Retrospective Examination of Peripubertal Return for Patients of Western Australia's Gender Diversity Service.

Purpose: Children far in advance of pubertal development may be deferred from further assessment for gender-affirming medical treatment until nearer puberty. It is vital that returning peripubertal patients are seen promptly to ensure time-sensitive assessment and provision of puberty suppression treatment where appropriate. This study investigates (1) how many referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital are deferred due to prepubertal status; and (2) how many deferred patients return peripubertally. Methods: A retrospective review of all closed referrals to the service was conducted to determine the frequency of prepubertal deferral and peripubertal re-referral. Results: Of 995 referrals received (2014 to 2020), 552 were closed. The reason for closure was determined for 548 referrals (99.3%). Prepubertal status was the second-most frequent reason for closure, and the most frequent for birth-registered males. Twenty-five percent of all deferred prepubertal patients returned peripubertally, before audit closure. A greater return frequency (55.6%) was estimated for those older than 13 years at audit closure. Conclusion: High rates of prepubertal referral indicate the importance of pediatric gender services in providing information, advice, and reassurance to concerned families. With increasing service demand, high rates of return peripubertally have implications for service planning to ensure that returning peripubertal patients are seen promptly for time-sensitive care. Frequency of peripubertal re-referral cannot, however, speak to the stability of trans identity or gender incongruence from childhood to adolescence. Clinics advising prepubertal deferral must proactively plan to ensure that sufficient clinical resources are reserved for this purpose.

Organizing the dissemination and implementation field: who are we, what are we doing, and how should we do it?

Two decades into its tenure as a field, dissemination and implementation (D&I) scientists have begun a process of self-reflection, illuminating a missed opportunity to bridge the gap between research and practice-one of the field's foundational objectives. In this paper, we, the authors, assert the research-to-practice gap has persisted, in part due to an inadequate characterization of roles, functions, and processes within D&I. We aim to address this issue, and the rising tension between D&I researchers and practitioners, by proposing a community-centered path forward that is grounded in equity.We identify key players within the field and characterize their unique roles using the translational science spectrum, a model originally developed in the biomedical sciences to help streamline the research-to-practice process, as a guide. We argue that the full translational science spectrum, from basic science research, or "T0," to translation to community, or "T4," readily applies within D&I and that in using this framework to clarify roles, functions, and processes within the field, we can facilitate greater collaboration and respect across the entire D&I research-to-practice continuum. We also highlight distinct opportunities (e.g., changes to D&I scientific conference structures) to increase regular communication and engagement between individuals whose work sits at different points along the D&I translational science spectrum that can accelerate our efforts to close the research-to-practice gap and achieve the field's foundational objectives.

Thermal stress and hospital admissions for cardiorespiratory disease in Brazil.

The growing body of scientific literature underscores the intricate relationship between meteorological conditions and human health, particularly in the context of extreme temperatures. However, conventional temperature-centric approaches often fall short in capturing the complexity of thermal stress experienced by individuals. Temperature alone, as a metric, fails to encompass the entirety of the thermal stress individuals face, necessitating a more nuanced understanding. In response to this limitation, climatologists have devised thermal indices-composite measures meticulously crafted to reflect the intricate interplay of meteorological factors influencing human perception of temperature. Recognizing the inadequacy of simplistic temperature-focused methodologies, our study aims to address the multifaceted nature of thermal stress. In this study, we explored the association between thermal indices and hospital admissions for circulatory and respiratory diseases in Brazil. We used an extensive dataset spanning 11 years (2008-2018) from the Brazilian Ministry of Health, encompassing a total of 23,791,093 hospitalizations for circulatory and respiratory diseases. We considered four distinct thermal indices-Discomfort Index (DI), Net Effective Temperature (NET), Humidex (H), and Heat Index (HI). We used an extension of the two-stage design with a case time series to assess this relationship. In the first stage, we applied a distributed lag non-linear modeling framework to create a cross-basis function. We next applied quasi-Poisson regression models adjusted by time-varying confounders. In the second stage, we applied meta-analysis with random effects to estimate the national relative risk (RR). Our findings suggest robust variations among the thermal indices under examination. These variations underscore the intricate nature of associations between temperature and health, with each index capturing distinct aspects of thermal conditions. Our results indicate that extreme thermal conditions, both at the low and high ends, are associated with increased risks of hospital admissions. The diverse impact observed among different indices emphasizes the complex interplay between various meteorological factors and their specific physiological consequences. This underscores the necessity for a comprehensive comprehension of temperature metrics to guide precise public health interventions, recognizing the multifaceted nature of temperature-health relationships.

Reidentification With Birth-Registered Sex in a Western Australian Pediatric Gender Clinic Cohort.

Importance: Some young people who identify as transgender and seek gender-affirming medical care subsequently reidentify with their sex registered at birth. Evidence regarding the frequency and characteristics of this experience is lacking. Objective: To determine the frequency of reidentification and explore associated characteristics in a pediatric gender clinic setting. Design, Setting, and Participants: This retrospective cohort study examined all referrals to the Child and Adolescent Health Service Gender Diversity Service at Perth Children's Hospital between January 1, 2014, and December 31, 2020. The Gender Diversity Service is the sole statewide specialist service in Western Australia that provides children and adolescents up to age 18 years with multidisciplinary assessment, information, support, and gender-affirming medical care. All closed referrals for this study were audited between May 1, 2021, and August 8, 2022. Exposure: Reidentification with birth-registered sex. Main Outcomes and Measures: The number of referrals closed due to reported reidentification with birth-registered sex was determined, as well as descriptives and frequencies of patient demographics (age, birth-registered sex), informant source, International Statistical Classification of Diseases, Tenth Revision gender-related diagnoses, pubertal status, any gender-affirming medical treatment received, and whether subsequent re-referrals were received. Results: Of 552 closed referrals during the study period, a reason for closure could be determined for 548 patients, including 211 birth-registered males (mean [SD] age, 13.88 [2.00] years) and 337 birth-registered females (mean [SD] age, 15.81 [2.22] years). Patients who reidentified with their birth-registered sex comprised 5.3% (29 of 548; 95% CI, 3.6%-7.5%) of all referral closures. Except for 2 patients, reidentification occurred before or during early stages of assessment (93.1%; 95% CI, 77.2%-99.2%). Two patients who reidentified with their birth-registered sex did so following initiation of puberty suppression or gender-affirming hormone treatment (1.0% of 196 patients who initiated any gender-affirming medical treatment; 95% CI, 0.1%-3.6%). Conclusions and Relevance: These findings from a pediatric gender clinic audit indicate that a small proportion of patients, and a very small proportion of those who initiated medical gender-affirming treatment, reidentified with their birth-registered sex during the study period. Longitudinal follow-up studies, including qualitative self-report, are required to understand different pathways of gender identity experience.

Development of best practice guidelines for clinical and community service providers to prevent suicide in LGBTQA+ young people: A Delphi expert consensus study.

OBJECTIVE: The aim of this study was to develop best practice guidelines for preventing suicide and reducing suicidal thoughts and behaviours in LGBTQA+ young people (lesbian, gay, bisexual, trans, queer/questioning, asexual, and those of other diverse sexualities and genders) within clinical and community service settings in Australia. METHODS: We conducted a Delphi expert consensus study. A systematic literature search and interviews with key informants informed an initial 270-item questionnaire. Two expert panels completed the questionnaire, delivered over two rounds: (1) Australian professionals with expertise in LGBTQA+ mental health/suicide prevention and (2) Australian LGBTQA+ young people aged 14-25 with lived experience of suicidal thoughts and/or behaviours. Items endorsed as 'essential' or 'important' by >80% of both expert panels were included in the guidelines. RESULTS: A total of 115 people participated in the Delphi process; n = 52 professionals completed Round 1, and n = 42 completed Round 2; n = 63 LGBTQA+ young people completed Round 1, and n = 50 completed Round 2. A total of 290 items were included in the guidelines and grouped into: (1) general principles for creating an affirming and inclusive environment for LGBTQA+ young people; (2) assessing suicide risk and working with suicidal LGBTQA+ young people; (3) considerations for specific LGBTQA+ populations; and (4) advocating for LGBTQA+ young people. CONCLUSION: These guidelines are the first of their kind in Australia. They provide practical support to service providers regardless of prior training in LGBTQ+ identities or mental health, with the aim of reducing suicidal thoughts and behaviours, and preventing suicide, in LGBTQA+ young people.

The Pathway Building Technique in Implementation Research Using Mixed Methods Design.

BACKGROUND: Data integration refers to combining quantitative and qualitative data in mixed methods. It can be achieved through several integration procedures. The building integration procedure can be used for developing quantitative instruments by integrating data from the qualitative phase. There are limited examples of data integration using the building procedure in mixed methods and implementation science. PURPOSE: The purpose of this article is to illustrate how the pathway building technique can be used to integrate data in mixed methods research through concurrent use of implementation science models and frameworks. METHODS: This two pathway building technique was developed based on a mixed methods implementation project of developing implementation strategies to promote compassionate nursing care of complex patients. RESULTS: The first pathway is the integration of qualitative data from the first phase of mixed methods study with implementation models and frameworks to create a quantitative instrument (i.e., a Q-sort survey) for the subsequent phase. The second pathway is the operationalization of the Q-sort survey results (i.e., implementation strategies) using an implementation science specification framework. CONCLUSION: The pathway technique is valuable for mixed methods research and implementation science as it offers a theory-based innovative method to tackle integration challenge.

The experiences and perceptions of health-care professionals regarding assistive technology training: A systematic review.

Worldwide, there is an increasing demand for assistive technologies (ATs) that can support people to live independently for longer. Health-care professionals (HCPs) often recommend AT devices, however there exists a lack of availability of devices and appropriate training in the field. This systematic review aimed to synthesize the available evidence into the experiences and training needs of HCPs in relation to AT. Six electronic databases were searched without date restrictions: MEDLINE, PsycINFO, SPP, SSCI, CINAHL, and ASSIA. Journal handsearching, searching reference lists of included studies and relevant reviews, and contacting experts in the field of AT were also conducted. Findings were analyzed using narrative synthesis. Data from 7846 participants from 62 studies were synthesized, eliciting perceived challenges in access to and provision of training, resulting in knowledge gaps across disciplines and geographic locations. Mechanisms to mitigate these issues included ongoing support following training and tailoring education to meet individual needs since comprehensive training is essential to maintain and improve competence, knowledge, and confidence. Further research is required to explore the impact and effectiveness of AT training for HCPs to ensure that users of devices are supported to live independent and healthy lives.

Emodin Inhibited Pathological Cardiac Hypertrophy in Response to Angiotensin-Induced Hypertension and Altered the Gut Microbiome.

OBJECTIVE: Evidence suggests that food bioactives affect the epigenome to prevent pathological cardiac hypertrophy. Recently, we showed that emodin, an anthraquinone, attenuated pathological cardiac hypertrophy and histone deacetylase (HDAC) activity. However, we only examined the cardioprotective effects of emodin's parent compound and not those of emodin metabolites or of emodin-gut microbiome interactions. The microbiome has emerged as a key player in chronic diseases such as metabolic and cardiac disease. Thus, we hypothesized that emodin could reverse hypertension-induced changes in microbial communities. METHODS: Normo- and hypertensive (angiotensin II) C57/BL6 female mice were randomly assigned to receive a vehicle (Veh; DMSO:PEG 1:1) or emodin (Emod; 30 mg/kg) for 14 days. Body weights were collected pre- and post-treatment, and blood pressure was assessed via tail cuff. At the study's end, the mice were euthanized and assessed for their heart weights. In addition, stool samples and cecal contents were collected to elucidate changes in the microbial populations using 16S rRNA sequencing. Lastly, the tissue was lysed, and RNA was isolated for qPCR. One-way ANOVA with Tukey's post hoc test was performed unless otherwise specified, and p < 0.05 was considered significant. RESULTS: Emodin significantly attenuated cardiac hypertrophy in the female mice. No significant changes were observed in body weight or systolic blood pressure in response to hypertension or emodin. Lastly, analysis suggests that hypertension altered the microbiome in the cecum and cecal content, with additional evidence to support that emodin affects gut microbiota in the feces and colon. CONCLUSIONS: Our data demonstrate that emodin attenuates pathological hypertrophy in female mice. Future research is needed to dissect if changes in the microbiome contributes to emodin-mediated attenuation in cardiac remodeling.

Gender non-conformity in childhood and adolescence and mental health through to adulthood: a longitudinal cohort study, 1995-2018.

BACKGROUND: Few studies have examined associations between gender non-conformity (GNC) in childhood or adolescence and mental health outcomes later in life. This study examined associations between (1) GNC and mental health over multiple time points in childhood and adolescence, and (2) GNC in childhood and/or adolescence and mental health in adulthood. METHOD: Second generation participants from the Raine Study, a longitudinal cohort from Perth, Western Australia. Data were collected between 1995 and 2018, comprising seven waves: ages 5 (N = 2236), 8 (N = 2140), 10 (N = 2048), 14 (N = 1864), 17 (N = 1726), 22 (N = 1236) and 27 (N = 1190) years. History of GNC, v. absence of this history, was based on responses to item 110 from the Child Behaviour Checklist (CBCL)/Youth Self Report (YSR) ('wishes to be of opposite sex'). The CBCL/YSR were used to measure internalising and externalising symptoms. Items 18 ('deliberate self-harm [DSH] or attempts suicide') and 91 ('talks/thinks about killing self') were used as measures of suicidal ideation (SI) and DSH. For adults, Depression, Anxiety and Stress Subscales and Kessler Psychological Distress Scale assessed mental health. RESULTS: Child and adolescent GNC was associated with elevated internalising and externalising behaviours and increased odds of DSH. A history of GNC was also associated with vulnerability for severe psychological distress in adulthood in some symptom scales. CONCLUSION: GNC over the child and adolescent period is associated with significant emotional and behavioural difficulties, and psychological distress. A history of GNC in childhood and/or adolescence also predicts poorer mental health in adulthood on multiple symptom domains.

The impact of facilitators and rural immersion on medical student engagement during a child and adolescent mental health videoconference workshop.

OBJECTIVE: Child and adolescent mental health (CAMH) disorders are a major public health problem in Australia, especially outside metropolitan areas. The issue is compounded by a shortage of child and adolescent psychiatrists (CAPs). CAMH receives minimal coverage in health professional training, training opportunities are scarce, and support for generalist health professionals, who treat most cases, is lacking. Novel approaches to early medical education and teaching are required to strengthen the available skilled workforce in rural and remote settings. METHOD: This qualitative study explored the factors influencing medical student engagement in a CAMH videoconferencing workshop as part of the Rural Clinical School of WA. RESULTS: Our results confirm the priority of personal characteristics of medical educators, over clinical and subject matter expertise, on student learning. This research affirms that general practitioners are well-placed to facilitate recognition of learning experiences, especially given that students may not readily recognise exposure to CAMH cases. CONCLUSION: Our findings support the effectiveness, efficiencies, and benefits of utilising general medical educators in supporting child and adolescent psychiatry expertise in delivering subspecialty training within medical school curricula.

Corrigendum to "Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis" [Int J Nurs Sci 9/4 (2022) 411-421].

[This corrects the article DOI: 10.1016/j.ijnss.2022.08.003.].

Phase 1b study of combined selinexor and eribulin for the treatment of advanced solid tumors and triple-negative breast cancer.

BACKGROUND: Selinexor (KPT-330) is a potent inhibitor of exportin 1 (XPO1), in turn inhibiting tumor growth. Selinexor enhances the antitumor efficacy of eribulin in triple-negative breast cancer (TNBC) in vitro and in vivo. Given the unmet medical need in TNBC and sarcoma, the authors explored the safety and efficacy of this combination. METHODS: The authors conducted a phase 1b trial of combined selinexor and eribulin using a 3 + 3 dose-escalation design in patients who had advanced solid tumors and in those who had TNBC in a dose-expansion cohort. RESULTS: Patients with TNBC (N = 19), sarcoma (N = 9), and other cancers (N = 3) were enrolled in the dose-escalation cohort (N = 10) and in the dose-expansion cohort (N = 21). The median number lines of prior therapy received was four (range, from one to seven prior lines). The most common treatment-related adverse events for selinexor were nausea (77%), leukopenia (77%), anemia (68%), neutropenia (68%), and fatigue (48%). One dose-limiting toxicity occurred at the first dose level with prolonged grade 3 neutropenia. The recommended phase 2 dose was 80 mg of selinexor orally once per week and 1 mg/m2 eribulin on days 1 and 8 intravenously every 3 weeks. The objective response rate (ORR) was 10% in three patients. In the dose-escalation cohort, the ORR was 10%, whereas six patients with had stable disease. In the TNBC dose-expansion cohort (n = 18), ORR was 11%, and there were two confirmed partial responses with durations of 10.8 and 19.1 months (ongoing). CONCLUSIONS: Selinexor and eribulin had an acceptable toxicity profile and modest overall efficacy with durable responses in select patients. PLAIN LANGUAGE SUMMARY: Effective therapies for advanced, triple-negative breast cancer and sarcoma represent an unmet need. Exportin 1 is associated with the transport of cancer-related proteins. Preclinical studies have demonstrated tumor growth inhibition and enhanced tumor sensitivity in patients who receive selinexor combined with eribulin. In this phase 1b study, the authors evaluated the safety profile and clinical activity of the combination of selinexor, a potent oral inhibitor of exportin 1, and eribulin in patients with advanced cancers enriched for triple-negative breast cancer or sarcoma. The combination was well tolerated; most adverse events were mild or moderate, reversible, and managed with dose modifications or growth factor support. The combination of selinexor and eribulin produced an antitumor response, particularly in some patients with triple-negative breast cancer. This work lays the foundation for prospective investigations of the role of selinexor and eribulin in the treatment of triple-negative breast cancer.

Implementation strategies to promote compassionate nursing care of complex patients: An exploratory sequential mixed methods study.

INTRODUCTION: Individuals with multiple physical and, or, mental health issues and, or, drug-related problems are known as complex patients. These patients are often recipients of poor-quality care. Compassionate nursing care is valuable to promote better care experiences among this patient population. Implementation strategies should be designed to enhance compassionate nursing care delivery. The study aimed to gain understanding of barriers to compassionate care delivery to propose implementation to promote compassionate nursing care of complex patients. DESIGN: An exploratory sequential mixed methods study was conducted. METHODS: Phase 1 was the qualitative component during which 23 individuals with multimorbidities were interviewed for exploring their perceptions of barriers to compassionate nursing care. The barriers were integrated with implementation science frameworks using the building technique during phase 2 to develop a Q-sort survey of implementation strategies for phase 3. Nurses, nurse managers, health care administrators, policymakers, and compassionate care experts responded to the survey by ranking the 21 implementation strategies, out of which five met the Q-factor analysis criteria. RESULTS: Participant-perceived barriers to nurse compassion could be categorized under knowledge, intentions, skills, social influences, behavioral regulation, reinforcement, emotion, and environmental context and resources. The five highest-ranked strategies included facilitation, consultation with stress experts, involvement of patients and families, modeling compassion through shadowing, and utilizing implementation teams. CONCLUSIONS: Enablement and modeling were the integration functions represented by the highest-ranked implementation strategies. Enabling nurses to provide compassionate care through emotional support and mental health counseling, and, modeling compassion and compassionate care through shadowing were recommended and rated as highly relevant by the majority of stakeholders. CLINICAL RELEVANCE: Enhancing nurses compassionate behaviors toward complex patients requires facilitating them in enacting compassion in practice through modeling and support from organizations and nurse managers.

Behavioural indicators of compassionate nursing care of individuals with complex needs: A naturalistic inquiry.

AIMS AND OBJECTIVES: To explore behavioural indicators of compassionate nursing care from the perspectives of individuals with multimorbidities and complex needs. BACKGROUND: Complex patients are individuals with multimorbidity and/or mental health concerns, andoften with medication and drug-related problems requiring ongoing person-centered care, mental health interventions, and family and community resources. They are frequent consumers of health-care services and it is documented that these patients experience discrimination and substandard care. Compassionate care can improve patient care experiences and health outcomes. However, missing is the guidance on how to provide compassionate care for this population from the perspectives of complex patients. DESIGN: A qualitative descriptive approach was conducted in eastern Canada from December 2020-April 2021. The COREQ guidelines were followed for reporting. METHODS: Data from in-person and virtual semi-structured interviews with 23 individuals having experiences as complex patients were analysed using reflexive thematic analysis. Among them 19 were homeless and lived in a shelter. FINDINGS: Six indicators of compassionate nursing care were generated: sensitivity, awareness, a non-judgmental approach, a positive demeanour, empathic understanding, and altruism. CONCLUSIONS: Individuals perceived that nurses who acknowledge personal biases are better at providing compassionate care by manifesting compassion through their genuine and selfless interest in the complicated health problems and underlying socio-cultural determinants of each patient. Kindness, positivity, and a respectful nursing approach elicit openness and the sharing of heartfelt concerns. RELEVANCE TO CLINICAL PRACTICE: Comprehensive health assessment, dedicated efforts to know the patient as a human being, and listening to the patient's preferences can improve health outcomes among individuals with complex needs. Healthcare administrators can effect the change by supporting nurses to address complex health and social care needs with compassion. PATIENT OR PUBLIC CONTRIBUTION: Patients and healthcare professionals helped in data collection at the community care centre.

Potential immunological effects of gender-affirming hormone therapy in transgender people - an unexplored area of research.

There are well-described sex-based differences in how the immune system operates. In particular, cisgender (cis) females have a more easily activated immune system; associated with an increased prevalence of autoimmune diseases and adverse events following vaccinations. Conversely, cis males have a higher threshold for immune activation, and are more prone to certain infectious diseases, such as coronavirus disease (COVID-19). Oestrogen and testosterone have immune-modulatory properties, and it is likely that these contribute to the sexual dimorphism of the immune system. There are also important immune-related genes located on the X chromosome, such as toll-like receptor (TLR) 7/8; and the mosaic bi-allelic expression of such genes may contribute to the state of immune hyperactivation in cis females. The scientific literature strongly suggests that sex-based differences in the functioning of the immune system are related to both X-linked genes and immune modulation by sex hormones. However, it is currently not clear how this impacts transgender (trans) people receiving gender-affirming hormonal therapy. Moreover, it is estimated that in Australia, at least 2.3% of adolescents identify as trans and/or gender diverse, and referrals to specialist gender-affirming care are increasing each year. Despite the improving social awareness of trans people, they remain chronically underrepresented in the scientific literature. In addition, a small number of case studies describe new onset autoimmune disorders in adult trans females following oestrogen use. However, there is currently minimal long-term research with an immunological focus on trans people. Therefore, to ensure the positive health outcomes of trans people, it is crucial that the role of sex hormones in immune modulation is investigated further.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis.

Objectives: To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care. Methods: We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles. Results: Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework. Conclusions: Social movement action can provide a lens through which we view implementation science. Collective action and collective identity - concepts less frequently canvassed in implementation science literature - can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability.

Detecting Physiological Responses Using Multimodal Earbud Sensors.

Continuous stress exposure negatively impacts mental and physical well-being. Physiological arousal due to stress affects heartbeat frequency, changes breathing pattern and peripheral temperature, among several other bodily responses. Traditionally stress detection is performed by collecting signals such as electrocardiogram (ECG), respiration, and skin conductance response using uncomfortable sensors such as a chestband. In this study, we use earbuds that passively measure photoplethysmography (PPG), core body temperature, and inertial measurements. We have conducted a lab study exposing 18 participants to an evaluated speech task and additional tasks aimed at increasing stress or promoting relaxation. We simultaneously collected PPG, ECG, impedance cardiography (ICG), and blood pressure using laboratory grade equipment as reference measurements. We show that the earbud PPG sensor can reliably capture heart rate and heart rate variability. We further show that earbud signals can be used to classify the physiological responses associated with stress with 91.30% recall, 80.52% precision, and 85.12% F1-score using a random forest classifier with leave-one-subject-out cross-validation. The accuracy can further be improved through multi-modal sensing. These findings demonstrate the feasibility of using earbuds for passively monitoring users' physiological responses.

Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches.

BACKGROUND: Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective. METHODS: We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights. RESULTS: We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the 'Identify the problem' phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the 'Assess barriers/facilitators to knowledge use' phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the 'Select, tailor, implement interventions' phase (mean = 6.36, SD = 1.08). CONCLUSIONS: Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future. TRIAL REGISTRATION: Open Science Framework Registration: osf.io/qgh64.