Clinical guidance indicates that methadone doses of 60–120mg are therapeutic as opioid substitution therapy (OST). Audit was completed to understand why patients open to Newcastle Treatment and Recovery (Addictions) are being prescribed doses below 60mg and to identify areas for improvement.

285 patients were identified via prescription software as currently prescribed <60mg methadone. A random sample of 50 cases was obtained for audit during signing of routine prescriptions. Case sample was adjusted to ensure even distribution between keyworkers. Review then completed of prescribing card and clinical entries in the last 6 months. Standards included reason for subtherapeutic dosing and evidence of instability with use of illicit opioids, or other substances (excluding alcohol or cannabis), alongside secondary outcomes.

54% of cases were found to currently be undergoing a change in their dose – mostly reducing though 2 increasing and 2 preparing to switch to buprenorphine. The remaining 46% were maintained on a consistent dose of methadone below 60mg. Of these 8 were advised to change their dose but this was declined. The remaining 15 had no additional advice recorded and remained on sub-therapeutic dose. Of 50 cases 8 were unstable with regards illicit opioid use, 21 were using other substances (1 gabapentin with the remaining using cocaine). For those using illicit opioids 63% were advised of an increase but declined whilst 25% were not advised of any change in their OST. Of those using other substances 48% had no change in OST considered whilst a further 10% continued with a reduction.

The audit found that a proportion of cases prescribed a sub-therapeutic dose were being maintained on this dose. Most concerning was the proportion of patients who were not advised to increase despite use of illicit opioids but also the proportion who were not following advice from their keyworker. Additional concerns highlighted uncertainty in practice around the role of OST in those who remain using other substances, in particular cocaine. Department of Health guidance recommends that doses in these cases should be optimised which would mean at least targeting therapeutic range. Recommendations made included to develop further training to ensure consistency of practice as well as requiring that all patients on sub-therapeutic doses of methadone should be booked for strategic care plan reviews at a minimum of 6 monthly.

To quantify the burden of communicable diseases and characterize the most reported infections during public health emergency of floods in Pakistan.

The study’s design is a descriptive trend analysis. The study utilized the disease data reported to District Health Information System (DHIS2) for the 12 most frequently reported priority diseases under the Integrated Disease Surveillance and Response (IDSR) system in Pakistan.

In total, there were 1,532,963 suspected cases during August to December 2022 in flood-affected districts (n = 75) across Pakistan; Sindh Province reported the highest number of cases (n = 692,673) from 23 districts, followed by Khyber Pakhtunkhwa (KP) (n = 568,682) from 17 districts, Balochistan (n = 167,215) from 32 districts, and Punjab (n = 104,393) from 3 districts. High positivity was reported for malaria (79,622/201,901; 39.4%), followed by acute diarrhea (non-cholera) (23/62; 37.1%), hepatitis A and E (47/252; 18.7%), and dengue (603/3245; 18.6%). The crude mortality rate was 11.9 per 10 000 population (1824/1,532,963 [deaths/cases]).

The study identified acute respiratory infection, acute diarrhea, malaria, and skin diseases as the most prevalent diseases. This suggests that preparedness efforts and interventions targeting these diseases should be prioritized in future flood response plans. The study highlights the importance of strengthening the IDSR as a Disease Early Warning System through the implementation of the DHIS2.

Hippocampal hyperperfusion has been observed in people at Clinical High Risk for Psychosis (CHR), is associated with adverse longitudinal outcomes and represents a potential treatment target for novel pharmacotherapies. Whether cannabidiol (CBD) has ameliorative effects on hippocampal blood flow (rCBF) in CHR patients remains unknown.

Using a double-blind, parallel-group design, 33 CHR patients were randomized to a single oral 600 mg dose of CBD or placebo; 19 healthy controls did not receive any drug. Hippocampal rCBF was measured using Arterial Spin Labeling. We examined differences relating to CHR status (controls v. placebo), effects of CBD in CHR (placebo v. CBD) and linear between-group relationships, such that placebo > CBD > controls or controls > CBD > placebo, using a combination of hypothesis-driven and exploratory wholebrain analyses.

Placebo-treated patients had significantly higher hippocampal rCBF bilaterally (all pFWE<0.01) compared to healthy controls. There were no suprathreshold effects in the CBD v. placebo contrast. However, we found a significant linear relationship in the right hippocampus (pFWE = 0.035) such that rCBF was highest in the placebo group, lowest in controls and intermediate in the CBD group. Exploratory wholebrain results replicated previous findings of hyperperfusion in the hippocampus, striatum and midbrain in CHR patients, and provided novel evidence of increased rCBF in inferior-temporal and lateral-occipital regions in patients under CBD compared to placebo.

These findings suggest that hippocampal blood flow is elevated in the CHR state and may be partially normalized by a single dose of CBD. CBD therefore merits further investigation as a potential novel treatment for this population.

Behavioural and Psychological Symptoms of Dementia (BPSD) include a range of neuropsychiatric disturbances such as agitation, aggression, depression, and psychotic symptoms. These common symptoms can impact patients’ functioning and quality of life. Antipsychotic medication can be prescribed to alleviate some symptoms, but this comes with significant risks including cerebrovascular events and increased mortality. We aimed to review antipsychotic prescribing of the Harrogate Older Adult Community Mental Health Team (CMHT); to measure compliance with NICE guidance and local policy and thus improve the prescribing and monitoring process.

Using electronic patient records, we identified all patients under the care of the CMHT with a diagnosis of dementia currently receiving antipsychotic treatment; a total of 55 patients. A random sample of 24 patients were reviewed; their records were hand searched for relevant information.

The standards measured were derived from the NICE Guideline (NG97) June 2018: ‘Dementia: assessment, management and support for people living with dementia and their carers’ as well as local trust guidance.

All 24 patients were receiving antipsychotics for severe distress or aggression. 88% of patients had an assessment of sources of distress before treatment was started, but only 42% had a non-pharmacological intervention before antipsychotic treatment was started. Once antipsychotic treatment had started this increased to 58%. For some patients, the reason for not receiving a non-pharmacological intervention was due to urgency of treatment or being on a waiting list for occupational therapy, but for most the reason was not explicitly documented.

For 63%, there was evidence of a discussion of the risks of treatment with the patient, carer or family member. 63% had initial baseline blood tests and 54% had a baseline ECG. Of the patients who did not have initial monitoring, a suitable reason was given for just over 60%. Only 33% of patients who had antipsychotic treatment for over 12 weeks had a trial of discontinuation or dose reduction. Less than 22% of patients had physical health monitoring at one year of treatment.

There were shortfalls in several areas including the offer of non-pharmacological interventions, regular review of the ongoing need for antipsychotics, and physical health monitoring.

Introduction of a checklist before antipsychotics are prescribed is recommended, to include discussion of risks and benefits, non-pharmacological interventions, and initial monitoring. Also recommended is a system to identify when monitoring and review of antipsychotics are due.