Heterogeneity of Human Research Ethics Committees and Research Governance Offices across Australia: An observational study

BACKGROUND

Conducting ethically grounded research is a fundamental facet of all investigations. Nevertheless, the administrative burdens of current ethics review are substantial, and calls have been made for a reduction in research waste.

AIMS

To describe the heterogeneity in administration and documentation required by Human Research Ethics Committees (HRECs) and Research Governance Offices (RGOs) across Australia.

METHODS

In establishing a nationwide study to investigate the molecular aetiology of Giant Cell Arteritis (GCA), for which archived pathological specimens from around Australia are being recruited, we identified variation across separate HREC and RGO requirements. Submission paperwork and correspondence from each collaborating site and its representative office for research were reviewed. This data was interrogated to evaluate differences in current guidelines.

RESULTS

Twenty-five pathology departments across seven Australian States collaborated in this study. All states, except Victoria, employed a single ethics review model. There was discrepancy amongst HRECs as to which application process applied to our study: seven requested completion of a "National Ethics Application Form" and three a "Low Negligible Risk" form. Noticeable differences in guidelines included whether electronic submission was sufficient. There was variability in the total number of documents submitted (range five to 22) and panel review turnaround time (range nine to 136 days).

CONCLUSION

We demonstrate the challenges and illustrate the heavy workload involved in receiving widespread ethics and governance approval across Australia. We highlight the need to simplify, homogenise, and nationalise human ethics for non-clinical trial studies. Reducing unnecessary administration will enable investigators to achieve research aims more efficiently.

Water sources and mixing in riparian wetlands revealed by tracers and geospatial analysis

Mixing of waters within riparian zones has been identified as an important influence on runoff generation and water quality. Improved understanding of the controls on the spatial and temporal variability of water sources and how they mix in riparian zones is therefore of both fundamental and applied interest. In this study, we have combined topographic indices derived from a high-resolution Digital Elevation Model (DEM) with repeated spatially high-resolution synoptic sampling of multiple tracers to investigate such dynamics of source water mixing. We use geostatistics to estimate concentrations of three different tracers (deuterium, alkalinity, and dissolved organic carbon) across an extended riparian zone in a headwater catchment in NE Scotland, to identify spatial and temporal influences on mixing of source waters. The various biogeochemical tracers and stable isotopes helped constrain the sources of runoff and their temporal dynamics. Results show that spatial variability in all three tracers was evident in all sampling campaigns, but more pronounced in warmer dryer periods. The extent of mixing areas within the riparian area reflected strong hydroclimatic controls and showed large degrees of expansion and contraction that was not strongly related to topographic indices. The integrated approach of using multiple tracers, geospatial statistics, and topographic analysis allowed us to classify three main riparian source areas and mixing zones. This study underlines the importance of the riparian zones for mixing soil water and groundwater and introduces a novel approach how this mixing can be quantified and the effect on the downstream chemistry be assessed.

Stream water age distributions controlled by storage dynamics and nonlinear hydrologic connectivity: Modeling with high-resolution isotope data

To assess the influence of storage dynamics and nonlinearities in hydrological connectivity on time-variant stream water ages, we used a new long-term record of daily isotope measurements in precipitation and streamflow to calibrate and test a parsimonious tracer-aided runoff model. This can track tracers and the ages of water fluxes through and between conceptual stores in steeper hillslopes, dynamically saturated riparian peatlands, and deeper groundwater; these represent the main landscape units involved in runoff generation. Storage volumes are largest in groundwater and on the hillslopes, though most dynamic mixing occurs in the smaller stores in riparian peat. Both streamflow and isotope variations are generally well captured by the model, and the simulated storage and tracer dynamics in the main landscape units are consistent with independent measurements. The model predicts that the average age of stream water is ∼1.8 years. On a daily basis, this varies between ∼1 month in storm events, when younger waters draining the hillslope and riparian peatland dominates, to around 4 years in dry periods when groundwater sustains flow. This variability reflects the integration of differently aged water fluxes from the main landscape units and their mixing in riparian wetlands. The connectivity between these spatial units varies in a nonlinear way with storage that depends upon precipitation characteristics and antecedent conditions. This, in turn, determines the spatial distribution of flow paths and the integration of their contrasting nonstationary ages. This approach is well suited for constraining process-based modeling in a range of northern temperate and boreal environments.

Storage dynamics in hydropedological units control hillslope connectivity, runoff generation, and the evolution of catchment transit time distributions

We examined the storage dynamics and isotopic composition of soil water over 12 months in three hydropedological units in order to understand runoff generation in a montane catchment. The units form classic catena sequences from freely draining podzols on steep upper hillslopes through peaty gleys in shallower lower slopes to deeper peats in the riparian zone. The peaty gleys and peats remained saturated throughout the year, while the podzols showed distinct wetting and drying cycles. In this region, most precipitation events are <10 mm in magnitude, and storm runoff is mainly generated from the peats and peaty gleys, with runoff coefficients (RCs) typically <10%. In larger events the podzolic soils become strongly connected to the saturated areas, and RCs can exceed 40%. Isotopic variations in precipitation are significantly damped in the organic-rich soil surface horizons due to mixing with larger volumes of stored water. This damping is accentuated in the deeper soil profile and groundwater. Consequently, the isotopic composition of stream water is also damped, but the dynamics strongly reflect those of the near-surface waters in the riparian peats. "pre-event" water typically accounts for >80% of flow, even in large events, reflecting the displacement of water from the riparian soils that has been stored in the catchment for >2 years. These riparian areas are the key zone where different source waters mix. Our study is novel in showing that they act as "isostats," not only regulating the isotopic composition of stream water, but also integrating the transit time distribution for the catchment.

KEY POINTS

Hillslope connectivity is controlled by small storage changes in soil unitsDifferent catchment source waters mix in large riparian wetland storageIsotopes show riparian wetlands set the catchment transit time distribution.

Oxidation of manganese(II) during chlorination: role of bromide

The oxidation of dissolved manganese(II) (Mn(II)) during chlorination is a relatively slow process which may lead to residual Mn(II) in treated drinking waters. Chemical Mn(II) oxidation is autocatalytic and consists of a homogeneous and a heterogeneous process; the oxidation of Mn(II) is mainly driven by the latter process. This study demonstrates that Mn(II) oxidation during chlorination is enhanced in bromide-containing waters by the formation of reactive bromine species (e.g., HOBr, BrCl, Br2O) from the oxidation of bromide by chlorine. During oxidation of Mn(II) by chlorine in bromide-containing waters, bromide is recycled and acts as a catalyst. For a chlorine dose of 1 mg/L and a bromide level as low as 10 μg/L, the oxidation of Mn(II) by reactive bromine species becomes the main pathway. It was demonstrated that the kinetics of the reaction are dominated by the adsorbed Mn(OH)2 species for both chlorine and bromine at circumneutral pH. Reactive bromine species such as Br2O and BrCl significantly influence the rate of manganese oxidation and may even outweigh the reactivity of HOBr. Reaction orders in [HOBr]tot were found to be 1.33 (±0.15) at pH 7.8 and increased to 1.97 (±0.17) at pH 8.2 consistent with an important contribution of Br2O which is second order in [HOBr]tot. These findings highlight the need to take bromide, and the subsequent reactive bromine species formed upon chlorination, into account to assess Mn(II) removal during water treatment with chlorine.

AA Amyloidosis in a patient with glycogen storage disorder and progressive chronic kidney disease

Type 1 glycogen storage diseases (GSD) are inherited metabolic diseases caused by defects in the activity of the glucose-6-phosphate transporter. We present the case of a 40-year-old male with glycogen storage disease type 1b (GSD1b) who was referred to our nephrology service for evaluation of his chronic kidney disease and found to have AA amyloid deposition on renal biopsy. Amyloid is a described complication of GSD1b. As the treatment of GSD has improved, patients are surviving longer and are now presenting more frequently to adult services. It is important that clinicians are aware of the possible renal complications of GSD1b.

Abdominal aortic aneurysm secondary to infection with Pseudomonas aeruginosa: a rare cause of mycotic aneurysm

Infection is a cause of rapidly enlarging aortic aneurysms. Pseudomonas aeruginosa is an uncommon pathogen affecting blood vessels and has mainly been seen following invasive procedures in immunosuppressed patients. Pseudomonas aortitis has a high mortality. We describe a case of a rapidly enlarging juxta-renal aortic aneurysm in an immunocompetent patient who was treated with open surgery. In this patient, intra-operative specimens revealed infection with Pseudomonas aeruginosa. The patient received a long course of antibiotics and remains well at 8 months postsurgery.

Functional differences between myeloid leukemia-initiating and transient leukemia cells in Down's syndrome

Children with constitutional trisomy 21 or Down's syndrome (DS) are predisposed to develop myeloid leukemia (ML) at a young age. DS-ML is frequently preceded by transient leukemia (TL), a spontaneously resolving accumulation of blasts during the newborn period. Somatic mutations of GATA1 in the blasts of TL and DS-ML likely function as an initiating event. We hypothesized that the phenotypic difference between TL and DS-ML is due to a divergent functional repertoire of the leukemia-initiating cells. Using an NOD/SCID model, we found that cells initiating DS-ML engrafted, disseminated to distant bone marrow sites, and propagated the leukemic clone in secondary recipients. In contrast, TL cells lacked the ability to expand and to migrate, but were able to persist in the recipient bone marrow. We found some evidence of genomic progression with 1 of 9 DS-ML samples and none of 11 TL samples harboring a mutation of N-RAS. The findings of this pilot study provide evidence for the functional impact of second events underlying the transformation of TL into DS-ML and a needed experimental tool for the functional testing of these promoting events.

Ureolytic phosphate precipitation from anaerobic effluents

In this work, the elimination of phosphate from industrial anaerobic effluents was evaluated at lab-scale. For that purpose, the ureolytic method previously developed for the precipitation of Ca(2 + ) from wastewater as calcite was adapted for the precipitation of phosphate as struvite. In the first part of the study, computer simulations using MAPLE and PHREEQC were performed to model phosphate precipitation from wastewater as struvite. The results obtained showed that relative high concentrations of ammonium and magnesium are needed to precipitate phosphate as struvite. The total molar concentrations ratio of Mg(2 + ):PO(4) (3-)-P:NH(4) (+) required to decrease PO(4) (3-)-P concentrations from 20 to 6 mg PO(4) (3-)-P/l at pH 8.4-8.5 was estimated on 4.6:1:8. In the second part of the study, lab-scale experiments with either synthetic wastewater or the anaerobic effluent from a vegetable processing industry were carried out in batch and continuous mode. Overall, the continuous operation at a hydraulic retention time (HRT) of 2.4 h and an added molar concentration [Mg(2 + )]:[PO(4) (3-)-P]:[NH(4) (+)] ratio of 1.6:1:2.3 resulted in a constant pH value in the reactor (around 8.5) and an efficient phosphate removal (>90%) to residual levels of 1-2 mg PO(4) (3-)-P/l. Different operational conditions, such as the initial phosphate concentration, HRT and the use of CaCl(2) or MgO instead of MgCl(2), were analysed and the performance of the reactor was satisfactory under a broad range of them. Yet, overall, optimal results (higher phosphate removal) were obtained with MgCl(2).

Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector

BACKGROUND

Early detection and effective case management of tuberculosis (TB) among a high-risk group of materially poor farm workers in an area of the Cape Winelands, South Africa, presents special challenges to the health community, where resource constraints lead to service reduction. In order to address this problem, local nurses established a collaborative partnership between permanent farm workers and their families, their employers, selected non-governmental organizations and the public health sector. In consultation with stakeholders, they developed an intervention primarily focusing on having peer selected trained lay health workers (LHWs) on farms, mentored and managed by nurses.

PURPOSE

To describe the complex process of implementation and evaluation of the LHW project, and provide a summary of a number of discrete studies evaluating the effectiveness, cost implications, and the perceptions and experiences of key stakeholders of the intervention.

METHODS

Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster randomized control trial were used. Emphasis was placed on an iterative participatory interaction between the researchers and key stakeholders.

RESULTS

The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases. The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme.

CONCLUSIONS

The use of peer-selected LHWs within a wider programme of integrated care designed to merge technical biomedical approaches to disease management with more holistic social development activities, appears essential to meet the complex health needs in conjunction with public health of the rural poor.

Functional outcomes after nonrecurrent dislocation of primary total hip arthroplasty

The influence of dislocation on functional outcomes of primary total hip arthroplasty is unclear. The purpose of this study was to assess the effect of nonrecurrent dislocations treated with closed reduction after primary total hip arthroplasty on postoperative outcome in the short to medium term. Ninety-six patients were enrolled in this retrospective case-control study. There were 32 patients who had a postoperative dislocation. The control group consisted of 64 matched patients who did not dislocate. All patients had a minimum of 1-year follow-up. The 2 groups were compared using the SF-12, reduced WOMAC, and satisfaction questionnaire. There was no statistical difference between the 2 groups in subjective functional outcomes using the WOMAC or SF-12. However, there was a trend toward better quality of life scores in the control group, and they were more satisfied with their surgery compared with the dislocation group.

Allergic reactions in the community: a questionnaire survey of members of the anaphylaxis campaign

BACKGROUND

Allergic reactions to food are well recognized in both children and adults, but because of their relative infrequency their typical features may not be readily recognized by patients and their medical care givers who are not allergists.

OBJECTIVE

We sought to investigate the circumstances and clinical characteristics of food allergies in adults and children in the community.

METHODS

Self-completed questionnaire responses over a 6-month period from 109 members of the Anaphylaxis Campaign, the major British patient resource group for people who have suffered severe allergic reactions.

RESULTS

One hundred and nine respondents reported 126 reactions during the study period. Seventy-five were children (under 16 years, median age 6 years at the time of reaction). Predictably more boys than girls were reported to have had reactions but more women reported reactions than men (P<0.05). Although the groups were equally aware of their food allergies the children had undergone diagnostic tests more often (P<0.001). Foods were implicated in 112 (89%) of reports. Restaurants were implicated less often (14%) than in other series, probably reflecting British eating habits. Children with asthma reported more severe reactions than those without asthma (P=0.008), although frequency or severity of recent asthma symptoms was not associated with severity of allergic reaction reported. When available, self-injectable adrenaline was used in 35% of severe reactions and 13% of non-severe reactions (P=0.01). A quarter of adults who received one dose of adrenaline also received a second dose.

CONCLUSION

The allergens implicated in this report reflect previous data from similar patient groups in North America. Asthmatic children suffer more severe reactions than non-asthmatic children. It appears that British adults need better access to expert care of their allergies. Even when it is prescribed and available self-injectable adrenaline appears under-used in severe reactions. The incidence of severe but non-fatal allergic reactions in the UK may have been underestimated in the past.

Multiple cellular antigen detection by ICP-MS

There is a great need in cell biology for the simultaneous detection of many intracellular and extracellular proteins within single cells. Current optical methods based on fluorescence activated flow cytometry are difficult to multiplex. We have developed a novel application of ICP-MS-linked metal-tagged immunophenotyping which has great potential for highly multiplexed proteomic analysis. Expression of intracellular oncogenic kinase BCR/Abl, myeloid cell surface antigen CD33, human stem cell factor receptor c-Kit and integrin receptor VLA-4 were investigated using model human leukemia cell lines. Antigens to which specific antibodies are available and are distinguishably tagged can be determined simultaneously, or multiplexed. Four commercially available tags (Au, Sm, Eu, and Tb) conjugated to secondary antibodies enable a 4-plex assay assuming that the primary antibodies are not cross-reactive. Results obtained by ICP-MS were compared with data from FACS. ICP-MS as an analytical detector possesses several advantages that enhance the performance of immunoassays, which are discussed in detail. Although multiplexing using metal-conjugated reagents is in a very early stage of research and feasibility studies, it is already apparent that more than four antigens could be accurately detected simultaneously using the ICP-MS instrument.

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction

BACKGROUND

The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD).

METHODS

Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI.

RESULTS

Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups.

CONCLUSION

We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.

Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial

SETTING

Farms in the Boland health district, Western Cape Province, South Africa.

OBJECTIVE

To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence.

DESIGN

Pragmatic, unblinded cluster randomised control trial.

METHODS

This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomisation, and analysis was by intention to treat.

RESULTS

A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95%CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group.

CONCLUSION

Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services.