Globally, burns are responsible for around 11 million injuries and 180 000 burn-related deaths yearly. Unfortunately, 9 of 10 burn injuries and deaths happen in low-and-middle-income countries (LMICs) such as Pakistan. One in three people admitted to hospitals with burn injuries die within three weeks, and survivors face serious lifelong physical, emotional and psychosocial problems. This may result in anxiety, depression, post-traumatic stress disorder, increased mortality and social disintegration. This study aims to evaluate if implementation of a culturally adapted multidisciplinary rehabilitation programme for burn survivors is clinically and cost-effective, sustainable and scalable across Pakistan.

• - To understand lived experiences of burn survivors, families, and other stakeholders including the experience of care and impact of burns To work together with key stakeholders (such as burn survivors, family members) to adapt a culturally appropriate affordable burn rehabilitation programme

• - To undertake social media campaigns to promote burn prevention and risk assessment at communities, workplaces/industries/households; improve first aid; and address burn related stigma

• - To work with policy makers/parliamentarians to develop national guidelines for burns care and prevention in Pakistan

There are 6 work-packages (WPs). WP1 is to co-adapt a culturally appropriate burn care and rehabilitation programme. WP2 will develop and implement national burn registry on WHO’s initiative. WP3 is a cluster randomised controlled trial to determine clinical and cost-effectiveness in Pakistan. WP4 will evaluate social media campaigns for burn prevention and reduce stigma. WP5 involves working with key-stakeholders for burns-related care and policy and WP6 offers sustainable capacity and capability for burns treatment and rehabilitation.

A clinical and cost-effective burn care quality and rehabilitation programme may have a huge potential to save lives and contribute health and socio-economic benefits for patients, families, and the healthcare system in Pakistan. The nation-wide implementation and involvement of burn centres across all provinces offer an excellent opportunity to overcome the problem of burn care access experienced in LMICs.

To date, burns prevention, care and rehabilitation have not received sufficient attention in policy initiatives in Pakistan and other LMICs. This study is an excellent opportunity to evaluate culturally adapted burn care and rehabilitation programmes that can be implemented across LMICs. We will disseminate our findings widely, using a variety of approaches, supported by our stakeholder and patient advisory groups.

None Declared

Low and middle-income countries (LMICs) hold the majority of disease burden attributed to major depressive disorder (MDD). Despite this, there remains a substantial gap for access to evidence-based treatments for MDD in LMICs like Pakistan. Measurement-based care (MBC) incorporates systematic administration of validated outcome measures to guide treatment decision making and is considered a low-cost approach to optimise better clinical outcomes for individuals with MDD but there is a paucity of evidence on the efficacy of MBC in LMICs.

This protocol highlights a randomized trial which will include Pakistani outpatients with moderate to severe major depression.

Participants will be randomised to either MBC (guided by schedule), or standard treatment (guided by clinicians’ judgement), and will be prescribed with paroxetine (10–60mg/day) or mirtazapine (7.5–45mg/day) for 24 weeks. Outcomes will be evaluated by raters blind to study protocol and treatment.

National Bioethics Committee (NBC) of Pakistan has given full ethics approval. The trial is being conducted and reported as per recommendation of the CONSORT statement for RCTs.

With increasing evidence from high-income settings supporting the effectiveness of MBC for MDD, it is now necessary to explore its feasibility, utility. and efficacy in low-resource settings. The results of the proposed trial could inform the development of a low-cost and scalable approach to efficiently optimise outcomes for individuals with MDD in Pakistan.

None Declared

Suicide is a leading cause of death among young people and most deaths by suicide occur in low and middle-income countries. School is the best place where we can identify and respond to youth suicide risk. School-based interventions for suicide prevention in young people have been successful across US, Europe and Australia, but require adaptations to be acceptable and feasible in Pakistan.

To develop and test culturally adapted preventative interventions for suicidal behaviours among pupils in secondary schools in Pakistan. The qualitative component aimed at exploring the views of students, parents, teachers and general practitioners on cultural adaptation, experience of participation, areas of improvement and suggestions for scale-up of the school-based suicide prevention program (SEPAK).

A clustered randomised controlled trial. The four culturally modified interventions 1) Linking Education and Awareness of Depression and Suicide Awareness (LEADS) Training for pupils (students=260) 2) the Question, Persuade, and Refer (QPR) for teachers (students=203) 3) QPR for parents (students=445); 4) Screening by Professionals (Profscreen) (students=260) were compared against control intervention (educational posters) (students=227). Structured questionnaires were administered at baseline and 1-month post-intervention to assess suicidal behaviours, psychological well-being and quality of life. A total of 8 focus groups (FGs) were conducted at pre and post intervention stage with each stakeholders.

Patient and public involvement and Engagement (PPIE) was strongly embedded in the project to ensure meaningful benefits for participants. A total of 40 schools were recruited from 8 cities across Pakistan. A total of 243 students attended LEADS intervention, 92 teachers and 304 parents completed QPR training, and 9 general practitioners were trained in ProfScreen. The retention rate at follow-up was 99% that shows feasibility of delivering intervention package in Pakistan. All participants marked SEPAK as effective in identifying risk of and preventing self-harm and suicide in young people and in improving pathways to treatment. Interventions were perceived as helpful in improving knowledge about mental health, impact of mental health difficulties on functioning, reducing stigma, equipping stakeholders to identify and signpost at-risk people. Improvement in clinical and teaching practice as well as understanding others behaviors were also reported.

This study suggest feasibility of integrating a suicide prevention program in existing educational system and highlights positive role of creating awareness about suicide in youth, introduction of school-based mental health programs, parental counseling and strengthening of the health system by training general practitioners in early identification of suicide risk and promoting suicide prevention strategies

None Declared

During the last decade there has been a resurgence of interest on the use of psychedelics as novel treatments for mental disorders, including treatment-resistant depression (TRD). Psilocybin, the chemical component of “magic mushrooms”, has been administered with psychotherapy in randomized clinical trials (RCTs) showing large and sustained antidepressant effects. As the use of psilocybin expands, it is becoming more important to understand whether psilocybin’s psychedelic effects are required for psilocybin’s antidepressant effects. Psilocybin’s psychedelic effects are known to be dependent on serotonin 2A receptor (5-HT2AR) activation. Given the safety concerns associated with psilocybin’s psychedelic effects, all studies have used it in conjunction with at least 12 hours of intensive psychotherapy. This makes psilocybin-assisted psychotherapy (PAP) highly resource intensive and impedes scalability given limited resources and access to trained therapists in most jurisdictions. Studies in healthy volunteers have shown that psilocybin’s psychedelic effects are blocked by 5-HT2AR antagonists like risperidone and ketanserin. In a pre-clinical study using a mouse model of depression, administration of ketanserin followed by psilocybin had the same antidepressant effect as psilocybin alone. We propose to conduct the first study to test in humans whether the antidepressant effects of psilocybin are attenuated by 5-HT2AR blockade from risperidone.

Aim 1: To evaluate the feasibility and tolerability of administering psilocybin with risperidone in adults with TRD by evaluating recruitment, retention, tolerability, and safety.

Aim 2: To evaluate psychedelic effects (measured with the 5-Dimensional Altered States of Consciousness Rating Scale) in the three groups.

Aim 3: To evaluate antidepressant effects (measured with the Montgomery Asberg Depression Rating Scale; MADRS) in the three groups. .

A three-arm, 4-week, double blind, proof-of-concept RCT for patients with a DSM-5 major depressive episode that has failed to respond to at least two adequate trials of antidepressants. Participants will be randomized to: 1) psilocybin 25 mg plus risperidone 1 mg; 2) psilocybin 25 mg plus placebo; 3) placebo plus risperidone 1 mg. All participants will receive 12 hours of manualized psychotherapy.

Ethics approval for the proposed study has been obtained. We will present preliminary feasibility data at the meeting in March.

If the study demonstrates that psilocybin’s psychedelic effects are not necessary for psilocybin’s antidepressant effects, the combination of psilocybin and a 5-HT2AR antagonist, such as risperidone, could increase acceptability and access to the use of psilocybin to treat MDD and related conditions.

None Declared

Despite replicated cross-sectional evidence of aberrant levels of peripheral inflammatory markers in individuals with major depressive disorder (MDD), there is limited literature on associations between inflammatory tone and response to sequential pharmacotherapies.

To assess associations between plasma levels of pro-inflammatory markers and treatment response to escitalopram and adjunctive aripiprazole in adults with MDD.

In a 16-week open-label clinical trial, 211 participants with MDD were treated with escitalopram 10– 20 mg daily for 8 weeks. Responders continued on escitalopram while non-responders received adjunctive aripiprazole 2–10 mg daily for 8 weeks. Plasma levels of pro-inflammatory markers – C-reactive protein, Interleukin (IL)-1β, IL-6, IL-17, Interferon gamma (IFN)-Γ, Tumour Necrosis Factor (TNF)-α, and Chemokine C–C motif ligand-2 (CCL-2) - measured at baseline, and after 2, 8 and 16 weeks were included in logistic regression analyses to assess associations between inflammatory markers and treatment response.

Pre-treatment levels of IFN-Γ and CCL-2 were significantly higher in escitalopram non-responders compared to responders. Pre-treatment IFN-Γ and CCL-2 levels were significantly associated with a lower of odds of response to escitalopram at 8 weeks. Increases in CCL-2 levels from weeks 8 to 16 in escitalopram non-responders were significantly associated with higher odds of non-response to adjunctive aripiprazole at week 16.

Pre-treatment levels of IFN-Γ and CCL-2 were predictive of response to escitalopram. Increasing levels of these pro-inflammatory markers may predict non-response to adjunctive aripiprazole. These findings require validation in independent clinical populations.

None Declared

Bipolar disorder (BD) is a source of marked disability, morbidity, and premature death. There is a paucity of research on personalized psychosocial interventions for BD, especially in lowresource settings. A previously published pilot randomized controlled trial (RCT) of a Culturally adapted PsychoEducation (CaPE) intervention for BD in Pakistan reported higher patient satisfaction, enhanced medication adherence, knowledge and attitudes towards BD, and improvement in mood symptom scores and health-related quality of life measures compared to treatment-as-usual (TAU).

This protocol describes a larger multicentre RCT to confirm the clinical and cost-effectiveness of CaPE in Pakistan.

A multicentre individual, parallel arm, RCT of CaPE in 300Pakistani adults with BD. Participants over the age of 18, with adiagnosis of bipolar I and II and who are currently euthymic, will berecruited from seven sites including Karachi, Lahore, Multan, Rawalpindi,Peshawar, Hyderabad and Quetta. Time to recurrence will be the primaryoutcome assessed using Longitudinal Interval Follow-up Evaluation(LIFE). Secondary measures will include mood symptomatology, qualityof life and functioning, adherence to psychotropic medications, andknowledge and attitudes towards BD.

Full ethics approval has been received from National Bioethics Committee (NBC) of Pakistan and Centre for Addiction and Mental Health (CAMH), Toronto, Canada. The study has completed sixty-five screening across the seven centres, of which forty-eight participants have been randomised.

A successful trial will lead to rapid implementation of CaPE in clinical practice, not only in Pakistan, but also in other low-resource settings including those in high-income countries, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority patients with BD.

None Declared

Depression is the leading cause of disability worldwide and low and middle-income countries (LMICs) carry over 80% of this disease burden. Attempts have been made to address depression in LMICs, with improvements in the home environment and maternal knowledge. However paternal depression is a neglected and under-researched area. Since maternal depression is associated with depression in fathers there is a need for partner inclusive parenting programs to address parental mental health and improve child outcomes.

To evaluate the clinical and cost effectiveness of partner inclusive Learning through play plus (LTP+) intervention in reducing depression in fathers and mothers.

To evaluate the effectiveness of LTP + intervention in improving child outcomes.

To conduct process evaluation and identify challenges in transition to scale up of the intervention across Karachi, Pakistan from the perspective of fathers, mothers, and other stakeholders.

This is a cluster randomised controlled (cRCT) trial of partner inclusive group parenting program called (Learning Through Play (LTP+) across 18 towns in the city of Karachi. Over 5000 parents (fathers and partners) will participate in the study with a capacity building component of training 4000 Community Health Workers across Pakistan.

This large cRCT will confirm the clinical and cost-effectiveness of LTP+ in reducing depression in parents and improving child outcomes along with the barriers and facilitators to implement the LTP+ group parenting program and the possibilities to roll out the innovation at national level through engagement with policy makers.

Addressing depression in parents is hugely important because of its adverse effects both for child and parents. This low-cost group parenting program will help in scaling up the innovation across health services in Pakistan and other LMICs.

None Declared

Several studies have reported on the feasibility and impact of e-monitoring using computers, or smartphones, in patients with mental disorders, including Bipolar Disorder (BD). Despite some promising early results, concerns have been raised about the motivation and ability of patients with BD to adhere to e-monitoring, in particular when they are depressed or manic. While studies on e-monitoring have examined the role of demographic factors, such as age, gender, or socioeconomic status and use of health apps, to our knowledge, no study has examined clinical characteristics that might impact adherence with e-monitoring of patients with BD.

We analyzed adherence to e-monitoring in patients with BD who participated in an ongoing e-monitoring study and evaluated whether demographic and clinical factors would predict adherence.

Eighty-seven participants with BD in different phases of the illness were included. Patterns of adherence for wearable use, daily and weekly self-rating scales over 15 months were analyzed to identify adherence trajectories using growth mixture models (GMM). Multinomial logistic regression models and Multiple Component Analyses were fitted to compute the effects of predictors on GMM classes.

Adherence rates were 79.5% for the wearable; 78.5% for weekly self-ratings; and 74.6% for daily self-ratings. GMM identified three latent class subgroups: (i) participants with good adherence with the protocol; (ii) participants with partial adherence; (iii) participants with poor adherence. Women, participants with a history of suicide attempt, and those with a history of inpatient admission were more likely to belong to the group with good adherence.

Participants with higher illness burden (e.g., history of admission to hospital, history of suicide attempts) have higher adherence rates to e-monitoring. This is important because our findings debunk myths around illness burden as an obstacle to adhere to e-monitoring studies. Participants might have seen e-monitoring as a tool for better documenting symptom change and better managing their illness, thus motivating their engagement.

None Declared

Transposition of great arteries with intact ventricular septum and left ventricular outflow tract obstruction (TGA + IVS + LVOTO) is uncommon. We reviewed operations performed in patients with TGA + IVS + LVOTO in the European Congenital Heart Surgeons Association Congenital Database (ECHSA-CD).

All 109 patients with a diagnosis of TGA + IVS + LVOTO in ECHSA-CD who underwent cardiac surgery during a 21-year period (01/2000-02/2021, inclusive) were included. Preoperative variables, operative data, and postoperative outcomes were collected.

These 109 patients underwent 176 operations, including 37 (21.0%) arterial switch operations (ASO), 26 (14.2%) modified Blalock-Taussig-Thomas shunts (MBTTS), 11 (6.2%) Rastelli operations, and 13 (7.3%) other palliative operations (8 superior cavopulmonary anastomosis[es], 4 Fontan, and 1 other palliative procedure). Of 37 patients undergoing ASO, 22 had a concomitant procedure.

There were 68 (38.6%) reoperations, including 11 pacemaker procedures and 8 conduit operations. After a systemic-to-pulmonary artery shunt, reoperations included shunt reoperation (n = 4), Rastelli (n = 4), and superior cavopulmonary anastomosis (n = 3).

Overall Operative Mortality was 8.2% (9 deaths), including three following ASO, two following “Nikaidoh, Kawashima, or LV-PA conduit” procedures, and two following Rastelli. Postoperative complications occurred after 36 operations (20.4%). The most common complications were delayed sternal closure (n = 11), postoperative respiratory insufficiency requiring mechanical ventilation >7 days (n = 9), and renal failure requiring temporary dialysis (n = 8).

TGA + IVS + LVOTO is rare (109 patients in ECHSA-CD over 21 years). ASO, MBTTS, and Rastelli are the most common operations performed for TGA + IVS + LVOTO. Larger international studies with long-term follow-up are needed to better define the anatomy of the LVOTO and to determine the optimal surgical strategy.

Bipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. The predictive power of heart rate variability (HRV) for mortality has been confirmed in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, their results are incongruent; and none has analyzed the effect of the clinical factors characterizing illness burden on HRV.

To assess the association between HRV and the following factors characterizing illness burden: illness duration, number and type of previous episode(s), duration of the most severe depressive or hypomanic/manic episode, severity of episodes, co-morbid psychiatric disorders, family history of BD or suicide, and duration and polarity of current episode in participants experiencing one.

We used a wearable device in 53 BD participants to assess the association between HRV using 4 measures (RMSSD, SDANN, SDNN and RR Triangular Index) and the abovementioned clinical factors characterizing illness burden. For each of the 4 HRV measures we ran 11 models, one for each burden of illness clinical factor as an independent variable.

Longer illness duration, higher number of depressive episodes, and family history of suicide were negatively correlated with HRV; in the 14 participants experiencing a depressive episode, the MADRS score was negatively correlated with HRV

Our study analyzed the association between burden of illness and HRV in BD, while controlling for functional cardiovascular status, age, sex, BMI, education, and treatment. Our results showed that high illness burden is associated with reduced HRV.

No significant relationships.

Depression is a global public health problem with highest rates in women in low income countries including Pakistan. Paediatricians may be a resource to help with maternal depression. Little is known in low income countries about the prevalence of depression and its social correlates in mothers of children attending paediatric clinics.

Using cross-sectional design consecutive women attending the paediatric clinic were screened using the Edinburgh Postnatal Depression Scale (n=185). Women scoring 12 or more (n=70) and a random sample of low scorers (n=16) were interviewed using the Clinical Interview Schedule Revised (CIS-R) to confirm the diagnosis of depression, the Oslo scale was used to measure social stress and EQ-5D for health related quality of life.

The prevalence of maternal depression was 51%. The mean age of the sample was 26 years. Depressed mothers were more likely to be living in a joint family household, they were less educated and they and their husbands were less likely to be employed. The depressed mothers had more financial difficulties and they were more likely to sleep hungry during the last month due to financial problems. The depressed mothers had less social support and poorer quality of life compared to non depressed mothers.

Maternal depression in this health care setting is high and it is associated with social stress and poor social support. Paediatric appointments may be an opportunity for care and care delivery for maternal depression.

Perinatal depression (PND) has adverse effects on the well being of the mother-infant dyad. Women with PND often show different patterns of help seeking behaviour.

We aimed to examine the association between PND and the reporting of health events and healthcare use in a cohort of British women of Pakistani origin.

Participants were recruited from antenatal clinics in the North West of England and followed up 6 months postnatal. Sixty-seven women diagnosed with depression using the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) were compared with 156 non depressed controls in terms of reporting of health events elicited using the Life Events and Difficulties Schedule (LEDS). Health events included any condition that involved attending primary or secondary care.

Depressed mothers were 1.5 times more likely to report a health event within the perinatal period (p=0.005) and 1.8 times more likely to report a health event (0.031) outside the perinatal period. Depressed mothers were more likely to attend secondary care services for their children (p=0.001) but there was no significant difference in terms of attendance at primary care.

Depressed mothers were more likely to report personal health events and more likely to access secondary care rather than primary care services for health events affecting their children. This highlights the hidden costs of this condition and the need for adequate diagnosis and management of this treatable but under recognised illness.

Irritable bowel syndrome is one of the most commonly diagnosed functional gastrointestinal disorders. Irritable bowel syndrome (IBS) and its association with stress have not been researched in regards to foreign medical students in Cluj-Napoca, Romania.

To establish the prevalence of IBS in foreign medical school students and the relationship with stress.

This observational case-controlled study was carried out in “Iuliu Hatieganu” University of Medicine and Pharmacy in Cluj-Napoca, Romania. The sample size was 102, and the data was collected using an online self-report questionnaire. The ‘Rome 3 criteria’ was used to diagnose IBS and ‘Stressful Life Events Check-list’ was used to measure levels of stress.

The prevalence of IBS was 24.5%, with females having higher rates (34%) compared to males (16.4%). The types of IBS were IBS-M (mixed form) 8.8%, IBS-D (diarrhoea dominant) 6.9%, IBS-C (constipation dominant) 5.9% and IBS-U (undefined) 2.9%. Students with IBS reported higher social stress compared to students without IBS.

More efforts should be made to combat stress that medical students experience in order to reduce the number of IBS cases. This may involve an increased role of the medical school to develop initiatives and support, with the aim of helping medical school students better cope with stress and stressful events.

The authors have not supplied their declaration of competing interest.

Suicide is a major public-health problem in Canada. Data from ‘Statistics Canada’ suggests that there was a 10% increase in suicide rate between the years 1997 and 1999. Studies have found substantial differences in suicide rates (and patterns) amongst ethnic immigrants compared to Canadian-born individuals.

The aim of the study was to investigate whether ethnic-immigrant patients differed from Canadian-born patients in their social, demographic, psychiatric and historical associations.

All registered patients (n = 276) known to have completed suicide from 1966–1997 constituted the study sample. Data were extracted from the written case audits, autopsy and toxicology reports, and medical records.

Of the 276 known cases of suicide, 11 were Afro-Caribbean, 24 were Eastern European, 14 were Asian and 215 were Canadian-born patients. The ethnic-immigrant groups were broadly comparable to the Canadian-born group in terms of the social, demographic, psychiatric and background historical factors (except that the latter had a higher prevalence of alcohol and substance misuse). There were no significant differences between different ethnic immigrant groups themselves.

The most salient implication of the findings are that social, psychiatric and historical associations of mentally ill patients who complete suicide are common across different ethnic immigrant groups, and as such a universal approach to mental health promotion, early identification and treatment would be similarly applicable to patients belonging to all groups.

The authors have not supplied their declaration of competing interest.

A third of patients diagnosed with major depressive disorder (MDD) experience treatment-resistant depression (TRD). Relatively few pharmacological agents have established efficacy for TRD. Therefore, the evaluation of novel treatments for TRD is a pressing priority. Statins are pleiotropic agents and preclinical studies as well as preliminary clinical trials have suggested that these drugs may have antidepressant properties.

To report on a protocol for a 12-week, randomised, double-blind, placebo-controlled trial of add-on treatment with simvastatin for patients meeting DSM-5 criteria for MDD who have failed to respond to at least two adequate trials with approved antidepressants. The trial has been registered with Clinicaltrials.gov in (ClinicalTrials.gov identifier: NCT03435744).

After screening and randomisation to the two parallel arms of the trial, 75 patients will receive simvastatin and 75 patients will receive placebo as adjuncts to treatment as usual. The primary outcome is change in Montgomery–Åsberg Depression Rating Scale scores from baseline to week 12 and secondary outcomes include changes in scores on the 24-item Hamilton Rating Scale for Depression, the Clinical Global Impression scale, the 7-item Generalized Anxiety Disorder scale and change in body mass index from baseline to week 12. Assessments will take place at screening, baseline, and weeks 2, 4, 8 and 12. Checklists for adverse effects will be undertaken at each visit. Simvastatin (20 mg) will be given once daily. Other secondary outcomes include C-reactive protein and plasma lipids measured at baseline and week 12.

This trial will assess simvastatin's efficacy and tolerability as an add-on treatment option for patients with TRD and provide insights into its putative mechanisms of action.

As the first trial investigating the use of simvastatin as an augmentation strategy in patients with TRD, if the results indicate that adjuvant simvastatin is efficacious in reducing depressive symptoms, it will deliver immediate clinical benefit.

I.B.C. and N.H. have given lectures and advice to Eli Lilly, Bristol Myers Squibb, Lundbeck, Astra Zeneca and Janssen pharmaceuticals for which they or their employing institution have been reimbursed. R.R. and M.M.H. have received educational grants and support for academic meetings from Pfizer, Roche, Novartis and Nabiqasim. A.H.Y. has been commissioned to provide lectures and advice to all major pharmaceutical companies with drugs used in affective and related disorders. A.H.Y. has undertaken investigator-initiated studies from Astra Zeneca, Eli Lilly, Lundbeck and Wyeth. None of the companies have a financial interest in this research.

To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications.

Outbreak investigation.

Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit.

Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases.

In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive.

We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.

This study investigated improvements in quality of life associated with eight weeks of montelukast and/or intranasal steroid treatment for moderate to severe allergic rhinitis.

A single-centre, prospective, randomised, double-blind, placebo-controlled study was carried out. Assessments were made using the Rhinoconjunctivitis Quality of Life Questionnaire and symptom scales.

A total of 128 patients (aged 13–51 years) were randomly assigned to one of two groups. In the montelukast group, patients were treated with montelukast tablets and fluticasone propionate nasal spray (n = 64). In the placebo group, treatment comprised a placebo and fluticasone propionate. The results showed significant improvements in symptom scores and quality of life scores for both groups after one month and two months of treatment, compared with baseline values; these improvements were significantly greater for the montelukast group compared with the placebo group. The mean number of loratadine tablets taken by each patient during the study period was only 0.73 for the montelukast group compared with 9 for the placebo group.

The combination of montelukast tablets and fluticasone propionate nasal spray improved symptom control and overall quality of life for moderate to severe allergic rhinitis patients.

Painful physical symptoms (PPS) are both common and reduce the likelihood of remission in major depressive disorder (MDD), based upon results of clinical trials in selected populations. Whether PPS significantly contribute to poorer treatment outcome overall in primary or specialty psychiatric care settings remains unclear.

Out-patients (n=2876) with MDD were treated in the first step of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial with citalopram up to 60 mg/day for up to 14 weeks. Presence of painful symptoms, as well as severity of depression, physical illness, and demographic and treatment factors were examined. Time to and overall rates of remission were analysed in relation to the presence of PPS.

Of the participants, 80% complained of PPS. These patients, both in primary and specialty psychiatric settings, had significantly lower remission rates and took longer to remit. Increasing severity of PPS was associated with greater physical illness burden, lower socio-economic status, absence of private insurance and being female, African-American or Hispanic. After adjustment for these factors, patients with PPS no longer had significantly poorer treatment outcomes.

Presence and severity of PPS is an indicator of MDD that may have poorer treatment outcome with an initial selective serotonin reuptake inhibitor. These poorer treatment outcomes are multifactorial, however, and are not explained by the presence and severity of pain per se.