Propagation of large numbers of T cells with natural killer cell markers

Previously, a subset of T cells co-expressing the NK cell antigen CD56 has been described. These CD3+CD56+ cells are rare in peripheral blood collections and have been poorly characterized. We have developed culture conditions which allow for the rapid expansion of CD3+CD56+ cells. The protocol for cellular expansion includes the addition of interferon-gamma on day 0, interleukin-1, interleukin-2 and a monoclonal antibody against CD3 on day 1 to peripheral blood lymphocytes. Cells of the CD3+CD56+ phenotype increased up to 6000-fold using this protocol after 16 d in culture. These cells have been characterized by flow cytometry and have been found to express the alpha, beta T cell receptor, co-express the CD5 and CD8 antigens and do not express the CD16 antigen. Morphologically, these cells cannot be distinguished from NK cells. CD3+CD56+ killer cells lyse a variety of tumour cells with intermediate activity between CD3-CD56+ NK cells and CD3+CD56- T cells.

Smoking behaviours in a remote Australian Indigenous community: the influence of family and other factors

In Australia, tobacco smoking is more than twice as common among Indigenous people as non-Indigenous people. Some of the highest smoking rates in the country are in remote Indigenous communities in the Northern Territory of Australia. Owing to this high prevalence, tobacco use today is the single biggest contributing risk factor for excess morbidity and mortality among Indigenous Australians. Despite this, there is a lack of published research which qualitatively explores the social context of Indigenous smoking behaviour or of meanings and perceptions of smoking among Indigenous people. The aim of this study was to understand why Indigenous people start to smoke, the reasons why they persist in smoking and the obstacles and drivers of quitting. We conducted semi-structured interviews with a purposive sample of 25 Indigenous community members in two remote communities in the Northern Territory and 13 health staff. The results indicate that there is a complex interplay of historical, social, cultural, psychological and physiological factors which influence the smoking behaviours of Indigenous adults in these communities. In particular, the results signal the importance of the family and kin relations in determining smoking behaviours. While most community participants were influenced by family to initiate and continue to smoke, the health and well being of the family was also cited as a key driver of quit attempts. The results highlight the importance of attending to social and cultural context when designing tobacco control programs for this population. Specifically, this research supports the development of family-centred tobacco control interventions alongside wider policy initiatives to counter the normalisation of smoking and assist individuals to quit.

Sensitivity of multidrug-resistant tumor cell lines to immunologic effector cells

The ability of malignant cells to survive exposure to cytotoxic agents is a major obstacle to cure in patients with cancer. Multidrug resistance and the expression of P-glycoprotein are emerging as a cause of chemotherapy failure. Immunologic effector cells such as lymphokine-activated killer (LAK) cells or cytokine-induced killer (CIK) cells are capable of killing a broad range of tumor cell lines or freshly isolated tumor cells. As demonstrated here, LAK, and CIK cells possess a high level of cytotoxic activity against tumor cell lines both resistant and sensitive to chemotherapeutic agents such as doxorubicin or vinblastine. CIK cells possessed a higher level of cytotoxic activity than LAK cells as determined by 51Cr release and a tumor colony assay. Monoclonal antibodies against P-glycoprotein did not block the lysis of tumor cells resistant to chemotherapy by CIK cells. In contrast, antibodies to LFA-1 and ICAM-1 blocked CIK cell-mediated tumor cell lysis. These data demonstrate that immunological approaches to cancer therapy may be useful in overcoming disease caused by drug resistance.

Assessment of predictors of response and long-term survival of patients with neuroendocrine tumour treated with peptide receptor chemoradionuclide therapy (PRCRT)

PURPOSE

To review the response and outcomes of (177)Lu-DOTA-octreotate chemoradionuclide therapy (LuTate PRCRT) in patients with neuroendocrine tumour (NET) expressing high levels of somatostatin receptors with uncontrolled symptoms or disease progression.

METHODS

A total of 68 patients (39 men; 17 - 76 years of age) who had completed an induction course of at least three cycles of LuTate PRCRT between January 2006 and June 2010 were reviewed. Ten patients were treated for uncontrolled symptoms and 58 had disease progression despite conventional treatment. The majority had four induction LuTate cycles (median treatment duration 5 months and cumulative activity 31 GBq), and 63 patients had concomitant 5-FU radiosensitizing infusional chemotherapy. Factors predicting overall survival were assessed using the log-rank test and Cox proportional hazards regression.

RESULTS

Of those treated for uncontrolled symptoms, 70 % received benefit maintained for at least 6 months after treatment. Among patients with progressive disease 68 % showed stabilization or regression on CT, 67 % on molecular imaging and 56 % biochemically up to 12 months after treatment; 32 patients died. Overall survival rates at 2 and 5 year were 72.1 % and 52.1 %, respectively. Median overall survival was not estimable at a median follow-up of 60 months (range 5 - 86 months). Nonpancreatic primary sites, dominant liver metastases, lesion size <5 cm and the use of 5-FU chemotherapy were statistically significantly associated with objective response. A disseminated pattern and a high disease burden (whole-body retention index) were associated with an increased risk of death. Objective biochemical, molecular imaging and CT responses were all associated with longer overall survival.

CONCLUSION

A high proportion of patients with progressive NET or uncontrolled symptoms received therapeutic benefit from LuTate with concomitant 5-FU chemotherapy. The achievement of objective biochemical, molecular or CT responses within 12 months was associated with improved overall survival. Patients with a primary pancreatic site and larger lesions (>5 cm) appeared to have lower objective response rates and may need a more aggressive treatment approach.

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

ISSUE

Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation.

APPROACH

The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people's participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data.

KEY FINDINGS

Facilitators enabling Indigenous people's participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems.

IMPLICATION

The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Interruption of parturition in rats by morphine: a result of inhibition of oxytocin secretion

Oxytocin secretion is inhibited by opioids, and oxytocin is important in parturition. The effects on parturition of morphine, a relatively selective mu-opioid receptor agonist, were studied in the rat. Morphine or vehicle with or without the opiate antagonist naloxone were administered immediately after the birth of the second pup and the subsequent course of parturition was recorded in a total of 80 rats. Both s.c. morphine (10 mg/kg) and intracerebroventricular (i.c.v.) morphine (18 micrograms through a previously implanted cannula) interrupted parturition, delaying the birth of the sixth pup after treatment to 187.3 +/- 35.9 (S.E.M.) min and 195.4 +/- 19.5 min respectively, compared with 46.4 +/- 3.7 and 66.1 +/- 17.5 min after vehicle alone. The dose of morphine given i.c.v. had no effect when given s.c. Naloxone given concurrently prevented the effects of morphine. Eventually the rate of parturition in the morphine-treated groups recovered. Perinatal pup mortality rate was not increased when morphine was given to the mothers, but it did inhibit the expression of normal intrapartum maternal behaviour. Pup mortality was increased 48 h post partum by morphine given during parturition, and it reduced the proportion of rats with normal maternal behaviour 24 h post partum. Morphine did not affect spontaneous or oxytocin-stimulated contractile activity of the parturient uterus in vitro. The concentration of oxytocin in trunk blood plasma was decreased 40 min after i.c.v. morphine (24.3 +/- 3.9 vs 39.3 +/- 6.5 pmol/l in controls), as was vasopressin (7.2 +/- 1.5 vs 19.7 +/- 4.5 pmol/l in controls). Intravenous infusion of oxytocin (2-5 mU/min for 144.3 +/- 8.2 min; total infused 448.5 +/- 61.9 mU) after i.c.v. morphine re-started parturition; all pups were born to these rats (mean time to pup 6, 110.3 +/- 12.7 min) before the i.v. vehicle-infused rats given i.c.v. morphine re-started (mean time to pup 6, 406.3 +/- 125.2 min). It is concluded that morphine given during parturition acts centrally through opioid receptors to inhibit oxytocin secretion, and impairs the expression of maternal behaviour. Reversal of the effects of morphine on parturition by i.v. oxytocin demonstrates the important role of oxytocin in fetus ejection and expulsion.

Alterations in cervical muscle activity in functional and stressful tasks in female office workers with neck pain

This study determined differences between computer workers with varying levels of neck pain in terms of work stressors, employee strain, electromyography (EMG) amplitude and heart rate response to various tasks. Participants included 85 workers (33, no pain; 38, mild pain; 14, moderate pain) and 22 non-working controls. Work stressors evaluated were job demands, decision authority, and social support. Heart rate was recorded during three tasks: copy-typing, typing with superimposed stress and a colour word task. Measures included electromyography signals from the sternocleidomastoid (SCM), anterior scalene (AS), cervical extensor (CE) and upper trapezius (UT) muscles bilaterally. Results showed no difference between groups in work stressors or employee strain measures. Workers with and without pain had higher measured levels of EMG amplitude in SCM, AS and CE muscles during the tasks than controls (all P < 0.02). In workers with neck pain, the UT had difficulty in switching off on completion of tasks compared with controls and workers without pain. There was an increase in heart rate, perceived tension and pain and decrease in accuracy for all groups during the stressful tasks with symptomatic workers producing more typing errors than controls and workers without pain. These findings suggest an altered muscle recruitment pattern in the neck flexor and extensor muscles. Whether this is a consequence or source of the musculoskeletal disorder cannot be determined from this study. It is possible that workers currently without symptoms may be at risk of developing a musculoskeletal disorder.

Measuring the health impact of human rights violations related to Australian asylum policies and practices: a mixed methods study

Background

Human rights violations have adverse consequences for health. However, to date, there remains little empirical evidence documenting this association, beyond the obvious physical and psychological effects of torture. The primary aim of this study was to investigate whether Australian asylum policies and practices, which arguably violate human rights, are associated with adverse health outcomes.

Methods

We designed a mixed methods study to address the study aim. A cross-sectional survey was conducted with 71 Iraqi Temporary Protection Visa (TPV) refugees and 60 Iraqi Permanent Humanitarian Visa (PHV) refugees, residing in Melbourne, Australia. Prior to a recent policy amendment, TPV refugees were only given temporary residency status and had restricted access to a range of government funded benefits and services that permanent refugees are automatically entitled to. The quantitative results were triangulated with semi-structured interviews with TPV refugees and service providers. The main outcome measures were self-reported physical and psychological health. Standardised self-report instruments, validated in an Arabic population, were used to measure health and wellbeing outcomes.

Results

Forty-six percent of TPV refugees compared with 25% of PHV refugees reported symptoms consistent with a diagnosis of clinical depression (p = 0.003). After controlling for the effects of age, gender and marital status, TPV status made a statistically significant contribution to psychological distress (B = 0.5, 95% CI 0.3 to 0.71, p ≤ 0.001) amongst Iraqi refugees. Qualitative data revealed that TPV refugees generally felt socially isolated and lacking in control over their life circumstances, because of their experiences in detention and on a temporary visa. This sense of powerlessness and, for some, an implicit awareness they were being denied basic human rights, culminated in a strong sense of injustice.

Conclusion

Government asylum policies and practices violating human rights norms are associated with demonstrable psychological health impacts. This link between policy, rights violations and health outcomes offers a framework for addressing the impact of socio-political structures on health.

"Only your blood can tell the story"--a qualitative research study using semi-structured interviews to explore the hepatitis B related knowledge, perceptions and experiences of remote dwelling Indigenous Australians and their health care providers in northern Australia

BACKGROUND

Hepatitis B is endemic in the Indigenous communities of the Northern Territory of Australia and significantly contributes to liver-related morbidity and mortality. It is recognised that low health literacy levels, different worldviews and English as a second language all contribute to the difficulties health workers often have in explaining biomedical health concepts, relevant to hepatitis B infection, to patients. The aim of this research project was to explore the knowledge, perceptions and experiences of remote dwelling Indigenous adults and their health care providers relating to hepatitis B infection with a view to using this as the evidence base to develop a culturally appropriate educational tool.

METHODS

The impetus for this project came from health clinic staff at a remote community in Arnhem Land in the Northern Territory, in partnership with a visiting specialist liver clinic from the Royal Darwin Hospital. Participants were clinic patients with hepatitis B (n = 12), community members (n = 9) and key informants (n = 13); 25 were Indigenous individuals.A participatory action research project design was used with purposive sampling to identify participants. Semi-structured interviews were undertaken to explore: current understanding of hepatitis B, desire for knowledge, and perspectives on how people could acquire the information needed. All individuals were offered the use of an interpreter. The data were examined using deductive and inductive thematic analysis.

RESULTS

Low levels of biomedical knowledge about Hepatitis B, negative perceptions of Hepatitis B, communication (particularly language) and culture were the major themes that emerged from the data. Accurate concepts grounded in Indigenous culture such as "only your blood can tell the story" were present but accompanied by a feeling of disempowerment due to perceived lack of "medical" understanding, and informed partnerships between caregiver and patient. Culturally appropriate discussions in a patient's first language using visual aids were identified as vital to improving communication.

CONCLUSIONS

Having an educational tool in Indigenous patient's first language is crucial in developing treatment partnerships for Indigenous patients with hepatitis B. Using a culturally appropriate worldview as the foundation for development should help to reduce disempowerment and improve health literacy.

Starting to smoke: a qualitative study of the experiences of Australian indigenous youth

BACKGROUND

Adult smoking has its roots in adolescence. If individuals do not initiate smoking during this period it is unlikely they ever will. In high income countries, smoking rates among Indigenous youth are disproportionately high. However, despite a wealth of literature in other populations, there is less evidence on the determinants of smoking initiation among Indigenous youth. The aim of this study was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group.

METHODS

This project was undertaken in northern Australia. We undertook group interviews with 65 participants and individual in-depth interviews with 11 youth aged 13-20 years led by trained youth 'peer researchers.' We also used visual methods (photo-elicitation) with individual interviewees to investigate the social context in which young people do or do not smoke. Included in the sample were a smaller number of non-Indigenous youth to explore any significant differences between ethnic groups in determinants of early smoking experiences. The theory of triadic influence, an ecological model of health behaviour, was used as an organising theory for analysis.

RESULTS

Family and peer influences play a central role in smoking uptake among Indigenous youth. Social influences to smoke are similar between Indigenous and non-Indigenous youth but are more pervasive (especially in the family domain) among Indigenous youth. While Indigenous youth report high levels of exposure to smoking role models and smoking socialisation practices among their family and social networks, this study provides some indication of a progressive denormalisation of smoking among some Indigenous youth.

CONCLUSIONS

Future initiatives aimed at preventing smoking uptake in this population need to focus on changing social normative beliefs around smoking, both at a population level and within young peoples' immediate social environment. Such interventions could be effectively delivered in both the school and family environments. Specifically, health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.

U-500 insulin: why, when and how to use in clinical practice

Some patients with type 2 diabetes mellitus (T2DM) have severe insulin resistance. Their insulin requirements are significantly greater. These patients need to take 2-3 injections at the same time to take the correct insulin dose or to redial the insulin pen. When daily insulin requirements are in excess of 300 units/day, the volume of the injected insulin becomes an issue. Large-volume injection can cause discomfort and lead to poor concordance with treatment. Using high-strength insulin e.g. U-500 insulin can reduce the volume of the injected insulin. Despite publications of small case reports or case series, no universal guidelines exist on the use of U-500 insulin. We discuss common sense approaches when considering the use of U-500 insulin in clinical practice.

The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service

Accurate data on the health of refugees in primary care is vital to inform clinical practice, monitor disease prevalence, influence policy and promote coordination. We undertook a retrospective clinical audit of newly arrived refugees attending the Darwin refugee primary health service in its first 12 months of operation. Data were collected from the clinic files of refugee patients who attended for their initial health assessment from 1 July 2009 to 30 June 2010 and were analysed descriptively. Among 187 refugees who attended in 2009–2010, ~60% were from Asia and 42% were female. The most common diagnoses confirmed by testing were vitamin D deficiency (23%), hepatitis B carrier status (22%), tuberculosis infection (18%), schistosomiasis (17%) and anaemia (17%). The most common documented health conditions recorded by the GPs were vitamin D deficiency or insufficiency (66%), followed by schistosomiasis (24%) and dental disease (23%). This clinical audit adds to a limited evidence base suggesting a high prevalence of infectious disease, nutrient deficiency and dental disease among refugees arriving to Australia. GPs involved in the care of refugees must be aware of the epidemiology of disease in this group, as some diseases are rare among the general Australian population. Our results also highlight the ongoing need for advocacy to address service constraints such as limited public dental access for this population.

Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High-Burden Setting: Outcome of a Stepped-Wedge, Community, Randomized Trial

BACKGROUND

Health system strengthening is needed to improve delivery of secondary prophylaxis against rheumatic heart disease.

METHODS AND RESULTS

We undertook a stepped-wedge, randomized trial in northern Australia. Five pairs of Indigenous community clinics entered the study at 3-month steps. Study phases comprised a 12 month baseline phase, 3 month transition phase, 12 month intensive phase and a 3- to 12-month maintenance phase. Clinics received a multicomponent intervention supporting activities to improve penicillin delivery, aligned with the chronic care model, with continuous quality-improvement feedback on adherence. The primary outcome was the proportion receiving ≥80% of scheduled penicillin injections. Secondary outcomes included "days at risk" of acute rheumatic fever recurrence related to late penicillin and acute rheumatic fever recurrence rates. Overall, 304 patients requiring prophylaxis were eligible. The proportion receiving ≥80% of scheduled injections during baseline was 141 of 304 (46%)-higher than anticipated. No effect attributable to the study was evident: in the intensive phase, 126 of 304 (41%) received ≥80% of scheduled injections (odds ratio compared with baseline: 0.78; 95% confidence interval, 0.54-1.11). There was modest improvement in the maintenance phase among high-adhering patients (43% received ≥90% of injections versus 30% [baseline] and 28% [intensive], P<0.001). Also, the proportion of days at risk in the whole cohort decreased in the maintenance phase (0.28 versus 0.32 [baseline] and 0.34 [intensive], P=0.001). Acute rheumatic fever recurrence rates did not differ between study sites during the intensive phase and the whole jurisdiction (3.0 versus 3.5 recurrences per 100 patient-years, P=0.65).

CONCLUSIONS

This strategy did not improve adherence to rheumatic heart disease secondary prophylaxis within the study time frame. Longer term primary care strengthening strategies are needed.

CLINICAL TRIAL REGISTRATION

URL: www.anzctr.org.au. Unique identifier: ACTRN12613000223730.

Adaptation of the Ages and Stages Questionnaire for Remote Aboriginal Australia

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

Incentives for preventing smoking in children and adolescents

BACKGROUND

Adult smoking usually has its roots in adolescence. If individuals do not take up smoking during this period it is unlikely that they ever will. Further, once smoking becomes established, cessation is challenging; the probability of subsequently quitting is inversely proportional to the age of initiation. One novel approach to reducing the prevalence of youth smoking is the use of incentives.

OBJECTIVES

To determine whether incentives prevent children and adolescents from starting to smoke. We also attempted to assess the dose-response of incentives, the costs of incentive programmes, whether incentives are more or less effective in combination with other interventions to prevent smoking initiation and any unintended consequences arising from the use of incentives.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL, CSA databases and PsycINFO for terms relating to incentives, in combination with terms for smoking and tobacco use, and children and adolescents. The most recent searches were in May 2012.

SELECTION CRITERIA

We considered randomized controlled trials allocating children and adolescents (aged 5 to 18 years) as individuals, groups or communities to intervention or control conditions, where the intervention included an incentive aimed at preventing smoking uptake. We also considered controlled trials with baseline measures and post-intervention outcomes.

DATA COLLECTION AND ANALYSIS

Data were extracted by two authors and assessed independently. The primary outcome was the smoking status of children or adolescents at follow-up who reported no smoking at baseline. We required a minimum follow-up of six months from baseline and assessed each included study for risk of bias. We used the most rigorous definition of abstinence in each trial; we did not require biochemical validation of self-reported tobacco use for study inclusion. Where possible we combined eligible studies to calculate pooled estimates at the longest follow-up using the Mantel-Haenszel fixed-effect method, grouping studies by study design.

MAIN RESULTS

We identified seven controlled studies that met our inclusion criteria, including participants with an age range of 11 to 14 years. Of the seven trials identified, only five had analysable data relevant for this review and contributed to the meta-analysis (6362 participants in total who were non-smokers at baseline; 3466 in intervention and 2896 in control). All bar one of the studies was a trial of the so-called Smokefree Class Competition (SFC), which has been widely implemented throughout Europe. In this competition, classes with youth generally between the ages of 11 to 14 years commit to being smoke free for a six month period. They report regularly on their smoking status; if 90% or more of the class is non-smoking at the end of the six months, the class goes into a competition to win prizes. The one study that was not a trial of the SFC was a controlled trial in which schools in two communities were assigned to the intervention, with schools in a third community acting as controls. Students in the intervention community with lower smoking rates at the end of the project (one school year) received rewards.Only one study of the SFC competition, a non-randomized controlled trial, reported a significant effect of the competition on the prevention of smoking at the longest follow-up. However, this study had a risk of multiple biases, and when we calculated the adjusted RR we no longer detected a statistically significant difference. The pooled RR for the more robust RCTs (3 studies, n = 3056 participants) suggests that, from the available data, there is no statistically significant effect of incentives to prevent smoking initiation among children and adolescents in the long term (RR 1.00, 95% CI 0.84 to 1.19). Pooled results from non-randomized trials also did not detect a significant effect, and we were unable to extract data on our outcome of interest for the one trial that did not study the SFC. There is little robust evidence to suggest that unintended consequences (such as youth making false claims about their smoking status and bullying of smoking students) are consistently associated with such interventions, although this has not been the focus of much research. There was insufficient information to assess the dose-response relationship or to report costs.

AUTHORS' CONCLUSIONS

To date, incentive programmes have not been shown to prevent smoking initiation among youth, although there are relatively few published studies and these are of variable quality. Trials included in this meta-analysis were all studies of the SFC competition, which distributed small to moderately sized prizes to whole classes, usually through a lottery system.Future studies might investigate the efficacy of incentives given to individual participants to prevent smoking uptake. Future research should consider the efficacy of incentives on smoking initiation, as well as progression of smoking, evaluate these in varying populations from different socioeconomic and ethnic backgrounds, and describe the intervention components in detail.

Development of a Culturally Appropriate Bilingual Electronic App About Hepatitis B for Indigenous Australians: Towards Shared Understandings

Background

Hepatitis B is endemic in Indigenous communities in Northern Australia; however, there is a lack of culturally appropriate educational tools. Health care workers and educators in this setting have voiced a desire for visual, interactive tools in local languages. Mobile phones are increasingly used and available in remote Indigenous communities. In this context, we identified the need for a tablet-based health education app about hepatitis B, developed in partnership with an Australian remote Indigenous community.

Objective

To develop a culturally appropriate bilingual app about hepatitis B for Indigenous Australians in Arnhem Land using a participatory action research (PAR) framework.

Methods

This project was a partnership between the Menzies School of Health Research, Miwatj Aboriginal Health Corporation, Royal Darwin Hospital Liver Clinic, and Dreamedia Darwin. We have previously published a qualitative study that identified major knowledge gaps about hepatitis B in this community, and suggested that a tablet-based app would be an appropriate and popular tool to improve this knowledge. The process of developing the app was based on PAR principles, particularly ongoing consultation, evaluation, and discussion with the community throughout each iterative cycle. Stages included development of the storyboard, the translation process (forward translation and backtranslation), prelaunch community review, launch and initial community evaluation, and finally, wider launch and evaluation at a viral hepatitis conference.

Results

We produced an app called “Hep B Story” for use with iPad, iPhone, Android tablets, and mobile phones or personal computers. The app is culturally appropriate, audiovisual, interactive, and users can choose either English or Yolŋu Matha (the most common language in East Arnhem Land) as their preferred language. The initial evaluation demonstrated a statistically significant improvement in Hep B-related knowledge for 2 of 3 questions (P=.01 and .02, respectively) and overwhelmingly positive opinion regarding acceptability and ease of use (median rating of 5, on a 5-point Likert-type scale when users were asked if they would recommend the app to others).

Conclusions

We describe the process of development of a bilingual hepatitis B-specific app for Indigenous Australians, using a PAR framework. The approach was found to be successful with positive evaluations.

Management of paediatric thyroid carcinoma: recent experience with recombinant human thyroid stimulating hormone in preparation for radioiodine therapy

BACKGROUND

Thyroid carcinoma in children is rare and raises unique management issues. Although metastatic disease is more common in this age group, prognosis remains good with appropriate treatment. The aim of the study was to report recent experience in the management of differentiated thyroid carcinoma in children, especially in the use of radioiodine after recombinant human thyroid stimulating hormone (rhTSH) stimulation.

METHODS

Eight patients, aged 5-17 years (five were boys) presented following total thyroidectomy for thyroid carcinoma between May 2003 and June 2005. Seven had papillary carcinoma and one had follicular carcinoma. Five had known lymph node metastases and one had pulmonary metastases at presentation. Four patients had previously received therapeutic irradiation for malignancy. All eight underwent diagnostic iodine scans, seven with rhTSH stimulation. Seven went on to receive radioiodine treatment as hospital inpatients, comanaged by the paediatric and nuclear medicine units. The dosage of 131I ranged from 1.5 to 3.7 x 10(9) Bq. All except one were prepared by rhTSH stimulation.

RESULTS

Seven of eight patients had significant uptake in the neck on diagnostic scan and two had pulmonary abnormalities. Six of seven evaluable patients achieved complete thyroid ablation. Both patients with pulmonary abnormalities had scan resolution, although one of them only after a second radioiodine treatment. All patients had thyroxine replacement in doses to suppress TSH and all remain alive and well at time of carrying out this study.

CONCLUSION

Optimal management of paediatric thyroid carcinoma necessitates a multidisciplinary approach. Radioiodine therapy under rhTSH is an effective and safe adjuvant treatment in this special subgroup.

Infants attend to second-order relational properties of faces

Two experiments investigated whether 7-month-old infants attend to the spatial distance measurements relating internal features of the human face. A visual preference paradigm was used, in which two versions of the same female face (one either lengthened or shortened, and one nonmodified) were presented simultaneously. In Experiment 1, infants looked longer at the nonmodified faces, which were determined to match the average distance relationships found in a sample of faces drawn from the same population. Longer looking times for modified faces were found in Experiment 2, in which the nonmodified faces were unusually long and the modified faces conformed to average distance measurements. It is proposed that infants' attention to the spatial relations of internal face features is an optimal tool for lifelong face recognition.

Maternal smoking and smoking in the household during pregnancy and postpartum: findings from an Indigenous cohort in the Northern Territory

OBJECTIVE

To describe the trends in maternal smoking and smoking in the household for a cohort of Indigenous women followed from late pregnancy to 7 months postpartum.

DESIGN AND SETTING

Prospective cohort study embedded within a randomised controlled trial (RCT) performed in the Northern Territory involving participants recruited between 30 June 2006 and 4 May 2010.

PARTICIPANTS

215 Indigenous women aged 17-39 years who had been recruited into the RCT, 162 of whom had completed their last study visit at 7 months postpartum by 1 June 2010.

MAIN OUTCOME MEASURES

Smoking status of women, and smoking within their households, in their third trimester, and at 1 month, 2 months and 7 months postpartum.

RESULTS

There were complete data on women's smoking status for 121 participants. Among these, the self-reported smoking rate was 45% (95% CI, 36%-55%) during pregnancy, increasing to 63% (95% CI, 54%-71%) at 7 months postpartum. Of the 66 women who were non-smokers at the antenatal visit, 23 (35%; 95% CI, 23%-47%) were smoking by the time their baby reached 7 months of age. Thirty-one per cent (95% CI, 23%-39%) of households included people who smoked inside during the antepartum period, whereas 16% (95% CI, 10%-23%) included people who smoked inside at 7 months postpartum.

CONCLUSIONS

While an apparent reduction in indoor exposure to tobacco smoke during the postpartum period is encouraging, this is offset by an increase in the proportion of antenatal non-smokers who subsequently reported smoking after the birth of their child. More health care service delivery and research attention needs to be directed to smoking during pregnancy and to postpartum relapse in this population.

Community-based asylum seekers' use of primary health care services in Melbourne

OBJECTIVE

To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne.

DESIGN AND SETTING

Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006.

MAIN OUTCOME MEASURES

Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals.

RESULTS

Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55-65), followed by musculoskeletal conditions (27.1; 95% CI, 24-30), and psychological problems (26.5; 95% CI, 23-30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16-21).

CONCLUSIONS

The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Contrast-enhanced dynamic magnetic resonance imaging of finger joints in osteoarthritis and rheumatoid arthritis: an analysis based on pharmacokinetic modeling

PURPOSE

To investigate a two-compartment kinetic model applied to the dynamic time course of contrast enhancement as a method to differentiate between finger-joint synovitis in established osteoarthritis (OA) and rheumatoid arthritis (RA).

MATERIAL AND METHODS

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of one hand in 19 patients and six healthy volunteers was undertaken. Eight patients had OA of the hand and eleven patients had RA. From the signal intensity curves, the three parameters Kps (endothelial transfer constant), Kep (elimination rate constant from extracellular space back to plasma) and Kel (elimination rate constant from plasma by renal excretion) were calculated.

RESULTS

The rate constant Kps showed the best separation between the groups with significantly higher values in the RA group compared to the OA group (P<0.005) and in the OA group compared to the control group (P<0.005). Significantly higher values of Kep were also found in the RA group compared with the OA group (P<0.005).

CONCLUSION

DCE-MRI may provide useful information that can help differentiate synovitis in OA from synovitis in RA.

Depression after childbirth: the views of medical students and women compared

BACKGROUND

Little research has been conducted on the views of health professionals about women's experiences of depression after childbirth. This study compared the views held by undergraduate medical students about postnatal depression with those of women who had themselves experienced it.

METHODS

Fourth- and sixth-year medical students at one Australian university were surveyed (n = 134). Their views about prevalence, duration, contributing factors, and advice for dealing with postnatal depression were compared with the findings from 60 women in a population-based study of mothers who gave birth in Victoria in 1989, in which women scoring as depressed 8 to 9 months after birth on the Edinburgh Postnatal Depression Scale were interviewed 12 to 18 months later about their experiences of depression and their advice to other mothers.

RESULTS

Women's and students' views differed markedly, with students much more likely to view hormonal and biologic factors and a "tendency to depression" as playing an important role than women who identified a wide range of social, physical health, and life event factors as contributing to their experience of depression. Fourth-year students tended to overestimate the prevalence of depression and sixth-year students to underestimate it. Both groups underestimated the duration of depression compared with women's actual experiences.

CONCLUSION

Medical students need to develop a broader understanding of maternal depression after the birth of a baby, and women's own views of the experience can and should make an important contribution to medical teaching on this topic.

Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis

BACKGROUND

Rheumatic heart disease is a high-burden condition in Australian Aboriginal communities. We evaluated a stepped-wedge, community, randomized trial at 10 Aboriginal communities from 2013 to 2015. A multifaceted intervention was implemented using quality improvement and chronic care model approaches to improve delivery of penicillin prophylaxis for rheumatic heart disease. The trial did not improve penicillin adherence. This mixed-methods evaluation, designed a priori, aimed to determine the association between methodological approaches and outcomes.

METHODS AND RESULTS

An evaluation framework was developed to measure the success of project implementation and of the underlying program theory. The program theory posited that penicillin delivery would be improved through activities implemented at clinics that addressed elements of the chronic care model. Qualitative data were derived from interviews with health-center staff, informants, and clients; participant observation; and project officer reports. Quantitative data comprised numbers and types of "action items," which were developed by participating clinic staff with project officers to improve delivery of penicillin injections. Interview data from 121 health-center staff, 22 informants, and 72 clients revealed barriers to achieving the trial's aims, including project-level factors (short trial duration), implementation factors (types of activities implemented), and contextual factors (high staff turnover and the complex sociocultural environment). Insufficient actions were implemented addressing "self-management support" and "community linkage" streams of the chronic care model. Increased momentum was evident in later stages of the study.

CONCLUSIONS

The program theory underpinning the study was sound. The limited impact made by the study on adherence was attributable to complex implementation challenges.

Effect of a family-centered, secondhand smoke intervention to reduce respiratory illness in indigenous infants in Australia and New Zealand: a randomized controlled trial

INTRODUCTION

Secondhand smoke (SHS) is a significant cause of acute respiratory illness (ARI) and 5 times more common in indigenous children. A single-blind randomized trial was undertaken to determine the efficacy of a family centered SHS intervention to reduce ARI in indigenous infants in Australia and New Zealand.

METHODS

Indigenous mothers/infants from homes with ≥ 1 smoker were randomized to a SHS intervention involving 3 home visits in the first 3 months of the infants' lives (plus usual care) or usual care. The primary outcome was number of ARI-related visits to a health provider in the first year of life. Secondary outcomes, assessed at 4 and 12 months of age, included ARI hospitalization rates and mothers' report of infants' SHS exposure (validated by urinary cotinine/creatinine ratios [CCRs]), smoking restrictions, and smoking cessation.

RESULTS

Two hundred and ninety-three mother/infant dyads were randomized and followed up. Three quarters of mothers smoked during pregnancy and two thirds were smoking at baseline (as were their partners), with no change for more than 12 months. Reported infant exposure to SHS was low (≥ 95% had smoke-free homes/cars). Infant CCRs were higher if one or both parents were smokers and if mothers breast fed their infants. There was no effect of the intervention on ARI events [471 intervention vs. 438 usual care (reference); incidence rate ratio = 1.10, 95% confidence intervals (CI) = 0.88-1.37, p = .40].

CONCLUSIONS

Despite reporting smoke-free homes/cars, mothers and their partners continue to smoke in the first year of infants' lives, exposing them to SHS. Emphasis needs to be placed on supporting parents to stop smoking preconception, during pregnancy, and postnatal.

What works in Indigenous tobacco control? The perceptions of remote Indigenous community members and health staff

ISSUES ADDRESSED

To explore the perceptions of remote Indigenous community members and health staff regarding the acceptability and effectiveness of different tobacco control health promotion interventions.

METHODS

Qualitative methods were used for this exploratory study, including interviews with remote Indigenous community members and health staff, as well as observations of the delivery of different tobacco control activities in three remote communities in the Northern Territory (NT).

RESULTS

Several tobacco control interventions for which there is strong evidence in other settings were generally perceived as acceptable and efficacious in the remote Indigenous setting. Primary care interventions, such as brief advice and pharmaceutical quitting aids, when available and accessible, were perceived as important and effective strategies to help people quit, as were the promotion of smokefree areas. By contrast unmodified Quit programs were perceived to have questionable application in this context and there were conflicting findings regarding taxation increases on tobacco and social marketing campaigns.

CONCLUSIONS

Several evidence-based 'mainstream' activities are perceived to be acceptable to this population, but we may also need to address the concerns raised by health staff and community members about the acceptability of some unmodified activities. Additionally, organisational barriers within the health system may be contributing to the reduced effectiveness of tobacco control in this setting.