To evaluate the potential sources and current screening strategies for the multidrug-resistant fungal pathogen Candida auris in the US Military Health System (MHS).

Utilizing the Multidrug-Resistant Organism Repository and Surveillance Network (MRSN), 6 instances of C. auris colonization or infection were identified within the MHS in 2024. Relevant medical and social history, drug susceptibilities, and next-generation genetic sequencing were obtained from MRSN and the electronic medical record. Hospital screening protocols for C. auris were reviewed in the affected facilities.

One case of C. auris infection and 5 cases of C. auris colonization in 2024 were identified in the MHS. Only 1 case of colonization was likely related to international travel; 5 patients had no recent travel history before infection or colonization. One patient was an active duty service member. Prior hospitalizations and infections were the most common risk factors present in each case. Two isolates had antimicrobial susceptibilities analyzed, both of which suggested resistance to fluconazole. Two of the 3 facilities had C. auris screening protocols in place to screen select individuals with risk factors; however, only 1 of the 6 cases presented was identified through these screening protocols. No cases of nosocomial transmission were found.

C. auris remains a formidable threat to the MHS, with 6 cases identified in 3 treatment facilities, with 2 isolates demonstrating resistance to azoles. Screening protocols should reflect the domestic and international threats of this pathogen.

Natural remission from common mental disorders (CMDs), in the absence of intervention, varies greatly. The situation in India is unknown.

This study examined individual, village and primary health centre (PHC)-level determinants for remission across two rural communities in north and south India and reports natural remission rates.

Using pre-intervention trial data from 44 PHCs in Andhra Pradesh and Haryana, adults ≥18 years were screened for CMDs. Screen-positive people (Patient Health Questionnaire-9 Item (PHQ9) or Generalised Anxiety Disorder-7 Item (GAD7) score ≥10, or a score ≥2 on the self-harm PHQ9 question) were re-screened after 5–7 months (mean). Remission was defined <5 scores on both PHQ9 and GAD7 and <2 score on self-harm. Multilevel Poisson regression models with random effects at individual, village and PHC levels were developed for each state to identify factors associated with remission. Time to re-screening was included as offset in regression models.

Of 100 013 people in Andhra Pradesh and 69 807 people in Haryana, 2.4% and 7.1%, respectively, were screen positive. At re-screening, remission rate in Andhra Pradesh was 82.3% (95% CI 77.5–87.4%) and 59.4% (95% CI 55.7–63.3%) in Haryana. Being female, increasing age and higher baseline depression and anxiety scores were associated with lower remission rates. None of the considered village- and PHC-level factors were found to be associated with remission rate, after adjusting for individual-level factors.

Natural remission for CMDs vary greatly in two Indian states and are associated with complex, multilevel factors. Further research is recommended to better understand natural remission.

In acute ischemic stroke, a longer time from onset to endovascular treatment (EVT) is associated with worse clinical outcome. We investigated the association of clinical outcome with time from last known well to arrival at the EVT hospital and time from hospital arrival to arterial access for anterior circulation large vessel occlusion patients treated > 6 hours from last known well.

Retrospective analysis of the prospective, multicenter cohort study ESCAPE-LATE. Patients presenting > 6 hours after last known well with anterior circulation large vessel occlusion undergoing EVT were included. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes were good (mRS 0–2) and poor clinical outcomes (mRS 5–6) at 90 days, as well as the National Institutes of Health Stroke Scale at 24 hours. Associations of time intervals with outcomes were assessed with univariable and multivariable logistic regression.

Two hundred patients were included in the analysis, of whom 85 (43%) were female. 90-day mRS was available for 141 patients. Of the 150 patients, 135 (90%) had moderate-to-good collaterals, and the median Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7–10). No association between ordinal mRS and time from last known well to arrival at the EVT hospital (odds ratio [OR] = 1.01, 95% CI = 1.00–1.02) or time from hospital arrival to arterial access (OR = -0.01, 95% CI = -0.02–0.00) was seen in adjusted regression models.

No relationship was observed between pre-hospital or in-hospital workflow times and clinical outcomes. Baseline ASPECTS and collateral status were favorable in the majority of patients, suggesting that physicians may have chosen to predominantly treat slow progressors in the late time window, in whom prolonged workflow times have less impact on outcomes.

Rapid tranquillisation – the parenteral administration of a sedating psychotropic – is frequently utilised to manage acute behavioural disturbances. Each mental health trust in England utilises independent guidelines for rapid tranquillisation, which vary geographically in both recommendations for therapeutic agents, as well as the format in which this information presented. Audits have identified that there is currently poor adherence to rapid tranquillisation protocol guidelines; this may be due to a lack of guideline clarity allowing for personal interpretation. This service evaluation aims to determine the clarity and uniformity of protocols outlined in mental health trust guidelines, in addition to analysing the outcomes of guideline testing to identify if there is consistency between policies, or whether outcomes varied depending on the trust guidelines used.

Five reviewers (of differing positions throughout clinical training) utilised 52 guidelines from each mental health trust in England, as well as Maudsley and NICE. These were assessed using the same fictional scenario, which simulated a common presentation in which the use of rapid tranquillisation is required. Reviewers deduced the most appropriate therapeutic agent according to the guideline, rated the clarity of each guideline and were invited to leave comments highlighting the guideline's useability.

Seven different management plans were generated by the majority of respondents from the 52 guidelines. Lorazepam was the most frequently selected therapeutic agent. Guidelines with better subjective ratings of clarity had more agreement between reviewers, but full agreement between reviewers was only present for 10 out of 52 guidelines. For 11 guidelines, consensual agreement between reviewers was not reached. Qualitative analysis of comments identified the inclusion of past medical history, drug history and flow charts as positive sub-themes. Redundant language, contradictions and the suggestion to seek senior intervention before trialling a second agent were viewed negatively. Many guidelines did not sufficiently emphasise the need for performing an ECG before administering therapeutic agents, such as haloperidol, which may lead to potentially fatal arrhythmias.

There is no national consensus on the most appropriate rapid tranquillisation agents, with the available evidence being interpreted variously by different trusts and organisations. Poor guideline comprehensibility impacts clinician adherence and allows for personal preference to influence choice of drug. Clear guidelines utilising flow charts to succinctly outline relevant doses and absolute contraindications were viewed favourably by reviewers. The findings of this project highlights to relevant stakeholders the attributes that should be implemented when improving guidelines for the future.

Digital Mental Health Interventions (DMHIs) that meet the definition of a medical device are regulated by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK. The MHRA uses procedures that were originally developed for pharmaceuticals to assess the safety of DMHIs. There is recognition that this may not be ideal, as is evident by an ongoing consultation for reform led by the MHRA and the National Institute for Health and Care Excellence.

The aim of this study was to generate an experts’ consensus on how the medical regulatory method used for assessing safety could best be adapted for DMHIs.

An online Delphi study containing three rounds was conducted with an international panel of 20 experts with experience/knowledge in the field of UK digital mental health.

Sixty-four items were generated, of which 41 achieved consensus (64%). Consensus emerged around ten recommendations, falling into five main themes: Enhancing the quality of adverse events data in DMHIs; Re-defining serious adverse events for DMHIs; Reassessing short-term symptom deterioration in psychological interventions as a therapeutic risk; Maximising the benefit of the Yellow Card Scheme; and Developing a harmonised approach for assessing the safety of psychological interventions in general.

The implementation of the recommendations provided by this consensus could improve the assessment of safety of DMHIs, making them more effective in detecting and mitigating risk.

To assess cost-effectiveness of late time-window endovascular treatment (EVT) in a clinical trial setting and a “real-world” setting.

Data are from the randomized ESCAPE trial and a prospective cohort study (ESCAPE-LATE). Anterior circulation large vessel occlusion patients presenting > 6 hours from last-known-well were included, whereby collateral status was an inclusion criterion for ESCAPE but not ESCAPE-LATE. A Markov state transition model was built to estimate lifetime costs and quality-adjusted life-years (QALYs) for EVT in addition to best medical care vs. best medical care only in a clinical trial setting (comparing ESCAPE-EVT to ESCAPE control arm patients) and a “real-world” setting (comparing ESCAPE-LATE to ESCAPE control arm patients). We performed an unadjusted analysis, using 90-day modified Rankin Scale(mRS) scores as model input and analysis adjusted for baseline factors. Acceptability of EVT was calculated using upper/lower willingness-to-pay thresholds of 100,000 USD/50,000 USD/QALY.

Two-hundred and forty-nine patients were included (ESCAPE-LATE:n = 200, ESCAPE EVT-arm:n = 29, ESCAPE control-arm:n = 20). Late EVT in addition to best medical care was cost effective in the unadjusted analysis both in the clinical trial and real-world setting, with acceptability 96.6%–99.0%. After adjusting for differences in baseline variables between the groups, late EVT was marginally cost effective in the clinical trial setting (acceptability:49.9%–61.6%), but not the “real-world” setting (acceptability:32.9%–42.6%).

EVT for LVO-patients presenting beyond 6 hours was cost effective in the clinical trial setting and “real-world” setting, although this was largely related to baseline patient differences favoring the “real-world” EVT group. After adjusting for these, EVT benefit was reduced in the trial setting, and absent in the real-world setting.

Protecting all human rights of people with mental health conditions is globally important. However, to facilitate practical implementation of rights, it is often necessary to decide which of these rights should be given priority, especially when they conflict with each other.

The aim of the Priorities of Human Rights and Mental Health (PHRAME) project is to develop a replicable approach to establish a proposed set of high-priority human rights of people with mental health conditions, to facilitate practical decision-making and implementation of such rights.

A two-stage Delphi-style study with stakeholders was conducted to generate a list of key rights of people with mental health conditions, and rank priorities among these rights in terms of feasibility, urgency and overall importance.

The stakeholders in this study consistently ranked three rights as top priorities: (a) the right to freedom from torture, cruel inhuman treatment and punishment; (b) the right to health and access to services/treatment; and (c) the right to protection and safety in emergency situations.

Insights from PHRAME can support decision-making about the priority to be given to human rights, to guide practical action. This approach can also be used to assess how human rights are prioritised in different settings and by different stakeholders. This study identifies the clear need for a central voice for people with lived experience in research and implementation of decisions about the priority of human rights, ensuring that action respects the opinion of people whose rights are directly affected.

Pain, depression, anxiety, and psychosis are common non-cognitive symptoms of dementia. They are often underdiagnosed and can cause significant distress and carer strain. Numerous standardised assessment tools (SATs) exist and are recommended for the assessment of non-cognitive symptoms of dementia. Anecdotal evidence suggests that SATs are used rarely and inconsistently. This study aims to explore which SATs to detect non-cognitive symptoms of dementia are recommended in local guidelines and used in practice across different organisations. Secondary aims were to identify barriers and facilitators to using these tools.

This service evaluation is cross-sectional in design. A questionnaire was developed and distributed to clinicians working with patients with advanced dementia in any setting, across four geographical locations (Leeds, Bradford, Hull, and Cambridge). Quantitative data were analysed descriptively, and qualitative data from free-text comments were interpreted using thematic analysis.

135 professionals from a range of backgrounds and clinical settings completed the survey. Respondents indicated that SATs for non-cognitive symptoms in dementia were rarely used or recommended. Respondents were unaware of the existence of most SATs listed. 80% respondents felt that SATs were a useful adjunct to a structured clinical assessment. The most recommended tool was the Abbey Pain Scale, with 41 respondents indicating its recommendation by their Trust. Perceived facilitators to using SATs include education and training, reliable IT systems and accessibility. Barriers include lack of time and training.

Numerous SATs are available for use in dementia, but they are rarely recommended in local policy or used in practice. There appears to be a lack of consensus on which, if any, are superior diagnostic tools, and on how or when they should be applied.

To assess the frequency of prescription of psychotropic medication in patients with a primary diagnosis of emotionally unstable personality disorder (EUPD) following admission to Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.

A retrospective analysis of the electronic (RiO) record of 50 patients discharged from Clock View Hospital between 1 January 2020 and 1 November 2020 was performed to assess prescribing practice.

Twenty-five patients with a diagnosis of EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with a diagnosis of EUPD and associated psychiatric comorbidities.

80% of the 25 patients with EUPD and associated psychiatric comorbidities were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 24% a mood stabiliser, 60% an antipsychotic and 8% a benzodiazepine). 64% of patients were prescribed two or more psychotropic medications. 28% were initiated on new psychotropic medications following admission. For four of the seven prescriptions commenced on psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.

Of the 25 patients with EUPD and no associated psychiatric comorbidities, 96% of the patients were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 20% a mood stabiliser, 72% an antipsychotic and 12% a benzodiazepine). 68% of patients were prescribed two or more psychotropic medications. Following admission, 28% of patients were initiated on new regular psychotropic medications. For five of the eight prescriptions for new psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.

78% of the 50 patients were prescribed as required (PRN) psychotropic medication. In 21 patients, PRN medication was prescribed for longer than one week.

There is a higher rate of prescribing of antipsychotic prescription in those EUPD patients with no psychiatric comorbidities compared to associated psychiatric comorbidities (72% vs 60%). Surprisingly, there was a lower rate of psychotropic polypharmacy in those with psychiatric comorbidities.

Use of PRN psychotropic medication for longer than a week was higher in those patients with psychiatric comorbidities compared to those without psychiatric comorbidities (58% vs 50%). Benzodiazepines were overwhelmingly the most consistently prescribed PRN medication for patients with EUPD.

One action to consider would be highlighting the importance of trialling psychologically-minded interventions and supportive psychotherapy prior to initiation of psychotropic medication. There also needs to be consideration to use of the sedative antihistamine promethazine as a first-line PRN medication for acute agitation.