Increasing rates of involuntary treatment in the UK and persisting ethnic disparities in detentions have led to the reform of the Mental Health Act (MHA) in 2025. The MHA bill introduces several new measures including the offer of Advance Choice Documents (ACDs) to people who wish to make them. ACDs are written statements of a person’s wishes and preferences for treatment and care, made when a person is well and has the capacity to do so. Systematic reviews show that ACDs can reduce detention rates by up to 25%. The South London and Maudsley NHS Foundation Trust (SLaM) rolled out ACDs as part of routine care, ahead of the MHA 2025. This study describes the implementation of ACDs as part of routine care at SLaM.

SLaM recruited independent senior mental health professionals (ACD facilitators) to lead the creation, use and review of ACDs. The facilitators underwent training and utilised resources previously developed through previous research. The resources included an ACD template, an ACD manual and role description for facilitators, simulation training and Recovery College courses. A clinical lead and clinical supervisor were also employed to provide oversight for the implementation project. Data on implementation were collected through case note reviews, and interviews with service users and staff. Analyses on how ACDs were created and used when people experienced crises were conducted.

At the time of abstract submission, 77 ACDs have been created with service users at SLaM. The implementation of ACDs has been aided by service user-led initiatives such as the Patient Carer Race Equality Framework, staff training, and Recovery College courses which enabled people to create ACDs with high fidelity to the evidenced interventions. Staff and service users report that the ACD creation process is a holistic experience that is empowering and beneficial for improving therapeutic alliance between service users and mental health professionals. The main barrier cited by staff was a lack of time due to large caseloads.Service users expressed scepticism about their ACDs being accessed and honoured during times of crisis.

Implementing evidence-based interventions in healthcare settings is complex. SLaM has replicated the implementation of ACDs with high fidelity to the intervention trials that reported reductions in Mental Health Act detentions and greater autonomy for service users. Our results show that multiple strategies are needed to accelerate the reach and adoption of ACDs in other Trusts.

Health technology management (HTM) involves systems designed to ensure the safe, effective, and cost-effective use of health technologies following reimbursement. This study examines the recommendations of Ireland’s Health Service Executive-Drugs Group (HSE-DG), exploring the characteristics and patterns of positive or conditional positive recommendations and HTM-related requirements.

We reviewed the minutes of HSE-DG meetings between January 2018 and December 2023. Data on medicines reviewed during this period were extracted into Microsoft Excel and analyzed narratively.

Over the study period, the HSE-DG reviewed 192 medicines (including new medicines and new indications for existing medicines), of which 157 received positive (115) or conditional positive recommendations (42). Of these, thirty-three were subject to HTM conditions, typically involving a managed access protocol or a specific reimbursement application process. Due to inconsistent reporting of key information, quantitative analysis was not feasible. However, common characteristics among HTM-linked recommendations emerged. These included submissions for reimbursement targeting a subset of the licensed population (45.5 percent vs. 5.6 percent in non-HTM cases), designation as orphan medicines (39.4 percent vs. 29.8 percent), and having both first-in-class and new chemical entity designations (75.8 percent vs. 47.6 percent).

Findings indicate an increasing trend toward positive/conditional positive reimbursement recommendations with HTM in the Irish setting, with an average of 21 percent of positive/conditional positive recommendations over the study period contingent on HTM. More granular and consistent reporting of key indicators would enable the determination of characteristics associated with reimbursement recommendations with HTM.

There is growing public health interest in ultra-processed foods (UPF), but limited research exploring consumers’ perceptions of these foods in the United States. We aimed to characterise consumers’ beliefs about UPF, the association between perceived food processing and perceived food healthfulness and alignment between consumers’ perceptions and objective measures of food processing and healthfulness.

In a cross-sectional survey, participants answered questions regarding their beliefs about UPF. They rated the healthfulness and processing levels of a random selection of ten out of forty possible foods. We used descriptive statistics to examine participant beliefs about UPF. We used linear regression models to test associations between perceived processing and perceived healthfulness and between objective and perceived measures of food healthfulness and processing.

We fielded an online survey in the USA in November 2023.

This study included US adults aged ≥ 18 years (n 4455).

Fifty-four percent of participants correctly identified UPF as ‘Food products submitted to a series of industrial processing’ and 52 % correctly identified UPF as, ‘Food products that contain artificial ingredients’. However, one-third of participants believed UPF were genetically modified products. While foods with higher perceived processing tended to have lower perceived healthfulness and individuals perceived UPF as more processed and less healthful than minimally processed foods, healthfulness perceptions better aligned with Food Compass 2.0, a measure that integrates food processing and nutrient-profile.

Educational and policy efforts (e.g. food labeling) are needed to help consumers distinguish UPF and holistically assess the healthfulness of foods and beverages.

The first year of life is a critical period when nutrient intakes can affect long-term health outcomes. Although household food insecurity may result in inadequate nutrient intakes or a higher risk of obesity, no studies have comprehensively assessed nutrient intakes of infants from food insecure households. This study aimed to investigate how infant nutrient intakes and BMI differ by household food security.

Cross-sectional analysis of the First Foods New Zealand study of infants aged 7–10 months. Two 24-h diet recalls assessed nutrient intakes. ‘Usual’ intakes were calculated using the multiple source method. BMI z-scores were calculated using WHO Child Growth Standards.

Dunedin and Auckland, New Zealand.

Households with infants (n 604) classified as: severely food insecure, moderately food insecure or food secure.

Nutrient intakes of food insecure and food secure infants were similar, aside from slightly higher free and added sugars intakes in food insecure infants. Energy intakes were adequate, and intakes of most nutrients investigated were likely to be adequate. Severely food insecure infants had a higher mean BMI z-score than food secure infants, although no significant differences in weight categories (underweight, healthy weight and overweight) were observed between groups.

Household food insecurity, in the short term, does not appear to adversely impact the nutrient intakes and weight status of infants. However, mothers may be protecting their infants from potential nutritional impacts of food insecurity. Future research should investigate how food insecurity affects nutrient intakes of the entire household.

Cystic neck masses have a wide differential diagnosis. Fine-needle aspiration cytology with or without thyroglobulin washout may be non-diagnostic or false-negative, while a primary thyroid tumour may be sonographically occult. We aim to demonstrate the value of biochemical thyroglobulin measurement in directly aspirated cyst fluid in diagnosis or exclusion of papillary thyroid cancer cystic nodal metastases.

Prospective case series (n = 10) of patients presenting with a lateral cystic neck mass with or without thyroid abnormality, where thyroglobulin measurement of aspirated cyst fluid was part of the diagnostic workup.

N1b papillary thyroid cancer diagnosis was predicted by elevated thyroglobulin in cyst fluid aspirate in seven cases, all greater than 200 µg/L, confirmed at surgical resection. Papillary thyroid cancer nodal metastasis was refuted by low thyroglobulin result in three benign cystic lesions, all less than 6 µg/L.

Biochemical thyroglobulin analysis of fluid aspirate is a valuable adjunct for evaluation of cystic neck masses and pre-operative diagnosis of papillary thyroid cancer cystic nodal metastases.

Understanding how different symptoms co-occur and are correlated may provide insights into the pathophysiology of disease. The lack of group-to-individual generalizability of co-occurrence of symptoms was recently demonstrated by comparing intra-individual and inter-individual correlations in several psychological studies. Here, we investigate this phenomenon for lower urinary tract symptoms (LUTS).

We analyzed data collected in the Symptoms of Lower Urinary Tract Dysfunction Research Network Recall Study. Participants responded to questions about their urinary symptoms for 25 consecutive days. These questions queried urologic symptoms including storage (urinary urgency, frequency, nocturia, and urinary incontinence), voiding (slow/weak stream), and post-micturition (incomplete emptying and post-micturition dribble) symptoms. We calculated Pearson correlation coefficients and cosine similarity measures and compared distributions of intra-individual and inter-individual (cohort) metrics.

Among 234 participants, distributions of intra-individual measures were 10-fold wider than those of inter-individual correlations. There are pairs of questions with distributions of correlations and cosine similarities containing individuals with extreme positive (>0.8) and extreme negative values (<–0.8). There are groups of participants with strong positive and negative correlations of urinary frequency and nocturia, urinary incontinence and weak flow, as well as strong negative and positive correlations of urinary frequency and dribbling. Information on these extreme groups is averaged out and lost in the inter-individual correlations.

Lack of group-to-individual generalizability previously shown for psychological symptoms is confirmed for LUTS. Wealth of information on the co-occurrence and co-evolution of LUTS in the intra-individual correlations and cosine similarities corroborates heterogeneity of LUTS and can be useful for deep phenotyping and for identifying personalized treatments of LUTS.

Advance Choice Documents (ACDs) have been recommended for inclusion in new mental health legislation for England and Wales based on evidence they reduce compulsory psychiatric admission, with particular benefit for Black people. As Black people disproportionately experience compulsory psychiatric admission in the UK, our aim was to explore potential barriers and enablers to effective ACD implementation for Black people with previous experience of compulsory admission.

Six stakeholder workshops and one consensus workshop were held with: Black service users who had previously been involuntarily admitted, carers/supporters of Black service users, and mental health staff. Thematic analysis was conducted on workshop transcripts.

Participants were service users (n = 13), carers/supporters (n = 7), service users and carers/supporters (n = 3), and staff (n = 18). Thematic analysis identified themes of ‘training’, ‘completion’, ‘access’, and ‘use’ concerning ACD implementation. Stakeholders highlighted the importance of understanding the racialised experience of Black service users for effective ACD implementation. Strong communication between and amongst stakeholders and helpful systems for access were also emphasised. Stakeholders also recommended joint training and independent facilitation of ACDs to address Black service user-staff power imbalances.

Known enablers and barriers to ACD implementation are important when considering ACDs for Black people, as is explicitly engaging with their experiences holistically, including racialised historical and individual experiences that underline some treatment preferences. Independent facilitation and shifts in service user-staff power dynamics present as key to realising the potential of ACDs to empower Black service users in relation to their care, and in turn to potentially reduce coercive care.

Following a health technology assessment, the Health Service Executive (HSE) supported reimbursement of dupilumab subject to a managed access protocol (MAP) being implemented. Reimbursement is restricted to a subgroup of the fully licensed indication, that is, moderate-to-severe refractory atopic dermatitis (AD) in adults and adolescents 12 years and older. This study provides an overview of the first year of the MAP.

All reimbursement applications submitted to the HSE Medicines Management Programme between 1 April 2021 and 31 March 2022 were reviewed. Key demographic and clinical characteristics of the approved population were analyzed. Reimbursement claims data within the specified period were extracted from the HSE Primary Care Reimbursement Services national pharmacy claims database. All data were compiled and analyzed using SPSS Statistics 27. Expenditure estimates were based on wholesale prices and were exclusive of value-added tax, fees, and confidential rebates.

During the study period, 382 applications were submitted, 96 percent (n=365) of which were approved. Among approved patients, the mean age was 35 years (range 12 to 79 years), the mean number of years between AD diagnosis and approval was 22.65 years (range 1 to 78 years), and 65 percent (n=238) were men. The mean Eczema Area and Severity Index score was 28.72 and the mean (Children’s) Dermatology Life Quality Index score was 19.72. Approved patients who had unsuccessfully tried other systemic immunosuppressants had trialed up to five different medicines (mean=1.6). Year one expenditure was EUR2.4million, with 70 percent of approved patients accessing treatment.

Most applications submitted through the MAP were approved. These patients met the predefined evidence-based eligibility criteria for treatment. Patient numbers were higher than estimated, suggesting that the MAP did not hinder access. Utilizing health technology management by way of a MAP has facilitated access to expensive medicines for patients with the greatest need, while controlling expenditure for the payer.

The calcitonin gene-related peptide monoclonal antibodies (CGRP MABs) erenumab, fremanezumab, and galcanezumab are reimbursed in Ireland under the High Tech Arrangement, subject to a managed access protocol (MAP), for the prophylaxis of chronic migraine in adults in whom three or more prophylactic treatments have failed. This study provides an overview of submitted reimbursement applications and the utilization of CGRP MABs.

The MAP for CGRP MABs was introduced on 1 September 2021 and is operated by the Health Service Executive (HSE) Medicines Management Programme. Individual patient reimbursement applications for CGRP MABs submitted through an online reimbursement application system between 1 September 2021 and 30 April 2023 were reviewed. Utilization data from 1 September 2021 to 30 April 2023 were extracted from the HSE Primary Care Reimbursement Service national pharmacy reimbursement claims database for the High Tech Arrangement. Analysis was performed using SAS® 9.4 software.

A total of 1,517 reimbursement applications were submitted in the study period. Reimbursement was approved for 96.1 percent (n=1,458) of the applications. A total of 1,399 individual patients (mean age 45 years) were dispensed a CGRP MAB under the High Tech Arrangement between September 2021 and April 2023, the majority of whom were women (n=1,141). Almost 90 percent of patients were considered treatment adherent. In April 2023, the market share of the individual CGRP MABs on the High Tech Arrangement was 56 percent (n=599) for fremanezumab, 38.3 percent (n=409) for erenumab, and 5.7 percent (n=61) for galcanezumab.

MAPs are part of the health technology management approach to drug reimbursement in the Irish healthcare setting, ensuring that reimbursement is in line with approved subgroups of the licensed indication. Used in conjunction with health technology assessment, MAPs enable access to high-cost drug treatments for patients with the greatest unmet need, while providing budgetary oversight and certainty for the payer.