The complexities of defining nurse practitioner scope of practice in the Australian context.

AIMS: To explore the legislative and regulatory constraints that defines nurse practitioner scope of practice within the Australian context. BACKGROUND: Nurse practitioners have been endorsed to practice in Australia for over 13 years. However, despite this lengthy period, there still remains confusion amongst newly endorsed nurse practitioners and their employers as to what determines the scope of their practice in Australia. DESIGN: A review of available policy and regulatory documents related to the Australian operational requirements for nurse practitioner scope of practice cited within or referred to by the Nursing and Midwifery Board of Australia. DATA SOURCES: Data were collected over a 2-month period in 2013. This utilized the current standards, codes and guidelines cited by the Nursing and Midwifery Board of Australia related to scope of practice and nurse practitioner, as well as legislation and regulation referred to in relation to nurse practitioner practice. Information was also obtained through government health and professional organization websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant. Implications for nursing: Providing a means of interpreting the determinants of nurse practitioner scope of practice within Australia. CONCLUSIONS: The factors that determine nurse practitioner scope of practice, education, clinical experience, and competence leading to endorsement, are straightforward. However, the context of clinical practice, including jurisdictional restrictions, is major barriers to the expression of nurse practitioner scope of practice. These restrictions, although not insurmountable, continue to hinder nurse practitioners from practicing to their full scope of practice.

Influence of Prosolv and Prosolv:Mannitol 200 direct compression fillers on the physicomechanical properties of atorvastatin oral dispersible tablets.

The objective of the present study was to evaluate the influence of Prosolv® and Prosolv®: Mannitol 200 direct compression (DC) fillers on the physicomechanical characteristics of oral dispersible tablets (ODTs) of crystalline atorvastatin calcium. ODTs were formulated by DC and were analyzed for weight uniformity, hardness, friability, drug content, disintegration and dissolution. Three disintegration time (DT) test methods; European Pharmacopoeia (EP) method for conventional tablets (Method 1), a modification of this method (Method 2) and the EP method for oral lyophilisates (Method 3) were compared as part of this study. All ODTs showed low weight variation of <2.5%. Prosolv® only ODTs showed the highest tablet hardness of ∼ 73 N, hardness decreased with increasing mannitol content. Friability of all formulations was <1% although friability of Prosolv®:Mannitol ODTs was higher than for pure Prosolv®. DT of all ODTs was <30 s. Method 2 showed the fastest DT. Method 3 was non-discriminatory giving a DT of 13-15 s for all formulations. Atorvastatin dissolution from all ODTs was >60% within 5 min despite the drug being crystalline. Prosolv® and Prosolv®:Mannitol-based ODTs are suitable for ODT formulations by DC to give ODTs with high mechanical strength, rapid disintegration and dissolution.

Application of a novel 3-fluid nozzle spray drying process for the microencapsulation of therapeutic agents using incompatible drug-polymer solutions.

The aim of this study was to evaluate a novel 3-fluid concentric nozzle (3-N) spray drying process for the microencapsulation of omeprazole sodium (OME) using Eudragit L100 (EL100). Feed solutions containing OME and/or EL100 in ethanol were assessed visually for OME stability. Addition of OME solution to EL100 solution resulted in precipitation of OME followed by degradation of OME reflected by a colour change from colourless to purple and brown. This was related to the low pH of 2.8 of the EL100 solution at which OME is unstable. Precipitation and progressive discoloration of the 2-fluid nozzle (2-N) feed solution was observed over the spray drying time course. In contrast, 3-N solutions of EL100 or OME in ethanol were stable over the spray drying period. Microparticles prepared using either nozzle showed similar characteristics and outer morphology however the internal morphology was different. DSC showed a homogenous matrix of drug and polymer for 2-N microparticles while 3-N microparticles had defined drug and polymer regions distributed as core and coat. The results of this study demonstrate that the novel 3-N spray drying process can allow the microencapsulation of a drug using an incompatible polymer and maintain the drug and polymer in separate regions of the microparticles.

Fast disintegrating crystalline solid dispersions of simvastatin for incorporation into orodispersible tablets.

AIM: Spray dried solid dispersion (SDP) of crystalline simvastatin (SIM) in a fast disintegrating matrix of superdisintegrants was studied as a method to enhance SIM dispersibility, rheology, compactibility and compressibility for incorporation into orodispersible tablets (ODTs). MATERIALS AND METHODS: The superdisintegrants investigated were crospovidone (CP), sodium starch glycollate (SSG) and calcium silicate (CS) were spray dried with simvastatin to form SDPs. RESULTS: The SDPs were characterized and the median particle size of SDPs was similar or greater than the SIM, contributing to good rheology of SDPs, while the low bulk density of SDPs indicated a high compactibility. Interestingly electron micrographs for SDPs showed a CP or CS carrier coating of the SIM crystals, contributing to its rheology. Thermal analysis and X-ray diffraction confirmed that SIM was crystalline in the SDPs and no interaction between SIM and any of the carrier(s) was shown by Fourier transform-infra red. Drug content analysis showed a SIM content of 90-95% in SDPs containing CP or CS, while a higher SIM content of 143% was found in SDP containing SSG. When formulated as ODTs, blend containing SIM SDPs in CP showed ease of tableting, regardless of the turret speed. In comparison, tablet blend consisting of a physical mix (PM) of SIM and CP could only be tableted at the lower turret speed of 7 rpm. ODTs formulated using SIM SDPs in CP showed a higher extent of dissolution, compared to the ODTs containing corresponding PM or the commercially available SIM Zocor(®) tablets (ANOVA, P < 0.05). CONCLUSION: SDP using disintegrants as carriers may offer an alternative formulation approach for ODTs of poorly soluble drugs.

A naturalistic trial of brief psychodynamic therapy for recurrent major depression.

We examined disposition, course, and outcome for 100 outpatients offered short-term individual dynamic therapy as a primary treatment for recurrent major depression. Evaluations using the Hamilton Rating Scale for Depression (HAM-D) were conducted regularly during the year after referral. Patients failing to show a response (50% decrease in pre-treatment HAM-D scores) were referred for consultation regarding "augmentation" of therapy with antidepressant medication. Nineteen referrals failed to meet inclusion-exclusion criteria, reflecting therapist overestimation of the severity of patients' depressive symptoms; referring therapists also missed other salient clinical issues. Fourteen patients completed assessments but did not start therapy; "decliners" were more likely to report previous admissions and thus may have opted for hospitalization. Sixty-seven patients started therapy; 18 dropped out (26.9%). Of the 49 therapy completers, 23 (46.9%) did not receive augmented treatment; 20 (40.8%) demonstrated evidence of recovery during the year while 3 (6.1%) did not. Of the 26 patients (53.1%) prescribed antidepressants, 16 (32.7%) demonstrated evidence of recovery and 10 (20.4%) did not. Patient clusters also showed distinct trajectories of change on the HAM-D over the year after referral. Patients who received augmented treatment but showed no evidence of recovery scored significantly higher on indices of alexithymia. Clinical implications of the findings are considered.

Investigation of the interaction of biodegradable micro- and nanoparticulate drug delivery systems with platelets.

OBJECTIVES: Biodegradable micro- and nanoparticles are being increasingly investigated for drug delivery and targeting of therapeutics. The size and surface properties of these particles are important factors influencing their interaction and uptake by various cells, tissues and organs. Optimising these properties, to enhance cellular uptake, may increase their potential for interaction with other physiological components such as platelets resulting in platelet activation and inappropriate thrombus formation. The aim of this study was to investigate the potential interaction of particulates with platelets. METHODS: Biodegradable micro- and nanoparticles based on poly-lactide-co-glycolide (PLGA), poly-lactide-co-glycolide-macrogol (PLGA-macrogol) and chitosan were prepared using solvent evaporation, spray drying or solvent dispersion techniques. KEY FINDINGS: Microparticles formulated had a median diameter (D50%) of 2-9 µm, while nanoparticles had an average diameter of 100-500 nm. The surface morphology ranged from smooth and spherical to irregular depending on polymer and preparation method used. Particles, reconstituted in the concentration range of 0.1-500 µg/ml, were tested for their ability to induce or inhibit platelet aggregation. No effects on either induction of platelet activity or inhibition of aggregation were detected. CONCLUSIONS: None of the particles examined were found to alter platelet activity. These results suggested that the biodegradable micro- and nanoparticles tested were safe for use as potential drug carriers of therapeutic agents.

A comparative study of a range of polymeric microspheres as potential carriers for the inhalation of proteins.

The aim of this study was to compare protein-loaded inhalable microparticles manufactured using a range of biocompatible polymers including hydroxypropyl cellulose (HPC), chitosan, hyaluronic acid, alginate, gelatin, ovalbumin and poly(lactide-co-glycolide) (PLGA). Spray-drying was used to prepare microparticles containing bovine serum albumin labeled with fluorescein isothiocyanate (BSA-FITC). Particles of respirable size and high protein loading were obtained. No evidence of BSA degradation was seen from PAGE analysis. The microparticles were mixed with mannitol as a carrier and powder aerosolization was assessed with a multi-dose dry powder inhaler (DPI) using a multi-stage cascade impactor. The mass median aerodynamic diameter (MMAD) ranged between 2.9 and 4.7 microm. Potential polymer toxicity in the lungs was compared by impinging the particles on Calu-3 monolayers and assessing the cytotoxicity, induction of cytokine release, changes in transepithelial permeability and electrical resistance. No toxic effects were observed with most of the polymers though some evidence of compromised cell monolayer integrity was seen for PLGA and ovalbumin. PLGA and gelatin microparticles caused a significant increase in IL-8 release. Of the polymers studied, PLGA showed the greatest toxicity. Certain polymers showed particular promise for specific protein delivery needs in the lungs, such as HPC to improve flow properties, sodium hyaluronate for controlled release, and chitosan and ovalbumin for systemic delivery.

'Outfoxed' - out of season.

A 65 year old woman presented to the Emergency Department of our district general hospital three hours following ingestion of a blended mixture of apples and foxglove leaves, mistaking them for spinach leaves. She complained of nausea, vomiting, abdominal cramps, dizziness and blurred vision.

A survey of adherence to community-generated safety guidelines in rotor-wing air medical programs.

INTRODUCTION: Operational safety, both crash prevention and improved crash survival, is a central concern in the air medical community. Professional organizations have published operational safety guidelines, but the extent to which those guidelines are followed is unclear. We report the results of a survey of adherence with selected safe practice recommendations. METHODS: An anonymous survey of adherence with 8 individual and 11 program safety guidelines was distributed to flight team members at 10 Association of Air Medical Services-member rotor-wing air medical programs selected by stratified random sample to ensure geographic diversity. Descriptive statistics are reported and relationships are evaluated with the chi-square test. The sample size provided 80% power at a .05 significance level for the comparisons. RESULTS: Data were analyzed from 126 of the 200 surveys distributed. Adherence with program-wide safety behaviors ranged from 41.3% (complete a pre-departure checklist) to 99.2% (program has an annual safety review). Adherence to individual behaviors ranged from 15.1% (wear fire-resistant gloves) to 99.2% (wear seatbelts and shoulder harnesses on approach and departure). There was 100% adherence to wearing helmets by the respondents whose program provided a helmet at no cost to the staff member. There were no associations between job description and any individual behavior. Hospital-operated programs were less likely to have a daily briefing (P < .05), less likely to have a written policy allowing flight refusal for fatigue (P < .01), and tended toward lower rates of having a written policy allowing flight refusal for fatigue (P = .07). Non-hospital-operated programs were less likely to provide helmets (P < .001), to operate in an airframe with a clear headstrike area (P < .001), and to wear long-sleeved fire-resistant flight suits (P = .01). CONCLUSION: Both organizational and individual adherence to community safety recommendations are variable and not universal. There is variability by operational models.

Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts.

INTRODUCTION: Twenty-four hour availability creates physiological and psychological challenges for air medical teams. The 24-hour shift (24H) is a common staffing pattern in the air medical community. We report sleep dept and pre-duty activity patterns for 24H medical staff members at helicopter air medical transport programs. METHODS: An anonymous survey collecting self-reported sleep quantities for off-duty, immediate pre-duty, and on-duty periods, along with self-reported outside employment patterns, was distributed to medical team members at cluster sample of 10 rotor wing air medical programs selected by stratified random sample to ensure geographic and operational diversity. Both matched-sample comparisons of sleep quantities in different phases of the duty-cycle and independent-sample comparisons between staff with and without outside employment had 80% power to detect a difference in means of 60 minutes at a 0.05 two-sided significance level using the appropriate t-test. Descriptive statistics are also reported; means are reported with the standard deviation. RESULTS: A total of 138 surveys were returned (69.0%) and the 133 (66.5%) that were fully completed were utilized for analysis. 24H crewmembers average nearly the same amount of sleep in 24 hour periods on both duty and non-duty days (6.9 +/- 1.3 v. 6.4 +/- 1.8 hours, p = NS, range 3 - 10 for duty days and 4 - 10 for non-duty days). On duty, they average 1.1 +/- 1.3 hours of sleep in the first half of their shifts (range 0 to 5) and 5.3 +/- 1.4 hours in the overnight portion (range 2 - 9). The lowest amount of on-duty sleep reported in the past 30 days ranged from 0 to 6 hours, averaging 1.9 +/- 1.7 hours. The minimum pre-duty sleep reported by 24H crewmembers prior to any shift in the past month averaged 4.6 +/- 1.6 hours (range 0-8), with 3.8% having reported in the past month with no sleep before their 24-hour shift. Outside employment (OE) in addition to the flight position was common for 24H crewmembers (81.1% of respondents). Pre-duty sleep did not differ significantly between 24H crewmembers with and without OE, but 16.3% of surveyed 24H crewmembers with OE had reported for flight duty within eight hours of leaving OE within the past 30 days. CONCLUSION: In the programs surveyed, 24H crewmembers completed an average duty cycle with little sleep debt and were unlikely to be sleepless prior to reporting for a shift. OE is common for 24H medical staff and some personnel report for flight duty within eight hours of leaving an OE position. As the industry considers the impact of fatigue on operational safety, shift length, on-duty rest, and outside employment will be important considerations.

Increased intracellular targeting to airway cells using octaarginine-coated liposomes: in vitro assessment of their suitability for inhalation.

Delivery of macromolecular drugs to airway cells after inhalation can be limited by rapid clearance, in vivo degradation, and poor intracellular targeting. Liposome carriers offer an effective method of improving drug stability, but conventional liposomes have limited intracellular targeting capacity and are cleared rapidly by the lungs. Further modification is required to improve liposome-cell interaction and intracellular targeting. Therefore, we proposed conjugating three arginine-rich membrane translocating peptides, namely, HIV-TAT, Antennapedia, and octaarginine, to neutral liposomes as a biocompatible alternative to cationic lipids for intracellular delivery of macromolecules to airway cells. Conjugation did not significantly affect liposome stability, and each system was nebulized to produce aerosols of mean aerodynamic diameter < 1.5 microm. The peptides caused a significant (p < 0.05) increase in liposome-airway cell association compared to untagged liposomes and to DOTAP liposomes. Up to 30% of the peptide-conjugated liposomes added were bound and internalized (via a temperature-dependent, endocytic process) after just 2 h. The novel carriers all delivered encapsulated dextrans rapidly and efficiently to the cytoplasm of Calu-3 cells. Once internalized by the cells, the modified carriers localize for the most part in the cytoplasm with only a small amount of nuclear localization. These peptide-conjugated liposomes were significantly (p < 0.05) less toxic than DOTAP liposomes with octaarginine-coated liposomes the least toxic. These systems, particularly octaarginine-coated liposomes, offer many advantages for drug delivery to airway epithelial cells including increased stability, improved cell binding, and cell uptake with an improved toxicity profile.

Parallel synthesis and in vitro activity of novel anthranilic hydroxamate-based inhibitors of the prostaglandin H2 synthase peroxidase activity.

Currently available non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin are directed at the cyclooxygenase (COX) site, but not the peroxidase (POX) activity of prostaglandin H2 synthase (PGHS). They are thus unable to inhibit the free-radical induced tissue injury associated with PGHS peroxidase activity, which can occur independently of the COX site. A lead compound, anthranilic hydroxamic acid (AHA) was found to have significant PGHS-POX inhibitory activity (IC50= 72 microM). To define the critical parameters for PGHS-POX inhibition, we investigated 29 AHA derivatives, synthesised from their acid precursors, using solid phase synthesis. In vitro analysis demonstrated a ten-fold improvement in inhibition with 3,5-diiodoanthranilic hydroxamic acid (IC50= 7 microM).

Off-duty preparation for overnight work in rotor wing air medical programs.

INTRODUCTION: Air medical teams provide around-the-clock critical care, risking performance-altering fatigue from circadian disruption and sleep deprivation. Although safety is an essential issue in the air medical industry, there is little understanding of off-duty preparation for overnight shifts. METHODS: An anonymous survey was distributed to pilots and medical team members at participating programs with variable program, staffing, and shift models. Eighty responses from crewmembers working 12-hour night shifts (12N) were analyzed with appropriate t-tests and nonparametric tests. RESULTS: 12N crewmembers sleep significantly less in off-duty periods than before night shifts: 7.3 +/- 1.2 hours versus 4.8 +/- 1.9 hours (P < 0.01). Preshift sleep does not differ between crewmembers permitted on-duty rest and those for whom it is prohibited. 34.1% of 12N crewmembers permitted on-duty rest say they report to work planning to sleep. The minimum preshift sleep reported by 12N crewmembers before any shift in the past month averaged 2.4 +/- 2.3 hours, with 36.3% having worked overnight in the past month with no sleep before their shift On-duty rest permission was not a significant factor. Fifty-five percent of 12N crewmembers report outside employment (OE) in addition to their flight position. 12N crewmembers with OE averaged significantly less preshift sleep than those without OE: 4.4 +/- 2.1 hours versus 5.3 +/- 1.6 hours (P < 0.05). 54.5% of 12N crewmembers with OE described reporting to a flight shift within 8 hours of leaving their other job at least once within the past month. OE was more common when the flight program permitted on-duty rest (P < 0.01). CONCLUSION: Air medical team members report for 12N shifts with a significant sleep debt that does not differ between crewmembers permitted on-duty rest and those with on-duty rest prohibitions. More than half of flight team members surveyed have OE and many report for flight duty within 8 hours of leaving their other job. 12N shift crewmembers are at a particularly high risk for the consequences of fatigue. This is an important consideration as the industry develops on-duty rest guidelines to optimize safe operations.

Shift length and on-duty rest patterns in rotor-wing air medical programs.

INTRODUCTION: Air medical teams provide around-the-clock critical care, a pattern at risk of inducing performance-altering fatigue from circadian disruption and sleep deprivation. Safety is an essential issue in the air medical industry, but little data are available on shift length and on-duty rest practices. We report the results of a survey concerning those practices and analyze the relationships to crew duty practices by program model (hospital-operated, vendor-operated, independent, or public safety), base location, flight volume, and job requirements. METHODS: A survey was mailed to 182 Association of Air Medical Services-member rotor-wing air medical programs in the United States that complete scene flights with a flight nurse. One-hundred-twenty-nine programs (70.9%) returned anonymous surveys, all of which were used for data analysis. Results were analyzed with descriptive and nonparametric statistics. RESULTS: All pilots work shifts between 10 and 14 hours. For medical team members the shift distribution is: 24 hours, 3.5%. An independent association exists between shift length greater than 12 hours and each of the following: flight volume per-aircraft under 731 flights/year, program model other than hospital operated, and nonhospital base (Fisher's exact test with Bonferroni correction, P < .01 for each). All pilots are allowed on-duty rest on both day and night shifts. On-duty rest is permitted for 67.4% of medical team members: 18.2% only at night, and 49.2% at any time of day. The presence of any period of on-duty crew rest is significantly associated with nonhospital base, program model other than hospital-operated, and shift length exceeding 12 hours (Fisher's exact test with Bonferroni correction, P < .01 for each). The presence of a nonflight clinical assignment while on flight duty is associated with a prohibition against on-duty rest (Fisher's exact test with Bonferroni correction, P < .05). CONCLUSION: Notable differences arose between on-duty work and rest patterns for pilots and medical team members. Medical team members generally work longer shifts than pilots do, with shifts exceeding 12 hours as the most common staffing pattern. Medical team members also have less access to on-duty rest than do pilots. Traditional hospital-operated programs are more likely to use shorter shifts and prohibit on-duty rest for the medical teams, whereas vendor-operated, independent, or public safety programs are more likely to use longer shifts and permit on-duty rest. As the industry works toward a unified approach to mitigating the impact of fatigue on safe operation, variable practices based on job description and program style may be a factor.

The psychodynamic psychiatry service of the University of Alberta Hospital: a thirty year history.

This paper describes the Psychodynamic Psychiatry Service (PPS) of the University of Alberta Hospital over its 30 years of development. This psychiatric organization consists of three clinical programs-an outpatient clinic and intensive day and evening programs-and an integral evaluation and research unit. The PPS is unique in its group therapy clinical orientation, its psychodynamic theoretical orientation, and its integration of an ongoing research program that establishes empirical validation of its clinical work. The productivity and longevity of this psychiatric organization appear to derive from several strengths, including cooperation between leaders of the clinical and research programs; the institution of staff relations groups in the three clinical programs; the operation of the fully integrated evaluation and research program that serves to provide empirical support for the treatments offered; and a unifying ideology characterized by the valuing of both psychodynamic and group oriented work. Other important factors to the success of the PPS include the strengths of the founder of the service and financial and other support of the academic department in which it is housed. This paper describes the historical development and present structure and functioning of the PPS, the challenges it has been confronted with, and the responses to those challenges. We conclude with factors contributing to its survival and productivity and with thoughts about the future.