From the Bush to the Brain: Preclinical Stages of Ethnobotanical Anti-Inflammatory and Neuroprotective Drug Discovery-An Australian Example

The Australian rainforest is a rich source of medicinal plants that have evolved in the face of dramatic environmental challenges over a million years due to its prolonged geographical isolation from other continents. The rainforest consists of an inherent richness of plant secondary metabolites that are the most intense in the rainforest. The search for more potent and more bioavailable compounds from other plant sources is ongoing, and our short review will outline the pathways from the discovery of bioactive plants to the structural identification of active compounds, testing for potency, and then neuroprotection in a triculture system, and finally, the validation in an appropriate neuro-inflammatory mouse model, using some examples from our current research. We will focus on neuroinflammation as a potential treatment target for neurodegenerative diseases including multiple sclerosis (MS), Parkinson's (PD), and Alzheimer's disease (AD) for these plant-derived, anti-inflammatory molecules and highlight cytokine suppressive anti-inflammatory drugs (CSAIDs) as a better alternative to conventional nonsteroidal anti-inflammatory drugs (NSAIDs) to treat neuroinflammatory disorders.

An adaptable research platform for ex vivo normothermic machine perfusion of the liver

PURPOSE

This paper presents an assessment of a low-cost organ perfusion machine designed for use in research settings. The machine is modular and versatile in nature, built on a robotic operating system (ROS2) pipeline allowing for the addition of specific sensors for different research applications. Here we present the system and the development stages to achieve viability of the perfused organ.

METHODS

The machine's perfusion efficacy was assessed by monitoring the distribution of perfusate in livers using methylene blue dye. Functionality was evaluated by measuring bile production after 90 min of normothermic perfusion, while viability was examined using aspartate transaminase assays to monitor cell damage throughout the perfusion. Additionally, the output of the pressure, flow, temperature, and oxygen sensors was monitored and recorded to track the health of the organ during perfusion and assess the system's capability of maintaining the quality of data over time.

RESULTS

The results show the system is capable of successfully perfusing porcine livers for up to three hours. Functionality and viability assessments show no deterioration of liver cells once normothermic perfusion had occurred and bile production was within normal limits of approximately 26 ml in 90 min showing viability.

CONCLUSION

The developed low-cost perfusion system presented here has been shown to keep porcine livers viable and functional ex vivo. Additionally, the system is capable of easily incorporating several sensors into its framework and simultaneously monitor and record them during perfusion. The work promotes further exploration of the system in different research domains.

How to Use Microhistory Methodology in Mental Health Research

Incorporating anthropological principles, microhistory is a research methodology useful for exploring the interplay between ordinary people and social abstractions such as, the market, social systems, and governments. In this paper, the background and characteristics of microhistory are described, and a novel six-stage approach for conducting microhistories in mental healthcare is introduced. Each stage of the process is illustrated using sections from a microhistory focussed on the earliest recorded case comparison between British colonial mental healthcare and Aboriginal Australian traditional healing. Microhistory provides a way to uncover new insights about past mental healthcare, which may contribute to re-conceptualisations of modern-day beliefs and practices.

Twelve tips for engaging students and community partners in medical education

There is increasing evidence on the positive outcomes of engaging students and community partners in medical education, especially in achieving social accountability. However, less is known about the steps through which these engagements are established. This paper outlines twelve tips on establishing a robust and enduring partnership with students and community partners in medical education, using examples from the Western Sydney University School of Medicine. While context is paramount in any engagement program, these tips are formulated to be transferable to medical education settings in different countries, education systems, and the broader context of health professional education.

Developmental Screening Tools Used with First Nations Populations: A Systematic Review

Developmental surveillance and screening is recommended for all children under five years of age, especially for those from at-risk populations such as First Nations children. No review to date has, however, evaluated the use of developmental screening tools with First Nations children. This review aimed to examine and synthesise the literature on developmental screening tools developed for, or used with, First Nations populations children aged five years or younger. A PRISMA-compliant systematic review was performed in the PsychInfo, PubMed, and Embase databases. Additional searches were also undertaken. In total 444 articles were identified and 13 were included in the final review. Findings indicated that several developmental screening tools have been administered with First Nations children. Most tools, however, have only been evaluated in one study. Results also found that no studies evaluated actions taken following positive screening results. More research evaluating the accuracy, acceptability, and feasibility of using developmental screeners with First Nations children is required before widespread implementation of developmental screening in clinical settings with First Nations children is recommended.

82 THE IMPACT OF THE COVID-19 PANDEMIC ON THE ACTIVITY OF A RAPID-ACCESS GERIATRIC DAY HOSPITAL SERVICE

Background

In the 1970s, Jack Flanagan developed the first Geriatric Day Hospital (GDH) in Ireland. Since, the GDH model of care has evolved to accommodate for the growing demands of our ageing population. Before the COVID-19 pandemic, the operational scope of our GDH was extended to allow for the rapid medical and multidisciplinary assessment and follow-up of older patients. During the pandemic, the GDH did not suspend operations and remained open as a COVID-negative ambulatory pathway. We evaluated the activity of this GDH service.

Methods

Retrospective Service Evaluation Approval was granted by our Research & Innovation Office (Reference: 7419). Pseudonymised data corresponding to all GDH attendances between January 2017 and December 2021 were retrieved from the hospital electronic records. Yearly trends in proportions were tested with the Chi-square for trend statistic. Trends in monthly attendances were assessed via Statistical Process Control (SPC) charts with three-sigma limits. Statistical significance was set at p<0.05.

Results

There were 27,278 attendances of patients aged 65 and over to the GDH over the 5-year period (6,362, 5,978, 6,115, 4,306, and 4,517, respectively). Mean age was 82 every year. Of the 7,813 new episodes, yearly proportions referred directly by primary care teams were 10.4%, 29.5%, 38.6%, 24.5%, and 16.3% (p<0.001). SPC charts showed that Apr-May 2020 and Jan-Feb 2021 had significantly lower numbers of review attendances (50-59 and 146-142, respectively, average 324 p/m). However, new appointments did not significantly decline (average 130 p/m). Of the 7,813 new episodes, 2,595 (33.2%) were seen by Physiotherapy, and 1,860 (23.8%) by Occupational Therapy.

Conclusion

Our GDH saw a sustained number of new attendances and demonstrated increased community availability during the unprecedented COVID-19 crisis, especially during the first wave of the pandemic when hospital access was most affected. A rapid access GDH model can facilitate integrated care at times of crisis to promote ageing in place.

131 USE OF FDG-PET BRAIN IMAGING IN THE DIAGNOSIS AND MANAGEMENT OF DEMENTIA IN A UNIVERSITY HOSPITAL

Background

Neuroimaging is an increasingly important tool dementia work-up. Subtype diagnosis helps predict the course of the disease, aiding prognostication and management. Amyloid-beta peptide is intrinsic to the pathogenesis of Alzheimer’s disease (AD), forming characteristic neuritic plaques which can be imaged in vivo on positron emission tomography (PET) scans. NICE recommendations advise use of PET imaging if dementia sub-type diagnosis is unclear and AD is suspected. We sought to establish the referral patterns for FDG-PET brain scans for patients aged 60 and over in a university hospital and to establish whether this imaging modality contributed to a change in diagnosis or treatment.

Methods

Requests for FDG-PET CT brain from 2019 – 2022 were retrospectively reviewed. Information was obtained from clinical notes and patient information software. Patient demographics, indication for scan, source of referral and whether imaging results led to a change in diagnosis or treatment was recorded.

Results

A total of 32 patients were reviewed, with a mean age of 65 years (13 females; 41%). We further analysed the 25 who were aged over 60; this subgroup had a mean age of 70 (9 females; 36%). All 25 patients were appropriately referred to assess for dementia subtype. A revision in diagnosis based on PET imaging was made in 17 (68%) cases. In 9 (30%) cases, results prompted change in dementia-specific pharmacological treatment, including donepezil and memantine. A further 6 (24%) had pharmacological treatment for non-cognitive symptoms of dementia adjusted, such as anti-depressants or anti-psychotics. The majority of referrals had come from neurologists (n = 15; 60%) rather than geriatricians (n = 10; 40%). The final diagnosis was AD in 12 cases (48%) and fronto-temporal dementia in 3 cases (12%).

Conclusion

PET scans are a useful functional imaging modality which can help to differentiate dementia subtypes and influence management.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Evaluation of A Novel Organ Perfusion Research Platform

This paper presents a novel, low cost, organ perfusion machine designed for use in research. The modular and versatile nature of the system allows for additional sensing equipment to be added or adapted for specific use. Here we introduce the system and present its preliminary evaluation by assessing its ability to maintain a predetermined input pressure. A proportional-integral-derivative (PID) controller was implemented and tested on a porcine liver to maintain input pressure to the hepatic artery and compared to bench tests. The results confirmed the effectiveness of the controller for maintaining input through the hepatic artery (HA) in a timely manner. Clinical Relevance-Machine Perfusion (MP) is proving to be an invaluable adjunct in clinical practice. With its ongoing success in the transplant arena, we propose MP for use in research. A cost-effective, versatile system that can be modified for specific research use to test new pharmacological therapies, imaging techniques or develop simulation training would be beneficial.

Screening and social prescribing in healthcare and social services to address housing issues among children and families: a systematic review

OBJECTIVES

Housing is a social determinant of health that impacts the health and well-being of children and families. Screening and referral to address social determinants of health in clinical and social service settings has been proposed to support families with housing problems. This study aims to identify housing screening questions asked of families in healthcare and social services, determine validated screening tools and extract information about recommendations for action after screening for housing issues.

METHODS

The electronic databases MEDLINE, PsycINFO, EMBASE, Ovid Emcare, Scopus and CINAHL were searched from 2009 to 2021. Inclusion criteria were peer-reviewed literature that included questions about housing being asked of children or young people aged 0-18 years and their families accessing any healthcare or social service. We extracted data on the housing questions asked, source of housing questions, validity and descriptions of actions to address housing issues.

RESULTS

Forty-nine peer-reviewed papers met the inclusion criteria. The housing questions in social screening tools vary widely. There are no standard housing-related questions that clinical and social service providers ask families. Fourteen screening tools were validated. An action was embedded as part of social screening activities in 27 of 42 studies. Actions for identified housing problems included provision of a community-based or clinic-based resource guide, and social prescribing included referral to a social worker, care coordinator or care navigation service, community health worker, social service agency, referral to a housing and child welfare demonstration project or provided intensive case management and wraparound services.

CONCLUSION

This review provides a catalogue of housing questions that can be asked of families in the clinical and/or social service setting, and potential subsequent actions.

The socioemotional challenges and consequences for caregivers of Aboriginal and Torres Strait Islander children with otitis media: A qualitative study

INTRODUCTION

Living with ear disease can have extensive impacts on physical, emotional and social well-being. This study explored otitis media (OM) and its management from the perspective of caregivers of Aboriginal and Torres Strait Islander children.

METHODS

Semi-structured interviews were conducted from 2015 to 2020 with caregivers of Aboriginal and Torres Strait Islander children with OM. Thematic analysis of transcripts was undertaken using a constructivist grounded theory approach through the leadership and the cultural lens of an Aboriginal community-based researcher.

RESULTS

Caregivers described OM as having profound impacts on their child's physical, developmental, and emotional well-being, with long waits for specialist treatment contributing to extra strain on families. Children's well-being suffered when OM was mistaken for poor behaviour and children were punished, with caregivers subsequently experiencing strong feelings of guilt. Concerns were conveyed about the social implications of having a sick child. The variable nature of OM symptoms meant that caregivers had to monitor closely for sequelae and advocate for appropriate treatment. Success in navigating the diagnosis and treatment of OM can be strongly impacted by the relationship between caregivers and health professionals and the perceived access to respectful, collaborative and informative healthcare.

CONCLUSION

OM may have substantial social and emotional consequences for children and their caregivers. A holistic understanding of the way in which OM impacts multiple facets of health and well-being, as well as recognition of challenges in accessing proper care and treatment, will aid families managing OM and its sequelae.

PATIENT OR PUBLIC CONTRIBUTION

Governing boards, managers, staff and community members from five Australian Aboriginal Medical Services were involved in the approval, management and conduct of this study and the wider clinical trials. The caregivers of Aboriginal and Torres Strait Islander patients at these services informed the interview study and guided its purpose.

Randomised clinical trial research within Aboriginal and Torres Strait Islander primary health services: a qualitative study

OBJECTIVE

To better understand how to undertake valuable, ethical and sustainable randomised controlled clinical trial (RCT) research within Aboriginal and Torres Strait Islander primary health services.

DESIGN

In a qualitative approach, we utilised data collected between 2013 and 2020 during the planning and implementation of two RCTs. The data comprised agreed records of research meetings, and semistructured interviews with clinical trial stakeholders. The stakeholders were parents/carers of child participants, and site-based research officers, healthcare providers and community advisory groups. Our thematic analysis was informed by constructivist grounded theory.

SETTING

The RCTs investigated the management of otitis media in Aboriginal and Torres Strait Islander children, with the first RCT commencing recruitment in 2014 and the second in 2017. They took place in Aboriginal Medical Services (AMSs), large primary health services for Aboriginal and Torres Strait Islander people, based in urban and regional communities across two Australian states and one territory.

RESULTS

We analysed data from 56 meetings and 67 interviews, generating themes on making research valuable and undertaking ethical and sustainable RCTs. Aboriginal and Torres Strait Islander leadership, and support of AMSs in their service delivery function were critical. The broad benefits of the trials were considered important to sustainability, including workforce development, enhanced ear healthcare and multidirectional research capacity building. Participants emphasised the long-term responsibility of research teams to deliver benefits to AMSs and communities regardless of RCT outcomes, and to focus on relationships, reciprocity and creating positive experiences of research.

CONCLUSION

We identify principles and strategies to assist in undertaking ethical and sustainable RCTs within Aboriginal and Torres Strait Islander primary health services. Maintaining relationships with AMSs and focusing on mutual workforce development and capacity building creates opportunities for long-term benefits so that health research and RCTs work for Aboriginal and Torres Strait Islander peoples, services, communities and researchers.

TRIAL REGISTRATION NUMBER

ACTRN12613001068752 (Pre-results); ACTRN12617001652369 (Pre-results).

99 ASSESSMENT AND MANAGEMENT OF PAIN IN OLDER ADULTS WITH ACUTE FRACTURE ADMITTED UNDER AN ORTHOPAEDIC SERVICE

Background

Older adults with acute fractures often have suboptimal pain control, in particular those with cognitive impairment. Effective pain management improves rehabilitation engagement and earlier discharge from acute care. Our study aimed to evaluate pain management of older adults with acute fracture admitted under an orthopaedic service in a tertiary hospital.

Methods

Prospective review of patients over 65 years with an acute fracture admitted under an orthopaedic service. Review of chart, medication prescription and pain status. Data included type of fracture, comorbidities, cognitive status and analgesia prescribed. Data analysed using Excel.

Results

40 inpatients included. Median age 82 years (range 65-93 years), 70% female. 53% had cognitive impairment, ranging from mild to severe dementia. 75% had &gt;5 regular medications pre-admission. 80% had &gt;5 comorbidities.

Two-thirds (73%) had an acute hip fracture. Most (80%) inpatients had a surgical intervention, the remaining were managed conservatively.

Analgesia prescriptions included paracetamol for almost all patients (95%), non-steroidal anti-inflammatory drugs for 3 (8%) and regular opioids in only 3 (8%).

43% of patients reported pain at time of data collection. 13% had analgesia changed in the 24 hours beforehand. Pain adversely affected function in 205 and mobility in 28%.

2 patients were unable to verbalise pain however no pain scales or visual assessments were used.

Documentation of pain assessment was best by nurses (100%) followed by doctors (60%) and allied health professionals (40%).

Conclusion

Older adults with acute fracture are often multimorbid with cognitive impairment. This patient population are often untreated for pain with suboptimal pain assessment and analgesia review or prescriptions. Consequently we developed a pain policy for use on our orthopaedic service as a guide for effective pain assessment and management for older adults with acute fracture.

141 USING A TEMPLATE TO IMPROVE COMMUNICATION ON DISCHARGE LETTERS REGARDING BONE PROTECTION THERAPY AFTER HIP FRACTURE

Background

Hip fractures are a significant cause of morbidity and mortality amongst older adults. The Irish Hip Fracture Database Standard 5 requires that all patients with hip fracture have a bone health assessment completed; most are commenced on bone protection therapy (BPT) to reduce future fractures. Communication to general practitioners (GPs) regarding long-term BPT is often incomplete and challenging to improve. We aimed to upgrade this communication process at discharge.

Methods

Initial audit was conducted assessing documentation of BPT after hip fracture in discharge letters to GPs. Subsequently we created a detailed BPT template for discharge letters containing clear information for GPs regarding medication initiation and advice for ongoing management. The template was introduced and doctors were educated on its use. We then re-audited discharge letters following this intervention. Patients included were over 60 years old with hip fracture. Patients deemed clinically unsuitable for BPT were excluded.

Results

Ninety discharge letters were reviewed, 45 at initial audit and another 45 after introducing the BPT template. Mean age was 80 years old, 66 (73%) were female. In the first audit cycle, 28/45 discharge letters (62%) briefly specified BPT. On repeating the audit cycle (following introduction of the discharge letter template) all 45/45 discharge letters (100%) clearly specified BPT. Most letters (41/45; 91%) included the detailed BPT template. Following this intervention all doctors reported increased awareness and understanding of BPT, and satisfaction with template use in discharge letters.

Conclusion

Effective implementation of a discharge letter template significantly improved communication to GPs regarding BPT following hip fracture.

138 DELAYED BLOOD PRESSURE RECOVERY AFTER STANDING INDEPENDENTLY PREDICTS FRACTURE IN COMMUNITY-DWELLING OLDER PEOPLE

Background

Orthostatic hypotension, characterized by delayed blood pressure recovery (DBPR) after standing, is a risk factor for falls but the longitudinal relationship with fracture is not yet known. The aim of this study was to examine the prospective risk of fracture associated with DBPR.

Methods

This study, embedded within the Irish Longitudinal Study on Ageing (TILDA), examined prospective risk of fracture (hip, wrist or vertebral) associated with DBPR at 8-year follow-up in a population-representative sample of more than 3,000 (54% female) community-dwelling older people. Orthostatic blood pressure (BP) was measured using a finometer during active stand at TILDA Wave 1. DBPR was defined as systolic BP ≤ 20 mmHg lower and/or diastolic BP ≤ 10 mmHg from baseline value at 30, 60 and 90 seconds after standing. Participants with a fracture reported at any of Waves 2–5 were defined as having ‘Incident Fracture’. Logistic regression models were used to estimate odds ratios (ORs) for the association between DBPR and incident fracture.

Results

Seven percent (212/3117) of participants sustained a fracture during follow-up. DBPR at 30 seconds was a significant predictor of any fracture [OR 1.80, 95% confidence interval (CI) 1.28–2.53] and hip fracture (OR 4.44, 95% CI 2.03–9.71) in fully adjusted models. DBPR at 30 seconds did not predict wrist or vertebral fracture. DBPR at 60 seconds also predicted any fracture (OR 1.74, 95% CI 1.19–2.54) and hip fracture (OR 4.66, 95% CI 2.12–10.26) whereas DBPR at 90 seconds predicted any (OR 1.99, 95% CI 1.38–2.87), wrist (OR 1.87, 95% CI 1.19–2.95), and hip fracture (OR 3.39, 95% CI 1.45–7.93) in fully adjusted models.

Conclusion

Delayed BP recovery independently predicts fracture in community-dwelling older people, is potentially modifiable, and can be measured in an ambulatory setting. Given the morbidity and mortality associated with fractures, identification of such risk factors is crucial in order to inform preventative strategies.

"Watch Me Grow- Electronic (WMG-E)" surveillance approach to identify and address child development, parental mental health, and psychosocial needs: study protocol

Background

The COVID-19 pandemic and the associated economic recession has increased parental psychosocial stress and mental health challenges. This has adversely impacted child development and wellbeing, particularly for children from priority populations (culturally and linguistically diverse (CALD) and rural/regional communities) who are at an already increased risk of health inequality. The increased mental health and psychosocial needs were compounded by the closure of in-person preventive and health promotion programs resulting in health organisations embracing technology and online services. Watch Me Grow- Electronic (WMG-E) – developmental surveillance platform- exemplifies one such service.

WMG-E was developed to monitor child development and guide parents towards more detailed assessments when risk is identified. This Randomised Controlled Trial (RCT) aims to expand WMG-E as a digital navigation tool by also incorporating parents’ mental health and psychosocial needs. Children and families needing additional assessments and supports will be electronically directed to relevant resources in the ‘care-as-usual’ group. In contrast, the intervention group will receive continuity of care, with additional in-person assessment and ‘warm hand over’ by a ‘service navigator’ to ensure their needs are met.

Methods

Using an RCT we will determine: (1) parental engagement with developmental surveillance; (2) access to services for those with mental health and social care needs; and (3) uptake of service recommendations. Three hundred parents/carers of children aged 6 months to 3 years (recruited from a culturally diverse, or rural/regional site) will be randomly allocated to the ‘care-as-usual’ or ‘intervention’ group. A mixed methods implementation evaluation will be completed, with semi-structured interviews to ascertain the acceptability, feasibility and impact of the WMG-E platform and service navigator.

Conclusions

Using WMG-E is expected to: normalise and de-stigmatise mental health and psychosocial screening; increase parental engagement and service use; and result in the early identification and management of child developmental needs, parental mental health, and family psychosocial needs. If effective, digital solutions such as WMG-E to engage and empower parents alongside a service navigator for vulnerable families needing additional support, will have significant practice and policy implications in the pandemic/post pandemic period.

Trial registration

The trial (Protocol No. 1.0, Version 3.1) was registered with ANZCTR (registration number: ACTRN12621000766819) on July 21st, 2021 and reporting of the trial results will be according to recommendations in the CONSORT Statement.

Gambling Interventions in Indigenous Communities, from Theory to Practice: A Rapid Qualitative Review of the Literature

Indigenous populations globally experience problem gambling at higher rates than mainstream communities, often leading to adverse outcomes in social, cultural, and health domains (The term 'indigenous' within this paper refers to all first nations people from the specified countries. When capitalised, this refers to Australian Indigenous people specifically.). Problem gambling in indigenous communities has been linked to relative poverty and social disadvantage. The sweeping impacts of problem gambling for indigenous communities are holistic in nature and are felt throughout many aspects of the community, including the local economy, education, employment, and cultural kinship obligations. The social links inherent in many gambling activities in addition to the motivations of players and complex socio-cultural milieu can make it very difficult to renounce the practice. This paper aims to evaluate the indigenous gambling literature to discern appropriate and effective principles to guide intervention development in the context of problem gambling pertaining to the Australian Indigenous population. A rapid review will be undertaken to gather, analyse, and interpret appropriate theoretical and empirical literature relating to gambling interventions for indigenous populations. Papers from Canada, Australia, New Zealand, and U.S.A (CANZUS) will be considered in the review and thematic analysis will be undertaken to ascertain a broad understanding of effective and appropriate problem gambling intervention principles applicable to these population groups. Despite the relative dearth of empirical evidence within this field, approaches to problem gambling intervention within indigenous populations must be culturally-centred and underpinned by a public health framework that considers the broad socio-politico-cultural context of the whole community. The importance of community-control, collaboration, community capacity building, workforce competence, a holistic approach, and gambling regulation cannot be overstated. The available literature focusses on an alternative approach to addressing problem gambling in indigenous communities, with much of the findings highlighting key indigenist principles within a context-based method of engagement and intervention, including addressing the social, political, and cultural determinants of problem gambling at a community-level.

Identification of tetragocarbone C and sideroxylin as the most potent anti-inflammatory components of Syncarpia glomulifera

In contrast to ancient Western and Asian cultures, medicinal plants of the Aboriginal and Torres Strait Islanders in Australia have not been as intensively studied for their molecular composition and molecular bioactivity. Syncarpia glomulifera subsp. glomulifera is a species in the plant family Myrtaceae. The resin of the plant has been traditionally used by the D'harawal people of Western Sydney to heal inflamed sores and ulcers. Hence, the anti-inflammatory activity of its leaf extract was investigated in RAW 264.7 macrophage and N11 microglia cell lines to isolate and identify the most active compounds. One new compound, tetragocarbone C, and three known compounds, tetragocarbone B, sideroxylin, and lumaflavanone A showed potent anti-inflammatory activity by downregulating nitric oxide and TNF-α production in LPS and IFN-γ stimulated cells. Except for the less potent tetragocarbone B, all compounds had an IC₅₀ value (for nitric oxide downregulation) of <10 μg/mL and moderate cytotoxicity in both cell lines. The molecular targets along pro-inflammatory signaling pathways were further investigated in RAW 264.7 cells. All four compounds suppressed phosphorylation of ERK, c-Jun, and limited the phosphorylation of STAT-1 and STAT-3 in response to LPS and IFN-γ activation. The four compounds also suppressed NF-κB activation by preventing the translocation of the p65 subunit into the nucleus. Collectively, these findings suggest that the compounds isolated from Syncarpia glomulifera, especially tetragocarbone C and sideroxylin are promising anti-inflammatory agents, and could be further investigated for the treatment of diseases characterized by chronic inflammation.

Eating disorders amongst Aboriginal and Torres Strait Islander Australians: a scoping review

BACKGROUND

Aboriginal and Torres Strait Islander Australians (Indigenous Australians) have poorer mental health compared to other Australians. Yet, there is a lack of research into mental disorders among this population, especially for eating disorders (ED), which are amongst the most lethal and debilitating mental disorders.

AIM

We aimed to answer 2 questions: 1. What is the volume and content of literature on ED among Indigenous Australians? 2. Has a screening or diagnostic tool/instrument been developed for the assessment of ED amongst Indigenous Australians?

METHOD

We conducted a scoping review of electronic databases (Pubmeb, Embase, PsychInfo, Proquest, Cochrane Library, Indigenous HealtInfoNet and Scopus), for studies addressing ED, body image, muscle dysmorphia, weight and shape concern among Indigenous Australians, as well as diagnostic and screening tools. All relevant studies were reviewed in full by 2 researchers. Narrative synthesis of the data was performed.

RESULTS

There is limited evidence for ED among Indigenous Australians, however, the evidence available strongly suggests that ED are more common among Indigenous Australians compared to other Australians. Eating disorders among Indigenous Australians are also associated with high levels of overvaluation of weight and shape. The increased risk of ED among Indigenous Australians was largely explained by factors such as poorer psychosocial wellbeing. No evidence was found for the existence of validated diagnostic or screening tools for ED in Indigenous Australians.

CONCLUSION

The evidence suggests ED are common among Indigenous Australians, and there are no diagnostic or screening tools available to assist clinicians in assessing them. More research is required in this field, especially towards the development of a validated and culturally specific screening or diagnostic tool for ED among Indigenous Australians.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

The Yerin Dilly Bag Model of Indigenist Health Research

In this article, we discuss indigenist approaches to health research, including indigenist knowledges, cultural proficiency, and core values. We also highlight the importance of conducting Indigenous research in ways that are congruent with the needs and interests of Indigenous peoples. The discussion includes consideration of how indigenist approaches can be utilized to generate new Indigenous knowledges, in culturally appropriate ways. We then introduce the Yerin Dilly Bag Model for indigenist health research, an approach that allows for indigenist knowledges to be employed and created by the research/er/ed within an Indigenous framework. Use of the Yerin Dilly Bag Model enables research/er/ed concordance, together with the privileging of Indigenous voices. This is achieved by guiding researchers to align their research with the core values of the researched, with the Yerin Dilly Bag a metaphor for the holder of these core values.

Study of intra-racial exclusion within Australian Indigenous communities using eco-maps

In Australia, 'indigeneity' is not determined by skin colour, but rather by a person's heritage, acceptance by an indigenous community, and active participation in the affairs of that indigenous community. Some people who identify as indigenous, however, have experienced 'colourism' - that is, experiences of social exclusion because of the colour of their skin - from non-Indigenous and also Indigenous Australians. This paper describes research that explored the effect of intra-racial exclusion on the mental health and wellbeing of Indigenous Australians, with a particular focus on skin colour or 'manifest indigeneity'. Framed within a qualitative design, an eco-map was used to guide in-depth interviews with 32 participants that gave rise to personal stories that described the distress of experiencing intra-racial colourism. Findings were derived from a thematic analysis that identified four major themes: 'Growing up black', 'Living on black country', 'Looking black', and 'Fitting in black'. These findings are important because they suggest a way forward for mental health nurses to better understand and support the mental health and wellbeing of Indigenous Australians who have experienced social exclusion as a result of colourism.

Happy to help/happy to be here: Identifying components of successful clinical placements for undergraduate nursing students

INTRODUCTION

The clinical placement learning environment is a critical component of nursing education where Australian nursing students spend a minimum of 800h. Identifying components of successful clinical placements for undergraduate nursing students is therefore paramount.

PURPOSE

To assess nursing students' views of the learning environment during clinical placement with an emphasis on the pedagogical atmosphere, leadership style of the ward manager, and premises of nursing on the unit or ward.

MATERIAL AND METHODS

The study used Clinical Learning Environment, Supervision and nurse teacher (CLES+T) questionnaire to examine 150 final year undergraduate students' perceptions of the clinical placement learning environment. The questionnaire was anonymous and completed by the students at the end of their clinical placement. The statistical program SPSS v22 was used. Principal components analysis (PCA) for data reduction was run on the 42-question section of the first dimension ('pedagogical atmosphere on the ward') of the questionnaire that measured the perceptions of the learning environment of the clinical placement of the 150 final-year undergraduate nursing students. The comments sections of the factors were subjected to interpretive content analysis to create the themes for the two components.

RESULTS

Principle Component Analysis revealed two components that had eigenvalues greater than one: 'Happy to Help' Component 1 and 'Happy to be Here' Component 2. These components were statistically significant (p<0.0005), using Bartlett's Test of Sphericity indicating that the data was likely factorizable. These components scored higher than any other related factors.

CONCLUSIONS

Student nurses value a welcoming workplace where staff and educators are happy to help and have a positive attitude to student presence on the wards. More than any other factors these ward-based factors appear to have the strongest influence on student satisfaction.

Leadership as a Personal Journey: An Indigenous Perspective

Indigenous Australians have higher levels of mental illness, self-harm, suicide and substance abuse than non-Indigenous Australians, as well as more frequent contact with the criminal justice system. These indices point to the need for strong leadership to support Close the Gap programmes that have now been implemented across Australia. This article considers leadership as a journey of learning for Australian Indigenous leaders. Through the use of story, it is suggested that a situational leadership approach, incorporating the principles of mindfulness, provides the most appropriate framework for Indigenous leaders who work with Indigenous communities. Flexible approaches are needed to meet the needs of diverse Indigenous populations, and address the complex challenges involved, including lateral violence. Such flexibility will enable Indigenous leaders and communities to work together to achieve improvements in the health outcomes, not only for Indigenous Australians, but also for Indigenous populations worldwide.

Adapting evidence-based interventions to accommodate cultural differences: where does this leave effectiveness?

Evidence-based interventions are an essential part of delivering contemporary mental health services. Many such interventions, however, are developed with and for mainstream population groups. Practitioners and researchers alike will often adapt tools, practices, processes or programmes to meet the needs of culturally diverse populations groups, but wonder if and how such adaptations will affect outcomes. This paper considers the processes by which evidence-based interventions can be adapted by health professionals in any context; and includes an example of a successful cultural adaptation to an evidence-based intervention. The successful implementation of the Aboriginal Mental Health First Aid programme in Australia illustrates the potential for adapted interventions to support improvements in the health outcomes of people from culturally diverse backgrounds. The paper concludes by outlining the steps mental health professionals can take when adapting evidence-based interventions for use in their own workplace settings.

Reviewing Tribunal cases and nurse behaviour: putting empathy back into nurse education with Bloom's taxonomy

Recent events in the UK and Australia have shown how poor patient outcomes are achieved when the behaviour of nurses lacks empathy. The UK's Francis Inquiry and the Keogh Report both call for an increase in the 'caring and compassion' of health care workers. A review of cases presented to the nurses' disciplinary tribunal in New South Wales' (Australia) also suggests that the majority of complaints against nurses in this jurisdiction is the result of callousness or lack of empathy. Such events reinforce the need for nurse educators to support nursing students to develop the affective attributes of caring and empathy. This paper considers how to raise the awareness of undergraduate students as a first step to developing empathy by using Bloom's Taxonomy of Educational Objectives; and includes a description of how to facilitate interactions with undergraduate nursing students about caring with empathy. Enculturating empathy is an evidence-based method of increasing compassionate care in health organisations generally.

The management of bipolar disorder in the perinatal period and risk factors for postpartum relapse

Aims

The perinatal period is a time of high risk of relapse for women with a history of bipolar affective disorder (BPAD). We describe the pregnancy management of women with BPAD and identify risk factors for postpartum relapse.

Methods

The case records of 78 women with BPAD referred to perinatal mental health services before conception, during pregnancy or the postpartum period, between 1998 and 2009 in Birmingham UK, were screened. In women who were managed during pregnancy, those who relapsed in the postpartum were compared with those who remained well.

Results

Forty-seven percent of women with BPAD referred in pregnancy suffered postpartum relapse. Women who were unwell at referral, younger, with unplanned pregnancy, previous perinatal episodes or a family history of BPAD were more likely to suffer postpartum illness.

Conclusion

Identifying risk factors for postpartum relapse enables us to individualise the estimation of a woman's risk and modify care plans accordingly. Duration of wellness prior to pregnancy is not associated with a lower risk of postpartum illness and so it is imperative that all women with BPAD receive referral in pregnancy.

The New Beginnings Program for Divorcing and Separating Families: Moving from Efficacy to Effectiveness

This article describes a program of research on effectively transporting the New Beginnings Program (NBP), a university-tested prevention program for divorced families, to community settings. The status of four steps in this research are described: (1) Selecting a community partner; (2) Developing effective methods of engaging parents; (3) Redesigning the NBP to be easily delivered with high quality and fidelity in community agencies, and (4) Adapting the NBP to meet the needs of the full population of divorcing families. The article concludes with a discussion of plans for an effectiveness trial to evaluate the NBP when delivered in community settings.

Synthesis of halogenated trimetoquinol derivatives and evaluation of their .beta.-agonist and thromboxane A2 (TXA2) antagonist activities

The 5,8-difluoro (4), 5-iodo (5), 8-iodo (6), and 5-trifluoromethyl (7) derivatives of trimetoquinol (TMQ, 1) have been synthesized and evaluated for their ability to stimulate beta 1 (guinea pig atria) and beta 2 (guinea pig trachea) adrenoceptors as well as for their inhibitory activity against U46619 [a thromboxane A2 (TXA2) mimetic]-mediated contraction of rat thoracic aorta and human platelet aggregation. Both 5 and 6 were considerably less active than TMQ on both beta-adrenergic systems and gave a rank order of stimulatory potency of 1 much greater than 6 greater than or equal to 5. Similarly, iodine substitution at either position also caused a reduction in TXA2 antagonist activity with a rank order potency of 1 greater than 6 much greater than 5. Compared to 1, however, 5-iodo-TMQ (5) showed a marked selectivity for blockade of U46619 responses in rat aorta over human platelets. On beta-systems, 4 had reduced potency compared to TMQ and was similarly nonselective. Introduction of a trifluoromethyl group at the 5-position of TMQ completely abolished both beta 1- and beta 2-adrenergic agonist activities while imparting weak antagonist activity on beta 1 receptors. On TXA2 systems, both 4 and 7 possessed significantly decreased inhibitory activity compared to TMQ. The synthetic approaches to the synthesis of 8-(trifluoromethyl)-TMQ (8) are also described. The enantiomers of the 8-fluoro derivative (3) of TMQ were separated on a preparative Chiralcel OD column and evaluated on beta-adrenergic systems and TXA2 systems. On beta-adrenergic systems, (S)-(+)-8-fluoro-TMQ was at least 10-fold more potent than (R)-(-)-8-fluoro-TMQ. Conversely, (R)-(-)-8-fluoro-TMQ was approximately 14-fold more potent as an antagonist of TXA2-mediated aggregation in human platelets than (S)-(+)-8-fluoro-TMQ. In contrast to platelets, (S)-(+)-8-fluoro-TMQ was an agonist in rat aorta whereas (R)-(-)-8-fluoro-TMQ was an antagonist.