Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review.

BACKGROUND: Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE: The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS: A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS: Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS: This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.

Barriers and enablers to implementation of COVID-19 vaccine programs in a rural and regional Queensland: A provider perspective.

INTRODUCTION: Vaccines formed the core of Australia's National COVID-19 Plan in combination with other public health measures. Vaccine rates varied geographically, and lower uptake was seen in some regional and remote areas. OBJECTIVE: Explore barriers and enablers to implementing COVID-19 vaccine programs and recommendations for improvement from a vaccine provider perspective in rural and regional Queensland (QLD). DESIGN: Participants included eleven healthcare personnel (HCP) from rural (45%) and regional (55%) settings in the Wide Bay region, QLD, Australia. Semi-structured interviews were conducted to identify barriers and enabling factors HCP experienced implementing COVID-19 programs, in addition to their recommendations to optimise ongoing implementation of vaccine programs. Braun and Clarke's reflexive thematic analysis of interview transcripts was performed, and over-arching themes were identified. FINDINGS: Four barrier themes were identified: 1. operational barriers, 2. communication issues, 3. financial constraints, and 4. leadership and coordination. Four enabler themes were also identified: 1. adaptability; 2. prior experience and knowledge; 3. collaboration and teamwork; and 4. community engagement. Recommendations for optimising ongoing vaccine rollout included reducing the administrative burden on providers, increasing involvement of primary care and the private sector in planning and decision making, improving communication methods, reviewing financial remuneration for private providers, and decentralising decision-making. DISCUSSION: There were multiple barriers and enablers to implementation of COVID-19 programs experienced by rural and regional HCP in the Wide Bay region of QLD which were consistent with existing literature. CONCLUSION: A range of actionable recommendations were identified that could optimise the COVID-19 vaccine program and future vaccine programs in rural and regional areas.

Sexual knowledge of Queensland forensic mental health patients: A cross-sectional quantitative study.

Forensic patients with serious mental illnesses (SMI) encounter significant challenges including active symptomatology, associated social and interpersonal impairments, psychotropic medication side effects and institutionalization, all of which negatively affect sexual functioning and possibly their acquirement of sexual knowledge. Evidence shows an increased prevalence of high-risk sexual behavior by this group however, there is an absence of literature examining the sexual knowledge of forensic patients. This quantitative cross-sectional study enrolled N = 50 patients currently under the treatment requirements of a Forensic Order and utilized the validated General Sexual Knowledge Questionnaire (GSKQ) to quantify the participants' sexual knowledge over the domains of physiology, sexual intercourse, pregnancy, contraception, sexually transmitted diseases, and sexuality. Male forensic patients scored lower than females on all domains of sexual knowledge. All participants had reasonable knowledge of physiology, sexual intercourse and sexuality; of concern were poor scores on pregnancy, contraception and sexually transmitted diseases. Thirty-five (70%) of the respondents indicated that they had some limited sex education, mostly at school. Only six (12%) received any sexual education from a health professional despite extensive contact with the forensic mental health services across many years. There is a need to assess the deficit in sexual knowledge of forensic patients in order to develop sexual health education, intervention and rehabilitative programmes that cater to the specific needs of this group to improve their sexual knowledge, encourage safe and positive sexual experiences, and enhance their quality of life.

Higher blood nicotine concentrations following smokeless tobacco (pituri) and cigarette use linked to adverse pregnancy outcomes for Central Australian Aboriginal pregnancies.

BACKGROUND: In central Australia, Aboriginal women use wild tobacco plants, Nicotiana spp. (locally known as pituri) as a chewed smokeless tobacco, with this use continuing throughout pregnancy and lactation. Our aim was to describe the biological concentrations of nicotine and metabolites in samples from mothers and neonates and examine the relationships between maternal self-reported tobacco use and maternal and neonatal outcomes. METHODS: Central Australian Aboriginal mothers (and their neonates) who planned to birth at the Alice Springs Hospital (Northern Territory, Australia) provided biological samples: maternal blood, arterial and venous cord blood, amniotic fluid, maternal and neonatal urine, and breast milk. These were analysed for concentrations of nicotine and five metabolites. RESULTS: A sample of 73 women were enrolled who self-reported: no-tobacco use (n = 31), tobacco chewing (n = 19), or smoking (n = 23). Not all biological samples were obtained from all mothers and neonates. In those where samples were available, higher total concentrations of nicotine and metabolites were found in the maternal plasma, urine, breast milk, cord bloods and Day 1 neonatal urine of chewers compared with smokers and no-tobacco users. Tobacco-exposed mothers (chewers and smokers) with elevated blood glucose had higher nicotine and metabolite concentrations than tobacco-exposed mothers without elevated glucose, and this was associated with increased neonatal birthweight. Neonates exposed to higher maternal nicotine levels were more likely to be admitted to Special Care Nursery. By Day 3, urinary concentrations in tobacco-exposed neonates had reduced from Day 1, although these remained higher than concentrations from neonates in the no-tobacco group. CONCLUSIONS: This research provides the first evidence that maternal pituri chewing results in high nicotine concentrations in a wide range of maternal and neonatal biological samples and that exposure may be associated with adverse maternal and neonatal outcomes. Screening for the use of all tobacco and nicotine products during pregnancy rather than focusing solely on smoking would provide a more comprehensive assessment and contribute to a more accurate determination of tobacco and nicotine exposure. This knowledge will better inform maternal and foetal care, direct attention to targeted cessation strategies and ultimately improve long-term clinical outcomes, not only in this vulnerable population, but also for the wider population. NOTE TO READERS: In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader group of Australian First Peoples. That choice has been maintained in the reporting of the research findings.

The sexuality and sexual experiences of forensic mental health patients: An integrative review of the literature.

Introduction: Sexuality is an integral aspect of the human experience that defines an individual. Robust research, substantiated by the World Health Organization, demonstrates that healthy sexuality improves mental health and quality of life. Despite this level of global advocacy and clinical evidence, sexuality and sexual health as determinants of health have been largely overlooked in the mental healthcare of patients being treated under the requirements of a forensic order (forensic patients). In this review, the authors have evaluated the literature related to the sexual development, sexual health, sexual knowledge and risks, sexual experiences, sexual behavior and sexual desires of forensic patients to inform policy and clinical practice. Furthermore, the review explored how forensic patients' sexual healthcare needs are managed within a forensic mental healthcare framework. The paper concludes with recommendations for service providers to ensure that sexual health and sexuality are components of mental health policy frameworks and clinical care. Methods: An integrative review was utilized to summarize empirical and theoretical literature to provide a greater comprehensive understanding of the sexuality and sexual experiences of forensic patients. This included identifying original qualitative, quantitative, or mixed-method research, case reports, case series and published doctoral thesis pertaining to the research topic. Results: Twenty-one articles were selected for review. We grouped the review findings into three main themes: 1) Forensic patient themes, 2) Forensic mental health staff themes and 3) Forensic mental health organization themes. The review demonstrated scant information on the sexual healthcare needs of forensic patients or how health services manage these needs while the patient is in a hospital or reintegrating into the community. Conclusion: There is a dearth of evidence-based, individualized or group approaches which clinicians can utilize to assist forensic patients to achieve a healthy sexual life and it is recommended that such services be developed. Before that however, it is essential to have a clear understanding of the sexual healthcare needs of forensic patients to identify areas where this vulnerable population can be supported in achieving optimal sexual health. Urgent changes to clinical assessment are required to incorporate sexual healthcare as a component of routine mental healthcare.

Post COVID-19 vaccination: AusVaxSafety survey participation and adverse events - a community-based regional Queensland study.

OBJECTIVE: To describe adverse events following COVID-19 immunisation (AEFI) and participation in AusVaxSafety surveillance in a Queensland regional community. METHODS: Participants presenting for second dose COVID-19 vaccine at the Hervey Bay Wide Bay Hospital and Health Service (WBHHS) vaccine clinic in July 2021 completed a survey pertaining to their first COVID-19 vaccine. Data collected included participation in AusVaxSafety surveillance, vaccine type (BNT162b2 (Pfizer/BioNTech) or ChAdOx1-S(Oxford/AstraZeneca), AEFI experienced and impact on work/routine activities. Multivariable logistic regression related demographic factors to odds of surveillance participation and AEFI occurrence. RESULTS: Of 1,148 participants, 37.6% participated in AusVaxSafety surveillance and 44.8% reported an AEFI. Participation in surveillance was higher in older (≥50 vs <50 years: OR 1.36, 95%CI:1.04-1.78) and less-educated participants (university vs. high school/below: OR 0.68, 95%CI:0.48-0.95). Reporting an AEFI was higher in younger (≥50 years vs. <50 years: BNT162b2: OR 0.69, 95%CI:0.51-0.93; ChAdOx1-S: OR 0.42, 95%CI:0.10-1.89), female (female vs. male: BNT162b2: OR 2.28, 95%CI:1.67-3.12; ChAdOx1-S: OR 1.85, 95%CI:1.17-2.94) and more educated participants (university vs. high school/below: BNT162b2:OR 1.63, 95%CI: 1.08-2.45; ChAdOx1-S: OR 3.98, 95%CI:2.03-7.79). Of participants with an AEFI, 15% reported missing work/routine activities. CONCLUSIONS: Participation in surveillance was modest in this regional population, despite AEFI being frequent, and impacts of absenteeism in this setting warrants further research. IMPLICATIONS FOR PUBLIC HEALTH: The findings can inform strategies to improve surveillance participation and inform workforce planning in regional areas.

COVID-19 Vaccination: An Exploratory Study of the Motivations and Concerns Detailed in the Medical Records of a Regional Australian Population.

Understanding motivations and concerns surrounding COVID-19 vaccine uptake is important to reduce vaccine hesitancy and inform strategies to mitigate concerns and increase vaccine uptake. This study aimed to explore motivations and concerns associated with COVID-19 vaccination among adults seeking their first COVID-19 vaccine in a regional Australian community with low prevalence of COVID-19, who received a medical consult prior to vaccination. Medical records from consults were audited and the modified Framework Method was used to conduct qualitative content analysis of data, generating themes and overall core concepts related to motivations for COVID-19 vaccination and associated concerns. There were 102 people included in the study, 81% of whom were aged ≥60 years. Concerns surrounding COVID-19 vaccination included five core concepts: 1. Perceived vaccine risks, 2. Perceived vaccine performance, 3. Uncertainty, 4. Autonomy, and 5. Fairness in access; and a further five core concepts were generated from motivations to seek vaccination: 1. Protection, 2. Occupational or facility responsibility or requirement, 3. Trust in primary healthcare physician, 4. Autonomy, and 5. Civic duty. These motivating factors and concerns can be used to inform strategies and education to increase vaccine uptake in ongoing and future vaccine rollouts.

A Qualitative Study on Sexuality and Sexual Experiences in Community Forensic Mental Health Patients in Queensland, Australia.

This qualitative study reports on the sexuality and sexual experiences of community-based forensic mental health participants. The findings indicate that these participants feel the need for intimacy and want to engage in sexual activity more often than their neurotypical Australian peers. Participants identified their mental health and the side effects of compliance with prescribed psychotropic medications were barriers to achieving their desired level of sexual activity. Participants supported the notion that mental health teams were positioned to assist patients navigate the psychological, cultural, education and physical barriers to achieving sexual health and wellbeing. We propose several interventions to support these participants and other community forensic mental health patients in attaining healthy relationships, understanding their sexual health, and gaining more fulfilling sexual experiences. These interventions, which include sex education, upskilling in socialization and communication, and regular medication reviews, could be delivered as part of the holistic care provided by mental health teams. Mental health clinicians should be offered appropriate training to assess patients and have discussions related to sexuality, sexual experiences and sexual health needs.

Methods of Detecting Medication Administration Point-of-Care Errors in Acute Adult Inpatient Settings: A Scoping Review Protocol.

Medication administration is recognized as a risk-prone activity where errors and near misses have multiple opportunities to occur along the route from manufacturing, through transportation, storage, prescription, dispensing, point-of-care administration, and post-administration documentation. While substantial research, education, and tools have been invested in the detection of medication errors on either side of point-of-care administration, less attention has been placed on this finite phase, leaving a gap in the error detection process. This protocol proposes to undertake a scoping review of the literature related to the detection of medication errors at the point-of-care to understand the potential size, nature, and extent of available literature. The aim is to identify research evidence to guide clinical practice and future research at the medication and patient point-of-care intersection. The search strategy will review literature from PubMed, CINAHL, Cochrane Collaboration, Embase, Scopus, PsychInfo, Web of Science, TRIP, TROVE, JBI Systematic Reviews, Health Collection (Informit), Health Source Nursing Academic, Prospero, Google Scholar, and graylit.org dated 1 January 2000-31 December 2021. Two independent reviewers will screen the literature for relevancy to the review objective, and critically appraise the citations for quality, validity, and reliability using the Joanna Briggs scoping review methodology and System for Unified Management, Assessment and Review of Information (SUMARI) tool. The data will be systematically synthesized to identify and compare the medication error administration detection method findings. A descriptive narrative discussion will accompany the findings.

Referral patterns, disease progression and impact of the kidney failure risk equation (KFRE) in a Queensland Chronic Kidney Disease Registry (CKD.QLD) cohort: a study protocol.

INTRODUCTION: Chronic kidney disease (CKD) is a rapidly increasing and global phenomenon which carries high morbidity and mortality. Although timely referral from primary care to secondary care confers favourable outcomes, it is not possible for every patient with CKD to be managed at secondary care. With 1 in 10 Australians currently living with markers of CKD against a workforce of about 600 nephrology specialists, a risk stratification strategy is required that will reliably identify individuals whose kidney disease is likely to progress. METHODS AND ANALYSIS: This study will undertake a retrospective secondary analysis of the Chronic Kidney Disease Queensland Registry (CKD.QLD) data of consented adults to examine the referral patterns to specialist nephrology services from primary care providers and map the patient trajectory and outcomes to inform the optimal referral timing for disease mitigation. Patient data over a 5-year period will be examined to determine the impact of the kidney failure risk equation-based risk stratification on the referral patterns, disease progression and patient outcomes. The results will inform considerations of a risk stratification strategy that will ensure adequate predialysis management and add to the discussion of the time interval between referral and initiation of kidney replacement therapy or development of cardiovascular events. ETHICS AND DISSEMINATION: This protocol was approved by the Ethics Committee of the Royal Brisbane and Women's Hospital in January 2021 (LNR/2020/QRBW/69707 14/01/2021). The HREC waived the requirement for patient consent as all patients had consented for the use of their data for the purpose of research on recruitment into CKD.QLD Registry. The results will be presented as a component of a PhD study with The University of Queensland. It is anticipated that the results will be presented at health-related conferences (local, national and possibly international) and via publication in peer-reviewed academic journals.

Central Australian Aboriginal women's placental and neonatal outcomes following maternal smokeless tobacco, cigarette or no tobacco use.

OBJECTIVE: To describe the placental characteristics and neonatal outcomes of Central Australian Aboriginal women based on maternal self-report of tobacco use. METHODS: Placental and neonatal variables were collected from a prospective maternal cohort of 19 smokeless tobacco chewers, 23 smokers and 31 no-tobacco users. RESULTS: Chewers had the lowest placental weight (460 g) while the no-tobacco group had the heaviest placental weight (565 g). Chewers and the no-tobacco group had placental areas of similar size (285 cm2 and 288 cm2 , respectively) while the placentas of smokers were at least 13 cm2 smaller (272 cm2 ). There were two stillbirths in the study and more than one-third (36%) of neonates (newborns) were admitted to the Special Care Nursery, with the chewers' neonates having a higher admission rate compared with smokers' neonates (44% vs. 23%). The cohort mean birthweight (3348 g) was not significantly different between the groups. When stratified for elevated maternal glucose, the chewers' neonates had the lowest mean birthweight (2906 g) compared to the neonates of the no-tobacco group (3242 g) and smokers (3398 g). CONCLUSIONS: This research is the first to demonstrate that the maternal use of Australian Nicotiana spp. (pituri) as smokeless tobacco may negatively impact placental and neonatal outcomes. IMPLICATIONS FOR PUBLIC HEALTH: Maternal smokeless tobacco use is a potential source of placental and foetal nicotine exposure. Maternal antenatal screening should be expanded to capture a broader range of tobacco and nicotine products, and appropriate cessation support is required.

The Sexual Development, Sexual Health, Sexual Experiences, and Sexual Knowledge of Forensic Mental Health Patients: A Research Design and Methodology Protocol.

Introduction: There is substantial evidence that severe mental illness (SMI) can have significant impacts on general development, knowledge acquisition, and quality of life including sexual function. However, whilst the sexual development, sexual health, sexual experiences and sexual knowledge of the broader Australian community and the Australian prisoner population have been well-described, these concepts have been less explored in people with a SMI. In particular, there is an absence of research around these topics involving people who are subject to a treatment order (aka a Forensic Order) under the relevant jurisdictional Mental Health Act. Methods and Analysis: People currently under the treatment requirements of a Queensland Forensic Order will be invited to participate in this descriptive, mixed-method study. The study will be conducted in three phases. The first two phases will involve 50 participants (100 face-to-face quantitative interviews) with the aim of mapping sexual development, sexual health, sexual experiences, and sexual knowledge. The third phase will involve qualitative semi-structured interviews with a purposely enrolled, informant-rich cohort identified through the quantitative surveys until saturation is reached. Quantitative data will be analyzed using descriptive and comparative statistics. Qualitative data will be analyzed by content analysis of the major themes. Ethics and dissemination: The project has ethics approval from a Queensland Health Human Research Ethics Committee. Results will be reported to participants and other stakeholders at seminars and conferences and through peer-reviewed publications. Strengths and Limitations of this Study: This is a mixed-method study which engages with participants by using face-to-face interviews. The study is conducted in three phases which sub-divide the research into the following areas: (1) demographics, general health, and sexual health, (2) sexual knowledge and experiences, and (3) sexual knowledge gaps. This study uses electronic data capture to efficiently record and analyse participant responses. This study captures self-reported data and uses non-probability sampling from a population who have been pre-selected through an arms-length approach-both these processes elevate the risk of bias.

Central Australian Aboriginal women's pregnancy, labour and birth outcomes following maternal smokeless tobacco (pituri) use, cigarette use or no-tobacco use: a prospective cohort study.

BACKGROUND: Outcomes related to maternal smoked tobacco (cigarette) use have been substantially examined over the past 50 years with resultant public health education targeted towards the reduction of use during pregnancy. However, worldwide the effects of maternal smokeless tobacco use have been less well explored and in Australia, there has been no examination of maternal outcomes in relation to the use of Australian Nicotiana spp. (tobacco plant) as a smokeless tobacco, colloquially known as pituri. The aim of this study is to describe the maternal outcomes of a group of central Australian Aboriginal women in relation to their self-reported tobacco use. METHODS: Eligible participants were > 18 years of age, with a singleton pregnancy, > 28 weeks gestation, and who planned to birth at the Alice Springs Hospital (the major regional hospital for central Australia, in the Northern Territory, Australia). The sample consisted of 73 conveniently recruited women categorized by tobacco-use status as no-tobacco users (n = 31), pituri chewers (n = 19), and smokers (n = 23). RESULTS: There were differences in the groups in relation to teenage pregnancies; 35% of no-tobacco users, compared with 5% of pituri users, and 13% of smokers were <  20 years of age. The chewers had a higher rate (48%) of combined pre-existing and pregnancy-related elevated glucose concentrations compared with smokers (22%) and no-tobacco users (16%).The pituri chewers had the lowest rate (14%) of clinically significant post-partum hemorrhage (> 1000 ml) compared with 22% of smokers and 36% of the no-tobacco users. CONCLUSIONS: This is the first research to examine pituri use in pregnancy and the findings indicate possible associations with a range of adverse maternal outcomes. The use of smokeless tobacco needs to be considered in maternal healthcare assessment to inform antenatal, intrapartum and postpartum care planning. IMPLICATIONS FOR PUBLIC HEALTH: Female smokeless tobacco use is a global phenomenon and is particularly prevalent in low and middle income countries and in Indigenous populations. The findings contribute to the developing knowledge around maternal smokeless tobacco use and maternal outcomes. Maternal screening for a broader range of tobacco and nicotine products is required. NOTE TO READERS: In this research, the central Australian Aboriginal women chose the term 'Aboriginal' to refer to themselves, and 'Indigenous' to refer to the broader First Peoples. That choice has been maintained in the reporting of the research findings.

Case Report: The Sexual Experiences of Forensic Mental Health Patients.

The recovery-based approach to forensic mental health rehabilitation is to support the patient to achieve a fulfilling life-a principle which should include achieving a fulfilling sexual life. This paper presents four vignettes from forensic mental health patients. The four cases demonstrate the omission, avoidance and then judgement by forensic mental health clinicians around the intimate and sensitive, yet important domain of the patient's sexual life. The cases illustrate that gap in the clinical domain and demonstrate the requirement for forensic mental health clinicians to have a greater awareness, acknowledgment, and assessment of their patient's sexuality and sexual health needs. Incorporating sexual health into standard clinical assessments will contribute to improved patient management in addition to supporting the principles of holistic forensic mental health recovery and rehabilitation.

Comparison of Opioid-Free Anesthesia Versus Opioid-Containing Anesthesia for Elective Laparoscopic Surgery (COFA: LAP): A Protocol Measuring Recovery Outcomes.

The administration of opioids is a central element in contemporary anesthetic techniques in Australia; however, opioids have a range of side effects. As an alternative, opioid-free anesthesia (OFA) is an emerging mode of anesthesia intended to avoid these side effects. This study is the first to publish the use of OFA in Australia and is conducted in a regional Queensland Health Service. The design will utilize a randomized clinical trial (RCT) to investigate the impact of OFA for patients having an elective laparoscopic cholecystectomy (n = 40) or tubal ligation (n = 40). Participant outcomes to be measured include: Quality of Recovery (QoR-15); Oral Morphine Equivalent Daily Dose (OMEDD) at 24-h post-operatively; time to first opioid (TTFO) dose; post-operative nausea and vomiting (PONV); Post Anesthetic Care Unit length of stay (PACU-LOS); and hospital length of stay (LOS). The findings may challenge the essentiality of opioids in the peri-operative period, which in turn would influence the future intra-operative management of surgical patients. Ultimately, a reduction in anesthesia-associated opioid use will support a more general decline in opioid use.

Developing and testing a matrix to achieve ready-everyday nursing standards (RENS): an observational study protocol.

INTRODUCTION: The Australian Council on Healthcare Standards (ACHS) set criteria for the delivery of healthcare services in Australia. While a voluntary process, continual accreditation with ACHS is an expectation of, and for, Australian healthcare providers. Juxtapositioned with the ACHS, the Nursing and Midwifery Board of Australia (NMBA) set the mandatory practice requirements of, and for, Australian nurses. Despite these overarching quality and governance directives, a regional Queensland Hospital and Health Service (HHS) demonstrated deficits in the quality of nursing care. Accordingly, a HHS project was commissioned with the aim of producing a quantum shift in the quality of nursing services such that the service was ready-everyday for accreditation assessment, and nursing practice exemplified the NMBA standards.Several barriers to achieving the aim were identified and it was considered that the implementation of critical system changes would structurally and operationally support the achievement of the aim. The system changes are pivoted around an interactive matrix that links nursing care services to the array of nursing professional and practice standards and provides real-time quantitative output measures. This paper outlines the protocol that will be used to establish, implement and evaluate the matrix. METHODS AND ANALYSIS: A participatory action research design with a modified Delphi methodology will be used for the development the matrix. The organisational change management around the matrix implementation will be informed by Kotter's model and supported by the use of the McKinsey 7S. The matrix implementation phase will be conducted using a modified Promoting Action on Research Implementation in Health Services model. Quantitative and qualitative data will be collected over a 12 month pre-test/post-test design to measure the statistical significance of the matrix in supporting compliance with nursing standards and the achievement of quality nursing care. Quantitative data from quality of care assessments will be analysed using descriptive and comparative statistics. Qualitative data from staff surveys will be analysed by content analysis of the major themes (n~200). ETHICS AND DISSEMINATION: The project has ethics approval from a Queensland Health Human Research Ethics Committee. Results will be reported to participants and other stakeholders at seminars and conferences and through peer-reviewed publications.

Tobacco and Pituri Use in Pregnancy: A Protocol for Measuring Maternal and Perinatal Exposure and Outcomes in Central Australian Aboriginal Women.

Maternal tobacco smoking is a recognized risk behavior that has adverse impacts onmaternal and fetal health. However, in some populations, the use of smokeless tobacco exceeds theuse of smoked tobacco. In central Australia, Aboriginal populations utilize wild tobacco plants(Nicotiana spp.) as a smokeless product. These plants are known by a variety of names, one of whichis pituri. The plants are masticated and retained in the oral cavity for extended periods of time andtheir use continues throughout pregnancy, birth, and lactation. In contrast to the evidence related tocombusted tobacco use, there is no evidence as to the effects of pituri use in pregnancy. CentralAustralian Aboriginal women who were at least 28 weeks pregnant were stratified into three tobaccoexposure groups: (a) Pituri chewers, (b) smokers, and (c) non-tobacco users. Routine antenatal andbirth information, pre-existing and pregnancy-related maternal characteristics, fetal characteristics,and biological samples were collected and compared. The biological samples were analysed fortobacco and nicotine metabolite concentrations. Samples from the mother included venous blood,urine, hair and colostrum and/or breast milk. From the neonate, this included Day 1 and Day 3 urineand meconium, and from the placenta, arterial and venous cord blood following delivery. This is thefirst study to correlate the pregnancy outcomes of central Australian Aboriginal women with differenttobacco exposures. The findings will provide the foundation for epidemiological data collection inrelated studies. Note to readers: In this article, the term "Aboriginal" was chosen by central Australianwomen to refer to both themselves and the Aboriginal people in their communities. "Indigenous" waschosen to refer to the wider Australian Aboriginal and Torres Strait Islander people.

Nicotine alkaloid levels, and nicotine to nornicotine conversion, in Australian Nicotiana species used as chewing tobacco.

A range of endemic Nicotiana species are chewed as a smokeless tobacco by several Aboriginal populations of Australia. In tobacco research, nicotine to nornicotine conversion is important because nornicotine lowers tobacco quality and is detrimental to health. A diverse group of cytochrome P450 genes with different transcriptional regulations are involved in this conversion. The primary aims of this study were to quantify the pyridine alkaloids and investigate nicotine to nornicotine conversion in laboratory-grown Australian Nicotiana spp. Nicotine, nornicotine, anatabine, anabasine, myosmine and cotinine were quantified in fresh leaves of 24 out of the 26 recognised Australian Nicotiana taxa. Conserved regions of CYP82E related genes were PCR amplified in all studied taxa. The conversion process in fresh leaves was compared with that in leaves that underwent a simulated curing process for species that we identified as being high converters (N. cavicola, N. goodspeedii, N. velutina) and low converters (N. benthamiana, N. excelsior, N. gossei). Agarose gel electrophoretic analysis of CYP82E related genes obtained from the PCR amplification of the cDNA in fresh versus leaves with simulated curing showed about a 3-fold increase in transcript accumulation levels in cured leaves of the high converter species, while the transcript accumulation in N. gossei and N. excelsior maintained a steady basal level and increased by a small amount in N. benthamiana. This suggests the presence of functional loci that are triggered by curing in only high converter species and indicates a potential risk for chewers of high converter species.

The Pituri Learning Circle: central Australian Aboriginal women's knowledge and practices around the use of Nicotiana spp. as a chewing tobacco.

INTRODUCTION: Tobacco smoking has a range of known and predictable adverse outcomes, and across the world sustained smoking reduction campaigns are targeted towards reducing individual and public risk and harm. Conversely, more than 87 million women, mostly in low- and middle-income countries, use smokeless tobacco, yet the research examining the effect of this form of tobacco exposure on women is remarkably scant. In central Australia, the chewing of wild Nicotiana spp., a tobacco plant, commonly known as pituri and mingkulpa, is practised by Aboriginal groups across a broad geographical area. Until recently, there had been no health research conducted on the effects of chewing pituri. METHODS: This article reports on one component of a multidimensional pituri research agenda. A narrative approach utilising the methodology of the Learning Circle was used to interview three key senior central Australian Aboriginal women representative of three large geographical language groupings. The participants were selected by a regional Aboriginal women's organisation. With the assistance of interpreters, a semistructured interview, and specific trigger resources, participants provided responses to enable an understanding of the women's ethnobotanical pituri knowledge and practices around the use of pituri within the context of Aboriginal women's lives. Data were transcribed, and by using a constant comparison analysis, emergent themes were categorised. The draft findings and manuscript were translated into the participants' language and validated by the participants. RESULTS: Three themes around pituri emerged: (a) the plants, preparation and use; (b) individual health and wellbeing; and (c) family and community connectedness. The findings demonstrated similar participant ethnobotanical knowledge and practices across the geographical area. The participants clearly articulated the ethnopharmacological knowledge associated with mixing pituri with wood ash to facilitate the extraction of nicotine from Nicotiana spp., the results of which were biochemically verified. The participants catalogued the pleasurable and desired effects obtained from pituri use, the miscellaneous uses of pituri, as well as the adverse effects of pituri overdose and toxicity, the catalogue of which matched those of nicotine. The participants' overarching pituri theme was related to the inherent role pituri has in the connectiveness of people to family, friends and community. CONCLUSIONS: Central Australian Aboriginal women have a firmly established knowledge and understanding of the pharmacological principles related to the content of Nicotiana spp. and the extraction of nicotine from the plant. Widespread use of Nicotiana spp. as a chewing tobacco by Aboriginal populations in the southern, central and western desert regions of Australia is attested to by participants who assert that everyone uses it, with girls in these remote areas commencing use between 5 and 7 years of age. Central Australian Aboriginal people who chew Nicotiana spp. do not consider it to be a tobacco plant, and will strongly refute that they are tobacco users. Central Australian Aboriginal people do not consider that the Western health information regarding tobacco (as a smoked product) is applicable or aligned to their use of pituri. Nicotiana spp. users will deny tobacco use at health assessment. There is a requirement to develop and provide health information on a broader range of tobacco and nicotine products in ways that are considered credible by the Aboriginal population. Health messages around pituri use need to account for the dominant role that pituri occupies in the context of central Australian Aboriginal women's lives.
Information for readers: A consultative organisation of Aboriginal women has as a strategic intent and operational agenda the improvement of Aboriginal women's and children's health across the research region. The group seeks opportunities to enhance their knowledge based on legitimate collaborative research; accordingly, they sought to participate in a range of research activities regarding the use of pituri and women's health outcomes. Of particular note, the group's participants chose to be identified by name in the publication of this research activity. In this article, the term 'Aboriginal' has been chosen by the central Australian women to refer to both themselves and the Aboriginal people in their communities; 'Indigenous' has been chosen to refer to the wider Australian Aboriginal and Torres Strait Islander people. The term Nicotiana spp. is used when referring to the plants from a Western perspective; pituri is used when referring to the plants, the tobacco quid, and the practice of chewing from a general Aboriginal perspective; and mingkulpa is used when the participants are voicing their specific knowledge and practices.