"What if I'm not trans enough? What if I'm not man enough?": Transgender young adults' experiences of gender-affirming healthcare readiness assessments in Aotearoa New Zealand

Background

A growing body of transgender health research reports that transgender people often feel pressure to conform to a dominant narrative during gender-affirming readiness assessments. In New Zealand, however, no study to date has specifically examined transgender people's experiences of readiness assessments for gender-affirming healthcare.

Aims

This study aimed to explore the experiences of transgender young adults (aged 16-30) during gender-affirming readiness assessments in New Zealand. We also sought participants' views on improving transgender healthcare provision.

Methods

Thirteen transgender young adults took part in individual interviews or focus groups. Participants were asked to describe how they felt about the questions asked during readiness assessments and how the readiness assessment process could be improved. We used thematic analysis to identify patterns of meaning across the dataset.

Results

We identified two themes. Firstly, proving gender explores participants' views of readiness assessments as designed to establish whether they were "trans enough" or "truly" transgender, and why readiness assessments are conducted in this manner. Secondly, the trans narrative describes the pressure participants felt to adhere to a dominant transgender narrative in order to gain access to the healthcare they needed.

Discussion

Our findings call attention to the importance of a trans-affirmative approach and the need to clarify the purpose of gender-affirming healthcare readiness assessments in New Zealand.

COBRE on Opioid and Overdose: A Collaborative Research-Based Center Addressing the Crises in Rhode Island and Beyond

Overdose deaths across the country have spiked since the onset of the COVID-19 pandemic. It is crucial now, more than ever, to address the continuing and worsening, complex and dynamic opioid and overdose epidemics. In 2018, The Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, based at Rhode Island Hospital, launched with three major goals: 1) establish a center of scientific excellence on opioids and overdose; 2) train the next generation of scientists to become independent investigators and address the opioid and overdose crises; and 3) contribute to the scientific progress and solutions to combat these epidemics. To date, we have made substantial progress. While the opioid and overdose crises continue to evolve, the COBRE on Opioid and Overdose and its team of investigators are well poised to address the daunting task of understanding and meaningfully addressing these deadly epidemics, with the ultimate goal of saving lives.

An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 1: background and development

This paper (Part 1) describes the development of a new online system that estimates long-term carrying capacity (LTCC) for grazing properties across Queensland, Australia. High year-to-year and multi-year rainfall variability is a dominating feature of the climate of Queensland’s grazing lands, and poses major challenges for extensive livestock production. The use of LTCC is one approach used by graziers to reduce the impact of rainfall variability on land condition and financial performance. Over the past 30 years, scientists, graziers and their advisors have developed a simple approach to calculating LTCC ((average annual pasture growth × safe pasture utilisation) ÷ annual animal intake). This approach has been successful at a property scale (regional south-west Queensland) and in a wider application through Grazing Land Management (GLM) regional workshops. We have built on these experiences to develop an online system (as described in detail in Part 2; Zhang et al. 2021; this issue) that incorporates the simple LTCC approach with advances in technology and grazing science to provide LTCC information for Queensland grazing properties. Features of the LTCC system are: (1) assimilation of spatial datasets (cadastral data, grazing land types, climate data, remotely-sensed woody vegetation cover); (2) a pasture growth simulation model; (3) land type parameter sets of biophysical attributes; and (4) estimates of safe pasture utilisation. The ‘FORAGE LTCC report’ is a major product of the system, describing individual property information that allows detailed analysis and explanation of the components of the LTCC calculation by land type and land condition. The online system rapidly analyses property spatial data and calculates paddock/property LTCC information. For the 10 months between November 2020 and August 2021, over 4000 grazing property reports have been requested in Queensland, and has proven to be a sound basis for ‘discussion support’ with grazier managers and their advisors.

An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 2: modelling and outputs

A combination of field data and models have been used to estimate long-term carrying capacity (LTCC) of domestic livestock in Queensland grazing lands. These methods have been synthesised and coupled with recent developments in science and information technology to provide a fully-automated approach of modelling LTCC through the FORAGE online system. In this study, the GRASP model was used to simulate pasture growth with parameter sets and safe pasture utilisation rates defined for 225 land types across Queensland. Distance to water points was used to assess the accessibility of pastures to livestock. Spatial analysis classified the property into unique areas based on paddock, land type and distance to water points, which estimated pasture growth, pasture utilisation and accessibility at a sub-paddock scale. Thirteen foliage projective cover (FPC) classes were used in modelling the pasture system to deal with the non-linear relationship between tree and grass interactions. As ‘proof of concept’, remotely-sensed individual-date green ground cover data were used to optimise the GRASP model parameters to improve the model performance, and a Monte Carlo analysis provided uncertainty estimates for model outcomes. The framework provides an efficient and standardised method for estimating LTCC. To test the system, LTCCs from 43 ‘benchmark’ properties were compared with simulated LTCCs, and 65% of the modelled LTCCs were within ± 25% of the benchmark LTCCs. Due to uncertainties in model inputs at the property scale and in model simulation, the modelled LTCC should be used as a starting point for further refinement of actual property LTCC.

First-line therapy, autologous stem-cell transplantation, and post-transplantation maintenance in the management of newly diagnosed mantle cell lymphoma

Background

In Ontario, no clearly defined standard of care for the management of mantle cell lymphoma (mcl) has been developed, and substantial variability from centre to centre is evident. This guidance document was prompted by the need to harmonize practice in Ontario with respect to first-line, conditioning, and post-transplantation maintenance therapy for patients newly diagnosed with transplantation-eligible mcl.

Methods

The medline and embase databases were systematically searched from January 2013 to January 2020 for evidence, and the best available evidence was used to draft recommendations relevant to first-line therapy, autologous stem-cell transplantation, and post-transplantation maintenance in the management of transplantation-eligible newly diagnosed mcl. Final approval of this guidance document was obtained from the Stem Cell Transplant Advisory Committee.

Recommendations

These recommendations apply to all cases of transplantation-eligible newly diagnosed mcl:■ Alternating cycles of r-chop (rituximab plus cyclophosphamide-doxorubicin-vincristine-prednisolone) and r-dhap [rituximab plus dexamethasone-high-dose cytarabine-cisplatin] is the recommended first-line treatment for symptomatic patients newly diagnosed with mcl before autologous stem-cell transplantation (asct).■ Rituximab plus hyperfractionated cyclophosphamide-vincristine-doxorubicin-dexamethasone (r-hypercvad), alternating with methotrexate and cytarabine, is not recommended for the treatment of patients with newly diagnosed mcl.■ beam (carmustine-etoposide-cytarabine-melphalan), beac (carmustine-etoposide-cytarabine-cyclophosphamide), and total-body irradiation-based regimens are reasonable conditioning options for patients with mcl who have responded to first-line therapy and who are undergoing asct.■ Maintenance therapy with rituximab is recommended for patients with newly diagnosed mcl who have undergone asct.

MEDiastinal Irradiation and CArdio-Toxic Effects (MEDICATE): Exploring the Relationship between Cardiac Irradiation and High Sensitivity Troponins

AIMS

Radiation-induced heart disease is a late effect of cardiac irradiation and has been shown in patients with lymphoma and thoracic cancers. There is no established measurement tool to detect acute cardiac damage. However, high sensitivity troponin I and T (HsTnI and HsTnT) and echocardiograms have shown promise in some studies. A pilot trial was conducted to characterise whether these instruments may detect subclinical radiotherapy-induced cardiac damage.

MATERIALS AND METHODS

Eligible patients received high cardiac doses defined by either at least 30 Gy to 5% of cardiac volume or a mean dose of 4 Gy. HsTnI and HsTnT were measured before radiotherapy and after 2 and 4 weeks of radiotherapy; three-dimensional echocardiograms were completed before and 1 year after radiotherapy.

RESULTS

Of 19 patients, the median 'mean left ventricular dose' was 3.1 Gy and the 'mean cardiac dose' was 8.6 Gy. Significant positive associations between HsTnI and HsTnT were observed at all time points, but there was no significant association with cardiac dose. The mean left ventricular dose and the maximum left ventricular dose were, however, associated with a decrease in ejection fraction (P = 0.054, 0.043) as well as an increase in left ventricular strain (P = 0.058).

CONCLUSION

This study suggests that HsTnI and HsTnT are intimately related, but detection of acute cardiac damage was not shown, potentially due to limitations of these markers or low radiotherapy doses using conformal techniques. Our results also suggest subacute damage at 1 year may depend on the dose to the left ventricle. Further studies are needed, as identification of early damage could facilitate the ability to closely monitor and intervene in patients at risk for radiation-induced heart disease.

Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma

We report follow-up results from the randomized, placebo-controlled, phase 3 HELIOS trial of ibrutinib+bendamustine and rituximab (BR) for previously treated chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) without deletion 17p. Overall, 578 patients were randomized 1:1 to either ibrutinib (420 mg daily) or placebo, in combination with 6 cycles of BR, followed by ibrutinib or placebo alone. Median follow-up was 34.8 months (range: 0.1-45.8). Investigator-assessed median progression-free survival (PFS) was not reached for ibrutinib+BR, versus 14.3 months for placebo+BR (hazard ratio [HR] [95% CI], 0.206 [0.159-0.265]; P < 0.0001); 36-month PFS rates were 68.0% versus 13.9%, respectively. The results are consistent with the primary analysis findings (HR = 0.203, as assessed by independent review committee, with 17-month median follow-up). Median overall survival was not reached in either arm; HR (95% CI) for ibrutinib+BR versus placebo: 0.652 (0.454-0.935; P = 0.019). Minimal residual disease (MRD)-negative response rates were 26.3% for ibrutinib+BR and 6.2% for placebo+BR (P < 0.0001). Incidence of treatment-emergent adverse events (including grades 3-4) were generally consistent with the initial HELIOS report. These long-term data support improved survival outcomes and deepening responses with ibrutinib+BR compared with BR in relapsed CLL/SLL.

Canadian evidence-based guideline for the first-line treatment of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In Canada, no unified national guideline exists for the front-line treatment of cll; provincial guidelines vary and are largely based on funding. A group of clinical experts from across Canada developed a national evidence-based treatment guideline to provide health care professionals with clear guidance on the first-line management of cll. Consensus recommendations based on available evidence are presented for the first-line treatment of cll.

Examining the medical resource utilization and costs of relapsed and refractory chronic lymphocytic leukemia in Ontario

PURPOSE

The purpose of the present study was to collect medical resource utilization data and costs in Ontario for the management of patients with relapsed or refractory chronic lymphocytic lymphoma (cll) who have undergone at least 1 treatment course and have been stratified by Rai staging.

METHODS

This retrospective longitudinal cohort study, conducted by chart review, analyzed anonymized patient records from two cancer centres in Ontario. Comprehensive records of 86 patients meeting the inclusion criteria were used to obtain resource utilization, which, multiplied by unit costs, were used to determine overall and mean costs. Descriptive statistics are presented for patient demographics, medical resource utilization, and costing data.

RESULTS

The total cost for the cohort was $2.2 million over a mean follow-up period of 4.7 years. The mean total cost per patient (regardless of follow-up) was $25,736. In terms of Rai staging, overall mean costs were highest for stage iv patients. Almost 50% of the total cost was attributable to cll treatments, among which fludarabine-based treatments had the highest utilization.

CONCLUSIONS

For this Canadian cll cohort, medical resource utilization and costs were determined to be $2.2 million, with cll treatments accounting for about half the cost. Costs generally increased with Rai stage.

Co-expression of truncated and full-length tau induces severe neurotoxicity

Abundant tau inclusions are a defining hallmark of several human neurodegenerative diseases, including Alzheimer's disease. Protein fragmentation is a widely observed event in neurodegenerative proteinopathies. The relevance of tau fragmentation for the neurodegenerative process in tauopathies has yet remained unclear. Here we found that co-expression of truncated and full-length human tau in mice provoked the formation of soluble high-molecular-weight tau, the failure of axonal transport, clumping of mitochondria, disruption of the Golgi apparatus and missorting of synaptic proteins. This was associated with extensive nerve cell dysfunction and severe paralysis by the age of 3 weeks. When the expression of truncated tau was halted, most mice recovered behaviorally and functionally. In contrast, co-expression of full-length tau isoforms did not result in paralysis. Truncated tau thus induces extensive but reversible neurotoxicity in the presence of full-length tau through the formation of nonfilamentous high-molecular-weight tau aggregates, in the absence of tau filaments. Targeting tau fragmentation may provide a novel approach for the treatment of human tauopathies.

Follow-up care for survivors of lymphoma who have received curative-intent treatment

OBJECTIVE

This evidence summary set out to assess the available evidence about the follow-up of asymptomatic survivors of lymphoma who have received curative-intent treatment.

METHODS

The medline and embase databases and the Cochrane Database of Systematic Reviews were searched for evidence published between 2000 and August 2015 relating to lymphoma survivorship follow-up. The evidence summary was developed by a Working Group at the request of the Cancer Care Ontario Survivorship and Cancer Imaging programs because of the absence of evidence-based practice documents in Ontario for the follow-up and surveillance of asymptomatic patients with lymphoma in complete remission.

RESULTS

Eleven retrospective studies met the inclusion criteria. The proportion of relapses initially detected by clinical manifestations ranged from 13% to 78%; for relapses initially detected by imaging, the proportion ranged from 8% to 46%. Median time for relapse detection ranged from 8.6 to 19 months for patients initially suspected because of imaging and from 8.6 to 33 months for those initially suspected because of clinical manifestations. Only one study reported significantly earlier relapse detection for patients initially suspected because of clinical manifestations (mean: 4.5 months vs. 6.0 months, p = 0.042). No benefit in terms of overall survival was observed for patients depending on whether their relapse was initially detected because of clinical manifestations or surveillance imaging.

SUMMARY

Findings in the present study support the importance of improving awareness on the part of survivors and clinicians about the symptoms that might be associated with recurrence. The evidence does not support routine imaging for improving outcomes in this patient population.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up

BACKGROUND

Increasing evidence shows attachment security influences symptom expression and adaptation in people diagnosed with schizophrenia and other psychoses.

AIMS

To describe the distribution of secure and insecure attachment in a cohort of individuals with first-episode psychosis, and to explore the relationship between attachment security and recovery from positive and negative symptoms in the first 12 months.

METHOD

The study was a prospective 12-month cohort study. The role of attachment, duration of untreated psychosis (DUP), baseline symptoms and insight in predicting and mediating recovery from symptoms was investigated using multiple regression analysis and path analysis.

RESULTS

Of the 79 participants, 54 completed the Adult Attachment Interview (AAI): 37 (68.5%) were classified as insecure, of which 26 (48.1%) were insecure/dismissing and 11 (20.4%) insecure preoccupied. Both DUP and insight predicted recovery from positive symptoms at 12 months. Attachment security, DUP and insight predicted recovery from negative symptoms at 12 months.

CONCLUSIONS

Attachment is an important construct contributing to understanding and development of interventions promoting recovery following first-episode psychosis.

An unexpected undetectable viral load in a vulnerable woman

We present a case of a vulnerable HIV-positive African woman who on initial visits to the clinic had an undetectable HIV viral load without giving a history of being on antiretroviral therapy (ART) who then had an abrupt and significant rise in viral load and fall in CD4 count to below the recommended treatment level of 350 cells/μL. She gave a history of having been given a 'white tablet' from the man who had trafficked her. As genuine 'elite controllers' are rare and do not usually follow this pattern, we suspect that this woman was unknowingly on ART.

Comparison of Computer-based Clinical Decision Support Systems and Content for Diabetes Mellitus

BACKGROUND

Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known.

OBJECTIVE

We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care.

METHODS

We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites.

RESULTS

The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines.

CONCLUSION

Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the provider and providing messages that are actionable recommendations.

Epidemiology of internal contamination with polonium-210 in the London incident, 2006

BACKGROUND

More than 700 UK residents were tested for possible contamination with polonium-210 ((210)Po) following the alleged poisoning of Mr Alexander Litvinenko in London in November 2006. This paper describes the epidemiology of internal contamination with the radionuclide in this group.

METHODS

11 locations in London had been identified as sufficiently environmentally contaminated with (210)Po to present a health risk to people associated with them. Public health consultant teams identified individuals at risk and offered 24-h urine testing for (210)Po excretion. Prevalence of internal contamination was estimated, and a retrospective cohort analysis was completed for each location.

RESULTS

Overall 139 individuals (prevalence 0.19 (95% CI 0.13 to 0.27)) showed evidence of internal contamination with (210)Po, although none with uptakes likely to cause adverse health effects. Substantial prevalence was seen among specific hotel service staff, customers, staff and other users of a hotel bar, office and hospital staff, staff of one restaurant and residents of and visitors to the family home. Increased risks of contamination were seen for a hotel bar in association with occupational, behavioural and temporal factors. Occupational and guest exposure to contaminated areas of hotels were also associated with increased contamination risk. Nurses were more likely to become contaminated than other staff involved in direct patient care.

CONCLUSIONS

Uptake of trace amounts of radionuclide in this incident was frequent. Occupational, behavioural and temporal gradients in contamination risk were mostly consistent with a priori site risk assessments. Utility of the investigation methods and findings for future accidental or deliberate environmental contamination incidents are discussed.

Copy number variations of chromosome 16p13.1 region associated with schizophrenia

Deletions and reciprocal duplications of the chromosome 16p13.1 region have recently been reported in several cases of autism and mental retardation (MR). As genomic copy number variants found in these two disorders may also associate with schizophrenia, we examined 4345 schizophrenia patients and 35,079 controls from 8 European populations for duplications and deletions at the 16p13.1 locus, using microarray data. We found a threefold excess of duplications and deletions in schizophrenia cases compared with controls, with duplications present in 0.30% of cases versus 0.09% of controls (P=0.007) and deletions in 0.12 % of cases and 0.04% of controls (P>0.05). The region can be divided into three intervals defined by flanking low copy repeats. Duplications spanning intervals I and II showed the most significant (P = 0.00010) association with schizophrenia. The age of onset in duplication and deletion carriers among cases ranged from 12 to 35 years, and the majority were males with a family history of psychiatric disorders. In a single Icelandic family, a duplication spanning intervals I and II was present in two cases of schizophrenia, and individual cases of alcoholism, attention deficit hyperactivity disorder and dyslexia. Candidate genes in the region include NTAN1 and NDE1. We conclude that duplications and perhaps also deletions of chromosome 16p13.1, previously reported to be associated with autism and MR, also confer risk of schizophrenia.

A threonine to isoleucine missense mutation in the pericentriolar material 1 gene is strongly associated with schizophrenia

Markers at the pericentriolar material 1 gene (PCM1) have shown genetic association with schizophrenia in both a University College London (UCL) and a USA-based case-control sample. In this paper we report a statistically significant replication of the PCM1 association in a large Scottish case-control sample from Aberdeen. Resequencing of the genomic DNA from research volunteers who had inherited haplotypes associated with schizophrenia showed a threonine to isoleucine missense mutation in exon 24 which was likely to change the structure and function of PCM1 (rs370429). This mutation was found only as a heterozygote in 98 schizophrenic research subjects and controls out of 2246 case and control research subjects. Among the 98 carriers of rs370429, 67 were affected with schizophrenia. The same alleles and haplotypes were associated with schizophrenia in both the London and Aberdeen samples. Another potential aetiological base pair change in PCM1 was rs445422, which altered a splice site signal. A further mutation, rs208747, was shown by electrophoretic mobility shift assays to create or destroy a promoter transcription factor site. Five further non-synonymous changes in exons were also found. Genotyping of the new variants discovered in the UCL case-control sample strengthened the evidence for allelic and haplotypic association (P=0.02-0.0002). Given the number and identity of the haplotypes associated with schizophrenia, further aetiological base pair changes must exist within and around the PCM1 gene. PCM1 protein has been shown to interact directly with the disrupted-in-schizophrenia 1 (DISC1) protein, Bardet-Biedl syndrome 4, and Huntingtin-associated protein 1, and is important in neuronal cell growth. In a separate study we found that clozapine but not haloperidol downregulated PCM1 expression in the mouse brain. We hypothesize that mutant PCM1 may be responsible for causing a subtype of schizophrenia through abnormal cell division and abnormal regeneration in dividing cells in the central nervous system. This is supported by our previous finding of orbitofrontal volumetric deficits in PCM1-associated schizophrenia patients as opposed to temporal pole deficits in non-PCM1-associated schizophrenia patients. Caution needs to be exercised in interpreting the actual biological effects of the mutations we have found without further cell biology. However, the DNA changes we have found deserve widespread genotyping in multiple case-control populations.

Factors associated with radiation exposure in patients with inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) patients undergo multiple radiological evaluations.

AIM

To estimate total and abdominal radiation exposure from diagnostic X-ray investigations in IBD patients and the associated risk factors.

METHODS

Patients with Crohn's disease (CD) or ulcerative colitis (UC) treated in the IBD clinic were recruited. Clinical data were extracted from patient files and radiological data were obtained from the central HMO computer data base.

RESULTS

A total of 199 CD and 125 UC patients were included. The mean cumulative estimated doses (CED) for CD and UC were 21.1 19.5 and 15.1 20.4 millisieverts (mSv) respectively (P < 0.001). Twenty-three patients (7.1%) had an estimated CED of > or =50 mSv. In multivariate analyses, predictors of increased CED were: surgery (OR 5.68, 95% CI: 2.73-11.8, P < 0.001), CD (OR 2.56, 95% CI: 1.29-5.07, P = 0.007), prednisone use (OR 2.0, 95% CI: 1.11-3.67, P = 0.02), first year of disease (OR 6.4, 95% CI: 1.3-32, P = 0.02) and age in the upper quartile(OR 3.26, 95% CI: 1.68-6.3, P = 0.001).

CONCLUSIONS

Diagnosis of CD, IBD-related surgery, prednisone use, first year of diagnosis and age on the upper quartile are independent predictors of increased exposure in IBD patients. Alternative investigations which do not require radiation exposure should be considered for patients at risk for increased radiation exposure.

An investigation of medication information transfer and application in aged care facilities in an Australian rural setting

INTRODUCTION

As patients move within Australia's increasingly complex healthcare system, it is desirable that they receive uninterrupted, timely and accurate administration of medication. For this to occur, effective communication of medication information is required, and mechanisms must be in place to ensure timely administration. This study focused on these issues as they apply to patients being admitted to aged care facilities in an Australian rural setting, including investigation of the transfer and early application of information about their current medications (or 'medication information'). Electronic prescribing and associated information transfer may improve the transfer of medication information in the future; however, this study focused on the current situation in rural Australia.

METHOD

In this observational study, patient outcomes and participating nurses' experience of medication issues related to admissions to rural residential aged care facilities from an acute hospital, a rehabilitation facility, another aged care facility or the community were investigated. Data were collected using a customised questionnaire completed by nursing staff at participating aged care facilities.

RESULTS

Data relating to 59 individual patient transfers were obtained from 14 aged care facilities. A number of pathways for the communication of medication information were identified, with timely and effective information transfer occurring for most patients. However, one in five patients experienced a delay of up to 4 hours, and a limited number of incidents of inadequate information transfer were identified. While most patient transfers occurred with 12 or more hours notice, one in ten transfers occurred with no more than one hour of notice. Transfers were not evenly distributed among week days; however, very few transfers occurred after 5 pm on Friday. A number of staff reported that they had felt it necessary to act beyond their normal employee duties to ensure timely medication delivery to their aged care residents.

CONCLUSIONS

This study identified pathways used to transfer medication information about patients being admitted to aged care facilities, and also immediate responses to that information. The study indicates that these processes, while generally satisfactory, are at times less than ideal. Health professionals in rural Australia may be in an ideal position to develop and implement effective local responses to identified problems, by activating interprofessional links. The study also highlights the issue of aged care staff acting outside their designated role in an attempt to ensure timely medication administration to their patients, a potentially inefficient use of limited staff time.

The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study

INTRODUCTION

The timing of surgery in cauda equina syndrome due to prolapsed intervertebral disc remains controversial. Assessment of these patients requires magnetic resonance imaging (MRI), which is of limited availability outside normal working hours in the UK.

PATIENTS AND METHODS

We reviewed radiological results in all patients undergoing emergency MRI within our unit for suspected cauda equina syndrome over a 2-year period, and all subjects undergoing emergency lumbar discectomy for cauda equina syndrome within the same period. Outcome measures were: proportion of positive findings in symptomatic patients and proportion of patients referred with diagnostic MRI scans undergoing emergency surgery. We also assessed outcomes of patients having surgery for cauda equina syndrome in terms of improvement of pain, sensory and sphincter disturbance.

RESULTS

A total of 76 patients were transferred for assessment and 'on-call' MRI; 27 were subsequently operated upon. Only 5 proceeded to emergency discectomy that night (prior to next scheduled list). This may be due to delays in timing--from referral to acceptance, to arrival in the department, to diagnostic scan and to theatre. With the second group of patients, 43 had emergency discectomy for cauda equina syndrome during the study period. Of these, 6 patients had an out-of-hours MRI at our hospital for assessment (one patient living locally). Most surgically treated patients experienced improvement in their pain syndrome, with approximately two-thirds experiencing improvement in sensory and sphincter disturbance.

CONCLUSIONS

These data support a policy of advising MRI scan for cauda equina syndrome at the earliest opportunity within the next 24 h in the referring hospital, rather than emergency transfer for diagnostic imaging which has a relatively low yield in terms of patients operated on as an emergency.

Alemtuzumab in chronic lymphocytic leukemia

QUESTIONS

With respect to outcomes such as survival, response rate, response duration, time to progression, and quality of life, is alemtuzumab a beneficial treatment option for patients with B-cell chronic lymphocytic leukemia (cll)?What toxicities are associated with the use of alemtuzumab?Which patients are more likely-or less likely-to benefit from treatment with alemtuzumab?

PERSPECTIVES

Evidence was selected and reviewed by one member of the Hematology Disease Site Group (dsg) of Cancer Care Ontario's Program in Evidence-Based Care (pebc) and by methodologists. The practice guideline report was reviewed and approved by the Hema-tology dsg, which comprises hematologists, medical and radiation oncologists, and a patient representative. As part of an external review process, the report was disseminated to obtain feedback from practitioners in Ontario.

OUTCOMES

Outcomes of interest were overall survival, quality of life, response rates and duration, and adverse event rates.

METHODOLOGY

A systematic review of the medline, embase, HealthStar, cinahl, and Cochrane Library databases was conducted to search for primary articles and practice guidelines. The evidence informed the development of clinical practice recommendations. The evidence review and recommendations were appraised by a sample of practitioners from Ontario, Canada, and were modified in response to the feedback received. The systematic review and modified recommendations were approved by a review body within the pebc.

RESULTS

The literature review found no published randomized controlled trials (rcts) that evaluated alem-tuzumab alone or in combination with other chemotherapeutic agents for the treatment of relapsed or refractory cll. One rct evaluated alemtuzumab administered to consolidate a complete or partial response to first-line fludarabine-containing chemotherapy. That study was stopped early because of excessive grades 3 and 4 infection-related toxicity in the alemtuzumab arm. Patients receiving alemtuzumab experienced significantly improved progression-free survival as compared with patients undergoing observation. Six single-arm studies evaluated disease response with administration of alemtuzumab as a single agent in the treatment of patients with relapsed or refractory cll post-fludarabine. The pooled overall response rate was 38% (complete response: 6%; partial response: 32%). Adverse events associated with the use of alemtuzumab were commonly reported and included serious infusion-related, hematologic, and infection-related toxicities.

RECOMMENDATION

This evidence-based recommendation applies to adult patients with B-cell cll. Treatment with alemtuzumab is a reasonable option for patients with progressive and symptomatic cll that is refractory to both alkylator-based and fludarabine-based regimens.

QUALIFYING STATEMENTS

The evidence supporting treatment with alemtuzumab comes principally from case series that evaluated disease response as the primary outcome measure. Patients should be informed that any possible beneficial effect of alemtuzumab on other outcome measures such as duration of response, quality of life, and overall survival are not supported in evidence and currently remain speculative. Treatment with alemtuzumab is associated with significant and potentially serious treatment-related toxicities. Patients must be carefully informed of the uncertain balance between potential risks of harm and the chance for benefit reported in studies. Given the current substantial uncertainty in this balance, patient preferences will likely play a large role in determining the appropriate treatment choice. Given the potential toxicities associated with alemtuzumab, and given the limited nature of the agent's testing in clinical trials in broad populations of patients with cll, the use of alemtuzumab in patients with important comorbidities may be associated with excessive risks.

Misunderstanding of prostate cancer (CaP) among African American (AA) men of lower socioeconomic status (Lo-SES)

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Background: CaP disproportionately affects AA men. The objective of this investigation was to assess understanding of the prostate and CaP among Lo-SES, predominantly AA men. Methods: We performed cross sectional, semistructured interviews of 105 men, age 40 and older, in two low-income medical clinics. CaP knowledge was assessed using a subset of questions by Mercer et al. Can J of Public Health 88(5):327, 1997. Patients were shown two male anatomic figures and asked to identify the prostate, bladder, bowels, and penis: 1) Please point to the _____ on the picture of the man. 2) What does the ____ do? Patients’ understanding of sexual, urinary, and bowel function was evaluated using semi-qualitative methods coded by two independent investigators. Demographic data were collected and literacy measured using REALM. Results: Patients’ median age was 58 and 87% self-identified their race as AA. Median annual household income was $16,000. Median reading level was 4th-6th grade. Although 87% of patients had heard of the prostate, only 24% could locate the prostate, and 3% could explain prostate function. Because many men learn about the prostate in the context of CaP screening during physical exam, 23% of patients thought the prostate was synonymous with prostate cancer, 15% of patients believed the prostate is located in the rectum and 4% confused prostate cancer with colorectal cancer. Prostate cancer knowledge was poor and the concept of a risk factor was not understood well. Only 7% could name a single risk factor for CaP including 3% who named race. Just 22% of men cited surgery or radiation therapy as treatments for CaP and 11% could name a side effect of early CaP treatment. Domain confusion was common: 43% of patients confused bowel function with urinary function, 21% confused urinary with sexual function, and 20% confused bowel with sexual function. Conclusions: Baseline understanding of CaP, anatomy, bowel, urinary, and sexual function is poor among older, lo-SES AA men. Substantial patient education is required for CaP screening and treatment efforts in this population with consideration for low literacy.

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Nutrient loss and water quality under extensive grazing in the upper Burdekin river catchment, North Queensland

Increased sediment and nutrient losses resulting from unsustainable grazing management in the Burdekin River catchment are major threats to water quality in the Great Barrier Reef Lagoon. To test the effects of grazing management on soil and nutrient loss, five 1 ha mini-catchments were established in 1999 under different grazing strategies on a sedimentary landscape near Charters Towers. Reference samples were also collected from watercourses in the Burdekin catchment during major flow events. Soil and nutrient loss were relatively low across all grazing strategies due to a combination of good cover, low slope and low rainfall intensities. Total soil loss varied from 3 to 20 kg ha(-1) per event while losses of N and P ranged from 10 to 1900 g ha(-1) and from 1 to 71 g ha(-1) per event respectively. Water quality of runoff was considered moderate across all strategies with relatively low levels of total suspended sediment (range: 8-1409 mg l(-1)), total N (range: 101-4000 microg l(-1)) and total P (range: 14-609 microg l(-1)). However, treatment differences are likely to emerge with time as the impacts of the different grazing strategies on land condition become more apparent. Samples collected opportunistically from rivers and creeks during flow events displayed significantly higher levels of total suspended sediment (range: 10-6010 mg l(-1)), total N (range: 650-6350 microg l(-1)) and total P (range: 50-1500 microg l(-1)) than those collected at the grazing trial. These differences can largely be attributed to variation in slope, geology and cover between the grazing trial and different catchments. In particular, watercourses draining hillier, grano-diorite landscapes with low cover had markedly higher sediment and nutrient loads compared to those draining flatter, sedimentary landscapes. These preliminary data suggest that on relatively flat, sedimentary landscapes, extensive cattle grazing is compatible with achieving water quality targets, provided high levels of ground cover are maintained. In contrast, sediment and nutrient loss under grazing on more erodable land types is cause for serious concern. Long-term empirical research and monitoring will be essential to quantify the impacts of changed land management on water quality in the spatially and temporally variable Burdekin River catchment.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Protective effect of faecal occult blood test screening for colorectal cancer: worse prognosis for screening refusers

BACKGROUND AND AIMS

Screening for colorectal cancer (CRC) by faecal occult blood testing (FOBT) decreases CRC mortality by 15-33%. Compliance remains an obstacle to maximising the benefit of FOBT screening. We tested the hypothesis that individuals offered FOBT screening but refused would have an increased incidence and worse prognosis for CRC compared with those tested and with controls.

METHODS

Annual screening was offered to 3548 average risk individuals, > or = 40 years of age, from a highly stable population. A total of 2538 agreed to testing (group 1) and 1010 (28%) refused (group 2). Another 1376 individuals were never offered the test and served as controls (group 3). The groups were followed for 11 years: a three year screening period (1985-1987) and an eight year follow up period at the end of the screening programme (1988-1995). Incidence, stage, and mortality were compared. Characterisation of refusers was completed in 188 and 130 subjects of groups 1 and 2, respectively.

RESULTS

In the screening phase, mortality from CRC was significantly lower in group 1 than in groups 2 and 3. The cumulative incidence of CRC in the eight year follow up period was 21 (0.88%), 23 (2.28%), and 13 (0.94%) in groups 1, 2, and 3, respectively. This shows a reduction of 61.4% in group 1 compared with group 2 (relative risk 0.28 (95% confidence interval (CI) 0.19-0.32)) (p<0.001) and 6.4% compared with group 3 (relative risk 0.93 (95% CI 0.93-1.00)) (NS). During follow up, group 1 subjects also demonstrated a decrease in advanced Dukes' stage and mortality rate by 80% and 64%, and 79% and 62%, compared with groups 2 and 3, respectively. Refusers were more likely to be male, of Asian-African descent, and more likely to smoke, consume more coffee, and less tea or dairy foods.

CONCLUSIONS

When accepted, FOBT may protect against CRC for prolonged periods. Individuals who refuse FOBT have a significantly higher CRC incidence and mortality rates than those who accept testing.

Umbravirus gene expression helps potato leafroll virus to invade mesophyll tissues and to be transmitted mechanically between plants

Potato leafroll virus (PLRV) was mechanically transmissible when inocula also contained the umbravirus Pea enation mosaic virus-2 (PEMV-2). In plants infected with PLRV and PEMV-2, PLRV accumulated in clusters of mesophyll cells in both inoculated and systemically infected leaves. No transmissions were obtained by coinoculation with Potato virus Y, Potato virus X (PVX), Tobacco mosaic virus, or Cucumber mosaic virus (CMV), although PLRV was transmissible from mixtures with CMV(ORF4) (a recombinant that contained the movement protein (MP) gene of the umbravirus Groundnut rosette virus (GRV) in place of the CMV MP gene). In contrast, neither a recombinant PVX that expressed GRV MP nor a mutant of CMV(ORF4), in which the CMV 2b gene was untranslatable, was able to help PLRV transmission. Possibly both a cell-to-cell movement function and counterdefense mechanisms such as those that block posttranscriptional gene silencing are involved in movement of PLRV within plants and its mechanical transmission between plants.