A systems science leverage point analysis of climate change advocacy.

Failure of governments across the world to address climate change has fuelled social movements focused on climate-related policy and action. Research analysing these movements has focused mainly on the types of strategies employed including blockades and occupations, marches and petitions, divestment, boycotts and litigation as well as how groups are framing climate change as a problem. What has been largely missed are the ways these groups are framing the change they want to see, that is their demands to governments. Not all demands and actions have the same potential to create the changes needed to mitigate climate change. Used in public health and health promotion, the systems science Intervention Level Framework (ILF) is a tool that can help analyse to what extent different demands have the leverage to create change in a system. We use the ILF to analyse 131 demands from 35 different climate-related advocacy groups in Australia. Results show demands are more focused on lower system leverage points, such as stopping particular projects, rather than on more impactful leverage points, such as the governance structures that determine climate-related policy and decision-making mechanisms. Further, the results highlight the lack of attention on public health related topics of transport and food systems. This paper shows how a systems science framework used in health promotion, the ILF, could enable climate advocacy groups to more effectively target demands to achieve more impactful outcomes from governments, corporations and the public.

What Can Public Health Administration Learn from the Decision-Making Processes during COVID-19?

Human decision-making is prone to biases and the use of heuristics that can result in making logical errors and erroneous causal connections, which were evident during COVID-19 policy developments and potentially contributed to the inadequate and costly responses to COVID-19. There are decision-making frameworks and tools that can improve organisational decision-making. It is currently unknown as to what extent public health administrations have been using these structured organisational-level decision-making processes to counter decision-making biases. Current reviews of COVID-19 policies could examine not just the content of policy decisions but also how decisions were made. We recommend that understanding whether these decision-making processes have been used in public health administration is key to policy reform and learning from the COVID-19 pandemic. This is a research and practice gap that has significant implications for a wide range of public health policy areas and potentially could have made a profound difference in COVID-19-related policy responses.

Application of theories of the policy process in research on consumption of sustainable diets: a systematic review.

BACKGROUND: There is a significant global lack of policy action on consumption of sustainable diets. Application of political science theories such as theories of the policy process can help in understanding policy inaction. Applying these theories could provide a more in-depth understanding of how various influences on the policy process shape decision making for consumption of sustainable diet policy. METHODS: A systematic review to examine application of eight key political science theories of the policy process to research on consumption of sustainable diets was conducted. RESULTS: The review identified no papers applying a theory of the policy process although 17 papers did mention or discuss influences on the policy process that are common elements within theories of the policy process. Most notably these elements were the influence of coalitions/networks, evidence use, narratives and framing, institutional and political system factors, and the importance of value and belief systems and socio-cultural norms. However, in most papers these influences were not examined in a detailed or in-depth way and often presented as suggestions for lack of policy action without the support of empirical data or application of any theory. CONCLUSIONS: Most research discussing policy inaction on the consumption of sustainable diets fails to utilise political science theories of the policy process, although a small number of papers include mention of or discussion of influences on the policy process. Application of political science theories could provide a more in-depth understanding of how different determinants might shape decision making at various points in the policy process. This could help identify key reasons for policy inaction on the consumption of sustainable diets and suggest possible ways to increase attention and action on the issue from policy decision makers.

Women's experiences of accessing individualized disability supports: gender inequality and Australia's National Disability Insurance Scheme.

BACKGROUND: Care services in industrialized nations are increasingly moving towards individualized funding models, which aim to increase individuals' flexibility, choice and control over their services and supports. Recent research suggests that such schemes have the potential to exacerbate inequalities, however none has explored gendered dimensions of inequality. The Australian National Disability Insurance Scheme (NDIS) is a major individualized funding reform, and has a female participation rate of only 37%, despite women and girls making up half of the disability population. METHODS: The objective of the study is to explore possible gendered barriers to applying for and receiving adequate support through the NDIS, and to suggest directions for future research. We report on semi-structured interviews with 30 women with disability and explore their experiences with the NDIS and their perspectives on challenges associated with being a woman seeking disability support in Australia. We analyse the results using thematic analysis. RESULTS: Most women in our sample reported differences between the experiences of men and women seeking disability support in Australia. Commonly reported gendered barriers to women being able to access the right supports for their disability involve a) confidence, negotiation and self-advocacy, b) gendered discrimination in diagnosis and the medical system, which has implications for disability support access, and c) support for and recognition of caring roles. CONCLUSIONS: These results suggest that women are not receiving equitable treatment with regard to the NDIS, and that further research and policy reform are needed to ensure that women with disability are not further disadvantaged as a result of the move toward individualized funding models.

Primary leptomeningeal melanoma: the prognostic significance of its genetic signature and embryological origin.

Primary leptomeningeal melanomas are rare, comprising less than one percent of all brain tumours. They are aggressive and radioresistant tumours, with a poor prognosis. The mainstay of treatment is complete surgical resection and chemotherapy with limited success. Distinguishing a primary leptomeningeal melanoma from the more common metastatic disease can be difficult, and often requires the use of ancillary molecular testing. Primary central nervous system melanomas, including uveal melanomas, frequently exhibit mutations in GNAQ and GNA11, rare in the cutaneous and mucosal counterparts.A case of a primary leptomeningeal melanoma of the cerebellopontine angle is described. Molecular studies identified a GNA11 p.Q209L and a KIT p.M541L missense variant, with losses of chromosomes 1p and 3p demonstrated with cytogenetic studies. Complete surgical resection was not possible and leptomeningeal metastatic disease rapidly ensued despite immunotherapy. Further understanding of the molecular signature may translate to improved diagnosis, prognostication and development of targeted therapies.

The Occurrence of Richter's Syndrome during Treatment with Obinutuzumab and Chlorambucil.

Chronic lymphocytic leukaemia is a slow-growing leukaemia of developing B-lymphocytes, which may transform to an aggressive lymphoma known as Richter's syndrome. While Richter's syndrome can present in untreated or relapsed-refractory cases, it may occur upon the commencement of less intensity treatment regimens. We present a case of Richter's syndrome following treatment with chlorambucil and obinutuzumab and review of available literature on the topic.

Alignment and political will: upscaling an Australian respectful relationships program.

Many small scale efficacious programs and interventions need to be 'scaled-up' in order to reach a larger population. Although it has been argued that interventions deemed suitable for upscaling need to have demonstrated effectiveness, be able to be implemented cost-effectively and be accepted by intended recipients, these factors alone are insufficient in explaining which programs are adopted more broadly. Upscaling research often identifies political will as a key factor in explaining whether programs are supported and up-scaled, but this research lacks any depth into how political will is formed and has not applied policy theories to understanding the upscaling process. This article uses a political science lens to examine the key factors in the upscaling process of a Respectful Relationships in Schools Program. Focus groups and interviews were conducted with project staff, managers and community organizations involved in the program. The results reveal how a key focusing event related to a highly profiled personal tragedy propelled family violence into the national spotlight. At the same time, the organization leading the respectful relationships program leveraged their networks to position the program within the education department which enabled the government to quickly respond to the issue. The study highlights that political will is not a stand-alone factor as depicted by up-scaling models, but rather is the end point of a complex process that involves many elements including the establishment of networks and aligned programs that can capitalize when opportunities arise.

Adapting to a marketised system: Network analysis of a personalisation scheme in early implementation.

As governments worldwide turn to personalised budgets and market-based solutions for the distribution of care services, the care sector is challenged to adapt to new ways of working. The Australian National Disability Insurance Scheme (NDIS) is an example of a personalised funding scheme that began full implementation in July 2016. It is presented as providing greater choice and control for people with lifelong disability in Australia. It is argued that the changes to the disability care sector that result from the NDIS will have profound impacts for the care sector and also the quality of care and well-being of individuals with a disability. Once established, the NDIS will join similar schemes in the UK and Europe as one of the most extensive public service markets in the world in terms of numbers of clients, geographical spread, and potential for service innovation. This paper reports on a network analysis of service provider adaptation in two locations-providing early insight into the implementation challenges facing the NDIS and the reconstruction of the disability service market. It demonstrates that organisations are facing challenges in adapting to the new market context and seek advice about adaptation from a stratified set of sources.

Clear cell sarcoma of the gastrointestinal tract and malignant gastrointestinal neuroectodermal tumour: distinct or related entities? A review.

Clear cell sarcoma is an uncommon sarcoma which rarely occurs as a primary tumour in the gastrointestinal tract (CCS-GIT). It shares common molecular genetic abnormalities with the more recently described entity, malignant gastrointestinal neuroectodermal tumour (GNET) but is distinguished by its morphological and immunohistochemical findings. The exact nosological relationship between these tumours continues to be debated. In this review, we present two cases of these rare neoplasms from our files and perform a statistical comparison of all published cases to determine if significant differences exist in their clinicopathological features and biological behaviour. Thirteen cases of CCS-GIT and 58 of GNET were included. CCS-GIT occurred more commonly in males (84.6% vs 46.6%, p = 0.01) and in an older age group (median 57 vs 33 years, p < 0.01). There was no significant difference in their location in the gastrointestinal tract, median tumour size and proportion of cases with an EWSR1-ATF1 vs EWSR1-CREB1 fusion. Median survival for CCS-GIT was 13.5 months and for GNET, 9.5 months (p = 0.78). There was no significant difference in the Kaplan-Meier survival curves for either time to first metastasis (p = 0.88) or overall survival (p = 0.18), including after controlling for tumour size using regression models. Our analysis confirms that aside from morphological variations between these tumours, they also exhibit epidemiological and clinical differences. Despite the prevalent perception that GNET is associated with a more aggressive clinical course, our findings indicate that there is no significant difference in their biological behaviour, although both clearly share a bleak prognosis. Further experience is awaited to determine optimal treatment strategies and whether CCS-GIT and GNET would differ in their response to various therapies.

Applying systems theory to the evaluation of a whole school approach to violence prevention.

Issue addressed Our Watch led a complex 12-month evaluation of a whole school approach to Respectful Relationships Education (RRE) implemented in 19 schools. RRE is an emerging field aimed at preventing gender-based violence. This paper will illustrate how from an implementation science perspective, the evaluation was a critical element in the change process at both a school and policy level. Methods Using several conceptual approaches from systems science, the evaluation sought to examine how the multiple systems layers - student, teacher, school, community and government - interacted and influenced each other. A distinguishing feature of the evaluation included 'feedback loops'; that is, evaluation data was provided to participants as it became available. Evaluation tools included a combination of standardised surveys (with pre- and post-intervention data provided to schools via individualised reports), reflection tools, regular reflection interviews and summative focus groups. Results Data was shared during implementation with project staff, department staff and schools to support continuous improvement at these multiple systems levels. In complex settings, implementation can vary according to context; and the impact of evaluation processes, tools and findings differed across the schools. Interviews and focus groups conducted at the end of the project illustrated which of these methods were instrumental in motivating change and engaging stakeholders at both a school and departmental level and why. Conclusion The evaluation methods were a critical component of the pilot's approach, helping to shape implementation through data feedback loops and reflective practice for ongoing, responsive and continuous improvement. Future health promotion research on complex interventions needs to examine how the evaluation itself is influencing implementation. So what? The pilot has demonstrated that the evaluation, including feedback loops to inform project activity, were an asset to implementation. This has implications for other health promotion activities, where evaluation tools could be utilised to enhance, rather than simply measure, an intervention. The findings are relevant to a range of health promotion research activities because they demonstrate the importance of meta-evaluation techniques that seek to understand how the evaluation itself was influencing implementation and outcomes.

Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children.

BACKGROUND AND OBJECTIVES: Perioperative pain in children can be effectively managed with systemic opioids, but addition of paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce opioid requirements and potentially improve analgesia and/or reduce adverse effects. METHODS: A systematic literature search was conducted to identify trials evaluating postoperative opioid requirements in children and comparing NSAID and/or paracetamol with placebo. Studies were stratified according to design: continuous availability of intravenous opioid (PCA/NCA) vs intermittent 'as needed' bolus; and single vs multiple dose paracetamol/NSAIDs. Primary outcome data were extracted, and the percentage decrease in mean opioid consumption was calculated for statistically significant reductions compared with placebo. Secondary outcomes included differences in pain intensity, adverse effects (sedation, respiratory depression, postoperative nausea and vomiting, pruritus, urinary retention, bleeding), and patient/parent satisfaction. RESULTS: Thirty-one randomized controlled studies, with 48 active treatment arms compared with placebo, were included. Significant opioid sparing was reported in 38 of 48 active treatment arms, across 21 of the 31 studies. Benefit was most consistently reported when multiple doses of study drug were administered, and 24 h PCA or NCA opioid requirements were assessed. The proportion of positive studies was less with paracetamol, but was influenced by dose and route of administration. Despite availability of opioid for titration, a reduction in pain intensity by NSAIDs and/or paracetamol was reported in 16 of 29 studies. Evidence for clinically significant reductions in opioid-related adverse effects was less robust. CONCLUSION: This systematic review supports addition of NSAIDs and/or paracetamol to systemic opioid for perioperative pain management in children.

Elevated serum cytokine levels using cytometric bead arrays predict culture-positive infections in childhood oncology patients with febrile neutropenia.

Neutropenic patients with bacteraemia need prolonged intravenous antibiotic treatment. Using cytometric bead array technology, we show in children with febrile neutropenia that bacteraemia is associated with an elevation of at least 1 of 3 plasma cytokines plus C-reactive protein. The combination of interleukin (IL)-8, IL-6, IL-10, and C-reactive protein values above operator-defined cutoff levels identified 15 of 16 episodes of bacteraemia, making this a potentially useful technique in identifying high-risk patients who should not be discharged early from hospital. Furthermore, low risk of bacteraemia may be predicted by a combination of below threshold cytokines and negative clinical examination.