Ethnic differences in treatment outcome for children and young people accessing mental health support.

Children and Young People (CYP) from minoritized ethnic backgrounds experience structural inequalities in Children and Young People's Mental Health Settings (CYPMHS). This mixed methods study explores whether CYP's ethnicity is associated with their treatment outcomes (operationalised as 'measurable change') from CYPMHS. A multilevel multi-nominal regression analysis, controlling for age, gender, referral source, presenting difficulty, case closure reason, suggests that CYP from Asian backgrounds (OR = 0.82, CI [0.70, 0.96]) and Mixed-race (odds ratio (OR) = 0.80; 95% CI [0.69, 0.92]) are less likely to report measurable improvement in mental health difficulties compared to White British CYP. Three themes from a thematic analysis of semi-structured interviews with 15 CYP from minoritized ethnic backgrounds focused on views and experiences of ending mental health support are also presented. CYP view personalised support and the right therapist as conducive to good endings and valued a range of outcomes pertaining to empowerment. Experiences of stigma and inequalities may begin to explain the less positive outcomes experienced by Asian and Mixed-race CYP found in the regression analysis. The implications of these findings and future areas of research are suggested.

A comprehensive mapping of outcomes following psychotherapy for adolescent depression: The perspectives of young people, their parents and therapists.

As mental health systems move towards person-centred care, outcome measurement in clinical research and practice should track changes that matter to young people and their families. This study mapped the types of change described by three key stakeholder groups following psychotherapy for depression, and compared the salience of these outcomes with the frequency of their measurement in recent quantitative treatment effectiveness studies for adolescent depression.Using qualitative content analysis, this study identified and categorized outcomes across 102 semi-structured interviews that were conducted with depressed adolescents, their parents, and therapists, as part of a randomized superiority trial. Adolescents had been allocated to Cognitive-Behavioral Therapy, Short-Term Psychoanalytic Psychotherapy, or a Brief Psychosocial Intervention.The study mapped seven high-level outcome domains and 29 outcome categories. On average, participants discussed change in four domains and six outcome categories. The most frequently discussed outcome was an improvement in mood and affect (i.e., core depressive symptoms), but close to half of the participants also described changes in family functioning, coping and resilience, academic functioning, or social functioning. Coping had specific importance for adolescents, while parents and therapists showed particular interest in academic functioning. There was some variation in the outcomes discussed beyond these core themes, across stakeholder groups and treatment arms.Of the outcomes that were frequently discussed in stakeholder narratives, only symptomatic change has been commonly reported in recent treatment studies for adolescent depression. A shift towards considering multiple outcome domains and perspectives is needed to reflect stakeholder priorities and enable more nuanced insights into change processes.

Barriers and facilitators to shared decision making in child and youth mental health: clinician perspectives using the Theoretical Domains Framework.

Shared decision making (SDM) is increasingly being suggested as an integral part of mental health provision. Yet, there is little research on what clinicians believe the barriers and facilitators around practice to be. At the same time, there is also increasing recognition of a theory-practice gap within the field, with calls for more pragmatic uses of theory to inform and improve clinical practice. Using the Theoretical Domains Framework (TDF), a comprehensive, theoretical-led framework, underpinned by 33 behaviour change theories and 128 constructs, clinician perceived barriers and facilitators to SDM are investigated. The sample comprised of 15 clinicians across two sites in England, who took part in qualitative semi-structured interviews and focus groups. Transcripts were analysed using a deductive thematic analysis, and themes were coded under each theoretical domain. Overall, 21 barriers and facilitators for SDM in child and youth mental health were identified across ten domains of the TDF. Under capability, barriers and facilitators were found for knowledge, skills, memory/attention/decision making processes, and behavioural regulation. For opportunity, barriers and facilitators were found for social influences, as well as environmental context and resources. Finally, for motivation, domains covered included: beliefs about consequences, beliefs about capabilities, emotions, and professional role and identity. Findings suggest that a range of barriers and facilitators affect clinicians' abilities to engage in SDM with young people and parents. Interventions which target different domains related to capability, opportunity and motivation should be developed to better facilitate young people and their families in care and treatment decisions.

Evidence of multiple intraspecific transmission routes for Leptospira acquisition in Norway rats (Rattus norvegicus).

Infectious diseases frequently have multiple potential routes of intraspecific transmission of pathogens within wildlife and other populations. For pathogens causing zoonotic diseases, knowing whether these transmission routes occur in the wild and their relative importance, is critical for understanding maintenance, improving control measures and ultimately preventing human disease. The Norway rat (Rattus norvegicus) is the primary reservoir of leptospirosis in the urban slums of Salvador, Brazil. There is biological evidence for potentially three different transmission routes of leptospire infection occurring in the rodent population. Using newly obtained prevalence data from rodents trapped at an urban slum field site, we present changes in cumulative risk of infection in relation to age-dependent transmission routes to infer which intra-specific transmission routes occur in the wild. We found that a significant proportion of animals leave the nest with infection and that the risk of infection increases throughout the lifetime of Norway rats. We did not observe a significant effect of sexual maturity on the risk of infection. In conclusion, our results suggest that vertical and environmental transmission of leptospirosis both occur in wild populations of Norway rats.

Changes in severity of psychosocial difficulties in adolescents accessing specialist mental healthcare in England (2009-2014).

In England, clinicians and professional organisations report that higher numbers of adolescents with more severe psychosocial difficulties are accessing specialist services. A lack of national data on patterns of access to specialist services means there is limited information to inform policy. We examined whether severity of psychosocial difficulties in adolescents accessing mental healthcare has changed over time. Adolescents seen in specialist child mental healthcare in 2009 vs. 2014 were matched on demographics and problem types using propensity score matching; final sample N = 2776 adolescents. We found: 1) stability over time in overall severity of difficulties, 2) an increase in severity of young women's emotional problems, and 3) a decrease in adolescents' conduct problems. The findings suggest the intriguing possibility that the criteria for accessing mental healthcare are not universally rising, but rather the patterns in access to specialist services may mirror epidemiological changes in severity of psychosocial difficulties in the population.

The psychometric properties of the Ages & Stages Questionnaires for ages 2-2.5: a systematic review.

BACKGROUND: Early identification of children with potential development delay is essential to ensure access to care. The Ages & Stages Questionnaires (ASQ) is used as population outcome indicators in England as part of the 2.5-year review. METHOD: The aim of this article was to systematically review the worldwide evidence for the psychometric properties of the ASQ third edition (ASQ-3TM ) and the Ages & Stages Questionnaires®: Social-Emotional (ASQ:SE). Eight electronic databases and grey literature were searched for original research studies available in English language, which reported reliability, validity or responsiveness of the ASQ-3TM or ASQ:SE for children aged between 2 and 2.5 years. Twenty studies were included. Eligible studies used either the ASQ-3TM or the ASQ:SE and reported at least one measurement property of the ASQ-3TM and/or ASQ:SE. Data were extracted from all papers identified for final inclusion, drawing on Cochrane guidelines. RESULTS: Using 'positive', 'intermediate' and 'negative' criteria for evaluating psychometric properties, results showed 'positive' reliability values in 11/18 instances reported, 'positive' sensitivity values in 13/18 instances reported and 'positive' specificity values in 19/19 instances reported. CONCLUSIONS: Variations in age or language versions used, quality of psychometric properties and quality of papers resulted in heterogeneous evidence. It is important to consider differences in cultural and contextual factors when measuring child development using these indicators. Further research is very likely to have an important impact on the interpretation of the ASQ-3TM and ASQ:SE psychometric evidence.

Factors affecting carriage and intensity of infection of Calodium hepaticum within Norway rats (Rattus norvegicus) from an urban slum environment in Salvador, Brazil.

Urban slum environments in the tropics are conducive to the proliferation and the spread of rodent-borne zoonotic pathogens to humans. Calodium hepaticum (Brancroft, 1893) is a zoonotic nematode known to infect a variety of mammalian hosts, including humans. Norway rats (Rattus norvegicus) are considered the most important mammalian host of C. hepaticum and are therefore a potentially useful species to inform estimates of the risk to humans living in urban slum environments. There is a lack of studies systematically evaluating the role of demographic and environmental factors that influence both carriage and intensity of infection of C. hepaticum in rodents from urban slum areas within tropical regions. Carriage and the intensity of infection of C. hepaticum were studied in 402 Norway rats over a 2-year period in an urban slum in Salvador, Brazil. Overall, prevalence in Norway rats was 83% (337/402). Independent risk factors for C. hepaticum carriage in R. norvegicus were age and valley of capture. Of those infected the proportion with gross liver involvement (i.e. >75% of the liver affected, a proxy for a high level intensity of infection), was low (8%, 26/337). Sixty soil samples were collected from ten locations to estimate levels of environmental contamination and provide information on the potential risk to humans of contracting C. hepaticum from the environment. Sixty percent (6/10) of the sites were contaminated with C. hepaticum. High carriage levels of C. hepaticum within Norway rats and sub-standard living conditions within slum areas may increase the risk to humans of exposure to the infective eggs of C. hepaticum. This study supports the need for further studies to assess whether humans are becoming infected within this community and whether C. hepaticum is posing a significant risk to human health.

Leptospira in breast tissue and milk of urban Norway rats (Rattus norvegicus).

Leptospirosis is a zoonosis caused by bacteria of the genus Leptospira. The disease is globally distributed and a major public health concern. The Norway rat (Rattus norvegicus) is the main reservoir of the pathogen in urban slums of developing and developed countries. The potential routes of intra-specific leptospire transmission in rats are largely unknown. Herein, we identified pathogenic Leptospira spp. in breast tissue and milk of naturally infected rats. We examined kidney, breast tissue and milk from 24 lactating rats for the presence of leptospires using immunofluorescence, immunohistochemistry, polymerase chain reaction (PCR) and scanning electronic microscopy. All 24 rats had evidence for Leptospira in the kidneys, indicating chronic carriage. The majority of kidney-positive rats had detectable leptospires in milk (18, 75%) and breast tissue (16, 67%), as evidenced by immunofluorescence assay and immunohistochemistry. Four (17%) milk samples and two (8%) breast tissue samples were positive by quantitative real-time PCR. Scanning electron microscopy confirmed the presence of leptospires in breast tissue. No major pathological changes in breast tissue were found. This study, for the first time, identified leptospires in the milk and breast tissue of wild Norway rats, suggesting the possibility of milk-borne transmission of leptospirosis to neonates.

Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial.

OBJECTIVE: (1) Do treatment effects differ between participants receiving manual therapy (MT) with exercise compared to subjects who don't, (2) are treatment effects sustained better when participants receive booster sessions compared to those who don't over a one year period in subjects with knee osteoarthritis (KOA)? DESIGN: Multi-center, 2 × 2 factorial randomized clinical trial. 300 participants with knee OA were randomized to four groups: exercise-no boosters (Ex), exercise-with boosters (Ex+B), manual therapy+exercise-no boosters (MT+Ex), manual therapy+exercise-with boosters (MT+Ex+B). The primary outcome was the Western Ontario and McMaster osteoarthritis index (WOMAC) at 1 year. Secondary outcomes included knee pain, physical performance tests, and proportions of participants meeting treatment responder criteria. RESULTS: There were no differences between groups on the WOMAC at 1 year or on any performance-based measures. Secondary analyses indicated a) better scores on the WOMAC and greater odds of being a treatment responder at 9 weeks for participants receiving MT, b) greater odds of being a treatment responder at 1 year for participants receiving boosters. Exploratory interaction analysis suggested knee pain decreases for participants receiving boosters and increases for participants not receiving boosters from 9 weeks to 1 year. CONCLUSIONS: MT or use of boosters with exercise did not result in additive improvement in the primary outcome at 1 year. Secondary outcomes suggest MT may have some short term benefit, and booster sessions may improve responder status and knee pain at 1 year. However, the role of booster sessions remains unclear in sustaining treatment effects and warrants further study. CLINICAL TRIALS: gov (NCT01314183).

When is Sessional Monitoring More Likely in Child and Adolescent Mental Health Services?

Sessional monitoring of patient progress or experience of therapy is an evidence-based intervention recommended by healthcare systems internationally. It is being rolled out across child and adolescent mental health services (CAMHS) in England to inform clinical practice and service evaluation. We explored whether patient demographic and case characteristics were associated with the likelihood of using sessional monitoring. Multilevel regressions were conducted on N = 2609 youths from a routinely collected dataset from 10 CAMHS. Girls (odds ratio, OR 1.26), older youths (OR 1.10), White youths (OR 1.35), and youths presenting with mood (OR 1.46) or anxiety problems (OR 1.59) were more likely to have sessional monitoring. In contrast, youths under state care (OR 0.20) or in need of social service input (OR 0.39) were less likely to have sessional monitoring. Findings of the present research may suggest that sessional monitoring is more likely with common problems such as mood and anxiety problems but less likely with more complex cases, such as those involving youths under state care or those in need of social service input.

Realistic evaluation of Situation Awareness for Everyone (SAFE) on paediatric wards: study protocol.

INTRODUCTION: Evidence suggests that health outcomes for hospitalised children in the UK are worse than other countries in Europe, with an estimated 1500 preventable deaths in hospital each year. It is presumed that some of these deaths are due to unanticipated deterioration, which could have been prevented by earlier intervention, for example, sepsis. The Situation Awareness For Everyone (SAFE) intervention aims to redirect the 'clinical gaze' to encompass a range of prospective indicators of risk or deterioration, including clinical indicators and staff concerns, so that professionals can review relevant information for any given situation. Implementing the routine use of huddles is central to increasing situation awareness in SAFE. METHODS AND ANALYSIS: In this article, we describe the realistic evaluation framework within which we are evaluating the SAFE programme. Multiple methods and data sources are used to help provide a comprehensive understanding of what mechanisms for change are triggered by an intervention and how they have an impact on the existing social processes sustaining the behaviour or circumstances that are being targeted for change. ETHICS AND DISSEMINATION: Ethics approval was obtained from London-Dulwich Research Ethics Committee (14/LO/0875). It is anticipated that the findings will enable us to understand what the important elements of SAFE and the huddle are, the processes by which they might be effective and-given the short timeframes of the project-initial effects of the intervention on outcomes. The present research will add to the extant literature by providing the first evidence of implementation of SAFE and huddles in paediatric wards in the UK.

Inferior outcomes of total knee replacement in early radiological stages of osteoarthritis.

BACKGROUND: Total knee replacement (TKR) for osteoarthritis (OA) is a common and successful operation; the severity of radiographic changes plays a key role as to when it should be performed. This study investigates whether an early radiological grade of OA has an adverse effect on the outcome of TKR in patients with arthroscopically confirmed OA. METHODS: Between January 2006 and January 2011 data was collected prospectively on all patients undergoing a primary TKR for OA. We included all patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph who had had an arthroscopy to confirm significant OA. Our primary outcomes were the Oxford Knee Score (OKS) and a satisfaction rating. RESULTS: Over the study period 1708 primary TKRs were performed in 1381 patients. We identified 44 TKRs in 43 patients with a Kellgren-Lawrence score of two or less on their pre-operative radiograph. In this group the mean age was 63 years, 66% were female and the mean BMI was 31.7 kg/m(2). At a mean follow-up of 37 months the mean OKS was only 30 points compared to 36 in all TKRs performed over the same period (p=0.0004). Only 68% were either satisfied or very satisfied. Eight knees (18%) underwent further surgery, three (6.8%) of which were revision procedures, compared to a revision rate of 1.6% in all patients. CONCLUSION: The outcomes of TKR in patients with early radiological changes of OA are inferior to those with significant radiological changes and should be performed with caution. LEVEL OF EVIDENCE: Level IV case-series.

Timing and magnitude of C partitioning through a young loblolly pine (Pinus taeda L.) stand using 13C labeling and shade treatments.

The dynamics of rapid changes in carbon (C) partitioning within forest ecosystems are not well understood, which limits improvement of mechanistic models of C cycling. Our objective was to inform model processes by describing relationships between C partitioning and accessible environmental or physiological measurements, with a special emphasis on short-term C flux through a forest ecosystem. We exposed eight 7-year-old loblolly pine (Pinus taeda L.) trees to air enriched with (13)CO(2) and then implemented adjacent light shade (LS) and heavy shade (HS) treatments in order to manipulate C uptake and flux. The impacts of shading on photosynthesis, plant water potential, sap flow, basal area growth, root growth and soil CO(2) efflux rate (CER) were assessed for each tree over a 3-week period. The progression of the (13)C label was concurrently tracked from the atmosphere through foliage, phloem, roots and surface soil CO(2) efflux. The HS treatment significantly reduced C uptake, sap flow, stem growth and fine root standing crop, and resulted in greater residual soil water content to 1 m depth. Soil CER was strongly correlated with sap flow on the previous day, but not the current day, with no apparent treatment effect on the relationship. Although there were apparent reductions in new C flux belowground, the HS treatment did not noticeably reduce the magnitude of belowground autotrophic and heterotrophic respiration based on surface soil CER, which was overwhelmingly driven by soil temperature and moisture. The (13)C label was immediately detected in foliage on label day (half-life = 0.5 day), progressed through phloem by Day 2 (half-life = 4.7 days), roots by Days 2-4, and subsequently was evident as respiratory release from soil which peaked between Days 3 and 6. The δ(13)C of soil CO(2) efflux was strongly correlated with phloem δ(13)C on the previous day, or 2 days earlier. While the (13)C label was readily tracked through the ecosystem, the fate of root C through respiratory, mycorrhizal or exudative release pathways was not assessed. These data detail the timing and relative magnitude of C flux through various components of a young pine stand in relation to environmental conditions.

Common variation at 3p22.1 and 7p15.3 influences multiple myeloma risk.

To identify risk variants for multiple myeloma, we conducted a genome-wide association study of 1,675 individuals with multiple myeloma and 5,903 control subjects. We identified risk loci for multiple myeloma at 3p22.1 (rs1052501 in ULK4; odds ratio (OR) = 1.32; P = 7.47 × 10(-9)) and 7p15.3 (rs4487645, OR = 1.38; P = 3.33 × 10(-15)). In addition, we observed a promising association at 2p23.3 (rs6746082, OR = 1.29; P = 1.22 × 10(-7)). Our study identifies new genomic regions associated with multiple myeloma risk that may lead to new etiological insights.

Sensory properties of meal replacement bars and beverages made from whey and soy proteins.

Whey and soy proteins have a variety of applications. Previous work has documented flavors of rehydrated whey and soy proteins. It is necessary to understand what flavors whey and soy proteins contribute to product applications to optimize protein performance in desired applications. This research was conducted to characterize sensory properties of meal replacement products containing whey and soy proteins. Flavor and texture lexicons were developed for meal replacement bars and beverages. Commercial peanut butter-flavored meal replacement bars and vanilla meal replacement shakes were evaluated by an experienced, trained descriptive panel (n= 9). Prototypes of bars and beverages were developed with 3 levels of whey and soy protein and subsequently evaluated. Consumer acceptance testing (n= 85) was conducted on the prototype bars and beverages. Protein type as well as product-specific formulation contributed differences in flavor and texture of commercial bars and beverages (P < 0.05). Sensory properties of prototype bars and beverages fell within the spectrum of commercial products. Prototype bars made with whey protein were characterized by sweet aromatic and vanillin flavor notes while the texture was characterized by adhesiveness and cohesiveness. Prototype bars made with soy protein were characterized by nutty flavor while the texture was characterized by tooth-pack and denseness. Whey protein contributed to sweet aromatic and vanillin flavors in prototype beverages while soy protein contributed cereal/grainy flavors. Consumer acceptance scores were higher for prototype bars and beverages containing whey protein or a mixture of whey/soy protein than for products made with soy protein alone (P < 0.05). These results will aid researchers and product developers in optimizing sensory quality in meal replacement products.

Introduction: conceptualizing and partitioning the emergence process of zoonotic viruses from wildlife to humans.

This introduction provides a telegraphic overview of the processes of zoonotic viral emergence, the intricacies of host-virus interactions, and the distinct role of biological transitions and modifying factors. The process of emergence is conceptualized as two transition stages which are common and required for all disease emergence, (1) human contact with the infectious agent and (2) cross-species transmission of the agent, and two transition stages which are not required for emergence and appear unavailable to many zoonotic pathogens, (3) sustained human-to-human transmission and (4) genetic adaptation to the human host. The latter two transitions are presumably prerequisites for the pandemic emergence of a pathogen. The themes introduced herein are amplified and explored in detail by the contributors to this volume. Each author explores the mechanisms and unique circumstances by which evolution, biology, history, and current context have contrived to drive the emergence of different zoonotic agents by a series of related events; although recognizable similarities exist among the events leading to emergence the details and circumstances are never repetitive.

Pre-spillover prevention of emerging zoonotic diseases: what are the targets and what are the tools?

The uneven standards of surveillance, human- or animal-based, for zoonotic diseases or pathogens maintained and transmitted by wildlife H(R)s, or even domestic species, is a global problem, readily apparent even within the United States, where investment in public health, including surveillance systems, has a long and enviable history. As of 2006, there appears to be little scientific, social, or political consensus that animal-based surveillance for zoonoses merits investment in international infrastructure, other than the fledgling efforts with avian influenza, or targeted nontraditional avenues of surveillance and research. National institutions charged with strategic planning for emerging diseases or intentional releases of zoonotic agents have emphasized improving diagnostic capabilities for detecting human infections, modifying the immune status of human or domestic animals through vaccines, producing better antiviral or antibacterial drugs, and enhancing human-based surveillance as an early warning system. With the possible exception of extensive human vaccination, each of these approaches target post-spillover events and none of these avenues of research will have the slightest impact on reducing the risk of additional emergence of viruses or other pathogens from wildlife. Novel schemes of preventing spillover of human pathogens from animal H(R)s can only spring from improving our understanding of the ecological context and biological interactions of pathogen maintenance among H(R)s. Although the benefit derived from investments to improve surveillance and knowledge of zoonotic pathogens circulating among wildlife H(R) populations is uncertain, our experience with HIV and the looming threat of pandemic avian influenza A inform us of the outcomes we can expect by relying on detection of post-spillover events among sentinel humans.

Factors regulating cheese shreddability.

Two sets of cheeses were evaluated to determine factors that affect shred quality. The first set of cheeses was made up of 3 commercial cheeses, Monterey Jack, Mozzarella, and process. The second set of cheeses was made up of 3 Mozzarella cheeses with varying levels of protein and fat at a constant moisture content. A shred distribution of long shreds, short shreds, and fines was obtained by shredding blocks of cheese in a food processor. A probe tack test was used to directly measure adhesion of the cheese to a stainless-steel surface. Surface energy was determined based on the contact angles of standard liquids, and rheological characterization was done by a creep and recovery test. Creep and recovery data were used to calculate the maximum and initial compliance and retardation time. Shredding defects of fines and adhesion to the blade were observed in commercial cheeses. Mozzarella did not adhere to the blade but did produce the most fines. Both Monterey Jack and process cheeses adhered to the blade and produced fines. Furthermore, adherence to the blade was correlated positively with tack energy and negatively with retardation time. Mozzarella cheese, with the highest fat and lowest protein contents, produced the most fines but showed little adherence to the blade, even though tack energy increased with fat content. Surface energy was not correlated with shredding defects in either group of cheese. Rheological properties and tack energy appeared to be the key factors involved in shredding defects.

Animal-based national surveillance for zoonotic disease: quality, limitations, and implications of a model system for monitoring rabies.

Surveillance for zoonotic diseases among wildlife is a research and public health challenge. The inherent limitations posed by the requisite human-animal interactions are often undefined and underappreciated. The national surveillance system for animal rabies in the United States was examined as a model system; reporting of animal rabies is legally mandated, each case of rabies is laboratory confirmed, and data have been consistently collected for more than 50 years. Factors influencing the monthly counts of animal rabies tests reported during 1992-2001 were assessed by univariate and multivariable regression methods. The suitability of passively collected surveillance data for determining the presence or absence of the raccoon-associated variant of rabies within states and within individual counties was assessed by determining critical threshold values from the regression analyses. The size of the human population and total expenditures within a county accounted for 72% and 67%, respectively, of the variance in testing. The annual median number of rabies tests performed was seven for counties without rabies, 22 for counties with non-raccoon rabies, and 34 for counties with raccoon rabies. Active surveillance may be required in locales with sparse human populations when a high degree of confidence in the status of rabies is required.