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.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period.

BACKGROUND: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care. METHODS: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62). RESULTS: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58). CONCLUSION: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

Incorporating indigenous knowledge in health services: a consumer partnership framework.

OBJECTIVES: Healthcare policy and planning should be informed by a partnership between healthcare services and healthcare users. This is critical for people who access care frequently such as indigenous Australians who have a high burden of chronic kidney disease. This study aimed to explore the most appropriate ways of enhancing services by incorporating renal patients' expectations and satisfaction of care in Australia's Northern Territory. STUDY DESIGN: This is a participatory action research. METHODS: Six aboriginal health users with end-stage kidney disease were recruited to form an Indigenous Reference Group. This group met bimonthly between April and November 2017 and meetings took the same structure as a focus group. Findings from these meetings were presented to health policy and planners in a feedback loop implemented by the study. RESULTS: This framework enabled indigenous knowledge to guide the project, indigenous priorities to be identified in this context and timely feedback of information to inform the strengths and priorities of the health service. Changes were recognised and addressed immediately. CONCLUSIONS: This qualitative research framework is a useful mechanism for providing local data to inform patient-centred health system change as expressed by health users. We recommend this consumer partnership framework be embedded into existing operational structures to support the ongoing sustainability of this group.

Health service changes to address diabetes in pregnancy in a complex setting: perspectives of health professionals.

BACKGROUND: Australian Aboriginal and Torres Strait Islander women have high rates of gestational and pre-existing type 2 diabetes in pregnancy. The Northern Territory (NT) Diabetes in Pregnancy Partnership was established to enhance systems and services to improve health outcomes. It has three arms: a clinical register, developing models of care and a longitudinal birth cohort. This study used a process evaluation to report on health professional's perceptions of models of care and related quality improvement activities since the implementation of the Partnership. METHODS: Changes to models of care were documented according to goals and aims of the Partnership and reviewed annually by the Partnership Steering group. A 'systems assessment tool' was used to guide six focus groups (49 healthcare professionals). Transcripts were coded and analysed according to pre-identified themes of orientation and guidelines, education, communication, logistics and access, and information technology. RESULTS: Key improvements since implementation of the Partnership include: health professional relationships, communication and education; and integration of quality improvement activities. Focus groups with 49 health professionals provided in depth information about how these activities have impacted their practice and models of care for diabetes in pregnancy. Co-ordination of care was reported to have improved, however it was also identified as an opportunity for further development. Recommendations included a central care coordinator, better integration of information technology systems and ongoing comprehensive quality improvement processes. CONCLUSIONS: The Partnership has facilitated quality improvement through supporting the development of improved systems that enhance models of care. Persisting challenges exist for delivering care to a high risk population however improvements in formal processes and structures, as demonstrated in this work thus far, play an important role in work towards improving health outcomes.

Measurements of Argon-39 from locations near historic underground nuclear explosions.

Measurement of radioactive gas seepage from an underground nuclear explosion is one of the primary methods to confirm whether an event was nuclear in nature. Radioactive noble gas indicators that are commonly targeted by such measurements (e.g. 133Xe, 37Ar) have half-lives of 35 days or less. Argon-39, an activation product similar to 37Ar, is produced by the interaction between neutrons and potassium in the surrounding geology and has a half-life of 269 years. Measurements taken at three sites near three historic underground nuclear test locations at the Nevada National Security Site have all shown highly elevated levels of 39Ar in soil gas decades after the test events. Elevated levels of 39Ar were also detected in atmospheric air collected near two of these sites, and outside the entrance of the one tunnel site. These measurements demonstrate that 39Ar has the potential to be a long-term signature of an underground nuclear event which can be reliably detected at the surface or in the shallow subsurface. This radionuclide detection of an underground nuclear event decades after the event takes place is in contrast to the commonly held assumption that detecting underground nuclear events via radionuclides at the surface needs to be done in a matter of months. Depending upon what further studies show about the robustness of this signature in a variety of geological settings, it may in fact be easy to detect underground nuclear events at the surface for a very long time post-detonation.

'No sugar', 'no junk food', 'do more exercise' - moving beyond simple messages to improve the health of Aboriginal women with Hyperglycaemia in Pregnancy in the Northern Territory - A phenomenological study.

BACKGROUND: Globally, rates of hyperglycaemia in pregnancy are highest among Indigenous women. The highest prevalence has been documented among Aboriginal women in the Northern Territory of Australia. Despite knowledge of this for over two decades, there has been very limited examination of the specific needs and experiences of Aboriginal women regarding this condition. QUESTION: How do Aboriginal women with hyperglycaemia in pregnancy understand and experience this condition, and how can their care be improved? METHODS: A phenomenological methodology underpinned semi-structured in-depth interviews with 35 Aboriginal women and seven health professionals across the Northern Territory. Data were inductively analysed. FINDINGS: The findings revealed that in general, participants in this study could recite simple health messaging regarding diabetes (e.g. 'no sugar'), but many lacked in-depth knowledge and this affected the management of their condition. Nevertheless, many identified pregnancy as a powerful motivator for change, signalling scope to improve health messaging. Women consistently expressed the need for diabetes education that was culturally appropriate, a clear desire for maternity care that was family-centred, based on respectful relationships with the same care provider, and respected Aboriginal ways of knowing and being. CONCLUSION: Existing health messaging around hyperglycaemia in pregnancy has limited reach with Aboriginal women in the Northern Territory. Reducing the burden of hyperglycaemia in pregnancy among these women requires a sustained commitment to redesign of maternity and diabetes care to incorporate the cultural and social context of women's lives.

Migration of noble gas tracers at the site of an underground nuclear explosion at the Nevada National Security Site.

As part of an underground gas migration study, two radioactive noble gases (37Ar and 127Xe) and two stable tracer gases (SF6 and PFDMCH) were injected into a historic nuclear explosion test chimney and allowed to migrate naturally. The purpose of this experiment was to provide a bounding case (natural transport) for the flow of radioactive noble gases following an underground nuclear explosion. To accomplish this, soil gas samples were collected from a series of boreholes and a range of depths from the shallow subsurface (3 m) to deeper levels (~160 m) over a period of eleven months. These samples have provided insights into the development and evolution of the subsurface plume and constrained the relative migration rates of the radioactive and stable gas species in the case when the driving pressure from the cavity is low. Analysis of the samples concluded that the stable tracer SF6 was consistently enriched in the subsurface samples relative to the radiotracer 127Xe, but the ratios of SF6 and 37Ar remained similar throughout the samples.

Emotional labour and aboriginal maternal infant care workers: The invisible load.

BACKGROUND: The term 'emotional labour' has been used to describe the competing demands on midwives to empathize with clients whilst maintaining a level of professional detachment. Previous research indicates that when individuals experience difficulty managing these emotions, burnout may result. Aboriginal health care workers often have roles with large emotional demands, as they are relied upon heavily to engage clients in care. However, the concept of emotional labour has received little attention in relation to this group. AIM: To explore potential sources of emotional labour for Aboriginal Maternal Infant Care workers in a maternity care program for Aboriginal women in South Australia. The program involves these workers providing care for women in partnership with midwives. METHODS: We employed a phenomenological approach. Thirty in-depth interviews were conducted with staff and clients of the program. Recorded interviews were transcribed and coded and emerging themes identified. FINDINGS: This workforce undertakes extensive emotional labour. Key sources include the cultural and family obligations they have to clients, complex social needs of many clients, and potential for community backlash when poor perinatal outcomes occur. A lack of respect for the role within the workplace further contributes to these experiences. CONCLUSION: This study found that the responsibilities inherent to the role as both cultural broker and carer create significant emotional labour for workers. Recommendations to address this and enhance the sustainability of this workforce include: recognition and valuing of emotional work by management and other staff, enhancing cultural awareness training, and building stress-relieving activities into the workplace.

Preconception care for women with type 2 diabetes mellitus: A mixed-methods study of provider knowledge and practice.

AIMS: Preconception care may decrease adverse pregnancy outcomes associated with pre-existing diabetes mellitus. Aboriginal Australians are at high risk of type 2 diabetes mellitus (T2DM), with earlier onset. We explored practitioner views on preconception care delivery for women with T2DM in the Northern Territory, where 31% of births are to Aboriginal women. METHODS: Mixed-methods study including cross-sectional survey of 156 health practitioners and 11 semi-structured interviews. RESULTS: Practitioners reported low attendance for preconception care however, 51% provided counselling on an opportunistic basis. Rural/remote practitioners were most likely to find counselling feasible. The majority (69%) utilised appropriate guidelines and addressed lifestyle modifications including smoking (81%), weight management (79%), and change medications appropriately such as ceasing ACE inhibitors (69%). Fewer (40%) prescribed the recommended dose of folate (5mg) or felt comfortable recommending delaying pregnancy to achieve optimal preconception glucose control (42%). Themes identified as barriers to care included the complexity of care setting and infrequent preconception consultations. There was a focus on motivation of women to make informed choices about conception, including birth spacing, timing and contraception. Preconception care enablers included cross-cultural communication, a multi-disciplinary care team and strong client-based relationships. CONCLUSIONS: Health practitioners are keen to provide preconception counselling and reported knowledge of evidence-based guidelines. Improvements are needed in recommending high dose folate and optimising glucose control. Cross-cultural communication and team-based care were reported as fundamental to successful preconception care in women with T2DM. Continued education and policy changes are required to support practitioners in opportunities to enhance pregnancy planning.

Measurements of Argon-39 at the U20az underground nuclear explosion site.

Pacific Northwest National Laboratory reports on the detection of 39Ar at the location of an underground nuclear explosion on the Nevada Nuclear Security Site. The presence of 39Ar was not anticipated at the outset of the experimental campaign but results from this work demonstrated that it is present, along with 37Ar and 85Kr in the subsurface at the site of an underground nuclear explosion. Our analysis showed that by using state-of-the-art technology optimized for radioargon measurements, it was difficult to distinguish 39Ar from the fission product 85Kr. Proportional counters are currently used for high-sensitivity measurement of 37Ar and 39Ar. Physical and chemical separation processes are used to separate argon from air or soil gas, yielding pure argon with contaminant gases reduced to the parts-per-million level or below. However, even with purification at these levels, the beta decay signature of 85Kr can be mistaken for that of 39Ar, and the presence of either isotope increases the measurement background level for the measurement of 37Ar. Measured values for the 39Ar measured at the site ranged from 36,000 milli- Becquerel/standard-cubic-meter-of-air (mBq/SCM) for shallow bore holes to 997,000 mBq/SCM from the rubble chimney from the underground nuclear explosion.

Visualising coordination chemistry: fluorescence X-ray absorption near edge structure tomography.

Coordination chemistry underlies the structure/function of biological metal complexes. Contextualising this chemical information within an organism's physiology is critical for enhancing the understanding of bioinorganic chemistry but few high-fidelity probes are available. Here we develop fluorescence X-ray absorption near-edge structure tomography as a means for studying the spatial arrangement of biological coordination chemistry within intact organisms, and demonstrate the approach by mapping the distribution of cuprous and cupric complexes within Drosophila melanogaster.

Sex differences in the distribution of traffic law enforcement.

All instances of formal traffic law enforcement during a two week period in Western Australia were categorized by type of offence and by the age and sex of the offender. A number of apparent anomalies in the distribution of law enforcement were discovered. In particular young men were overrepresented in the enforcement figures and women underrepresented, even after allowing for exposure.

Hypoxemia during outpatient gastrointestinal endoscopy: the effects of sedation and supplemental oxygen.

STUDY OBJECTIVES: To compare the effects on oxygen saturation as measured by pulse oximetry (SpO2) and ECG changes of endoscopy alone, sedation followed by endoscopy, and sedation followed by endoscopy with supplemental oxygen (O2) during upper gastrointestinal (GI) endoscopy. STUDY DESIGN: Randomized trial. SETTING: Outpatient gastroenterology clinic at a university medical center. PATIENTS: 58 healthy patients scheduled for outpatient upper GI endoscopy, with no clinical evidence of respiratory disease. INTERVENTIONS: Patients were randomly allocated to three groups: Group 1 received no benzodiazepines before endoscopy and breathed room air throughout (n = 18), Group 2 received midazolam intravenously (i.v.) before endoscopy and breathed room air throughout (n = 20), and Group 3 received i.v. midazolam and 2 L/min O2 through nasal cannulae during endoscopy (Group 3; n = 20). MEASUREMENTS AND MAIN RESULTS: Data collection, which included heart rate, cardiac rhythm, and SpO2 were recorded at seven intervals: baseline, topical anesthesia of the oropharynx, mouth gag insertion, endoscope insertion, biopsy, endoscope removal, and five minutes postendoscopy. In Group 2, mean SpO2 decreased after midazolam was administered and remained depressed during endoscopy (p < 0.05). After midazolam was given, Group 2 patients differed significantly from patients in Groups 1 and 3 (p < 0.05). CONCLUSIONS: The use of hypnotic doses of benzodiazepines is the primary factor responsible for the reduced oxygenation seen during endoscopy. Neither the presence of the endoscope alone nor the use of midazolam with supplemental O2 caused a decreased oxygenation. This study also suggests that the routine use of benzodiazepines is unnecessary when the endoscopy is of short duration, and the endoscopist employs good topicalization of the oropharynx. In patients who require sedation for endoscopy, O2 administration prevents hypoxemia.

Foreign body complications of central venous catheterisation in critically ill patients.

In three critically ill patients, central venous catheter--associated foreign bodies were identified while the patients were in the intensive care unit. Two patients had fragments of retained catheter; in the third patient a guide-wire was lost within the vascular tree. The catheter fragments were associated with clinical symptoms while side effects were not observed with loss of the guide-wire. All three foreign bodies were removed without complications.

Off-air recording licences.

The scheme operated by the Educational Recording Agency Ltd. (ERA) to licence educational establishments to make off-air recordings of television and radio broadcasts became effective from 30 May 1990. Rob Kirkham who is launching the scheme on behalf of ERA describes the current position and how the licence will work in practice.

The application of experimental design in bioengineering.

The use of factorial designs in experimentation and the careful planning of the three basic phases of experimental projects, will maximize the reliable information from the experiment and minimize the cost and effort to the experimentor. The application of the principles of good experimental design are illustrated in a case study of experimentation which investigates a new mode of peritoneal dialysis.

A study of the routine use of the Imugard IG500 Leukocyte Removal Filter illustrating a possible cause of transfusion reactions and a method of prevention.

The results of the use of the Imugard IG500 Leukocyte Removal Filter in the transfusion of 100 patients requiring leucocyte poor blood are presented. The patients were suffering from a variety of disorders. Many of them had previously received leucocyte poor blood prepared by other methods. Five patients developed non-haemolytic transfusion reactions. Subsequent investigations suggested that these were reactions to the plasma proteins present in the leucocyte poor blood prepared by filtration. A simple method of removal of these plasma proteins combined with filtration is described. The resultant product has been transfused, without incident, into the patients who previously reacted.

The fast flush test: evaluation in radial artery catheter-manometer systems.

The 'fast flush test' is commonly used to determine the dynamic response of catheter-manometer systems in vivo. We compared the fast flush test with an established bench top test in vitro. The results of the two tests were compared in fifteen underdamped radical artery catheter-manometer systems. There were significant differences between the results, (P less than 0.001 for both resonant frequency and damping factor), and the variance of estimates within measurement systems was significantly greater in the case of the fast flush test (P less than 0.05 and P less than 0.005 for resonant frequency and damping factor respectively). Nevertheless, the differences between the tests were small by comparison with the errors associated with either test; in addition there was a significant linear correlation between the results of the two tests (r = 0.91, P less than 0.001 and r = 0.85, P less than 0.001 for resonant frequency and damping factor respectively). In the in vitro situation, therefore, the fast flush test provides a crude estimate of the dynamic parameters of underdamped catheter-manometer systems.