Rethinking mental healthcare for refugees.

After several years of downturn in new resettlement, the United States is projected to admit 125,000 refugees in the current fiscal year. Refugee communities have known risks of developing mental health problems due to high rates of exposure to war and conflict-related trauma and chronic stressors associated with displacement and resettlement. In this commentary, we examine limitations in the current system of mental health care available to newly arriving refugee communities and make recommendations for expanding and redesigning services to better meet the needs of culturally diverse refugee communities. This includes drawing on public health and prevention frameworks to implement a continuum of services including basic services and security, trauma-informed prevention services to meet the needs of individuals, families and communities and specialized clinical care for those that need it. Across all services, we recommend robust engagement and partnership with refugee community leaders to design and deliver programs.

Stress, Coping, and Quality of Life Among Custodial Grandparents.

An increasing number of custodial grandparents are raising grandchildren, and intensive childcare is stressful with many negative personal, interpersonal, economic, and health implications. Grandparents' strengths, including resilience, positive caregiving appraisal, and social support should be considered in the face of parenting stress and adversity. Guided by the stress and resilience model, the current study investigated the associations of parenting stress and coping resources with life satisfaction and mental wellness among custodial grandparents (N = 76). Data were collected between December 2020 and April 2021, through collaborations with community-based agencies located in two metropolitan areas, which provide supportive services to custodial grandparents and their families. Findings showed that more parenting stress was associated with less life satisfaction and worse mental health, and that stress management boosted life satisfaction and mental wellness. Grandparents with more informal social support and social service utilization fared better than their counterparts with less social support and no experience of service use. The results of this study suggest that social work interventions should focus on improving stress management to cope with daily and caregiving stressors. Social workers can help with informal social support and formal social services utilization to address caregiving needs among custodial grandparents.

Can web-based implementation interventions improve physician early diagnosis of cerebral palsy? Protocol for a 3-arm parallel superiority randomised controlled trial and cost-consequence analysis comparing adaptive and non-adaptive virtual patient instructional designs with control to evaluate effectiveness on physician behaviour, diagnostic skills and patient outcomes.

INTRODUCTION: Cerebral palsy (CP) is the most common childhood physical disability. Accurate diagnosis before 6 months is possible using predictive tools and decision-making skills. Yet diagnosis is typically made at 12-24 months of age, hindering access to early interventions that improve functional outcomes. Change in practice is required for physicians in key diagnostic behaviours. This study aims to close the identified research-practice gap and increase accurate CP diagnosis before 6 months of age through tailored web-based implementation interventions. This trial will determine whether adaptive e-learning using virtual patients, targeting CP diagnostic behaviours and clinical decision-making skills, effectively changes physician behaviour and practice compared with non-adaptive e-learning instructional design or control. METHODS AND ANALYSIS: This study is a 3-arm parallel superiority randomised controlled trial of two tailored e-learning interventions developed to expedite physician CP diagnosis. The trial will compare adaptive (arm 1) and non-adaptive (arm 2) instructional designs with waitlist control (arm 3) to evaluate change in physician behaviour, skills and diagnostic practice. A sample size of 275 paediatric physicians enables detection of small magnitude effects (0.2) of primary outcomes between intervention comparators with 90% power (α=0.05), allowing for 30% attrition. Barrier analysis, Delphi survey, Behaviour Change Wheel and learning theory frameworks guided the intervention designs. Adaptive and non-adaptive video and navigation sequences utilising virtual patients and clinical practice guideline content were developed, integrating formative key features assessment targeting clinical decision-making skills relative to CP diagnosis.Physician outcomes will be evaluated based on postintervention key feature examination scores plus preintervention/postintervention behavioural intentions and practice measures. Associations with CP population registers will evaluate real-world diagnostic patient outcomes. Intervention costs will be reported in a cost-consequence analysis from funders' and societal perspectives. ETHICS AND DISSEMINATION: Ethics approved from The University of Sydney (Project number 2021/386). Results will be disseminated through peer-reviewed journals and scientific conferences. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry: ACTRN 12622000184774.

Petroleum-derived naphthenic acids disrupt hormone-dependent sexual behaviours in male Western clawed frogs.

Naphthenic acids (NAs), the carboxylic acids found in petroleum, are of emerging concern as they contaminate coastlines after oil spills, leech into freshwater ecosystems of oil sands areas and have wide industrial applications. They are acutely toxic in fish and tadpoles and may be endocrine disruptors at sublethal levels. We characterized androgen-dependent courtship behaviours and their disruption by NAs in male Western clawed frogs, Silurana tropicalis. Courtship primarily consists of males producing low trills and achieving amplexus, a mating position where a male clasps a female. Adult males were exposed for 5 days to 20 mg/l NA and injected with human chorionic gonadotropin to induce calling. The duration of calling activity was significantly reduced by NA exposure. Other acoustic parameters such as dominant frequency, click rate and trill length were not affected. Vocalization and amplexus were both inhibited after NA exposure and restored after 2 weeks of recovery in clean water. To determine possible disruption at the level of the testes, the effects of NA exposure on gene expression of key players in steroidogenesis was determined. Exposure to NAs decreased srd5a on average by ~ 25%. The enzyme 5α-reductase, encoded by srd5a, converts testosterone to its more bioactive form 5α-dihydrotestosterone (DHT), so NAs may be affecting this steroidogenic step. However, the observed upregulation of lhr, star and cyp17a1 suggests that NA-exposed males may be attempting to counteract the reduced potential to produce DHT. Yet, these NA-exposed frogs have dramatically reduced calling duration, so the observed upregulation of star and cyp17a1 is decoupled from the vocalizations. Calling duration and the ability of males to amplex females is reversibly disrupted by NA exposure, implying that environmental reduction and removal of NAs may help improve habitability of contaminated ecosystems.

Correction to: Multisource feedback as part of the medical board of Australia's professional performance framework: outcomes from a preliminary study.

Following publication of the original article [1], the author reported that Fig. 4 was missing. This has now been corrected in the original article.

Multisource feedback as part of the Medical Board of Australia's Professional Performance Framework: outcomes from a preliminary study.

BACKGROUND: The recent introduction of the Professional Performance Framework by the Medical Board of Australia is intended to strengthen continuing professional development for the 100,000 or so medical practitioners in Australia. An important option within the Framework is the use of multisource feedback from patients, colleagues and self-evaluations to allow doctors to reflect on their performance and identify methods for self-improvement. The aim of this study is to explore the relationships between patient feedback, colleague feedback, and self-evaluation using the same questionnaires as used by patients and colleagues. METHODS: Feedback data for around 2000 doctors belonging to four different groups were collected through non-probability sampling from nearly 100,000 patients and 24,000 colleagues. Reliability analysis was performed using single measures intraclass coefficients, Cronbach' alpha and signal-to-noise ratios. Analysis of variance was used to identify significant differences in scores between items and sub-populations of doctors; principal component analysis involving Kaiser-Meyer-Olkin (KMO) sampling adequacy and Bartlett's test for sphericity was used to reveal components of doctor performance; and correlation analysis was used for identifying convergence between sets of scores from different sources. RESULTS: Patients rated doctors highest on respect shown and lowest on reassurance provided. Colleagues rated doctors highest on trustworthiness and lowest on ability to say 'no'. With regard to self-evaluation, doctors gave themselves lower scores on the patient questionnaire and the colleague questionnaire (10 and 12%, respectively) than they received from their patients and colleagues. There were weak but positive correlations between self-scores and scores received indicating some convergence of agreement, with doctors feeling more comfortable with self-evaluation from the perspective of patients than from colleagues. CONCLUSIONS: Supplementing patient and colleague feedback with self-evaluation may help doctors confirm for themselves areas for enhanced CPD through convergence. If self-evaluation is used, the colleague questionnaire may be sufficient, since aspects of clinical competence, management, communication and leadership as well as patient care can be addressed through colleague items. Mentoring of doctors in CPD should aim to make doctors feel more comfortable about being rated by colleagues to enhance convergence between self-scores and evaluations from the perspective of colleagues.

Is more better? Examining whether enhanced consultation/coaching improves implementation.

It is extremely challenging to implement evidence-based interventions in community-based agencies with sufficient quality, fidelity, and intensity to produce desired changes in practice and outcomes. This is particularly difficult to do within the confines of existing service providers' time, personnel, and resource constraints. Over the past 15 years, Together Facing the Challenge (TFTC) has been developed, tested, and disseminated in an effort to address this set of issues to improve treatment foster care (TFC). Data from the initial randomized trial showed improved practice and outcomes in TFTC compared to usual TFC. These initial results came from study-led training and follow-up consultation. Subsequent dissemination activities suggested potential need for more intensive support for TFTC supervisors to produce more consistent and sustained implementation of the model. The current randomized trial extends this work by comparing the previously tested standard consultation versus enhanced consultation that incorporated more of a coaching approach. Initial results suggest that enhanced coaching/consultation was associated with improvements in the small- to medium-effect size range. Results are promising, but require additional work to more fully understand how and whether to enhance supports as agencies implement new evidence-based approaches. (PsycINFO Database Record

Does Model Matter? Examining Change Across Time for Youth in Group Homes.

Group homes are a frequently used but controversial treatment setting for youth with mental health problems. Within the relatively sparse literature on group homes, there is some evidence that some models of treatment may be associated with more positive outcomes for youth. This article explores this possibility by examining differences across time for youth served in group homes utilizing the Teaching Family Model (TFM) and geographically proximate homes using more eclectic approaches. Data come from a longitudinal quasi-experimental study that included 554 youth. Results suggest that youth showed, on average, significant and rapid improvement during initial months in a group home. Improvement did not differ for TFM and non-TFM homes during this initial period. Post-discharge results, though, show that TFM was associated with continued improvement after discharge and significantly better outcomes by 8 months post-discharge. Results also discuss youth-level factors that may influence outcomes as well as need for additional work to more fully understand processes and practices that are key for maximizing and maintaining youths' positive outcomes during and after group home placements.

The clinical academic workforce in Australia and New Zealand: report on the second binational summit to implement a sustainable training pathway.

There has been a decline in the proportion of clinical academics compared with full-time clinicians, since 2004. A Working Party was established to help develop and implement a model for the training of clinical academics. After a highly successful first summit in 2014 that summarised the challenges faced by clinical academics in Australia and New Zealand, a second summit was convened late in 2015 to report on progress and to identify key areas for further action. The second summit provided survey results that identified the varied training pathways currently offered to clinical academics and the institutions willing to be involved in developing improved pathways. A literature review also described the contributions that clinical academics make to the health sector and the challenges faced by this workforce sector. Current training pathways created for clinical academics by Australasian institutions were presented as examples of what can be done. The perspectives of government and research organisations presented at the summit helped define how key stakeholders can contribute. Following the summit, there was a strong commitment to continue to work towards developing a sustainable and defined training pathway for clinical academics. The need for a coordinated and integrated approach was highlighted. Some key objectives were agreed upon for the next phase, including identifying and engaging key advocates within government and leading institutions; publishing and profiling the contributions of successful clinical academics to healthcare outcomes; defining the stages of a clinical academic training pathway; and establishing a mentoring programme for training clinical academics.

Longitudinal integrated clerkships.

There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.

Who Goes Where? Exploring Factors Related to Placement Among Group Homes.

Despite their widespread use as a placement option for youth with mental health problems, there is relatively little research on group homes for youth. Available data highlight concerns with practices and treatment within group homes and mixed results on youth-level outcomes. However, existing research appears to collapse a wide range of group residential settings into a single amorphous category. This article explores potential variations among group homes to examine whether different programs are systematically serving different types of youth. It examines, in particular, placement in homes using the teaching family model (TFM) versus homes that do not. Findings suggest that demographics are not significantly associated with TFM placement. However, custody status, types of mental health problems, and use of psychotropic medications are. Homes appear to be serving distinct niches within a geographic area. Implications for future research and policy/practice are discussed.

Global impacts of energy demand on the freshwater resources of nations.

The growing geographic disconnect between consumption of goods, the extraction and processing of resources, and the environmental impacts associated with production activities makes it crucial to factor global trade into sustainability assessments. Using an empirically validated environmentally extended global trade model, we examine the relationship between two key resources underpinning economies and human well--being-energy and freshwater. A comparison of three energy sectors (petroleum, gas, and electricity) reveals that freshwater consumption associated with gas and electricity production is largely confined within the territorial boundaries where demand originates. This finding contrasts with petroleum, which exhibits a varying ratio of territorial to international freshwater consumption, depending on the origin of demand. For example, although the United States and China have similar demand associated with the petroleum sector, international freshwater consumption is three times higher for the former than the latter. Based on mapping patterns of freshwater consumption associated with energy sectors at subnational scales, our analysis also reveals concordance between pressure on freshwater resources associated with energy production and freshwater scarcity in a number of river basins globally. These energy-driven pressures on freshwater resources in areas distant from the origin of energy demand complicate the design of policy to ensure security of fresh water and energy supply. Although much of the debate around energy is focused on greenhouse gas emissions, our findings highlight the need to consider the full range of consequences of energy production when designing policy.

Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability.

BACKGROUND: Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability. Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of 'block rotations' with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation. WHAT WAS DONE: A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque's research in business. The framework's four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the 'whole of class' innovation. DISCUSSION: Roberto and Levesque's framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators. Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.

Patterns of maltreatment and diagnosis across levels of care in group homes.

Patterns of Axis I psychiatric diagnosis and maltreatment history were explored among youth in group homes, including match of clinical need to level or restrictiveness of care. Data on demographics, diagnoses, maltreatment, and group home level of care (Level I, II, or III homes, representing lower to higher intensity of supervision and treatment) were obtained from 523 youth who participated in a quasi-experimental study of group homes. Three quarters of youth had a diagnosis and two-thirds of youth had a maltreatment history. Youth in higher level homes had more diagnoses and higher rates of all disorders except adjustment disorders. Youth in Level I homes had a history of more maltreatment types, particularly high rates of neglect. Sexual abuse, physical abuse, and emotional abuse were most common among youth in higher level homes. Regardless of diagnosis history, comparable proportions of youth had a maltreatment history, and similar patterns were found across levels of care. Together, findings indicate that group homes with varying degrees of restrictiveness serve youth with different psychiatric diagnosis and maltreatment histories. Youth triaged to higher level homes had more diagnoses, while youth placed in the least restrictive homes had a history of more maltreatment subtypes. Further, distinct patterns of diagnosis types and maltreatment subtypes were seen across homes. Implications include the importance of assessing unique clinical needs of youth to promote an appropriate match to level of care and treatment plan.

Family Involvement in Treatment Foster Care.

Child mental health policy and practice has increasingly embraced family-driven practice which promotes family involvement in all aspects of planning and service delivery. While evidence for positive outcomes related to family involvement is mounting in traditional residential treatment, there is little information about family involvement in treatment foster care. This study provides data on family involvement in a statewide randomized trial of treatment foster care. The types of family involvement, factors associated with such involvement, and placement outcomes were examined. Nearly eighty percent of youth experienced recent family contact and/or family participation in treatment planning. Implications for research, policy, and practice to increase understanding the role of family involvement are discussed.

Use of Psychotropic Medications among Youth in Treatment Foster Care.

We describe the use of psychotropic medications among youth in treatment foster care (TFC). Data from 240 youth were coded to examine rates of medication use, including polypharmacy and an indicator of "questionable polypharmacy." Fifty-nine percent of youth in TFC had taken a psychotropic medication within the past two months. Of the youth taking psychotropics, 61% took two or more and 22% met criteria for questionable polypharmacy. The majority of youth taking psychotropics also received psychosocial mental health services and were more likely to receive such services than youth not taking medication. Use of psychotropic medication use was not significantly related to demographic factors, maltreatment history, or custody. However, youth with more severe symptoms were more likely to be on medications and to be on multiple medications. Youth with "questionable polypharmacy" were less likely than other youth on multiple medications to have a recent visit to a psychiatrist.

Porphyromonas gingivalis peptidylarginine deiminase substrate specificity.

UNLABELLED: While a group of oral commensals have been implicated in the aetiology of chronic periodontitis; the asaccharolytic Gram negative anaerobe Porphyromonas gingivalis is most commonly reported to be associated with severe forms of the disease. Although a variety of human tissues can produce a number of peptidylarginine deiminase (PAD), enzymes that convert peptide bound arginine residues to citrulline, P. gingivalis is one of the few prokaryotes known to express PAD. Protein and peptide citrullination are important in the development of rheumatoid arthritis and in recent years a number of authors have suggested a possible link between periodontitis and rheumatoid arthritis (RA). Indeed, some have linked P. gingivalis directly to RA via the action of PAD. Accordingly, the prime purpose of this study was to further characterise PAD in P. gingivalis cells particular emphasis on substrate specificity, using arginine containing peptides and RA relevant proteins. METHODS: P. ginigvalis W50 was anaerobically cultured in BHI broth, cells harvested and resuspended in assay buffer. A colourimetric assay was developed to measure citrulline and employed to determine enzyme activity using the substrate BAEE. The assay was employed to investigate the effects of environmental pH and temperature on activity. Citrullination of BAEE by sonicated cells allowed the proportion of intracellular enzyme to be estimated. Enzyme specificity and substrate preference were investigated by using various arginine containing peptides, proteins and arginine analogues, as substrates and measuring the rate of citrullination. The influence of gingipains on citrullination was assessed by measuring the rates of citrullination of bovine serum albumin in the presence of protease inhibitors. RESULTS: Enzyme activity decreased by 13% following exposure of cells to 60 °C for 10 min. A comparison of intact and disrupted cells indicated that 90% of PAD activity is cell surface associated and the remainder cytoplasmic. Optimal pH for enzyme activity was between pH 7.5 and 8. All small arginine-containing peptides were citrullinated with reaction rates faster than that for free arginine with rates that varied with arginine residue position and number. Arginine analogues exhibited minimal effect and influence when tested as either substrates or competitive inhibitors. Cells were able to citrullinate yeast enolase, human vimentin and fibrin at varying rates. All proteins were modified at slower rates than those for peptide substrates. Inhibition of gingipains had no influence on the rate of protein citrullination. CONCLUSIONS: P. gingivalis PAD is a primarily cell surface associated, heat stable, enzyme that exhibits optimal activity under alkaline conditions similar to those present in the inflammatory environment. The enzyme displays high specificity for arginine residues in peptides and modified arginine in all positions and the gingipains did not influence the rate of protein citrullination. The ability of the enzyme to convert arginine residues in all proteins tested would indicate that its presence in inflamed tissue may promote autoimmune reactions by creation of altered host epitopes.