Mental health systems modelling for evidence-informed service reform in Australia

Australia's Fifth National Mental Health Plan required governments to report, not only on the progress of changes to mental health service delivery, but to also plan for services that should be provided. Future population demand for treatment and care is challenging to predict and one solution involves modelling the uncertain demands on the system. Modelling can help decision-makers understand likely future changes in mental health service demand and more intelligently choose appropriate responses. It can also support greater scrutiny, accountability and transparency of these processes. Australia has an emerging national capacity for systems modelling in mental health which can enhance the next phase of mental health reform. This paper introduces concepts useful for understanding mental health modelling and identifies where modelling approaches can support health service planners to make evidence-informed decisions regarding planning and investment for the Australian population.

Liposomal bupivacaine reduces opioid requirements following Ravitch repair for pectus excavatum

Background and Aims

The management of post-operative pain after surgical repair of pectus excavatum with the Ravitch procedure is challenging. Although previous studies have compared various methods of pain control in these patients, few have compared different local anesthetics. This retrospective analysis compares the use of bupivacaine to its longer-acting form, liposomal bupivacaine, in patients who had undergone pectus excavatum repair with the Ravitch method.

Material and Methods

Eleven patients who received local infiltration with liposomal bupivacaine were matched to 11 patients who received local infiltration utilizing bupivacaine with epinephrine. The primary outcome was total morphine milligram equivalents per kilogram body weight (MME/kg) over the complete length of hospital stay. Secondary outcomes included total cumulative diazepam, acetaminophen, ondansetron, and NSAID dose per kilogram body weight (mg/kg) over the course of the hospital stay, chest tube drainage (ml/kg body weight), number of post-operative hours until the first bowel movement, Haller Index, patient request for magnesium hydroxide, average pain scores from post-operative day 1 to post-operative day 5, and length of hospital stay. Continuous variables were reported as medians with inter-quartile ranges, and categorical values were reported as percentages and frequencies.

Results

The total MME/kg [1.7 (1.2-2.4) vs 2.9 (2.0-3.9), P = 0.007] and hydromorphone (mg/kg) [0.1 (0.0-0.2) vs 0.3 (0.1-0.4), P = 0.006] use in the liposomal bupivacaine group versus bupivacaine with epinephrine was significantly reduced over total length of hospital stay. Similarly, there was a reduction in diazepam use in the liposomal bupivacaine group versus the bupivacaine group [0.4 (0.1-0.8) vs 0.6 (0.4-0.7), P = 0.249], but this did not reach statistical significance. The total dose of ondansetron (mg/kg) was not statistically different when comparing the liposomal bupivacaine group to the bupivacaine group [0.3 (0.0-0.5) vs 0.3 (0.2-0.6), P = 0.332]. Interestingly, the total dose of acetaminophen (mg/kg) was statistically increased in the liposomal bupivacaine group compared to the bupivacaine with epinephrine group [172 (138-183) vs 74 (55-111), P = 0.007]. Additionally, the total chest tube drainage (ml/kg) was significantly reduced in the liposomal bupivacaine group [9.3 (7.5-10.6) vs 12.8 (11.3-18.5), P = 0.027]. Finally, the percentage of patients without requests for magnesium hydroxide to promote laxation was significantly higher in the liposomal bupivacaine group than in the bupivacaine group (63.6% vs 18.2%, P = 0.027).

Conclusion

The use of liposomal bupivacaine for local infiltration in patients who undergo the Ravitch procedure for pectus repair offers advantages over plain bupivacaine, including reduced opioid consumption and opioid-related side effects. However, more data are needed to understand the significance of these findings.

Expression and characterization of spore coat CotH kinases from the cellulosomes of anaerobic fungi (Neocallimastigomycetes)

Anaerobic fungi (Neocallimastigomycetes) found in the guts of herbivores are biomass deconstruction specialists with a remarkable ability to extract sugars from recalcitrant plant material. Anaerobic fungi, as well as many species of anaerobic bacteria, deploy multi-enzyme complexes called cellulosomes, which modularly tether together hydrolytic enzymes, to accelerate biomass hydrolysis. While the majority of genomically encoded cellulosomal genes in Neocallimastigomycetes are biomass degrading enzymes, the second largest family of cellulosomal genes encode spore coat CotH domains, whose contribution to fungal cellulosome and/or cellular function is unknown. Structural bioinformatics of CotH proteins from the anaerobic fungus Piromyces finnis shows anaerobic fungal CotH domains conserve key ATP and Mg²⁺ binding motifs from bacterial Bacillus CotH proteins known to act as protein kinases. Experimental characterization further demonstrates ATP hydrolysis activity in the presence and absence of substrate from two cellulosomal P. finnis CotH proteins when recombinantly produced in E. coli. These results present foundational evidence for CotH activity in anaerobic fungi and provide a path towards elucidating the functional contribution of this protein family to fungal cellulosome assembly and activity.

Radiation Exposure from the Patient Perspective: An Argument for the Inclusion of Dose History

ABSTRACT

Patients in diagnostic imaging departments often ask about the risk of injury from x radiation. They are referred to wall posters or consent forms that declare (rightly) that the risk of harm from the proposed exam is very small and is far outweighed by the benefit. If a comparative risk value is provided, most likely it is based on a single exposure and derived from population estimates of cancer incidence and mortality. But is that information the most relevant for the patient? In a recent position statement, the AAPM recommends that only current exam risk should be considered, and that risk is independent of previous exams. We argue that if an exam carries risk of a negative event, the likelihood that a negative event occurred over all events increases with the number of exams. This cumulative risk, though still very small, must be a relevant consideration for health management.Health Phys. 000(0):000-000; 2023.

Syringocystadenoma papilliferum: case series and review of the literature

Syringocystadenoma papilliferum (SCAP) is a rare, hamartomatous tumor of the apocrine glands, which typically manifests in the head and neck region. We present a case of 60-year-old male with a several-year history of the lesion located on the abdominal wall and a second case of a 58-year-old male with a history of a slow-growing lesion located on the tragus. Despite varying presentations and locations, both patients were identified to have SCAP on pathological evaluation. Appropriate treatments of SCAP range from CO2 laser treatment to surgical excision; we recommend surgical excision due to the risk of malignant transformation.

A10 OVEREXPRESSION OF ASCL2 ALTERS DIFFERENTIATION, CELL CYCLE AND RESISTANCE TO ANTI-CANCER TREATMENT IN ESOPHAGEAL ORGANOIDS

Background

The esophagus is in constant contact with the austere environment caused by food and gastric reflux. It is protected by a squamous epithelium which maintenance is provided by a rare subpopulation of basal cells: Keratin 15+ (Krt15+) stem cells. However, little is known about the mechanisms underlying the expansion and the function of these stem cells. It was shown that the transcription factor ASCL2 is strongly upregulated in Krt15+ cells compared to Krt15- cells. Interestingly, ASCL2 is a gene target of the Wnt/β-catenin pathway, which acts as a regulator of proliferation and maintenance of the stemness state.

Purpose

The ultimate goal of my research project is to determine the role of ASCL2 in the maintenance of esophageal stem cells. To do so, I will investigate the role of ASCL2 in esophageal epithelial biology.

Method

Lentiviral infection approach was used to obtain mouse esophageal organoids overexpressing ASCL2 (ASCL2^OE). Organoid culture, immunostaining (such as IF and H&E), qPCR, WB, mass spectrometry and proliferation assay were used to characterize the effect of ASCL2^OE on morphology, differentiation, proliferation, self-renewal, and gene expression.

Result(s)

ASCL2^OE severely altered the morphology of organoids, which were smaller and less differentiated. Defects in differentiation was investigated by IF which showed that some cells expressed both p63 and K13, respectively basal and suprabasal markers. Thus, cells seem to be blocked in an intermediate state of differentiation suggesting a default in cell fate decision. Mass spectrometry analysis confirmed a change in biological processes related to differentiation of keratinocytes and of epithelial cells. We also investigated the role of ASCL2 in self-renewal and observed that organoid formation rate (OFR) was reduced in ASCL2^OE organoids. Furthermore, proliferation was also reduced in WST-1 and EdU assays. We then observed significant changes in the cell cycle by flow cytometry: there is an increased in the number of cells in G0/G1 and a major decrease in G2/M cells, suggesting a blockade in G1. Interestingly, CDNK2a (p16INK4a), an inhibitor of cell cycle progression, was increased in our mass spectrometry results. Finally, ASCL2 could also play a role in radio and chemoresistance of Krt15+ stem cells, as ASCL2^OE organoids are less sensitive to radiation and chemotherapy agents than control.

Conclusion(s)

ASCL2 could play a role in orchestrating cell fate decision in the esophageal epithelium as ASCL2^OE organoids showed alteration in differentiation, proliferation, and cell cycle.

Please acknowledge all funding agencies by checking the applicable boxes below

Other

Please indicate your source of funding;

NSERC, Canada Research Chairs and CRCHUS scolarship

Disclosure of Interest

None Declared

Implementing a combined individual placement and support and vocational peer work program in integrated youth mental health settings

AIM

To describe the implementation and outcomes of a combined individual placement and support (IPS) and vocational peer work program for young people with mental ill-health.

METHODS

This uncontrolled pilot study co-located IPS workers and vocational peer workers within two integrated youth mental health services (provided to clients aged 15-25 years old). Employment outcomes included job placements (working 15 hours or more per week in a paid competitive job in the open employment market) and sustained employment (employed for at least 26 weeks). Participants who required additional assistance also received peer work.

RESULTS

Of the 326 young people enrolled, 195 (59.8%) achieved competitive employment, including 157 (48.2%) in funder-approved placements. Among those in approved placements, 87 (55.4%) achieved sustained employment. For the 116 participants additionally receiving vocational peer work, 54 (46.6%) worked in funder-approved placements, of whom 27 (50.0%) achieved sustained employment. Among 210 participants who did not receive peer work, 103 (49.0%) worked in funder-approved placements, of whom 60 (58.3%) achieved sustained employment.

CONCLUSIONS

The program achieved positive vocational outcomes and good fidelity to the IPS model. Approximately half of young people had employment placements, with a relatively high proportion maintained over time. The similar proportion of placements for those who did and did not receive peer work was encouraging given the IPS team determined that the former group needed additional support. Recommendations include upskilling the workforce, a data linkage system to obtain placement evidence, and using implementation science methodologies to understand how IPS programs are successfully embedded. This demands a coordinated effort between governments and funders, policymakers, services, and professional bodies.

Circulating CD200 is increased in the secretory phase of women with endometriosis as is endometrial mRNA, and endometrial stromal cell CD200R1 is increased in spite of reduced mRNA

PROBLEM

Estrogen-dependent extrauterine implantation and growth of menstrual endometrial tissue affects roughly 10% of reproductive age women and depends on suppression of local innate immune defenses to prevent ectopic tissue rejection. Immunohistochemistry has shown the immune check-point inhibitor CD200 which can suppress rejection is expressed in eutopic endometrium and in ectopic deposits. Soluble CD200 accumulated in venules draining eutopic and ectopic endometrium of endometriosis cases in the secretory phase but not proliferative phase of the menstrual cycle, and should be increased in the circulation.

METHOD OF STUDY

Sera from endometriosis and non-endometriosis controls were tested by ELISA for CD200. Endometrial CD200, CD200R1 and CD200R2 mRNA in eutopic was quantified by RT-PCR and localized by in situ hybridization. CD200R1 protein was quantified by immunohistochemistry.

RESULTS

Secretory phase serum CD200 was elevated in women with endometriosis compared to controls. Serum CD200 correlated with matched endometrial CD200 mRNA levels. Expression of mRNA for CD200R1 which signals immune suppression was decreased whereas mRNA for the CD200R2 activating receptor was increased. In situ staining of CD200R1 and CD200R2 mRNA showed both receptors were expressed and the fraction of CD200R that is CD200R1 was reduced in secretory and menstrual phase endometriosis endometrium consistent with the RT-PCR result. By contrast, CD200R1 protein and CD200R1 fraction of total CD200R protein were increased in endometriosis.

CONCLUSIONS

Failure to suppress circulating CD200 levels in the secretory phase had an 87% specificity and 90% sensitivity for endometriosis. CD200 and increased CD200R1 expression may facilitate development of ectopic deposits by suppressing rejection mechanisms.

Assessing spermatozoal small ribonucleic acids and their relationship to blastocyst development in idiopathic infertile males

Clinical testing strategies for diagnosing male factor infertility are limited. A deeper analysis of spermatozoa-derived factors could potentially diagnose some cases of 'unexplained infertility'. Spermatozoa carry a rich and dynamic profile of small RNAs, which have demonstrated potential developmental importance and association with fertility status. We used next-generation sequencing to correlate sperm small RNA profiles of normozoospermic males (n = 54) with differing blastocyst development rates, when using young donor oocytes. While ribosomal RNAs accounted for the highest number of sequencing reads, transfer RNA fragments of tRNA^Gly/GCC and tRNA^Val-CAC were the most abundant sequences across all sperm samples. A total of 324 small RNAs were differentially expressed between samples with high (n = 18) and low (n = 14) blastocyst rates (p-adj < 0.05). Ninety three miRNAs were differentially expressed between these groups (p-adj < 0.05). Differentially expressed transfer RNA fragments included: 5'-tRF-Asp-GTC; 5'-tRF-Phe-GAA; and 3'-tRF-Ser-GCA. Differentially expressed miRNAs included: let-7f-2-5p; miR-4755-3p; and miR-92a-3p. This study provides the foundation on which to validate a clinical panel of fertility-related sperm small RNAs, as well as to pursue potential mechanisms through which they alter blastocyst development.

Left ventricular morphology in patients with aortic coarctation and bicuspid aortic valve: novel insights from a statistical shape modelling framework

Background

The functional implications of left ventricular (LV) morphological characterization in congenital heart disease (CHD) are not widely explored.

Purpose

This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV).

Methods

A statistical shape modelling (SSM) framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) imaging data in n=110 cases including: isolated CoA (n=25), CoA+BAV (n=30), isolated BAV (n=30), and age-matched healthy controls (n=25). Average 3D templates (Picture 1) and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e. sphericity, conicity) as well as CMR-derived global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture (i.e. gothicity, tortuosity) was also explored by means of regression analysis.

Results

The LV template was shorter and more spherical in CoA patient (Picture 1), as also confirmed by statistical analysis of the SSM-derived shape modes. LV sphericity, which was higher in CoA, was associated (p≤0.04) with lower global longitudinal, radial and circumferential strain, irrespective of the presence of aortic stenosis and/or regurgitation. Conversely, neither LV morphology nor LV strain was not associated with arch architecture.

Conclusions

Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and NIHR BRC

Reimagine fire science for the anthropocene

Fire is an integral component of ecosystems globally and a tool that humans have harnessed for millennia. Altered fire regimes are a fundamental cause and consequence of global change, impacting people and the biophysical systems on which they depend. As part of the newly emerging Anthropocene, marked by human-caused climate change and radical changes to ecosystems, fire danger is increasing, and fires are having increasingly devastating impacts on human health, infrastructure, and ecosystem services. Increasing fire danger is a vexing problem that requires deep transdisciplinary, trans-sector, and inclusive partnerships to address. Here, we outline barriers and opportunities in the next generation of fire science and provide guidance for investment in future research. We synthesize insights needed to better address the long-standing challenges of innovation across disciplines to (i) promote coordinated research efforts; (ii) embrace different ways of knowing and knowledge generation; (iii) promote exploration of fundamental science; (iv) capitalize on the "firehose" of data for societal benefit; and (v) integrate human and natural systems into models across multiple scales. Fire science is thus at a critical transitional moment. We need to shift from observation and modeled representations of varying components of climate, people, vegetation, and fire to more integrative and predictive approaches that support pathways toward mitigating and adapting to our increasingly flammable world, including the utilization of fire for human safety and benefit. Only through overcoming institutional silos and accessing knowledge across diverse communities can we effectively undertake research that improves outcomes in our more fiery future.

O-135 Sperm-borne small ribonucleic acid profile significantly impacts embryo development

Study question

Do normozoospermic males with reduced pre-implantation embryo development have aberrant sperm small RNA profiles?

Summary answer

Small RNA sequencing suggests the small RNA profile may differ in normozoospermic males with low blastocyst development rates, compared to males with higher blastocyst progression.

What is known already

Current male factor infertility diagnostics are insufficient, with 30-50% of subfertile males having unknown etiology. Spermatozoa contain a complex, epigenetically-marked genome and a collection of RNAs and proteins, which are not adequately assessed by current diagnostic methods. The sperm small RNA payload is reportedly modified during epididymal transit and in response to paternal exposures, influencing which sperm small RNA species are delivered to the oocyte. Mechanistic animal studies and correlative human and animal studies have suggested that sperm small RNAs may be important for early embryonic development and health of offspring, though their diagnostic and therapeutic value are still unclear.

Study design, size, duration

Human semen samples were collected between April 2017 and August 2020 from a total of 56 male patients presenting to CReATe Fertility Centre for fertility evaluation. Clinical data was accessed retrospectively. All patients were normozoospermic, according to standard semen analysis and were using donor oocytes. Samples were divided into high (n = 20), average (n = 16), and low (n = 20) fertility groups based on their deviation (1 standard deviation) from the mean blastocyst rate.

Participants/materials, setting, methods

Semen analysis was undertaken immediately following sample collection and spermatozoa were isolated by centrifugation. Sperm small RNA was purified and eluted using the RNeasy and MiRNeasy Kits (Qiagen). Barcoded and amplified cDNA libraries were prepared from small RNA using the NEXTFLEX Small RNA-Seq Kit v3 (Bioo Scientific). Resulting libraries were pooled, size-selected to a range of 140-190 base pairs, denatured and diluted for sequencing. Single-end, 75 bp sequencing was performed using the NextSeq 550 (Illumina).

Main results and the role of chance

Sequencing generated approximately 300 million raw reads, with 30 samples exceeding 2 million reads included in the differential expression analysis. Most reads were mapped to rRNAs (69%), miRNAs (11%), and piRNAs (12%). However, transfer RNA fragments from tRNA-Gly-GCC and tRNA-Val-CAC were the most abundant sequences. Top annotated miRNAs include: miR-12136-5p; miR-21-5p; and miR-122-5p. Principal component analysis revealed 222 genes that were differentially expressed between the high (n = 14) and low (n = 11) fertility groups (p &lt; 0.05). Interestingly, the top 50 differentially expressed sRNAs are sufficient to effectively cluster sperm with poor blastocyst development rates.

Limitations, reasons for caution

The results are limited by a relatively low sequencing depth (mean of 4.1 million reads per sample) and sample size. Fertility groups were determined by blastocyst rates, which can be confounded by non-sperm-derived variables, including technical skill, embryo culturing conditions, and maternal factors (though donor oocytes were used).  

Wider implications of the findings

With additional validation, a clinically-useful panel of differentially expressed sperm small RNAs could be used to predict IVF success and evaluate therapies aimed at improving male reproductive health. Augmenting traditional semen analytics with diagnostic sperm small RNA analysis could reduce time to pregnancy and the psychosocial impacts of fertility treatment.

Trial registration number

Not applicable

Differential hydrogen sulfide production by a human cohort in response to animal- and plant-based diet interventions

BACKGROUND

Hydrogen sulfide (H2S) is a toxic end-product of microbial fermentation produced in the colon that may play a role in the pathogenesis of several diseases, including ulcerative colitis and colon cancer. However, the effect of diet interventions on intestinal burden of H2S gas exposure remains poorly understood.

OBJECTIVE

Determine the effect of short-term (1-week) plant- and animal-based eating patterns on ex vivo fecal H2S production in healthy human volunteers.

METHODS

The study design was an open-label, cross-over diet study and diets were self-administered. Each participant consumed two interventional diets: 1) an animal-based, low fiber (i.e. western) diet and 2) a plant-based, high fiber diet, separated by a two-week washout period. Participants collected full stool samples at the end of each week, which were processed within 2 h of collection to capture H2S production. Microfluidic qPCR (MFQPCR) was used to simultaneously quantify multiple taxonomic and functional groups involved in sulfate reduction and the fecal microbiota was characterized through high-throughput DNA sequencing.

RESULTS

Median H2S production was higher following the animal-based diet compared to the plant-based diet (p = 0.02; median difference 29 ppm/g, 95% CI 16-97). However, there was substantial individual variability and 2 of 11 individuals (18%) produced more H2S on the plant-based diet. Using the top and bottom quartiles of H2S percent change between animal- and plant-based diet weeks to define responders and non-responders, significant taxonomic differences were observed between the responder and non-responder cohorts.

CONCLUSIONS

Here we report that substrate changes associated with a 1-week plant-based diet intervention resulted in lower ex vivo H2S production compared to a 1-week animal-based diet intervention in most healthy individuals. However, H2S responsiveness to diet was not uniform across the entire cohort, and potential H2S production enterotypes were characterized that may predict individualized H2S responsiveness to diet.

Peripheral NOD-like receptor deficient inflammatory macrophages trigger neutrophil infiltration into the brain disrupting daytime locomotion

Inflammation is known to disrupt normal behavior, yet the underlying neuroimmune interactions remain elusive. Here, we investigated whether inappropriate macrophage-evoked inflammation alters CNS control of daily-life animal locomotion using a set of zebrafish mutants selected for specific macrophage dysfunction and microglia deficiency. Large-scale genetic and computational analyses revealed that NOD-like receptor nlrc3l mutants are capable of normal motility and visuomotor response, but preferentially swim less in the daytime, suggesting possible low motivation rather than physical impairment. Examining their brain activities and structures implicates impaired dopaminergic descending circuits, where neutrophils abnormally infiltrate. Furthermore, neutrophil depletion recovered daytime locomotion. Restoring wild-type macrophages reversed behavioral and neutrophil aberrations, while three other microglia-lacking mutants failed to phenocopy nlrc3l mutants. Overall, we reveal how peripheral inflammatory macrophages with elevated pro-inflammatory cues (including il1β, tnfα, cxcl8a) in the absence of microglia co-opt neutrophils to infiltrate the brain, thereby potentially enabling local circuitry modulation affecting daytime locomotion.

Changes in antioxidant enzyme levels following capture in juvenile American Alligators (Alligator mississippiensis) are tissue dependent

Many parameters used to investigate stress in vertebrates are temporally sensitive. The act of capture and sampling can influence them, hindering their functionality for evaluating the effects of stressors. Consequently, the investigation and subsequent incorporation of less time sensitive parameters are necessary to better evaluate stressors affecting vertebrates. In this study, we investigated how capture stress and handling associated with sampling influences antioxidant status in American Alligators (Alligator mississippiensis, Daudin, 1802; hereafter Alligator), long-lived, top-trophic carnivores found in the southeastern United States, by measuring levels of two antioxidant enzymes in destructive (brain and pancreas) and nondestructive (tail scutes) tissues: superoxide-dismutase-1 (SOD1) and glutathione peroxidase-1 (GPX1). Capture stress had no effect on pancreatic SOD1 and no effect on brain and pancreatic GPX1 (all p > 0.05). However, brain SOD1, scute SOD1, and scute GPX1 were all impacted by capture stress. These disparate results illustrate that the influence of capture stress on antioxidant enzymes in Alligators is tissue and marker dependent, necessitating further investigation. Our results provide a firm foundation to further investigate oxidative status in crocodilians.

Study protocol for the Multimodal Approach to Preventing Suicide in Schools (MAPSS) project: a regionally based randomised trial of an integrated response to suicide risk among secondary school students

Background

Suicide is the leading cause of death among young Australians, accounting for one-third of all deaths in those under 25. Schools are a logical setting for youth suicide prevention activities, with universal, selective and indicated approaches all demonstrating efficacy. Given that international best practice recommends suicide prevention programmes combine these approaches, and that to date this has not been done in school settings, this study aims to evaluate a suicide prevention programme incorporating universal, selective and indicated components in schools.

Methods

This study is a trial of a multimodal suicide prevention programme for young people. The programme involves delivering universal psychoeducation (safeTALK) to all students, screening them for suicide risk, and delivering internet-based Cognitive Behavioural Therapy (Reframe IT) to those students identified as being at high risk for suicide. The programme will be trialled in secondary schools in Melbourne, Australia, and target year 10 students (15 and 16 year-olds). safeTALK and screening will be evaluated using a single group pre-test/post-test case series, and Reframe IT will be evaluated in a Randomised Controlled Trial. The primary outcome is change in suicidal ideation; other outcomes include help-seeking behaviour and intentions, and suicide knowledge and stigma. The programme’s cost-effectiveness will also be evaluated.

Discussion

This study is the first to evaluate a suicide prevention programme comprising universal, selective and indicated components in Australian schools. If the programme is found to be efficacious and cost-effective, it could be more widely disseminated in schools and may ultimately lead to reduced rates of suicide and suicidal behaviour in school students across the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06072-8.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

A21 OVEREXPRESSION OF ASCL2 ALTERS DIFFERENTIATION IN ESOPHAGEAL ORGANOIDS

Background

The first population of stem cells in the esophageal epithelium was recently identified with the marker Keratin 15 ( Krt15). However, little is known about the mechanisms underlying the expansion and the function of these stem cells. It was shown that the transcription factor ASCL2 is upregulated in Krt15+ cells compared to Krt15- cells. Interestingly, ASCL2 is a gene target of the Wnt/β-catenin pathway, which acts as a regulator of proliferation and maintenance of the stemness state. The ultimate goal of my research project is to determine the role of ASCL2 in the maintenance of esophageal stem cells and to identify its binding partners.

Aims

Investigate the role of ASCL2 in esophageal epithelial biology.

Methods

Lentiviral infection approach was used to obtain mouse esophageal organoids overexpressing ASCL2. Organoid culture, immunostaining (such as IF and H&E), qPCR, WB and proliferation assay were used to characterize the effect of ASCL2 overexpression on morphology, differentiation, proliferation, self-renewal and gene expression.

Results

First, ASCL2 overexpression was confirmed by WB. Interestingly, the morphology of organoid overexpressing ASCL2 was severely altered: organoids were smaller and less differentiated. Defect in differentiation was investigated by qPCR and IF using relevant markers such as p63, Krt13, Wnt5a and NT5E. Indeed, we observed an increase in basal marker ( p63), a decrease in suprabasal markers ( Krt13, Wnt5a) and in a stem cell marker ( NT5E). We also investigated the role of ASCL2 in self-renewal and observed that organoid formation capacity was reduced in ASCL2-overexpressing organoids. Furthermore, proliferation was also reduced in WST-1 assays. We also observed lower expression of the gene Top2a, a recently identified marker of the proliferative basal cell population in the human esophagus. Finally, we observed significant changes in the expression of genes associated with quiescent stem cells (Clu, ZFP36L2 and Anxa1).

Conclusions

ASCL2 overexpression alters differentiation and proliferation in organoids. ASCL2 could play a role in orchestrating cell fate decision in the esophageal epithelium.

Funding Agencies

NSERC, Canada Research Chair

Social inclusion, intersectionality, and profiles of vulnerable groups of young people seeking mental health support

BACKGROUND

headspace centres provide enhanced primary mental healthcare for young people. A priority is to provide services for all young people irrespective of a range of social disadvantages or social exclusion. The aims of this study were to: (i) delineate extent of social inclusion across domains of housing, studying/employment, functioning, alcohol, and other drug use; and (ii) map profiles of young people deemed vulnerable to experiencing additional barriers to accessing services based on their social inclusion domains (e.g., those living in unstable housing, not in employment/education, and/or experiencing intersecting or multiple forms of disadvantage or difficulties), including detailing their clinical characteristics.

METHODS

Young people were recruited from five headspace centres. Data relevant to social inclusion were examined. Multivariate logistic regression models were used to determine overlap between vulnerable groups, functional, social, clinical, and behavioural factors.

RESULTS

1107 young people participated, aged 12-25 years (M = 18.1 years, SD = 3.3), most living in stable housing (96.5%) and engaged in studying/employment (84.8%). Specific vulnerabilities were evident in young people with NEET status (15.2%); in unstable accommodation (3.5%); of culturally diverse backgrounds (CALD) (12.2%); living in regional areas (36.1%); and identifying as lesbian, gay, bisexual, transgender, intersex, queer/questioning, and asexual plus (LGBTIQA+; 28.2%). Higher levels of distress, substance use, functional impairment, and lower social support were reported by those who were NEET and/or in unstable housing. LGBTIQA+ status was associated with high distress, depressive symptoms, and suicidal ideation.

CONCLUSIONS

Most participants reported good social support, stable housing, and engagement in work or education. Those deemed vulnerable were likely to experience social exclusion across multiple domains and reported more mental health problems. The co-occurrence of mental ill-health and social exclusion highlights the importance of integrated mental healthcare.

A Selective Single Step Amidation of Polyfluoroarenes

This chemistry establishes a method for the synthesis of per- and poly-fluoroaryl acid amides, utilizing nucleophilic aromatic substitution. Traditionally, such amides are constructed in a two-step process, namely, ammonolysis and then N-acylation. Herein, good yields of N-polyfluoroaryl acid amides were achieved in a single step under mild reaction conditions. Key to achieving optimal yields is the use of two equivalents of the nucleophile. In addition, the mechanism of the reaction is discussed which has implications for other related nucleophilic substitutions.

Surgical management of superficial digital flexor tendon luxation in dogs: 48 cases (2005-2020)

OBJECTIVES

To report the outcome, frequency of complications and potential prognostic factors associated with surgical repair of superficial digital flexor tendon (SDFT) luxation in dogs.

MATERIALS AND METHODS

Medical records from 10 referral hospitals were reviewed retrospectively for cases of SDFT luxation in dogs that underwent surgical stabilisation. Signalment, clinical presentation, diagnostic imaging, surgical method, type and length of post-operative limb immobilisation, nature of and length of exercise restriction, presence of post-operative complications and outcomes were recorded. Data were summarised descriptively and prognostic risk factors assessed for association with surgical outcome using risk ratios.

RESULTS

Forty-eight cases were included. A successful surgical outcome was recorded in 35 of 48 (73%) cases. Re-luxation of the SDFT occurred in seven of 48 (15%). Six out of 48 (13%) had a persistent lameness despite a stable non-luxating SDFT. A high frequency of post-operative complications occurred (71%), with the majority resolved medically. The risk of surgical failure was 60% higher (risk ratio 1.6, 95% confidence interval 1.1 to 2.4) where absorbable suture material was used compared to non-absorbable suture material. Surgical failure was more common in cases managed with non-rigid immobilisation post-operatively (57% failure) compared to cases managed with rigid immobilisation (19% failure), although this result was not statistically significant. Limb immobilisation of 6 weeks or longer did not significantly affect surgical outcome, compared to shorter periods of exercise restriction or limb immobilisation.

CLINICAL SIGNIFICANCE

A good outcome can be expected following surgical stabilisation of SDFT luxation. The use of non-absorbable suture was associated with a more successful surgical outcome.

The youth online training and employment system: Study protocol for a randomized controlled trial of an online vocational intervention for young people with mental ill health

AIM

People diagnosed with mental disorders experience higher rates of unemployment than those without. Career adaptability, defined as the ability to respond flexibly and make informed career decisions in work and throughout career transitions, is becoming increasingly important as the nature of work changes rapidly. Early vocational intervention may ameliorate poor education and employment outcomes experienced by young people with mental ill-health and promote transferable skills and adaptability. Online-based career support allows for ongoing access throughout different career stages. The current study combines mental health-informed digital career and peer motivation, to create a Youth Online Training and Employment System (YOTES) that supports young people with mental ill-health obtain and remain in education or employment.

METHODS

This study is an unblinded randomized controlled trial for young people with mental ill-health, aged 16-25, who are seeking vocational support. Participants will be randomized to receive either YOTES, a moderated, online intervention with vocational, social, and peer motivation, or a control intervention, the headspace Digital Work and Study Service. Both groups will have access to in-person career support if seeking employment. The primary outcome will be career adaptability compared between the YOTES and control groups at 6-months post baseline. Secondary outcomes include number of hours worked in the past 7 days, hope, career confidence, psychological distress and health economic outcomes at 6- and 12-months post baseline.

CONCLUSION

Results will demonstrate whether an online career intervention moderated by career practitioners with peer motivation can result in improved career adaptability in young people with mental ill-health.

The psychometric characteristics of the Kessler Psychological Distress Scale (K6) in help-seeking youth: What do you miss when using it as an outcome measure?

This is the first study to describe psychometric properties of the Kessler Psychological Distress Scale (K6) in a large cohort of help-seeking young people presenting to primary mental health care services. The aim was to determine whether the K6 was appropriate for monitoring outcomes in such settings. 1067 young people were recruited from Australian headspace services. We examined dimensionality of the K6, measurement invariance, and how the K6 correlated with the the Patient Health Questionnaire-9 (PHQ-9)and the Generalised Anxiety Disorder-7 Scale (GAD-7). Standardised Response Mean (SRM) and Cohen's d effect size (ES) were used to examine 3-month stability of the K6. The best-fitting model was a two-factor model: (i) nervous and restlessness; and (ii) hopeless, worthless, depressed and effort. Measurement non-invariance was observed for sex and age groups. K6 strongly correlated with the PHQ-9 and GAD-7. The K6 was less sensitive to change compared to these other two measures. There was some support for the K6 being a screener for young people presenting to primary care; however, there issues arise with its use as an outcome measure. These issues include measurement non-invariance, concern about the dimensionality and focus of items, and its sensitivity to change.

Evaluating the Dynamic Performance of Interfacial Pressure Sensors at a Simulated Body-Device Interface

BACKGROUND

Pressure sensing at the body-device interface can help assess the quality of fit and function of assistive devices during physical activities and movement such as walking and running. However, the dynamic performance of various pressure sensor configurations is not well established.

OBJECTIVES

Two common commercially available thin-film pressure sensors were tested to determine the effects of clinically relevant setup configurations focusing on loading areas, interfacing elements (i.e. 'puck') and calibration methods.

METHODOLOGY

Testing was performed using a customized universal testing machine to simulate dynamic, mobility relevant loads at the body-device interface. Sensor performance was evaluated by analyzing accuracy and hysteresis.

FINDINGS

The results suggest that sensor calibration method has a significant effect on sensor performance although the difference is mitigated by using an elastomeric loading puck. Both sensors exhibited similar performance during dynamic testing that agree with accuracy and hysteresis values reported by manufacturers and in previous studies assessing mainly static and quasi-static conditions.

CONCLUSION

These findings suggest that sensor performance under mobility relevant conditions may be adequately represented via static and quasi-testing testing. This is important since static testing is much easier to apply and reduces the burden on users to verify dynamic performance of sensors prior to clinical application. The authors also recommend using a load puck for dynamic testing conditions to achieve optimal performance.

A53 STUDYING THE ROLE OF ASCL2 IN THE ESOPHAGEAL EPITHELIUM USING ORGANOIDS

Background

The esophagus is lined with a stratified squamous epithelium that assure protection against the austere environment found in the esophageal lumen. The maintenance of this epithelium is ensured by a rare population of cells: stem cells. Those cells have increased capacity of self-renewal and multipotency, which is the capacity to give rise to every cell types of a tissue. The marker Krt15 was used to identify the first stem cell population in the esophagus. Krt15+ cells display an extended lifespan and they are radioresistant, multipotent and capable of self-renewal. Moreover, it was observed by RNA sequencing that the expression of the transcription factor ASCL2 is strongly increased in Krt15+ cells compared to Krt15- cells. Interestingly, ASCL2 is necessary to maintain the stemness of Lgr5+ intestinal stem cells. It is also a target of the Wnt/β-catenin pathway. The overall goal of this project is to determine the role of ACSL2 in the maintenance of esophageal stem cells and to identify its binding partners since ASCL2 needs to dimerize to efficiently bind DNA.

Aims

Confirm that esophageal organoids are adapted to study ASCL2 in the esophagus.

Methods

Esophageal organoids were established from esophageal epithelial cells from wildtype mice. Following this, organoids were treated with an inhibitor of the Notch pathway (DAPT) to induce hyperplasia or infected with lentiviruses to invalidate Ascl2 (CRISPR/Cas9 approach).

Results

To validate that Ascl2 plays an important role in esophageal cell proliferation, Notch pathway was inhibited through DAPT treatment in esophageal organoids to induce hyperplasia, which was confirmed by increased number of proliferative cells (Ki-67+). ASCL2 protein expression was also increased in DAPT-treated organoids supporting its role in proliferation and confirming that organoid is a good model to study ASCL2 role in esophageal epithelial cells. In this optic, organoids lines invalidated for Ascl2 (CRISPR/Cas9 approach) were established. Our preliminary results suggest that Ascl2 loss affects cell proliferation and organoid size under normal conditions.

Conclusions

The expression of ASCL2 correlates with hyperplasia which supports its role in esophageal epithelium homeostasis.

Funding Agencies

Canada research chair et NSERC