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Background: A large number of individuals suffer from post-COVID-19 condition (PCC), characterised by persistent symptoms following a SARS-CoV-2 infection with an impact on daily personal and professional activities. This study aims at examining which (health) care services are used by PCC patients in the German federal state of Lower Saxony, and how these patients manage their condition. The perspectives of patients, informal caregivers and general practitioners (GPs) will be considered., Methods: The study will employ a mixed methods design. Patients' perspective will be evaluated through an online survey of: (1) 21,000 adult individuals with a PCC diagnosis (ICD10 U09.9!) in their statutory health insurance claims data in 2022 ("AOK survey") and (2) a self-selected sample of adult individuals with a proven SARS-CoV-2 infection in 2023 and persistent symptoms ("public survey"). Additional data sources will be claims data (n = 27,275) and 25-30 semi-structured interviews. Informal caregivers' perspective will be collected through an online survey and semi-structured interviews. GPs' perspective will be evaluated through four focus groups involving six to eight participants each and an online survey of all registered and practicing GPs in Lower Saxony (approximately 5,000). All survey data will be descriptively analysed. In addition, correlation analyses and multivariable regression analyses will be conducted, for example on factors influencing affected individuals' use of medical services. Interview and focus group data will be subjected to qualitative content analysis. A health economic analysis will be used to determine the costs of PCC to health care payers, patients and society. The project will conclude with an expert workshop to discuss the results and derive recommendations., Discussion: The results of the study will provide a multidimensional description of the (health) care situation and needs of patients with PCC, and derive recommendations for improving health care., Trial Registration: The VePoKaP study is registered at the German Clinical Trials Register (DRKS00032846)., Competing Interests: CH-L has received a lecture honorarium from Novartis and royalties from Hogrefe Publish-ers for the German version of the Hospital Anxiety and Depression Scale. His research is supported by grants from the German Ministry of Education and Research, the German Re-search Foundation and the European Commission. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The other authors declare that they have no competing interests., (Copyright: © 2024 Brinkmann 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.)

Household income and caregiver mental health are important drivers of children's health and development. The COVID-19 pandemic created huge economic and mental health disruptions. This study examines financial hardship and its relationship with caregiver and child mental health using Australia's only representative data spanning three years of the pandemic. Analysis of the repeated, cross-sectional National Child Health Poll included 12,408 caregivers and 20,339 children over six waves (June 2020-April 2023). Caregivers reported their income (dichotomised into low versus not) and deprivation (missing one or more of eight essential items, versus not) and mental health for themselves (Kessler-6, poor versus not) and each child (Self-Rated Mental Health, poor/fair versus good/very good/excellent). Binary logistic models were fitted to predict marginal probabilities of mental health measures by low income and deprivation, over time. Results show that while low income decreased from 41% to 34% over the study period, deprivation increased from 30% to 35%. Poor mental health peaked with stay-at-home orders in 2021 before recovering. Caregivers experiencing low income or deprivation had higher rates of poor mental health throughout the study and slower recovery compared to those without financial hardship. Children in families experiencing financial hardship had slightly higher proportions of poor/fair mental health in 2021-2022, but they were mostly equivalent in June 2020 and April 2023 (range 6-8%). Addressing financial hardship may offer an avenue for improving caregiver mental health. This has implications for post-pandemic recovery and addressing contemporary issues of increasing cost of living and limited mental health supports and services.

The COVID-19 pandemic had a global impact on daily lives, and this study aimed to assess the effects on broader aspects of health in the general population of Norway. This population-based cohort study assessed changes in health of the Norwegian general population from 3 months before to 9 months during the COVID-19 pandemic. Sampling was based on the results of Norwegian surveys designed for collecting general population norms for health measurement instruments. In December 2019, 12,790 randomly selected adults aged ≥18 years received a postal questionnaire. The 3,200 respondents received a similar follow-up postal questionnaire including the EQ-5D-5L, PROMIS-29 instruments, and questions about respondents having or having had COVID-19. Score changes were compared to estimates for the minimal important change (MIC) and age-related change. Association of instrument change scores with baseline characteristics, health problems, and having had COVID-19 was determined using multivariable linear regression. Of 3101 respondents with unchanged addresses, 2423 (78.1%) responded to the second survey. For all respondents, EQ VAS and PROMIS-29 scores for 6 of 8 domains were slightly poorer (p<0.01) than before COVID-19, and the mean change was below the MIC. In multivariable analyses, the greatest number of poorer outcomes were associated with being female, 18-29 years, or ≥80 years of age (p<0.01); > MIC for ≥ 80 years of age and EQ-5D index, PROMIS-29 physical function and social participation. Respondents who had COVID-19 had poorer outcomes for PROMIS-29 social participation (> MIC). Those reporting COVID-19 in their partner/family and not themselves, had poorer outcomes for PROMIS-29 anxiety and social participation. About 9 months into the COVID-19 pandemic, EQ-5D-5L and PROMIS-29 domain scores showed slightly poorer health in the Norwegian adult general population compared to 1 year earlier in the same respondents. The overall changes were less than expected for age-related change. Relatively poor outcomes defined as important, included general health and social participation for the elderly, and the latter for those having had COVID-19. In conclusion, this study found no evidence for a decline in important aspects of adult general population health in Norway that might be attributed to the pandemic at approximately 9 months., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Garratt, Stavem. 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.)

Introduction: Long COVID is a life-limiting condition that affects 65 million people worldwide. It devastates lives with uncertain illness trajectories, and yet, there are many research uncertainties as there is a lack of understanding of its causes, effective treatments and management plans. We set out to identify current research priorities for people with Long COVID, carers, healthcare professionals and researchers., Methods: A systematic literature review and previous Long COVID priority-setting exercises identified three broad under-researched areas of Long COVID research within the fields of Public Health and Health Services Research: symptoms; managing day-to-day life; and the emotional impact of Long COVID. We disseminated an elicitation survey that asked for research questions in these areas; responses were analysed and summarised into 42 research questions. A survey was then disseminated, asking respondents to prioritise these 42 questions. Workshops were held with people with Long COVID, carers, healthcare professionals and researchers to analyse responses and agree the top 10 priorities., Results: The top priorities in order were pharmacological treatment of Long COVID; understanding the pathophysiology; nonpharmacological symptom management; improving public and professional understanding of Long COVID; understanding of the long-term risks of Long COVID; improving financial and social supports; improving understanding of postviral syndromes; diagnostics; service redesign/pathways; and the well-being of children with Long COVID., Conclusion: Four years into the pandemic, there is an emphasis on the need for research on treatment, understanding and support for people living with Long COVID., Patient and Public Contribution: People with Long COVID and carers were involved in the study design, survey design, dissemination, data analysis, interpretation and reviewing and editing the manuscript., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Background: The COVID-19 pandemic was associated with an increase in child and adolescent mental health disorders, with subsequent worsening of patient access to specialist mental health care. Clinicians working in the community were faced with increased demands to diagnose and manage pediatric mental health disorders, without always having the confidence and knowledge to do so. We therefore developed COnnecting Mental-health PAediatric Specialists and community Services (COMPASS)-a collaborative model designed to upskill community clinicians in child and adolescent mental health care and provide them with better access to child and adolescent psychiatry expertise. COMPASS comprises (1) an online Community of Practice (CoP) with fortnightly one-hour sessions covering: anxiety; aggression and challenging behaviours; depression; self-harm and suicidality; eating disorders; and autism spectrum disorder/complex cases and (2) primary and secondary consultations for general practitioners and paediatricians with an experienced child psychiatrist. We aimed to assess the impact of COMPASS on community clinician self-reported confidence in: managing common child and adolescent mental health disorders (Objective 1, primary outcome); navigating the mental health care system (i.e. knowing how services are organised, accessed, and how to refer patients, Objective 2); diagnosing conditions (Objective 3); prescribing psychotropic medications (Objective 4) as well as the impact on, clinician practice and wellbeing (Objective 5) and outcomes of patients referred by COMPASS clinicians to the child psychiatrist (Objective 6)., Methods: We evaluated COMPASS in its first year, with COMPASS running from March to July 2021. Participating clinicians completed pre-post surveys evaluating change in Objectives 1 to 4 above, using study-designed measures. A purposive sample of clinicians was then invited to a semi-structured interview to understand their experience of COMPASS and its impacts on practice and wellbeing (Objective 5). We adopted an inductive approach to the qualitative analysis using the Framework Method. This involved selecting five random transcripts which were double coded and categorized, to generate an initial framework against which all subsequent transcripts were analysed. Themes and subthemes were generated from the data set, by reviewing the matrix and making connections within and between clinicians, codes and categories One child psychiatrist completed a 2-week logbook of the nature and outcomes of primary and secondary consultations (Objective 6)., Findings: 51 (86%) clinicians attended CoP sessions and completed pre-post surveys, with 92% recommending COMPASS to peers. Clinicians reported increased confidence in the pharmacological and non-pharmacological management of all conditions, most notably for management of self-harm. They also reported increased knowledge of how to navigate the mental health system and prescribe medications. Qualitative analysis (n = 27 interviews) found that COMPASS increased clinician wellbeing and reduced feelings of professional isolation and burnout. Over the 2-week snapshot, the child psychiatrist consulted on 22 patients and referred all back to the community clinician., Conclusions: COMPASS is associated with improved clinician confidence to manage child and adolescent mental health concerns, navigate the mental health system, improved clinician wellbeing, and reduced need for ongoing mental health care by specialists., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 D’Abaco 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.)

Background: The COVID-19 pandemic presented unprecedented challenges, particularly for vulnerable populations residing in confined settings such as refugee shelters: Physical distancing measures were challenging to implement in shelters due to shared rooms or communal use of kitchens and sanitary facilities, which increased the risk of infections. Meanwhile, individuals' capabilities for individual protection strategies were severely impaired by the structure of the shelters. Consequently, shelters had the duty to develop and implement strategies for the prevention and handling of SARS-CoV-2 infections. The aim of this study was to explore the perspectives of refugees, NGO employees, and shelter directors regarding COVID-19-related measures in German refugee shelters. The study aimed to identify challenges and conflicts arising from implemented measures, as well as expectations for improved support during the pandemic., Methods: Semi-structured and narrative interviews were conducted with 6 refugees, 6 facility managers, 12 NGO staff, and 2 social service agency staff from February to August 2022. Qualitative content analysis was employed to analyze the data, identifying overarching themes and codes., Results: The study uncovered challenges and conflicts resulting from pandemic measures, particularly mass quarantine orders, within refugee shelters. Lack of transparency and ineffective communication worsened tensions, with refugees feeling distressed and anxious. The quarantine experience had a negative impact on refugees' mental health, which was exacerbated by limited social interaction and leisure-time activities. Shelter managers encountered administrative challenges when implementing measures due to facility constraints and limited resources, while NGO employees encountered obstacles in providing immediate assistance due to legal regulations and a lack of cooperation from shelter managers., Conclusions: The study highlights that shelters are problematic institutions from a public health perspective. It shows the importance of implementing customized pandemic interventions in refugee shelters that take account of the diverse needs and experiences of both refugee and staff. To achieve this, we recommend to establish an ethics committee and involve various stakeholders in decision-making processes. Additionally, enhancing information dissemination to promote transparency and public understanding of measures is crucial. These insights can help develop comprehensive and effective pandemic plans for refugee shelters, ensuring better preparedness for future public health crises., (© 2024. The Author(s).)

While the world recovers from the COVID-19 pandemic, another outbreak of contagious disease remains the most likely future risk to public safety. Now is therefore the time to equip health authorities with effective tools to ensure they are operationally prepared for future events. We propose a direct approach to obtain reliable nearly instantaneous time-varying reproduction numbers for contagious diseases, using only the number of infected individuals as input and utilising the dynamics of the susceptible-infected-recovered (SIR) model. Our approach is based on a multivariate nonlinear regression model simultaneously assessing parameters describing the transmission and recovery rate as a function of the SIR model. Shortly after start of a pandemic, our approach enables estimation of daily reproduction numbers. It avoids numerous sources of additional variation and provides a generic tool for monitoring the instantaneous reproduction numbers. We use Norwegian COVID-19 data as case study and demonstrate that our results are well aligned with changes in the number of infected individuals and the change points following policy interventions. Our estimated reproduction numbers are notably less volatile, provide more credible short-time predictions for the number of infected individuals, and are thus clearly favorable compared with the results obtained by two other popular approaches used for monitoring a pandemic. The proposed approach contributes to increased preparedness to future pandemics of contagious diseases, as it can be used as a simple yet powerful tool to monitor the pandemics, provide short-term predictions, and thus support decision making regarding timely and targeted control measures.

Background:  The EuroQol Health and Wellbeing Short Version (EQ-HWB-S) instrument has been developed to measure the health and wellbeing of care-recipients and their caregivers for use in economic evaluation.The EQ-HWB-S has nine items, and pilot UK preference weights have now been developed., Objective: We aimed to investigate the validity of the instrument in parents of children with and without health conditions., Methods: EQ-HWB-S data were sourced from an Australian paediatric multi-instrument comparison study. We analysed the baseline characteristics and response distribution of the EQ-HWB-S items. Assessment of known-group validity was conducted for EQ-HWB-S items, level sum-scores and preference-weighted scores, including partial effects. Known-group analyses included three child health variables and where caregivers reported coronavirus disease 2019 (COVID-19) had impacted their wellbeing. We included analyses across gender, controlled for child and parent demographic variables, and compared scores across child health conditions., Results:  Item responses were distributed as expected, with higher skew for mobility and activities. Parents experienced high levels of exhaustion. We detected significant differences between groups for level sum-scores and preference-weighted scores, as hypothesised; all tests were significant (p < 0.001), with moderate effect sizes (effect sizes were slightly higher for female than male parents). The regression analysis identified significantly different EQ-HWB-S scores for child health samples compared with the general population after controlling for demographic variables. Differences were observed between child health conditions., Conclusion: The EQ-HWB-S is a useful instrument to measure parent quality of life for economic evaluation in this population. Data were limited to one time point; further research should investigate the instrument's sensitivity to change and test-retest reliability in this population., (© 2024. The Author(s).)

Background and Objectives: Coronavirus disease 2019 (COVID-19) lockdowns (stay-at-home orders) had significant mental health consequences in 2020 to 2021 for caregivers and children. Little is known about "postlockdown" periods in 2022 to 2023. We investigated the mental health experiences of Australian families throughout the 3 years of the COVID-19 pandemic (2020-2023), by demographic characteristics and lockdown length., Methods: A total N = 12 408 caregivers (N = 20 339 children, aged 0-17 years) completed Australia's only representative, repeated, cross-sectional, National Child Health Poll across 6 waves (June 2020-April 2023). Caregivers reported mental health for themselves (Kessler-6, poor versus not) and each child (self-rated mental health, poor/fair versus good/very good/excellent), and perceived impacts of the pandemic on own/child mental health (negative versus none/positive). Binary logistic models were fitted to predict marginal probabilities of each mental health measure by state/territory group (proxy for lockdown length), over time, adjusted for potential demographic confounders., Results: Poor caregiver Kessler-6 was similar between genders but more common for sole caregivers, and those with a home language other than English and lower education. Poor/fair child self-rated mental health was similar between genders and increased with child age. Perceived negative impacts were more common for females and socially advantaged caregivers. Overall, negative mental health experiences increased with lockdown length, peaking with the height of lockdown in July 2021, before declining., Conclusions: Negative mental health experiences of Australian caregivers and children decreased during postlockdown periods of 2022-2023; however, social gradients persisted. These data can inform more precise mental health policies that enable better use of limited mental health infrastructure., (Copyright © 2024 by the American Academy of Pediatrics.)

Background: Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP., Aim: To investigate HCPs' experiences of conducting PCSP conversations remotely and consider implications for the fulfilment of PCSP ambitions as remote consulting continues beyond COVID-19 restrictions., Methods: 19 semi-structured interviews with HCPs in England and Scotland; interpretive analysis., Results: HCPs' accounts made clear that COVID-19 restrictions impacted multiple aspects of PCSP delivery, not just the mode of conversation. Broader disruption to general practice systems for gathering and sharing information ahead of PCSP conversations, and moves to 'wide window' appointment times, made it harder for patients to be prepared for PCSP conversations. This constrained scope to achieve PCSP ambitions even with the best professional communication skills. Most remote PCSP conversations were conducted by telephone. In the absence of visual communication with patients, it was sometimes harder to achieve the ambitions of PCSP conversations, including to balance patient and professional agendas, fulfil key planning activities, and foster a relational ethos of equal, collaborative partnership. The challenges were particularly severe when working with new patients and people with complex clinical and social problems. Although options for telephone appointments now offer valued flexibility, sustained experience of struggling to achieve PCSP ambitions via remote consulting led some HCPs to lower their standards for judging a "good" PCSP conversation, and to diminished professional satisfaction., Conclusions: There are significant challenges to fulfilling the ambitions of PCSP via telephone, especially when preparatory support is limited. This study provides grounds for scepticism about how compatible telephone appointments can be with this person-centred model of working, especially for people who are socially disadvantaged and live with complex health conditions. These threats to the provision of person-centred support for people with long-term conditions warrant careful attention going forward if the PCSP model and its benefits are to be sustained., (© 2024. The Author(s).)

Objectives: To investigate changes in chest CT between 3 and 12 months and associations with disease severity in patients hospitalized for COVID-19 during the first wave in 2020., Materials and Methods: Longitudinal cohort study of patients hospitalized for COVID-19 in 2020. Chest CT was performed 3 and 12 months after admission. CT images were evaluated using a CT severity score (CSS) (0-12 scale) and recoded to an abbreviated version (0-3 scale). We analyzed determinants of the abbreviated CSS with multivariable mixed effects ordinal regression., Results: 242 patients completed CT at 3 months, and 124 (mean age 62.3±13.3, 78 men) also at 12 months. Between 3 and 12 months (n = 124) CSS (0-12 scale) for ground-glass opacities (GGO) decreased from median 3 (25th-75th percentile: 0-12) at 3 months to 0.5 (0-12) at 12 months (p<0.001), but increased for parenchymal bands (p<0.001). In multivariable analysis of GGO, the odds ratio for more severe abbreviated CSS (0-3 scale) at 12 months was 0.11 (95%CI 0.11 0.05 to 0.21, p<0.001) compared to 3 months, for WHO severity category 5-7 (high-flow oxygen/non-invasive ventilation/ventilator) versus 3 (non-oxygen use) 37.16 (1.18 to 43.47, p = 0.032), and for age ≥60 compared to <60 years 4.8 (1.33 to 17.6, p = 0.016). Mosaicism was reduced at 12 compared to 3 months, OR 0.33 (95%CI 0.16 to 0.66, p = 0.002)., Conclusions: GGO and mosaicism decreased, while parenchymal bands increased from 3 to 12 months. Persistent GGO were associated with initial COVID-19 severity and age ≥60 years., Competing Interests: Haseem Ashraf reports grant from Boehringer-Ingelheim, Norway. Knut Stavem reports personal fees from UCB Pharma and MSD Norway, unrelated to this study., (Copyright: © 2024 Aaløkken 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.)

Background: The national breast screening programme in the United Kingdom is under pressure due to workforce shortages and having been paused during the COVID-19 pandemic. Artificial intelligence has the potential to transform how healthcare is delivered by improving care processes and patient outcomes. Research on the clinical and organisational benefits of artificial intelligence is still at an early stage, and numerous concerns have been raised around its implications, including patient safety, acceptance, and accountability for decisions. Reforming the breast screening programme to include artificial intelligence is a complex endeavour because numerous stakeholders influence it. Therefore, a stakeholder analysis was conducted to identify relevant stakeholders, explore their views on the proposed reform (i.e., integrating artificial intelligence algorithms into the Scottish National Breast Screening Service for breast cancer detection) and develop strategies for managing 'important' stakeholders., Methods: A qualitative study (i.e., focus groups and interviews, March-November 2021) was conducted using the stakeholder analysis guide provided by the World Health Organisation and involving three Scottish health boards: NHS Greater Glasgow & Clyde, NHS Grampian and NHS Lothian. The objectives included: (A) Identify possible stakeholders (B) Explore stakeholders' perspectives and describe their characteristics (C) Prioritise stakeholders in terms of importance and (D) Develop strategies to manage 'important' stakeholders. Seven stakeholder characteristics were assessed: their knowledge of the targeted reform, position, interest, alliances, resources, power and leadership., Results: Thirty-two participants took part from 14 (out of 17 identified) sub-groups of stakeholders. While they were generally supportive of using artificial intelligence in breast screening programmes, some concerns were raised. Stakeholder knowledge, influence and interests in the reform varied. Key advantages mentioned include service efficiency, quicker results and reduced work pressure. Disadvantages included overdiagnosis or misdiagnosis of cancer, inequalities in detection and the self-learning capacity of the algorithms. Five strategies (with considerations suggested by stakeholders) were developed to maintain and improve the support of 'important' stakeholders., Conclusions: Health services worldwide face similar challenges of workforce issues to provide patient care. The findings of this study will help others to learn from Scottish experiences and provide guidance to conduct similar studies targeting healthcare reform., Study Registration: researchregistry6579, date of registration: 16/02/2021., (© 2024. The Author(s).)

Background: Older adults and people with dementia were anticipated to be particularly unable to use health and care services during the lockdown period following the COVID-19 pandemic. To better prepare for future pandemics, we aimed to investigate whether the use of health and care services changed during the pandemic and whether those at older ages and/or dementia experienced a higher degree of change than that observed by their counterparts., Methods: Data from the Norwegian Trøndelag Health Study (HUNT4 70 + , 2017-2019) were linked to two national health registries that have individual-level data on the use of primary and specialist health and care services. A multilevel mixed-effects linear regression model was used to calculate changes in the use of services from 18 months before the lockdown, (12 March 2020) to 18 months after the lockdown., Results: The study sample included 10,607 participants, 54% were women and 11% had dementia. The mean age was 76 years (SD: 5.7, range: 68-102 years). A decrease in primary health and care service use, except for contact with general practitioners (GPs), was observed during the lockdown period for people with dementia (p < 0.001) and those aged ≥ 80 years without dementia (p = 0.006), compared to the 6-month period before the lockdown. The use of specialist health services decreased during the lockdown period for all groups (p ≤ 0.011), except for those aged < 80 years with dementia. Service use reached levels comparable to pre-pandemic data within one year after the lockdown., Conclusion: Older adults experienced an immediate reduction in the use of health and care services, other than GP contacts, during the first wave of the COVID-19 pandemic. Within primary care services, people with dementia demonstrated a more pronounced reduction than that observed in people without dementia; otherwise, the variations related to age and dementia status were small. Both groups returned to services levels similar to those during the pre-pandemic period within one year after the lockdown. The increase in GP contacts may indicate a need to reallocate resources to primary health services during future pandemics., Trial Registration: The study is registered at ClinicalTrials.gov, with the identification number NCT04792086., (© 2024. The Author(s).)

Background: COVID-19 has been associated with cardiac troponin T (cTnT) elevations and changes in cardiac structure and function, but the link between cardiac dysfunction and high-sensitive cardiac troponin T (hs-cTnT) in the acute and convalescent phase is unclear., Objective: To assess whether hs-cTnT concentrations are associated with cardiac dysfunction and structural abnormalities after hospitalization for COVID-19, and to evaluate the performance of hs-cTnT to rule out cardiac pathology., Methods: Patients hospitalized with COVID-19 had hs-cTnT measured during the index hospitalization and after 3-and 12 months, when they also underwent an echocardiographic study. A subset also underwent cardiovascular magnetic resonance imaging (CMR) after 6 months. Cardiac abnormalities were defined as left ventricular hypertrophy or dysfunction, right ventricular dysfunction, or CMR late gadolinium., Results: We included 189 patients with hs-cTnT concentrations measured during hospitalization for COVID-19, and after 3-and 12 months: Geometric mean (95%CI) 13 (11-15) ng/L, 7 (6-8) ng/L and 7 (6-8) ng/L, respectively. Cardiac abnormalities after 3 months were present in 45 (30%) and 3 (8%) of patients with hs-cTnT ≥ and < 5 ng/L at 3 months, respectively (negative predictive value 92.3% [95%CI 88.5-96.1%]). The performance was similar in patients with and without dyspnea. Hs-cTnT decreased from hospitalization to 3 months (more pronounced in intensive care unit-treated patients) and remained unchanged from 3 to 12 months, regardless of the presence of cardiac abnormalities., Conclusion: Higher hs-cTnT concentrations in the convalescent phase of COVID-19 are associated with the presence of cardiac pathology and low concentrations (< 5 ng/L) may support in ruling out cardiac pathology following the infection., (© 2024. The Author(s).)

Healthcare workers (HCWs) were at high risk of experiencing psychological distress during COVID-19 pandemic. The objective of this study was to evaluate the impact on HCWs' mental health in a Spanish hospital. Cross-sectional study of HCW, active between May and June 2020. A web-based survey assessed probable current mental disorders (major depressive disorder [PHQ-8 ≥ 10], generalized anxiety disorder [GAD-7 ≥ 10], panic attacks, post-traumatic stress disorder [PTSD; PLC-5 ≥ 7], or substance use disorder [CAGE-AID ≥ 2]). The Sheehan Disability Scale (SDS) was used to assess severe impairment and items taken from the modified self-report version of the Columbia Suicide Severity Rating Scale (C-SSRS) assessed suicidal thoughts and behaviors. A total of 870 HCWs completed the survey. Most frequent probable mental disorders were major depressive disorder (33.6%), generalized anxiety disorder (25.5%), panic attacks (26.9%), PTSD (27.2%), and substance use disorder (5.0%). Being female, having aged 18-29 years, being an auxiliary nurse, direct exposure to COVID-19-infected patients, and pre-pandemic lifetime mental disorders were positively associated with mental issues. Hospital HCWs presented a high prevalence of symptoms of mental disorders, especially depression, PTSD, panic attacks, and anxiety. Younger individuals and those with lifetime mental disorders have been more vulnerable to experiencing them., (© 2024. The Author(s).)

Objectives: To make recommendations regarding factors that affect COVID-19 vaccine uptake by ethnic minority individuals in the United Kingdom, together with strategies that could be used to increase uptake., Study Design and Setting: The results of two rapid systematic reviews-one identifying factors that affect respiratory vaccine uptake in ethnic minority adults and the other identifying experimental evaluations of strategies to increase vaccine uptake in ethnic minority adults-were put into Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Evidence to Decision frameworks to support discussion with a panel of ethnic minority community organizations, community-focused small companies, and academics of the relevance of the review findings to the UK COVID context. Aided by the frameworks, the panel made recommendations for factors that need to be addressed to increase vaccine uptake, and for which strategies might be used to increase uptake., Results: Our two reviews contained 31 relevant research studies published in English between 2016 and 2021, all of which were from the United Kingdom (8/31), the United States (20), and Australia (3). We identified six factors-two linked to trust, three linked to information, and one on accessibility-that affected uptake. Strategies that had been evaluated fell into three categories: using trusted messengers, tailoring the message, and increasing convenience. These were put into GRADE Evidence to Decision frameworks and discussed over a series of meetings with individuals from nine ethnic minority community organizations and two community-focused small companies and academics. Community partners provided insight into why ethnic minority individuals in the United Kingdom had lower vaccine uptake, particularly with regard to the impact of nonhealth-related UK Government policy on individuals' heath decision-making. Recommendations included recognizing that trust will be low among some ethnic groups, thinking more broadly as to who messengers should be in a low-trust environment, ensuring that information is tailored to the information needs of specific ethnic groups and working to increase convenience. Our results are at https://www.collaborationforchange.co.uk., Conclusion: GRADE Evidence to Decision frameworks could be used more widely to structure discussions of research evidence between researchers, community organizations, and other nonresearch partners., Competing Interests: Declaration of competing interest None. The GRADE Working Group was not involved with the work described in this article., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Long COVID is a devastating, long-term, debilitating illness which disproportionately affects healthcare workers, due to the nature of their work. There is currently limited evidence specific to healthcare workers about the experience of living with Long COVID, or its prevalence, pattern of recovery or impact on healthcare., Objective: Our objective was to assess the effects of Long COVID among healthcare workers and its impact on health status, working lives, personal circumstances, and use of health service resources., Methods: We conducted a systematic rapid review according to current methodological standards and reported it in adherence to the PRISMA 2020 and ENTREQ statements., Results: We searched relevant electronic databases and identified 3770 articles of which two studies providing qualitative evidence and 28 survey studies providing quantitative evidence were eligible. Thematic analysis of the two qualitative studies identified five themes: uncertainty about symptoms, difficulty accessing services, importance of being listened to and supported, patient versus professional identity and suggestions to improve communication and services for people with Long COVID. Common long-term symptoms in the survey studies included fatigue, headache, loss of taste and/or smell, breathlessness, dyspnoea, difficulty concentrating, depression and anxiety., Conclusion: Healthcare workers struggled with their dual identity (patient/doctor) and felt dismissed or not taken seriously by their doctors. Our findings are in line with those in the literature showing that there are barriers to healthcare professionals accessing healthcare and highlighting the challenges of receiving care due to their professional role. A more representative approach in Long COVID research is needed to reflect the diverse nature of healthcare staff and their occupations. This rapid review was conducted using robust methods with the codicil that the pace of research into Long COVID may mean relevant evidence was not identified., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Cruickshank 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.)

The social and behavioural determinants of COVID-19 vaccination have been described previously. However, little is known about how vaccinated people use and rate their health system. We used surveys conducted in 14 countries to study the health system correlates of COVID-19 vaccination. Country-specific logistic regression models were adjusted for respondent age, education, income, chronic illness, history of COVID-19, urban residence, and minority ethnic, racial, or linguistic group. Estimates were summarised across countries using random effects meta-analysis. Vaccination coverage with at least two or three doses ranged from 29% in India to 85% in Peru. Greater health-care use, having a regular and high-quality provider, and receiving other preventive health services were positively associated with vaccination. Confidence in the health system and government also increased the odds of vaccination. By contrast, having unmet health-care needs or experiencing discrimination or a medical mistake decreased the odds of vaccination. Associations between health system predictors and vaccination tended to be stronger in high-income countries and in countries with the most COVID-19-related deaths. Access to quality health systems might affect vaccine decisions. Building strong primary care systems and ensuring a baseline level of quality that is affordable for all should be central to pandemic preparedness strategies., Competing Interests: Declaration of interests Research for this Series paper was supported by grants to MEK and the QuEST Network from the Bill & Melinda Gates Foundation and the Swiss Federal Department of Foreign Affairs. This research was also supported by grants to CA and MEK from Merck Sharp & Dohme; to EGE and HHL from the Inter-American Development Bank; and to JO from the Taejae Foundation. The funders of the study had no role in study design or conduct, data collection, data management, data analysis, data interpretation, the writing of the Series paper, or the decision to submit the Series paper for publication., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: COVID-19 is associated with an increased risk of venous thromboembolism (VTE), but there is great variation among reported incidence rates. Most previous studies have focused on hospitalized patients with COVID-19, and only a few reports are from population-based registries., Methods: We studied the 90-day incidence of VTE, associated risk factors and all-cause mortality in hospitalized and nonhospitalized patients with COVID-19 in a nationwide cohort. Data on hospitalizations and outpatient visits were extracted from two national registries with mandatory reporting linked by a unique national identification number carried by all Norwegian residents. We performed Cox proportional hazards regression to determine risk factors for VTE after infection with SARS-CoV-2., Results: Our study included 30,495 patients with positive SARS-CoV-2 polymerase chain reaction with a mean (SD) age of 41.9 (17.3) years, and 53% were males. Only 2081 (6.8%) were hospitalized. The 90-day incidence of VTE was 0.3% (95% CI: 0.21-0.33) overall and 2.9% (95% CI: 2.3-3.7) in hospitalized patients. Age (hazard ratio [HR] 1.28 per decade, 95% CI: 1.11-1.48, p < 0.05), history of previous VTE (HR 4.69, 95% CI: 2.34-9.40, p < 0.05), and hospitalization for COVID-19 (HR 23.83, 95% CI: 13.48-42.13, p < 0.05) were associated with risk of VTE., Conclusions: The 90-day incidence of VTE in hospitalized and nonhospitalized patients with COVID-19 was in the lower end compared with previous reports, with considerably higher rates in hospitalized than nonhospitalized patients. Risk factors for VTE were consistent with previously reported studies., (© 2023 The Authors. Journal of Internal Medicine published by John Wiley & Sons Ltd on behalf of Association for Publication of The Journal of Internal Medicine.)

Background: Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments., Methods: Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them., Results: Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP 'going well' all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals' accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers' person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals' ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP., Conclusion: Health professionals' interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Psychological, socio-demographics, and clinical factors play an important role in patients with COVID-19, but their relationship is complex. The network approach might be used to disentangle complex interactions in different systems. Using data from a multicentre, cross-sectional, survey among patients with COVID-19 in Spain (July-November 2020), we investigated the network structure of mental disorders symptoms, social support, and psychological resilience, and changes in network structures according to the presence of a pre-existing mental disorder or hospitalization for COVID-19., Methods: Subjects completed a survey to evaluate sociodemographic characteristics, COVID-19 infection status, resilience, social support, and symptoms of depression, anxiety disorders, post-traumatic stress disorder, panic attacks, and substance use disorder. 2084 patients with COVID-19 were included in the analysis. Network analysis was conducted to evaluate network and bridge centrality, and the network properties were compared between COVID-19 patients with and without a history of lifetime mental disorder, and between hospitalized and non-hospitalized patients., Limitations: Generalization of our findings may be difficult since differences in network connectivity may exist in different populations or samples., Results: Anxiety and depression showed high centrality in patients with COVID-19 and anxiety showed the highest bridge influence in the network. Resilience and social support showed a low influence on mental disorder symptoms. Global network estimations show no statistically significant changes between patients with and without pre-existing mental disorders or between hospitalized and non-hospitalized patients., Conclusions: Anxiety might be a key treatment target in patients with COVID-19 since its treatment might prevent other mental health adverse outcomes., Competing Interests: Declaration of competing interest GA has received CME-related honoraria, or consulting fees from Janssen-Cilag, Lundbeck, Lundbeck/Otsuka, and Angelini, with no financial or other relationship relevant to the subject of this article. AF has received CME-related educational support from Lundbeck, not related to the subject of this article. AM has received grants and served as consultant, advisor or CME speaker for the following entities: Angelini, Idorsia, Lundbeck, Pfizer, Takeda, outside of the submitted work. EV has received grants and served as consultant, advisor or CME speaker for the following entities: AB-Biotics, AbbVie, Adamed, Angelini, Biogen, Boehringer-Ingelheim, Celon Pharma, Dainippon Sumitomo Pharma, Ferrer, Gedeon Richter, GH Research, Glaxo-Smith Kline, Janssen, Lundbeck, Merck, Novartis, Orion Corporation, Organon, Otsuka, Rovi, Sage, Sanofi-Aventis, Sunovion, Takeda, and Viatris, outside the submitted work., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: To explore the impact of Long Covid (LC) on the school experiences of children and young people (CYP)., Design: Qualitative study using narrative interviews., Participants: 22 CYP (aged 10-18 years, 15 female) with LC and 15 parents/caregivers (13 female) of CYP (aged 5-18 years) with LC., Setting: Interviews were conducted between October 2021 and July 2022 via online video call or telephone. Recruitment routes included social media, LC support groups, clinicians, community groups and snowballing., Results: Three key findings were identified. Finding 1: Going to school is a valued part of CYP's lives and participants viewed educational attainment as important for their future trajectories. Returning to school full time was highlighted as a key part of regaining 'normal life'. Finding 2: Attending school (in-person or online) with LC is extremely difficult; even a gradual return required CYP to balance the impact of being at and engaging with school, with the need to manage symptoms to prevent relapse. Often this meant prioritising school and rest over other aspects of their lives. Finding 3: School responses to CYP with LC were reported to be mixed and hampered by difficulties communicating with healthcare professionals during the pandemic and a lack of awareness of LC among healthcare and education professionals. Participants viewed supportive school responses as staff believing, understanding and taking them seriously, alongside schools offering tailored and flexible adaptations which allowed engagement with school while limiting any deterioration of symptoms., Conclusions: This study describes how LC affects the school experiences of CYP and generates recommendations for supportive school responses alongside supportive healthcare professionals. Further research could explore the approaches that facilitate a successful return to school for CYP with LC and investigate education professionals' perspectives on support they require to positively engage with returning pupils., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Importance: During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking., Objective: To compare personnel costs of HaH and ACT with inpatient care., Design, Setting, and Participants: In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore., Exposures: HaH for dengue and ACT for chest pain., Main Outcomes and Measures: A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs., Results: Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%., Conclusions and Relevance: This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.

Introduction: Despite the end of the COVID-19 pandemic being declared by the WHO, the economic consequences are far from over. One of these implications was the cost of inpatient care for health institutions. To date, some studies have examined the economic burden of COVID-19 in the adult population but only a few have focused on child populations., Objective: To estimate the direct medical costs of COVID-19, focusing on children in Mexico., Method: Data about resources consumed during hospital stays were extracted from the medical records of patients hospitalized at a Mexican tertiary healthcare institution. Other sources of information were the unit prices of inputs and the salaries of health personnel. A micro-costing methodology was used to obtain cost results by age group over different hospital areas. Data analysis was performed with descriptive statistics and regression models to evaluate the predictors of total cost., Results: One hundred and ten medical records were reviewed of which 57.3% corresponded to male patients and the mean age was 7.2 years old. The estimated average cost per patient was US$5,943 (95% CI: US$4,249-7,637). When the costs of the three clinical areas were summed, only the 5-10 years old group showed a maximum cost of US$14,000. The regression analysis revealed the following factors as significant: sex, age, staying at an emergency room, having a positive bacterial culture, and having comorbidities., Discussion: The cost results were somewhat similar to those reported in children from the USA, but only regarding low severity COVID-19 cases. However, comparability between these types of studies should be done with caution due to the huge differences between the healthcare systems of countries. The study cost results may help public decision-makers in budget planning and as inputs for future cost-effectiveness studies about interventions regarding COVID-19., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor GM is currently organizing a Research Topic with the author GS-E. The handling editor GM declared a past collaboration [10.1007/S12098-021-03959-3 (2021) and 10.1016/J.ARCMED.2022.04.003 (2022) with the author(s) JG-E., (Copyright © 2023 Reyes-López, Jimenez-Juárez, Salinas-Escudero, Avilés-Robles, Martínez-Valverde, Granados-García and Garduño-Espinosa.)

Aim: To investigate the occurrence of traumatic stress symptoms (TSS) among healthcare workers active during the COVID-19 pandemic and to obtain insight as to which pandemic-related stressful experiences are associated with onset and persistence of traumatic stress., Methods: This is a multicenter prospective cohort study. Spanish healthcare workers ( N  = 4,809) participated at an initial assessment (i.e., just after the first wave of the Spain COVID-19 pandemic) and at a 4-month follow-up assessment using web-based surveys. Logistic regression investigated associations of 19 pandemic-related stressful experiences across four domains (infection-related, work-related, health-related and financial) with TSS prevalence, incidence and persistence, including simulations of population attributable risk proportions (PARP)., Results: Thirty-day TSS prevalence at T1 was 22.1%. Four-month incidence and persistence were 11.6% and 54.2%, respectively. Auxiliary nurses had highest rates of TSS prevalence (35.1%) and incidence (16.1%). All 19 pandemic-related stressful experiences under study were associated with TSS prevalence or incidence, especially experiences from the domains of health-related (PARP range 88.4-95.6%) and work-related stressful experiences (PARP range 76.8-86.5%). Nine stressful experiences were also associated with TSS persistence, of which having patient(s) in care who died from COVID-19 had the strongest association. This association remained significant after adjusting for co-occurring depression and anxiety., Conclusions: TSSs among Spanish healthcare workers active during the COVID-19 pandemic are common and associated with various pandemic-related stressful experiences. Future research should investigate if these stressful experiences represent truly traumatic experiences and carry risk for the development of post-traumatic stress disorder.

Despite the proven safety and clinical efficacy of the Measles vaccine, many countries are seeing new heights of vaccine hesitancy or refusal, and are experiencing a resurgence of measles infections as a consequence. With the use of novel machine learning tools, we investigated the prevailing negative sentiments related to Measles vaccination through an analysis of public Twitter posts over a 5-year period. We extracted original tweets using the search terms related to "measles" and "vaccine," and posted in English from January 1, 2017, to December 15, 2022. Of these, 155,363 tweets were identified to be negative sentiment tweets from unique individuals, through the use of Bidirectional Encoder Representations from Transformers (BERT) Named Entity Recognition and SieBERT, a pretrained sentiment in English analysis model. This was followed by topic modeling and qualitative thematic analysis performed inductively by the study investigators. A total of 11 topics were generated after applying BERTopic. To facilitate a global discussion of results, the topics were grouped into four different themes through iterative thematic analysis. These include (a) the rejection of "anti-vaxxers" or antivaccine sentiments, (b) misbeliefs and misinformation regarding Measles vaccination, (c) negative transference due to COVID-19 related policies, and (d) public reactions to contemporary Measles outbreaks. Theme 1 highlights that the current public discourse may further alienate those who are vaccine hesitant because of the disparaging language often used, while Themes 2 and 3 highlight the typology of misperceptions and misinformation underlying the negative sentiments related to Measles vaccination and the psychological tendency of disconfirmation bias. Nonetheless, the analysis was based solely on Twitter and only tweets in English were included; hence, the findings may not necessarily generalize to non-Western communities. It is important to further understand the thinking and feeling of those who are vaccine hesitant to address the issues at hand.

Introduction: The present study aims to investigate the courses of loneliness following a national state of emergency including a curfew due to a rise in COVID-19 cases, associated risk factors, and the effect of loneliness on symptoms of depression and anxiety., Methods: Data of 2,000 adults in Spain which were interviewed by telephone at the first follow-up of the MINDCOVID project (February-March 2021) and of whom 953 were interviewed nine months later (November-December 2021) were analyzed. Group-based trajectories and mixed models were constructed., Results: Three courses of loneliness were detected: (1) invariant low loneliness (42.6%), (2) decreasing medium loneliness (51.5%), and (3) fairly invariant high loneliness (5.9%). Loneliness courses were associated with the severity and variability of symptoms of depression and anxiety. In contrast to the majority of pre-pandemic studies, younger adults more frequently reported loneliness compared to middle-aged and, particularly, older individuals. Other risk factors for loneliness were being female, being unmarried, and, notably, having pre-pandemic mental disorders., Conclusions: Future studies should validate whether the newly observed loneliness patterns across age groups persist and assess the evolution of loneliness courses and their impact on mental health, with particular attention given to young adults and individuals with pre-existing mental disorders., Competing Interests: Declaration of Competing Interest The authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: Immune responses following SARS-CoV-2 vaccination in patients with inflammatory bowel disease (IBD) are not well characterized. The aims of this study were to explore the serological response associated with IBD, and immunosuppressive medications including serum concentrations of biologics and thiopurine metabolites., Materials and Methods: This prospective, observational study included adult patients with ulcerative colitis (UC) and Crohn's disease (CD), and healthy controls. Antibodies to the receptor-binding domain of SARS-CoV-2 spike proteins, and serum concentrations of ongoing biologic and immunomodulatory medications were assessed prior to, and 2-5 weeks after the second vaccine dose. Serologic response was defined as anti-Spike antibodies ≥70 AU/ml., Results: In 958 IBD patients (380 UC, 578 CD) and 323 healthy controls, the median (Q 1; Q 3 ) anti-Spike antibody level (AU/ml) was lower in patients (618 (192; 4370)) compared to controls (3355 (896; 7849)) ( p  < 0.001). The antibody levels were lower in CD (439 (174; 3304)) compared to UC (1088 (251; 5975)) ( p  < 0.001). No associations were demonstrated between antibody levels and serum drug concentrations for TNF inhibitor (TNFi), vedolizumab and ustekinumab. Patients receiving TNFi + thiopurines with a subtherapeutic 6-thioguanine nucleotide (6-TGN) level had higher response rate (93%) compared to patients with 6-TGN within the therapeutic range (53%) ( p  = 0.003). A diagnosis of UC, mRNA-1273 vaccine, and other treatments than TNFi + thiopurines were associated with humoral response., Conclusions: Patients with CD had an attenuated humoral response to SARS-COV-2 vaccination as compared to patients with UC. The lack of association between serum levels of biologics and serologic response indicates vaccination regardless of proximity to drug administration.

Objective: Examine time trends in suicidal ideation in post-secondary students over the first three waves of the COVID-19 pandemic in Canada and identify subpopulations of students with increased risk., Method: We analysed 14 months of data collected through repeated cross-sectional deployment of the World Health Organization (WHO) World Mental Health-International College Student (WMH-ICS) survey at the University of British Columbia. Estimated log odds weekly trends of 30-day suicidal ideation (yes/no) were plotted against time with adjustments for demographics using binary logistic generalized additive model (GAM). Risk factors for 30-day suicidal ideation frequency (four categories) were examined using the ordered logistic GAM, with a cubic smoothing spline for modelling time trend in obervation weeks and accounting for demographics., Results: Nearly one-fifth (18.9%) of students experienced suicidal ideation in the previous 30 days. While the estimated log odds suggested that binary suicidal ideation was relatively stable across the course of the pandemic, an initial drop followed by an increasing trend was observed. Risk factors for suicidal ideation frequency during the pandemic included identifying as Chinese or as another non-Indigenous ethnic minority; experiencing current symptoms of depression or anxiety; having a history of suicidal planning or attempts; and feeling overwhelmed but unable to get help as a result of COVID-19. Older age was identified as a protective factor., Conclusions: The general university student population in our study was relatively resilient with respect to suicidal ideation during the first three waves of the pandemic, but trends indicate the possibility of delayed impact. Specific sub-populations were found to be at increased risk and should be considered for targeted support. Further analyses should be undertaken to continue monitoring suicidality trends throughout the remainder of the pandemic and beyond.

Objectives: Unsafe medical care causes morbidity and mortality among the hospital patients. In a postanaesthesia care unit (PACU), increasing patient safety is a joint effort between different professions. The Green Cross (GC) method is a user-friendly incident reporting method that incorporates daily safety briefings to support healthcare professionals in their daily patient safety work. Thus, this study aimed to describe healthcare professionals' experiences with the GC method in a PACU setting 3 years after its implementation, including the period of the coronavirus disease 2019 pandemic's three waves., Design: An inductive, descriptive qualitative study was conducted. The data were analysed using qualitative content analysis., Setting: The study was conducted at a PACU of a university hospital in South-Eastern Norway., Participants: Five semistructured focus group interviews were conducted in March and April 2022. The informants (n=23) were PACU nurses (n=18) and collaborative healthcare professionals (n=5) including physicians, nurses and a pharmacist., Results: The theme 'still active, but in need of revitalisation' was created, describing the healthcare professionals' experiences with the GC method, 3 years post implementation. The following five categories were found: 'continuing to facilitate open communication', 'expressing a desire for more interprofessional collaboration regarding improvements', 'increasing reluctance to report', 'downscaling due to the pandemic' and 'expressing a desire to share more of what went well'., Conclusions: This study offers information regarding the healthcare professionals' experiences with the GC method in a PACU setting; further, it deepens the understanding of the daily patient safety work using this incident reporting method., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020., Methods: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors., Findings: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model., Conclusions: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks., (© 2023. The Author(s).)

Objectives: The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic., Design: Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis., Results: The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions., Conclusion: This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite the lack of knowledge about the SARS-CoV2 virus, the lack of personal protection gear among frontline healthcare workers, and lack of vaccines in the beginning of the pandemic, paramedic students in Norway contributed to the National response against the COVID-19 pandemic by working in test-stations, ambulance services, ambulance decontamination stations etc. Despite fear of contracting the COVID-19 reported by healthcare workers worldwide, paramedic students in Norway reported higher-than-average quality of life after four months of the COVID-19 pandemic (first pandemic wave). In this study we aimed to investigate how students reported their quality of life, study motivation and job satisfaction after one year of living with the COVID-19 pandemic., Method: At two data collection point, all paramedic students enrolled at Oslo Metropolitan University were invited to participate in a digital, online, self-administered survey. The first data collection was in June 2020 (the first pandemic wave), while the second data collection was in March 2021 (the third pandemic wave). Results from both samples were analyzed independently with descriptive statistics. Differences between the groups were analyzed using an independent T-test and Mann-Whitney-U test to discover changes over time. Multiple linear regression analysis was used to estimate the difference attributable to timing (first vs. the third wave), seniority, and student gender., Results: The samples consist of slightly more female students than male students. The mean age in both samples is 24.6 years. Despite the higher-than-average level of quality of life in the first pandemic wave, results show that there was a significant reduction in students' health-related quality of life (p < 0.001, B -0.059, SE 0.016), study motivation (p = 0.002, 95% CI:0.09,0.41), and job satisfaction (p = 0.005, 95% CI:1.62,9.00) after the third pandemic wave in Norway. Surprisingly, students experienced more technical challenges in the third wave, e.g., poor internet connection, sound pollution, and poor picture quality, despite more experience among students and teachers., Conclusion: Our results show that paramedic students had significant worsening experiences in the late pandemic wave compared to the first pandemic wave. Universities and governments should learn from the COVID-19 pandemic to develop better preparedness plans for future pandemics and knowledge about students' well-being should be considered in future preparedness plans for higher education and the government plans for the education of front-line healthcare workers during a pandemic to facilitate the continuation of necessary education., (© 2023. The Author(s).)

To examine the prevalence of 12-month mood disorders and receipt of mental health treatment among a volunteer sample of higher education students during the 2nd and 3rd COVID-19 wave in the Flanders region. Web-based self-report surveys were obtained from 9101 students in higher education in the Flemish College Surveys (FLeCS) in Flanders, Belgium. As part of the World Health Organization's World Mental Health-International College Student Initiative, we screened for 12-month mood disorders (major depressive episode (MDE), mania/hypomania), and service use. We used poststratification weights to generate population-representative data on key socio-demographic characteristics. 50.6% of the respondents screened positive for 12-month mood disorders (46.8% MDE, of which 22.9% with very severe impact). Use of services was very low, with estimates of 35.4% for MDE, 31.7% for mania, and 25.5% for hypomania. Even among students with very severe disorders, treatment rates were never higher than 48.3%. Most common barriers for not using services were: the preference to handle the problem alone (83.4%) and not knowing where to seek professional help (79.8%). We found a high unmet need for mood problems among college students; though caution is needed in interpreting these findings given the volunteer nature of the sample. A reallocation of treatment resources for higher education students should be considered, particulary services that focus on innovative, low-threshold, and scalable interventions., Competing Interests: Declaration of competing interest In the past 3 years, Dr. Kessler was a consultant for Datastat, Inc., Holmusk, RallyPoint Networks, Inc., and Sage Therapeutics. He has stock options in Mirah, PYM, and Roga Sciences., (Copyright © 2023. Published by Elsevier Ltd.)

Background: Research suggests that changes in social support and loneliness have affected mental disorder symptoms during the COVID-19 pandemic. However, there are a lack of studies comparing the robustness of these associations., Aims: The aims were to estimate the strength of the associations of loneliness and social support with symptoms of depression, anxiety, and posttraumatic stress during the COVID-19 pandemic (2020-2022) in the general population., Method: The method entailed a systematic review and random-effects meta-analysis of quantitative studies., Results: Seventy-three studies were included in the meta-analysis. The pooled correlations of the effect size of the association of loneliness with symptoms of depression, anxiety, and posttraumatic stress were 0.49, 0.40, and 0.38, respectively. The corresponding figures for social support were 0.29, 0.19, and 0.18, respectively. Subgroup analyses revealed that the strength of some associations could be influenced by the sociodemographic characteristics of the study samples, such as age, gender, region, and COVID-19 stringency index, and by methodological moderators, such as sample size, collection date, methodological quality, and the measurement scales., Conclusions: Social support had a weak association with mental disorder symptoms during the COVID-19 pandemic while the association with loneliness was moderate. Strategies to address loneliness could be highly effective in reducing the impact of the pandemic on social relationships and mental health.

Studies on the cessation of face mask use after a COVID-19 vaccine in patients with diabetes are not available, despite their greater predisposition to complications. We estimated the prevalence of cessation of face mask use after receiving the COVID-19 vaccine in patients with diabetes and identified which factor was most strongly associated with non-use. This was a cross-sectional study in patients with diabetes 18-70 years with at least one dose of vaccine against COVID-19 ( n = 288). Participants were asked to respond face-to-face to a questionnaire in a primary care center. Descriptive statistics, chi-square tests, and multivariate binary logistic regression were used for analyzing the association between vulnerability, benefits, barriers, self-efficacy, vaccine expectations (independent variables), and cessation of use (dependent variable), controlling for sociodemographic, smoking, medical, vaccine, and COVID-19 history. The prevalence of cessation of face masks was 25.3% (95% CI 20.2, 30.5). Not feeling vulnerable to hospitalization increased the odds of non-use (adjusted OR = 3.3, 95% CI 1.2, 8.6), while perceiving benefits did the opposite (adjusted OR = 0.4, 95% CI 0.2, 0.9). The prevalence was low, and only two factors were associated with the cessation of face mask use after COVID-19 vaccination in patients with type 2 diabetes.

Rationale: To describe cardiopulmonary function during exercise 12 months after hospital discharge for coronavirus disease 2019 (COVID-19), assess the change from 3 to 12 months, and compare the results with matched controls without COVID-19., Methods: In this prospective, longitudinal, multicentre cohort study, hospitalised COVID-19 patients were examined using a cardiopulmonary exercise test (CPET) 3 and 12 months after discharge. At 3 months, 180 performed a successful CPET, and 177 did so at 12 months (mean age 59.3 years, 85 females). The COVID-19 patients were compared with controls without COVID-19 matched for age, sex, body mass index and comorbidity. Main outcome was peak oxygen uptake ( V ' O 2  peak )., Results: Exercise intolerance ( V ' O 2  peak <80% predicted) was observed in 23% of patients at 12 months, related to circulatory (28%), ventilatory (17%) and other limitations including deconditioning and dysfunctional breathing (55%). Estimated mean difference between 3 and 12 months showed significant increases in V ' O 2  peak % pred (5.0 percentage points (pp), 95% CI 3.1-6.9 pp; p<0.001), V ' O 2  peak ·kg -1 in COVID-19 patients compared to 2972 mL·min V ' O 2  peak was 2440 mL·min -1 in COVID-19 patients compared to 2972 mL·min -1 in matched controls., Conclusions: 1 year after hospital discharge for COVID-19, the majority (77%), had normal exercise capacity. Only every fourth had exercise intolerance and in these circulatory limiting factors were more common than ventilator factors. Deconditioning was common. V ' O 2  peak and oxygen pulse improved significantly from 3 months., Competing Interests: Conflict of interest: C.B. Ingul has received lecture fees from Bayer AS, unrelated to the current study. I. Skjørten has provided lectures for doctors’ education paid by Norwegian Directorate of Health and Norwegian Medical Association. G. Einvik has received research grants from AstraZeneca to perform the current study. A. Edvardsen has received payment or honoraria for lectures, presentations or educational events from GlaxoSmithKline and Chiesi. K. Stavem has received consulting fees from UCB Pharma and MSD, unrelated to the present study. All other authors have nothing to disclose., (Copyright ©The authors 2023.)

Objectives This study sought to describe the patterns in emergency department (ED) presentations and hospital admissions in children with Ambulatory Care Sensitive Conditions (ACSCs) before and during the coronavirus disease 2019 (COVID-19) pandemic restrictions in Victoria, Australia, to assess if changes in out-of-hospital care resulted in an increase in delayed/severe presentations. Methods This study involved secondary analysis of Victorian Emergency Minimum Dataset and Victorian Admitted Episode Dataset data. Patients (<18 years) attending EDs with a diagnosis of an ACSC were included. We compared the number and severity of ASCS presentations pre-COVID-19 (1January 2018-27 March 2020) and during COVID-19 (28 March-31 October 2020). A linear regression prediction model was built to compare the observed versus predicted presentation number in the 2020 period. Results In total, there were 108 104 paediatric ACSC ED presentations in Victoria during the study period. Females accounted for 51 462/108 104 (47.6%) of all presentations, with a median age of 3 years. A significant decrease in ED presentations was seen in 2020 (41 319 in 2018; 44 978 in 2019; and 21 807 until October 2020), predominantly due to reductions in conditions that are typically mediated by viruses in childhood (i.e. asthma, convulsions/epilepsy and ear, nose and throat conditions). The proportion of high-urgency presentations and those requiring admission was stable in 2020. Conclusions An overall reduction in the number of ED presentations and admissions with paediatric ACSCs was seen in Victoria in 2020, indicating that rates of delayed or more severe presentations did not occur as a result of changes in out-of-hospital care.

Background: One in eight children in the United Kingdom are estimated to have a mental health condition, and many do not receive support or treatment. The COVID-19 pandemic has negatively impacted mental health and disrupted the delivery of care. Prevalence of poor mental health is not evenly distributed across age groups, by sex or socioeconomic groups. Equity in access to mental health care is a policy priority but detailed socio-demographic trends are relatively under-researched., Methods: We analysed records for all mental health prescriptions and referrals to specialist mental health outpatient care between the years of 2015 and 2021 for children aged 2 to 17 years in a single NHS Scotland health board region. We analysed trends in prescribing, referrals, and acceptance to out-patient treatment over time, and measured differences in treatment and service use rates by age, sex, and area deprivation., Results: We identified 18,732 children with 178,657 mental health prescriptions and 21,874 referrals to specialist outpatient care. Prescriptions increased by 59% over the study period. Boys received double the prescriptions of girls and the rate of prescribing in the most deprived areas was double that in the least deprived. Mean age at first mental health prescription was almost 1 year younger in the most deprived areas than in the least. Referrals increased 9% overall. Initially, boys and girls both had an annual referral rate of 2.7 per 1000, but this fell 6% for boys and rose 25% for girls. Referral rate for the youngest decreased 67% but increased 21% for the oldest. The proportion of rejected referrals increased steeply since 2020 from 17 to 30%. The proportion of accepted referrals that were for girls rose to 62% and the mean age increased 1.5 years., Conclusions: The large increase in mental health prescribing and changes in referrals to specialist outpatient care aligns with emerging evidence of increasing poor mental health, particularly since the start of the COVID-19 pandemic. The static size of the population accepted for specialist treatment amid greater demand, and the changing demographics of those accepted, indicate clinical prioritisation and unmet need. Persistent inequities in mental health prescribing and referrals require urgent action., (© 2022. The Author(s).)

Objective: Older adults may be at lower risk of common mental disorders than younger adults during the coronavirus disease 2019 (COVID-19) pandemic. Previous research has shown shown differences by age in psychosocial well-being during the pandemic and have highlighted the moderating effect of prepandemic mental disorders on that association. In this line, we examined the association of age with self-reported symptoms of loneliness, depression, anxiety, and posttraumatic stress, as well as potential roles of loneliness symptoms and prepandemic mental disorders on the association between age and mental disorder symptoms., Methods: Cross-sectional data of 2000 adults in Spain interviewed by telephone during the COVID-19 pandemic (February-March 2021) were analyzed. Depression, anxiety, and posttraumatic stress were measured with the eight-item Patient Health Questionnaire, the seven-item Generalized Anxiety Disorder Scale, and the four-item checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), respectively. Loneliness was measured with the three-item University of California at Los Angeles Loneliness Scale. Several regression models were constructed to assess factors related to loneliness and mental disorders., Results: According to cutoff points used, 12.4% of participants revealed depression, 11.9% revealed anxiety, and 11.6% revealed posttraumatic stress. Age was negatively related to mental disorder symptoms and loneliness. Loneliness was associated with higher levels of mental disorder symptoms. This association was stronger in younger adults without prepandemic mental disorders and in older adults with them. The association between age and loneliness was stronger in those with prepandemic mental disorders. Loneliness mediated the association of age with mental disorder symptoms., Conclusions: Interventions focused on loneliness could alleviate the impact of the COVID-19 pandemic on mental health., (Copyright © 2022 by the American Psychosomatic Society.)

Background: COVID-19 health emergency caused an increase in the demand for hospitalization and high costs for the health system., Objective: To estimate COVID-19 care direct costs from the perspective of the healthcare provider in a secondary care hospital that underwent conversion during the first year of health emergency., Material and Methods: Retrospective, observational study. Information on quantities of goods and services was obtained from the SINOLAVE and CVOED platforms and from hospital administrative sources. Four cost groups were defined and estimated with 2021 unit prices in US dollars., Results: Mean hospital length of stay (n = 3,241 patients) was 10.8 ± 8.2 days. Average cost of care per patient was USD 6,557 ± 4,997. Respiratory therapy with assisted mechanical ventilation was used by 13% of patients., Conclusions: The costs of COVID-19 medical care represent a large amount of resources. Most part of the costs (95%) were derived from hospital stay, respiratory therapy without assisted mechanical ventilation and costs related to personal protective equipment, hygiene, infrastructure adaptation and payments to medical personnel., (Copyright: © 2023 Permanyer.)

(1) Background: The global health crisis caused by the coronavirus disease (COVID-19) pandemic has led to extreme overloading of different public healthcare systems worldwide. The Spanish Public Healthcare System is one of them. This study aimed to conduct a comparative cost analysis to assess the impact of the COVID-19 pandemic on small- and medium-sized regional hospitals in Andalusia (Spain). (2) Methods: This comparative, multicentre, observational, and retrospective study was designed to perform a comparative cost analysis between the Alto Guadalquivir Health Agency (AGHA) and Poniente University Hospital (PUH), both of which belong to the Spanish Public Health System (PHS). The data included in this study corresponds to the total costs by area and year incurred by the 61,335 patients from both healthcare institutions (AGHA = 36,110; PUH = 25,225) in the areas of hospital emergency service (HES), hospitalisation, and intensive care unit (ICU), during the 24 months of the study period (from 1 January 2019 to 31 December 2020). (3) Results: The analysis results showed a significant increase in costs incurred in 2020 for HES relative to those incurred in 2019 for both AGHA (+14%; p < 0.003) and PUH (+36%; p = 0.002). Additionally, costs incurred for ICU increased significantly in 2020 relative to those incurred in 2019 for both AGHA (+30%; p = 0.003) and PUH (+46%; p = 0.002). Hospitalisation costs for AGHA also increased significantly (+9%; p < 0.012) in 2020 versus those obtained in 2019; however, no significant differences were found for PUH (+6%; p = 1) in the same period analysed. However, the number of patients treated in the areas of HES, hospitalisation, and ICU was significantly reduced throughout 2020 compared to 2019. (4) Conclusions: Our findings show that the costs incurred during 2020 in the regional hospitals of Andalusia (Spain) increased significantly in most of the parameters analysed relative to those incurred in the year before the pandemic (i.e., 2019).

Background: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, demand for deep cleaning and environmental services workers grew exponentially. Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers, less emphasis has been placed on environmental services workers, who play an equally important front-line role., Aim: To examine the impact of the COVID-19 pandemic on environmental services workers employed in healthcare settings., Methods: Scoping review methodology. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Four bibliographical databases were searched from inception to 5 th July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database., Results: In total, 24 studies were included in this review. The studies were generally cross-sectional in design. Seroprevalence studies highlighted significantly higher rates of COVID-19 among environmental services workers (housekeeping, cleaning and janitorial staff) compared with other clinical and non-clinical staff in the same institutions. In addition, based on qualitative interviews, environmental services workers experienced greater psychological stress working during the pandemic., Conclusions: Environmental services workers were particularly vulnerable to increased work stress and COVID-19 during the pandemic. Health systems need to do more to support these workers. Further research could investigate specific policy and procedural changes to benefit this under-recognized group in the greater healthcare workforce., (Copyright © 2022 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.)

Background: The type of pre-existing disorder might determine changes in mental health symptoms (i.e., anxiety, depression) during the COVID-19 pandemic and influence the effect of psychological factors (e.g., social support, resilience, stress) on such symptoms., Methods: Longitudinal data from two assessments (June-2020 and February/March-2021) collected through telephone interviews (Spanish general population) were analysed. Outcome variables included anxiety (GAD-7) and depressive symptoms (PHQ-8). Psychological factors included COVID-perceived stress (adapted COVID-perceived risk scale), social support (OSSS-3), and resilience (CD-RISC). Pre-existing mental conditions (3 groups: mood, anxiety, and comorbid depression+anxiety) were assessed using the CIDI checklist. Changes in anxiety and depressive symptoms between baseline and follow-up were assessed with the paired samples Wilcoxon test. Tobit regression and interaction models were conducted to test associations between psychological factors and these symptoms in follow-up., Results: Final sample included 1942 participants (mean age 49.6 yrs., ±16.7; 51.7 % females). Anxiety symptoms increased in all groups except for those with pre-existing mood conditions. Depressive symptoms only increased in those without pre-existing mental disorders and in those with pre-existing anxiety. Higher baseline resilience, increases in social support, and decreases in COVID-perceived stress were associated with lower anxiety and depressive symptoms. The type of pre-existing mental disorder did not modify these associations., Limitations: Lack of pre-pandemic data and the limited number of pre-existing mental conditions., Conclusions: Having pre-pandemic mental disorders is associated with different patterns of anxiety and depressive symptoms during the pandemic. COVID-related stress, social support, and resilience are key factors in improving mental health regardless of the mental diagnosis., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: An increased prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes in children was observed in various diabetes centres worldwide during the COVID-19 pandemic. We aimed to evaluate trends in the prevalence of diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes before and during the COVID-19 pandemic, and to identify potential predictors of changes in diabetic ketoacidosis prevalence during the pandemic., Methods: For this international multicentre study, we used data from 13 national diabetes registries (Australia, Austria, Czechia, Denmark, Germany, Italy, Luxembourg, New Zealand, Norway, Slovenia, Sweden, USA [Colorado], and Wales). The study population comprised 104 290 children and adolescents aged 6 months to younger than 18 years, who were diagnosed with type 1 diabetes between Jan 1, 2006, and Dec 31, 2021. The observed diabetic ketoacidosis prevalence in 2020 and 2021 was compared to predictions based on trends over the pre-pandemic years 2006-19. Associations between changes in diabetic ketoacidosis prevalence and the severity of the COVID-19 pandemic and containment measures were examined with excess all-cause mortality in the whole population and the Stringency Index from the Oxford COVID-19 Government Response Tracker., Findings: 87 228 children and adolescents were diagnosed with type 1 diabetes between 2006 and 2019, 8209 were diagnosed in 2020, and 8853 were diagnosed in 2021. From 2006 to 2019, diabetic ketoacidosis at diagnosis of type 1 diabetes was present in 23 775 (27·3%) of 87 228 individuals and the mean annual increase in the prevalence of diabetic ketoacidosis in the total cohort from 2006 to 2019 was 1·6% (95% CI 1·3 to 1·9). The adjusted observed prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes was 39·4% (95% CI 34·0 to 45·6) in 2020 and 38·9% (33·6 to 45·0) in 2021, significantly higher than the predicted prevalence of 32·5% (27·8 to 37·9) for 2020 and 33·0% (28·3 to 38·5) for 2021 (p&lt;0·0001 for both years). The prevalence of diabetic ketoacidosis was associated with the pandemic containment measures, with an estimated risk ratio of 1·037 (95% CI 1·024 to 1·051; p&lt;0·0001) per ten-unit increase in the Stringency Index for 2020 and 1·028 (1·009 to 1·047; p=0·0033) for 2021, but was not significantly associated with excess all-cause mortality., Interpretation: During the COVID-19 pandemic, there was a marked exacerbation of the pre-existing increase in diabetic ketoacidosis prevalence at diagnosis of type 1 diabetes in children. This finding highlights the need for early and timely diagnosis of type 1 diabetes in children and adolescents., Funding: German Federal Ministry for Education and Research, German Robert Koch Institute, German Diabetes Association, German Diabetes Foundation, Slovenian Research Agency, Welsh Government, Central Denmark Region, and Swedish Association of Local Authorities and Regions., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The COVID19 pandemic revealed and deepened existing inequalities. These were exacerbated by institutional and interpersonal racism and poorly conceived public health messaging. As a result, people from minority ethnic backgrounds in the UK were disproportionately affected. We conducted a creative interdisciplinary session to support interactive reflection and discussion on these inequalities between the actors and the audience, who was comprised of public health scientists and NHS practitioners, to come up with practical ways to address ethnicity-based health inequalities going forward., Methods: We prepared a 45 min interactive scenario drawing on forum theatre approaches, which are based on the Theatre of the Oppressed: a set of dramatical techniques created by Augusto Boal. To understand what to include the interactive scenario we carried out a workshop built on a narrative interview study with 70 adults who had Covid between March, 2020, and November, 2021. We adopted a maximum variation sampling strategy focusing on people from minority ethnic backgrounds (45 of total sample). Interviews were done remotely and recorded via video or audio. Study participants were invited to tell their story in their own words, alongside semi-structured prompting. After thematic analysis, the research team worked with theatre practitioners from the Performing Medicine company to create scenarios from verbatim interview content. The format allows audience members to watch scenarios and interact directly with actors, giving advice on how to improve the situation. The study was approved by Berkshire Ethics Committee. Informed verbal and written consent were obtained from all participants., Findings: Five themes from analysis explored in the workshop emerged: (1) existing racialised disadvantages that impacted COVID-19 exposure: employment, housing, and caring responsibilities; (2) unequal access to care, welfare, and support; (3) fears about the health-care system regarding quality of care and vaccine safety; (4) perceptions that the media and public health messaging blamed minority ethnic groups for spreading infection; and (5) increases in acts of direct racism. These informed the development of a 45-minute interactive scenario, which will be performed at the 10th UK Public Health Science conference., Interpretation: There is an urgent need to re-evaluate public health messaging and care for people from minority ethnic backgrounds. This theatre workshop will support reflection to refine workshop content for further dissemination., Funding: UK Economic and Social Research Council., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Many studies have forewarned the profound emotional and psychosocial impact of the protracted COVID-19 pandemic. This study thus aimed to examine how individuals relate to suicide amid the COVID-19 pandemic from a global perspective via the public Twitter discourse around suicide and COVID-19. Original Twitter tweets from 1 February 2020 to 10 February 2021 were searched, with terms related to "COVID-19", "suicide", or "self-harm". An unsupervised machine learning approach and topic modelling were used to identify topics from unique tweets, with each topic further grouped into themes using manually conducted thematic analysis by the study investigators. A total of 35,904 tweets related to suicide and COVID-19 were processed into 42 topics and six themes. The main themes were: (1) mixed reactions to COVID-19 public health policies and their presumed impact on suicide; (2) biopsychosocial impact of COVID-19 pandemic on suicide and self-harm; (3) comparing mortality rates of COVID-19, suicide, and other leading causes of death; (4) mental health support for individuals at risk of suicide; (5) reported cases and public reactions to news related to COVID-19, suicide, and homicide; and (6) figurative usage of the word suicide. The general public was generally concerned about governments' responses as well as the perturbing effects on mental health, suicide, the economy, and at-risk populations.

Objective To determine the association between coronavirus disease 2019 (COVID-19) restrictions and paediatric mental health emergency department presentations. Methods Secondary analysis of Victorian Emergency Minimum Dataset data from 38 Victorian public hospital emergency departments. Paediatric patients (birth to <18 years) attending emergency departments with an International Classification of Disease-Australian Modification (ICD-10-AM) diagnosis of a mental health problem between 1 January 2018 and 31 October 2020 were included. We compared pre-COVID-19 (1 January 2018-27 March 2020) to the COVID-19 period (28 March-26 October 2020) to examine the number of mental health presentations by patient age, socioeconomic status, location, and emergency department triage category. A Poisson regression prediction model was built for each diagnosis group to predict the presentation number in the COVID-19 period, assuming the pandemic and associated restrictions had not happened. Results There were 15 898 presentations (589 presentations/month on average) in the pre-COVID-19 period and 4747 presentations (678 presentations/month on average) in the COVID-19 period. Compared with predicted presentations, there was an increase in observed presentations for eating disorders throughout lockdown (on average, an increase of 36 presentations/month) and for anxiety (11/month) and self-harm (18/month). There were no meaningful changes for mood disorders or developmental and behavioural problems, and presentations for substance abuse mostly fell. Conclusions Pandemic restrictions were associated with increased emergency department presentations for eating disorders and, to a lesser extent, anxiety and self-harm. Given the ongoing pandemic, clinicians and policy makers must work together to find timely, accessible solutions to better manage these conditions.