Principles and clinical application of assessing alterations in renal elimination pathways

Drugs and metabolites are eliminated from the body by metabolism and excretion. The kidney makes the major contribution to excretion of unchanged drug and also to excretion of metabolites. Net renal excretion is a combination of three processes - glomerular filtration, tubular secretion and tubular reabsorption. Renal function has traditionally been determined by measuring plasma creatinine and estimating creatinine clearance. However, estimated creatinine clearance measures only glomerular filtration with a small contribution from active secretion. There is accumulating evidence of poor correlation between estimated creatinine clearance and renal drug clearance in different clinical settings, challenging the 'intact nephron hypothesis' and suggesting that renal drug handling pathways may not decline in parallel. Furthermore, it is evident that renal drug handling is altered to a clinically significant extent in a number of disease states, necessitating dosage adjustment not just based on filtration. These observations suggest that a re-evaluation of markers of renal function is required. Methods that measure all renal handling pathways would allow informed dosage individualisation using an understanding of renal excretion pathways and patient characteristics. Methodologies have been described to determine individually each of the renal elimination pathways. However, their simultaneous assessment has only recently been investigated. A cocktail of markers to measure simultaneously the individual renal handling pathways have now been developed, and evaluated in healthy volunteers. This review outlines the different renal elimination pathways and the possible markers that can be used for their measurement. Diseases and other physiological conditions causing altered renal drug elimination are presented, and the potential application of a cocktail of markers for the simultaneous measurement of drug handling is evaluated. Further investigation of the effects of disease processes on renal drug handling should include people with HIV infection, transplant recipients (renal and liver) and people with rheumatoid arthritis. Furthermore, changes in renal function in the elderly, the effect of sex on renal function, assessment of living kidney donors prior to transplantation and the investigation of renal drug interactions would also be potential applications. Once renal drug handling pathways are characterised in a patient population, the implications for accurate dosage individualisation can be assessed. The simultaneous measurement of renal function elimination pathways of drugs and metabolites has the potential to assist in understanding how renal function changes with different disease states or physiological conditions. In addition, it will further our understanding of fundamental aspects of the renal elimination of drugs.

Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Teamwork in Health and Rehabilitation Sciences: Evaluation of a multiprofessional workshop

This paper outlines a multiprofessional education workshop piloted and subsequently conducted with a cohort of 81 graduate entry students of occupational therapy, physiotherapy, speech pathology and audiology. The rationale for, and format of, the workshop is outlined, followed by comparisons between students' knowledge about teamwork prior to and after the four-hour workshop. The workshop was based on a real case scenario of a child with Developmental Coordination Disorder (DCD). Students completed pre- and post-workshop questionnaires about their knowledge of DCD, teamwork and the roles of various professionals and parents; and a post-workshop questionnaire about their views regarding the utility of the workshop, its strengths, and learning outcomes. The evaluation indicated that the workshop was overwhelmingly successful from the students' perspective in: (1) enhancing their understanding about DCD and its multifaceted impact on school age children; (2) developing a deeper appreciation of the importance of teamwork itself; (3) refining their understanding of their own profession's role and (4) developing an appreciation of the role of other professions and parents in working with children with complex needs, and their families. Limitations of this study and directions for future research are discussed.

Rehabilitation of pelvic floor muscles utilizing trunk stabilization

The pelvic floor muscles (PFM) are part of the trunk stability mechanism. Their function is interdependent with other muscles of this system. They also contribute to continence, elimination, sexual arousal and intra-abdominal pressure. This paper outlines some aspects of function and dysfunction of the PFM complex and describes the contribution of other trunk muscles to these processes. Muscle pathophysiology of stress urinary incontinence (SUI) is described in detail. The innovative rehabilitation programme for SUI presented here utilizes abdominal muscle action to initiate tonic PFM activity. Abdominal muscle activity is then used in PFM strengthening, motor relearning for functional expiratory actions and finally impact training. (C) 2003 Elsevier Ltd. All rights reserved.

Learning of foraging skills by fish

This chapter outlines the relationships between a number of key factors that influence learning and memory, and illustrates them by reference to studies on the foraging behaviour of fish. Learning can lead to significant improvements in foraging performance in only a few exposures, and at least some fish species are capable of adjusting their foraging strategy as patterns of patch profitability change. There is also evidence that the memory window for prey varies between fish species, and that this may be a function of environmental predictability. Convergence between behavioural ecology and comparative psychology offers promise in terms of developing more mechanistically realistic foraging models and explaining apparently 'suboptimal' patterns of behaviour. Foraging decisions involve the interplay between several distinct systems of learning and memory, including those that relate to habitat, food patches, prey types, conspecifics and predators. Fish biologists, therefore, face an interesting challenge in developing integrated accounts of fish foraging that explain how cognitive sophistication can help individual animals to deal with the complexity of the ecological context.

A model for the integration of legal research into Australian undergraduate law curricula

The marginalisation of the teaching and learning of legal research in the Australian law school curriculum is, in the author's experience, a condition common to many law schools. This is reflected in the reluctance of some law teachers to include legal research skills in the substantive law teaching schedule — often the result of unwillingness on the part of law school administrators to provide the resources necessary to ensure that such integration does not place a disproportionately heavy burden of assessment on those who are tempted. However, this may only be one of many reasons for the marginalisation of legal research in the law school experience. Rather than analyse the reasons for this marginalisation, this article deals with what needs to be done to rectify the situation, and to ensure that the teaching of legal research can be integrated into the law school curriculum in a meaningful way. This requires the use of teaching and learning theory which focuses on student-centred learning. This article outlines a model of legal research. It incorporates five transparent stages which are: analysis, contextualisation, bibliographic skills, interpretation and assessment and application.

The relationship between the mismatch negativity (MMN) and psycholinguistic models of spoken word processing

Background: The results from previous studies have indicated that a pre-attentive component of the event-related potential (ERP), the mismatch negativity (MMN), may be an objective measure of the automatic auditory processing of phonemes and words. Aims: This article reviews the relationship between the MMN data and psycholinguistic models of spoken word processing, in order to determine whether the MMN may be used to objectively pinpoint spoken word processing deficits in individuals with aphasia. Main Contribution: This article outlines the ways in which the MMN data support psycholinguistic models currently used in the clinical management of aphasic individuals. Furthermore, the cell assembly model of the neurophysiological mechanisms underlying spoken word processing is discussed in relation to the MMN and psycholinguistic models. Conclusions: The MMN data support current theoretical psycholinguistic and neurophysiological models of spoken word processing. Future MMN studies that include normal and aphasic populations will further elucidate the role that the MMN may play in the clinical management of aphasic individuals.

US hegemony and Southeast Asia - The impact of, and limits to, US power and influence

The United States has exerted a major influence on Southeast Asia, especially since World War II. As both a promoter of neoliberal reform and as the key strategic actor in the wider East Asian region, the impact of U.S. power has been immense. But both the Asian economic crisis and its aftermath, and the more recent war on terror, have highlighted the contradictory impact of evolving U.S. foreign policy and intervention in the region. At both an elite and a mass level there is evidence of resentment about, and hostility toward, U.S. policy and its perceived negative effects. This article outlines how U.S. foreign policy has impacted the region in the economic, political, and security spheres, and argues that not only has it frequently not achieved its goals, but it may in fact be undermining both America's long-term hegemonic position in the region and any prospects for political liberalization.

Clinical practice guidelines for the psychosocial care of adults with cancer

Clinical practice guidelines are increasingly being developed in medical settings to provide evidence-based recommendations to guide the clinical care of patients. The development of Clinical practice guidelines for the psychosocial care of patients with medical illness is a newer initiative, and more complex as the target audience includes health care professionals from diverse backgrounds. In Australia, the National Breast Cancer Centre and National Cancer Control Initiative have collaborated to develop Clinical practice guidelines for the psychosocial care of adults with cancer, funded by the Australian Government Department of Health and Ageing. This paper outlines the development of these guidelines in the international context, gives an overview of their content, and describes strategies for their implementation and evaluation. Copyright (c) 2005 John Wiley C Sons, Ltd.

The effect of ionic strength variation and anion competition on the development of nitrate accumulations in variable charge subsoils

The leaching of N fertilisers has led to the formation of nitrate (NO3) accumulations in deep subsoils (>5 m depth) of the Johnstone River catchment. This paper outlines the chemical mechanism by which these NO3 accumulations are formed and maintained. This was achieved via a series of column experiments designed to investigate NO3 leaching in relation to the soil charge chemistry and the competition of anions for exchange sites. The presence of variable charge minerals has led to the formation positive surface charge within these profiles. An increase in the soil solution ionic strength accompanying the fertiliser leaching front acts to increase the positive (and negative) charge density, thus providing adsorption sites for NO3. A decrease in the soil solution ionic strength occurs after the fertiliser pulse moves past a point in the profile, due to dilution with incoming rainwater. Nitrate is then released from the exchange back into the soil solution, thus buffering the decrease in the soil solution ionic strength. Since NO3 was adsorbed throughout the profile in this experiment it does not effectively explain the situation occurring in the field. Previous observations of the sulfate (SO4) profile distribution indicated that large SO4 accumulations in the upper profile may influence the NO3 distribution through competition for adsorption sites. A subsequent experiment investigating the effect of SO4 additions on NO3 leaching showed that NO3 adsorption was minimal in the upper profile. Adsorption of NO3 did occur, though only in the region of the profile where SO4 occupancy was low, i.e. in the lower profile. Therefore, the formation of the NO3 accumulations is dependent on the variable charge mineralogy, the variation of charge density with soil solution ionic strength, and the effects of SO4 competition for adsorption sites.

The Corrosion Performance of Magnesium Alloy AM-SC1 in Automotive Engine Block Applications

The magnesium alloy AM-SC1 has been developed as a creep-resistant automotive engine block material. This paper outlines its corrosion performance under laboratory test conditions, considering corrosion on both the external and internal surfaces. This study found that AM-SC1 has a corrosion performance comparable to AZ91 when subjected to an aggressive salt-spray environment or in galvanic-coupling environments. This article further demonstrates that, with the appropriate selection of a commercially available engine coolant, the internal corrosion of AM-SC1 can be maintained at a tolerable level. In addition, internal corrosion resistance can be significantly improved by the addition of fluorides to the coolant solution. It is concluded that AM-SC1 can be successfully used in an engine environment provided that some simple corrosion-prevention strategies are adopted.

Computerizing the welfare state: An international comparison of computerization in social security

Although computer technology is central to the operation of the modern welfare state, there has been little analysis of its role or of the factors shaping the way in which it is used. Using data generated by expert informants from 13 OECD countries, this paper provides an indicative comparison of the aims of computerization in national social security systems over a 15-year period from 1985 to 2000. The paper seeks to identify and explain patterns in the data and outlines and examines four hypotheses. Building on social constructivist accounts of technology, the first three hypotheses attribute variations in the aims of computerization to different welfare state regimes, forms of capitalism, and structures of public administration. The fourth hypothesis, which plays down the importance of social factors, assumes that computerization is adopted as a means of improving operational efficiency and generating expenditure savings. The findings suggest that, in all 13 countries, computerization was adopted in the expectation that it would lead to increased productivity and higher standards of performance, thus providing most support for the fourth hypothesis. However, variations between countries suggest that the sociopolitical values associated with different welfare state regimes have also had some effect in shaping the ways in which computer technology has been used in national social security systems.

Rural and Isolated Practice Registered Nurse (RIPRN)-Emergency nurses of the Queensland `bush'

The Rural and Isolated practice endorsement for Queensland Registered Nurses has attracted interest from other state health authorities with respect to expanding the scope of practice of nurses working in rural and remote Australia. This discussion article outlines the endorsement program and sheds a spotlight on the program for the emergency and greater nursing community. The paper draws a similarity between rural and emergency nursing and stimulates the notion that other states could look to Queensland's model, for scope of practice expansion in other specialties such as emergency Nursing.