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BackgroundAdherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists’ workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. ObjectiveThe research aimed to explore patients’ and therapists’ views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. MethodsWe conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. ResultsWorkshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists’ workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. ConclusionsTo meet clients’ and therapists’ needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists’ workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context.

BackgroundChronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adolescents is common and disabling. Teenagers in the United Kingdom are more likely to recover if they access specialist care, but most do not have access to a local specialist CFS/ME service. Delivering treatment remotely via the internet could improve access to treatment. ObjectiveThis study aims to assess (1) the feasibility of recruitment and retention into a trial of internet-delivered specialist treatment for adolescents with CFS/ME and (2) the acceptability of trial processes and 2 web-based treatments (to inform continuation to full trial). MethodsThis study is an internal pilot for the initial 12 months of a full randomized controlled trial (RCT), with integrated qualitative methods (analysis of recruitment consultations and participant and clinician interviews). Recruitment and treatment were delivered remotely from a specialist pediatric CFS/ME treatment service within a hospital in South West United Kingdom. Adolescents (aged 11-17 years) from across the United Kingdom with a diagnosis of CFS/ME and no access to local specialist treatment were referred by their general practitioner to the treatment center. Eligibility assessment and recruitment were conducted via remote methods (telephone and on the web), and participants were randomized (via a computer-automated system) to 1 of 2 web-based treatments. The trial intervention was Fatigue in Teenagers on the InterNET in the National Health Service, a web-based modular CFS/ME-specific cognitive behavioral therapy program (designed to be used by young people and their parents or caregivers) supported by individualized clinical psychologist electronic consultations (regular, scheduled therapeutic message exchanges between participants and therapist within the platform). The comparator was Skype-delivered activity management with a CFS/ME clinician (mainly a physiotherapist or occupational therapist). Both treatments were intended to last for up to 6 months. The primary outcomes were (1) the number of participants recruited (per out-of-area referrals received between November 1, 2016, to October 31, 2017) and the proportion providing 6-month outcome data (web-based self-report questionnaire assessing functioning) and (2) the qualitative outcomes indicating the acceptability of trial processes and treatments. ResultsA total of 89 out of 150 (59.3% of potentially eligible referrals) young people and their parents or caregivers were recruited, with 75 out of 89 (84.2%) providing 6-month outcome data. Overall, web-based treatment was acceptable; however, participants and clinicians described both the advantages and disadvantages of remote methods. No serious adverse events were reported. ConclusionsRecruiting young people (and their parents or caregivers) into an RCT of web-based treatment via remote methods is feasible and acceptable. Delivering specialist treatment at home via the internet is feasible and acceptable, although some families prefer to travel across the United Kingdom for face-to-face treatment. Trial RegistrationISRCTN 18020851; http://www.isrctn.com/ISRCTN18020851 International Registered Report Identifier (IRRID)RR2-10.1186/s13063-018-2500-3

Background: Early detection could reduce the duration of untreated psychosis. GPs are a vital part of the psychosis care pathway, but find it difficult to detect the early features. An accurate risk prediction tool, P Risk, was developed to detect these. Aim: To externally validate P Risk. Design and setting: This retrospective cohort study used a validation dataset of 1 647 934 UK Clinical Practice Research Datalink (CPRD) primary care records linked to secondary care records. Method: The same predictors (age; sex; ethnicity; social deprivation; consultations for suicidal behaviour, depression/anxiety, and substance misuse; history of consultations for suicidal behaviour; smoking history; substance misuse; prescribed medications for depression/anxiety/post-traumatic stress disorder/obsessive compulsive disorder; and total number of consultations) were used as for the development of P Risk. Predictive risk, sensitivity, specificity, and likelihood ratios were calculated for various risk thresholds. Discrimination (Harrell's C-index) and calibration were calculated. Results were compared between the development (CPRD GOLD) and validation (CPRD Aurum) datasets. Results: Psychosis risk increased with values of the P Risk prognostic index. Incidence was highest in younger age groups and, in the main, higher in males. Harrell's C was 0.79 (95% confidence interval = 0.78 to 0.79) in the validation dataset and 0.77 in the development dataset. A risk threshold of 1.0% gave sensitivity of 65.9% and specificity of 86.6%. Conclusion: Further testing is required, but P Risk has the potential to be used in primary care to detect future risk of psychosis. [ABSTRACT FROM AUTHOR]

Background: Incident benzodiazepine prescriptions in primary care for anxiety decreased between 2003 and 2018. However, from 2008, incident prescribing of benzodiazepines for anxiety increased among those aged 18–34 years. There are increasing concerns around prescribing of benzodiazepines. Further, although guidelines state benzodiazepines should only be prescribed short term, in 2017, 44% of incident prescriptions were prescribed for longer than the recommended duration of 2–4 weeks. Aim: To understand when and why GPs prescribe benzodiazepines for anxiety in young adults. Design and setting: A qualitative study was undertaken using in-depth interviews with 17 GPs from 10 general practices in South West England. Method: Interviews were conducted by telephone or videocall. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and data analysed using reflexive thematic analysis. Results: GPs described caution in prescribing benzodiazepines for anxiety in young adults, but thought they had an important role in acute situations. GPs described caution in prescribing duration, but some thought longer-term prescriptions could be appropriate. In light of these views, some GPs questioned whether primary care needs to revisit how clinicians are using benzodiazepines. GPs perceived that some young adults requested benzodiazepines and suggested this might be because they wanted quick symptom relief. GPs noted that refusing to prescribe felt uncomfortable and that the number of young adults presenting to general practice, already dependent on benzodiazepines, had increased. Conclusion: Patient-driven factors for prescribing benzodiazepines suggest there are current unmet treatment needs among young adults with anxiety. Given increases in prescribing in this age group, it may be timely to revisit the role of benzodiazepines in the management of people with anxiety in primary care. [ABSTRACT FROM AUTHOR]

Background: Between 2003 and 2018, incident prescriptions of beta-blockers for anxiety increased substantially, particularly for young adults. National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers, probably due to a lack of evidence to support such use. Recent reports have highlighted the potential risks of beta-blockers. Aim: To understand when and why GPs prescribe beta-blockers for people with anxiety. Design and setting: In-depth interviews with 17 GPs in Bristol and the surrounding areas. Method: Interviews were held by telephone or video call. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Results: Many GPs viewed beta-blockers as 'low risk', particularly for young adults. Some GPs viewed beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs reflected that some patients appeared to want an 'immediate fix' to their symptoms, which GPs thought beta-blockers could potentially offer. This is salient in light of substantial waiting lists for talking therapies and delays in antidepressants taking effect. GPs described how some patients seemed more willing to try beta-blockers than antidepressants, as patients did not perceive them as 'mental health drugs' and therefore viewed them as potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as 'patient-led', with patients managing their own dose and frequency, without GP input. Conclusion: Many GPs believe that beta-blockers have a role to play in the management of anxiety. Given recent increases in the prescribing of these drugs in primary care, there is a need to assess their safety and effectiveness as a treatment for people with anxiety disorders. [ABSTRACT FROM AUTHOR]

Low-intensity cognitive behaviour therapy including behavioural activation is an evidence-based treatment for depression, a condition frequently co-occurring with autism. The feasibility of adapting low-intensity cognitive behaviour therapy for depression to meet the needs of autistic adults via a randomised controlled trial was investigated. The adapted intervention (guided self-help) comprised materials for nine individual sessions with a low-intensity psychological therapist. Autistic adults (n = 70) with depression (Patient Health Questionnaire-9 score ?10) recruited from National Health Service adult autism services and research cohorts were randomly allocated to guided self-help or treatment as usual. Outcomes at 10-, 16- and 24-weeks post-randomisation were blind to treatment group. Rates of retention in the study differed by treatment group with more participants attending follow-up in the guided self-help group than treatment as usual. The adapted intervention was well-received, 86% (n = 30/35) of participants attended the pre-defined 'dose' of five sessions of treatment and 71% (25/35) attended all treatment sessions. The findings of this pilot randomised controlled trial indicate that low-intensity cognitive behaviour therapy informed by behavioural activation can be successfully adapted to meet the needs of autistic people. Evaluation of the effectiveness of this intervention in a full scale randomised controlled trial is now warranted.

Purpose: The purpose of this study was to investigate the relationship between speech recognition benefit derived from the addition of a hearing aid (HA) to the nonimplanted ear (i.e., bimodal benefit) and spectral modulation detection (SMD) performance in the nonimplanted ear in a large clinical sample. An additional purpose was to investigate the influence of low-frequency pure-tone average (PTA) of the nonimplanted ear and age at implantation on the variance in bimodal benefit. Method: Participants included 311 unilateral cochlear implant (CI) users who wore an HA in the nonimplanted ear. Participants completed speech recognition testing in quiet and in noise with the CI-alone and in the bimodal condition (i.e., CI and contralateral HA) and SMD in the nonimplanted ear. Results: SMD performance in the nonimplanted ear was significantly correlated with bimodal benefit in quiet and in noise. However, this relationship was much weaker than previous reports with smaller samples. SMD, low-frequency PTA of the nonimplanted ear from 125 to 750 Hz, and age at implantation together accounted for, at most, 19.1% of the variance in bimodal benefit. Conclusions: Taken together, SMD, low-frequency PTA, and age at implantation account for the greatest amount of variance in bimodal benefit than each variable alone. A large portion of variance (~80%) in bimodal benefit is not explained by these variables.

Purpose: We employed a time-gated word recognition task to investigate how children who are hard of hearing (CHH) and children with normal hearing (CNH) combine cognitive-linguistic abilities and acoustic--phonetic cues to recognize words in sentence-final position. Method: The current study included 40 CHH and 30 CNH in 1st or 3rd grade. Participants completed vocabulary and working memory tests and a time-gated word recognition task consisting of 14 high- and 14 low-predictability sentences. A time-to-event model was used to evaluate the effect of the independent variables (age, hearing status, predictability) on word recognition. Mediation models were used to examine the associations between the independent variables (vocabulary size and working memory), aided audibility, and word recognition. Results: Gated words were identified significantly earlier for high-predictability than low-predictability sentences. First-grade CHH and CNH showed no significant difference in performance. Third-grade CHH needed more information than CNH to identify final words. Aided audibility was associated with word recognition. This association was fully mediated by vocabulary size but not working memory. Conclusions: Both CHH and CNH benefited from the addition of semantic context. Interventions that focus on consistent aided audibility and vocabulary may enhance children's ability to fill in gaps in incoming messages.

Background: Management of in-hospital cardiac arrest includes many component skills that require considerable training in order to gain mastery. Practicing defibrillation skills in a simulated setting improves performance and time to shock delivery but is cumbersome and costly. Virtual reality (VR) simulation training may provide an alternative platform to help medical students learn and build confidence in the critical steps required to operate a manual defibrillator. Intervention: We performed a pilot study to implement a VR simulation that trains learners on the stepwise operation of a manual defibrillator. Methods: We conducted a cross-sectional survey that measured the feasibility, usability, and likeability of a VR simulation among fourth-year medical students at a large urban academic medical center. Secondary outcomes included self-efficacy with operating a defibrillator before and after the VR simulation, and time to defibrillation within the simulation. Results: Twenty-six participants completed the VR simulation. The majority of participants found the VR simulation easy to use (71% agreed), liked the experience (96% agreed), found it realistic (87.5% agreed), and would recommend it to their peers (96% agreed). Most students (96%) agreed that the training improved their knowledge of how to use a defibrillator, and all (100%) students agreed that they were more confident than beforehand in using the defibrillator to defibrillate a patient with cardiac arrest. Self-reported knowledge and comfort with using the defibrillator significantly improved from before to after the VR training, as did average time to defibrillation. Discussion: VR simulation for defibrillator training is feasible and well-liked by senior medical students and is associated with improved self-perceived knowledge and comfort with using a manual defibrillator. [ABSTRACT FROM AUTHOR]

Background and objectives: Severe pneumonia is the leading cause of death among young children worldwide, disproportionately impacting children who lack access to advanced diagnostic imaging. Here our objectives were to develop and test the accuracy of an artificial intelligence algorithm for detecting features of pulmonary consolidation on point-of-care lung ultrasounds among hospitalized children. Methods: This was a prospective, multicenter center study conducted at academic Emergency Department and Pediatric inpatient or intensive care units between 2018–2020. Pediatric participants from 18 months to 17 years old with suspicion of lower respiratory tract infection were enrolled. Bedside lung ultrasounds were performed using a Philips handheld Lumify C5-2 transducer and standardized protocol to collect video loops from twelve lung zones, and lung features at both the video and frame levels annotated. Data from both affected and unaffected lung fields were split at the participant level into training, tuning, and holdout sets used to train, tune hyperparameters, and test an algorithm for detection of consolidation features. Data collected from adults with lower respiratory tract disease were added to enrich the training set. Algorithm performance at the video level to detect consolidation on lung ultrasound was determined using reference standard diagnosis of positive or negative pneumonia derived from clinical data. Results: Data from 107 pediatric participants yielded 117 unique exams and contributed 604 positive and 589 negative videos for consolidation that were utilized for the algorithm development process. Overall accuracy for the model for identification and localization of consolidation was 88.5%, with sensitivity 88%, specificity 89%, positive predictive value 89%, and negative predictive value 87%. Conclusions: Our algorithm demonstrated high accuracy for identification of consolidation features on pediatric chest ultrasound in children with pneumonia. Automated diagnostic support on an ultraportable point-of-care device has important implications for global health, particularly in austere settings. [ABSTRACT FROM AUTHOR]

Background: Recent advances in non-invasive physiologic monitoring leverage machine learning to provide unobtrusive, real-time assessments of a learner's cognitive load (CL) as they engage in specific tasks. However, the performance characteristics of these novel composite physiologic CL measures are incompletely understood. Objectives: We aimed to 1) explore the feasibility of measuring CL in real time using physiologically-derived inputs; 2) evaluate the performance characteristics of a novel composite CL measure during simulated virtual reality resuscitations; and 3) understand how this measure compares to traditional, self-reported measures of CL. Methods: Novice (PGY1-2 pediatric residents) and expert (pediatric emergency medicine fellows and attendings) participants completed four virtual reality simulations as team leader. The scenario content (status epilepticus versus anaphylaxis) and level of distraction (high versus low) were manipulated. Cognitive load was measured in all participants using electroencephalography and electrocardiography data ("real-time CL ") as well as through self-report (NASA-TLX). Scenario performance also was measured. Results: Complete data were available for 6 experts and 6 novices. Experts generally had lower CL than novices on both measures. Both measures localized the most significant differences between groups to the anaphylaxis scenarios (real-time CL [low-distraction] Cohen's d -1.33 [95% CI -.2.56, -0.03] and self-reported CL [high-distraction] Cohen's d -1.41 [95% CI -2.67, -0.10]). No consistent differences were seen with respect to level of distraction. Performance was similar between the two groups, though both exhibited fewer errors over time (F(3,48) = 5.75, p =.002). Conclusion: It is feasible to unobtrusively measure cognitive load in real time during virtual reality simulations. There was convergence between the two CL measures: in both, experts had lower CL than novices, with the most significant effect size differences in the more challenging anaphylaxis scenarios. [ABSTRACT FROM AUTHOR]

Background: CBT is an effective treatment for depression, but access varies across the United Kingdom. Online CBT increases access. The INTERACT platform was designed to support patient engagement in CBT, enabling therapists to deliver high‐intensity CBT via typed instant messaging and allowing patients and therapists access to an integrated online library of resources during and between sessions. Methods: The INTERACT trial aimed to evaluate this integrated approach to delivering CBT for primary care patients with depression. A nested qualitative study was conducted within the trial. Interviews were conducted with 20 patients who received the intervention, 9 therapists who delivered it and 3 therapist supervisors. Data were analysed using thematic analysis. Results: The combination of receiving support from a therapist and having access to integrated online CBT resources enabled patients to better manage their depression. Platform benefits included the opportunity to review transcripts to clarify how to complete homework tasks and track progress in managing their depression. The typing process allowed reflection and a focused discussion. However, less could be covered than during an in‐person session, which reduced therapists' expectations around goal setting. Patients who did not complete therapy struggled with the typing and found the CBT approach too demanding. Conclusion: Findings highlight the importance of establishing patient and therapist goals and expectations about what can be achieved in CBT mediated by typing. Some patients are comfortable communicating via typing and are motivated to utilise online resources in between sessions. Exploring the benefits and challenges of typed CBT with patients will enable them to make an informed choice about referral for this novel approach to therapy. Patient or Public Contribution: Patients, service users and members of the public were involved in the study design and management. Substantial pilot work gathered stakeholder feedback and informed the design of the intervention, before undertaking the RCT. Coauthor P.L. is a service user representative co‐applicant and member of the management group responsible for developing the intervention and the trial. Two PPI members sit on the Independent Steering Committee. PPI members provided valuable feedback on the study resources and documents. [ABSTRACT FROM AUTHOR]