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Abstract Background Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision. Methods A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts. Results Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations). Conclusions The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.

Verena Schneider,1 Tom Norris,2 Manjula Nugawela,3 Emma Dalrymple,3 Dougal Hargreaves,4 Anton Käll,5,6 Kelsey McOwat,7 Roz Shafran,3 Terence Stephenson,3 Laila Xu,3 Snehal M Pinto Pereira2 On behalf of CLoCk Consortium members1Department of Epidemiology & Public Health, University College London, London, UK; 2Department of Targeted Intervention, University College London, London, UK; 3UCL Great Ormond Street Institute of Child Health, University College London, London, UK; 4Mohn Centre for Children’s Health & Wellbeing, School of Public Health, Imperial College London, London, UK; 5Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; 6Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; 7Immunisation Department, UK Health Security Agency, London, UKCorrespondence: Verena Schneider, Department of Epidemiology and Public Health, University College London, 1– 19, Torrington Place, London, WC1E 7HB, UK, Tel +44 7985 682045, Email verena.schneider.19@ucl.ac.ukPurpose: Loneliness is common amongst children and young people (CYP) and is an independent risk factor for poor health. This study aimed to i) determine whether subgroups of CYP with different loneliness trajectories (during the second year of the pandemic) exist; ii) examine associations with socio-demographic characteristics and subsequent health; and iii) understand whether associations between loneliness and subsequent health were modified by SARS-CoV-2 infection.Methods: A total of 5851 CYP (N=3260 SARS-CoV-2 positive and 2591 SARS-CoV-2 negative) provided data on loneliness (via the validated 3-item version of the UCLA Loneliness Scale for Children) at least twice in a 12-month period post PCR index-testing (conducted October 2020-March 2021). Latent class growth analyses were used to identify distinct classes of loneliness trajectories. Multinomial logistic regression was used to identify socio-demographic characteristics associated with class membership. Logistic regression models assessed the odds of reporting impairing symptoms 12-months post index-test.Results: Four distinct loneliness trajectories were identified: three mostly stable (low, medium, high) and one low-increasing trajectory. Being older, female, living in more deprived areas and testing negative were associated with greater odds of being in the highest vs lowest loneliness trajectory; eg OR for female vs male: 5.6 (95% CI:4.1,7.8); OR for 15– 17 vs 11– 14 years: 4.5 (95% CI:3.4,6.0). Following higher loneliness trajectories was associated with higher odds of experiencing impairing symptoms 12-months post index-test: ORadjusted (compared to lowest loneliness trajectory) were 15.9 (95% CI:11.9,21.3) (high loneliness), 6.5 (5.3,7.9) (medium loneliness) and 2.3 (1.9,2.8) (low-increasing loneliness). There was no evidence that this association was modified by PCR index-test result.Conclusion: About 5.3% of CYP were classified into a group experiencing (chronically) high loneliness. Being female, older and from more deprived areas were risk factors of belonging to this group. Results suggest that even small increases from low loneliness levels may be associated with worse health outcomes.Plain Language Summary: Why was the study done?Multiple lockdowns and school closures during the COVID-19 pandemic may have led to a rise in loneliness in children and young people (CYP). Loneliness can harm health and loneliness research often examines adult populations. We wanted to know if feelings of loneliness in CYP changed during the pandemic and which factors were associated with different loneliness patterns. Furthermore, we wanted to know how different patterns of loneliness linked to later health.What did the researchers do and find?We used data on almost 6000 CYP from the CLoCk study who completed multiple surveys during the pandemic. CYP were asked about feelings of loneliness using questions like: “how often do you feel you have no one to talk to”. We also asked about their health.We identified four patterns of loneliness in CYP between April 2021 and April 2022: 1) stable low loneliness levels, 2) initial low loneliness levels which increased over time, 3) stable medium loneliness levels, and 4) stable high loneliness levels. 5.3% of CYP had stable high loneliness levels and they were also more likely to be older, female, living in more deprived areas and testing negative for COVID-19. Compared to those following the lowest loneliness pattern, those with higher levels of loneliness were at greater risk of impaired health.What do these result mean?We identify CYP who may experience high levels of loneliness and highlight that even small increases in loneliness may be associated with worse health outcomes.Keywords: Adolescence, Loneliness, Pandemic, Mental Health, Physical Health, Longitudinal Studies

This article is unique because it fills a significant gap among COVID-19 related educational research in three ways. First, it analyses data from face-to-face interviews with 23 children, whilst most COVID-19 related research has been based on online data collection methods. Second, it involves 'lower-attaining' children who were already part of an ongoing five-year research project set in England, UK. Third, it captures a 'before' and 'after' picture of the children's experiences during schooling-as-normal and after the two periods of school closures, in relation to their well-being. Within the context of Seligman's PERMA theory, we found that the absence-of-schooling-as-normal had adversely affected their well-being, but in so doing, the children's perspective on schooling had altered, as they had missed being part of something bigger than themselves, in a setting which offered socialisation, structure and purpose.

A considerable body of global educational literature has examined how schooling policy based on measuring and managing performance has narrowed children's access both to curriculum breadth and to diversity in pedagogy. This article approaches these curriculum dilemmas within the global concern for children's wellbeing and social justice. In particular, it focuses on the experiences of children designated by this system as lower-attaining, which is a much under-researched aspect of these concerns. Based on an innovative five-year life-history study of 23 seven to 12 year-old lower-attaining school-children in the English system, this article examines how these children themselves depicted their schooling experiences. We conclude, drawing on term-by-term experiences narrated by these children, that the current curriculum and assessment arrangements narrowed their opportunities for participation in engaged learning, especially in comparison to higher-attaining children; which undermined their wellbeing and brought social justice into question. The children highlighted the negative impact of curriculum emphases on mathematics and English rather than on non-core and outside-school curriculum areas for lower-attaining in particular; and the emphasis on attainment rather than participation in learning. They had few opportunities to have their specific preferences validated, leading in some cases to these lower-attainers being excluded from participation in school-learning.

This article tracks the life-histories of 23 British schoolchildren aged from seven to 12 who were designated as 'lower-attaining' at age seven. Drawing on Self Determination Theory's mini-theory of Causality Orientations, the authors explored whether/how children with a Controlled or Impersonal Orientation approached creative learning differently from those with an Autonomy Orientation. Six detailed life-histories presented illuminate that children with a Controlled or Impersonal Orientation often channelled their energies into conformity, as well as avoidance of subordination and punishment, diverting them away from creative learning. Relationships with peers also influenced their orientations significantly. Using Chris Watkins' concepts of Learning Orientation and Performance Orientation, based on Carol Dweck's Growth and Fixed Mindset theories, they conclude that their life-histories highlight a focus in schooling on both prior attainment and the end product -- 'performances' -- rather than children's motivated engagement with learning. This threatens the chance that they achieve positive-experience and wellness outcomes through creative learning.

Self-regulation and metacognition are important for lifelong functioning and can be strengthened with intervention at a young age. Research proposes that musical play enables self-regulatory development, but lacks rigorous approaches to investigate whether a causal relationship between the two exists. We introduced a musical play intervention in a real-world classroom, and examined its impact on self-regulation and metacognition. We adopted a quasi-experimental, pre-test and post-test control-group design, with 98 children aged 6. The intervention group (N = 45) participated in 13 musical play sessions, while the control group (N = 53) had 13 music lessons following the usual music curriculum. Children's self-regulation and metacognition, including metacognitive knowledge, metacognitive regulation and emotional/motivational regulation, was assessed before and after the intervention through three validated instruments: a) an observational assessment of children's self-regulation and metacognition while completing a task, b) a metacognitive knowledge interview following the task, and c) a teacher-reported assessment of self-regulation and metacognition. The results were equivocal: according to the teacher ratings, the intervention group's self-regulation and metacognition improved significantly more than controls following the intervention, but this result was not corroborated by assessment of children's self-regulation on task. Despite this, from the three areas of self-regulation and metacognition, there was a statistically significant improvement in metacognitive knowledge in the intervention group compared to controls, a result indicated by the teacher-reported assessment and by the metacognitive knowledge interview, which revealed a significant effect on children's metacognitive knowledge of strategies. This study can further the discussions on the use of different methodological approaches when exploring self-regulation, and can inform policy and practice in relation to music and play in schools.

Objective To identify barriers to hospital participation in controlled cluster trials of clinical decision support (CDS) and potential strategies for addressing barriers.Design Qualitative descriptive design comprising semistructured interviews.Setting Five hospitals in New South Wales and one hospital in Queensland, Australia.Participants Senior hospital staff, including department directors, chief information officers and those working in health informatics teams.Results 20 senior hospital staff took part. Barriers to hospital-level recruitment primarily related to perceptions of risk associated with not implementing CDS as a control site. Perceived risks included reductions in patient safety, reputational risk and increased likelihood that benefits would not be achieved following electronic medical record (EMR) implementation without CDS alerts in place. Senior staff recommended clear communication of trial information to all relevant stakeholders as a key strategy for boosting hospital-level participation in trials.Conclusion Hospital participation in controlled cluster trials of CDS is hindered by perceptions that adopting an EMR without CDS is risky for both patients and organisations. The improvements in safety expected to follow CDS implementation makes it challenging and counterintuitive for hospitals to implement EMR without incorporating CDS alerts for the purposes of a research trial. To counteract these barriers, clear communication regarding the evidence base and rationale for a controlled trial is needed.

Ex vivo normothermic machine perfusion (NMP) preserves donor organs and permits real-time assessment of allograft health, but the most effective indicators of graft viability are uncertain. Mitochondrial DNA (mtDNA), released consequent to traumatic cell injury and death, including the ischemia-reperfusion injury inherent in transplantation, may meet the need for a biomarker in this context. We describe a real time PCR-based approach to assess cell-free mtDNA during NMP as a universal biomarker of allograft quality. Measured in the perfusate fluid of 29 livers, the quantity of mtDNA correlated with metrics of donor liver health including International Normalized Ratio (INR), lactate, and warm ischemia time, and inversely correlated with inferior vena cava (IVC) flow during perfusion. Our findings endorse mtDNA as a simple and rapidly measured feature that can inform donor liver health, opening the possibility to better assess livers acquired from extended criteria donors to improve organ supply.

Anterior cruciate ligament (ACL) tears are one of the most common knee injuries experienced by active individuals engaging in cutting sports. Despite improved surgical techniques and rehabilitation, the return to sport rate and re-tear rates remain unsatisfactory. Lateral extra-articular tenodesis (LET) is a procedure that has been growing in interest when performed in conjunction with ACL reconstruction. The benefits of adding an LET procedure to an ACL surgery may include greater rotational stability, decreased re-tear rates, and improved return to play. Level of evidence: V

Abstract Introduction Disparities in the uptake of routine and COVID‐19 vaccinations have been observed in migrant populations, and attributed to issues of mistrust, access and low vaccine confidence. Participatory research approaches and behaviour change theory hold the potential for developing tailored vaccination interventions that address these complex barriers in partnership with communities and should be explored further. Methods This study used a theory‐informed, community‐based participatory research approach to co‐design a culturally tailored behaviour change intervention aimed at increasing COVID‐19 vaccine uptake among Congolese migrants in London, United Kingdom (2021–2022). It was designed and led by a community‐academic partnership in response to unmet needs in the Congolese community as the COVID‐19 pandemic started. Barriers and facilitators to COVID‐19 vaccination, information and communication preferences, and intervention suggestions were explored through qualitative in‐depth interviews with Congolese migrants, thematically analysed, and mapped to the theoretical domains framework (TDF) and the capability, opportunity, motivation, behaviour model to identify target behaviours and strategies to include in interventions. Interventions were co‐designed and tailored in workshops involving Congolese migrants. Results Thirty‐two Congolese adult migrants (24 (75%) women, mean 14.3 (SD: 7.5) years in the United Kingdom, mean age 52.6 (SD: 11.0) years) took part in in‐depth interviews and 16 (same sample) took part in co‐design workshops. Fourteen barriers and 10 facilitators to COVID‐19 vaccination were identified; most barrier data related to four TDF domains (beliefs about consequences; emotion; social influences and environmental context and resources), and the behavioural diagnosis concluded interventions should target improving psychological capability, reflective and automatic motivations and social opportunities. Strategies included culturally tailored behaviour change techniques based on education, persuasion, modelling, enablement and environmental restructuring, which resulted in a co‐designed intervention comprising community‐led workshops, plays and posters. Findings and interventions were disseminated through a community celebration event. Conclusions Our study demonstrates how behavioural theory can be applied to co‐designing tailored interventions with underserved migrant communities through a participatory research paradigm to address a range of health issues and inequalities. Future research should build on this empowering approach, with the goal of developing more sensitive vaccination services and interventions which respond to migrant communities' unique cultural needs and realities. Patient or Public Contribution Patient and public involvement (PPI) were embedded in the participatory study design and approach, with community members co‐producing all stages of the study and co‐authoring this paper. An independent PPI board (St George's Migrant Health Research Group Patient and Public Involvement Advisory Board) comprising five adult migrants with lived experience of accessing healthcare in the United Kingdom were also consulted at significant points over the course of the study.

Context: Social care need in prisons is increasing in many countries. However, the delivery of social care in prisons has been (at best) inconsistent and there has been no previous review to inform provision for people on release. Objective: To identify and synthesise what is known about the social care needs of people on release from prison and how best to meet these. Method: A scoping review encompassing systematic searches of 26 electronic databases (January 2010–July 2021) included a wide range of literature. No exclusions were made on the basis of study design, method or quality. Findings were organised according to their contribution to the research questions. Findings: Forty-six documents met the review criteria of which 27 were from the UK. Just two focused specifically on the topic of interest and most of the extracted material was descriptive in nature. Almost no information was found on the number of people released from prison in need of social care. However, the challenges of providing care for this group appeared well understood. Although there were many examples of good practice and widespread consensus about its enablers, outcome information was lacking. Limitations: In keeping with the nature of the review, the quality of the literature was not formally assessed. Implications: The review identified several promising initiatives ranging from prison buddy schemes to pre-release training in everyday living skills and personalised pathway documents. Conclusions: Policy makers and researchers must now shift their attention to the effectiveness of particular interventions in improving social care outcomes.

Mammals have limited regenerative capacity, whereas some vertebrates, like fish and salamanders, are able to regenerate their organs efficiently. The regeneration in these species depends on cell dedifferentiation followed by proliferation. We generate a mouse model that enables the inducible expression of the four Yamanaka factors (Oct-3/4, Sox2, Klf4, and c-Myc, or 4F) specifically in hepatocytes. Transient in vivo 4F expression induces partial reprogramming of adult hepatocytes to a progenitor state and concomitantly increases cell proliferation. This is indicated by reduced expression of differentiated hepatic-lineage markers, an increase in markers of proliferation and chromatin modifiers, global changes in DNA accessibility, and an acquisition of liver stem and progenitor cell markers. Functionally, short-term expression of 4F enhances liver regenerative capacity through topoisomerase2-mediated partial reprogramming. Our results reveal that liver-specific 4F expression in vivo induces cellular plasticity and counteracts liver failure, suggesting that partial reprogramming may represent an avenue for enhancing tissue regeneration.