PROTEUS Study: A Prospective Randomized Controlled Trial Evaluating the Use of Artificial Intelligence in Stress Echocardiography.

BACKGROUND: Stress echocardiography (SE) is one of the most commonly used diagnostic imaging tests for coronary artery disease (CAD) but requires clinicians to visually assess scans to identify patients who may benefit from invasive investigation and treatment. EchoGo Pro provides an automated interpretation of SE based on artificial intelligence (AI) image analysis. In reader studies, use of EchoGo Pro when making clinical decisions improves diagnostic accuracy and confidence. Prospective evaluation in real world practice is now important to understand the impact of EchoGo Pro on the patient pathway and outcome. METHODS: PROTEUS is a randomized, multicenter, 2-armed, noninferiority study aiming to recruit 2,500 participants from National Health Service (NHS) hospitals in the UK referred to SE clinics for investigation of suspected CAD. All participants will undergo a stress echocardiogram protocol as per local hospital policy. Participants will be randomized 1:1 to a control group, representing current practice, or an intervention group, in which clinicians will receive an AI image analysis report (EchoGo Pro, Ultromics Ltd, Oxford, UK) to use during image interpretation, indicating the likelihood of severe CAD. The primary outcome will be appropriateness of clinician decision to refer for coronary angiography. Secondary outcomes will assess other health impacts including appropriate use of other clinical management approaches, impact on variability in decision making, patient and clinician qualitative experience and a health economic analysis. DISCUSSION: This will be the first study to assess the impact of introducing an AI medical diagnostic aid into the standard care pathway of patients with suspected CAD being investigated with SE. TRIAL REGISTRATION: Clinicaltrials.gov registration number NCT05028179, registered on 31 August 2021; ISRCTN: ISRCTN15113915; IRAS ref: 293515; REC ref: 21/NW/0199.

Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study.

OBJECTIVES: Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability. METHODS: 15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis. RESULTS: Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments. CONCLUSIONS: These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.

Moral injury and psychological wellbeing in UK healthcare staff.

BACKGROUND: Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury. AIM: To examine the impact of PMIE on healthcare staff wellbeing. METHODS: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing. RESULTS: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9). CONCLUSION: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Increasing access to evidence-based treatment for child anxiety problems: online parent-led CBT for children identified via schools.

BACKGROUND: Anxiety problems are extremely common and have an early age of onset. We previously found, in a study in England, that fewer than 3% of children with an anxiety disorder identified in the community had accessed an evidence-based treatment (Cognitive Behavioural Therapy; CBT). Key ways to increase access to CBT for primary school-aged children with anxiety problems include (a) proactive identification through screening in schools, (b) supporting parents and (c) the provision of brief, accessible interventions (and capitalising on technology to do this). METHOD: We provided a brief, therapist guided treatment called Online Support and Intervention (OSI) to parents/carers of children identified, through school-based screening, as likely to have anxiety problems. Fifty out of 131 children from 17 Year 4 classes in schools in England screened positive for 'possible anxiety problems' and 42 (84%) of these (and 7 who did not) took up the offer of OSI. We applied quantitative and qualitative approaches to assess children's outcomes and families' experiences of this approach. RESULTS: Inbuilt outcome monitoring indicated session on session improvements throughout the course of treatment, with substantial changes across measures by the final module (e.g. Child Outcome Rating Scale d = 0.84; Goal Based Outcomes d = 1.52). Parent engagement and satisfaction was high as indicated by quantitative and qualitative assessments, and intervention usage. CONCLUSIONS: We provide promising preliminary evidence for the use of OSI as an early intervention for children identified as having anxiety problems through school-based screening.

Out of sight out of mind: an examination of mental health problems in UK military reservists and veterans.

BACKGROUND: Reservists often have different experiences to regular military personnel which may impact their mental health. AIMS: To investigate the incidence of mental health problems in both active and veteran reservists and determine how this compares to regular service personnel and ex-regular veterans. METHOD: Five studies which included reservist and/or veteran participants, a validated assessment of mental health problems, and provided primary data were included in the synthesis. Common mental health disorders, post-traumatic stress disorder and alcohol use disorder were examined. RESULTS: Nondeployed mobilized reservists were significantly less likely to report common mental health disorders than nondeployed regulars. There were no other significant differences between groups. Regardless deployed reservists reported more mental health problems than nondeployed reservists. Similarly, ex-regular deployed veterans were more likely to experience mental health difficulties than nondeployed ex-regular veterans. Notably, a large proportion of non-deployed reservists reported probable alcohol use disorders, indicating that problematic alcohol consumption may not be due to deployment in this group. CONCLUSION: These results highlight the need for ongoing support for military regular, ex-regular and reservist personnel. Additional research is needed to examine potential risk and protective factors for mental health problems in both deployed and nondeployed reservists.Key pointsOverall, mobilized deployed reservists were more likely to experience mental health problems than non-deployed reservists. Nondeployed regulars reported significantly more common mental health problems than nondeployed mobilized reservists.Reservists and (ex-)regulars reported similar rates of PTSD. This suggests reservists are vulnerable to developing PTSD following non-combat related trauma that may not lead to PTSD in regulars and this warrants future research.Reservists were less likely to report problematic alcohol consumption compared to regular personnel and ex-regular veterans. The greatest amount of reservist problematic drinking was reported in non-deployed veteran reservists. This indicates problematic alcohol consumption is not deployment related in this group and highlights the need for ongoing formal support for alcohol use disorders in the UK Armed Forces.

Delivering treatment to morally injured UK military personnel and Veterans: The clinician experience.

This study explored the experiences of clinicians in providing treatment in cases of military-related moral injury (MI). Qualitative interviews were carried out with 15 clinicians. Clinicians found patients experienced particular maladaptive appraisals following MI, which were considered different from the responses experienced after threat-based trauma. To address MI-related distress, clinicians utilized a range of treatment approaches. Several difficulties in providing care to patients following MI were described, including the impact of providing treatment on the clinicians own mental health. This study provides detailed insight into the approaches currently used to identify and treat UK Veterans with MI-related psychological problems. These findings highlight the need to evaluate the effectiveness of the treatments currently provided for MI-related psychological problems and suggest developing best practice guidance may improve clinician confidence in delivering care to those adversely impacted by MI.

On Performance and Perceived Effort in Trail Runners Using Sensor Control to Generate Biosynchronous Music.

Music has been shown to be capable of improving runners' performance in treadmill and laboratory-based experiments. This paper evaluates a generative music system, namely HEARTBEATS, designed to create biosignal synchronous music in real-time according to an individual athlete's heartrate or cadence (steps per minute). The tempo, melody, and timbral features of the generated music are modulated according to biosensor input from each runner using a combination of PPG (Photoplethysmography) and GPS (Global Positioning System) from a wearable sensor, synchronized via Bluetooth. We compare the relative performance of athletes listening to music with heartrate and cadence synchronous tempos, across a randomized trial (N = 54) on a trail course with 76 ft of elevation. Participants were instructed to continue until their self-reported perceived effort went beyond an 18 using the Borg rating of perceived exertion. We found that cadence-synchronous music improved performance and decreased perceived effort in male runners. For female runners, cadence synchronous music improved performance but it was heartrate synchronous music which significantly reduced perceived effort and allowed them to run the longest of all groups tested. This work has implications for the future design and implementation of novel portable music systems and in music-assisted coaching.

The impact of military service on the mental health of older UK veterans: A qualitative study.

BACKGROUND: There may be ongoing psychological problems associated with military service later in life; yet as the elderly in the general population also suffer from mental health problems, whether such issues can be attributed to military service or are a feature of ageing remains unclear. This study aimed to explore veteran and nonveteran perceptions of the impact of their occupation on their psychological well-being later in life. METHODS: Twenty-five veterans (≥65 y); 25 nonveterans (≥65 y); 10 veterans with diagnoses of mental health issues (≥65 y); and a close companion of all participants (≥18 y, spouse, child, and close friend) were recruited. Using a qualitative approach, participants completed semistructured qualitative interviews with measures of psychological adjustment used to describe the sample. RESULTS: Veterans were found to experience higher levels of workplace stress and trauma exposure compared with nonveterans. When such challenges were positively appraised, veterans described increased confidence and resilience. Social support in response to occupational stress was central to veteran and nonveteran well-being, especially for those with mental health problems. Nonetheless, providing support was challenging for close companions, with many feeling overwhelmed and requiring additional guidance from the veteran's clinical care team. CONCLUSIONS: The findings delineate the impact of occupation on the well-being of older veterans and nonveterans. The results illustrated the psychological support needs and formal guidance desired by veterans, nonveterans, and their families, which could ultimately improve coping of both the individual and family.

Identifying probable post-traumatic stress disorder: applying supervised machine learning to data from a UK military cohort.

BACKGROUND: Early identification of probable post-traumatic stress disorder (PTSD) can lead to early intervention and treatment. AIMS: This study aimed to evaluate supervised machine learning (ML) classifiers for the identification of probable PTSD in those who are serving, or have recently served in the United Kingdom (UK) Armed Forces. METHODS: Supervised ML classification techniques were applied to a military cohort of 13,690 serving and ex-serving UK Armed Forces personnel to identify probable PTSD based on self-reported service exposures and a range of validated self-report measures. Data were collected between 2004 and 2009. RESULTS: The predictive performance of supervised ML classifiers to detect cases of probable PTSD were encouraging when compared to a validated measure, demonstrating a capability of supervised ML to detect the cases of probable PTSD. It was possible to identify which variables contributed to the performance, including alcohol misuse, gender and deployment status. A satisfactory sensitivity was obtained across a range of supervised ML classifiers, but sensitivity was low, indicating a potential for false negative diagnoses. CONCLUSIONS: Detection of probable PTSD based on self-reported measurement data is feasible, may greatly reduce the burden on public health and improve operational efficiencies by enabling early intervention, before manifestation of symptoms.

Understanding the Diverse Forms of Spiritual Expression of Older People in Residential Aged Care in Australia.

The ability of older people to express their spirituality is an important component of aged care. Spirituality is not specifically religiousness although, for some, religion offers a means for spiritual expression. This paper aimed to explore what constitutes spiritual life for residents in three residential aged care facilities in South Australia. The findings of the research demonstrated that the majority of older resident participants defined spirituality as 'connection/s'. Three unexpected results of the study became obvious during analysis, reported here as 'loss', 'adaptation' and 'they're busy'. It is offered here that these adjustments enabled participants to compensate for their losses.

Occupational moral injury and mental health: systematic review and meta-analysis.

BACKGROUND: Many people confront potentially morally injurious experiences (PMIEs) in the course of their work which can violate deeply held moral values or beliefs, putting them at risk for psychological difficulties (e.g. post-traumatic stress disorder (PTSD), depression, etc.).AimsWe aimed to assess the effect of moral injury on mental health outcomes. METHOD: We conducted a systematic review and meta-analysis to assess the association between work-related PMIEs and mental health disorders. Studies were independently assessed for methodological quality and potential moderator variables, including participant age, gender and PMIE factors, were also examined. RESULTS: Thirteen studies were included, representing 6373 participants. PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the variance in depression and 2.0% of the variance in suicidality. PMIEs were associated with more symptoms of anxiety and behavioural problems (e.g. hostility), although this relationship was not consistently significant. Moderator analyses indicated that methodological factors (e.g. PMIE measurement tool), demographic characteristics and PMIE variables (e.g. military v. non-military context) did not affect the association between a PMIE and mental health outcomes. CONCLUSIONS: Most studies examined occupational PMIEs in military samples and additional studies investigating the effect of PMIEs on civilians are needed. Given the limited number of high-quality studies available, only tentative conclusions about the association between exposure to PMIEs and mental health disorders can be made.Declaration of interestNone.

Prevalence of Mental Health Disorders in Elderly U.S. Military Veterans: A Meta-Analysis and Systematic Review.

OBJECTIVE: Older veterans may be vulnerable to mental health problems. Meta-analytic and systematic review methods sought to determine the prevalence rate of mental health disorders in older military veterans (≥65 years). METHODS: Eleven studies were eligible, and meta-analyses of veteran depression, substance abuse, post-traumatic stress disorder (PTSD), anxiety, dementia, bipolar disorder, and schizophrenia were conducted. RESULTS: Although conducted exclusively with U.S. veterans, high prevalence rates of substance (5.7%) and alcohol use disorders (5.4%) in older veterans were found. However, the prevalence of other mental health disorders, including PTSD and depression, in older veterans was not markedly high. CONCLUSION: The rates of disorder prevalence observed indicates a need for continued awareness of mental health difficulties, particularly substance and alcohol use disorders, in older veterans. In the future studies with non-U.S. military samples using a longitudinal design are required to further understand the prevalence of mental health disorders in geriatric veterans.

Towards a new methodological approach: A novel paradigm for covertly inducing and sampling different forms of spontaneous cognition.

A wide range of cognitions is generated involuntarily in the human mind daily. We developed a paradigm, which covertly induces and samples spontaneous cognitions in the visual and auditory modalities, focusing on 3 key characteristics: spontaneity, repetition, and emotional valence. Sixty participants watched two visual clips while listening to music and assessed their characteristics. Post-induction, participants closed their eyes for 5 min and then completed a questionnaire, which indirectly samples different forms of spontaneous cognition. Induction was effective in all categories. Results indicated that different forms of spontaneous musical cognitions are experienced as longer in duration and less negative in emotional valence compared to visual cognitions. The findings are discussed in relation to spontaneous cognition methodology and experiences in different modalities. Spontaneous cognitions are multifaceted and not unitary constructs as previously considered and studied, and as such the novel induction and sampling paradigm presents a promising line of research.

Caregiver Responses to Child Posttraumatic Distress: A Qualitative Study in a High-Risk Context in South Africa.

Many low- and middle-income countries (LMIC) have high rates of child trauma exposure and limited access to psychological services. Caregivers are often a child's key source of support following trauma in such contexts. The aim of this study was to explore the experiences of primary caregivers in supporting their child posttrauma. Qualitative interviews were conducted with 20 female caregivers from a high-risk settlement in Cape Town following child trauma exposure. Children were exposed to significant traumatic events, including gang violence, assault, and fatalities of close relatives. The data were analyzed using thematic analysis; several key themes emerged. First, caregivers were typically aware of child distress posttrauma, based primarily on manifest behaviors. Second, caregivers identified varied ways of providing support, including being warm and responsive; seeking to ensure physical safety by encouraging the child's perceptions of the community as dangerous; and encouraging forgetting as a way of coping, with limited discussions of the event. Third, many barriers existed to accessing psychological treatment, and caregivers had low involvement in any interventions. Finally, caregivers also experienced significant distress that could impact their responses to their child. The results illustrate the challenges faced by caregivers in supporting children following trauma in LMIC contexts and the need for accessible psychological interventions.

The impact of music on learning and consolidation of novel words.

Music can be a powerful mnemonic device, as shown by a body of literature demonstrating that listening to text sung to a familiar melody results in better memory for the words compared to conditions where they are spoken. Furthermore, patients with a range of memory impairments appear to be able to form new declarative memories when they are encoded in the form of lyrics in a song, while unable to remember similar materials after hearing them in the spoken modality. Whether music facilitates the acquisition of completely new information, such as new vocabulary, remains unknown. Here we report three experiments in which adult participants learned novel words in the spoken or sung modality. While we found no benefit of musical presentation on free recall or recognition memory of novel words, novel words learned in the sung modality were more strongly integrated in the mental lexicon compared to words learned in the spoken modality. This advantage for the sung words was only present when the training melody was familiar. The impact of musical presentation on learning therefore appears to extend beyond episodic memory and can be reflected in the emergence and properties of new lexical representations.

Torn between dual roles: the experiences of nurse-family members when a loved one is hospitalised in a critical condition.

AIMS AND OBJECTIVES: To understand and interpret the experiences of nurse-family members when a family member or loved one is hospitalised in a critical condition. BACKGROUND: Having a family member hospitalised with a critical illness is a traumatic stressor, often with long-term sequelae. Providing holistic care for family members who are also nurses makes the provision of care more complex because of their professional expertise; yet few studies have explored this issue. DESIGN: In this descriptive study, qualitative data were collected using a questionnaire and analysed using van Manen's (Researching Lived Experience: Human Science for an Action Sensitive Pedagogy, 1990, State University of New York Press, London, ON) six-step approach. METHODS: Twenty nurse-family members completed an online questionnaire in June 2013. Qualitative findings from 19 participants were included in the analysis. The phenomenological analysis approach described by van Manen (Researching Lived Experience: Human Science for an Action Sensitive Pedagogy, 1990, State University of New York Press, London, ON) was used to describe and interpret nurse-family member experiences. RESULTS: Nurse-family members experience significant dual role conflicts between their personal and professional personas due to their specialised knowledge, need for watchfulness and competing expectations. Our findings describe how dual role conflicts developed and were managed, and reveal the resultant emotional toll and psychological distress as nurse-family members struggled to resolve these conflicts. CONCLUSIONS: Nurse-family members require a different type of care than general public family members, yet their unique needs are often unmet, leading to increased anxiety and distress that could potentially be minimised. An increased awareness and emphasis on the nurse-family member experience can ensure health care professionals are better placed to provide appropriate and targeted care to minimise distressing dual role conflicts. RELEVANCE TO CLINICAL PRACTICE: There is a need for targeted and specialised communication appropriate to each nurse-family members' needs and level of understanding, and to clarify expectations to ensure nurse-family members' professional knowledge and skills are recognised and respected without being exploited.