Increasing Children's Vegetable Consumption: Translating a Review of the Evidence Base to Develop Best Practice Guidelines.

Introduction: Dietary guidelines worldwide emphasize the importance of consuming vegetables as part of a healthy diet. Despite this, translating this information into messages for consumers that change behavior has been difficult. There have been population-level social marketing campaigns as well as several smaller campaigns directed specifically toward children, which have demonstrated small increases in consumption. However, achieving meaningful and sustained increases in children's vegetable consumption remains a challenge. This article describes the process of synthesizing the published literature and translating these findings to inform the development of 7 best practice guidelines to increase children's vegetable intake. Methods: The first step in this process was a systematic review of scientific literature to identify the components of interventions that were associated with successfully increasing vegetable intake. The synthesis of effective intervention components was guided by the Behavior Change Wheel. These scientific findings were translated to guidelines for best practice. This process involved a team of nutrition and behavioral researchers and nutrition practitioners translating the science into actionable advice that could be adopted by a range of stakeholders. The 6 selected stakeholders included long daycare centers, after-hours school care providers, primary schools, industry groups and growers, researchers, and government policy makers. Stakeholders were involved in the development process through surveys and interviews to understand their requirements for resources to support adoption of the best practice guidelines within each setting and within the context of existing practice. Results: The guidelines center on coordination of effort, with a focus on components such as planning, environmental restructuring, barrier reduction, feedback, and monitoring. In consultation with key stakeholders, a range of resources were developed for each setting to support the implementation of best practice, with the aim of achieving meaningful increases in intake. The resources and tools have been made available at http://www.vegkit.com.au. Conclusions: The translation of knowledge into practice is not traditionally included as part of the research process. Therefore, combining the process of reviewing the science and translating the evidence to stakeholder resources to influence practice in 1 research study is novel, and the study could be used to guide future research translation activities within and beyond the field of public health nutrition.

Evaluation of a long day care intervention targeting the mealtime environment and curriculum to increase children's vegetable intake: a cluster randomised controlled trial using the multiphase optimisation strategy framework.

OBJECTIVE: To determine the reach, adoption, implementation and effectiveness of an intervention to increase children's vegetable intake in long day care (LDC). DESIGN: A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children's vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework. SETTING: Australian LDC centres. PARTICIPANTS: Thirty-nine centres, 120 educators and 719 children at follow-up. RESULTS: There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34-1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40-1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88-1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20-1·82) and 1·40 (95 % CI 1·08-1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres. CONCLUSIONS: The pragmatic self-delivered online intervention positively impacted educator's knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children' vegetable intake.

Evaluation of a menu box delivery service for Australian long-day care services to improve food provision and child intake: a cluster randomised controlled trial.

OBJECTIVE: To evaluate the impact of a menu box delivery service tailored to the long-day care (LDC) setting on improving menu compliance with recommendations, children's diet quality and dietary intake while in care. DESIGN: A cluster randomised controlled trial in LDC centres randomly assigned to an intervention (menu box delivery) or comparison (menu planning training) group. The primary outcome was child food provision and dietary intake. Secondary outcomes include menu compliance and process evaluation, including acceptability, fidelity and menu cost (per child, per day). SETTING: South Australian LDC centres. PARTICIPANTS: Eight LDC centres (n 224 children) provided data. RESULTS: No differences were observed in serves/d between intervention and comparison centres, for provision (intervention, 0·9 inter-quartile range (IQR) 0·7-1·2; comparison, 0·8 IQR 0·5-1·3) or consumption (intervention, 0·5 IQR 0·2-0·8; comparison, 0·5 IQR 0·3-0·9) of vegetables. Child food provision and dietary intake were similar across both groups for all food groups (P < 0·05). At follow-up, all intervention centres met menu planning guidelines for vegetables, whereas only one comparison centre met guidelines. Intervention centre directors found the menu box delivery more acceptable than cooks. Cost of the intervention was AUD$2·34 greater than comparison centres (intervention, AUD$4·62 (95 % CI ($4·58, $4·67)); comparison, AUD$2·28 (95 % CI ($2·27, $2·30)) per child, per day). CONCLUSIONS: Menu compliance can be improved via a menu delivery service, delivering equivalent impacts on child food provision and dietary intake compared with an online training programme. Further exploration of cooks acceptability and cost is essential before scaling up to implementation.

Development of an initiatives package to increase children's vegetable intake in long day care centres using the Multiphase Optimisation Strategy (MOST) randomised factorial experiment.

OBJECTIVE: To inform a package of initiatives to increase children's vegetable intake while in long day care (LDC) by evaluating the independent and combined effects of three initiatives targeting food provision, the mealtime environment and the curriculum. DESIGN: Using the Multiphase Optimisation Strategy (MOST) framework, a 12-week, eight-condition (n 7 intervention, n 1 control) randomised factorial experiment was conducted. Children's dietary intake data were measured pre- and post-initiative implementation using the weighed plate waste method (1× meal and 2× between-meal snacks). Vegetable intake (g/d) was calculated from vegetable provision and waste. The optimal combination of initiatives was determined using a linear mixed-effects model comparing between-group vegetable intake at follow-up, while considering initiative fidelity and acceptability. SETTING: LDC centres in metropolitan Adelaide, South Australia. PARTICIPANTS: 32 centres, 276 staff and 1039 children aged 2-5 years. RESULTS: There were no statistically significant differences between any of the intervention groups and the control group for vegetable intake (all P > 0·05). The curriculum with mealtime environment group consumed 26·7 g more vegetables/child/day than control (ratio of geometric mean 3·29 (95 % CI 0·96, 11·27), P = 0·06). Completion rates for the curriculum (> 93 %) and mealtime environment (61 %) initiatives were high, and acceptability was good (4/5 would recommend), compared with the food provision initiative (0-50 % completed the menu assessment, 3/5 would recommend). CONCLUSION: A programme targeting the curriculum and mealtime environment in LDC may be useful to increase children's vegetable intake. Determining the effectiveness of this optimised package in a randomised controlled trial is required, as per the evaluation phase of the MOST framework.

Working together to increase Australian children's liking of vegetables: a position statement by the Vegetable Intake Strategic Alliance (VISA).

Children need to be repeatedly and consistently exposed to a variety of vegetables from an early age to achieve an increase in vegetable intake. A focus on enjoyment and learning to like eating vegetables at an early age is critical to forming favourable lifelong eating habits. Coordinated work is needed to ensure vegetables are available and promoted in a range of settings, using evidence-based initiatives, to create an environment that will support children's acceptance of vegetables. This will help to facilitate increased intake and ultimately realise the associated health benefits. The challenges and evidence base for a new approach are described.

Child and caregiver experiences and perceptions of asthma self-management.

Asthma is the most common chronic condition of childhood. Self-management is integral to good asthma control. This qualitative paper explores how children with asthma and their parents perceive asthma, their experience with asthma, and how they manage symptoms, preventions and medications within and outside the home. We undertook 15 focus groups with 41 school-aged (6-11 years) children with asthma and 38 parents. Parents and their children attended the same focus groups. We used thematic analysis to analyse the transcripts. Our findings show the impact asthma can have on children's social and emotional wellbeing and highlight how reliant school-aged children are on their parents to effectively manage their asthma. Parents reported being unsure when their child's symptoms warranted visiting their doctor or hospital. Schools were identified as a source of difficulty regarding asthma management; families reported that children may be self-conscious about their asthma and using their inhaler at school. School policies and teachers' lack of asthma knowledge were reported to exacerbate children's reluctance to use their inhaler at school. Our results have implications for the design and implementation of children's self-management interventions for their asthma, particularly when they are at school and away from their parents.

Identifying opportunities for strengthening advice to enhance vegetable liking in the early years of life: qualitative consensus and triangulation methods.

OBJECTIVE: To prioritise and refine a set of evidence-informed statements into advice messages to promote vegetable liking in early childhood, and to determine applicability for dissemination of advice to relevant audiences. DESIGN: A nominal group technique (NGT) workshop and a Delphi survey were conducted to prioritise and achieve consensus (≥70 % agreement) on thirty evidence-informed maternal (perinatal and lactation stage), infant (complementary feeding stage) and early years (family diet stage) vegetable-related advice messages. Messages were validated via triangulation analysis against the strength of evidence from an Umbrella review of strategies to increase children's vegetable liking, and gaps in advice from a Desktop review of vegetable feeding advice. SETTING: Australia. PARTICIPANTS: A purposeful sample of key stakeholders (NGT workshop, n 8 experts; Delphi survey, n 23 end users). RESULTS: Participant consensus identified the most highly ranked priority messages associated with the strategies of: 'in-utero exposure' (perinatal and lactation, n 56 points) and 'vegetable variety' (complementary feeding, n 97 points; family diet, n 139 points). Triangulation revealed two strategies ('repeated exposure' and 'variety') and their associated advice messages suitable for policy and practice, twelve for research and four for food industry. CONCLUSIONS: Supported by national and state feeding guideline documents and resources, the advice messages relating to 'repeated exposure' and 'variety' to increase vegetable liking can be communicated to families and caregivers by healthcare practitioners. The food industry provides a vehicle for advice promotion and product development. Further research, where stronger evidence is needed, could further inform strategies for policy and practice, and food industry application.

Supporting strategies for enhancing vegetable liking in the early years of life: an umbrella review of systematic reviews.

BACKGROUND: Many children worldwide do not eat recommended amounts of vegetables. Disliking vegetables is a key factor associated with low intake. OBJECTIVE: This umbrella review synthesized systematic reviews to determine the effectiveness of sensory and behavioral strategies to facilitate liking of vegetables (primary outcome) in young children up to 5 y of age, as key predictors of vegetable intake (secondary outcome). METHODS: Nine databases were searched up to May 2019 (updated in September 2020). Two reviewers independently conducted study screening and selection, data extraction, and assessment of methodological quality using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Eleven reviews (n = 1 rated strong quality, n = 4 moderate quality, n = 6 low/critically low quality) examining 85 primary studies met the review criteria: systematic reviews and meta-analyses of primary studies (any quantitative design) that examined sensory or behavioral strategies on vegetable liking or intake (outcomes reported separately for children ≤5 y). Strategy effectiveness was synthesized into 3 categories based on evidence strength: 1) promising (large and consistent body of moderate quality evidence), 2) emerging (small to moderate body of mixed consistency and quality evidence), and 3) limited (small body of limited consistency and quality evidence). RESULTS: Promising evidence was identified for repeated exposure to a single or a variety of vegetables. Emerging evidence was identified for several strategies that increase familiarity with vegetable flavors (e.g., via exposure in utero and through breast milk, and a "vegetable first" approach to complementary feeding) and/or willingness to try vegetables (e.g., via parental role modeling, nonfood rewards, and vegetable-based story books). CONCLUSIONS: Current evidence supports incorporation of tailored advice into guideline documents for parents and carers to repeatedly expose their children to a variety of vegetables to increase vegetable intake. Ongoing robust research on strategies to facilitate children's liking of vegetables is warranted to strengthen the evidence base underpinning advice for parents and health professionals.

Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an "implementation to innovation" system.

Objectives: Many barriers exist to delivering high-value care for people with low back pain (LBP). We have developed a multistrategy implementation system to overcome these barriers. Here we describe a qualitative evaluation of the experiences of private-sector physiotherapists implementing the system. Design: PRISM (Practice-based innovation and implementation system) is an iterative clinician-as-scientist implementation program, tailored here for acute and subacute LBP. PRISM integrates strategies from behavioral change, implementation, and educational science fields. Semistructured interviews, group discussion forums, and electronic questionnaires were used to collect data at multiple time points that were then analyzed using an interpretative descriptive approach. Participants: Six physiotherapists (purposive sample) practicing in private practice physiotherapy clinics in the Adelaide region, South Australia, were enrolled in the study. Interventions: Interventions included an educational pain science and care workshop incorporating self-regulated learning principles, a co-planned clinical pathway, an electronic decision support tool, development and support of a community of practice, case study simulations, audit and feedback, and collaborative problem solving and innovation for physiotherapists. Results: Participants' experiences and perceptions centered around five themes: (1) knowledge and skills training; (2) networking and mentoring; (3) a clear clinical pathway; (4) practical tools; and (5) data feedback. Participants appraised the implementation process positively but identified patient receptiveness as a challenge at times. Suggestions for improvement included streamlining/automating data collection forms and processes and providing more simulation opportunities. Conclusions: PRISM appears to be a promising approach to overcoming several barriers that prevent people with back pain from receiving high-value care. It consolidates and increases pain science knowledge and increases physiotherapist confidence in delivering high-value care. It appears to legitimize some current practices, enhance clinical reasoning and communication skills, extend knowledge in line with contemporary pain science, and facilitate the application of a biopsychosocial management approach. The high-level acceptance by participants provides a foundation for further research to test outcomes and delivery in different settings. Contribution of the article A quality improvement intervention designed to improve delivery of high-value care was well received by private practice physiotherapists.Physiotherapists particularly valued using experiential learning to improve fluency in communicating with, and educating patients about, contemporary pain science.A structured clinical pathway and tools guided physiotherapists on the basic elements of necessary care and allowed them to concentrate on higher levels of decision making and communication with patients.

Objectifs: Il existe de nombreux obstacles à la prestation de soins de grande valeur aux personnes souffrant de lombalgies. Nous avons développé un système de mise en œuvre multi-stratégies pour surmonter ces obstacles. Nous décrivons ici une évaluation qualitative de l'expérience des physiothérapeutes du secteur privé dans le cadre de ce système.Devis: PRISM (Practice-based Innovation & Implementation System) est un programme itératif de mise en œuvre par les cliniciens en tant que scientifiques, adapté à la lombalgie aigüe et subaigüe. PRISM intègre des stratégies issues des domaines du changement de comportement, de la mise en œuvre et des sciences de l'éducation. Des entretiens semi-structurés, des forums de discussion de groupe et des questionnaires électroniques ont été utilisés pour collecter des données à plusieurs moments et analysés selon une approche descriptive interprétative.Contexte: Cliniques de physiothérapie en cabinet privé.Participants: Six physiothérapeutes (échantillon ciblé) de la région d'Adélaïde, en Australie méridionale.Interventions: Un atelier de formation portant sur la science et les soins de la douleur intégrant des principes d'apprentissage autonome, un parcours clinique coplanifié, un outil électronique d'aide à la décision, l'établissement et le soutien d'une communauté de pratique, des simulations d'études de cas, l'évaluation et la rétroaction, ainsi que la résolution collaborative de problèmes et l'innovation pour les physiothérapeutes.Résultats: Les expériences et les perceptions des participants se sont articulées autour de cinq thèmes : (1) l'acquisition de connaissances et de compétences ; (2) la mise en réseau et le mentorat ; (3) un parcours clinique clair ; (4) des outils pratiques ; et (5) la rétroaction. Les participants ont évalué positivement le processus de mise en œuvre, bien qu'ils aient déclaré que la réceptivité des patients constituait parfois un défi. Parmi les suggestions d'amélioration, citons la rationalisation et l'automatisation des formulaires et processus de collecte de données et l'augmentation des possibilités de simulation.Conclusions: PRISM semble être une approche prometteuse pour surmonter plusieurs obstacles qui empêchent les personnes souffrant de maux de dos de recevoir des soins de haute valeur. Il consolide et augmente les connaissances en matière de science de la douleur et renforce la confiance des physiothérapeutes dans leur capacité de fournir des soins de grande valeur. Le programme a semblé légitimer certaines pratiques actuelles, améliorer le raisonnement clinique et les compétences en matière de communication, étendre les connaissances conformément à la science contemporaine de la douleur et faciliter l'application d'une approche de gestion biopsychosociale. Son haut niveau d'acceptation par les participants constitue une base pour la poursuite des recherches visant à tester les résultats et la prestation des soins dans différents contextes.Contribution de l'article: Une intervention d'amélioration de la qualité conçue pour améliorer la prestation de soins de haute valeur a été bien accueillie par les physiothérapeutes en cabinet privé.Les physiothérapeutes ont particulièrement apprécié l'utilisation de l'apprentissage par l'expérience pour améliorer la fluidité de la communication avec les patients et les informer sur la science contemporaine de la douleur.Un cheminement clinique structuré accompagné d'outils a guidé les physiothérapeutes en ce qui concerne les éléments de base des soins nécessaires et leur ont permis de se concentrer sur les niveaux supérieurs de prise de décision et de communication avec les patients.

Assessing appropriateness of paediatric asthma management: A population-based sample survey.

BACKGROUND AND OBJECTIVE: We conducted a comprehensive assessment of guideline adherence in paediatric asthma care, including inpatient and ambulatory services, in Australia. METHODS: National and international clinical practice guidelines (CPG) relating to asthma in children were searched and 39 medical record audit indicator questions were developed. Retrospective medical record review was conducted across hospital inpatient admissions, emergency department (ED) presentations, general practice (GP) and paediatrician consultations in three Australian states for children aged ≤15 years receiving care in 2012 and 2013. Eligibility of, and adherence to, indicators was assessed from medical records by nine experienced and purpose-trained paediatric nurses (surveyors). RESULTS: Surveyors conducted 18 453 asthma indicator assessments across 1600 visits for 881 children in 129 locations. Overall, the adherence for asthma care across the 39 indicators was 58.1%, with 54.4% adherence at GP (95% CI: 46.0-62.5), 77.7% by paediatricians (95% CI: 40.5-97.0), 79.9% in ED (95% CI: 70.6-87.3) and 85.1% for inpatient care (95% CI: 76.7-91.5). For 14 acute asthma indicators, overall adherence was 56.3% (95% CI: 47.6-64.7). Lowest adherences were for recording all four types of vital signs in children aged >2 years presenting with asthma attack (15.1%, 95% CI: 8.7-23.7), and reviewing patients' compliance, inhaler technique and triggers prior to commencing a new drug therapy (20.5%, 95% CI: 10.1-34.8). CONCLUSION: The study demonstrated differences between existing care and CPG recommendations for paediatric asthma care in Australia. Evidence-based interventions to improve adherence to CPG may help to standardize quality of paediatric asthma care and reduce variation of care.

Assessing the quality of health care in the management of bronchiolitis in Australian children: a population-based sample survey.

BACKGROUND: Bronchiolitis is the most common cause of respiratory hospitalisation in children aged <2 years. Clinical practice guidelines (CPGs) suggest only supportive management of bronchiolitis. However, the availability of CPGs do not guarantee that they are used appropriately and marked variation in the clinical management exists. We conducted an assessment of guideline adherence in the management of bronchiolitis in children at a subnationally representative level including inpatient and ambulatory services in Australia. METHODS: We searched for national and international CPGs relating to management of bronchiolitis in children and identified 16 recommendations which were formatted into 40 medical record audit indicator questions. A retrospective medical record review assessing compliance with the CPGs was conducted across three types of healthcare setting: hospital inpatient admissions, emergency department (ED) presentations and general practice (GP) consultations in three Australian states for children aged <2 years receiving care in 2012 and 2013. RESULTS: Purpose-trained surveyors conducted 13 979 eligible indicator assessments across 796 visits for bronchiolitis at 119 sites. Guideline adherence for management of bronchiolitis was 77.3% (95% CI 72.6 to 81.5) for children attending EDs, 81.6% (95% CI 78.0 to 84.9) for inpatients and 52.3% (95% CI 44.8 to 59.7) for children attending GP consultations. While adherence to some individual indicators was high, overall adherence to documentation of 10 indicators relating to history taking and examination was poorest and estimated at 2.7% (95% CI 1.5 to 4.4). CONCLUSIONS: The study is the first to assess guideline-adherence in both hospital (ED and inpatient) and GP settings. Our study demonstrated that while the quality of care for bronchiolitis was generally adherent to CPG indicators, specific aspects of management were deficient, especially documentation of history taking.

Structure-based design, synthesis and biological evaluation of a novel series of isoquinolone and pyrazolo[4,3-c]pyridine inhibitors of fascin 1 as potential anti-metastatic agents.

Fascin is an actin binding and bundling protein that is not expressed in normal epithelial tissues but overexpressed in a variety of invasive epithelial tumors. It has a critical role in cancer cell metastasis by promoting cell migration and invasion. Here we report the crystal structures of fascin in complex with a series of novel and potent inhibitors. Structure-based elaboration of these compounds enabled the development of a series with nanomolar affinities for fascin, good physicochemical properties and the ability to inhibit fascin-mediated bundling of filamentous actin. These compounds provide promising starting points for fascin-targeted anti-metastatic therapies.

Evaluating Medical Students' Clinical Reasoning in Psychiatry Using Clinical and Basic Science Concepts Presented in Session-level Integration Sessions.

OBJECTIVE: The objective of this study was to evaluate improvement in clinical reasoning by preclinical medical students following participation in a clinical presentation curriculum that included both course and session-level integration of psychiatric and basic science concepts. A Script Concordance Test (SCT) for psychiatry was developed to assess differences in clinical reasoning in the students. METHODS: Pre- and post-integration session tests were used to evaluate clinical reasoning among second-year medical students (MSII) who attended three integration sessions. Scores were compared between experts and medical students, and the validity and reliability of the SCT for psychiatry was assessed. RESULTS: MSII scores improved 11% between the pre-and post-test (p < .001). There was no significant difference in scores between experts and MSII after attending the integration sessions. The SCT for psychiatry that was developed and used in this study provides reliable and valid results. CONCLUSION: The concepts included in the integration sessions for this study highlighted possibilities for helping novice learners elaborate causal networks with the intention of cultivate illness script formation and clinical reasoning. Additional studies in this area should be considered to further enhance understanding of the possible benefits of this curriculum model.

Neural mechanisms of brain plasticity with complex cognitive training in healthy seniors.

Complex mental activity induces improvements in cognition, brain function, and structure in animals and young adults. It is not clear to what extent the aging brain is capable of such plasticity. This study expands previous evidence of generalized cognitive gains after mental training in healthy seniors. Using 3 MRI-based measurements, that is, arterial spin labeling MRI, functional connectivity, and diffusion tensor imaging, we examined brain changes across 3 time points pre, mid, and post training (12 weeks) in a randomized sample (n = 37) who received cognitive training versus a control group. We found significant training-related brain state changes at rest; specifically, 1) increases in global and regional cerebral blood flow (CBF), particularly in the default mode network and the central executive network, 2) greater connectivity in these same networks, and 3) increased white matter integrity in the left uncinate demonstrated by an increase in fractional anisotropy. Improvements in cognition were identified along with significant CBF correlates of the cognitive gains. We propose that cognitive training enhances resting-state neural activity and connectivity, increasing the blood supply to these regions via neurovascular coupling. These convergent results provide preliminary evidence that neural plasticity can be harnessed to mitigate brain losses with cognitive training in seniors.

A randomized, double-blind, placebo-controlled trial of pregnenolone for bipolar depression.

Depression in bipolar disorder (BPD) is challenging to treat. Therefore, additional medication options are needed. In the current report, the effect of the neurosteroid pregnenolone on depressive symptoms in BPD was examined. Adults (n=80) with BPD, depressed mood state, were randomized to pregnenolone (titrated to 500 mg/day) or placebo, as add-on therapy, for 12 weeks. Outcome measures included the 17-item Hamilton Rating Scale for Depression (HRSD), Inventory of Depressive Symptomatology-Self-Report (IDS-SR), Hamilton Rating Scale for Anxiety (HRSA), and Young Mania Rating Scale (YMRS). Serum neurosteroid levels were assessed at baseline and week 12. Data were analyzed using a mixed model ANCOVA with a between factor of treatment assignment, a within factor (repeated) of visit, and the baseline value, as well as age and gender, as covariates. In participants with at least one postbaseline visit (n=73), a significant treatment by week interaction for the HRSD (F(5,288)=2.61, p=0.025), but not IDS-SR, was observed. Depression remission rates were greater in the pregnenolone group (61%) compared with the placebo group (37%), as assessed by the IDS-SR (χ(2)(1)=3.99, p=0.046), but not the HRSD. Large baseline-to-exit changes in neurosteroid levels were observed in the pregnenolone group but not in the placebo group. In the pregnenolone group, baseline-to-exit change in the HRSA correlated negatively with changes in allopregnanolone (r(22)=-0.43, p=0.036) and pregNANolone (r(22)=-0.48, p=0.019) levels. Pregnenolone was well tolerated. The results suggest that pregnenolone may improve depressive symptoms in patients with BPD and can be safely administered.

Evaluating the effectiveness of reasoning training in military and civilian chronic traumatic brain injury patients: study protocol.

BACKGROUND: Individuals who sustain traumatic brain injuries (TBIs) often continue to experience significant impairment of cognitive functions mediated by the prefrontal cortex well into chronic stages of recovery. Traditional brain training programs that focus on improving specific skills fall short of addressing integrative functions that draw upon multiple higher-order processes critical for social and vocational integration. In the current study, we compare the effects of two short-term, intensive, group-based cognitive rehabilitation programs for individuals with chronic TBI. One program emphasizes learning about brain functions and influences on cognition, while the other program adopts a top-down approach to improve abstract reasoning abilities that are largely reliant on the prefrontal cortex. These treatment programs are evaluated in civilian and military veteran TBI populations. METHODS/DESIGN: One hundred individuals are being enrolled in this double-blinded clinical trial (all measures and data analyses will be conducted by blinded raters and analysts). Each individual is randomly assigned to one of two treatment conditions, with each condition run in groups of five to seven individuals. The primary anticipated outcomes are improvement in abstract reasoning and everyday life functioning, measured through behavioral tasks and questionnaires, and attention modulation, as measured by functional neuroimaging. Secondary expected outcomes include improvements in the cognitive processes of working memory, attention, and inhibitory control. DISCUSSION: Results of this trial will determine whether cognitive rehabilitation aimed at teaching TBI-relevant information about the brain and cognition versus training in TBI-affected thinking abilities (e.g., memory, attention, and executive functioning) can improve outcomes in chronic military and civilian TBI patient populations. It should shed light on the nature of improvements and the characteristics of patients most likely to benefit. This trial will also provide information about the sustainability of treatment-related improvements 3 months post-training. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01552473.

Improving children's dairy food and calcium intake: can intervention work? A systematic review of the literature.

OBJECTIVE: Strategies are needed to address the shortfall in children's dairy food and Ca intakes. The present review identified interventions targeting an increase in children's dairy food or Ca intakes, and determined characteristics associated with successful intervention. DESIGN: A systematic literature search identified fourteen intervention studies, published in English, between 1990 and 2010. Studies were evaluated for study population, setting and mode of delivery, dietary targets and outcome measures, measures of intervention intensity, intervention description, the use of behaviour change techniques and intervention effectiveness. SETTING: Interventions targeting an increase in dairy food or Ca intake. SUBJECTS: Children aged 5-12 years. RESULTS: Ten of the fourteen studies were considered to be effective. Studies focusing on encouraging intake of dairy foods or Ca alone were all effective, compared with 55 % of studies promoting dairy within the context of a healthy diet. Effective interventions tended to be higher in intensity, provide dairy foods and were delivered across a variety of settings to a range of primary targets. The number of behaviour change techniques used did not differentiate effective and ineffective interventions, but the use of taste exposure and prompting practice appeared to be important for effective intervention. CONCLUSIONS: Interventions that target an increase in children's dairy food or Ca intake could potentially increase children's dairy food intake by about one serving daily. Research conducted outside the USA is needed. The review has identified some promising strategies likely to be part of effective interventions for improving dairy and Ca intakes in countries where children's intake is insufficient.

Combined home and school obesity prevention interventions for children: what behavior change strategies and intervention characteristics are associated with effectiveness?

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior-health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.

Assessing the impact older people from care homes place on the emergency services.

OBJECTIVE: The increasing size of our older population will provide more pressure to UK emergency services. Studies show that older people are more likely to be admitted from the emergency department (ED). This study aimed to evaluate the impact care home (CH) patients have on the ED within a large urban UK city and whether end-of-life planning and alternative pathways can improve quality of care for these patients. METHODS: Data were collected for 11760 patients of over 65 years of age. CH and non-care home patients attending the ED were compared and an in-depth analysis of the sickest patients was carried out. RESULTS: CH patients were more likely to arrive by ambulance, odds ratio (OR) of 8.09 [95% confidence interval (CI) 6.17-10.6; P<0.001]; have an investigation, OR of 1.51 (95% CI: 1.28-1.77; P<0.001); present with a medical condition or fall, OR of 2.05 (95% CI: 1.75-2.40; P<0.001); to spend more than 4 h in the ED, OR of 1.48 (95% CI: 1.30-1.69; P<0.001); to be admitted, OR of 1.32 (95% CI: 1.16-1.50; P<0.001). Of the sickest CH patients admitted (n=73), 63.9% (46 of 72) died within 24 h of admission, 8.3% (6 of 72) had a postmortem, 90.4% (66/73) had a 'do not attempt resuscitation' order after admission. Most, however, had investigations and treatments: venous blood (60 of 73), arterial blood gases (38 of 73), X-rays (48 of 73), intravenous fluids (52 of 73), and intravenous antibiotics (24 of 73). CONCLUSION: This reflects the demand that CH patients place on emergency services compared with non-care home patients. The results also highlight the importance of end-of-life decisions before ED attendance. Further work is required to identify alternative pathways to improve the quality of care and reduce the impact on secondary care.

Understanding parent concerns about children's diet, activity and weight status: an important step towards effective obesity prevention interventions.

OBJECTIVE: To identify parents' concerns and attitudes towards children's diets, activity habits and weight status. DESIGN: Computer-assisted telephone interviewing administration of a 37-item survey. Data were weighted for parental education level. Descriptive results are presented, and comparisons are made by the age, gender and parental characteristics of the child. SETTING: Online research panel of Australian parents. SUBJECTS: A total of 1202 randomly selected parents of children aged 2-16 years, broadly representative of the Australian population. RESULTS: Parents were concerned about their child's education (reported by 35 % of respondents), child's health and well-being (25 %), and violence, drugs and alcohol (20 %). Concern about nutrition was indicated by 14 % of respondents and concern about fitness/exercise was indicated by 3 % of the sample. Factors perceived as making a healthy diet difficult to achieve for their child were child resistance (89 %), the availability of healthy food (72 %), a busy lifestyle (67 %) and the influence of food advertising (63 %). Ninety-two per cent of parents thought that it was realistic for their child to be active for at least 1 h/d, with 75 % of parents feeling that it was realistic for their child to have less than 2 h recreational screen time per d. Despite this, common barriers to achieving the activity guidelines were lack of time, weather and keeping children occupied. CONCLUSIONS: Insights into parental concerns from the current study may be useful in guiding development of interventions to improve children's nutrition and physical activity habits by framing messages in a way that are most likely to resonate with parents.