A randomised controlled trial of the effectiveness of parent-based models of language intervention for 2- to 3-year-old children with speech, language and communication needs (SLCN) in areas of social disadvantage.

BACKGROUND: Early language delay is exacerbated by social disadvantage. Factors such as parents' low levels of literacy, confidence and self-perception can affect the capacity to act on advice received, critical to empowerment. Methods used to achieve successful health outcomes in socially disadvantaged clinical populations may need enhancing. AIMS: To compare the impact of standard parent-based intervention (PBI) to enhanced PBI for young children with speech, language and communication needs (SCLN) and their families living in more socially disadvantaged populations. METHODS AND PROCEDURES: A multicentre clustered blind randomised controlled trial was used to compare the effect of parent-based group interventions to improve early language development with children (mean age 27.5 months) from more socially disadvantaged populations with an expressive vocabulary of 40 or less single words. Intervention sessions were delivered by a speech and language therapist, over a 20-week period. Participants received one of two interventions: (1) Standard Care - indirect group PBI - (PBI) (2) Enhanced Care: indirect group enhanced PBI - (EPBI). Both standardised and non-standardised measures were used as outcomes. Parent engagement in the intervention was captured through analysis of attendance and the Parent Activation Measure - Speech & Language Therapy (PAM-SLT) (Insignia Health, 2014). The PAM measures a person's knowledge, skills and confidence to manage their own health and well-being (NHS England, 2018). In this study, activation referred to parents' knowledge, skills and confidence to manage their child's language development. OUTCOMES AND RESULTS: One hundred fifty-five participants were randomised at baseline. Children in both groups made significant improvements in the outcome on MacArthur-Bates Communicative Development Inventories Sentence Length, from pre-intervention to post-intervention and 6 months post-intervention (p < 0.05). Changes in vocabulary and expressive language skills were more equivocal, showing wide variation in confidence intervals for both groups. Where parents attended at least one intervention session almost all effect sizes were in favour of the EPBI intervention. Parents' activation levels significantly increased for both groups (EPBI p < 0.001, PBI p = 0.003), with a moderate effect size in favour of EPBI (Hedges' G 0.37, confidence interval -0.02 to 0.76), although wide variation was found. CONCLUSIONS AND IMPLICATIONS: This trial provides some evidence of facilitating the language development of children with SLCN from more socially disadvantaged areas through supporting caregivers. However, we found variation in outcomes; some children made excellent progress, whilst others did not. Further exploration of parent engagement and its relationship to child language outcomes will be valuable to understanding more about mechanisms of change in interventions that involve parents. WHAT THIS PAPER ADDS: What is already known on the subject Speech, language and communication needs (SLCN) have a knock-on effect on emotional well-being, school readiness, literacy and school attainment, putting children at increased risk of long-term consequences such as poor literacy, mental health problems and unemployment. In disadvantaged areas, the prevalence of language difficulties is higher than elsewhere. Factors such as parents' low levels of literacy, confidence and self-perception can affect the capacity to act on advice received, critical to empowerment. What this paper adds to existing knowledge Children with SLCN from more socially disadvantaged areas can make improvements in their language development through parent intervention, although wide individual variation was found. There was some evidence that children achieve better outcomes with EPBI, which employed an interagency collaborative approach. Parent's engagement (activation levels) increased significantly over time with intervention, with the increase twice as big for EPBI. What are the potential or actual clinical implications of this work? This trial provides some evidence that it is possible to facilitate the language development of children from more socially disadvantaged areas through supporting their caregivers. Further research would be useful to determine whether increases in parent engagement are related to adherence to intervention and change in child outcomes.

Shifting school health priorities pre-post cannabis legalization in Canada: Ontario secondary school rankings of student substance use as a health-related issue.

This study examined how schools prioritize ten key health concerns among their student populations over time and whether schools' prioritization of alcohol and other drug use (AODU) corresponds to students' substance use behaviours and cannabis legalization as a major policy change. Data were collected from a sample of secondary schools in Ontario, Canada across four years (2015/16-2018/19 [N2015/16 = 65, N2016/17 = 68, N2017/18 = 61 and N2018/19 = 60]) as a part of the COMPASS study. School-level prevalence of cannabis and alcohol use between schools that did and did not prioritize student AODU as a health concern was examined. Ordinal mixed models examined whether student cannabis and alcohol use were associated with school prioritization of AODU. Chi-square tests examined changing health priorities among schools pre-post cannabis legalization. School priority ranking for AODU was mostly stable over time. While AODU was identified as an important health concern, most schools identified mental health as their first priority across the four years of the study. No significant changes to school AODU priorities were observed pre-post cannabis legalization nor was school prioritization of AODU associated with student cannabis and alcohol use behaviours. This study suggests that schools may benefit from guidance in identifying and addressing priority health concerns among their student population.

International school-related sedentary behaviour recommendations for children and youth.

BACKGROUND: Existing sedentary behaviour guidelines for children and youth target overall sedentary behaviour and recreational screen time, without any specific recommendations regarding school-related sedentary behaviours (i.e., sedentary behaviours performed during the school day, or within the influence of school). The purpose of this paper is to describe the development of international evidence-based recommendations for school-related sedentary behaviours for children and youth, led by the Sedentary Behaviour Research Network (SBRN). METHODS: A panel of international experts was convened by SBRN in November 2020 to guide the development of these recommendations for children and youth aged ~ 5-18 years. The recommendations were informed by 1) age-relevant existing sedentary behaviour guidelines, 2) published research on the relationship between overall sedentary behaviour and health, 3) a de novo systematic review on the relationship between school-related sedentary behaviours and health and/or academic outcomes, and 4) a de novo environmental scan of the grey literature to identify existing recommendations for school-related sedentary behaviours. Draft recommendations were presented to the Expert Panel in June 2021. Following thorough discussion and modifications, updated recommendations were distributed for stakeholder feedback from July 9-26. Feedback was received from 148 stakeholders across 23 countries, leading to additional updates to the recommendations. Following further rounds of discussion and updates with the Expert Panel in August and September 2021, consensus was achieved on the final recommendations. RESULTS: A healthy day includes breaking up extended periods of sedentary behaviour and incorporating different types of movement into homework whenever possible, while limiting sedentary homework. School-related screen time should be meaningful, mentally or physically active, and serve a specific pedagogical purpose that enhances learning. Replacing sedentary learning activities with movement-based learning activities, and replacing screen-based learning activities with non-screen-based learning activities, can further support students' health and wellbeing. DISCUSSION: This paper presents the first evidence-based recommendations for school-related sedentary behaviours for children and youth. These recommendations will support the work of parents, caregivers, educators, school system administrators, policy makers, researchers and healthcare providers interested in promoting student health and academic success.

The SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention.

BACKGROUND: Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes. METHODS: This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation. RESULTS: 20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors. CONCLUSION: Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications. TRIAL REGISTRATION: PROSPERO CRD42019118834 .

Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review.

BACKGROUND: Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making. OBJECTIVES: The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings. REVIEW METHODS: A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool). RESULTS: Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors. LIMITATIONS: Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains. CONCLUSIONS: Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019118834. 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. 26, No. 5. See the NIHR Journals Library website for further project information.

AIM: The aim of this study was to summarise what is known about shock-absorbing flooring for reducing injurious falls in hospitals and care homes. BACKGROUND: Falls and fall-related injuries are a major problem for older adults in both hospitals and care homes. Shock-absorbing flooring (such as carpet, sports floors or specially designed floors) provides a more cushioned surface and is one potential solution to help reduce the impact forces from a fall. METHODS: From literature searches, we identified relevant studies on shock-absorbing flooring use in hospitals and care homes. We gathered data on the quality of the studies' methods, what and who the studies involved, and the study findings. Members of the public were involved throughout the project. They helped improve the clarity of the reporting and collaborated in meetings to help guide the study team. FINDINGS: One high-quality study in a care home found that vinyl overlay with novel shock-absorbing underlay was no better at reducing injuries than vinyl overlay with plywood underlay on concrete subfloors. We found very low-quality evidence that shock-absorbing flooring may reduce injuries in hospitals and care homes, without increasing falls; if this were true, then economic evidence suggested that shock-absorbing flooring would be the best-value option for patients (lower cost and improved outcomes). There was insufficient evidence to determine the effects of shock-absorbing flooring on fractures or head injuries, although wooden subfloors resulted in fewer hip fractures than concrete subfloors. Shock-absorbing flooring made it harder for staff to move equipment such as beds and trolleys, and led to staff changing how they work. IMPLICATIONS: The evidence suggests that one type of shock-absorbing floor may not work in care homes, compared with rigid flooring; however, gaps still exist in the knowledge. The evidence in favour of shock-absorbing flooring was of very low quality, meaning it is uncertain. There is a lack of robust evidence in hospitals, which often have concrete subfloors and different population characteristics. If planning to install shock-absorbing flooring, it is important to consider the wider impacts on the workplace and how best to manage these.

Implementation of Telemedicine in Pediatric and Neonatal Transport.

OBJECTIVE: Telemedicine uses video technology to communicate visual clinical information. This study aimed to implement telemedicine in pediatric and neonatal transport, assess its value, and identify barriers. METHODS: This prospective study implemented telemedicine before transport to a tertiary care children's hospital. A preimplementation survey assessed attitudes toward telemedicine and perceived barriers. During the 12-week pilot, a video connection was initiated between transport and medical control. We collected survey results measuring telemedicine usefulness and hindrance after each use. A postimplementation survey assessed opinions about when telemedicine was useful. RESULTS: Initially, 82% of users had no direct experience with telemedicine. Perceived utility and burden of telemedicine varied significantly by department. During the study, telemedicine was offered 65% of the time, initiated in 47% of cases, and successful in 30% of cases. The greatest barrier was connectivity. Over time, transport members and physicians found telemedicine to be significantly more useful. In 14 cases, telemedicine changed patient outcome or management. Providers who reported a change in management rated telemedicine as significantly more useful. CONCLUSION: This prospective pilot successfully implemented telemedicine before pediatric transport. Telemedicine was more useful in patients with visual findings on examination and, in some cases, changed the clinical outcome.

Labial trauma post birth: A delphi study of classification and suturing requirements.

OBJECTIVES: Primary objectives were to establish consensus of opinion for classification of post birth labial trauma and which types of post birth labial trauma require suturing. Secondary objectives were to establish optimal method, material and anaesthetic for suturing labial trauma. DESIGN: Delphi study consisting of 3 rounds. SETTING: UK and Europe PARTICIPANTS: 8 midwives, 4 obstetricians, 7 specialist perineal midwives, 1 consultant midwife and 2 midwifery lecturers all with relevant expertise and or recent, regular clinical experience of assessing and suturing labial trauma from 2 United Kingdom (UK) universities, 12 UK healthcare trusts and 1 European healthcare organisation. METHODS: A Delphi study consisting of an initial round of 6 professional medical illustrations of labial trauma with 6 open questions attached to each sent to panel members. 2 further rounds developed from the first round with between 2 and 10 opt-in statements for the 6 questions for each illustration to 20 and 22 panel members respectively. Consensus was set at 70% opt-in for each statement. FINDINGS: Consensus was reached that unilateral or bilateral vertical skin separation with minimal trauma to underlying tissues was described as a graze and does not require suturing. Consensus was reached that unilateral or bilateral deeper vertical trauma with involvement of the underlying tissue and horizontal trauma across the labia does require suturing with interrupted technique, injected local anaesthetic and using Vicryl Rapide 3.0 or equivalent. CONCLUSION: A pilot study and definitive randomised controlled trial are required to establish in vivo whether labial tears including those which are transverse, are less painful and heal better with interrupted suturing compared to continuous or subcuticular sutures.

Neuropeptide Y impairs the acquisition of conditioned defeat in Syrian hamsters.

Recent evidence indicates that Neuropeptide Y (NPY) may function as a potent anxiolytic as well as a resilience factor that can insulate the brain from the effects of stress. However, most of these studies have utilized physical stressors such as shock or restraint. In the present study, we use an ethologically-based model in Syrian hamsters (Mesocricetus auratus) called Conditioned Defeat (CD) to investigate whether NPY can ameliorate the effect of social defeat stress. In the CD model, a male Syrian hamster is socially defeated by a larger, more aggressive conspecific. Subsequently, when paired with a smaller, non-aggressive intruder (NAI) in its own home cage, changes in its behavioral repertoire occur, including a reduction in aggression and chemosensory (social) investigation, and a concomitant increase in submissive behaviors. In Experiment 1, hamsters were infused intracerebroventricularly (icv) with NPY prior to social defeat, and 24-hours later, hamsters were exposed to a NAI. Results indicate that NPY significantly reduced submissive/defensive behaviors in socially defeated hamsters compared to control animals. In Experiment 2, we examined whether this effect was mediated by the NPY Y1 receptor. Subjects were first pre-treated with the Y1 receptor antagonist BIBP 3226 or vehicle, followed by NPY and then socially defeated. Upon testing with a NAI 24-hours later, pretreatment with BIBP 3226 failed to block the NPY effect compared to controls. These results demonstrate that NPY may function as an important resilience factor in socially defeated hamsters, but that these effects are not mediated by the Y1 receptor.

A pilot study to evaluate the effectiveness of an individualized and cognitive behavioural communication intervention for informal carers of people with dementia: The Talking Sense programme.

BACKGROUND: People with dementia and family carers often experience difficulties communicating together. These difficulties are considered to contribute significantly to the depression, anxiety and negative feelings such as guilt often reported by dementia family carers. AIMS: To develop and contribute to the theory and evidence base for single-component, psychosocial interventions that address these difficulties by evaluating the effectiveness of the Talking Sense programme which was designed to reflect existing best evidence. METHODS & PROCEDURES: Talking Sense was delivered as an individualized, one to one, cognitive behavioural approach for developing knowledge, skills, thinking and behaviour of dementia family carers in managing communication difficulties. In this study, a randomized controlled trial compared 27 carers who completed three one-to-one individualized sessions using Talking Sense with 25 carers who received a single, knowledge-only, control discussion. OUTCOMES & RESULTS: There were no significant differences for the primary outcome measure of carer anxiety and depression as well as carer quality of life and general self-efficacy. Statistically significant results suggested carers receiving the Talking Sense intervention had fewer communication difficulties happening (p = 0.046) and felt more valued by their relatives (p = 0.046). A score close to significance (p = 0.052) suggested they perceived their relatives to be more communicatively competent. CONCLUSIONS & IMPLICATIONS: The intervention and research design were shown to be effective with low attrition and high adherence to treatment. A non-significant finding for the primary outcome measure does not support the potential for this intervention to effect carer anxiety and depression. The potential for perceived change in the person with dementia, with statistically fewer communication difficulties happening and the carer feeling more valued by their relative, was the most significant finding from this programme of research. Recommendations for further research are made.

Voluntary exercise increases resilience to social defeat stress in Syrian hamsters.

Exposure to social stressors can cause profound changes in an individual's well-being and can be an underlying factor in the etiology of a variety of psychopathologies, such as post-traumatic stress disorder (PTSD). In Syrian hamsters, a single social defeat experience results in behavioral changes collectively known as conditioned defeat (CD), and includes an abolishment of territorial aggression and the emergence of high levels of defensive behaviors. In contrast, voluntary exercise has been shown to promote stress resilience and can also have anxiolytic-like effects. Although several studies have investigated the resilience-inducing effects of voluntary exercise after exposure to physical stressors, such as restraint and electric shock, few studies have examined whether exercise can impart resilience in response to ethologically-based stressors, such as social defeat. In Experiment 1, we tested the hypothesis that voluntary exercise can have anxiolytic-like effects in socially defeated hamsters. In the elevated plus maze, the exercise group exhibited a significant reduction in risk assessment, a commonly used index of anxiety, compared to the no-exercise group. In the open-field test, animals in the exercise group exhibited a significant reduction in locomotor behavior and rearing, also an indication of an anxiolytic-like effect of exercise. In Experiment 2, we examined whether exercise can reverse the defeat-induced potentiation of defensive behaviors using the CD model. Socially defeated hamsters in the exercise group exhibited significantly lower levels of defensive/submissive behaviors compared to the no-exercise group upon exposure to the resident aggressor. Taken together, these results are among the first to suggest that voluntary exercise may promote resilience to social defeat stress in Syrian hamsters.

The bargaining of professionalism in emergency care practice: NHS paramedics and higher education.

Over the past 2 decades, as part of reforms to the National Health Service and with it organizational changes to ambulance work in the UK, paramedic education has undergone a process of academisation and a shift from in-house, apprenticeship weeks-long occupational training, to university-based undergraduate programs. While the professional regulation and standardization of Allied Health Professionals' education in high-income countries has captured scholarly attention, the study of paramedic practice is still in its infancy and there is a need to explore its evolvement in relation to the fluid societal-political circumstances affecting its provision and demand. Based on interviews with front-line paramedics, paramedic educators and paramedic science students in the South of England, this article examines how the reforms to paramedic education have impacted the professionalization of paramedics and their discourse of professionalism. Framed within to the 'new' sociology of professions, the case of British paramedics demonstrates the complex nature of the relationship between the university and professional practice. It appears that universities, the providers of paramedic education, are caught between two opposing discourses of professionalism: on the one hand, that of providing a platform for students' socialization and engagement with professionalism 'from within' practice which is based on students' common goals and mutual experiences, and, on the other hand, serving as a conduit for managerial/organizational strategies of professionalism which appear to undermine the role of university socialization.

Transfusion Decision Making in Pediatric Critical Illness.

Transfusion decision making (TDM) in the critically ill requires consideration of: (1) anemia tolerance, which is linked to active pathology and to physiologic reserve, (2) differences in donor RBC physiology from that of native RBCs, and (3) relative risk from anemia-attributable oxygen delivery failure vs hazards of transfusion, itself. Current approaches to TDM (e.g. hemoglobin thresholds) do not: (1) differentiate between patients with similar anemia, but dissimilar pathology/physiology, and (2) guide transfusion timing and amount to efficacy-based goals (other than resolution of hemoglobin thresholds). Here, we explore approaches to TDM that address the above gaps.

Controlling Phlebotomy Volume Diminishes PICU Transfusion: Implementation Processes and Impact.

BACKGROUND AND OBJECTIVES: Phlebotomy excess contributes to anemia in PICU patients and increases the likelihood of red blood cell transfusion, which is associated with risk of adverse outcomes. Excessive phlebotomy reduction (EPR) strategies may reduce the need for transfusion, but have not been evaluated in a PICU population. We hypothesized that EPR strategies, facilitated by implementation science methods, would decrease excess blood drawn and reduce transfusion frequency. METHODS: Quantitative and qualitative methods were used. Patient and blood draw data were collected with survey and focus group data to evaluate knowledge and attitudes before and after EPR intervention. The Consolidated Framework for Implementation Research was used to interpret qualitative data. Multivariate regression was employed to adjust for potential confounders for blood overdraw volume and transfusion incidence. RESULTS: Populations were similar pre- and postintervention. EPR strategies decreased blood overdraw volumes 62% from 5.5 mL (interquartile range 1-23) preintervention to 2.1 mL (interquartile range 0-7.9 mL) postintervention (P < .001). Fewer patients received red blood cell transfusions postintervention (32.1% preintervention versus 20.7% postintervention, P = .04). Regression analyses showed that EPR strategies reduced blood overdraw volume (P < .001) and lowered transfusion frequency (P = .05). Postintervention surveys reflected a high degree of satisfaction (93%) with EPR strategies, and 97% agreed EPR was a priority postintervention. CONCLUSIONS: Implementation science methods aided in the selection of EPR strategies and enhanced acceptance which, in this cohort, reduced excessive overdraw volumes and transfusion frequency. Larger trials are needed to determine if this approach can be applied in broader PICU populations.

GABAA receptor activation in the lateral septum reduces the expression of conditioned defeat and increases aggression in Syrian hamsters.

Exposure to social stressors can cause profound changes in an individual's physiology and behavior. In Syrian hamsters, even a single social defeat results in conditioned defeat, which includes an abolishment of territorial aggression and the emergence of high levels of submissive behavior. The purpose of the current study was to determine whether the lateral septum (LS) is a component of the putative neural circuit underlying conditioned defeat. Experiment 1 explored the possibility that plasticity in the LS is necessary for the induction of conditioned defeat. Infusions of the protein synthesis inhibitor, anisomycin, prior to defeat training, however, failed to alter conditioned defeat during testing on the following day, suggesting that synaptic plasticity in the LS is not critical for defeat-induced suppression of aggression. Experiment 2 tested whether the LS is necessary for the expression of conditioned defeat. Infusions of the GABA(A) agonist muscimol into the LS prior to testing significantly increased aggression and decreased submission in previously defeated animals suggesting that the LS is an important component of the neural circuit mediating the expression of both aggression and submission in conditioned defeat. Experiment 3 examined whether the effects of muscimol on aggression were dependent on prior social defeat. Non-defeated animals receiving muscimol infusions prior to testing with a non-aggressive intruder displayed significantly more aggression than did hamsters receiving control injections. Thus, these data suggest that the activation of GABA(A) receptors in the LS increases aggression regardless of whether or not a hamster has previously experienced social defeat.

The medial prefrontal cortex is both necessary and sufficient for the acquisition of conditioned defeat.

We have previously demonstrated that the basolateral amygdala (BLA) is a key component of a neural circuit mediating memory formation for emotionally relevant stimuli in an ethologically-based model of conditioned fear, termed conditioned defeat (CD). In this model, subjects are socially defeated by a larger, more aggressive hamster. Upon subsequent exposure to a smaller, non-aggressive intruder, the defeated animal will show high levels of submissive behaviors and fail to defend its territory. Here we examined whether the medial prefrontal cortex (mPFC), an area with extensive connections with the amygdala, is also a component of this circuit. Temporary inactivation of the mPFC using muscimol, a GABA(A) receptor agonist, significantly enhanced the acquisition but not expression of CD, while blockade of GABA(A) receptors in the mPFC using bicuculline, a GABA(A) antagonist, impaired acquisition of CD. Given these findings, we next sought to test whether plasticity related to the defeat experience occurs in the mPFC. We infused anisomycin, a protein synthesis inhibitor, in the mPFC but this treatment did not alter the acquisition of CD. In our final experiment, we demonstrated that bicuculline failed to alter the acquisition of CD. Together, these results demonstrate for the first time that while the mPFC is both necessary and sufficient for the acquisition of CD, it does not appear to mediate plasticity related to the defeat experience. In contrast, while plasticity underlying CD does appear to occur in the BLA, GABAergic receptor inhibition in the BLA is not sufficient to enhance CD. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

NR2B subunit of the NMDA receptor in the basolateral amygdala is necessary for the acquisition of conditioned defeat in Syrian hamsters.

Reversible inactivation of the basolateral amygdala (BLA) disrupts the acquisition and expression of conditioned defeat (CD), an ethological model of conditioned fear, suggesting that the BLA may be a critical component of the neural circuit mediating behavioral plasticity associated with the experience of social defeat. We have also shown that this effect is N-methyl-d-aspartic acid (NMDA) receptor-dependent, because infusion of d,l-2-amino-5-phosphovalerate (APV) into the BLA also impairs the acquisition of CD. APV is a non-selective NMDA antagonist, however, thus it disrupts the entire heteromeric receptor complex, making it difficult to distinguish the relative contributions of either the NR2A or NR2B receptor subtypes on the acquisition of CD. There is ample evidence, however, that the NR2B subunit of the NMDA receptor in the amygdala is critical for mediating long-term potentiation and plasticity related to fear learning. The purpose of the present experiment was to determine whether infusion of ifenprodil, a selective antagonist of the NR2B subunit, into the BLA would block the acquisition (but not expression) of CD. In Experiment 1, infusion of ifenprodil immediately before defeat training significantly decreased submissive behaviors and restored territorial aggression when hamsters were later paired with a non-aggressive intruder (NAI). Conversely, infusion of ifenprodil immediately before CD testing failed to inhibit the expression of submissive behaviors in previously defeated hamsters. These results support the hypothesis that the BLA is a critical site for the plasticity underlying social defeat-induced changes in behavior.

Role of amygdala and hippocampus in the neural circuit subserving conditioned defeat in Syrian hamsters.

We examined the roles of the amygdala and hippocampus in the formation of emotionally relevant memories using an ethological model of conditioned fear termed conditioned defeat (CD). Temporary inactivation of the ventral, but not dorsal hippocampus (VH, DH, respectively) using muscimol disrupted the acquisition of CD, whereas pretraining VH infusions of anisomycin, a protein synthesis inhibitor, failed to block CD. To test for a functional connection between the VH and basolateral amygdala (BLA), we used a classic functional connectivity design wherein injections are made unilaterally in brain areas either on the same or opposite sides of the brain. A functional connection between the BLA and VH necessary for the acquisition of CD could not be found because unilateral inactivation of either BLA alone (but not either VH alone) was sufficient to disrupt CD. This finding suggested instead that there may be a critical functional connection between the left and right BLA. In our final experiment, we infused muscimol unilaterally in the BLA and assessed Fos immunoreactivity on the contralateral side following exposure to social defeat. Inactivation of either BLA significantly reduced defeat-induced Fos immunoreactivity in the contralateral BLA. These experiments demonstrate for the first time that whereas the VH is necessary for the acquisition of CD, it does not appear to mediate the plastic changes underlying CD. There also appears to be a critical interaction between the two BLAs such that bilateral activation of this brain area must occur in order to support fear learning in this model, a finding that is unprecedented to date.

Gonadal hormones modulate the display of conditioned defeat in male Syrian hamsters.

It has been widely reported that gonadal hormones influence the display of aggression in Syrian hamsters; conversely, much less is known about whether gonadal hormones modulate submissive/defensive behaviors in these animals. Following social defeat, male hamsters no longer display normal territorial aggression but instead display submissive/defensive behavior in the presence of a smaller opponent, a phenomenon we have termed conditioned defeat (CD). The purpose of the present study was to examine the effect of gonadal hormones on the display of CD in male hamsters. In Experiment 1, males were castrated or sham-operated. The castrated males were significantly more submissive following social defeat relative to their intact counterparts. The increased submissive behavior in the castrated males during CD testing was particularly surprising, given the fact that they were attacked significantly less during CD training. In Experiment 2a, males were castrated and given hormone replacement. Castrated males treated with testosterone or dihydrotestosterone displayed significantly less submissive behavior following social defeat than did those treated with cholesterol or estradiol. Finally, in Experiment 2b, there was no effect of hormone replacement on aggressive behavior in non-defeated hamsters suggesting that the decrease in submissive behavior in males treated with dihydrotestosterone or testosterone is specific to being previously defeated. Taken together the data indicate that the presence of androgens reduces the display of submission in defeated male hamsters. More importantly, these findings suggest that androgens may have a protective effect against the development of depression-like or anxiety-like behaviors following exposure to an ethologically relevant stressor.

Role of the bed nucleus of the stria terminalis in the acquisition and expression of conditioned defeat in Syrian hamsters.

When Syrian hamsters (Mesocricetus auratus) are defeated by a larger, more aggressive opponent, they subsequently produce more defensive and submissive behaviors and less chemosensory investigation and aggression, even when they are paired with a smaller, non-aggressive intruder. This persistent change in the behavior of defeated animals has been termed conditioned defeat. In the present study, we tested the hypothesis that the bed nucleus of the stria terminalis (BNST) is important for the acquisition and expression of conditioned defeat. We found that the GABA(A) receptor agonist muscimol infused into the BNST immediately prior to initial defeat training failed to disrupt the acquisition of conditioned defeat, while muscimol infused prior to testing caused a significant reduction in submissive/defensive behaviors and an increase in investigatory behaviors of the non-aggressive intruder. These results indicate that (1) the BNST, unlike the amygdala, does not appear to be critically involved in the consolidation process related to the memory of social defeat and (2) the BNST may be an important site for the execution of fear behaviors associated with social defeat. Considering the high degree of connectivity between the BNST and the amygdala, these findings provide further insight into the neural circuitry governing conditioned defeat and support the view of a functional dissociation between the amygdala and the BNST in the modulation of conditioned fear in an ethologically relevant model.

Children with speech, language and communication needs: their perceptions of their quality of life.

BACKGROUND: This study is part of a programme of research aiming to develop a quantitative measure of quality of life for children with communication needs. It builds on the preliminary findings of Markham and Dean ( 2006 ), which described some of the perception's parents and carers of children with speech language and communication needs had regarding children's experience of quality of life. However, this earlier study did not observe and evaluate the perceptions of children themselves and consequently left a vital gap in the evidence. The study reported here seeks to address this by describing the quality of life experiences reported by children and young people themselves. AIMS: The study aimed to provide a qualitative, child-centred, description of the quality of life experiences of children and young people with speech language and communication needs. METHODS & PROCEDURES: The study used a qualitative methodology to provide a credible and thick description of the quality of life experiences of children and young people with speech language and communication needs. Children and young people participating in the study were selected to represent a range of speech and language pathologies, according to their capacity to comprehend and participate within the data-collection activities. A modified focus group technique was used as a method of data collection and data were analysed according to the principles of Grounded Theory and Framework analysis. OUTCOMES & RESULTS: Seven focus group interviews were conducted with a range of children and young people in full-time education and in receipt of speech and language therapy. The data showed a number of key themes regarding children's quality of life experiences. These themes ranged from the participant's perceptions of what improves their daily lives to the difficulties they experience and consequently the negative impacts perceived on their quality of life. CONCLUSIONS & IMPLICATIONS: This study illuminates the quality of life experiences of children with speech language and communication needs. The findings are of direct benefit to clinicians, researchers, and policy-makers alike as they broaden the understanding of children's speech and language difficulties. Despite the potential bias inherent in qualitative research with children, the findings provide support for the development of a quality of life scale for children with speech language and communication needs. Such an outcome measure would enable clinicians and researchers to quantify children's quality of life, thereby broadening the range of clinical outcomes available.