface before helium ignition and the amount of internal mixing from rotation and other processes. Progress is hampered by our inability to distinguish between red giants burning helium in the core and those still only burning hydrogen in a shell. Asteroseismology offers a way forward, being a powerful tool for probing the internal structures of stars using their natural oscillation frequencies. Here we report observations of gravity-mode period spacings in red giants that permit a distinction between evolutionary stages to be made. We use high-precision photometry obtained by the Kepler spacecraft over more than a year to measure oscillations in several hundred red giants. We find many stars whose dipole modes show sequences with approximately regular period spacings. These stars fall into two clear groups, allowing us to distinguish unambiguously between hydrogen-shell-burning stars (period spacing mostly ∼ 50 seconds) and those that are also burning helium (period spacing ∼ 100 to 300 seconds).

Kepler planet-detection mission: introduction and first results.

The Kepler mission was designed to determine the frequency of Earth-sized planets in and near the habitable zone of Sun-like stars. The habitable zone is the region where planetary temperatures are suitable for water to exist on a planet's surface. During the first 6 weeks of observations, Kepler monitored 156,000 stars, and five new exoplanets with sizes between 0.37 and 1.6 Jupiter radii and orbital periods from 3.2 to 4.9 days were discovered. The density of the Neptune-sized Kepler-4b is similar to that of Neptune and GJ 436b, even though the irradiation level is 800,000 times higher. Kepler-7b is one of the lowest-density planets (approximately 0.17 gram per cubic centimeter) yet detected. Kepler-5b, -6b, and -8b confirm the existence of planets with densities lower than those predicted for gas giant planets.

CoRoT measures solar-like oscillations and granulation in stars hotter than the Sun.

Oscillations of the Sun have been used to understand its interior structure. The extension of similar studies to more distant stars has raised many difficulties despite the strong efforts of the international community over the past decades. The CoRoT (Convection Rotation and Planetary Transits) satellite, launched in December 2006, has now measured oscillations and the stellar granulation signature in three main sequence stars that are noticeably hotter than the sun. The oscillation amplitudes are about 1.5 times as large as those in the Sun; the stellar granulation is up to three times as high. The stellar amplitudes are about 25% below the theoretic values, providing a measurement of the nonadiabaticity of the process ruling the oscillations in the outer layers of the stars.

Cost-effectiveness analysis of two management strategies for dyspepsia.

OBJECTIVES: To compare the cost-effectiveness of endoscopy and empirical proton pump inhibition (PPI) therapy for management of dyspepsia in primary care. METHODS: A randomized controlled trial, including prospective collection of economic resource data, was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. We randomly assigned 368 dyspeptic patients from thirty-two general practices to treatment with omeprazol 40 mg for 2 weeks (n=184) or endoscopy (n=184). The study adopted a societal perspective, and the year of costing was 2006. OUTCOME MEASURES: days free of dyspeptic symptoms and proportion of patients with dyspepsia after 1 year based on patients' and general practitioners' (GPs) assessment. Costs were estimated from patient and GP questionnaires and from medical records. RESULTS: The incremental cost-effectiveness (CE) ratio for 1 day free of dyspeptic symptoms using the endoscopy strategy was euro/day 154 compared with the PPI strategy. The incremental CE ratio for one person free of dyspeptic symptoms after 1 year using the endoscopy strategy was euro13,905 based on the patients' evaluation, and the incremental CE ratio for one person free of predominant symptoms after 1 year was euro5,990 according to the GPs' evaluation. The PPI strategy was both cheaper and more effective than the endoscopy strategy when reflux was the predominant symptom. CONCLUSIONS: A strategy using empirical antisecretory PPI therapy should be recommended if the alternative is an endoscopy strategy for managing dyspeptic patients in general practice, especially if reflux was the predominant symptom.