Assistive technology for cognition (ATC), particularly smartphone-based apps, can significantly enhance rehabilitation outcomes for individuals with acquired brain injury (ABI). Despite demonstrated efficacy, challenges persist in initial uptake and long-term engagement with such technologies. This study employed a mixed-methods approach to examine factors influencing sustained engagement with the Neumind app over 13-14 months among individuals with ABI. Twelve adult participants were interviewed, and their app usage data was quantitatively analysed over nine months post-interview. Eleven participants used the app when interviewed 4-5 months after download (3 highly active, 3 moderately active and 5 occasional users). The six active users maintained their use nine months later. Qualitative thematic analysis identified six major themes impacting sustained ATC engagement: Introduction and Initial Use (recommendation by others, ease of setup), Perceived Benefits (increased confidence, independence), Technical and Functional Challenges (technical issues, reliability, simplicity), User Customisation Preferences (reminder features, calendar scheduling), Community and Social Support (sense of belonging, helping others), and Integration into Rehabilitation and Daily Life (integration with rehabilitation, habit formation, established strategies, timing of introduction). Participants who maintained consistent use reported tangible benefits, effective habit formation, emotional engagement through community participation, and successful integration into rehabilitation routines. Non-users faced technical difficulties, perceived irrelevance of content, and preferred existing strategies. This study underscores the critical role of early introduction, ease of use, community integration, and habit formation in sustaining ATC engagement. Addressing usability barriers, enhancing customisation, and incorporating structured social support may significantly improve long-term use and effectiveness of ATC interventions in neuro-rehabilitation.

Postnatal mental health difficulties are common and often under-treated. Nature-based interventions have potential mental health benefits, but little research has focussed on their applicability postnatally. This study examined the acceptability and feasibility of delivering a co-designed, 5-week group nature-based intervention, The Mother Nature Programme (MNP), for mothers experiencing postnatal mental health difficulties and their infants, in preparation for a future trial. A single-arm, mixed-methods feasibility study with a prospective pre/post design, delivered across six intervention groups. We recruited mothers self-reporting postnatal mental health difficulties, with infants under 12 months (extended to under 24 months in some groups), via community and third-sector organisations. The programme comprised weekly 2-h sessions of invitational activities guiding participants to notice and connect with the natural world. It was delivered in local urban outdoor settings, by a nature-based practitioner and peer support worker. Feasibility outcomes included recruitment, retention rates, attendance, and completeness of the following participant-reported outcome measures (collected at baseline and week 5): Edinburgh Postnatal Depression Scale (EPDS), Generalised Anxiety Disorder-7 Scale (GAD-7), Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), and Nature Relatedness Scale-6 (NR-6). We explored participants’ experiences of the intervention through a nested qualitative study. Analysis of feasibility outcomes was based on descriptive statistics. We analysed qualitative data thematically. Forty-three mothers, from diverse ethnic backgrounds, were enrolled in the study. Forty-two started the programme, of whom 90.5

Background Ambulatory assessment and mood monitoring offer a promising, flexible, and efficient approach for assessing mood, mental state, and behaviour, potentially improving on traditional clinical outcome measures. However, the real-world utility of these novel technologies fundamentally depends on their demonstrated performance. Aims This systematic review aimed to assess the performance and validity of active and passive ambulatory assessment and mood monitoring outcome measures in randomised and non-randomised studies in depression over 3 months or longer, evaluating their performance against established clinical measures and through inter-ambulatory assessment comparisons. Methods Systematic review of performance of ambulatory assessment and mood monitoring protocols in RCTs and non-randomised studies in depression (PROSPERO: CRD42023396473). Studies were identified and rated for risk of bias. We were not able to pool performance data to calculate effect sizes so we were unable to complete meta-analysis. Results 35 studies including 9310 participants used 28 different ambulatory assessment/mood tracking procedures and included 436 performance metrics. There was large inconsistency and heterogeneity in these reported metrics which prevented robust comparison and definitive inferences around performance. Active ambulatory assessment measures demonstrated stronger correlation coefficients than passive ambulatory assessment when compared to established measures. Aggregate passive ambulatory assessment measures may perform better than single item measures. Most studies had low-moderate risk of bias. Conclusions Despite ambulatory assessment’s promise, our findings indicate a critical knowledge gap: it remains unclear whether passive ambulatory assessment approaches have sufficient performance to provide a less subjective method of mood measurement. The reported methodological heterogeneity across studies, particularly in measurement and reporting of performance metrics prevents robust comparison and replication of findings. Increased standardization in ambulatory assessment methodology and reporting is needed to enable reliable assessment and widespread implementation of these novel behavioural measures.

BACKGROUND:Perinatal anxiety (PNA) is experienced by about 21% of women throughout the perinatal period. Identifying women at risk of PNA through primary care patient records could enable early intervention to improve treatment outcomes. The acceptability of doing this, however, is unknown. AIM:To explore patients' and practitioners' views on identifying women at risk of developing PNA using primary care patient records. DESIGN AND SETTING:Qualitative data are presented from a mixed-methods study, which used online and in-person interviews that were conducted in England. METHOD:Semi-structured interviews were held with 19 women with lived experience of PNA and 27 healthcare professionals (HCPs). Data were analysed thematically. A patient and public involvement and engagement group were involved throughout the study. RESULTS:Both women and practitioners thought it was acceptable to identify women at increased risk of PNA using medical records, providing that sufficient acceptable help and support was in place. All participants also highlighted that an increased risk of PNA needed to be communicated sensitively, with women preferring phrasing such as 'more vulnerable' or 'more susceptible' than 'high risk'. Challenges with identifying risk factors within patient records, such as limited sharing between HCPs and poor coding, were discussed by practitioners. CONCLUSION:There are challenges to identifying risk factors within patient records. It was felt that not all possible risk factors would be recorded in primary care records. The issues of limited sharing between HCPs and poor coding were discussed by practitioners, many of whom thought that clinical intuition was a more appropriate way to assess risk.

Introduction Bipolar disorder affects around 2% of the population and is linked with reduced life expectancy and socioeconomic burden. Depressive episodes are difficult to treat and typically more prevalent, enduring and burdensome than manic episodes. The use of antidepressants alone has limited effect and is associated with significant clinical risk through polarity switch. Current National Institute for Health and Care Excellence guidelines recommend quetiapine, olanzapine (with or without fluoxetine) and lamotrigine; however, these medications have limited efficacy, tolerability and acceptability. The ASCEnD study aims to assess the clinical and cost-effectiveness of aripiprazole plus sertraline compared with quetiapine, offering potential improvements for outcomes in bipolar depression. The study is funded by the National Institute for Health and Care Research Health Technology Assessment programme (NIHR132773).Methods and analysis ASCEnD is a prospective, two-arm, superiority, individually 1:1 randomised, controlled, pragmatic, parallel group, type A open-label clinical trial of aripiprazole/sertraline medication combination compared with quetiapine for bipolar depression. The study is conducted in the UK National Health Service setting with the aim of recruiting and randomising 270 participants followed-up for 24 weeks. Adults with bipolar disorder self-refer or are recruited through primary and secondary care services. The primary outcome is change in depressive symptoms 12–16 weeks after randomisation. Secondary outcomes include measures of symptom change, treatment satisfaction, tolerability, medication adherence, concomitant medication use, psychosocial functioning, quality of life and cost-effectiveness and informal carer measures of quality of life and costs of caring. The exploratory outcome is change in participant reward and punishment responsiveness. Analysis will follow a prespecified statistical analysis plan. A nested qualitative study is included to examine feasibility and acceptability of the trial design.Ethics and dissemination A Clinical Trial Authorisation from Medicines and Healthcare products Regulatory Agency, and approval from the Health Research Authority (IRAS 1007468) and North East – Newcastle and North Tyneside 1 Research Ethics Committee (23/NE/0132) were obtained. Results will be disseminated through peer-reviewed publications, conference presentations and lay summaries for participants and patient and public groups.Trial registration number ISRCTN63917405.

Traditional executive function (EF) assessments rely predominantly on paper-and-pencil tests that arguably lack ecological validity and fail to capture the complexity of real-world cognitive demands. Recent advances in game development offer an opportunity to address this through interactive virtual environments that assess cognitive performance in naturalistic settings. Here, we present CogniCart, a virtual supermarket task that 1) combines automatically logged behavioural measures with 2) eye tracking data to assess EF in an ecologically valid context and examine the effect of cognitive support on participants' performance. The task was implemented in two versions: 1) a prompted intervention condition providing external cognitive support features designed to assist executive functioning during the task, targeting planning, working memory, and inhibitory control, and 2) an unprompted control condition without any such support. This between-subjects design allows CogniCart to serve dual purposes, as an ecologically valid assessment tool for executive function and as a platform for examining the behavioural effects of targeted cognitive support. Twenty-four healthy university students were recruited to this study, in which they self-reported cognitive failures measured alongside their in-game behavioural data. Results suggested that CogniCart behavioural features correlated with external cognitive assessments, with regression models explaining up to 86.6% of the variance in shopping list completion rate and classification models distinguishing between the two prompt conditions with up to 87.5% accuracy, validated through permutation testing and Bayesian posterior inference. These findings suggest that CogniCart shows early promise as a scalable and ecologically valid framework for the quantitative assessment and modelling of executive functions in neurodiverse populations.

Importance: Much research investigates sequelae arising from traumatic brain injury (TBI), however few studies investigate risk factors for TBI in the first instance. This could have implications for representativeness, risk mitigation and prevention. Objectives: Test for associations between multiple sociodemographic and individual difference variables, and their interaction with sex, on risk of subsequent incident TBI. Design, setting and participants: General population prospective cohort, UK Biobank. Main outcomes and measures: Baseline lifestyle, cognitive, personality and sociodemographic variables versus risk of later TBI, ascertained via ICD-10 codes. We used Cox regressions, and tested 11 predictors individually, then adjusted for baseline age and sex, then combined in one multivariable model. Results: After exclusions, 5764/500,035 (1.15%) participants recorded a TBI over median 14 years follow-up. Most predictors were individually associated with increased risk of TBI in expected directions. The largest associations were for male sex (versus female; hazard ratio [HR] = 1.56, 95% confidence intervals [CIs] = 1.48-1.65) and self-reported ‘risk-taker’ status (HR = 1.28, 95 CIs = 1.21-1.36). These remained significant in multivariable regressions. There was significant interaction between educational attainment and sex, where degree possession (versus not) was protective in males only (HR = 0.76, 95% CIs = 0.70-0.82, all P <0.001). Conclusion and relevance: Prominent risk factors for TBI include male sex and identifying as a ‘risk-taker’. Higher educational attainment was protective in males. Studies comparing TBI cases versus controls routinely underestimate premorbid group differences. These findings represent targetable opportunities for public health intervention.

BackgroundQuality of life (QoL) is an important surgical outcome, commonly assessed through self-reports, and has the potential to be enhanced by objective information from personal technologies such as smartphone apps and wearables. Understanding patients’ perspectives on this application of personal technologies is scarce. ObjectiveThis study aimed to identify operational aspects of smartphone- and wearable-based assessments, as well as human and operational factors that may influence the acceptability of already owned (mostly smartphone) or new (mostly wearable) technologies by patients for pre- and post-surgery QoL assessments. MethodsThrough purposive sampling, 41 patients from 3 health care centers in Switzerland, the United States, and the United Kingdom, who were undergoing or scheduled for surgery for degenerative cervical myelopathy (DCM), liver transplantation, or total hip replacement, were interviewed about their perceptions of QoL, current use of smartphones, health apps, and wearables for self-management and their views on using these technologies to assess QoL before and after surgery. ResultsAcross the 3 studies (n=41), most (n=36) patients reported improved QoL after surgery, mainly due to reduced pain and fatigue and regained autonomy, while a few patients with DCM reported no change (n=2) or worsening (n=1). Patients were generally comfortable using smartphones and tablets, but few (n=4) used them for health management. Wearables were perceived differently across groups: they were well accepted in transplant@US, moderately in hip@UK, and least in myelopathy@CH. Many patients with DCM found wearables “useless,” believing they added little to their self-awareness or recovery and could not replace human clinical judgment. Others expressed concerns about privacy, complexity, notifications, and battery life, while some acknowledged their motivational value when the data were clearly interpreted. Despite varying acceptance levels, most participants said they would consider using such devices if they contributed to research or improved care. ConclusionsGiven a mostly negative attitude of patients toward wearables, we discuss the use of smartphone-based automated logging of physical functioning (sleep and physical activity) instead. Such logging may be less accurate than a dedicated wearable, but it may be accurate enough to measure their pre- and post-surgery physical functioning changes. Additionally, a smartphone has the advantage of being already well integrated into the daily life of patients from the perspective of its functionality and the patients’ routines, contrary to wearable devices, which would have been provided to the patients in the context of pre- and post-surgery clinical care and require additional attention for their continuous wear, charging, and data synchronization, among others.

BACKGROUND:About 30% of patients with depression treated with antidepressant medication do not respond sufficiently to the first agents used. Pramipexole might usefully augment antidepressant medication in such cases of treatment-resistant depression, but data on its effects and tolerability are scarce. We aimed to assess the efficacy and tolerability of pramipexole augmentation of ongoing antidepressant treatment, over 48 weeks, in patients with treatment-resistant depression. METHODS:We did a multicentre, double-blind, placebo-controlled randomised trial in which adults with resistant major depressive disorder were randomly assigned (1:1; using an online randomisation system) to 48 weeks of pramipexole (titrated to 2·5 mg) or placebo added to their ongoing antidepressant medication. The study was conducted in nine National Health Service Trusts in England. Participants, investigators, and researchers involved in recruitment and assessment were masked to group allocation, and the central pharmacy team dispensing the medication was not masked. The primary outcome was change from baseline to week 12 in the total score of the 16-item Quick Inventory of Depressive Symptomology self-report version (QIDS-SR16). The primary analysis was performed on the intention-to-treat population that included all eligible, randomly assigned participants. People with lived experience were involved in the design, oversight, and interpretation of the study. The trial was registered with ISCTRN (ISRCTN84666271) and EudraCT (2019-001023-13) and is complete. FINDINGS:Between Feb 16 and May 29, 2024, 217 participants attended a screening visit, of whom 66 were excluded due to ineligibility. 151 participants were randomly assigned (75 to the pramipexole group and 75 to the placebo group, after one participant was found to be ineligible after randomisation). 84 (56%) participants were female and 66 (44%) were male and the mean age of participants was 44·9 years (SD 14·0). Ethnicity data were not available. The mean QIDS-SR16 total score at baseline was 16·4 (SD 3·4) in the pramipexole group and 16·2 (3·5) in the placebo group. The mean dose of pramipexole received at week 12 was 2·3 mg (SD 0·45). Adjusted mean decrease from baseline to week 12 of the QIDS-SR16 total score was 6·4 (SD 4·9) for the pramipexole group and 2·4 (4·0) for the placebo group; the mean difference between groups was -3·91 (95% CI -5·37 to -2·45; p<0·0001). Termination of trial treatment due to adverse events was more frequent in the pramipexole group (15 participants [20%]) than in the placebo group (four participants [5%]), with reported adverse events consistent with known side-effects of pramipexole, in particular nausea, headache, and sleep disturbance or somnolence. INTERPRETATION:In this trial involving participants with treatment-resistant depression, pramipexole augmentation of antidepressant treatment, at a target dose of 2·5 mg, demonstrated a reduction in symptoms relative to placebo at 12 weeks but was associated with some adverse effects. These results suggest that pramipexole is a clinically effective option for reducing symptoms in patients with treatment-resistant depression. Future trials directly comparing pramipexole with existing treatments for this disorder are needed. FUNDING:National Institute of Health and Care Research, Efficacy and Mechanism Evaluation Programme.

We analyzed the 7.92 × 10 ^11 cosmic-ray-induced muon events collected by the IceCube Neutrino Observatory from 2011 May 13, when the fully constructed experiment started to take data, to 2023 May 12. This data set provides an up-to-date cosmic-ray arrival direction distribution in the Southern Hemisphere with unprecedented statistical accuracy covering more than a full period length of a solar cycle. Improvements in Monte Carlo event simulation and better handling of year-to-year differences in data processing significantly reduce systematic uncertainties below the level of statistical fluctuations compared to the previously published results. We confirm the observation of a change in the angular structure of the cosmic-ray anisotropy between 10 TeV and 1 PeV, more specifically in the 100–300 TeV energy range. For the first time, we analyzed the angular power spectrum at different energies. The observed variations of the power spectra with energy suggest relatively reduced large-scale features at high energy compared to those of medium and small scales. The large volume of data enhances the statistical significance at higher energies, up to the PeV scale, and smaller angular scales, down to approximately 6° compared to previous findings.

The recent IceCube detection of TeV neutrino emission from the nearby active galaxy NGC 1068 suggests that active galactic nuclei (AGNs) could make a sizable contribution to the diffuse flux of astrophysical neutrinos. The absence of TeV γ -rays from NGC 1068 indicates neutrino production in the vicinity of the supermassive black hole, where the high radiation density leads to γ -ray attenuation. Therefore, any potential neutrino emission from similar sources is not expected to correlate with high-energy γ -rays. Disk-corona models predict neutrino emission from Seyfert galaxies to correlate with keV X-rays because they are tracers of coronal activity. Using through-going track events from the Northern Sky recorded by IceCube between 2011 and 2021, we report results from a search for individual and aggregated neutrino signals from 27 additional Seyfert galaxies that are contained in the Swift's Burst Alert Telescope AGN Spectroscopic Survey. Besides the generic single power law, we evaluate the spectra predicted by the disk-corona model assuming stochastic acceleration parameters that match the measured flux from NGC 1068. Assuming all sources to be intrinsically similar to NGC 1068, our findings constrain the collective neutrino emission from X-ray bright Seyfert galaxies in the northern sky, but, at the same time, show excesses of neutrinos that could be associated with the objects NGC 4151 and CGCG 420-015. These excesses result in a 2.7 σ significance with respect to background expectations.

Background:Pramipexole augmentation of antidepressant treatment for treatment-resistant depression (TRD) has been shown to improve symptom burden over 12 weeks but with some adverse effects compared to placebo augmentation. We aimed to evaluate the cost-effectiveness of pramipexole augmentation for TRD. Methods:We conducted an economic evaluation as part of the PAX-D trial over 12 and 48 weeks. Two costing perspectives, National Health Service and Personal Social Services (NHS + PSS) and societal, were adopted. The primary outcome was quality-adjusted life year (QALY) based on the EQ-5D-5L. Secondary outcomes included year of full capability (YFC) based on the ICECAP-A, and capability-weighted life year (CWLY) based on the OxCAP-MH. Incremental cost-effectiveness ratios (ICERs), cost-effectiveness planes and cost-effectiveness acceptability curves were reported alongside sensitivity analyses. The trial was registered with ISCTRN (ISRCTN84666271) and EudraCT (2019-001023-13) and is complete. Findings:From the NHS + PSS perspective, mean incremental cost of pramipexole was £60 (95% CI: -£55, £176) over 12 weeks and £811 (95% CI: £110, £1513) over 48 weeks. The difference in QALY gained was 0.012 (95% CI: 0.003, 0.021) over 12 weeks and 0.090 (95% CI: 0.036, 0.144) over 48 weeks, equivalent to 4 (95% CI: 1, 8) and 33 (95% CI: 13, 52) days in perfect health. The ICER was £5069/QALY (95% CI: -£3642, £35,608) over 12 weeks and £9007/QALY (95% CI: £2,219, £27,258) over 48 weeks, representing over 90% probability of cost-effectiveness at £20,000/QALY threshold. From the societal perspective, pramipexole was on average cost saving and more effective over 48 weeks. Alternative analyses provided consistent conclusions. Interpretation:Pramipexole augmentation for TRD has demonstrated both clinical and cost-effectiveness. Further trials, directly comparing pramipexole to other augmentation strategies, will be useful in determining the position of this repurposed medication in the treatment pathway of depression. Funding:National Institute for Health and Care Research, Efficacy and Mechanism Evaluation Programme.

BACKGROUND:A crucial part of delirium care is assessing for recovery, yet there are no validated methods for this. The 4AT is a widely used delirium assessment tool, but its performance in assessing recovery remains unstudied. This study evaluated the 4AT's performance in assessing recovery from delirium. MATERIALS AND METHODS:In this prospective diagnostic accuracy study, older hospitalised patients (≥70 years) with reference standard delirium on enrolment were assessed 2-4 times over ≤9 days. Paired researchers independently conducted blinded assessments of (i) a reference standard (Diagnostic and Statistical Manual for Mental Disorders, 5th edition), including the Delirium Rating Scale-Revised-98 and neuropsychological tests and (ii) the 4AT (index test, score ≥ 4 positive) plus brief measures of distress and psychotic symptoms. RESULTS:A total of 120 people with delirium participated [median age 86.3, range 70-99, 67 (55.8%) female and 55 (45.8%) with dementia]. All of them completed the first two assessments, 103 (85.8%) completed three and 69 (57.5%) four. Reference standard delirium was present in 102/120 (85%), 72/103 (69.9%) and 53/69 (76.8%) cases at assessments two to four, respectively. In Receiver Operating Characteristic analyses, the 4AT's sensitivity for detecting delirium was 0.95 (confidence interval 0.91-0.99), 0.96 (0.91-1) and 0.94 (0.88-1), and specificity was 0.67 (0.13-1), 0.88 (0.71-1) and 1 (1-1) at assessments two to four. In total 18 (15%) participants recovered from delirium. Distress was common in delirium and decreased with recovery. CONCLUSION:The 4AT maintains diagnostic accuracy on repeated admissions and may effectively assess delirium recovery in acute hospital settings. Fewer patients than expected recovered within 9 days, suggesting more studies on the natural history of delirium in different settings would be informative.

Active galactic nuclei (AGN) are promising candidate sources of high-energy astrophysical neutrinos, since they provide environments rich in matter and photon targets where cosmic-ray interactions may lead to the production of gamma rays and neutrinos. We searched for high-energy neutrino emission from AGN using the Swift-BAT Spectroscopic Survey catalog of hard X-ray sources and 12 yr of IceCube muon track data. First, upon performing a stacked search, no significant emission was found. Second, we searched for neutrinos from a list of 43 candidate sources and found an excess from the direction of two sources, the Seyfert galaxies NGC 1068 and NGC 4151. We observed NGC 1068 at flux ϕ ν μ + ν ¯ μ = 4.0 2 − 1.52 + 1.58 × 1 0 − 11 TeV −1 cm −2 s −1 normalized at 1 TeV, with a power-law spectral index γ = 3.10 − 0.22 + 0.26 , consistent with previous IceCube results. The observation of a neutrino excess from the direction of NGC 4151 is at a posttrial significance of 2.9 σ . If interpreted as an astrophysical signal, the excess observed from NGC 4151 corresponds to a flux ϕ ν μ + ν ¯ μ = 1.5 1 − 0.81 + 0.99 × 1 0 − 11 TeV −1 cm −2 s −1 normalized at 1 TeV and γ = 2.83 − 0.28 + 0.35 .

BACKGROUND:Evidence regarding the dynamics of the longitudinal reciprocal associations between maternal and paternal depression over time is lacking. The current study examines reciprocal longitudinal associations between maternal and paternal depressive symptoms (DS) from pregnancy (18 weeks-gestation) to 11 years 2 months (study child's age) to gain insights into the joint course of DS. METHODS:The study sample comprised 6296 mothers and fathers from the UK-based birth cohort, the Avon Longitudinal Study of Parents and Children. Reciprocal longitudinal associations between maternal and paternal DS, assessed at nine time-points (Edinburgh Postnatal Depression Scale; continuous scores), were examined using random intercept cross-lagged panel models to differentiate between stable covariance (between-person differences in DS) and dynamic processes (within-person level). Analyses were adjusted for parental and socioeconomic confounders. RESULTS:There were strong correlations between random intercepts of maternal and paternal DS (β = 0.305, SE = 0.015, p ≤ 0.001), suggesting positive associations between the overall mean levels of parental DS (i.e., a between-person association). There were strong stability effects for maternal and paternal DS across all nine measurement occasions (i.e., within-person associations), with larger effects evident for both maternal and paternal DS later in childhood (between ages 5 and 11 years). There was evidence for bidirectional longitudinal within-person effects between maternal and paternal DS at some but not other measurement occasions. CONCLUSIONS:These findings have important implications for screening, prevention and intervention programmes. Depression in one parent may require screening efforts directed at the other parent, with prevention and intervention programmes focused on the family, rather than one parent.

Introduction Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) are both efficacious treatments for depression, but it is less clear how both compare on outcome domains other than depression and in the longer term. Moreover, it is unclear which of these two psychotherapies works better for whom. This article describes the protocol for a systematic review and individual participant data (IPD) meta-analysis that aims to compare the efficacy of CBT and IPT for adults with depression on a range of outcomes in both the short and long term, and to explore moderators of the treatment effect. This study can enhance our understanding of treatments for depression and inform treatment personalisation.Methods and analysis Systematic literature searches will be conducted in PubMed, PsycINFO, EMBASE and the Cochrane Library from inception to 1 January 2026, to identify randomised clinical trials (RCTs) comparing CBT and IPT for adult depression. Researchers of eligible studies will be invited to contribute their participant-level data. One-stage IPD meta-analyses will be conducted with mixed-effects models to examine (a) treatment efficacy on all outcome measures that are assessed at post-treatment or follow-up in at least two studies, and (b) various baseline participant characteristics as potential moderators of depressive symptom level at treatment completion.Ethics and dissemination Ethical approval is not required for this study since it will be based on anonymised data from RCTs that have already been completed. The findings of the present study will be disseminated through a peer-reviewed journal or conference presentation.

PURPOSE:This systematic review and meta-analysis aimed to establish the relationship between the number of procedures a hospital or surgeon performs with outcomes following revision knee replacement (RevKR). METHODS:MEDLINE and Embase were searched using Ovid silver platter up to December 2024 for randomised controlled trials and cohort studies that reported RevKR volumes, in at least two categories, performed by hospitals and surgeons and their relationship to patient and provider level outcomes. The primary outcome was re-revision rate. Secondary outcomes included mortality, post-operative complications, patient-reported outcomes measures (PROMs), emergency readmissions and hospital length of stay. The effect estimates were pooled and plotted using a random-effects, non-linear dose-response meta-analysis (DRMA). Where limitations in the data prohibited DRMA, a narrative approach was utilised. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively. RESULTS:A total of 10 cohort studies with data from 1993 to 2021 were included. The confidence in the cumulative evidence exploring the relationship between surgeon/hospital volume and all outcomes after RevKR was very low. An inconsistent relationship was seen between hospital and surgeon volume and re-revision at any point. There was a non-linear dose-response relationship between higher hospital volume and lower odds of adverse post-operative events (p < 0.05, n = 3 studies, n = 35,524 patients). There was no association between increased surgeon volumes and improvements in PROMs (n = 2 studies, n = 2289). CONCLUSION:There is a lack of high-quality studies establishing the relationship between the number of procedures a hospital or surgeon performs and outcomes following RevKR. Studies are limited to observational designs and are difficult to effectively power due to the rarity of outcomes. Pooling data from multiple studies provides valuable insights but highlights significant heterogeneity and limitations in the existing literature. LEVEL OF EVIDENCE:Level III, systematic review-lowest level of evidence analysed-was from retrospective cohort study of prospectively collected data.

PurposeRevision knee replacement (RevKR) for infection is rare but increasing. It is hypothesised that higher hospital volume reduces adverse outcomes. The aim was to estimate the association of surgical unit volume with outcomes following first, single-stage RevKR for infection.MethodsThis population-based cohort study merged data from the United Kingdom National Joint Registry, Hospital Episode Statistics, National Patient Reported Outcome Measures and the Civil Registrations of Death. Patients undergoing procedures between 1 January 2009 and 30 June 2019 were included. Early outcomes were chosen to reflect the quality of the surgical provision and included re-revision at 2 years, mortality, serious medical complications, length of stay and patient-reported outcome measures (PROMs). Adjusted fixed effect multivariable regression models were used to examine the association between surgical unit mean annual caseload and the risk of adverse outcomes.ResultsA total of 1477 patients underwent first-time single-stage RevKRs for infection across 267 surgical units and 716 surgeons. Following adjustment for age, gender, American Society of Anaesthesiologists grade, surgeon volume, year of surgery and operation funder and modelling surgical unit volume with restricted cubic spline, a greater mean annual volume was associated with a lower risk of re-revision at 2 years. The odds of re-revision in hospitals performing fewer than or equal to 12 cases per year was 2.53 (95% confidence interval = 1.50-4.31) times more likely than hospitals performing three to four cases per month. Annual variation in surgical unit volume was not associated with mortality and serious medical complications within 90 days. Only 99 out of 1477 (7%) of patients had linked PROMs which precluded subsequent analysis.ConclusionOverall, higher volume surgical units had lower rates of early re-revision following the first RevKR for infection. We were unable to provide recommended specific volume thresholds for units; however, the probability of re-revision appears to be lowest in the highest volume units.Level of EvidenceLevel III, retrospective cohort study of prospectively collected data.