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Explore the feasibility of an integrated Child and Family Hub within Victorian Community Health Services (CHS) to identify and respond to family adversities as preventable determinants of child mental health problems.Thirteen Victorian CHS staff and government policy makers (PMs), recruited via snowball sampling, participated in semi-structured interviews exploring: 1) barriers and facilitators for implementing a hub; 2) feasibility of a proposed integrated hub; and 3) resources needed to scale and sustain a hub. Transcripts were analysed employing framework analysis.1) Barriers included inadequate and activity-based funding, inability to fund community paediatricians and inadequate workforce competencies. Facilitators included CHS engagement with vulnerable communities and readiness to act. 2) The proposed hub model was identified as feasible to implement. Local co-design, co-location, and virtual delivery would support hub implementation. 3) To sustainably scale a hub, clear policy leadership and workforce and funding model reviews are needed.A hub was perceived as feasible when based in CHS; however, local and system-wide issues need consideration to support its sustainable scaling.Findings will inform the scaling of hub models of care across Victoria and other states to potentially optimise broader child and family health outcomes.

Background National systems-based suicide prevention approaches are increasingly being implemented. Community participation is fundamental to the successful implementation of these approaches, but can be challenging to undertake. We present findings from the evaluation of Australia’s National Suicide Prevention Trial (the Trial). Methods We completed consultations with 127 community members and 46 Primary Health Network (PHN) staff. Thematic analysis was undertaken to understand the process of community participation in the planning and implementation of the Trial. Results Themes were identified regarding: a collaborative PHN; an engaged and passionate community; maintaining engagement; getting the right people involved; and getting stakeholders to work together. Continuous negotiation about Trial ownership, acceptability of the Trial model, and choice of activities was required. Community participation was somewhat challenging for PHNs, taking much longer than anticipated for a range of reasons. Conclusions Future system-based approaches could benefit from the provision of community participation skills training and support to enable a more coordinated, and perhaps more easily achieved, approach to the involvement of community. Despite a long process of relationship building between stakeholders, this led to improved community cohesion and integration in local suicide prevention, ready for future collaborative work.

Objectives: The National Suicide Prevention Trial was announced by the Australian Government in 2016 and aimed to prevent suicidal behaviour in 12 trial sites (representing a population of ~8 million). This study investigated the early population-level impact of the National Suicide Prevention Trial activity on rates of suicide and hospital admissions for self-harm in comparison to control areas. Methods: Relative and absolute differences in monthly rates of suicide and hospital admissions for self-harm were compared in the period after the National Suicide Prevention Trial implementation (July 2017–November 2020) to the period prior to implementation (January 2010–June 2017) in (1) ‘National Suicide Prevention Trial areas’ and (2) ‘Control areas’, using a difference-in-difference method in a series of negative binomial models. Analyses also investigated whether associations for suicide and self-harm rates differed by key socio-demographic factors, namely sex, age group, area socio-economic status and urban–rural residence. Results: There were no substantial differences between ‘National Suicide Prevention Trial areas’ and ‘Control areas’ in rates of suicide (2% relative decrease, relative risk = 0.98, 95% confidence interval = [0.91, 1.06]) or self-harm (1% relative decrease, relative risk = 0.99, 95% confidence interval = [0.96, 1.02]), adjusting for sex, age group and socio-economic status. Stronger relative decreases in self-harm only were evident for those aged 50–64 years, high socio-economic status areas, metropolitan and remote geographic areas. Conclusion: There was limited evidence that the National Suicide Prevention Trial resulted in reductions in suicide or hospital admissions for self-harm during the first 4 years of implementation. Continued monitoring of trends with timely data is imperative over the next 2–3 years to ascertain whether there are any subsequent impacts of National Suicide Prevention Trial activities.

Introduction When rotator cuff tears occur after a primary repair at the footprint, they often fail medially at the myotendinous junction, also called type II tears. These are difficult tears to treat, and little research has been published on how to address tears at the myotendinous junction and the clinical outcomes of the revised repairs. The purpose of this study is to evaluate the outcomes of type II rotator cuff tears repaired with a dermal allograft augmentation. Materials and methods We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound. Results Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist. Discussion Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

Background In China, little evidence exists on the effect of mental and physical multimorbidity on individuals and the health system. This study aims to examine the prevalence of mental-physical multimorbidity and its impact on health service utilization and health expenditures. Methods We conducted a panel study using two waves of data (in 2011 and 2015) from the China Health and Retirement Longitudinal Study, including 10,181 participants aged 45 years and older. Generalized linear regression models were used to assess the association of multimorbidity with total health expenditure and out-of-pocket expenditure (OOPE) on outpatient and inpatient care. Random-effects logistic regression models were used to examine the impact of multimorbidity on outpatient visits, admission to hospital and incidence of catastrophic health expenditure (CHE). Results Overall, 3210 participants (31.53% of 10,181) had mental-physical multimorbidity in 2015 in China. Compared to patients with a single physical disease, individuals with physical-mental multimorbidity had over 150% of the increase in the number of outpatient visits and days of hospitalization. The percentage change of OOPE for outpatient and inpatient care was 156.8% and 163.6%, respectively. Mental-physical multimorbidity was associated with an increased likelihood of experiencing CHE (OR = 2.205, 95% CI = 2.048, 2.051). Conclusion Multimorbidity, particularly mental-physical multimorbidity, is associated with higher levels of health service use and a greater financial burden to individuals in China. Healthcare system needs to shift from single-disease models to new financing and service delivery models to more effectively manage mental-physical multimorbidity.

CONTEXT Adverse childhood experiences (ACEs) are associated with increased risk of poor mental health outcomes. Although there is interest in screening for ACEs for early identification and intervention, it is not known whether screening improves outcomes for children. OBJECTIVE To systematically review whether screening for ACEs in children leads to an increase in (1) identification of ACEs, (2) referrals to services, (3) increased uptake of services, and (4) improved mental health outcomes for children and parents. DATA SOURCES Ovid Medline, PsycINFO, CINAHL, and Center for Clinical and Translational Research electronic databases were searched between 2009 and 2021. STUDY SELECTION Studies were included if researchers screened for current ACEs in children aged 0 to 12 years and they had a control comparison. DATA EXTRACTION Information was extracted, including study characteristics, sample demographics, screening tool characteristics, referral rates to services, uptake rates, and mental health outcomes. RESULTS A total of 5816 articles were screened, with 4 articles meeting inclusion criteria. Screening for ACEs increases identification of adversity and may increase referrals to services. There are limited data about whether this leads to an increase in referral uptake by families. There are no reported data addressing mental health outcomes. LIMITATIONS There are few published control trials of moderate quality. CONCLUSIONS There is limited evidence that screening for ACEs improves identification of childhood adversity and may improve referrals. If we are to realize the hypothesized benefits of ACEs screening on child and parent mental health, it is essential to understand the barriers for families taking up referrals.

Background Despite the well-established link between childhood adversity and mental health problems, there is a dearth of evidence to inform decision making about the most acceptable and feasible interventions for preventing mental health problems for children experiencing adversity. Expert consensus is an important input into evidence-informed policy and practice but is often employed at the national level which misses important local contextual factors shaping decision making. This study aimed to: (1) reach consensus on local priority interventions for preventing mental health problems for children living with adversity in Wyndham, Victoria; and (2) understand the enabling factors and barriers to implementing these interventions. Methods This study employed six online modified nominal group technique (NGT) workshops with 19 stakeholders; intersectoral service providers from health, social and education sectors and caregivers of children aged 0–8 years. Results Three interventions reached consensus among the mixed stakeholder groups as being a high or very high priority for implementation in Wyndham: nurse home visiting, parenting programs and community-wide programs. Key rationales were the ability for these interventions to act as a gateway for families to increase their knowledge about topics immediately relevant to them (i.e. parenting), increase their knowledge about available supports and build relationships with service providers. Conclusions Local priorities for preventing mental health problems for children living with adversity emphasized relational approaches to service provision and were shaped by the availability of existing interventions and supports in the locality. The NGT was found to be an effective method for prioritising evidence-based practice interventions in health settings, engaging local stakeholders, and identifying enablers and barriers to implementation.

BACKGROUND: Iatrogenic hypothyroidism can develop after radioiodine-I131 (RAI) treatment of hyperthyroid cats and can be diagnosed using the thyroid stimulating hormone (TSH) stimulation test. OBJECTIVES: To assess the effect of noncritical illness on TSH stimulation test results in euthyroid and RAI-treated cats. To assess the correlation of low total-thyroxine (tT4), low free-thyroxine (fT4), and high TSH concentrations with TSH stimulation test results. ANIMALS: Thirty-three euthyroid adult cats and 118 client-owned cats previously treated with RAI. METHODS: Total-thyroxine, fT4, and TSH were measured, and a TSH stimulation test was performed in all cats. Euthyroid control cats were divided into apparently healthy and noncritical illness groups. RAI-treated cats were divided into RAI-hypothyroid (after-stimulation tT4 ≤ 1.5 μg/dL), RAI-euthyroid (after-stimulation tT4 ≥ 2.3 μg/dL OR after-stimulation tT4 1.5-2.3 μg/dL and before : after tT4 ratio > 1.5), and RAI-equivocal (after stimulation tT4 1.5-2.3 μg/dL and tT4 ratio < 1.5) groups. RESULTS: Noncritical illness did not significantly affect the tT4 following TSH stimulation in euthyroid (P = .38) or RAI-treated cats (P = .54). There were 21 cats in the RAI-equivocal group. Twenty-two (85%) RAI-hypothyroid cats (n = 26) and 10/71 (14%) of RAI-euthyroid cats had high TSH (≥0.3 ng/mL). Twenty-three (88%) RAI-hypothyroid cats had low fT4 (

Category: Ankle; Ankle Arthritis; Hindfoot Introduction/Purpose: The effect of tibial torsion on lower extremity mechanical alignment has been well studied in the literature, including its effect on lower extremity osteoarthritis. It has been suggested that external tibial torsion is associated with cavus hindfoot deformity and may lead to varus osteoarthritis of the ankle. To our knowledge, there are no studies investigating this relationship. The purpose of this study is to characterize the relationship of tibial torsion with ankle coronal plane deformity in patients with ankle arthritis. Methods: The study is a retrospective, cohort of 223 patients who have undergone total ankle arthroplasty at a single institution. Preoperative computerized tomography was used to measure tibial torsion and coronal deformity. Descriptive statistics and regression analysis were used to analyze the data. Results: Descriptive analysis of all 223 patients demonstrated a maximum of 23.9 degrees varus and 20.5 degrees valgus among all patients. The mean for varus deformity was 6.86 degrees with a standard deviation of +- 6.39. Tibial rotation was calculated at an average of 20.8 degrees external rotation, with a maximum of 15.2 degrees internal rotation and 59.5 degrees external rotation in all patients. Plotting overall coronal ankle tilt versus tibial torsion revealed overall varus deformity with R2 of 0.016. Regression analysis of all varus deformities against external tibial torsion revealed a R2 of 0.02. Varus deformity 1 standard deviation above the mean against external tibial torsion demonstrated a R2 of 0.072. Valgus deformity against external tibial torsion revealed a R2 of 6.75 x10-5. Conclusion: An association between external tibial torsion and varus ankle arthritis has been proposed in the literature. The results of our study did not show an association between tibial torsion and coronal deformity in ankle arthritis in all patients undergoing total ankle arthroplasty at our institution. A difference may exist in certain subgroups, such as patients with neuromuscular disorders, but further investigation will be necessary to determine this relationship.

BackgroundParticipation in mental health system strengthening by people with mental health problems and their families is a cornerstone of people-centred mental health care, yet there is a dearth of research about participation from low- and middle-income countries (LMICs), particularly from the Asia Pacific region. Hence, this study aimed to assess the current situation, challenges, enabling factors and future actions for service user and family participation in mental health policy making in Timor-Leste.MethodsIn-depth interviews were conducted with 85 adults (≥18 years) who were: (1) mental health service users (n = 20) and their families (n = 10); (2) government decision makers (n = 10); (3) mental health and social service providers (n = 23); (4) civil society (n = 9); and (5) other groups (n = 13). Interview data was analysed using framework analysis.ResultsThere was limited service user, family and community participation in mental health policy making in Timor-Leste. Perceptions that policy making is a technical exercise and that people with mental health problems lack cognitive capacity, and a lack of supportive mechanisms challenged participation. Enabling factors were a strong focus on human rights within the social sector, and existing mechanisms for advocacy and representation of people with disabilities in social policy making. Participants suggested bolstering civil society representation of people with mental health problems, and increasing mental health awareness and literacy, including government competencies to facilitate service user participation.ConclusionThe findings highlight the need for theoretical and practical focus on the role of family within mental health system development in LMICs. Global mental health research and practice should adopt a critical approach to mental health service user and family participation to ensure that the concept and strategies to achieve this are embedded in LMIC knowledge.

BackgroundIntersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle-income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system.MethodsThis study employed a mixed-methods convergent design. Qualitative data elicited from in-depth interviews with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system.ResultsThere was consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density = 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services and system strengthening are led by the Ministry of Health, the mixed-methods data sources identified a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation = 0.28 and 0.47 for information and resource sharing, respectively).ConclusionsOverall, the findings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste.

CONTEXT Well established in the Emergency Department (ED) literature is that the most important factor in decreasing subsequent infection rate in open fractures is the time to first administration of antibiotics. As such, the authors developed a new ED open fracture antibiotic protocol to facilitate more expeditious antibiotic administration and appropriate choice of antibiotics. METHODS During Phase 1 of this project, the authors identified the 2012 - 2016 historical length of time from presentation of an open fracture to the possible initiation of antibiotic therapy at their institution. Results demonstrated critical areas for improvement in both timing and types of antibiotics administered. Phase 2 of the study evaluated the effect of the new open fracture antibiotic protocol. Sample cases from both phases were then further identified based on type of open fracture, time to initiation of antibiotics from ED presentation, type of antibiotics, and time to definitive treatment. Analyses were performed using GraphPad proprietary software. RESULTS A random sample of 110 patients were included from Phase 1 and 27 patients from Phase 2. A total of 43 Phase 1 patients were administered cefazolin (Kefzol, Ancef); the remainder of the patients received a number of different antibiotics. During Phase 2, all 27 patients received cefazolin and Gentamycin if necessary per the new protocol. The average time to initiation of antibiotics was 0.907 hours during Phase 1 compared to 0.568 hours in Phase 2. The new protocol also significantly decreased the average time to antibiotics in ED from 2.17 hours to 1.82 hours when including EMS transfer time. Average time to definitive treatment in the operating room was 6.63 hours during Phase 1 and was significantly lowered to 3.97 hours during Phase 2. CONCLUSIONS Timing to initiation of antibiotics after open fractures is the most important aspect to decrease infection rates. In order to decrease these times, the authors implemented a new ED protocol that specifically stated the type of antibiotic to be given based on the open fracture without orthopedics needing to be notified before administration. Ideally, the use of such protocols in ED settings will serve to greatly decrease infection risks after open fracture.

Sri Lanka has been a model country for many decades in terms of quality of population health outcomes in a low- or middle-income country, with relatively small but smart investment in population health. It has, however, experienced 30 years of civil conflict, ending in a brutal civil war in 2009. The island’s coastal regions were devastated, with massive loss of life and population displacement, by the Indian Ocean tsunami in 2004. The conflict and the tsunami brought to the fore the importance of renewed attention to the mental health of the Sri Lanka population, particularly among the most affected communities. While indigenous conceptions of mental health and illness, and strong Ayurvedic and other traditional forms of health practice, continue to be important across the Sri Lankan population, Western forms of psychiatry and systems of care have become dominant over a long period, particularly during the British colonial era. Human resources and physical infrastructure for mental health treatment and care have been very limited. Although general hospital, inpatient psychiatric units in several parts of the country were established much earlier in Sri Lanka than in many other countries, until recent times three national psychiatric institutions, all near Colombo, were the main locus of care and the main resource for psychiatric treatment. Conditions in these institutions were very poor. The impact of the tsunami, and the influx of aid and technical expertise, created an opportunity for major reform of the mental health system, with an orientation to community-based treatment and care, major improvements in Angoda Psychiatric Hospital, and establishment of small inpatient units in most district general hospitals across the country. Major innovations in dealing with the shortage of mental health human resources have been a particular feature of the mental health system development in Sri Lanka in the past decade. A focus on suicide prevention has yielded very positive results. These and other aspects of the process of reform of the Sri Lankan mental health system have generated international interest. This chapter provides a brief account of a very effective process of mental health system reform in a middle-income country.

Introduction: A seemingly large percentage of geriatric patients with isolated low-energy femur fractures undergo a head computed tomography (CT) scans during initial work up in the emergency department. This study aimed to evaluate the pertinent clinical variables that are associated with positive CT findings with the objective to decrease the number of unnecessary CT scans performed. Methods: A retrospective review performed at a level II trauma center including 713 patients over the age of 65 sustaining a femur fracture following a low-energy fall. The main outcome measure was pertinent clinical variables that are associated with CT scans that yielded positive findings. Results: A total of 713 patients over the age of 65 were included, with a low-energy fall, of which 76.2% (543/713) underwent a head CT scan as part of their evaluation. The most common presenting symptom reported was the patient hitting their head, 13% (93/713), and 1.8% (13/713) were unsure if they had hit their head. Of those evaluated with a head CT scan, only 3 (0.4%) had acute findings and none required acute neurosurgical intervention. All three patients with acute changes on the head CT scan had an Injury Severity Score (ISS) greater than 9, Glasgow Coma Scale (GCS) less than 15, and evidence of trauma above the clavicles. Discussion: None of the patients with a traumatic injury required a neurosurgical intervention after sustaining a low-energy fall (0/713). Conclusion: Head CT scans should have a limited role in the workup of this patient population and should be reserved for patients with a history and physical exam findings that support head trauma, an ISS > 9 and GCS < 15.

This article provides a synopsis of how articulation agreements serve postsecondary education institutions and their constituents, provides an overview on the types of agreements, and discusses some of the issues associated with development of these agreements. The following questions frame the narrative: As community colleges grew in number and format, what prompted the development of articulation agreements? What types of articulation agreements have been and are currently being developed? What are the incentives for either administrators or faculty to pursue development of articulation agreements?

Objective The possible molecular mimicry of the Epstein-Barr virus (EBV) peptide PPPGRRP by the peptide PPPGMRPP from Sm B'/B of the human spliceosome is consistent with the possibility that EBV infection is related to the origin of systemic lupus erythematosus (SLE) in some patients. Association of EBV exposure with SLE was therefore tested for and subsequently found in children and adolescents (odds ratio [OR] 49.9, 95% confidence interval [95% CI] 9.3-1,025, P 10, 95% CI 2.53-infinity, P Methods We selected 196 antinuclear antibody-positive adult SLE patients (age > or =20 years) and 2 age-, race-, and sex-matched controls per patient. SLE patients and matched controls were tested for evidence of previous infection with EBV, cytomegalovirus (CMV), herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), or varicella-zoster virus (VZV) by standardized enzyme-linked immunosorbent assays. Results Of the 196 lupus patients tested, all but 1 had been exposed to EBV, while 22 of the 392 controls did not have antibodies consistent with previous EBV exposure (OR 9.35, 95% CI 1.45-infinity, P = 0.014). No differences were observed between SLE patients and controls in the seroconversion rate against CMV, HSV-2, or VZV. Conclusion These new data from adults, along with the many suggestive features of EBV infection, are consistent with the contribution of this infection to the etiology of SLE.

IntroductionIntegrated community healthcare Hubs may offer a ‘one stop shop’ for service users with complex health and social needs, and more efficiently use service resources. Various policy imperatives exist to implement Hub models of care, however, there is a dearth of research specifically evaluating Hubs targeted at families experiencing adversity. To contribute to building this evidence, we propose to co-design, test and evaluate integrated Hub models of care in two Australian community health services in low socioeconomic areas that serve families experiencing adversity: Wyndham Vale in Victoria and Marrickville in New South Wales.Methods and analysisThis multisite convergent mixed-methods study will run over three phases to (1) develop the initial Hub programme theory through formative research; (2) test and, then, (3) refine the Hub theory using empirical data. Phase 1 involves co-design of each Hub with caregivers, community members and practitioners. Phase 2 uses caregiver and Hub practitioner surveys at baseline, and 6 and 12 months after Hub implementation, and in-depth interviews at 12 months. Two stakeholder groups will be recruited: caregivers (n=100–200 per site) and Hub practitioners (n=20–30 per site). The intervention is a co-located Hub providing health, social, legal and community services with no comparator. The primary outcomes are caregiver-reported: (i) identification of, (ii) interventions received and/or (iii) referrals received for adversity from Hub practitioners. The study also assesses child, caregiver, practitioner and system outcomes including mental health, parenting, quality of life, care experience and service linkages. Primary and secondary outcomes will be assessed by examining change in proportions/means from baseline to 6 months, from 6 to 12 months and from baseline to 12 months. Service linkages will be analysed using social network analysis. Costs of Hub implementation and a health economics analysis of unmet need will be conducted. Thematic analysis will be employed to analyse qualitative data.Ethics and disseminationRoyal Children’s Hospital and Sydney Local Health District ethics committees have approved the study (HREC/62866/RCHM-2020). Participants and stakeholders will receive results through meetings, presentations and publications.Trial registration numberISRCTN55495932.