Does proactive care in care homes improve survival? A quality improvement project.

BACKGROUND: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING: Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD: All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS: By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION: A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

IT-assisted comprehensive geriatric assessment for residents in care homes: quasi-experimental longitudinal study.

BACKGROUND: Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations. METHOD: As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves. RESULTS: At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013. CONCLUSIONS: Proactive, community-based i-CGA can improve documentation of care home residents' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.

Virtual simulation in healthcare education: a multi-professional, pan-Canadian evaluation.

BACKGROUND: As we experience a shortage of healthcare providers in Canada, it has become increasingly challenging for healthcare educators to secure quality clinical placements. We evaluated the impact of virtual simulations created for the virtual work-integrated learning (Virtu-WIL) program, a pan-Canadian project designed to develop, test, and offer virtual simulations to enrich healthcare clinical education in Canada. Evaluation was important since the virtual simulations are freely available through creative commons licensing, to the global healthcare community. METHODS: Students self-reported their experiences with the virtual simulations and the impact on their readiness for practice using a survey that included validated subscales. Open-ended items were included to provide insight into the students' experiences. RESULTS: The evaluation included 1715 Nursing, Paramedicine and Medical Laboratory students enrolled in the Virtu-WIL program from 18 post-secondary universities, colleges, and institutions. Results showed most students found the virtual simulations engaging helped them learn and prepare for clinical practice. A key finding was that it is not sufficient to simply add virtual simulations to curriculum, careful planning and applying simulation pedagogy are essential. CONCLUSION: Virtual simulation experiences are increasingly being used in healthcare education. Results from this rigorous, large-scale evaluation identified ways to enhance the quality of these experiences to increase learning and to potentially decrease the number of hours healthcare students need in clinical practice to meet professional competencies. Further research is needed regarding many aspects of virtual simulations and, in particular, curriculum integration and the timing or sequencing of virtual simulations to best prepare students for practice.

Adolescents' Physical Activity and Psychological Adjustment Across the First Year of the COVID-19 Pandemic.

The outbreak of the COVID-19 virus dramatically changed daily life and created many obstacles for adolescents to engage in physical activity (PA). This study tracked rates of self-reported PA and examined its impact on adjustment among adolescents during the first 14 months of the pandemic. Canadian adolescents (N = 1068, 14-18 y, meanage = 16.95 y) reported on their frequency of PA, context of activity, and adjustment across 4 time points (April 2020 to June 2021). In line with our hypothesis, higher average levels of vigorous PA across the pandemic predicted less anxiety and depression and higher self-esteem at our study's end. Vigorous PA also buffered the relationships COVID-19 stress had with anxiety and self-esteem. The results further support recommendations for PA throughout the pandemic and while dealing with lockdown situations.

Lockdown, bottoms up? Changes in adolescent substance use across the COVID-19 pandemic.

The COVID-19 pandemic notably altered adolescent substance use during the initial stage (Spring 2020) of the pandemic. The purpose of this longitudinal study is to examine trajectories of adolescent substance use across the pandemic and subsequent periods of stay-at-home orders and re-opening efforts. We further examined differences as a function of current high school student versus graduate status. Adolescents (n = 1068, 14-18 years, Mage = 16.95 years and 76.7% female at T1) completed 4 different self-report surveys, starting during the first stay-at-home order and ending approximately 14 months later. Negative binomial hurdle models predicted: (1) the likelihood of no substance use and (2) frequency of days of substance use. As hypothesized, results demonstrated significant increases in adolescents' likelihood of alcohol use, binge drinking, and cannabis use once initial stay-at-home orders were lifted, yet few changes occurred as a result of a second stay-at-home order, with rates never lowering again to that of the first lockdown. Further, graduates (and particularly those who transitioned out of high school during the study) demonstrated a greater likelihood and frequency of substance use and were more stable in their trajectories across periods of stay-at-home orders than current high school students. Unexpectedly, however, there was a strong increase in current high school students' likelihood of e-cigarette use and a significant linear increase in participants' frequency of e-cigarette use over the study. Results suggest adolescent substance use, and in particular, e-cigarette use among current high school students, may be of increasing concern as the pandemic evolves.

Community Resilience: A Dynamic Model for Public Health 3.0.

OBJECTIVE: To establish a model for Public Health 3.0 in order to define and measure community resilience (CR) as a method to measure equity, address structural racism, and improve population health. DESIGN: To develop the CR model, we conducted a literature review in medicine, psychology, early childhood development, neurobiology, and disaster preparedness and response and applied system dynamics modeling to analyze the complex interactions between public systems, policies, and community. MAIN OUTCOME MEASURES: The CR model focuses on community and population health outcomes associated with the policies and practices of the housing, public education, law enforcement, and criminal justice sectors as CR measures. The model demonstrates how behaviors of these systems interact and produce outcome measures such as employment, homelessness, educational attainment, incarceration, and mental and physical health. RESULTS: The policies and practices within housing, public schools, law enforcement, and criminal justice can suppress resilience for families and communities because they are shaped by structural racism and influence the character and nature of resources that promote optimal community health and well-being. CONCLUSIONS: Community resilience is relational and place-based and varies depending on the demographic makeup of residents, historical patterns of place-based racism and discrimination, jurisdictional policy, and investment priorities-all influenced by structural racism. IMPLICATIONS FOR POLICY AND PRACTICE: Using system dynamics modeling and the CR approach, chief health strategists can convene partners from multiple sectors to systematically identify, measure, and address inequities produced by structural racism that result in and contribute to adverse childhood and community experiences.

Uploading Risk: Examining the Social Profile of Young Adults Most Susceptible to Engagement in Risky Social Media Challenges.

The aim of this study was to determine the social profile of individuals who are most at risk of engaging in risky social media challenges (RSMCs). Young adults (N = 331, 56.3 percent female) aged 18-25 years (Mage = 21.4) completed an online survey in which they indicated which RSMCs they had done (e.g., Cinnamon Challenge, Fire Challenge), and completed measures of social motives (i.e., need to belong, need for popularity, and fear of missing out [FoMO]) and perceived social status (i.e., popularity and peer belonging). Results demonstrated that almost half (48.3 percent) of participants had engaged in at least one RSMC. Furthermore, findings from a latent-class analysis revealed a three-class solution. Participants in Class 1 (stable social position, low social motives) had moderate-to-high probabilities for perceived popularity and peer belonging, but low probabilities for all three social motives. Participants in Class 2 (high perceived popularity and related concerns) had the highest probability for perceived popularity, need to be popular, and FoMO, and participants in Class 3 (high need to belong) had the highest probability for need to belong, but the lowest probabilities for need to be popular and perceived popularity. Although results differed somewhat by gender, overall, and in line with hypotheses, participants in Class 2 (high perceived popularity and related concerns) were most at risk for engagement in RSMCs. Thus, results suggest that engagement in RSMCs may be more about standing out and gaining online popularity and attention than about fitting in with peers. These findings contribute to a larger conversation about the provision of popularity markers on social media (likes, views) and their ability to shape young people's behavior.

What Does Adolescent Substance Use Look Like During the COVID-19 Pandemic? Examining Changes in Frequency, Social Contexts, and Pandemic-Related Predictors.

PURPOSE: The overarching goal of this study was to provide key information on how adolescents' substance use has changed since the corona virus disease (COVID)-19 pandemic, in addition to key contexts and correlates of substance use during social distancing. METHODS: Canadian adolescents (n = 1,054, Mage = 16.68, standard deviation = .78) completed an online survey, in which they reported on their frequency of alcohol use, binge drinking, cannabis use, and vaping in the 3 weeks before and directly after social distancing practices had taken effect. RESULTS: For most substances, the percentage of users decreased; however, the frequency of both alcohol and cannabis use increased. Although the greatest percentage of adolescents was engaging in solitary substance use (49.3%), many were still using substances with peers via technology (31.6%) and, shockingly, even face to face (23.6%). Concerns for how social distancing would affect peer reputation was a significant predictor of face-to-face substance use with friends among adolescents with low self-reported popularity, and a significant predictor of solitary substance use among average and high popularity teens. Finally, adjustment predictors, including depression and fear of the infectivity of COVID-19, predicted using solitary substance use during the pandemic. CONCLUSIONS: Our results provide preliminary evidence that adolescent substance use, including that which occurs face to face with peers, thereby putting adolescents at risk for contracting COVID-19, may be of particular concern during the pandemic. Further, solitary adolescent substance use during the pandemic, which is associated with poorer mental health and coping, may also be a notable concern worthy of further investigation.

The Pathfields Tool: a frailty case-finding tool using primary care IT-implications for population health management.

BACKGROUND: older people living with frailty benefit from targeted interventions which improve health and independence. However, it has been challenging within primary care to systematically identify patients living with frailty. METHODS: primary care IT was re-programmed to create a 'Pathfields High Risk Cohort' (PHRC, patients felt likely to have undiagnosed frailty) and invite clinicians to opportunistically assess and diagnose frailty. Results were compared with NHS England's current approach to frailty identification using Electronic Frailty Index (eFI) to see which approach had the highest diagnostic yield. RESULTS: the Pathfields Tool identified 1,348 patients in PHRC group, of whom 951 (70.5%) were clinically assessed and diagnosed:eFI (moderate and severe) identified 683 patients of whom 598 (87.6%) were clinically assessed and diagnosed:Extrapolated data would estimate frailty prevalence at 22.5% (1,024/4,552) (5.5% severe, 8.8% moderate, and 8.1% mild) in the practice population aged 65+. CONCLUSIONS: the Pathfields Tool identified more patients with clinically confirmed previously undiagnosed frailty than eFI 'moderate and severe frailty' alone.Sub-segmenting frailty by residential status could significantly improve the population health management of older people.

The Moderating Role of Clique Hierarchical Organization on Resource Control by Central Clique Members.

Accessing resources in peer groups is essential for youth's survival and reproduction. To date, little is known about the behavioral strategies used by socially prominent preadolescent and early adolescent resource controllers in peer cliques, groups of individuals who hang out together during free time at school. Theory suggests that clique hierarchical organization should influence forceful resource control behavior of central (prominent) clique members, but evidence is mixed. This study examined the effects of clique hierarchical organization on forceful behavior used by central clique members to obtain a special toy during a 5-minute resource contest with clique-mates. Participants were 696 children (59.91% girls) ranging from 9 to 14 years (Mage = 11.59) in 147 cliques. Resource control, and prosocial, coercive, and bistrategic (hybrid prosocial and coercive) bids were recorded. Neither centrality nor hierarchy predicted resource control bid use, but centrality and bistrategic bids predicted resource control. Clique stratification (status differences among members) but not clique structure (shape of hierarchy) moderated the outcome of central clique members' bistrategic bids. Bistrategic bids advantaged central members of low-stratified but not highly stratified cliques, indicating that greater power is needed for resource control in cliques with numerous central members. However, high clique stratification did not quell the need for forceful behavior by central (or other) clique members. These findings suggest that for prominent preadolescent and early adolescent clique members, material resource control is the product of both mitigated force and acquiescence by clique-mates.

Social sensitivity and social, school, and psychological adjustment among children across contexts.

This study examined relations of social sensitivity to social, school, and psychological adjustment in rural Chinese, urban Chinese, and Canadian children. Participants were 4th to 6th grade students (Mage = 11 years) in China (n = 593 and 443 for the rural and urban samples) and Canada (n = 325). A self-report measure of social sensitivity was developed for the study. In addition to data on social sensitivity, information on adjustment was obtained from multiple sources. The analyses revealed that social sensitivity was associated with positive adjustment in rural Chinese children but with adjustment problems in Canadian children. The relations were largely mixed and nonsignificant in urban Chinese children. These results indicate the role of context in defining the functional meaning of children's social sensitivity. (PsycINFO Database Record

Peer Groups as a Context for School Misconduct: The Moderating Role of Group Interactional Style.

Peer group interactional style was examined as a moderator of the relation between peer group school misconduct and group members' school misconduct. Participants were 705 students (Mage  = 11.59 years, SD = 1.37) in 148 peer groups. Children reported on their school misconduct in fall and spring. In the winter, group members were observed in a limited-resource task and a group conversation task, and negative and positive group interactional styles were assessed. Multilevel modeling indicated that membership in groups that were higher on school misconduct predicted greater school misconduct only when the groups were high on negative or low on positive interactional style. Results suggest that negative laughter and a coercive interactional style may intensify group effects on children's misconduct.

A New Framework for Addressing Adverse Childhood and Community Experiences: The Building Community Resilience Model.

OBJECTIVE: We propose a transformative approach to foster collaboration across child health, public health, and community-based agencies to address the root causes of toxic stress and childhood adversity and to build community resilience. METHODS: Physicians, members of social service agencies, and experts in toxic stress and adverse childhood experiences (ACEs) were interviewed to inform development of the Building Community Resilience (BCR) model. Through a series of key informant interviews and focus groups, we sought to understand the role of BCR for child health systems and their partners to reduce toxic stress and build community resilience to improve child health outcomes. RESULTS: Key informants indicated the intentional approach to ACEs and toxic stress through continuous quality improvement (data-driven decisions and program development, partners testing and adapting to changes to their needs, and iterative development and testing) which provides a mechanism by which social determinants or a population health approach could be introduced to physicians and community partners as part of a larger effort to build community resilience. Structured interviews also reveal a need for a framework that provides guidance, structure, and support for child health systems and community partners to develop collective goals, shared work plans, and a means for data-sharing to reinforce the components that will contribute to community resilience. CONCLUSIONS: Key informant interviews and focus group dialogues revealed a deep understanding of the factors related to toxic stress and ACEs. Respondents endorsed the BCR approach as a means to explore capacity issues, reduce fragmented health care delivery, and facilitate integrated systems across partners in efforts to build community resilience. Current financing models are seen as a potential barrier, because they often do not support restructured roles, partnership development, and the work to sustain upstream efforts to address toxic stress and community resilience.

Chest radiographic features of human metapneumovirus infection in pediatric patients.

BACKGROUND: Human metapneumovirus (HMPV) was identified in 2001 and is a common cause of acute respiratory illness in young children. The radiologic characteristics of laboratory-confirmed HMPV acute respiratory illness in young children have not been systematically assessed. OBJECTIVE: We systematically evaluated the radiographic characteristics of acute respiratory illness associated with HMPV in a prospective cohort of pediatric patients. MATERIALS AND METHODS: We included chest radiographs from children <5 years old with acute respiratory illness who were enrolled in the prospective New Vaccine Surveillance Network (NVSN) study from 2003 to 2009 and were diagnosed with HMPV by reverse transcription-polymerase chain reaction (RT-PCR). Of 215 HMPV-positive subjects enrolled at our tertiary care children's hospital, 68 had chest radiographs obtained by the treating clinician that were available for review. Two fellowship-trained pediatric radiologists, independently and then in consensus, retrospectively evaluated these chest radiographs for their radiographic features. RESULTS: Parahilar opacities were the most commonly observed abnormality, occurring in 87% of children with HMPV. Hyperinflation also occurred frequently (69%). Atelectasis (40%) and consolidation (18%) appeared less frequently. Pleural effusion and pneumothorax were not seen on any radiographs. CONCLUSION: The clinical presentations of HMPV include bronchiolitis, croup and pneumonia. Dominant chest radiographic abnormalities include parahilar opacities and hyperinflation, with occasional consolidation. Recognition of the imaging patterns seen with common viral illnesses like respiratory syncytial virus (RSV) and HMPV might facilitate diagnosis and limit unnecessary antibiotic treatment.

Social Sensitivity and Adjustment in Chinese and Canadian Children.

This study examined relations of social sensitivity to socioemotional and school adjustment in Chinese and Canadian children. Participants were fourth- to eighth-grade students (Mage  = 12 years) in China (n = 723) and Canada (n = 568). Data were obtained from multiple sources. The analyses revealed that the pattern of relations between social sensitivity and indexes of adjustment differed in the two countries. Social sensitivity was negatively associated with social and school adjustment and positively associated with psychological distress in Canadian children. However, social sensitivity was positively associated with school competence and psychological well-being in Chinese children. The results indicate that children's social sensitivity may have different functional meanings in Chinese and North American societies.

A rare accessory muscle in the hand--the flexor digitorum superficialis indicis.

Accessory muscles are easily overlooked during imaging evaluation. Although usually discovered incidentally, they are occasionally symptomatic. With increasing utilization of cross-sectional imaging, the radiologist should be prepared to readily identify these anomalous muscles. It is particularly important to distinguish these anatomical variants from soft-tissue tumors prior to invasive intervention, reserving biopsy and surgery for children who are symptomatic. This report discusses a case of a flexor digitorum superficialis indicis muscle, an extremely rare but well-described accessory muscle, presenting as a painful mass in a 15-year-old girl. The report includes the clinical presentation, radiologic findings, and the significance to management.

Affiliation with Socially Withdrawn Groups and Children's Social and Psychological Adjustment.

This 1-year longitudinal study examined the effects of membership in socially withdrawn peer groups on children's social and psychological adjustment in a sample of 979 children (417 boys, 562 girls, M age = 11.84 years). Data on children's social and psychological adjustment and problems were collected from peer nominations and self-reports in the fall and spring of a single academic year. Using the Social Cognitive Map, 162 peer groups were identified. Multilevel analyses showed that affiliation with withdrawn groups negatively predicted social competence and school attitude, and positively predicted victimization and depression. The results suggest that affiliation with socially withdrawn groups is a risk factor for the development of social and psychological problems.

Bullying Predicts Reported Dating Violence and Observed Qualities in Adolescent Dating Relationships.

The relationship between reported bullying, reported dating violence, and dating relationship quality measured through couple observations was examined. Given past research demonstrating similarity between peer and dating contexts, we expected that bullying would predict negative dating experiences. Participants with dating experience (n = 585; 238 males, M(age) = 15.06) completed self-report assessments of bullying and dating violence perpetration and victimization. One month later, 44 opposite-sex dyads (M(age) = 15.19) participated in behavioral observations. In 10-min sessions, couples were asked to rank and discuss areas of relationship conflict while being video-recorded. Qualities of the relationship were later coded by trained observers. Regression analysis revealed that bullying positively predicted dating violence perpetration and victimization. Self-reported bullying also predicted observations of lower relationship support and higher withdrawal. Age and gender interactions further qualified these findings. The bullying of boys, but not girls, was significantly related to dating violence perpetration. Age interactions showed that bullying was positively predictive of dating violence perpetration and victimization for older, but not younger adolescents. Positive affect was also negatively predicted by bullying, but only for girls. These findings add to the growing body of evidence that adolescents carry forward strategies learned in the peer context to their dating relationships.