Factors relating to sustainability and scalability of the 'Food, Move, Sleep (FOMOS) for Postnatal Mental Health' program: Qualitative perspectives from key stakeholders across Australia

ISSUE ADDRESSED

Supporting healthy behaviours (quality diet, physical activity, sleep) through home-based interventions is feasible to improve postnatal mental health. Involving stakeholders in developing interventions is essential for maximising accessibility, implementation and scale-up. This study aimed to identify factors affecting the sustainable implementation and scalability of the Food, Move, Sleep (FOMOS) for Postnatal Mental Health program, including strategies to enhance research-practice translation.

METHODS

Stakeholders (n = 13) involved in promoting physical activity, healthy eating, postnatal and mental health, public health and/or policy participated in semi-structured interviews. Interviews, based on PRACTIS Guide recommendations for implementation and scale-up, explored perceptions of program design, implementation and scalability. Reflexive thematic analysis was undertaken. Identified implementation and scale-up strategies were mapped against the Expert Recommendations for Implementing Change compendium and PRACTIS Guide.

RESULTS

Individual-level: Targeting multiple systems (primary, tertiary, community-based care) and entry points (early, mid-postpartum) for uptake was important. For equity, screening women in public hospitals, engaging with community agencies and targeting most at-risk women, was suggested. Provider-level: Stakeholders identified strategies to enhance future roll-out (organisations assisting with recruitment). Factors impacting sustainability included high demand for the FOMOS program, and governance around screening and funding; online delivery, connecting with partners and providers and integration into existing services may enhance sustainability. Systems-level: Political support and community champions were perceived important for program dissemination. Nine strategies addressing program uptake, reach, implementation, potential scalability and sustainability were identified.

CONCLUSIONS

For sustainable implementation and potential scalability of a home-based multi-behaviour postnatal intervention, multi-level implementation and scale-up strategies, aligned with existing health systems, policies and initiatives to support postnatal mental health should be considered. SO WHAT?: This paper provides a comprehensive list of strategies that can be used to enhance sustainable implementation and scalability of healthy behaviour programs targeting postnatal mental health. Further, the interview schedule, systematically developed and aligned with the PRACTIS Guide, may serve as a useful resource for researchers conducting similar studies in future.

Evaluating a multi-behavioural home-based intervention for reducing depressive symptoms in postnatal women : The food, move, sleep (FOMOS) for postnatal mental health randomised controlled trial protocol

BACKGROUND

Postnatal depression (PND) is a leading cause of illness and death among women following childbirth. Physical inactivity, sedentary behaviour, poor sleep, and sub-optimal diet quality are behavioural risk factors for PND. A feasible, sustainable, and scalable intervention to improve healthy behaviours and reduce PND symptoms among women at postpartum is needed. This study aims to examine the effectiveness of a multi-behavioural home-based program Food, Move, Sleep (FOMOS) for Postnatal Mental Health designed to improve PND symptoms in women at postpartum.

METHODS

This randomised clinical trial will recruit 220 Australian women (2-12 months postpartum) experiencing heightened PND symptoms (Edinburgh Postnatal Depression Scale score ≥ 10). Participants will be randomised to FOMOS or wait-list control receiving standard clinical care. FOMOS is a 6-month mobile health (mHealth) intervention targeting diet quality, physical activity, sedentary behaviour, sleep, and mental health. The intervention, informed by the Social Cognitive Theory and incorporating behaviour change techniques defined in the CALO-RE taxonomy and Cognitive Behavioural Treatment of Insomnia, provides exercise equipment, and educational/motivational material and social support via mHealth and social media. Data collection pre-intervention and at 3, 6 and 12 months will assess the primary outcome of PND symptoms and secondary outcomes (diet quality, physical activity, sitting time, sleep quality) using self-report and device measures. Process evaluation will explore acceptability, appropriateness, cost-effectiveness, feasibility, and sustainability via analytic tools, record keeping, interviews, and surveys.

DISCUSSION

If effective, FOMOS could be a feasible and potentially scalable management strategy to support improvement of health behaviours and mental health for women with PND symptoms.

TRIAL REGISTRATION

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12622001079730p.

Traction-induced aneurysm of an accessory left hepatic artery: a potentially fatal but synchronously treatable complication of a large hiatus hernia

A 59-year-old man presented to our surgical clinic with a long-standing history of heart burn, and upper abdominal pain. Gastroscopy showed a large sliding hiatus hernia associated with severe reflux oesophagitis. Oesophageal pH manometry revealed a high DeMeester score of 36.03. A computed tomography (CT) scan was performed for preoperative hiatal hernia repair planning. This showed the incidental finding of an accessory left hepatic artery (ALHA) and an aneurysm of this accessory artery. The aneurysm occurred at the point where the ALHA traversed the diaphragmatic crus and was only present in association with the hiatus hernia. These observations suggest that the aetiology of the aneurysm was due to traction during development of the hiatus hernia. The patient went onto have a laparoscopic hiatus hernia repair and Toupet fundoplication with ligation of the accessory left hepatic artery and made an excellent recovery. ALHAs are not uncommon, occurring in around 15% of the general population, with aneurysms of the hepatic arteries accounting for about 20% of cases of visceral artery aneurysms. The case presented herein highlights the importance of performing an arterial phase CT when planning surgery for large hiatus hernias to detect more cases like this one. This would allow early detection and concurrent treatment of an associated aneurysm with repair of the hiatus hernia, to prevent aneurysmal complications later on.

Acute adrenal insufficiency: an aide-memoire of the critical importance of its recognition and prevention

Adrenal crisis is a life-threatening emergency that causes significant excess mortality in patients with adrenal insufficiency. Delayed recognition by medical staff of an impending adrenal crisis and failure to give timely hydrocortisone therapy within the emergency department continue to be commonly encountered, even in metropolitan teaching hospitals. Within the authors' institutions, several cases of poorly handled adrenal crises have occurred over the last 2 years. Anecdotal accounts from members of the Addison's support group suggest that these issues are common in Australia. This manuscript is a timely reminder for clinical staff on the critical importance of the recognition, treatment and prevention of adrenal crisis. The manuscript: (i) outlines a case and the clinical outcome of sub-optimally managed adrenal crisis, (ii) summarises the clinical features and acute management of adrenal crisis, (iii) provides recommendations on the prevention of adrenal crisis and (iv) provides guidance on the management of 'sick days' in patients with adrenal insufficiency.

Ipilimumab-induced hypophysitis in melanoma patients: an Australian case series

BACKGROUND

Ipilimumab (Yervoy; Bristol-Myers Squibb) is a novel fully humanised monoclonal antibody that blocks cytotoxic T-lymphocyte antigen 4, an immune checkpoint molecule, to augment anti-tumour T-cell responses. It is associated with significant immune-related side-effects including hypophysitis.

AIM

We reviewed the clinical and biochemical characteristics of 10 patients with ipilimumab-induced hypophysitis (IH), and developed guidelines for the early detection and management of IH based on our experiences at three major teaching hospitals in Sydney.

METHODS

All patients were evaluated at the Crown Princess Mary Cancer Centre and Department of Endocrinology, Westmead Hospital, Department of Endocrinology, Royal Prince Alfred Hospital, the Melanoma Institute Australia and Macarthur Cancer Therapy Centre, Campbelltown Hospital from 2010 to 2014. Relevant data were extracted by review of medical records. Main outcome measures included clinical features, hormone profile and radiological findings associated with IH, and presence of pituitary recovery.

RESULTS

Ten patients were identified with IH. In four patients who underwent monitoring of plasma cortisol, there was a fall in levels in the weeks prior to presentation. The pituitary-adrenal and pituitary-thyroid axes were affected in the majority of patients, with the need for physiological hormone replacement. Imaging abnormalities were identified in five of 10 patients, and resolved without high-dose glucocorticoid therapy. To date, all patients remain on levothyroxine and hydrocortisone replacement, where appropriate.

CONCLUSIONS

There is significant morbidity associated with development of IH. We suggest guidelines to assist with early recognition and therapeutic intervention.

The LRRK2 Gly2385Arg variant is associated with Parkinson’s disease: genetic and functional evidence

Evidence of LRRK2 haplotypes associated with Parkinson's disease (PD) risk was recently found in the Chinese population from Singapore, and a common LRRK2 missense variant, Gly2385Arg, was independently detected as a putative risk factor for PD in the Chinese population from Taiwan. To test the association between the Gly2385Arg variant in a large case-control sample of Chinese ethnicity from Singapore, and to perform functional studies of the wild type and Gly2385Arg LRRK2 protein in human cell lines. In a case-control study involving 989 Chinese subjects, the frequency of the heterozygous Gly2385Arg genotype was higher in PD compared to controls (7.3 vs. 3.6%, odds ratio = 2.1, 95% CI: 1.1-3.9, P = 0.014); these values yield an estimated population attributable risk (PAR) of approximately 4%. In a multivariate logistic regression analysis with the disease group (PD vs. controls) as the dependent variable and the genotype as an independent factor with adjustments made for the effect of age and gender, the heterozygous Gly2385Arg genotype remained associated with an increased risk of PD compared to wild type genotype (odds ratio = 2.67, 95% CI: 1.43-4.99, P = 0.002). The glycine at position 2385 is a candidate site for N-myristoylation, and the Gly2385Arg variant replaces the hydrophobic glycine with the hydrophilic arginine, and increases the net positive charge of the LRRK2 WD40 domain. In transfection studies, we demonstrated that both the wild type and Gly2385Arg variant LRRK2 protein localize to the cytoplasm and form aggregates. However, under condition of oxidative stress, the Gly2385Arg variant was more toxic and associated with a higher rate of apoptosis. Our study lends support to the contention that the Gly2385Arg is a common risk factor for PD in the Chinese population. Our bioinformatics and in-vitro studies also suggest that the Gly2385Arg variant is biologically relevant and it might act through pro-apoptotic mechanisms.

Exploring an interaction of adenosine A2A receptor variability with coffee and tea intake in Parkinson's disease

Caffeine is an adenosine receptor A1 and A2A receptor antagonist and a putative functional genetic variant of the A2A receptor (2592C > Tins) mediates caffeine-induced anxiety. Here we investigated the potential interaction of this A2A genetic variant with the quantity of coffee and tea intake and their relationship with the risk of PD. A total of 441 subjects consisting of 222 PD and 219 race, gender and age matched controls were included. A multivariate analysis of the variables including the 2592C > Tins A2A genotypes, age of onset, gender, and the quantity of tea and coffee intake, interaction of the A2A genotypes with coffee intake, interaction of A2A genotypes with tea intake demonstrated the quantity of coffee intake to be significantly associated with PD (P < 0.0005, OR = 0.922, 95% CI: 0.881, 0.964). However, there was no significant interaction of the A2A genotypes with the quantity of coffee and tea intake in modulating the risk of PD. The dose dependent protective effect of coffee intake in PD was independent of the 2592C > Tins A2A genotype suggesting that the pharmacogenetic action of caffeine in PD may be mediated differently from other caffeine-induced neurologic syndromes.

Genetic analysis of SCA2, 3 and 17 in idiopathic Parkinson's disease

Recent reports of SCA2 and SCA3 patients who presented with levodopa responsive parkinsonism have generated considerable interest as they have implications for genetic testing. It is unclear whether ethnic race alone or founder effects within certain geographical region explain such an association. In this study, we conducted genetic analysis of SCA2, 3, 17 in an ethnic Chinese cohort with early onset and familial Parkinson's disease (PD) and healthy controls. A total of 191 subjects comprising of 91 PD and 100 healthy controls were examined. We identified one positive case of SCA2 in an early-onset sporadic PD patient who had CAG 36 repeats, yielding a prevalence of 2.2% in early-onset sporadic PD patients and less than 1.0% in our study PD population. The size of the repeats was lower than the expanded repeats (38-57) in SCA2 patients with ataxia in our population. All the children of the patient were physically normal even though some of them carried the repeat expansion of similar size. No cases and controls were positive for SCA3 and SCA17. We do not think routine screening of SCA2, SCA3 and SCA17 for all idiopathic PD patients is cost-effective in our ethnic Chinese population. However, SCA2 should be a differential diagnosis in young onset sporadic PD when genetic mutations of other known PD genes have been excluded.

Analysis of LRRK2 functional domains in nondominant Parkinson disease

A comprehensive sequence analysis of 29 exons that code for the functional domains of LRRK2 in 160 nondominant Parkinson disease (PD) patients was performed. Novel variant screening in a further 470 sporadic PD patients and 630 controls revealed two novel variants (R1067Q and IVS33 + 6 T>A), which are likely to be pathogenic in five patients. One patient presented initially with a typical essential tremor phenotype, expanding the phenotypic spectrum of LRRK2 mutations.

The G2019S LRRK2 mutation is uncommon in an Asian cohort of Parkinson's disease patients

A common heterozygous leucine-rich repeat kinase 2 (LRRK2) mutation 6055G > A transition (G2019S) accounts for about 3-7% of familial Parkinson's disease (PD) and 1-1.6% sporadic PD in a number of European populations. To determine the prevalence of the G1019S mutation in our Asian population, we conducted genetic analysis of this mutation in 1000 PD and healthy controls. The G2019S mutation was not detected in any of our study subjects. The prevalence of G2019S mutation is rare (< 0.1%) in our population, suggesting that occurrence of this mutation may vary amongst different ethnic races. This has important clinical implication when implementing guidelines for genetic testing.

Retinopathy in a Chinese population with type 2 diabetes: factors affecting the presence of this complication at diagnosis of diabetes

This study examined the prevalence of retinopathy in 2131 patients with type 2 diabetes attending a Beijing hospital for the first time. The median age of patients was 58 years (IQR 50-65). The overall prevalence of retinopathy was 27.3% (95% CI: 25.4-29.2) and for proliferative retinopathy 7.8% (95% CI: 6.7-8.9). When all patients were considered together, duration of diabetes (OR=1.8; P=0.001) and albumin excretion rate (OR=1.5; P=0.019) were independent risk factors for retinopathy. Blue-collar occupation (OR=1.5; P=0.047) and blood pressure (OR=1.2; P=0.021) were additional risk factors for non-proliferative and proliferative retinopathy respectively. Amongst the 773 newly diagnosed patients, 21% (95% CI: 17.8-23.6) already had retinopathy. The median age of those patients with retinopathy at diagnosis of diabetes was 3 years higher that those without retinopathy, and blue-collar workers (OR=2.2; P=0.012) as well as female gender were particularly at risk (OR=2.0; P=0.033). There was a strong correlation between duration of diabetes with the presence of retinopathy (r=0.95; P=0.01). By extrapolation, it could be estimated that some degree of hyperglycaemia might have been present for more than 20 years before diabetes was diagnosed. These findings emphasise the importance of earlier diagnosis of diabetes and its complications, especially in socially disadvantaged groups.

Temperature distribution produced in brain tissue and other media by a radiofrequency hyperthermia generator

The temperature distribution produced in living brain tissue by a radiofrequency, Neuro N-50, hyperthermia probe was measured as a function of probe temperature, heating duration, and distance from the heating probe by a sensor containing five thermocouples for durations up to 2 min. Brain sections were examined to determine the effects of heating at various temperatures. It was found that a simple theoretical conductive heat transfer model predicted the steady-state temperature distributions quite well. At distances up to 7.4 mm from the heating probe, a heating time of 20 s was sufficient to produce about 90% of the temperature rise measured at 120 s. The equilibrium temperature at any distance from the center of the probe was a linear function of the reciprocal of this distance. The time constant for heating was approximately 3 s at 0. 95 mm from the heating probe and about 10 s at 7.4 mm for brain tissue, while these values are about 5-20 s in egg white. For a given probe size, higher probe temperatures increased the size of the region of cell death. According to the heat transfer model, the diameter of the region of tissue that attains a given temperature is proportional to the diameter of the probe. The use of probe temperatures up to 90 degrees C would enable an increase in the volume of the region of cell death, or the use of a smaller diameter probe to produce a lesion of a given size.

Myasthenia gravis and recurrent falls in an elderly patient

PRESENTATION

An elderly man had recurrent hospital admissions with falls.

OUTCOME

Acetylcholine receptor antibodies and single-fibre electromyogram were useful in the diagnosis of myasthenia gravis. Treatment prevented further hospital admissions.

Serum transferrin receptor assay in iron deficiency anaemia and anaemia of chronic disease in the elderly

The most common cause of anaemia in the elderly is anaemia of chronic disease (ACD). However, iron deficiency anaemia (IDA) may coexist, and can be difficult to diagnose. The serum transferrin receptor (sTfR) blood test may be a better indicator of iron status as it is not affected by inflammation nor by advancing age. We evaluated it in four groups (10 males, 10 females each): 'young' controls, 'elderly' controls, IDA and ACD. All patients in the IDA group had elevated sTfR levels (mean +/- SD 65.2 +/- 17.7 nmol/l). All 'young' controls had normal sTfR (22.3 +/- 7.3 nmol/l) and ferritin levels (92.7 +/- 61.1 micrograms/l). Although all subjects in the 'elderly' controls and ACD group had normal, and raised or normal serum ferritin, respectively (88 +/- 62.3 micrograms/l; 631.2 +/- 509.5 micrograms/l), three (15%) 'elderly' controls and four (20%) ACD patients had raised sTfR levels, suggesting depleted iron stores. Bone-marrow aspirates were available in 3/4 ACD patients with raised sTfR. Haemosiderin was absent in two. The sTfR blood test is comparable to serum ferritin in diagnosing IDA in the elderly but also seems capable of differentiating ACD from IDA. Its potential as a non-invasive test of iron status, especially in elderly anaemic patients, deserves further evaluation.

A method for examining differential mRNA expression along the crypt-villus axis of the human small intestine

1. The aim of this study was to devise a method of segregating crypt and villus cell subpopulations from endoscopic human small intestinal biopsies which might be used to examine changes associated with functional differentiation at the molecular level. 2. Routine endoscopic biopsies from the human small intestine were subjected to a modified protocol of mechanical disruption and chelation to yield subpopulations of different cell types. The purity and character of the cell populations isolated was assessed by measuring enzyme activity and thymidine incorporation and by histology. A guanidinium isothiocyanate method was adapted for small samples to extract RNA from the isolated subpopulations, and probes for RNA with a known predilection for crypt and villus cells were used to further investigate the application and usefulness of the technique. 3. Sequential histological examination during the segregation protocol demonstrated that different cell types were removed serially from the biopsy samples. Cell-type enrichment of the segregated subpopulations was demonstrated by differential alkaline phosphatase activity and by differences in thymidine incorporation in the samples isolated. Sufficient quantities of RNA could be extracted from the segregated subpopulations for Northern blot analysis and the differential expression of mRNA for sucrase-isomaltase and transferrin receptor was demonstrated in the villus and crypt subpopulations respectively. 4. Messenger RNA can be successfully extracted from different cell types segregated from routine human endoscopic small intestinal biopsies. This technique should prove useful for investigating the mechanisms regulating the functional differentiation of epithelial cells in the small intestine and the regulatory mechanisms governing absorption of macromolecules.

Inspecting the Colon from inside and Out to Solve Pyrexia of Unknown Origin

A man with longstanding intermittent symptoms of abdominal pain, diarrhoea and pyrexia of unknown origin was diagnosed with the novel technique of laparoscopic-assisted colonoscopy. At subsequent laparotomy, a longstanding perforation of sigmoid diverticular disease was resected, with resolution of his symptoms.

Speech and nasendoscopic evaluation of velopharyngeal incompetence (VPI) in cleft palate patients

Cleft lip and palate patients exhibit several problems prior to and following surgical repair of their deformities. Hypernasality and speech defects remain one of the outstanding problems. 82 cleft palate patients were subjected to a systematised speech evaluation and an examination of the velopharyngeal mechanism. Nineteen patients did not have any surgery of the palate whilst the remaining 63 had at least one surgical procedure to the palate. 54 had a Veau-Wardill-Kilner (V-W-K) procedure and the remaining had either a second palatal repair or a superiorly based pharyngoplasty. Good correlation of speech assessment to nasendoscopic evaluation was found. An improvement in the speech and nasendoscopic coding was found in patients who had surgical intervention to the palate. A nasendoscopic examination, ideally performed by the surgeon and a speech therapist, is a useful adjunct to speech evaluation.