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Background: Antibiotics targeted against Clostridioides difficile bacteria are necessary, but insufficient, to achieve a durable clinical response because they have no effect on C. difficile spores that germinate within a disrupted microbiome. ECOSPOR-III evaluated SER-109, an investigational, biologically derived microbiome therapeutic of purified Firmicute spores for treatment of rCDI. Herein, we present the interim analysis in the ITT population at 8 and 12 weeks. Methods: Adults ≥18 years with rCDI (≥3 episodes in 12 months) were screened at 75 US and CAN sites. CDI was defined as ≥3 unformed stools per day for <48 hours with a positive C. difficile assay. After completion of 10–21 days of vancomycin or fidaxomicin, adults with symptom resolution were randomized 1:1 to SER-109 (4 capsules × 3 days) or matching placebo and stratified by age (≥ or <65 years) and antibiotic received. Primary objectives were safety and efficacy at 8 weeks. Primary efficacy endpoint was rCDI (recurrent toxin+ diarrhea requiring treatment); secondary endpoints included efficacy at 12 weeks after dosing. Results: Overall, 287 participants were screened and 182 were randomized (59.9% female; mean age, 65.5 years). The most common reason for screen failure was a negative C. difficile toxin assay. A significantly lower proportion of SER-109 participants had rCDI after dosing compared to placebo at week 8 (11.1% vs 41.3%, respectively; relative risk [RR], 0.27; 95% confidence interval [CI], 0.15–0.51; p-value <0.001). Efficacy rates were significantly higher with SER-109 vs placebo in both stratified age groups (Figure 1). SER-109 was well-tolerated with a safety profile similar to placebo. The most common treatment-emergent adverse events (TEAEs) were gastrointestinal and were mainly mild to moderate. No serious TEAEs, infections, deaths, or drug discontinuations were deemed related to study drug. Conclusions: SER-109, an oral live microbiome therapeutic, achieved high rates of sustained clinical response with a favorable safety profile. By enriching for Firmicute spores, SER-109 achieves high efficacy while mitigating risk of transmitting infectious agents, beyond donor screening alone. SER-109 represents a major paradigm shift in the clinical management of patients with recurrent CDI. Clinicaltrials.gov Identifier NCT03183128. These data were previously presented as a late breaker at American College of Gastroenterology 2020.
This study was designed to test the feasibility of running a trial to compare the effectiveness of a combined weight management and physical function programme for patients with knee osteoarthritis ARMED (Arthritis Rehabilitation through the Management of Exercise and Diet) with usual care ESCAPE pain (Enabling Self-management and Coping with Arthritic Pain using Exercise). The COVID-19 pandemic interruption allowed additional measurement of the qualitative ‘lived in’ experiences of this patient group during the pandemic and also their appetite for virtual health.
Thirty-two patients with knee osteoarthritis were recruited from a combined primary/secondary care waiting list and were allocated to either a six-week intervention group (ARMED) or to the six-week usual care ESCAPE pain group (Enabling Self-management and Coping with Arthritic Pain using Exercise) group.
The intervention programme was interrupted after three weeks by COVID-19. Fifteen patients were reassessed after the first stage. The average attendance was 92% with 6 patients attending all sessions, 5 attending 5/6, 1 attending 4/6 and 2 attending 3/6. One subject dropped out and 15/16 patients completed all outcome measurements. All patients completed the KOOS knee score and the Short Warwick-Edinburgh Mental Well Being Scale to evaluate anxiety and depression. There was a statistically significant improvement in pain, activities of daily living, quality of life and mental health and well-being scores from time one to time 2. The mean weight, BMI and waist measurements were reduced also from time one to time 2, but these failed to reach significance. The semi-structured interviews provided rich information on enablers and barriers to coping in lockdown, benefits of the ARMED programme to increasing physical activity and weight management and enablers and barriers to redesigning the programme for online delivery.
Evaluation of preliminary data from this feasibility study supports the three-week intervention combining education, exercise and weight management in this patient group even during a pandemic. Based on the results of the qualitative interviews, we have now redesigned our programme to present it virtually. We hope to present the results of our virtual feasibility study later in 2021.
Previously reported associations between hospital-level antibiotic use and hospital-onset Clostridioides difficile infection (HO-CDI) were reexamined using 2012–2018 data from a new cohort of US acute-care hospitals. This analysis revealed significant positive associations between total, third-generation, and fourth-generation cephalosporin, fluoroquinolone, carbapenem, and piperacillin-tazobactam use and HO-CDI rates, confirming previous findings.
To assess the quality and quantity of foods and beverages provided to children aged 0–5 years in family day care and identify structural and sociodemographic factors associated with the nutritional quality of food provided.
A cross-sectional study measured the food and beverages provided to children using weighed food records. The number of serves from different food groups was calculated according to the Australian Guide to Healthy Eating, and a healthy food provision index score was created. Associations between structural and sociodemographic factors and healthy food provision index scores were analysed using linear mixed models.
Family day care services in two large geographic areas in New South Wales, Australia.
One hundred and four children in thirty-three family day care services.
During attendance at childcare, most children met recommended servings of fruit but not dairy, vegetables, lean meat and meat alternatives and wholegrains. Discretionary foods exceeded recommendations. Children’s age, socio-economic status and the type of main meal provided were significantly associated with the healthy food provision index score.
Foods provided to children in family day care are aligned with dietary recommendations for fruit but not vegetables, dairy, lean meat and meat alternatives, wholegrains or discretionary foods. Interventions to promote healthy eating are needed to support families and educators to improve the nutritional quality of food provided to children.
Due to shortages of N95 respirators during the coronavirus disease 2019 (COVID-19) pandemic, it is necessary to estimate the number of N95s required for healthcare workers (HCWs) to inform manufacturing targets and resource allocation.
We developed a model to determine the number of N95 respirators needed for HCWs both in a single acute-care hospital and the United States.
For an acute-care hospital with 400 all-cause monthly admissions, the number of N95 respirators needed to manage COVID-19 patients admitted during a month ranges from 113 (95% interpercentile range [IPR], 50–229) if 0.5% of admissions are COVID-19 patients to 22,101 (95% IPR, 5,904–25,881) if 100% of admissions are COVID-19 patients (assuming single use per respirator, and 10 encounters between HCWs and each COVID-19 patient per day). The number of N95s needed decreases to a range of 22 (95% IPR, 10–43) to 4,445 (95% IPR, 1,975–8,684) if each N95 is used for 5 patient encounters. Varying monthly all-cause admissions to 2,000 requires 6,645–13,404 respirators with a 60% COVID-19 admission prevalence, 10 HCW–patient encounters, and reusing N95s 5–10 times. Nationally, the number of N95 respirators needed over the course of the pandemic ranges from 86 million (95% IPR, 37.1–200.6 million) to 1.6 billion (95% IPR, 0.7–3.6 billion) as 5%–90% of the population is exposed (single-use). This number ranges from 17.4 million (95% IPR, 7.3–41 million) to 312.3 million (95% IPR, 131.5–737.3 million) using each respirator for 5 encounters.
We quantified the number of N95 respirators needed for a given acute-care hospital and nationally during the COVID-19 pandemic under varying conditions.
Sense of place describes both affective and cognitive — emotional and intellectual — connections to place. Affective outcomes, tied to arts and humanities education, can facilitate these connections. But little research explores environmental science, arts and humanities (eSAH) curricula on place relationships. Additionally, most research on the sense of place focuses on repeated visits to a place over time, rather than short-term experiences like a field trip. Finally, digital technology is a growing trend across science education, but little research investigates its use in field-based contexts. Our research begins to address these gaps. This article describes an eSAH field trip for middle and high school learners. Using a conventional content analysis, we present pilot data from two high school field trips. Our findings illuminate a framework for understanding active and passive place relationships in the context of short-term interdisciplinary field learning experiences.
Background: Surgical site infections (SSIs) among cardiothoracic (CT) patients are associated with high rates of morbidity and mortality. Data are limited regarding SSI incidence among pediatric patients undergoing primary reparative procedures for congenital cardiac disease. Published evidence on targeted interventions to prevent pediatric CT-surgery SSI is lacking. We aimed to establish standard metrics for measuring CT-surgery SSI incidence and to implement bundled interventions for SSI prevention. Methods: A dedicated CT-surgery SSI prevention workgroup was established, consisting of hospital leadership, CT surgeons, cardiac critical care unit staff, anesthesia, perfusion, environmental services, instrument sterile processing, risk management, infection prevention and antibiotic stewardship. We created a standard definition for CT-surgery SSI and calculated retrospective SSI rates over a 24-month period (2017–2019). The outcome measured was incidence of CT-surgery SSI per 100 primary cardiac procedures with delayed ( 3 days after primary surgery) or non-delayed chest closure. The difference in proportion of SSI was reported separately for delayed closure and non-delayed closure; statistical significance was tested using a Fisher’s Exact test. We identified many potential improvement opportunities, including gaps in SSI surveillance, poor compliance with daily bathing, inconsistent perioperative antimicrobial prophylaxis, lack of controlled environment for bedside chest closures, and lapses in environmental cleaning. These issues informed the enhanced SSI prevention bundle, which included education on sterility with the operating room (OR) staff. Protocols for care of cardiac patients with delayed chest closures focused on universal daily and preoperative chlorhexidine baths. In addition, the bundle incorporated stringent environmental cleaning interventions including scheduled decluttering of patient rooms and clinical spaces, terminal cleaning of patient rooms prior to returning from the OR, and use of adjunctive ultraviolet light for the daily cleaning of operating rooms and patient rooms at discharge. Results: Surveillance definition of microbiological growth from a clinical sample obtained within 30 days of primary cardiac procedure sufficiently captured all CT-surgery SSIs. Of 551 CT-surgery procedures prior to intervention, 91 (17%) had delayed final operative closures. Prior to the intervention, 16 SSIs were identified from July 2017 – May 2019 for a rate of 2.90 per /100 procedures, and was higher among patients with delayed chest closure 6.59 per /100 procedures (6 SSIs/91 procedures) versus those with primary chest closure 2.17 per /100 procedures (10 SSIs/460 procedures; P = 0.034). Gram-positive organisms, including coagulase coagulase-negative Staphylococci, were most frequently identified as the causative organisms for SSIs. Compliance with bundled intervention, rolled out over a 2-month period, was associated with an immediate decrease in the number of SSIs for primary and delayed chest closures 6SSIs /185 procedures in the initial quarters (August – December 2019) of the post-intervention period. However, this decrease was not reflected in the overall rate (3.24 per /100 procedures) due to fewer procedures performed. Data collection to measure sustainability is ongoing. Conclusions: Bundled interventions targeting skin antisepsis and environmental cleaning may be associated with a decrease in SSIs among pediatric CT-surgery patients. Ongoing surveillance is required to determine sustainability of these interventions.
Background: Acute respiratory infections (ARIs) are a key target to improve antibiotic use in the outpatient setting. The Core Elements of Outpatient Antibiotic Stewardship provide a framework for improving antibiotic use, but data on safety and effectiveness of interventions to improve antibiotic use are limited. We report the impact of Core Elements implementation within Veterans’ Healthcare Administration clinics on antibiotic prescribing and patient outcomes. Methods: The intervention targeting treatment of uncomplicated ARIs (sinusitis, pharyngitis, bronchitis, and viral upper respiratory infections [URIs]) in emergency department and primary care settings was initiated within 10 sites between September 2017 and January 2018. The intervention was developed using the Core Elements and included local site champions, audit-and-feedback with peer comparison, and academic detailing. We evaluated the following outcomes: per-visit antibiotic prescribing rates overall and by diagnosis; appropriateness of treatment; 30-day ARI revisits; 30-day infectious complications (eg,, pneumonia,); 30-day adverse medication effects; 90-day Clostridium difficile infection (CDI); and 30-day hospitalizations. Multilevel logistic regression was used to calculate rate ratios (RR) with 95% CI for each outcome in the postintervention period (12 months) compared to the preintervention period (39–42 months). Results: There were 14,020 uncomplicated ARI visits before the intervention and 4,866 uncomplicated ARI visits after the intervention. The proportions of uncomplicated ARI visits with antibiotics prescribed were 59.17% before the intervention versus 44.34% after the intervention. A trend in reduced antibiotic prescribing for ARIs throughout the entire (before and after) observation period was evident (0.92; 95% CI, 0.90–0.94); however, a significant reduction in antibiotic prescribing after the intervention was identified (0.74; 95% CI, 0.59–0.93). Per-visit antibiotic prescribing rates decreased significantly for bronchitis and URI (0.54; 95% CI, 0.44–0.65), pharyngitis (0.76; 95% CI, 0.67–0.86), and sinusitis (0.92; 95% CI, 0.85–1.0). Appropriate therapy for pharyngitis increased (1.43; 95% CI, 1.21–1.68), but appropriate therapy for sinusitis remained unchanged (0.92; 95% CI, 0.85–1.0) after the intervention. Complications associated with antibiotic undertreatment were not different after the intervention: ARI-related revisit rates (1.01; 95% CI, 0.98–1.05) and infectious complications (1.01; 95% CI, 0.79–1.28). A potential benefit of improved antibiotic use included a reduction in visits for adverse medication effects (0.82; 95% CI, 0.72–0.94). Furthermore, 90-day CDI events were too sparse to model: preintervention incidence was 0.08% and postintervention incidence was 0.06%. Additionally, 30-day hospitalizations were significantly lower in the postintervention period (0.79; 95% CI, 0.72–0.87). Conclusions: Implementation of the Core Elements was safe and effective and was associated with reduced antibiotic prescribing rates for uncomplicated ARIs, improvements in diagnosis-specific appropriate therapy, visits for adverse antibiotic effects, and 30-day hospitalization rates. No adverse events were noted in ARI-related revisit rates or infectious complications. CDI rates were low and unchanged.
The aim of this paper is to investigate the effectiveness of physical exercise in managing fatigue during radiotherapy for prostate cancer patients. It explores the impact of various physical exercise regimes and their role in the prevention and management of fatigue to help inform best practice.
A literature search was conducted on OVID Medline database with a follow-up search on google scholar to include relevant references found during the initial search. Relevant systematic reviews and randomised controlled trials (RCTs) arising from this search were reviewed.
There is evidence to support the notion that physical exercise in all its forms is an effective and safe intervention for fatigue management for prostate cancer patients undergoing radiotherapy. Although widely studied, there is limited evidence of fatigue management strategies being clearly implemented into current radiotherapy practice for patients with prostate cancer. This information is essential to enable therapeutic radiographers to educate prostate cancer patients regarding effective exercise strategies and ensure that fatigue is managed optimally.
Further research is required into the optimum physical exercise prescription to reduce radiation-induced fatigue, and standardised best practice guidelines should be developed nationally. A future move toward patient education into physical exercise and wellbeing should be a central component of the therapeutic radiographer role with specialist advice offered by review radiographers, empowering patients to become more physically active during treatment. Therapeutic radiographers have a unique opportunity to educate and promote physical exercise through a holistic wellbeing approach that aims to mitigate fatigue and improve quality of life.
Subjective cognitive difficulties are common in mental illness and have a negative impact on role functioning. Little is understood about subjective cognition and the longitudinal relationship with depression and anxiety symptoms in young people.
To examine the relationship between changes in levels of depression and anxiety and changes in subjective cognitive functioning over 3 months in help-seeking youth.
This was a cohort study of 656 youth aged 12–25 years attending Australian headspace primary mental health services. Subjective changes in cognitive functioning (rated as better, same, worse) reported after 3 months of treatment was assessed using the Neuropsychological Symptom Self-Report. Multivariate multinomial logistic regression analysis was conducted to evaluate the impact of baseline levels of and changes in depression (nine-item Patient Health Questionnaire; PHQ9) and anxiety symptoms (seven-item Generalised Anxiety Disorder scale; GAD7) on changes in subjective cognitive function at follow-up while controlling for covariates.
With a one-point reduction in PHQ9 at follow-up, there was an estimated 11–18% increase in ratings of better subjective cognitive functioning at follow-up, relative to stable cognitive functioning. A one-point increase in PHQ9 from baseline to follow-up was associated with 7–14% increase in ratings of worse subjective cognitive functioning over 3 months, relative to stable cognitive functioning. A similar attenuated pattern of findings was observed for the GAD7.
A clear association exists between subjective cognitive functioning outcomes and changes in self-reported severity of affective symptoms in young people over the first 3 months of treatment. Understanding the timing and mechanisms of these associations is needed to tailor treatment.
To explore stakeholder perspectives regarding online diabetes nutrition education for American Indians and Alaska Natives (AI/AN) with type 2 diabetes (T2D).
Qualitative data were collected through focus groups and interviews. Focus group participants completed a brief demographic and internet use survey.
Focus groups and community participant interviews were conducted in diverse AI/AN communities. Interviews with nationally recognised content experts were held via teleconference.
Eight focus groups were conducted with AI/AN adults with T2D (n 29) and their family members (n 22). Community participant interviews were conducted with eleven clinicians and healthcare administrators working in Native communities. Interviews with nine content experts included clinicians and researchers serving AI/AN.
Qualitative content analysis used constant comparative method for coding and generating themes across transcripts. Descriptive statistics were computed from surveys. AI/AN adults access the internet primarily through smartphones, use the internet for many purposes and identify opportunities for online diabetes nutrition education.
Online diabetes nutrition education may be feasible in Indian Country. These findings will inform the development of an eLearning diabetes nutrition education programme for AI/AN adults with T2D.
The mechanism through which developmental programming of offspring overweight/obesity following in utero exposure to maternal overweight/obesity operates is unknown but may operate through biologic pathways involving offspring anthropometry at birth. Thus, we sought to examine to what extent the association between in utero exposure to maternal overweight/obesity and childhood overweight/obesity is mediated by birth anthropometry. Analyses were conducted on a retrospective cohort with data obtained from one hospital system. A natural effects model framework was used to estimate the natural direct effect and natural indirect effect of birth anthropometry (weight, length, head circumference, ponderal index, and small-for-gestational age [SGA] or large-for-gestational age [LGA]) for the association between pre-pregnancy maternal body mass index (BMI) category (overweight/obese vs normal weight) and offspring overweight/obesity in childhood. Models were adjusted for maternal and child socio-demographics. Three thousand nine hundred and fifty mother–child dyads were included in analyses (1467 [57.8%] of mothers and 913 [34.4%] of children were overweight/obese). Results suggest that a small percentage of the effect of maternal pre-pregnancy BMI overweight/obesity on offspring overweight/obesity operated through offspring anthropometry at birth (weight: 15.5%, length: 5.2%, head circumference: 8.5%, ponderal index: 2.2%, SGA: 2.9%, and LGA: 4.2%). There was a small increase in the percentage mediated when gestational diabetes or hypertensive disorders were added to the models. Our study suggests that some measures of birth anthropometry mediate the association between maternal pre-pregnancy overweight/obesity and offspring overweight/obesity in childhood and that the size of this mediated effect is small.
Current dietary recommendations encourage increased fibre and reduced sugar consumption. In the UK, specific targets and benchmarks have been established for the sugar content of some foods but not for fibre. National Food Consumption Surveys provide comprehensive information of all foods consumed by representative population samples. The Irish national food surveys as completed by the Irish Universities Nutrition Alliance (IUNA) capture dietary data at brand level with all details as gathered on pack entered into a discrete but inter-linked database, the Irish National Food Ingredient Database (INFID). The aim of this study was to profile the carbohydrate quality of a convenience sub-sample of packaged foods as eaten by Irish children during the National Children's Food Survey II (2017/2018) as entered into INFID.
Materials and Methods:
All on-pack details from 385 available foods in the categories ‘white breads and rolls’; ‘brown breads and rolls’; ‘other breads and scones’; ‘ready to eat breakfast cereals (RTEBC)’; ‘biscuits’; and ‘cakes, buns and pastries’ were entered in to INFID and quality control completed. The carbohydrate profile of the products was assessed with respect to fibre labelling criteria and UK sugar guidelines and targets. SPSS Version 25 was used for all analyses.
Although 56% (n210) of all products entered were eligible to make a ‘source of’ or ‘high’ fibre claim, only 20% (n78) made such a claim. Of this, 46% stated ‘high fibre’ and 32% ‘source’, predominately in the ‘brown breads and rolls’ and ‘RTEBC’ groups. When compared to UK Department of Health guidance for ‘low’, ‘medium’ and ‘high’ sugar, 65% of all products examined (n250) were either ‘low’ or ‘medium’ sugar. Comparison of median sugar contents with Public Health England sugar reformulation targets revealed different responses in each category, with all categories other than foods deemed as “morning goods” yet to meet the 2020 target of 20% reduction in sugar content.
This small pilot study of a convenience sample of foods suggests that for the limited number of foods examined, for some there remains challenges to reduce sugar and increase fibre contents. Strategies such as reformulation, change in portion size, flexibility in labelling and/or a shift in sales portfolios could be considered but only alongside technological and safety considerations. Further research to broaden this analysis and to link nutrient levels as listed on pack with actual consumption patterns could help ensure all recent initiatives including reformulation are recognised.
Food portion sizes routinely consumed by children have increased over time and consumption of larger portion sizes is associated with higher weight status. Parents often have the critical role of deciding portion sizes of foods to serve their children. It is not well understood, however, how parents decide the amount of food to serve. This research aimed to investigate parental views on portion sizes of foods and beverages served to children.
A purposive sample of preschools and primary schools geographically located in either urban or rural areas of Northern Ireland and the Republic of Ireland, and classified as either high or low deprivation were recruited. Selected schools were invited to facilitate this research. Parents with at least one child aged 2–12 years attending a recruited school were then invited to participate in a focus group. A maximum of three groups were scheduled with interested parents at each school. One researcher moderated the focus groups, assisted by another researcher in all groups where possible. A semi-structured discussion guide was followed, using probes to stimulate discussion. The guide explored practices in portioning foods and beverages for children, factors influencing portioning and views on portion sizes of foods and beverages served to children. Discussions were audio-recorded, transcribed verbatim and data was analysed thematically. Nvivo software was used to manage the coded data.
Focus groups (n = 24) ranging in size from 3–12 parents were conducted across 19 schools. The response rate from parents at recruited schools ranged from 1–16%. A total of 144 parents (86% female, mean age 46y) participated, of which 60% had a child attending a high deprivation school and 64% had a child attending a rural school. Factors influencing parental portioning included seven themes comprised of sub-themes: parent knowledge (portion size knowledge, serving a learned amount), parent motivations (ensure child is fed, encourage healthier food), child-related factors (appetite, body size, food preferences, eating patterns), family influence (spouses and grandparents serving), food retail and other settings (restaurants, takeaways, special occasions), socio-cultural influences (parent childhood experiences, parents’ portion size norms) and portioning resources used (serve ware, utensils, hand sizes).
Parents’ main concern regarding the amount they feed their children was to ensure that they are fed a sufficient amount to feel full. Parents learned this amount through experience and felt it was specific to each child's appetite. These findings will inform future interventions and information campaigns to help parents understand child portion sizes.
Unlike most other countries, in the United States, subnational governments (states) have substantial authority over collective bargaining and union organization laws. Because states compete for business investment and union (dis)organization likely has spillover effects beyond state borders, weak unions in one state may affect union organization in other states. We examine how union decline in one state is associated with union decline in neighboring states, and whether the presence of prounion (left-leaning) governments may limit the spread of union decline. Examining a period of major union decline (1983-2014), we find that union weakness in one state is associated with union weakness in nearby states. We observe that Democratic power in Congress is associated with higher unionization rates, but that liberal state governments have been relatively powerless to stop union decline in this period. These findings have important implications for understanding the historical and contemporary weakness of American unions and for the future of union strength in the United States.
Psychiatric disorders are associated with increased risk of ischaemic heart disease (IHD) and stroke, but it is not known whether the associations or the role of sociodemographic factors have changed over time.
To investigate the association between psychiatric disorders and IHD and stroke, by time period and sociodemographic factors.
We used Scottish population-based records from 1991 to 2015 to create retrospective cohorts with a hospital record for psychiatric disorders of interest (schizophrenia, bipolar disorder or depression) or no record of hospital admission for mental illness. We estimated incidence and relative risks of IHD and stroke in people with versus without psychiatric disorders by calendar year, age, gender and area-based deprivation level.
In all cohorts, incidence of IHD (645 393 events) and stroke (276 073 events) decreased over time, but relative risks decreased for depression only. In 2015, at the mean age at event onset, relative risks were 2- to 2.5-fold higher in people with versus without a psychiatric disorder. Age at incidence of outcome differed by cohort, gender and socioeconomic status. Relative but not absolute risks were generally higher in women than men. Increasing deprivation conveys a greater absolute risk of IHD for people with bipolar disorder or depression.
Despite declines in absolute rates of IHD and stroke, relative risks remain high in those with versus without psychiatric disorders. Cardiovascular disease monitoring and prevention approaches may need to be tailored by psychiatric disorder and cardiovascular outcome, and be targeted, for example, by age and deprivation level.
In this article we engage in a critical examination of how local authority Housing Solutions staff, newly placed centre stage in preventing homelessness amongst prison leavers in Wales, understand and go about their work. Drawing on Carlen’s concept of ‘imaginary penalities’ and Ugelvik’s notion of ‘legitimation work’ we suggest practice with this group can be ritualistic and underpinned by a focus on prison leavers’ responsibilities over their rights, and public protection over promoting resettlement. In response we advocate for less-punitive justice and housing policies, underpinned by the right to permanent housing for all prison leavers and wherein stable accommodation is understood as the starting point for resettlement. The analysis presented in this article provides insights to how homelessness policies could play out in jurisdictions where more joint working between housing and criminal justice agencies are being pursued and/or preventative approaches to managing homelessness are being considered.