The impact of physician training on child maltreatment reporting: a multi-specialty study

BACKGROUND: Past studies have suggested that physicians underreport suspected child maltreatment (CM) cases, possibly because of a lack of knowledge of the subject. OBJECTIVES: To evaluate the amount, format, and content of CM training received in residency (graduate medical education) and continuing medical education (CME), and to compare its relationship to the likelihood of reporting CM. METHODS: A total of 482 U.S. Air Force emergency physicians, family practice physicians, and pediatricians were surveyed regarding the amount/type of CM training received as well as their CM reporting practices. RESULTS: Pediatricians report receiving more CM training during CME than either emergency physicians or family practice physicians, whereas during residency, both pediatricians and emergency physicians received more training than family practice physicians. Two-thirds of the training related solely to physical and sexual abuse, with little attention paid to other forms of CM. Regression analysis indicated that the only factor associated with the likelihood of reporting maltreatment was the amount of CME received. CONCLUSION: CME seems to positively influence physician reporting practices for CM cases, suggesting a need for universal training protocols.     

Clinical Outcomes of Patients Hospitalized with Coronavirus Disease 2019 (COVID-19) in Boston

BackgroundOutcomes of hospitalized patients with COVID-19 have been described in health systems overwhelmed with a surge of cases. However, studies examining outcomes of patients admitted to hospitals not in crisis are lacking.ObjectiveTo describe clinical characteristic and outcomes of all patients with COVID-19 who are admitted to hospitals not in crisis, and factors associated with mortality in this population.DesignA retrospective analysisParticipantsIn total, 470 consecutive patients with COVID-19 requiring hospitalization in one health system in Boston from January 1, 2020 to April 15, 2020.Main MeasuresWe collected clinical outcomes during hospitalization including intensive care unit (ICU) admission, receipt of mechanical ventilation, and vasopressors. We utilized multivariable logistic regression models to examine factors associated with mortality.Key ResultsA total of 470 patients (median age 66 [range 23–98], 54.0% male) were included. The most common comorbidities were diabetes (38.5%, 181/470) and obesity (41.3%, 194/470). On admission, 41.9% (197/470) of patients were febrile and 60.6% (285/470) required supplemental oxygen. During hospitalization, 37.9% (178/470) were admitted to the ICU, 33.6% (158/470) received mechanical ventilation, 29.4% (138/470) received vasopressors, 16.4% (77/470) reported limitations on their desire for life-sustaining therapies such as intubation and cardiopulmonary resuscitation, and 25.1% (118/470) died. Among those admitted to the ICU (N=178), the median number of days on the ventilator was 10 days (IQR 1–29), and 58.4% (104/178) were discharged alive. Older age (OR=1.04, P<0.001), male sex (OR=2.14, P=0.007), higher comorbidities (OR=1.20, P=0.001), higher lactate dehydrogenase on admission (2nd tertile: OR=4.07, P<0.001; 3rd tertile: OR=8.04, P<0.001), and the need for supplemental oxygen on admission (OR=2.17, P=0.014) were all associated with higher mortality.ConclusionsThe majority of hospitalized patients with COVID-19 and those who received mechanical ventilation survived. These data highlight the need to examine public health and system factors that contribute to improved outcomes for this population.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06622-x.     

Incorporation of human complement C8 into the membrane attack complex is mediated by a binding site located within the C8beta MACPF domain

Human C8 is one of five complement components (C5b, C6, C7, C8, C9) that interact to form the membrane attack complex (MAC). C8 is an oligomeric protein composed of a disulfide-linked C8alpha-gamma heterodimer and a noncovalently associated C8beta chain. C8alpha and C8beta are homologous; both contain N- and C-terminal modules and an intervening approximately 40 kDa segment referred to as the membrane attack complex/perforin (MACPF) domain. C8beta participates in at least two binding interactions. It has a high affinity binding site for C8alpha, which facilitates its interaction with C8alpha-gamma. C8beta also mediates incorporation of C8 into the MAC by binding to C5b-7, an intermediate in the MAC assembly pathway. Little is known about the location or properties of the respective binding sites on C8beta. In this study, the MACPF domain of C8beta (betaMACPF) was expressed in Escherichia coli and its role in binding C8alpha and C5b-7 examined. Recombinant betaMACPF was shown to bind C8alpha-gamma in solution and form a noncovalent complex (betaMACPF*C8alpha-gamma) that exhibited C8 hemolytic activity. betaMACPF was also capable of binding independently to erythrocytes carrying C5b-7. Subsequent addition of C8alpha-gamma and C9 to these cells produced a hemolytically active MAC. The ability to produce a soluble, recombinant betaMACPF that retains the binding functions of C8beta suggests this segment of C8beta is an independently folded domain. Furthermore, results indicate the principal binding sites for C8alpha and C5b-7 are located within this domain, and that C8beta binding specificity is not determined by the N- and C-terminal modules.     

HOSPITAL AND FURTHER EDUCATION — A COMING TOGETHER

SUMMARY: There has been recent interest in the extension of adult education facilities to mentally handicapped people. However this idea has tended to be limited to day courses for mentally handicapped people living in the community or activities for students attending adult training centres. At Blofield Hall, a hostel attached to Little Plumstead Hospital on the outskirts of Norwich, the need for further education in an adult setting was identified by staff and residents. This paper details the setting up and operation of evening courses for the residents by Norwich City College, and comments on the success of this venture.     

Amyloid precursor protein regulates differentiation of human neural stem cells

Although amyloid beta (Abeta) deposition has been a hallmark of Alzheimer's disease (AD), the absence of a phenotype in the beta amyloid precursor protein (APP) knockout mouse, tends to detract our attention away from the physiological functions of APP. Although much attention has been focused on the neurotoxicity of Abeta, many studies suggest the involvement of APP in neuroplasticity. We found that secreted amyloid precursor protein (sAPP) increased the differentiation of human neural stem cells (hNSCs) in vitro, while an antibody-recognizing APP dose-dependently inhibited these activities. With a high dose of sAPP treatment or wild-type APP gene transfection, hNSCs were differentiated into astrocytes rather than neurons. In vivo, hNSCs transplanted into APP-transgenic mouse brain exhibited glial differentiation rather than neural differentiation. Our results suggest that APP regulates neural stem cell biology in the adult brain, and that altered APP metabolism in Down syndrome or AD may have implications for the pathophysiology of these diseases.     

Susceptibility to severe Streptococcal sepsis: use of a large set of isogenic mouse lines to study genetic and environmental factors

Variation in responses to pathogens is influenced by exposure history, environment and the host's genetic status. We recently demonstrated that human leukocyte antigen class II allelic differences are a major determinant of the severity of invasive group A streptococcal (GAS) sepsis in humans. While in-depth controlled molecular studies on populations of genetically well-characterized humans are not feasible, it is now possible to exploit genetically diverse panels of recombinant inbred BXD mice to define genetic and environmental risk factors. Our goal in this study was to standardize the model and identify genetic and nongenetic covariates influencing invasive infection outcomes. Despite having common ancestors, the various BXD strains (n strains=33, n individuals=445) showed marked differences in survival. Mice from all strains developed bacteremia but exhibited considerable differences in disease severity, bacterial dissemination and mortality rates. Bacteremia and survival showed the expected negative correlation. Among nongenetic factors, age -- but not sex or weight -- was a significant predictor of survival (P=0.0005). To minimize nongenetic variability, we limited further analyses to mice aged 40-120 days and calculated a corrected relative survival index that reflects the number of days an animal survived post-infection normalized to all significant covariates. Genetic background (strain) was the most significant factor determining susceptibility (P< or =0.0001), thus underscoring the strong effect of host genetic variation in determining susceptibility to severe GAS sepsis. This model offers powerful unbiased forward genetics to map specific quantitative trait loci and networks of pathways modulating the severity of GAS sepsis.     

Extracorporeal shock-wave lithotripsy (ESWL) of pelvic kidney calculus. Use of C-arm fluoroscopy for correct patient positioning

Extracorporeal shock-wave lithotripsy (ESWL) is the preferred treatment modality for renal and upper ureteral calculi. It is usually reserved, however, for urinary tract calculi above the iliac crest of the bony pelvis. A calyx calculus in a pelvic kidney was successfully treated with ESWL by using a C-arm fluoroscope to simulate the exact direction of the shock waves. The patient was then positioned so that the shock waves entered below the sacrosciatic notch. This same technique of exact patient positioning may have application in the treatment of some lower ureteral calculi.     

Critical issues in bioterrorism preparedness: before and after September 2001.

The Bioterrorism Preparedness and Response Survey (BPRS) was a survey of Ohio local health departments' capacity to respond to bioterrorism. Soon after completion of the BPRS, the events of September 11 occurred, followed by the human cases of anthrax. The Ohio Response to Bioterrorism 2001 Survey (ORB) identified bioterrorism preparedness issues related to the suspected anthrax incidents. The BPRS measured capacity before September 11, 2001, and the ORB measured Ohio communities' response to white powder incidents. The BPRS and ORB provided independent and outcome measures related to the 2001-bioterrorism events. The significant bioterrorism response issues were: monitoring critical or unexplained deaths and clusters or symptoms; training on bioterrorism agents; integration of medical and criminal investigations of bioterrorism incidents; development of bioterrorism emergency response plans to include agencies to be contacted, management strategies for implementing mass vaccination, prophylaxis, treatment distribution and administration; and participation in a bioterrorism field or tabletop exercise. These results are confirmed and extended by studies by the US General Accounting Office, the Rand Corporation, Trust in the Future of America's Health foundation, and a follow-up survey of issues during a simulated covert smallpox attack.