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1. Describe the ethical issues commonly encountered when tracheostomy placement is considered for children with severe neurologic impairment, and empathize with the diversity of perspectives on how these ethical questions should be answered. 2. Appreciate the need for systematic processes for determining tracheostomy eligibility in children with severe neurologic impairment and related comorbidities. Tracheostomy placement in children with severe neurologic impairment raises ethical questions and the potential for provider moral distress. This presentation will describe commonly confronted ethical considerations. The presentation then describes a multidisciplinary national survey being implemented to evaluate the diversity of provider perspectives and practices on tracheostomy placement in children with severe neurologic impairment. Tracheostomies are increasingly being considered in pediatric patients with severe neurologic impairment (SNI). The decision to pursue tracheostomy is weighty in part due to the frequency of clinical complications and the level of care required of caregivers. Pediatric care team members may experience moral distress when tracheostomies are considered in patients with SNI. Commonly cited ethical issues include concerns for quantitative futility, poor quality of life, parental decision making that is not fully informed, and poor utilization of a scarce resource. Because these concerns are value-laden, conflicts can occur between the medical team and parents and within the medical team itself. We hypothesize that providers from different subspecialties may hold differing perspectives. 1. Identify ethical considerations in tracheostomy placement in children with SNI, and 2. Describe a national survey which will evaluate the diversity of care team perspectives re: tracheostomy placement in children with SNI. A clinical case of a child with SNI being considered for tracheostomy will be presented, including perspectives from the parents and members of the care team. Ethical considerations will be enumerated and discussed. A national survey which assesses personal and institutional perspectives of providers from varied subspecialties across the country (planned implementation in Fall 2023) will be introduced. Survey results (preliminary or final) will be presented. The decision surrounding tracheostomy placement in children with SNI is complex, and reasonable people often disagree on its appropriateness. Systematic processes are necessary to ensure that clinical and ethical concerns are negotiated equitably and consistently from patient to patient. Ethical / Legal Aspects of Care; Management of Medical Interventions [ABSTRACT FROM AUTHOR]

Objectives. To compare the incidence, case-hospitalization rates, and vaccination rates of COVID-19 between people experiencing sheltered homelessness (PESH) and the broader community in Chicago, Illinois, and describe the impact of a whole community approach to disease mitigation during the public health emergency. Methods. Incidence of COVID-19 among PESH was compared with community-wide incidence using case-based surveillance data from March 1, 2020, to May 11, 2023. Seven-day rolling means of COVID-19 incidence were assessed for the overall study period and for each of 6 distinct waves of COVID-19 transmission. Results. A total of 774 009 cases of COVID-19 were detected: 2579 among PESH and 771 430 in the broader community. Incidence and hospitalization rates per 100 000 in PESH were more than 5 times higher (99.84 vs 13.94 and 16.88 vs 2.14) than the community at large in wave 1 (March 1, 2020-October 3, 2020). This difference decreased through wave 3 (March 7, 2021-June 26, 2021), with PESH having a lower incidence rate per 100 000 than the wider community (8.02 vs 13.03). Incidence and hospitalization of PESH rose again to rates higher than the broader community in waves 4 through 6 but never returned to wave 1 levels. Throughout the study period, COVID-19 incidence among PESH was 2.88 times higher than that of the community (70.90 vs 24.65), and hospitalization was 4.56 times higher among PESH (7.51 vs 1.65). Conclusions. Our findings suggest that whole-community approaches can minimize disparities in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission between vulnerable populations and the broader community, and reinforce the benefits of a shared approach that include multiple partners when addressing public health emergencies in special populations. ( Am J Public Health . 2024;114(S7):S590-S598. https://doi.org/10.2105/AJPH.2024.307801).

Background: Vaccine hesitancy has been a significant concern throughout the COVID-19 pandemic. Vaccine hesitancy can be attributed to lack of confidence in vaccines, complacency about the health threat, or lack of convenience of vaccination. To date, few studies have used methods designed to include populations underrepresented in research when identifying factors associated with vaccine hesitancy., Methods: Between January and July 2021, potential participants were recruited from community venues selected through time-location sampling in 15 defined communities in the United States. Study staff administered a questionnaire on demographics, COVID-19 behaviors and attitudes, and vaccination status or intention to consenting individuals. Vaccine hesitancy was analyzed among those age 18 years and older from nine of the 15 sites and was defined as self-reported neutral, unlikely, or very unlikely vaccine intention. Logistic regression modeling, adjusted for site, identified factors associated with vaccine hesitancy., Results: Among 11,559 individuals, vaccine hesitancy by site ranged from 8.7 to 31.1%. Vaccine hesitancy was associated with being Black compared to White, being White compared to Asian, younger age, unstable housing, being unemployed, lower income, having a disability, providing care in home, not reporting inability to visit sick or elderly relatives during the pandemic, not reporting increased anxiety during the pandemic, and not spending more time with loved ones during the pandemic., Conclusions: In these selected US communities, early in vaccine rollout, there were significant racial disparities in vaccine hesitancy. Additionally, individuals who were more marginalized due to their socioeconomic status were more likely to report vaccine hesitancy. Vaccine campaigns should make efforts to remove barriers to vaccination, by improving convenience., (© 2024. The Author(s).)

Background: Various effective treatments for depression exist. We aimed to identify the most effective first-line treatments for new episodes of less and more severe depression (defined by depression scale cut-off scores), to update NICE guidance on the management of Depression in Adults in England., Methods: Systematic review and network meta-analysis of randomised controlled trials (RCTs) published up to June 2020 (PROSPERO registration number CRD42019151328). We analysed interventions by class and individually. The primary efficacy outcome was depressive symptom change (expressed as standardised mean difference [SMD]). The review for this outcome was updated in November 2023., Findings: We included 676 RCTs, 105,477 participants and 63 treatment classes. For less severe depression, group cognitive/cognitive behavioural therapy (CT/CBT) class was efficacious versus treatment as usual [TAU], the reference treatment for this population [SMD -1.01 (95% Credible Interval [CrI] -1.76; -0.06)]. For more severe depression, efficacious classes versus pill placebo (reference treatment for this population) included combined individual CT/CBT with antidepressants [-1.18 (-2.07; -0.44)], individual behavioural therapies [-0.86 (-1.65; -0.16)], combined light therapy with antidepressants [-0.86 (-1.59; -0.12)], combined acupuncture with antidepressants [-0.78 (-1.12; -0.44)], individual CT/CBT [-0.78 (-1.42; -0.33)], mirtazapine [-0.35 (-0.48; -0.22)], serotonin and norepinephrine reuptake inhibitors [-0.32 (-0.43; -0.22)], tricyclic antidepressants [-0.29 (-0.50; -0.05)], and selective serotonin reuptake inhibitors [-0.24 (-0.32; -0.16)]. Additional treatments showed evidence of efficacy at the intervention level. Evidence for less and more severe depression was of low and low-to-moderate quality, respectively. In the 2023 update, group yoga and self-help without support emerged as efficacious for less severe depression. For more severe depression, combined group exercise with antidepressants emerged as efficacious, whereas combined light therapy with antidepressants failed to remain efficacious., Interpretation: Group CT/CBT (and possibly group yoga and self-help) appears efficacious in less severe depression, whereas antidepressants do not show evidence of effect. Combined antidepressants with individual CT/CBT, acupuncture and, possibly, group exercise, individual psychological therapies (behavioural therapies, CT/CBT) alone, and antidepressants alone appear efficacious in more severe depression. Quality of evidence, cost-effectiveness, applicability and implementation issues also need to be considered when formulating clinical practice recommendations., Funding: National Institute for Health and Care Excellence., Competing Interests: HE, KJMOD, IM, OMV, SA, SS and SP received support from NICE for the submitted work. CHD, DMC, HP, NJW, EK, and SD received support from the NICE Guidelines TSU for the submitted work. EW, NK and NN declared the following interests based on NICE's policy on conflicts of interests: https://www.nice.org.uk/guidance/ng222/documents/register-of-interests. The authors report no other relationships or activities that could appear to have influenced the submitted work., (© 2024 The Author(s).)

Background: Overdose deaths continue to rise within the United States, despite effective treatments such as buprenorphine and methadone for opioid use disorder (OUD). Mobile medical units with the ability to dispense buprenorphine have been developed to engage patients and eliminate barriers to accessing OUD treatment. This study reports survey responses of patients of a mobile medical unit dispensing buprenorphine in areas of Chicago, IL with high overdose rates., Methods: All patients who were dispensed buprenorphine via the mobile medical unit were invited to participate in a 7-item anonymous survey between May 24, 2023, and August 25, 2023. The survey included 5-point satisfaction scale, multiple-choice, and open-ended questions. Outcomes included satisfaction with buprenorphine dispensing from the mobile medical unit, satisfaction with filling buprenorphine at a pharmacy in the past, barriers experienced at pharmacies when filling buprenorphine, and whether the client would have started treatment that day if the mobile medical unit had not been present. Satisfaction scale and multiple-choice question responses were assessed using descriptive statistics. Wilcoxon signed-rank test was used to compare median satisfaction levels between receiving buprenorphine from the mobile medical unit versus filling a buprenorphine prescription at a community pharmacy. Open-ended questions were analyzed qualitatively using inductive thematic analysis., Results: 106 unique patients were dispensed buprenorphine from the mobile unit during the study period. Of these patients, 54 (51%) completed the survey. Respondents reported high satisfaction with the buprenorphine dispensing process as a part of a mobile medical unit. Of those who had previously filled buprenorphine at a pharmacy, 83% reported at least one barrier, with delays in prescription dispensing from a community pharmacy, lack of transportation to/from the pharmacy, and opioid withdrawal symptoms being the most common barriers. 87% reported they would not have started buprenorphine that same day if the mobile medical unit had not been present. Nearly half of survey participants reported having taken buprenorphine that was not prescribed to them. Qualitative analysis of open-ended survey responses noted the importance of convenient accessibility, comprehensive care, and a non-judgmental environment., Conclusions: Mobile medical units that dispense buprenorphine are an innovative model to reach patients with OUD who have significant treatment access barriers. This study found that patients who experienced barriers to accessing buprenorphine from a pharmacy were highly satisfied with the mobile medical unit's buprenorphine dispensing process. Programs seeking to develop mobile buprenorphine dispensing programs should consider patient priorities of accessibility, comprehensive care, and welcoming, non-judgmental environments., (© 2024. The Author(s).)

During January-August 2021, the Community Prevalence of SARS-CoV-2 Study used time/location sampling to recruit a cross-sectional, population-based cohort to estimate SARS-CoV-2 seroprevalence and nasal swab sample PCR positivity across 15 US communities. Survey-weighted estimates of SARS-CoV-2 infection and vaccine willingness among participants at each site were compared within demographic groups by using linear regression models with inverse variance weighting. Among 22,284 persons >2 months of age and older, median prevalence of infection (prior, active, or both) was 12.9% across sites and similar across age groups. Within each site, average prevalence of infection was 3 percentage points higher for Black than White persons and average vaccine willingness was 10 percentage points lower for Black than White persons and 7 percentage points lower for Black persons than for persons in other racial groups. The higher prevalence of SARS-CoV-2 infection among groups with lower vaccine willingness highlights the disparate effect of COVID-19 and its complications.

Clonal hematopoiesis (CH) can be caused by either single gene mutations (eg point mutations in JAK2 causing CHIP) or mosaic chromosomal alterations (e.g., loss of heterozygosity at chromosome 9p). CH is associated with a significantly increased risk of hematologic malignancies. However, the absolute rate of transformation on an annualized basis is low. Improved prognostication of transformation risk is urgently needed for routine clinical practice. We hypothesized that the co-occurrence of CHIP and mCAs at the same locus (e.g., transforming a heterozygous JAK2 CHIP mutation into a homozygous mutation through concomitant loss of heterozygosity at chromosome 9) might have important prognostic implications for malignancy transformation risk. We tested this hypothesis using our discovery cohort, the UK Biobank (n = 451,180), and subsequently validated it in the BioVU cohort (n = 91,335). We find that individuals with a concurrent somatic mutation and mCA were at significantly increased risk of hematologic malignancy (for example, In BioVU cohort incidence of hematologic malignancies is higher in individuals with co-occurring JAK2 V617F and 9p CN-LOH; HR = 54.76, 95% CI = 33.92-88.41, P < 0.001 vs. JAK2 V617F alone; HR = 44.05, 95% CI = 35.06-55.35, P < 0.001). Currently, the 'zygosity' of the CHIP mutation is not routinely reported in clinical assays or considered in prognosticating CHIP transformation risk. Based on these observations, we propose that clinical reports should include 'zygosity' status of CHIP mutations and that future prognostication systems should take mutation 'zygosity' into account., (© 2024. The Author(s).)

The photoisomerization reaction of a fluorescent protein chromophore occurs on the ultrafast timescale. The structural dynamics that result from femtosecond optical excitation have contributions from vibrational and electronic processes and from reaction dynamics that involve the crossing through a conical intersection. The creation and progression of the ultrafast structural dynamics strongly depends on optical and molecular parameters. When using X-ray crystallography as a probe of ultrafast dynamics, the origin of the observed nuclear motions is not known. Now, high-resolution pump-probe X-ray crystallography reveals complex sub-ångström, ultrafast motions and hydrogen-bonding rearrangements in the active site of a fluorescent protein. However, we demonstrate that the measured motions are not part of the photoisomerization reaction but instead arise from impulsively driven coherent vibrational processes in the electronic ground state. A coherent-control experiment using a two-colour and two-pulse optical excitation strongly amplifies the X-ray crystallographic difference density, while it fully depletes the photoisomerization process. A coherent control mechanism was tested and confirmed the wave packets assignment., (© 2023. The Author(s).)

Background: Patients with advanced esophageal cancer carry poor prognoses; limited data exist to guide second-line therapy in the metastatic setting. Paclitaxel has been used yet is associated with limited efficacy. There is preclinical evidence of synergy between paclitaxel and cixutumumab, a monoclonal antibody targeting insulin-like growth factor-1 receptor. We conducted a randomized phase II trial of paclitaxel (arm A) versus paclitaxel plus cixutumumab (arm B) in the second-line for patients with metastatic esophageal or gastroesophageal junction (GEJ) cancers., Methods: The primary endpoint was progression-free survival (PFS); 87 patients (43 in arm A, 44 in arm B) were treated., Results: Median PFS was 2.6 months in arm A [90% CL 1.8-3.5] and 2.3 months in arm B [90% 2.0-3.5], P = .86. Stable disease was observed in 29 (33%) patients. Objective response rates for Arms A and B were 12% [90% CI, 5-23%] and 14% [90% CI, 6-25%]. Median overall survival was 6.7 months [90% CL 4.9-9.5] in arm A and 7.2 months [90% CL 4.9-8.1] in arm B, P = 56., Conclusion: The addition of cixutumumab to paclitaxel in second-line therapy of metastatic esophageal/GEJ cancer was well tolerated but did not improve clinical outcomes relative to standard of care (ClinicalTrials.gov Identifier: NCT01142388)., (© The Author(s) 2023. Published by Oxford University Press.)

Introduction: Opioid overdoses in Chicago are unevenly distributed, affecting medically underserved neighborhoods most acutely. Innovations in reaching patients perceived to be hard-to-reach (e.g., unstably housed, marginalized), especially in these underserved neighborhoods, are urgently needed to combat the overdose crisis. This study characterizes the pilot year of a mobile medical unit partnership between a large urban academic center and a community-based harm reduction organization in Chicago., Methods: This is a retrospective cohort study of all patients who were seen on a mobile medical unit focused on providing low-threshold buprenorphine and primary care in areas with high opioid overdose rates on Chicago's West Side. Treatment episodes were accrued between July 1, 2021, and June 30, 2022 in the first year of operation. The main outcomes were number of patients seen, demographic characteristics of patients, and reason(s) for visit over time., Results: The study saw 587 unique patients on the mobile medical unit between July 1, 2021, and June 30, 2022. Approximately 64.6 % were African American, and more than half lacked active insurance or could not confirm insurance status at the time of visit. The most common reason for initial visit was COVID-19 vaccination (42.4 %), and the most common reason for follow-up visit was buprenorphine treatment (51.0 %). Eleven patients initially presented for other health concerns and later returned to initiate buprenorphine., Conclusions: The mobile medical unit successfully reached nearly 600 patients in traditionally medically underserved Chicago neighborhoods with the highest overdose rates. The mobile unit's integrated approach met a variety of health needs, including buprenorphine initiation, with a unique opportunity for postoverdose initiation. Several patients initiated buprenorphine after presenting for different health concerns, showing the potential of an integrated approach to build on past mobile outreach programs and reach people with opioid use disorder who are not yet ready to initiate treatment., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Inc.)

WHAT IS KNOWN ON THE SUBJECT?: It is known that people with a diagnosis of borderline personality disorder often experience crises in their mental wellbeing. There is little evidence about the approaches of mental health nurses in community-based crisis teams when working with people with a diagnosis of BPD. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: This paper highlights that limited resources, work-patterns and issues of stigma present challenges to delivering recovery-oriented care. The paper highlights that nurses typically try to navigate the challenges to continue to provide individualized care, though their self-assessment is that this is with mixed success. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings suggest that support is needed to develop brief interventions specific to teams working with people with a diagnosis of BPD who are at a point of crisis. ABSTRACT: Introduction People with a diagnosis of borderline personality disorder (BPD) are often in contact with mental health services at a point of crisis, and in the UK, this includes Crisis Resolution Home Treatment teams (CRHTT). There is a drive for services to be recovery orientated; however, there is little evidence about the degree to which community services achieve this for people with a diagnosis of BPD when in crisis. Research Aim To understand the perceptions held by CRHTT clinicians about their provision of recovery-orientated acute care, for people with a diagnosis of BPD. Method From a purposive sample of a single CRHTT, seven registered mental health nurses were interviewed and Braun and Clarke's thematic analysis framework was used to interpret the data. Results Five themes emerged: person-centred care; the timing is wrong; inconsistent staffing; the risks are too great; and BPD as a label. Discussion The results demonstrate tensions between a drive to deliver person-centred care and a range of challenges that inhibit this, with the possibility of reframing a recovery approach as "recovery-ready". Implications for Practice A whole-system approach is required to enable a consistent recovery-oriented approach, but research is also needed for brief interventions specific to this context., (© 2022 John Wiley & Sons Ltd.)

Objectives: Persons who inject drugs (PWID) commonly experience venous degradation as a complication of prolonged injection, which makes routine phlebotomy difficult. Clients may decline care due to the perceived lack of skilled phlebotomy services, and this contributes to significant delays in infectious disease screening and treatment. In this study, we investigated ultrasound-guided phlebotomy in clients with difficult venous access receiving care at two low-threshold buprenorphine clinics. Our objectives were to increase the accuracy of vascular access, expedite infectious disease treatment for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), and increase client satisfaction with phlebotomy services., Methods: PWID who declined routine phlebotomy at two clinic sites were offered ultrasound-guided vascular access by a trained clinician. Participants completed a survey to collect data regarding acceptability of the intervention., Results: Throughout a 14-month period, 17 participants were enrolled. Of the total 30 procedures, 41.2% of clients returned for more than one phlebotomy visit, and 88.2% of clients achieved vascular access within 1 attempt. Of participating clients, 52.9% described themselves as having difficult venous access and at conclusion of the study, 58.8% expressed more willingness to have phlebotomy performed with an ultrasound device., Conclusions: Offering ultrasound-guided phlebotomy for PWID with difficult venous access resulted in decreased access attempts, increased patient satisfaction, and expedited screening and treatment for HIV and HCV point-of-care ultrasound technology is an effective approach to improving care for persons who inject drugs., (© 2023. The Author(s).)

Background: An increased posterior tibial slope (PTS) results in greater force on the anterior cruciate ligament (ACL) and is a risk factor for ACL injuries. Biomechanical studies have suggested that a reduction in the PTS angle may lower the risk of ACL injuries. However, the majority of these investigations have been in the adult population., Purpose: To assess the mean medial and lateral PTS on pediatric cadaveric specimens without known knee injuries., Study Design: Cross-sectional study; Level of evidence, 3., Methods: A total of 39 pediatric knee specimens with computed tomography scans were analyzed. Specimens analyzed were between the ages of 2 and 12 years. The PTS of each specimen was measured on sagittal computed tomography slices at 2 locations for the medial and lateral angles. The measurements were plotted graphically by age to account for the variability in development within age groups. The anterior medial and lateral tibial plateau widths were measured. The distance between the top of the tibial plateau and the physis was measured. The independent-samples t test and analysis of variance were used to analyze the measurements., Results: The mean PTS angle for the medial and lateral tibial plateaus was 5.53° ± 4.17° and 5.95° ± 3.96°, respectively. The difference between the PTS angles of the medial and lateral tibial plateaus was not statistically significant ( P > .05). When plotted graphically by age, no trend between age and PTS was identified., Conclusion: This data set offers values for the PTS in skeletally immature specimens without a history of ACL injury and suggests that age may not be an accurate predictive factor for PTS., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: N.L.G. has received hospitality payments from Smith & Nephew. T.A.M. has received education payments from Arthrex and consulting fees from Medtronic, OrthoPediatrics, and Zimmer Biomet. T.J.G. has received education payments from Arthrex and is a paid associate editor for The American Journal of Sports Medicine. P.D.F. has received hospitality payments from Medical Device Business Services. K.G.S. has received education payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: To analyze the influence of radiation dose on late radiation-associated taste impairment in oropharyngeal cancer (OPC) patients treated with intensity-modulated radiotherapy (IMRT) using the taste bud bearing tongue mucosa as organ at risk., Material and Methods: This study is part of an ongoing, prospective observational study. Cancer-free OPC survivors with at least 24 months from IMRT were included in this analysis. Scores for taste impairment and dry mouth were extracted from the MD Anderson Symptom Inventory Head and Neck module (MDASI-HN) with scores of ≥5 considered as moderate-to-severe symptoms. The mean dose, minimum and maximum dose to the taste bud bearing tongue mucosa, the ipsi- and contralateral parotid and submandibular glands were extracted and analyzed for correlation with moderate-to-severe taste impairment., Results: One hundred sixteen T1-4 OPC patients were included (81% males, median age: 55). The primary tumor was in the tonsil in 92 cases (79%) and in the base of tongue in 21 cases (18%). Patients were treated with 64.2-72.0 Gy; 37 patients (32%) received concurrent chemotherapy and 22 (19%) concurrent targeted therapy. After a median of 58 months from RT (IQR: 43-68) 38 patients (33%) suffered from moderate-to-severe long-term radiation-associated taste impairment. No dose volume parameter of the taste bud bearing tongue mucosa and the salivary glands was significantly associated with moderate-to-severe taste impairment for the whole patient cohort. For patients without concurrent chemotherapy, the minimum and mean dose to the ipsilateral parotid gland, and the maximum dose to the submandibular gland was significantly associated with late taste impairment (all p  < 0.05). A significant correlation was found between taste impairment and dry mouth ( p  < 0.001)., Conclusion: The dose to the ipsilateral parotid gland seems to play an important role in the development of late taste impairment. The influence of dose to the taste bud bearing tongue mucosa remains unclear and needs further investigation.

Background: Breastfeeding is associated with health benefits to mothers and babies and cost-savings to the health service. Breastfeeding rates in the UK are low for various reasons including cultural barriers, inadequate support to initiate and sustain breastfeeding, lack of information, or choice not to breastfeed. Education and support interventions have been developed aiming at promoting breastfeeding rates. The objective of this study was to assess the cost-effectiveness of such interventions for women, initiated antenatally or in the first 8 weeks postnatally, aiming at improving breastfeeding rates, in the UK., Methods: A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of a breastfeeding intervention from the perspective of health and personal social services in England. Data on intervention effectiveness and the benefits of breastfeeding were derived from systematic reviews. Other model input parameters were obtained from published sources, supplemented by expert opinion., Results: The incremental cost-effectiveness ratio (ICER) of the modelled intervention added on standard care versus standard care was £51,946/QALY, suggesting that the intervention is not cost-effective under National Institute for Health and Care Excellence (NICE) criteria in England. Sensitivity analysis suggested that the cost-effectiveness of the intervention improved as its effectiveness increased and intervention cost decreased. At the base-case effect (increase in breastfeeding rates 16-26 weeks after birth by 19%), the intervention was cost-effective (<£20,000/QALY) if its cost per woman receiving the intervention became ≈£40-£45. At the base-case cost (£84), the intervention was cost-effective if it increased breastfeeding rates by at least 35-40%., Conclusions: Available breastfeeding interventions do not appear to be cost-effective under NICE criteria in England. Future breastfeeding interventions need to have higher effectiveness or lower cost compared with currently available interventions in order to become cost-effective. Public health and other societal interventions that protect, promote and support breastfeeding may be key in improving breastfeeding rates in the UK., (© 2022. The Author(s).)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has the potential for rapid transmission in congregate settings. We describe the multidisciplinary response to an outbreak of coronavirus disease (COVID-19) in a large homeless shelter in Chicago, Illinois, USA. The response to the outbreak included 4 rounds of mass PCR testing of all staff and residents and subsequent isolation of persons who tested positive for SARS-CoV-2. We further describe the dynamics of the shelter outbreak by fitting a modified susceptible-exposed-infectious-recovered compartmental model incorporating the widespread SARS-CoV-2 testing and isolation measures implemented in this shelter. Our model demonstrates that rapid transmission of COVID-19 in the shelter occurred before the outbreak was detected; rates of transmission declined after widespread testing and isolation measures were put in place. Overall, we demonstrate the feasibility of mass PCR testing and isolation in congregate settings and suggest the necessity of prompt response to suspected COVID-19 outbreaks in homeless shelters.

Background: Respiratory syncytial virus (RSV) is the leading cause of acute respiratory infections (ARIs) in hospitalized children. Although prematurity and underlying medical conditions are known risk factors, most of these children are healthy, and factors including RSV load and subgroups may contribute to severity. Therefore, we aimed to evaluate the role of RSV in ARI severity and determine factors associated with increased RSV-ARI severity in young children., Methods: Children aged <5 years with fever and/or ARI symptoms were recruited from the emergency department (ED) or inpatient settings at Vanderbilt Children's Hospital. Nasal and/or throat swabs were tested using quantitative reverse-transcription polymerase chain reaction for common respiratory viruses, including RSV. A severity score was calculated for RSV-positive children., Results: From November 2015 through July 2016, 898 participants were enrolled, and 681 (76%) had at least 1 virus detected, with 191 (28%) testing positive for RSV. RSV-positive children were more likely to be hospitalized, require intensive care unit admission, and receive oxygen compared with children positive for other viruses. Higher viral load, White race, younger age, and higher severity score were independently associated with hospitalization in RSV-positive children. No differences in disease severity were noted between RSV A and RSV B., Conclusions: RSV was associated with increased ARI severity in young children enrolled from the ED and inpatient settings, but no differences in disease severity were noted between RSV A and RSV B. These findings emphasize the need for antiviral therapy and/or preventive measures such as vaccines against RSV in young children., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

We evaluated treatment duration and viral suppression (VS) outcomes with integrase strand transfer inhibitor (INSTI)-based regimens versus other contemporary regimens among adults in routine HIV care. Eligible participants were seen during January 1, 2007 to June 30, 2018 at nine U.S. HIV clinics, initiated antiretroviral therapy (ART) (baseline date), and had ≥2 clinic visits thereafter. We assessed the probability of remaining on a regimen and achieving HIV RNA <200 copies/mL on initial INSTI versus non-INSTI ART by Kaplan-Meier analyses and their correlates by Cox regression. Among 1,005 patients, 335 (33.3%) were prescribed an INSTI-containing regimen and 670 (66.7%) a non-INSTI regimen, which may have included non-nucleoside reverse transcriptase inhibitors, protease inhibitors, and other agents. In both groups, most patients were male, nonwhite, and aged <50 years. Comparing the INSTI with non-INSTI group, the median baseline log 10 HIV viral load (VL; copies/mL) was 4.6 versus 4.5, and the median CD4 + cell count (cells/mm 3 ) was 352 versus 314. In Kaplan-Meier analysis, the estimated probabilities of remaining on initial regimens at 2 and 4 years were 58% and 40% for INSTI and 51% and 33% for non-INSTI group, respectively (log-rank test p  = .003). In multivariable models, treatment with an INSTI (vs. non-INSTI) ART was negatively associated with a regimen switch [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.56-0.81, p  < .001] and was positively associated with achieving VS (HR 1.52; CI 1.29-1.79, p  < .001), both irrespective of baseline VL levels. Initial INSTI-based regimens were associated with longer treatment durations and better VS than non-INSTI regimens. Results support INSTI regimens as the initial therapy in U.S. treatment guidelines.

Background: People experiencing homelessness are at increased risk of coronavirus disease 2019 (COVID-19), but little is known about specific risk factors for infection within homeless shelters., Methods: We performed widespread severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction testing and collected risk factor information at all homeless shelters in Chicago with at least 1 reported case of COVID-19 (n = 21). Multivariable, mixed-effects log-binomial models were built to estimate adjusted prevalence ratios (aPRs) for SARS-CoV-2 infection for both individual- and facility-level risk factors., Results: During March 1 to May 1, 2020, 1717 shelter residents and staff were tested for SARS-CoV-2; 472 (27%) persons tested positive. Prevalence of infection was higher for residents (431 of 1435, 30%) than for staff (41 of 282, 15%) (prevalence ratio = 2.52; 95% confidence interval [CI], 1.78-3.58). The majority of residents with SARS-CoV-2 infection (293 of 406 with available information about symptoms, 72%) reported no symptoms at the time of specimen collection or within the following 2 weeks. Among residents, sharing a room with a large number of people was associated with increased likelihood of infection (aPR for sharing with >20 people compared with single rooms = 1.76; 95% CI, 1.11-2.80), and current smoking was associated with reduced likelihood of infection (aPR = 0.71; 95% CI, 0.60-0.85). At the facility level, a higher proportion of residents leaving and returning each day was associated with increased prevalence (aPR = 1.08; 95% CI, 1.01-1.16), whereas an increase in the number of private bathrooms was associated with reduced prevalence (aPR for 1 additional private bathroom per 100 people = 0.92; 95% CI, 0.87-0.98)., Conclusions: We identified a high prevalence of SARS-CoV-2 infections in homeless shelters. Reducing the number of residents sharing dormitories might reduce the likelihood of SARS-CoV-2 infection. When community transmission is high, limiting movement of persons experiencing homelessness into and out of shelters might also be beneficial., (© The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

People who inject drugs (PWID) are at increased risk for developing wounds in addition to skin and soft tissue infections. The University of Illinois at Chicago College of Nursing, College of Medicine, and School of Public Health collaborated to establish a medical clinic serving PWID attending a Chicago syringe exchange program. A wound care program was implemented to improve clinicians' competence. During October 2018 to August 2019, 24% of all encounters were related to wound complaints.

Purpose: The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period following orbital floor fractures in children., Materials/methods: A retrospective review of all pediatric patients who presented to our emergency department with an orbital floor fracture from May 1, 2016 to June 1, 2018 were included. Basic demographic data was collected as well as mechanism of injury, presence of bradycardia, and time to operating room. Morbidity was based on the need for medications to treat bradycardia., Results: Thirty-five pediatric patients with orbital floor fractures were reviewed. 6 (17.1%) patients had post injury bradycardia, with one patient requiring medication to stabilize their heart rate. There was no statistically significant difference in sex, race/ethnicity, or age in patients with or without bradycardia (p > 0.05) however there was a significant relationship between bradycardia and need for operative repair (X 2  = 7.88, df = 1, p = 0.005). The most common mechanism of injury was motor vehicle collision (45.7%). The average time to the operating room was 145 h (6.04 days)., Conclusions: While activation of the oculocardiac reflex is a legitimate concern in the post injury period, there is unlikely to be significant morbidity due to bradycardia, and the greater concern should be for the ischemic muscle injury incurred from the fracture., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To evaluate whether the use of oral stents during intensity modulated radiation therapy (IMRT) for oropharyngeal cancer (OPC) is associated with long-term patient reported symptoms., Materials and Methods: Data was obtained from a prospective observational study of disease-free head and neck cancer survivors. Radiation-associated patient reported symptoms were assessed using the MD Anderson Symptom Inventory Head and Neck module (MDASI-HN). Scores of ≥5 (11-point Likert scale, 0-10) were considered moderate/severe. Stratification was performed regarding IMRT volume (uni- versus bilateral neck) and stent utilization, with non-parametric analyses between groups., Results: 462 OPC survivors formed the cohort (54% tonsil, 46% base of tongue primaries). A tongue-deviating stent was used in 17%, tongue-depressing stent in 46%, and no stent in 37%. Median prescribed dose to the high dose clinical target volume was 66.0 Gy. Median follow-up from RT to MDASI-HN assessment was 68 months. Twenty percent had received unilateral neck RT (all had tonsil primaries), in whom a significant improvement in the proportion of patients with moderate/severe taste impairment (2% vs. 15%, p = 0.047) and lack of appetite (0% vs. 9%, p = 0.019) was associated with the use of tongue-deviating stents compared to no oral stent. In those who had received bilateral neck RT, a significant improvement in the proportion of patients with moderate/severe difficulty swallowing/chewing was associated with use of a tongue-depressing stent (21% vs. 31% without oral stent, p = 0.013)., Conclusion: Disease-site specific select use of oral stents during IMRT was associated with reduced long-term patient reported symptoms in OPC survivors., (© 2020 The Authors.)

Background: PTSD in youth may lead to long-lasting psychological implications, educational difficulties and increased healthcare costs. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of psychological interventions for children and young people with PTSD., Methods: A decision-analytic model was constructed to compare costs and quality-adjusted life years (QALYs) of 10 psychological interventions and no treatment for children and young people with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion., Results: Cognitive therapy for PTSD, a form of individual trauma-focused cognitive behavioural therapy (TF-CBT), appeared to be the most cost-effective intervention for children and young people with PTSD (with a probability of .78 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by narrative exposure (another form of individual TF-CBT), play therapy, and other forms of individual TF-CBT. After excluding cognitive therapy from the analysis, narrative exposure appeared to be the most cost-effective option with a .40 probability of being cost-effective amongst the remaining 10 options. EMDR, parent training and group TF-CBT occupied middle cost-effectiveness rankings. Family therapy and supportive counselling were less cost-effective than other active interventions. There was limited evidence for some interventions, in particular cognitive therapy for PTSD and parent training., Conclusions: Individual forms of TF-CBT and, to a lesser degree, play therapy appear to be cost-effective in the treatment of children and young people with PTSD. Family therapy and supportive counselling are unlikely to be cost-effective relative to other interventions. There is a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of psychological treatments for children and young people with PTSD., (© 2019 Association for Child and Adolescent Mental Health.)

Background: Post-traumatic stress disorder (PTSD) is a severe and disabling condition that may lead to functional impairment and reduced productivity. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of interventions for adults with PTSD., Methods: A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of 10 interventions and no treatment for adults with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion., Results: Eye movement desensitisation and reprocessing (EMDR) appeared to be the most cost-effective intervention for adults with PTSD (with a probability of 0.34 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, selective serotonin reuptake inhibitors (SSRIs), trauma-focused cognitive behavioural therapy (TF-CBT), self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appeared to be less cost-effective than no treatment. TF-CBT had the largest evidence base., Conclusions: A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD., Competing Interests: IM, OMV, SS and SP received support from the National Collaborating Centre for Mental Health and the National Guideline Alliance, which were in receipt of funding from the National Institute for Health and Care Excellence (NICE), for the submitted work. CD, SD and NJW received support from the NICE Guidelines Technical Support Unit, University of Bristol, with funding from the Centre for Clinical Practice (NICE). SD and NJW were co-applicants on a grant (unrelated to this work) from the MRC Methodology Research Programme which included an MRC Industry Collaboration Agreement with Pfizer Ltd, who part-funded a researcher to work on statistical methodology in a project underlated to this work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. GB is a coinvestigator on a NIHR RfPB grant, Eye Movement Desensitization and Reprocessing Therapy in Early Psychosis (EYES): A feasibility randomised controlled trial. NGreenberg is the Royal College of Psychiatrists Lead for Military and Veterans’ Health and is a trustee of two military charities. He is also a senior researcher with King’s College London working on a number of military mental health r studies. NGrey is a member of the Wellcome Trust Anxiety Disorders Group developing, testing and disseminating Cognitive Therapy for PTSD (CT-PTSD), a trauma-focused cognitive behavioural therapy (TF-CBT). He has published papers and book chapters on CT-PTSD, and facilitates teaching workshops for which payment is received. As editor, he receives royalties from sales of a trauma book, A Casebook of Cognitive Therapy for Traumatic Stress Reactions. CK is Medical Director of the Helen Bamber Foundation (a human rights charity) and refugee and asylum mental health lead for the Royal College of Psychiatrists. He writes expert psychiatric reports in the context of asylum mental health. JL is NHS England Medical Director for Military and Veterans Health. SP receives funding from NICE for the development of clinical guidelines and is also supported by the NIHR UCLH Biomedical Research Centre. The authors report no other relationships or activities that could appear to have influenced the submitted work.

Background: Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established., Methods: We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1-4-month follow-up, and remission post-treatment., Results: We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) -2.07; 95% credible interval (CrI) -2.70 to -1.44], combined somatic/cognitive therapies (SMD -1.69; 95% CrI -2.66 to -0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD -1.46; 95% CrI -1.87 to -1.05) and self-help with support (SMD -1.46; 95% CrI -2.33 to -0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1-4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence., Conclusions: EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.

Background: Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder that affects a significant minority of youth exposed to trauma. Previous studies have concluded that trauma-focused cognitive behavioural therapy (TF-CBT) is an effective treatment for PTSD in youth, but the relative strengths of different psychological therapies are poorly understood., Methods: We undertook a systematic review and network meta-analyses of psychological and psychosocial interventions for children and young people with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1-4-month follow-up, and remission post-treatment., Results: We included 32 trials of 17 interventions and 2,260 participants. Overall, the evidence was of moderate-to-low quality. No inconsistency was detected between direct and indirect evidence. Individual forms of TF-CBT showed consistently large effects in reducing PTSD symptoms post-treatment compared with waitlist. The order of interventions by descending magnitude of effect versus waitlist was as follows: cognitive therapy for PTSD (SMD -2.94, 95%CrI -3.94 to -1.95), combined somatic/cognitive therapies, child-parent psychotherapy, combined TF-CBT/parent training, meditation, narrative exposure, exposure/prolonged exposure, play therapy, Cohen TF-CBT/cognitive processing therapy (CPT), eye movement desensitisation and reprocessing (EMDR), parent training, group TF-CBT, supportive counselling and family therapy (SMD -0.37, 95%CrI -1.60 to 0.84). Results for parent training, supportive counselling and family therapy were inconclusive. Cohen TF-CBT/CPT, group TF-CBT and supportive counselling had the largest evidence base. Results regarding changes in PTSD symptoms at follow-up and remission post-treatment were uncertain due to limited evidence., Conclusions: Trauma-focused cognitive behavioural therapy, in particular individual forms, appears to be most effective in the management of PTSD in youth. EMDR is effective but to a lesser extent. Supportive counselling does not appear to be effective. Results suggest a large positive effect for emotional freedom technique, child-parent psychotherapy, combined TF-CBT/parent training, and meditation, but further research is needed to confirm these findings as they were based on very limited evidence., (© 2019 Association for Child and Adolescent Mental Health.)

Background: The quadriceps tendon (QT) is increasingly considered for primary and revision anterior cruciate ligament reconstruction in skeletally immature patients, as it may be harvested as a purely soft tissue graft with considerable tissue volume. Because of distinct rectus tendon (RT) separation from the QT complex, the potential for RT retraction exists and could lead to QT weakness after QT graft harvest., Purpose: To describe the anatomy of the pediatric QT and clarify decussation of the RT and QT to avoid the risk of delayed RT retraction and QT weakness after QT graft harvest., Study Design: Descriptive epidemiology study., Methods: Nine cadaveric knee specimens (aged 4-11 years) underwent gross dissection. Coronal-plane width and depth of the QT were measured at intervals proximal to the superior pole of the patella at distances of 0.0, 0.5, 1.0, and 1.5 times the length of the patella. The distance was measured from the superior patellar pole to the point of RT separation from the remainder of the deeper/posterior QT., Results: The median patellar length was 28 mm (interquartile range, 26-37 mm). The coronal-plane width of the QT was larger superficially/anteriorly when closest to the patella but wider when measured deeper/posteriorly as the tendon extended proximally. The median distance between the superior pole of the patella and RT separation from the QT was 0.95 times the patellar length. The distance to widening of the deeper/posterior aspect of the QT was 1.14 times the patellar length proximal to the patella., Conclusion: The RT begins a distinct separation from the QT above the superior pole of the patella at a median of 0.95 times the patellar length in skeletally immature specimens. The deeper/posterior aspect of the QT begins to increase in coronal-plane width proximally after a distance of 1.14 times the patellar length above the knee, while the superficial/anterior aspect of the tendon continues to narrow. Awareness of the separation of the RT from the QT, and the coronal-plane width variation aspects of the QT proximally, is important for surgeons utilizing the QT as a graft to avoid inadvertent release of the RT from the rest of the QT complex., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Cadaveric specimens in this study were donated by AlloSource. K.G.S. has received nonconsulting fees from DePuy and research support from Sanofi-Aventis (contested by the author). H.B.E. has received educational support from Pylant Medical, nonconsulting fees from Smith & Nephew and Synthes, and hospitality payments from Arthrex. P.L.W. has received educational support from Pylant Medical. P.D.F. has received educational support from Smith & Nephew and hospitality payments from Medical Device Business Services. S.M. has received educational support from Smith & Nephew and Gemini Mountain Medical, consulting fees from Arthrex, and hospitality payments from Stryker. T.J.G. has received educational support from Arthrex and Liberty. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Snow algae are found in snowfields across cold regions of the planet, forming highly visible red and green patches below and on the snow surface. In Antarctica, they contribute significantly to terrestrial net primary productivity due to the paucity of land plants, but our knowledge of these communities is limited. Here we provide the first description of the metabolic and species diversity of green and red snow algae communities from four locations in Ryder Bay (Adelaide Island, 68°S), Antarctic Peninsula. During the 2015 austral summer season, we collected samples to measure the metabolic composition of snow algae communities and determined the species composition of these communities using metabarcoding. Green communities were protein-rich, had a high chlorophyll content and contained many metabolites associated with nitrogen and amino acid metabolism. Red communities had a higher carotenoid content and contained more metabolites associated with carbohydrate and fatty acid metabolism. Chloromonas, Chlamydomonas and Chlorella were found in green blooms but only Chloromonas was detected in red blooms. Both communities also contained bacteria, protists and fungi. These data show the complexity and variation within snow algae communities in Antarctica and provide initial insights into the contribution they make to ecosystem functioning., (© 2019 The Authors. New Phytologist © 2019 New Phytologist Trust.)

Background: Bulimia nervosa (BN) is a severe eating disorder that can be managed using a variety of treatments including pharmacological, psychological, and combination treatments. We aimed to compare their effectiveness and to identify the most effective for the treatment of BN in adults., Methods: A search was conducted in Embase, Medline, PsycINFO, and Central from their inception to July 2016. Studies were included if they reported on treatments for adults who fulfilled diagnostic criteria for BN. Only randomised controlled trials (RCTs) that examined available psychological, pharmacological, or combination therapies licensed in the UK were included. We conducted a network meta-analysis (NMA) of RCTs. The outcome analysed was full remission at the end of treatment., Results: We identified 21 eligible trials with 1828 participants involving 12 treatments, including wait list. The results of the NMA suggested that individual cognitive behavioural therapy (CBT) (specific to eating disorders) was most effective in achieving remission at the end of treatment compared with wait list (OR 3.89, 95% CrI 1.19-14.02), followed by guided cognitive behavioural self-help (OR 3.81, 95% CrI 1.51-10.90). Inconsistency checks did not identify any significant inconsistency between the direct and indirect evidence., Conclusions: The analysis suggested that the treatments that are most likely to achieve full remission are individual CBT (specific to eating disorders) and guided cognitive behavioural self-help, although no firm conclusions could be drawn due to the limited evidence base. There is a need for further research on the maintenance of treatment effects and the mediators of treatment outcome.

Background: Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation., Methods: We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years., Results: Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs., Conclusions: Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP., (© 2016 Association for Child and Adolescent Mental Health.)

Background: People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex., Aims: To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm., Method: We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable., Results: Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38-2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91-3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16-3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70-2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%., Conclusions: The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed., (© The Royal College of Psychiatrists 2016.)

Introduction: Many antidepressants are indicated for the treatment of major depression. Two network meta-analyses have provided the most comprehensive assessments to date, accounting for both direct and indirect comparisons; however, these reported conflicting interpretation of results. Here, we present a protocol for a systematic review and network meta-analysis aimed at updating the evidence base and comparing all second-generation as well as selected first-generation antidepressants in terms of efficacy and acceptability in the acute treatment of major depression., Methods and Analysis: We will include all randomised controlled trials reported as double-blind and comparing one active drug with another or with placebo in the acute phase treatment of major depression in adults. We are interested in comparing the following active agents: agomelatine, amitriptyline, bupropion, citalopram, clomipramine, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, levomilnacipran, milnacipran, mirtazapine, nefazodone, paroxetine, reboxetine, sertraline, trazodone, venlafaxine, vilazodone and vortioxetine. The main outcomes will be the proportion of patients who responded to or dropped out of the allocated treatment. Published and unpublished studies will be sought through relevant database searches, trial registries and websites; all reference selection and data extraction will be conducted by at least two independent reviewers. We will conduct a random effects network meta-analysis to synthesise all evidence for each outcome and obtain a comprehensive ranking of all treatments. To rank the various treatments for each outcome, we will use the surface under the cumulative ranking curve and the mean ranks. We will employ local as well as global methods to evaluate consistency. We will fit our model in a Bayesian framework using OpenBUGS, and produce results and various checks in Stata and R. We will also assess the quality of evidence contributing to network estimates of the main outcomes with the GRADE framework., Ethics and Dissemination: This review does not require ethical approval., Prospero Registration Number: CRD42012002291., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Influenza acts synergistically with bacterial co-pathogens. Few studies have described co-infection in a large cohort with severe influenza infection., Objectives: To describe the spectrum and clinical impact of co-infections., Study Design: Retrospective cohort study of patients with severe influenza infection from September 2013 through April 2014 in intensive care units at 33 U.S. hospitals comparing characteristics of cases with and without co-infection in bivariable and multivariable analysis., Results: Of 507 adult and pediatric patients, 114 (22.5%) developed bacterial co-infection and 23 (4.5%) developed viral co-infection. Staphylococcus aureus was the most common cause of co-infection, isolated in 47 (9.3%) patients. Characteristics independently associated with the development of bacterial co-infection of adult patients in a logistic regression model included the absence of cardiovascular disease (OR 0.41 [0.23-0.73], p=0.003), leukocytosis (>11K/μl, OR 3.7 [2.2-6.2], p<0.001; reference: normal WBC 3.5-11K/μl) at ICU admission and a higher ICU admission SOFA score (for each increase by 1 in SOFA score, OR 1.1 [1.0-1.2], p=0.001). Bacterial co-infections (OR 2.2 [1.4-3.6], p=0.001) and viral co-infections (OR 3.1 [1.3-7.4], p=0.010) were both associated with death in bivariable analysis. Patients with a bacterial co-infection had a longer hospital stay, a longer ICU stay and were likely to have had a greater delay in the initiation of antiviral administration than patients without co-infection (p<0.05) in bivariable analysis., Conclusions: Bacterial co-infections were common, resulted in delay of antiviral therapy and were associated with increased resource allocation and higher mortality., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: The characteristics of Emergency Department (ED) attendances due to mental or behavioural health disorders need to be described to enable appropriate development of services. We aimed to describe the epidemiology of mental health-related ED attendances within health care systems free at the point of access, including clinical reason for presentation, previous service use, and patient sociodemographic characteristics., Method: Systematic review and meta-analysis of observational studies describing ED attendances by patients with common mental health conditions., Findings: 18 studies from seven countries met eligibility criteria. Patients attending due to mental or behavioural health disorders accounted for 4% of ED attendances; a third were due to self-harm or suicidal ideation. 58.1% of attendees had a history of psychiatric illness and up to 58% were admitted. The majority of studies were single site and of low quality so results must be interpreted cautiously., Conclusions: Prevalence studies of mental health-related ED attendances are required to enable the development of services to meet specific needs.

Background: Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment., Objective: To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2)., Data Sources: For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013., Review/research Methods: For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK., Results: For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects., Limitations: The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions., Conclusions: Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation., Study Registration: This study is registered as PROSPERO CRD42012002059., Funding: The National Institute for Health Research Health Technology Assessment programme.