Utilising the Implementation of Integrated Care to Develop a Pragmatic Framework for the Sustained Uptake of Service Innovations (SUSI)

The provision of integrated care (IC) across alcohol and other drug (AOD) and mental health (MH) services represents the best practice, yet the consistent delivery of IC in routine practice rarely occurs. Our hypothesis is that there is no practical or feasible systems-change approach to guide staff, researchers, or consumers through the complex transition that is required for the sustained uptake of IC across diverse clinical settings. To address this gap, we combined clinical and consumer expertise with the best available research evidence to develop a framework to drive the uptake of IC. The goal was to develop a process that is both standardised by the best available evidence and can be tailored to the specific characteristics of different health services. The result is the framework for Sustained Uptake of Service Innovation (SUSI), which comprises six core components that are applied in a specified sequence and a range of flexible activities that staff can use to deliver the core components according to their circumstances and preferences. The SUSI is evidence-based and practical, and further testing is currently underway to ensure it is feasible to implement in different AOD and MH services.

Influence of sediment quality and microbial community on the functioning capacity of a constructed wetland treating alkaline leachate after 5.5 years in operation

Constructed wetlands (CWs) have been demonstrated as a cost-effective alternative to chemical treatment systems for mine waters, with the microbial communities attributed to promoting carbonation and aiding pH neutralization. However, few data are available for the long-term use of CWs treating alkaline leachates nor the activity of microbes within them. To investigate the feasibility of CW to buffer alkaline pH, a pilot-scale wetland was implemented in 2015 to treat alkaline bauxite residue leachate. After 5.5 years, samples of supernatant water and sediment were taken at 0.5 m increments along the 11 m long wetland. Waters were analysed for pH, EC and metal(loid) content, while sediment was subjected to physico-chemical assessment and element fractionation. Microbial biomass and community were assessed by phospholipid fatty acid analysis (PLFA) and functionality by the Rapid Automated Bacterial Impedance Technique (RABIT). Evidence presented demonstrates that the CW operating for 66 months effectively treats bauxite residue leachate, with reduced influent pH from 11.5 to 7.8. Trace element analysis revealed effective reduction in Al (94.9 %), As (86.7 %) and V (57.6 %) with substrate analysis revealing a frontloading of elevated pH and trace element content in the first 5 m of the wetland. Sediment Al, As and V were present mostly (>94 % of total) in recalcitrant forms. Sediment Na was mostly soluble (48-62 %), but soils were not sodic (ESP < 15 %). Investigations into the microbial community revealed greatest biomass was in the first 5 m of the wetland, where pH, EC and metal contents were greatest. Microbial respiration using endemic Phragmites australis as a substrate demonstrates an ability to cycle recalcitrant carbon sources within a CW system. These novel microbial findings highlight the need for further investigation into the microbial communities in alkaline CWs.

The Australasian Professional Society on Alcohol and other Drugs' submission to the consultation draft National Tobacco Strategy 2022-2030

Tobacco use continues to be a leading cause of death and morbidity globally. At the core of Australia's response to tobacco-related harms is the National Tobacco Strategy which highlights a national collaborative framework to reduce prevalence, and associated health, social and economic impacts of tobacco use. A draft National Tobacco Strategy (2022-2030) has recently been released for consultation and as members of the Australasian Professional Society on Alcohol and other Drugs' Special Interest Group for Smoking Cessation Professionals we provide a commentary on key successes of the previous National Tobacco Strategy, and suggestions for improvement areas to strengthen Australia's policy response to tobacco and e-cigarette-related issues.

Geochemical analyses of metal(loid) fractions do not predict plant uptake behavior: Are plant bioassays better tools to predict mine rehabilitation success?

Management of metal(loid) tailings at historic sites presents environmental hazards usually requiring rehabilitation to mitigate pollution risks. Strategies employed include capping or establishing vegetation directly, which requires tailings assessments to determine suitable rehabilitation approaches. Assessments are typically geochemical analyses, but plant based approaches may provide a more accurate measure of revegetation success although they are often limited to germination indices. This study uses the plant bioassay (Rhizotest™) with common geochemical assessment to predict plant uptake of metal(loid)s and the subsequent likely rehabilitation success. Pb/Zn tailings from five legacy sites within the UK and Ireland were characterized for pH, EC, water soluble and CaCl₂-extractable content and aqua regia extractable content. Uptake of Sb, As, Cd, Cu, Ca, Mg, Mn, Zn, Pb was determined in shoots and roots of Lolium perenne. Total Zn, Pb, Sb, Cd and As in tailings ranged from 694 to 2683 mg kg^-1, 1252 to 8072 mg kg^-1, 14 to 148 mg kg^-1, 1.3 to 44 mg kg^-1 and 1.3 to 45 mg kg^-1, respectively. The only correlation found between total and water soluble or CaCl₂-extractable metal(loid) contents was for Cd, where r = 0.8 for total and CaCl₂-extractable fractions. Limited uptake and translocation risk was identified for major contaminants Zn and Pb in most tailings samples but in some cases exceedance of phytotoxic threshold values occurred that was not reflected in geochemical analysis. Crucially, although total Cd and Sb content was relatively low (< 20 mg kg^-1) in some tailings, elevated plant content for some samples highlights phytotoxic risk from minor elements. Results indicate that screening based on geochemical content is not sufficiently predictive of metal(loid) phytoavailability to reliably inform mine rehabilitation strategies. We therefore strongly recommend that geochemical analyses are supplemented with plant based bioassay to plan mine tailings revegetation and reduce risk of wider ecosystem metal(loid) transfer.

Household composition and smoking behaviour in a prospective longitudinal Australian cohort

Introduction

This study estimates the extent to which individuals’ smoking cessation and relapse patterns are associated with the smoking behaviour of their household members.

Methods

Longitudinal data on household members’ smoking behaviour was sourced from a representative sample of 12,723 Australians who ever reported smoking between 2001 and 2019. Controlling for a rich set of confounders, multivariate regression analyses were used to predict the likelihood of smoking cessation and relapse given other household members’ smoking status and their relationship type. The models were then used to forecast smoking prevalence over ten years across different household types.

Results

Individuals living with a smoking spouse were less likely to quit [OR0.77 (95%CI 0.72;0.83)] and more likely to relapse [OR1.47 (95%CI 1.28;1.69)] compared to those living with non-smoking spouses. Subsequently, the proportion of smokers living with other smoking household members increased by 15% between 2011 and 2019. A ten-year forecast using the smoking cessation and relapse models predicts that, on average, smokers living with non-smokers will reduce by 43%, while those living alone or with a smoking partner will only reduce by 26% and 28% respectively.

Conclusions

Over time, those who are still smoking are more likely to live with other smokers. Therefore, the current cohort of smokers are increasingly less likely to quit and more likely to relapse. Smoking projection models that fail to account for this dynamic risk may overstate the downstream health benefits and health cost savings. Interventions which encourage smoking cessation at the household level, particularly for spouses, may assist individuals to quit and abstain from smoking.

Implications

The current and future paradigm shift in the smoking environment suggests that smoking cessation and relapse prevention policies should consider household structure. Policies designed to affect smoking at the household level are likely to be particularly effective. When estimating the long-term benefits of current smoking policies intrahousehold smoking behaviour needs to be considered.

Long term field trials demonstrate sustainable nutrient supply and uptake in rehabilitated bauxite residue

Establishing a sustainable vegetation cover is one of the most important steps in progressive rehabilitation and final closure of ore-processing residues and tailings facilities. Sustainable rehabilitation partly depends on establishing and maintaining a supply of plant-available nutrients, but few long term field studies demonstrating the success or failure of rehabilitation of degraded land such as mineral processing tailings have been reported. Bauxite-processing residues are a highly sodic, highly alkaline, nutrient-poor by-product generated from alumina extraction, and pose many challenges for successful rehabilitation. This study investigated long term performance of rehabilitation established on bauxite-processing residue storage areas (RSAs) by comparing the nutrient content of the vegetation cover with nutrient concentrations in the underlying residue sand. Five plant species having diverse physiology were selected from rehabilitation varying in age from 1 to 10 years old; these being: Hardenbergia comptoniana - a vigorous growing legume ground cover/creeper), Acacia cochlearis and A. rostellifera - legume shrubs tolerant of sandy, alkaline conditions, Grevillea crithmifolia - a drought-tolerant proteaceous shrub tolerant of alkaline soil, and Spyridium globulosum - a robust, fast-growing shrub, commonly found on alkaline coastal soils. Gypsum incorporation reduced the pH and soluble aluminium levels in residue sand, but also acted as a long-term source of nutrients for the vegetation cover. Legume species contained more nitrogen than non-legumes (2.5% N and 1.5% N, respectively), and decomposition of surface litter increased organic carbon and total and mineral nitrogen contents of the residue sand over time. Nutrient cycling maintained a supply of macro- and micro- nutrients for the vegetation cover, and 10-year old rehabilitation exhibited characteristics similar to an analogue site. This study highlighted the importance of organic matter accumulation, developing a functional microbial community, and a diverse plant species mix on transforming the residue sand characteristics and encouraging nutrient cycling as key mechanisms for establishing a sustainable vegetation cover and functional ecosystem on residue sand embankments.

The impact of COVID-19 on Oral and Maxillofacial Surgery patient presentations to the emergency department: A West of Ireland experience

Following the outbreak of COVID-19 and subsequent restrictions in the Republic of Ireland, the number of Emergency Department attendances have reduced nationally. Concurrently, it would be expected that there would be a reduction in the number of patients attending the emergency department with specific oral and maxillofacial concerns. A retrospective analysis of Oral and Maxillofacial patients attending the Emergency Department in University Hospital Galway during the first three-month period of COVID-19 lockdown in 2020 was compared to patients presenting to the Emergency Department during the equivalent period in the preceding year. The analysis confirmed a 46% reduction in attendances during the COVID-19 lockdown period. There was also a significant decrease in the number of young patients attending due to maxillofacial trauma. Contributing factors to this reduction may include working from home, reducing face-to-face social activities and the closure of social settings. It must be noted that there was a two-fold increase in the number of patients attending with dental pain during the lockdown period in comparison to the preceding year. Similarly, there was a proportional increase in the number of those attending due to infection and requiring subsequent admission during the COVID-19 lockdown period. Patient anxiety related to contracting the virus may have contributed to patients presenting with infection during the COVID-19 lockdown period.

Cigarette smoking and e-cigarette use among university students in Queensland, Australia and New Zealand: results of two cross-sectional surveys

OBJECTIVES

Examine the patterns of cigarette smoking and e-cigarette use (vaping), the perceived harm of e-cigarettes compared with tobacco cigarettes, and associations between smoking and vaping with student characteristics.

DESIGN

Cross-sectional studies.

SETTING

The University of Queensland (UQ), Australia and eight New Zealand (NZ) universities.

PARTICIPANTS

Students at UQ: 4957 (70.8% aged <25 years, 63.0% women) and NZ: 1854 (82.5% aged <25 years, 60.1% women).

METHODS

Χ2 tests compared smoking by age and gender, and vaping by age, gender and smoking status. Two-sided p<0.05 was considered significant and 95% CIs reported where appropriate. Multinomial logistic regression examined associations between smoking and vaping (exclusive smoking, exclusive vaping, dual use and non-use) with age, gender and student type (domestic vs international).

RESULTS

Smoking (UQ vs NZ, 95% CI): ever 45.2% (43.8% to 46.6%) vs 50.0% (47.7% to 52.3%), current 8.9% (8.1% to 9.7%) vs 10.4% (9.1% to 11.9%) and daily 5.2% (4.6% to 5.8%) vs 5.6% (4.6% to 6.7%), and not smoking in indoor 98.3% vs 87.7% or outdoor smoke-free spaces 83.8% vs 65.3%.Vaping (UQ vs NZ, 95% CI): ever 20.9% (19.8% to 22.1%) vs 37.6% (35.4% to 39.9%), current 1.8% (1.5% to 2.2%) vs 6.5% (5.4% to 7.7%) and daily 0.7% (0.5% to 1.0%) vs 2.5% (1.9% to 3.4%), and not vaping in indoor 91.4% vs 79.6% or outdoor smoke-free spaces 84.4% vs 71.3%. Of respondents, 71.7% (70.3% to 73.2%) vs 75.3% (72.9% to 77.6%) perceived e-cigarettes as less harmful than tobacco cigarettes.Men were more likely than women to smoke and vape, and to believe that e-cigarettes are less harmful. Regression models containing all predictors for smoking and vaping were significant and the effect of gender was significant for dual use, exclusive smoking and exclusive vaping (all p<0.01). Men had higher odds for smoking, vaping or dual use.

CONCLUSIONS

Results suggest significant differences in patterns of smoking and vaping of university students in Australia and NZ, and a strong influence of gender on smoking and vaping.

Exploring the putative role of kallikrein-6, calpain-1 and cathepsin-D in the proteolytic degradation of α-synuclein in multiple system atrophy

AIMS

There is evidence that accumulation of α-synuclein (α-syn) in Parkinson's disease (PD) and dementia with Lewy bodies (DLB) results from impaired removal of α-syn rather than its overproduction. Kallikrein-6 (KLK6), calpain-1 (CAPN1) and cathepsin-D (CTSD) are among a small number of proteases that cleave α-syn and are dysregulated in PD and DLB. Our aim in this study was to determine whether protease activity is altered in another α-synucleinopathy, multiple system atrophy (MSA), and might thereby modulate the regional distribution of α-syn accumulation.

METHODS

mRNA and protein level and/or activity of KLK6, CAPN1 and CTSD were measured and assessed in relation to α-syn load in multiple brain regions (posterior frontal cortex, caudate nucleus, putamen, occipital cortex, pontine base and cerebellar white matter), in MSA (n = 20) and age-matched postmortem control tissue (n = 20).

RESULTS

CTSD activity was elevated in MSA in the pontine base and cerebellar white matter. KLK6 and CAPN1 levels were elevated in MSA in the putamen and cerebellar white matter. However, the activity or level of these proteolytic enzymes did not correlate with the regional distribution of α-syn.

CONCLUSIONS

Accumulation of α-syn in MSA is not due to reduced activity of the proteases we have studied. We suggest that their upregulation is likely to be a compensatory response to increased α-syn in MSA.

Aggressive Recurrence of Oral Squamous Cell Carcinoma in a patient with Fanconi's Anaemia (FA)

Fanconi's Anaemia is a rare autosomal recessive disease for which the incidence of head and neck cancer can be increased 700-fold1. We report a case of a 31-year old Caucasian male with FA who initially presented in July 2007 with oral squamous cell carcinoma for which he received radical surgery and radiotherapy. He was disease-free until August 2015 when he presented with an extremely aggressive recurrence.

The potential for constructed wetlands to treat alkaline bauxite-residue leachate: Phragmites australis growth

High alkalinity (pH > 12) of bauxite-residue leachates presents challenges for the long-term storage and managements of the residue. Recent evidence has highlighted the potential for constructed wetlands to effectively buffer the alkalinity, but there is limited evidence on the potential for wetland plants to establish and grow in soils inundated with residue leachate. A pot-based trial was conducted to investigate the potential for Phragmites australis to establish and grow in substrate treated with residue leachate over a pH range of 8.6-11.1. The trial ran for 3 months, after which plant growth and biomass were determined. Concentrations of soluble and exchangeable trace elements in the soil substrate and also in the aboveground and belowground biomass were determined. Residue leachate pH did not affect plant biomass or microbial biomass. With the exception of Na, there was no effect on exchangeable trace elements in the substrate; however, increases in soluble metals (As, Cd and Na) were observed with increasing leachate concentration. Furthermore, increases in Al, As and V were observed in belowground biomass and for Cd and Cr in aboveground biomass. Concentrations within the vegetation biomass were less than critical phytotoxic levels. Results demonstrate the ability for P. australis to grow in bauxite-residue leachate-inundated growth media without adverse effects.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Assessing metal transfer to vegetation and grazers on reclaimed pyritic Zn and Pb tailings

A study of the concentrations of zinc and lead in an engineered soil capping system overlying sulphide mine tailings was undertaken. Tailings geochemistry, soil cover and vegetation were monitored over a 4-year period, and a cattle grazing demonstration exercise was conducted over a 1-year period. Whilst the tailings had a relatively high pyrite content and demonstrated oxidation, a circum neutral pH was observed for the duration of the study period due to the high dolomitic content. No evidence of metal mobility into the soil cover and vegetation was observed over the monitoring period. Relatively high Zn herbage content is attributed to the glacial till component of the soil cover. Similarly, no evidence of metal transfer to grazing cattle was observed through blood and tissue analysis with Zn content not significantly different from control animals. Pb tissue content was below limit of detection.

Pantothenate kinase-associated neurodegeneration is not a synucleinopathy

Aims: Mutations in the pantothenate kinase 2 gene (PANK2) are responsible for the most common type of neurodegeneration with brain iron accumulation (NBIA), known as pantothenate kinase-associated neurodegeneration (PKAN). Historically, NBIA is considered a synucleinopathy with numerous reports of NBIA cases with Lewy bodies and Lewy neurites and some cases reporting additional abnormal tau accumulation. However, clinicopathological correlations in genetically proven PKAN cases are rare. We describe the clinical, genetic and neuropathological features of three unrelated PKAN cases. Methods: All three cases were genetically screened for the PANK2 gene mutations using standard Sanger polymerase chain reaction sequencing. A detailed neuropathological assessment of the three cases was performed using histochemical and immunohistochemical preparations. Results: All cases had classical axonal swellings and Perls' positive iron deposition in the basal ganglia. In contrast to neuroaxonal dystrophies due to mutation of the phospholipase A2, group VI (PLA2G6) gene, in which Lewy body pathology is widespread, no α-synuclein accumulation was detected in any of our PKAN cases. In one case (20-year-old male) there was significant tau pathology comprising neurofibrillary tangles and neuropil threads, with very subtle tau pathology in another case. Conclusions: These findings indicate that PKAN is not a synucleinopathy and, hence the cellular pathways implicated in this disease are unlikely to be relevant for the pathomechanism of Lewy body disorders.

Characteristics of progressive supranuclear palsy presenting with corticobasal syndrome: a cortical variant

Aims

Since the first description of the classical presentation of progressive supranuclear palsy (PSP) in 1963, now known as Richardson's syndrome (PSP-RS), several distinct clinical syndromes have been associated with PSP-tau pathology. Like other neurodegenerative disorders, the severity and distribution of phosphorylated tau pathology are closely associated with the clinical heterogeneity of PSP variants. PSP with corticobasal syndrome presentation (PSP-CBS) was reported to have more tau load in the mid-frontal and inferior-parietal cortices than in PSP-RS. However, it is uncertain if differences exist in the distribution of tau pathology in other brain regions or if the overall tau load is increased in the brains of PSP-CBS.

Methods

We sought to compare the clinical and pathological features of PSP-CBS and PSP-RS including quantitative assessment of tau load in 15 cortical, basal ganglia and cerebellar regions.

Results

In addition to the similar age of onset and disease duration, we demonstrated that the overall severity of tau pathology was the same between PSP-CBS and PSP-RS. We identified that there was a shift of tau burden towards the cortical regions away from the basal ganglia; supporting the notion that PSP-CBS is a ‘cortical’ PSP variant. PSP-CBS also had less severe neuronal loss in the dorsolateral and ventrolateral subregions of the substantia nigra and more severe microglial response in the corticospinal tract than in PSP-RS; however, neuronal loss in subthalamic nucleus was equally severe in both groups.

Conclusions

A better understanding of the factors that influence the selective pathological vulnerability in different PSP variants will provide further insights into the neurodegenerative process underlying tauopathies.

A randomized controlled trial of the effectiveness of a pre-recruitment primer letter to increase participation in a study of colorectal screening and surveillance

BACKGROUND

Recruiting cancer patients is a barrier often encountered in research trials. However, very few randomized trials explore strategies to improve participation rates. The purpose of this study was to evaluate the effectiveness of a pre-recruitment primer letter to recruit persons diagnosed with colorectal cancer for a research trial.

METHODS

Potentially eligible participants were identified by the Victorian Cancer Registry. A total of 1,062 participants were randomized to receive either a mailed explanatory primer letter designed to encourage research participation, or no primer letter. Two weeks after the intervention, the Victorian Cancer Registry sought permission from patients to release their contact details to researchers. Those who agreed were contacted and invited to the study.

RESULTS

Pre-recruitment encouragement was not effective at increasing recruitment, with no significant differences demonstrated between experimental groups. Overall, 40% (n = 425) consented to participate, 25% (n = 243) refused and 35% (n = 394) did not respond.

CONCLUSIONS

While this study demonstrated disappointing outcomes, pre-recruitment letters should not be ruled out as an approach altogether. Rather, future research should explore whether other factors to increase motivation, such as intensity and timing, are feasible and acceptable for contacting cancer patients.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12609000628246.

A randomized controlled trial of the effectiveness of a pre-recruitment primer letter to increase participation in a study of colorectal screening and surveillance

Background

Recruiting cancer patients is a barrier often encountered in research trials. However, very few randomized trials explore strategies to improve participation rates. The purpose of this study was to evaluate the effectiveness of a pre-recruitment primer letter to recruit persons diagnosed with colorectal cancer for a research trial.

Methods

Potentially eligible participants were identified by the Victorian Cancer Registry. A total of 1,062 participants were randomized to receive either a mailed explanatory primer letter designed to encourage research participation, or no primer letter. Two weeks after the intervention, the Victorian Cancer Registry sought permission from patients to release their contact details to researchers. Those who agreed were contacted and invited to the study.

Results

Pre-recruitment encouragement was not effective at increasing recruitment, with no significant differences demonstrated between experimental groups. Overall, 40% (n = 425) consented to participate, 25% (n = 243) refused and 35% (n = 394) did not respond.

Conclusions

While this study demonstrated disappointing outcomes, pre-recruitment letters should not be ruled out as an approach altogether. Rather, future research should explore whether other factors to increase motivation, such as intensity and timing, are feasible and acceptable for contacting cancer patients.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12609000628246

Posaconazole Pharmacokinetics, Safety, and Tolerability in Subjects With Varying Degrees of Chronic Renal Disease

Posaconazole is a triazole antifungal in development for the treatment of invasive fungal infections. The authors evaluated the pharmacokinetics and safety of posaconazole in healthy subjects and in those with mild (CL(CR) = 50-80 mL/min), moderate (CL(CR) = 20-49 mL/min), and severe chronic renal disease (CL(CR) <20 mL/min; receiving outpatient hemodialysis) (n = 6/group). Subjects received one 400-mg dose of posaconazole oral suspension with a standardized high-fat breakfast. For hemodialysis-dependent subjects, this dose was given on a nonhemodialysis day, and a second 400-mg dose was given 6 hours before hemodialysis. Blood samples were collected before dose and up to 120 hours postdose. For hemodialysis-dependent subjects following the second dose, additional samples (predialyzed and postdialyzed) were collected before, during, and after dialysis. There was no correlation between posaconazole pharmacokinetics and mild to moderate renal disease; the slopes of the linear regressions for creatinine clearance versus posaconazole AUC, C(max), CL/F, and t1/2 values were not significantly different from zero (P > .130). Mean CL/F values before and during hemodialysis were comparable. Furthermore, the difference in the predialyzed and postdialyzed posaconazole concentrations was only approximately 3%, supporting that posaconazole was not removed by hemodialysis. Protein binding was similar in all groups (approximately 98%) and was unaffected by hemodialysis. Posaconazole was generally well tolerated. One patient had elevated liver function test results that were not present at baseline and were thought to be possibly related to posaconazole. Results of this single-dose study indicate that dosage adjustments for patients with varying degrees of renal disease are not required.

Mine tailings composition in a historic site: implications for ecological restoration

Ecological restoration, using tolerant plant species and nutrient additions, is a low-cost option to decrease environmental risks associated with mine tailings. An attempt was previously made to establish such a vegetation cover on an abandoned tailings facility in Southern Ireland. Historically, the tailings site has been prone to dusting and is a potential source of contamination to the surrounding environment. The site was examined to determine the success of the previous restoration plan used to revegetate the site and to determine its suitability for further restoration. Three distinct floristic areas were identified (grassland, poor grassland and bare area) based on herbage compositions and elemental analysis. Surface and subsurface samples were taken to characterise tailings from within these areas of the tailings site. The pH of bare surface tailings (pH, 2.7) was significantly more acidic (p < 0.5) than in other areas. Additionally, negligible net neutralising potential resulted in the tailings being hostile to plant growth. Total metal concentrations in tailings were high (c. 10,000 mg kg(-1) for Pb and up to 20,000 mg kg(-1) for Zn). DTPA-extractable Zn and Pb were 16 and 11 % of the total amount, respectively. Metal content in grasses growing on some areas of the tailings were elevated and demonstrated the inability of the tailings to support sustainable plant growth. Due to the inherently hostile characteristics of these areas, future restoration work will employ capping with a barrier layer.

Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey

Waiting times can raise significant concern for cancer patients. This study examined cancer patients' concern levels at each phase of waiting. Demographic, disease and psychosocial characteristics associated with concern at each phase were also assessed. 146 consenting outpatients (n= 146) were recruited from two hospitals in Sydney, Australia. Each completed a touch-screen computer survey, asking them to recall concern experienced regarding waiting times at each treatment phase. Approximately half (52%) reported experiencing concern during at least one treatment phase, while 8.9% reported experiencing concern at every phase. Higher proportions of patients reported concern about waiting times from: deciding to have radiotherapy to commencement of radiotherapy (31%); the first specialist appointment to receiving a cancer diagnosis (28%); and deciding to have chemotherapy to commencement of chemotherapy (28%). Patient groups more likely to report concern were those of lower socio-economic status, born outside Australia, or of younger age. Although a small proportion of patients reported very high levels of concern regarding waiting times, the experience of some concern was prevalent. Opportunities for reducing this concern are discussed. Vulnerable groups, such as younger and socio-economically disadvantaged patients, should be the focus of efforts to reduce waiting times and patient concern levels.

Phase I safety and pharmacokinetic study of SU-014813 in combination with docetaxel in patients with advanced solid tumours

BACKGROUND

In pre-clinical models enhanced anti-tumour activity was observed when SU-014813, an oral multi-targeted tyrosine kinase inhibitor was combined with docetaxel. This synergy might be explained by improvement of the penetration of cytotoxic agents into tumours as a result of both VEGFR and PDGFR inhibition. We assessed the maximal tolerated dose (MTD), evaluated the pharmacokinetics and preliminary anti-tumour efficacy of oral SU-014813 administered continuously in combination with docetaxel to patients with advanced solid tumours.

METHODS

In this phase I study successive patient cohorts received docetaxel 60 or 75mg/m(2) every 3weeks in combination with chronic daily dosing of SU-014813. Dose limiting toxicity was assessed both in the first and second treatment cycle.

RESULTS

Twenty-five patients were entered on study of which 24 started treatment. Dose limiting toxicities were prolonged neutropenia, neutropenic fever, fatigue and diarrhoea. Other toxicities included fatigue, alopecia, nausea, vomiting, anorexia, rash, hypertension and hair discolouration. The recommended phase II dose was determined to be docetaxel 75mg/m(2) in combination with SU-014813 50mg/day. There was no clinically relevant pharmacokinetic drug-drug interaction. Two patients (8%) achieved a partial response (PR) and 7 patients (29%) had stabilisation of their disease (SD) >6months, for a clinical benefit rate of 37.5%. The activity observed in patients with melanoma and sunitinib refractory gastrointestinal stromal tumours (GIST) was particularly noteworthy.

CONCLUSIONS

Oral SU-014813 50mg/day with docetaxel 75mg/m(2) is a clinically feasible regimen with a manageable safety profile and anti-tumour activity. Further development is warranted in patients with melanoma and GIST.

A phase I dose escalation trial of a daily oral CDK 4/6 inhibitor PD-0332991

3550

Background: PD-0332991 is a novel oral inhibitor of CDK 4/6, which is active against Rb positive tumors and has never before been tested in humans. A phase I dose escalation trial of PD-0332991 administered as a daily oral single agent was conducted to investigate safety, pharmacokinetics and pharmacodynamics in patients with advanced cancer. Methods: PD-0332991 was administered daily for 21 days in 28-day cycles (Schedule 3/1) to patients in successive dose escalating cohorts at doses from 25 mg to 150 mg QD. An alternative schedule of 14 days dosing in 21-day cycles (Schedule 2/1) was tested at 100 mg to 225 mg QD. Patients with advanced Rb positive solid tumors were enrolled in the study. Results: Fifty-seven patients have been enrolled into the study. The most common tumor types were: breast, colorectal, liposarcoma, and melanoma. The median age across the study was 57 years. For Schedule 3/1, the MTD/RP2D was determined to be 125 mg QD. For Schedule 2/1, the MTD/RP2D is still to be identified but the maximum administered dose (MAD) was determined to be 225 mg QD. Six DLTs have been observed, all relating to myelosuppression. The most common AEs were neutropenia, anemia, fatigue, nausea, constipation, vomiting and diarrhea. Concentrations were moderately variable (% CV range in AUC on Day 8 of Cycle 1 was 14–64%) with dose-dependent increases in exposure observed following PD-0332991 administration (mean AUC(0–10 hr) values were 724 and 1,500 ng.hr/mL at the 125 mg and 225 mg dose levels, respectively). The effect of food on PD-0332991 pharmacokinetics is currently being evaluated. In Schedule 3/1, there have been 6 patients with stable disease (= 10 cycles) with 3 patients (one each with breast cancer, colon cancer and ovarian cancer) with stable disease for at least 20 cycles. In Schedule 2/1, one patient has had stable disease for at least 10 cycles. Updated data will be presented. Conclusions: The principal and dose limiting toxicity of PD- 0332991 is myelosuppression. The RP2D for Schedule 3/1 is 125 mg QD. The MAD has been determined for Schedule 2/1 as 225 mg QD and the dose in this schedule has been de-escalated to 200 mg QD to evaluate the MTD. Tumor specimens, when available, from patients in both schedules are also being tested for pharmacodynamic modulation of phospho-RB protein.

No significant financial relationships to disclose.

Plasminogen Activator Inhibitor-1 Promoter Polymorphism is Not Associated With the Aggressiveness of Disease in Prostate Cancer

AIMS

PAI-1 (plasminogen activator inhibitors-1) regulates plasminogen activation, and is related to tumour development. This study aims to test whether the promoter polymorphism in the PAI-1 gene is related to the aggressiveness of disease in prostate cancer.

MATERIALS AND METHODS

In the present study, Taqman SNP genotyping assay was used to detect PAI-1 4G/5G polymorphism in DNA from paraffin-embedded tissues of 98 Caucasian patients with prostate cancer.

RESULTS

The distribution of the genotypes is in Hardy-Weinberg equilibrium. The genotype had no statistically significant relationship with other prognostic factors. Similar risks for recurrence were seen in individuals with the 4G/4G and 4G/5G genotypes compared to those with 5G/5G genotype (odds ratio [OR] 2.65, 95% CI: 0.41-16.94, P = 0.30; OR = 2.19, 95% CI: 0.38-12.49, P = 0.38).

CONCLUSION

We concluded that PAI-1 promoter polymorphism is not associated with the aggressiveness of disease in prostate cancer.

Pharmacokinetics, safety, and efficacy of posaconazole in patients with persistent febrile neutropenia or refractory invasive fungal infection

The pharmacokinetic profiles, safety, and efficacies of different dosing schedules of posaconazole oral suspension in patients with possible, probable, and proven refractory invasive fungal infection (rIFI) or febrile neutropenia (FN) were evaluated in a multicenter, open-label, parallel-group study. Sixty-six patients with FN and 32 patients with rIFI were randomly assigned to one of three posaconazole regimens: 200 mg four times a day (q.i.d.) for nine doses, followed by 400 mg twice a day (b.i.d.); 400 mg q.i.d. for nine doses, followed by 600 mg b.i.d.; or 800 mg b.i.d. for five doses, followed by 800 mg once a day (q.d.). Therapy was continued for up to 6 months in patients with rIFI or until neutrophil recovery occurred in patients with FN. The 400-mg-b.i.d. dose provided the highest overall mean exposure, with 135% (P = 0.0004) and 182% (P < 0.0001) greater exposure than the 600-mg-b.i.d. and 800-mg-q.d. doses, respectively. However, exposure in allogeneic bone marrow transplant (BMT) recipients (n = 12) was 52% lower than in non-BMT patients. Treatment-related adverse events (occurring in 24% of patients) were mostly gastrointestinal in nature. Twenty-four percent of patients had adverse events leading to premature discontinuation (none were treatment related). In efficacy-evaluable patients, successful clinical response was observed in 43% with rIFI (56% of patients receiving 400 mg b.i.d., 17% receiving 600 mg b.i.d., and 50% receiving 800 mg q.d.) and 77% with FN (74% receiving 400 mg b.i.d., 78% receiving 600 mg b.i.d., and 81% receiving 800 mg q.d.). Posaconazole is well tolerated and absorbed. Divided doses of 800 mg (400 mg b.i.d.) provide the greatest posaconazole exposure.

Effect of posaconazole on cytochrome P450 enzymes: a randomized, open-label, two-way crossover study

Posaconazole is an antifungal with a wide-spectrum of activity against common and emerging fungal pathogens. In this randomised, open-label, two-way crossover study, the potential for drug interactions with posaconazole via the cytochrome P450 (CYP450) enzyme pathway was evaluated. Thirteen subjects received posaconazole tablets (2 x 100 mg) once daily for 10 days or no treatment; following a 14-day washout period, subjects were crossed over to the alternate treatment. The inhibition spectra of posaconazole were examined using a cocktail of the following probe substrates: caffeine (CYP1A2), tolbutamide (CYP2C8/9), dextromethorphan (CYP2D6 and total CYP3A4), chlorzoxazone (CYP2E1), and midazolam (hepatic CYP3A4). Except for midazolam, which was intravenously infused on Day 10, the cocktail probes were administered simultaneously on Day 9 during both treatment periods. Blood and urine samples were collected at specified times to quantitate probe substrates and/or metabolites. Based on insignificant differences in mean probe ratios, posaconazole did not inhibit CYP1A2, 2C8/9, 2D6, or 2E1. However, the midazolam AUC((tf)) was higher in the posaconazole than no-treatment group (93.4 n gh/ml versus 51.4 ng h/ml, P<0.01), indicating inhibition of hepatic CYP3A4. Drug interactions mediated by various CYP450 are common with the currently available triazole antifungals, however these results suggest that posaconazole may have an improved and more narrow drug interaction profile (CYP3A4 only) compared with other triazoles.

Monitoring cytomegalovirus retinitis prevalence in an HIV-seropositive cohort: the assessment of improvements observed following the introduction of highly active antiretroviral triple therapy

This paper concerns the ophthalmic assessment of patients with acquired immunodeficiency syndrome (AIDS) for a number of eye conditions and in particular cytomegalovirus (CMV) retinitis. CMV has been the most common opportunistic infection associated with AIDS and the leading cause of blindness among AIDS patients. There have been early indications of a widespread fall in CMV prevalence internationally following the introduction of a new highly active antiretroviral triple (HAART) therapy. Our study sought to assess the position for Ireland. Our cohort was the entire population of stage IV AIDS patients attending the country's leading referral centre. The total number of patients examined was 167 and the period of examination was 1 May 1995 to 30 April 1997. HAART was introduced in March 1996, so the data permitted a 'before and after' comparison of various clinical findings. The incidence of new CMV cases was found to be 4 among the 102 patients examined in the first 12-month period and one among 107 patients examined in the second 12-month period. There were accompanying declines in HIV-related noninfectious retinal vasculopathy (HIVR), keratitis and other conditions. The findings are promising, but we argue that caution is needed in assessing long-term trends. In the paper we discuss a number of methodological issues in the collection and analysis of the clinical data and in the interpretation of results.

Increasing cultural competence with the Latino community

There is growing recognition among health professionals that being familiar with the culture of a particular group and developing effective partnerships to involve group members in the production of their own health are essential strategies to promote health. Moreover, it is increasingly recognized that providing health care services that are culturally sensitive can result in improved health status for clients. This article describes selected Latino cultural customs that can enhance a nurse's ability to work sensitively and effectively with this ethnic group. Creative strategies to increase the cultural competence of nurses involved in primary care settings are also presented.

Investigation of nurse practitioner-patient interactions: using the Nurse Practitioner Rating Form

Primary care has become a major focus of health care reform. To create the most effective delivery of primary care services by nurse practitioners (NPs), researchers, clinicians, and administrators must continue to develop knowledge about the structure, process, and outcomes of NP primary care patient encounters. Few measures of NP-patient care encounters exist. This exploratory study examines a method of investigating NP practice and a description of the process of NP primary care. The Nurse Practitioner Rating Form (NPRF) was used to analyze 20 videotaped NP visits with Latino clients in a primary care setting. Major findings are that NPs spent visit time engaged in assessment (61%), management (29%), and charting, consultation, and other (10%). The content or focus of the majority of NP time during visits (90%) was directed to existing physical problems. NPs received high scores for communication style and degree of client participation. Problems with using the NPRF are noted and key recommendations are made to enhance NP care and improve investigation of primary care practice.

Localization of proliferating cell nuclear antigen in the developing and mature rat heart cell

BACKGROUND

The cardiac muscle cell ceases to divide shortly after birth; this cessation is followed by a limited period when DNA synthesis and karyokinesis occur without cytokinesis. The regulation of this process is not known. The purpose of this study is to explore the possible events that could lead to the cessation of cardiac muscle cell division. One protein requisite for DNA synthesis is proliferating cell nuclear antigen (PCNA). This protein is the auxiliary protein of DNA polymerase delta.

METHODS

Rats of fetal age day 18 or days 0, 4, 8, 12, and 16 after birth were obtained. In addition, adult hearts were used for this study. Hearts from the fetal day-18 rats and the day-0 neonatal rats were digested. Cardiac myocytes were isolated and placed in culture for an analysis of DNA synthesis by using tridiated thymidine. Ventricular muscle tissue was isolated from hearts of all ages and frozen in liquid nitrogen for Northern and Western blot analyses.

RESULTS

Tridiated thymidine analysis revealed that, although serum stimulation significantly increased the number of labeled fetal cardiac muscle cells, it did not have that effect on neonatal cardiac muscle cells in culture. Northern blot analysis revealed that the steady state levels of mRNA for PCNA remained constant from fetal day 18 through day 4 after birth. Steady state levels declined during the second postnatal week and then reached basal levels by day 16. PCNA message was still present in adult heart tissue. By using indirect immunofluorescence and Western blotting, PCNA protein could be located in the nucleus of cardiac muscle cells during the first 2 weeks after birth. At 16 days after birth, the protein was found in the cytoplasm in very low amounts but was not found in the nucleus. The protein was barely detectable by Western blotting in the cytoplasmic fraction from the adult myocardium.

CONCLUSIONS

The results of this study suggest that the PCNA message and protein product declined after birth, but both were present at low levels in the adult myocardium. However, the PCNA protein was not translocated to the nucleus in adult myocardial cells. The events involving PCNA correlated closely with the time period when cell division and then DNA synthesis ceased in these cells.

The partnership model: working with individuals, families, and communities toward a new vision of health

Increasingly, health professionals must learn to work in new partnership relationships with clients and community to promote health effectively. A partnership requires a transformation of the professional role from chief actor to partner, and the client role from passive recipient to partner. A partnership approach has particular merit in a reformed health care system that increasingly emphasizes active involvement and self-care actions of individuals and families to maintain health and prevent disease. A partnership approach is also important to professionals working with underserved, vulnerable, and/or minority populations. For too long professionals and policymakers have relegated these groups to passive roles in health decision making and action. This article will provide a description of the partnership process as it has been developed and implemented by nurse practitioners in an urban Hispanic community with emphasis on a community partnership. A partnership model is described and compared to the more traditional professional model. A definition and essential criteria for partnership are presented. Finally, a specific example of how the partnership process was implemented at the community level is discussed.

Community partnership primary care: a new paradigm for primary care

Primary care has become the focal point of health care reform. For too long primary care has been narrowly conceptualized as office-based care for common problems of individuals. In this article, a nurse practitioner describes a new model for primary care, community partnership primary care (CPPC), which moves beyond typical primary care practice to create what may be a new paradigm for primary care. This proposed new paradigm moves beyond older models of primary care into new dimensions of practice. The CPPC model emphasizes new roles for clinicians and a unique goal to foster the empowerment of individuals, families, and community. Innovative features of the CPPC model include blending a clinical role with a new area of practice called community practice. CPPC emphasizes new, innovative roles for nurse practitioners and nurses in community development and community empowerment activities. A 4-year funded project permitted the development and implementation of the CPPC model in an urban Hispanic community. This article provides an overview of the CPPC model and the initial steps of model implementation.

Using an encounter form to develop a clinical database for documenting nurse practitioner primary care

A clinical database will enable nurse practitioners to document and improve characteristics of their practices. This information is vital if nurse practitioners expect to achieve success in the changing U.S. health care system. This article describes the process of creating an encounter form and a related clinical database. Changes made in a family practice clinic that were derived from using a clinical database are presented. Additional uses for a clinical database, such as quality assurance, clinical evaluation, and clinical research, are discussed.

An immunohistochemical study of p53 and proliferating cell nuclear antigen expression in progressive multifocal leukoencephalopathy

Nuclear p53 immunoreactivity is demonstrated in infected oligodendroglia, as well as in a proportion of reactive and bizarre astrocytes, in seven progressive multifocal leukoencephalopathy (PML) biopsies. This likely represents binding to, and prolongation of the half-life of, wild-type p53 protein by JC virus T-antigen. Other possible mechanisms are considered. The same cells show proliferating cell nuclear antigen (PCNA) positivity, as do a proportion of morphologically normal oligodendroglia and astrocytes, reflecting proliferating populations of these glial sub-types. It is possible that functional inactivation of p53 in nonlytically infected astrocytes may allow neoplastic astrocyte clones to emerge. However, p53 and PCNA immunoreactivity per se cannot be regarded as indicative of neoplasia in PML, and caution must be exercised in the interpretation of such nuclear staining profiles.