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Background: Non-attendance at diabetes appointments is common, 1-4 and associated with higher HbA1c levels, reduced medication taking, and increased complications. 1-45 Barriers to attendance are multifactorial including both logistical and psychosocial factors. 6-11 A proposed solution is the implementation of a postal diabetes annual review box enabling self-collection of blood and urine samples, and measurement of blood pressure and weight., Aim: To explore the views of Healthcare Professionals (HCPs) who are involved in the organisation or delivery of diabetes care regarding the acceptability and implementation of a postal box as part of the diabetes annual review., Method: We conducted a qualitative study recruiting HCPs into semi-structured interviews and focus groups. Collected data were analysed using an inductive approach and following the principles of reflexive thematic analysis 12 ., Results: Twenty-one HCPs participated in the study. HCPs felt that a postal box could overcome many individual and service factors contributing to non-attendance. They felt the box could encourage self-management behaviours and could be used as a tool for communication. HCPs recognised that the postal box could free up time in appointments to focus on holistic care delivery without further stretching limited resources. HCPs were concerned about the possible additional administrative burden a postal box might create, and the public perception of an intervention which could reduce face-to-face care., Conclusion: Healthcare professionals seem receptive to the idea of a postal diabetes annual review box and feel it has the potential to offer people with diabetes an improved quality of care., (© 2025 Diabetes UK.)

Background and Aims: Burnout affects >50% of physicians and nurses. Spotlight-AQ is a personalized digital health platform designed to improve routine diabetes visits. We assessed cost-effectiveness, visit length, and association with health care professional (HCP) burnout., Materials and Methods: Complete case within-trial cost-effectiveness analysis embedded within a multicenter, parallel-group randomized controlled trial. Adults with diabetes were recruited from primary and secondary care. Intervention group participants completed the Spotlight-AQ pre-clinic assessment before each routine visit. Health status was assessed with EQ-5D-5L to calculate quality-adjusted life years (QALYs). Client Service Receipt Inventory measured downstream resource use. Total costs and QALYs were calculated using baseline-controlled seemingly unrelated regression with bootstrapping. Haemoglobin (HbA 1c ) data were collected. Health care professionals completed the Maslach Burnout Inventory at baseline and study end., Results: A total of 98 adults (49 intervention) and 18 HCPs participated. Total costs: £243 (US$310) intervention arm versus £230 (US$293) control arm; incremental cost: £13 (US$16). Total QALYs: 0.362 intervention arm and 0.358 control arm, with an incremental QALY: 0.004. Spotlight-AQ intervention dominated usual care with a 68% probability of cost-effectiveness at a threshold of £30 000 (US$38 294) per QALY gained. Health care professionals reported reduced burnout, emotional exhaustion, depersonalization, and a greater sense of personal achievement. Doctors are more so than nurses., Conclusion: Spotlight-AQ has demonstrated cost-effective while delivering improved care and reduced HCP burnout., Trial Registration: ISRCTN15511689, registration date: November 1, 2021., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Spotlight-AQ owns the pre-clinic assessment platform. RCK and KB-K are founders and shareholders in Spotlight-AQ. RIGH has received fees for lecturing from Boehringer-Ingelheim, EASD, Eli Lilly, Encore, Liberum, Novo Nordisk, and ROVI, and funding for conference attendance from Novo Nordisk and Eli Lilly. All other authors have no financial or other competing interests.

Miliarias are a group of eccrine disorders characterized by sweat retention due to the occlusion of eccrine ducts. Miliaria profunda is the rarest form of miliaria and occurs when eccrine ducts are obstructed at the dermal-epidermal junction. A granulomatous variant of centrifugal miliaria profunda classic findings of granulomatous infiltrate on histology and centrifugal expansion of deep nodules or plaques. We report a rare case of the granulomatous variant of centrifugal miliaria in an 8-month-old boy, with associated cardiofaciocutaneous syndrome (CFCS) due to a pathogenic MAP2K1 germline variant., (© 2025 The Author(s). Pediatric Dermatology published by Wiley Periodicals LLC.)

Background: Annual national diabetes audit data consistently shows most people with diabetes do not consistently achieve blood glucose targets for optimal health, despite the large range of treatment options available., Aim: To explore the efficacy of a novel clinical intervention to address physical and mental health needs within routine diabetes consultations across health care settings., Methods: A multicenter, parallel group, individually randomized trial comparing consultation duration in adults diagnosed with T1D or T2D for ≥6 months using the Spotlight-AQ platform versus usual care. Secondary outcomes were HbA1c, depression, diabetes distress, anxiety, functional health status, and healthcare professional burnout. Machine learning models were utilized to analyze the data collected from the Spotlight-AQ platform to validate the reliability of question-concern association; as well as to identify key features that distinguish people with type 1 and type 2 diabetes, as well as important features that distinguish different levels of HbA1c., Results: n = 98 adults with T1D or T2D; any HbA1c and receiving any diabetes treatment participated ( n = 49 intervention). Consultation duration for intervention participants was reduced in intervention consultations by 0.5 to 4.1 minutes (3%-14%) versus no change in the control group (-0.9 to +1.28 minutes). HbA1c improved in the intervention group by 6 mmol/mol (range 0-30) versus control group 3 mmol/mol (range 0-8). Moderate improvements in psychosocial outcomes were seen in the intervention group for functional health status; reduced anxiety, depression, and diabetes distress and improved well-being. None were statistically significant. HCPs reported improved communication and greater focus on patient priorities in consultations. Artificial Intelligence examination highlighted therapy and psychological burden were most important in predicting HbA1c levels. The Natural Language Processing semantic analysis confirmed the mapping relationship between questions and their corresponding concerns. Machine learning model revealed type 1 and type 2 patients have different concerns regarding psychological burden and knowledge. Moreover, the machine learning model emphasized that individuals with varying levels of HbA1c exhibit diverse levels of psychological burden and therapy-related concerns., Conclusion: Spotlight-AQ was associated with shorter, more useful consultations; with improved HbA1c and moderate benefits on psychosocial outcomes. Results reflect the importance of a biopsychosocial approach to routine care visits. Spotlight-AQ is viable across health care settings for improved outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Spotlight-AQ owns the preclinic assessment platform. RCK and KBK are founders and shareholders in Spotlight-AQ. All other authors have no financial or other competing interests.

Aim: The diabetes annual review is an important part of clinical care. Non-attendance is increasingly common and associated with poor health outcomes. At-home self-collection of blood tests, urine samples and anthropometric data through a postal box may facilitate engagement. We aimed to explore the views of people living with diabetes on the use of a postal box as an alternative to usual care for self-collecting blood samples, urine samples and anthropometric data and to understand whether the availability of a postal box would facilitate the uptake of the diabetes annual review., Methods: We conducted semi-structured interviews and focus groups with adults who have type 1 or type 2 diabetes. Purposive sampling was used to obtain a high representation of infrequent attendees of annual review appointments within the study population. Transcripts were collated and analysed thematically., Results: Twenty participants took part including eight infrequent attendees. All infrequent attendees and most regular attendees responded positively to a postal box, with convenience being the most prominent value described. Concerns raised related to capability of self-collection and the accuracy of results. Participants were asked for suggestions to improve the postal box. The most common themes related to communication; needing clearer information about each test in the postal box; feedback of results; and utilising the box to communicate priorities for discussion at future consultations., Conclusion: Postal boxes for annual reviews were well-received by those living with diabetes. Designed well, they have the potential to overcome more than just the physical barriers to annual review attendance., (© 2024 Diabetes UK.)

Introduction: Worldwide, 2.4 billion people rely on solid fuels such as wood or charcoal for cooking, leading to approximately 3.2 million deaths per year from illnesses attributable to household air pollution. Across Africa, household air pollution generated by solid fuel use accounts for nearly 700,000 deaths each year. Most studies to date have focused either household air pollution exposure, its impacts on particular health outcomes or on the efficacy of mitigation interventions. However, the economic, social, and cultural determinants of household air pollution in Africa are still poorly understood. The purpose of this study was to explore people's experience of using solid fuels for cooking in two informal settlements, Ndirande in Malawi and Mukuru in Kenya, and the associated harms caused by household air pollution., Methods: We adopted a community-based participatory method, photovoice, which was conducted with 9 participants in Ndirande and 10 participants in Mukuru. Participants took pictures reflecting their experiences and perceptions of household air pollution harms over a two-week period, and later discussed, sorted and analysed those in a series of meetings. Thematic analysis was used to analyse the data., Results: With their pictures, participants described fuel stacking and switching behaviours in their communities. They described a mix of charcoal, firewood and other biomass fuels use. They also expressed their awareness and perceptions of the harms caused by smoke when cooking. Participants explained the simple behaviours used by residents to minimize the harms of household air pollution to themselves and within their own household. Other themes explored the roles and responsibilities for procuring fuels in the home, and the stated solutions required to address the issues and manage the transition to cleaner fuels in those informal settlements., Conclusion: This study highlights not only the need to understand the daily life, priorities and concerns of those who use solid fuels on informal settlements, but also the urgency to place them and their experience at the heart of the solutions that will reduce the health harms of household air pollution., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Uny et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Understanding cellular responses to mechanical environmental stimuli is important for cellular mechanotransduction studies. While fluorescence microscopy has been used for aiding mechanotransduction research due to its molecular sensitivity, the ability of quantitative phase imaging (QPI) to visualize morphology has yet to be widely applied, perhaps due to its limited specificity. Here, we seek to expand on previous work which combined quantitative phase imaging with a molecularly sensitive Förster resonance energy transfer (FRET) construct by developing additional analysis techniques. This work seeks to characterize the response of individual cells to mechanical stimulus through a novel, to the best of our knowledge, QPI-guided cellular segmentation algorithm. The multimodal imaging instrument and analysis techniques are employed to examine cellular responses to hypo-osmotic stimulus by observing the calcium ion flux using a FRET-based sensor coupled with a mapping of intracellular mass reorganization using QPI. The combined imaging modality enables a discrimination of cell response by localized region, revealing distinct behavior between regions and relative to a control group. Our novel analysis techniques can be used to identify cell expansion and cell region specific responses in both modalities due to the stimulus. With the broad array of FRET sensors under development, the complementary addition of QPI offers new avenues for studying cell responses to a range of environmental stimuli.

Background and Objective: As the population and life expectancy of people with Down syndrome increases, identifying common skin conditions throughout the lifespan will help inform clinical care and research. We sought to evaluate dermatologic conditions diagnosed in pediatric and adult patients with Down syndrome., Methods: This multicenter retrospective study analyzed demographic and outpatient visit International Classification of Diseases codes of patients with Down syndrome evaluated at outpatient dermatology clinics in the United States or Canada between 2011 and 2021., Results: A total of 1529 patients with Down syndrome were identified from eight academic medical centers: 50.8% were children (0-12 years), 25.2% were adolescents (13-17 years), and 24% were adults (18 years and older). Eczematous dermatitis was the most common diagnosis overall (26%), followed by folliculitis (19.3%) and seborrheic dermatitis (15.6%). Other notable diagnoses included dermatophyte infections (13%), alopecia areata (11.6%), and psoriasis (6.7%). About 4.3% of visits included a code for high-risk medication use. Eczematous dermatitis, alopecia areata, and folliculitis were the most common diagnoses observed in children; folliculitis, hidradenitis suppurativa, and eczematous dermatitis in adolescents; and seborrheic dermatitis, eczematous dermatitis, and folliculitis in adults., Conclusions: Dermatologic conditions in patients with Down syndrome vary by age, but are most often eczematous, adnexal, and cutaneous autoimmune disorders. This multicenter retrospective review identifies skin diseases that should be prioritized for clinical care guideline development and research in the Down syndrome community., (© 2024 Wiley Periodicals LLC.)

Objectives: The objectives of this study is to estimate rates and identify factors associated with erythema nodosum (EN) and pyoderma gangrenosum (PG) in pediatric patients with inflammatory bowel disease (IBD)., Methods: This cohort study examined longitudinal visits of patients aged ≤ 21 years from the ImproveCareNow (ICN) registry. We evaluated the association of factors at the patient-level (demographics and IBD diagnosis age) and visit-level (IBD severity scores, markers and phenotypes, comorbidities, and treatment) with the presence of EN and PG, using longitudinal logistic regression models adjusted for time and within-patient clustering., Results: A total of 285,913 visits from 32,497 patients aged ≤ 21 years from the ICN registry were analyzed. The occurrence of EN was 1.57% (95% confidence interval [95% CI]: 1.43%-1.71%) and the occurrence of PG was 0.90% (95% CI: 0.80%-1.00%). Co-occurrence of EN and PG was reported in 0.30% (95% CI: 0.25%-0.37%) patients. Both EN and PG were associated (p < 0.0001) with worse intestinal disease, lower remission, higher inflammatory markers, and extraintestinal manifestations (EIMs) arthritis and uveitis., Conclusions: EN and PG were associated with increased disease severity and other noncutaneous EIMs (arthritis and uveitis). A small subset of patients had developed both EN and PG., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Background: Visceral leishmaniasis (VL) is an important public health problem, which mainly affects the poor rural dwelling communities in Low- and Middle-Income Countries. However, little is known about the health and economic burdens of this disease in East Africa, including Ethiopia. The aim of this study was to assess the household level economic burden of VL among affected communities in Tigray, Northern Ethiopia., Methods: Between April and August 2020, a cross-sectional household survey was conducted on 96 patients who had been treated for VL within 12 months prior to the survey, in six districts of Tigray. Data on households' health seeking behavior, direct and indirect costs and coping strategies were collected using a structured questionnaire and the responses were analyzed using SPSS software., Results: Most (82%) of the patients surveyed were males and the majority (74%) of them were between 16 and 30 years of age. The education level of participants was very low: over 33% had not received any form of education; 48% of patients were farmers dependent on subsistence agriculture and about 32% were daily laborers. Just under half of household families (46%) resided in "poor houses" with structures made from entirely local materials. Forty-one percent of patients from the surveyed households had traveled 48 to 72 kilometers to reach VL treatment hospitals. The median total household cost for one VL episode was estimated to be US$ 214. This is equated to 18% of the mean total annual household income or 72.5% of annual per capita income of the study population. More than 80% of the households surveyed incurred catastrophic costs of VL, where this is defined as exceeding 10% of annual household income. The median delay between the onset of symptoms and arrival at a care provider hospital was 37 days; once the patient arrived at hospital, the median delay during diagnosis was 3 days. Direct and indirect costs represented 44% and 56% of the total costs incurred, respectively. To cope with VL treatment costs, 43% of the households used more than one coping strategy: 48% took out loans, 43% sold livestock and 31% of households mobilized cash savings., Conclusions: VL in Tigray is concentrated among young males with low educational background and mostly engaged in subsistence economic activities. Despite the free diagnostic and treatment provisions that were available at public hospitals at the time of the study, our work shows that the household economic burden of the disease had significant impact among VL-affected communities in Tigray. Initiating community awareness towards prevention, early treatment seeking and decentralization of VL treatment centers are strongly recommended. In addition, we recommend efforts to reduce household treatment costs through transport and food provisions for patients (and their accompanying carers where possible) or through cash reimbursement for patients who complete treatment at public hospitals, in order to reduce the barriers to seeking treatment for this life-threatening disease., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Tessema et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: Competing interests: None declared.

Introduction: There is a growing body of evidence demonstrating the benefit of flash glucose monitoring in people living with type 2 diabetes mellitus (T2DM). This real-world study aimed to evaluate the effect of initiating flash glucose monitoring on change in HbA1c after 3-6 months in adults living with T2DM treated with multiple daily injections of insulin., Methods: A retrospective observational study using data from ten clinical centres in the UK for adults with T2DM treated with multiple daily injections of insulin for at least 1 year was conducted. Patients who had been using the FreeStyle Libre/Libre 2 Flash Glucose Monitoring System for at least 3 months with baseline HbA1c 64-108 mmol/mol (8.0-12.0%) recorded up to 3 months prior to system use were included. Pregnant patients and those on dialysis were excluded. Patients with an HbA1c value measured 3-6 months after commencing flash glucose monitoring were included in the final analysis for evaluation of change., Results: In total, 87 patients were included in the final analysis (mean age, 60.0 ± 11.8 years, 60.9% male, mean body mass index (BMI), 31.6 ± 5.4 [mean ± SD]). From a mean baseline HbA1c of 80 ± 11 mmol/mol (9.5% ± 1.0%), HbA1c lowered by 11 ± 14 mmol/mol (1.0% ± 1.3%) at 3-6 months (p < 0.0001). A decrease was observed independent of age, baseline HbA1c, sex, duration of insulin use and BMI subgroups., Conclusions: Initiation of flash glucose monitoring was associated with a clinically and statistically significant improvement in HbA1c in a real-world setting at 3-6 months., (© 2024. The Author(s).)

Background: Ovarian cancer with extensive metastatic disease involving pelvic structures often requires rectosigmoid resection for complete gross resection; however, it is associated with increased surgical morbidity. There are limited data, and none in ovarian cancer, on near-infrared assessment of perfusion in rectosigmoid resections with anastomosis., Primary Objective: To compare the rate of pelvic complications (pelvic abscesses, anastomotic leaks, and infections) within 30 days of surgery with and without near-infrared assessment of perfusion at time of rectosigmoid resection and re-anastomosis in patients undergoing cytoreductive surgery for ovarian cancer., Study Hypothesis: We hypothesize the use of near-infrared technology (intravenous indocyanine green and endoscopic near-infrared fluorescence imaging), compared with standard intra-operative assessment, to evaluate anastomotic perfusion at time of rectosigmoid resection and re-anastomosis will result in lower rates of post-operative pelvic complications., Trial Design: This is a planned multicenter randomized controlled trial. Patients who undergo rectosigmoid resection as part of their ovarian cytoreductive surgery will be randomized 1:1 to standard assessment of anastomosis with the surgeon's usual technique (control arm) or assessment with near-infrared angiography using indocyanine green and endoscopic fluorescence imaging (experimental arm). Randomization will occur after rectosigmoid resection has been completed and the surgeon declares their plan to create a diverting ostomy. Randomization will be stratified by plan for diverting ostomy., Major Inclusion/exclusion Criteria: Main inclusion criteria include patients with primary or recurrent ovarian, fallopian tube, or primary peritoneal cancer who are scheduled for cytoreductive surgery with suspected need for low-anterior rectosigmoid resection., Primary Endpoint: Rate of 30-day post-operative pelvic complications., Sample Size: 310 (155 per arm) ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: Q2 2027 and Q4 2027, respectively., Trial Registration: NCT04878094., Competing Interests: Competing interests: Dr Leitao reports personal fees from Medtronic, Intuitive Surgical, J&J/Ethicon, and Immunogen. Dr Abu-Rustum reports research funding paid to the institution from GRAIL. Memorial Sloan Kettering Cancer Center also has equity in GRAIL. Dr Chi reports personal fees from AstraZeneca, UptoDate, Biom’Up, Apyx Medical Corp, and Verthemia, as well as stock ownership in Doximity., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

One of the basic principles of risk management is that we should always keep an eye on ways that things could go badly wrong, even if they seem unlikely. The more disastrous a potential failure, the more improbable it needs to be, before we can safely ignore it. This principle may seem obvious, but it is easily overlooked in public discourse about risk, even by well-qualified commentators who should certainly know better. The present piece is prompted by neglect of the principle in recent discussions about the potential existential risks of artificial intelligence. The failing is not peculiar to this case, but recent debates in this area provide some particularly stark examples of how easily the principle can be overlooked., Competing Interests: I declare that I have no competing interests., (© 2024 The Authors.)

Introduction/aims: Myasthenia gravis (MG) is a rare, life-threatening immune-related adverse effect (irAE) of immune checkpoint inhibitor (ICI) treatment. C5-complement inhibitors are effective treatments for acetylcholine receptor antibody (AChR ab) positive generalized MG. We describe the use of eculizumab/ravulizumab in two patients with MG receiving concomitant pembrolizumab., Methods: This was a retrospective review of two medical records., Results: Patient 1: An 80-year-old male with recurrent, non-muscle invasive transitional cell carcinoma of the bladder developed ICI-induced AChR ab positive MG (ICI-MG), myositis, and myocarditis 2 weeks after the first dose of pembrolizumab. Myositis responded to corticosteroids. MG responded to eculizumab, followed by ravulizumab. He died of metastatic cancer 8 months later. Patient 2: A 58-year-old male had refractory thymoma-associated AChR ab-positive MG, which responded to eculizumab. He developed metastatic Merkel cell cancer necessitating pembrolizumab. MG remained stable on eculizumab. He had no irAEs for 22 months, with positron emission tomographic resolution of cancer. He then developed mild, indolent retinal vasculitis, which responded to prednisone. Discontinuation of pembrolizumab for 5 months resulted in cancer recurrence; pembrolizumab was resumed with peri-infusion pulse prednisone. MG remained stable and he continues eculizumab., Discussion: In the first patient, eculizumab, followed by ravulizumab, improved ICI-MG. In the second patient, eculizumab treatment may have had a prophylactic effect on the development of ICI-induced irAEs. The effect of complement inhibition on cancer outcomes of ICI therapy is unknown. A possible biologic basis for complement inhibitors in reducing irAEs of ICI, especially in the presence of underlying autoimmune disease, merits evaluation., (© 2024 Wiley Periodicals LLC.)

Sweet's syndrome (SS) is a neutrophilic dermatosis characterised by the acute onset of erythematous papules or plaques and a constellation of symptoms including fever, leucocytosis, and histopathology demonstrating nodular, pustular, or diffuse infiltrate of neutrophils with marked papillary oedema. SS can be a manifestation of inflammatory bowel disease and often coincides with periods of disease flares. Only a few cases of SS associated with ulcerative colitis are reported in the literature, and no cases have involved pulmonary manifestations in the paediatric population. We present a case of a 14-year-old girl presenting with new onset ulcerative colitis requiring emergent colectomy with subsequent development of pulmonary SS. Treatment consisted of intravenous and oral corticosteroids and dapsone. SS should be considered in the differential diagnosis of prolonged fever with cutaneous involvement and systemic symptoms. Special consideration should be given to paediatric patients with extracutaneous manifestations, particularly pulmonary involvement., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Skin Health and Disease published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

A 68-year-old woman with a history of diabetes mellitus type 2, depression, and migraines presented with painless, acute, consecutive vision loss affecting the right eye for 1 week and the left eye for 2 weeks. Neuro-ophthalmic examination was notable for visual acuities of finger-counting peripherally, a central scotoma, anterior uveitis, vitritis, and placoid macular pigmentary changes in each eye (OU). Proprioception was diminished in the bilateral lower extremities. Optical coherence tomography (OCT) revealed hyper-reflectivity and attenuation of the outer retina OU with normal inner retinal architecture and reflectivity. Fluorescein angiography (FA) demonstrated normal filling of the central retinal arteries with patchy choroidal perfusion in the right eye and targetoid punctate foci of leakage in the macula OU. Before the recognition of intraocular inflammation and findings on OCT and FA, the patient was treated for presumed central retinal artery occlusion at an outside hospital. Additional diagnostic testing at our institution revealed an alternate diagnosis. This case highlights a rare presentation of a well-known disease entity and underscores the importance of avoiding diagnostic anchoring in clinical practice., (© 2023 American Academy of Neurology.)

Disseminated blastomycosis can be challenging to diagnose given possible involvement of nearly any extrapulmonary organ system and the limitations of fungal diagnostic testing. Certain racial groups are at increased risk of disseminated fungal infections, even in immunocompetent patients. We describe a case of disseminated blastomycosis with cutaneous involvement in an African American adolescent with delayed diagnosis. Dermatologists can play an important role in the timely diagnosis of this disease entity by performing appropriate cutaneous biopsy techniques and should be involved early in these cases., (© 2023 Wiley Periodicals LLC.)

Background: Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms., Methods: Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM 2.5 ) was estimated., Results: 2373 children participated, 1277 in Mukuru (median age, IQR 11, 9-13 years, 53% girls), and 1096 in Buruburu (10, 8-12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM 2.5 . When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, 'current wheeze' (9.5% vs 6.4%, p=0.007) and 'trouble breathing' (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to 'vapours, dusts, gases, fumes', mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads., Conclusion: Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms., Competing Interests: Competing interests: RD has declared employment by the University of Stirling for the duration of the study. ML has declared employment by the Institute of Occupational Medicine and funding for the study from UKRI MRC/Kenya National Research Fund. JKQ has declared personal funding from GlaxoSmithKline, Boehringer Ingelheim, AstraZeneca, Chiesi, Teva, Insmed, Bayer and institutional funding from UKRI MRC, Health Data Research UK, GlaxoSmithKline, Bayer, Boehringer Ingelheim, Chiesi, AstraZeneca and Asthma and Lung UK. All other authors have declared they have nothing to disclose., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Sexual assault referral centres have been established to provide an integrated service that includes forensic examination, health interventions and emotional support. However, it is unclear how the mental health and substance use needs are being addressed., Aim: To identify what works for whom under what circumstances for people with mental health or substance use issues who attend sexual assault referral centres., Setting and Sample: Staff and adult survivors in English sexual assault referral centres and partner agency staff., Design: A mixed-method multistage study using realist methodology comprising five work packages. This consisted of a systematic review and realist synthesis (work package 1); a national audit of sexual assault referral centres (work package 2); a cross-sectional prevalence study of mental health and drug and alcohol needs (work package 3); case studies in six sexual assault referral centre settings (work package 4), partner agencies and survivors; and secondary data analysis of outcomes of therapy for sexual assault survivors (work package 5)., Findings: There is a paucity of evidence identified in the review to support specific ways of addressing mental health and substance use. There is limited mental health expertise in sexual assault referral centres and limited use of screening tools based on the audit. In the prevalence study, participants ( n  = 78) reported high levels of psychological distress one to six weeks after sexual assault referral centre attendance (94% of people had symptoms of post-traumatic stress disorder). From work package 4 qualitative analysis, survivors identified how trauma-informed care potentially reduced risk of re-traumatisation. Sexual assault referral centre staff found having someone with mental health expertise in the team helpful not only in helping plan onward referrals but also in supporting staff. Both sexual assault referral centre staff and survivors highlighted challenges in onward referral, particularly to NHS mental health care, including gaps in provision and long waiting times. Work package 5 analysis demonstrated that people with recorded sexual assault had higher levels of baseline psychological distress and received more therapy but their average change scores at end point were similar to those without sexual trauma., Limitations: The study was adversely affected by the pandemic. The data were collected during successive lockdowns when services were not operating as usual, as well as the overlay of anxiety and isolation due to the pandemic., Conclusions: People who attend sexual assault centres have significant mental health and substance use needs. However, sexual assault referral centres vary in how they address these issues. Access to follow-up support from mental health services needs to be improved (especially for those deemed to have 'complex' needs) and there is some indication that co-located psychological therapies provision improves the survivor experience. Routine data analysis demonstrated that those with sexual assault can benefit from therapy but require more intensity than those without sexual assault., Future Work: Further research is needed to evaluate the effectiveness and cost-effectiveness of providing co-located psychological therapy in the sexual assault referral centres, as well as evaluating the long-term needs and outcomes of people who attend these centres., Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (16/117/03) and is published in full in Health and Social Care Delivery Research ; Vol. 11, No. 21., Trial Registration: This trial is registered as PROSPERO 2018 CRD42018119706 and ISRCTN 18208347.