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Purpose Young people can often “fall through the gaps” between Child and Adolescent Mental Health services (CAMHS) and Adult Mental Health services (AMHS). This discursive viewpoint study aims to reflect a conversation among the authors on how CAMHS and AMHS psychiatry came together to develop and embed a UK community “Youth Mental Health Service”. Design/methodology/approach This reflective viewpoint study explores the perspectives of three of the lead CAMHS and AMHS psychiatrists from the implementation phase of a community youth mental health service. It explores, in a discursive way, these individuals’ views on some of the key facilitators and barriers in the development of the service that aimed to “bridge the gap” for young people. Findings These clinicians’ reflections recognise the importance of strong clinical leadership in enabling a youth/young adult model of mental health to be implemented. They also recognise how culture internal and external to a service has a key role to play in the success and sustainment of implementing an innovative model. This study describes a merging of CAMHS and AMHS psychiatry to meet the needs of young people in the most developmentally appropriate way. Originality/value This reflective study highlights the need for services and systems to think creatively about how they can allow flexibility for CAMHS and AMHS psychiatrists to learn and plan together, as well as gain experiences across the age ranges, to facilitate collaborative working that is developmentally appropriate and meets the needs of young people in a way that is accessible to them.

Ovarian cancer continues to be the leading cause of gynaecological cancer death in the UK. It has previously been described as the ‘silent killer’, as symptoms are typically absent or non-specific early in the disease leading to a later stage at diagnosis where fewer treatment options are available. Stage at presentation influences patient survival, and therefore, early detection within primary care is vital. Currently, there is no screening programme for ovarian cancer, and so diagnosis relies on investigation of symptomatic women presenting to healthcare professionals and an awareness of vague symptoms that could indicate ovarian cancer pathology. This article aims to provide an overview of ovarian cancer, including epidemiology, risk factors, signs and symptoms, and diagnosis within primary care. We will also briefly discuss current treatment strategies for ovarian cancer.

Borderline personality disorder (BPD) diagnosis in adolescents is a relatively recent concept and a fast-emerging research area. Regarded by some as controversial, it is important for research to provide greater understanding of differing perspectives and their impact on the use of this diagnosis. Perspectives of 13 clinicians (therapists, psychiatrists and mental health nurses) were explored, to provide a contemporary understanding of perceptions and use of BPD diagnosis within child and adolescent mental health services in England. A particular focus was to explore dilemmas faced by clinicians and how these dilemmas were negotiated. This research took a qualitative, social constructionist approach to explore the in-depth views and experiences of each participant. Interviews were analysed using thematic analysis, to seek out patterns and commonalities across these clinical perspectives. Three overarching themes were generated: ‘Who holds the power?’, ‘Dilemmas within the multidisciplinary team (MDT)’ and ‘The weightiness of making this decision’. Professional opinions of an adolescent BPD diagnosis are influenced by dominant and less dominant mental health discourses, including the impact of power, and availability of resources within the service context. The role of meaningful collaboration with young people, clinical implications and directions for future research are discussed.

Given the existing literature on the subject, there is obviously a need for specific advice on quality assurance (QA) tolerances for departments using or implementing 3D printed bolus for radiotherapy treatments. With a view to providing initial suggested QA tolerances for 3D printed bolus, this study evaluated the dosimetric effects of changes in bolus geometry and density, for a particularly common and challenging clinical situation: specifically, volumetric modulated arc therapy (VMAT) treatment of the nose. Film-based dose verification measurements demonstrated that both the AAA and the AXB algorithms used by the Varian Eclipse treatment planning system (Varian Medical Systems, Palo Alto, USA) were capable of providing sufficiently accurate dose calculations to allow this planning system to be used to evaluate the effects of bolus errors on dose distributions from VMAT treatments of the nose. Thereafter, the AAA and AXB algorithms were used to calculate the dosimetric effects of applying a range of simulated errors to the design of a virtual bolus, to identify QA tolerances that could be used to avoid clinically significant effects from common printing errors. Results were generally consistent, whether the treatment target was superficial and treated with counter-rotating coplanar arcs or more-penetrating and treated with noncoplanar arcs, and whether the dose was calculated using the AAA algorithm or the AXB algorithm. The results of this study suggest the following QA tolerances are advisable, when 3D printed bolus is fabricated for use in photon VMAT treatments of the nose: bolus relative electron density variation within [Formula: see text] (although an action level at [Formula: see text] may be permissible); bolus thickness variation within [Formula: see text] mm (or 0.5 mm variation on opposite sides); and air gap between bolus and skin [Formula: see text] mm. These tolerances should be investigated for validity with respect to other treatment modalities and anatomical sites. This study provides a set of baselines for future comparisons and a useful method for identifying additional or alternative 3D printed bolus QA tolerances.

BACKGROUND The extent of tick-borne disease (TBD) risk in the United States is generally unknown. Active surveillance using entomological measures, such as presence and density of infected nymphal I. scapularis ticks, have served as indicators for assessing human risk, but results have been inconsistent. Passive surveillance via the public health system suggests TBDs are underreported. OBJECTIVE The aim of our study was to geographically overlay electronic patient survey data of human tick bite encounters (TBEs) and concomitant reports of tick-borne disease with multimodal data sources, such as canine serological reports, to assess the use of various human TBD- risk proxies. METHODS This study employs a mixed-method research strategy, drawing on multiple data sources to provide insights into various aspects of human disease risk from tick-bite encounters (TBEs) and tick-borne diseases (TBDs) in the United States. TBEs among patients diagnosed with Lyme disease (LD) were analyzed at the county level and compared to Ixodes scapularis and Ixodes pacificus tick presence, human cases identified by the Centers for Disease Control and Prevention (CDC), and canine serological data. Engaging a One Health spatial approach, analyses employed multi-layer thematic mapping. RESULTS Results revealed spatial matching at the county level among patient survey reports of TBEs and disease risk indicators from official sources. The results included one-for-one county-level matching of reported TBEs with at least one official source of human disease risk (i.e., positive canine serological tests, CDC-reported LD, or known tick presence) as demonstrated by thematic mapping. CONCLUSIONS Use of triangulation methods that integrate electronic patient data on tick bite encounter recall with established canine serological reports, tick presence, and official human disease information offers clinicians and public health officials with more granular, county-level information regarding tick-borne disease risk. Data other than official public health sources may serve as robust proxies for tick-borne disease risk among humans. CLINICALTRIAL Not applicable

Neonatal Lupus (NLE) is a rare acquired autoimmune disorder caused by transplacental passage of maternal autoantibodies to Sjogren’s Syndrome A or B (SSA-SSB) autoantigens1 which target fetal and neonatal tissues for immune destruction. The cardiac trademark of NLE is autoimmune heart block, which accounts for more than 80% of cases of complete atrioventricular heart-block (AVB) in newborns with a structurally normal heart2. NLE presenting with cardiac alterations not involving rhythm disturbances are described in the literature, but they are rare. Here, we report a case of a neonate with high anti-SSA antibodies who developed severe systemic hypertension and transient ventricular dysfunction in absence of the most common cardiac presentations of NLE: rhythm abnormalities, endocardial fibroelastosis, and dilated cardiomyopathy3. The patient developed severe multiorgan dysfunction syndrome that required prolonged critical care support but fully recovered and was discharged home. We highlight the unusual clinical features of this NLE case and the importance of timely treatment of NLE allowing complete recovery of a critically ill neonate.

Purpose This work presents a novel method of visualising the results of patient-specific quality assurance (QA) for modulated radiotherapy treatment plans, using a three-dimensional distribution of gamma pass rates, referred to as the “gamma surface”. The method was developed to aid in comparing borderline and failing QA plans, and to better compare patient-specific QA results between departments. Methods Gamma surface plots were created for a representative sample of situations encountered during patient-specific QA. To produce a gamma surface plot, for each QA result, gamma pass rates were plotted as a heat map, with dose difference on one axis and distance-to-agreement on the other. This involved the calculation of 100 × 100 gamma pass rates over a dose difference and distance-to-agreement grid. As examples, five 220 × 680 arrays of dose points from radiotherapy treatment plans were compared against measurement data consisting of 21 × 66 arrays of dose points spaced 10 mm apart. Results The gamma surface plots facilitated the rapid evaluation of criteria combinations for each plan, clearly highlighting the difference between plans that are modelled and delivered well, and those that are not. Large scale features were also evident in each surface, hinting at potential over-modulation, systematic dose errors, and small or large scale areas of disagreement in the distributions. Conclusions Gamma surface plots are a useful tool for investigating QA failures and borderline results, and have the capacity to grant insights into treatment plan QA performance that may otherwise be missed.

Nonprofit organizations often adopt social media such as Facebook to encourage stakeholders to engage in the organizational mission. Calls to action via social media tend to reach subscribers who “like” or follow the organization via one-way communication. Researching effective approaches to dialogic communication, which asks followers to engage rather than observe, the authors focus on relationship management theory (RMT). RMT stresses organizational-stakeholder dynamic interactions. Using a quantitative modeling approach, the authors examine Facebook posts made by three different types of foundations (community, corporate, and independent) to determine how foundations call for stakeholder engagement. To date, few studies focus directly on types of posts and the response, or lack of response, to organizational messages via social media. Civic engagement requires action on the part of the stakeholder to address social problems. Defining participation and engagement varies by field and types of interaction. This research contributes to literature examining the “digital citizen.”

There is an increasing need to develop methods for in vivo verification of the delivery of radiotherapy treatments. Electronic portal imaging devices (EPID's) have been demonstrated to be of use for this application. The basic principle is relatively straightforward, the EPID is used to measure a two‐dimensional (2D) planar exit or portal dose map behind the patient during the treatment delivery that can provide information on any errors in linear accelerator output or changes in the patient anatomy. In this paper we focused on the effect of intra‐fraction motion, particularly respiratory motion, on the measured 2D EPID dose–response. Measurements were made with a breast phantom undergoing one‐dimensional (1D) sinusoidal motion with a range of amplitudes (0.5, 1.0, and 1.5 cm) and frequencies (12, 15, and 20 cycles/min). Further measurements were made with the phantom undergoing breathing sequences measured during patient planning computed tomography simulation. We made use of the quadratic calibration method that converts the EPID images to a surrogate for dose, equivalent thickness of Plastic Water®. Comparisons were made of the 2D thickness maps derived for the different motions compared to the static phantom case and the resulting dose difference analyzed over the “breast” region of interest. A 2D gamma analysis within the same region of interest was performed of the motion images compared to static reference image. Comparisons were made of 1D thickness profiles for the moving and static phantom. The 1D and 2D analyses show the method to be sensitive to the smallest motion amplitude of 0.5 cm tested in the phantom measurements. The results using the phantom demonstrate the method to be a potentially useful tool for monitoring intra‐fraction motion during the delivery of patient radiotherapy treatments as well as more generally providing information on the effects of motion on EPID based in vivo dosimetric verification.

Shielded garments are widely recommended for occupational radiation protection in diagnostic and interventional radiology. This study investigated a novel method for efficiently verifying shielded garment integrity while simultaneously acquiring data for lead-equivalence measurements, using two-dimensional topogram images from computed tomography (CT) scanners. This method was tested against more-conventional measurements with superficial and orthovoltage radiotherapy treatment beams, for 12 shielded garments containing 3 different lead-free shielding materials. Despite some energy-dependent results, all shielded garments approximately achieved their specified lead-equivalence for the energy range expected during clinical use for fluoroscopy procedures, except for three shielded skirts that required two layers of material to be overlapped at the front. All lead-equivalence measurements from CT topograms agreed with or conservatively underestimated the kV narrow-beam results. This method is potentially useful for independently assessing the shielding properties of new shielded garments and performing annual checks for damage or degradation of existing shielded garments.

Relapse of infection due to SARS-CoV-2 has been rarely described and there is little guidance regarding the management of such cases in immunocompromised hosts. We present a case of an adolescent female with B-cell acute lymphoblastic leukemia hospitalized multiple times for symptomatic SARS-CoV-2 infection who was safely treated with 2 courses of remdesivir (RDV) and has had no additional readmissions to date. Though additional studies are needed to confirm the safety and efficacy of an additional course of RDV in the setting of relapsed or prolonged severe COVID-19, our observations suggest that a second course of RDV may be considered.

The planning and delivery of kilovoltage (kV) radiotherapy treatments involves the use of custom shielding designed and fabricated for each patient. This study investigated methods by which the required thickness of custom shielding could be predicted for non-standard shielding materials fabricated using 3D printing techniques. Seven kV radiation beams from a WOmed T-300 X-ray therapy unit were modelled using SpekPy software, and AAPM TG-61 data were used to account for backscatter and spectral effects, for incrementally increasing thicknesses of Pb, W-PLA composite and Cu-PLA composite materials. The same beams were used to perform physical transmission measurements, and the thickness of each material required to achieve 5% beam transmission was determined. While the measured transmission factors for Pb, W-PLA and Cu-PLA shielding generally exceeded the calculated transmission factors, these differences had minimal effect on the derived thicknesses of shielding required to achieve 5% transmission, where calculations agreed with measurements within 0.5 mm for Pb at all available energies (70–300 kVp), within 1.4 mm for W-PLA at all available energies, and within 2.1 mm for Cu-PLA at superficial treatment energies (70–100 kVp). The incremental transmission factor calculation method described and validated in this study could be used, in combination with the conservative addition of 1–2 mm of additional material, to estimate shielding requirements for novel materials in therapeutic kilovoltage beams. However, if calculated shielding thicknesses equate to 10 mm or more, then additional verification measurements should be performed and the clinical suitability of the novel shielding material should be re-evaluated.

Objective: Sexual violence (SV) against adult women is prevalent and associated with a range of mental health issues. General practitioners could potentially have a role in responding, however, there is little information to help guide them. Data around prevalence of all forms of adult SV (not just rape) is inconsistent, particularly in clinical samples, and the links between other forms of SV and mental health issues are not well supported. This study aimed to address these gaps in the knowledge base. Methods: A descriptive, cross-sectional study was conducted in Australian general practice clinics. Two hundred and thirty adult women completed an anonymous iPad survey while waiting to see the doctor. Results: More than half the sample had experienced at least one incident of adult SV. Most commonly, women reported public harassment or flashing, unwanted groping and being coerced into sex. Women who had experienced adult SV were more likely to experience anxiety than women who had not, even after controlling for other factors. Women who had experienced adult SV were more likely to feel down, depressed or hopeless than women who had not; however, this association disappeared after controlling for childhood sexual abuse. Conclusions: The findings support the association between SV and poor mental health, even when ‘lesser’ incidents have occurred. Implications for public health: General practitioners should consider an experience of SV as a possible factor in otherwise unexplained anxiety and depressive symptoms in female patients.

Aims: Young people attempting to access mental health services in the United Kingdom often find traditional models of care outdated, rigid, inaccessible and unappealing. Policy recommendations, research and service user opinion suggest that reform is needed to reflect the changing needs of young people. There is significant motivation in the UK to transform mental health service for young people and this paper aims to describe the rationale, development and implementation of a novel youth mental health service in the UK, the Norfolk Youth Service. Methods: The Norfolk Youth Service model is described as a service model case study. The service rationale, national and local drivers, principles, aims, model, research priorities and future directions are reported. Results: The Norfolk Youth Service is an innovative example of mental health transformation in the United Kingdom, comprising a pragmatic, assertive and ‘youth friendly’ service for young people aged 14-25 that transcends traditional service boundaries. The service was developed in collaboration with young people and partnership agencies and is based upon an engaging and inclusive ethos. The service is social recovery oriented, evidence based and aims to satisfy recent policy guidance. Conclusions: The redesign and transformation of youth mental health services in the United Kingdom is long overdue. The Norfolk Youth Service represents an example of reform that aims to meet the developmental and transitional needs of young people, while remaining youth oriented.

Bolus plays an important role in the radiation therapy of superficial lesions and the application of 3D printing to its design can improve fit and dosimetry. This study quantitatively compares the fits of boluses designed from different imaging modalities. A head phantom was imaged using three systems: a CT simulator, a 3D optical scanner, and an interchangeable lens camera. Nose boluses were designed and 3D printed from each modality. A 3D printed phantom with air gaps of known thicknesses was used to calibrate mean HU to measure air gaps of unknown thickness and assess the fit of each bolus on the head phantom. The bolus created from the optical scanner data resulted in the best fit, with a mean air gap of 0.16 mm. Smoothing of the CT bolus resulted in a more clinically suitable model, comparable to that from the optical scanner method. The bolus produced from the photogrammetry method resulted in air gaps larger than 1 mm in thickness. The use of optical scanner and photogrammetry models have many advantages over the conventional bolus-from-CT method, however workflow should be refined to ensure accuracy if implemented clinically.

Aims and methodThe Norfolk Youth Service was created in 2012 in response to calls to redesign mental health services to better meet the needs of young people. The new service model transcends traditional boundaries by creating a single, ‘youth friendly’ service for young people aged 14–25 years. The aim of this study was to investigate the effect of the transition to this new model on patterns of referral, acceptance and service use. We analysed routinely collected data on young people aged 14–25 years referred for secondary mental healthcare in Norfolk before and after implementation of the youth mental health service. The number of referrals, their age and gender, proportion of referrals accepted and average number of service contacts per referral by age pre- and post-implementation were compared.ResultsReferrals increased by 68% following implementation of the new service model, but the proportion of referrals accepted fell by 27 percentage points. Before implementation of the youth service, there was a clear discrepancy between the peak age of referral and the age of those seen by services. Following implementation, service contacts were more equitable across ages, with no marked discontinuity at age 18 years.Clinical implicationsOur findings suggest that the transformation of services may have succeeded in reducing the ‘cliff edge’ in access to mental health services at the transition to adulthood. However, the sharp rise in referrals and reduction in the proportion of referrals accepted highlights the importance of considering possible unintended consequences of new service models.Declaration of interestsNone.

TPS9137 Background: Immune checkpoint inhibitors have led to durable remissions for some patients with advanced malignancies, including NSCLC; however, only a minority of patients benefit. The field of oncology is addressing this via the development of novel therapies, combinations and identification of biomarkers to select patients most likely to derive clinical benefit. ICOS, a novel therapeutic target, is a costimulatory molecule upregulated on activated T cells. Vopratelimab is an investigational IgG1 ICOS agonist monoclonal antibody that results in activation and proliferation of primed CD4 T effector cells. The preliminary efficacy of vopratelimab +/- nivolumab was assessed in the phase 1/2 ICONIC study in which durable responses were observed in a subset of patients who demonstrated on treatment emergence of peripheral ICOS hi CD4 T effector cells. Patients with peripheral ICOS hi CD4 T cells achieved significantly greater clinical benefit than patients whose CD4 T cells remained ICOS lo. An RNA based tumor inflammation signature (TIS) comprised of 18 genes associated with immune cell infiltration was previously identified as a predictive biomarker of response to anti-PD-1 therapy (Ayers et al, 2017); it was also associated with ICOS hi CD4 T cell emergence in ICONIC (ASCO-SITC 2020). The pre-treatment tumor TIS score, coupled with a specific threshold established by Jounce, referred to as TISvopra, was predictive of ICOS hi CD4 T cell emergence. TISvopra positive patients had improved RECIST response, PFS, and OS compared to those with a TISvopra negative score. Therefore, we hypothesize that patient selection by TISvopra will identify those who will display emergence of ICOS hi CD4 T cell populations and importantly, improved clinical outcomes when treated with vopratelimab in combination with JTX-4014 (a novel PD-1 inhibitor in development by Jounce) vs JTX-4014 alone. Methods: This Phase 2 open-label multicenter study is investigating JTX-4014 alone and in combination with vopratelimab in TISvopra selected patients with metastatic NSCLC after one prior platinum-containing regimen (NCT04549025). Patients must be PD-1/L1 inhibitor naïve and negative for activating EGFR mutations. TISvopra eligibility is determined using RNA isolated from a tumor sample. Eligible patients will be randomized to receive either JTX-4014 as monotherapy or in combination with one of two dose levels of vopratelimab. The primary endpoint is mean percent change from baseline tumor size of all measurable existing and new lesions averaged over 9 and 18 weeks. Secondary endpoints include ORR and PFS according to RECIST v1.1, OS, safety, and association of baseline TIS score with clinical outcomes. The study has a target enrollment goal of approximately 75 patients; the first patient was dosed October 2020. Clinical trial information: NCT04549025.

The prevalence of psychotic-like experiences (PLEs) was explored in a sample of 14- to 25-year-olds with non-psychotic mental health difficulties. Associations between PLEs, psychopathology, functioning, trauma history, and pathways to care were examined.Data were collected for 202 young people. Clinicians rated PLEs using the Primary Care Checklist (PCC) and functioning using Global Assessment Scales. Eighty-three young people completed self-report assessments of PLEs using the Prodromal Questionnaire (PQ-16) and measures of social anxiety, depression, trauma history, and pathways to care.There was a high prevalence of PLEs in the sample. The prevalence of PLEs was higher when young people self-rated their experiences. Endorsement frequencies for PLEs ranged from 3.5 to 24% on the PCC and 22 to 70% on the PQ-16. Higher scores on the PQ-16 were associated with more pathways into care and greater exposure to traumatic life events.PLEs are common in young people with non-psychotic mental health difficulties and may reflect increased severity and complexity of mental health difficulties. Routine screening and further assessment of PLEs are important in understanding and responding to such experiences. Screening should include self-rating of PLEs as well as clinician-rated scales.Clinical Implications Psychotic-like experiences are common in young people with severe non-psychotic mental health problems and should be routinely screened in mental health services. Psychotic-like experiences were found to be more prevalent when using a self-report screening tool compared to a clinician-rated measure. The presence of psychotic-like experiences may reflect more severe and complex mental health problems and may also cause delays in young people accessing the right kind of support. ;Limitations This study only assessed the presence or absence of psychotic-like experiences. Further studies should use more detailed assessments to understand more about the nature of such experiences and how they are appraised and responded to. This study is cross-sectional, and therefore, the direction of the relationships between psychotic-like experiences and depression, anxiety, functioning, and trauma cannot be specified. Longitudinal studies are needed to examine the impact of psychotic-like experiences on long-term outcomes.

The aim of this study was to examine the impact of social support on quality of life (QoL) in patients with polyneuropathy. One hundred and fifty-four patients with polyneuropathy were enrolled from a neuromuscular clinic. The QoL Instrument and the Medical Outcome Study-Social Support Survey (MOS-SSS) were used to assess QoL and social support, respectively. Disease severity and clinical factors were also assessed. Neuropathy patients had a lower QoL compared to a previously published normative sample (p 0.0001) and an MOS-SSS comparable to other patients with chronic disease. Social support correlated weakly with the self esteem and emotional well being mental health dimensions (rs :0.20-0.38) but not the physical health QoL (PH-QoL) domains. Physical and mental QoL also correlated significantly with presence of pain (rs : -0.39 and -0.42, respectively) and number of autonomic symptoms (rs : -0.39 and -0.30, respectively). Social support independently predicts MH-QoL when controlling for age, gender, pain, and the Toronto Clinical Neuropathy Score (TCNS; p 0.0001). TCNS and gender are independently related to PH-QoL (p 0.05). This study demonstrates that improved social support serves as an independent predictor of MH-QoL when controlling for age, gender, pain, and severity of neuropathy. Future studies examining the effects of improving social support on QoL in patients with polyneuropathy are recommended.

Young people attempting to access mental health services in the United Kingdom often find traditional models of care outdated, rigid, inaccessible and unappealing. Policy recommendations, research and service user opinion suggest that reform is needed to reflect the changing needs of young people. There is significant motivation in the United Kingdom to transform mental health services for young people, and this paper aims to describe the rationale, development and implementation of a novel youth mental health service in the United Kingdom, the Norfolk Youth Service. The Norfolk Youth Service model is described as a service model case study. The service rationale, national and local drivers, principles, aims, model, research priorities and future directions are reported. The Norfolk Youth Service is an innovative example of mental health transformation in the United Kingdom, comprising a pragmatic, assertive and "youth-friendly" service for young people aged 14 to 25 that transcends traditional service boundaries. The service was developed in collaboration with young people and partnership agencies and is based on an engaging and inclusive ethos. The service is a social-recovery oriented, evidence-based and aims to satisfy recent policy guidance. The redesign and transformation of youth mental health services in the United Kingdom is long overdue. The Norfolk Youth Service represents an example of reform that aims to meet the developmental and transitional needs of young people at the same time as remaining youth-oriented.

We sought to determine whether the use of specific unfractionated heparin brands during cardiopulmonary bypass for pediatric cardiac surgery was associated with differences in postoperative outcomes, especially regarding the incidence of bleeding and thromboembolic complications.We compared postoperative outcomes for pediatric cardiac surgeries performed with Hepalean (Organon Teknika) to those performed with PPC heparin (Pharmaceutical Partners of Canada). Differences in clinical outcomes were determined in multivariable logistic and linear regression models adjusted for patients and surgery characteristics.In all, 903 operations were reviewed, 289 (32%) using Hepalean and 614 (68%) using PPC heparin. Patient demographics and surgical variables were comparable between groups. In multivariable regression models, adjusted for patients' characteristics, heparin use and choice of antifibrinolytic agents, the use of PPC heparin was associated with greater use of red blood cell transfusions in the first 48 postoperative hours (estimates +1.6 mL/kg, p0.001), increased odds of bleeding complications (odds ratio 3.8, p=0.04), thromboembolic complications (odds ratio 4.7, p=0.01), early unplanned reoperation (odds ratio 6.9, p=0.03), longer postoperative intensive care unit stay (estimate +3.2 days, p0.001), and longer hospital stay (estimate +3.6 days, p0.001).Brand of unfractionated heparin used during cardiopulmonary bypass for pediatric cardiac surgery was associated with bleeding complications and clinical outcomes. Different brands of unfractionated heparin should not be considered equivalent without proper validation in formal trials.

e-commerce allows for many innovations in pricing: some have been embraced by consumers, others rejected. Using an online experiment, we explore the role of norms in predicting consumer responses to differential pricing arrived at either by violating an established pricing norm (dynamic posted pricing; setting prices based on individual consumer demand) or not (two retailers pricing differently). Our findings support the critical role of norms, such that belief in the norm is a strong predictor of negative responses (i.e., fairness, trust, purchase, search and complaint intentions) and priming people to consider norms generally increases the negative response. We also find that prior trust in the firm acts as a partial buffer against the negative response to norm breaking but at a diminishing rate as prior trust increases.

PurposeThe purpose of this paper is to identify some of the current social norms of pricing that constrain sellers' discriminatory pricing on the internet. Violations of such social norms can lead to perceptions of price unfairness and swift and potentially damaging negative reactions from consumers. This paper seeks to demonstrate a state‐of‐the‐art technique for assessing social norms, to identify current norms using a large representative sample of US consumers and to distinguish between social norms and personal beliefs.Design/methodology/approachThe study involves an online survey of 387 respondents. The survey was designed to measure both the consensus and the strength of consumer reaction to seller behaviors. To establish that a behavior is the norm, the consensus has to be greater than a 65 percent agreement and the strength of the response has to be significantly different from neutral. Both personal beliefs and perceptions of society's beliefs were collected.FindingsThe paper finds that some of the social norms constraining discriminatory pricing on the internet are as follows: a seller should charge the same price for a given item to all customers; a seller should not charge a higher price to either more loyal or more frequent customers; a seller should not charge more to new or infrequent customers; and a seller should not charge less to infrequent purchasers. In addition, although it is not established as a norm, a surprising 50 percent of the respondents think that Americans in general believe that all retailers should charge the same price for the same item. The paper also finds that personal beliefs are consistent with social norms but more extreme.Practical implicationsThe implications are that e‐tailers need to be careful about price discrimination on the internet – many of the most profitable practices violate current internet pricing norms. For example, consumers do not think that it is fair to give a cheaper price to a new buyer than to a repeat buyer. However, different e‐tailers can offer the same product at a different price. That is not considered price discrimination.Originality/valueBy identifying the social norms of pricing, sellers are provided with the information they need to avoid unwitting violations of those norms. Sellers can thus avoid angering their customers, as Amazon did when they allegedly charged new customers less than established customers.

PurposeThe research questions are whether there is a difference in how men and women respond to unfair prices and, if so, whether this gender difference extends across national cultures. Is the difference due to nature or to nurture? This paper aims to answer these questions.Design/methodology/approachThe study uses scenarios to conduct a survey‐based analysis of the effects of gender and country on responses to personally and socially unfair prices.FindingsThe results indicate that the response to price unfairness is due more to nurture than to nature. Although American females tend to be more sensitive than men to price unfairness, there is little or no difference between men and women in Germany and South Korea: both sexes there react negatively to an unfair price, particularly when the seller has acted unjustly.Practical implicationsIn the USA, the gender difference in response to unfair prices suggests that different pricing tactics should be used for men than for women. However, since males in South Korea and Germany are just as sensitive as females to unfair prices, pricing tactics acceptable to American men may not work in other countries.Originality/valueThis paper takes a look at the manner in which a price increase for a frequently purchased but essential product is viewed as unfair. The paper examines the issue in three contrasting countries – Germany, South Korea and the USA – to determine if any observed differences are universal or culture‐specific.

PurposeThe purpose of this paper is to summarize the current research in disciplines outside marketing that applies to price fairness: research by behavioral economists, primate behavior researchers and social neuroscientists.Design/methodology/approachThe approach is descriptive, summarizing the extensive research into fairness being done in disciplines other than marketing.FindingsResearch outside marketing indicates that a fair price is a preference. It has social utility that is independent of the economic utility of a low price. Consumers can actually harm themselves to punish what they perceive to be an unfair price. Conversely, a fair price triggers the reward center of the mind, stimulating happiness. The research also indicates that the response to a fair or unfair price is emotional: fast and automatic. The strength of that emotional response to unfairness varies across people. However, despite the variation in reactions, to ignore the concern for fairness is to miss a major motivation in economic decision making.Originality/valueThe fairness research in other disciplines both supports and informs the marketing research into what constitutes a fair price and how people respond to price (un)fairness.

BACKGROUND AND OBJECTIVE: Subjective social status (SSS), a person’s sense of their (or for youth, their family’s) position in the socioeconomic hierarchy, is strongly related to health in adults but not health in adolescence. Understanding this developmental discrepancy requires first understanding the developmental trajectory of SSS. The objective of this study was to identify the number and shape of SSS trajectories as adolescents transition to adulthood and explore if trajectory membership affects health. METHODS: Using data from 7436 assessments from the Princeton School District Study, a decade-long cohort study of non-Hispanic black and white youth, latent class growth models with 3 to 7 SSS trajectories were developed. Model fit, trajectory structure, and shape were used to guide optimal model selection. Using this optimal model, the associations of trajectory membership with BMI and depressive symptoms in young adulthood were explored. RESULTS: The 5-class model was optimal. In this model, trajectories were persistent high (7.8%), mid–high (32.2%), middle (43.4%), low–lower (7.4%), and high–low (9.1%). Non-Hispanic black race/ethnicity, lower household income, and low parent education were associated with membership in this high–low trajectory. High–low trajectory membership was associated with higher BMI and depressive symptoms in non-Hispanic white subjects but was not associated with depressive symptoms. It was associated with lower BMI only after adjustment for BMI in adolescence in non-Hispanic black subjects. CONCLUSIONS: SSS is relatively stable in adolescence and the transition to adulthood, and it generally reflects objective markers of social advantage. However, socially disadvantaged youth with high SSS in early adolescence may be at increased health risk.

Regardless of their home country, immigrants to the United States often arrive in search of personal freedom and a share of the riches of this country. Prior research has identified a range of knowledge and skills that immigrants must acquire in order to navigate such a consumer society. One aspect of joining a consumer society that has not been addressed, however, is the role of material goods in one's life. The purpose of this paper is to examine the changing role, if any, of material goods in the lives of immigrants arriving in the United States from a non-consumer society and to compare the level of materialism among such immigrants with that of Americans. The results of a study of 278 Soviet-era Russian immigrants and 200 native-born Americans indicate that at the time the immigrants arrived, they were just as materialistic as Americans and became no more materialistic, the longer they lived in the United States. Both Americans and Russians, however, became less materialistic with age. Copyright © 2006 John Wiley & Sons, Ltd.

PurposeThe purpose of the paper is to investigate the effect of the number of choices on judged fairness and willingness to purchase.Design/methodology/approachA survey‐based study was conducted with a between‐subject, two×five design having two levels of price ranges (high/low) and five levels of complexity (1, 3, 7, 11, and 21 choices). A total of 519 surveys were completed with a minimum of 42 respondents per cell.FindingsGreater choice initially has a positive effect on consumers' likelihood of purchase and their judgments of the fairness of the price. But too much choice has a negative effect, thereby creating an inverted “U” response curve. The effect of choice set size, however, is only triggered when combined with a high price. When the price is low, the number of choices has no effect on the judged fairness of the price and likelihood of purchase.Practical implicationsThe practical implication is that, although consumers like to have choices, there is no increased benefit to increasing the number of choices as long as the price is low. And there is a declining benefit from increasing the number when the price is high. Since there is a managerial cost to providing choices, it appears prudent to only provide between three and seven.Originality/valueThe value of the paper is in demonstrating that, although some choice is beneficial in overcoming the negative impact of a higher price, too many choices can be detrimental in causing confusion.

Shoppers in a negative mood state constitute a major market, some 10% of the population. Such shoppers are difficult to understand due to their conflicting motivations. These motivations influence shopper behavior, making it hard for those in a negative mood state to participate in the purchase process. To understand this difficult market segment, data from the 1996 Yankelovitch market research study of 4000 consumers were analyzed. The analysis shows that negative affect reduces shoppers' desire to search, to exert themselves, to make long-term plans. Shoppers who feel bad want “feel-good” purchases and are surprisingly interested in trying new products and new activities. These results suggest how retailers can better reach and satisfy those in this important market segment.