Longer-term outcome and safety data of repeated subcutaneous racemic ketamine for treatment-resistant depression (TRD) is lacking, as is knowledge of the impact of prior ketamine treatment on subsequent response.

To evaluate the effectiveness and safety of a 4-week course of subcutaneous racemic ketamine over 6 months and investigate whether prior ketamine treatment influences treatment response.

An open label extension (OLE) of a randomised controlled trial (RCT) was conducted at seven mood disorder centres in Australasia, enrolling consenting trial participants who had a Montgomery-Åsberg Depression Rating Scale (MADRS) score of ≥20 at post-trial assessment. Participants initially received twice-weekly 0.5 mg/kg subcutaneous racemic ketamine (fixed regimen) for 4 weeks. Dosing was revised after a Data Safety Monitoring Board recommendation, to a ‘flexible regimen’ (0.5–0.9 mg/kg with response-guided increments). Depression and safety outcomes were assessed throughout treatment, and 4 weeks and 6 months later.

130 RCT participants entered the OLE phase of whom 32 underwent the fixed OLE regimen and 98 the flexible regimen. At treatment end, 30% (36/116) had responded (MADRS reduction ≥50%), and 4 weeks later 17% (19/110) were ‘responders’. Over 50% experienced <25% MADRS reduction. There was no difference in depression response at any time point between regimens. Those treated with ketamine during the RCT showed a transient reduced response after first OLE treatment but at no other assessment point. There were no reports of suicide or suicidal behaviour requiring admission and only expected side-effects observed.

In a highly treatment-resistant sample, a 4-week course of subcutaneous racemic ketamine produced short-term clinical benefit in a minority of participants, with response rates declining substantially after treatment cessation, and no unexpected safety concerns. Exploratory subgroup analyses showed no association between prior RCT ketamine exposure and OLE outcomes.

ACTRN12616001096448 at www.anzctr.org.au.

Antimicrobial stewardship programs (ASPs) are designed to optimize antimicrobial use for healthcare facilities and are required at all acute care and critical access hospitals (CAHs). However, rural CAHs often lack the resources to implement robust ASPs. The purpose of this study was to evaluate the impact of adding regional remote antimicrobial stewardship services across a 14-hospital system consisting of one acute care and thirteen CAHs.

Remote ASP expansion consisted of adding an infectious disease (ID) pharmacist and two ID physicians (0.3 FTE) to provide daily stewardship activities including prospective feedback on antibiotic optimization and use education through remote chart review and communication. Antimicrobial utilization, cost savings, and Clostridioides difficile infection (CDI) rates were tracked. Intervention data and acceptance rates were also collected.

In the first twelve months following regional remote stewardship expansion, the ASP demonstrated a $619,053.97 reduction (56% decrease in Antibiotic Cost/CMI adjusted patient days) in antimicrobial expenses. While only aztreonam use was significantly reduced at the acute care facility (P < .01), the use of vancomycin, meropenem, linezolid, and aztreonam decreased by 33%, 31%, 18%, and 35%, respectively, among the CAHs (P < .001). A 53% reduction in CDI rates was observed across the health system (P < .01). The program averaged 92 interventions per month, with an overall intervention acceptance rate of 86%.

Remote ASPs represent a viable strategy for extending antibiotic stewardship expertise to resource-limited settings to achieve financial and clinical benefits.

Electronic medical records (EMRs) have become foundational to healthcare, improving communication, data access, and patient outcomes. However, increasing reliance on EMR’s has increased vulnerabitlity during downtime. In paediatric cardiac care, where patients require highly specialized, multidisciplinary treatment, the absence of a functional EMR significantly disrupts documentation workflows and threatens the accuracy of data submitted to national cardiac registries including the Paediatric Cardiac Critical Care Consortium and the Society of Thoracic Surgeons.

This article examines the impact of an unexpected 27-day complete EMR downtime followed by a 10-day partial downtime, where a data abstraction team manually managed data for 123 unique cardiac patient encounters totalling 762 patient days at a paediatric heart centre and the response of the cardiac data abstraction team. We describe how the team adapted its abstraction process during the downtime, used collaborative strategies, enhanced paper tracking, and proactively communicated to maintain data integrity. Efforts were grounded in a deep understanding of paediatric registry metrics and submission requirements.

Despite significant workflow disruptions, the team was able to preserve data accuracy and meet registry deadlines by identifying documentation gaps, supplementing data from paper records, and coordinating with frontline providers. The event revealed key vulnerabilities in downtime preparedness but also demonstrated the value of dedicated data abstractors in ensuring continuity of quality reporting.

Downtime events highlight the critical role of data abstractors and the need for institutional planning and registry-level guidance. Developing robust downtime protocols and embedding abstraction-aware workflows can mitigate documentation risks and protect data quality, ultimately supporting improved outcomes for paediatric cardiac patients.

To truly understand the efficacy of attention-deficit hyperactivity disorder (ADHD) psychoeducation, we need to know what is commonly included in it. This scoping review aims to describe the content of psychoeducation interventions for ADHD in published research. A literature search was conducted to identify relevant papers. Descriptions of psychoeducation aimed at children, parents/carers, adults and teachers were identified and compared narratively.

After screening, 57 papers were identified for data extraction and coding. Content themes included ‘information about ADHD’; ‘practical advice’; ‘impact of ADHD’; ‘treatment of ADHD’; ‘co-occurrence’; and ‘self-image/self-esteem’. ‘Information about ADHD’ and ‘practical advice’ were the most common themes, with variance on inclusion of other themes. Most of the identified research involved psychoeducation for parents of children with ADHD.

This review provides greater understanding of the content and delivery of ADHD psychoeducation. Further research could use this understanding to ascertain the efficacy of different content themes in supporting those with ADHD.

This study demonstrates a national programme which has been accepted in Wales as a mandatory part of the induction process for the rotating ENT SHO cohort.

The ENT Induction Bootcamp was established based on the learning needs of ENT SHOs. Pre- and post-course assessment of the subjective and objective benefit of the 1-day course was captured.

Between 2022 and 2024, 152 participants have attended the bootcamp; all of whom (100 per cent) found the course beneficial. The greatest improvements in participant confidence were observed in emergency tracheostomy management, flexible nasendoscopy and nasal examination (all p < 0.01). Based on objective assessment, participant knowledge improved from a mean of 68.5 per cent to 96.5 per cent.

This initiative highlights the value of a bootcamp approach to standardise junior doctors’ abilities to manage ENT emergencies. This bootcamp is now a mandatory component for all SHO entering ENT attachments in Wales, in an easily adoptable format.

Maintaining attention underlies many aspects of cognition and becomes compromised early in neurodegenerative diseases like Alzheimer’s disease (AD). The consistency of maintaining attention can be measured with reaction time (RT) variability. Previous work has focused on measuring such fluctuations during in-clinic testing, but recent developments in remote, smartphone-based cognitive assessments can allow one to test if these fluctuations in attention are evident in naturalistic settings and if they are sensitive to traditional clinical and cognitive markers of AD.

Three hundred and seventy older adults (aged 75.8 +/− 5.8 years) completed a week of remote daily testing on the Ambulatory Research in Cognition (ARC) smartphone platform and also completed clinical, genetic, and conventional in-clinic cognitive assessments. RT variability was assessed in a brief (20-40 seconds) processing speed task using two different measures of variability, the Coefficient of Variation (CoV) and the Root Mean Squared Successive Difference (RMSSD) of RTs on correct trials.

Symptomatic participants showed greater variability compared to cognitively normal participants. When restricted to cognitively normal participants, APOE ε4 carriers exhibited greater variability than noncarriers. Both CoV and RMSSD showed significant, and similar, correlations with several in-clinic cognitive composites. Finally, both RT variability measures significantly mediated the relationship between APOE ε4 status and several in-clinic cognition composites.

Attentional fluctuations over 20–40 seconds assessed in daily life, are sensitive to clinical status and genetic risk for AD. RT variability appears to be an important predictor of cognitive deficits during the preclinical disease stage.

There is concern that junior doctors are not prepared for their post-graduate attachments in ENT. The aims of this study were to capture the learning priorities of those in the ENT first on-call role and facilitate further educational opportunities to address these needs.

Semi-structured interviews were undertaken to explore the learning needs of junior doctors with seven junior and two senior ENT clinicians.

The thematic analysis generated three themes: the role of the ENT Junior; the perceived, expressed and prescribed learning needs; and attitudes towards future learning. These themes explored the misalignment between undergraduate training and post-graduate expectations, the lack of competence in ENT practical skills and the need for focused ENT training prior to commencing on-call shifts.

All interviewees identified the need for greater experience in practical interventional skills prior to their ENT attachments and expressed interest towards a standardised, bootcamp-style induction with simulated emergency experience.

Previous findings suggest that time setting errors (TSEs) in the Clock Drawing Test (CDT) may be related mainly to impairments in semantic and executive function. Recent attempts to dissociate the classic stimulus-bound error (setting the time to “10 to 11” instead of “10 past 11”) from other TSEs, did not support hypotheses regarding this error being primarily executive in nature or different from other time setting errors in terms of neurocognitive correlates. This study aimed to further investigate the cognitive correlates of stimulus-bound errors and other TSEs, in order to trace possible underlying cognitive deficits.

We examined cognitive test performance of participants with preliminary diagnoses associated with mild cognitive impairment. Among 490 participants, we identified clocks with stimulus-bound errors (n = 78), other TSEs (n = 41), other errors not related to time settings (n = 176), or errorless clocks (n = 195).

No differences were found on any dependent measure between the stimulus-bound and the other TSErs groups. Group comparisons suggested TSEs in general, to be associated with lower performance on various cognitive measures, especially on semantic and working memory measures. Regression analysis further highlighted semantic and verbal working memory difficulties as being the most prominent deficits associated with these errors.

TSEs in the CDT may indicate underlying deficits in semantic function and working memory. In addition, results support previous findings related to the diagnostic value of TSEs in detecting cognitive impairment.

Smartphones have the potential for capturing subtle changes in cognition that characterize preclinical Alzheimer’s disease (AD) in older adults. The Ambulatory Research in Cognition (ARC) smartphone application is based on principles from ecological momentary assessment (EMA) and administers brief tests of associative memory, processing speed, and working memory up to 4 times per day over 7 consecutive days. ARC was designed to be administered unsupervised using participants’ personal devices in their everyday environments.

We evaluated the reliability and validity of ARC in a sample of 268 cognitively normal older adults (ages 65–97 years) and 22 individuals with very mild dementia (ages 61–88 years). Participants completed at least one 7-day cycle of ARC testing and conventional cognitive assessments; most also completed cerebrospinal fluid, amyloid and tau positron emission tomography, and structural magnetic resonance imaging studies.

First, ARC tasks were reliable as between-person reliability across the 7-day cycle and test-retest reliabilities at 6-month and 1-year follow-ups all exceeded 0.85. Second, ARC demonstrated construct validity as evidenced by correlations with conventional cognitive measures (r = 0.53 between composite scores). Third, ARC measures correlated with AD biomarker burden at baseline to a similar degree as conventional cognitive measures. Finally, the intensive 7-day cycle indicated that ARC was feasible (86.50% approached chose to enroll), well tolerated (80.42% adherence, 4.83% dropout), and was rated favorably by older adult participants.

Overall, the results suggest that ARC is reliable and valid and represents a feasible tool for assessing cognitive changes associated with the earliest stages of AD.

Medically unexplained symptoms otherwise referred to as persistent physical symptoms (PPS) are debilitating to patients. As many specific PPS syndromes share common behavioural, cognitive, and affective influences, transdiagnostic treatments might be effective for this patient group. We evaluated the clinical efficacy and cost-effectiveness of a therapist-delivered, transdiagnostic cognitive behavioural intervention (TDT-CBT) plus (+) standard medical care (SMC) v. SMC alone for the treatment of patients with PPS in secondary medical care.

A two-arm randomised controlled trial, with measurements taken at baseline and at 9, 20, 40- and 52-weeks post randomisation. The primary outcome measure was the Work and Social Adjustment Scale (WSAS) at 52 weeks. Secondary outcomes included mood (PHQ-9 and GAD-7), symptom severity (PHQ-15), global measure of change (CGI), and the Persistent Physical Symptoms Questionnaire (PPSQ).

We randomised 324 patients and 74% were followed up at 52 weeks. The difference between groups was not statistically significant for the primary outcome (WSAS at 52 weeks: estimated difference −1.48 points, 95% confidence interval from −3.44 to 0.48, p = 0.139). However, the results indicated that some secondary outcomes had a treatment effect in favour of TDT-CBT + SMC with three outcomes showing a statistically significant difference between groups. These were WSAS at 20 weeks (p = 0.016) at the end of treatment and the PHQ-15 (p = 0.013) and CGI at 52 weeks (p = 0.011).

We have preliminary evidence that TDT-CBT + SMC may be helpful for people with a range of PPS. However, further study is required to maximise or maintain effects seen at end of treatment.

To estimate the impact of California’s antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals.

Centers for Medicare and Medicaid Services (CMS)–certified acute-care hospitals in the United States.

2013–2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports.

Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate.

In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017.

The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.