Innovation in mental health services: what are the key components of success?

Background

Service development innovation in health technology and practice is viewed as a pressing need within the field of mental health yet is relatively poorly understood. Macro-level theories have been criticised for their limited explanatory power and they may not be appropriate for understanding local and fine-grained uncertainties of services and barriers to the sustainability of change. This study aimed to identify contextual influences inhibiting or promoting the acceptance and integration of innovations in mental health services in both National Health Service (NHS) and community settings.

Methods

A comparative study using qualitative and case study data collection methods, including semi-structured interviews with key stakeholders and follow-up telephone interviews over a one-year period. The analysis was informed by learning organisation theory. Drawn from 11 mental health innovation projects within community, voluntary and NHS settings, 65 participants were recruited including service users, commissioners, health and non-health professionals, managers, and caregivers. The methods deployed in this evaluation focused on process-outcome links within and between the 11 projects.

Results

Key barriers to innovation included resistance from corporate departments and middle management, complexity of the innovation, and the availability and access to resources on a prospective basis within the host organisation. The results informed the construction of a proposed model of innovation implementation within mental health services. The main components of which are context, process, and outcomes.

Conclusions

The study produced a model of conducive and impeding factors drawn from the composite picture of 11 innovative mental health projects, and this is discussed in light of relevant literature. The model provides a rich agenda to consider for services wanting to innovate or adopt innovations from elsewhere. The evaluation suggested the importance of studying innovation with a focus on context, process, and outcomes.

     

Energy substrate partitioning and efficiency in individuals with atherogenic lipoprotein phenotype

Individuals with an atherogenic lipoprotein phenotype (ALP) characterized by increased levels of small dense low-density lipoprotein (LDL) particles tend to have greater adiposity compared to unaffected subjects. We sought to determine whether this may be related to alterations in energy substrate partitioning or efficiency. These were assessed by indirect calorimetry in men with ALP (ALP(+), n = 7) and unaffected controls (ALP(-), n = 8) during rest (30 min) and exercise (10 min). Gross, net and delta efficiencies were calculated during graded leg-cycle ergometry at workloads of 10 and 50 W. Respiratory exchange ratios (RER) were significantly (P < 0.05) higher in ALP(+) vs. ALP(-) during rest (0.86 ± 0.01 vs. 0.83 ± 0.02) and exercise at 10 W (0.88 ± 0.02 vs. 0.84 ± 0.02) and 50 W (0.92 ± 0.01 vs. 0.87 ± 0.01, respectively) (P < 0.05). Lipid oxidation (kcal/min) was lower in ALP(+) vs. ALP(-) during rest (0.56 ± 0.02 vs. 0.71 ± 0.07) and exercise at 10 W (1.52 ± 0.25 vs. 2.00 ± 0.20) and 50 W (1.28 ± 0.10 vs. 2.32 ± 0.22, respectively) (P < 0.05). Gross and net efficiencies were significantly increased (P = 0.005) in ALP(+) vs. ALP(-) at 10 W. RER was correlated positively with plasma triglyceride during exercise and inversely with high-density lipoprotein (HDL) cholesterol and LDL peak particle diameter during rest and exercise (P < 0.05). These findings suggest that increased muscular efficiency at low exercise intensity and reduced lipid oxidation during rest and exercise may contribute to both dyslipidemia and increased adiposity in individuals with ALP.     

Interferon-γ and proliferation responses to Salmonella enterica Serotype Typhi proteins in patients with S. Typhi Bacteremia in Dhaka, Bangladesh

Background

Salmonella enterica serotype Typhi is a human-restricted intracellular pathogen and the cause of typhoid fever. Cellular immune responses are required to control and clear Salmonella infection. Despite this, there are limited data on cellular immune responses in humans infected with wild type S. Typhi.

Methodology/Principal Findings

For this work, we used an automated approach to purify a subset of S. Typhi proteins identified in previous antibody-based immuno-affinity screens and antigens known to be expressed in vivo, including StaF-putative fimbrial protein-STY0202, StbB-fimbrial chaperone-STY0372, CsgF-involved in curli production-STY1177, CsgD- putative regulatory protein-STY1179, OppA-periplasmic oligopeptide binding protein precursor-STY1304, PagC-outer membrane invasion protein-STY1878, and conserved hypothetical protein-STY2195; we also generated and analyzed a crude membrane preparation of S. Typhi (MP). In comparison to samples collected from uninfected Bangladeshi and North American participants, we detected significant interferon-γ responses in PBMCs stimulated with MP, StaF, StbB, CsgF, CsgD, OppA, STY2195, and PagC in patients bacteremic with S. Typhi in Bangladesh. The majority of interferon-γ expressing T cells were CD4 cells, although CD8 responses also occurred. We also assessed cellular proliferation responses in bacteremic patients, and confirmed increased responses in infected individuals to MP, StaF, STY2195, and PagC in convalescent compared to acute phase samples and compared to controls. StaF is a fimbrial protein homologous to E. coli YadK, and contains a Pfam motif thought to be involved in cellular adhesion. PagC is expressed in vivo under the control of the virulence-associated PhoP-regulon required for intra-macrophage survival of Salmonella. STY2195 is a conserved hypothetical protein of unknown function.

Conclusion/Significance

This is the first analysis of cellular immune responses to purified S. Typhi antigens in patients with typhoid fever. These results indicate that patients generate significant CD4 and CD8 interferon-γ responses to specific S. Typhi antigens during typhoid fever, and that these responses are elevated at the time of clinical presentation. These observations suggest that an interferon-γ based detection system could be used to diagnose individuals with typhoid fever during the acute stage of illness.     

The Extended Synthesis: Something Old, Something New

The eclipse of Darwinism began to end in the 1980s and hangs in the balance today. We need an Extended Synthesis, using “extension” metaphorically. We must extend back in time to recover important aspects of Darwinism that were set aside, and then lost during neo-Darwinism, then move forward beyond neo-Darwinism to encompass new data and concepts. The most comprehensive framework for the Extended Synthesis is the Major Transitions in Evolution. The Extended Synthesis rests comfortably within a philosophical perspective in which biology does not need to be connected with other areas of science in order to justify itself. I am attracted to an older concept in which biology needs a covering law to connect it with the rest of the natural sciences. Darwin implicated a “higher law,” but did not specify it. If we can elucidate that law, the Extended Synthesis will become the Unified Theory of Biology called for by Brooks and Wiley 25 years ago.     

The role of neutrophils during mild and severe influenza virus infections of mice

Neutrophils have been implicated in both protective and pathological responses following influenza virus infections. We have used mAb 1A8 (anti-Ly6G) to specifically deplete LyG6(high) neutrophils and induce neutropenia in mice infected with virus strains known to differ in virulence. Mice were also treated with mAb RB6-8C5 (anti-Ly6C/G or anti-Gr-1), a mAb widely used to investigate the role of neutrophils in mice that has been shown to bind and deplete additional leukocyte subsets. Using mAb 1A8, we confirm the beneficial role of neutrophils in mice infected with virus strains of intermediate (HKx31; H3N2) or high (PR8; H1N1) virulence whereas treatment of mice infected with an avirulent strain (BJx109; H3N2) did not affect disease or virus replication. Treatment of BJx109-infected mice with mAb RB6-8C5 was, however, associated with significant weight loss and enhanced virus replication indicating that other Gr-1(+) cells, not neutrophils, limit disease severity during mild influenza infections.     

Chemical Oxidation (Using Ozone) of the Spore Wall of Lycopodium Clavatum

Spore walls of Lycopodium clavatum, after oxidation using ozone for varying times and treatment with dilute alkali, showed a striking loss of the outer layer (muri) of the exine. Almost all trace of the muri and undetermined portions of the remaining exine wall were removed after 20 hours' oxidation. The exine wall material seems to be evenly removed. The only degradation patterns observed are rare pits after 20 hours oxidation. A degradation-related colour change of the spore wall occurs after 11 to 16 hours' oxidation.     

Polymorphism in Human Cytomegalovirus UL40 Impacts on Recognition of Human Leukocyte Antigen-E (HLA-E) by Natural Killer Cells

Natural killer (NK) cell recognition of the nonclassical human leukocyte antigen (HLA) molecule HLA-E is dependent on the presentation of a nonamer peptide derived from the leader sequence of other HLA molecules to CD94-NKG2 receptors. However, human cytomegalovirus can manipulate this central innate interaction through the provision of a “mimic” of the HLA-encoded peptide derived from the immunomodulatory glycoprotein UL40. Here, we analyzed UL40 sequences isolated from 32 hematopoietic stem cell transplantation recipients experiencing cytomegalovirus reactivation. The UL40 protein showed a “polymorphic hot spot” within the region that encodes the HLA leader sequence mimic. Although all sequences that were identical to those encoded within HLA-I genes permitted the interaction between HLA-E and CD94-NKG2 receptors, other UL40 polymorphisms reduced the affinity of the interaction between HLA-E and CD94-NKG2 receptors. Furthermore, functional studies using NK cell clones expressing either the inhibitory receptor CD94-NKG2A or the activating receptor CD94-NKG2C identified UL40-encoded peptides that were capable of inhibiting target cell lysis via interaction with CD94-NKG2A, yet had little capacity to activate NK cells through CD94-NKG2C. The data suggest that UL40 polymorphisms may aid evasion of NK cell immunosurveillance by modulating the affinity of the interaction with CD94-NKG2 receptors.     

A miR‐34a‐SIRT6 axis in the squamous cell differentiation network

Squamous cell carcinomas (SCCs) are highly heterogeneous tumours, resulting from deranged expression of genes involved in squamous cell differentiation. Here we report that microRNA‐34a (miR‐34a) functions as a novel node in the squamous cell differentiation network, with SIRT6 as a critical target. miR‐34a expression increases with keratinocyte differentiation, while it is suppressed in skin and oral SCCs, SCC cell lines, and aberrantly differentiating primary human keratinocytes (HKCs). Expression of this miRNA is restored in SCC cells, in parallel with differentiation, by reversion of genomic DNA methylation or wild‐type p53 expression. In normal HKCs, the pro‐differentiation effects of increased p53 activity or UVB exposure are miR‐34a‐dependent, and increased miR‐34a levels are sufficient to induce differentiation of these cells both in vitro and in vivo. SIRT6, a sirtuin family member not previously connected with miR‐34a function, is a direct target of this miRNA in HKCs, and SIRT6 down‐modulation is sufficient to reproduce the miR‐34a pro‐differentiation effects. The findings are of likely biological significance, as SIRT6 is oppositely expressed to miR‐34a in normal keratinocytes and keratinocyte‐derived tumours.