Storylines of family medicine Ⅻ:family medicine and the healthcare system

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine,as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world.In‘Ⅻ:Family medicine and the future of the healthcare system’,authors address the following themes:‘Leadership in family medicine’,‘Becoming an academic family physician’,‘Advocare—our call to act’,‘The paradox of primary care and three simple rules’,‘The quadruple aim—melding the patient and the health system’,‘Fit-for-purpose medical workforce’,‘Universal healthcare—coverage for all’,‘The futures of family medicine’and‘The 100th essay.’May readers of these essays feel empowered to be part of family medicine’s exciting future.

Liver abnormalities following SARS-CoV 2 infection in children 1 to 10 years of age

Objective Beginning in October 2021 in the USA and elsewhere,cases of severe paediatric hepatitis of unknown aetiology were identified in young children.While the adenovirus and adenovirus-associated virus have emerged as leading aetiological suspects,we attempted to investigate a potential role for SARS-CoV 2 in the development of subsequent liver abnormalities.Design We conducted a study using retrospective cohorts of deidentified,aggregated data from the electronic health records of over 100 million patients contributed by US healthcare organisations.Results Compared with propensity score matched children with other respiratory infections,children aged 1-10 years with COVID-19 had a higher risk of elevated transaminases(HR(95%CI)2.16(1.74 to 2.69))or total bilirubin(HR(95%CI)3.02(1.91 to 4.78)),or new diagnoses of liver diseases(HR(95%CI)1.67(1.21 to 2.30))from 1 to 6 months after infection.Patients with pre-existing liver abnormalities,liver abnormalities surrounding acute infection,younger age(1-4 years)or illness requiring hospitalisation all had similarly elevated risk.Children who developed liver abnormalities following COVID-19 had more pre-existing conditions than those who developed abnormalities following other infections.Conclusion These results indicate that SARS-CoV 2 may prime the patient for subsequent development of liver infections or non-infectious liver diseases.While rare(~1 in 1000),SARS-CoV 2 is a risk for subsequent abnormalities in liver function or the diagnosis of diseases of the liver.

Looking forward

I am privileged to share with our readers the 2019 first issue of Family Medicine and Commu-nity Health(FMCH).In front of you is the inaugural issue of FMCH published by BMJ.It marks the beginning of a long-term part-nership of FMCH and BMJ in the pursuit of the shared vision for the journal to become a premier international scientific journal with a focus on family medicine and community health.Launched in 2014,FMCH has enjoyed tremendous growth in the past years and has entered into a new phase of development.

Cultural adaptation and content validity of a Chinese translation of the‘Person-Centered Primary Care Measure’:findings from cognitive debriefing

Objectives To develop an equivalent Chinese translation of the Person-Centered Primary Care Measure(PCPCM)and to establish its cultural adaptability and content validity through cognitive debriefing.Design The original English PCPCM was first translated into Chinese by double forward-translation by professional translators.The reconciliated Chinese version was then doubly back-translated into English by two other professional translators blinded to the forward-translation.On affirmation on its linguistic equivalence with the developers of the original English PCPCM,the reconciliated Chinese PCPCM was sent for cognitive debriefing with 20 Chinese-speaking primary care subjects by a trained interviewer using structured probing questions to collect their opinions on the clarity,comprehensibility and relevance of each item and response option in the Measure.Setting Subjects were invited from a primary care clinic in Hong Kong to undergo the cognitive debriefing interviews.The interviews were divided into four groups chronologically to allow revision of the items to be made in between.Participants Ten males and 10 females above the age of 18 completed the cognitive interviews.They were all Cantonese-speaking Chinese recruited by convenience sampling.Subjects with cognitive impairment,could not read Chinese,too old or too sick to complete the interviews were excluded from the study.Results An average of 3.3 min(range 3-4 min)was required for the subjects to self-complete the Measure.All items were generally perceived to be easily understood and relevant.Modifications were made to items with the content validity index(CVI)on clarity or understanding<0.8 in each round of the interviews or if a majority of the subjects suggested rewording.Revisions were made to two items in the Chinese PCPCM throughout the whole cognitive debriefing process before the final version was confirmed.The average CVI on clarity of the Chinese PCPCM items ranged from 0.75 to 1.The average CVI on understanding ranged from 0.7 to 1.The average CVI on relevance ranged from 0.55 to 1.Conclusions The content validity of the PCPCM was ascertained in terms of its clarity,understandability and relevance to allow further testing of its psychometric properties in a larger Chinese population.

Association of COVID- 19 with respiratory syncytial virus (RSV) infections in children aged 0-5 years in the USA in 2022: a multicentre retrospective cohort study

Objective To investigate whether COVID-19 infection was associated with increased risk for incident respiratory syncytial virus(RSV)infections and associated diseases among young children that might have contributed to the 2022 surge of severe paediatric RSV cases in the USA.Design This is a retrospective population-based cohort study.Five outcomes were examined,including overall RSV infection,positive lab test-confirmed RSV infection,clinically diagnosed RSV diseases,RSV-associated bronchiolitis and unspecified bronchiolitis.Risk ratio(RR)and 95%CI of the outcomes that occurred during the 2022 and 2021 RSV seasons were calculated by comparing propensity-score matched cohorts.Setting Nationwide multicentre database of electronic health records(EHRs)of 61.4million patients in the USA including 1.7million children 0–5 years of age,which was accessed through TriNetX Analytics that provides web-based and secure access to patient EHR data from hospitals,primary care and specialty treatment providers.Participants The study population consisted of 228940 children of 0–5 years with no prior RSV infection who had medical encounters in October 2022.Findings were replicated in a separate study population of 370919 children of 0–5 years with no prior RSV infection who had medical encounters in July 2021–August 2021 during a non-overlapping time period.Results For the 2022 study population(average age 2.4 years,46.8%girls,61%white,16%black),the risk for incident RSV infection during October 2022–December 2022 was 6.40%for children with prior COVID-19 infection,higher than 4.30%for the matched children without COVID-19(RR 1.40,95%CI 1.27 to 1.55);and among children aged 0–1year,the overall risk was 7.90%for those with prior COVID-19 infection,higher than 5.64%for matched children without(RR 1.40,95%CI 1.21 to 1.62).For the 2021 study population(average age 2.2 years,46%girls,57%white,20%black),the risk for incident RSV infection during July 2021–December 2021 was 4.85%for children with prior COVID-19 infection,higher than 3.68%for the matched children without COVID-19(RR 1.32,95%CI 1.12 to 1.56);and 7.30%for children aged 0–1year with prior COVID-19 infection,higher than 4.98%for matched children without(RR 1.47,95%CI 1.18 to 1.82).Conclusion COVID-19 was associated with a significantly increased risk for RSV infections among children aged 0-5 years in 2022.Similar findings were replicated for a study population of children aged 0-5 years in 2021.Our findings suggest that COVID-19 contributed to the 2022 surge of RSV cases in young children through the large buildup of COVID-19-infected children and the potential long-term adverse effects of COVID-19 on the immune and respiratory system.

Time trend and seasonality in medically attended respiratory syncytial virus (RSV) infections in US children aged 0-5 years, January 2010-January 2023

Objective The long-term time trend and seasonality variations of first-time medically attended respiratory syncytial virus(RSV)infections among young children are unknown.We aim to examine the time trend of medically attended first-time RSV infections among young children in the USA from January 2010 through January 2023.Design This is a population-based cohort study using electronic health records(EHRs).Monthly incidence rate of medically attended first-time RSV infection(cases per 10000000 person-days).A time-series regression model was used to model and predict time trends and seasonality.Setting Multicenter and nationwide TriNetX Network in the USA.Participants The study population comprised children aged 0–5 years who had medical visits during the period of January 2010 to January 2023.Results The data included 29013937 medical visits for children aged 0–5 years(46.5%girls and 53.5%boys)from January 2010 through January 2023.From 2010 through 2019,the monthly incidence rate of first-time medically attended RSV infection in children aged 0–5 years followed a consistent seasonal pattern.Seasonal patterns of medically attended RSV infections were significantly disrupted during the COVID-19 pandemic.In 2020,the seasonal variation disappeared with a peak incidence rate of 20 cases per 1000000 person-days,a decrease of 97.4%from the expected peak rate(rate ratio or RR:0.026,95%CI 0.017 to 0.040).In 2021,the seasonality returned but started 4 months earlier,lasted for 9 months,and peaked in August at a rate of 753 cases per 1000000 person-days,a decrease of 9.6%from the expected peak rate(RR:0.90,95%CI 0.82 to 0.99).In 2022,the seasonal pattern is similar to prepandemic years but reached a historically high rate of 2182 cases per 10000000 person-days in November,an increase of 143%from the expected peak rate(RR:2.43,95%CI 2.25 to 2.63).The time trend and seasonality of the EHR-based medically attended RSV infections are consistent with those of RSV-associated hospitalisations from the Centers for Disease Control and Prevention(CDC)survey-based surveillance system.Conclusion The findings show the disrupted seasonality during the COVID-19 pandemic and a historically high surge of paediatric RSV cases that required medical KEY POINTS⇒Question What are the long-term trends and recent seasonality pattern changes in medically attended respiratory syncytial virus(RSV)infections in chil-dren aged 0–5 years in the USA?⇒Findings This population-based cohort study of 29013937 medical visits for children aged 0–5 years found that the monthly incidence rate of first-time medically attended RSV infections followed a consistent seasonal pattern during 2010–2019,the seasonal pattern was significantly disrupted during the COVID-19 pandemic.The seasonal variation dis-appeared in 2020,returned in 2021 but started ear-lier and reached a historical high rate of 2182 cases per 10000000 person-days in November 2022.⇒Meaning These data suggest that COVID-19 pan-demic contributed to the disrupted seasonality and the 2022 surge of paediatric RSV cases that need-ed medical attention.This study demonstrates the potential of electronic health records as a cost-effective alternative for real-time surveillance of un-expected disease patterns including RSV infection.attention in 2022.Our study demonstrates the potential of EHRs as a cost-effective alternative for real-time pathogen and syndromic surveillance of unexpected disease patterns including RSV infection.

Combinations of chronic conditions,functional limitations and geriatric syndromes associated with periodontal disease

Objective To identify complex multimorbid conditions,including chronic conditions,functional limitations and geriatric syndromes,associated with the presence and severity of periodontal disease(PD),after accounting for a series of demographic and behavioural characteristics.Design This cross-sectional study used secondary data from a nationally representative sample,classification and regression tree analysis and random forest identified combinations of specific conditions constituting complex multimorbidity associated with the presence and severity of PD.Setting US National Health and Nutritional Examination Survey(2013-2014).Participants Individuals 60 years of age or older who completed a periodontal examination.Results Among 937 participants aged 60 and over,the prevalence of PD was 72.6%.PD was associated with sociodemographic factors and limitations in instrumental activities of daily living.Male sex and non-white race were the two most critical predictors of stage III/IV PD.Other important factors included age,education level and the federal poverty level.Conclusions Rather than chronic conditions or geriatric syndromes,PD was associated with sociodemographic factors and functional limitations.Accounting for the co-occurrence of sociodemographic and functional limitations will help recognise older adults who are at an increased vulnerability to the severity of PD.