Music During Cataract Surgery: Impact on Anxiety.

PURPOSE: To determine the effect of playing patient-selected music intra-operatively on patient self-reported anxiety and the amount of sedative administered during cataract surgery. SETTING: Yale New Haven Hospital health system, New Haven, CT. DESIGN: Prospective, randomized, controlled clinical trial. METHODS: Patients were randomized to either music group or control group, which had no music played. Patients were blinded to the purpose of the study. On postoperative day 1, patients were consented to participate in the study and asked to complete a six-question Likert-style survey (modified from the State-Trait Anxiety Inventory) assessing anxiety at baseline and during surgery. Patients' intraoperative and postoperative vitals were recorded. The medication, dosage, and number of sedative injections given were also recorded. Paired t-tests were used to assess for significant differences between the two groups. RESULTS: A total of 107 patients (mean age 71.2 years) were enrolled in the study. There was no significant difference in baseline anxiety between the two groups. Patients randomized to the music group had significantly lower total self-reported anxiety (mean 5.98) than the control group (mean 7.13, p=0.006). Moreover, patients exposed to music felt significantly less frightened, nervous, and confused during surgery (p=0.002, 0.007, and 0.017, respectively). There was no significant difference between the groups in number and dosage of sedatives given. CONCLUSION: Playing patient-selected music during cataract surgery is an effective way to decrease anxiety. Music has a direct impact on patient experience and is an inexpensive, low-risk method of reducing patient anxiety during surgery.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

Impact of Gender and Underrepresented in Medicine Status on Research Productivity Among Ophthalmology Residency Applicants.

PURPOSE: Insufficient representation of women and underrepresented in medicine (URiM) students remains a problem among the ophthalmology workforce. In the residency selection process, research productivity is an important factor. We aimed to determine the average research output listed by applicants and assess for differences by gender and race. DESIGN: Retrospective cohort study. METHODS: All San Francisco Match applications to the Wilmer Eye Institute for the 2019, 2020, and 2021 ophthalmology residency cycles were retrospectively reviewed. Each applicant's number of published research articles was recorded and subclassified into first-author publications in any field, publications in ophthalmology, and first-author publications in ophthalmology. Multivariable logistic regression was performed to determine factors associated with successful publication. RESULTS: A total of 1376 applications were reviewed. On average, women had a greater number of publications in ophthalmology (2.08 vs 1.73, P = .05) and presentations (4.52 vs 4.09, P = .01) compared with men. Self-identified URiMs were less likely to list publications in ophthalmology (odds ratio [OR] 0.650, P = .05) and first-author publications in ophthalmology (OR 0.570, P = .02) compared to non-URiMs. CONCLUSIONS: Our findings highlight disparities in research productivity by self-identified URiM status. On the other hand, women had similar if not higher research outputs than men. Greater research mentorship and opportunities to support URiM students may facilitate the recruitment of diverse trainees to ophthalmology programs.

Development and Evaluation of Aeyeconsult: A Novel Ophthalmology Chatbot Leveraging Verified Textbook Knowledge and GPT-4.

OBJECTIVE: There has been much excitement on the use of large language models (LLMs) such as ChatGPT in ophthalmology. However, LLMs are limited in that they are trained on unverified information and do not cite their sources. This paper highlights a new methodology to create a generative AI chatbot to answer eye care related questions which uses only verified ophthalmology textbooks as data and cites its sources. SETTING: Yale School of Medicine Department of Ophthalmology and Visual Science. DESIGN/METHODS: Aeyeconsult, an ophthalmology chatbot, was developed using GPT-4 (the LLM used to power the publicly available chatbot ChatGPT-4), LangChain, and Pinecone. Ophthalmology textbooks were processed into embeddings and stored in Pinecone. User queries were similarly converted, compared to stored embeddings, and GPT-4 generated responses. The interface was adapted from public code. Both Aeyeconsult and ChatGPT-4 were tested on the same 260 questions from OphthoQuestions.com, with the first response from Aeyeconsult and ChatGPT-4 recorded as the answer. RESULTS: Aeyeconsult outperformed ChatGPT-4 on the OKAP dataset, with 83.4% correct answers compared to 69.2% (p = 0.0118). Aeyeconsult also had fewer instances of no answer and multiple answers. Both systems performed best in General Medicine, with Aeyeconsult achieving 96.2% accuracy. Aeyeconsult's weakest performance was in Clinical Optics at 68.1%, but it still outperformed ChatGPT-4 in this category (45.5%). CONCLUSION: LLMs may be useful in answering ophthalmology questions but their trustworthiness and accuracy is limited due to training on unverified internet data and lack of source citation. We used a new methodology, using verified ophthalmology textbooks as source material and providing citations, to mitigate these issues, resulting in a chatbot more accurate than ChatGPT-4 in answering OKAPs style questions.

Eyes for Ears: Usage and Efficacy of a Podcast for Ophthalmic Education.

Purpose: To characterize listenership and perceived educational impact of the ophthalmic podcast "Eyes for Ears". Methods: A cross-sectional, internet-distributed, 9-question Qualtrics survey was made available to podcast listeners. Listenership metrics were analyzed from the podcast host platform. Results: From January 10, 2019 to September 2, 2021, the podcast was downloaded over 422,000 times, averaging about 4442 downloads per episode. 209 Qualtrics survey responses were analyzed from podcast listeners with backgrounds in eye care including medical students, residents, fellows, clinicians and technicians. The majority were residents (60.3%), representative of the target audience of the podcast. Listeners reported using the podcast while commuting (81.3%), felt it increased the time they could spend on self-care (63.2%), and thought it improved their fund of knowledge (99.0%). Respondents recalled feeling better prepared for the OKAP or written boards after using this podcast (before median = 50/100 on Likert Scale, IQR 30-65 vs median = 70/100, IQR 56-81, p <0.001). Respondents identified question banks as the most helpful for OKAP studying, followed by podcasts. Podcasts were preferred over articles and lectures in terms of helpfulness (p < 0.001). Conclusion: The Eyes for Ears podcast has achieved a robust international audience. The surveyed audience felt the podcast was useful for their education and well-being.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Fate of Research Articles Reported by Ophthalmology Residency Applicants: What Happens to "Submitted" and "In Preparation" Articles?

OBJECTIVE: As coronavirus disease 2019 affects clinical training opportunities and with the transition of U.S. Medical Licensing Examination Step 1 to pass-fail, research may become increasingly important for evaluating ophthalmology residency applicants. Though publication misrepresentation has been studied among ophthalmology residency applicants, eventual publication rates of incomplete articles remain unknown. We aimed to determine publication rates for manuscripts listed as "submitted" or "in preparation" on ophthalmology residency applications and identify factors associated with unpublished manuscripts. DESIGN: San Francisco Match applications to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle were retrospectively reviewed. Each applicant's number of "published," "submitted," and "in preparation" manuscripts was recorded, then verified 1.5 years later through PubMed, Google Scholar, or journal websites. Unverifiable manuscripts were deemed "unpublished." SETTING: Single academic institution (Wilmer Eye Institute, Baltimore, MD, USA) PARTICIPANTS: All 458 medical students who applied to the Wilmer Eye Institute for the 2019 ophthalmology residency cycle through the San Francisco Match. RESULTS: A total of 458 applications were reviewed. Of 428 "submitted" publications, 126 (29.4%) remained unpublished after 1.5 years. Of 324 manuscripts "in preparation," 215 (66.4%) remained unpublished. In a multivariate model, AOA was associated with not having an unpublished manuscript compared to applicants without AOA (OR: 0.423, p = 0.0163). Gender, Step 1 score, additional degrees, and a research year had no association. CONCLUSIONS: Nearly two-thirds of manuscripts listed as "in preparation" remained unpublished. Specific guidance from research mentors may help applicants better represent their publications in residency applications.

Treatment of ocular-involving monkeypox virus with topical trifluridine and oral tecovirimat in the 2022 monkeypox virus outbreak.

Purpose: To report a case of ocular involving monkeypox infection in the United States during the 2022 outbreak, and to review the literature regarding its clinical manifestations and management known to date. Observations: A 36-year-old man with well controlled HIV presented to the emergency department with anal pain, diffuse rash, right eye pain, and right eye redness after he tested positive for monkeypox one week prior. Ocular examination showed bilateral periorbital vesicular lesions, right eye conjunctival injection, and a single white plaque on his right medial bulbar conjunctiva. Macular, vesicular, and pustular lesions were noted throughout his body, including the genital and perianal region. His ocular and systemic symptoms completely resolved after treatment with a ten-day course of 1% trifluridine and moxifloxacin drops in both eyes, as well as two weeks of oral tecovirimat. Conclusion and Importance: In July of 2022, monkeypox virus was declared a global health emergency by the World Health Organization; however, there are no standard guidelines for monkeypox treatment. Data on its clinical presentation and course, especially pertaining to ocular manifestations, is limited. We highlight the importance of recognizing ophthalmic manifestations of monkeypox virus and a possible therapeutic approach to help guide the management of these patients.

Exploring Older Adults' Experiences of a Home-Based, Technology-Driven Balance Training Exercise Program Designed to Reduce Fall Risk: A Qualitative Research Study Within a Randomized Controlled Trial.

BACKGROUND AND PURPOSE: With an aging population, falls have become an increasing public health concern. While face-to-face exercise programs have demonstrated efficacy in reducing falls, their effectiveness is hampered by low participation and adherence. Digital technologies are a novel and potentially effective method for delivering tailored fall prevention exercise programs to older adults. In addition, they may increase the reach, uptake, and sustainability of fall prevention programs. Therefore, understanding older adults' experiences of using technology-driven methods is essential. This study explored the user experience of StandingTall , a home-based fall prevention program delivered through a tablet computer. METHODS: Fifty participants were recruited using purposive sampling, from a larger randomized controlled trial. Participants were selected to ensure maximum variability with respect to age, gender, experience with technology, and adherence to the program. Participants undertook a one-on-one structured interview. We followed an iterative approach to develop themes. RESULTS AND DISCUSSION: Eight themes were identified. These fall under 2 categories: user experience and program design. Participants found StandingTall enjoyable, and while its flexible delivery facilitated exercise, some participants found the technology challenging. Some participants expressed frustration with technological literacy, but most demonstrated an ability to overcome these challenges, and learn a new skill. Older adults who engaged in a technology-driven fall prevention program found it enjoyable, with the flexibility provided by the online delivery central to this experience. While the overall experience was positive, participants expressed mixed feelings about key design features. The embedded behavior change strategies were not considered motivating by most participants. Furthermore, some older adults associated the illustrated characters with gender-based stereotypes and negative views of aging, which can impact on motivation and preventive behavior. CONCLUSION: This study found digital technologies are an effective and enjoyable method for delivering a fall prevention program. This study highlights that older adults are interested in learning how to engage successfully with novel technologies.

An emotion-eliciting version of the Hayling Sentence Completion Test.

INTRODUCTION: Executive functions comprise a suite of higher-order cognitive processes, which interact with other processes, such as emotion, to drive goal-directed behavior. The Hayling Sentence Completion Test is a widely used standard neuropsychological tool to measure executive functions, namely verbal initiation and suppression. The current studies aimed to establish and validate an emotion-eliciting version of the Hayling Sentence Completion Test, in order to examine the executive processes of initiation and suppression in an emotional context. Study 1 aimed to provide a quantitative evaluation of the emotional content of the Emotional Hayling Test. Study 2 investigated the differences between the Standard and Emotional Hayling Tests, and explored how performance relates to specific emotional properties of the sentences within the Emotional Hayling. METHODS: Study 1 included N = 100 participants, who were asked to rate each Emotional Hayling Sentence stem in terms of valence (pleasant-unpleasant) and arousal (intensity: low-high). Study 2 included N = 204 participants who completed the Emotional Hayling Test, along with other neuropsychological measures of cognitive and affective functioning. RESULTS: As designed, the sentence stimuli in the Emotional Hayling were rated as significantly higher in absolute emotional valence and arousal, compared to the Standard Hayling (Study 1). Overall, initiation and suppression on the Emotional Hayling were significantly poorer than on the Standard Hayling (Study 2). Finally, within the Emotional Hayling, participants made more suppression errors in response to negative sentences compared to positive sentences, and this effect was present in younger but not older adults. CONCLUSIONS: Reduced performance on the Emotional Hayling Test, particularly in response to negative sentences, is consistent with the emotional content placing increased demands on the executive function system. We present the Emotional Hayling Test as a promising clinical tool, with the potential to capture disruptions in emotional processing.

Association of the Affordable Care Act with Eye-Related Emergency Department Utilization in the United States.

PURPOSE: To investigate the association of the Affordable Care Act (ACA) with nationwide eye-related emergency department (ED) use. DESIGN: Retrospective, cross-sectional study. PARTICIPANTS: All patients who presented to the ED with an eye-related primary diagnosis were eligible for inclusion. METHODS: Nationally representative data from the US Nationwide Emergency Department Sample were used to analyze eye-related ED visits before (2010-2013) and after (2014-2017) the ACA was mandated. All ED visits were categorized as emergent or nonemergent or could not be determined. MAIN OUTCOME MEASURES: The primary outcome was to compare the nationwide and regional incidence of eye-related ED visits per 100 000 US population before (2010-2013) and after (2014-2017) the ACA was mandated. Secondary outcome measures included change in payor status, proportion of urgent versus nonurgent visits, proportion of visits at teaching versus nonteaching hospitals, associated charges, and discharge disposition. RESULTS: A total of 16 808 343 eye-related ED visits occurred in the United States during the study period from 2010 to 2017. Of these, 8 088 203 ED visits occurred before the ACA was mandated (2010-2013), and 8 720 766 ED visits occurred after the ACA was mandated (2014-2017). After the ACA was mandated in 2014, there was an initial decline in incidence of eye-related ED visits from 652.4 per 100 000 population in 2013 to 593.0 per 100 000 population in 2014, followed by a rapid increase in incidence to 658.5 per 100 000 population in 2015, with a further increase to 746.6 per 100 000 population in 2016. The percentage of uninsured patients decreased from 19.0% to 14.3%. The increase in ED use was greatest for individuals in the lowest income quartile (895.1 per 100 000 population in 2013 to 964.0 per 100 000 in 2017). Overall, 44.8% of ED visits were due to nonemergent eye conditions. CONCLUSIONS: Although the ACA increased insurance coverage for Americans, theoretically increasing access to outpatient ophthalmic care, this did not decrease ED reliance for management of ophthalmic conditions. Additional measures beyond expanding insurance coverage may be necessary to provide high-quality, efficient, and equitable outpatient ophthalmic care to all Americans.

Economic evaluation of the e-Health StandingTall balance exercise programme for fall prevention in people aged 70 years and over.

BACKGROUND: globally, falls and fall-related injuries are the leading cause of injury-related morbidity and mortality in older people. In our ageing society healthcare costs are increasing, therefore programmes that reduce falls and are considered value for money are needed. OBJECTIVE: to complete an economic evaluation of an e-Health balance exercise programme that reduced falls and injurious falls in community-dwelling older people compared to usual care from a health and community-care funder perspective. DESIGN: a within-trial economic evaluation of an assessor-blinded randomised controlled trial with 2 years of follow-up. SETTING: StandingTall was delivered via tablet-computer at home to older community-dwelling people in Sydney, Australia. PARTICIPANTS: five hundred and three individuals aged 70+ years who were independent in activities of daily living, without cognitive impairment, progressive neurological disease or any other unstable or acute medical condition precluding exercise. MAIN OUTCOME MEASURES: cost-effectiveness was measured as the incremental cost per fall and per injurious fall prevented. Cost-utility was measured as the incremental cost per quality-adjusted life year (QALY) gained. MAIN RESULTS: the total average cost per patient for programme delivery and care resource cost was $8,321 (standard deviation [SD] 18,958) for intervention participants and $6,829 (SD 15,019) for control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. The incremental cost per QALY gained was $58,039 (EQ5D-5L) and $110,698 (AQoL-6D). CONCLUSION: this evaluation found that StandingTall has the potential to be cost-effective in specific subpopulations of older people, but not necessarily the whole older population. TRIAL REGISTRATION: ACTRN12615000138583.

Depressive affect moderates the effects of biological sex on the recognition of facial emotion.

Females show a small processing advantage relative to males in the ability to identify facial expressions of emotion. In laboratory studies, this is expressed as a sex difference in the accuracy of discrimination or in recognition latencies (the time required to identify an expression). Reasons for the sex difference are not well-understood. In the current pilot study, young adults (N = 62) with and without mild to moderate symptoms of depression were asked to discriminate facial images of infants and toddlers expressing six cardinal emotions. Results showed that elevated depressive affect was associated with more rapid recognition of negative emotions by females, and with potentiation of the typically observed sex difference, compared with non-depressed observers. Differences in endogenous affective status might be one proximate factor contributing to a female advantage in emotion recognition.

COVID-19 infection in liver transplant recipients: Clinical features and outcomes from a Canadian multicentre cohort.

BACKGROUND: Prior studies have assessed risk factors and clinical outcomes in liver transplant (LT) recipients infected with COVID-19 globally; however, there is a paucity of Canadian data. Our multicentre study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 infection in Canada. METHODS: Adult LT recipients with reverse transcription-polymerase chain reaction (RT-PCR) confirmed COVID-19, from Canadian tertiary care centres between March 2020 and June 2021 were included. RESULTS: A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty-nine patients (59%) were male, median time from LT was 66 months (IQR 1-128), and median age was 59 years (IQR 52-65). At COVID-19 diagnosis, the median alanine transaminase (ALT) was 37 U/L (IQR 21-41), aspartate aminotransferase (AST) U/L was 34 (IQR 20-37), alkaline phosphatase (ALP) U/L was 156 (IQR 88-156), total bilirubin was 11 µmol/L (IQR 7-14), and international normalized ratio (INR) was 1.1 (IQR 1.0-1.1). The majority of patients (86%) were on tacrolimus (monotherapy or combined with mycophenolate mofetil); median tacrolimus level at COVID-19 diagnosis was 5.3 µg/L (IQR 4.0-8.1). Immunosuppression was modified in eight (16%) patients post-infection. Eighteen patients (37%) required hospitalization, and three (6%) required intensive care unit (ICU) admission and mechanical ventilation. Four patients (8%) died from complications related to COVID-19 infection. On univariate analysis, neither age, sex, comorbidities, nor duration post-transplant were associated with risk of hospitalization or ICU admission. CONCLUSIONS: LT recipients with COVID-19 have high rates of hospitalization but fortunately have low rates of ICU admission and mortality in this national registry.

Post-liver transplantation chronic kidney disease is associated with increased cardiovascular disease risk and poor survival.

Chronic kidney disease (CKD) is common following liver transplantation (LT). We aimed to investigate the frequency, risk factors, and impact of CKD on cardiovascular disease (CVD), graft, and patient survival. We analyzed 752 patients who received LT at the University of Alberta. Development of CKD was defined as eGFR <60 ml/min for greater than 3 months, intrinsic renal disease or presence of end-stage renal disease requiring renal replacement therapy. 240 patients were female (32%), and mean age at LT was 53 ± 11 years. CKD was diagnosed in 448 (60%) patients. On multivariable analysis, age (OR 1.3; P = 0.01), female sex (OR 3.3; P < 0.001), baseline eGFR (OR 0.83; P < 0.001), MELD (OR 1.03; P = 0.01), de novo metabolic syndrome (OR 2.3; P = 0.001), and acute kidney injury (OR 3.5; P < 0.001) were associated with CKD. A higher tacrolimus concentration to dose ratio was protective for CKD (OR 0.69; P < 0.001). CKD was associated with post-transplant CVD (26% vs. 16% P < 0.001), reduced graft (HR 1.4; P = 0.02), and patient survival (HR 1.3; P = 0.03). CKD is a frequent complication following LT and is associated with an increased risk of CVD and reduced graft and patient survival.

DECRYPT trial: study protocol for a phase II randomised controlled trial of cognitive therapy for post-traumatic stress disorder (PTSD) in youth exposed to multiple traumatic stressors.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a distressing and disabling condition that affects significant numbers of children and adolescents. Youth exposed to multiple traumas (eg, abuse, domestic violence) are at particular risk of developing PTSD. Cognitive therapy for PTSD (CT-PTSD), derived from adult work, is a theoretically informed, disorder-specific form of trauma-focused cognitive-behavioural therapy. While efficacious for child and adolescent single-event trauma samples, its effectiveness in routine settings with more complex, multiple trauma-exposed youth has not been established. The Delivery of Cognitive Therapy for Young People after Trauma randomised controlled trial (RCT) examines the effectiveness of CT-PTSD for treating PTSD following multiple trauma exposure in children and young people in comparison with treatment as usual (TAU). METHODS/DESIGN: This protocol describes a two-arm, patient-level, single blind, superiority RCT comparing CT-PTSD (n=60) with TAU (n=60) in children and young people aged 8-17 years with a diagnosis of PTSD following multiple trauma exposure. The primary outcome is PTSD severity assessed using the Children's Revised Impact of Event Scale (8-item version) at post-treatment (ie, approximately 5 months post-randomisation). Secondary outcomes include structured interview assessment for PTSD, complex PTSD symptoms, depression and anxiety, overall functioning and parent-rated mental health. Mid-treatment and 11-month and 29-month post-randomisation assessments will also be completed. Process-outcome evaluation will consider which mechanisms underpin or moderate recovery. Qualitative interviews with the young people, their families and their therapists will be undertaken. Cost-effectiveness of CT-PTSD relative to TAU will be also be assessed. ETHICS AND DISSEMINATION: This trial protocol has been approved by a UK Health Research Authority Research Ethics Committee (East of England-Cambridge South, 16/EE/0233). Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations and clinical workshops. TRIAL REGISTRATION: ISRCTN12077707. Registered 24 October 2016 (http://www.isrctn.com/ISRCTN12077707). Trial recruitment commenced on 1 February 2017. It is anticipated that recruitment will continue until June 2021, with 11-month assessments being concluded in May 2022.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIAL REGISTRATION NUMBER: ACTRN12619001329156.

Protocol of a 12-month multifactorial eHealth programme targeting balance, dual-tasking and mood to prevent falls in older people: the StandingTall+ randomised controlled trial.

INTRODUCTION: Falls have a multifactorial aetiology, which may limit the effectiveness of the common approach of exercise as the sole intervention strategy. Multifactorial interventions could be more effective in people at high risk of falling; however, the focus of such interventions has traditionally been quite narrow. This paper describes the design of a randomised controlled trial that will evaluate the effectiveness of an eHealth programme, which addresses cumulative effects of key fall-risk factors across the triad of physical, affective and cognitive functions on falls in older people. METHODS AND ANALYSIS: 518 older people aged 65 years and over with high fall risk, defined as having a history of falls in the past 6 months, self-reported fear of falling or being aged 80 years or over, will be recruited via local advertisements, newsletters and presentations, and randomised to an intervention or health education control group. The intervention comprises balance exercise, cognitive-motor exercise and cognitive-behavioural therapy, with their dosage based on participant's baseline balance, executive function and mood. The primary outcome is the rate of falls in the 12 months after randomisation. Secondary outcomes at 6 and 12 months comprise programme adherence, healthcare use, physical activity, balance and mobility, cognitive function, psychological well-being, quality of life, health literacy and user experience and attitudes towards the programme. Data will be analysed following intention to treat to gauge real-world effectiveness. We will further determine complier averaged causal effects to correct for varying adherence and conduct economic analyses to gain insight into cost-effectiveness and cost-utility. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of New South Wales (UNSW) Human Research Ethics Committee in December 2017. Outcomes will be disseminated via peer-reviewed articles, conference presentations, community events and media releases. TRIAL REGISTRATION NUMBER: ACTRN12619000540112.