Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention.

BACKGROUND: Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes. METHODS: A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines. DISCUSSION: This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Understanding patient access patterns for primary health-care services for Aboriginal and Islander people in Queensland: a geospatial mapping approach.

This paperexplores the patterns ofpatients'accessingsix Aboriginal and Islander CommunityControlled Health Services (AICCHSs) in Queensland. Between August 2011 and February 2014, 26199 patients made at least one visit over a 2-year period prior to at least one of six Queensland AICCHS - one urban service (RA 1) in south-east Queensland, and five services in regional towns (RA 3) in Far North Queensland. Geospatial mapping of addresses for these registered patients was undertaken. The outcomes analysed included travel times to, the proportion of catchment populations using each AICCHS and an assessment of alternative mainstream general practice availability to these patients was made. In brief, the use of AICCHS was higher than Australian Bureau of Statistics census data would suggest. Approximately 20% of clients travel more than 30min to seek Aboriginal Health services, but only 8% of patients travelled longer than 60min. In the major city site, many other general practitioner (GP) services were bypassed. The data suggest Aboriginal and Islander patients in Queensland appear to value community-controlled primary care services. The number of Indigenous clients in regional locations in the Far North Queensland registered with services is often higher than the estimated resident population numbers.

Utility of field-based techniques to assess Indigenous Australians' functional fitness and sedentary time.

OBJECTIVE: To examine the utility of field-based techniques to assess functional exercise capacity and sedentary time in Indigenous and non-Indigenous regional Australian adults. STUDY DESIGN: Observational, analytic cohort study. METHODS: Ninety six adults residing in regional and remote Australian communities participated in this study (Indigenous n = 61 and non-Indigenous Australians n = 35). Participants undertook a field-based test of functional exercise capacity (6 min walk test; 6 MWT) and wore an accelerometer during waking hours for seven days, provided self-report data on physical activity and sedentary time and rated experiences in regard to the ease of complying with study protocols. RESULTS: There were high levels of compliance in this study (Indigenous: 91% and non-Indigenous: 97%). Functional exercise capacity was lower in Indigenous Australians (P < 0.001), and independently associated with advancing age, higher BMI, and indigeneity, with 45% of variability in the 6 MWT distance explained by these factors. The relationship between accelerometer and self-report measures of sedentary behaviour was significant (P < 0.001) but only explained 17% of the total variation. CONCLUSIONS: This study demonstrated very good compliance for the methods utilised and is the first to report reduced functional exercise capacity in Indigenous people. IMPLICATIONS: The field-based techniques from this study demonstrate good utility for larger scale implementation in regional Indigenous populations.

Prevention and management of chronic disease in Aboriginal and Islander Community Controlled Health Services in Queensland: a quality improvement study assessing change in selected clinical performance indicators over time in a cohort of services.

OBJECTIVE: To evaluate clinical healthcare performance in Aboriginal Medical Services in Queensland and to consider future directions in supporting improvement through measurement, target setting and standards development. DESIGN: Longitudinal study assessing baseline performance and improvements in service delivery, clinical care and selected outcomes against key performance indicators 2009-2010. SETTING: 27 Aboriginal and Islander Community Controlled Health Services (AICCHSs) in Queensland, who are members of the Queensland Aboriginal and Islander Health Council (QAIHC). PARTICIPANTS: 22 AICCHS with medical clinics. INTERVENTION: Implementation and use of an electronic clinical information system that integrates with electronic health records supported by the QAIHC quality improvement programme-the Close the Gap Collaborative. MAIN OUTCOME MEASURES: Proportion of patients with current recording of key healthcare activities and the prevalence of risk factors and chronic disease. RESULTS: Aggregated performance was high on a number of key risk factors and healthcare activities including assessment of tobacco use and management of hypertension but low for others. Performance between services showed greatest variation for care planning and health check activity. CONCLUSIONS: Data collected by the QAIHC health information system highlight the risk factor workload facing the AICCHS in Queensland, demonstrating the need for ongoing support and workforce planning. Development of targets and weighting models is necessary to enable robust between-service comparisons of performance, which has implications for health reform initiatives in Australia. The limited information available suggests that although performance on key activities in the AICCHS sector has potential for improvement in some areas, it is nonetheless at a higher level than for mainstream providers. IMPLICATIONS: The work demonstrates the role that the Community Controlled sector can play in closing the gap in Aboriginal and Torres Strait Islander health outcomes by leading the use of clinical data to record and assess the quality of services and health outcome.

An unusual complication of dental radiography: case report.

We present the case of a 46-year-old man who was undergoing a routine dental examination when a radiograph film plate became lodged in his upper aero-digestive tract. The foreign body was successfully removed in the ENT department of the local hospital without significant harm being done. The case highlights the potential risks of even the simplest procedures, and makes a good argument for using radiograph film holders, when possible.

Gibberellin inhibitors improve embryogenic tissue initiation in conifers.

Somatic embryogenesis (SE), the most promising technology to multiply high-value coniferous trees from advanced breeding and genetic engineering programs, is expected to play an important role in increasing productivity, sustainability, and uniformity of future forests in the United States. For commercial use, SE technology must work with a variety of genetically diverse trees. Initiation in loblolly pine (LP; Pinus taeda L.), our main focus species, is often recalcitrant for desirable genotypes. Initiation of LP, slash pine (SP; Pinus elliottii), Douglas-fir (DF; Pseudotsuga menziesii), and Norway spruce (NS; Picea abies) were improved through the use of paclobutrazol, a gibberellin synthesis inhibitor. Paclobutrazol was effective at concentrations ranging from 0.25 mg/l to 3.0 mg/l (0.85-10.2 microM) and optimal in LP at 1.0 mg/l. Using control media (no paclobutrazol) and 0.33-1.0 mg/l paclobutrazol, initiation percentages in LP, SP, DF, and NS were improved from 37.7% to 44.2% (across experiments), 19.3% to 28.5%, 16.9% to 23.7%, and 38.8% to 48.5%, respectively. Other gibberellin inhibitors such as flurprimidol, chlormequat-Cl, and daminozide also caused statistically significant increases in LP initiation when added to the medium at concentrations of 0.34, 10.0, and 1.0 microM, respectively. No detrimental effects on subsequent embryo development were observed when 29 new initiations from medium without GA inhibitor and 28 new initiations from medium containing paclobutrazol were tracked through culture capture, liquid culture establishment, cotyledonary embryo development, and germination.

Operation Safe Haven: an evaluation of health surveillance and monitoring in an acute setting.

From May to June 1999, 3,920 ethnic Albanians from Kosovo arrived in Australia as part of Operation Safe Haven. These people were evacuated from refugee camps in the former Yugoslav Republic of Macedonia. Initial processing in Australia occurred at East Hills Reception Centre, and accommodation for the duration of stay was provided in eight Haven Centres in five States. The arrival of a large number of refugees in a short time frame is unprecedented in Australia. A health surveillance system was developed and critical health data were collected to assess health status and needs, plan care, monitor for potential outbreaks of communicable diseases, track service use, to meet international reporting requirements and document our response to this crisis. In this article the health surveillance system is evaluated and suggestions are offered for the formulation of specific guidelines necessary for health surveillance in acute settings.

CSF bacterial antigen detection tests offer no advantage over Gram's stain in the diagnosis of bacterial meningitis.

While bacterial antigen detection (BAD) tests have been used on cerebrospinal fluid (CSF) with success in the diagnosis of bacterial infection in developing countries, their value in the developed world has been recently questioned. In Darwin, Northern Territory (NT), there are good diagnostic resources but high rates of infectious disease, so it was unclear which findings were applicable to our own population. This study aimed to determine the utility of the BAD tests in detection of bacterial meningitis from CSF in patients studied at Darwin, using a retrospective review of hospital case records and microbiology laboratory reports, over a 19 month period, and utilising a clinical component in the case definition of bacterial meningitis. The sensitivity of the BAD test in the diagnosis of acute bacterial meningitis was 28.6%, with a specificity of 98.7% and a positive predictive value of 85.7%. The cost per positive test was computed at $240. No cases of bacterial meningitis which were positive on the BAD test were missed on Gram's stain of CSF. We conclude that in our setting BAD tests alone are not sensitive enough to confidently diagnose bacterial meningitis. BAD tests are more costly and offer no advantage in speed of diagnosis or in antibiotic pre-treated patients, compared to routine Gram's stain.

Estimating the prevalence of Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus infection in indigenous women in northern Australia.

OBJECTIVE: To estimate more accurately the age specific prevalence of Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus infection (HPV) in indigenous women living in urban, rural, and remote areas of the "Top End" of the Northern Territory (NT). DESIGN: Analysis of data obtained from two community based studies using self administered tampon specimens tested by polymerase chain reaction for sexually transmitted disease (STD). Data pertaining to the notifiable STDs (N gonorrhoeae and C trachomatis) were obtained from the NT health department. PATIENTS: 1090 indigenous women (age range 12-73 years) were enrolled when they attended local community health centres, family planning clinics, and STD clinics. The majority attended clinics in their home community in the course of "well women's checks" which encourage women to undergo screening for a variety of general medical conditions. RESULTS: The overall prevalence of T vaginalis, C trachomatis, N gonorrhoeae, and HPV was 0.25 (95% CI: 0.22-0.28), 0.11 (0.09-0.13), 0.17 (0.15-0.19), and 0.42 (0.37-0.48) respectively. Of the women found to be infected (excluding HPV), 25.5% had two or more of the above organisms detected. There was a statistically significant increase in the age specific prevalence of T vaginalis but a significant decrease with age for C trachomatis and HPV infection. There was no statistically significant change for N gonorrhoeae with age. CONCLUSIONS: STDs are hyperendemic in this population of indigenous women and the notification data significantly underestimate their prevalence. Distinct patterns of age specific prevalence were demonstrated, highlighting the need to tailor control strategies to specific epidemiological features.

Dengue or Kokobera? A case report from the top end of the Northern Territory.

In early April 1998, the Centre for Disease Control in Darwin was notified of a possible case of dengue which appeared to have been acquired in the Northern Territory. Because dengue is not endemic to the Northern Territory, locally acquired infection has significant public health implications, particularly for vector identification and control to limit the spread of infection. Dengue IgM serology was positive on two occasions, but the illness was eventually presumptively identified as Kokobera infection. This case illustrates the complexity of interpreting flavivirus serology. Determining the cause of infection requires consideration of the clinical illness, the incubation period, the laboratory results and vector presence. Waiting for confirmation of results, before the institution of the public health measures necessary for a true case of dengue, was ultimately justified in this case. This is a valid approach in the Northern Territory, but may not be applicable to areas of Australia with established vectors for dengue.

A profile of inpatient STD-related pelvic inflammatory disease in the Top End of the Northern Territory of Australia.

OBJECTIVE: To obtain a profile of inpatient STD-related pelvic inflammatory disease (PID) in the Top End of the Northern Territory. DESIGN: Review of case records. SETTING: The Royal Darwin Hospital, the tertiary referral centre for the Top End, during the three years from June 1991 to May 1994. PATIENTS: All admissions with a diagnosis of STD-related PID. MAIN OUTCOME MEASURES: The presentation and incidence of STD-related PID in Aboriginal and non-Aboriginal women. RESULTS: PID was the reason for 14% of admissions of Aboriginal women and 2% of non-Aboriginal women. Of 175 episodes of PID in 169 patients admitted over the three years of the study, 41 (23%) had gonorrhoea, 64 (37%) had chlamydia and 7 (4%) had both organisms isolated on genital swab. Aboriginal women were more than twice as likely to have gonorrhoea (38% versus 18%; risk ratio, 2.12; 95% confidence interval, 1.27-3.53) as non-Aboriginal women. Median time from first symptoms to presentation was six days. All gonococcal isolates were penicillin susceptible. CONCLUSIONS: STD-related pelvic inflammatory disease is an important problem among women in the Top End of the Northern Territory. As PID is a preventable illness, further measures aimed at prevention and earlier, more effective treatment of STDs that cause PID are urgently required.

Pilot study of azithromycin in the treatment of genital donovanosis.

OBJECTIVES: To determine the effectiveness of azithromycin, an azalide antibiotic with long tissue half-life, in a pilot study of patients with genital donovanosis in the Northern Territory, Australia. DESIGN: Patients with histologically confirmed donovanosis were randomised to receive one of two open-label azithromycin dosage regimens: Regimen A--1.0 g once weekly for 4 weeks; or Regimen B--500 mg daily for 7 days. Patients were assessed at 6 weeks and classified as either "cured", "improved" or "failed". RESULTS: Seven patients received regimen A and 4 received regimen B. Six weeks after commencing treatment the genital ulcers of four patients receiving regimen A and one patient receiving regimen B had healed; the lesions of the other six patients (3 in each regimen) were "improved". No patient failed to respond and no significant adverse reaction was recognised. The eleven patients were reviewed after completing the six-week trial; all lesions had re-epithelialised without further antibiotic treatment, no relapses had occurred, the longest follow-up period being seven months. A further 17 patients with donovanosis who were unable to meet the entry criteria were also treated successfully with azithromycin during the study period. CONCLUSIONS: This is the first time that azithromycin has been shown to have clinical activity against donovanosis. Poor compliance with prolonged courses of antibiotics is one of the major barriers to control of the disease. Intermittent or short-course therapy, made possible by the long tissue half-life of the drug, could facilitate control of donovanosis in endemic populations if the high cost of medication can be addressed.

Natural history and associations of dissociated vertical divergence.

One hundred patients with dissociated vertical divergence (DVD) have been followed up for an average of 7.3 years. In contrast to some other reports, none of them has worthwhile binocular vision. There has been a constant association with nystagmus, often manifest, and the DVD has always been noted later than the nystagmus. In no case has the degree of DVD decreased significantly with age. The dissociation has only rarely caused a serious cosmetic problem, and then it has been markedly asymmetrical and has been improved by combined superior rectus recession and Faden procedure. DVD can simulate inferior oblique overactions, but is more commonly associated with an A phenomenon, and can be distinguished by careful cover/uncover testing. The common occurrence of associated congenital defects, especially of the central nervous system, is noted.