Breeding for water-use efficiency in wheat: progress, challenges and prospects.

Drought poses a significant challenge to wheat production globally, leading to substantial yield losses and affecting various agronomic and physiological traits. The genetic route offers potential solutions to improve water-use efficiency (WUE) in wheat and mitigate the negative impacts of drought stress. Breeding for drought tolerance involves selecting desirable plants such as efficient water usage, deep root systems, delayed senescence, and late wilting point. Biomarkers, automated and high-throughput techniques, and QTL genes are crucial in enhancing breeding strategies and developing wheat varieties with improved resilience to water scarcity. Moreover, the role of root system architecture (RSA) in water-use efficiency is vital, as roots play a key role in nutrient and water uptake. Genetic engineering techniques offer promising avenues to introduce desirable RSA traits in wheat to enhance drought tolerance. These technologies enable targeted modifications in DNA sequences, facilitating the development of drought-tolerant wheat germplasm. The article highlighted the techniques that could play a role in mitigating drought stress in wheat.

Cardiovascular Outcomes and Readmissions of Atrial Fibrillation Among Patent Foramen Ovale Occluder Device Recipients: A Propensity Matched National Readmission Study.

Patent foramen ovale (PFO) occluder devices are increasingly utilized in minimally invasive procedures used to treat cryptogenic stroke. Data on the impact of Atrial Fibrillation (AF) among PFO occluder device recipients are limited. The Nationwide Readmissions Database was queried between 2016 and 2019 to identify PFO patients with and without AF. The 2 groups were compared using propensity score matching (PSM) and multivariate regression models. The outcomes included in-hospital mortality, acute kidney injury (AKI), Mechanical circulatory support use (MCS), Cardiogenic shock (CS), acute ischemic stroke, bleeding, and other cardiovascular outcomes. Statistical analysis was performed using STATA v. 17. Out of 6508 Weighted hospitalizations for PFO occluder device procedure over the study period, 877 (13.4%) had AF compared to 5631 (86.6%) who did not. On adjusted analysis, PFO with AF group had higher rates of MCS (PSM, 4.5% vs 2.2 %, P value = 0.011) and SCA (PSM, 7.6% vs 4.6 %, P value = 0.015) compared to PFO with no AF. There was no statistically significant difference in the rate of in-hospital mortality (PSM, 5.4% vs 6.4 %, P value = 0.39), CS (PSM, 8.3% vs 5.9 %, P value = 0.075), AKI (PSM, 32.4% vs 32.3 %, P value = 0.96), bleeding (PSM, 2.08% vs 1.3%, P value = 0.235) or the readmission rates among both cohorts. Additionally, AF was associated with higher hospital length of stay (9.5 ± 13.2 vs 8.2 ± 24.3 days, P-value = 0.012) and total cost ($66,513 ± $80,922 vs $52,013±$125,136, 0.025, P-value = 0.025) compared to PFO without AF. AF among PFO occluder device recipients is associated with increased adverse outcomes, including MCS use and SCA, with no difference in mortality and readmission rates among both cohorts. Long-term follow-up needs further studies.

Play brick therapy to aid the social skills of children and young people with autism spectrum disorder: the I-SOCIALISE cluster RCT.

Background: Social skills interventions are commonly recommended to help children and young people with autism spectrum disorder develop social skills, but some struggle to engage in these interventions. LEGO® (LEGO System A/S, Billund, Denmark) based therapy, a group social skills intervention, aims to be more interesting and engaging. Objective: To evaluate the clinical effectiveness of LEGO® based therapy on the social and emotional skills of children and young people with autism spectrum disorder in school settings compared with usual support. Secondary objectives included evaluations of cost-effectiveness, acceptability and treatment fidelity. Design: A cluster randomised controlled trial randomly allocating participating schools to either LEGO® based therapy and usual support or usual support only. Setting: Mainstream schools in the north of England. Participants: Children and young people (aged 7-15 years) with autism spectrum disorder, their parent/guardian, an associated teacher/teaching assistant and a facilitator teacher/teaching assistant (intervention schools only). Intervention: Schools randomised to the intervention arm delivered 12 weekly sessions of LEGO® based therapy, which promotes collaborative play and encourages social problem-solving in groups of three children and young people with a facilitator (trained teacher or teaching assistant). Participants received usual support from school and community services. Participants in the control arm received usual support only. Research assistants and statisticians were blind to treatment allocation. Main outcome measure: The social skills subscale of the Social Skills Improvement System (SSIS), completed by the children and young people's unblinded teacher pre randomisation and 20 weeks post randomisation. The SSIS social skills subscale measures social skills including social communication, co-operation, empathy, assertion, responsibility and self-control. Participants completed a number of other pre- and post-randomisation measures of emotional health, quality of life, loneliness, problem behaviours, academic competence, service resource utilisation and adverse events. Results: A total of 250 children and young people from 98 schools were randomised: 127 to the intervention arm and 123 to the control arm. Intention-to-treat analysis of the main outcome measure showed a modest positive difference of 3.74 points (95% confidence interval -0.16 to 7.63 points, standardised effect size 0.18; p = 0.06) in favour of the intervention arm. Statistical significance increased in per-protocol analysis, with a modest positive difference (standardised effect size 0.21; p = 0.036). Cost-effectiveness of the intervention was found in reduced service use costs and a small increase in quality-adjusted life-years. Intervention fidelity and acceptability were positive. No intervention-related adverse events or effects were reported. Conclusions: The primary and pre-planned sensitivity analysis of the primary outcome consistently showed a positive clinical difference, with modest standardised effect sizes of between 0.15 and 0.21. There were positive health economics and qualitative findings, corroborated by the difference between arms for the majority of secondary outcomes, which were not statistically significant but favoured the intervention arm. Post hoc additional analysis was exploratory and was not used in drawing this conclusion. Given the small positive change, LEGO® based therapy for children and young people with autism spectrum disorder in schools should be considered. Limitations: The primary outcome measure was completed by an unblinded teacher (rather than by the facilitator). Future work: The study team recommends future research into LEGO® based therapy, particularly in school environments. Trial registration: This trial is registered as ISRCTN64852382. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/49/32) and is published in full in Public Health Research; Vol. 11, No. 12. See the NIHR Funding and Awards website for further award information.

Autism spectrum disorder is characterised by difficulties with social relationships and communication, which can make it difficult to make friends. Social skills training is commonly used to help children and young people learn different social skills, but some children and young people do not enjoy these therapies. LEGO^® (LEGO System A/S, Billund, Denmark) based therapy takes a new approach by focusing on making the process interesting and fun. This research investigated the effect of LEGO^® based therapy groups in schools on the social and emotional abilities of children and young people with autism spectrum disorder. It was a randomised controlled trial, so each school that was taking part was randomly chosen to provide either usual support (from the school or NHS services) or 12 sessions of LEGO^® based therapy with a trained school staff member as well as usual support. Children and young people played one of three roles ­ the 'engineer' (gives instructions), the 'supplier' (finds the pieces) or the 'builder' (builds the model) ­ and worked together. Questionnaires completed by children and young people, their parents/guardians and teachers were used to look at the intervention's effects. The main objective was to see if there was a change in social skills measured by a teacher-completed questionnaire. Results showed that the social skills of children and young people in the LEGO^® based therapy groups did improve a little. We found that the intervention is not very costly for schools to run. Many parents/guardians and teachers thought that the intervention was beneficial and that the children and young people enjoyed it.

An economic evaluation of universal and targeted case-finding strategies for identifying antenatal depression: a model-based analysis comparing common case-finding instruments.

Half of women with depression in the perinatal period are not identified in routine care, and missed cases reflect inequalities in other areas of maternity care. Case finding (screening) for depression in pregnant women may be a cost-effective strategy to improve identification, and targeted case finding directs finite resources towards the greatest need. We compared the cost-effectiveness of three case-finding strategies: no case finding, universal (all pregnant women), and targeted (only pregnant women with risk factors for antenatal depression, i.e. history of anxiety/depression, age < 20 years, and adverse life events). A decision tree model was developed to represent case finding (at around 20 weeks gestation) and subsequent treatment for antenatal depression (up to 40 weeks gestation). Costs include case finding and treatment. Health benefits are measured as quality-adjusted life years (QALYs). The sensitivity and specificity of case-finding instruments and prevalence and severity of antenatal depression were estimated from a cohort study of pregnant women. Other model parameters were derived from published literature and expert consultation. The most cost-effective case-finding strategy was a two-stage strategy comprising the Whooley questions followed by the PHQ-9. The mean costs were £52 (universal), £61 (no case finding), and £62 (targeted case finding). Both case-finding strategies improve health compared with no case finding. Universal case finding is cost-saving. Costs associated with targeted case finding are similar to no case finding, with greater health gains, although targeted case finding is not cost-effective compared with universal case finding. Universal case finding for antenatal depression is cost-saving compared to no case finding and more cost-effective than targeted case finding.

Risk stratification for treating people at ultra-high risk for psychosis: A cost-effectiveness analysis.

People who are at ultra-high risk (UHR) for psychosis receive clinical care with the aim to prevent first-episode psychosis (FEP), regardless of the risk of conversion to psychosis. An economic model from the Canadian health system perspective was developed to evaluate the cost-effectiveness of treating all with UHR compared to risk stratification over a 15-year time horizon, based on conversion probability, expected quality-of-life and costs. The analysis used a decision tree followed by a Markov model. Health states included: Not UHR, UHR with <20 % risk of conversion to FEP (based on the North American Prodrome Longitudinal Study risk calculator), UHR with ≥20 % risk, FEP, Remission, Post-FEP, and Death. The analysis found that: risk stratification (i.e., only treating those with ≥20 % risk) had lower costs ($1398) and quality-adjusted life-years (0.055 QALYs) per person compared to treating all. The incremental cost-effectiveness ratio for 'treat all' was $25,448/QALY, and suggests treating all may be cost-effective. The model was sensitive to changes to the probability of conversion.

Exploring the recuperative potential of brassinosteroids and nano-biochar on growth, physiology, and yield of wheat under drought stress.

Drought stress as a result of rapidly changing climatic conditions has a direct negative impact on crop production especially wheat which is the 2nd staple food crop. To fulfill the nutritional demand under rapidly declining water resources, there is a dire need to adopt a precise, and efficient approach in the form of different amendments. In this regard, the present study investigated the impact of nano-biochar (NBC) and brassinosteroids (BR) in enhancing the growth and productivity of wheat under different drought stress conditions. The field study comprised different combinations of amendments (control, NBC, BR, and NBC + BR) under three irrigation levels (D0, D1 and D2). Among different treatments, the synergistic approach (NBC + BR) resulted in the maximum increase in different growth and yield parameters under normal as well as drought stress conditions. With synergistic approach (NBC + BR), the maximum plant height (71.7 cm), spike length (17.1), number of fertile tillers m-2 (410), no. of spikelets spike-1 (19.1), no. of grains spike-1 (37.9), 1000 grain weight (37 g), grain yield (4079 kg ha-1), biological yield (10,502 kg ha-1), harvest index (43.5). In the case of physiological parameters such as leaf area index, relative water contents, chlorophyll contents, and stomatal conductance were maximally improved with the combined application of NBC and BR. The same treatment caused an increase of 54, 10, and 7% in N, P, and K contents in grains, respectively compared to the control treatment. Similarly, the antioxidant response was enhanced in wheat plants under drought stress with the combined application of NBC and BR. In conclusion, the combined application of NBC and BR caused a significant increase in the growth, physiological and yield attributes of wheat under drought stress.

The Global Dilemma of Soil Legacy Phosphorus and Its Improvement Strategies under Recent Changes in Agro-Ecosystem Sustainability.

Phosphorus (P) is one of the six key elements in plant nutrition and effectively plays a vital role in all major metabolic activities. It is an essential nutrient for plants linked to human food production. Although abundantly present in both organic and inorganic forms in soil, more than 40% of cultivated soils are commonly deficient in P concentration. Then, the P inadequacy is a challenge to a sustainable farming system to improve the food production for an increasing population. It is expected that the whole world population will rise to 9 billion by 2050 and, therefore, it is necessary at the same time for agricultural strategies broadly to expand food production up to 80% to 90% by handling the global dilemma which has affected the environment by climatic changes. Furthermore, the phosphate rock annually produced about 5 million metric tons of phosphate fertilizers per year. About 9.5 Mt of phosphorus enters human food through crops and animals such as milk, egg, meat, and fish and is then utilized, and 3.5 Mt P is physically consumed by the human population. Various new techniques and current agricultural practices are said to be improving P-deficient environments, which might help meet the food requirements of an increasing population. However, 4.4% and 3.4% of the dry biomass of wheat and chickpea, respectively, were increased under intercropping practices, which was higher than that in the monocropping system. A wide range of studies showed that green manure crops, especially legumes, improve the soil-available P content of the soil. It is noted that inoculation of arbuscular mycorrhizal fungi could decrease the recommended phosphate fertilizer rate nearly 80%. Agricultural management techniques to improve soil legacy P use by crops include maintaining soil pH by liming, crop rotation, intercropping, planting cover crops, and the consumption of modern fertilizers, in addition to the use of more efficient crop varieties and inoculation with P-solubilizing microorganisms. Therefore, exploring the residual phosphorus in the soil is imperative to reduce the demand for industrial fertilizers while promoting long-term sustainability on a global scale.

Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal.

Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Bacterial-Mediated Salinity Stress Tolerance in Maize (Zea mays L.): A Fortunate Way toward Sustainable Agriculture.

Sustainable agriculture is threatened by salinity stress because of the low yield quality and low crop production. Rhizobacteria that promote plant growth modify physiological and molecular pathways to support plant development and reduce abiotic stresses. The recent study aimed to assess the tolerance capacity and impacts of Bacillus sp. PM31 on the growth, physiological, and molecular responses of maize to salinity stress. In comparison to uninoculated plants, the inoculation of Bacillus sp. PM31 improved the agro-morphological traits [shoot length (6%), root length (22%), plant height (16%), fresh weight (39%), dry weight (29%), leaf area (11%)], chlorophyll [Chl a (17%), Chl b (37%), total chl (22%)], carotenoids (15%), proteins (40%), sugars (43%), relative water (11%), flavonoids (22%), phenols (23%), radical scavenging capacity (13%), and antioxidants. The Bacillus sp. PM31-inoculated plants showed a reduction in the oxidative stress indicators [electrolyte leakage (12%), H2O2 (9%), and MDA (32%)] as compared to uninoculated plants under salinity and increased the level of osmolytes [free amino acids (36%), glycine betaine (17%), proline (11%)]. The enhancement of plant growth under salinity was further validated by the molecular profiling of Bacillus sp. PM31. Moreover, these physiological and molecular mechanisms were accompanied by the upregulation of stress-related genes (APX and SOD). Our study found that Bacillus sp. PM31 has a crucial and substantial role in reducing salinity stress through physiological and molecular processes, which may be used as an alternative approach to boost crop production and yield.

Fall-Risk-Increasing Drugs and Gait Performance in Community-Dwelling Older Adults: Exploratory Results from the Gait and Brain Study.

BACKGROUND/OBJECTIVE: While several psychotropic and cardiovascular drugs have been identified as fall-risk-increasing drugs (FRIDs) in older adults, the intervening mechanisms linking FRIDs and falls are unclear. It is plausible that gait performance is an intermediate variable on the causal pathway between FRIDs and falls. The current evidence on the relationship between medication use and gait performance in older adults is scarce. We aimed to assess the association between FRIDs and gait performance in community-dwelling older adults. METHODS: This was a cross-sectional analysis using data from the Gait and Brain Study, a study of community-dwelling older adults aged 65 years old and over (N = 345). The following drug classes were assessed: antidepressants, benzodiazepines, alpha-blockers, beta-blockers, vasodilators, diuretics, statins and aspirin. Medication use was ascertained through validated questionnaires and electronic medical records. Multiple linear regression models were used to assess the association between each of the drug classes and gait speed and gait variability. Gait variability was expressed as the coefficient of variation (CV = mean/standard deviation) of stride time. Models were adjusted for age, sex, education, body mass index (BMI), mini-mental status exam (MMSE) score, Geriatric Depression Scale (GDS) score, general activity level, use of other FRIDs and comorbidity propensity score. RESULTS: Diuretic use was associated with significantly reduced gait speed (B = -7.97 cm/s, 95% CI: -13.94, -2.00, P = 0.009). Statin use was associated with significantly increased stride time CV (B = 0.13, 95% CI: 0.02, 0.24, P = 0.026). Other drugs did not have a statistically significant relationship with gait speed or variability. CONCLUSION: The association between diuretic use and reduced gait speed is consistent with existing evidence on diuretic use and increased fall risk. The association between statins and increased stride time variability is notable given inconclusive evidence in previous studies. Our results provide initial estimates of the association between FRIDs and gait performance in older adults for future longitudinal studies.

The double burden of malnutrition among women of reproductive age and preschool children in low- and middle-income countries: A scoping review and thematic analysis of literature.

The aim of this review was to map the literature on the double burden of malnutrition (DBM) among women of reproductive age (WRA) and preschool children in low- and middle-income countries (LMICs). The study aimed to provide an understanding of how DBM construct has been defined in the current literature and to elucidate plausible mechanisms underlying DBM development and its common risk factor among the two subgroups. We systematically searched for literature from the following databases: EMBASE, CINAHL, MEDLINE, LILACS, Scopus and ProQuest Dissertations & Thesis Global and identified articles that specifically reported on the coexistence of undernutrition and overnutrition sequalae at the population, household, or individual levels among WRA and preschool children in LMICs. A thematic analysis using the Braun and Clarke approach was conducted on excerpts from the articles to reveal emerging themes underlying the occurrence of DBM from the included studies. Of the initial 15 112 articles found, 720 met the inclusion criteria. Anthropometric measures for overnutrition and undernutrition including body mass index for WRA and height-for-age, weight-for-age, and weight-for-height Z-scores for preschool children were frequently used indicators for defining DBM across all levels of assessment. In fewer cases, DBM was defined by the pairing of cardiometabolic risk factors (e.g., hypertension) as measures for overnutrition and micronutrient deficiency (e.g., iron deficiency) as measures for undernutrition. The following themes emerged as plausible mechanisms for DBM development: nutrition transition, breastfeeding, diet behavior, biological mechanism, and statistical artifact. Factors such as child age, child sex, maternal age, maternal education, maternal occupation, household food security, household wealth, urbanicity, and economic development were commonly associated with most of the DBM phenotypes. Our review findings showed that the understanding of the DBM in current literature is very ambiguous. There is need for future research to better understand the DBM construct and its etiology.

An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments.

BACKGROUND: Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND. METHODS: A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding. RESULTS: More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding. LIMITATIONS: The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important. CONCLUSIONS: Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.

I-SOCIALISE: Results from a cluster randomised controlled trial investigating the social competence and isolation of children with autism taking part in LEGO® based therapy ('Play Brick Therapy') clubs in school environments.

LAY ABSTRACT: Autism is characterised by keen interests and differences in social interactions and communication. Activities that help autistic children and young people with social skills are commonly used in UK schools. LEGO® based therapy is a new activity that provides interesting and fun social opportunities for children and young people and involves building LEGO® models together. This study looked at LEGO® based therapy for the social skills of autistic children and young people in schools. It was a randomised controlled trial, meaning each school was randomly chosen (like flipping a coin) to either run LEGO® based therapy groups in school over 12 weeks and have usual support from school or other professionals, or only have usual support from school or other professionals. The effect of the LEGO® based therapy groups was measured by asking children and young people, their parents/guardians, and a teacher at school in both arms of the study to complete some questionnaires. The main objective was to see if the teacher's questionnaire answers about the children and young people's social skills changed between their first and second completions. The social skills of participants in the LEGO® based therapy groups were found to have improved in a small way when compared to usual support only. The study also found that LEGO® based therapy was not very costly for schools to run and parents/guardians and teachers said they thought it was good for their children and young people. We suggest further research into different potential benefits of LEGO® based therapy.

One-session treatment compared with multisession CBT in children aged 7-16 years with specific phobias: the ASPECT non-inferiority RCT.

BACKGROUND: Up to 10% of children and young people have a specific phobia that can significantly affect their mental health, development and daily functioning. Cognitive-behavioural therapy-based interventions remain the dominant treatment, but limitations to their provision warrant investigation into low-intensity alternatives. One-session treatment is one such alternative that shares cognitive-behavioural therapy principles but has a shorter treatment period. OBJECTIVE: This research investigated the non-inferiority of one-session treatment to cognitive-behavioural therapy for treating specific phobias in children and young people. The acceptability and cost-effectiveness of one-session treatment were examined. DESIGN: A pragmatic, multicentre, non-inferiority randomised controlled trial, with embedded economic and qualitative evaluations. SETTINGS: There were 26 sites, including 12 NHS trusts. PARTICIPANTS: Participants were aged 7-16 years and had a specific phobia defined in accordance with established international clinical criteria. INTERVENTIONS: Participants were randomised 1 : 1 to receive one-session treatment or usual-care cognitive-behavioural therapy, and were stratified according to age and phobia severity. Outcome assessors remained blind to treatment allocation. MAIN OUTCOME MEASURES: The primary outcome measure was the Behavioural Avoidance Task at 6 months' follow-up. Secondary outcomes included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety and Depression Scale, a goal-based outcome measure, Child Health Utility 9D, EuroQol-5 Dimensions Youth version and resource usage. Treatment fidelity was assessed using the Cognitive Behaviour Therapy Scale for Children and Young People and the One-Session Treatment Rating Scale. RESULTS: A total of 274 participants were recruited, with 268 participants randomised to one-session treatment (n = 134) or cognitive-behavioural therapy (n = 134). A total of 197 participants contributed some data, with 149 participants in the intention-to-treat analysis and 113 in the per-protocol analysis. Mean Behavioural Avoidance Task scores at 6 months were similar across treatment groups when both intention-to-treat and per-protocol analyses were applied [cognitive-behavioural therapy: 7.1 (intention to treat), 7.4 (per protocol); one-session treatment: 7.4 (intention to treat), 7.6 (per protocol); on the standardised scale adjusted mean difference for cognitive-behavioural therapy compared with one-session treatment -0.123, 95% confidence interval -0.449 to 0.202 (intention to treat), mean difference -0.204, 95% confidence interval -0.579 to 0.171 (per protocol)]. These findings were wholly below the standardised non-inferiority limit of 0.4, which suggests that one-session treatment is non-inferior to cognitive-behavioural therapy. No between-group differences in secondary outcome measures were found. The health economics evaluation suggested that, compared with cognitive-behavioural therapy, one-session treatment marginally decreased the mean service use costs and maintained similar mean quality-adjusted life-year improvement. Nested qualitative evaluation found one-session treatment to be considered acceptable by those who received it, their parents/guardians and clinicians. No adverse events occurred as a result of phobia treatment. LIMITATIONS: The COVID-19 pandemic meant that 48 children and young people could not complete the primary outcome measure. Service waiting times resulted in some participants not starting therapy before follow-up. CONCLUSIONS: One-session treatment for specific phobia in UK-based child mental health treatment centres is as clinically effective as multisession cognitive-behavioural therapy and highly likely to be cost-saving. Future work could involve improving the implementation of one-session treatment through training and commissioning of improved care pathways. TRIAL REGISTRATION: This trial is registered as ISRCTN19883421. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 42. See the NIHR Journals Library website for further project information.

A phobia is an intense, ongoing fear of an everyday object or situation. The phobia causes distress and the person with the phobia avoids that object or situation. Many children and young people have phobias that affect their daily lives. Cognitive­behavioural therapy helps by changing what people do or think when they have a phobia and is the most common treatment approach. However, cognitive­behavioural therapy is expensive, takes time and is not always easy to get. Different treatments are needed to help children and young people with specific phobias. One such therapy is one-session treatment, which works in similar ways to cognitive­behavioural therapy but takes place over one main 3-hour session. Our study, called ASPECT (Alleviating Specific Phobias Experienced by Children Trial), compared these two treatments to examine whether or not one-session treatment is as effective as cognitive­behavioural therapy. Overall, 274 children and young people aged 7­16 years from 26 sites nationally helped with our research, of whom 268 received either cognitive­behavioural therapy or one-session treatment. The results at 6 months found that one-session treatment and cognitive­behavioural therapy worked as well as each other for treating phobias in children and young people. We also found evidence that one-session treatment is cheaper than cognitive­behavioural therapy. We spoke with children and young people, their parents/guardians and the therapists of the single-session treatment, and we found one-session treatment to be acceptable for their needs. Future research could explore how to make one-session treatment more easily available for children and young people with specific phobias because it can save time and money, and works just as well as cognitive­behavioural therapy.

Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta.

OBJECTIVES: This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence. METHODS: A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence. RESULTS: There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC. CONCLUSIONS: There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.

Geographic inequalities in paediatric emergency department visits in Ontario and Alberta: a multilevel analysis of 2.5 million visits.

BACKGROUND: Research on intra- and inter-regional variations in emergency department (ED) visits among children can provide a better understanding of the patterns of ED utilization and further insight into how contextual features of the urban environment may be associated with these health events. Our objectives were to assess intra-urban and inter-urban variation in paediatric emergency department (PED) visits in census metropolitan areas (CMAs) in Ontario and Alberta, Canada and explore if contextual factors related to material and social deprivation, proximity to healthcare facilities, and supply of family physicians explain this variation. METHODS: A retrospective, population-based analysis of data on PED visits recorded between April 1, 2015 and March 31, 2017 was conducted. Random intercept multilevel regression models were constructed to quantify the intra- (between forward sortation areas [FSAs]) and inter- (between CMAs) variations in the rates of PED visits. RESULTS: In total, 2,537,442 PED visits were included in the study. The overall crude FSA-level rate of PED visits was 415.4 per 1,000 children population. Across CMAs, the crude rate of PED visits was highest in Thunder Bay, Ontario (771.6) and lowest in Windsor, Ontario (237.2). There was evidence of substantial intra- and inter-urban variation in the rates of PED visits. More socially deprived FSAs, FSAs with decreased proximity to healthcare facilities, and CMAs with a higher rate of family physicians per 1,000 children population had higher rates of PED visits. CONCLUSIONS: The variation in rates of PED visits across CMAs and FSAs cannot be fully accounted for by age and sex distributions, material and social deprivation, proximity to healthcare facilities, or supply of family physicians. There is a need to explore additional contextual factors to better understand why some metropolitan areas have higher rates of PED visits.

The Chronic Conditions Course: A Randomised Controlled Trial of an Internet-Delivered Transdiagnostic Psychological Intervention for People with Chronic Health Conditions.

INTRODUCTION: Psychological adjustment to chronic health conditions is important, as poor adjustment predicts a range of adverse medical and psychosocial outcomes. Psychological treatments demonstrate efficacy for people with chronic health conditions, but existing research takes a disorder-specific approach and they are predominately delivered in face-to-face contexts. The internet and remotely delivered treatments have the potential to overcome barriers to accessing traditional face-to-face treatment. OBJECTIVE: The current study examined the efficacy and acceptability of an internet-delivered transdiagnostic psychological intervention to promote adjustment to illness, based on cognitive behaviour therapy principles. METHODS: In a two-arm randomised controlled trial, participants (n = 676) were randomly allocated to the 8-week intervention or a waitlist control. Treatment included five core lessons, homework tasks, additional resources, and weekly contact with a psychologist. Primary outcomes included depression, anxiety, and disability, assessed at pre-treatment, post-treatment, 3-month follow-up, and 12-month follow-up. RESULTS: The treatment group reported significantly greater improvements in depression (between-groups d = 0.47), anxiety (d = 0.32), and disability (d = 0.17) at post-treatment (all ps <0.001). Improvements were sustained over the 3-month and 12-month follow-ups. High treatment completion rates (69%) and levels of satisfaction (86%) were reported by participants in treatment. The intervention required a mean clinician time of 56.70 min per participant. CONCLUSIONS: The findings provide preliminary and tentative support for the potential of internet-delivered transdiagnostic interventions to promote adjustment to chronic health conditions. Further research using robust control groups, and exploring the generalisability of findings, is needed before firm conclusions can be drawn.