Review: Improving access to mental health interventions for children from birth to five years: A Scoping Review.

BACKGROUND: In spite of infants and children aged 0-5 years experiencing mental health difficulties being estimated to be in the range of 6%-18% globally, the mental health care needs for this age group are often overlooked in the design of specialist mental health services. Although there is increasing recognition of the importance of infant mental health services and treatments for younger children, access remains a barrier. Mental health services specifically designed for children 0-5 years are vital; however, little is known about how these services ensure access for infants at risk of mental health difficulties and their families. This scoping review seeks to address this knowledge gap. METHODS: A scoping review methodology framework was used to search for relevant articles published between January 2000 and July 2021, identified using five databases: MEDLINE, CINAHL, PsycINFO, SocIndex and Web of Science. The selection of studies was based on empirical research about access to infant mental health services and models of care. A total of 28 relevant articles met the eligibility criteria for inclusion in this review. RESULTS: Findings can be summarised under five broad themes: (1) accessibility for at-risk populations (2) the importance of early detection of infants in need of mental health services and interventions; (3) the promotion of culturally responsive services and interventions; (4) ensuring the sustainability of IMH services and programs and (5) the integration of innovative interventions to improve existing practice models. CONCLUSIONS: The findings from this scoping review highlight barriers to access and provision of infant mental health services. Future infant mental health service design, informed by research, is needed to improve access for infants and young children with mental health difficulties and their families.

Outpatient encounters, continuity of care, and unplanned hospital care for children and young people with cerebral palsy.

AIM: To describe the relationships between outpatient encounters, continuity of care, and unplanned hospital care in children/young people with cerebral palsy (CP). METHOD: In this population-based data-linkage cohort study we included children/young people with CP identified in the New South Wales/Australian Capital Territory CP Register (birth years 1994-2018). We measured the frequency of outpatient encounters and unplanned hospital care, defined as presentations to emergency departments and/or urgent hospital admissions (2015-2020). Continuity of outpatient care was measured using the Usual Provider of Care Index (UPCI). RESULTS: Of 3267 children/young people with CP, most (n = 2738, 83.8%, 57.6% male) had one or more outpatient encounters (123 463 total encounters, median six outpatient encounters per year during childhood). High UPCI was more common in children/young people with mild CP (Gross Motor Function Classification System levels I-III, with no epilepsy or no intellectual disability), residing in metropolitan and areas of least socioeconomic disadvantage. Low UPCI was associated with four or more emergency department presentations (adjusted odds ratio [aOR] 2.34; 95% confidence interval [CI] 1.71-3.19) and one or more urgent hospital admissions (aOR 2.02; 95% CI 1.57-2.61). INTERPRETATION: Children/young people with CP require frequent outpatient services. Improving continuity of care, particularly for those residing in regional/remote areas, may decrease need for unplanned hospital care.

Unifying Activity, Structure, and Spectroscopy of [NiFe] Hydrogenases: Combining Techniques To Clarify Mechanistic Understanding.

Achieving a unified understanding of the mechanism of a multicenter redox enzyme such as [NiFe] hydrogenase is complicated by difficulties in reconciling information obtained by using different techniques and on samples in different physical forms. Measurements of the activity of the enzyme, and of factors which perturb activity, are generally carried out using biochemical assays in solution or with electrode-immobilized enzymes using protein film electrochemistry (PFE). Conversely, spectroscopy aimed at reporting on features of the metalloclusters in the enzyme, such as electron paramagnetic resonance (EPR) or X-ray absorption spectroscopy (XAS), is often conducted on frozen samples and is thus difficult to relate to catalytically relevant states as information about turnover and activity has been lost. To complicate matters further, most of our knowledge of the atomic-level structure of metalloenzymes comes from X-ray diffraction studies in the solid, crystalline state, which are again difficult to link to turnover conditions. Taking [NiFe] hydrogenases as our case study, we show here how it is possible to apply infrared (IR) spectroscopic sampling approaches to unite direct spectroscopic study with catalytic turnover. Using a method we have named protein film IR electrochemistry (PFIRE), we reveal the steady-state distribution of intermediates during catalysis and identify catalytic "bottlenecks" introduced by site-directed mutagenesis. We also show that it is possible to study dynamic transitions between active site states of enzymes in single crystals, uniting solid state and solution spectroscopic information. In all of these cases, the spectroscopic data complement and enhance interpretation of purely activity-based measurements by providing direct chemical insight that is otherwise hidden. The [NiFe] hydrogenases possess a bimetallic [NiFe] active site, coordinated by CO and CN- ligands, linked to the protein via bridging and terminal cysteine sulfur ligands, as well as an electron relay chain of iron sulfur clusters. Infrared spectroscopy is ideal for probing hydrogenases because the CO and CN- ligands are strong IR absorbers, but the suite of IR-based approaches we describe here will be equally valuable in studying substrate- or intermediate-bound states of other metalloenzymes where key mechanistic questions remain open, such as nitrogenase, formate dehydrogenase, or carbon monoxide dehydrogenase. We therefore hope that this Account will encourage future studies which unify information from different techniques across bioinorganic chemistry.

How do junior doctors in the UK learn to provide end of life care: a qualitative evaluation of postgraduate education.

BACKGROUND: The fundamental importance of good end of life care has been well documented however recent national publications have high-lighted inadequacies in training in this area. For many patients dying in the UK today care is provided in hospital and the number of inpatient deaths is forecast to climb significantly in future. The demands of providing medical care for these patients by junior doctors will continue to rise. However, there is currently only limited research on training for doctors in this setting. METHODS: A qualitative study using semi-structured interviews of trainees working in general medicine analysed utilising a grounded theory approach. RESULTS: Eleven medical trainees from nine different medical schools participated. They had worked in fifteen different UK hospitals in the course of their careers. All of the doctors interviewed felt generally confident in managing a dying patient. This had developed at postgraduate level and increased when working in certain key specialties. Emerging themes fell into five main categories: perceived ability in clinical management, different learning opportunities experienced, the impact of variations in approach to end of life care, the role of the specialist palliative care team and suggestions for improvements to training. All participants felt further teaching would be beneficial. CONCLUSIONS: This study identified key areas where training could be improved. This included small changes in everyday practice to shift the emphasis for trainees to education. There also needs to be focus on end of life care in the curriculum, formal teaching programmes and assessment of junior doctors. The specialist palliative care team played a vital role in training as well as service provision. For those working in this specialty, every clinical encounter provides an opportunity for education. Specifically targeting junior doctors will not only improve patient care today but empower the consultants of the future.

The crystalline state as a dynamic system: IR microspectroscopy under electrochemical control for a [NiFe] hydrogenase.

Controlled formation of catalytically-relevant states within crystals of complex metalloenzymes represents a significant challenge to structure-function studies. Here we show how electrochemical control over single crystals of [NiFe] hydrogenase 1 (Hyd1) from Escherichia coli makes it possible to navigate through the full array of active site states previously observed in solution. Electrochemical control is combined with synchrotron infrared microspectroscopy, which enables us to measure high signal-to-noise IR spectra in situ from a small area of crystal. The output reports on active site speciation via the vibrational stretching band positions of the endogenous CO and CN- ligands at the hydrogenase active site. Variation of pH further demonstrates how equilibria between catalytically-relevant protonation states can be deliberately perturbed in the crystals, generating a map of electrochemical potential and pH conditions which lead to enrichment of specific states. Comparison of in crystallo redox titrations with measurements in solution or of electrode-immobilised Hyd1 confirms the integrity of the proton transfer and redox environment around the active site of the enzyme in crystals. Slowed proton-transfer equilibria in the hydrogenase in crystallo reveals transitions which are only usually observable by ultrafast methods in solution. This study therefore demonstrates the possibilities of electrochemical control over single metalloenzyme crystals in stabilising specific states for further study, and extends mechanistic understanding of proton transfer during the [NiFe] hydrogenase catalytic cycle.

Doctors with Asperger's: the impact of a diagnosis.

BACKGROUND: Asperger syndrome (AS) is part of a spectrum of disorders encompassing difficulties with social interaction that may result in specific educational needs for doctors in training. There is currently limited research on the impact of AS on working as a doctor. METHODS: This is a qualitative study using semi-structured interviews to explore the perceptions of trainees diagnosed with AS following input from a professional support service, and the perspectives of the staff involved in their professional development. FINDINGS: Receiving a diagnosis of AS was viewed as a double-edged sword, allowing the development of insight into lifelong difficulties, but also creating the potential for prejudice. Understanding AS traits provided an explanation for challenges in the workplace and therefore opportunities to find solutions. Understanding AS traits provided an explanation for challenges in the workplace DISCUSSION: This study explores the benefits and disadvantages of defining and labelling a specific professional support need for a group of trainees. It also reveals the need for improved awareness of AS amongst all clinical educators.

Do trainees feel that they belong to a team?

BACKGROUND: Postgraduate medical education has undergone significant reorganisation in recent years, with changes to the traditional apprenticeship model and an increasing reliance on shift working. The importance of teamwork in clinical care is well established; however, there is little literature on the extent to which trainees actually feel part of a team in the context of current working patterns. METHOD: This is a qualitative study using semi-structured interviews of medical and surgical trainees. Data were analysed thematically using an inductive qualitative approach. RESULTS: Fifteen trainees who had worked in a range of hospitals across the UK participated. Emerging themes fell into several categories: what constitutes the team; the effect of shift patterns on the team; the role of the team in education, support and well-being; and influences on team rapport. Whilst in general interviewees felt part of a team, this was not true for all posts. The nature of the team was also highly variable, and had evolved from the traditional 'Firm' structure to a more nebulous concept. Shift-working patterns could result in the fragmentation of the team, which had implications for patient care as well as for training. DISCUSSION: The team played an important role in both education and well-being for trainees, and several factors were identified that could engender a more supportive team. With an ageing population and with increasing demands on limited resources, the requirement for shift work is likely to increase, and there is a fundamental need to maintain support for the next generation of doctors. There is little literature on the extent to which trainees actually feel part of a team.

Exhaled nitric oxide monitoring does not reduce exacerbation frequency or inhaled corticosteroid dose in paediatric asthma: a randomised controlled trial.

INTRODUCTION: Inhaled corticosteroid therapy (ICS) for asthma is currently modified according to symptoms and lung function. Fractional exhaled nitric oxide (FENO) has been demonstrated to be a non-invasive marker of eosinophilic inflammation. Studies of FENO-driven asthma management show variable success. Objectives: This study aimed to evaluate whether monitoring FENO can improve outpatient management of children with moderate to severe asthma using a pragmatic design. METHODS: Children aged 6­17 years with moderate to severe asthma were recruited. Their asthma was stabilised before randomisation to FENO-driven therapy or to a standard management group where therapy was driven by conventional markers of asthma control. ICS or long-acting bronchodilator therapies were altered according to FENO levels in combination with reported symptoms in the FENO group. Participants were assessed 2 monthly for 12 months. ICS dose and exacerbation frequency change were compared between groups in an intention to treat analysis. RESULTS: Ninety children were randomised. No difference was found between the two groups in either change in corticosteroid dose or exacerbation frequency. Results were similar in a planned secondary analysis of atopic asthmatics. CONCLUSION: FENO-guided ICS titration does not appear to reduce corticosteroid usage or exacerbation frequency in paediatric outpatients with moderate to severe asthma. This may reflect limitations in FENO-driven management algorithms, as there are now concerns that FENO levels relate to atopy as much as they relate to asthma control.