Nature-Based Design in Stroke Rehabilitation Environments: A Scoping Review.

OBJECTIVE: To identify, examine, and map the characteristics of knowledge of nature-based design in stroke rehabilitation facilities, examine how research in this field has been conducted and identify gaps in knowledge. BACKGROUND: Many stroke survivors have wide ranging impacts, resulting in long hospital stays to undertake rehabilitation. The physical environment can influence brain recovery; however, there is limited evidence to support the design of effective rehabilitation environments. Conversely, the health benefits available from connection with nature are well established. A nature-based design approach may have benefits and implications for the physical environment of inpatient stroke rehabilitation facilities; however, it is unclear what evidence exists in this field. METHOD: This scoping review followed the JBI methodological guidance for the conduct of scoping reviews, with systematic searches of six databases. RESULTS: Twenty-eight studies were included in the review. Aims and research methods varied widely. Investigations in 19 studies related to gardens and other designed outdoor nature-based environments. Other studies explored natural analogues, nature inside, inside/outside connections, and the natural environment. Findings from the studies were spread across the fields of design, use, exposure to, and engagement in nature-based environments. CONCLUSION: The characteristics of knowledge underpinning nature-based design in stroke rehabilitation environments are highly diverse, and significant gaps exist in the evidence base. A framework developed during this review for mapping knowledge on the intentions and impacts for spaces and services in this field assisted to identify these gaps and may be applied to other areas of healthcare design research.

Clinical outcomes of patients with acute myeloid leukemia and cardiovascular disease.

Incidence of both acute myeloid leukemia (AML) and cardiovascular disease (CVD) increases with age. We evaluated whether pre-existing CVD impacts clinical outcomes in AML. We retrospectively evaluated 291 consecutive adult AML patients treated at our institution, 2014-2020. Pretreatment comorbidities were identified by chart review. Outcomes included complete remission (CR) and CR with incomplete count recovery (CRi) rates, disease-free survival (DFS), overall survival (OS) and incidence of cardiovascular adverse events. CVD was present in 34% of patients at AML diagnosis. CVD patients had worse performance status (p=0.03) and more commonly had secondary AML (p=0.03) and received hypomethylating (HMA) agent-based therapy (72% vs 38%, p< 0.001). CVD (0.45 vs 0.71, p<0.001) and diabetes mellitus (HR= 0.24, 95% CI: 0.08 - 0.8, p= 0.01) were associated with lower probability of achieving CR/CRi. Accounting for age, performance status (PS), complex karyotype, secondary disease and treatment, CVD patients had shorter OS (HR=1.5, 95% CI: 1.1-2.2, p=0.002), with 1- and 3-year OS 44% vs 67% and 25% vs 40%, respectively, but there was no difference in cumulative incidence of relapse between patients with vs without CVD. Thus, CVD is an independent risk factor for lower response rate and shorter survival in AML patients.

The co-benefits of biodiversity citizen science for well-being and nature relatedness.

Human well-being is dependent on the health of our planet. Biodiversity-related citizen science supports conservation research, and there is increasing interest in its potential as a health co-benefits intervention. This randomized controlled study investigates the health co-benefits of biodiversity citizen science participation. Seventy participants were randomly assigned to a citizen science project or control group for an 8-month period. Both groups completed pre- and post-intervention surveys, evaluating nature relatedness, self-efficacy related to biodiversity loss, subjective well-being, and climate change anxiety. A subset (N = 13) of participants engaged in the citizen science project also took part in focus group discussions. The intervention group reported a significant increase in nature relatedness and self-efficacy to help address issues of biodiversity loss. Although no significant changes were observed for other well-being or anxiety scales, most participants reported positive outcomes related to mental or physical well-being in focus groups. There were stronger positive effects for participants without previous environmental volunteering experience. These results suggest that citizen science participation has the potential to contribute to Planetary Health goals, with sustained co-benefits for well-being and nature relatedness. Future interventions evaluating co-benefits should consider previous environmental volunteering experience and focus on participants with little experience to maximize health outcomes.

Olanzapine within steroid-sparing antiemetic regimen to prevent chemotherapy-induced nausea and vomiting in patients with acute leukemia receiving multi-day intensive chemotherapy.

INTRODUCTION: Olanzapine use for chemotherapy-induced nausea and vomiting (CINV) in hematological malignancies, for multi-day chemotherapy, and with a steroid-sparing antiemetic strategy is poorly understood. This study investigated if olanzapine is associated with improved prevention of CINV when added to a steroid-sparing antiemetic regimen in patients with acute leukemia receiving intensive, moderately emetogenic, multi-day chemotherapy. METHODS: This was a single-center, retrospective cohort study in patients with acute leukemia. Patients who received olanzapine for CINV prevention were compared to those who did not. All patients received a 5-HT3 antagonist. Adult patients receiving moderately emetogenic, multi-day, intensive chemotherapy for acute leukemia were included. Patients were excluded if they received steroids greater than physiological doses during the study period. The primary endpoint was the complete response of CINV (no emesis or rescue antiemetic usage). RESULTS: This study included 58 patients, 12 patients received olanzapine and 46 patients were in the control group. Baseline demographics were similar. In the study population, 89.7% had acute myeloid leukemia, median age was 54 (interquartile range 42-63) years, 34.5% were female, 27.6% had prior CINV. Complete response of CINV was similar between groups, 4 (33.3%) and 15 (32.6%) patients in the olanzapine and control groups, respectively. Safety events were similar between groups. CONCLUSION: Patients with acute leukemia receiving multi-day intensive chemotherapy are at high risk for CINV. The limited data in this study suggests that olanzapine use within a steroid-sparing antiemetic regimen was well tolerated and associated with similar incidence and severity of CINV compared to the control group.

Impact of pegaspargase dose capping on incidence of pegaspargase-related adverse events in adults.

INTRODUCTION: Asparaginase derivatives are essential components of the treatment of acute lymphoblastic leukemia in adolescent and young adult patients. However, their associated toxicities limit wider use in older populations. This study seeks to determine if the practice of capping the pegaspargase dose at 3750 units reduces the risk of related adverse events in adults. METHODS: Adverse event data were retrospectively collected 28 days following each administration of pegaspargase in a single center. Doses were categorized as either capped (≤3750 units) (n = 57, 47.5%) or non-capped (>3750 units) (n = 63, 52.5%). The primary endpoint of this study was the composite incidence of serious pegaspargase-related adverse events, defined as grade 3 or higher. RESULTS: Of the 120 doses administered, 47 (39.2%) were administered to patients > 39 years. For the primary endpoint, 26 doses (45.6%) in the dose capped group versus 22 doses (34.9%) in the non-dose capped group were associated with serious pegaspargase-related adverse events (p = 0.23). Isolated laboratory abnormalities accounted for all hepatotoxicity and pancreatic toxicity events, while venous thromboembolism and bleeding occurred after 8.3% and 13.3% of doses, respectively. Multivariate analysis of the primary outcome to adjust for differences in baseline characteristics found no difference between groups (OR 2.56 (0.84, 7.77, p = 0.098)). CONCLUSIONS: The incidence of serious clinical toxicities was low in this study, particularly pegaspargase-related venous thromboembolism. This suggests that the practice of capping pegaspargase doses at 3750 units, coupled with vigilant monitoring and prophylaxis for pegaspargase-related adverse events, can allow for the inclusion of this drug in the treatment of older individuals.

Lessons learned from a virtual Community-Based Participatory Research project: prioritizing needs of people who have diabetes and experiences of homelessness to co-design a participatory action project.

In Community-Based Participatory Research (CBPR), people with shared lived experiences (co-researchers) identify priority needs and work collaboratively to co-design an action-oriented research advocacy project. For this to occur, academic researchers must build mutually respectful partnerships with co-researchers by establishing trust. In the context of the COVID-19 pandemic, our objective was to virtually assemble a group of co-researchers (people with diverse but relevant experiences of homelessness and diabetes) and academic researchers who engaged in the CBPR process to identify a project that would address the difficulties of diabetes management while experiencing homelessness. Co-researchers were recruited to the committee from community homeless-serving organizations. Six co-researchers, one peer researcher and three academic researchers from Calgary, Alberta met virtually for bi-weekly committee meetings, from June 2021 to May 2022 to explore barriers to diabetes management and to complete a priority-setting exercise to determine the focus of our collective project. After reflecting on our virtual CBPR experience we present lessons learned related to: i) technical challenges and logistical considerations, ii) meeting virtually and building rapport, iii) driving engagement, and iv) challenges of transitioning from virtual to in-person meeting format. Overall, the process of conducting a CBPR project virtually to engage a group of co-researchers during a pandemic presents its challenges. However, a virtual CBPR project is feasible and can lead to meaningful experiences that benefit all group members, both from the community and academia.

In Community-Based Participatory Research (CBPR), we value peoples' lived experiences as knowledge and believe that it can help in the design of research projects. In these projects, people with similar lived experiences work with researchers to design a research advocacy project that will make meaningful changes in their community. Trust and respect between all team members are essential for working well together. Establishing trust and respect can be difficult, especially when done virtually. We virtually convened a committee and completed a CBPR project. Our group consisted of seven people with lived experience of diabetes and homelessness and three academic researchers in Calgary, Alberta. We met every two weeks between June 2021 and May 2022 to explore possible topics for our CBPR project, which we narrowed down to their top priority. As we reflected on our experience of working together, we came up with four categories of lessons learned: i) technical challenges, ii) building rapport, iii) driving engagement, and iv) challenges of transitioning from virtual to in-person meeting format. While our experience presented its challenges, we found working virtually to create a CBPR project is possible and can be meaningful for all group members.

Health empowerment scripts: Simplifying social/green prescriptions.

Social prescriptions are one term commonly used to describe non-pharmaceutical approaches to healthcare and are gaining popularity in the community, with evidence highlighting psychological benefits of reduced anxiety, depression and improved mood and physiological benefits of reduced risk of cardiovascular disease and reduced hypertension. The relationship between human health benefits and planetary health benefits is also noted. There are, however, numerous barriers, such as duration and frequencies to participate in activities, access, suitability, volition and a range of unpredictable variables (such as inclement weather, shifting interests and relocating home amongst others) impeding a comprehensive approach to their use on a wider scale. From a multidisciplinary perspective, this commentary incorporates a salutogenic and nature-based approach to health, we also provide a range of recommendations that can be undertaken at the patient level to assist in shifting the acknowledged systemic barriers currently occurring. These include using simple language to explain the purpose of health empowerment scripts, ensuing personal commitment to a minimum timeframe, enabling ease of access, co-designing a script program, providing ongoing motivational support and incorporating mindfulness to counter unexpected disruptions.

Planetary health indicators for the local level: opportunities and challenges in applying the happy planet index in Victoria, Australia.

The United Nations Sustainable Development Goals, New Urban Agenda and Paris Agreement on Climate Change are blueprints for health promotion action that mandate human health is linked inextricably to the health of the environment. In the Anthropocene, new indicators are required to promote community engagement with, and measurement of, healthy and sustainable wellbeing for people and planet. This study explored the need for a metric such as the Happy Planet Index that explicitly links human health to health of the environment for a local level scale in Australia. The project arose from an international coalition of health promoters advocating for 'planetary health' approaches. Qualitative description methods guided the study design involving key informant interviews (n = 17) and four focus groups (n = 27 participants) with health and/or sustainability academics, practitioners and policy-makers. Document analysis of health and environment indices and policy mandates augmented the analysis. Qualitative content analysis techniques were used to analyse the findings. There was strong interest for a local level composite indicator, such as a rescaled Happy Planet Index (life expectancy × life satisfaction × equity adjustment/ecological footprint) for use at a local level. The value of a composite index was: its ability to promote community engagement with planetary health thinking; an advocacy tool for joint health and sustainability policy; to justify programs on health and environmental co-benefits; and to provide a mechanism for correlative comparisons between local governments and national comparisons. However, disciplinary silos currently limit partnerships for health promotion and planetary health and a local composite index could help bridge these divides.

Pawsitive Connections: The role of Pet Support Programs and pets on the elderly.

OBJECTIVES: This study describes the experiences of Pet Support Program clients in Melbourne, Australia and how the programs reduce the social isolation of the elderly. The study also describes the role of pets and associated health benefits of pet ownership. METHOD: The qualitative description study comprised of two phases: a secondary data analysis of interviews with 14 PSP clients, and key informant interviews with four PSP providers. RESULTS: The interviews were thematically analysed which resulted in three interconnected themes: Attachment, Support and Social Isolation. Social isolation was reduced by the PSP through access to social support groups, as well as the provision of a regular visitor who provides meaningful conversation and companionship. CONCLUSION: These results align with literature on pet ownership and Attachment Theory. The results also offer an insight into how PSPs allow the elderly to maintain pet ownership and age in place, thus enhancing their health and well-being.

Evaluation of a framework for safe and appropriate prescribing of psychoactive medications in a UK prison.

BACKGROUND: The widespread use of drugs in prisons leads to avoidable deaths, poorer health and a poor living environment. The contribution of psychoactive prescription drugs to this problem has received little attention in prison policy or at individual prescriber level. AIMS: To determine the extent of unsafe and inappropriate prescribing of psychoactive medications in one UK prison using a newly developed medicines optimisation framework. METHOD: A medicines optimisation framework was developed based on principles of good prescribing. It was initiated on the opening of a new prison-HMP Berwyn-in February 2017. During the study period, all prisoners at HMP Berwyn were transferred from other prisons. The safety and appropriateness of psychoactive medications were evaluated de novo on reception at HMP Berwyn and during follow up, using the medicines optimisation framework. RESULTS: About 1941 sentenced men arrived at HMP Berwyn between February 2017 and November 2018. Nearly one-third (634, 33%) were on a prescribed psychoactive medication. Seventy-five percent of these (474/634) required a prescription change due to appropriateness or safety concerns. Nearly half (295, 46.5%) received changes at reception despite having already undergone medicines reconciliation at their previous prison. Forty-three percent (275/634) received changes at follow up, most commonly those who had no prior risks identified at reception. CONCLUSIONS: Inappropriate and unsafe prescribing of psychoactive medications is occurring in prisons despite mandatory medication reviews. Ongoing monitoring is required to reduce the risk from these medications. A medicines optimisation framework such as this could be adopted across other prisons, worldwide, to help contribute to risk reduction from drug use in prisons. Appropriately modified, a similar framework might help reduce inappropriate and harmful prescribing in hospitals and in the community.

Applying the Mandala of Health in the Anthropocene.

ISSUE ADDRESSED: The Anthropocene is a new era in which human activity has been the dominant influence on climate and the environment. The negative impact humans have on the earth's systems pose significant threats to human health. Health promotion is a discipline well placed to respond to planetary health challenges of the Anthropocene. The overarching aim of this paper is to describe the elements of 21st century socio-ecological health and apply them in a revised socio-ecological framework for health promotion. METHODS: A qualitative description study design was employed to explore the significance of ecological and cultural determinants of health and review models in contemporary health promotion to inform the development of a revised Mandala of Health. Purposeful sampling was used to recruit ten experts from across Australia including academics and practitioners working at the nexus of health promotion, environmental management and sustainability. Data were analysed thematically, using deductive and inductive methods. RESULTS: A revised Mandala of Health could address existing gaps in health promotion theory and practice. Ecological and cultural determinants of health were considered essential components of health promotion that is often lacking in socio-ecological frameworks. Indigenous Knowledge Systems were considered immensely important when addressing ecological and cultural determinants of health. CONCLUSIONS: A revised Mandala of Health could encourage development of contemporary health models, assisting health promotion to evolve with the health and environmental issues of the Anthropocene. This study highlights the need for more theoretical development and empirical research regarding ecological and cultural determinants of health in a health promotion context. SO WHAT?: In the context of the Anthropocene, this study highlights the potential gaps in health promotion theory and practice in terms of the natural environment and health and emphasises the need of a paradigm shift to embed ecological and cultural determinants with other determinants of health.

Optimizing pegylated asparaginase use: An institutional guideline for dosing, monitoring, and management.

The incorporation of L-asparaginase and pegylated asparaginase into pediatric-inspired regimens has conferred a survival advantage in treatment of adults with acute lymphoblastic leukemia. Use of asparaginase products requires careful prevention, monitoring, and management of adverse effects including hypersensitivity, hepatotoxicity, pancreatitis, coagulopathy, and thrombosis. Currently, there is limited published literature to offer guidance on management of these toxicities. At the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, a standard of practice guideline was created to prevent and manage asparaginase-related adverse events. By sharing our long-term experience with asparaginase products and clinical management of asparaginase-induced toxicities, this article aims to improve patient safety and optimize treatment outcomes.

Health promotion and food insecurity: Exploring environmental sustainability principles to guide practice within Australia.

ISSUE ADDRESSED: The Australian health promotion sector has made significant advances in food security over the years through recognition of social and economic factors. The incorporation of ecological determinants within health promotion practice to address food insecurity, however, is uncommon. This paper explores the potential of health promotion to use environmental sustainability principles to guide the development of health promotion food security programs in Australia. METHODS: A mixed-methods approach guided by a pragmatic framework was adopted for this study. A national online survey (n = 61) and semi-structured interviews (n = 16) targeting Australian health promotion practitioners was utilised. Triangulation involved seven stages to develop points of convergence and corroboration of the data. RESULTS: Practitioners were adopting principles of environmental sustainability such as ecological integrity and biodiversity protection to guide food security practice. The use of such principles demonstrates their compatibility within health promotion practice. This study, however, reveals that environmental sustainability principles were a relatively new area of practice for health promotion practitioners. CONCLUSION: The possibilities for integrating health promotion and environmental sustainability principles are promising for addressing multifaceted issues inherent within food security practice. At present, a lack of principles exist for guiding the sector to address food security that is cognisant of both human health and the environment. SO WHAT?: This study indicates a lack of integration between environmental sustainability and health promotion principles to guide food security practice. It would be pertinent for the sector to consider the development of a set of principles that considers both health promotion and environmental sustainability to ensure future food security and planetary health. Capacity building of current practitioners and pre-service graduates around the use of such principles to guide practice could assist the sector in this process.

Alectinib and Brigatinib: New Second-Generation ALK Inhibitors for the Treatment of Non-Small Cell Lung Cancer.

The treatment of non-small cell lung cancer (NSCLC) has been revolutionized by the discovery of genetic driver mutations and associated targeted therapies. Anaplastic lymphoma kinase (ALK) mutations are present in about 5% of NSCLC cases, and treatment with the first-generation ALK inhibitor crizotinib has shown better progression-free survival (PFS) and response rate compared to traditional chemotherapy. However, eventually, ALK-mutated NSCLC develops resistance to treatment with crizotinib, and second-generation ALK inhibitors such as ceritinib, brigatinib, and alectinib have been shown to be effective in the second-line setting after progression on crizotinib. In the second-line setting, alectinib showed an objective response rate (ORR) of 45% and PFS of 8 to 12 months. Brigatinib showed an ORR of 45% to 54% with a PFS of 9.2 to 12.9 months in the second-line setting. A more recent trial compared alectinib to crizotinib in the treatment-naive setting and showed a significant PFS benefit to treatment with alectinib. The second-generation ALK inihibitors brigatinib and alectinib offer new options for the treatment of ALK mutation-positive NSCLC.

Interactions between stress and physical activity on Alzheimer's disease pathology.

Physical activity and stress are both environmental modifiers of Alzheimer's disease (AD) risk. Animal studies of physical activity in AD models have largely reported positive results, however benefits are not always observed in either cognitive or pathological outcomes and inconsistencies among findings remain. Studies using forced exercise may increase stress and mitigate some of the benefit of physical activity in AD models, while voluntary exercise regimens may not achieve optimal intensity to provide robust benefit. We evaluated the findings of studies of voluntary and forced exercise regimens in AD mouse models to determine the influence of stress, or the intensity of exercise needed to outweigh the negative effects of stress on AD measures. In addition, we show that chronic physical activity in a mouse model of AD can prevent the effects of acute restraint stress on Aß levels in the hippocampus. Stress and physical activity have many overlapping and divergent effects on the body and some of the possible mechanisms through which physical activity may protect against stress-induced risk factors for AD are discussed. While the physiological effects of acute stress and acute exercise overlap, chronic effects of physical activity appear to directly oppose the effects of chronic stress on risk factors for AD. Further study is needed to identify optimal parameters for intensity, duration and frequency of physical activity to counterbalance effects of stress on the development and progression of AD.

Impact of Isotope Dilution Mass Spectrometry (IDMS) Standardization on Carboplatin Dose and Adverse Events.

BACKGROUND: When using area under the concentration-time curve-based strategies for dosing carboplatin, accurate estimation of glomerular filtration rate is required for determining dose. Commonly, the Cockcroft-Gault equation is used, which is dependent on measurement of serum creatinine (SCr). Because analysis of SCr changed to an isotope dilution mass spectrometry (IDMS) standard, we sought to determine the impact of this assay change on carboplatin dosing and related toxicity. METHODS: This was a single-center, retrospective chart review of adults treated with carboplatin between April 2008 and April 2010 divided into cohorts that initiated carboplatin before or after IDMS standardization. End points included grade 3 thrombocytopenia, decrease in platelet count, and hospitalization and were evaluated in cohorts based on concomitant chemotherapy. RESULTS: The chart review identified 158 patients, with 63 patients in the pre-IDMS group and 95 patients in the post-IDMS group. Average SCr (pre 1.01 mg/dl vs post 0.86 mg/dl, p<0.001) and average carboplatin dose (pre 580 mg vs post 703 mg, p<0.001) were significantly different between the groups. The frequency of grade 3 thrombocytopenia was not statistically significant across three partner chemotherapy cohorts before and after IDMS implementation. CONCLUSION: IDMS standardization led to an overall decrease in SCr with subsequent increase in carboplatin doses. However, no increase in recorded adverse events was observed, suggesting that the clinical relevance in toxicity from higher doses was minimal.