Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020.

BACKGROUND: Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment. METHODS: Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined. RESULTS: The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020. CONCLUSION: Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

Assessing Adolescent Functioning from Different Perspectives: Extending the Validation of the Adolescent Functioning Scale (AFS).

The study aimed to provide further evidence for the validity of the 33-item Adolescent Functioning Scale (AFS) as a parent- and adolescent-report scale of adolescent adjustment. In separate samples of parents (N = 542; 88% female) and adolescents (N = 303; 60% female), confirmatory factor analyses supported the original 4-factor structure of the AFS. Analyses produced a 28-item parent measure, and a 27-item adolescent measure. Parent and adolescent versions included positive development, oppositional behaviour, antisocial behaviour and emotional problems subscales. Evidence for convergent and construct validity was provided through correlations with existing measures of adolescent functioning and parenting. The AFS demonstrated configural and metric invariance, but not scalar variance. The study provided support for the validity and reliability of the revised AFS for parents and adolescents. The strong psychometric properties, and brief and multi-dimensional nature of the AFS means that it will have utility in research and applied contexts.

Psychological trajectories of mothers and fathers following their child's diagnosis of a life-threatening illness or injury: A longitudinal investigation.

OBJECTIVE: Explore the mental health trajectories of parents following their child's life-threatening illness/injury. METHODS: Participants were 217 parents (mean age: 34.9-40.0; 66 fathers) of 165 children who presented to a tertiary hospital with a life-threatening illness/injury. Parents completed questionnaires about their mental health and psychosocial stressors within 4 weeks of the child's illness/injury (T1), and 4 months (T2), 7 months (T3), and 19 months (T4) postdiagnosis. RESULTS: For both mothers and fathers, mental health symptoms were elevated at diagnosis declining to normal levels by T3, with a pattern of increase at T4. Fathers demonstrated a faster decline in symptoms between T1 and T2, and fathers, but not mothers, experienced a relapse in depressive symptoms at T4. Fathers reported higher rates of work changes. CONCLUSIONS: These findings have important implications for the design and timing of parental interventions to support families of children with life-threatening disease/injury.

Featured Article: Trajectories of Posttraumatic Stress Symptoms in Parents of Children With a Serious Childhood Illness or Injury.

Objective: Serious childhood illness is associated with significant parent psychological distress. This study aimed to (a) document acute and posttraumatic stress symptoms (PTSS) in parents of children with various life-threatening illnesses; (b) identify trajectory patterns of parental PTSS and recovery over 18 months; (c) determine psychosocial, demographic, and illness factors associated with trajectory group membership. Methods: In total, 159 parents (115 mothers, 44 fathers) from 122 families participated in a prospective, longitudinal study that assessed parent psychological responses across four time points-at diagnosis, and 3, 6, and 18 months later. Children were admitted to the Cardiology, Oncology, and Pediatric Intensive Care Departments in a tertiary pediatric hospital. The primary outcome was parent PTSS. Results: Three distinct parent recovery profiles were identified-"Resilient," "Recovery," and "Chronic." The "Resilient" class (33%) showed low distress responses across the trajectory period, whereas the "Recovery" class (52%) showed significantly higher levels of distress at the time of diagnosis that gradually declined over the first months following their child's illness. Both of these classes nevertheless remained within the normative range throughout. In contrast, the "Chronic" class (13%) was consistently high in severity, remaining within the clinical range across the entire period. Psychosocial factors such as mood, anxiety, and emotional responses predicted group membership, whereas demographic and illness factors did not. Conclusions: Parents show considerable resilience in the face of children's life-threatening illnesses. Early assessment of parent psychosocial factors may aid identification of those who would benefit from early intervention.

Measuring cancer-specific child adjustment difficulties: Development and validation of the Children's Oncology Child Adjustment Scale (ChOCs).

BACKGROUND: Childhood cancer is associated with child adjustment difficulties including, eating and sleep disturbance, and emotional and other behavioral difficulties. However, there is a lack of validated instruments to measure the specific child adjustment issues associated with pediatric cancer treatments. The aim of this study was to develop and evaluate the reliability and validity of a parent-reported, child adjustment scale. PROCEDURE: One hundred thirty-two parents from two pediatric oncology centers who had children (aged 2-10 years) diagnosed with cancer completed the newly developed measure and additional measures of child behavior, sleep, diet, and quality of life. Children were more than 4 weeks postdiagnosis and less than 12 months postactive treatment. Factor structure, internal consistency, and construct (convergent) validity analyses were conducted. RESULTS: Principal component analysis revealed five distinct and theoretically coherent factors: Sleep Difficulties, Impact of Child's Illness, Eating Difficulties, Hospital-Related Behavior Difficulties, and General Behavior Difficulties. The final 25-item measure, the Children's Oncology Child Adjustment Scale (ChOCs), demonstrated good internal consistency (α = 0.79-0.91). Validity of the ChOCs was demonstrated by significant correlations between the subscales and measures of corresponding constructs. CONCLUSION: The ChOCs provides a new measure of child adjustment difficulties designed specifically for pediatric oncology. Preliminary analyses indicate strong theoretical and psychometric properties. Future studies are required to further examine reliability and validity of the scale, including test-retest reliability, discriminant validity, as well as change sensitivity and generalizability across different oncology samples and ages of children. The ChOCs shows promise as a measure of child adjustment relevant for oncology clinical settings and research purposes.

Psychosocial, Demographic, and Illness-Related Factors Associated With Acute Traumatic Stress Responses in Parents of Children With a Serious Illness or Injury.

This study investigated factors associated with acute stress symptoms in parents of seriously ill children across a range of illnesses and treatment settings within a pediatric hospital setting. It was hypothesized that psychosocial variables would be more strongly associated with acute stress responses than demographic and child illness variables. Participants were 115 mothers and 56 fathers of children treated within the oncology, cardiology, and intensive care departments of a pediatric hospital. Acute stress, psychosocial, demographic, and medical data were collected within the first 4 weeks of the child's hospital admission. A robust hierarchical regression model revealed that psychosocial factors significantly explained 36.8% of the variance in parent acute stress responses (p < .001); demographic variables significantly added a further 4.5% (p = .022), but illness-related factors did not contribute to the model. Findings support the implementation of a general psychosocial screening approach for parents across the wider hospital system, and that psychosocial risk factors may be targeted in interventions across different illnesses and treatment settings to improve parent outcomes.

Family Psychosocial Risk Screening in Infants and Older Children in the Acute Pediatric Hospital Setting Using the Psychosocial Assessment Tool.

OBJECTIVE: To examine the validity of the Psychosocial Assessment Tool (PAT) with families of infants (<2 years) and children admitted to hospital with acute life-threatening illnesses. METHODS: A total of 235 parents of 177 children admitted to oncology, cardiology, or pediatric intensive care completed the PAT and measures of acute stress, trait anxiety, family functioning, and quality of life, a mean 3.7 weeks following diagnosis. A modified PAT was used for families of infants, rendering two forms, PAT (<2) and PAT (2+). RESULTS: Psychometrics for PAT (<2) and PAT (2+) were acceptable. PAT Total and Subscale scores for each version were significantly correlated with validation measures. Internal consistency for PAT subscales was variable. Receiver Operating Characteristics provided some support for PAT cutoffs. PAT scores across illness groups were comparable. CONCLUSIONS: This study provides promising support for the PAT as a psychosocial screener for families of infants and older children across illness conditions.

Take A Breath: study protocol for a randomized controlled trial of an online group intervention to reduce traumatic stress in parents of children with a life threatening illness or injury.

BACKGROUND: A substantial proportion of parents whose child is diagnosed with a life-threatening illness, experience high levels of distress that can lead to long-term difficulties in mental health, family functioning and child adjustment. This study evaluates the efficacy of an Acceptance Commitment Therapy-based group intervention designed to reduce distress symptoms in these parents. The program is delivered using videoconferencing to overcome factors that prevent participation in traditional face-to-face therapy. METHOD/DESIGN: The study is a randomized control trial of the Take A Breath group intervention for parents demonstrating elevated symptoms of acute stress, delivered via videoconferencing in six 90 min group sessions. Participants are the primary caregivers of children aged 0 to 18 years admitted for a life threatening illness or injury to the Oncology, Cardiology, Neurology or Intensive Care Departments of a tertiary pediatric hospital. Parents will be randomized to intervention or waitlist control 4-10 months after their child's diagnosis. Measures will be collected prior to and immediately post intervention for intervention and waitlist parents to assess program efficacy. Intervention parents will be followed up at 6 months to assess the maintenance of program effects. We predict that intervention parents will show fewer symptoms post intervention than waitlist parents (primary outcomes: traumatic stress, depression, anxiety, stress symptoms), reflecting improvements in the psychological skills addressed in the intervention (mediating factors). It is anticipated that reductions in mental health difficulties for intervention parents will be maintained up to 6 months post-intervention and will be associated with broader improvements in parents' adjustment, child adjustment and child wellbeing (secondary outcomes). DISCUSSION: This study is unique in evaluating a group intervention delivered to parents of children affected by of a diverse range life-threatening illness or injury. Online communication technology is employed to reduce participation barriers. If proven efficacious, this trans-diagnostic approach offers the potential for broad use as part of the suite of psychosocial services provided to families through tertiary pediatric settings. TRIAL REGISTRATION: ACTRN12611000090910 . Trial Registration Date: 14/09/2011 Protocol Date/version: September 2015, version M Study Status: Ongoing.

Measuring positive and negative aspects of youth behavior: Development and validation of the Adolescent Functioning Scale.

This paper outlines the development and validation of the Adolescent Functioning Scale (AFS) in an Australian sample of parents of young people aged 11-18 years (N = 278). The AFS, a parent self-report measure, was designed to assess problem behavior and positive development in adolescents. Principal components analysis produced a 33-item measure comprising four subscales: Positive Development, Oppositional Defiant Behavior, Antisocial Behavior and Emotional Difficulties. Convergent validity was established via correlations between the AFS and established measures of adolescent functioning and parenting, and discriminant validity was shown through no association between the AFS and a measure of technology use. Internal consistency for the subscales was high (H = .82-.92 for different age groups), as was test-retest reliability (r = .77-.86). The study indicated that the AFS is a potentially valuable tool for assessing levels of problem behaviors and positive development in adolescents.

Parent distress reactions following a serious illness or injury in their child: a protocol paper for the take a Breath Cohort Study.

BACKGROUND: Diagnosis of life threatening childhood illness or injury can lead to significant distress reactions in parents, with many experiencing clinically significant levels of post-traumatic stress symptoms. These symptoms can have long-term adverse impacts on parent mental health, family functioning, and the adjustment of the ill child. Independent studies have found such reactions in several different illness groups. However, very little research has systematically compared the prevalence, impact and trajectories over time of post-traumatic stress symptoms in parents across different childhood illness groups with an acute life threat. The current study seeks to map the course of post-traumatic stress reactions in parents of children with various life threatening illnesses over an 18 month period, and identify factors that predict successful adaptation in families. METHOD/DESIGN: The current study described is of a prospective, longitudinal design. The sample included parents of children admitted to four major hospital departments at the Royal Children's Hospital, Melbourne, Australia, for a life threatening illness or injury. Eligible parents were those who were caregivers of children aged 0-to 18-years admitted to the Oncology, Cardiology, Neurology and Pediatric Intensive Care Unit. Parents were recruited acutely, and completed self-report questionnaires at four time-points: within the first 4 weeks (T1:); then at 4 months (T2); 7 months (T3); and 19 months (T4) after admission. Questionnaires assessed parent and child mental health and wellbeing, and a number of risk and reliance factors such child illness factors, parent demographic factors, and psychosocial factors. DISCUSSION: This study is one of the first to document the trajectory of post-traumatic stress responses in parents of very ill children, across illness groups. Given that it will also identify risk and resilience factors, and map the course of parent outcomes over an 18 monthperiod, it has the potential to inform novel strategies for intervention.

Development of the Parental Psychological Flexibility Questionnaire.

This paper describes development and validation of the Parental Psychological Flexibility (PPF) Questionnaire, a parent-report measure designed to assess psychological flexibility among parents of pre-adolescents and adolescents (aged 10-18 years). Psychological flexibility within parenting refers to parents' accepting negative thoughts, emotions and urges about one's child and still acting in ways that are consistent with effective parenting. Exploratory factor analysis (n = 178 parents) of a 43-item draft measure, resulted in a 30-item, 3-factor structure. Three subscales were created, consistent with the psychological flexibility literature: acceptance, cognitive defusion and committed action. A second sample of parents (n = 192) was then used to confirm the factor structure and reliability and validity of the PPF. Results supported the 3-factor structure, reduced the number of items to 19 and demonstrated that the PPF subscales have adequate reliability and validity and are thus suitable for researching psychological flexibility among parents of pre-adolescents and adolescents.

Psychosocial risk in families of infants undergoing surgery for a serious congenital heart disease.

OBJECTIVE: The aim of this study was to explore the acute psychosocial risk in families with infants undergoing surgery for a congenital heart disease and, secondarily, to explore the psychosocial impact of antenatal versus post-natal diagnoses. METHOD: The study sample comprised 39 caregivers (28 mothers) of 29 children diagnosed with a congenital heart disease and requiring surgery within the first 4 weeks of life. Psychosocial risk was measured using the Psychosocial Assessment Tool, which was adapted to include four novel items examining infant risk factors, namely, sleeping, feeding, crying, and bonding difficulties. Parents' psychosocial risk was measured within 4 weeks after their child's surgery and stratified into a three-tiered framework: Universal, Targeted, and Clinical risk. RESULTS: Of the total sample, 61.5% of parents were classified as Universal, that is, at lowest risk; 35.9% as Targeted, and 2.6% as Clinical. The within-family parent total Psychosocial Assessment Tool score correlations were non-significant, and there were no differences between families of infants who received post-natal versus antenatal diagnosis or single ventricle versus biventricular repair. Linear regression found that a higher parent education significantly predicted a lower total Psychosocial Assessment Tool score. CONCLUSIONS: Findings indicate that, although the majority of parents adapt to the acute stress of surgery for a serious cardiac illness in their infant, the remaining 38.5% report an increased psychosocial risk associated with higher rates of emotional distress, which may impact on the parental quality of life and capacity for optimal parenting. The distribution of psychosocial risk in parents of children undergoing surgery for a congenital heart disease is consistent with that described for parents of children with other serious paediatric diagnoses.

A bacteriophage-based validation of a personal protective equipment doffing procedure to be used with high-consequence pathogens.

OBJECTIVE: To determine if the high-level personal protective equipment used in the treatment of high-consequence infectious diseases is effective at stopping the spread of pathogens to healthcare personnel (HCP) while doffing. BACKGROUND: Personal protective equipment (PPE) is fundamental to the safety of HCPs. HCPs treating patients with high-consequence infectious diseases use several layers of PPE, forming complex protective ensembles. With high-containment PPE, step-by-step procedures are often used for donning and doffing to minimize contamination risk to the HCP, but these procedures are rarely empirically validated and instead rely on following infection prevention best practices. METHODS: A doffing protocol video for a high-containment PPE ensemble was evaluated to determine potential contamination pathways. These potential pathways were tested using fluorescence and genetically marked bacteriophages. RESULTS: The experiments revealed existing protocols permit contamination pathways allowing for transmission of bacteriophages to HCPs. Updates to the doffing protocols were generated based on the discovered contamination pathways. This updated doffing protocol eliminated the movement of viable bacteriophages from the outside of the PPE to the skin of the HCP. CONCLUSIONS: Our results illustrate the need for quantitative, scientific investigations of infection prevention practices, such as doffing PPE.

Parenting, Child Maltreatment, and Social Disadvantage: A Population-Based Implementation and Evaluation of the Triple P System of Evidence-Based Parenting Support.

Child Maltreatment (CM) is a widespread public health problem, with adverse outcomes for children, families, and communities. Evidence-based parenting support delivered via a public health approach may be an effective means to prevent CM. The Every Family 2 population trial applied a public health approach to delivering evidence-based parenting support to prevent CM in disadvantaged communities. Using a quasi-experimental design, 64 matched low socioeconomic communities in the Australian states of Queensland and New South Wales received either the full multi-level Triple P system (TPS) of parenting support, or Care as Usual (CAU). Two population indicators of CM, the number of substantiated cases of CM, and the number of notifications of CM to protective services were compared using Welch's t-test to evaluate intervention effectiveness. After two years of intervention, medium to large effect sizes favoring TPS communities were found for substantiations (d = 0.57, p < .05) and notifications (d = 1.86, p < .001). These findings show the value of the TPS, deployed using a public health approach, in efforts to prevent CM in socially disadvantaged communities. A number of uncontrolled contextual factors are described that may have contributed to some of the differences detected between TPS and CAU communities.

Improving mental health of adolescents with Type 1 diabetes: protocol for a randomized controlled trial of the Nothing Ventured Nothing Gained online adolescent and parenting support intervention.

BACKGROUND: Management of Type 1 diabetes comes with substantial personal and psychological demands particularly during adolescence, placing young people at significant risk for mental health problems. Supportive parenting can mitigate these risks, however the challenges associated with parenting a child with a chronic illness can interfere with a parent's capacity to parent effectively. Interventions that provide support for both the adolescent and their parents are needed to prevent mental health problems in adolescents; to support positive parent-adolescent relationships; and to empower young people to better self-manage their illness. This paper presents the research protocol for a study evaluating the efficacy of the Nothing Ventured Nothing Gained online adolescent and parenting intervention which aims to improve the mental health outcomes of adolescents with Type 1 diabetes. METHOD/DESIGN: A randomized controlled trial using repeated measures with two arms (intervention and wait-list control) will be used to evaluate the efficacy and acceptability of the online intervention. Approximately 120 adolescents with Type 1 diabetes, aged 13-18 years and one of their parents/guardians will be recruited from pediatric diabetes clinics across Victoria, Australia. Participants will be randomized to receive the intervention immediately or to wait 6 months before accessing the intervention. Adolescent, parent and family outcomes will be assessed via self-report questionnaires at three time points (baseline, 6 weeks and 6 months). The primary outcome is improved adolescent mental health (depression and anxiety). Secondary outcomes include adolescent behavioral (diabetes self-management and risk taking behavior), psychosocial (diabetes relevant quality of life, parent reported child well-being, self-efficacy, resilience, and perceived illness benefits and burdens); metabolic (HbA1c) outcomes; parent psychosocial outcomes (negative affect and fatigue, self-efficacy, and parent experience of child illness); and family outcomes (parent and adolescent reported parent-adolescent communication, responsibility for diabetes care, diabetes related conflict). Process variables including recruitment, retention, intervention completion and intervention satisfaction will also be assessed. DISCUSSION: The results of this study will provide valuable information about the efficacy, acceptability and therefore the viability of delivering online interventions to families affected by chronic illnesses such as Type 1 diabetes. TRIAL REGISTRATION: Australian New Zealand clinical trials registry (ANZCTR); ACTRN12610000170022.

The Prevalence of PTSD of Mothers and Fathers of High-Risk Infants Admitted to NICU: A Systematic Review.

Admission of a preterm or sick full-term infant to the neonatal intensive care unit (NICU) is a stressful experience for parents. Indeed, the 'NICU experience' may constitute a traumatic event for parents, distinct from other birth-related trauma, leading to significant and ongoing posttraumatic stress disorder (PTSD) symptoms. However, the rates at which this outcome occurs are not well understood. This review aimed to identify the prevalence of PTSD in mothers and fathers of high-risk infants admitted to the NICU, specifically focusing on the NICU experience as the index trauma. The PRISMA-P: Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols were used to conduct this review. We searched PsycINFO, PubMed, Scopus, EMBASE, Web of Science, ProQuest Dissertations and Theses databases, and reference lists of included articles (1980-2021). Two independent reviewers screened titles and abstracts and conducted the full-text screening assessment. Of the 707 records identified, seven studies met the inclusion criteria. In this systematic review, PTSD symptomatology was assessed by self-report measures rather than a clinical interview. We identified significant variations in the methodologies and quality between studies, with a wide variation of reported prevalence rates of PTSD of 4.5-30% in mothers and 0-33% in fathers. Overall, the findings indicate that up to one-third of parents experience PTSD symptomatology related to the NICU experience. These results emphasize the importance of universal routine antenatal and postnatal screening for symptoms of PTSD to identify parents at risk of distress during the NICU experience and after discharge.Trial registration: The study protocol was registered with Prospero registration number CRD42020154548 on 28 April 2020.

Family Bonds with Pets and Mental Health during COVID-19 in Australia: A Complex Picture.

The COVID-19 pandemic has drawn attention to the health-promoting features of human-animal relationships, particularly for families with children. Despite this, the World Health Organization's (1986) Ottawa Charter remains human-centric. Given the reciprocal health impacts of human-animal relationships, this paper aims to (i) describe perceived pet-related benefits, worries, and family activities; and to (ii) examine differences in perceived benefits, worries, and activities for parents and children with and without clinical mental health symptoms. We recruited 1034 Australian parents with a child < 18 years and a cat or dog via a national online survey between July and October 2020. Most parents reported their pet was helpful for their own (78%) and their child's mental health (80%). Adjusted logistic regression revealed parents with clinical psychological distress were 2.5 times more likely to be worried about their pet's care, well-being, and behaviour (OR = 2.56, p < 0.001). Clinically anxious children were almost twice as likely to live in a family who engages frequently in pet-related activities (e.g., cooked treats, taught tricks, OR = 1.82, p < 0.01). Mental health and perceived benefits of having a pet were not strongly associated. Data support re-framing the Ottawa Charter to encompass human-animal relationships, which is an often-neglected aspect of a socioecological approach to health.

Reply to Obegi, J.H. Distinguishing Prevention from Treatment in Suicide Prevention. Comment on "Turner et al. The Paradox of Suicide Prevention. Int. J. Environ. Res. Public Health 2022, 19, 14983".

One of the aims of our paper "The Paradox of Suicide Prevention" is to promote greater discourse on suicide prevention, with a particular focus on the mental health models used for the identification of, and interventions with, individuals who come into contact with tertiary mental health services [...].

Connecting pathogen transmission and healthcare worker cognition: a cognitive task analysis of infection prevention and control practices during simulated patient care.

BACKGROUND: Relatively little is known about the cognitive processes of healthcare workers that mediate between performance-shaping factors (eg, workload, time pressure) and adherence to infection prevention and control (IPC) practices. We taxonomised the cognitive work involved in IPC practices and assessed its role in how pathogens spread. METHODS: Forty-two registered nurses performed patient care tasks in a standardised high-fidelity simulation. Afterwards, participants watched a video of their simulation and described what they were thinking, which we analysed to obtain frequencies of macrocognitive functions (MCFs) in the context of different IPC practices. Performance in the simulation was the frequency at which participants spread harmless surrogates for pathogens (bacteriophages). Using a tertiary split, participants were categorised into a performance group: high, medium or low. To identify associations between the three variables-performance groups, MCFs and IPC practices-we used multiblock discriminant correspondence analysis (MUDICA). RESULTS: MUDICA extracted two factors discriminating between performance groups. Factor 1 captured differences between high and medium performers. High performers monitored the situation for contamination events and mitigated risks by applying formal and informal rules or managing their uncertainty, particularly for sterile technique and cleaning. Medium performers engaged more in future-oriented cognition, anticipating contamination events and planning their workflow, across many IPC practices. Factor 2 distinguished the low performers from the medium and high performers who mitigated risks with informal rules and sacrificed IPC practices when managing tradeoffs, all in the context of minimising cross-contamination from physical touch. CONCLUSIONS: To reduce pathogen transmission, new approaches to training IPC (eg, cognitive skills training) and system design are needed. Interventions should help nurses apply their knowledge of IPC fluidly during patient care, prioritising and monitoring situations for risks and deciding how to mitigate risks. Planning IPC into one's workflow is beneficial but may not account for the unpredictability of patient care.

Enteric Populations of Escherichia coli are Likely to be Resistant to Phages Due to O Antigen Production.

Bioinformatic and experimental data show that bacteriophages are ubiquitous in human enteric microbiomes. However, there are gaps in understanding the contribution of these viruses in shaping the bacterial strain and species composition of the gut microbiome and how these phages are maintained over time. To address these questions, we adapted and analyzed the properties of a mathematical model of the population and evolutionary dynamics of bacteria and phage and performed experiments with Escherichia coli and phages isolated from four fecal microbiota transplantation (FMT) doses as representative samples of non-dysbiotic enteric microbiota. Our models predict and experiments confirm that due to production of the O antigen, E. coli in the enteric microbiome are likely to be resistant to infection with co-occurring phages. However, phages can be maintained in these populations in high densities due to high rates of transition between resistant and sensitive states, which we call leaky resistance. Based on these models and observations, we postulate that the phages found in the human gut are likely to play little role in shaping the composition of E. coli in the enteric microbiome in healthy individuals. How general this is for other species of bacteria in enteric microbiota is not yet clear, although O antigen production is broadly conserved across many taxa.