Multisystem Approach Research Articles

Exploring resilience processes of Filipino migrant domestic workers: A multisystemic approach.

This study identified resilience processes at the individual, family, and community levels among Filipino migrant domestic workers (MDWs). Resilience processes highlight strengths and resources that can enhance positive adaptation to problems that affect this vulnerable migrant group. Data came from focus groups and key informant interviews involving 27 MDWs and 7 key informants. Data was analyzed using thematic analysis and organized according to the socioecological model. Results revealed 7 resilience processes. Financial coping, health management, and spirituality were found across levels. Companionship and emotional support are transacted within family and community levels, whereas expanding knowledge and support occurs at individual and community levels. MDWs and their families prioritize each family member, whereas the community provides legal support. Resilience processes exist across ecological levels. However, individual resilience processes are insufficient, thus necessitating collective agency through familial and community resilience processes and building social structures that facilitate resilience.

Using body mapping to explore gender with adolescents in Uttar Pradesh

ABSTRACT Young women and girls in Uttar Pradesh (UP), India, face gender inequalities, which threaten their health and well-being. This study used body mapping, a visual participatory research method, to learn from adolescents ages 15 to 17 living in Lucknow slums about how gender norms affect their daily experiences. Forty adolescents participated in body mapping. Their body maps and narratives about those maps demonstrate that starting in adolescence, family and community members strongly enforce divergent gender norms for girls and boys. Girls face restrictions on their clothing, mobility, and education, whereas boys have comparative freedom in these domains. Girls experience persistent public harassment by boys and men, severely constraining their ability to move freely in public spaces. In contrast, the school was a setting where adolescent girls and boys experience more relaxed gender norms. Overall, this study describes the link between gender norms, health, and well-being for adolescents. It also illustrates the value of participatory and adolescent-friendly research methods for exploring gender norms among adolescent boys and girls in India. Finally, it indicates that multi-system approaches are needed to address gender-related inequalities in health and well-being.

Multifaceted and Age-Dependent Phenotypes Associated With Biallelic PNPLA6 Gene Variants: Eight Novel Cases and Review of the Literature.

A wide spectrum of neurodegenerative diseases has been associated with pathogenic variants in the PNPLA6 (patatin-like phospholipase domain-containing protein 6) gene, including spastic paraplegia type 39, Gordon—Holmes, Boucher—Neuhauser, Oliver—Mc Farlane, and Laurence—Moon syndromes. These syndromes present variable and overlapping clinical symptoms, encompassing cerebellar ataxia, hypogonadotropic hypogonadism, chorioretinal dystrophy, spastic paraplegia, muscle wasting, peripheral neuropathy, and cognitive impairment. In the present study, we performed a wide genetic screening in 292 patients presenting with ataxia or spastic paraplegia using a probe-based customized gene panel, covering >200 genes associated with spinocerebellar diseases. We identified six novel and four recurrent PNPLA6 gene variants in eight patients (2.7%). Six patients presented an infantile or juvenile onset (age <18), and two patients had an adult onset. Cerebellar ataxia was observed in seven patients and spastic paraplegia in one patient. Progression of cerebellar symptoms was slow in all patients, who retained ambulation even after a mean disease duration of 15 years. Brain MRI showed cerebellar atrophy in 6/8 patients, more pronounced in superior and dorsal vermis lobules (I to VII). Additional clinical features included hypogonadotropic hypogonadism (5/8), growth hormone deficiency (2/8), peripheral axonal neuropathy (4/8), cognitive impairment (3/8), chorioretinal dystrophy (2/8), and bilateral vestibular areflexia with a reduced visual vestibule-ocular reflex (1/8). In accordance with previous studies, chorioretinal dystrophy was the most frequent presenting symptom in early onset patients, hypogonadotropic hypogonadism in juvenile onset cases, and cerebellar ataxia in adult patients. One patient had an initial clinical presentation compatible with Cerebellar Ataxia with Neuropathy and Vestibular Areflexia Syndrome (CANVAS), but no pathological expansions in the RFC1 gene. In conclusion, patients with PNPLA6 variants present a variable age of onset spanning from infancy to adulthood, and each clinical symptom has an age-dependent manifestation thus requiring a multi-systemic diagnostic approach. The description of patients presenting very late-onset cerebellar ataxia suggests that PNPLA6 genetic screening should also be considered in the diagnostic workout of adult cerebellar ataxia.

Using a Multi-Systems Approach: Early Intervention, Changing Mindsets, Learning Opportunities, and Meaningful Data

Using a Multi-Systems Approach: Early Intervention, Changing Mindsets, Learning Opportunities, and Meaningful Data

Microfluidic Biosensor-Based Devices for Rapid Diagnosis and Effective Anti-cancer Therapeutic Monitoring for Breast Cancer Metastasis.

Breast cancer with unpredictable metastatic recurrence is the leading cause of cancer-related mortality. Early cancer detection and optimized therapy are the principal determining factors for increased survival rate. Worldwide, researchers and clinicians are in search of efficient strategies for the timely management of cancer progression. Efficient preclinical models provide information on cancer initiation, malignancy progression, relapse, and drug efficacy. The distinct histopathological features and clinical heterogeneity allows no single model to mimic breast tumor. However, engineering three-dimensional (3D) in vitro models incorporating cells and biophysical cues using a combination of organoid culture, 3D printing, and microfluidic technology could recapitulate the tumor microenvironment. These models serve to be preferable predictive models bridging the translational research gap in drug development. Microfluidic device is a cost-effective advanced in vitro model for cancer research, diagnosis, and drug assay under physiologically relevant conditions. Integrating a biosensor with microfluidics allows rapid real-time analytical validation to provide highly sensitive, specific, reproducible, and reliable outcomes. In this manner, the multi-system approach in identifying biomarkers associated with cancer facilitates early detection, therapeutic window optimization, and post-treatment evaluation.This chapter showcases the advancements related to in vitro breast cancer metastasis models focusing on microfluidic devices. The chapter aims to provide an overview of microfluidic biosensor-based devices for cancer detection and high-throughput chemotherapeutic drug screening.

Abstract PO-052: A multisystem approach doubles the number of patients referred for genetic testing and diagnosed with Lynch syndrome with equally success among ethnic/racial groups

Abstract Background: Lynch syndrome (LS) affects 1/279 individuals and accounts for 3-5% of all colorectal cancers (CRC). LS is due to germline mutations in mismatch repair (MMR) genes MLH1, MSH2, MSH6, or PMS2. Tumors exhibit MMR deficiency, expressed as loss of MMR protein expression on immunohistochemistry (IHC). A subset of sporadic tumors also has MMR deficiency due to inactivation of MLH1 via promoter methylation and about 2/3 have BRAFV600E mutations. Increased surveillance and chemoprevention reduce cancer incidence and mortality in LS. LS is largely underdiagnosed, particularly among minorities. Universal screening of CRC tumors through IHC is recommended in order to help identify patients for LS genetic testing. Nevertheless, even in programs that have implemented this, minority patients with MMR deficient tumors were found to be consistently under-referred mostly due to referral bias. We set up a strategy to increase LS and tackle disparities in cancer genetics (CG). Methods: This study reports on the analysis of universal CRC IHC testing for MMR expression, initially followed by BRAF V600E and later by MLH1 testing for loss of MLH1/PMS2 expression, from implementation (1/1012) until 1/1021. In 6/2015, a system was established where a designated Pathologist reviewed all results and a list of identified candidates for germline LS testing (abnormal MMR expression/wild type BRAF or methylation of MLH1) was sent to the CG program. After a two-week period, if no referral had been placed, a genetic counselor (GC) messaged the provider requesting a referral. The pathology side was fully automated in 9/2018 through the monitoring engine Repetitive Tasks Scheduling Engine (RTSE) that pulls data stored in the underlying relational database-Adaptive Server Enterprise, which is accessible to RTSE via a Java Database Connectivity API. This process automatically generates weekly emails that report all cases with suspicion criteria for LS to CG. Results: Since 1-2012, 1,433 patients with CRC underwent tumor testing and were included in this study: 78.5% non-Hispanic white (NHW); 12.2% African American (AA); 6.77% Hispanic (H). Prior to the interventions 25% of eligible patients were referred to CG and none among AA. Once the interventions were established, appropriate referrals prior to messaging the provider were 39.5% for NHW, 35.7% for AA, and 42.8% for H. As a result of the messages, referral rates increased to 80.5% (p=0.00) in NHW, 85.7% in AA (p=0.05), and 71.5% in H (ns). The total number of patients diagnosed with LS since universal testing started was 19: 2 prior to the interventions (0.8% of all CRC); 17 during the interventions (1.5% of all CRC). Conclusion: A systematic, automated, multi-system approach, that includes a targeted message to providers can double the number of appropriate referrals for genetic testing to rule out Lynch syndrome and resulted in almost twice the percentage of LS diagnosis with equal success among AA, H, and NHW. Citation Format: Vinit Singh, Amanda Ganzak, Peter Gershkovich, Joanna Gibson, Rosa M. Xicola, Xavier Llor. A multisystem approach doubles the number of patients referred for genetic testing and diagnosed with Lynch syndrome with equally success among ethnic/racial groups [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-052.

Abnormal Morphology: Mitral Dysplasia in a Cat

Mitral dysplasia is a pathology that describes abnormal mitral valve and valve-related structures. This congenital disease, which has been diagnosed increasingly with advancing technology, creates congestive heart failure when it progresses. Although echocardiography is accepted as the primary standard at the diagnosis stage, it may not be sufficient alone, and advanced tests may be required. The prognosis of the patients is poor. A two-month-old, mixed breed, female cat has respiratory problems and anorexia symptoms. The patient, who was taken to two different clinics, was diagnosed with bronchitis. Our hospital revealed that the diagnosis was not bronchitis but congestive heart failure due to mitral dysplasia. Medical treatment was applied to reduce the symptoms in the patient. Two days after the start of the medication, the patient began to eat and was significantly active. After the patient was stabilized, the patient was handed over to the owner in order to avoid nosocomial infections and to minimize stress. There was no further news from the patient. This is the first case reported for this disease in our country. It is also important because it is a case that reveals the importance of the multisystemic approach.

A Multi-Systems Approach to Human Movement after ACL Reconstruction: The Nervous System

Postoperative rehabilitation of anterior cruciate ligament (ACL) reconstruction mainly focuses on the restoration of strength and range of motion with a long-term goal to return athletes to their prior level of activity. Of those wanting to return to sport, many are either unable and/or experience protracted recovery despite extensive rehabilitation. To holistically care for patients recovering from ACL reconstructions, reframing rehabilitation to consider a comprehensive systems approach (including musculoskeletal, cardiovascular, endocrine, and neurologic systems) may help improve treatment outcomes. The American Physical Therapy Association has adopted a vision statement that embraces the concept of a ‘movement system,’ but validation of the movement system has been challenging. Application of a multi-physiologic systems approach may provide a unique perspective to better understand the nervous system and its interactions after ACL reconstruction. The purpose is to focus on the nervous system contributions to a multi-physiologic system approach to rehabilitation from ACL reconstruction. Level of Evidence 5

Contingent intramuscular boosting of P2XR7 axis improves motor function in transgenic ALS mice

Amyotrophic lateral sclerosis is a fatal neurodegenerative disorder that leads to progressive degeneration of motor neurons and severe muscle atrophy without effective treatment. Most research on the disease has been focused on studying motor neurons and supporting cells of the central nervous system. Strikingly, the recent observations have suggested that morpho-functional alterations in skeletal muscle precede motor neuron degeneration, bolstering the interest in studying muscle tissue as a potential target for the delivery of therapies. We previously showed that the systemic administration of the P2XR7 agonist, 2′(3′)-O‐(4-benzoylbenzoyl) adenosine 5-triphosphate (BzATP), enhanced the metabolism and promoted the myogenesis of new fibres in the skeletal muscles of SOD1G93A mice. Here we further corroborated this evidence showing that intramuscular administration of BzATP improved the motor performance of ALS mice by enhancing satellite cells and the muscle pro-regenerative activity of infiltrating macrophages. The preservation of the skeletal muscle retrogradely propagated along with the motor unit, suggesting that backward signalling from the muscle could impinge on motor neuron death. In addition to providing the basis for a suitable adjunct multisystem therapeutic approach in ALS, these data point out that the muscle should be at the centre of ALS research as a target tissue to address novel therapies in combination with those oriented to the CNS.

Understanding Twice-exceptionality (2e): A Multi-systems Perspective

Although research and interests in twice-exceptionality (2e) have been increasing in the last few decades, most studies have focused on the definition, identification, and academic achievement in twice-exceptional students. Such focus can be understandable due to varying definitions, research operationalizations, and the lack of a typical twice-exceptional profile (Lee &amp; Ritchotte, 2018; Wellisch &amp; Brown, 2013). There is considerably less research focused on cognitive characteristics and least research focused on investigating non-cognitive factors influencing twice-exceptional performance and development (Beckmann &amp; Minnaert, 2018). This paper serves to summarize factors that have been found to impact twice-exceptional, organized through a multi-systems (e.g., interpersonal, intrapersonal, contextual/situational, sociocultural, and socio-economical) approach, starting from individual variables to larger and more distal systems.

As formas de tratamento na abordagem multissistémica: um novo modelo teórico de análise

Address Forms in a Multisystemic Approach: A New Theoretical Model of Analysis. The aim of this paper is to propose a new theoretical model for the analysis of address forms. In the first part of the paper, I do a critical evaluation of existing theoretical models, showing, on the one hand, that the divergent approaches reflect the complexity of address research, and, on the other hand, that there is a need for a unified model to englobe morphosyntactic, semantic, pragmatic, discursive, and diachronic approaches. In the second part of the paper, I present the multisystemic theory developed by the Brazilian linguist Ataliba de Castilho and demonstrate that it can be successfully used for the analysis of address forms. In the last part of the paper, I show that lexicalization, semanticization, discursivization, and grammaticalization (linguistic processes identified by Ataliba de Castilho in his theory) can explain linguistic phenomena of the address systems in Portuguese and Romanian. Keywords: address forms, European Portuguese, Brazilian Portuguese, Romanian, multisystemic theory, multisystemic theory of Ataliba de Castilho

Becoming More Rugged and Better Resourced: The R2 Resilience Program's© Psychosocial Approach to Thriving.

The past decade has seen growing interest in interventions that build resilience as a complementary practice to trauma-informed care. From school-based programs focused on self-regulation and academic success to programs that support the well-being of disadvantaged populations or healthcare workers at risk of burnout, the concept of resilience is being used most commonly for programming that builds the capacity of individuals to adapt under conditions of adversity. Critiques have raised concerns that resilience-promoting programs demonstrate bias toward changing individual-level factors such as cognitions (e.g., mindfulness and grit), behavior (e.g., expressing gratitude and changing personal routines), or attachments (e.g., feeling secure in relationships) which help people adapt to socially toxic situations without changing access to the resources they require to overcome exposure to adverse psychosocial factors. This trend belies advances to the theory of resilience which support a more contextualized, multisystemic understanding of how external protective factors (resources) enhance individual qualities (ruggedness) and vice versa. Building on a multisystemic description of resilience, the R2 Resilience Program© was developed and piloted with six different populations ranging from clients of urban social services to workers in a long-term care facility, managers in the health care sector, staff of a Fortune 500 corporation, students in a primary to grade 12 school, and adult volunteers affiliated with an international NGO. Focused on building both individual ruggedness and enhancing people’s resources (the two Rs), the program provides contextualized content for each population by selecting from 52 resilience promoting factors with a strong evidence base to create training curricula that enhance the personal qualities and social, physical, and institutional resources most likely to support resilience. This paper reviews the justification for a multisystemic approach to designing resilience interventions and then explains the process of implementation of the R2 program. Preliminary findings are reported, which suggest the program is experienced as effective, with evaluations ongoing.

A Multi-Systems Approach to Human Movement after ACL Reconstruction: The Integumentary System.

Postoperative management of anterior cruciate ligament (ACL) reconstruction has traditionally focused on the evaluation and intervention of musculoskeletal components such as range of motion and patients’ reports of function. The integumentary system can provide early indications that rehabilitation may be prolonged due to protracted or poor healing of the incision sites. Full evaluation of the reconstruction over time, including direction of the incisions, appearance of surgical sites, level of residual innervation, and health of the individual should be considered when determining time-based goals and plans for returning an athlete to activity. Skin care techniques should be used to minimize strain and promote wound healing at the surgical sites, which in turn allows for implementation of other interventions that target other body systems such as locomotion, strength training, and cardiopulmonary conditioning. The integration of the integumentary system with cardiovascular, neurological, and muscular systems is required for a successful return to activity. A multi-physiologic systems approach may provide a unique viewpoint when aiming to attain a greater appreciation of the integumentary system and its integration with other body systems following ACL reconstruction. The purpose of this clinical commentary is to discuss integumentary considerations within a multi-physiologic systems approach to human movement after ACL reconstruction, including an anatomical review, key elements of assessment, and integrated intervention strategies.Level of Evidence5

A Multi-Systems Approach to Human Movement after ACL Reconstruction: The Cardiopulmonary System.

The cardiopulmonary system plays a pivotal role in athletic and rehabilitative activities following anterior cruciate ligament reconstruction, along with serving as an important support for the functioning of other physiologic systems including the integumentary, musculoskeletal, and nervous systems. Many competitive sports impose high demands upon the cardiorespiratory system, which requires careful attention and planning from rehabilitation specialists to ensure athletes are adequately prepared to return to sport. Cardiopulmonary function following anterior cruciate ligament reconstruction (ACLR) can be assessed using a variety of methods, depending on stage of healing, training of the clinician, and equipment availability. Reductions in cardiovascular function may influence the selection and dosage of interventions that are not only aimed to address cardiopulmonary impairments, but also deficits experienced in other systems that ultimately work together to achieve goal-directed movement. The purpose of this clinical commentary is to present cardiopulmonary system considerations within a multi-physiologic systems approach to human movement after ACLR, including a clinically relevant review of the cardiopulmonary system, assessment strategies, and modes of cardiopulmonary training to promote effective, efficient movement.Level of Evidence5

Sulfur mustard and biological ageing: A multisystem biological health score approach as an extension of the allostatic load in Sardasht chemical veterans

BackgroundMustard gas as a chemical weapon has been used in wars and its long-term side effects are substantial in the human body. This study was aimed to apply an extension of allostatic load, known as synthetic biological health score (BHS), including the wear-and-tear of four physiological systems (endocrine, inflammatory, cardiovascular and metabolic systems) and two organs (liver and kidney) to estimate biological aging caused by sulfur mustard (SM) gas poisoning. MethodsThe plasma samples were prepared from two following groups of people; 1) 446 individuals exposed to SM gas in 1987. 2) 115 healthy members, at the same range of age and residence, as the non-exposed group. These people were chosen from the same patients’ families and have not had any exposure to SM or pulmonary dysfunction. To estimate BHS, 18 blood-derived biomarkers of the mentioned systems and organs were measured and the relative contribution of many social and body parameters across the age groups was explored. ResultsIt was revealed, in BHS calculation, the cardiovascular system had the most effect. Also, in the SM group, BHS was significantly higher than in the control group. This feature has a positive correlation with physical parameter (BMI) and a negative correlation with social parameters (salary and educational levels). ConclusionThe multisystem BHS could be useful in the evaluation of biological aging due to SM exposure. Social (education, good-paying job) and physical (BMI) parameters could influence BHS and the higher BHS indicates the progress of biological aging due to mustard gas.

Expert opinion on monitoring symptomatic hereditary transthyretin-mediated amyloidosis and assessment of disease progression

BackgroundHereditary transthyretin-mediated amyloidosis, also known as ATTRv amyloidosis (v for variant), is a rare, autosomal dominant, fatal disease, in which systemic amyloid progressively impairs multiple organs, leading to disability and death. The recent approval of disease-modifying therapies offers the hope of stabilization or eventual reversal of disease progression, and yet highlights a lack of disease-management guidance. A multidisciplinary panel of expert clinicians from France and the US came to consensus on monitoring the disease and identifying progression through a clinical opinion questionnaire, a roundtable meeting, and multiple rounds of feedback.Monitoring disease and progressionA multidisciplinary team should monitor ATTRv amyloidosis disease course by assessing potential target organs at baseline and during follow-up for signs and symptoms of somatic and autonomic neuropathy, cardiac dysfunction and restrictive cardiomyopathy, and other manifestations. Variability in penetrance, symptoms, and course of ATTRv amyloidosis requires that all patients, regardless of variant status, undergo regular and standardized assessment in all these categories. Progression in ATTRv amyloidosis may be indicated by: worsening of several existing quantifiable symptoms or signs; the appearance of a new symptom; or the worsening of a single symptom that results in a meaningful functional impairment.ConclusionsWe suggest that a multisystem approach to monitoring the signs and symptoms of ATTRv amyloidosis best captures the course of the disease. We hope this work will help form the basis of further, consensus-based guidance for the treatment of ATTRv amyloidosis.

ICU TRANSITION OF CARE

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: The aim of our project is to formulate a standardized process for transfering patients from the intensive care unit to the medical wards which improves documentation, policy and puts emphasis on communication through a multidisciplinary approach by utilization of a novel hand-off template and implementation of transfer medication reconciliation. METHODS: Following the IHI model, a fishbone diagram was used to identify areas of improvement in the hand-off process. The persons involved, process, policy, and communication were identified as contributing factors in formulating a standardized Transition Of Care (TOC) process. PDSA cycles were used to test change. We measure use of proposed standardized TOC method and number of ICU re-admissions as part of adverse events. RESULTS: After observing the need for this process to become ubiquitous, using the Plan Do Study Act (PDSA) cycle, literature was reviewed, and a TOC template was formulated in PDSA1 which resulted in no significant change. In PDSA2, there was creation of a policy to utilize an existing Transfer Medication Reconciliation (Med Rec.) with our EMR prior to transferring a patient out of ICU. Internal medicine residents, faculty, ICU attendings, ICU committee, ICU Pharmacy, and EMR Department were educated on the implementation of the new procedure was initiated. 100 charts were analyzed post-intervention; of those 61 charts met inclusion criteria. Twenty seven of the 61 charts had an appropriate use of the TOC Template and use of Transfer Med Rec. in addition to communication with the primary attending (44%). Of these, there was 1 Rapid Response (RR) that warranted an ICU readmission (3.7%). There were 0 code blues after transfer from ICU. Of the 34 charts that did not abide to procedure, there were 3 RRs (8.8%). CONCLUSIONS: There were fewer RR when comparing the patients with the ICU TOC implemented compared to those without the documented communication (3.7% vs 8.8%). The ICU readmission noted, should take into account the inherit fragility of this patient population and associated morbidly. Despite our small sample size, the trends are promising that align with the impact of our implementation of ICU TOC process.The goal of this QI project was to use a multisystem approach to standardized transfer process to ensure patient safety. In our next PDSA cycle, there will be a pop-up screen when a Transfer Order out of ICU is clicked, that directs user to Transfer Med Rec. page before proceeding. With this new implementation, there will be an increased compliance to abiding to the process with integration of the EMR with Transfer Med Rec. CLINICAL IMPLICATIONS: The transition of patient care from the Intensive Care Unit (ICU) to the medical wards has been identified as a crucial time for communication and accuracy in these patients who are at high risk for potential harm due to medical errors. Proper transition process is critical, as the lack of a universal standardized hand-off could lead to detrimental consequences. Our community hospital has an “open” ICU and inconsistent transition of care process has been observed. The focus of our project is to formulate a standardized transfer process that improves documentation, policy and puts emphasis on communication through a multidisciplinary approach with utilization of a hand-off template and implementation of transfer medication reconciliation. DISCLOSURES: No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Zain Kulairi, source=Web Response No relevant relationships by Sarwan Kumar, source=Web Response No relevant relationships by Bernadette Schmidt, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response

Resilience and mental health in children and adolescents: an update of the recent literature and future directions.

Purpose of reviewIn order to promote optimal development of children and adolescents at risk for psychiatric disorders, a better understanding of the concept resilience is crucial. Here, we provide an overview of recent work on clinical and epidemiological correlates of resilience and mental health in children and adolescents.Recent findingsOur systematic literature search revealed 25 studies that unanimously show that higher levels of resilience are related to fewer mental health problems, despite the heterogeneity of study populations and instruments. Correlates of resilience included multisystem factors, such as social, cultural, family and individual aspects, which is in line with the multisystem approach as described by recent resilience theories. Longitudinal studies are scarce but confirm the dynamical character of resilience and mental health. The application of longitudinal studies and innovative measurement techniques will improve our understanding on the cascade effects of stressors on resilience and mental health outcomes.SummaryResilience is strongly associated with mental health in children and adolescents and deserves a more prominent role in research, prevention programs and routine clinical care. Including social, cultural and family context in the evaluation of resilience is of great value, as this can identify targets for early and preventive interventions.

Reducing Violence against Health Professionals

There is a rising trend of violence against healthcare professionals across the world, especially after the COVID-19 pandemic. Many countries report between 43-75% of professionals experiencing at least one incident in any annual survey. The most recent incident of doctors and healthcare staff in a Manchester City General Practice raised alarms. As the healthcare infrastructure and services are severely stretched following the disruption of 2020, there are more reasons for disquiet and frustration from the public. The media and political portrayal of primary care physicians as not caring enough to provide face-to-face appointments in the UK is believed to increase the public angst. There are protests from professional organisations but this is not heard by the public. In any violence prevention strategy, a multi-system approach is critical. While tackling misinformation is essential, so is the tackling the root causes, the waiting lists and a balanced information to the public. Political and organisational leaders need to be visible and vocal in explaining why the healthcare infrastructure is beyond breaking point. This will justify the additional resources needed and reduce the frustrations of the public, in need of care. There is also a vital need to help new doctors and nurses as well as all frontline staff in violence dissipation techniques, self-preservation. The Voluntary community organisations including those that support professional groups have a vital role to play. The NHS People Plan has recommended that VSCEs should join robust and reliable partnerships with Integrated Care Organisations in developing strategies and interventions. There is more work to be done. This article is a call for action and invites all VSCEs interested in the reduction of violence against staff to join with employing organisations to set up collaborative working groups with specific actions to implement. This is essential to reduce harm and reduce the demoralisation of an already burnt-out healthcare workforce.

An Enhanced Recovery After Surgery Protocol Decreases the Use of Post Bypass Narcotics

“Enhanced recovery after surgery” (ERAS) protocols use a multisystem approach to target homeostatic physiology in surgical patients perioperatively and target pain control via opioid-minimizing analgesia. As prescription opioid misuse is the second most commonly used illicit drug in the United States, alternative pain control pathways in the postoperative setting are strongly favored. The aim of this study is to determine if implementing an ERAS protocol for lower extremity bypass surgeries improves pain control and morbidity after surgery.