GIP mediates the incretin effect and glucose tolerance by dual actions on α cells and β cells

Glucose-dependent insulinotropic polypeptide (GIP) communicates nutrient intake from the gut to islets, enabling optimal levels of insulin secretion via the GIP receptor (GIPR) on β cells. The GIPR is also expressed in α cells, and GIP stimulates glucagon secretion; however, the role of this action in the postprandial state is unknown. Here, we demonstrate that GIP potentiates amino acid-stimulated glucagon secretion, documenting a similar nutrient-dependent action to that described in β cells. Moreover, we demonstrate that GIP activity in α cells contributes to insulin secretion by invoking paracrine α to β cell communication. Last, specific loss of GIPR activity in α cells prevents glucagon secretion in response to a meal stimulus, limiting insulin secretion and driving glucose intolerance. Together, these data uncover an important axis by which GIPR activity in α cells is necessary to coordinate the optimal level of both glucagon and insulin secretion to maintain postprandial homeostasis.

Electrophoretic deposition of polymethylmethacrylate and composites for biomedical applications

For the first time, an electrophoretic deposition (EPD) method has been developed for the deposition of polymethylmethacrylate (PMMA) and PMMA-alumina films for biomedical implant applications. The proposed biomimetic approach was based on the use of a bile salt, sodium cholate (NaCh), which served as a multifunctional solubilizing, charging, dispersing and film-forming agent. Investigations revealed PMMA-Ch^- and PMMA-alumina interactions, which facilitated the deposition of PMMA and PMMA-alumina films. This approach allows for the use of a non-toxic water-ethanol solvent for PMMA. The proposed deposition strategy can also be used for co-deposition of PMMA with other functional materials. The PMMA and composite films were tested for biomedical implant applications. The PMMA-alumina films showed statistically improved metabolic results compared to both the bare stainless steel substrate and pure PMMA films. Alkaline phosphatase (ALP) activity affirmed the bioactivity and osteoconductive potential of PMMA and composite films. PMMA-alumina films showed greater ALP activity than both the PMMA-coated and uncoated stainless steel.

Birthing on Country (in Our Community): a case study of engaging stakeholders and developing a best-practice Indigenous maternity service in an urban setting

Developing high-quality and culturally responsive maternal and infant health services is a critical part of 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes.

Colloidal-electrochemical fabrication strategies for functional composites of linear polyethylenimine

Colloidal-electrochemical fabrication strategies have been developed for the deposition of linear polyethylenimine (LPEI) composite materials. Electrophoretic deposition (EPD) allowed for the fabrication of composite films containing Mn₃O₄ and ZnO nanoparticles, as well as advanced flame retardant materials, such as halloysite nanotubes and memory-type Al-Mg-Zr complex hydroxide (AMZ) in the matrix of the water-insoluble LPEI. A liquid-liquid extraction method has been designed for the agglomerate-free processing of AMZ particles. Efficient extraction was achieved using decylphosphonic acid as an extractor. A conceptually new polymer complex (PC)-EPD method has been developed, which is based on the use of LPEI-metal ion complexes. Proof-of-concept studies involved the fabrication of LPEI-Ni(OH)₂ and LPEI-MnOx nanocomposites. The composites showed valuable flame retardant and charge-storage properties. The analysis of basic EPD and PC-EPD mechanisms as well as complexing properties of LPEI has driven the development of new strategies for the fabrication of organic composites. Hemoglobin was used as a model protein for the fabrication of composite films. Another important finding was the fabrication of composites, containing cyclodextrin, which is a unique carrier of various functional organic molecules. EPD and PC-EPD are versatile methods, which allow for the deposition of novel LPEI based composites containing various functional materials.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia

BACKGROUND

With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation.

METHODS

Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff.

DISCUSSION

This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

The development of a healing model of care for an Indigenous drug and alcohol residential rehabilitation service: a community-based participatory research approach

BACKGROUND

Given the well-established evidence of disproportionately high rates of substance-related morbidity and mortality after release from incarceration for Indigenous Australians, access to comprehensive, effective and culturally safe residential rehabilitation treatment will likely assist in reducing recidivism to both prison and substance dependence for this population. In the absence of methodologically rigorous evidence, the delivery of Indigenous drug and alcohol residential rehabilitation services vary widely, and divergent views exist regarding the appropriateness and efficacy of different potential treatment components. One way to increase the methodological quality of evaluations of Indigenous residential rehabilitation services is to develop partnerships with researchers to better align models of care with the client's, and the community's, needs. An emerging research paradigm to guide the development of high quality evidence through a number of sequential steps that equitably involves services, stakeholders and researchers is community-based participatory research (CBPR). The purpose of this study is to articulate an Indigenous drug and alcohol residential rehabilitation service model of care, developed in collaboration between clients, service providers and researchers using a CBPR approach.

METHODS/DESIGN

This research adopted a mixed methods CBPR approach to triangulate collected data to inform the development of a model of care for a remote Indigenous drug and alcohol residential rehabilitation service.

RESULTS

Four iterative CBPR steps of research activity were recorded during the 3-year research partnership. As a direct outcome of the CBPR framework, the service and researchers co-designed a Healing Model of Care that comprises six core treatment components, three core organisational components and is articulated in two program logics. The program logics were designed to specifically align each component and outcome with the mechanism of change for the client or organisation to improve data collection and program evaluation.

CONCLUSION

The description of the CBPR process and the Healing Model of Care provides one possible solution about how to provide better care for the large and growing population of Indigenous people with substance misuse issues. [corrected].

A bibliometric review of drug and alcohol research focused on Indigenous peoples of Australia, New Zealand, Canada and the United States

ISSUES

Indigenous peoples of Australia, New Zealand, Canada and the United States experience a disproportionately high burden of harms from substance misuse. Research is therefore required to improve our understanding of substance use in Indigenous populations and provide evidence on strategies effective for reducing harmful use.

APPROACH

A search of 13 electronic databases for peer-reviewed articles published between 1993 and 2014 focusing on substance use and Indigenous peoples of Australia, New Zealand, Canada and the United States. Relevant abstracts were classified as data or non-data based research. Data-based studies were further classified as measurement, descriptive or intervention and their trends examined by country and drug type. Intervention studies were classified by type and their evaluation designs classified using the Cochrane Effective Practice and Organisation of Care (EPOC) data collection checklist.

KEY FINDINGS

There was a statistically significant increase from 1993 to 2014 in the percentage of total publications that were data-based (P < 0.001). Overall, data-based publications were mostly descriptive for all countries (84-93%) and drug types (74-95%). There were fewer measurement (0-4%) and intervention (0-14%) publications for all countries and the percentage of these did not change significantly over time. Forty-two percent of intervention studies employed an EPOC evaluation design.

IMPLICATIONS

Strategies to increase the frequency and quality of measurement and intervention research in the Indigenous drug and alcohol field are required.

CONCLUSION

The dominance of descriptive research in the Indigenous drug and alcohol field is less than optimal for generating evidence to inform Indigenous drug and alcohol policy and programs. [Clifford A, Shakeshaft A. A bibliometric review of drug and alcohol research focused on Indigenous peoples of Australia, New Zealand, Canada and the United States. Drug Alcohol Rev 2017;36:509-522].

Interventions to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA: a systematic review

PURPOSE

This article describes the characteristics and reviews the methodological quality of interventions designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA.

DATA SOURCES

A total of 17 electronic databases and 13 websites for the period of 2002-13.

STUDY SELECTION

Studies were included if they evaluated an intervention strategy designed to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, the USA or Canada.

DATA EXTRACTION

Information on the characteristics and methodological quality of included studies was extracted using standardized assessment tools.

RESULTS OF DATA SYNTHESIS

Sixteen published evaluations of interventions to improve cultural competency in health care for Indigenous peoples were identified: 11 for Indigenous peoples of the USA and 5 for Indigenous Australians. The main types of intervention strategies were education and training of the health workforce, culturally specific health programs and recruitment of an Indigenous health workforce. Main positive outcomes reported were improvements in health professionals' confidence, and patients' satisfaction with and access to health care. The methodological quality of evaluations and the reporting of key methodological criteria were variable. Particular problems included weak study designs, low or no reporting of consent rates, confounding and non-validated measurement instruments.

CONCLUSION

There is a lack of evidence from rigorous evaluations on the effectiveness of interventions for improving cultural competency in health care for Indigenous peoples. Future evaluations should employ more rigorous study designs and extend their measurement of outcomes beyond those relating to health professionals, to those relating to the health of Indigenous peoples.

Offending, custody and opioid substitution therapy treatment utilisation among opioid-dependent people in contact with the criminal justice system: comparison of Indigenous and non-Indigenous Australians

BACKGROUND

Although Indigenous Australians are over-represented among heroin users, there has been no study examining offending, time in custody, and opioid substitution therapy (OST) treatment utilisation among Indigenous opioid-dependent (including heroin) people at the population level, nor comparing these to non-Indigenous opioid-dependent people. The aims of this study were to compare the nature and types of charges, time in custody and OST treatment utilisation between opioid-dependent Indigenous and non-Indigenous Australians in contact with the criminal justice system.

METHODS

This was a population-based, retrospective data linkage study using records of OST entrants in New South Wales, Australia (1985-2010), court appearances (1993-2011) and custody episodes (2000-2012). Charge rates per 100 person-years were compared between Indigenous and non-Indigenous Australians by sex, age and calendar year. Statistical comparisons were made for variables describing the cumulative time and percentage of follow-up time spent in custody, as well as characteristics of OST initiation and overall OST treatment utilisation.

RESULTS

Of the 34,962 people in the cohort, 6,830 (19.5%) were Indigenous and 28,132 (80.5%) non-Indigenous. Among the 6,830 Indigenous people, 4,615 (67.6%) were male and 2,215 (32.4%) female. The median number of charges per person against Indigenous people (25, IQR 31) was significantly greater than non-Indigenous people (9, IQR 16) (p < 0.001). Overall, Indigenous people were charged with 33.2% of the total number of charges against the cohort and 44.0% of all violent offences. The median percentage of follow-up time that Indigenous males and females spent in custody was twice that of non-Indigenous males (21.7% vs. 10.1%, p < 0.001) and females (6.0% vs. 2.9%, p < 0.001). The percentage of Indigenous people who first commenced OST in prison (30.2%) was three times that of non-Indigenous people (11.2%) (p < 0.001). Indigenous males spent less time in OST compared to non-Indigenous males (median percentage of follow-up time in treatment: 40.5% vs. 43.1%, p < 0.001).

CONCLUSIONS

Compared to non-Indigenous opioid-dependent people, Indigenous opioid-dependent people in contact with the criminal justice system are charged with a greater number of offences, spend longer in custody and commonly initiate OST in prison. Hence, contact with the criminal justice system provides an important opportunity to engage Indigenous people in OST.

Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cutoff scores for at-risk, high-risk, and likely dependent drinkers using measures of agreement with the 10-item Alcohol Use Disorders Identification Test

Background

The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item alcohol screener that has been recommended for use in Aboriginal primary health care settings. The time it takes respondents to complete AUDIT, however, has proven to be a barrier to its routine delivery. Two shorter versions, AUDIT-C and AUDIT-3, have been used as screening instruments in primary health care. This paper aims to identify the AUDIT-C and AUDIT-3 cutoff scores that most closely identify individuals classified as being at-risk drinkers, high-risk drinkers, or likely alcohol dependent by the 10-item AUDIT.

Methods

Two cross-sectional surveys were conducted from June 2009 to May 2010 and from July 2010 to June 2011. Aboriginal Australian participants (N = 156) were recruited through an Aboriginal Community Controlled Health Service, and a community-based drug and alcohol treatment agency in rural New South Wales (NSW), and through community-based Aboriginal groups in Sydney NSW. Sensitivity, specificity, and positive and negative predictive values of each score on the AUDIT-C and AUDIT-3 were calculated, relative to cutoff scores on the 10-item AUDIT for at-risk, high-risk, and likely dependent drinkers. Receiver operating characteristic (ROC) curve analyses were conducted to measure the detection characteristics of AUDIT-C and AUDIT-3 for the three categories of risk.

Results

The areas under the receiver operating characteristic (AUROC) curves were high for drinkers classified as being at-risk, high-risk, and likely dependent.

Conclusions

Recommended cutoff scores for Aboriginal Australians are as follows: at-risk drinkers AUDIT-C ≥ 5, AUDIT-3 ≥ 1; high-risk drinkers AUDIT-C ≥ 6, AUDIT-3 ≥ 2; and likely dependent drinkers AUDIT-C ≥ 9, AUDIT-3 ≥ 3. Adequate sensitivity and specificity were achieved for recommended cutoff scores. AUROC curves were above 0.90.

Tailoring a family-based alcohol intervention for Aboriginal Australians, and the experiences and perceptions of health care providers trained in its delivery

BACKGROUND

Aboriginal Australians experience a disproportionately high burden of alcohol-related harm compared to the general Australian population. Alcohol treatment approaches that simultaneously target individuals and families offer considerable potential to reduce these harms if they can be successfully tailored for routine delivery to Aboriginal Australians. The Community Reinforcement Approach (CRA) and Community Reinforcement and Family Training (CRAFT) are two related interventions that are consistent with Aboriginal Australians' notions of health and wellbeing. This paper aims to describe the process of tailoring CRA and CRAFT for delivery to Aboriginal Australians, explore the perceptions of health care providers participating in the tailoring process, and their experiences of participating in CRA and CRAFT counsellor certification.

METHODS

Data sources included notes recorded from eight working group meetings with 22 health care providers of a drug and alcohol treatment agency and Aboriginal Community Controlled Health Service (November 2009-February 2013), and transcripts of semi-structured interviews with seven health care providers participating in CRA and CRAFT counsellor certification (May 2012). Qualitative content analysis was used to categorise working group meeting notes and interview transcripts were into key themes.

RESULTS

Modifying technical language, reducing the number of treatment sessions, and including an option for treatment of clients in groups, were key recommendations by health care providers for improving the feasibility and applicability of delivering CRA and CRAFT to Aboriginal Australians. Health care providers perceived counsellor certification to be beneficial for developing their skills and confidence in delivering CRA and CRAFT, but identified time constraints and competing tasks as key challenges.

CONCLUSIONS

The tailoring process resulted in Aboriginal Australian-specific CRA and CRAFT resources. The process also resulted in the training and certification of health care providers in CRA and CRAFT and the establishment of a local training and certification program.

The effectiveness of community action in reducing risky alcohol consumption and harm: a cluster randomised controlled trial

BACKGROUND

The World Health Organization, governments, and communities agree that community action is likely to reduce risky alcohol consumption and harm. Despite this agreement, there is little rigorous evidence that community action is effective: of the six randomised trials of community action published to date, all were US-based and focused on young people (rather than the whole community), and their outcomes were limited to self-report or alcohol purchase attempts. The objective of this study was to conduct the first non-US randomised controlled trial (RCT) of community action to quantify the effectiveness of this approach in reducing risky alcohol consumption and harms measured using both self-report and routinely collected data.

METHODS AND FINDINGS

We conducted a cluster RCT comprising 20 communities in Australia that had populations of 5,000-20,000, were at least 100 km from an urban centre (population ≥ 100,000), and were not involved in another community alcohol project. Communities were pair-matched, and one member of each pair was randomly allocated to the experimental group. Thirteen interventions were implemented in the experimental communities from 2005 to 2009: community engagement; general practitioner training in alcohol screening and brief intervention (SBI); feedback to key stakeholders; media campaign; workplace policies/practices training; school-based intervention; general practitioner feedback on their prescribing of alcohol medications; community pharmacy-based SBI; web-based SBI; Aboriginal Community Controlled Health Services support for SBI; Good Sports program for sports clubs; identifying and targeting high-risk weekends; and hospital emergency department-based SBI. Primary outcomes based on routinely collected data were alcohol-related crime, traffic crashes, and hospital inpatient admissions. Routinely collected data for the entire study period (2001-2009) were obtained in 2010. Secondary outcomes based on pre- and post-intervention surveys (n = 2,977 and 2,255, respectively) were the following: long-term risky drinking, short-term high-risk drinking, short-term risky drinking, weekly consumption, hazardous/harmful alcohol use, and experience of alcohol harm. At the 5% level of statistical significance, there was insufficient evidence to conclude that the interventions were effective in the experimental, relative to control, communities for alcohol-related crime, traffic crashes, and hospital inpatient admissions, and for rates of risky alcohol consumption and hazardous/harmful alcohol use. Although respondents in the experimental communities reported statistically significantly lower average weekly consumption (1.90 fewer standard drinks per week, 95% CI = -3.37 to -0.43, p = 0.01) and less alcohol-related verbal abuse (odds ratio = 0.58, 95% CI = 0.35 to 0.96, p = 0.04) post-intervention, the low survey response rates (40% and 24% for the pre- and post-intervention surveys, respectively) require conservative interpretation. The main limitations of this study are as follows: (1) that the study may have been under-powered to detect differences in routinely collected data outcomes as statistically significant, and (2) the low survey response rates.

CONCLUSIONS

This RCT provides little evidence that community action significantly reduces risky alcohol consumption and alcohol-related harms, other than potential reductions in self-reported average weekly consumption and experience of alcohol-related verbal abuse. Complementary legislative action may be required to more effectively reduce alcohol harms.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12607000123448.

Applying what works: a systematic search of the transfer and implementation of promising Indigenous Australian health services and programs

Background

The transfer and implementation of acceptable and effective health services, programs and innovations across settings provides an important and potentially cost-effective strategy for reducing Indigenous Australians' high burden of disease. This study reports a systematic review of Indigenous health services, programs and innovations to examine the extent to which studies considered processes of transfer and implementation within and across Indigenous communities and healthcare settings.

Methods

Medline, Informit, Infotrac, Blackwells Publishing, Proquest, Taylor and Francis, JStor, and the Indigenous HealthInfoNet were searched using terms: Aborigin* OR Indigen* OR Torres AND health AND service OR program* OR intervention AND Australia to locate publications from 1992–2011. The reference lists of 19 reviews were also checked. Data from peer reviewed journals, reports, and websites were included. The 95% confidence intervals (95% CI) for proportions that referred to and focussed on transfer were calculated as exact binomial confidence intervals. Test comparisons between proportions were calculated using Fisher's exact test with an alpha level of 5%.

Results

Of 1311 publications identified, 119 (9.1%; 95% CI: 7.6% - 10.8%) referred to the transfer and implementation of Indigenous Australian health services or programs, but only 21 studies (1.6%; 95% CI: 1.0% - 2.4%) actually focused on transfer and implementation. Of the 119 transfer studies, 37 (31.1%; 95% CI: 22.9 - 40.2%) evaluated the impact of a service or program, 28 (23.5%; 95% CI: 16.2% - 32.2%) reported only process measures and 54 were descriptive. Of the 37 impact evaluation studies, 28 (75.7%; 95% CI: 58.8% - 88.2%) appeared in peer reviewed journals but none included experimental designs.

Conclusion

While services and programs are being transferred and implemented, few studies focus on the process by which this occurred or the effectiveness of the service or program in the new setting. Findings highlight a need for partnerships between researchers and health services to evaluate the transfer and implementation of Indigenous health services and programs using rigorous designs, and publish such efforts in peer-reviewed journals as a quality assurance mechanism.

A systematic review of family-based interventions targeting alcohol misuse and their potential to reduce alcohol-related harm in indigenous communities

OBJECTIVE

Alcohol misuse is a major risk factor for harm in indigenous communities. The indigenous family unit is often the setting for, and is most adversely affected by, alcohol-related harm. Therefore, family-based alcohol interventions offer great potential to reduce alcohol-related harm in indigenous communities. This systematic review aims to identify peer-reviewed published evaluations of family-based alcohol interventions, critique the methodological quality of those studies, describe their intervention characteristics, and identify which interventions appear most promising to reduce alcohol-related harm in indigenous communities.

METHOD

Eleven electronic databases were searched. The reference lists of reviews of family-based approaches focused on alcohol interventions were hand-searched for additional relevant studies not identified by the electronic database search.

RESULTS

Initially, 1,369 studies were identified, of which 21% (n = 142) were classified as intervention studies. Nineteen intervention studies were family-based alcohol interventions. Eleven of these studies included family members in the treatment of problem drinkers, and eight studies specifically targeted family members of problem drinkers. Methodological quality of studies varied, particularly in relation to study design, including confounding variables in the analyses, and follow-up rates.

CONCLUSIONS

The evidence for the effectiveness of family-based alcohol interventions is less than optimal, although the reviewed studies did show improved outcomes. Given the important role of family in indigenous communities, there is merit in exploring family-based approaches to reduce alcohol-related harms. Tailored family-based approaches should be developed that include direct consultation with targeted indigenous communities.

Training and tailored outreach support to improve alcohol screening and brief intervention in Aboriginal Community Controlled Health Services

INTRODUCTION AND AIMS

Aboriginal Community Controlled Health Services (ACCHSs) are often the primary point of contact for Indigenous Australians experiencing alcohol-related harms. Screening and brief intervention (SBI) is a cost-effective treatment for reducing these harms. Factors influencing evidence-based alcohol SBI delivery in ACCHSs have been identified. Evaluations of strategies targeting these factors are required. The aim of this paper is to quantify the effect of training and tailored outreach support on the delivery of alcohol SBI in four Aboriginal Community Controlled Health Services (ACCHSs).

DESIGN AND METHODS

A pre- post- assessment of alcohol information recorded in computerised patient information systems of four ACCHSs.

RESULTS

For ACCHSs combined there was a statistically significant increase in the proportion of eligible clients with an electronic record of any alcohol information (3.2% to 7.5%, P < 0.0001) and a valid alcohol screen (1.6% to 6.5%, P < 0.0001), and brief intervention (25.75% to 47.7%, P < 0.0001). All four ACCHSs achieved statistically significant increases in the proportion of clients with a complete alcohol screen (10.3%; 7.4%; 2%, P < 0.0001 and 1.3%, P < 0.05), and two in the proportion with a heavy drinking screen (7% and 3.1%, P < 0.0001).

DISCUSSION AND CONCLUSIONS

Implementing evidence-based alcohol SBI in ACCHSs is likely to require multiple strategies tailored to the characteristics of specific services. Outreach support provided by local drug and alcohol practitioners and a one item heavy drinking screen offer considerable promise for increasing routine alcohol SBI delivery in ACCHSs. Training and outreach support appear to be effective for achieving modest improvements in alcohol SBI delivery in ACCHSs.

'You're less complete if you haven't got a can in your hand': alcohol consumption and related harmful effects in rural Australia: the role and influence of cultural capital

AIMS

This study aimed to explore rural Australians' perceptions of social and cultural factors influencing alcohol use in their communities.

METHODS

Semi-structured interviews exploring rural community key informants' (n = 46) perceptions of social and cultural factors influencing alcohol consumption in their community were conducted. A narrative analysis identified cultural capital as a salient concept for explaining how rural community life is created and sustained via drinking practices.

RESULTS

Themes relating to participants' accounts of learning to drink, normal drinking; exclusion because of not drinking and problematic drinkers are described.

CONCLUSION

In rural communities, beliefs and values about drinking as a positive social practice are transmitted, rewarded and reproduced across multiple groups and settings, reinforcing that drinking is an integral part of Australian rural culture. Drinking is so important that engaging in drinking practices creates and sustains cultural capital. As a result, alcohol-related harm is of little concern to rural dwellers.

Evaluation of the safety of a novel knee load-bypassing device in a sheep model

BACKGROUND

Unloading treatments for osteoarthritis of the knee, such as valgus braces, have been shown to reduce medial joint-loading and pain. The purpose of this preclinical study was to investigate the tissue response to an extracapsular implantable device (KineSpring System; Moximed, Hayward, California) that is designed to reduce loading across the medial compartment of the knee.

METHODS

Eleven sheep were implanted with the KineSpring System, consisting of bases secured to the medial femoral and tibial cortices with bone screws and also consisting of a joint-spanning load-absorber composed of a piston and spring assembly inside a polymeric sheath. In nine sheep, titanium alloy washers with either an uncoated or a plasma-sprayed titanium-hydroxyapatite (TPS-HA) coated undersurface were fixed with screws to the contralateral femur and tibia to investigate the effects of surface treatment on extracortical bone apposition. The functionality of the KineSpring System was assessed by fluoroscopy, tissue response was determined by gross and microscopic histology, and implant fixation was determined by radiography, microradiography, and histomorphometry at four, twelve, twenty-six, and fifty-two weeks.

RESULTS

The function of the KineSpring System was confirmed in all sheep. Seventeen of eighteen TPS-HA coated bases and thirty-six of thirty-six washers had stable bone fixation; one coated base was loose with evidence of infection. At four weeks, there was an early, expected inflammatory response, but this response resolved by twelve weeks and a pseudosynovial membrane formed around the sheath. Bone apposition increased over time for the TPS-HA coated bases and for uncoated washers (p &lt; 0.05). There was good apposition of the TPS-HA coated washers even at early time points, with no subsequent increase in apposition over time.

CONCLUSIONS

The KineSpring System demonstrated safety in a simulated use model for periods of up to fifty-two weeks. Screws result in stable implant fixation and TPS-HA coating allows for early and long-lasting cortical bone apposition and integration.

CLINICAL RELEVANCE

This implant warrants further investigation as a means of reducing medial compartment loading and pain in patients with osteoarthritis of the knee.

The KineSpring load absorber implant: rationale, design and biomechanical characterization

Osteoarthritis (OA) of the knee is the leading cause of disability in the adult population. Although a number of treatments for knee OA are available, none effectively prevent OA progression. Currently, a wide therapeutic gap exists for patients who have unsuccessfully exhausted conservative OA treatments but who are hesitant or ineligible to undergo invasive surgery. The KineSpring device is a novel, joint preserving, minimally invasive implant that reduces medial compartment loading without significantly impacting the loading of the lateral compartment. This article describes the rationale for and the design of the KineSpring device and summarizes results of initial biomechanical testing in an OA cadaver model.

Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous Australians: rigorous evaluations and new directions needed

OBJECTIVE

To describe and critique methodological aspects of interventions targeting reductions in smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) among Indigenous Australians.

METHODS

An electronic search of eight databases and a manual search of reference lists of literature reviews and reference libraries for Indigenous-specific intervention studies published in peer-reviewed journals (January 1990 to August 2007) were undertaken. Alcohol, smoking, nutrition or physical activity needed to be the primary focus of the study and the intervention needed to specifically target Indigenous Australians.

RESULTS

Twenty studies were selected for inclusion in the review. Methodologically, few studies employed randomisation or a control group, most omitted important details (e.g. costs), some did not report process measures (e.g. attrition rates), and some did not use validated measures. Two-thirds of interventions were implemented at the community level and employed multiple strategies.

CONCLUSION

There is a need for more rigorous evaluations of interventions targeting reductions in SNAP risk factors among Indigenous Australians, and to establish the reliability and validity of measures to quantify their effect.

IMPLICATIONS

It may be beneficial for future Indigenous-specific intervention research to focus on the evaluation of secondary prevention to complement the current concentration of effort targeting primary prevention. Community-wide interventions, combining strategies of greater intensity for high risk individuals with those of less intensity targeting lower risk individuals, might also offer considerable promise.

Reducing alcohol related harm experienced by Indigenous Australians: identifying opportunities for Indigenous primary health care services

OBJECTIVE

Identify key issues and opportunities relating to the dissemination of cost-effective interventions for alcohol in Indigenous-specific settings.

METHODS

Update previous reviews of the Indigenous alcohol literature, particularly in relation to intervention and dissemination studies aimed at identifying and integrating into routine clinical care those strategies that are most cost-effective in reducing alcohol-related harm.

RESULTS

The harmful use of alcohol has been identified as a major public health issue, which has a disproportionately high negative impact on Indigenous Australians. While the disproportionately high burden of harm borne by Indigenous Australian communities is well documented in descriptive studies, attempts to redress this imbalance through well controlled intervention and dissemination studies appear to have been inadequate to date. There is compelling evidence from the non-Indigenous community that brief intervention is an effective treatment for harmful alcohol use, compared to the relatively lower levels of evidence for primary and tertiary level interventions. The effectiveness of brief intervention for alcohol in Indigenous Australian communities should, therefore, be examined.

CONCLUSIONS AND IMPLICATIONS

An opportunity exists to implement brief intervention into Indigenous primary health care settings, as an evidence-based strategy using established resources. There is the possibility that such Indigenous-specific health services research will lead the dissemination field in demonstrating how the implementation process can be successfully tailored to specific and defined clinical settings.

Disseminating best-evidence health-care to Indigenous health-care settings and programs in Australia: identifying the gaps

Indigenous Australians experience a disproportionately greater burden of harm from smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) than the general Australian population. A critical step in further improving efforts to reduce this harm is to review existing efforts aimed at increasing the uptake of evidence-based interventions in Indigenous-specific health-care settings and programs. This study systematically identifies and reviews published Indigenous-specific dissemination studies targeting SNAP interventions. An electronic search of eight databases and a manual search of reference lists of previous literature reviews were undertaken. Eleven dissemination studies were identified for review: six for nutrition and physical activity as a component of diabetes care, three for alcohol and two for smoking. The majority of studies employed continuing medical education (n = 9 studies), suggesting that improving health-care providers' knowledge and skills is a focus of current efforts to disseminate best-evidence SNAP interventions in Indigenous health-care settings. Only two studies evaluated reminder systems, despite their widespread use in Indigenous-specific health-care services, and only one study employed academic detailing, despite its cost-effectiveness at modifying health-care provider behavior. There is a clear need for more Indigenous-specific dissemination research targeting the uptake of secondary prevention and to establish reliable and valid measures of Indigenous-specific health-care delivery, in order to determine which dissemination strategies are most likely to be effective in Indigenous health-care settings and programs.

Florfenicol residues in three species of fish after 10-day oral dosing in feed

Nile tilapia Oreochromis niloticus, walleye Sander vitreus, and hybrid striped bass (female white bass Morone chrysops x male striped bass M. saxatilis) were medicated with florfenicol (AQUAFLOR type A medicated article; Schering-Plough Animal Health, Summit, New Jersey) via a medicated ration of 10 mg florfenicol x kg fish body weight(-1) d(-1) for 10 d to compare the elimination kinetics of the test article. This study was part of a larger effort in support of a species grouping concept that could contribute to the regulatory approval process for therapeutic compounds for cultured fishes. The trials in this study were conducted at the ideal water temperature for each species and at the temperature 5 degrees C lower than the ideal. The test temperatures were 30 degrees C and 25 degrees C for Nile tilapia, 25 degrees C and 20 degrees C for both walleyes and hybrid striped bass. In all cases, the elimination kinetics of florfenicol were more rapid at higher temperatures. The time to reach the tolerance of 1 microg/g in muscle-skin, as set by the U.S. Food and Drug Administration for channel catfish Ictalurus punctatus and salmonids, ranged from 6.1 to 4.1 d for Nile tilapia, from 12.6 to 9.7 d for walleyes, and from 2.6 to 0.7 d for hybrid striped bass at temperatures between 20 degrees C and 30 degrees C.

Sulfadimethoxine and ormetoprim residues in three species of fish after oral dosing in feed

Nile tilapia Oreochromis niloticus, summer flounder Paralichthys dentatus, and walleyes Sander vitreus were treated with Romet-30 (PHARMAQ AS, Oslo, Norway) via a medicated ration at 50 mg Romet-30 kg fish body weight(- 1) d(-1) for 10 d to compare the elimination kinetics of the test substance. This study was part of a larger effort to develop a species grouping concept for the labeling of therapeutic compounds for cultured fishes. The fish tests were conducted at the ideal water temperature for each species and at 5 degrees C lower than the ideal temperature except for summer flounder, which would not feed at the lower temperature of 15 degrees C. Test temperatures were 30 degrees C and 25 degrees C for Nile tilapia, 20 degrees C and 17 degrees C for summer flounder, and 25 degrees C and 20 degrees C for walleyes. Neither component of Romet-30 (sulfadimethoxine and ormetoprim) could be detected in samples of the edible portion of walleyes (muscle plus skin) collected at day 10 posttreatment or thereafter. In studies with summer flounder, only one fish had a detectable concentration of either component on day 21 or thereafter. Elimination of Romet-30 by Nile tilapia was extremely rapid. The limited number of Nile tilapia with detectable sulfadimethoxine or ormetoprim during the posttreatment period prevented the determination of elimination half-life or elimination in this species.

Studies on itraconazole delivery and pharmacokinetics in mallard ducks (Anas platyrhynchos)

Avian aspergillosis is commonly treated with itraconazole (ITZ). This paper describes two studies using mallard ducks (Anas platyrhynchos). The first study evaluated in vivo release of ITZ from subcutaneously injected controlled-release gel formulations and the second study compared pharmacokinetic parameters for two ITZ oral suspensions. ITZ-A suspension was prepared by mixing contents of commercially available capsules with hydrochloric acid and orange juice. ITZ-B suspension was prepared by dispersing the complex of the drug with hydroxypropyl-beta-cyclodextrin in water. Concentrations of ITZ and its active metabolite, hydroxyitraconazole (OH-ITZ), in plasma and tissue samples were measured using high-performance liquid chromatography. In the second study, drug concentrations in plasma samples were also analyzed using a bioassay. After administration of two ITZ controlled-release formulations, plasma and tissue concentrations of ITZ and OH-ITZ were either very low (< or = 52 ng/mL) or undetectable. Exceptions included skin, subcutaneous fat, and muscle adjacent to the injection site. The drug from ITZ-A and ITZ-B suspensions was absorbed after oral administration. ITZ pharmacokinetic parameters for both suspensions in mallard ducks were similar and the bioassay successfully measured ITZ equivalents in plasma samples from ducks.

Intravenous and subcutaneous pharmacokinetics of florfenicol in sheep

Pharmacokinetic parameters of florfenicol were determined in 10 adult sheep (five wethers and five ewes) after a single 40 mg/kg intravenous (i.v.) dose, and three daily subcutaneous (s.c.) doses of 40 mg/kg of a commercial preparation (Nuflor((R))). The concentration of florfenicol in serum samples was assayed using a proprietary HPLC assay method, and pharmacokinetic parameters derived for individual animal data by each route using compartmental and noncompartmental approaches. Two animals (one male and one female) were excluded due to observed i.v. dosing problems, and a biexponential model was found to fit the i.v. data well for six of the other eight animals. Data from two males showed prolonged low concentrations of florfenicol in serum and were better fit by a three-compartment model. The mean +/- SD for the half-lives of the distribution and elimination phases for the six sheep best fit with a two-compartment model were 0.069 +/- 0.018 and 1.01 +/- 0.09 h respectively, and for the V(d(ss)) and clearances were 0.503 +/- 0.035 L/kg and 366 +/- 53 mL/h/kg respectively. The data collected during the s.c. multiple dose study were analyzed using noncompartmental methods only. The bioavailability (F%) after s.c. dosing was calculated in three ways to compare estimation methods as steady-state had not been reached and single dose s.c. data were not obtained past 24 h. Using the AUC(0--24) and AUC(0--> infinity ) from the first dose, the F% values averaged 27 and 40% respectively. Using the AUC(0--> infinity ) for all doses, the F% was 65%. Calculations of the mean time during which the serum concentration exceeded 0.5 and 1.0 microg/mL were 105 +/- 3.9 and 74.7 +/- 12.2 h respectively.

Influence of bone invasion and extent of mandibular resection on local control of cancers of the oral cavity and oropharynx

The aim of this paper was to evaluate the influence of bone invasion on treatment outcome among patients with cancers of the oral cavity and oropharynx and to determine whether or not outcome was influenced by the extent of mandibular resection. A review of 127 prospectively documented patients who were treated with marginal or segmental resection for oral (n = 110) and oropharyngeal (n = 17) cancers was undertaken. There were 97 males and 30 females with a median age of 61 years. Clinical T stages were: T1 17 patients, T2 33, T3 22, T4 55. Median followup was 4 years. A total of 94 patients underwent marginal resections and 33 underwent segmental resections. Histological bone invasion was present in 17 patients (16%) in the marginal resection group and 21 patients (64%) in the segmental group (P<0.05). Soft tissue surgical margins were positive in 11 patients (12%) in the marginal group and in seven patients (21%) in the segmental group (P=not significant). Local control did not correlate significantly with T stage, the extent of mandibular resection or the presence of histological bone invasion, but was significantly influenced by positive soft tissue margins (P<0.01). Among patients with bone invasion, the local control rate was higher following segmental resection when compared to marginal resections (87% vs 75%) but this was not statistically significant. Survival was significantly influenced by positive soft tissue margins but not bone invasion or the type of resection. We conclude that bone invasion alone did not predict for local control or survival rates among patients with oral and oropharyngeal cancers. Involved soft tissue margins were highly predictive of local recurrence and decreased survival. Conservative resection of the mandible is safe as long as marginal mandibulectomy does not lead to compromise of soft tissue margins. Segmental resection should be reserved for patients extensive bone invasion or those with limited invasion in a thin atrophic mandible.

The influence of calcium to phosphate ratio on the nucleation and crystallization of apatite glass-ceramics

The nucleation and crystallization behavior of a series of glasses based on 4.5SiO2-3Al2O3-YP2O5-3CaO-1.51CaF2 was studied. The parameter Y was varied to give calcium to phosphate ratios between one and two. All of the glasses studied crystallized firstly to fluorapatite (Ca5PO4)3F). The glass with a calcium to phosphate ratio of 1.67, corresponding to apatite, bulk nucleated to give fluorapatite (FAP). The glasses with calcium : phosphate ratios either less than that of apatite, or greater than that of apatite all exhibited surface nucleation of FAP. However, following a nucleation hold of one hour at approximately 50 K above the glass transition temperature these glasses exhibited bulk nucleation of FAP.

Life threatening laryngeal toxicity following treatment with combined chemoradiotherapy for nasopharyngeal cancer: a case report with review of the literature

Nasopharyngeal carcinoma is a rare cancer in Western society, however there is a higher incidence in Asian. Chinese and African populations. A significant number of Asians reside in Australia, and consequently patients with nasopharyngeal carcinoma are an increasing clinical problem. Radiotherapy has been the predominant treatment in the past, but more recently multi-modality treatments have been utilised. The results of an Intergroup trial, coordinated by the Southwest Oncology Group (SWOG) demonstrated markedly superior progression free and overall survival for combined chemoradiotherapy compared to radiotherapy alone. At three years progression free survival was 24% for the radiotherapy arm and 69% for the chemoradiotherapy group (P < 0.001), and three-year survival was 47% for the radiotherapy arm compared with 78% for the combined arm (P = 0.005). There was minimum toxicity reported for either of the arms and no treatment related deaths. Based on these survival data the administration of concomitant cisplatin and radiotherapy has become standard of care for nasopharyngeal carcinoma in the USA. Our institution has also adopted a similar combined therapy protocol for patients with stage III and IV nasopharyngeal cancer and good performance status. The patients treated at our institution have experienced significant side effects. We describe the case of a woman so treated with this protocol who subsequently developed severe life threatening laryngeal necrosis.

Testing for technical files: avoiding too little and too much

Since 13 June 1998, it has been mandatory for all new and existing medical devices to be CE-marked according to the Medical Device Directive. However, for certain electromedical devices full compliance with the requirements of EN 60601-1 as a means of obtaining the CE mark may not be necessary. This article looks at some of these products and explains how they may still qualify for distribution in the European medical market.

Role of ornithine decarboxylase in epidermal tumorigenesis

Ornithine decarboxylase (ODC) plays a key role in the biosynthesis of polyamines, which are necessary for cell growth and differentiation. ODC expression is very tightly controlled in all normal cells; however, regulation of its expression is altered in many tumor cells resulting in much higher basal levels of ODC in tumors. To investigate the potential role of ODC overexpression in epidermal tumorigenesis, we constructed a replication-defective retroviral vector to overexpress a truncated ODC protein in epidermal cells. Stable viral infection of mouse epidermal cells dramatically increases not only the basal ODC activity but also the basal putrescine and spermidine levels. In all infected epidermal cells with high polyamine levels, DNA synthesis is increased as measured by [3H]thymidine incorporation into DNA as well as increased bromodeoxyuridine staining in the nuclei of ODC-infected epidermal cells. ODC viral infection of nontumorigenic BK-1 epidermal cells and primary cultures of mouse keratinocytes and fibroblasts from newborn mouse skin yields no tumors when injected s.c. into athymic nude mice or when transplanted as skin grafts onto nude mice. Epidermal cell lines SP-1 and 308 (which possess an activated rasHa gene) are not tumorigenic when injected s.c. into nude mice. However, following infection with the ODC virus, they form tumors filled with keratin and papilloma-like projections of hyperplastic epidermal cells displaying dysplasia and many mitotic figures. These data indicate that ODC overexpression by itself is not sufficient to induce tumors in normal cells but that increased expression of ODC enhances tumor development in initiated premalignant epidermal cells.

Effects of a carotene-deficient diet on measures of oxidative susceptibility and superoxide dismutase activity in adult women

The effect of consuming a low carotene diet (approximately 60 micrograms carotene/day) on oxidative susceptibility and superoxide dismutase (SOD) activity in women living in a metabolic research unit was evaluated. The diet had sufficient vitamins A, E, and C. The women ate the diet supplemented with 1500 micrograms/day beta-carotene for 4 days (baseline), then the unsupplemented diet for 68 days (depletion), followed by the diet supplemented with > 15,000 micrograms/day carotene for 28 days (repletion). Production of hexanal, pentanal, and pentane by copper-oxidized plasma low density lipoproteins from carotene-depleted women was greater than their production of these compounds when repleted with carotene. Erythrocyte SOD activity was depressed in carotene-depleted women; it recovered with repletion. Thiobarbituric acid reactive substances in plasma of carotene-depleted women were elevated and diminished with repletion. Dietary carotene seems to be needed, not only as a precursor of vitamin A, but also to inhibit oxidative damage and decrease oxidation susceptibility.

Giant Teflon granuloma of the larynx

Endolaryngeal injection of Teflon paste to augment and medialize the paralyzed hemilarynx aims to improve dysphonia and relieve aspiration. After an initial short-lived inflammatory reaction in the laryngeal tissues, a foreign body granuloma forms around the Teflon. In most cases the results are good but it may occasionally be necessary to consider removal of the granuloma if too large a volume has been injected, if it is inappropriately placed, or if the paralyzed vocal cord subsequently recovers. Surgical removal is difficult and the results are unpredictable. This case illustrates, for the first time, that evaluation using both a high-resolution computed tomographic (CT) scan and endoscopy with telescopes permits satisfactory assessment before removal of Teflon.