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BACKGROUND A third of adolescents experiencing a concussion will suffer from persistent post-concussion symptoms lasting a month or beyond. The ability to cope with concussion symptoms, regulate emotions, and manage stress is an important determinant of risk for prolonged symptoms. Early psychological interventions, such as mindfulness-based interventions, might improve concussion recovery. OBJECTIVE This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion. METHODS Participants aged 12-18 years were recruited from an emergency department within 48 hours of a concussion (acute cohort) or from a tertiary care clinic at least 1 month post-concussion (persistent symptom cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10-15 min/day, at a minimum of 4 days/week. At 2 weeks post-concussion, participants completed a credibility questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability, and working alliance, as well as a semi-structured phone interview. RESULTS 10 participants completed the study outcomes, including 7 acute (5 females; median [IQR] age=14.73 [13.94,16.94] years and 3 persistent symptom patients (2 females; median [IQR] age=17.62 [17.48,17.86] years). Across cohorts, half-way through the intervention, the treatment expectation was moderate (median=6.00 [3.58,7.75], maximum possible=9.00). Moreover, the intervention was perceived as credible (median=6.50 [6.83,8.75], maximum possible=9.00). At 4 weeks, the DTx was considered usable (median=70.00 [55.00,82.50], maximum possible=100.00). Participants rated their satisfaction with the DTx (median=27.00 [24.50,29.50], maximum possible=32.00) and the working alliance with the digital mindfulness guides (median=3.92 [3.38-4.33], maximum possible=5.00) as high. Four themes were identified from the qualitative data: 1) positive attributes (including accessibility, ease of use, perceived effectiveness, variety of features, and meditation guides); 2) negative attributes (technical issues that acted as a barrier to use, and sounds and lights that were triggering headaches); 3) ideas for modifications; and 4) technical issues. CONCLUSIONS Adolescents were very satisfied with a mindfulness-based intervention delivered via a smartphone app and considered it to be usable and credible. Results inform modifications to the DTx, instructions, and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx to decrease the risk of persistent symptoms and reduce the symptom burden following pediatric concussion. The present mixed-methods study and the iterative approach to intervention design we are using will ensure better translation and impact of interventions for adolescents with concussions.

Background Blended therapy describes the use of computerised therapy combined with face-to-face therapy to extend the depth, range and nature of the face-to-face therapy. We wanted to develop a treatment manual for a randomised trial of blended therapy combining face-to-face problem solving and a smartphone app in men who present to hospital with self-harm. Objective To develop a treatment manual and to describe the experience of receiving and delivering a blended therapy. Methods After completion of the blended therapy, semistructured qualitative interviews were conducted with participants to describe their experience of the treatment. Two independent coders analysed the material using a thematic, grounded theory approach. Findings Seven men were enrolled in the study, and six completed the qualitative interviews. The two main themes identified were of trust and connection. Participants attended 85% of their appointments. Conclusions In the treatment manual, we emphasised the themes of trust and connection by allowing time to discuss the app in the face-to-face to sessions, ensuring that therapists are familiar with the app and know how to respond to technical queries. Identification of trust and connection generates novel questions about the importance of the therapeutic alliance with technology rather than with people. Clinical implications Clinicians and app developers need to pay attention to the therapeutic relationship with technology as trust and good communication can be easily damaged, resulting in disengagement with the app. Blended therapy may result in increased adherence to face-to-face sessions. Trial registration number NCT02718248

There is a paucity of literature on the quality and effectiveness of institutional morbiditymortality (MM) rounds processes.We sought to implement and evaluate the effectiveness of a hospital-wide structured MM rounds model at improving the quality of MM rounds across multiple specialties.We conducted a prospective interventional study involving 24 clinical groups (1584 physicians) at a tertiary care teaching hospital from January 2013 to June 2015.We implemented the published Ottowa MM Model (OM3): appropriate case selection, cognitive/system issues analyses, interprofessional participation, dissemination of lessons and effector mechanisms.We created an OM3 scoring index reflecting these elements to measure the quality of MM rounds. Secondary outcomes include explicit discussions of cognitive/system issues and resultant action items.OM3 scores for all participating groups improved significantly from a median of 12.0/24 (95% CI 10 to 14) to 20.0/24 (95% CI 18 to 21). An increased frequency of in-rounds discussion around cognitive biases (pre 154/417 (37%), post 256/466 (55%); p0.05) and system issues (pre 175/417 (42%), post 259/466 (62%); p0.05) were reported by participants via online surveys postintervention, while in-person surveys throughout the intervention period demonstrated even higher frequencies (cognitive biases 1222/1437 (85%); system issues 1250/1437 (87%)). We found 45 action items resulting directly from MM rounds postintervention, compared with none preintervention.Implementation of a structured model enhanced the quality of MM rounds with demonstrable policy improvements hospital wide. The OM3 can be feasibly implemented at other hospitals to effectively improve quality of MM rounds across different specialties.

KEY POINTS Suicide is one of the leading causes of death in Canada, with about 10 Canadians dying by suicide each day.[1][1] Men represent nearly two-thirds of those who die by suicide after an index episode of self-harm.[2][2] However, interventions for these men have had modest effects, with poor

The recent closure of rural health services in many developed countries has been a natural experiment as health planners strategically adopt regionalized systems of care to combat staggering healthcare system costs. Regionalization is predicated on offering health services in selected discrete locations (‘referral centers’) as opposed to in every local community of reasonable size. Where complex, specialistbased care is required, this approach is fiscally sensible, professionally sustainable and leads to good patient outcomes. When the dislocated service falls under the umbrella of ‘primary care’ (those services that in usual circumstances do not require specialist support but instead benefit from a generalist, wholistic model of care), the efficacy of care in referral communities is not as clear. Notions of ‘risk’, both of local care and care in a referral center, is at the heart of this discussion. This phenomenon is perhaps best illustrated with the case of rural maternity care. The purpose of this Editorial is to extrapolate contemporary theories of risk and apply them to a current and pressing health service delivery issue as a way of illuminating their usefulness in framing the discussion.