Fluoroscopy is routinely used for transvenous permanent pacemaker implantation, but a standardized transthoracic echocardiography (TTE)-only workflow has not been prospectively evaluated.

The objective of the study was to evaluate the feasibility, acute safety, and procedural performance of fluoroscopy-free transvenous pacemaker implantation guided exclusively by TTE.

In this prospective, single-center feasibility study (RADIANCE [Radiation-free Anatomical Direct Imaging Approach for No-fluoroscopy Cardiac Electrode Implantation]; NCT07458724), 52 consecutive patients referred to the Department of Structural Heart Disease were screened. Thirty-one selected patients (59.6%) with guideline-based pacing indications and adequate prespecified supine TTE acoustic windows underwent attempted TTE-only implantation. Acute procedural success required completion without fluoroscopic conversion and fulfillment of prespecified TTE-defined anatomical, electrical, and safety criteria.

TTE-only implantation was successful in 30/31 patients (96.8%; 95% CI: 83.3-99.9), with fluoroscopic conversion in 1/31 (3.2%). The mean procedure time was 55.4 ± 5.6 minutes. No major acute procedural complications occurred. During a median follow-up of 8.8 months (IQR: 6-12 months), atrial lead dislodgement requiring revision occurred in 1/21 dual-chamber recipients (4.8%; 95% CI: 0.1-23.8). Procedure time decreased with chronological case order (-0.59 minutes/case; Newey-West 95% CI: -0.68 to -0.49), an exploratory team-level association.

In selected patients with adequate supine acoustic windows, TTE-guided fluoroscopy-free pacemaker implantation was feasible with acceptable acute outcomes. The lead-position findings and exploratory case-order association require further validation in larger and more diverse populations.

Within Australia, evidence is limited regarding how access to mental health care varies across geographical regions, and which areas experience the lowest levels of service use. This study aimed to provide new population-level evidence on the geographic variation in the use of Medicare-subsidised psychotherapy over the past decade and identify regions with the lowest service use.

We used administrative data from the Medicare Benefits Schedule to identify 2.7 million adults aged 25-54 years across mainland Australian states with a new mental health treatment plan from a general practitioner between 2014 and 2023. State-level trends were examined by calculating the proportion of individuals who accessed Medicare-subsidised psychotherapy within 3 months of receiving their mental health treatment plan in each state per year. We then examined variation in the use of psychotherapy across regions in 2023 (Statistical Area Level 4), and assessed how this psychotherapy use was associated with area-level socioeconomic disadvantage.

Between 2014 and 2023, psychotherapy use among adults with a mental health treatment plan declined substantially across all states, from approximately 60% of adults in 2014 to <50% in 2023. Psychotherapy use also varied markedly across sub-state regions (Statistical Area Level 4s) in 2023, with uptake ranging from 36% in Sydney's Outer South West to 60% in Perth's inner suburbs. Access was generally lower in non-metropolitan regions and in areas with higher socioeconomic disadvantage.

The results highlight the need for system supports that make psychological services more accessible, particularly in socioeconomically disadvantaged areas. Addressing access gaps will require coordinated efforts across general practice, service delivery and policy settings. Prioritising support and policies towards regions with the poorest access can assist with designing a more equitable mental health system.

Long-acting injectable (LAI) antiretroviral therapy (ART) for treatment of HIV requires more frequent healthcare interactions than standard care, offering opportunities to enhance monitoring and management of comorbid chronic conditions among people with HIV (PWH). We conducted in-depth interviews with PWH to explore perspectives on LAI-ART uptake and readiness to switch from oral ART, as well as opportunities to integrate chronic disease care into routine LAI-ART visits. Participants who were virally suppressed and had one or more chronic medical conditions were eligible. Transcripts were analyzed using applied thematic analysis, and readiness for LAI-ART was characterized using the Transtheoretical Model. Twenty-four PWH were interviewed (8 on LAI-ART and 16 on oral ART). Perceived advantages of LAI-ART included logistical convenience and relief from pill-related emotional burden, while disadvantages included dislike of injections and increased visit frequency. Provider guidance played a central role in decision-making, and satisfaction with current regimens reduced interest in LAI-ART. All participants receiving LAI-ART intended to continue this regimen, and readiness to switch among those receiving oral ART ranged from little interest to actively planning a transition. Despite varied views on LAI-ART as a personal treatment choice, most participants viewed integrating chronic disease management into LAI-ART visits as acceptable and beneficial, particularly for cardiovascular risk assessments, mental health, and social needs. Some participants on oral ART reported that access to integrated services could increase openness to initiating LAI-ART. Overall, LAI-ART visits were viewed as a potentially valuable platform for integrating chronic disease management that aligns with patient priorities.

Perinatal mental health (PMH) conditions often go unrecognized, undiagnosed, and untreated. Perinatal Psychiatry Access Programs (Access Programs) provide consultation, resources, and referrals to support frontline perinatal care clinicians in addressing PMH conditions. Most Access Programs also offer professional training for perinatal care clinicians. This article describes the goals of and approaches to professional training among 14 Access Programs.

We conducted surveys (n = 13) and semi-structured interviews (n = 28) with Access Program team members, and reviewed policy and procedure documents that were publicly available or provided by the program.

Access Programs articulated 1-4 (mean 2.2) goals for their training component, including increasing awareness and utilization of the program, increasing PMH knowledge and clinical skills, and affecting clinic or systems change. Trainings were conducted virtually and in-person and used toolkits and innovative methods tailored for each program's setting and learners. Learners included obstetric, primary care, and mental health clinicians. In several cases, educational methods were well-aligned with training goals. Programs reported mutually reinforcing interactions between training and other Access Program components such as expert case consultation and technical assistance.

The varying training goals and approaches reported here can inform how Access Programs and other psychiatric consultation programs develop or modify their professional training. This study also provides a framework for summarizing Access Program training activities, aligning professional training activities with program goals, and conceptualizing formal training as part of a multicomponent intervention ultimately aiming to affect outcomes ranging from clinician knowledge, awareness, and skills to clinic and systems change.

Behavioral health (BH) is a critical component of value-based primary care. However, access to BH services is a challenge, with a limited, geographically concentrated supply of providers. The Collaborative Care Model (CoCM) is an evidence-based, cost-effective way for value-based primary care leaders to deliver high-quality BH services. Despite a robust clinical and implementation science evidence base, real-world adoption of CoCM remains limited. A key barrier to CoCM adoption is a one-size-fits-all fee-for-service reimbursement methodology, which fails to adequately capture the value of CoCM. Studies show CoCM can deliver a 6:1 return on investment and multiply the impact of psychiatry effort by 7×. The movement of primary care toward value-based payment presents an opportunity to align incentives to increase CoCM adoption and improve access to evidence-based behavioral health. Using the Health Care Payment Learning & Action Network's framework of alternative payment models, we propose policies to facilitate the implementation of CoCM for primary care organizations at different stages of value-based payment-from fee-for-service, to pay-for-performance, to shared savings, to population-based payment. By taking this segmented approach, policymakers can align incentives to accelerate adoption of CoCM and increase access to evidence-based behavioral health at scale.

Surveys suggest mental health conditions are more common among physicians than the general population. However, whether these challenges are being driven by profession specific factors compared to broader societal change is unclear. Little is known about whether these challenges disproportionately affect resident physicians, who may experience unique stressors, or differ by sex.

To examine sex-based mental health visits among physicians in residency relative to non-physicians.

We conducted a retrospective, sex-stratified, population-based cohort study of resident physicians matched (1:5 on index year, sex, age, rurality, and income quintile) to non-physicians from April 1, 2004, to March 31, 2018.

Mental health visit rates during the five-year residency period, defined by any diagnostic or billing code for a mental health condition, compared to non-physicians.

We included 10,925 resident physicians and 54,625 matched non-physicians (mean [SD] age, 27.2 [3.0] years; 5,941 [54.37%] female physicians; 4,984 [45.62%] male physicians). Overall, 34.35% of physicians had a mental health visit compared to 36.13% of non-physicians. Anxiety was the most common diagnosis across all groups, highest among female physicians (67.38% of visits). Among physicians, females had a higher risk of a mental health visit than males (adjusted HR, 1.44; 95% CI, 1.35-1.54). Comparing physicians to non-physicians, female physicians were less likely to have a mental health visit than female non-physicians (39.71% vs 41.24%; adjusted HR, 0.89; 95% CI, 0.85-0.93). A similar pattern was observed among male physicians compared to male non-physicians (27.97% vs 30.03%; adjusted HR, 0.81; 95% CI, 0.76-0.85).

One in three physicians had a mental health visit during their residency. However, visit rates were lower than those of matched non-physicians, despite persistent concerns about physician mental health. Female physicians were more likely than male physicians to seek care, mirroring the general population.

Chronotype is associated with depression and PTSD, which are common mental health conditions among military veterans. Few studies have examined chronotype in this population, which is known to also have more severe sleep difficulties than non-veteran community-residing adults.

In the current study, self-reported sleep and mental health symptoms were examined by chronotype using data collected from US military veterans (N = 144) participating in a multi-site post-deployment health repository. Analysis of covariance was used to assess symptom measure differences by chronotype after adjusting for age and sex.

Consistent with prior research, evening types endorsed greater symptomology across measures of depression and PTSD as compared to morning types. Evening types also endorsed more severe insomnia symptoms and poorer sleep quality, and these relationships were not mediated by sleep duration. Chronotype was not associated with trauma-associated sleep disturbance.

Consideration of chronotype may be important for case conceptualization in military veterans and those with elevated depression, suicidality, and/or trauma. Assessing chronotype may be important for identifying phenotypes at increased risk of greater psychiatric symptom burden, in addition to understanding treatment response to interventions targeting sleep timing, such as cognitive behavioral therapy for insomnia.

Few studies have examined chronotype in military veterans, a population known to have more severe sleep difficulties than non-veteran community-residing adults. In this study, a registry of US military veterans serving since 911 was leveraged to examine chronotype relationship to mental health symptoms.

Evening types endorsed greater symptomology across self-report measures of insomnia severity, sleep quality, PTSD, and depression. Consideration of chronotype may be important for case conceptualization among military veterans and for identifying phenotypes at increased risk of greater psychiatric burden. Assessment of chronotype may also be important for understanding response to interventions targeting sleep timing, such as cognitive behavioral therapy for insomnia (CBTi).

Social insurance systems provide essential financial support to cover living expenses and medical treatment needs during times of work incapacity. However, many ill and injured workers experience the administrative processes involved in accessing these systems as difficult to navigate, which can stifle recovery and slow return to work. The present study centres workers' lived experiences to better understand facilitators and barriers to recovery, and to identify solutions grounded in workers' perspectives.

Twenty Australian workers with work-related injuries, health, and mental health conditions completed an online interview between February and August 2024. Thematic analysis was used to interpret and group participant responses.

Three themes describing recovery experiences emerged, whereby each theme described a facilitator and a barrier subtheme. Additionally, four solution themes emerged, emphasising the importance of shifting systems towards including workers in decision-making steps, increasing transparency and ease of claim processing, and reducing financial strain.

Findings are discussed in light of Administrative Burden Theory (ABT). ABT introduces concepts of learning, compliance, and psychological costs that ill and injured workers bear while engaging with social insurance systems. ABT proposes that these costs are not equally distributed, often disadvantaging those with fewer resources or support networks. We argue that ABT provides a useful framework through which to understand ill and injured workers' experiences with workers' compensation, and that it provides mechanisms to explain workers' suggested solutions.

Pain is the leading cause of disability worldwide, yet no harmonized self-reported reference framework exists to characterize how its burden is distributed across the lifespan and world regions. In this study, we harmonized individual-level self-reported pain data from 6,125,459 participants across 902 population-based data sources in 118 countries to establish global reference trajectories of pain. We implemented these trajectories in an open-access benchmarking platform for positioning external datasets against global pain norms. Pain prevalence ranged from roughly 2% for facial pain to 40% for back pain, was consistently higher in women across all 11 anatomical sites (risk ratio range: 1.08-1.83) and increased most steeply before age 55 years. Contrary to existing estimates that generally project higher prevalence of pain conditions in higher Human Development Index (HDI) regions, we found that individuals in the lowest HDI countries experienced a substantially higher late-life prevalence of any bodily pain than those in the highest (risk difference: 30.6 percentage points (95% confidence interval: 26.9-34.3)), with low back pain approaching twice the prevalence at the oldest ages. Globally, 18.3% of pain burden across anatomical sites was attributable to three modifiable risk factors (smoking, obesity and low income), but this varied from 12.6% in sub-Saharan Africa to 27.1% in eastern Europe, indicating that the factors underlying pain in lower-HDI settings remain poorly characterized. Together, these reference trajectories provide a common framework for defining and comparing pain burden and informing more equitable global surveillance and prevention.

Motherhood is inherently demanding, and some of these demands may be amplified for women with borderline personality disorder (BPD). The exacerbation of BPD symptoms from parenting-related stressors can have adverse impacts on mother-infant relationships and infant development. This qualitative study explores Australian mothers' views of the impacts of mother-infant dialectical therapy plus (MI-DBT+). MI-DBT+ is an innovative therapeutic intervention which integrates mother-infant dialectical behavior Therapy (MI-DBT), a known effective intervention for the mental health of mothers with BPD, with attachment and biobehavioral catch-up (ABC) therapy. Specifically, eight mothers completed semi-structured interviews about their experiences of intervention following completion of the MI-DBT+ program. A thematic analysis of this interview data found that mothers appreciated learning more skills to enhance their understanding of their infants' needs, behaviors and emotions. Mothers also reported improved reflective functioning and better control of their emotional responses. These skills assisted in managing emotional distress at both the individual and dyadic level. The study was limited due to available demographic data, with only maternal and child age available. Discussion also focuses on the fit between DBT and ABC, longer term developmental concerns and sustainability.