Childhood attention-deficit hyperactivity disorder: socioeconomic inequalities in symptoms, impact, diagnosis and medication

BACKGROUND

Children from disadvantaged backgrounds are at greater risk of attention-deficit hyperactivity disorder (ADHD)-related symptoms, being diagnosed with ADHD, and being prescribed ADHD medications. We aimed to examine how inequalities manifest across the 'patient journey', from perceptions of impacts of ADHD symptoms on daily life, to the propensity to seek and receive a diagnosis and treatment.

METHODS

We investigated four 'stages': (1) symptoms, (2) caregiver perception of impact, (3) diagnosis and (4) medication, in two data sets: UK Millennium Cohort Study (MCS, analytic n ~ 9,000), with relevant (parent-reported) information on all four stages (until 14 years); and a population-wide 'administrative cohort', which includes symptoms (child health checks) and prescriptions (dispensing records), born in Scotland, 2010-2012 (analytic n ~ 100,000), until ~6 years. We described inequalities according to maternal occupational status, with percentages and relative indices of inequality (RII).

RESULTS

The prevalence of ADHD symptoms and medication receipt was considerably higher in the least compared to the most advantaged children in the administrative cohort (RIIs of 5.9 [5.5-6.4] and 8.1 [4.2-15.6]) and the MCS (3.08 [2.68-3.55], 3.75 [2.21-6.36]). MCS analyses highlighted complexities between these two stages, however, those from least advantaged backgrounds, with ADHD symptoms, were the least likely to perceive impacts on daily life (15.7% vs. average 19.5%) and to progress from diagnosis to medication (44.1% vs. average 72.5%).

CONCLUSIONS

Despite large inequalities in ADHD symptoms and medication, parents from the least advantaged backgrounds were less likely to report impacts of ADHD symptoms on daily life, and their children were less likely to have received medication postdiagnosis, highlighting how patient journeys differed according to socioeconomic circumstances.

The Relationship Between Time Spent on Social Media and Adolescent Cigarette, E-cigarette, and Dual Use: A Longitudinal Analysis of the UK Millennium Cohort Study

INTRODUCTION

To estimate the effect of social media use in 14 year olds on risk of and inequalities in cigarette, e-cigarette, and dual use at 17 years, using the UK-representative Millennium Cohort Study (born 2000-2002).

AIMS AND METHODS

The relationship of time spent on social media (using questionnaires [n = 8987] and time-use-diaries [n = 2520]) with cigarette, e-cigarette, and dual use was estimated using adjusted odds ratios (AORs) or relative risk ratios (ARRRs). Effect modification was examined (using parental education as an indicator for socioeconomic circumstances) by comparing adjusted risk differences within low and high-parental education groups. Analyses accounted for prespecified confounders (identified via directed acyclic graphs), baseline outcome measures (to address reverse causality), sample design, attrition, and item-missingness (through multiple imputation).

RESULTS

Time spent on social media was associated with increased risk of cigarette, e-cigarette, and dual use in a dose-response manner. Social media use for ≥2 hours/day (vs. 1-<30 minutes) was associated with increased cigarette (AOR 2.76 [95% confidence interval 2.19 to 3.48]), e-cigarette (3.24 [2.59 to 4.05]), and dual use (ARRR 4.11 [2.77 to 6.08]). The risk of cigarette use among 30 minutes-<1 hour/day users (vs. non-users) were smaller in those with high versus low parental education (ARDs 1.4% vs. 12.4%). Similar findings were observed across the higher time categories. Analyses using time-use-diaries, in complete case samples, and with additional adjustment for baseline outcome measures generally revealed similar findings.

CONCLUSIONS

After accounting for observed confounders and potential reverse causality, findings suggest social media use increases the risk of cigarette, e-cigarette, and dual use in a dose-response manner. Guidance addressing adolescent online safety should be prioritized.

IMPLICATIONS

This study's identification of a dose-response relationship and differential effects across socioeconomic groups, could assist in the development of guidance on time spent on social media. The adverse effects of social media use on adolescent cigarette, e-cigarette, and dual use supports legislation aimed at promoting adolescent online safety. Study findings strengthen calls to prohibit social media marketing of nicotine-related products and importantly highlight the need to increase awareness and understanding of the underlying algorithms which drive adolescent exposure to nicotine-related content on social media to ensure they are functioning in a way that best serves the adolescent population.

Short-term impacts of Universal Basic Income on population mental health inequalities in the UK: A microsimulation modelling study

BACKGROUND

Population mental health in the United Kingdom (UK) has deteriorated, alongside worsening socioeconomic conditions, over the last decade. Policies such as Universal Basic Income (UBI) have been suggested as an alternative economic approach to improve population mental health and reduce health inequalities. UBI may improve mental health (MH), but to our knowledge, no studies have trialled or modelled UBI in whole populations. We aimed to estimate the short-term effects of introducing UBI on mental health in the UK working-age population.

METHODS AND FINDINGS

Adults aged 25 to 64 years were simulated across a 4-year period from 2022 to 2026 with the SimPaths microsimulation model, which models the effects of UK tax/benefit policies on mental health via income, poverty, and employment transitions. Data from the nationally representative UK Household Longitudinal Study were used to generate the simulated population (n = 25,000) and causal effect estimates. Three counterfactual UBI scenarios were modelled from 2023: "Partial" (value equivalent to existing benefits), "Full" (equivalent to the UK Minimum Income Standard), and "Full+" (retaining means-tested benefits for disability, housing, and childcare). Likely common mental disorder (CMD) was measured using the General Health Questionnaire (GHQ-12, score ≥4). Relative and slope indices of inequality were calculated, and outcomes stratified by gender, age, education, and household structure. Simulations were run 1,000 times to generate 95% uncertainty intervals (UIs). Sensitivity analyses relaxed SimPaths assumptions about reduced employment resulting from Full/Full+ UBI. Partial UBI had little impact on poverty, employment, or mental health. Full UBI scenarios practically eradicated poverty but decreased employment (for Full+ from 78.9% [95% UI 77.9, 79.9] to 74.1% [95% UI 72.6, 75.4]). Full+ UBI increased absolute CMD prevalence by 0.38% (percentage points; 95% UI 0.13, 0.69) in 2023, equivalent to 157,951 additional CMD cases (95% UI 54,036, 286,805); effects were largest for men (0.63% [95% UI 0.31, 1.01]) and those with children (0.64% [95% UI 0.18, 1.14]). In our sensitivity analysis assuming minimal UBI-related employment impacts, CMD prevalence instead fell by 0.27% (95% UI -0.49, -0.05), a reduction of 112,228 cases (95% UI 20,783, 203,673); effects were largest for women (-0.32% [95% UI -0.65, 0.00]), those without children (-0.40% [95% UI -0.68, -0.15]), and those with least education (-0.42% [95% UI -0.97, 0.15]). There was no effect on educational mental health inequalities in any scenario, and effects waned by 2026. The main limitations of our methods are the model's short time horizon and focus on pathways from UBI to mental health solely via income, poverty, and employment, as well as the inability to integrate macroeconomic consequences of UBI; future iterations of the model will address these limitations.

CONCLUSIONS

UBI has potential to improve short-term population mental health by reducing poverty, particularly for women, but impacts are highly dependent on whether individuals choose to remain in employment following its introduction. Future research modelling additional causal pathways between UBI and mental health would be beneficial.

Quality of ethnicity data within Scottish health records and implications of misclassification for ethnic inequalities in severe COVID-19: a national linked data study

BACKGROUND

We compared the quality of ethnicity coding within the Public Health Scotland Ethnicity Look-up (PHS-EL) dataset, and other National Health Service datasets, with the 2011 Scottish Census.

METHODS

Measures of quality included the level of missingness and misclassification. We examined the impact of misclassification using Cox proportional hazards to compare the risk of severe coronavirus disease (COVID-19) (hospitalization & death) by ethnic group.

RESULTS

Misclassification within PHS-EL was higher for all minority ethnic groups [12.5 to 69.1%] compared with the White Scottish majority [5.1%] and highest in the White Gypsy/Traveller group [69.1%]. Missingness in PHS-EL was highest among the White Other British group [39%] and lowest among the Pakistani group [17%]. PHS-EL data often underestimated severe COVID-19 risk compared with Census data. e.g. in the White Gypsy/Traveller group the Hazard Ratio (HR) was 1.68 [95% Confidence Intervals (CI): 1.03, 2.74] compared with the White Scottish majority using Census ethnicity data and 0.73 [95% CI: 0.10, 5.15] using PHS-EL data; and HR was 2.03 [95% CI: 1.20, 3.44] in the Census for the Bangladeshi group versus 1.45 [95% CI: 0.75, 2.78] in PHS-EL.

CONCLUSIONS

Poor quality ethnicity coding in health records can bias estimates, thereby threatening monitoring and understanding ethnic inequalities in health.

Trends in inequalities in childhood overweight and obesity prevalence: a repeat cross-sectional analysis of the Health Survey for England

OBJECTIVE

To examine trends in socio-economic and ethnic inequalities in childhood overweight and obesity in the England between 1995 and 2019 in survey data and to compare these to administrative data.

DESIGN

Observational repeated cross-sectional study using the Health Survey for England (HSE) and National Child Measurement Programme (NCMP).

OUTCOME

Age and sex standardised overweight, obesity and overweight including obesity.

ANALYSIS

Inequalities assessed by parental education, family structure, ethnicity (binary non-white vs white) and area-level Index of Multiple Deprivation. Estimates stratified by age and sex. Trends compared against NCMP data (age 4-5 and 10-11 years).

RESULTS

Prevalence of childhood overweight including obesity increased from 26.0% in 1995 to 31.7% in 2019, with the highest and fastest growing levels in those aged 11-15 years, rising from 29.7% to 38.0%. Despite a plateau in overall childhood obesity since 2004, differences between groups demonstrated widening inequalities over time. Inequalities widened by area-level deprivation, household educational attainment, household structure and ethnicity driven primarily by increased prevalence among socioeconomically disadvantaged children. For example, the gap between children from households with no qualifications versus degree-level qualifications increased from -1.1% to 13.2%, and the gap between single-parent households and couple households increased from 0.5% to 5.3%. HSE trends in prevalence of childhood overweight and obesity by deprivation quintile were consistent with those in NCMP.

CONCLUSION

Overall levels of child overweight and obesity increased between 1995 and 2004. Since then, increases in prevalence among less advantaged groups have driven widening of inequalities.

The relationship between time spent on social media and adolescent alcohol use: a longitudinal analysis of the UK Millennium Cohort Study

BACKGROUND

To estimate the effect of social media use in 14 year olds on risk of and inequalities in alcohol use and binge drinking at 17 years.

METHODS

Using the UK-representative Millennium Cohort Study, the relationship between time spent on social media (assessed using questionnaires [n = 8987] and time-use-diaries [n = 2520]) with frequency of alcohol use in the past month and binge drinking was estimated using adjusted odds ratios (AORs) or adjusted relative risk ratios (ARRRs). Associations within low and high parental education groups were compared to examine effect modification. Analyses accounted for pre-specified confounders, baseline outcome measures (to address reverse causality), sample design, attrition and item-missingness (through multiple imputation).

RESULTS

Questionnaire-reported time spent on social media was associated with increased risk of alcohol use and binge drinking in a dose-response manner. Compared to 1-< 30 min/day social media users, 30 min-<1 h/day users were more likely to report alcohol use ≥6 times/month (ARRR 1.62 [95% confidence interval 1.20 to 2.20]) and binge drinking (AOR 1.51 [1.22 to 1.87]), as were 1-<2 h/day users (ARRR 2.61 [1.90 to 3.58]; AOR 2.06 [1.69 to 2.52]) and ≥2 h/day users (ARRR 4.80 [3.65 to 6.32]; AOR 3.07 [2.54 to 3.70]). Social media measured by time-use-diary was associated with higher risks, although not always demonstrating a dose-response relationship. The effect of social media use (vs no-use) on binge drinking was larger in the higher (vs lower) parental education groups. Analyses repeated in complete case samples, and with adjustment for baseline outcome measures revealed consistent findings.

CONCLUSIONS

Findings suggest social media use may increase risk of alcohol use and binge drinking. Regulatory action protecting adolescents from harmful alcohol-related social media content is necessary.

Inequalities in children's mental health before and during the COVID-19 pandemic: findings from the UK Household Longitudinal Study

BACKGROUND

There are concerns that child mental health inequalities may have widened during the COVID-19 pandemic. We investigated whether child mental health inequalities changed in 2020/2021 compared with prepandemic.

METHODS

We analysed 16 361 observations from 9272 children in the population representative UK Household Longitudinal Study. Child mental health was measured using the Strengths and Difficulties Questionnaire (SDQ) at ages 5 and 8 years in annual surveys 2011-2019, and at ages 5-11 years in July 2020, September 2020 and March 2021. Inequalities in cross-sectional SDQ scores among 5 and 8 year olds, before and during the pandemic, were modelled using linear regression. Additionally, interactions between time (before/during pandemic) and: sex, ethnicity, family structure, parental education, employment, household income and area deprivation on mental health were explored.

RESULTS

A trend towards poorer mental health between 2011 and 2019 continued during the pandemic (b=0.12, 95% CI 0.08 to 0.17). Children with coupled, highly educated, employed parents and higher household income experienced greater mental health declines during the pandemic than less advantaged groups, leading to narrowed inequalities. For example, the mean difference in child SDQ scores for unemployed compared with employed parents was 2.35 prepandemic (1.72 to 2.98) and 0.02 during the pandemic (-1.10 to 1.13). Worse scores related to male sex and area deprivation were maintained. White children experienced worse mental health than other ethnicities, and greater declines during the pandemic.

CONCLUSION

Mental health among UK 5 and 8 year olds deteriorated during the pandemic, although several inequalities narrowed. Interventions are needed to improve child mental health while ensuring inequalities do not widen.

Social media use and health risk behaviours in young people: systematic review and meta-analysis

OBJECTIVES

To examine the association between social media use and health risk behaviours in adolescents (defined as those 10-19 years).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

EMBASE, Medline, APA PsycINFO, SocINDEX, CINAHL, SSRN, SocArXic, PsyArXiv, medRxiv, and Google Scholar (1 January 1997 to 6 June 2022).

METHODS

Health risk behaviours were defined as use of alcohol, drugs, tobacco, electronic nicotine delivery systems, unhealthy dietary behaviour, inadequate physical activity, gambling, and anti-social, sexual risk, and multiple risk behaviours. Included studies reported a social media variable (ie, time spent, frequency of use, exposure to health risk behaviour content, or other social media activities) and one or more relevant outcomes. Screening and risk of bias assessments were completed independently by two reviewers. Synthesis without meta-analysis based on effect direction and random-effects meta-analyses was used. Effect modification was explored using meta-regression and stratification. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

RESULTS

Of 17 077 studies screened, 126 were included (73 included in meta-analyses). The final sample included 1 431 534 adolescents (mean age 15.0 years). Synthesis without meta-analysis indicated harmful associations between social media and all health risk behaviours in most included studies, except inadequate physical activity where beneficial associations were reported in 63.6% of studies. Frequent (v infrequent) social media use was associated with increased alcohol consumption (odds ratio 1.48 (95% confidence interval 1.35 to 1.62); n=383 068), drug use (1.28 (1.05 to 1.56); n=117 646), tobacco use (1.85, 1.49 to 2.30; n=424 326), sexual risk behaviours (1.77 (1.48 to 2.12); n=47 280), anti-social behaviour (1.73 (1.44 to 2.06); n=54 993), multiple risk behaviours (1.75 (1.30 to 2.35); n=43 571), and gambling (2.84 (2.04 to 3.97); n=26 537). Exposure to content showcasing health risk behaviours on social media (v no exposure) was associated with increased odds of use of electronic nicotine delivery systems (1.73 (1.34 to 2.23); n=721 322), unhealthy dietary behaviours (2.48 (2.08 to 2.97); n=9892), and alcohol consumption (2.43 (1.25 to 4.71); n=14 731). For alcohol consumption, stronger associations were identified for exposure to user generated content (3.21 (2.37 to 4.33)) versus marketer generated content (2.12 (1.06 to 4.24)). For time spent on social media, use for at least 2 h per day (v <2 h) increased odds of alcohol consumption (2.12 (1.53 to 2.95); n=12 390). GRADE certainty was moderate for unhealthy dietary behaviour, low for alcohol use, and very low for other investigated outcomes.

CONCLUSIONS

Social media use is associated with adverse health risk behaviours in young people, but further high quality research is needed to establish causality, understand effects on health inequalities, and determine which aspects of social media are most harmful.

STUDY REGISTRATION

PROSPERO, CRD42020179766.

Using administrative data to evaluate national policy impacts on child and maternal health: a research framework from the Maternal and Child Health Network (MatCHNet)

Reducing health inequalities by addressing the social circumstances in which children are conceived and raised is a societal priority. Early interventions are key to improving outcomes in childhood and long-term into adulthood. Across the UK nations, there is strong political commitment to invest in the early years. National policy interventions aim to tackle health inequalities and deliver health equity for all children. Evidence to determine the effectiveness of socio-structural policies on child health outcomes is especially pressing given the current social and economic challenges facing policy-makers and families with children. As an alternative to clinical trials or evaluating local interventions, we propose a research framework that supports evaluating the impact of whole country policies on child health outcomes. Three key research challenges must be addressed to enable such evaluations and improve policy for child health: (1) policy prioritisation, (2) identification of comparable data and (3) application of robust methods.

To what extent does income explain the effect of unemployment on mental health? Mediation analysis in the UK Household Longitudinal Study

BACKGROUND

Employment and income are important determinants of mental health (MH), but the extent that unemployment effects are mediated by reduced income is unclear. We estimated the total effect (TE) of unemployment on MH and the controlled direct effect (CDE) not acting via income.

METHODS

We included adults 25-64 years from nine waves of the UK Household Longitudinal Study (n = 45 497/obs = 202 297). Unemployment was defined as not being in paid employment; common mental disorder (CMD) was defined as General Health Questionnaire-12 score ≥4. We conducted causal mediation analysis using double-robust marginal structural modelling, estimating odds ratios (OR) and absolute differences for effects of unemployment on CMD in the same year, before (TE) and after (CDE) blocking the income pathway. We calculated percentage mediation by income, with bootstrapped standard errors.

RESULTS

The TE of unemployment on CMD risk was OR 1.66 (95% CI 1.57-1.76), with 7.09% (6.21-7.97) absolute difference in prevalence; equivalent CDEs were OR 1.55 (1.46-1.66) and 6.08% (5.13-7.03). Income mediated 14.22% (8.04-20.40) of the TE. Percentage mediation was higher for job losses [15.10% (6.81-23.39)] than gains [8.77% (0.36-17.19)]; it was lowest for those 25-40 years [7.99% (-2.57 to 18.51)] and in poverty [2.63% (-2.22 to 7.49)].

CONCLUSIONS

A high proportion of the short-term effect of unemployment on MH is not explained by income, particularly for younger people and those in poverty. Population attributable fractions suggested 16.49% of CMD burden was due to unemployment, with 13.90% directly attributable to job loss rather than resultant income changes. Similar analytical approaches could explore how this differs across contexts, by other factors, and consider longer-term effects.

Ethnic inequalities in positive SARS-CoV-2 tests, infection prognosis, COVID-19 hospitalisations and deaths: analysis of 2 years of a record linked national cohort study in Scotland

BACKGROUND

This study aims to estimate ethnic inequalities in risk for positive SARS-CoV-2 tests, COVID-19 hospitalisations and deaths over time in Scotland.

METHODS

We conducted a population-based cohort study where the 2011 Scottish Census was linked to health records. We included all individuals ≥ 16 years living in Scotland on 1 March 2020. The study period was from 1 March 2020 to 17 April 2022. Self-reported ethnic group was taken from the census and Cox proportional hazard models estimated HRs for positive SARS-CoV-2 tests, hospitalisations and deaths, adjusted for age, sex and health board. We also conducted separate analyses for each of the four waves of COVID-19 to assess changes in risk over time.

FINDINGS

Of the 4 358 339 individuals analysed, 1 093 234 positive SARS-CoV-2 tests, 37 437 hospitalisations and 14 158 deaths occurred. The risk of COVID-19 hospitalisation or death among ethnic minority groups was often higher for White Gypsy/Traveller (HR 2.21, 95% CI (1.61 to 3.06)) and Pakistani 2.09 (1.90 to 2.29) groups compared with the white Scottish group. The risk of COVID-19 hospitalisation or death following confirmed positive SARS-CoV-2 test was particularly higher for White Gypsy/Traveller 2.55 (1.81-3.58), Pakistani 1.75 (1.59-1.73) and African 1.61 (1.28-2.03) individuals relative to white Scottish individuals. However, the risk of COVID-19-related death following hospitalisation did not differ. The risk of COVID-19 outcomes for ethnic minority groups was higher in the first three waves compared with the fourth wave.

INTERPRETATION

Most ethnic minority groups were at increased risk of adverse COVID-19 outcomes in Scotland, especially White Gypsy/Traveller and Pakistani groups. Ethnic inequalities persisted following community infection but not following hospitalisation, suggesting differences in hospital treatment did not substantially contribute to ethnic inequalities.

Measurement of the Prompt D^{0} Nuclear Modification Factor in p-Pb Collisions at sqrt[s_{NN}]=8.16 TeV

The production of prompt D^{0} mesons in proton-lead collisions in both the forward and backward rapidity regions at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=8.16  TeV is measured by the LHCb experiment. The nuclear modification factor of prompt D^{0} mesons is determined as a function of the transverse momentum p_{T}, and the rapidity in the nucleon-nucleon center-of-mass frame y^{*}. In the forward rapidity region, significantly suppressed production with respect to pp collisions is measured, which provides significant constraints on models of nuclear parton distributions and hadron production down to the very low Bjorken-x region of ∼10^{-5}. In the backward rapidity region, a suppression with a significance of 2.0-3.8 standard deviations compared to parton distribution functions in a nuclear environment expectations is found in the kinematic region of p_{T}>6  GeV/c and -3.25 Collapse

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Maternal and child nutrition programme of investigation within the 100 Million Brazilian Cohort: study protocol

INTRODUCTION

There is a limited understanding of the early nutrition and pregnancy determinants of short-term and long-term maternal and child health in ethnically diverse and socioeconomically vulnerable populations within low-income and middle-income countries. This investigation programme aims to: (1) describe maternal weight trajectories throughout the life course; (2) describe child weight, height and body mass index (BMI) trajectories; (3) create and validate models to predict childhood obesity at 5 years of age; (4) estimate the effects of prepregnancy BMI, gestational weight gain (GWG) and maternal weight trajectories on adverse maternal and neonatal outcomes and child growth trajectories; (5) estimate the effects of prepregnancy BMI, GWG, maternal weight and interpregnancy BMI changes on maternal and child outcomes in the subsequent pregnancy; and (6) estimate the effects of maternal food consumption and infant feeding practices on child nutritional status and growth trajectories.

METHODS AND ANALYSIS

Linked data from four different Brazilian databases will be used: the 100 Million Brazilian Cohort, the Live Births Information System, the Mortality Information System and the Food and Nutrition Surveillance System. To analyse trajectories, latent-growth, superimposition by translation and rotation and broken stick models will be used. To create prediction models for childhood obesity, machine learning techniques will be applied. For the association between the selected exposure and outcomes variables, generalised linear models will be considered. Directed acyclic graphs will be constructed to identify potential confounders for each analysis investigating potential causal relationships.

ETHICS AND DISSEMINATION

This protocol was approved by the Research Ethics Committees of the authors' institutions. The linkage will be carried out in a secure environment. After the linkage, the data will be de-identified, and pre-authorised researchers will access the data set via a virtual private network connection. Results will be reported in open-access journals and disseminated to policymakers and the broader public.

Measurement of the Time-Integrated CP Asymmetry in D^{0}→K^{-}K^{+} Decays

The time-integrated CP asymmetry in the Cabibbo-suppressed decay D^{0}→K^{-}K^{+} is measured using proton-proton collision data, corresponding to an integrated luminosity of 5.7  fb^{-1} collected at a center-of-mass energy of 13 TeV with the LHCb detector. The D^{0} mesons are required to originate from promptly produced D^{*+}→D^{0}π^{+} decays, and the charge of the companion pion is used to determine the flavor of the charm meson at production. The time-integrated CP asymmetry is measured to be A_{CP}(K^{-}K^{+})=[6.8±5.4±1.6]×10^{-4} where the first uncertainty is statistical and the second systematic. The direct CP asymmetries in D^{0}→K^{-}K^{+} and D^{0}→π^{-}π^{+} decays, a_{K^{-}K^{+}}^{d} and a_{π^{-}π^{+}}^{d}, are derived by combining A_{CP}(K^{-}K^{+}) with the time-integrated CP asymmetry difference, ΔA_{CP}=A_{CP}(K^{-}K^{+})-A_{CP}(π^{-}π^{+}), and other inputs, giving a_{K^{-}K^{+}}^{d}=(7.7±5.7)×10^{-4},a_{π^{-}π^{+}}^{d}=(23.2±6.1)×10^{-4},with a correlation coefficient corresponding to ρ=0.88. The compatibility of these results with CP symmetry is 1.4 and 3.8 standard deviations for D^{0}→K^{-}K^{+} and D^{0}→π^{-}π^{+} decays, respectively. This is the first evidence for direct CP violation in a specific D^{0} decay.

Measurement of the Branching Fractions B(B^{0}→pp[over ¯]pp[over ¯]) and B(B_{s}^{0}→pp[over ¯]pp[over ¯])

Searches for the rare hadronic decays B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] are performed using proton-proton collision data recorded by the LHCb experiment and corresponding to an integrated luminosity of 9  fb^{-1}. Significances of 9.3σ and 4.0σ, including statistical and systematic uncertainties, are obtained for the B^{0}→pp[over ¯]pp[over ¯] and B_{s}^{0}→pp[over ¯]pp[over ¯] signals, respectively. The branching fractions are measured relative to the topologically similar normalization decays B^{0}→J/ψ(→pp[over ¯])K^{*0}(→K^{+}π^{-}) and B_{s}^{0}→J/ψ(→pp[over ¯])⁢ϕ(→K^{+}K^{-}). The branching fractions are measured to be B(B^{0}→pp[over ¯]pp[over ¯])=(2.2±0.4±0.1±0.1)×10^{-8} and B(B_{s}^{0}→pp[over ¯]pp[over ¯])=(2.3±1.0±0.2±0.1)×10^{-8}. In these measurements, the first uncertainty is statistical, the second is systematic, and the third one is due to the external branching fraction of the normalization channel.

Observation of a Resonant Structure near the D_{s}^{+}D_{s}^{-} Threshold in the B^{+}→D_{s}^{+}D_{s}^{-}K^{+} Decay

An amplitude analysis of the B^{+}→D_{s}^{+}D_{s}^{-}K^{+} decay is carried out to study for the first time its intermediate resonant contributions, using proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV. A near-threshold peaking structure, referred to as X(3960), is observed in the D_{s}^{+}D_{s}^{-} invariant-mass spectrum with significance greater than 12 standard deviations. The mass, width, and the quantum numbers of the structure are measured to be 3956±5±10  MeV, 43±13±8  MeV, and J^{PC}=0^{++}, respectively, where the first uncertainties are statistical and the second systematic. The properties of the new structure are consistent with recent theoretical predictions for a state composed of cc[over ¯]ss[over ¯] quarks. Evidence for an additional structure is found around 4140 MeV in the D_{s}^{+}D_{s}^{-} invariant mass, which might be caused either by a new resonance with the 0^{++} assignment or by a J/ψϕ↔D_{s}^{+}D_{s}^{-} coupled-channel effect.

Evidence for Modification of b Quark Hadronization in High-Multiplicity pp Collisions at sqrt[s]=13 TeV

The production rate of B_{s}^{0} mesons relative to B^{0} mesons is measured by the LHCb experiment in pp collisions at a center-of-mass energy sqrt[s]=13  TeV over the forward rapidity interval 2 Collapse

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First Observation of a Doubly Charged Tetraquark and Its Neutral Partner

A combined amplitude analysis is performed for the decays B^{0}→D[over ¯]^{0}D_{s}^{+}π^{-} and B^{+}→D^{-}D_{s}^{+}π^{+}, which are related by isospin symmetry. The analysis is based on data collected by the LHCb detector in proton-proton collisions at center-of-mass energies of 7, 8, and 13 TeV. The full data sample corresponds to an integrated luminosity of 9  fb^{-1}. Two new resonant states with masses of 2.908±0.011±0.020  GeV and widths of 0.136±0.023±0.013  GeV are observed, which decay to D_{s}^{+}π^{+} and D_{s}^{+}π^{-} respectively. The former state indicates the first observation of a doubly charged open-charm tetraquark state with minimal quark content [cs[over ¯]ud[over ¯]], and the latter state is a neutral tetraquark composed of [cs[over ¯]u[over ¯]d] quarks. Both states are found to have spin-parity of 0^{+}, and their resonant parameters are consistent with each other, which suggests that they belong to an isospin triplet.

Search for Rare Decays of D^{0} Mesons into Two Muons

A search for the very rare D^{0}→μ^{+}μ^{-} decay is performed using data collected by the LHCb experiment in proton-proton collisions at sqrt[s]=7, 8, and 13 TeV, corresponding to an integrated luminosity of 9  fb^{-1}. The search is optimized for D^{0} mesons from D^{*+}→D^{0}π^{+} decays but is also sensitive to D^{0} mesons from other sources. No evidence for an excess of events over the expected background is observed. An upper limit on the branching fraction of this decay is set at B(D^{0}→μ^{+}μ^{-})<3.1×10^{-9} at a 90% C.L. This represents the world's most stringent limit, constraining models of physics beyond the standard model.

Nuclear Modification Factor of Neutral Pions in the Forward and Backward Regions in p-Pb Collisions

The nuclear modification factor of neutral pions is measured in proton-lead collisions collected at a center-of-mass energy per nucleon of 8.16 TeV with the LHCb detector. The π^{0} production cross section is measured differentially in transverse momentum (p_{T}) for 1.5 Collapse

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Grants Collapse

Observation of a J/ψΛ Resonance Consistent with a Strange Pentaquark Candidate in B^{-}→J/ψΛp[over ¯] Decays

An amplitude analysis of B^{-}→J/ψΛp[over ¯] decays is performed using 4400 signal candidates selected on a data sample of pp collisions recorded at center-of-mass energies of 7, 8, and 13 TeV with the LHCb detector, corresponding to an integrated luminosity of 9  fb^{-1}. A narrow resonance in the J/ψΛ system, consistent with a pentaquark candidate with strangeness, is observed with high significance. The mass and the width of this new state are measured to be 4338.2±0.7±0.4  MeV and 7.0±1.2±1.3  MeV, where the first uncertainty is statistical and the second systematic. The spin is determined to be 1/2 and negative parity is preferred. Because of the small Q-value of the reaction, the most precise single measurement of the B^{-} mass to date, 5279.44±0.05±0.07  MeV, is obtained.

Identifying opportunities for upstream evaluations relevant to child and maternal health: a UK policy-mapping review

OBJECTIVE

Interventions to tackle the social determinants of health can improve outcomes during pregnancy and early childhood, leading to better health across the life course. Variation in content, timing and implementation of policies across the 4 UK nations allows for evaluation. We conducted a policy-mapping review (1981-2021) to identify relevant UK early years policies across the social determinants of health framework, and determine suitable candidates for evaluation using administrative data.

METHODS

We used open keyword and category searches of UK and devolved Government websites, and hand searched policy reviews. Policies were rated and included using five criteria: (1) Potential for policy to affect maternal and child health outcomes; (2) Implementation variation across the UK; (3) Population reach and expected effect size; (4) Ability to identify exposed/eligible group in administrative data; (5) Potential to affect health inequalities. An expert consensus workshop determined a final shortlist.

RESULTS

336 policies and 306 strategy documents were identified. Policies were mainly excluded due to criteria 2-4, leaving 88. The consensus workshop identified three policy areas as suitable candidates for natural experiment evaluation using administrative data: pregnancy grants, early years education and childcare, and Universal Credit.

CONCLUSION

Our comprehensive policy review identifies valuable opportunities to evaluate sociostructural impacts on mother and child outcomes. However, many potentially impactful policies were excluded. This may lead to the inverse evidence law, where there is least evidence for policies believed to be most effective. This could be ameliorated by better access to administrative data, staged implementation of future policies or alternative evaluation methods.

Understanding inequalities in mental health by family structure during COVID-19 lockdowns: evidence from the UK Household Longitudinal Study

PURPOSE

The COVID-19 pandemic increased psychiatric distress and impacts differed by family structure. We aimed to identify mechanisms contributing to these inequalities.

METHODS

Survey data were from the UK Household Longitudinal Study. Psychiatric distress (GHQ-12) was measured in April 2020 (first UK lockdown; n = 10,516), and January 2021 (lockdown re-introduced following eased restrictions; n = 6,893). Pre-lockdown family structure comprised partner status and presence of children (< 16 years). Mediating mechanisms included: active employment, financial strain, childcare/home-schooling, caring, and loneliness. Monte Carlo g-computation simulations were used to adjust for confounding and estimate total effects and decompositions into: controlled direct effects (effects if the mediator was absent), and portions eliminated (PE; representing differential exposure and vulnerability to the mediator).

RESULTS

In January 2021, after adjustment, we estimated increased risk of distress among couples with children compared to couples with no children (RR: 1.48; 95% CI 1.15-1.82), largely because of childcare/home-schooling (PE RR: 1.32; 95% CI 1.00-1.64). Single respondents without children also had increased risk of distress compared to couples with no children (RR: 1.55; 95% CI 1.27-1.83), and the largest PE was for loneliness (RR: 1.16; 95% CI 1.05-1.27), though financial strain contributed (RR: 1.05; 95% CI 0.99-1.12). Single parents demonstrated the highest levels of distress, but confounder adjustment suggested uncertain effects with wide confidence intervals. Findings were similar in April 2020 and when stratified by sex.

CONCLUSION

Access to childcare/schooling, financial security and social connection are important mechanisms that need addressing to avoid widening mental health inequalities during public health crises.

Comparing the unified protocol for transdiagnostic treatment of emotional disorders to prolonged exposure for the treatment of PTSD: Design of a non-inferiority randomized controlled trial

Background

Prolonged Exposure (PE), a trauma-focused therapy, is one of the most efficacious treatments available for PTSD. However, many people with PTSD do not lose their diagnosis following delivery of PE. The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders is a non-trauma focused treatment that may offer an alternative treatment for PTSD.

Methods

This paper describes the study protocol for IMPACT, an assessor-blinded randomized controlled trial that examines the non-inferiority of UP relative to PE for participants who meet DSM-5 criteria for current PTSD. One hundred and twenty adult participants with PTSD will be randomized to receive either 10 × 90-min sessions of UP or PE with a trained provider. The primary outcome is severity of PTSD symptoms assessed by the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at post-treatment.

Discussion

While evidence-based treatments are available for PTSD, high levels of treatment dropout and non-response require new approaches to be tested. The UP is based on emotion regulation theory and is effective in treating anxiety and depressive disorders, however, there has been limited application to PTSD. This is the first rigorous study comparing UP to PE in a non-inferiority randomized controlled trial and may help improve clinical outcomes for those with PTSD.

Trial registration

This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry, Trial ID (ACTRN12619000543189).

Study protocol: examining the impacts of COVID-19 mitigation measures on pregnancy and birth outcomes in Scotland-a linked administrative data study

INTRODUCTION

This protocol outlines aims to test the wider impacts of the COVID-19 pandemic on pregnancy and birth outcomes and inequalities in Scotland.

METHOD AND ANALYSIS

We will analyse Scottish linked administrative data for pregnancies and births before (March 2010 to March 2020) and during (April 2020 to October 2020) the pandemic. The Community Health Index database will be used to link the National Records of Scotland Births and the Scottish Morbidity Record 02. The data will include about 500 000 mother-child pairs. We will investigate population-level changes in maternal behaviour (smoking at antenatal care booking, infant feeding on discharge), pregnancy and birth outcomes (birth weight, preterm birth, Apgar score, stillbirth, neonatal death, pre-eclampsia) and service use (mode of delivery, mode of anaesthesia, neonatal unit admission) during the COVID-19 pandemic using two analytical approaches. First, we will estimate interrupted times series regression models to describe changes in outcomes comparing prepandemic with pandemic periods. Second, we will analyse the effect of COVID-19 mitigation measures on our outcomes in more detail by creating cumulative exposure variables for each mother-child pair using the Oxford COVID-19 Government Response Tracker. Thus, estimating a potential dose-response relationship between exposure to mitigation measures and our outcomes of interest as well as assessing if timing of exposure during pregnancy matters. Finally, we will assess inequalities in the effect of cumulative exposure to lockdown measures on outcomes using several axes of inequality: ethnicity/mother's country of birth, area deprivation (Scottish Index of Multiple Deprivation), urban-rural classification of residence, number of previous children, maternal social position (National Statistics Socioeconomic Classification) and parental relationship status.

ETHICS AND DISSEMINATION

NHS Scotland Public Benefit and Privacy Panel for Health and Social Care scrutinised and approved the use of these data (1920-0097). Results of this study will be disseminated to the research community, practitioners, policy makers and the wider public.

Avasopasem manganese (GC4419) protects against cisplatin-induced chronic kidney disease: An exploratory analysis of renal metrics from a randomized phase 2b clinical trial in head and neck cancer patients

Head and neck squamous cell carcinoma (HNSCC) patients treated with high-dose cisplatin concurrently with radiotherapy (hdCis-RT) commonly suffer kidney injury leading to acute and chronic kidney disease (AKD and CKD, respectively). We conducted a retrospective analysis of renal function and kidney injury-related plasma biomarkers in a subset of HNSCC subjects receiving hdCis-RT in a double-blinded, placebo-controlled clinical trial (NCT02508389) evaluating the superoxide dismutase mimetic, avasopasem manganese (AVA), an investigational new drug. We found that 90 mg AVA treatment prevented a significant reduction in estimated glomerular filtration rate (eGFR) three months as well as six and twelve months after treatment compared to 30 mg AVA and placebo. Moreover, AVA treatment may have allowed renal repair in the first 22 days following cisplatin treatment as evidenced by an increase in epithelial growth factor (EGF), known to aid in renal recovery. An upward trend was also observed in plasma iron homeostasis proteins including total iron (Fe-blood) and iron saturation (Fe-saturation) in the 90 mg AVA group versus placebo. These data support the hypothesis that treatment with 90 mg AVA mitigates cisplatin-induced CKD by inhibiting hdCis-induced renal changes and promoting renal recovery.

Effects of poverty on mental health in the UK working-age population: causal analyses of the UK Household Longitudinal Study

BACKGROUND

Addressing poverty through taxation or welfare policies is likely important for public mental health; however, few studies assess poverty's effects using causal epidemiology. We estimated the effect of poverty on mental health.

METHODS

We used data on working-age adults (25-64 years) from nine waves of the UK Household Longitudinal Survey (2009-19; n = 45 497/observations = 202 207 following multiple imputation). We defined poverty as a household equivalized income <60% median, and the outcome likely common mental disorder (CMD) as a General Health Questionnaire-12 score ≥4. We used double-robust marginal structural modelling with inverse probability of treatment weights to generate absolute and relative effects. Supplementary analyses separated transitions into/out of poverty, and stratified by gender, education, and age. We quantified potential impact through population attributable fractions (PAFs) with bootstrapped standard errors.

RESULTS

Good balance of confounders was achieved between exposure groups, with 45 830 observations (22.65%) reporting poverty. The absolute effect of poverty on CMD prevalence was 2.15% [%-point change; 95% confidence interval (CI) 1.45, 2.84]; prevalence in those unexposed was 20.59% (95% CI 20.29%, 20.88%), and the odds ratio was 1.17 (95% CI 1.12, 1.24). There was a larger absolute effect for transitions into poverty [2.46% (95% CI 1.56, 3.36)] than transitions out of poverty [-1.49% (95% CI -2.46, -0.53)]. Effects were also slightly larger in women than men [2.34% (95% CI 1.41, 3.26) versus 1.73% (95% CI 0.72, 2.74)]. The PAF for moving into poverty was 6.34% (95% CI 4.23, 8.45).

CONCLUSIONS

PAFs derived from our causal estimates suggest moves into poverty account for just over 6% of the burden of CMD in the UK working-age population, with larger effects in women.

To what extent does time spent on social media influence adolescent use of cigarettes and e-cigarettes: a longitudinal analysis of the UK Millennium Cohort Study

BACKGROUND

We estimated the effect of social media use on adolescents aged 14 years and risk of cigarette, e-cigarette, and dual use when aged 17 years. Data was from the UK Millennium Cohort Study, which followed up approximately 19 000 children born between 2000 and 2002.

METHODS

Representative longitudinal data were collected at ages 14 years and 17 years. Directed acyclic graphs identified confounders (eg, demographics, mental health, in-person interactions, cognitive ability, risk-taking, antisocial behaviour, previous or current parental cigarette or e-cigarette use, and socioeconomic circumstances). The relationship between self-reported social media use per weekday (reference category: from 1 min to under 30 mins) and cigarette, e-cigarette, and dual use was examined using longitudinal analysis to estimate adjusted odds ratios (OR) or relative risk ratios (RRRs). A complete case sample was used; weights accounted for sample design and attrition. This study was a secondary data analysis of the UK Millennium Cohort Study (prospective longitudinal study). Ethical approval was received from a Research Ethics Committee at each study sweep.

FINDINGS

In total, 6234 individuals (168 314 observations) were included. 5778 (92·7%) reported social media use, 1730 (27·8%) cigarette use, 1389 (22·3%) e-cigarette use, and 479 (7·68%) dual use. Social media use was associated with all outcomes in a dose-response manner. For cigarette use, ORs increased from 1·67 (95% CI 1·26-2·21) for 30 mins to 1 h, to 3·09 (2·43-3·91) for 2 h or longer of social media use. For e-cigarette use, ORs increased from 1·90 (1·41-2·55) for 30 mins to 1 h, to 3·34 (2·60-4·28) for 2 h or longer of social media use. For dual use, RRRs increased from 1·91 (1·16-3·15) for 30 mins to 1 h, to 4·26 (2·81-6·46) for 2 h or longer of social media use. For e-cigarette and dual use, associations were stronger for males than for females; the opposite was found for cigarette use.

INTERPRETATION

After accounting for observed confounders and reverse causality, our findings suggest social media use, although only measured at one point in time, is associated with increased risk of cigarette, e-cigarette, and dual use. The greatest risk was observed in those who used social media for 2 h or longer. Given the potential health harms of social media use, guidance for parents and caregivers about safe social media use and regulation on time spent on social media is required.

FUNDING

Medical Research Council, Chief Scientist Office, Wellcome Trust.

How much of the unemployment effect on mental health is due to income? Mediation analysis in UK data

Background

Employment and income are important determinants of mental health (MH), but the extent to which unemployment effects are mediated by reduced income is unclear. We estimated the total effect (TE) of unemployment on MH and the controlled direct effect (CDE) not acting via income.

Methods

We studied adults 25-64y from nine waves of the representative UK Household Longitudinal Study (n = 45,497/obs=202,297). Unemployment was defined as not being in paid employment; common mental disorder (CMD) was defined as a General Health Questionnaire-12 score ≥4. We conducted causal mediation analysis using inverse probability of treatment weights to estimate odds ratios (OR) and absolute differences for the effects of unemployment on CMD as measured in the same sweep, before (TE) and after (CDE) blocking the income pathway. The percentage mediated by income was 100*(TE-CDE)/TE, with standard errors calculated via bootstrapping. Multiple imputation addressed missingness.

Results

The TE of unemployment on short-term CMD risk was OR: 1.66 (95% CI 1.57-1.76), with 7.09% (6.21-7.97) absolute difference in prevalence; equivalent CDEs were OR 1.55 (1.46-1.66) and 6.08% (5.13-7.03). Income mediated 14.22% (8.04-20.40) of the TE. Percentage mediation was higher for job losses (15.10% [6.81-23.39]) than job gains (8.77% [0.36-17.19]). Mediation by income was lowest for those aged 25-40y (7.99% [-2.57, 18.51]) and those in poverty (2.63% [-2.22, 7.49]).

Conclusions

In the UK, a high proportion of the short-term effect of unemployment on MH is not explained by income, particularly for those who are younger or already living in poverty. Population attributable fractions suggested 16.5% of CMD burden was due to unemployment, with 13.9% directly attributable to job loss rather than resultant income changes. Further research is needed across different European countries to determine how different welfare regimes might moderate these effects, and to investigate longer-term effects.

Key messages

• Unemployment has a clear detrimental effect on MH in the short-term.

• Only a small proportion of this effect appears to be mediated by income.

The LoCo (Lockdown Cohort)-effect: Socioeconomic differences in fertility during the pandemic

Background

The economic and social disruptions caused by the COVID-19 pandemic and its mitigation measures may have affected fertility unequally across social strata. If a compositional change in maternal socioeconomic characteristics is confirmed, counterintuitive changes in future population health - the LoCo-effect - are likely.

Methods

We analysed data from maternal inpatient discharge records containing births between January 2018 and November 2021 by Scottish Index of Multiple Deprivation (SIMD) quintile. We used monthly number of births before November 2020 to estimate expected monthly births after November 2020 and compared against observed births in each SIMD quintile. Further, we estimated associations between monthly average stringency of national mitigation measures (Stringency Index (0-100)) and births 9 to 13 months later using distributed lag models.

Results

Between November 2020 and November 2021, there were 1301 (10.3%) fewer births than expected for the most deprived quintile (Q1; 953 (8.7%) and 375 (4.1%) less in Q2 and Q3). In the two least deprived quintiles, however, fertility remained mostly unchanged. A 10-point increase in monthly average Stringency Index in Q1 was associated with an average cumulative decrease of 8.5 births (95%CI: -14.1; -2.8, p = 0.006) 9 to 13 months later. Conversely, this estimate was a 4.4 increase (95%CI: 1.3; 7.5, p = 0.008) in Q5 and a 5.9 increase (95%CI: 1.4; 10.4, p = 0.013) in Q4.

Conclusions

Apart from their exposure to pandemic and lockdowns, it is likely that, due to compositional changes in births, the observed LoCo started life, on average, more socially advantaged than previous birth cohorts in Scotland. We show a substantial decrease in fertility in the most deprived areas, while fertility remained little changed in the least deprived areas. Increases in the stringency of lockdown measures were associated with a decrease in births in the most deprived but an increase in the least deprived areas 9 to 13 months later.

Key messages

• Between November 2020 and November 2021, there were substantial decreases in births among deprived areas in Scotland while fertility in the least deprived areas remained mostly unchanged.

• For these births, the observed compositional shift in maternal socioeconomic characteristics may lead to changes in current and future health and health needs – the LoCo (Lockdown Cohort)-effect.

Causal inference and effect estimation using observational data

Observational studies aiming to estimate causal effects often rely on conceptual frameworks that are unfamiliar to many researchers and practitioners. We provide a clear, structured overview of key concepts and terms, intended as a starting point for readers unfamiliar with the causal inference literature. First, we introduce theoretical frameworks underlying causal effect estimation methods: the counterfactual theory of causation, the potential outcomes framework, structural equations and directed acyclic graphs. Second, we define the most common causal effect estimands, and the issues of effect measure modification, interaction and mediation (direct and indirect effects). Third, we define the assumptions required to estimate causal effects: exchangeability, positivity, consistency and non-interference. Fourth, we define and explain biases that arise when attempting to estimate causal effects, including confounding, collider bias, selection bias and measurement bias. Finally, we describe common methods and study designs for causal effect estimation, including covariate adjustment, G-methods and natural experiment methods.

First Measurement of the Z→μ^{+}μ^{-} Angular Coefficients in the Forward Region of pp Collisions at sqrt[s]=13 TeV

The first study of the angular distribution of μ^{+}μ^{-} pairs produced in the forward rapidity region via the Drell-Yan reaction pp→γ^{*}/Z+X→ℓ^{+}ℓ^{-}+X is presented, using data collected with the LHCb detector at a center-of-mass energy of 13 TeV, corresponding to an integrated luminosity of 5.1  fb^{-1}. The coefficients of the five leading terms in the angular distribution are determined as a function of the dimuon transverse momentum and rapidity. The results are compared to various theoretical predictions of the Z-boson production mechanism and can also be used to probe transverse-momentum-dependent parton distributions within the proton.

Causal assessment in evidence synthesis: A methodological review of reviews

In fields (such as population health) where randomised trials are often lacking, systematic reviews (SRs) can harness diversity in study design, settings and populations to assess the evidence for a putative causal relationship. SRs may incorporate causal assessment approaches (CAAs), sometimes called 'causal reviews', but there is currently no consensus on how these should be conducted. We conducted a methodological review of self-identifying 'causal reviews' within the field of population health to establish: (1) which CAAs are used; (2) differences in how CAAs are implemented; (3) how methods were modified to incorporate causal assessment in SRs. Three databases were searched and two independent reviewers selected reviews for inclusion. Data were extracted using a standardised form and summarised using tabulation and narratively. Fifty-three reviews incorporated CAAs: 46/53 applied Bradford Hill (BH) viewpoints/criteria, with the remainder taking alternative approaches: Medical Research Council guidance on natural experiments (2/53, 3.8%); realist reviews (2/53, 3.8%); horizontal SRs (1/53, 1.9%); 'sign test' of causal mechanisms (1/53, 1.9%); and a causal cascade model (1/53, 1.9%). Though most SRs incorporated BH, there was variation in application and transparency. There was considerable overlap across the CAAs, with a trade-off between breadth (BH viewpoints considered a greater range of causal characteristics) and depth (many alternative CAAs focused on one viewpoint). Improved transparency in the implementation of CAA in SRs in needed to ensure their validity and allow robust assessments of causality within evidence synthesis.

Study of the doubly charmed tetraquark [Formula: see text]

Quantum chromodynamics, the theory of the strong force, describes interactions of coloured quarks and gluons and the formation of hadronic matter. Conventional hadronic matter consists of baryons and mesons made of three quarks and quark-antiquark pairs, respectively. Particles with an alternative quark content are known as exotic states. Here a study is reported of an exotic narrow state in the D0D0π+ mass spectrum just below the D*+D0 mass threshold produced in proton-proton collisions collected with the LHCb detector at the Large Hadron Collider. The state is consistent with the ground isoscalar [Formula: see text] tetraquark with a quark content of [Formula: see text] and spin-parity quantum numbers JP = 1+. Study of the DD mass spectra disfavours interpretation of the resonance as the isovector state. The decay structure via intermediate off-shell D*+ mesons is consistent with the observed D0π+ mass distribution. To analyse the mass of the resonance and its coupling to the D*D system, a dedicated model is developed under the assumption of an isoscalar axial-vector [Formula: see text] state decaying to the D*D channel. Using this model, resonance parameters including the pole position, scattering length, effective range and compositeness are determined to reveal important information about the nature of the [Formula: see text] state. In addition, an unexpected dependence of the production rate on track multiplicity is observed.

Angular Analysis of D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} Decays and Search for CP Violation

The first full angular analysis and an updated measurement of the decay-rate CP asymmetry of the D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} decays are reported. The analysis uses proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV. The dataset corresponds to an integrated luminosity of 9  fb^{-1}. The full set of CP -averaged angular observables and their CP asymmetries are measured as a function of the dimuon invariant mass. The results are consistent with expectations from the standard model and with CP symmetry.

How do income changes impact on mental health and wellbeing for working-age adults? A systematic review and meta-analysis

BACKGROUND

Lower incomes are associated with poorer mental health and wellbeing, but the extent to which income has a causal effect is debated. We aimed to synthesise evidence from studies measuring the impact of changes in individual and household income on mental health and wellbeing outcomes in working-age adults (aged 16-64 years).

METHODS

For this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science, PsycINFO, ASSIA, EconLit, and RePEc on Feb 5, 2020, for randomised controlled trials (RCTs) and quantitative non-randomised studies. We had no date limits for our search. We included English-language studies measuring effects of individual or household income change on any mental health or wellbeing outcome. We used Cochrane risk of bias (RoB) tools. We conducted three-level random-effects meta-analyses, and explored heterogeneity using meta-regression and stratified analyses. Synthesis without meta-analysis was based on effect direction. Critical RoB studies were excluded from primary analyses. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This study is registered with PROSPERO, CRD42020168379.

FINDINGS

Of 16 521 citations screened, 136 were narratively synthesised (12·5% RCTs) and 86 meta-analysed. RoB was high: 30·1% were rated critical and 47·1% serious or high. A binary income increase lifting individuals out of poverty was associated with 0·13 SD improvement in mental health measures (95% CI 0·07 to 0·20; n=42 128; 18 studies), considerably larger than other income increases (0·01 SD improvement, 0·002 to 0·019; n=216 509, 14 studies). For wellbeing, increases out of poverty were associated with 0·38 SD improvement (0·09 to 0·66; n=101 350, 8 studies) versus 0·16 for other income increases (0·07 to 0·25; n=62 619, 11 studies). Income decreases from any source were associated with 0·21 SD worsening of mental health measures (-0·30 to -0·13; n=227 804, 11 studies). Effect sizes were larger in low-income and middle-income settings and in higher RoB studies. Heterogeneity was high (I²=79-87%). GRADE certainty was low or very low.

INTERPRETATION

Income changes probably impact mental health, particularly where they move individuals out of poverty, although effect sizes are modest and certainty low. Effects are larger for wellbeing outcomes, and potentially for income losses. To best support population mental health, welfare policies need to reach the most socioeconomically disadvantaged.

FUNDING

Wellcome Trust, Medical Research Council, Chief Scientist Office, and European Research Council.

Comparing population-level mental health of UK workers before and during the COVID-19 pandemic: a longitudinal study using Understanding Society

OBJECTIVES

The COVID-19 pandemic has substantially affected workers' mental health. We investigated changes in UK workers' mental health by industry, socioeconomic class and occupation and differential effects by UK country of residence, gender and age.

METHODS

We used representative Understanding Society data from 6474 adults (41 207 observations) in paid employment who participated in pre-pandemic (2017-2020) and at least one COVID-19 survey. The outcome was General Health Questionnaire-12 (GHQ-12) caseness (score: ≥4). Exposures were industry, socioeconomic class and occupation and are examined separately. Mixed-effects logistic regression was used to estimate relative (OR) and absolute (%) increases in distress before and during pandemic. Differential effects were investigated for UK countries of residence (non-England/England), gender (male/female) and age (younger/older) using three-way interaction effects.

RESULTS

GHQ-12 caseness increased in relative terms most for 'professional, scientific and technical' (OR: 3.15, 95% CI 2.17 to 4.59) industry in the pandemic versus pre-pandemic period. Absolute risk increased most in 'hospitality' (+11.4%). For socioeconomic class, 'small employers/self-employed' were most affected in relative and absolute terms (OR: 3.24, 95% CI 2.28 to 4.63; +10.3%). Across occupations, 'sales and customer service' (OR: 3.01, 95% CI 1.61 to 5.62; +10.7%) had the greatest increase. Analysis with three-way interactions showed considerable gender differences, while for UK country of residence and age results are mixed.

CONCLUSIONS

GHQ-12 caseness increases during the pandemic were concentrated among 'professional and technical' and 'hospitality' industries and 'small employers/self-employed' and 'sales and customers service' workers. Female workers often exhibited greater differences in risk by industry and occupation. Policies supporting these industries and groups are needed.

Tests of Lepton Universality Using B^{0}→K_{S}^{0}ℓ^{+}ℓ^{-} and B^{+}→K^{*+}ℓ^{+}ℓ^{-} Decays

Tests of lepton universality in B^{0}→K_{S}^{0}ℓ^{+}ℓ^{-} and B^{+}→K^{*+}ℓ^{+}ℓ^{-} decays where ℓ is either an electron or a muon are presented. The differential branching fractions of B^{0}→K_{S}^{0}e^{+}e^{-} and B^{+}→K^{*+}e^{+}e^{-} decays are measured in intervals of the dilepton invariant mass squared. The measurements are performed using proton-proton collision data recorded by the LHCb experiment, corresponding to an integrated luminosity of 9  fb^{-1} . The results are consistent with the standard model and previous tests of lepton universality in related decay modes. The first observation of B^{0}→K_{S}^{0}e^{+}e^{-} and B^{+}→K^{*+}e^{+}e^{-} decays is reported.

Observation of the Decay Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ}

The first observation of the semileptonic b-baryon decay Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ}, with a significance of 6.1σ, is reported using a data sample corresponding to 3  fb^{-1} of integrated luminosity, collected by the LHCb experiment at center-of-mass energies of 7 and 8 TeV at the LHC. The τ^{-} lepton is reconstructed in the hadronic decay to three charged pions. The ratio K=B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})/B(Λ_{b}^{0}→Λ_{c}^{+}π^{-}π^{+}π^{-}) is measured to be 2.46±0.27±0.40, where the first uncertainty is statistical and the second systematic. The branching fraction B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})=(1.50±0.16±0.25±0.23)% is obtained, where the third uncertainty is from the external branching fraction of the normalization channel Λ_{b}^{0}→Λ_{c}^{+}π^{-}π^{+}π^{-}. The ratio of semileptonic branching fractions R(Λ_{c}^{+})≡B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})/B(Λ_{b}^{0}→Λ_{c}^{+}μ^{-}ν[over ¯]_{μ}) is derived to be 0.242±0.026±0.040±0.059, where the external branching fraction uncertainty from the channel Λ_{b}^{0}→Λ_{c}^{+}μ^{-}ν[over ¯]_{μ} contributes to the last term. This result is in agreement with the standard model prediction.

Observation of Two New Excited Ξ_{b}^{0} States Decaying to Λ_{b}^{0}K^{-}π^{+}

Two narrow resonant states are observed in the Λ_{b}^{0}K^{-}π^{+} mass spectrum using a data sample of proton-proton collisions at a center-of-mass energy of 13 TeV, collected by the LHCb experiment and corresponding to an integrated luminosity of 6  fb^{-1}. The minimal quark content of the Λ_{b}^{0}K^{-}π^{+} system indicates that these are excited Ξ_{b}^{0} baryons. The masses of the Ξ_{b}(6327)^{0} and Ξ_{b}(6333)^{0} states are m[Ξ_{b}(6327)^{0}]=6327.28_{-0.21}^{+0.23}±0.12±0.24 and m[Ξ_{b}(6333)^{0}]=6332.69_{-0.18}^{+0.17}±0.03±0.22  MeV, respectively, with a mass splitting of Δm=5.41_{-0.27}^{+0.26}±0.12  MeV, where the uncertainties are statistical, systematic, and due to the Λ_{b}^{0} mass measurement. The measured natural widths of these states are consistent with zero, with upper limits of Γ[Ξ_{b}(6327)^{0}]<2.20(2.56) and Γ[Ξ_{b}(6333)^{0}]<1.60(1.92)  MeV at a 90% (95%) credibility level. The significance of the two-peak hypothesis is larger than nine (five) Gaussian standard deviations compared to the no-peak (one-peak) hypothesis. The masses, widths, and resonant structure of the new states are in good agreement with the expectations for a doublet of 1D Ξ_{b}^{0} resonances.

Measurement of the Nuclear Modification Factor and Prompt Charged Particle Production in p-Pb and pp Collisions at sqrt[s_{NN}]=5 TeV

The production of prompt charged particles in proton-lead collisions and in proton-proton collisions at the nucleon-nucleon center-of-mass energy sqrt[s_{NN}]=5  TeV is studied at LHCb as a function of pseudorapidity (η) and transverse momentum (p_{T}) with respect to the proton beam direction. The nuclear modification factor for charged particles is determined as a function of η between -4.8<η<-2.5 (backward region) and 2.0<η<4.8 (forward region), and p_{T} between 0.2<p_{T}<8.0  GeV/c. The results show a suppression of charged particle production in proton-lead collisions relative to proton-proton collisions in the forward region and an enhancement in the backward region for p_{T} larger than 1.5  GeV/c. This measurement constrains nuclear PDFs and saturation models at previously unexplored values of the parton momentum fraction down to 10^{-6}.

Study of Z Bosons Produced in Association with Charm in the Forward Region

Events containing a Z boson and a charm jet are studied for the first time in the forward region of proton-proton collisions. The data sample used corresponds to an integrated luminosity of 6  fb^{-1} collected at a center-of-mass energy of 13 TeV with the LHCb detector. In events with a Z boson and a jet, the fraction of charm jets is determined in intervals of Z-boson rapidity in the range 2.0<y(Z)<4.5. A sizable enhancement is observed in the forwardmost y(Z) interval, which could be indicative of a valencelike intrinsic-charm component in the proton wave function.

Evidence for a New Structure in the J/ψp and J/ψp[over ¯] Systems in B_{s}^{0}→J/ψpp[over ¯] Decays

An amplitude analysis of flavor-untagged B_{s}^{0}→J/ψpp[over ¯] decays is performed using a sample of 797±31 decays reconstructed with the LHCb detector. The data, collected in proton-proton collisions between 2011 and 2018, correspond to an integrated luminosity of 9  fb^{-1}. Evidence for a new structure in the J/ψp and J/ψp[over ¯] systems with a mass of 4337_{-4}^{+7} _{-2}^{+2}  MeV and a width of 29_{-12}^{+26} _{-14}^{+14}  MeV is found, where the first uncertainty is statistical and the second systematic, with a significance in the range of 3.1 to 3.7σ, depending on the assigned J^{P} hypothesis.

Assessing the causal relationship between income inequality and mortality and self-rated health: protocol for systematic review and meta-analysis

BACKGROUND

Income inequality has been linked to health and mortality. While there has been extensive research exploring the relationship, the evidence for whether the relationship is causal remains disputed. We describe the methods for a systematic review that will transparently assess whether a causal relationship exists between income inequality and mortality and self-rated health.

METHODS

We will identify relevant studies using search terms relating to income inequality, mortality, and self-rated health (SRH). Four databases will be searched: MEDLINE, ISI Web of Science, EMBASE, and the National Bureau of Economic Research. The inclusion criteria have been developed to identify the study designs best suited to assess causality: multilevel studies that have conditioned upon individual income (or a comparable measure, such as socioeconomic position) and natural experiment studies. Risk of bias assessment of included studies will be conducted using ROBINS-I. Where possible, we will convert all measures of income inequality into Gini coefficients and standardize the effect estimate of income inequality on mortality/SRH. We will conduct random-effects meta-analysis to estimate pooled effect estimates when possible. We will assess causality using modified Bradford Hill viewpoints and assess certainty using GRADE.

DISCUSSION

This systematic review protocol lays out the complexity of the relationship between income inequality and individual health, as well as our approach for assessing causality. Understanding whether income inequality impacts the health of individuals within a population has major policy implications. By setting out our methods and approach as transparently as we can, we hope this systematic review can provide clarity to an important topic for public policy and public health, as well as acting as an exemplar for other "causal reviews".

Analysis of Neutral B-Meson Decays into Two Muons

Branching fraction and effective lifetime measurements of the rare decay B_{s}^{0}→μ^{+}μ^{-} and searches for the decays B^{0}→μ^{+}μ^{-} and B_{s}^{0}→μ^{+}μ^{-}γ are reported using proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV, corresponding to a luminosity of 9  fb^{-1}. The branching fraction B(B_{s}^{0}→μ^{+}μ^{-})=(3.09_{-0.43-0.11}^{+0.46+0.15})×10^{-9} and the effective lifetime τ(B_{s}^{0}→μ^{+}μ^{-})=2.07±0.29±0.03  ps are measured, where the first uncertainty is statistical and the second systematic. No significant signal for B^{0}→μ^{+}μ^{-} and B_{s}^{0}→μ^{+}μ^{-}γ decays is found and upper limits B(B^{0}→μ^{+}μ^{-})<2.6×10^{-10} and B(B_{s}^{0}→μ^{+}μ^{-}γ)<2.0×10^{-9} at the 95% C.L. are determined, where the latter is limited to the range m_{μμ}>4.9  GeV/c^{2}. The results are in agreement with the standard model expectations.