Risk and Protective Factors of Self-harm and Suicidality in Adolescents: An Umbrella Review with Meta-Analysis.

Suicide remains the second most common cause of death in young people aged 10-24 years and is a growing concern globally. The literature reports a vast number of factors that can predispose an adolescent to suicidality at an individual, relational, community, or societal level. There is limited high-level research identifying and understanding these risk and protective factors of adolescent suicidality. The present study used an umbrella review and meta-analysis to synthesize evidence from the review literature in the past 20 years on risk and protective factors of self-harm and suicidality (behavior and ideation) in adolescents. The umbrella review included 33 quantitative reviews with 1149 individual studies on suicidality and self-harm. Based on the data synthesis, it compared the public health impact of exposure on the population of the identified exposure. Bullying victimization was the most attributed environmental exposure for suicidality. The other identified significant school and individual factors were sleeping disturbance, school absenteeism, and exposure to antidepressants. Several significant vulnerable young populations were identified with significantly higher prevalence of suicidality, including lesbian, gay, bisexual, transgender, queer (or questioning) youth and those with mental health disorders, problem behaviors, previous suicidality, self-harm, and gender (female). A person-centered approach emphasizing connectedness and bully-free school environments should be a priority focus for schools, health professionals, and public health policymakers.

Environmental Influences on the Behavioural and Emotional Outcomes of Children: A Network Analysis.

BACKGROUND: Intellectual developmental disorders are a serious source of health morbidity with negative consequences for adults as well as children. However, there is limited evidence on the environmental, trace element, behavioural, and emotional outcomes in children. Here, we investigated whether there is any association between child behaviour and emotional outcomes and micronutrients using network analysis. METHODS: A cross-sectional study was conducted in 9-year-old children within a Pacific Island Families study birth cohort. Elemental concentration was determined in children's toenails after acid digestion and analysed using inductively coupled plasma mass spectrometry. We used network analysis to identify closely associated trace elements and tested the directions and strength of these trace elements. MANCOVA were used to identify the significant associations between individual elements and the behavioural/emotional function of the children using the children behaviour checklist (CBCL). At the final step, quantile regression analysis was used to assess and quantify the identified associations between CBCL function scores and manganese, adjusted by sex, ethnicity, and standardized BMI. RESULTS: Three major nutrient networks were identified. In the Mn network, Mn was strongly positively associated with Al (0.63) and Fe (r = 0.65) and moderately associated with Pb (r = 0.45) and Sb (r = 0.42). Al was also strongly associated with Fe (r = 0.9). Children in the second or third clinical group, with an elevated externalized CBCL score, had a much higher mean and median level of Mn as compared to the normal range group. The aggression score was significantly associated with Mn concentration and sex. Higher Mn concentrations were associated with a higher aggression score. A 1 ug/g unit increase in Mn was associated with a 2.44-fold increase (95% confidence interval: 1.55-4.21) in aggression score, and boys had higher median aggression score than girls (difference: 1.7, 95% CI: 0.9-2.8). Attention and rule breaking scores were both significantly associated with Mn concentration. Higher Mn concentrations were associated with higher attention behaviour problem and rule breaking scores. A 1 ug/g unit increase in Mn was found to be associated with a 1.80-fold increase (95% confidence interval: 1.37-2.82) in attention score, and a 1.46-fold increase (95% confidence interval: 1.01-1.74) in the rule breaking score. Thought score was not significantly associated with Mn concentration (p = 0.13) but was significantly lower in boys (p = 0.004). CONCLUSIONS: Exceeding Mn levels is potentially toxic and has been identified to be associated with worse externalized children's behavioural health and emotional well-being. Future studies are necessary to find the exposure paths so that advice shall be provided to family and care providers in public health and environmental protection.

A Secondary-Primary Mental Health Integrated Care Model for Communities with Diverse Population and Complex Health Needs - a Case Study with Health Care Utilization Evaluation.

Integrated care is expected to improve patient experience, patient outcomes and assist with the increasing demand on health services from those with long term conditions including mental disorder. Few studies have evaluated health care utilization as a consequence of increased integration of mental health care. This study considers the factors known to influence secondary health service utilization and investigated the impact of a locality based mental health integrated model of care (ILoC) providing specialist consultation and liaison advice to primary care, to support early diagnosis and treatment. Using existing hospital databases, the study-cohort was identified (service users supported by ILoC, and then referred within 6 months to specialist mental health services (MHS) care between 2017- 2018) and compared on health services utilization with a matched-cohort (without ILoC support before referral to specialist services). The length-of-care in the non-acute MHS was 71% shorter for the ILoC study-cohort, and differences increased in the subgroup taking antidepressants. The ILoC study-cohort was less likely to be admitted to acute MHS on first referral post ILoC intervention and had a 25% lower relative risk of acute MHS admissions at any time in follow-up. There was no difference in the average MHS inpatient length-of-stay. The risk of general hospital acute inpatient admission was marginally higher in the ILoC study-cohort. Conclusions: ILoC appears to shorten non-acute length-of-specialist-care and reduce acute mental health admission. The study provides a first step in understanding the clinical characteristics and specialist services health-care utilization of patients supported by an integrated mental care approach.

Status and interrelationship of toenail elements in Pacific children.

OBJECTIVE: Elemental deficiencies or in excess effects growth and development. Pacific population are at a disadvantage due to food insecurity as compared to New Zealand European households. This study aims to evaluate the status and interrelationship of elements (essential, non-essential and toxic) in nine-year-old Pacific children who were part of the Pacific Island Families Study living in New Zealand. MATERIALS AND METHODS: This observational study included 278 eligible nine-year-old children. Essential elements (including calcium, chromium, cobalt, copper, iodine, iron, magnesium, manganese, selenium, zinc, molybdenum), non-essential and toxic elements (arsenic, aluminum, antimony, boron, cadmium, lead, mercury, nickel,) were determined in toenails and after acid digestion, analysed using inductively coupled plasma mass spectrometry. Principal component analysis and multivariate analysis of covariance was used to identify differences in the groups of elements and the inter-correlations between elements. RESULTS: The mean calcium (868µg/g Ca), selenium (0.35µg/g Se) and zinc (129µg/g Zn) concentrations were lower while the mean cadmium (0.21µg/g Cd) lead (0.86µg/g Pb) and mercury (0.72µg/g Hg) concentrations were higher than the optimal health requirements. Ethnic differences in relation to toenail elemental concentrations were observed for aluminium and iron. Gender differences were observed for aluminium, antimony, arsenic and lead. Selenium and molybdenum were inversely associated with mercury. Manganese, zinc and calcium were positively associated. CONCLUSIONS: This research contributes to the understanding of the elemental concentrations for Pacific children by using tissue samples from toenails, which improves the completeness of sampling than other tissues and provides a longer exposure time frame. The study also reports several inter-correlations between essential, non-essential and toxic elements in Pacific Island population.

Comparison of four methods of endotracheal tube passage in simulated airways: There is room for improved techniques.

OBJECTIVE: Endotracheal intubation requires laryngoscopy followed by passage of the endotracheal tube (ETT). Tube passage can be difficult, but there is little evidence to support which adjunct for tube passage is most effective. METHODS: The four tube passage adjuncts tested were the naked ETT, stylet ETT, railroaded bougie and preloaded bougie. Participants completed pre- and post-test surveys identifying demographics, experience and method preference. After instruction, participants completed eight intubations on manikins with 'easy' and 'difficult' airways. RESULTS: One hundred and seventeen practitioners who were experienced emergency medicine physicians, anaesthesiologists and out-of-hospital providers completed 936 total ETT attempts. For the 'difficult' airway, the percentage first pass success (95% confidence interval [CI]) for the naked ETT was 30.8% (23.1-39.7%). This was significantly lower than the stylet ETT (95.7% [86.6-100%]), the railroaded bougie (75.2% [63.8-86.6%]), or the preloaded bougie (89.7% [79.7-99.7%]). On difficult airways, the median (interquartile range [IQR]) time-to-intubation was fastest in the stylet ETT (25.0 s [20.9-32.2 s]) with the railroaded bougie being the slowest (43.2 s [36.5-56.2 s]). Seventy-nine per cent of participants stated that they would change their practice based on participating in this study. Participants increased their preference for the preloaded bougie from 30.6% to 69.4%. CONCLUSION: The data show that tube passage with a stylet ETT or a preloaded bougie is superior in terms of higher first pass success, faster time-to-intubation and higher post-test preference. The naked ETT is clearly inferior to other methods. This research supports the recommendation to use a stylet ETT or bougie for every predicted difficult intubation.