Restoration from out-of-home care for Aboriginal children: Evidence from the pathways of care longitudinal study and experiences of parents and children

BACKGROUND

Restoration of Aboriginal children (also called reunification) is an under-researched area despite being the preferred permanency outcome for children.

OBJECTIVE

To investigate the rate of restoration for Aboriginal children, the factors that influence restoration, and to explore the experiences of parents whose Aboriginal children have been restored, and their children.

PARTICIPANTS AND SETTING

Analyses were conducted using data from the NSW Department of Communities and Justice Pathways of Care Longitudinal Study (POCLS).

METHODS

The quantitative sample includes all Aboriginal children in NSW who were on final Children's Court care and protection orders by 30 April 2013. Qualitative data were extracted from the POCLS survey instruments.

RESULTS

Of the 1018 Aboriginal children in the study, 15.2% were restored. Around 40 % of children entered care following just one (or no) substantiated Risk of Significant Harm reports. Children entering care under the age of 2 years were the least likely to be restored. Parents expressed dissatisfaction with child protection agencies and family support services both at the time their child was removed and in the restoration period. Parents and children expressed the importance of being supported to maintain family relationships while children are in care.

CONCLUSIONS

Despite policy priorities to the contrary, few Aboriginal children are considered for restoration. More support is needed for Aboriginal parents interfacing with all stages of the care system and following restoration. Additional research is needed to understand the factors underlying decisions to remove Aboriginal children from their families and whether restoration to their family is considered or achieved.

C-Reactive Protein (CRP) is Associated With Chronic Pain Independently of Biopsychosocial Factors

Inflammation is linked with chronic pain but the extent to which this relationship is associated with biopsychosocial factors is not known. We investigated relationships between blood C-reactive protein (CRP) and regional chronic pain conditions adjusting for a large range and number of potential confounders. We performed cross-sectional analyses using the UK Biobank (N = 415,567) comparing CRP in people reporting any of 9 types of regional chronic pain with pain-free controls. Using logistic regression modelling, we explored relationships between CRP and the presence of chronic pain, with demographic, socioeconomic, psychological/lifestyle factors, and medical comorbidities as covariates. CRP was higher in chronic pain at any site compared with controls (Females: median [interquartile range] 1.60 mg/L [2.74] vs 1.17 mg/L [1.87], P < .001; Males: 1.44 mg/L [2.12] vs 1.15 mg/L [1.65], P < .001). In males, associations between CRP and all types of chronic pain were attenuated but remained significant after adjustment for biopsychosocial covariates (OR range 1.08-1.49, P ≤ .001). For females, adjusted associations between CRP and pain remained significant for most chronic pain types (OR range 1.07-1.34, P < .001) except for facial pain (OR 1.04, P = .17) and headache (OR 1.02, P = .07)-although these non-significant findings may reflect reduced sample size. The significant association between CRP and chronic pain after adjustment for key biopsychosocial confounders implicates an independent underlying biological mechanism of inflammation in chronic pain. The presence of yet unknown or unmeasured confounding factors cannot be ruled out. Our findings may inform better-targeted treatments for chronic pain. PERSPECTIVE: Using a large-scale dataset, this article investigates associations between chronic pain conditions and blood C-reactive protein (CRP), to evaluate the confounding effects of a range of biopsychosocial factors. CRP levels were higher in those with chronic pain versus controls after adjusting for confounders-suggesting a possible independent biological mechanism.

Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia

Background

Providing cultural education to health professionals is essential in improving the quality of care and outcomes for Aboriginal and Torres Strait Islander patients. This study reports the evaluation of a novel training workshop used as an intervention to improve communication with Aboriginal and Torres Strait Islander patients of persistent pain services.

Methods

In this single-arm intervention study, health professionals undertook a one-day workshop, which included cultural capability and communication skills training based on a clinical yarning framework. The workshop was delivered across three adult persistent pain clinics in Queensland. At the end of the training, participants completed a retrospective pre/post evaluation questionnaire (5 points Likert scale, 1 = very low to 5 = very high), to rate their perceived importance of communication training, their knowledge, ability and confidence to communicate effectively. Participants also rated their satisfaction with the training and suggested improvements for future trainings.

Results

Fifty-seven health professionals were trained (N = 57/111; 51% participation rate), 51 completed an evaluation questionnaire (n = 51/57; 90% response rate). Significant improvements in the perceived importance of communication training, knowledge, ability and confidence to effectively communicate with Aboriginal and Torres Strait Islander patients were identified (p < 0.001). The greatest increase was in the perceived confidence pre-training mean of 2.96 (SE = 0.11) to the post-training mean of 4.02 (SE = 0.09).

Conclusion

This patient-centred communication training, delivered through a novel model that combines cultural capability and the clinical yarning framework applied to the pain management setting, was highly acceptable and significantly improved participants' perceived competence. This method is transferrable to other health system sectors seeking to train their clinical workforce with culturally sensitive communication skills.

Early Life Maltreatment and Adolescent Interpretations of Ambiguous Social Situations: Investigating Interpersonal Cognitions and Emotional Symptoms

In the general population, negative interpretations of social situations have been associated with risk of developing emotional disorders such as anxiety and depression. Given that childhood maltreatment poses risk for later emotional disorders, this study examined whether interpersonal cognitive style differentiated maltreated adolescents from their non-maltreated peers and correlated with emotional symptoms across each group. Forty-seven maltreated and 28 non-maltreated adolescents were recruited from New South Wales, Australia to complete a battery of questionnaires that assessed interpersonal cognitions and levels of anxiety and depression. Comparable endorsement of threatening interpretations of social situations between maltreated adolescents and their non-maltreated peers across measures was found. Furthermore, an association between anxiety and depressive symptoms and interpretation bias was found within the non-maltreatment group but not the maltreated group. Unlike general population samples, negative cognitions do not associate with emotional symptoms in victims of early maltreatment. More research is needed to investigate the cognitive factors maintaining emotional symptoms in adolescent victims of maltreatment.

Use of sensory modulation approaches to improve compression garment adherence in adults after burn: An e-Delphi study

BACKGROUND

Sensory over-responsiveness, identified through self-report and quantitative sensory testing, has been associated with compression garment non-adherence in a burn-injured cohort. This study sought expert consensus on the usefulness of, and recommendations for, sensory modulation strategies to improve compression garment adherence in sensory over-responsive adults after burn.

METHOD

Experts in the field of sensory modulation were invited to participate in a mixed-methods, three-round electronic Delphi study.

RESULTS

Experts (N = 18) agreed that sensory modulation therapy may be a useful clinical tool to improve compression garment adherence. Twenty-two items reached consensus as essential to assessment, treatment, or therapist training.

CONCLUSION

With adequate therapist training and individualized assessment and treatment, sensory modulation strategies may be a useful clinical approach to improving compression garment adherence in those who are sensory over-responsive after burn. Further research is needed to gather perceptions from burns therapists, and to implement and evaluate the effectiveness in clinical practice.

Communication and access to healthcare: Experiences of Aboriginal and Torres Strait Islander people managing pain in Queensland, Australia

Background

Pain management requires a multidisciplinary approach and a collaborative relationship between patient-provider in which communication is crucial. This study examines the communication experiences of Aboriginal and Torres Strait Islander patients and Aboriginal and Torres Strait Islander Hospital Liaison Officers (ATSIHLOs), to improve understanding of how pain is managed in and through patient-health professional communication.

Methods

This qualitative study involved a purposive sample of patients attending three persistent pain clinics and ATSIHLOs working in two hospitals in Queensland, Australia. Focus groups and in-depth interviews explored the communication experiences of patients managing pain and ATSIHLOs supporting patients with pain. This study adopted a descriptive phenomenological methodology, as described by Colaizzi (1978). Relevant statements (patient and ATSIHLOs quotes) about the phenomenon were extracted from the transcripts to formulate meanings. The formulated meanings were subsequently sorted into thematic clusters and then integrated into themes. The themes were then incorporated into a concise description of the phenomenon of communication within pain management. Findings were validated by participants.

Results

A total of 21 Aboriginal and Torres Strait Islander participants were involved in this study. Exploration of the communication experiences of patients and ATSIHLOs revealed overlapping themes of important barriers to and enablers of communication that affected access to care while managing pain. Acknowledging historical and cultural factors were particularly important to build trust between patients and health professionals. Some patients reported feeling stigmatized for identifying as Aboriginal and Torres Strait Islander, while others were reluctant to disclose their background for fear of not having the same opportunity for treatment. Differences in the expression of pain and the difficulty to use standard pain measurement scales were identified. Communication was described as more than the content delivered, it is visual and emotional expressed through body language, voice intonation, language and the speed of the conversation.

Conclusion

Communication can significantly affect access to pain management services. Aboriginal and Torres Strait Islander patients highlighted the burden of emotional pain caused by historical factors, negative stereotypes and the fear of discrimination. Pain management services and their health professionals need to acknowledge how these factors impact patients trust and care.

A loss-of-function IFNAR1 allele in Polynesia underlies severe viral diseases in homozygotes

Globally, autosomal recessive IFNAR1 deficiency is a rare inborn error of immunity underlying susceptibility to live attenuated vaccine and wild-type viruses. We report seven children from five unrelated kindreds of western Polynesian ancestry who suffered from severe viral diseases. All the patients are homozygous for the same nonsense IFNAR1 variant (p.Glu386*). This allele encodes a truncated protein that is absent from the cell surface and is loss-of-function. The fibroblasts of the patients do not respond to type I IFNs (IFN-α2, IFN-ω, or IFN-β). Remarkably, this IFNAR1 variant has a minor allele frequency >1% in Samoa and is also observed in the Cook, Society, Marquesas, and Austral islands, as well as Fiji, whereas it is extremely rare or absent in the other populations tested, including those of the Pacific region. Inherited IFNAR1 deficiency should be considered in individuals of Polynesian ancestry with severe viral illnesses.

Study protocol: Clinical yarning, a communication training program for clinicians supporting aboriginal and Torres Strait Islander patients with persistent pain: A multicentre intervention feasibility study using mixed methods

Objectives

Ineffective communication between healthcare clinicians and Aboriginal and Torres Strait Islander patients with persistent pain is a significant barrier to optimal pain management. This manuscript is a study protocol and describes the development and evaluation methods of a tailored, culturally-informed training program, to improve clinicians’ communication with patients.

Study design

This is a single-arm, multicentre (2 metropolitan and 1 regional persistent pain service) intervention feasibility study that will be evaluated using mixed methods.

Methods

A communication training program will be developed informed by qualitative interviews with key stakeholders, and adapt the patient-centred ‘clinical yarning’ framework for the Queensland context. Evaluation of the effectiveness of the training will involve the analysis of quantitative data collected at three study sites over a 12-month period. At the patient level, communication experience will be rated at differing times of the training rollout to reflect participants' experience of communication either prior to or following the treating clinician attending the communication training. At the clinician level, evaluation of the training program will be based on changes of ratings in the importance of training, knowledge, ability and confidence to communicate with Aboriginal and Torres Strait Islander patients; satisfaction, acceptance and relevance to their clinical practice. This study will be grounded in the needs and preferences of communication of Aboriginal and Torres Strait Islander people living with pain.

Conclusion

It is hypothesized that the patient-centred intervention will have immediate benefits for patients, improving patient experience of care. This research will focus on an area of unmet need in addressing persistent pain.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

The FOXP3 full-length isoform controls the lineage-stability of CD4+FOXP3+ regulatory T cells

The transcription factor FOXP3 is essential for CD4 + FOXP3+ regulatory T (Treg) cell development and function. Human FOXP3 exists in distinct isoforms and alterations in isoform expression is associated with inflammatory disease progression, however, the exact functions of FOXP3 isoforms remain poorly understood. Herein we used flow cytometry and RNA-sequencing to analyze subsets of Treg cells from two IPEX patients, and a healthy carrier, of a recently described FOXP3 mutation (c.305delT). This mutation is located in exon 2 and results in the loss of the full-length FOXP3 isoform. Treg cells lacking full-length FOXP3 are found at lower-than-expected frequencies. This loss cannot be explained solely by altered thymic output, changes in proliferation, peripheral induction of Treg cells, or apoptosis. Instead, fulllength FOXP3 control a distinct genetic program, involving the previously identified FOXP3 regulators ID3, BCL6 and eIF4E, that upholds Treg cell lineage stability, while it appears nonessential for Treg cell activation.

Mental health and well-being of Aboriginal and Torres Strait Islander peoples in Australia during COVID-19

In May 2020, an independent working party was convened to determine the mental health and well-being needs of Aboriginal and Torres Strait Islander peoples in Australia, in response to COVID-19. Thirty Aboriginal and Torres Strait Islander leaders and allies worked together in a two-month virtual collaboration process. Here, we provide the working party's five key recommendations and highlight the evidence supporting these proposals. Aboriginal and Torres Strait Islander self-determination and governance must be prioritised to manage the COVID-19 recovery in Aboriginal and Torres Strait Islander communities. To mitigate long-term social and economic impacts of COVID-19 to Australian society, the historical underinvestment in Aboriginal and Torres Strait Islander peoples must be reconciled. Equitable, needs-based funding is required to support strengths-based, place-based initiatives that address the determinants of health. This includes workforce and infrastructure development and effective evaluation. There is a clear, informed pathway to health and healing for Aboriginal and Torres Strait Islander peoples being enacted by Aboriginal and Torres Strait Islander leadership and community organisations; it remains to be seen how these recommendations will be implemented.

Heterozygous OAS1 gain-of-function variants cause an autoinflammatory immunodeficiency

Analysis of autoinflammatory and immunodeficiency disorders elucidates human immunity and fosters the development of targeted therapies. Oligoadenylate synthetase 1 is a type I interferon-induced, intracellular double-stranded RNA (dsRNA) sensor that generates 2'-5'-oligoadenylate to activate ribonuclease L (RNase L) as a means of antiviral defense. We identified four de novo heterozygous OAS1 gain-of-function variants in six patients with a polymorphic autoinflammatory immunodeficiency characterized by recurrent fever, dermatitis, inflammatory bowel disease, pulmonary alveolar proteinosis, and hypogammaglobulinemia. To establish causality, we applied genetic, molecular dynamics simulation, biochemical, and cellular functional analyses in heterologous, autologous, and inducible pluripotent stem cell-derived macrophages and/or monocytes and B cells. We found that upon interferon-induced expression, OAS1 variant proteins displayed dsRNA-independent activity, which resulted in RNase L-mediated RNA cleavage, transcriptomic alteration, translational arrest, and dysfunction and apoptosis of monocytes, macrophages, and B cells. RNase L inhibition with curcumin modulated and allogeneic hematopoietic cell transplantation cured the disorder. Together, these data suggest that human OAS1 is a regulator of interferon-induced hyperinflammatory monocyte, macrophage, and B cell pathophysiology.

The impact of the 2016 Psychoactive Substances Act on synthetic cannabinoid use within the homeless population: Markets, content and user harms

BACKGROUND

On 26 May 2016, the UK introduced the Psychoactive Substances Act. The Act made it an offence to produce, supply, or offer to supply, any psychoactive substance likely to be used for its psychoactive effects. While a Home Office review of the Act in 2018 proclaimed that the Act had been successful in achieving its main goal of preventing the open sale of psychoactive substances, significantly, the review acknowledged that high levels of synthetic cannabinoid use remain amongst vulnerable user groups, in particular the homeless population.

METHODS

The research adopted an innovative interdisciplinary approach drawing on sociology and chemistry. The sociological element involved 82 face-to-face qualitative semi-structured interviews with 37 homeless synthetic cannabinoid users, 45 stakeholders, and over 100 h of fieldwork observations. The chemical analysis element involved the testing (using Gas Chromatography-Mass Spectrometry) of 69 synthetic cannabinoid street samples obtained by a local police force.

RESULTS

The introduction of the Act was associated with a number of significant changes to the synthetic cannabinoid market, including the integration of synthetic cannabinoids into the existing illicit street market, new dealers, the adoption of more targeted and aggressive supply practices, and variability in the content and potency of synthetic cannabinoids. Combined, these changes have increased the risk of harm to homeless users and homeless sector staff and resulted in a concomitant increase in the demand on emergency services.

CONCLUSION

The foreseen concerns that the Act would result in detrimental market changes and increased harms to vulnerable user groups have been manifested in the homeless population. The failure of the Act to reduce synthetic cannabinoid use within this group, combined with the increased risk of individual and societal harm, highlights the importance of reducing the demand for synthetic cannabinoids.

The Role of ZEB2 in Human CD8 T Lymphocytes: Clinical and Cellular Immune Profiling in Mowat-Wilson Syndrome

The Zeb2 gene encodes a transcription factor (ZEB2) that acts as an important immune mediator in mice, where it is expressed in early-activated effector CD8 T cells, and limits effector differentiation. Zeb2 homozygous knockout mice have deficits in CD8 T cells and NK cells. Mowat–Wilson syndrome (MWS) is a rare genetic disease resulting from heterozygous mutations in ZEB2 causing disease by haploinsufficiency. Whether ZEB2 exhibits similar expression patterns in human CD8 T cells is unknown, and MWS patients have not been comprehensively studied to identify changes in CD8 lymphocytes and NK cells, or manifestations of immunodeficiency. By using transcriptomic assessment, we demonstrated that ZEB2 is expressed in early-activated effector CD8 T cells of healthy human volunteers following vaccinia inoculation and found evidence of a role for TGFß-1/SMAD signaling in these cells. A broad immunological assessment of six genetically diagnosed MWS patients identified two patients with a history of recurrent sinopulmonary infections, one of whom had recurrent oral candidiasis, one with lymphopenia, two with thrombocytopenia and three with detectable anti-nuclear antibodies. Immunoglobulin levels, including functional antibody responses to protein and polysaccharide vaccination, were normal. The MWS patients had a significantly lower CD8 T cell subset as % of lymphocytes, compared to healthy controls (median 16.4% vs. 25%, p = 0.0048), and resulting increased CD4:CD8 ratio (2.6 vs. 1.8; p = 0.038). CD8 T cells responded normally to mitogen stimulation in vitro and memory CD8 T cells exhibited normal proportions of subsets with important tissue-specific homing markers and cytotoxic effector molecules. There was a trend towards a decrease in the CD8 T effector memory subset (3.3% vs. 5.9%; p = 0.19). NK cell subsets were normal. This is the first evidence that ZEB2 is expressed in early-activated human effector CD8 T cells, and that haploinsufficiency of ZEB2 in MWS patients had a slight effect on immune function, skewing T cells away from CD8 differentiation. To date there is insufficient evidence to support an immunodeficiency occurring in MWS patients.

Diagnosis and management of severe combined immunodeficiency in Australia and New Zealand

This consensus document outlines the recommendations from the Australasian Society of Clinical Immunology and Allergy Transplantation and Primary Immunodeficiency group for the diagnosis and management of patients with severe combined immunodeficiency. It also provides a proposed framework for the early investigation, management and supportive care prior to haematopoietic stem cell transplantation.

A recessive form of hyper-IgE syndrome by disruption of ZNF341-dependent STAT3 transcription and activity

Heterozygosity for human signal transducer and activator of transcription 3 (STAT3) dominant-negative (DN) mutations underlies an autosomal dominant form of hyper-immunoglobulin E syndrome (HIES). We describe patients with an autosomal recessive form of HIES due to loss-of-function mutations of a previously uncharacterized gene, ZNF341 ZNF341 is a transcription factor that resides in the nucleus, where it binds a specific DNA motif present in various genes, including the STAT3 promoter. The patients' cells have low basal levels of STAT3 mRNA and protein. The autoinduction of STAT3 production, activation, and function by STAT3-activating cytokines is strongly impaired. Like patients with STAT3 DN mutations, ZNF341-deficient patients lack T helper 17 (T_H17) cells, have an excess of T_H2 cells, and have low memory B cells due to the tight dependence of STAT3 activity on ZNF341 in lymphocytes. Their milder extra-hematopoietic manifestations and stronger inflammatory responses reflect the lower ZNF341 dependence of STAT3 activity in other cell types. Human ZNF341 is essential for the STAT3 transcription-dependent autoinduction and sustained activity of STAT3.

Mining FDA resources to compute population-specific frequencies of adverse drug reactions

Adverse drug reactions (ADRs) represent one of the main health and economic problems in the world. With increasing data on ADRs, there is an increased need for software tools capable of organizing and storing the information on drug-ADR associations in a form that is easy to use and understand. Here we present a step by step computational procedure capable of extracting drug-ADR frequency data from the large collection of patient safety reports stored in the Federal Drug Administration database. Our procedure is the first of its type capable of generating population specific drug-ADR frequencies. The drug-ADR data generated by our method can be made specific to a single patient population group (such as gender or age) or a single therapy characteristic (such as drug dosage, duration of therapy) or any combination of such.