Systematic Review and Meta-Analysis of Policies and Interventions that Improve Health, Psychosocial, and Economic Outcomes for Young People Leaving the Out-of-Home Care System.

Young people who transition to adulthood from out-of-home care (OOHC) are more likely to experience a range of poorer outcomes relative to their same-age peers in the community. This systematic review assessed the effectiveness of policies or interventions (hereafter "interventions") aimed at improving housing, health, education, economic, and psychosocial outcomes for youth leaving OOHC (hereafter "care leavers"). Eleven databases of published literature were reviewed along with gray literature. Eligible studies used randomized or quasi-experimental designs and assessed interventions that provided support to care leavers prior to, during, or after they left OOHC. Primary outcomes were housing and homelessness, health and well-being, education, economic and employment, criminal and delinquent behavior, and risky behavior, while secondary outcomes were supportive relationships and life skills. Where possible, results were pooled in a meta-analysis. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. Fourteen studies published in 27 reports were identified that examined independent living programs (ILPs) (n = 5), intensive support services (n = 2), coaching and peer support (C&PSP) (n = 2), transitional housing (n = 1), health information or coaching (n = 2), and extended care (n = 2). All but one study was conducted in the United States. Twenty small meta-analyses were undertaken encompassing ILPs and C&PSP, with two showing results that favored the intervention with certainty. The level of confidence in each meta-analysis was considered very low. A significant risk of bias was identified in each of the included studies. While some interventions showed promise, particularly extended care, the scope and strength of included evidence is insufficient to recommend any included approach.

Patterns and predictors of ten-year mortality after discharge from community-based post-acute care for acquired brain injury: A retrospective cohort study (ABI-RESTaRT), Western Australia, 1991-2017.

BACKGROUND: Survivors of acquired brain injury (ABI) are left with long-term disability and an increased risk of mortality years post-injury. OBJECTIVE: To examine 10-year mortality in adults with ABI after discharge from post-acute care and identify modifiable risk factors to reduce long-term mortality risk. METHODS: Retrospective cohort study of 586 adults with traumatic (TBI) or non-traumatic brain injury (NTBI), or neurologic condition, consecutively discharged from a post-acute rehabilitation service in Western Australia from 1-Mar-1991 to 31-Dec-2017. Data sources included rehabilitation records, and linked mortality, hospital, and emergency department data. Survival status at 10 years post-discharge was determined. All-cause and cause-specific age- and sex-adjusted standardised mortality ratios (SMR) by ABI diagnosis were calculated using Australian population reference data. Risk factors were examined using multilevel cox proportional hazards regression. RESULTS: Compared with the Australian population, 10-year all-cause mortality was significantly elevated for all diagnosis cohorts, with the first 12 months the highest risk period. Accidents or intentional self-harm deaths were elevated in TBI (13.2, 95%CI 5.4; 12.1). Neurodegenerative disease deaths were elevated in Neurologic (21.9, 95%CI 13.0; 30.9) and Stroke (19.8; 95%CI 2.4; 27.2) cohorts. Stroke (20.8; 95%CI 7.9; 33.8) and circulatory disease deaths (6.2; 95%CI 2.3; 9.9) were also elevated in Stroke. Psychiatric comorbidity was the strongest risk factor followed by older age, geographical remoteness, and cardiac, vascular, genitourinary and renal comorbidity. Clinically significant improvement in functional independence and psychosocial functioning significantly reduced mortality risk. CONCLUSIONS: Individuals with ABI have an elevated risk of mortality years post-injury. Comorbidity management, continuity of care, and rehabilitation are important to reduce long-term mortality risk.

IMproving psYchosocial adjustment to Traumatic Brain Injury from acute to chronic injury through development and evaluation of the myTBI online psychoeducation platform: protocol for a mixed-methods study.

INTRODUCTION: This protocol describes the myTBI study which aims to: (1) develop an online psychoeducation platform for people with traumatic brain injury (TBI), their family members/caregivers, and healthcare staff to improve psychosocial adjustment to TBI across different phases of injury (acute, postacute, and chronic), and (2) undertake an evaluation of efficacy, acceptability, and feasibility. METHODS AND ANALYSIS: A three-stage mixed-methods research design will be used. The study will be undertaken across four postacute community-based neurorehabilitation and disability support services in Western Australia. Stage 1 (interviews and surveys) will use consumer-driven qualitative methodology to: (1) understand the recovery experiences and psychosocial challenges of people with TBI over key stages (acute, postacute, and chronic), and (2) identify required areas of psychosocial support to inform the psychoeducation platform development. Stage 2 (development) will use a Delphi expert consensus method to: (1) determine the final psychoeducation modules, and (2) perform acceptance testing of the myTBI platform. Finally, stage 3 (evaluation) will be a randomised stepped-wedge trial to evaluate efficacy, acceptability, and feasibility. Outcomes will be measured at baseline, postintervention, follow-up, and at final discharge from services. Change in outcomes will be analysed using multilevel mixed-effects modelling. Follow-up surveys will be conducted to evaluate acceptability and feasibility. ETHICS AND DISSEMINATION: Ethics approval was granted by North Metropolitan Health Service Mental Health Research Ethics and Governance Office (RGS0000005877). Study findings will be relevant to clinicians, researchers, and organisations who are seeking a cost-effective solution to deliver ongoing psychoeducation and support to individuals with TBI across the recovery journey. TRIAL REGISTRATION NUMBER: ACTRN12623000990628.

Sex/gender differences in service use patterns, clinical outcomes and mortality risk for adults with acquired brain injury: a retrospective cohort study (ABI-RESTART).

OBJECTIVE: To identify sex/gender differences in functional, psychosocial and service use patterns in community-based post-acute care for acquired brain injury.  Design: Retrospective cohort study. SUBJECTS/PATIENTS: Adults with acquired brain injury enrolled in post-acute neurorehabilitation and disability support in Western Australia (n = 1,011). METHODS: UK Functional Independence Measure and Functional Assessment Measure (FIM + FAM), Mayo-Portland Adaptability Inventory-4, goal attainment, length of stay (LOS), number of episodes of care and deaths were evaluated using routinely collected clinical and linked administrative data. RESULTS: At admission, women were older (p < 0.001) and displayed poorer functional independence (FIM + FAM; p < 0.05) compared with men. At discharge, there were no differences in goal attainment, psychosocial function or functional independence between men and women. Both groups demonstrated functional gains; however, women demonstrated clinically significant gains (+ 15.1, p < 0.001) and men did not (+ 13.7, p < 0.001). Women and men had equivalent LOS (p = 0.205). Aboriginal and/or Torres Strait Islander status predicted longer LOS for women but not for men. Being partnered predicted reduced LOS for women but not men. Women had a higher risk of multiple episodes of care (p < 0.001), but not death (p = 0.409), compared with that of men. CONCLUSION: At admission to rehabilitation and disability support services for acquired brain injury, women have poorer functional independence and higher risk of multiple episodes of care, compared with men, suggesting greater disability in the community. By the time of discharge from these services, women and men make equivalent functional and psychosocial gains. The higher risk of multiple episodes of care for women relative to men suggest women may need additional post-discharge support, to avoid readmission.

Psychosocial functioning mediates change in motor and cognitive function throughout neurorehabilitation for adults with acquired brain injury (ABI-RESTaRT).

OBJECTIVES: This study aimed to evaluate the mediational role of change in psychosocial abilities, adjustment and participation on change in motor and cognitive function from admission to discharge from a staged community-based brain injury rehabilitation (SCBIR) service in Western Australia, 2011-2020. METHODS: A retrospective cohort study of n = 324 adults with ABI enrolled in SCBIR using routinely collected rehabilitation outcome measures data. Motor and cognitive function were assessed with the UK Functional Independence and Assessment Measure and psychosocial function with the Mayo-Portland Adaptability Inventory-4. Six multilevel mediation regression analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation) mediated change in motor and cognitive function from admission to discharge. RESULTS: Participants demonstrated clinically significant improvements in both motor (+ 11.8, p < 0.001) and cognitive (+ 9.5, p < 0.001) functioning from admission to discharge. Statistically significant improvements in psychosocial abilities (- 4.8, p < 0.001), adjustment (- 2.9, p = 0.001) and participation (- 2.5, p < 0.001) were also seen but were not clinically significant. Mediation analyses showed that participation accounted for 81% of improvements in motor function at discharge and 71% of cognitive function improvements. Adjustment accounted for 26% and 32% of change in motor and cognitive function, respectively. Abilities accounted for 60% of change in cognitive function but did not significantly influence change in motor function. Changes in psychosocial participation fully mediated change in motor function during neurorehabilitation. CONCLUSIONS: Psychosocial function, particularly participation, is an important driver of motor and cognitive recovery throughout neurorehabilitation. Functional rehabilitation programs should target psychosocial improvement as an important mechanism of change.

Effects of comorbidity on post-acute outcomes in acquired brain injury: ABI-RESTaRT 1991-2020.

BACKGROUND: Current understanding of comorbidities associated with acquired brain injury (ABI) and the effects on post-acute ABI outcomes is poor. OBJECTIVE: To describe the prevalence, severity and patterns of comorbidity for the pre-injury, acute and post-acute phases, and to examine the effects of post-acute comorbidities on functional independence and length of stay (LOS) at discharge from post-acute care. METHODS: Retrospective whole-population cohort study of n = 1,011 individuals with traumatic (TBI) or non-traumatic brain injury (NTBI), or eligible neurologic conditions admitted to a post-acute neurorehabilitation and disability support service in Western Australia (WA) between 1991 and 2020. Comorbidities were ascertained from internal electronic medical records and linked hospital and emergency department data from the WA Data Linkage System. We measured comorbidities across 14 body systems using the Cumulative Illness Rating Scale (CIRS) and Elixhauser Comorbidity Index (ECI), and functional independence with the UK Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). We used multilevel mixed-effect regression models to determine the effects of comorbidity on post-acute outcomes. RESULTS: NTBI was the most common diagnosis (54%), followed by TBI (34%) and neurologic conditions (10%). Pre-injury comorbidities were present in over half the cohort. Comorbidity prevalence increased significantly from 57% to 84% (∆+27%) and severity (mean ECI score) increased significantly from 2.1 to 13.8 (∆+11.7) between pre-injury and the acute phase and remained elevated at admission to post-acute services (82%, mean ECI score 7.3). Psychiatric comorbidity was the most prevalent (56%) and was associated with significantly poorer functional outcomes at discharge and an increase in LOS of 6.5 months. Genitourinary, musculoskeletal, eye, ear nose and throat, and renal comorbidities also had significant effects on post-acute outcomes. CONCLUSIONS: ABI has a long-term impact on multiple body systems. Identification and management of comorbidities is critical to maximize functional outcomes and reduce the cost of post-acute care.

Change in care hours, cost, and functional independence following continence and assistive technology intervention in an acquired brain injury population.

PURPOSE: After acquired brain injury (ABI) dependence on intervention for continence management is common. This preliminary investigation aimed to (i) quantify toileting care hours and costs in a community-based ABI rehabilitation and disability setting, and (ii) measure change in care needs, costs, and functional independence after intervention with assistive technologies (ATs). METHOD: Pragmatic pre-post intervention pilot study of 14 adults with ABI and toileting disability accessing community-based neurorehabilitation or disability support in Western Australia. Toileting and functional independence were assessed monthly from baseline (T0) to 3-month follow-up (T3). Basic and nursing care hours (Northwick Park Dependency Score), cost of care estimates (Northwick Park Care Needs Assessment), functional independence (Functional Independence and Assessment Measure), and cost of consumables were examined pre- and post-intervention with ATs. Multilevel mixed-effects models with bootstrap estimation were conducted. RESULTS: Cost of consumables significantly declined (AU$69/week), and functional independence significantly improved following intervention (+23.5 points). There was a non-significant reduction in care needs for toileting (4 h/week) and in the cost of toileting care (AU$633/week). CONCLUSION: Toileting disability substantially impacts care hours and costs. This study provides preliminary evidence that comprehensive continence management is beneficial in reducing costs and supporting people with an ABI to increase their independence.IMPLICATIONS FOR REHABILITATIONA comprehensive continence assessment and management plan reduces the number of care hours, cost of care, and cost of continence products in a neurorehabilitation and disability support sample for people with acquired brain injury (ABI).Assistive technologies for continence management are beneficial in supporting people with ABI to increase independence, and reduce costs.Providing comprehensive continence assessment and management plan reduces reliance on staff for continence care, and improves functional independence.

Rehabilitation outcomes at discharge from staged community-based brain injury rehabilitation: A retrospective cohort study (ABI-RESTaRT), Western Australia, 2011-2020.

Objective: To evaluate change in functional independence, psychosocial functioning, and goal attainment at discharge from a slow-stream Staged Community-Based Brain Injury Rehabilitation (SCBIR) service in Western Australia, 2011-2020. Methods: Retrospective cohort study of n = 323 adults with acquired brain injury (ABI) enrolled in a post-acute SCBIR service compared against a control cohort of n = 312 with ABI admitted to three non-rehabilitation programs. Outcome measures were the UK Functional Independence Measure and Functional Assessment Measure (FIM+FAM), Mayo Portland Adaptability Inventory-4 (MPAI-4), and Goal Attainment Scale. Change in FIM+FAM and MPAI-4 scores and predictors of goal attainment at discharge were evaluated using multilevel mixed-effects regression. Results: Median SCBIR length of stay was 20.5 months. Rehabilitation clients demonstrated clinically significant functional gains at discharge, adjusted mean change = +20.3, p < 0.001 (FIM+FAM). Peak gains of +32.3 were observed after 24-30 months and clinically significant gains were observed 5 years post-admission. Individuals discharged ≤6 months had the smallest functional gains (+12.7). Small psychosocial improvements were evidenced at discharge, mean reduction = -2.9T, p < 0.001 (MPAI-4) but not clinically significant. 47% of rehabilitation clients achieved their goals at the expected level or higher at discharge. Compared to the control, rehabilitation clients evidenced significantly greater functional gains and psychosocial improvement but lower goal attainment. Significant predictors of goal attainment at discharge were >2 years since injury, higher cognitive function and higher emotional adjustment at admission. Conclusions: Functional recovery after ABI is a gradual and ongoing process. SCBIR is effective for functional rehabilitation post-injury but can be improved to achieve clinically meaningful psychosocial improvement.

The association between functional independence and quality of life for individuals with acquired brain injury undergoing community-based rehabilitation and disability support.

BACKGROUND: Following acquired brain injury (ABI), cognitive and physical barriers can prevent access to a previously enjoyed lifestyle, reducing quality of life. OBJECTIVE: This study aimed to examine predictors of health-related quality of life (HRQoL) in adults with ABI receiving post-acute community-based rehabilitation and disability support services, using tools developed for this population. METHODS: Retrospective cross-sectional design. Main outcome measures were the Quality of Life after Brain Injury Inventory (QOLIBRI) and Functional Independence and Assessment Measure (FIM + FAM) for adults with ABI (n = 67) undergoing post-acute rehabilitation in Western Australia, 2015-2021. RESULTS: Mean QOLIBRI total score (±standard deviation) was 57.2±17.4, indicating impaired HRQoL, with mood disorders likely prevalent. Regression analysis demonstrated no differences in HRQoL between different age groups, sexes or brain injury types. Shorter time since injury and lower total FIM + FAM score significantly predicted poorer HRQoL in the model. CONCLUSION: This population appears vulnerable to psychological illness, although HRQoL is addressed for a minority of clients during routine post-acute care (19%). As improvement in quality of life is a fundamental goal of rehabilitation post-ABI, understanding the relationship between potentially modifiable factors such as functional independence and HRQoL is critical to improve outcomes and provide the best chance at a satisfying life.

The influence of three-dimensional cues on body size judgements.

Research has shown that body size judgements are frequently biased, or inaccurate. Critically, judgement biases are further exaggerated for individuals with eating disorders, a finding that has been attributed to difficulties integrating body features into a perceptual whole. However, current understanding of which body features are integrated when judging body size is lacking. In this study, we examine whether individuals integrate three-dimensional (3D) cues to body volume when making body size judgements. Computer-generated body stimuli were presented in a 3D Virtual Reality environment. Participants (N = 412) were randomly assigned to one of the two conditions: in one condition, the to-be-judged body was displayed binocularly (containing 3D cues to body volume); in the other, bodies were presented monocularly (two-dimensional [2D] cues only). Across 150 trials, participants were required to make a body size judgement of a target female body from a third-person point of view using an unmarked visual analogue scale (VAS). It was found that 3D cues significantly influenced body size judgements. Namely, thin 3D bodies were judged smaller, and overweight 3D bodies were judged larger, than their 2D counterpart. Furthermore, to reconcile these effects, we present evidence that the two perceptual biases, regression to the mean and serial dependence, were reduced by the additional 3D feature information. Our findings increase our understanding of how body size is perceptually encoded and creates testable predictions for clinical populations exhibiting integration difficulties.

Sizing up the crowd: Assessing spatial integration difficulties in body size judgements across eating disorder symptomatology.

Introduction: Body size judgements are frequently biased, or inaccurate, and these errors are further exaggerated for individuals with eating disorders. Within the eating disorder literature, it has been suggested that exaggerated errors in body size judgements are due to difficulties with integration. Across two experiments, we developed a novel integration task, named the Ebbinghaus Illusion for Bodies in Virtual Reality (VR), to assess whether nearby bodies influence the perceived size of a single body. VR was used to simulate the appearance of a small crowd around a central target body. Method and Results: In Experiment 1 (N = 412), participants were required to judge the size of a central female target within a crowd. Experiment 1 revealed an Ebbinghaus Illusion, in which a central female appeared larger when surrounded by small distractors, but comparatively smaller when surrounded by large distractors. In other words, the findings of Experiment 1 demonstrate that surrounding crowd information is integrated when judging an individual's body size; a novel measure of spatial integration (i.e., an Ebbinghaus Illusion for Bodies in VR). In Experiment 2 (N = 96), female participants were selected based on high (n = 43) and low (n = 53) eating disorder symptomatology. We examined whether the magnitude of this illusion would differ amongst those with elevated versus low eating disorder symptomatology, in accordance with weak central coherence theory, with the high symptomatology group displaying less spatial integration relative to the low group. The results of Experiment 2 similarly found an Ebbinghaus Illusion for Bodies in VR. However, illusion magnitude did not vary across high and low symptomatology groups. Discussion: Overall, these findings demonstrate that surrounding crowd information is integrated when judging individual body size; however, those with elevated eating disorder symptomatology did not show any integration deficit on this broader measure of spatial integration.

Cohort profile: the Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT), Western Australia, 1991-2020.

PURPOSE: Transition back into the community following acute management of acquired brain injury (ABI) is a critical part of recovery. Post-acute rehabilitation and transitional care can significantly improve outcomes. The Acquired Brain Injury Community REhabilitation and Support Services OuTcomes CohoRT (ABI-RESTaRT) is a novel whole-population cohort formed to better understand the needs of individuals with ABI receiving post-acute rehabilitation and disability services in Western Australia (WA), and to improve their outcomes. To do this a unique combination of (1) internal clinical/rehabilitation data, and (2) externally linked health data from the WA Data Linkage System was used, including hospitalisations, emergency department presentations, mental health service use and death records, to measure longitudinal needs and outcomes of individuals with ABI over 29 years, making this the largest, most diverse post-acute ABI cohort in Australia to date. PARTICIPANTS: Whole-population cohort of individuals (n=1011) with an ABI who received post-acute community-based neurorehabilitation or disability support services through Brightwater Care Group from 1991 to 2020. FINDINGS TO DATE: Comprehensive baseline demographic, clinical and rehabilitation data, outcome measures and linked health data have been collected and analysed. Non-traumatic brain injury (eg, stroke, hypoxia) was the main diagnostic group (54.9%, n=555), followed by traumatic brain injury (34.9%, n=353) and eligible neurological conditions (10.2%, n=103). Mean age at admission was 45.4 years, and 67.5% were men (n=682). The cohort demonstrated significant heterogeneity, socially and clinically, with differences between ABI groups across a number of domains. FUTURE PLANS: ABI-RESTaRT is a dynamic whole-population cohort that will be updated over time as individuals enrol in the service. Future analyses will assess longitudinal brain injury outcomes, the changing health and social needs of individuals with ABI and evaluate and inform post-acute services to best support these individuals. REGISTRATION: This cohort is not linked to a clinical trial, and is not registered.

Review of the literature on self-injurious thoughts and behaviours in gender-diverse children and young people in the United Kingdom.

International literature suggests that gender-diverse people are at increased risk of thoughts and acts of self-injury compared to their cisgender peers. The current review aimed to investigate the prevalence of self-injurious thoughts and behaviours (SITBs) among children and young people (CYP) in the United Kingdom identifying as a gender not typically associated with the sex they were assigned at birth and, further, to examine relevant prevalence rates of SITBs reported both in academic and grey literature. In total, seven studies were included in the review and indicated an increased prevalence of SITBs among gender-diverse CYP compared to the general population. However, methodological limitations and significant heterogeneity in the rates of SITBs reported require that the available literature be interpreted with some caution. Important factors to consider when interpreting SITB rates, as well as recommendations for future research, are discussed.

Density and enhancement of the pancreatic tail on computer tomography predicts acinar score and pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Acinar score calculated at the pancreatic resection margin is associated with postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). The present study evaluates the association between (i) computed tomography (CT) density of the pancreas and the acinar score of the pancreatic resection margin, and (ii) CT density of the pancreas and POPF after PD. METHODS: Consecutive patients who underwent PD were included for analysis. CT densities of the pancreatic head, neck, body and tail were measured in non-contrast (NC), arterial (ART) and portal venous (PV) phases. Histologic slides of the pancreatic resection margin were scored for acinar cell density. RESULTS: Ninety patients were included for analysis. Non-contrast density of the pancreatic tail was a good predictor of POPF (AUROC 0.704, p = 0.036), and a cut-off value of >40 Hounsfield units predicted POPF with 70.0% sensitivity and 73.4% specificity. The ratio of densities between PV and NC phases in the pancreatic tail was also a good predictor of POPF (AUROC 0.712, p = 0.030), and a cut-off value of <2.29 predicted POPF with 70.9% sensitivity and 80% specificity. CONCLUSION: Non-contrast CT density of the pancreatic tail correlates with acinar cell density of the pancreatic resection margin and predicts the development of POPF after PD.