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AimsPatients with disordered eating in psychiatry are considered highly complex in the acute hospital setting. In Spring 2023 a pilot for a specialised dietitian was introduced to identify and target such patients; aimed at reducing length of stay to the acute medical wards. Hospital admissions for eating disorder increased by 84% between 2015/16 and 2020/21; with increasing complexity of presentations and a demand for Specialist Eating Disorder (SEDU) beds, there are increasing numbers admitted to acute medical beds for initial treatment and management. In 2021 the Royal College of Psychiatrists published its updated guidance, Medical Emergencies in Eating Disorders (MEED). There is recognition that acute trusts must identify care pathways for the management of patients with eating disorders and severe food restriction for psychiatric reasons. This audit aims to show how these guidelines are being implemented locally and where there is a need for improvements in care pathways focusing particularly on length of stay, frequent attenders and avoiding hospital admissions.MethodsA retrospective audit of 26 patients presenting between 01/03/2023 and 31/12/2023 was completed. Patients were identified from data collated by the specialist dietitian as having presented with an existing diagnosis of eating disorder or disordered eating in the context of psychiatry. Some patients were detained under the Mental Health Act. Some patients presented on multiple occasions to the acute hospital during this period; each inpatient episode was analysed independently. Data was collected retrospectively by analysing PICS documentation (electronic notes system) and entered into a data collection spreadsheet. A Google Form checklist was created to capture whether key points from MEED guidelines were met.ResultsDemographic data, details of initial presentation and admission events were collated including the team initially referred to and how long after the initial admission this occurred. Outcomes of admission were also recorded. Data was quantitatively analysed to understands trends in referral process, MDT working (inclusion of emergency clinicians, acute medicine, psychiatrist, specialist dieticians and nursing colleagues). Average lengths of stay, number of attendances and planned admissions were also captured.ConclusionAn overall reduction in length of stay for detained patients with dietetic and wider MDT input was noted from 50 days prior to January 2023, to 29 in the period from March 2023 onwards. Frequent attendance for electrolyte abnormalities was significantly improved though implementing MDT working with teams in the community and planned admissions from inpatient units or SEDUs for medical management reduced overall length of stay for those patients.

Within the context of the Australian higher education sector and the organisational interactions facilitated by a university, the politics of Anglo-Australian identity continues to limit the ability of 'whitefella' Australians to engage with Indigenous people in a way that might be said to be truly ethical and self-transformative. Instead, the identity politics of Anglo-Australia, a politics that originates in the old colonial stories of the 19th century, continues to function in a way that marginalises those individuals who choose to engage in a way that goes beyond the organisational rhetoric of government and civil institutions in promoting causes such as reconciliation and 'closing the gap'. The history of Australian colonialism teaches us that, when a deep and productive engagement between settler and native has occurred, the stability of Anglo-Australian identity is destabilised as the colonial establishment is reminded of Indigenous dispossession and the moral and legal legitimacy of the contemporary Australian state become subject to problematic questions that arise from this fact of Australian history. Framing the contemporary context of change and resistance, the authors discuss the importance of inclusive institutional practice, in the quest for a democratic modelling that points to a pathway for a truer recognition, acceptance and inclusion of Indigenous peoples in the 'mainstream' of Australian university life.

Body integrity identity disorder (BIID) is a rare and complex identity disorder described by the desire to acquire a physical disability and an associated sense of incompleteness at being able-bodied. Individuals with the disorder often delay presentation until later in life because of perceived stigma about wishing to acquire a physical disability, and may have sought amputation already through ‘underground’ means or self-harm (attempts at self-amputation). In this article we present an account of the recent history and origins of the disorder, from its early descriptions and case reports through to the current neuropsychiatric theory of right superior parietal lobe dysfunction as basis for the disorder. We consider the epidemiology, pathogenesis and clinical features of this identity disorder of bodily integrity, highlighting the associations with conditions such as gender identity disorder. With this we then discuss the ethical considerations for available treatment options, mainly elective surgical amputation.

Lynch Syndrome, or hereditary non-polyposis colorectal cancer (HNPCC) is an autosomal dominant cancer predisposition syndrome caused by inactivating mutations in DNA mismatch repair genes. It accounts for 2–4 % of all incident colorectal cancers. Mutation carriers are at risk of early onset colorectal cancer, endometrial cancer, and a spectrum of other tumours. Accurate estimation of cancer risk for mutation carriers is essential for counselling, and establishing appropriate screening guidelines. This study reviews the current data on cancer risk, and emerging risk reduction strategies.

Background:There has been a growing national focus on the mental health of children and young people (CYP). Despite increasing incidence rates of mental health difficulties, only a small proportion of adolescents will access support. It is proposed that schools have the potential to provide an integral, universal access point to deliver services that endeavour to support the assessment and identification of mental health difficulties and promote positive wellbeing. There is a key role for Educational Psychologists (EPs) in supporting school-based mental health approaches. Methods/participants:Paper One is a systematic literature review (SLR) that sought to explore school-based barriers and facilitators to mental health help-seeking. Twelve eligible studies were identified and critically appraised. Paper Two is an empirical study, employing an exploratory design around the implementation of a novel student-led mental health strategy. Individual and paired depth interviews were carried out with five participants, including students, school staff and the school's link Education Psychologist (EP). The interviews were thematically analysed.Analysis/findings:The findings of the SLR identified a range of barriers and facilitators to adolescent mental health help-seeking, highlighting important implications for improving the propensity to seek help. The empirical investigation identified factors impacting on the implementation of a student-led mental health strategy and future considerations for the replication of similar initiatives. Reflections on the findings with relevance to the EP role are presented.Conclusion/implications:Strategies to promote help-seeking behaviours in adolescents are outlined, along with implications for future research and practice. Following an empirical investigation of a student-led mental health strategy, an ecological model of implementation is proposed, along with recommendations for future replication. Finally, Paper Three includes a dissemination strategy for sharing the findings highlighted in Papers One and Two with the research site, within the local and organsiational contexts and the EP community.

IntroductionLynch syndrome is known to cause an increased risk of malignancies, including bowel and endometrial cancers. However, the risk of breast cancer associated with mutations in the mismatch repair (MMR) genes that cause Lynch syndrome is still unclear.Materials and methodsThis study assesses the cumulative risk of breast cancer in 106 MLH1 and 118 MSH2 families. Families were referred on the basis of clinical criteria. Pedigree information was obtained, and tumour immunohistochemistry and microsatellite testing performed. Appropriate patients underwent sequencing and multiple ligation dependent probe amplification of all relevant exons of the MMR genes. Kaplan–Meier analysis of cumulative lifetime risk of breast cancer was made combining proven mutation carriers and their first-degree female relatives.ResultsAfter allocation of mutation status, the cumulative risk of breast cancer to 70 years in MLH1 carriers was 18.6% (95% CI 11.3 to 25.9)). This is significantly higher than the cumulative risk for MSH2 which was 11.2% (95% CI 1.4 to 21.0) to age 70 years (p=0.014). The UK population risk is 7.5%–8% at the age of 70 years. Prospective analysis identified six breast cancers in 1120 years of follow-up with an OR of 3.41 (95% CI 1.53 to 7.59).DiscussionsFemale MLH1 carriers would appear to be at moderate risk of breast cancer and should be considered for breast screening at ages earlier than national screening programmes.

AimsSimulation (sim) is an excellent but underused tool suited to key skills in psychiatry such as communication, managing agitated patients and exploring the mental-physical health interface. Access to complex psychiatric patients has always been challenging and this has been exacerbated by the current COVID-19 pandemic. This has further increased fear amongst students creating another barrier to engaging with psychiatric patients. Our aim of the study was to evaluate the use of simulation within psychiatry as the literature in this field is underrepresented compared to other medical specialities. We hope to advocate its use in future undergraduate training.MethodsWe developed 3 simulated scenarios for fourth year medical students; these involved identifying lithium toxicity and steroid-induced psychosis in ward settings and conducting an A&E risk assessment. The scenarios were developed following feedback from a focus group of foundation doctors on their psychiatry rotations. Data were collected pre- and post-simulation from a cohort of psychiatry students in this academic year. We assessed confidence levels in 7 domains using a 10-point Likert scale and obtained qualitative data to give context to the data collected.Results81 and 83 students respectively completed the pre and post questionnaires. Quantitative data found that the student's confidence in all domains improved from pre to post simulation training. For example, confidence in performing a risk assessment improved from M = 4.12 to M = 7.04 and in making a basic management plan from M = 3.43 to M = 6.72. Qualitative data looked at skills gained, empathy and how the scenarios related to clinical practice. Key themes found improvements in de-escalation skills, handing over and self-reflection.ConclusionThe study supports the evidence that high-fidelity simulation is an important education tool in psychiatry. As facilitators, we feel that confidence scores improved due to the debrief. The standard tool often used is the diamond debrief however we found we had to adapt this model due to fourth year students not having developed sufficient skills to reflect on complex psychiatric scenarios. Therefore, an adjusted debrief was developed featuring technical knowledge and constructive feedback. In the future, we hope to explore the long-term benefits of simulation and its impact on clinical practice.

AimsLynch Syndrome is caused by mutations in DNA mismatch repair (MMR) genes. Mutation carrier identification is facilitated by immunohistochemical detection of the MMR proteins MHL1 and MSH2 in tumour tissue and is desirable as colonoscopic screening reduces mortality. However, protein detection by conventional immunohistochemistry (IHC) is subjective, and quantitative techniques are required. Quantum dots (QDs) are novel fluorescent labels that enable quantitative multiplex staining. This study compared their use with quantitative 3,3′-diaminobenzidine (DAB) IHC for the diagnosis of Lynch Syndrome.MethodsTumour sections from 36 mutation carriers and six controls were obtained. These were stained with DAB on an automated platform using antibodies against MLH1 and MSH2. Multiplex QD immunofluorescent staining of the sections was performed using antibodies against MLH1, MSH2 and smooth muscle actin (SMA). Multispectral analysis of the slides was performed. The staining intensity of DAB and QDs was measured in multiple colonic crypts, and the mean intensity scores calculated. Receiver operating characteristic (ROC) curves of staining performance for the identification of mutation carriers were evaluated.ResultsFor quantitative DAB IHC, the area under the MLH1 ROC curve was 0.872 (95% CI 0.763 to 0.981), and the area under the MSH2 ROC curve was 0.832 (95% CI 0.704 to 0.960). For quantitative QD IHC, the area under the MLH1 ROC curve was 0.812 (95% CI 0.681 to 0.943), and the area under the MSH2 ROC curve was 0.598 (95% CI 0.418 to 0.777).ConclusionsDespite the advantage of QD staining to enable several markers to be measured simultaneously, it is of lower utility than DAB IHC for the identification of MMR mutation carriers. Automated DAB IHC staining and quantitative slide analysis may enable high-throughput IHC.

Lynch Syndrome is caused by mutations in the DNA mismatch repair (MMR) genes; MLH1, MSH2, MSH6 and PMS2. An accurate estimation of cancer risk for MMR mutation carriers is essential for counselling and screening. United Kingdom (UK) specific cancer risks for MMR mutation carriers and cumulative colorectal cancer risks by decade have not been described to date. Using data from 121 Lynch Syndrome families, the cumulative lifetime risks of Lynch Syndrome spectrum cancers in mutation carriers were calculated, correcting for ascertainment bias. This data provides reassurance that current UK screening guidelines are appropriate. For colorectal cancer, tables of risk by decade were compiled for carriers of the different gene mutations. This novel data represents a useful counselling tool. Despite an increased cancer risk, individuals with Lynch Syndrome lack clear phenotypic characteristics. Mutation carrier identification is desirable as screening reduces mortality. After counselling and assessment of family history against clinical criteria, molecular diagnosis of tumour tissue is performed. Immunohistochemistry (IHe) of the MMR proteins has great potential as a method of identifying the most likely mutation and guiding mutation analyse. However IHC of the MMR proteins is not yet well established and problems have been reported with staining and slide interpretation. IHC slide assessment methods in the reported literature have been qualitative. This thesis describes the development and validation of a robust, semiquantitative scoring technique to be used in the assessment of IHC stained tumour sections from patients with possible Lynch Syndrome. Colorectal tumour sections from 51 MMR mutation carriers were stained with 3,3' Diaminobenzidine (DAB) using antibodies against the MMR proteins. Slide assessment was semiquantified using a 0-12 scale, and was found to be highly sensitive and specific for the identification of mutation carriers. It was found however, that protein expression may occur in the context of known pathogenic mutations, a potential pitfall in the screening process. Two quantitative techniques of slide assessment that could potentially obviate the need for human operator slide analysis were explored. Semiconductor quantum dots (QOs) are quantifiable fluorescent labels that can be used for multiplex staining. Quantitative QO IHC was compared to quantitative DAB IHC. Both are novel methodologies. Tumour sections from 36 mutation carriers were stained using each method, and multispectral analysis of the slides was performed. Quantitative analysis of the DAB stained slides was less sensitive than semi-quantitative analysis in this study, but was sufficiently sensitive to be used as a pre-screen in Lynch Syndrome. However despite the potential advantages of quantitative QD staining, it was less sensitive and specific than quantitative DAB IHC. The development of automated DAB IHC staining and quantitative multispectral slide analysis may enable future high throughput IHC for MMR mutation carrier identification. Around 15% of sporadic colorectal cancers develop along the MSI pathway due epigenetic MLH1 inactivation. The evidence suggests that patients with such tumours do not benefit from 5-Fluorouracil based chemotherapy. The cost effectiveness of identifying patients with such tumours was explored. Potential chemotherapeutic savings are substantial, supporting the introduction of this biomarker into clinical practice. The improved diagnostic accuracy of semi-quantitative IHC slide assessment and the potential for automation of quantitative IHC slide assessment would facilitate the introduction of this service.

The ProLife Alliance branded their online sale \"a flagrant abuse of abortion law\". Catt, a solicitor's office worker of Sherburn in Elmet, North Yorks, faces a possible life sentence on return to Leeds Crown Court next month.