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Governments in some of the world’s richest nations appear to be caught in a double challenge of declining social budgets even as social needs are increasing. In this context, Outcomes Based Commissioning (OBC), has been suggested as one way in which ‘more’ social services can be provided for ‘less’ public resources. This form of commissioning is often linked with a new financing tool for social services, referred to in the US as ‘Pay for Success and Payment by Results in the UK or as a ‘Social Impact Bond’ (SIB). However, to date, this approach is under-theorised and this is a limiting factor both for shaping a research and evaluation agenda around SIBs and in understanding how such instruments might develop in future. Without a theoretical rationale for SIBs, it is not straightforward to assess whether, and how well, they have achieved their goals, and how they might be developed further. In this paper we consider two broad approaches to theorising SIBs. One draws on public administration theories, the other on innovation theories. To date, SIBs have often been theorised as the logical next step in the New Public Management (NPM). But NPM itself is a contested theory and recent theoretical innovations in public administration, particularly the concept of New Public Governance might provide a more useful theoretical framework. A second broad approach through which to understand SIBs is their potential to improve the rate and dissemination of innovation. There are many different innovation models that might be applied to better understanding of SIBs. We look first at the concept of Open Innovation with its focus on distributed innovation processes in which knowledge flows across organisational boundaries and more recent articulations – Open Innovation 2.0 – which place greater emphasis on mixed economy collabarations involving: industry; government; universities; and communities and users (the so-called ‘quadruple helix’) to solve societal challenges. We go on to consider social innovation, with its clearer focus on using social means to deliver social outcomes and whether SIBs can be theorised through this lens. No one model is entirely satisfactory as an explanatory framework for SIBs and we conclude by suggesting that a supporting theory combining NPG with elements of Open Innovation 2.0 and social innovation might be a productive approach for shaping future research and, in addition, might suggest some future directions for the next generation of SIBs.

Purpose: Foster youth are at increased risk for negative sexual health outcomes and rarely receive the information or social/familial support needed to reduce risks. Foster and kinship caregivers report lacking the information and skills needed to effectively talk to youth in their care about sexual health. In a sample of caregivers from 2 large urban jurisdictions, our goals were to: 1) describe caregiver sexual health variables including communication and monitoring characteristics; and 2) assess associations between self-reported emotion regulation and caregiver-youth conflict and these variables., Methods: We administered surveys to foster and kinship caregivers in New York, New York and Los Angeles, California. Surveys assessed caregiver emotion regulation, caregiver-youth conflict, sexual/reproductive health knowledge, communication expectations and behaviors, and caregiver monitoring/youth disclosure. We generated descriptive statistics for all variables (aim 1) then performed multivariate regression analyses for aim 2., Results: Our sample included 127 foster and kinship caregivers who were primarily female (92%) and African American (55%). Most reported having >4 years of caregiving experience with foster youth (66%). On average, caregivers answered sexual health knowledge questions correctly 68% of the time. Caregiver-youth conflict was the only variable significantly associated with assessed sexual health variables; it was inversely associated with percent correct on the knowledge scale, outcomes expectations, number of topics discussed, and monitoring/disclosure., Conclusion: Our study suggests that caregiver-youth conflict behaviors are related to sexual health knowledge, communication, and monitoring variables. Further prospective and longitudinal investigation is warranted to better characterize the complex relationship between these variables., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating., Methods: A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006)., Results: The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA., Conclusion: By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA., Competing Interests: No competing financial interests exist., (Copyright 2023, Mary Ann Liebert, Inc., publishers.)

Purpose: Gender-affirming treatment for transgender and nonbinary adolescents has been shown to decrease anxiety, depression, and suicidality, but treatments have medical consequences. Specifically, hormone replacement and pubertal blocking may impact patients' fertility and childbearing capabilities. We interviewed gender diverse adolescents regarding their thoughts on family and fertility., Methods: We completed semistructured interviews with 23 gender diverse adolescents recruited from the Seattle Children's Gender Clinic. Interviewees included transfeminine, transmasculine, and nonbinary youth. Interviews were recorded, transcribed, and analyzed using Braun and Clarke's theory of thematic analysis, a flexible framework for qualitative analysis., Results: Gender diverse adolescents have myriad views on fertility, but four main themes were identified: (1) an interest in future family, including ideas regarding adoption and biological children; (2) barriers to fertility, including cost and procedure-related dysphoria; (3) factors unique to the developmental stage of adolescents, including the age discordance of making fertility decisions as a teenager and parental influence on decision-making; and (4) suggestions for clinicians approaching fertility counseling with adolescents considering hormone therapy., Conclusions: Many gender diverse youth asserted an interest in building families, although the process of fertility preservation remains fraught. Relative to other studies, our participants were hopeful, imaginative, and interested in having children. Participants wanted to receive specific counseling on fertility, to receive help navigating the logistics of fertility preservation, and to be listened to when their hopes for children (or no children) were stated. Further research is needed to create care paradigms that address fertility of transgender youth in an affirming, developmentally appropriate manner., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Foster youth have high rates of unintended teen pregnancies and other negative sexual health outcomes. Foster and kinship caregivers (FKC) are an untapped resource to reduce risks. We conducted a two-phase pilot study to evaluate feasibility, acceptability and assess preliminary efficacy of a training designed to improve caregiver communication, monitoring and conflict behaviors and improve sexual health outcomes for youth in foster care. Our study included a Randomized Controlled Trial (RCT) component., Method: Phase 1: We recruited 49 FKC and assessed feasibility quantitatively, and acceptability both qualitatively and quantitatively of our intervention (Heart to Heart). Phase 2 : We conducted an RCT with 71 participants and evaluated caregiver communication, monitoring, and conflict behaviors as well as the psychological determinants thereof in intervention and control groups at 1, 3, and 6 months., Results: Phase 1: Facilitators delivered all intervention content; >90% participants received the entire training. The intervention was highly acceptable (mean score 4.9/5 on two questions). Phase 2: 71 participants were eligible and completed baseline (68 completed at least one follow up survey). We found significant improvements in the intervention group in knowledge, communication expectations, and caregiver-youth conflict behaviors in one or more waves; the control group demonstrated no significant improvements. When groups were compared, we found significant differences in knowledge, communication frequency, and conflict behaviors at 6 months., Conclusions: Heart to Heart is feasible, acceptable, and preliminary outcomes data is promising. More research is needed to better establish evidence of efficacy for long-term behavior change in caregivers and youth., Clinicaltrialsgov Identifer: NCT03331016., Competing Interests: Conflict of Interest The first author (Ahrens) has confirmed with all co-authors that no authors have conflicts of interest related to this publication.

Purpose: News stories about transgender and gender nonconforming (TGNC) people have become more common in recent years and TGNC youth may be disparately affected by this information compared with their cisgender peers. The aim of this study was to understand how TGNC youth react to news stories about TGNC and other gender and sexual minority (GSM) identifying persons., Methods: As part of a larger study, 23 TGNC youth were recruited from the Seattle Children's Gender Clinic to participate in a semistructured interview. Interviews were audio recorded, transcribed, and thematically analyzed., Results: Participating youth ranged in age from 13 to 19 years (mean = 16.9 years). Of the 23 participants, 43% identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Four main themes were identified: (1) news coverage of current political climate affects gender transition; (2) negative news coverage of GSM people contributes to concerns about mental well-being and safety; (3) geographical location affects perception of news; and (4) positive news coverage of TGNC people increases visibility and hope., Conclusions: Exposure to negative news about GSM people may contribute to increased levels of stress among TGNC youth. With increased visibility, participants described frustration associated with inaccurate portrayals of the TGNC community in the news; however, with increased visibility, there is also a growing sense of shared community and opportunity for acceptance of TGNC people. Given the scope of responses to negative and positive news on GSM people, TGNC youth may benefit from increased support to promote resilience when interpreting the news., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess youth and parent/caregiver satisfaction with care at a pediatric multidisciplinary gender clinic. Methods: Transgender/gender nonconforming youth ( n =33) and their parent/caregiver ( n =29) completed self-report questionnaires and individual interviews ( n =20) about experiences and satisfaction with care. Results: Quantitatively, participants reported being extremely satisfied with care experiences (parents 97%; youth 94%). Qualitatively, main themes included (1) affirmation due to use of preferred name/pronouns, (2) access barriers due to scheduling and readiness assessments, and (3) positive interactions with Care Navigator. Conclusion: Youth and parents/caregivers are highly satisfied with multidisciplinary, coordinated health care for transgender/gender nonconforming youth; however, some challenges remain., Competing Interests: No competing financial interests exist.

Here, we demonstrate the use of phospholipid micelles to enhance O 2 concentrations by two-fold at the surface of a bilirubin oxidase biocathode. Specifically, 1,2-diarachidoyl-sn-glycero-3-phosphocholine was used in a glucose enzymatic fuel cell to limit power losses due to O 2 transport, even in a quiescent solution.

Warmer, drier summers brought by climate change increase the potential risk of wildfires on the moorland of the Peak District of northern England. Fires are costly to fight, damage the ecosystem, harm water catchments, cause erosion scars and disrupt transport. Fires release carbon dioxide to the atmosphere. Accurate forecasts of the timing of fires help deployment of fire fighting resources. A probit model is used to assess the chance of fires at different times of the year, days of the week and under various weather conditions. Current and past rainfall damp fire risk. The likelihood of fire increases with maximum temperature. Dry spells or recent fire activity also signal extra fire hazard. Certain days are fire prone due to visitors and some months of the year are more risky reflecting the changing flammability of moorland vegetation. The model back-predicts earlier fires during a hot dry summer. The impact of climate change on fire incidence is not straightforward. Risks may be reduced if wetter winters and earlier onset of spring add to plant moisture content. Yet a warm spring increases biomass and potential fuel load in summer. Climate change may cause the timing of moorland wildfires to shift from a damper and more verdant spring to drought-stressed summer.

We reviewed nine cases of acquired radial clubhand due to osteomyelitis. Goals were cosmetic improvement, maintenance of any wrist mobility, and a stable, painless wrist and forearm. All patients achieved these goals, although residual forearm shortening ranged from 4-8 cm. Treatment of acquired radial clubhand is difficult. The options and guidelines for treating the congenital variety may not be applicable in the treatment of the acquired type. Surgical options include interposition bone grafting, centralization, and radioulnar transposition. Recently the circular external fixator has been used for correction of this complex deformity.

Large segmental bone grafts are a standard of reconstructing long bone defects. Nonunion or delayed union at the host-graft junction is a major complication of these procedures. In six patients, a nonunion was treated by locally available bone, vascularized by its periosteum as an onlay autograft to improve fixation and speed incorporation of the allograft into the host bone. At three months, all were pain free and using their allografts without limitation. By four months, all had roentgenographic evidence of allograft and autograft incorporation. During the follow-up period from two to four years, all have incorporated the allografts and are pain free.

The clinical, roentgenographic and aortographic data were reviewed in 12 patients with localised descending, thoracic aortic aneurysms. The current study indicates that arteriosclerotic peripheral vascular disease not infrequently produced localised saccular aneurysms of the descending thoracic aorta. Characteristic symptomatology was unusual; most aneurysms were detected as incidental roentgenographic findings. The aneurysms projected from the posteroloteral aspect of the aorta and roentgenographically appeared as left hilar masses or left retrocardiac masses when located in the mid and lower descending thoracic aorta, respectively. Specific rim calcification or vertebral erosion was not encountered in any case. During aortography only a small portion of the aneurysm was outlined with contrast material due to partial obliteration of the aneurysmal cavity with thrombus.