London Borough of Hackney

Introduction: Genetic mutations are a well-known cause of dilated cardiomyopathy (DCM), occurring in approximately 30% of the cases. Mutations in the ryanodine receptor 2 (RYR2) gene are shown to be associated with catecholaminergic polymorphic ventricular tachycardia (CPVT) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Here, we present a rare case of a novel early nonsense mutation in the RYR2 gene associated with arrhythmogenic DCM. Case Description: A 44-year-old male patient who presented with exertional dyspnea and volume overload was found to be in new-onset decompensated heart failure secondary to non-ischemic cardiomyopathy. His telemetry monitoring showed continuous runs of non-sustained ventricular tachycardia. His ejection fraction (EF) was <10%, with global hypokinesis, biventricular dilation, and severely reduced right ventricular function. He rapidly decompensated into cardiogenic shock and was placed on inotropic support and an Impella 5.5. Cardiac magnetic resonance imaging revealed severe biventricular dilation and global hypokinesis without any left ventricular delayed enhancement, suggesting DCM with no evidence of ARVC. His genetic testing revealed a novel disease-causing mutation in the RYR2 gene, which caused a premature stop codon. The patient was diagnosed to have arrhythmogenic genetic dilated cardiomyopathy. Given the severity of his heart failure, the patient is currently being evaluated for an orthotopic heart transplant. Discussion: RYR2 is the major sarcoplasmic reticulum calcium release channel responsible for the excitation-contraction coupling of cardiac myocytes. RYR2 mutations are a known cause of CPVT and ARVC, but the literature on the occurrence of DCM in the setting of RYR2 gene mutation is scant. Studies have shown that Lamin A/C (LMNA) and the sodium channel alpha-subunit 5a (SCN5a) are the most commonly associated genes with arrhythmogenic DCM. This case highlights a unique unreported nonsense mutation in the RYR2 gene presenting as arrhythmogenic DCM. Given the occurrence of these rare mutations, further research efforts are needed to determine the significance of these novel mutations and their effect on future clinical outcomes and management of DCM. Once genetic cardiomyopathy is diagnosed, generational family screening should be considered. Patients should also be educated on their disease and the risks of familial transmission and provided with extensive genetic counseling.

The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.

AimsChildren and young people may have health needs which are unmet or have long term health conditions or disabilities which require ongoing monitoring. The role of the School Age Clinic at Hackney Ark is to address and review the health needs of children in school age where their health needs might impact on their progress in educational settings.We sought to review the caseload and report the underlying diagnosis and co-morbidities of the children seen in School Age Clinic at Hackney Ark, highlighting the importance of an evidence-based approach in planning and monitoring of services.MethodsThe School Age Clinic at Hackney Ark is run by the Community Paediatricians and their services are primarily for children above 5 years old who live in the City and Hackney areas of London and are registered with a local GP.We evaluated the caseload open to the School Age Clinic until 2022. All the medical records of the children seen in the clinic were reviewed to ascertain their demographic details, diagnosis, co-morbidities, motor, sensory, communication disabilities, learning difficulties and educational needs.ResultsOf the 282 children that met the assessment criteria, 56% (n=169) were male and the mean age of the children seen in clinic was 10 years old. 28% of the of the children had an underlying known chromosomal or genetic condition. The conditions most commonly seen in the School Age Clinic were Autism Spectrum Disorder (15%), Social communication concerns (15%), Speech and Language difficulties (14%) and Trisomy 21 (11%).The majority of children seen in the clinic had an Education, Health and Care Plan (EHCP) in place (n=171, 61%), while 32% had documented learning difficulties at school, without an EHCP. The majority of the children with an EHCP had a formal diagnosis (78%) and their mean age was 10.7 years old. The mean age of the children with documented learning difficulties and without an EHCP was 8.7 years old and 64% did not have a formal diagnosis.Behavioural, sleep difficulties and overweight were co-morbidities commonly present in the children seen in the clinic (58%, 32% and 20%, respectively).ConclusionThis is the first evaluation of diagnosis and co-morbidities of children seen in School Age Clinic at Hackney Ark. This work supports the need for a comprehensive epidemiological database to inform the aetiology as well as consider effective preventative and intervention strategies for the children being seen in School Age Clinic.

ContextThis work was carried out alongside the Association of Directors of Public Health (ADPHL) Steering Group on Supporting Black, Asian and minority ethnic communities during and beyond Covid – working with public health leaders in London, particularly local authority directors of public health and their teams.Issue/ChallengeDuring the first wave of the Covid pandemic, in 2020, there was renewed public and professional interest in ethnic inequalities in health, following the release of the Public Health England (PHE) reports, which highlighted the disproportionate impacts of COVID-19, particularly amongst Black, Asian and minority ethnic communities.At the same time, there was an increased social awareness of the impacts of racism and the Black Lives Matter movement, following the murder of George Floyd.There was a moment in time to speak out on the situation and that emboldened us to be heard in a way we haven’t been heard before. Reflecting on our experience as black female public health leaders in the London public health landscape, the challenge was how we capture this and respond to this matter in a way that brings real change and maintains momentum.A particular piece of work was supporting the development of the ADPHL policy statement ‘Racism is a public health issue’ and its related action plans.Traditionally, the medical/healthcare professions have been challenged in understanding and taking into account the impact of racism in health. There is an identified need for a different kind of health leadership during these uncertain times.-Although there is increased interest and discussion of racism and its impacts currently, we anticipate challenges with maintaining momentum, particularly at senior level, to embed lasting changeThere is limited research on the experiences of black leaders working in this context and how they are heard, involved or valuedAssessment of issue and analysis of its causesWe looked at examples of leadership on this subject matter at local, regional and national level, including an understanding, lived experiences and perception of discrimination, support at work and in health outcomes, health literacy and access, behaviour and attitudes, black and ethnic minority workforce experiences and morale.ImpactOur work has been recognised across London local authorities, wider health and care partners and national public health forums.We were awarded the Faculty of Public Health Sam Ramaiah Award.Our work has influenced partner organisations to develop actions plans or strategies around tackling structural racism (e.g. Greater London Authority).Our work has motivated fellow Directors and Consultants to have conversations on this uncomfortable subject matter, in a way they’ve never done before and consider how we maintain this momentum.It has also led to creating a safe space through a network of ‘Black’ leaders, where we can reflect on our professional development in uncertain times.InterventionAs above, we wanted our voices to be heard in response to the challenges that were faced. During the process of developing the position statement and action plan, we considered our own positions as effective leaders in this space, how we continue to maintain momentum of this agenda, and influence other system leaders in tackling racism in public health.We invited speakers from other organisations to our working group to challenge us on these concepts as system leaders, and considered how we could bring the service users’ voice to hold us to account, as well as provide their perspectives.We also organised and facilitated workshops with London local authority public health Directors and Consultants on this subject matter.Involvement of stakeholders, such as patients, carers or family members:There was no direct patient involvement, however we shared our lived experiences.Key MessagesReflecting on our experience as senior black healthcare leaders leading effective multicultural teams and addressing health inequalities we found that:There is change and changing language around racism and healthCultural competency and cultural humility in leadership plays a crucial role and there are different views so we need to look at the different perspectives and actually understand what it meansAlthough leading whilst holding discomfort is universal there appears to be disproportionate burdenThe impact on perception, behaviour and morale from a workforce and patient/community perspectiveSupport and peer engagement does not always happenThe narrative can be deemed to be repetitive and nuances get missedLessons learntThere is interest in leading this wayHolding the ambiguity and discomfort is universal to leadership in this context and so as leaders of this agenda we need to ensure we do not respond to the pressure to react with immediacyWe learnt that we still need allies and we need timeMeasurement of improvementThis is ongoing and will be measured using qualitative approaches such as through the various dialogues across the public system, training and organisational development.Strategy for improvementWe will look at this as part of the workforce development, share at conferences and through the work with ADPH.

ObjectivesA WHO Tailoring Immunization Programmes (TIP) evaluation was conducted in 2014-16 to investigate suboptimal childhood vaccination coverage in the north London Orthodox Jewish community. In 2021-22 a qualitative evaluation of the COVID-19 vaccine programme (CVP) was conducted in the same setting. This paper examines whether the issues identified by the TIP affected the CVP and what differences emerged between these two vaccine programme evaluations. Study designQualitative study. MethodsThe CVP evaluation involved conducting 28 semi-structured interviews with public health professionals, Orthodox Jewish welfare and religious representatives, and household members in February-May 2021. The key considerations arising from the thematic analysis of this data was then compared systematically with the overarching findings from the TIP study. ResultsThe issues identified in the TIP study diverged and converged with results from the CVP evaluation: i) participants did not express concerns of unmet CVP information needs; ii) the social value of COVID-19 vaccines was influenced by international travel requirements; iii) in contrast to commissioning constraints noted to have limited flexible delivery of childhood immunisations in the TIP evaluation, the CVP was characterised by a flexible commissioning and delivery model. This model was facilitated by significant government investment as part of the COVID-19 pandemic response. ConclusionsThe comparative analysis indicates that flexible vaccine commissioning and fit for purpose public health investment can influence how documented knowledge is translated into action. Implications are raised for how routine vaccination services are equipped to serve the needs of minority populations with historically suboptimal coverage levels.

This paper sets out to explore the use of a systemic reflexive exercise called “Collective Cut‐Outs”, detailing its methodology and usefulness with “frontline” mental health practitioners within supervision and teaching contexts. We draw on the use of storytelling, image, creativity and the usefulness of the left hand (right brain) in clinical mental health contexts and focus on its value in reflexive supervisory groups. We also aim to give voice to the experiences of “frontline” Black Asian Minority Ethnic (BAME) clinicians in an inner‐city mental health team during the COVID‐19 pandemic. The Collective Cut‐Out exercise and its methodology provide a framework to help facilitate reflexive spaces that promote mindful group exercise and the subsequent expression of personal and professional resonance. The subjects of clinical challenge and collective resilience are also brought forth. We offer a case study in the second part of the paper, outlining the use of the exercise in a reflexive group supervisory context. The team in focus have kindly given us, the authors, permission to use their experiences and “cut‐outs”. We have either adapted or removed identifiable information from the writing to protect and respect the identity of the team and individuals involved.

The concept of mattering can be helpful for understanding the ways in which structural and historical factors affect individual psychologies. This paper lays out the usefulness of mattering as a lens through which to examine why a small minority of young people in Britain commit violent acts. We first explore what it means to matter and the evidence linking the quest to matter with violence, and then examine the factors in contemporary Britain which can diminish a young person’s sense of mattering, using recent community research. We then critique the British government’s attempt to address the problem of violence through Gang Injunctions and Knife Crime Prevention Orders. We conclude by suggesting that policy-makers could gain substantial insight from investigating the connections between marginalisation, mattering and violence, rather than focusing disproportionately on the music young people choose to listen to or create, or the specific weapon that they opt to carry.

ABSTRACT Young offenders disproportionately present with Developmental Language Disorder and are likely to struggle with the communication demands of the justice system. Professional guidance outlines strategies for facilitating successful communication, but it is unknown to what extent recommendations are substantiated by evidence. This review mapped academic and grey literature regarding the communication requirements, barriers and recommendations for routine youth justice interactions, such as forensic interview and courtroom testimony. Academic papers were identified through searches of five online databases, and OpenGrey, Google Scholar and organizational websites were searched to identify grey literature. 75 of 505 retrieved papers met inclusion criteria. Extracted data were presented regarding a) requirements and barriers a young person would encounter in the youth justice system, b) communication recommendations made for each stage of this journey, and c) type of evidence underlying the outlined findings. Communication barriers included exposure to unfamiliar vocabulary, repairing misunderstandings, constructing narratives and displaying the appropriate attitude. Recommendations were wide-ranging and broadly consistent, though very few had been evaluated for effectiveness. Some papers queried the practicality and effectiveness of recommendations such as rephrasing difficult terminology. A relatively small number of papers considered the views of young offenders or observed real youth justice interactions. Future research should include observational studies of real youth justice interactions to evaluate the effectiveness of widely recommended strategies. Policymakers may wish to consider concerns raised that rephrasing the language used in the youth justice system is not practical or sufficiently effective, and that broader changes to the communication environment are required.

Accessible summaryWhat is known on the subject? With the ongoing and possible evolving use of face coverings as a public health protection measure against the transmission of COVID‐19, this is likely to be an ongoing challenge for those who find their use challenging.The wearing of face coverings following trauma is likely to be of ongoing relevance, making this an area that would benefit from further research. What this paper adds to existing knowledge? The authors present their personal and professional experiences as a means of highlighting the difficulties that can be faced as a result of the use of face coverings.The window of tolerance helps to understand the difficulties that can be caused by wearing face coverings and provides a visual means of conceptualizing the cognitive, behavioural, physiological and emotional reactions that can occur as a result of their use. What are the implications for practice? This paper provides an awareness of the link between trauma and the wearing of face coverings, and how their use could be re‐traumatizing for those accessing services.This topic is relevant across all sectors where it is only just beginning to be acknowledged that for many, particularly those with experiences of interpersonal trauma, difficulties can arise due to the use of face coverings.The sharing of grounding techniques and an introduction to the window of tolerance provides a means of collaboratively developing skills and developing a shared understanding of the difficulties associated with the use of face coverings.