Robotic assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomised controlled trials.

The aim of this study is To compare robotic-assisted and conventional total knee arthroplasty (TKA) on both short- and long-term outcomes A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane, Scopus, and Web of Science databases were searched for relevant studies. The studies included were randomised controlled trials directly comparing robotic-assisted versus conventional TKA. The outcomes were pooled as mean difference (MD) or risk ratio (RR), with 95% confidence interval. RevMan software version 5.4 was used for performing the statistical analysis. Nine studies deemed eligible for inclusion. The data showed a significant favouring of robotic-assisted than the conventional TKA in mechanical alignment, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and femoral coronal plane outliers (MD = - 1.10, 95% CI [- 1.51, - 0.69], p < 0.00001), (MD = - 1.19, 95% CI [- 2.35, - 0.03], p = 0.04), and (RR = 0.49, 95% CI [0.30, 0.80], p = 0.004), respectively. On the other hand, conventional TKA was better in range of motion-flexion (long-term) than the robotic-assisted one (MD = - 3.02, 95% CI [- 3.68, - 2.37], p < 0.00001). There were no significant differences between them in knee society score-knee score, knee society score-function score, change in hospital for special surgery (HSS) knee rating scale, and change in range of motion-extension (MD = - 0.36, 95% CI [- 2.43, 1.70], p = 0.73), (MD = - 0.34, 95% CI [- 2.36, 1.68], p = 0.74), (MD = 0.78, 95% CI [- 0.84, 2.40], p = 0.34), and (MD = 0.16, 95% [- 1.32, 1.64], p = 0.83), respectively. Robotic-assisted TKA demonstrated better outcomes than conventional TKA in terms of mechanical alignment and WOMAC scores. However, the conventional TKA showed a better range of motion-flexion in the long term. More data are needed to assess long-term outcomes comprehensively.

A literature review assessing the perioperative efficacy and safety of tranexamic acid in elective total hip and knee arthroplasty in UK practice.

Hip and knee arthroplasty are frequently associated with significant blood loss, often necessitating blood transfusions. A variety of methods are employed to minimise blood loss and consequently mitigate the necessity for transfusions. This review explores the incidence of blood loss in hip and knee arthroplasty alongside perioperative strategies aimed at its reduction in UK practice. Given the increasing prevalence of tranexamic acid utilisation, we systematically examine the extant literature concerning its application in patients undergoing hip and knee arthroplasty. Our analysis discerns a prevailing consensus within published studies favouring the implementation of tranexamic acid as a safe and efficacious measure for reducing blood loss during hip and knee arthroplasty procedures.

Identification and optimisation of perioperative factors for patients with von Willebrand disease undergoing elective total hip and knee arthroplasty.

Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

Five historical innovations that have shaped modern otolaryngological surgery.

Throughout history, many innovations have contributed to the development of modern otolaryngological surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern otolaryngological surgery: Operative Microscope, Hopkins Rigid Endoscope, Laryngeal Nerve monitoring, Cochlear implants and Laser surgery. The selection of innovations for inclusion in this article was meticulously determined through expert consensus and an extensive literature review. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of otolaryngological surgery and their ongoing relevance in contemporary and perioperative practice.

Children's and adults' evaluations of self-enhancement and self-deprecation depend on the usual performance of the self-presenter.

This study examined how evaluations of self-presentation vary with age depending on the self-presenter's usual performance. People's usual performance is a key factor because it generally influences the social evaluations and judgments that others make about them. Children aged 7 and 8 years (second graders) and 10 and 11 years (fifth graders), as well as adults, were presented with scenarios in which protagonists responded to praise after a good performance using either self-enhancement or self-deprecation. The other person in scenarios knew that the protagonist's usual performance on the task was either good or poor. After the protagonist responded to praise in a self-enhancing or self-deprecating way, the participants judged how the other person would evaluate the protagonist's ability (good/poor) and character (nice/mean). For ability evaluations specifically concerning protagonists who usually performed poorly, the results showed that by around 10 years of age children no longer tended to give more positive ability evaluations for self-enhancement than for self-deprecation. Adults gave less positive ability evaluations for self-deprecation than for self-enhancement, but only when the protagonists usually performed well. In relation to the character evaluations, by around 10 years of age self-enhancement led to less positive character evaluations than self-deprecation, but only when the protagonists usually performed poorly. Overall, second graders evaluated self-presenters as more competent and nicer. These results indicate that the expected evaluation of self-enhancement and self-deprecation is influenced by the usual level of performance but that there are developmental changes in this aspect of social cognition.

An overview of bone cement: Perioperative considerations, complications, outcomes and future implications.

Polymethyl methacrylate is commonly known as bone cement and is widely used for implant fixation in various orthopaedic arthroplasty and trauma surgery. The first bone cement use in orthopaedics is widely accredited to the famous English surgeon, John Charnley, who in 1958, used it for total hip arthroplasty. Since then, there have been many developments in cementing techniques in arthroplasty surgery. This overview aims to cover the perioperative considerations of bone cement, including cementing techniques, current outcomes and complications such as bone cement implantation syndrome. The overview will additionally consider future developments involving bone cement in orthopaedic arthroplasty.

Five historical innovations that have shaped modern orthopaedic surgery.

Throughout history, many innovations have contributed to the development of modern orthopaedic surgery, improving patient outcomes and expanding the range of treatment options available to patients. This article explores five key historical innovations that have shaped modern orthopaedic surgery: X-ray imaging, bone cement, the Thomas splint, the Pneumatic tourniquet and robotic-assisted surgery. We will review the development, impact and significance of each innovation, highlighting their contributions to the field of orthopaedic surgery and their ongoing relevance in contemporary and perioperative practice.

The incidence and risk factors for abnormal postoperative blood tests following primary total joint replacement.

Aims: We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods: This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na+), potassium (K+), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results: The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion: The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern.

"I miss the normalness": Mother and child perspectives of well-being and effective remote support from primary schools during Covid-19 school closures.

BACKGROUND: Covid-19 related school closures radically disrupted children's access to social and educational opportunities and changed daily life for millions of families across the world. Emerging evidence indicates that, overall, closures were associated with a decline in children's mental health and well-being, although individual experiences varied widely. The extent to which primary schools adapted remote well-being support is likely to have contributed to child and family adjustment, although this has not yet been fully explored in Covid related research. METHODS: This longitudinal qualitative study examines variability in remote well-being provision in primary schools during the pandemic, and following school reopening, from the perspective of mothers and children using a whole school approaches framework. Twenty-one primary school aged children and their mothers took part in a semi-structured interview at two time points: time one during the first UK national lockdown and time two approximately seven months later after most children had returned to school. A hybrid inductive-deductive thematic analysis approach identified key themes relating to trajectories of well-being and remote school approaches over this period. RESULTS: School closures were associated with a decline in well-being for most children. Disrupted contact with friends and teachers, and limited opportunities for enriched, meaningful activity were identified as key risk factors. Protective factors included family and child characteristics that mitigated against the loss of wider systems of support, including family socioeconomic status, parental availability, child temperament, and structured daily routines. Four key dimensions of effective remote well-being provision were identified (the 4Cs). The 4Cs - contact, content, creativity and community - provide an accessible framework for schools to foster children's social relationships and sense of belonging during periods of closure. Analysis of pupil reintegration outcomes suggest that post-Covid support priorities should include extending social and play-based universal interventions in schools. CONCLUSION: Remote well-being support for children during Covid-related school closures varied in quality with implications for children's mental health and well-being. Findings from this study highlight the importance of ongoing social contact and enriched daily activities to protect children's well-being and development and present a framework of effective remote wellbeing support for primary schools in the event of future closures or prolonged pupil absence.

The Upscale Manufacture of Chondrocytes for Allogeneic Cartilage Therapies.

Allogeneic chondrocyte therapies need to be developed to allow more individuals to be treated with a cell therapy for cartilage repair and to reduce the burden and cost of the current two-stage autologous procedures. Upscale manufacture of chondrocytes using a bioreactor could help provide an off-the-shelf allogeneic chondrocyte therapy with many doses being produced in a single manufacturing run. In this study, we assess a good manufacturing practice-compliant hollow-fiber bioreactor (Quantum®) for adult chondrocyte manufacture. Chondrocytes were isolated from knee arthroplasty-derived cartilage (n = 5) and expanded in media supplemented with 10% fetal bovine serum (FBS) or 5% human platelet lysate (hPL) on tissue culture plastic (TCP) for a single passage. hPL-supplemented cultures were then expanded in the Quantum bioreactor for a further passage. Matched, parallel cultures in hPL or FBS were maintained on TCP. Chondrocytes from all culture conditions were characterized in terms of growth kinetics, morphology, immunoprofile, chondrogenic potential (chondrocyte pellet assays), and single telomere length analysis. Quantum expansion of chondrocytes resulted in 86.4 ± 38.5 × 106 cells in 8.4 ± 1.5 days, following seeding of 10.2 ± 3.6 × 106 cells. This related to 3.0 ± 1.0 population doublings in the Quantum bioreactor, compared with 2.1 ± 0.6 and 1.3 ± 1.0 on TCP in hPL- and FBS-supplemented media, respectively. Quantum- and TCP-expanded cultures retained equivalent chondropotency and mesenchymal stromal cell marker immunoprofiles, with only the integrin marker, CD49a, decreasing following Quantum expansion. Quantum-expanded chondrocytes demonstrated equivalent chondrogenic potential (as assessed by ability to form and maintain chondrogenic pellets) with matched hPL TCP populations. hPL manufacture, however, led to reduced chondrogenic potential and increased cell surface positivity of integrins CD49b, CD49c, and CD51/61 compared with FBS cultures. Quantum expansion of chondrocytes did not result in shortened 17p telomere length when compared with matched TCP cultures. This study demonstrates that large numbers of adult chondrocytes can be manufactured in the Quantum hollow-fiber bioreactor. This rapid, upscale expansion does not alter chondrocyte phenotype when compared with matched TCP expansion. Therefore, the Quantum provides an attractive method of manufacturing chondrocytes for clinical use. Media supplementation with hPL for chondrocyte expansion may, however, be unfavorable in terms of retaining chondrogenic capacity.

Twelve tips for optimising learning for postgraduate doctors in the operating theatre.

Learning in the operating theatre forms a critical part of postgraduate medical education. Postgraduate doctors present a diverse cohort of learners with a wide range of learning needs that will vary by their level of experience and curriculum requirements. With evidence of both trainee dissatisfaction with the theatre learning experience and reduced time spent in the operating theatre, which has been exacerbated by the effects of the Covid-19 pandemic, it is vital that every visit to the operating theatre is used as a learning opportunity. We have devised 12 tips aimed at both learners and surgeons to optimise learning in the operating theatre, set out into four domains: educational context, preparation, learning in theatre, feedback and reflection. These tips have been created by a process of literature review and acknowledgment of established learning theory, with further discussion amongst surgical trainees, senior surgical faculty, surgical educators and medical education faculty.

Greater trochanteric pain syndrome: focused shockwave therapy versus an ultrasound guided injection: a randomised control trial.

BACKGROUND: Greater trochanteric pain syndrome (GTPS) is a common problem with an incidence of 1.8-5.6 per 1000 population. Physiotherapy, anti-inflammatories, corticosteroid injections and surgery have all been described in the management of GTPS, with limited, temporal success. Extracorporeal shockwave therapy (ESWT) has been proposed as a potential non-invasive management option for this difficult presentation. METHOD: We ran a prospective, 2-arm, single-blinded, randomised control trial comparing focused shockwave therapy (f-ESWT) to an ultrasound guided corticosteroid injection. Primary outcome measure was the visual analogue pain score. Secondary outcome measures included the Harris Hip Score (HHS) and Trendelenburg test for function; SF-36 for quality of life (QoL); and a Likert scale question for subjective assessment of symptom improvement. RESULTS: 104 patients (10 males and 94 females), of mean age 61.5 years were recruited. 53 were randomised to receive ESWT and 51 to receive an image-guided injection. 11 patients were lost to follow-up. There were no significant differences in baseline scores between groups.At 3 months, pain, function and QoL scores had improved in both groups but were not statistically significant. The Trendelenburg test was significantly improved in the f-ESWT group with 80% patients being negative compared to 20% at baseline (p < 0.001).At 12 months, across all outcomes, the ESWT group had significantly improved scores compared to the injection group; VAS 37.1 versus 55.0 (p = 0.007, 95% confidence interval [CI], 6.3-30.8), HHS 69.7 versus 57.5 (p = 0.002, 95% CI, -20.0 to -4.6) and SF-36 52.4 versus 47.7 (p = 0.048, 95% CI, -9.31 to -0.04). The improvement in Trendelenburg test was maintained in the ESWT group, but the injection group had reverted to baseline (p < 0.001). CONCLUSIONS: We have shown f-ESWT is an effective treatment for patients with GTPS. We would advocate f-ESWT as an effective non-invasive treatment modality for this challenging patient population.Trial Registration No. ISRCTN8338223.

"Are They Going to Play Nicely?" Parents' Evaluations of Young Children's Play Dates.

Over the last 20 years, opportunities for young children to engage in self-directed free play with peers outdoors or during the school day has dramatically declined. Consequently, it is likely that play dates, defined as pre-arranged social contact at home, have become increasingly significant play environments for children. Preliminary research suggests that play dates are positively associated with young children's social and emotional development, but that access can be strongly influenced by parental social networking priorities. However, little is currently known about the nature and frequency of play dates, the types of play children engage in, or the impact of parental management and supervision on children's play in this context. Exploratory qualitative research is essential to understand the extent to which parental gatekeeping may limit opportunities for children and families perceived to have low social capital, and to begin to define the nature and content of young children's play dates more broadly. Parents of children aged 5-6 years old took part in a semi-structured interview to describe common practices and attitudes (N = 11). Inductive thematic analysis indicated that play dates are complex play environments that parents associate with a range of social, emotional, and cognitive benefits for children. However, close parental monitoring and supervision may limit the extent to which play dates provide opportunities for self-directed free play. Findings also show that access to play dates is strongly influenced by parents' motivations to enhance children's social status which restricts access to some children. Implications for future research are discussed.

"It Almost Makes Her Human": How Female Animal Guardians Construct Experiences of Cat and Dog Empathy.

Understanding how humans perceive and construct experiences of non-human animal empathy (hereafter, 'animal/s') can provide important information to aid our understanding of how companion animals contribute to social support. This study investigates the phenomenology of animal empathy by examining how humans construct sense-making narratives of these experiences, with the hypothesis that anthropomorphic attributions would play a key role in these constructions. Comprehensive, semi-structured interviews were conducted with six participants, using established interpretative phenomenological analysis methodology to facilitate deep examination of how they interpreted and reacted emotionally. Participants were consistent in reporting changes to their companion animals' normal behaviour as the key to the identification of animal empathy experiences, yet they were highly paradoxical in their constructions of perceived internal drivers within their dogs and cats. Explanations were highly dichotomous, from highly anthropomorphic to highly anthropocentric, and these extremes were combined both within individual participant narratives and within some thematic constructs. This research demonstrates that experiences of companion animal empathy can be powerful and meaningful for humans, but the inconsistent mixture of anthropomorphic and anthropocentric reasoning illustrates the confused nature of human understanding of animals' internal states. Insight into how humans construct animal empathy has implications for the moral status of these animals and an application for companion animals used explicitly for social support, such as in animal-assisted therapy and emotional support animals.

Schematic beliefs, negative affect and paranoia in at-risk youth.

OBJECTIVES: Attenuated symptoms of psychosis are a core feature of At-Risk Mental States. However, subthreshold levels of paranoia are also common among nonpsychosis populations. At present, little is known about whether the processes underpinning the experience of paranoid ideation in high-risk youth differ as a consequence of meeting At-Risk Mental States (ARMS) for psychosis criteria. METHODS: This study utilized path analysis techniques to examine the relationships between schematic beliefs, negative affect and the experience of paranoia for two groups: a group meeting criteria for ARMS (n = 133) and a group presenting with emerging complex mental health difficulties who did not meet the criteria for ARMS (n = 137). RESULTS: While the ARMS group displayed significantly greater maladaptive schematic beliefs and more severe symptomatology, the associations between schematic beliefs, symptoms of negative affect and paranoia did not differ as a consequence of ARMS status. CONCLUSIONS: While meeting the ARMS criteria is associated with experiencing more maladaptive cognitions and more negative symptomatology among at-risk youth, the associations between these cognitive beliefs and symptoms may be similar for youth who do not meet ARMS. These findings have implications for broadening the scope of at-risk/high-risk and for developing effective interventions for young people presenting with emerging difficulties.

'People like me don't do well at school': The roles of identity compatibility and school context in explaining the socioeconomic attainment gap.

BACKGROUND: School students who are eligible for reduced or free school meals (FSM) - an indicator of economic disadvantage - have lower academic attainment than their peers. AIMS: We investigated whether identity compatibility - the perceived compatibility between one's social identities and the stereotype of a high-achieving student - contributes to this socioeconomic attainment gap, and whether the association between socioeconomic status and identity compatibility is moderated by school context. SAMPLE: Our sample was 4,629 students aged 15-16 years old across 29 schools in England. METHOD: We assessed students' perceptions of identity compatibility via self-report questionnaires 8 months prior to them taking national, standardized exams. RESULTS: Multilevel regression analyses revealed a negative indirect effect from eligibility for FSM to exam results via identity compatibility. These effects existed even while accounting for students' gender and language status, other psychological variables known to predict academic attainment, and their previous exam results. Furthermore, school context moderated the relationship between FSM eligibility and identity compatibility. In line with the identities in context model of educational inequalities, there was a significant negative association between FSM and identity compatibility only for students attending schools in which there was previously a relatively large socioeconomic attainment gap. CONCLUSIONS: Our results demonstrate the importance of social psychological variables in explaining educational inequalities, and of the local educational context in determining the educational experience of students from lower socioeconomic status backgrounds.

Clinical and cost-effectiveness of social recovery therapy for the prevention and treatment of long-term social disability among young people with emerging severe mental illness (PRODIGY): randomised controlled trial.

BACKGROUND: Young people with social disability and severe and complex mental health problems have poor outcomes, frequently struggling with treatment access and engagement. Outcomes may be improved by enhancing care and providing targeted psychological or psychosocial intervention. AIMS: We aimed to test the hypothesis that adding social recovery therapy (SRT) to enhanced standard care (ESC) would improve social recovery compared with ESC alone. METHOD: A pragmatic, assessor-masked, randomised controlled trial (PRODIGY: ISRCTN47998710) was conducted in three UK centres. Participants (n = 270) were aged 16-25 years, with persistent social disability, defined as under 30 hours of structured activity per week, social impairment for at least 6 months and severe and complex mental health problems. Participants were randomised to ESC alone or SRT plus ESC. SRT was an individual psychosocial therapy delivered over 9 months. The primary outcome was time spent in structured activity 15 months post-randomisation. RESULTS: We randomised 132 participants to SRT plus ESC and 138 to ESC alone. Mean weekly hours in structured activity at 15 months increased by 11.1 h for SRT plus ESC (mean 22.4, s.d. = 21.4) and 16.6 h for ESC alone (mean 27.7, s.d. = 26.5). There was no significant difference between arms; treatment effect was -4.44 (95% CI -10.19 to 1.31, P = 0.13). Missingness was consistently greater in the ESC alone arm. CONCLUSIONS: We found no evidence for the superiority of SRT as an adjunct to ESC. Participants in both arms made large, clinically significant improvements on all outcomes. When providing comprehensive evidence-based standard care, there are no additional gains by providing specialised SRT. Optimising standard care to ensure targeted delivery of existing interventions may further improve outcomes.

Peer audience effects on children's vocal masculinity and femininity.

Existing evidence suggests that children from around the age of 8 years strategically alter their public image in accordance with known values and preferences of peers, through the self-descriptive information they convey. However, an important but neglected aspect of this 'self-presentation' is the medium through which such information is communicated: the voice itself. The present study explored peer audience effects on children's vocal productions. Fifty-six children (26 females, aged 8-10 years) were presented with vignettes where a fictional child, matched to the participant's age and sex, is trying to make friends with a group of same-sex peers with stereotypically masculine or feminine interests (rugby and ballet, respectively). Participants were asked to impersonate the child in that situation and, as the child, to read out loud masculine, feminine and gender-neutral self-descriptive statements to these hypothetical audiences. They also had to decide which of those self-descriptive statements would be most helpful for making friends. In line with previous research, boys and girls preferentially selected masculine or feminine self-descriptive statements depending on the audience interests. Crucially, acoustic analyses of fundamental frequency and formant frequency spacing revealed that children also spontaneously altered their vocal productions: they feminized their voices when speaking to members of the ballet club, while they masculinized their voices when speaking to members of the rugby club. Both sexes also feminized their voices when uttering feminine sentences, compared to when uttering masculine and gender-neutral sentences. Implications for the hitherto neglected role of acoustic qualities of children's vocal behaviour in peer interactions are discussed. This article is part of the theme issue 'Voice modulation: from origin and mechanism to social impact (Part II)'.

Social recovery therapy for young people with emerging severe mental illness: the Prodigy RCT.

BACKGROUND: Young people with social disability and non-psychotic severe and complex mental health problems are an important group. Without intervention, their social problems can persist and have large economic and personal costs. Thus, more effective evidence-based interventions are needed. Social recovery therapy is an individual therapy incorporating cognitive-behavioural techniques to increase structured activity as guided by the participant's goals. OBJECTIVE: This trial aimed to test whether or not social recovery therapy provided as an adjunct to enhanced standard care over 9 months is superior to enhanced standard care alone. Enhanced standard care aimed to provide an optimal combination of existing evidence-based interventions. DESIGN: A pragmatic, single-blind, superiority randomised controlled trial was conducted in three UK centres: Sussex, Manchester and East Anglia. Participants were aged 16-25 years with persistent social disability, defined as < 30 hours per week of structured activity with social impairment for at least 6 months. Additionally, participants had severe and complex mental health problems, defined as at-risk mental states for psychosis or non-psychotic severe and complex mental health problems indicated by a Global Assessment of Functioning score ≤ 50 persisting for ≥ 6 months. Two hundred and seventy participants were randomised 1 : 1 to either enhanced standard care plus social recovery therapy or enhanced standard care alone. The primary outcome was weekly hours spent in structured activity at 15 months post randomisation. Secondary outcomes included subthreshold psychotic, negative and mood symptoms. Outcomes were collected at 9 and 15 months post randomisation, with maintenance assessed at 24 months. RESULTS: The addition of social recovery therapy did not significantly increase weekly hours in structured activity at 15 months (primary outcome treatment effect -4.44, 95% confidence interval -10.19 to 1.31). We found no evidence of significant differences between conditions in secondary outcomes at 15 months: Social Anxiety Interaction Scale treatment effect -0.45, 95% confidence interval -4.84 to 3.95; Beck Depression Inventory-II treatment effect -0.32, 95% confidence interval -4.06 to 3.42; Comprehensive Assessment of At-Risk Mental States symptom severity 0.29, 95% confidence interval -4.35 to 4.94; or distress treatment effect 4.09, 95% confidence interval -3.52 to 11.70. Greater Comprehensive Assessment of At-Risk Mental States for psychosis scores reflect greater symptom severity. We found no evidence of significant differences at 9 or 24 months. Social recovery therapy was not estimated to be cost-effective. The key limitation was that missingness of data was consistently greater in the enhanced standard care-alone arm (9% primary outcome and 15% secondary outcome missingness of data) than in the social recovery therapy plus enhanced standard care arm (4% primary outcome and 9% secondary outcome missingness of data) at 15 months. CONCLUSIONS: We found no evidence for the clinical superiority or cost-effectiveness of social recovery therapy as an adjunct to enhanced standard care. Both arms made large improvements in primary and secondary outcomes. Enhanced standard care included a comprehensive combination of evidence-based pharmacological, psychotherapeutic and psychosocial interventions. Some results favoured enhanced standard care but the majority were not statistically significant. Future work should identify factors associated with the optimal delivery of the combinations of interventions that underpin better outcomes in this often-neglected clinical group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47998710. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment Vol. 25, No. 70. See the NIHR Journals Library website for further project information.

Young people with social disability and non-psychotic severe and complex mental health problems are an important group. Their problems are often long-standing and they often have difficulty doing 'structured activity', such as work, sports and leisure activities (e.g. going shopping or to the cinema). They often avoid such activities because of anxiety or low mood. Other barriers may include financial and practical issues, and stigma from activity providers. Non-participation in structured activity increases the risk that mental health problems will continue and prevent these young people from reaching meaningful goals. We tested whether or not social recovery therapy might help. This is a talking and activity therapy, in which young people (participants) work individually with a social recovery therapy therapist. Social recovery therapy aims to help participants identify what activities they would like to do, practise spending more time doing them, and work through barriers to maintaining increased activity. By improving structured activity, young people feel more hopeful and better able to manage their symptoms. However, social recovery therapy has never been evaluated properly using the best research methods. The best way to evaluate treatments like this is a randomised controlled trial in which participants are allocated by chance, like tossing a coin, to have the new therapy or not to have the therapy. Both groups are followed up for a period to see if the new therapy works. We tested social recovery therapy in this way. We also tested whether or not it was cost-effective. We recruited 270 16- to 25-year-old participants in Sussex, East Anglia and Manchester. Participants had non-psychotic severe and complex mental health problems (not psychosis) and were doing < 30 hours of structured activity per week at the start of the study. All participants had enhanced standard care. This involved standard NHS treatment plus a full assessment and feedback from the study team, and a best practice guide to local support services that encouraged the best provision of standard evidence-based interventions. Half of the participants were randomly allocated to have social recovery therapy in addition to enhanced standard care over 9 months. All participants were invited to assessments 9, 15 and 24 months later. Therapists recorded the tasks and activities undertaken with participants. We asked both participants and therapists what they thought of the trial and the social recovery therapy. We found no evidence that adding social recovery therapy improved outcomes. Participants in both arms made large and clinically worthwhile improvements in structured activity and mental health outcomes. If anything, there was some evidence that people allocated to enhanced standard care improved more than those allocated to social recovery therapy plus enhanced standard care. The differences were small, however, and could have occurred by chance.

"It All Makes Us Feel Together": Young People's Experiences of Virtual Group Music-Making During the COVID-19 Pandemic.

We know little about the psychological experiences of children and young people who have participated in virtual group music-making during the Coronavirus disease (COVID-19) pandemic. Adopting a mixed-methods design, we worked across three music education hubs in the UK, with a total 13 virtual music groups. These included a range of mainstream ensembles, inclusive ensembles targeting young people with special educational needs and/or disabilities, and inclusive music production spaces, targeting young people from lower socio-economic backgrounds. Reported progress in intra- and inter-personal psychological outcomes was investigated using quantitative and qualitative staff session reports, which were collected since before the pandemic (n1 for in-person sessions = 87, n2 for virtual sessions = 68), and surveys distributed to tutors, young people, and their parents during the first and second United Kingdom (UK) national lockdowns (n3 for qualitative responses = 240, n4 for quantitative responses = 96). Satisfaction of three basic psychological needs of self-determination theory and their relation to joint music-making in virtual spaces was also observed in real time by the researchers performing quantitative checklist observations on 16 separate occasions. Findings indicated that virtual music groups represented a meaningful psychological resource for the participating children and young people, especially considering the lack of opportunities offered by their schools and other extra-curricular activities. Through their participation with virtual group music-making activities, young people used music as a tool for self-expression and emotion management, restored lost musical identities and confidence, and preserved treasured social connections. Virtual alternatives to group music-making appear to indirectly nurture the sense of belongingness, mediated by supportive staff behaviors, but their direct connection, which has been widely reported for in-person group music-making experiences, has not been observed in virtual music groups.