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Gender-affirming hormone therapy modifies body composition and lean muscle mass in transgender persons. We sought to characterize the change in serum creatinine, other kidney function biomarkers, and GFR in transgender persons initiating masculinizing and feminizing gender-affirming hormone therapy.We searched PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov from inception to September 16, 2020 for randomized controlled trials, observational studies, and case series that evaluated the change in serum creatinine, other kidney function biomarkers, and GFR before and after the initiation of gender-affirming hormone therapy in adult transgender persons. Two reviewers independently screened and abstracted data, and disagreements were resolved by a third reviewer. A random effects meta-analysis was performed to determine the change in outcomes over follow-up of 3, 6, and 12 months.Of the 4758 eligible studies, 26 met the inclusion criteria, including nine studies that recruited 488 transgender men and 593 women in which data were meta-analyzed. There was heterogeneity in study design, populations, gender-affirming hormone therapy routes, and dosing. At 12 months after initiating gender-affirming hormone therapy, serum creatinine increased by 0.15 mg/dl (95% confidence interval, 0.00 to 0.29) in 370 transgender men and decreased by -0.05 mg/dl (95% confidence interval, -0.16 to 0.05) in 361 transgender women. No study reported the effect of gender-affirming hormone therapy on albuminuria, proteinuria, cystatin C, or measured GFR.Gender-affirming hormone therapy increases serum creatinine in transgender men and does not affect serum creatinine in transgender women. The effect on gender-affirming hormone therapy on other kidney function biomarkers and measured GFR is unknown.Change in Kidney Function Biomarkers in Transgender Persons on Gender Affirmation Hormone Therapy-A Systematic Review and Meta-Analysis, CRD42020214248.

An ageing population, an estimated 47 million people currently living with dementia, and predictions of a threefold increase in people living with a diagnosis by 2050 have led the WHO to declare dementia a public health priority. Emerging research also suggests that dementia is linked to poor oral health and that oral health declines alongside cognitive decline. Drawing on Bourdieu’s concepts of field and capital, this paper presents an analysis of interview data from participants with dementia, carers and carer/diagnosed dyads participating in a qualitative study of the mouth and oral health. We argue that Bourdieu’s conceptual toolkit provides a way of contextualising experiences of oral health within dementia and un-picking the multi-layered impact of structure, institutions, biology, resource mobilisation and self in the context of a progressive disease which ultimately challenges knowledge of the self and the ability to interact with the world around us.

Background International literature shows unemployment and income loss during the Great Recession worsened population mental health. This individual-level longitudinal study examines how regional economic trends and austerity related to depression using administrative prescription data for a large and representative population sample. Methods Records from a sample of the Scottish Longitudinal Study (N=86 500) were linked to monthly primary care antidepressant prescriptions (2009–15). Regional economic trends were characterized by annual full-time employment data (2004–14). Economic impact of austerity was measured via annual income lost per working age adult due to welfare reforms (2010–15). Sequence analysis identified new cases of antidepressant use, and group-based trajectory modelling classified regions into similar economic trajectories. Multi-level logistic regression examined relationships between regional economic trends and new antidepressant prescriptions. Structural equation mediation analysis assessed the contributory role of welfare reforms. Results Employed individuals living in regions not recovering post-recession had the highest risk of beginning a new course of antidepressants (AOR 1.23; 95% CI 1.08–1.38). Individuals living in areas with better recovery trajectories had the lowest risk. Mediation analyses showed that 50% (95% CI 7–61%) of this association was explained by the impact of welfare benefit reforms on average incomes. Conclusions Following the Great Recession, local labour market decline and austerity measures were associated with growing antidepressant usage, increasing regional inequalities in mental health. The study evidences the impact of austerity on health inequalities and suggests that economic conditions and welfare policies impact on population health. Reducing the burden of mental ill-health primarily requires action on the social determinants.

Indigenous peoples often endure significant health disparities fueled by historic and ongoing marginalizing policies and practices. In many cases, Indigenous groups are isolated from mainstream health care services (geographically, economically, or culturally) and lack the preventive health benefits associated with continuity of care.1 In Canada, this manifests in disproportionately high rates of chronic disease, often diagnosed at a younger age and greater severity than non-Indigenous groups. Of these, chronic kidney disease (CKD), diabetes, and hypertension are highly prevalent, reaching epidemic levels in many communities.2 Kidney Check is a comprehensive screen, triage, and treat initiative working to bring preventive kidney care to rural and remote Indigenous communities across Manitoba, Ontario, British Columbia, Alberta, and Saskatchewan. Modeled after the 2015 FINISHED initiative in Manitoba,3 and working within the CanSOLVE CKD network (www.cansolveckd.ca/), Kidney Check employs point-of-care testing (POCT) to identify CKD, diabetes, and hypertension in individuals aged 10 and up regardless of preexisting risk factors. To ensure the efficacy and sustainability of the program, Kidney Check relies on a strategic quality management system that addresses all aspects of the screening process. The intent of this manuscript is to describe the development process of all procedures and components related to the deployment of the Kidney Check program with specific focus on organizational structure, point-of-care testing devices, and data management. The Kidney Check Team Kidney Check’s management structure consists of the leadership team, advisory committee, patient partner committee, and mobile screening teams. Leadership provides guidance to the provincial teams to ensure the appropriate objectives, processes, and tools are in place to support high-functioning groups. This includes working closely with the advisory committee to preemptively identify potential barriers and risk issues in order to develop efficient mitigation strategies. Largely composed of Indigenous stakeholders and closely affiliated with the CanSOLVE CKD Indigenous People’s Engagement Council (IPERC), the advisory committee provides valuable insight on how to best use engagement strategies to maximize participation in the screening event. They are supported by the patient partner committee that oversees the execution of knowledge translation activities including but not limited to community selection criteria, community engagement procedures, and review of communication materials and strategies. Screening teams operate under the auspices of the Diabetes Integration Project and First Nations Health and Social Secretariat of Manitoba (FNHSSM). Stationed in various communities across the country, the team’s primary aim is to accommodate high throughput while maintaining quality control (QC) standards. As an affiliate of the CanSOLVE CKD network, members of all committees within Kidney Check have linkages to the broader network.

Objectives We compared the addition of iPad distraction to standard care, versus standard care alone, to manage the pain and distress of intravenous (IV) cannulation. Methods Eighty-five children aged 6 to 11 years requiring IV cannulation (without child life services present) were recruited for a randomized controlled trial from a paediatric emergency department. Primary outcomes were self-reported pain (Faces Pain Scale-Revised [FPS-R]) and distress (Observational Scale of Behavioral Distress-Revised [OSBD-R]), analyzed with two-sample t-tests, Mann–Whitney U-tests, and regression analysis. Results Forty-two children received iPad distraction and 43 standard care; forty (95%) and 35 (81%) received topical anesthesia, respectively (P=0.09). There was no significant difference in procedural pain using an iPad (median [interquartile range]: 2.0 [0.0, 6.0]) in addition to standard care (2.0 [2.0, 6.0]) (P=0.35). There was no significant change from baseline behavioural distress using an iPad (mean ± SD: 0.53 ± 1.19) in addition to standard care (0.43 ± 1.56) (P=0.44). Less total behavioural distress was associated with having prior emergency department visits (odds ratio [95% confidence interval]: −1.90 [−3.37, −0.43]) or being discharged home (−1.78 [−3.04, −0.52]); prior hospitalization was associated with greater distress (1.29 [0.09, 2.49]). Significantly more parents wished to have the same approach in the future in the iPad arm (41 of 41, 100%) compared to standard care (36 of 42, 86%) (P=0.03). Conclusions iPad distraction during IV cannulation in school-aged children was not associated with less pain or distress than standard care alone. The effects of iPad distraction may have been blunted by topical anesthetic cream usage. Clinical trials registration ClinicalTrials.gov: NCT02326623.

Background Accidental awareness during general anaesthesia (AAGA) is a complex and rare outcome to investigate in surgical patient populations, particularly obstetric patients. We report the protocol of the Direct Reporting of Awareness in Maternity patients (DREAMY) study, illustrating how the research was designed to address practical and methodological challenges for investigating AAGA in an obstetric cohort. Methods This is the trial protocol of a prospective, multicentre cohort study of patients undergoing obstetric surgery under general anaesthesia. Accidental awareness during general anaesthesia will be detected using three repetitions of standardised direct questioning over 30 days, with responses indicating memories during general anaesthesia verified using structured interviews. Reports will be adjudicated, then classified, in accordance with pre-defined and pre-validated structures, including the Michigan Awareness Classification tool. Quantitative data will be collected on general anaesthesia conduct for all participants. This descriptive study is being conducted in England and aims to recruit a minimum of 2015 patients. Results The DREAMY study was prospectively registered (ClinicalTrials.gov Identifier: NCT03100396) and ethical approval granted. Participant recruitment began in May 2017 and one year follow up concluded in August 2019. Publication of the results is anticipated in 2020. Conclusions The DREAMY study will provide data on incidence, experience and implications of AAGA for obstetric patients, using a robust methodology that will reliably detect and translate subjective AAGA reports into objective outcomes. In addition, the study is expected to improve vigilance for AAGA in participating hospitals and encourage adoption of recommendations for support of patients experiencing AAGA.

All aspects of public health research require longitudinal analyses to fully capture the dynamics of outcomes and risk factors such as ageing, human mobility, non-communicable diseases (NCDs), climate change, and endemic, emerging, and re-emerging infectious diseases. Studies in geospatial health are often limited to spatial and temporal cross sections. This generates uncertainty in the exposures and behavior of study populations. We discuss a research agenda, including key challenges and opportunities of working with longitudinal geospatial health data. Examples include accounting for residential and human mobility, recruiting new birth cohorts, geoimputation, international and interdisciplinary collaborations, spatial lifecourse studies, and qualitative and mixed-methods approaches.

This cohort study assesses the association between intravenous magnesium therapy administered in the emergency department and subsequent hospitalization among pediatric patients with refractory acute asthma in Canada., Key Points Question Is receipt of intravenous (IV) magnesium sulfate therapy in the emergency department associated with subsequent hospitalization among children with refractory acute asthma after adjustment for patient-level characteristics? Findings In this secondary analysis of a randomized clinical trial of 816 children who experienced moderate to severe respiratory distress after stabilization therapy and inhaled magnesium therapy or placebo, 88.4% of those who received IV magnesium therapy were hospitalized compared with 29.0% of those who did not receive this therapy. After adjustment, children who received IV magnesium therapy had greater odds of hospitalization compared with those who did not receive this therapy. Meaning The findings suggest that, after adjustment of patient-level characteristics, receipt of IV magnesium in the emergency department is associated with subsequent hospitalization among children with asthma., Importance Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization. Objective To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. Design, Setting, and Participants This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. Exposures Intravenous magnesium sulfate therapy (40-75 mg/kg). Main Outcomes and Measures The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. Results Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P

This paper reviews how community wellbeing is defined and measured in relation to individual subjective wellbeing, the assumptions underlying the dominant approaches and what gets left out. An important distinction in approaches to community wellbeing concerns the primary purpose. The focus may be on community only in so far as community scale characteristics impact individual subjective wellbeing, or there may be a focus on community scale aspects of living together in which community wellbeing is more than the sum of the individual parts. Most existing frameworks for assessment of community wellbeing are premised on the centrality of an autonomous and independently acting or feeling individual and the primary interest is on how community aspects of life impact on individual wellbeing. Areas of life typically assessed notably omit attention to inequalities, intangible culture, settings and scale, sustainability and inter-generationality. However, social theory offers alternative understandings of individual experience as primarily relational which aligns with an interest in community and demands different ways of thinking about wellbeing and wellbeing assessments. Capturing subjective aspects of local life that are not simply individual but reflect the ways in which people feel and are well together is more challenging. Alternative forms of data collection are needed through deliberative processes or the analysis of narrative and other local culturally shared resources.

The current study aimed to examine children's experiences of using tablet technology within the home. Eighteen children aged between eight and nine years old took part in four separate focus group discussions. Thematic analysis revealed three predominant themes: a battle of boundaries, a tool to escape the surrounding world, and an emerging dependency on tablet technology. The data implies that there is a growing dependency on tablet technology use among this age group. The current study also outlines that many children engage in a variety of techniques to circumvent parental limits on their tablet usage. However, other children discussed a lack of clear rules and restrictions for their use of tablet devices. The findings suggest that covert and unregulated use of tablet technology may have a detrimental impact upon children, particularly in relation to reduced social interaction, fatigue and increased family tensions due to excessive usage. Further research of child interactions with a wide variety of digital technology and media is warranted. Such exploration would further our understanding of the potential advantages and disadvantages for such technology use, as well as presenting a pathway to produce more effective guidance on home use.

Aim To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers. Materials and methods A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality. Results Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent. Conclusion There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.

"The shift towards online communication has impacted many aspects of our lives, in that we increasingly use the internet in ways that have a lasting impact on our lived experience. One of the ways this impact occurs is through the virtual manifestation of phenomena related to death. Customs related to death - such as funerals and memorials - are being remediated on the internet in ways that are varied and complex. Remediation, a term introduced by Jay Bolter and Richard Grusin, involves the reinvention of previous forms of media using new media technologies.1 In this way, every form of media is understood to be a new version of a form of media that already existed. Looking at sites of memorialization of all kinds through the framework of remediation illuminates the ways that the manifestation of issues related to death and memorialization on the internet has and will continue to both complicate and enhance the ways these sites are experienced and conceptualized by those that visit them. While traditional physical memorial sites have always existed - and will continue to exist - sites of remembrance that appear on the internet are emerging as a complementary medium of memorialization"--From the Introduction.

Access to health care services remains a significant barrier for many Indigenous people's living in rural and remote regions of Canada. Driven by geographical isolation and compounded by socioeconomic and environmental disparities, individuals living under these circumstances face disproportionately poor health outcomes. Kidney Check is a comprehensive screening, triage, and treatment initiative working to bring culturally safe preventive care to rural and remote Indigenous communities across Manitoba, Ontario, BC, Alberta, and Saskatchewan. The project's patient-oriented approach addresses concerns raised by kidney patients and their caregivers using culturally safe practices. Using the various expertise of their multidisciplinary team, Kidney Check seeks to further collaborative efforts to improve access to preventive health care for these groups. Meaningful engagement with patients, communities, and local health care stakeholders ensures Indigenous voices are heard and incorporated into the project in a way that promotes shared decision-making and sustainability.As an affiliate program of the Can-SOLVE CKD Network, Kidney Check's guiding priorities were developed over 3 years of patient consultation and finalized during 2 workshops held with more than 30 patients, caregivers, Indigenous peoples, researchers, and policy makers using a modified Delphi process. Today, patients continue to participate in project development via 2 governing bodies: The Patient Governance Circle and the Indigenous Peoples Engagement and Research Council (IPERC).Modeled after the Indigenous-led 2015 FINISHED project in Manitoba, Kidney Check employs point-of-care testing to identify diabetes, hypertension, and chronic kidney disease (CKD) in individuals, ages 10 and above, regardless of pre-existing risk factors. The Kidney Check team consists of 4 working groups: project leadership, provincial management, local community partners, and patient partners. By using and building on existing relationships between local and provincial health care stakeholders and various Indigenous communities, the program furthers collaborative efforts to bridge gaps in health equity.The Kidney Check program has established an infrastructure that integrates patient engagement at all stages of the program from priority setting to deployment and dissemination strategies.While we encourage and offer screening services to all, many still choose not to attend for a variety of reasons which may introduce selection bias. Kidney Check uses patient engagement as a foundational component of the program; however, there is currently a limited amount of research documenting the benefits of patient engagement in health care settings. More formal qualitative evaluations of these activities are needed. In addition, as the COVID-19 pandemic has halted screening procedures in most communities, we currently do not have quantitative data to support the efficacy of the Kidney Check program.For many Indigenous people, lack of accessibility to health care services is compounded by sociopolitical barriers that disrupt relationships between patients and providers. Meaningful engagement presents one opportunity to ensure the voices and perspectives of Indigenous patients and communities are incorporated into health services. In addition, this screening paradigm has shown to be cost effective as shown by analyses done on the FINISHED screening program.L’accès aux services de santé demeure un obstacle important pour de nombreuses populations autochtones vivant dans les régions rurales et éloignées du Canada. En raison de l’isolement géographique et de disparités environnementales et socio-économiques, les personnes vivant dans ces situations sont confrontées à de pauvres conditions de santé. Kidney Check est une initiative complète de dépistage, de triage et de traitement qui vise à offrir des soins préventifs et respectueux de leurs valeurs culturelles aux communautés autochtones rurales et éloignées du Manitoba, de l’Ontario, de la Colombie-Britannique, de l’Alberta et de la Saskatchewan. L’approche axée sur le patient répond aux préoccupations soulevées par les patients atteints de néphropathies et leurs soignants grâce à des pratiques adaptées à leur culture. En exploitant les compétences d’une équipe multidisciplinaire, Kidney Check s’efforce de poursuivre les efforts de collaboration visant l’amélioration de l’accès à des soins de santé préventifs pour ces groupes. Un engagement significatif des patients, des communautés et des acteurs locaux du secteur de la santé garantit que les voix autochtones sont entendues et intégrées dans le projet d’une manière qui favorise la pérennité et la prise de décision partagée.Kidney Check étant un programme affilié du réseau CAN-SOLVE CKD, ses priorités directrices ont été élaborées à partir d’une consultation de 3 ans auprès des patients et finalisées au cours de deux ateliers utilisant une version modifiée de la méthode Delphi et réunissant plus d’une trentaine de patients, soignants, membres des communautés autochtones, chercheurs et décideurs. Les patients continuent à ce jour de participer au développement du projet par l’entremise de deux organes directeurs: le Conseil des patients et le Conseil de la recherche et de l’engagement des peuples autochtones (IPICER).Inspiré du projet de dépistage FINISHED mené en 2015 auprès des Autochtones du Manitoba, Kidney Check utilise des tests au point de service pour dépister le diabète, l’hypertension et l’insuffisance rénale chronique chez les personnes âgées de 10 ans et plus, quels que soient les facteurs de risque préexistants. L’équipe de Kidney Check se compose de quatre groupes de travail: direction du projet, gestion provinciale, partenaires communautaires locaux et patients partenaires. En utilisant et en s’appuyant sur les relations existantes entre les intervenants locaux et provinciaux du secteur de la santé et les diverses communautés autochtones, le programme favorise les efforts de collaboration pour combler les écarts en matière d’équité en santé.Le programme Kidney Check a mis en place une infrastructure impliquant la participation des patients à toutes les étapes du programme, de l’établissement des priorités aux stratégies de déploiement et de diffusion.Nous encourageons et offrons ces services de dépistage à tous, mais, pour diverses raisons, beaucoup choisissent de ne pas y participer, ce qui peut introduire un biais de sélection. La participation des patients est un élément fondamental du programme Kidney Check; néanmoins, les avantages d’un engagement des patients dans les établissements de soins de santé demeurent peu documentés. Davantage d’évaluations qualitatives formelles de ces activités sont donc nécessaires. De plus, la pandémie de COVID-19 ayant interrompu les procédures de dépistage dans la plupart des collectivités, nous ne disposons pas actuellement de données quantitatives pour soutenir l’efficacité du programme.Pour de nombreuses populations autochtones, le manque d’accessibilité aux services de santé est aggravé par des obstacles sociopolitiques qui perturbent les relations entre les patients et les fournisseurs de soins. La participation significative des patients et des communautés autochtones permet d’assurer que leurs voix et perspectives soient intégrées dans les services de santé. En outre, ce paradigme de dépistage s’est révélé rentable, comme le montrent les analyses effectuées sur le programme de dépistage FINISHED.

Little is known about how community-dwelling people with dementia, as well as their carers, look after their oral health and use dental care. This exploratory study aimed to explore the beliefs, experiences and practices about oral health of people living with dementia and their carers. We used an ethnographic qualitative approach conducting face-to-face interviews at home with people living with dementia and/or carers. Interview data and field notes were analysed thematically using framework methods. We approached volunteers registered with the online UK. Join Dementia Research network from whom a total of 17 participants were recruited in 2018. Five interviews were conducted with carers alone, two with a person living with dementia alone, and five with a carer and person with dementia jointly. Three main themes emerged: oral health is not prioritised; access to dental care is shaped by increasing disability; and the importance of continuity of care. While people living with dementia and their carers may view oral health important once prompted, many reported difficulties in undertaking or assisting with daily self-care and accessing dental services, particularly as dementia progresses. We draw out implications for the organisation and delivery of public and private dental services.

This paper examines trends in mental health among adults in England during the period of economic recovery and austerity following the 2008 ‘great recession’. We report analysis of data on 17,212 individuals living in England, from the longitudinal Understanding Society Survey (USS). We examined how individual’s self-reported mental health over time (2011 -2017), related to their changing socio-geographical status.Self-reported mental health is reported in the USS using version 2 of the SF12 Mental Component Summary. Trends in this score (across 5 observations per subject) were categorised into Mental Health Trajectory Groups (MHTGs) using Group Based Trajectory Modelling. We used maximum-likelihood multinomial logit models to estimate for individuals the relative likelihood of belonging to different Mental Health Trajectory categories as compared with a ‘base’ category, for whom mental health was good and stable throughout the period. We focus on likelihood of belonging to a group showing ‘declining’ mental health. Predictor variables included individuals’ attributes and area conditions in their places of residence (including Office of National Statistics indicators of local employment deprivation and data on average income loss within districts due to welfare benefit reforms, published by the Centre of Regional Economic and Social Research at Sheffield Hallam University, UK).Our results emphasise the multiple socio-geographical ‘determinants’ likely to be operating on individual mental health. Declining mental health was associated both with conditions at the start of the study period and with social and socio-geographical mobility by the end of the study period. Risks of declining mental health were significantly greater for more deprived individuals and also (controlling for individual attributes) among those living in English neighbourhoods that were already economically disadvantaged at the beginning of the ‘great recession’ and located in districts where average incomes were most severely impacted by the effects of governmental austerity programmes on welfare benefits.

BackgroundOver the past decade, antidepressant prescriptions have increased in European countries and the United States, partly due to an increase in the number of new cases of mental illness. This paper demonstrates an innovative approach to the classification of population level change in mental health status, using administrative data for a large sample of the Scottish population. We aimed to identify groups of individuals with similar patterns of change in pattern of prescribing, validate these groups by comparison with other indicators of mental illness, and characterise the population most at risk of increasing mental ill health.MethodsNational Health Service (NHS) prescription data were linked to the Scottish Longitudinal Study (SLS), a 5.3% sample of the Scottish population (N = 151,418). Antidepressant prescription status over the previous 6 months was recorded for every month for which data were available (January 2009–December 2014), and sequence dissimilarity was computed by optimal matching. Hierarchical clustering was used to create groups of participants who had similar patterns of change, with multi-level logistic regression used to understand group membership.ResultsFive distinct prescription pattern groups were observed, indicating: no prescriptions (76%), occasional prescriptions (10%), continuation of prior use of prescriptions (8%), a new course of prescriptions started (4%) or ceased taking prescriptions (3%). Young, white, female participants, of low social grade, residing in socially deprived neighbourhoods, living alone, being separated/divorced or out of the labour force, were more likely to be in the group that started a new course of antidepressant prescriptions.ConclusionsThe use of sequence analysis for classifying individual antidepressant trajectories offers a novel approach for capturing population-level changes in mental health risk. By classifying individuals into groups based on their anti-depressant medication use we can better identify how over time, mental health is associated with individual risk factors and contextual factors at the local level and the macro political and economic scale.

Importance While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. Objective To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. Design, Setting, and Participants A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. Interventions Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). Main Outcomes and Measures The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. Results Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, −4.2%; absolute risk difference 95% [exact] CI, −11% to 2.8%];P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, −0.23 to 0.50];P = .46); respiratory rate (0.17 breaths/min [95% CI, −1.32 to 1.67];P = .82); oxygen saturation (−0.04% [95% CI, −0.53% to 0.46%];P = .88); systolic blood pressure (0.78 mm Hg [95% CI, −1.48 to 3.03];P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11];P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). Conclusions and Relevance Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. Trial Registration ClinicalTrials.gov Identifier:NCT01429415

Background: Dietary modifications represent an important intervention to reduce the risk of chronic disease. Appropriate dietary changes can be simple to implement and are usually suggested as first line recommendations for many types of chronic disease management including diseases like hypertension and diabetes. Resistant starch is a non-digestible carbohydrate which passes through untouched to the colon where it becomes a digestible substrate for beneficial colonic bacteria. The normal gut flora becomes damaged in patients with chronic kidney disease with an additional buildup of uremic toxins and resulting intra-renal inflammation. Resistant starch supplementation has been studied for its effects on reducing harmful metabolite buildup through a restoration of normal gut flora. The following systematic review aims to compile the evidence of resistant starch use in adult patients with chronic kidney disease to answer whether or not the dietary intervention can reduce the progression of renal disease. Methods: We will perform a literature search with a knowledge synthesis librarian including the following databases: MEDLINE, Cochrane Central, Embase, CINAHL, and Web of Science. Collected data will be extracted and organized in MS Excel 2019. The extraction of the data will include study details, study population details, intervention details, and outcome details.Discussion: Results from this systematic review may help to determine a simple and effective method for prolonging the need for renal replacement therapy through resistant starch supplementation. Lack of evidence may highlight the need for additional trials or new interventions. PROSPERO ID: Currently being assessed, ID: 203138.

Our objectives were to evaluate the effectiveness of humanoid robot-based distraction on reducing distress and pain in children undergoing intravenous insertion.A two-arm, open-label randomized controlled trial was conducted April 2017-May 2018, in a pediatric emergency department (ED). A sample of 86 children aged 6-11 years who required intravenous insertion were recruited. Exclusion criteria included hearing/visual impairments, neurocognitive delay, sensory impairment to pain, previous enrollment, and ED clinical staff discretion. Outcome measures included the Observed Scale of Behavioral Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain).Of the 86 children recruited (median age 9 years, IQR 7,10); 55% (47/86) were male, 9% (7/82) were premature, 82% (67/82) had a previous ED visit, 31% (25/82) had a previous hospitalization and 78% (64/82) had previous intravenous insertion. Ninety-six percent (78/81) received topical anesthetic prior to intravenous insertion. Total OSBD-R distress score was 1.49 ± 2.36 (standard care) versus 0.78 ± 1.32 (robot) (p 0.05). FPS-R pain score was 4 (IQR 2,6) (standard care) versus 2 (IQR 0,4) (robot) (p = 0.13). Parental anxiety immediately after the procedure was 36.7 (11.1) (standard care) versus 31.3 (8.5) (robot) (p = 0.04). Parents were more satisfied with pain management in the robotic distraction group (95% vs 72% very satisfied) (p = 0.002).Humanoid robot-based distraction therapy is associated with a modest positive impact on child distress for pediatric intravenous insertion, but not pain. It can be considered a potential tool in the ED toolkit for procedural pain-associated distress reduction.Clinicaltrials.gov Identifier: NCT02997631.RéSUMé: OBJECTIFS: Nos objectifs étaient d'évaluer l'efficacité de la distraction robotique humanoïde pour réduire la détresse et la douleur chez les enfants subissant une insertion intraveineuse. MéTHODES: Un essai contrôlé randomisé ouvert à deux bras a été mené d'avril 2017 à mai 2018, dans un service d'urgence pédiatrique. Un échantillon de 86 enfants âgés de 6 à 11 ans ayant besoin d'une insertion intraveineuse a été recruté. Les critères d'exclusion comprenaient des déficiences auditives / visuelles, un retard neurocognitif, une déficience sensorielle de la douleur, une inscription antérieure et la discrétion du personnel clinique des urgences. Les mesures des résultats comprenaient l’échelle d’hétéro-évaluation comportementale (OSBD-R: Observational Scale of Behavioral Distress – Revised) (détresse) et l’échelle de visages (FPS-R: Faces Pain Scale-Revised) (douleur). RéSULTATS: Sur les 86 enfants recrutés (âge médian 9 ans, IQR 7,10) ; 55 % (47/86) étaient de sexe masculin, 9 % (7/82) étaient prématurés, 82 % (67/82) avaient une visite antérieure aux urgences, 31 % (25/82) avaient déjà été hospitalisés et 78 % (64/82) avaient déjà été insérés par voie intraveineuse. Quatre-vingt-seize pour cent (78/81) ont reçu une anesthésie topique avant l'insertion intraveineuse. Le score total de détresse OSBD-R était de 1,49 ± 2,36 (soins standard) contre 0,78 ± 1,32 (robot) (p0,05). Le score de douleur FPS-R était de 4 (IQR 2,6) (soins standard) contre 2 (IQR 0, 4) (robot) (p=0,13). L’anxiété parentale immédiatement après l’intervention était de 36,7 (11,1) (soins standard) contre 31,3 (8,5) (robot) (p=0,04). Les parents étaient plus satisfaits de la gestion de la douleur dans le groupe de distraction robotique (95 % vs 72 % très satisfaits) (p = 0,002). CONCLUSIONS: La thérapie de distraction à base de robot humanoïde est associée à un impact positif modeste sur la détresse de l’enfant pour l’insertion intraveineuse pédiatrique, mais pas la douleur. Il peut être considéré comme un outil potentiel dans la boîte à outils des Services d’Urgences pour la réduction de la détresse associée à la douleur procédurale.

Alcohol and alcohol-related harm are key public health challenges. Research has shown that individual-level factors, such as age and sex, are important predictors of alcohol consumption, but such factors provide only a partial account of the drivers of consumption. In this article, we argue that individual-level factors interact with features of the risk environment to increase the vulnerability of individuals to such environments. Features of the alcohol risk environment include the density of alcohol premises in a neighborhood. Previous research has shown that neighborhoods with a higher density of alcohol outlets have higher levels of both alcohol consumption and alcohol-related harm. There has, however, been a distinct lack of attention paid to the differential ways in which particular sociodemographic groups might be more vulnerable to such risk environments. In this article, we address the risk environment through a primary focus on the local supply and availability of alcohol products (captured using a measure of outlet density) and the relationship with the harmful use of alcohol. Using responses to the Scottish Health Survey (2008–2011), we explore vulnerability through the interaction between individual-level socioeconomic position, measured using household income, and environmental risk to assess differential social vulnerability to such environments. We report findings showing that those in the lowest income groups might be disproportionately affected by outlet density. This evidence suggests that risk environments might not affect us all equally and that there could be socially differentiated vulnerability to such environments.

Background Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents’ experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact. Objective Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically (Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments (Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents. Methods Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children—2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS. Results Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents (P Conclusions Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety. Trial Registration ClinicalTrials.gov Identifier: NCT02970734 https://clinicaltrials.gov/ct2/show/NCT02970734

BackgroundProblematic alcohol use is associated with detrimental cognitive, physiological and social consequences. In the emergency department (ED), Screening, Brief Intervention, and Referral to Treatment (SBIRT) is the recommended approach to identify and treat adolescent alcohol-related concerns, but is underused by physicians.ObjectiveThis study examined pediatric emergency physicians’ perceptions of adolescent drinking and treatment, and their current self-reported SBIRT practices.MethodPhysicians in the Pediatric Emergency Research Canada database (n=245) received a 35-item questionnaire that was administered through a web-based platform and paper-based mail-outs. Recruitment followed a modified Dillman four-contact approach.ResultsFrom October 2016 to January 2017, 166 pediatric emergency physicians (46.4% males; mean age=43.6 years) completed the questionnaire. The response rate was 67.8%. Physicians recognized the need (65%) and responsibility (86%) to address adolescent alcohol problems. However, confidence in knowledge and abilities for SBIRT execution was low. Twenty-five percent of physicians reported never having practiced all, or part of, SBIRT while 1.3% reported consistent SBIRT delivery for adolescents with alcohol-related visits. More alcohol education and counselling experience was associated with higher SBIRT use; however, physicians generally reported to have received minimal alcohol training. SBIRT practices were also associated with physician perceptions of problematic alcohol use and its treatability.ConclusionsPediatric emergency physicians acknowledge the need to address problematic adolescent alcohol use, but routine SBIRT use is lacking. Strategies to educate physicians about SBIRT and enhance perceived self-competency may improve SBIRT use. Effectiveness trials to establish SBIRT impact on patient outcomes are also needed.

Aim: To examine Australian and New Zealand Emergency Department staff’s training, knowledge and confidence regarding trauma-informed care for children after trauma, and barriers to implementation. Methods: Emergency Department staff’s perspectives on trauma-informed care were assessed with a web-based self-report questionnaire. Participants included 468 Emergency Department staff (375 nursing and 111 medical staff) from hospitals in Australia and New Zealand. Data analyses included descriptive statistics, chi-square tests and multiple regressions. Results: Over 90% of respondents had not received training in trauma-informed care and almost all respondents (94%) wanted training in this area. While knowledge was associated with respondent’s previous training and profession, confidence was associated with respondent’s previous training, experience level, and workplace. Dominant barriers to implementation of trauma-informed care were lack of time and lack of training. Conclusions: There is a need and desire for training and education of Australian and New Zealand Emergency Department staff in trauma-informed care. This study demonstrates that experience alone is not sufficient for the development of knowledge of paediatric traumatic stress reactions and trauma-informed care practices. Existing education materials can be adapted for use in the Emergency Department and to accommodate the training preferences of Australian and New Zealand Emergency Department staff.

Background Deinstitutionalisation in Europe has led to the development of community-based accommodation for people with mental health problems. The type, setting, and intensity of support provided vary and the costs are substantial. Yet, despite the large investment in these services, there is little clarity on their aims and outcomes or how they are regarded by staff and the clients. Methods We interviewed 30 staff and 30 clients from the three main types of supported accommodation in England (residential care, supported housing, floating outreach) to explore their perspectives on the purpose of these services, and the components of care considered most helpful. The interviews were coded and analysed using thematic analysis. Results There were generally consistent understandings amongst clients and staff across service types on the goals and purposes of supported accommodation services as: building independence and confidence; supporting people with their mental health; and providing safety and stability. We also noted a competing theme of anxiety about the continuity of support when clients move on from a service. Themes on the experience of what aided effective practice centred on: the supportive presence of others; incremental steps to progress; working together to avoid deskilling and dependency; feeling known and personally understood; tailoring support for social and community engagement; and building confidence through encouragement. Conclusions The findings provide an understanding of the commonalities in service approach, and goals of clients in these services, as well as the facilitators of goal attainment. However, they also highlight a common tension between providing safe and supportive living environments, whilst also promoting independence and facilitating rehabilitative change.

Study objective We determine the optimal correction factor for cerebrospinal fluid WBC counts in infants with traumatic lumbar punctures. Methods We performed a secondary analysis of a retrospective cohort of infants aged 60 days or younger and with a traumatic lumbar puncture (cerebrospinal fluid RBC count ≥10,000 cells/mm3) at 20 participating centers. Cerebrospinal fluid pleocytosis was defined as a cerebrospinal fluid WBC count greater than or equal to 20 cells/mm3 for infants aged 28 days or younger and greater than or equal to 10 cells/mm3 for infants aged 29 to 60 days; bacterial meningitis was defined as growth of pathogenic bacteria from cerebrospinal fluid culture. Using linear regression, we derived a cerebrospinal fluid WBC correction factor and compared the uncorrected with the corrected cerebrospinal fluid WBC count for the detection of bacterial meningitis. Results Of the eligible 20,319 lumbar punctures, 2,880 (14%) were traumatic, and 33 of these patients (1.1%) had bacterial meningitis. The derived cerebrospinal fluid RBCs:WBCs ratio was 877:1 (95% confidence interval [CI] 805 to 961:1). Compared with the uncorrected cerebrospinal fluid WBC count, the corrected one had lower sensitivity for bacterial meningitis (88% uncorrected versus 67% corrected; difference 21%; 95% CI 10% to 37%) but resulted in fewer infants with cerebrospinal fluid pleocytosis (78% uncorrected versus 33% corrected; difference 45%; 95% CI 43% to 47%). Cerebrospinal fluid WBC count correction resulted in the misclassification of 7 additional infants with bacterial meningitis, who were misclassified as not having cerebrospinal fluid pleocytosis; only 1 of these infants was older than 28 days. Conclusion Correction of the cerebrospinal fluid WBC count substantially reduced the number of infants with cerebrospinal fluid pleocytosis while misclassifying only 1 infant with bacterial meningitis of those aged 29 to 60 days.

Background Alkaptonuria is a rare, debilitating autosomal recessive disorder affecting tyrosine metabolism. Deficiency of homogentisate 1,2-dioxygenase leads to increased homogentisic acid which is deposited as ochronotic pigment. Clinical sequelae include severe early onset osteoarthritis, increased renal and prostate stone formation and cardiac complications. Treatment has been largely based on analgaesia and arthroplasty. The National Alkaptonuria Centre in Liverpool has been using 2 mg nitisinone (NTBC) off-license for all patients in the United Kingdom with alkaptonuria and monitoring the tyrosine metabolite profiles. Methods Patients with confirmed alkaptonuria are commenced on 2 mg dose (alternative days) of NTBC for three months with daily dose thereafter. Metabolite measurement by LC-MS/MS is performed at baseline, day 4, three-months, six-months and one-year post-commencing NTBC. Thereafter, monitoring and clinical assessments are performed annually. Results Urine homogentisic acid concentration decreased from a mean baseline 20,557 µmol/24 h (95th percentile confidence interval 18,446–22,669 µmol/24 h) by on average 95.4% by six months, 94.8% at one year and 94.1% at two year monitoring. A concurrent reduction in serum homogentisic acid concentration of 83.2% compared to baseline was also measured. Serum tyrosine increased from normal adult reference interval to a mean ± SD of 594 ± 184 µmol /L at year-two monitoring with an increased urinary excretion from 103 ± 81 µmol /24 h at baseline to 1071 ± 726 µmol /24 h two years from therapy. Conclusions The data presented represent the first longitudinal survey of NTBC use in an NHS service setting and demonstrate the sustained effect of NTBC on the tyrosine metabolite profile.

Background Between 10 and 25 percent of pediatric patients present to the emergency department (ED) with difficult to cannulate veins. Recent RCT evidence suggests that in pediatric patients assessed at being a predicted difficult IV start (by DIVA score of 3 or more), ultrasound guided catheter placement decreased the number of IV attempts, decreased time to successful IV placement, and improved first pass success, patient satisfaction, and catheter dwell time. Our QI project examines the specific learnings around ultrasound guided peripheral IV in pediatric patients and suggests opportunity for non-pediatric specialist hospitals to consider with the overall aim of minimizing IV attempts on all pediatric patients within our EDs. Building on a RCT led by Dr Curtis in pediatrics patients conducted at the Stollery from 2012-2014, a standardized ultrasound guided nurse performed procedure was implemented in 2016 at the University of Alberta and Stollery EDs, and expanded to the Royal Alexandra ED in 2017 and the Misericordia ED in 2019. Using the same education package and QI study methodology as previously reported in adult patients this study focused specifically on pediatric patients. Methods A quality improvement (QI) registry was utilized to track complications and success of pediatric patients at all sites. The aim was to assess for program success, and improve education, training, and procedural success as required. Staff who had achieved independent practice voluntarily completed a tracking form whenever an ultrasound procedure occurred. Completed forms were assessed on a continual basis for any opportunities for improvement. Qualitative feedback was also obtained from informal interviews, a focus group, and a survey of the trained nurses. Feedback was thematically analyzed and grouped into themes for reporting. Results There were no reported pediatric UGIV placed at the MCH and RAH during the study period. At the Stollery 126 cases were reported. Immediate insertion complications were noted in three cases as ‘pain or swelling at site’, and ‘unable to advance catheter’. In the first and second years of data collection the average number of traditional IV attempts prior to UGIV attempt decreased from 3.9 to 2.8; first ultrasound pass success increased from 65% to 86%; overall ultrasound success improved from 85% to 97.6% respectively. Increasing nurse skill was significant with a linear increase of first pass and overall success seen with increasing number of ultrasound starts: From 6-20 starts (54% first pass 64% overall success) through to >150 starts (97% first pass and 100% overall). QI staff feedback included ensure adequate pediatric specific supplies such as longer length small gauge catheters, and a procedural focus of patient, provider, and assistant set up. Location of IV placement was noted to change in a number of cases from hand and A/C to forearm. Advice and Lessons Learned The key for staff to transition to procedural competance was to ensure initial and ongoing oportunities to place many ultrasound guided IVs (i.e. when time allows in all patients with non-optimal IV placement locations or with non-easy predicted tradititional IV starts) Further work is required at non specilaist hospitals with trained staff to increase ultrasound guided use in pedatric patients At all particapting sites work continues on unit level QI to minimize the number of IV attempts on all pedatric patients as well as work towards a cohort of available staff that are comforable and competent with ultrasound that can provide 24/7 unit coverage. (with limited numbers of trained staff there is increase burden on these staff to assist others while also completing their own nursing assignment.

Our research examines how local labour market trends during the early stages of the ‘great recession’ (in the period 2007-2011) related to change in individuals’ self-reported illness. We report results from analyses of a dataset drawn from the Longitudinal Study (LS) for England and Wales (source: Office of National Statistics), a very large longitudinal sample of individuals from the population census, followed up over time at each decennial census. These were linked to employment trend data for Local Authority Districts for the period 2007-2011, based on employment statistics for Local Authority Districts (LAs) in England and Wales. Controlling for various individual attributes, the risk of development of a ‘new’ long term illness during the ‘great recession’ was greater for those living in LAs where levels of employment were persistently low or declining to relatively low levels.

Background Across England, around 60,000 people live in mental health supported accommodation: residential care, supported housing and floating outreach. Residential care and supported housing provide on-site support (residential care provides the highest level), whereas floating outreach staff visit people living in their own tenancies. Despite their abundance, little is known about the quality and outcomes of these services. Objectives The aim was to assess the quality, costs and effectiveness of mental health supported accommodation services in England. The objectives were (1) to adapt the Quality Indicator for Rehabilitative Care (QuIRC) and the Client Assessment of Treatment scale for use in mental health supported accommodation services; (2) to assess the quality and costs of these services in England and the proportion of people who ‘move on’ to less supported accommodation without placement breakdown (e.g. to move from residential care to supported housing or supported housing to floating outreach, or, for those receiving floating outreach, to manage with fewer hours of support); (3) to identify service and service user factors (including costs) associated with greater quality of life, autonomy and successful move-on; and (4) to carry out a feasibility trial to assess the required sample size and appropriate outcomes for a randomised evaluation of two existing models of supported accommodation. Design Objective 1 – focus groups with staff (n = 12) and service users (n = 16); psychometric testing in 52 services, repeated in 87 services (adapted QuIRC) and with 618 service users (adapted Client Assessment of Treatment scale). Objectives 2 and 3 – national survey and prospective cohort study involving 87 services (residential care, n = 22; supported housing, n = 35; floating outreach, n = 30) and 619 service users followed over 30 months; qualitative interviews with 30 staff and 30 service users. Objective 4 – individually randomised, parallel-group feasibility trial in three centres. Setting English mental health supported accommodation services. Participants Staff and users of mental health supported accomodation services. Interventions Feasibility trial involved two existing models of supported accommodation: supported housing and floating outreach. Main outcome measures Cohort study – proportion of participants who successfully moved to less supported accommodation at 30 months’ follow-up without placement breakdown. Feasibility trial – participant recruitment and withdrawal rates. Results The adapted QuIRC [QuIRC: Supported Accomodation (QuIRC-SA)] had excellent inter-rater reliability, and exploratory factor analysis confirmed its structural validity (all items loaded onto the relevant domain at the > ± 0.3 level). The adapted Client Assessment of Treatment for Supported Accommodation had good internal consistency (Cronbach’s alpha 0.89) and convergent validity (r s = 0.369; p p = 0.306), whereas autonomy was greater for supported housing users (mean difference 0.145, 95% confidence interval 0.010 to 0.279; p = 0.035). Qualitative interviews showed that staff and service users shared an understanding of service goals and what constituted effective support. After adjusting for clinical differences, those in floating outreach were more likely to move on successfully at 30 months’ follow-up than those in residential care [odds ratio (OR) 7.96; p p p = 0.04). Successful move-on was positively associated with scores on two QuIRC-SA domains: the degree to which the service promoted ‘human rights’ (e.g. facilitating access to advocacy) and ‘recovery-based practice’ (e.g. holding therapeutic optimism and providing collaborative, individualised care planning). Service use costs for those who moved on were significantly lower than for those who did not. Recruitment in the feasibility trial was difficult: 1432 people were screened but only eight were randomised. Barriers included concerns about accommodation being decided at random and a perceived lack of equipoise among clinicians who felt that individuals needed to ‘step down’ from supported housing to floating outreach services. Conclusions We did not find clear evidence on the most effective model(s) of mental health supported accommodation. Indeed, our feasibility study suggests that trials comparing effectiveness cannot be conducted in this country. A range of options are required to provide appropriate support to individuals with differing needs. Future work Future research in this field requires alternatives to trials. Service planners should be guided by the mental health needs of the local population and the pros and cons of the different services that our study identified, rather than purely financial drivers. Trial registration Current Controlled Trials ISRCTN19689576. Funding This programme was funded by the National Institute for Heath Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 7. See the NIHR Journals Library website for further project information. The fundholders are Camden and Islington NHS Foundation Trust and the research is a collaboration between University College London, Queen Mary University of London, King’s College London, the University of Ulster and Durham University.

BACKGROUND Internet-based cognitive behavioral therapy (iCBT) increases treatment access for adolescents with anxiety; however, completion rates of iCBT programs are typically low. Understanding adolescents’ experiences with iCBT, what program features and changes in anxiety (minimal clinically important difference [MCID]) are important to them, may help explain and improve iCBT program use and impact. OBJECTIVE Within a randomized controlled trial comparing a six-session iCBT program for adolescent anxiety, Being Real, Easing Anxiety: Tools Helping Electronically (Breathe), with anxiety-based resource webpages, we aimed to (1) describe intervention use among adolescents allocated to Breathe or webpages and those who completed postintervention assessments (Breathe or webpage respondents); (2) describe and compare user experiences between groups; and (3) calculate an MCID for anxiety and explore relationships between iCBT use, experiences, and treatment response among Breathe respondents. METHODS Enrolled adolescents with self-reported anxiety, aged 13 to 19 years, were randomly allocated to Breathe or webpages. Self-reported demographics and anxiety symptoms (Multidimensional Anxiety Scale for Children—2nd edition [MASC-2]) were collected preintervention. Automatically-captured Breathe or webpage use and self-reported symptoms and experiences (User Experience Questionnaire for Internet-based Interventions) were collected postintervention. Breathe respondents also reported their perceived change in anxiety (Global Rating of Change Scale [GRCS]) following program use. Descriptive statistics summarized usage and experience outcomes, and independent samples t tests and correlations examined relationships between them. The MCID was calculated using the mean MASC-2 change score among Breathe respondents reporting somewhat better anxiety on the GRCS. RESULTS Adolescents were mostly female (382/536, 71.3%), aged 16.6 years (SD 1.7), with very elevated anxiety (mean 92.2, SD 18.1). Intervention use was low for adolescents allocated to Breathe (mean 2.2 sessions, SD 2.3; n=258) or webpages (mean 2.1 visits, SD 2.7; n=278), but was higher for Breathe (median 6.0, range 1-6; 81/258) and webpage respondents (median 2.0, range 1-9; 148/278). Total user experience was significantly more positive for Breathe than webpage respondents (PBreathe respondents reported program design and delivery factors that may have challenged (eg, time constraints and program support) or facilitated (eg, demonstration videos, self-management activities) program use. The MCID was a mean MASC-2 change score of 13.8 (SD 18.1). Using the MCID, a positive treatment response was generated for 43% (35/81) of Breathe respondents. Treatment response was not correlated with respondents’ experiences or use of Breathe (P=.32 to P=.88). CONCLUSIONS Respondents reported positive experiences and changes in their anxiety with Breathe; however, their reports were not correlated with program use. Breathe respondents identified program design and delivery factors that help explain their experiences and use of iCBT and inform program improvements. Future studies can apply our measures to compare user experiences between internet-based interventions, interpret treatment outcomes and improve treatment decision making for adolescents with anxiety. CLINICALTRIAL ClinicalTrials.gov NCT02970734; https://clinicaltrials.gov/ct2/show/NCT02970734

This paper explores the contextualised relationship between disability and oral health, locating questions about the oral health and oral health care of disabled people within wider debates about the material, social and cultural barriers that disabled people face when accessing health care. Sociological and disability studies research is drawn on to highlight potential barriers to oral health for disabled people and outline alternative ways of looking at, thinking about and challenging these barriers. Starting with a brief look at definitions and understandings of disability and the impact of this on attitudes, research on the multi-level barriers faced by disabled people within oral health care is then highlighted. The article concludes with some thoughts on how research from other disciplinary traditions can be useful in helping to make dentistry more prepared to appropriately and successfully meet the needs of disabled people, both in a special care setting but also, more crucially, in a general dental setting.