Effects of In-Person Navigation to Address Family Social Needs on Child Health Care Utilization: A Randomized Clinical Trial

IMPORTANCE

While many organizations endorse screening for social risk factors in clinical settings, few studies have examined the health and utilization effects of interventions to address social needs.

OBJECTIVE

To compare the acute care utilization effects of a written resources handout vs an in-person navigation service intervention to address social needs.

DESIGN, SETTINGS, AND PARTICIPANTS

In this secondary analysis of a randomized clinical trial, 1809 adult caregivers of pediatric patients seen in primary and urgent care clinics of 2 safety-net hospitals in northern California were recruited between October 13, 2013, and August 27, 2015. Each participating family was randomly assigned to an in-person navigator intervention vs active control to address the family's social needs. Analyses were conducted between February 28, 2018, and September 25, 2019.

INTERVENTIONS

Caregivers either received written information about relevant local resources related to social needs (active control) or met with a patient navigator focused on helping them resolve social needs (navigator intervention). After an initial in-person visit, navigation services included telephone, email, and/or in-person follow-up for up to 3 months.

MAIN OUTCOME AND MEASURES

Child emergency department visit or hospitalization within 12 months of study enrollment.

RESULTS

Among the 1300 caregivers enrolled in the study without missing follow-up data, most spoke English (878 [67.5%]) and were women (1127 [86.7%]), with a mean (SD) age of 33.0 (9.33) years. Most children were aged 0 to 5 years (779 of 1300 [59.9%]), 723 children (55.6%) had Hispanic ethnicity, and 462 children (35.5%) were in excellent health; 840 families (64.6%) were recruited from urgent care. In total, 637 families (49.0%) were randomized to the in-person navigator group and 663 (51.0%) to the active control group. There was no difference in risk of an emergency department visit between the 2 groups. Children enrolled in the in-person navigator group had a decreased risk of hospitalization within 12 months (hazard ratio, 0.59; 05% CI, 0.38-0.94; P = .03), making them 69% less likely to be hospitalized.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial evaluating heath care utilization effects of programs designed to address social needs among families, children enrolled in the navigation group were significantly less likely to be hospitalized after the intervention but equally likely to have an emergency department visit. These findings strengthen our understanding of the effects of addressing social needs in clinical settings as part of a comprehensive strategy to improve health and reduce health care utilization.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01939704.

Effects of chronic irradiation on the reproductive success of the polychaete worm, Neanthes arenaceodentata

Effects of lifetime exposure to chronic irradiation on reproductive success were assessed for laboratory populations of Neanthes arenaceodentata. Exposure was initiated upon the spawning of the parental (P1) female and was terminated upon spawning of the first filial (F1) generation female; broods from the F1 pairs were sacrificed before hatching occurred. Groups of worms in the experiments received either no radiation (controls) or 0.19, 2.1 or 17 mGy h-1. The total dose received was either background or approximately 0.55, 6.5 or 54 Gy, respectively. The mean number of embryos in the broods from the F1 females exposed to 17 mGy h-1 was statistically significantly different from the mean number of embryos from control females; however, the mean number of embryos in the broods from the F1 females exposed to 0.19 and 2.1 mGy h-1 was not significantly different from the mean number from control females. For all the radiation-exposed groups, there was a statistically significant reduction in the number and percentage of live embryos in the broods from the F1 pairs as well as a statistically significant increase in the numbers and percentages of abnormal embryos. Results on embryo abnormalities and mortalities indicate that dominant- and recessive-lethal mutations were most likely induced in the germ cells and that these mutations had an adverse effect on reproductive success by affecting the survival of early-life stages. Except for pairs exposed to 17 mGy h-1, there was no evidence of gamete killing or reduced fertilization success, because the number of developing embryos in the broods did not decrease with increased dose. Data for the estimated hatch number and actual hatch number indicated that doses as low as 0.19 mGy h-1 can reduce significantly the number of larvae that hatch when lifetime doses are given.

Effects of acute irradiation on reproductive success of the polychaete worm, Neanthes arenaceodentata

Effects of acute irradiation on the reproductive success of a relatively low-fecundity species were investigated by exposing pairs of female and male polychaete worms (Neanthes arenaceodentata) to either no radiation (controls) or 0.5, 1.0, 2.0, 5.0, 10 or 50 Gy of acute irradiation (5 Gy min-1) at the time when oocytes were visible in the female. The broods from the pairs were sacrificed before hatching occurred, and information was obtained on the number in the brood, the number of normal and abnormal embryos, and the number of embryos that were living, dying and dead. Developing gametes of N. arenaceodentata appeared to be sensitive to acute irradiation. There was a significant reduction in the percentage of live embryos in the broods from pairs receiving doses as low as 0.5 Gy, which is lower than the lowest dose at which effects in invertebrates have been reported previously. This was most likely due to the induction of lethal mutations in the developing gametes, which affected the survival of embryos in early stages of life. Except for those pairs receiving 10 or 50 Gy, there was no evidence of decreased fertility or fecundity or of reduced fertilization success; the number of embryos in the broods from only these irradiated groups was significantly different from the controls.

The 14 kDa beta-galactoside binding lectin in myoblast and myotube cultures: localization by confocal microscopy

The endogenous 14 kDa beta-galactoside-specific lectin has been localised in myoblasts and myotubes by indirect immunofluorescence using confocal microscopy. The antibodies used in these experiments suggest that in myoblast cultures the lectin is abundant on the cell surface and concentrated at ruffled edges of migrating cells. The quantity and distribution of cell surface lectin is independent of the nature of the substratum and undiminished by brief trypsinisation or lactose-washing of the cell suspension. The lectin is also abundant intracellularly, apparently relatively free in the cytoplasm until the cells approach confluency, when the lectin is concentrated into particular areas of cytoplasm resulting in a ‘patchy’ appearance of stained cells. After fusion to form multinucleate myotubes, intracellular lectin is less abundant and concentrated at the periphery of myotubes, from where lectin appears to be released in vesicles packed with lectin which ‘bud off’ from the myotube surface. In recolonising cultures, lectin is apparently more abundant and lectin-packed vesicles can also be seen ‘budding off’ from myoblasts. In differentiated cultures, extracellular lectin is detected both on the myotube surface and in fibrillar arrays of extracellular material.

The sugared path to a normal lung: soluble beta-galactoside-specific lectins

The diverse functions of a family of soluble beta-galactoside-binding proteins in lung are discussed. The smallest and most abundant member, a 14-kDa lectin, appears to be a negative modulator of cell growth. Larger members of this family include RL29, a protein involved in the regulation of cytoplasmic RNA levels, and one subunit of the cell surface elastin receptor involved in the regulation of elastic fibrillogenesis. The structure and function of other members of this family remain to be elucidated, but probably homologous carboxy-terminal domains will specify the galactose-binding function and varied amino-terminal domains will specify the diverse biological functions. Although currently these functions are being described at the cellular level, these beta-galactoside-binding proteins appear to have important roles in regulating lung physiology.

The sequence of the mouse 14 kDa beta-galactoside-binding lectin and evidence for its synthesis on free cytoplasmic ribosomes

The partial amino acid sequence of the mouse 14 kDa beta-galactoside-binding lectin has been deduced from cDNA clones corresponding to 86% of the coding sequence and extending to the polyadenylation signal. The deduced amino acid sequence for the murine lectin shows 94% identity with the rat, 89% with human, 86% with bovine and 46% with the chicken 14 kDa lectins. A cDNA probe has been used to analyse genomic DNA and identify a single mRNA of approx. 570 bp in 3T3 fibroblasts, murine erythroleukaemia cells and the murine basement-membrane-secreting Engelbreth-Holm-Swarm tumour. Analysis of free and bound polyribosomes has shown that the lectin message is translated on free cytoplasmic ribosomes.

Distribution of an endogenous beta-galactoside-specific lectin during foetal and neonatal rabbit development

The tissue concentration of an endogenous beta-galactoside-specific lectin is developmentally regulated in rabbit tissues during foetal and neonatal development. Immunoassay data and localization studies both indicate that the lectin is particularly associated with late embryonic and early postnatal development. No lectin could be detected in embryos prior to 21 days of gestation, whereas many tissues showed an increase in lectin around the time of birth. It is likely that in most tissues the high concentrations of lectin are largely due to increased synthesis by fibroblasts, which are particularly abundant and active in connective tissue during the extensive tissue reorganization taking place at this time. The lectin appears to be synthesized by other differentiated cell types also, notably myoblasts, alveolar cells and erythroblasts. The peak of lectin concentration seen in foetal liver probably reflects lectin associated with foetal erythropoiesis. The rabbit lectin has a low specific activity but its tissue concentration is correspondingly higher than lectin concentrations in other mammals. This conservation of total lectin activity suggests a fundamental role for the lectin dependent upon its saccharide binding activity. This and other indirect evidence suggests that these lectins are involved in the synthesis, secretion or organization of extracellular matrix components.

Intra- and extracellular distribution of an endogenous lectin during erythropoiesis

An endogenous beta-galactoside-specific lectin has previously been isolated from rabbit bone marrow. The quantification of extracted lectin now indicates that approximately 75% of the lectin is intracellular in marrow. Indirect immunofluorescence studies show the extracellular lectin is associated with the erythroblast cell surface and is also found in some acellular areas of the marrow stroma. At enucleation, lectin surrounds the extruded nucleus while some residual lectin is observed in the cytoplasm of circulating reticulocytes and erythrocytes.

Selective association of an endogenous lectin with connective tissues

Using indirect immunofluorescence we have localized an endogenous beta-galactoside-specific lectin in resin-embedded rabbit tissue sections. The pattern of lectin distribution correlates well with biochemical estimations of lectin levels, being abundant in intestine, lung and heart tissue and relatively less abundant in skeletal muscle, liver and kidney. In all tissues lectin is found in connective tissue associated with fibroblasts and the extracellular matrix, and at the periphery of morphologically recognizable smooth muscle cells. The lectin is abundant in skin, intestine and blood vessels, where connective tissue forms the tissue architecture. It is also abundant in heart, where it is particularly associated with the capillaries and lung, where it is also found in alveolar cells. Discrete localization of lectin occurs in areas of connective tissue where epithelial elements are differentiating, such as the crypts of Lieberkuhns in the small intestine and hair follicles in the skin. From these observations we suggest that in cells of mesenchymal origin these endogenous lectins may play a role in the elaboration or organization of the extracellular matrix that regulates tissue differentiation in a number of embryonic and adult tissues.

Surface localization of an endogenous lectin in rabbit bone marrow

A lectin, which may be involved in cell to cell adhesion during erythropoiesis in rabbit bone marrow, has been isolated and characterized. Several electron microscopical techniques have been used to investigate the cell surface distribution of this lectin in bone marrow utilizing colloidal gold conjugates of anti-lectin IgG or protein A. The lectin is present at the surface of erythroid cells at all stages of development but no lectin was detected on the surface of myeloid cells. The limitations and complementary nature of the techniques used are discussed.

Endogenous beta-galactoside-specific lectins in rabbit tissues

Soluble beta-galactoside-specific lectins have been detected in many rabbits tissues and are relatively abundant in certain organs. These lectins are apparently identical to the lectin in rabbit bone marrow, which may be involved in inter-erythroblast associations during differentiation, and are very similar in structure and activity to lectins described in a number of species both in adult and embryonic tissues. The rabbit lectin is a monomer with a relative molecular mass of approximately 12 000 and has a low specific activity in the haemagglutination of trypsinized rabbit erythrocytes relative to lectins from other species, which are predominantly dimeric. In addition to the major antigen two minor isoforms of the rabbit galaptin were detected in all tissues. Since these lectins are widely distributed, it seems probable that they are involved in cellular functions that are prominent during development and also maintained in certain differentiated tissues. Experimental evidence currently available suggests that these lectins may be involved in the organization of extracellular matrix components.

Isoforms of an endogenous lectin in rabbit bone marrow

A lectin which may mediate inter-erythroblast associations during red blood cell development in rabbit bone marrow has previously been purified and characterised. We have now detected different forms of this lectin in purified preparations and crude tissue extracts, by isoelectric focusing in agarose gels followed by rocket immunoelectrophoresis and by indirect antibody staining of focused proteins blotted onto nitrocellulose paper. These minor antigens are probably isoforms of the bone marrow lectin previously characterised.

An in vivo sister-chromatid exchange assay in the larvae of the mussel Mytilus edulis: response to 3 mutagens

An in vivo sister-chromatid exchange (SCE) assay using the larvae of the mussel Mytilus edulis was developed. Larvae were exposed to mutagens beginning 12 h after fertilization and harvested 12 h later in the late trochophore stage. Dose responses to the mutagens bromodeoxyuridine, mitomycin C and methyl methanesulfonate were linear. The sensitivity of the SCE response of mussel larvae to these mutagens compares favorably with that of other systems and indicates this assay to be valuable in marine genetic toxicological monitoring.

Separation of haemopoietic cells for biochemical investigation. Preparation of erythroid and myeloid cells from human and laboratory-animal bone marrow and the separation of erythroblasts according to their state of maturation

The separation of haemopoietic bone-marrow cells by centrifugation through discontinuous density gradients of Percoll is described. This method was used to prepare fractions enriched in erythroblasts, myeloid blast cells or reticulocytes from bone marrow of anaemic and non-anaemic rabbits, from the marrow of other anaemic laboratory animals and from human samples. It is a simple, rapid, reproducible and inexpensive technique that can be readily adapted to suit individual requirements. Secondly, a convenient method is presented for the separation of large quantities of bone-marrow cells into fractions enriched in erythroblasts at different stages of maturation, by velocity sedimentation through a linear gradient of 1-2% sucrose at unit gravity. In vitro, erythroblasts adhere together strongly via a mechanism almost certainly involving a beta-galactoside-specific surface lectin termed erythroid developmental agglutinin. Since the efficiency of cell-separation techniques depends heavily on the maintenance of a single cell suspension in which each unit can move independently, the presence of an adhesive molecule at the cell surface is of considerable significance. The effect of washing the marrow with a lactose-containing medium, which has been shown to remove the agglutinin, was therefore investigated in relation to both methods. The separation on Percoll gradients is considerably enhanced by this treatment. In addition, the unit-gravity sedimentation gradient can be loaded with 5-10 times more cells after lactose extraction in comparison with intact marrow. Although enrichment is less, a useful fractionation according to maturation is still obtained.

The influence of organic chelators on the toxicity of copper to embryos of the Pacific oyster, Crassostrea gigas

The effects of copper on the development of Crassostrea gigas embryos were determined with a 48-hr static bioassay. In filtered, sterilized seawater from Bodega Bay, California, the LC100 was 20 microgram Cu/L, and the LC50 was 12 microgram Cu/L. Destruction of the naturally occurring dissolved organic material in the culture water by UV oxidation decreased embryo survival at 10 microgram Cu/L. The addition to seawater of five organic chelators (ethylenediaminetetraacetic acid (EDTA), sodium citrate, glycine, and oxalate at 1 x 10(-6) M, and humic matter at 2 mg/L) increased embryo survival. EDTA and humic matter were the most effective chelators; EDTA significantly increased survival at 100 microgram Cu/L and humic matter did so at 40 microgram Cu/L. The ability of a chelator to increase survival was related to the stability constant of the copper-chelator complex.

Erythroid developmental agglutinin is a protein lectin mediating specific cell-cell adhesion between differentiating rabbit erythroblasts

In many developmental systems beta-galactoside-specific protein lectins have been identified as components which appear at the cell surface in concert with an initial requirement for cell-cell adhesion during tissue formation. Although some of these lectins have been purified, there has been little direct evidence concerning their role in establishing specific cell-cell contact. A mammalian system where selective cell-cell adhesion is evident and which is amenable to study is that of erythroid differentiation in the adult bone marrow. Here, the differentiation of erythroblasts takes place with the participants clustered together in the vicinity of a macrophage 'nurse' cell until the enucleation stage, when the immature reticulocyte is released and passes through the sinusoidal wall into the circulation. We show here that a small, beta-galactoside-specific, protein lectin can be extracted from erythroblast-enriched marrow and purified to homogeneity. This factor, termed erythroid developmental agglutinin (EDA), exhibits properties which strongly suggest that it is responsible for inter-erythroblast recognition and adhesion in vivo.