Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial.

BACKGROUND: Extended pleurectomy decortication for complete macroscopic resection for pleural mesothelioma has never been evaluated in a randomised trial. The aim of this study was to compare outcomes after extended pleurectomy decortication plus chemotherapy versus chemotherapy alone. METHODS: MARS 2 was a phase 3, national, multicentre, open-label, parallel two-group, pragmatic, superiority randomised controlled trial conducted in the UK. The trial took place across 26 hospitals (21 recruiting only, one surgical only, and four recruiting and surgical). Following two cycles of chemotherapy, eligible participants with pleural mesothelioma were randomly assigned (1:1) to surgery and chemotherapy or chemotherapy alone using a secure web-based system. Individuals aged 16 years or older with resectable pleural mesothelioma and adequate organ and lung function were eligible for inclusion. Participants in the chemotherapy only group received two to four further cycles of chemotherapy, and participants in the surgery and chemotherapy group received pleurectomy decortication or extended pleurectomy decortication, followed by two to four further cycles of chemotherapy. It was not possible to mask allocation because the intervention was a major surgical procedure. The primary outcome was overall survival, defined as time from randomisation to death from any cause. Analyses were done on the intention-to-treat population for all outcomes, unless specified. This study is registered with ClinicalTrials.gov, NCT02040272, and is closed to new participants. FINDINGS: Between June 19, 2015, and Jan 21, 2021, of 1030 assessed for eligibility, 335 participants were randomly assigned (169 to surgery and chemotherapy, and 166 to chemotherapy alone). 291 (87%) participants were men and 44 (13%) women, and 288 (86%) were diagnosed with epithelioid mesothelioma. At a median follow-up of 22·4 months (IQR 11·3-30·8), median survival was shorter in the surgery and chemotherapy group (19·3 months [IQR 10·0-33·7]) than in the chemotherapy alone group (24·8 months [IQR 12·6-37·4]), and the difference in restricted mean survival time at 2 years was -1·9 months (95% CI -3·4 to -0·3, p=0·019). There were 318 serious adverse events (grade ≥3) in the surgery group and 169 in the chemotherapy group (incidence rate ratio 3·6 [95% CI 2·3 to 5·5], p<0·0001), with increased incidence of cardiac (30 vs 12; 3·01 [1·13 to 8·02]) and respiratory (84 vs 34; 2·62 [1·58 to 4·33]) disorders, infection (124 vs 53; 2·13 [1·36 to 3·33]), and additional surgical or medical procedures (15 vs eight; 2·41 [1·04 to 5·57]) in the surgery group. INTERPRETATION: Extended pleurectomy decortication was associated with worse survival to 2 years, and more serious adverse events for individuals with resectable pleural mesothelioma, compared with chemotherapy alone. FUNDING: National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/188/31), Cancer Research UK Feasibility Studies Project Grant (A15895).

The pairs training effect in unfamiliar face matching.

A wealth of studies have shown that humans are remarkably poor at determining whether two face images show the same person or not (face matching). Given the prevalence of photo-ID, and the fact that people employed to check photo-ID are typically unfamiliar with the person pictured, there is a need to improve unfamiliar face matching accuracy. One method of improvement is to have participants complete the task in a pair, which results in subsequent improvements in the low performer ("the pairs training effect"). Here, we sought to replicate the original finding, to test the longevity of the pairs training effect, and to shed light on the potential underlying mechanisms. In two experiments, we replicated the pairs training effect and showed it is maintained after a delay (Experiment 1). We found no differences between high and low performers in confidence (Experiment 1) or response times (Experiment 2), and the content of the pairs' discussions (Experiment 2) did not explain the results. The pairs training effect in unfamiliar face matching is robust, but the mechanisms underlying the effects remain as yet unexplained.

Feasibility of delivering parent-implemented NDBI interventions in low-resource regions: a pilot randomized controlled study.

BACKGROUND: This implementation feasibility study was conducted to determine whether an evidence-based parent-implemented distance-learning intervention model for young children at high likelihood of having ASD could be implemented at fidelity by Part C community providers and by parents in low-resource communities. METHODS: The study used a community-academic partnership model to adapt an evidence-based intervention tested in the current pilot trial involving randomization by agency in four states and enrollment of 35 coaches and 34 parent-family dyads. After baseline data were gathered, providers in the experimental group received 12-15 h of training while control providers received six webinars on early development. Providers delivered 6 months of intervention with children-families, concluding with data collection. Regression analyses were used to model outcomes of the coach behaviors, the parent fidelity ratings, and child outcomes. RESULTS: A block design model-building approach was used to test the null model followed by the inclusion of group as a predictor, and finally the inclusion of the planned covariates. Model fit was examined using changes in R2 and F-statistic. As hypothesized, results demonstrated significant gains in (1) experimental provider fidelity of coaching implementation compared to the control group; and (2) experimental parent fidelity of implementation compared to the control group. There were no significant differences between groups on child developmental scores. CONCLUSIONS: Even though the experimental parent group averaged less than 30 min of intervention weekly with providers in the 6 months, both providers and parents demonstrated statistically significant gains on the fidelity of implementation scores with moderate effect sizes compared to control groups. Since child changes in parent-mediated models are dependent upon the parents' ability to deliver the intervention, and since parent delivery is dependent upon providers who are coaching the parents, these results demonstrated that two of these three links of the chain were positively affected by the experimental implementation model. However, a lack of significant differences in child group gains suggests that further work is needed on this model. Factors to consider include the amount of contact with the provider, the amount of practice children experience, the amount of contact both providers and parents spend on training materials, and motivational strategies for parents, among others. TRIAL REGISTRATION: Registry of Efficacy and Effectiveness Studies: #4360, registered 1xx, October, 2020 - Retrospectively registered, https://sreereg.icpsr.umich.edu/sreereg/.

COVID-19-The impact of variable and "low normal" pulse oximetry scores on Oximetry@Home services and clinical pathways: Confounding variables?

COVID-19 Oximetry@Home services have been commissioned nationally. This allows higher-risk patients with mild COVID-19 symptoms to remain at home, being supplied with a Pulse Oximeter to measure their oxygen saturation (SpO2 ) two to three times daily for two weeks. Patients record their readings manually or electronically which are monitored by a clinical team. Clinical decisions, using an algorithm, are based on SpO2 readings in a narrow range with 1-2 point changes potentially affecting care. In this article, we discussed the problem that multiple factors affect SpO2 readings, and that some "normal" individuals will have "low-normal" scores at the threshold of clinical management, without any known respiratory problem. We discuss the potential magnitude of this problem based on the associated literature and consider how this will have an impact on the use of the Oximetry@home services, potentially partially confounding their purpose; to reduce face-to-face medical care.

Dental attendance and behavioural pathways to adult oral health inequalities.

BACKGROUND: While inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland. METHODS: Using nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways. RESULTS: Lower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, -0.21 (SE=0.01) and -0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects. CONCLUSION: Reducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

The Noninvasive Ventilation Outcomes (NIVO) score: prediction of in-hospital mortality in exacerbations of COPD requiring assisted ventilation.

INTRODUCTION: Acute exacerbations of COPD (AECOPD) complicated by acute (acidaemic) hypercapnic respiratory failure (AHRF) requiring ventilation are common. When applied appropriately, ventilation substantially reduces mortality. Despite this, there is evidence of poor practice and prognostic pessimism. A clinical prediction tool could improve decision making regarding ventilation, but none is routinely used. METHODS: Consecutive patients admitted with AECOPD and AHRF treated with assisted ventilation (principally noninvasive ventilation) were identified in two hospitals serving differing populations. Known and potential prognostic indices were identified a priori. A prediction tool for in-hospital death was derived using multivariable regression analysis. Prospective, external validation was performed in a temporally separate, geographically diverse 10-centre study. The trial methodology adhered to TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) recommendations. RESULTS: Derivation cohort: n=489, in-hospital mortality 25.4%; validation cohort: n=733, in-hospital mortality 20.1%. Using six simple categorised variables (extended Medical Research Council Dyspnoea score 1-4/5a/5b, time from admission to acidaemia >12 h, pH <7.25, presence of atrial fibrillation, Glasgow coma scale ≤14 and chest radiograph consolidation), a simple scoring system with strong prediction of in-hospital mortality is achieved. The resultant Noninvasive Ventilation Outcomes (NIVO) score had area under the receiver operating curve of 0.79 and offers good calibration and discrimination across stratified risk groups in its validation cohort. DISCUSSION: The NIVO score outperformed pre-specified comparator scores. It is validated in a generalisable cohort and works despite the heterogeneity inherent to both this patient group and this intervention. Potential applications include informing discussions with patients and their families, aiding treatment escalation decisions, challenging pessimism and comparing risk-adjusted outcomes across centres.

Does Social Support Affect Older Adults' General Practitioner Attendance Rates? Findings from the North West Coast Household Health Survey.

OBJECTIVE: The aim of this study was to explore whether social support and socio-economic status have an effect on primary care attendance in older adults (aged 65+). METHODS: This study used data from the longitudinal North West Coast (NWC) Household Health Survey (HHS) from across 20 disadvantaged and 8 less disadvantaged neighborhoods. Data included the EQ-5D, social support, frailty-related measures, healthcare utilization, and the Index of Multiple Deprivation (IMD). Principal component analysis was used to derive a factor for social support. Poisson regression analysis was employed to explore the effects of frailty, social support, General Practitioner (GP) distance, education, IMD, living situation, and depression on the number of GP attendances in the past 12 months. RESULTS: 1,685 older adults were included in this analysis. Of those older adults who visited their GP (87.4%), most had visited their GP twice in the past 12 months. Having an educational qualification, higher levels of social support, and being physically fit reduced GP utilization. Being moderately frail, depressed, and living further away from the nearest GP increased attendance. Older adults living in the most disadvantaged neighborhoods were more likely to visit their GP. CONCLUSIONS: Increasing social support impacts to a small, but important, extent on reducing GP attendance in older adults. Future research needs to explore whether improving social support in old age can reduce GP utilization. CLINICAL IMPLICATIONS: Findings suggest a need for improving social prescribing in older adults to reduce some GP visits which could be avoided and might not be necessary.

Multi-component communication intervention for children with autism: A randomized controlled trial.

LAY ABSTRACT: This study reports the results of a randomized trial for preverbal preschoolers with autism that demonstrates the effects of multiple intervention strategies including caregiver training. About 50% of children with autism are not talking by age 3 and up to 30% of children with autism will remain minimally verbal past age 5. Interventions delivered by clinicians and caregivers have the greatest effects on spoken language and may reduce the rate of those who remain minimally verbal. Sixty-eight children ages 3-5 with autism and their caregivers participated in this randomized trial comparing the communication intervention to a comparison group. A brief, multi-component, communication intervention (including a speech-generating device) for children with autism that addresses core deficits may be effective in improving joint attention skills immediately following intervention and social communication skills 4 months following intervention. Future research is needed to understand for whom and under what conditions this intervention is most effective.

The Effects of the Early Start Denver Model for Children with Autism Spectrum Disorder: A Meta-Analysis.

This meta-analysis examined the effects of the Early Start Denver Model (ESDM) for young children with autism on developmental outcome measures. The 12 included studies reported results from 640 children with autism across 44 unique effect sizes. The aggregated effect size, calculated using a robust variance estimation meta-analysis, was 0.357 (p = 0.024), which is a moderate effect size with a statistically significant overall weighted averaged that favored participants who received the ESDM compared to children in control groups, with moderate heterogeneity across studies. This result was largely driven by improvements in cognition (g = 0.412) and language (g = 0.408). There were no significant effects observed for measures of autism symptomology, adaptive behavior, social communication, or restrictive and repetitive behaviors.

Implementation of targeted screening for lung cancer in a high-risk population within routine NHS practice using low-dose computed tomography.

We report a primary care-based lung cancer targeted screening programme using low-dose CT (LDCT) in South Tyneside and Sunderland. Ever smokers with ≥10 pack-years aged 55-74 years were identified at annual COPD review. 925 individuals attended for LDCT. 2% (n=19/925) had lung cancer diagnosed. 66.7% (n=14/21) had early stage disease and 78.9% (n=15/19) were offered treatment with curative intent. 79.3% of individuals attending for LDCT were ranked in the lowest deprivation quintiles. This approach has been successfully established in routine NHS practice; it is effective with improvements in stage of disease and engages individuals in deprived areas.

Activation of mosquito immunity blocks the development of transmission-stage filarial nematodes.

Mosquito-borne helminth infections are responsible for a significant worldwide disease burden in both humans and animals. Accordingly, development of novel strategies to reduce disease transmission by targeting these pathogens in the vector are of paramount importance. We found that a strain of Aedes aegypti that is refractory to infection by Dirofilaria immitis, the agent of canine heartworm disease, mounts a stronger immune response during infection than does a susceptible strain. Moreover, activation of the Toll immune signaling pathway in the susceptible strain arrests larval development of the parasite, thereby decreasing the number of transmission-stage larvae. Notably, this strategy also blocks transmission-stage Brugia malayi, an agent of human lymphatic filariasis. Our data show that mosquito immunity can play a pivotal role in restricting filarial nematode development and suggest that genetically engineering mosquitoes with enhanced immunity will help reduce pathogen transmission.

Predictors of emergency department and GP use among patients with mental health conditions: a public health survey.

BACKGROUND: High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services. AIM: To examine the social determinants of health service use in people with mental health issues. DESIGN AND SETTING: Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation. METHOD: A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors. RESULTS: Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38). CONCLUSION: Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed.

The Effects of Early Intervention on Social Communication Outcomes for Children with Autism Spectrum Disorder: A Meta-analysis.

This meta-analysis examined the effects of early interventions on social communication outcomes for young children with autism spectrum disorder. A systematic review of the literature included 1442 children (mean age 3.55 years) across 29 studies. The overall effect size of intervention on social communication outcomes was significant (g = 0.36). The age of the participants was related to the treatment effect size on social communication outcomes, with maximum benefits occurring at age 3.81 years. Results did not differ significantly depending on the person implementing the intervention. However, significantly larger effect sizes were observed in studies with context-bound outcome measures. The findings of this meta-analysis highlight the need for further research examining specific components of interventions associated with greater and more generalized gains.

Enhanced milieu teaching for children with autism spectrum disorder in South Africa.

Purpose: Efficient and effective interventions are required to meet the communication needs of children with autism spectrum disorders (ASDs). However, most children with ASD living in South Africa do not receive individualised interventions.Method: This multiple baseline study examined the effects of therapist-implemented enhanced milieu teaching (EMT) on the diversity and frequency of spoken language of three children with ASD in South Africa.Result: A moderate functional relation was demonstrated between the introduction of EMT and increases in (1) the number of different words and (2) the number of spontaneous utterances used by each participant. Some evidence of generalisation to novel partners and contexts was observed.Conclusion: Results indicated that EMT may be effective for improving communication in South African children with ASD. Implications for clinical practice and cultural and linguistic adaptations are discussed.

Early specialist palliative care on quality of life for malignant pleural mesothelioma: a randomised controlled trial.

PURPOSE: Malignant pleural mesothelioma (MPM) has a high symptom burden and poor survival. Evidence from other cancer types suggests some benefit in health-related quality of life (HRQoL) with early specialist palliative care (SPC) integrated with oncological services, but the certainty of evidence is low. METHODS: We performed a multicentre, randomised, parallel group controlled trial comparing early referral to SPC versus standard care across 19 hospital sites in the UK and one large site in Western Australia. Participants had newly diagnosed MPM; main carers were additionally recruited. INTERVENTION: review by SPC within 3 weeks of allocation and every 4 weeks throughout the study. HRQoL was assessed at baseline and every 4 weeks with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30. PRIMARY OUTCOME: change in EORTC C30 Global Health Status 12 weeks after randomisation. RESULTS: Between April 2014 and October 2016, 174 participants were randomised. There was no significant between group difference in HRQoL score at 12 weeks (mean difference 1.8 (95% CI -4.9 to 8.5; p=0.59)). HRQoL did not differ at 24 weeks (mean difference -2.0 (95% CI -8.6 to 4.6; p=0.54)). There was no difference in depression/anxiety scores at 12 weeks or 24 weeks. In carers, there was no difference in HRQoL or mood at 12 weeks or 24 weeks, although there was a consistent preference for care, favouring the intervention arm. CONCLUSION: There is no role for routine referral to SPC soon after diagnosis of MPM for patients who are cared for in centres with good access to SPC when required. TRIAL REGISTRATION NUMBER: ISRCTN18955704.

Sexual identity, attraction and behaviour in Britain: The implications of using different dimensions of sexual orientation to estimate the size of sexual minority populations and inform public health interventions.

BACKGROUND: Sexual orientation encompasses three dimensions: sexual identity, attraction and behaviour. There is increasing demand for data on sexual orientation to meet equality legislation, monitor potential inequalities and address public health needs. We present estimates of all three dimensions and their overlap in British men and women, and consider the implications for health services, research and the development and evaluation of public health interventions. METHODS: Analyses of data from Britain's third National Survey of Sexual Attitudes and Lifestyles, a probability sample survey (15,162 people aged 16-74 years) undertaken in 2010-2012. FINDINGS: A lesbian, gay or bisexual (LGB) identity was reported by 2·5% of men and 2·4% of women, whilst 6·5% of men and 11·5% of women reported any same-sex attraction and 5·5% of men and 6·1% of women reported ever experience of same-sex sex. This equates to approximately 547,000 men and 546,000 women aged 16-74 in Britain self-identifying as LGB and 1,204,000 men and 1,389,000 women ever having experience of same-sex sex. Of those reporting same-sex sex in the past 5 years, 28% of men and 45% of women identified as heterosexual. INTERPRETATION: There is large variation in the size of sexual minority populations depending on the dimension applied, with implications for the design of epidemiological studies, targeting and monitoring of public health interventions and estimating population-based denominators. There is also substantial diversity on an individual level between identity, behaviour and attraction, adding to the complexity of delivering appropriate services and interventions.

Asking about Sex in General Health Surveys: Comparing the Methods and Findings of the 2010 Health Survey for England with Those of the Third National Survey of Sexual Attitudes and Lifestyles.

OBJECTIVES: Including questions about sexual health in the annual Health Survey for England (HSE) provides opportunities for regular measurement of key public health indicators, augmenting Britain's decennial National Survey of Sexual Attitudes and Lifestyles (Natsal). However, contextual and methodological differences may limit comparability of the findings. We examine the extent of these differences between HSE 2010 and Natsal-3 and investigate their impact on parameter estimates. METHODS: Complex survey analyses of data from men and women in the 2010 HSE (n = 2,782 men and 3,588 women) and Natsal-3 undertaken 2010-2012 (n = 4,882 men and 6,869 women) aged 16-69y and resident in England, both using probability sampling, compared their characteristics, the amount of non-response to, and estimates from, sexual health questions. Both surveys used self-completion for the sexual behaviour questions but this was via computer-assisted self-interview (CASI) in Natsal-3 and a pen-and-paper questionnaire in HSE 2010. RESULTS: The surveys achieved similar response rates, both around 60%, and demographic profiles largely consistent with the census, although HSE participants tended to be less educated, and reported worse general health, than Natsal-3 participants. Item non-response to the sexual health questions was typically higher in HSE 2010 (range: 9-18%) relative to Natsal-3 (all <5%). Prevalence estimates for sexual risk behaviours and STI-related indicators were generally slightly lower in HSE 2010 than Natsal-3. CONCLUSIONS: While a relatively high response to sexual health questions in HSE 2010 demonstrates the feasibility of asking such questions in a general health survey, differences with Natsal-3 do exist. These are likely due to the HSE's context as a general health survey and methodological limitations such as its current use of pen-and-paper questionnaires. Methodological developments to the HSE should be considered so that its data can be interpreted in combination with those from dedicated sexual health surveys, thus improving our ability to monitor trends in sexual health.

Socioeconomic position and subjective oral health: findings for the adult population in England, Wales and Northern Ireland.

BACKGROUND: The objective of this study was to assess socioeconomic inequalities in subjective measures of oral health in a national sample of adults in England, Wales and Northern Ireland. METHODS: We analysed data from the 2009 Adult Dental Health Survey for 8,765 adults aged 21 years and over. We examined inequalities in three oral health measures: self-rated oral health, Oral Health Impact Profile (OHIP-14), and Oral Impacts on Daily Performance (OIDP). Educational attainment, occupational social class and household income were included as socioeconomic position (SEP) indicators. Multivariable logistic regression models were fitted and from the regression coefficients, predictive margins and conditional marginal effects were estimated to compare predicted probabilities of the outcome across different SEP levels. We also assessed the effect of missing data on our results by re-estimating the regression models after imputing missing data. RESULTS: There were significant differences in predicted probabilities of the outcomes by SEP level among dentate, but not among edentate, participants. For example, persons with no qualifications showed a higher predicted probability of reporting bad oral health (9.1 percentage points higher, 95% CI: 6.54, 11.68) compared to those with a degree or equivalent. Similarly, predicted probabilities of bad oral health and oral impacts were significantly higher for participants in lower income quintiles compared to those in the highest income level (p < 0.001). Marginal effects for all outcomes were weaker for occupational social class compared to education or income. Educational and income-related inequalities were larger among young people and non-significant among 65+ year-olds. Using imputed data confirmed the aforementioned results. CONCLUSIONS: There were clear socio-economic inequalities in subjective oral health among adults in England, Wales and Northern Ireland with stronger gradients for those at younger ages.

Using a Health in All Policies approach to address social determinants of sexually transmitted disease inequities in the context of community change and redevelopment.

OBJECTIVES: We used a Health in All Policies (HiAP) framework to determine what data, policy, and community efficacy opportunities exist for improving sexual health and reducing sexually transmitted diseases (STDs) in an area surrounding an Army base undergoing redevelopment in Atlanta, Georgia. METHODS: We conducted a literature review, consulted with experts, mapped social determinants in the community, conducted key informant interviews with community leaders to explore policy solutions, used Photovoice with community members to identify neighborhood assets, and shared data with all stakeholder groups to solicit engagement for next steps. RESULTS: We identified the following HiAP-relevant determinants of STD inequities in the literature: education, employment, male incarceration, drug and alcohol marketing, and social capital. Quantitative data confirmed challenges in education, employment, and male incarceration in the area. Interviews identified policy opportunities such as educational funding ratios, Community Hire Agreements, code and law enforcement, addiction and mental health resources, lighting for safety, and a nonemergency public safety number. Photovoice participants identified community assets to protect including family-owned businesses, green spaces, gathering places, public transportation resources, historical sites, and architectural elements. Stakeholder feedback provided numerous opportunities for next steps. CONCLUSIONS: This study contributes to the HiAP literature by providing an innovative mixed-methods design that locates social determinants of STDs within a geographic context, identifies policy solutions from local leaders, highlights community assets through the lens of place attachment, and engages stakeholders in identifying next steps. Findings from this study could inform other redevelopments, community-based studies of STDs, and HiAP efforts.

Obstetrician-gynecologists' knowledge, attitudes and practices regarding major depressive disorder.

BACKGROUND: Obstetrician-gynecologists (ob-gyns) provide depression screening and treatment, but these practices could be improved. This study investigated the use of depression screening tools and treatment of adolescents with depressive symptoms. METHODS: Surveys were sent to 220 members of the American College of Obstetricians and Gynecologists (ACOG) who had responded to a survey on depression in the past two years. Response rate was 66% (n = 145). Questions included those related to standardized depression screening, antidepressant prescribing behavior, use of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) and knowledge of adolescent depression. RESULTS: A total of 40% use standardized screening tools for depression with 46% using the Beck Depression Inventory-II and only 5% using the Patient Health Questionnaire-2 (PHQ-2). The majority (89%) of ob-gyns do not employ the DSM-IV to confirm a diagnosis of major depressive disorder. Of the ob-gyns indicating treating depression with antidepressants, 97% prescribe selective serotonin reuptake inhibitors. Only 19 respondents do not prescribe antidepressants, and instead refer depressed patients to mental health specialists. Most (79%) ob-gyns identified sexual problems as the primary side effect deterring prescribing of antidepressant medication. Ob-gyns were fairly accurate at estimating the prevalence of adolescent depression. CONCLUSION: Ob-gyns are not utilizing the recommended validated resources such as the DSM-IV or PHQ-2 for diagnosis of depression or prior to prescribing antidepressants.