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BackgroundAs the availability and performance of artificial intelligence (AI)–based clinical decision support (CDS) systems improve, physicians and other care providers poised to be on the front lines will be increasingly tasked with using these tools in patient care and incorporating their outputs into clinical decision-making processes. Vignette studies provide a means to explore emerging hypotheses regarding how context-specific factors, such as clinical risk, the amount of information provided about the AI, and the AI result, may impact physician acceptance and use of AI-based CDS tools. To best anticipate how such factors influence the decision-making of frontline physicians in clinical scenarios involving AI decision-support tools, hypothesis-driven research is needed that enables scenario testing before the implementation and deployment of these tools. ObjectiveThis study’s objectives are to (1) design an original, web-based vignette-based survey that features hypothetical scenarios based on emerging or real-world applications of AI-based CDS systems that will vary systematically by features related to clinical risk, the amount of information provided about the AI, and the AI result; and (2) test and determine causal effects of specific factors on the judgments and perceptions salient to physicians’ clinical decision-making. MethodsUS-based physicians with specialties in family or internal medicine will be recruited through email and mail (target n=420). Through a web-based survey, participants will be randomized to a 3-part “sequential multiple assignment randomization trial (SMART) vignette” detailing a hypothetical clinical scenario involving an AI decision support tool. The SMART vignette design is similar to the SMART design but adapted to a survey design. Each respondent will be randomly assigned to 1 of the possible vignette variations of the factors we are testing at each stage, which include the level of clinical risk, the amount of information provided about the AI, and the certainty of the AI output. Respondents will be given questions regarding their hypothetical decision-making in response to the hypothetical scenarios. ResultsThe study is currently in progress and data collection is anticipated to be completed in 2024. ConclusionsThe web-based vignette study will provide information on how contextual factors such as clinical risk, the amount of information provided about an AI tool, and the AI result influence physicians’ reactions to hypothetical scenarios that are based on emerging applications of AI in frontline health care settings. Our newly proposed “SMART vignette” design offers several benefits not afforded by the extensively used traditional vignette design, due to the 2 aforementioned features. These advantages are (1) increased validity of analyses targeted at understanding the impact of a factor on the decision outcome, given previous outcomes and other contextual factors; and (2) balanced sample sizes across groups. This study will generate a better understanding of physician decision-making within this context. International Registered Report Identifier (IRRID)DERR1-10.2196/54787

Russia’s invasion of Ukraine in February 2022 astounded political commentators across the globe. Seemingly nonsensical from a physical security perspective, the announcement of invasion resulted in economic sanctions against Russia, the rapid decline of President Vladimir Putin’s reputation in the international sphere, and dissent amongst Russian citizens. This article contends that while invasion is difficult to justify from a physical security approach, the pursuit of ontological security is a convincing and meaningful explanation for Russia’s invasion of Ukraine. Unpacking how biographical narratives and behavioural patterns sustain a state’s sense of Self demonstrates that Russian state selfhood was reaffirmed through invasion. This argument is developed in reference to masculinist narratives surrounding the Russian Self, including an imperialist role identity, a masculine Self contrasted with a feminine Ukrainian Other, and a drive to defeat supposed fascist forces within Ukraine. In addition, Russia’s invasion of Ukraine sustains ontological security through fitting into a behavioural pattern of consistent conflict. Ontological security is a highly necessary consideration when analysing global conflict, particularly in the case of the 2022 Ukraine invasion.

A 41-year-old male presented to the Emergency Department with a 6-month history of back and hip pain. Skeletal survey revealed bilateral pubic rami fractures and MRI of the spine demonstrated multiple thoracic and lumbar fractures. Secondary work up for osteoporosis was undertaken. There was no evidence of hyperparathyroidism and the patient was vitamin D replete. Testosterone (T) was low at 1.7 nmol/L (8.6–29.0) and gonadotrophins were undetectable. The patient failed a 1 mg dexamethasone suppression test (DST) with a morning cortisol of 570 nmol/L (

Mandibular arteriovenous malformations (AVMs) are vascular lesions that are rare in pregnancy but that can be life threatening due to the potential for massive haemorrhage when ruptured.This report describes a 30-year-old woman who presented at 39 weeks of gestation with hypovolemic shock secondary to a massive haemorrhage from her oral cavity. After resuscitation, she underwent an emergency caesarean section indicated for fetal distress. A live infant was born who required neonatal intensive care support. An angiogram was performed post-operatively which demonstrated a mandibular AVM that was selectively embolised. The patient and her newborn ultimately recovered with no further bleeding or complications.This report describes the fourth case of a mandibular AVM in pregnancy published in the literature, that was managed with selective embolisation. More research is required to determine the effect of pregnancy on AVM manifestation and rupture. Antenatal management should be on a case-by-case basis with multi-disciplinary team involvement.

Digital mental health services (DMHS) have proven effectiveness and play an important role within the broader mental health system by reducing barriers to evidence-based care. However, improved understanding of the factors associated with successful treatment uptake, treatment completion and positive clinical outcomes will facilitate efforts to maximise outcomes. Previous studies have demonstrated that patient age is positively associated, and initial symptom severity negatively associated with treatment uptake and treatment completion rates in both DMHS and other mental health services. The current study sought to extend these findings by examining the effect of other patient characteristics, in particular, self-reported psychosocial difficulties, using data from a large-scale national DMHS. Using a prospective uncontrolled observational cohort study design, we collected self-reported demographic, psychosocial and clinical data from 15,882 patients who accessed the MindSpot Clinic, Australia, between 1 January and 31 December 2019. Using a series of univariate regression models and multivariate classification algorithms we found that older age, higher educational attainment, and being in a relationship were all positively associated with uptake, completion and significant symptom improvement, while higher initial symptom severity was negatively associated with those outcomes. In addition, self-reported psychosocial difficulties had a significant negative impact on uptake, completion, and symptom improvement. Consistent with previous literature, the presence of these characteristics in isolation or in combination have a significant impact on treatment uptake, completion, and symptomatic improvement. Individual and multiple psychosocial difficulties are associated with reduced capacity to participate in treatment and hence an increased treatment burden. Identifying patients with lower capacity to complete treatment, modifications to treatments and the provision of supports to reduce treatment burden may promote greater engagement and completion of treatments offered by digital mental health services.

Background: The MindSpot Clinic provides services to Australians with anxiety and depression. Routine data collection means that MindSpot has been able to monitor trends in mental health symptoms and service use prior to and during the COVID-19 pandemic, and these have been reported in two earlier studies. This third study describes user characteristics and volumes in the first 8 months of COVID-19, including a comparison between users from states and territories with significantly different COVID-19 infection rates. Methods: We examined trends in demographics and symptoms for participants starting an online assessment during the COVID-19 pandemic, from March to October 2020. Participants from the state of Victoria (n = 4203), which experienced a significantly larger rate of COVID-19 infections relative to the rest of Australia, were compared to participants from the rest of Australia (n = 10,500). Results were also compared to a baseline “comparison period” prior to the COVID-19 pandemic. Results: A total of 14,703 people started a mental health assessment with MindSpot between 19th March and 28th October 2020. We observed two peaks in service demand, one in the early weeks of the pandemic, and the second in August–September when COVID-19 transmission was high in Victoria. Mean symptom scores on standardised measures of distress (K-10), depression (PHQ-9) and anxiety (GAD-7) were lower during this second peak in service demand, but there were significantly higher levels of concern about COVID-19 in participants from Victoria, and a higher proportion of Victorian respondents reported that they had made significant changes in response to the pandemic. Many respondents reported changes to their mental health, such as increased feelings of worry. Most respondents reported implementing strategies to help manage the psychological impact of COVID-19, such as maintaining social connections and limiting exposure to news or social media. Conclusions: We did not observe increased levels of clinical anxiety or depression on standardised symptom measures. However, there were increases in service demand, and increased levels of concern and difficulties related to COVID-19, particularly in Victoria. Encouragingly, a significant proportion of participants have implemented coping strategies. These results continue to suggest that the mental health impacts of COVID-19 represent a normal response to an abnormal situation rather than an emerging mental health crisis. This distinction is important as we develop individually appropriate and proportional mental health system responses.

Background: The MindSpot Clinic, funded by the Australian Government, is a national digital mental health service (DMHS) providing services to people experiencing anxiety and depression. We recently reported increased service use in the early weeks of the COVID-19 pandemic (19 March to 15 April 2020), and a small increase in anxiety symptoms. This follow-up paper examines trends in service use and symptoms, over 12 weeks from 19 March to 10 June 2020. Methods: Demographics, symptoms, and psychosocial stressors were compared for participants starting an online assessment over four time-periods: A baseline “Comparison period” prior to the COVID-19 pandemic (1 to 28 September 2019), “Weeks 1–4” of the COVID-19 pandemic in Australia (19 March–15 April 2020), “Weeks 5–8” (16 April–13 May 2020) and “Weeks 9–12” (14 May–10 June). Responses to questions about the impact of COVID-19 and strategies used by participants to improve their mental wellbeing are also reported. Results: A total of 5455 people started a mental health assessment with MindSpot from 19 March to 10 June 2020. The number of assessments per week rose steadily from 303 in week 1 to a peak of 578 in week 5. Symptoms of anxiety were highest in Weeks 1–4, declining steadily over subsequent weeks. Psychological distress and depression, as measured by the K-10 and PHQ-9 respectively, remained stable. Concern about COVID-19 was highest in the first week then steadily declined during the following weeks. The proportions of participants reporting changes to routine were consistent across the 12 weeks, and most participants reported adopting helpful strategies to improve their mental wellbeing. Conclusions: We observed an initial increase in service use, which reduced over the 12 weeks. The initial rise in anxiety symptoms returned to baseline. Reported concern about the effect of COVID-19 declined steadily over 12 weeks. Symptoms of psychological distress and depression measured by the K-10 and PHQ-9, and the proportion reporting suicidal thoughts and plans did not change, and to date we have not identified indications of a mental health crisis. However, the long-term effects of COVID-19 on the economy and large sections of society are yet to be fully realised, indicating the importance of ongoing monitoring and reporting of trends as indicators of the mental health of the nation.

Background: Trends in contact with a high volume national digital mental health service (DMHS), the MindSpot Clinic, provide a unique opportunity to assess the mental health effects of the COVID-19 pandemic. Methods: Three methods were used to assess changes in responses to COVID-19. First, website visits and call centre traffic were compared across two time periods: the “comparison period” (1 to 28 September 2019), and during the early weeks of the “COVID-19 pandemic” (19 March to 15 April 2020). Second, demographic and symptom data were compared across all patients who started an assessment during the comparison (n = 1650) and the COVID-19 period (n = 1668). Third, responses to questions about the impact of COVID-19 introduced to the assessment from 19 March 2020, and reports from treating therapists were examined. Results: There was an 89% increase in website visits and a 90% increase in telephone calls to the clinic in the early COVID-19 period compared to the comparison period. There was a higher proportion of females in the COVID-19 sample (76.9% vs. 72.9%), and a lower proportion reported being in employment (52.8% vs. 60.8%). There was a small but significant increase in the severity of anxiety symptoms, and an increase in the number of people reporting recent onset of anxiety and depression. However, there were no differences between groups in severity of symptoms of distress or depression. Most people (94%) reported concern about the impact of COVID-19, and 88% reported making changes in lifestyle. Older adults had higher levels of concern about COVID-19. Therapists reported that patients were concerned about how to access testing, manage quarantine, financial security and the effect of social isolation. Conclusions: COVID-19 has resulted in a significant increase in contact with an established DMHS, but we have not yet detected increases in baseline symptom severity. With the prospect of prolonged restriction of movement, DMHS such as MindSpot could play an important role in both providing clinical services and monitoring the mental health of the population.