Multidisciplinary case conference reviews: Improving outcomes for nursing home residents, carers and health professionals

Aim of study: This study sought to determine whether multidisciplinary case conference reviews improved outcomes for nursing home residents, and the effects of this team approach to resident care on carers, including the hands-on carers employed by the nursing home, and health professionals. Method: 245 residents of three Canberra nursing homes were enrolled in this non-randomised controlled trial. The intervention consisted of sessions of three case conference reviews held between 10/4/96 and 4/12/96. These sessions were attended by the General Practitioners (GPs) of the residents discussed, the GP project officer from the ACT Division of General Practice, a clinical pharmacist, senior nursing staff, other health professionals eg physiotherapist, and occasionally the resident concerned or their representative. At each review, a case presentation by the resident's GP was followed by a multidisciplinary discussion of all aspects, medical and non-medical, of the resident's care. The review concluded with a management plan for the resident. In total 75 residents were reviewed. Main outcome measures: Medication use and cost, and mortality. Results: One month after the reviews were completed comparisons between those who were reviewed and those who were not showed non-significant reductions in medication orders, medication cost, and mortality in the reviewed group. Many of the 92 recommendations in the management plans that were carried out benefited the residents (n=37) and/or carers (n=24). The responses of the GPs and the Directors of Nursing to the reviews were overwhelmingly positive. Conclusion: Recommendations arising from multidisciplinary case conferences were carried out to the benefit of patients and carers. Given the support shown by key stakeholders, multidisciplinary conferences should be used more.

Beyond sex and cooking: Health education for individuals with intellectual disability

Issues of health education programming for people with intellectual disability are discussed. As environments in which such individuals live become more inclusive, and they are encouraged to make their own choices, the issue of whether current health education is sufficient to enable them to make healthy life choices is considered. More attention should be focused on programs in schools and the community to fulfill this need. Three aspects of health education programming are considered: physical activity, general health knowledge, and social supports for health. Continuity of information is viewed as important in policy development as well as in interprofessional coordination and cooperation to assure that these individuals are not further handicapped by poor health.

Why farmers continue to use pesticides despite environmental, health and sustainability costs

Use of chemical inputs such as pesticides has increased agricultural production and productivity. However, negative externalities from such use have increased too. These externalities include damage to agricultural land, fisheries, fauna and flora. Another major externality is the unintentional destruction of beneficial predators of pests thereby increasing the virulence of many species of agricultural pests. Furthermore, increased mortality and morbidity of humans due to exposure to pesticides are recorded especially in developing countries. The costs from these externalities are large and affect farmers' returns. However, despite these high costs, farmers continue to use pesticides and in most countries in increasing quantities. In this paper, we examine this paradox and show why farmers continue to use pesticides despite the increasing costs. We also emphasize 'lock-in' aspects of pesticide use. (C) 2001 Elsevier Science B.V. All rights reserved.

Loss as a universal concept: Review of the literature to identify common aspects of loss in diverse situations

It has long been recognized that loss and its associated grief are important elements of many adverse life events that affect the entire global population: death, disability, traumatic events, abuse., terminal and chronic illness, aging, addiction, unemployment, relationship breakdown, war, migration, and educational failure. While there is significant empirical evidence of the potential deleterious effects of specific situations of loss across the global community, systematic discussion concerning the common elements of loss that are associated with adverse life situations in general has been limited. This review of the theoretical and empirical literature concerning various losses and the recommendations for care of those affected by such losses identifies common aspects of situations of loss and common recommendations in the care of those confronted by such losses. These common themes of loss are described by simple summary statements that can be communicated to a broad audience, hence enhancing community education and, potentially, community-wide mental health promotion.

A risk-based system to penalize and reward line management for occupational safety and health performance

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.

The design of hazard risk assessment matrices for ranking occupational health risks and their application in mining and minerals processing

Two hazard risk assessment matrices for the ranking of occupational health risks are described. The qualitative matrix uses qualitative measures of probability and consequence to determine risk assessment codes for hazard-disease combinations. A walk-through survey of an underground metalliferous mine and concentrator is used to demonstrate how the qualitative matrix can be applied to determine priorities for the control of occupational health hazards. The semi-quantitative matrix uses attributable risk as a quantitative measure of probability and uses qualitative measures of consequence. A practical application of this matrix is the determination of occupational health priorities using existing epidemiological studies. Calculated attributable risks from epidemiological studies of hazard-disease combinations in mining and minerals processing are used as examples. These historic response data do not reflect the risks associated with current exposures. A method using current exposure data, known exposure-response relationships and the semi-quantitative matrix is proposed for more accurate and current risk rankings.

Mechanistic aspects of HIV-1 reverse transcription initiation

During reverse transcription, the positive-strand HIV-1 RNA genome is converted into a double-stranded DNA copy which can be permanently integrated into the host cell genome. Recent analyses show that HIV-1 reverse transcription is a highly regulated process. The initiation reaction can be distinguished from a subsequent elongation reaction carried out by a reverse transcription complex composed of (at least) heterodimeric reverse transcriptase, cellular tRNA(lys3) and HIV-1 genomic RNA sequences. In addition, viral factors including Tat, Nef, Vif, Vpr, IN and NCp7, cellular proteins, and TAR RNA and other RNA stem-loop structures appear to influence this complex and contribute to the efficiency of the initiation reaction. As viral resistance to many antiretroviral compounds is a continuing problem, understanding the ways in which these factors influence the reverse transcription complex will likely lead to novel antiretroviral strategies. Copyright (C) 2001 John Wiley Sons, Ltd.

A review of animal models for the study of arsenic carcinogenesis

As inorganic arsenic is a proven human carcinogen, significant effort has been made in recent decades in an attempt to understand arsenic carcinogenesis using animal models, including rodents (rats and mice) and larger mammals such as beagles and monkeys. Transgenic animals were also used to test the carcinogenic effect of arsenicals, but until recently all models had failed to mimic satisfactorily the actual mechanism of arsenic carcinogenicity. However, within the past decade successful animal models have been developed using the most common strains of mice or rats. Thus dimethylarsinic acid (DMA), an organic arsenic compound which is the major metabolite of inorganic arsenicals in mammals, has been proven to be tumorigenic in such animals. Reports of successful cancer induction in animals by inorganic arsenic (arsenite and arsenate) have been rare, and most carcinogenetic studies have used organic arsenicals such as DMA combined with other tumor initiators. Although such experiments used high concentrations. of arsenicals for the promotion of tumors, animal models using doses of arsenicals species closed to the exposure level of humans in endemic areas are obviously the most significant. Almost all researchers have used drinking water or food as the pathway for the development of animal model test systems in order to mimic chronic arsenic poisoning in humans; such pathways seem more likely to achieve desirable results. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

HPLC measurement of harderoporphyrin in the harderian glands of rodents as a biomarker for sub-lethal or chronic arsenic exposure

An improved HPLC method has been established for the measurement of harderoporphyrin (HP) in the harderian gland of rats and mice. Groups of female Wistar rats were given a single oral dose of sodium arsenite at 0, 0.5 or 5.0 mg As(III)/kg body weight, or a slurry of arsenic-contaminated soil at equivalent dose rates and the animals were sacrificed 96 h after dosing. A group of C57BL/6J female mice were chronically exposed to drinking water containing 500 mug As(V)/I of sodium arsenate ad libitum for over 2 years. Porphyrins were measured in the harderian glands of rats and mice. Our results suggest that HP and the alteration of the porphyrin profile in the harderian glands of rodents is a highly sensitive biomarker for both single sub-lethal and chronic arsenic exposure. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

Arsenic inhibits the repair of DNA damage induced by benzo(a)pyrene

In order to study the effect of arsenic on DNA damage, Sprague-Dawley rats were dosed with sodium arsenite (10 mg/kg) with or without 800 mug of benzo(a)pyrene (BP) by intramammilary injection. The animals were sacrificed on day 1, 3, 5, 10 and 27 and the mammary gland tissues were collected for DNA adduct measurement using a P-32 post-labeling assay. Animals dosed with arsenic alone did not show any DNA adducts. DNA adduct levels in rats dosed with BP alone reached a maximum level by day 5, reducing to 13% of this level by day 27. Adduct levels in rats dosed with arsenic and BP also reached a maximum by day 5 but only 80% of the level observed in the BP group. However, 84% of this amount still remained by day 27. The First Nucleotide Change (FNC) technique was used for the screening of 115 samples of various tissues from mice that had been chronically exposed to sodium arsenate for over 2 years revealed that inorganic arsenic did not attack the two putative hotspots (codons 131 and 154) of the hOGG1 gene. These results support the hypothesis that arsenic exerts its biological activity through DNA repair inhibition. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

Porphyrin profiles in blood and urine as a biomarker for exposure to various arsenic species

A sensitive method using HPLC with fluorescence detection has been established for the measurement of porphyrins in biological materials. The assay recoveries were 88.0 +/- 1.8% for protoporphyrin IX in the blood, and ranged from 98.3 +/- 2.7% to 111.1 +/- 7.4% for various porphyrins in the urine. This method was employed to investigate the altered porphyrin profiles in rats after a single dose of various arsenicals including soluble sodium arsenate and sodium arsenite, and the relatively insoluble calcium arsenite, calcium arsenate and arsenic-contaminated soils at dose rates of 5 mg/kg or 0.5 mg/kg body weight. Porphyrin concentrations increased within 24-48hr after the arsenic treatment in blood and urine. Protoporphyrin IX is the predominant porphyrin in the blood. In rats administered 5 mg As(III)/kg body weight, protoporphyrin IX concentration elevated to 123% of them control values in rats, 24 hr after the treatment. Higher increases were recorded in the urinary protoporphyrin IX (253% at 24 hr; 397% on day 2), uroporphyrin (121% at 24 hr; 208% on day 2) and coproporphyrin 111 (391% at 24 hr; 304% on day 2), while there was no significant increase (109% on day 3) observed in the urinary coproporphyrin I excretion. In rats administered 5 mg As(V)/kg, urinary excretion of protoporphyrin IX, uroporphyrin, coproporphyrin Ill and coproporphyrin I elevated to the maximum levels by 48 hr with the corresponding percentage values compared to the control being 177%, 158%, 224% and 143%, respectively. In rats dosed with 5 mg As(III)/kg, the increases (expressed as % of the control values) of protoporphyrin IX in the blood were in the order: sodium arsenite (144%) > sodium arsenate (125%) greater than or equal to calcium arsenite (123%) > calcium arsenate. In contrast, there was no significant increase of protoporphyrin K when the six arsenic-contaminated cattlei dip soils and nine copper chrome arsenate (CCA-contaminated) soils were administered to the rats. Probable explanations are discussed.

The absorption and excretion of fluoride and arsenic in humans

The absorption and excretion of fluoride and arsenic were measured in a group of healthy volunteers given drinking water with naturally high concentration of fluoride (F 2.3 mg/l), or high concentration of arsenic (As 0.15 mg/l), or high concentrations of both fluoride and arsenic (F 2.25 mg/l, As 0.23 mg/l and F 4.05 mg/l, As 0.58 mg/l), respectively. The results indicated that, for arsenic, the absorption rate, the proportion of urinary excretion and the biological-half-life did not show statistically significant differences between drinking water containing high arsenic alone and drinking water containing different levels of high arsenic and fluoride. Excretion and retention of arsenic were positively correlated to the total arsenic intake. Similar results were observed for fluoride. This suggests that there are different metabolic processes for arsenic and fluoride in respect to absorption and excretion; and no joint action can be attributed by these two elements. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.

A field study conducted at Kidston Gold Mine, to evaluate the impact of arsenic and zinc from mine tailing to grazing cattle

The grazing trial at Kidston Gold Mine, North Queensland, was aimed specifically to assess the uptake of metals from the tailing and the potential for unacceptable contamination of saleable meat. Further aims included estimating metal dose rates and identifying potential exposure pathways including plant uptake of heavy metals, mine tailings adhered to plants and direct ingestion of mine tailing. It was found that of the 11 metals analysed (As, Zn, Co, Cd, Cr, Sn, Pb, Sb, Hg, Se and Ni) in the animal's liver, muscle and blood during the 8-month trial period, only accumulation of arsenic and zinc occurred. A risk assessment including these two metals was conducted to determine the potential for chronic metal toxicity and long-term contamination, using the estimates of metal dose rate. It was concluded that no toxicity or long-term contamination in cattle was likely at this site. Management procedures were therefore not required at this site; however, the results highlight percent ground cover and standing dry matter (DM) as important factors in decreasing metal exposure from direct ingestion of tailings and dust adhered to plants. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.