Partner-Involved Financial Incentives for Smoking Cessation in Dual-Smoker Couples: A Randomized Pilot Trial.

INTRODUCTION: Members of dual-smoker couples (in which both partners smoke) are unlikely to try to quit smoking and are likely to relapse if they do make an attempt. The purpose of this study was to investigate the feasibility, tolerability, and preliminary outcomes of dyadic adaptations of financial incentive treatments (FITs) to promote smoking cessation in dual-smoker couples. AIMS AND METHODS: We enrolled 95 dual-smoker couples (N = 190) in a three-arm feasibility RCT comparing two partner-involved FITs (single vs. dual incentives) against a no-treatment control condition. Participants in all conditions were offered nicotine replacement and psychoeducation. A 3-month follow-up provided information about retention, tolerability (ie, self-reported benefits and costs of the study), and preliminary efficacy (ie, program completion, quit attempts, point-prevalent abstinence, and joint quitting). RESULTS: Results suggest dyadic adaptations were feasible to implement (89% retention rate) and highly tolerable for participants (p < .001). Neither feasibility nor tolerability varied across the treatment arm. Preliminary efficacy outcomes indicated partner-involved FITs have promise for increasing smoking cessation in dual-smoker couples (OR = 2.36-13.06). CONCLUSIONS: Dyadic implementations of FITs are feasible to implement and tolerable to participants. IMPLICATIONS: The evidence that dyadic adaptations of FITs were feasible and tolerable, and the positive preliminary efficacy outcomes suggest that adequately powered RCTs formally evaluating the efficacy of dyadic adaptations of FITs for dual-smoker couples are warranted.

Designing clinical trials for future space missions as a pathway to changing how clinical trials are conducted on Earth.

OBJECTIVE: The project aims to build a framework for conducting clinical trials for long-term interplanetary missions to contribute to innovation in clinical trials on Earth, especially around patient involvement and ownership. METHODS: We conducted two workshops in which participants were immersed in the speculative scenario of an interplanetary mission in which health problems emerged that required medical trials to resolve. The workshops used virtual reality and live simulation to mimic a zero-gravity environment and visual perception shifts and were followed by group discussion. RESULTS: Some key aspects for the framework that emerged from the workshops included: (a) approaches to be inclusive in the management of the trial, (b) approaches to be inclusive in designing the research project (patient preference trials, n-of-1 trials, designing clinical trials to be part of a future prospective meta-analysis, etc), (c) balancing the research needs and the community needs (eg, allocation of the participants based on both research and community need), (d) ethics and partnerships (ethics and consent issues and how they relate to partnerships and relationships). CONCLUSION: In identifying some key areas that need to be incorporated in future planning of clinical trials for interplanetary missions, we also identified areas that are relevant to engaging patients in clinical trials on Earth. We will suggest using the same methodology to facilitate more in-depth discussions on specific aspects of clinical trials in aerospace medicine. The methodology can be more widely used in other areas to open new inclusive conversations around innovating research methodology.

The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs.

INTRODUCTION: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background. METHODS: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated. RESULTS: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally. CONCLUSION: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Combined chemical (fluoranthene) and drought effects on Lumbricus rubellus demonstrate the applicability of the independent action model for multiple stressor assessment.

The combined effect of a chemical (fluoranthene) and a nonchemical stress (reduced soil moisture content) to the widely distributed earthworm Lumbricus rubellus were investigated in a laboratory study. Neither fluoranthene (up to 500 microg/g) nor low soil moisture (15% below optimal) had a significant effect on the survival of the exposed worms, but a significant effect on reproduction (cocoon production rate) was found for both stressors (p < 0.001 in both cases). The response of cocoon production to each stressor could be well described by a logistic model; this suggested that the joint effects may be applicable to description using the independent action (IA) model that is widely used in pharmacology and chemical mixture risk assessment. Fitting of the IA model provided a good description of the combined stressor data (accounting for 53.7% of total variation) and was the most parsimonious model describing joint effect (i.e., the description of the data was not improved by addition of further parameters accounting for synergism or antagonism). Thus, the independent action of the two responses was further supported by measurement of internal fluoranthene exposure. The chemical activity of fluoranthene in worm tissue was correlated only with soil fluoranthene concentration and not with soil moisture content. Taken together these results suggest that the IA model can help interpret the joint effects of chemical and nonchemical stressors. Such analyses should, however, be done with caution since the literature data set suggests that there may be cases where interactions between stressors result in joint effects that differ significantly from IA predictions.

Biological assessment of contaminated land using earthworm biomarkers in support of chemical analysis.

Biological indicators can be used to assess polluted sites but their success depends on the availability of suitable assays. The aim of this study was to investigate the performance of two earthworm biomarkers, lysosomal membrane stability measured using the neutral red retention assay (NRR-T) and the total immune activity (TIA) assay, that have previously been established as responsive to chemical exposure. Responses of the two assays were measured following in situ exposure to complexly contaminated field soils at three industrial sites as well as urban and rural controls. The industrial sites were contaminated with a range of metal (cadmium, copper, lead, zinc, nickel and cobalt) and organic (including polycyclic aromatic hydrocarbons) contaminants, but at concentrations below the 'New Dutch List' Intervention concentrations. Exposed earthworms accumulated both metals and organic compounds at the contaminated sites, indicating that there was significant exposure. No effect on earthworm survival was found at any of the sites. Biomarker measurements, however, indicated significant effects, with lower NRR-T and TIA found in the contaminated soils when compared to the two controls. The results demonstrate that a comparison of soil pollutant concentrations with guideline values would not have unequivocally identified chemical exposure and toxic effect for soil organisms living in these soils. However, the earthworm biomarkers successfully identified significant exposure and biological effects caused by the mixture of chemicals present.

Impact of a high-dependency care area on the nutritional management of patients with acute uremia.

At this institution, all non-intensive care unit (ICU)-based patients with acute uremia were previously managed on the general nephrology ward, and there were concerns that these patients may not have been benefiting from optimal management, particularly with regard to nutrition. In 1998, a renal high-dependency care (RHDC) unit was established within the ward, providing opportunity to compare the clinical management and outcomes of acutely uremic patients in 2 annual cohorts that were admitted both before and after implementation of the RHDC unit. Retrospective case reviews complemented data collected prospectively on the unit since 1995. There were 108 patients included from 1995 to 1996 and 86 patients included from 1998 to 1999; no patients were excluded, but a few case records were unobtainable. Both patient groups were demographically similar (median age, 68 years pre-RHDC, 62.5 years with the RHDC unit), and initial illness severity/comorbidity showed no significant differences. Nutritional support increased significantly (P <.05) from 22.4% in 1995 to 1996 to 38.4% of patients in 1998 to 1999, reflecting increased oral supplementation. Dialysis requirements were similar (60.2% v 63.5%). The proportion of patients requiring admission to the ICU (17.6% v 8.1%) and the total number of ICU bed days used (195 v 86) was reduced in 1998 to 1999. Cost analysis showed little overall difference between the 2 cohorts; the actual cost of improved nutritional management was negligible. The RHDC area and its nurse-based protocols have increased nutritional support for acutely uremic patients, allowing a reduction in ICU usage without any worsening in outcomes.