In paediatric cardiac patients requiring staged palliation, superior cavopulmonary anastomosis is common. Pain control is a crucial aspect of postoperative care as agitation, untreated pain, and hypoventilation can cause increased pulmonary vascular resistance reduction and pulmonary blood flow.

This was a large volume single-centre, retrospective cohort study evaluating the impact of gabapentin on opioid and benzodiazepine exposure in infants undergoing superior cavopulmonary anastomosis between January 2018 and December 2022. The primary endpoint was opioid exposure in morphine milligram equivalents per kilogram in infants receiving gabapentin compared to no gabapentin.

The study analysed 85 infants, 40 of which received perioperative gabapentin. Other than there being more males in the gabapentin group (70% versus 47%; p = 0.03), there was no difference in baseline characteristics. Opioid use, measured in morphine milligram equivalents per kilogram, was similar in the no gabapentin group compared to the gabapentin group during the first 5 POD’s (2.66 (interquartile range1.76, 3.30) versus 2.27 (interquartile range R 1.75, 3.40); p = 0.93. However, there was a lower benzodiazepine exposure, measured in midazolam equivalents per kilogram, in the gabapentin group both on POD 2 (0.05 (interquartile range 0.00, 0.11) versus 0 (interquartile range 0.00, 0.08); p = 0.031) and cumulative (0.15 (interquartile range 0.00, 0.35) versus 0.05 (interquartile range 0.00, 0.15); p = 0.031).

Gabapentin did not significantly reduce opioid exposure; however, its use was associated with modest reduction in benzodiazepine exposure. There were no differences in adverse events. Our findings suggest gabapentin is safe in infants undergoing superior cavopulmonary anastomosis; however, additional studies should be conducted to evaluate optimal gabapentin dosing.

Ultrasound-guided wire localisation may improve intra-operative identification and outcomes of non-palpable cervical lymphadenopathy in a previously treated neck. We undertook a literature search and present our case series to determine the safety and efficacy of ultrasound-guided wire localisation.

A search of databases up to 29 April 2024 was performed. At our tertiary centre, ultrasound-guided wire localisation was utilised for 20 patients with cervical lymphadenopathy between February 2021 and April 2024.

Seventeen studies with a combined total of 92 patients were identified, with one complication reported. Within our case series, all 20 patients had accurate lesion localisation using ultrasound-guided wire localisation and none required repeat operations.

Ultrasound-guided wire localisation is a safe and cost-effective technique for lesions in an otherwise difficult area to operate, providing confidence to the multidisciplinary team, particularly where histopathology indicates benignity. Surgical outcomes do not appear worse than outcomes without ultrasound-guided wire localisation. We advocate its use provided appropriate patient selection is considered.

Co-occurring self-harm and aggression (dual harm) is particularly prevalent among forensic mental health service (FMHS) patients. There is limited understanding of why this population engages in dual harm.

This work aims to explore FMHS patients’ experiences of dual harm and how they make sense of this behaviour, with a focus on the role of emotions.

Participants were identified from their participation in a previous study. Sixteen FMHS patients with a lifetime history of dual harm were recruited from two hospitals. Individuals participated in one-to-one, semi-structured interviews where they reflected on past and/or current self-harm and aggression. Interview transcripts were analysed using reflexive thematic analysis.

Six themes were generated: self-harm and aggression as emotional regulation strategies, the consequences of witnessing harmful behaviours, relationships with others and the self, trapped within the criminal justice system, the convergence and divergence of self-harm and aggression, and moving forward as an FMHS patient. Themes highlighted shared risk factors of dual harm across participants, including emotional dysregulation, perceived lack of social support and witnessing harmful behaviours. Participants underlined the duality of their self-harm and aggression, primarily utilising both to regulate negative emotions. These behaviours also fulfilled distinct purposes at times (e.g. self-harm as punishment, aggression as defence). The impact of contextual factors within FMHSs, including restrictive practices and institutionalisation, were emphasised.

Findings provide recommendations that can help address dual harm within forensic settings, including (a) transdiagnostic, individualised approaches that consider the duality of self-harm and aggression; and (b) cultural and organisational focus on recovery-centred practice.

Accurate diagnosis of bipolar disorder (BPD) is difficult in clinical practice, with an average delay between symptom onset and diagnosis of about 7 years. A depressive episode often precedes the first manic episode, making it difficult to distinguish BPD from unipolar major depressive disorder (MDD).

We use genome-wide association analyses (GWAS) to identify differential genetic factors and to develop predictors based on polygenic risk scores (PRS) that may aid early differential diagnosis.

Based on individual genotypes from case–control cohorts of BPD and MDD shared through the Psychiatric Genomics Consortium, we compile case–case–control cohorts, applying a careful quality control procedure. In a resulting cohort of 51 149 individuals (15 532 BPD patients, 12 920 MDD patients and 22 697 controls), we perform a variety of GWAS and PRS analyses.

Although our GWAS is not well powered to identify genome-wide significant loci, we find significant chip heritability and demonstrate the ability of the resulting PRS to distinguish BPD from MDD, including BPD cases with depressive onset (BPD-D). We replicate our PRS findings in an independent Danish cohort (iPSYCH 2015, N = 25 966). We observe strong genetic correlation between our case–case GWAS and that of case–control BPD.

We find that MDD and BPD, including BPD-D are genetically distinct. Our findings support that controls, MDD and BPD patients primarily lie on a continuum of genetic risk. Future studies with larger and richer samples will likely yield a better understanding of these findings and enable the development of better genetic predictors distinguishing BPD and, importantly, BPD-D from MDD.

Although atypical antipsychotics have lowered the prevalence and severity of extrapyramidal symptoms (EPS), they still contribute to the overall side-effect burden of approved antipsychotics. Drugs with novel mechanisms without D2 dopamine receptor blocking activity have shown promise in treating schizophrenia without the side effects of currently available treatments. KarXT (xanomeline–trospium chloride) represents a possible alternative that targets muscarinic receptors. KarXT demonstrated efficacy compared with placebo in 3 out of 3 short-term acute studies and has not been associated with many of the side effects of D2 dopamine receptor antagonists. Here, we further characterize EPS rates with KarXT in these trials.

EMERGENT-1 (NCT03697252), EMERGENT-2 (NCT04659161), and EMERGENT-3 (NCT04738123) were 5-week, randomized, double-blind, placebo-controlled, inpatient trials in people with schizophrenia experiencing acute psychosis. Data from the safety populations, defined as all participants who received ³1 dose of trial medication, were pooled. For this analysis, we used a broader definition of EPS-related adverse events (AEs) to encompass any new onset of dystonia, dyskinesia, akathisia, or extrapyramidal disorder reported any time after the first dose of medication. Additionally, EPS were assessed by examining change from baseline to week 5 on the Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), and Abnormal Involuntary Movement Scale (AIMS).

A total of 683 participants (KarXT, n=340; placebo, n=343) were included in the analyses. The rate of treatment-emergent AEs (TEAEs) associated with EPS was 3.2% in the KarXT group vs 0.9% in the placebo group. The most commonly reported TEAE was akathisia (KarXT, 2.4%; placebo 0.9%); half of possible akathisia cases in the KarXT group (4/8 TEAEs) were from a single US site, considered by the investigator to be unrelated to trial drug, and resolved without treatment. Overall rates of akathisia TEAEs deemed related to trial drug were low (KarXT, 0.6%; placebo 0.3%). Dystonia, dyskinesia, and extrapyramidal disorder TEAEs were reported by only a single subject each (0.3%) in the KarXT arm. All reported TEAEs were mild to moderate in severity. KarXT was associated with no clinically meaningful mean±SD changes from baseline to week 5 on the SAS (-0.1±0.6), BARS (-0.1±0.9), or AIMS (0.0±0.7).

The incidence of EPS-related TEAEs with KarXT was low in comparison to those observed in similar trials of antipsychotics (D2 dopamine receptor antagonists), although head-to-head studies have not been completed. Moreover, KarXT was not associated with increased scores on EPS scales (SAS, BARS, AIMS) across 5 weeks of treatment. These results, combined with the robust efficacy of KarXT in trials to date, suggest that KarXT’s novel mechanism of action may provide therapeutic benefit in the absence of EPS frequently associated with currently available antipsychotics.

Karuna Therapeutics

Second primary breast cancers are among the most common risks to female patients who have received radiotherapy for mediastinal lymphoma.

This study aims to audit breast dose in women who received mediastinal radiotherapy for lymphoma and compare the combined dose parameter values measured to those in the literature.

Twenty-three patient datasets from 2017 to 2021 were obtained. Inclusion criteria, such as female gender and 30Gy prescription dose, were applied. Target volumes were delineated using involved site radiotherapy and planned on Eclipse (Varian, Palo Alto, CA) using either fixed field or VMAT. Breast contours were retrospectively outlined according to RTOG/EORTC guidance and descriptive statistics were used to compare findings to those from the literature.

Differences were found in V4gy, V5Gy and mean dose compared to the literature with mean dose being 2Gy in the literature and 4Gy in this audit.

Breast dose parameter values between patients in this study vary due to multiple factors. These include the treatment delivery method used and the position of the treatment field in relation to the location of breast tissue. Mean dose and V4% and V5% to breast tissue found in this study differ from that found in the literature. This study highlights the importance of accurate contouring and optimising breast tissue when possible.

Early intervention in psychosis (EIP) services improve outcomes for young people, but approximately 30% disengage.

To test whether a new motivational engagement intervention would prolong engagement and whether it was cost-effective.

We conducted a multicentre, single-blind, parallel-group, cluster randomised controlled trial involving 20 EIP teams at five UK National Health Service (NHS) sites. Teams were randomised using permuted blocks stratified by NHS trust. Participants were all young people (aged 14–35 years) presenting with a first episode of psychosis between May 2019 and July 2020 (N = 1027). We compared the novel Early Youth Engagement (EYE-2) intervention plus standardised EIP (sEIP) with sEIP alone. The primary outcome was time to disengagement over 12–26 months. Economic outcomes were mental health costs, societal costs and socio-occupational outcomes over 12 months. Assessors were masked to treatment allocation for primary disengagement and cost-effectiveness outcomes. Analysis followed intention-to-treat principles. The trial was registered at ISRCTN51629746.

Disengagement was low at 15.9% overall in standardised stand-alone services. The adjusted hazard ratio for EYE-2 + sEIP (n = 652) versus sEIP alone (n = 375) was 1.07 (95% CI 0.76–1.49; P = 0.713). The health economic evaluation indicated lower mental healthcare costs linked to reductions in unplanned mental healthcare with no compromise of clinical outcomes, as well as some evidence for lower societal costs and more days in education, training, employment and stable accommodation in the EYE-2 group.

We found no evidence that EYE-2 increased time to disengagement, but there was some evidence for its cost-effectiveness. This is the largest study to date reporting positive engagement, health and cost outcomes in a total EIP population sample. Limitations included high loss to follow-up for secondary outcomes and low completion of societal and socio-occupational data. COVID-19 affected fidelity and implementation. Future engagement research should target engagement to those in greatest need, including in-patients and those with socio-occupational goals.

The primary objective of our study was to survey ENT surgeons who perform functional endoscopic sinus surgery in the UK regarding their post-sinus surgery practices.

A 28-item questionnaire on post-functional endoscopic sinus surgery practices was distributed electronically to ENT UK members specialising in rhinology.

Ninety (90 per cent) surgeons prescribe saline nasal irrigation post-functional endoscopic sinus surgery but administration timing and methods vary. Following functional endoscopic sinus surgery, 17.7 per cent (n = 17) of respondents routinely prescribe antibiotics, whilst about a quarter (26.0 per cent, n = 25) do not prescribe antibiotics at all. The rest of the respondents only prescribe antibiotics in specific cases. Thirty-three (34.7 per cent) respondents do not prescribe oral steroids whilst most clinicians (83.9 per cent, n = 78) prescribe intranasal corticosteroids post-operatively.

Our study highlights homogeneous, evidence-based practices post-functional endoscopic sinus surgery from UK-based specialists, specifically in the use of saline irrigation and intranasal corticosteroids. However, our cohort displayed significant heterogeneity regarding oral antibiotics, oral steroids, and other specific aspects of post-operative care.

Understanding variations in knowledge and attitudes of psychiatrists to psilocybin therapy is important for the collective discourse about the potential impact on clinical practice and public health in Ireland.

A 28-item questionnaire was designed based on previous studies and distributed to psychiatrists in Ireland via online mailing lists and at in-person academic events.

151 psychiatrists completed the questionnaire (73.3% were under 40 years of age, 76.0% were trainees, and 49.0% were female). In the total sample, 81.5% agreed that psilocybin therapy shows promise in the treatment of psychiatric disorders and 86.8% supported funding research, 86.8% would be willing to refer a patient if it was licensed and indicated, and 78.1% would consider the treatment for themselves, if indicated. Conversely, 6.6% agreed that psilocybin therapy was unsafe even under medical supervision, and 21.9% thought it was potentially addictive. 15.9% of the total sample reported at least one concern including, lack of robust evidence, long-term effectiveness, superiority to current interventions, potential harmful effects, cost and accessibility, and impartiality. Less than half of respondents felt knowledgeable (40.0%) and 9.9% felt adequately prepared to participate in psilocybin therapy. Consultant psychiatrists trended towards less optimism for a potential role in bipolar depression and emotionally unstable personality disorder compared to trainee psychiatrists.

Overall psychiatrists in Ireland held positive attitudes towards psilocybin therapy. However, there was a lack of knowledge evident. Addressing the knowledge gap and aligning with the best available evidence will be key if psychedelic therapy is to prevail in a clinical setting.