Patients with posttraumatic stress disorder (PTSD) exhibit smaller regional brain volumes in commonly reported regions including the amygdala and hippocampus, regions associated with fear and memory processing. In the current study, we have conducted a voxel-based morphometry (VBM) meta-analysis using whole-brain statistical maps with neuroimaging data from the ENIGMA-PGC PTSD working group.

T1-weighted structural neuroimaging scans from 36 cohorts (PTSD n = 1309; controls n = 2198) were processed using a standardized VBM pipeline (ENIGMA-VBM tool). We meta-analyzed the resulting statistical maps for voxel-wise differences in gray matter (GM) and white matter (WM) volumes between PTSD patients and controls, performed subgroup analyses considering the trauma exposure of the controls, and examined associations between regional brain volumes and clinical variables including PTSD (CAPS-4/5, PCL-5) and depression severity (BDI-II, PHQ-9).

PTSD patients exhibited smaller GM volumes across the frontal and temporal lobes, and cerebellum, with the most significant effect in the left cerebellum (Hedges’ g = 0.22, pcorrected = .001), and smaller cerebellar WM volume (peak Hedges’ g = 0.14, pcorrected = .008). We observed similar regional differences when comparing patients to trauma-exposed controls, suggesting these structural abnormalities may be specific to PTSD. Regression analyses revealed PTSD severity was negatively associated with GM volumes within the cerebellum (pcorrected = .003), while depression severity was negatively associated with GM volumes within the cerebellum and superior frontal gyrus in patients (pcorrected = .001).

PTSD patients exhibited widespread, regional differences in brain volumes where greater regional deficits appeared to reflect more severe symptoms. Our findings add to the growing literature implicating the cerebellum in PTSD psychopathology.

Recent stressful life events (SLEs) are an established risk factor for a range of psychiatric disorders. Animal studies have shown evidence of gray matter (GM) reductions associated with stress, and previous work has found similar associations in humans. However longitudinal studies investigating the association between stress and changes in brain structure are limited.

The current study uses longitudinal data from the UK Biobank and comprises 4,543 participants with structural neuroimaging and recent SLE data (mean age = 61.5 years). We analyzed the association between recent SLEs and changes in brain structure, determined using the longitudinal FreeSurfer pipeline, focusing on total GM volume and five a priori brain regions: the hippocampus, amygdala, anterior cingulate cortex, orbitofrontal cortex, and insula. We also examined if depression and childhood adversity moderated the relationship between SLEs and brain structure.

Individuals who had experienced recent SLEs exhibited a slower rate of hippocampal decrease over time compared to individuals who did not report any SLEs. Individuals with depression exhibited smaller GM volumes when exposed to recent SLEs. There was no effect of childhood adversity on the relationship between SLEs and brain structure.

Our findings suggest recent SLEs are not directly associated with an accelerated decline in brain volumes in a population sample of older adults, but instead may alter brain structure via affective disorder psychopathology. Further work is needed to investigate the effects of stress in younger populations who may be more vulnerable to stress-induced changes, and may yet pinpoint brain regions linked to stress-related disorders.

Recent stressful life events (SLE) are a risk factor for psychosis, but limited research has explored how SLEs affect individuals at clinical high risk (CHR) for psychosis. The current study investigated the longitudinal effects of SLEs on functioning and symptom severity in CHR individuals, where we hypothesized CHR would report more SLEs than healthy controls (HC), and SLEs would be associated with poorer outcomes.

The study used longitudinal data from the EU-GEI High Risk study. Data from 331 CHR participants were analyzed to examine the effects of SLEs on changes in functioning, positive and negative symptoms over a 2-year follow-up. We compared the prevalence of SLEs between CHR and HCs, and between CHR who did (CHR-T) and did not (CHR-NT) transition to psychosis.

CHR reported 1.44 more SLEs than HC (p < 0.001), but there was no difference in SLEs between CHR-T and CHR-NT at baseline. Recent SLEs were associated with poorer functioning and more severe positive and negative symptoms in CHR individuals (all p < 0.01) but did not reveal a significant interaction with time.

CHR individuals who had experienced recent SLEs exhibited poorer functioning and more severe symptoms. However, as the interaction between SLEs and time was not significant, this suggests SLEs did not contribute to a worsening of symptoms and functioning over the study period. SLEs could be a key risk factor to becoming CHR for psychosis, however further work is required to inform when early intervention strategies mitigating against the effects of stress are most effective.

The diverse implant landscape, the rising and disparate costs of implants in public healthcare institutions (PHIs), and the limited application of health technology assessment (HTA) impede fair and sustainable implant subsidies in Singapore. This study described the Agency for Care Effectiveness (ACE) Implant Subsidy List (ISL) methodology and the key enablers for supporting government subsidy of clinically effective and cost-effective implants in Singapore.

A multi-tiered implant grouping scheme on the ISL was established by adapting overseas implant classifications, consulting clinicians, and conducting HTA evaluations, with subsidy extensions at the product group tier. Implants within a product group share similar biomechanical actions and patient outcomes and are subject to the same clinical criteria and pricing requirement. Implants on the ISL must be approved by the regulatory authority. Patients who meet the clinical criteria for ISL implants are eligible for subsidy. ACE conducted value-based pricing (VBP) and partnered with the public healthcare supply chain agency to harmonize PHI implant prices. The ISL is updated three times per year.

Implants listed on the ISL were deemed clinically and cost effective. Underpinned by HTA principles, the implant grouping scheme promoted parsimonious classification, while allowing the creation of new product groups for implants offering superior benefits for patients. Reasonable prices set for the product groups aided affordability and cost sustainability. The ISL clinical criteria and standardized implant identifiers encouraged the appropriate use of subsidized implants and facilitated implementation. By ISL implementation in December 2023, ACE assessed 42,165 implants and listed 22,689 ISL implants spanning 143 product groups. Industry can apply for ISL listing three times per year, which keeps the ISL updated and relevant.

The ISL adopts a fit-for-purpose methodology to standardize implant classifications, enable scalable application of HTA, drive appropriate use of subsidized implants, and bring cost sustainability to the government subsidy of implants in Singapore. A strategic partnership with the public healthcare supply chain agency to concurrently establish national procurement contracts reduced disparate implant prices in PHIs and provided greater leverage for better implant prices.

Salvage neck dissection for squamous cell carcinoma is performed for residual or recurrent nodal disease after chemoradiotherapy or radical radiotherapy for locally advanced head and neck cancer. Our study aims to investigate the extent to which salvage neck dissection can be safely performed in treating recurrent or residual nodal metastasis.

A retrospective analysis of 53 patients with suspected residual or recurrent nodal disease after primary treatment (January 2016 to December 2018) was performed.

Pathological confirmation of viable squamous cell carcinoma following surgery was found in 43.4 per cent of patients. Post-operative infection, accessory and vagal nerve injuries were more common in patients with dissection of levels I–V than that of levels II–IV. There was no significant difference in three-year survival rate between patients with levels II–IV dissection and that of levels I–V dissection (p = 0.84).

The extent of salvage neck dissection can be limited to reduce post-operative complications while maintaining acceptable oncological outcomes.

Persistent cognitive deficits and functional impairments are associated with bipolar disorder (BD), even during the euthymic phase. The dysfunction of default mode network (DMN) is critical for self-referential and emotional mental processes and is implicated in BD. The current study aims to explore the balance of excitatory and inhibitory neurotransmitters, i.e. glutamate and γ-aminobutyric acid (GABA), in hubs of the DMN during the euthymic patients with BD (euBD).

Thirty-four euBD and 55 healthy controls (HC) were recruited to the study. Using proton magnetic resonance spectroscopy (1H-MRS), glutamate (with PRESS sequence) and GABA levels (with MEGAPRESS sequence) were measured in the medial prefrontal cortex/anterior cingulate cortex (mPFC/ACC) and the posterior cingulate gyrus (PCC). Measured concentrations of excitatory glutamate/glutamine (Glx) and inhibitory GABA were used to calculate the excitatory/inhibitory (E/I) ratio. Executive and attentional functions were respectively assessed using the Wisconsin card-sorting test and continuous performance test.

euBD performed worse on attentional function than controls (p = 0.001). Compared to controls, euBD had higher E/I ratios in the PCC (p = 0.023), mainly driven by a higher Glx level in the PCC of euBD (p = 0.002). Only in the BD group, a marginally significant negative association between the mPFC E/I ratio (Glx/GABA) and executive function was observed (p = 0.068).

Disturbed E/I balance, particularly elevated Glx/GABA ratio in PCC is observed in euBD. The E/I balance in hubs of DMN may serve as potential biomarkers for euBD, which may also contribute to their poorer executive function.

Although effective treatments for bulimic-spectrum eating disorders exist, access is often delayed because of limited therapist availability and lengthy waiting lists. Web-based self-help interventions have the potential to bridge waiting times for face-to-face treatment and overcome existing treatment gaps.

This study aims to assess the effectiveness of a web-based guided self-help intervention (everyBody Plus) for patients with bulimia nervosa, binge eating disorder and other specified feeding and eating disorders who are waiting for out-patient treatment.

A randomised controlled trial was conducted in Germany and the UK. A total of 343 patients were randomly assigned to the intervention ‘everyBody Plus’ or a waitlist control condition. The primary outcome was the number of weeks after randomisation until a patient achieved a clinically relevant improvement in core symptoms for the first time. Secondary outcomes included eating disorder attitudes and behaviours, and general psychopathology.

At 6- and 12-month follow-up, the probability of being abstinent from core symptoms was significantly larger for the intervention group compared with the control group (hazard ratio: 1.997, 95% CI 1.09–3.65; P = 0.0249). The intervention group also showed larger improvements in eating disorder attitudes and behaviours, general psychopathology, anxiety, depression and quality of life, compared with the control group at most assessment points. Working alliance ratings with the online therapist were high.

The self-help intervention everyBody Plus, delivered with relatively standardised online guidance, can help bridge treatment gaps for patients with bulimic-spectrum eating disorders, and achieve faster and greater reductions in core symptoms.

The increasing pace at which artificial intelligence medical devices (AI-MDs) or digital health technologies (DHTs) have been introduced and integrated in healthcare has not been matched with appropriate selection criteria for health technology assessment (HTA) to inform funding decision-making. To align with international best practice and local regulatory guidance, the Agency for Care Effectiveness (ACE) developed criteria to include AI-MDs as part of its 2022 topic prioritization process for medical technologies. This abstract describes ACE’s approach to develop the inclusion criteria.

To develop key principles for including AI-MDs in ACE’s topic prioritization process, relevant information from overseas HTA agencies, local regulatory guidelines, and ACE’s existing topic selection criteria were reviewed. A search of international HTA agency websites was conducted in September 2022 to identify relevant information on inclusion of AI-MDs in healthcare for reimbursement recommendations.

Additionally, local regulatory guidelines for AI-MDs in healthcare were also identified. The inclusion criteria were then piloted with AI-MDs identified from ACE’s horizon scanning workstream to examine their feasibility for HTA topic selection.

One overseas framework on DHTs from the National Institute for Health and Care Excellence (NICE) and two local regulatory guidelines were identified. Based on the key finding that the purpose of AI-MD use in guiding clinical management and its associated risks were important considerations, the following criteria were developed: (i) full registration with the regulatory body;(ii) device characteristics should be interventional, have direct impact on patient safety, or support accurate diagnosis or treatment which is critical to avoid death and serious health deterioration; and (iii) the AI algorithm should be fixed as opposed to adaptable as per regulatory requirements. Using this inclusion criteria, eight AI-MDs surfaced from horizon scanning were screened with the above criteria and deemed suitable for HTA topic selection.

As AI technologies are increasingly used to replace or supplement current clinical practice, continuous adaptation of HTA method is needed to ensure appropriate topic selection.

Given time and resource constraints, health technology assessments (HTAs) should avoid duplicating prior HTAs. This abstract describes the experience of the Agency for Care Effectiveness (ACE) with adapting and building on published HTAs of medical technologies to support efficient decision-making.

Upon defining the scope of an evaluation topic, searches were performed on reference agency websites and HTA networks, such as the International Network of Agencies for Health Technology Assessment, to identify relevant published HTAs. Identified reports were included for evidence synthesis if the inclusion criteria were met. If multiple relevant HTAs were identified, the most recent or comprehensive HTA identified was used as the foundational evidence base and supplemented by additional primary or secondary literature as needed. When deemed necessary, de novo economic models were developed. Where available, reimbursement decisions or recommendations from published HTAs and their applicability to Singapore’s context were also considered. Following ACE’s evaluations, the Ministry of Health Medical Technology Advisory Committee (MTAC) made subsidy recommendations.

To date, ACE has completed 54 HTA evaluations of medical technologies, 47 (87%) of which incorporated published HTA evidence. Although some MTAC recommendations were aligned with published HTAs, discrepancies were observed that were mainly attributed to evolution of the technology or evidence since publication of HTAs; different local clinical needs or management algorithms; and different local costs of the intervention and comparator. Key challenges in adapting published HTAs included differences in the target population and intervention or comparator in published HTAs, mixed recommendations from published HTAs, and non-English language reports, which may underscore the need to adapt published HTAs to Singapore’s context. To overcome some of these challenges, close consultation with stakeholders is critical to understand local clinical need and care pathways and to gather key information such as costs.

Published HTAs, when used as an evidence base and supplemented by evidence updates and local contextualization, allow for efficient and robust HTA to support decision-making.

This paper aims to report South East Asian Nutrition Surveys (SEANUTS) II Malaysia data on nutritional status, dietary intake and nutritional biomarkers of children aged 6 months to 12 years.

Cross-sectional survey conducted in 2019–2020.

Multistage cluster sampling conducted in Central, Northern, Southern and East Coast regions of Peninsular Malaysia.

2989 children aged 0·5–12·9 years.

Prevalences of stunting, thinness, overweight and obesity among children aged 0·5–12·9 years were 8·9 %, 6·7 %, 9·2 % and 8·8 %, respectively. Among children below 5 years old, 11·4 % were underweight, 13·8 % had stunting and 6·2 % had wasting. Data on nutritional biomarkers showed that a small proportion of children aged 4–12 years had Fe (2·9 %) and vitamin A deficiencies (3·1 %). Prevalence of anaemia was distinctly different between children below 4 years old (40·3 %) and those aged 4 years and above (3·0 %). One-fourth of children (25·1 %) had vitamin D insufficiency, which was twice as prevalent in girls (35·2 % v. boys: 15·6 %). The majority of children did not meet the recommended dietary intake for Ca (79·4 %) and vitamin D (94·8 %).

Data from SEANUTS II Malaysia confirmed that triple burden of malnutrition coexist among children in Peninsular Malaysia, with higher prevalence of overnutrition than undernutrition. Anaemia is highly prevalent among children below 4 years old, while vitamin D insufficiency is more prevalent among girls. Low intakes of dietary Ca and vitamin D are also of concern. These findings provide policymakers with useful and evidence-based data to formulate strategies that address the nutritional issues of Malaysian children.

This study sought to elucidate the occupational health risk perception and psychological impact during the early phase of the COVID-19 pandemic on healthcare workers in a general hospital in Singapore, and factors that influenced risk perception and psychological impact.

Healthcare workers from a general hospital in Singapore were invited to participate in an online survey in June 2020. It posed questions on demographic and occupational information (age, gender, nationality, marital status, profession, working area, length of working experience in healthcare), 20 items on occupational health risk perception and psychological impact of COVID-19, and the Depression Anxiety and Stress Scale-21 (DASS-21).

The 20 items were adapted from a previous study during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak and designed to assess participants’ perceived exposure risk, risk acceptance, families’ perception, stigmatisation, feelings of appreciation, workload, and perceived effectiveness of workplace protective measures. Participants’ responses were obtained on a 6-point Likert scale (strongly agree, agree, somewhat agree, somewhat disagree, disagree, strongly disagree).

For data analysis, responses on occupational risk perception were regrouped into three levels. Depression, anxiety, and stress scores were categorised into quartiles. Ordinal logistics regression was used to compare the association of occupational risk perception with DASS-21 scores, and demographic factors with occupational risk perception. Variables that showed statistical significance (set at P <0.05) in univariate analysis were included in the multivariate ordinal logistics regression model to identify independent predictors.

There were 1252 respondents (92 doctors, 661 nurses, 318 allied health professionals, 181 administrative and support personnel). 85% felt an increased risk of exposure to COVID-19 while 90% accepted the risk as part of their jobs. Stigmatisation against healthcare workers was present, with 45% reported they were shunned and 21% reported their families were avoided. 78% experienced increased workload. Fortunately, most (94%) found workplace protective measures adequate, and felt appreciated by their employer (87%) and society (81%).

Increased perception of occupational health risk was significantly associated with nursing profession, workers in patient-facing areas, and staff with shortest working experience in healthcare.

The mean DASS-21 scores were 9.2 (borderline normal) for Depression, 8.5 (borderline mild) for Anxiety, and 10.9 (normal) for Stress. Increased DASS-21 scores were significantly associated with greater occupational risk perception, younger age, and less years of working experience.

Occupational risk perception amid the early COVID-19 pandemic is associated with adverse mental health among healthcare workers. Nurses, younger staff, and staff with least working experience are more vulnerable.

Ward rounds are key to treatment-related decision-making, but are often stressful. This project aimed to explore and improve patients’ experiences of the clinical team meeting (CTM; historically known as ward round) in an adult in-patient eating disorders unit. A mixed-method approach was adopted with in vivo observations, two focus groups and an interview. Six patients participated. Two former patients contributed to data analysis, co-production of service improvement initiatives and write-up.

The mean CTM duration was 14.3 min. Patients spoke half of the time, followed by psychiatry colleagues. ‘Request’ was the most discussed category. Three themes were identified: CTMs are important but impersonal, a sense of palpable anxiety was generated and staff and patients had divergent views regarding CTM goals.

The co-produced changes to CTMs were implemented and improved patient's experiences despite COVID-19 challenges. Factors beyond CTMs, including the ward's power hierarchy, culture and language, need addressing to facilitate shared decision-making.