The implications of isolation for remote industrial health workers.

INTRODUCTION: Recent literature has explored the health and social implications of industrial workers who are involved in a variety of long-distance commute (LDC) work arrangements including fly-in, fly-out; bus-in, bus-out; and drive-in, drive-out. However, the role of an industrial health worker in caring for this special population of workers is poorly understood and documented in current literature. In Australia, the health role has existed primarily to meet minimum standards of safety legislation and carry out compliance activities. The combination of low social risk tolerance, increasingly remote locations and changing health and safety legislation are driving changes to accountability for the health as well as the safety of remote industrial workers. Health staff are recruited from the ranks of registered nurses, paramedics and diploma-qualified medics. Often, they work in autonomous transdisciplinary roles with little connection to other health workers. The lack of a clear professional identity contributes to increased tension between the regulatory requirements of the role and organisations who don't always value input from a specialist health role. The aim of this study was to understand the experience of isolation for health workers in industrial settings to better inform industry and education providers. METHODS: A phenomenological methodology was chosen for this study owing to the paucity of qualitative literature that explored this role. This study utilised face-to-face or telephone interviews with nurses and paramedics working in remote offshore and onshore industrial health roles seeking to understand their experience of working in this context of health practice. RESULTS: Three thematically significant experiences of the role related to role dissonance, isolation, and gaining and maintaining skills. The second theme, isolation, will be presented to provide context for nurses' and paramedics' experiences of geographical, personal and professional isolation. CONCLUSIONS: Nurses and paramedics working in remote industrial roles are not prepared for the broad scope of practice of the role, and the physical and profession isolation presents barriers to obtaining skills and confidence necessary to meet the needs of the role. Limited resources in rural and remote areas combined with the isolation of many industrial sites pose challenges for industrial staff in accessing primary healthcare services, yet industrial organisations are resisting attempts to make them responsible for the health as well as the safety of their onsite workers, particularly in off-duty hours. Health workers in remote locations have to cope with their own experience of isolation but also have to treat and counsel other industrial workers experiencing chronic illness complications, separation from family and other consequences of the fly-in, fly-out 'workstyle'. In addition to the tyranny presented by distance and the emotional isolation common to all remote industrial workers, health workers are isolated from professional networks, access to education/professional development opportunities and other remote industrial peers. Their inclusion within a professional network and educational framework would help to mitigate these factors and provides opportunities for collaboration between industrial and rural health staff.

Mapping workforce configuration and operational models in Australian emergency departments: a national survey.

Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population sample (n=135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P=0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development.

Investigating nurse practitioners in the private sector: a theoretically informed research protocol.

AIMS AND OBJECTIVES: To report a study protocol and the theoretical framework normalisation process theory that informs this protocol for a case study investigation of private sector nurse practitioners. BACKGROUND: Most research evaluating nurse practitioner service is focused on public, mainly acute care environments where nurse practitioner service is well established with strong structures for governance and sustainability. Conversely, there is lack of clarity in governance for emerging models in the private sector. In a climate of healthcare reform, nurse practitioner service is extending beyond the familiar public health sector. Further research is required to inform knowledge of the practice, operational framework and governance of new nurse practitioner models. DESIGN: The proposed research will use a multiple exploratory case study design to examine private sector nurse practitioner service. METHODS: Data collection includes interviews, surveys and audits. A sequential mixed method approach to analysis of each case will be conducted. Findings from within-case analysis will lead to a meta-synthesis across all four cases to gain a holistic understanding of the cases under study, private sector nurse practitioner service. Normalisation process theory will be used to guide the research process, specifically coding and analysis of data using theory constructs and the relevant components associated with those constructs. CONCLUSIONS: This article provides a blueprint for the research and describes a theoretical framework, normalisation process theory in terms of its flexibility as an analytical framework. RELEVANCE TO CLINICAL PRACTICE: Consistent with the goals of best research practice, this study protocol will inform the research community in the field of primary health care about emerging research in this field. Publishing a study protocol ensures researcher fidelity to the analysis plan and supports research collaboration across teams.

The experiences of homicide victims' families with the criminal justice system: an exploratory study.

Although the crime of homicide has received significant attention from scholars, little research exists that examines the impact of homicide on surviving family members. Because opportunities for victims and family members of victims to participate in the criminal justice system are increasing, it is important to understand the impact of these forms of participation on those who choose to participate. This study uses data from focus groups to examine the experiences of homicide survivors within the criminal justice system, including views about how system involvement and specific outcomes (i.e., sentencing) may help or hinder healing. Findings suggest that many families leave the criminal justice system feeling marginalized and revictimized. This study calls into question the current criminal justice system's ability to meet the needs of crime victim and their families.

Outcomes of a home telehealth intervention for patients with diabetes and hypertension.

BACKGROUND: Home telehealth programs often focus on a single disease, yet many patients who need monitoring have multiple conditions. This study evaluated secondary outcomes from a clinical trial evaluating the efficacy of home telehealth to improve outcomes of patients with co-morbid diabetes and hypertension. SUBJECTS AND METHODS: A single-center randomized controlled clinical trial compared two remote monitoring intensity levels (low and high) and usual care in patients with type 2 diabetes and hypertension being treated in primary care. Secondary outcomes assessed were knowledge (diabetes, hypertension, medications), self-efficacy, adherence (diabetes, medications), and patient perceptions of the intervention mode. RESULTS: Knowledge scores improved in the high-intensity intervention group participants, but upon further analysis, we found the intervention effect was not mediated by gain in knowledge. No significant differences were found across the groups in self-efficacy, adherence, or patient perceptions of the intervention mode. CONCLUSIONS: Home telehealth can enhance detection of key clinical symptoms that occur between regular physician visits. While our intervention improved glycemic and blood pressure control, the mechanism of the effect for this improvement was not clear.

Anticoagulants in pediatric cerebral sinovenous thrombosis: a safety and outcome study.

OBJECTIVE: Clinical trials are lacking in pediatric cerebral sinovenous thrombosis (CSVT). Neonates and children increasingly receive anticoagulant therapy (ACT) based on adult studies. Safety data for ACT in pediatric CSVT are scant and urgently needed. The objective was to assess the safety and outcome of ACT in pediatric CSVT. METHODS: In a single-center prospective study, neonates and children with CSVT received ACT (standard/low molecular weight heparin, warfarin) by standardized protocol. A study neuroradiologist (M.S.) assessed all initial and follow-up neuroimaging for intracranial hemorrhage (ICH), thrombus propagation, and recanalization. Clinical outcome was assessed with the Pediatric Stroke Outcome Measure. RESULTS: Among 162 pediatric patients, 85 received ACT at diagnosis, including 29/83 (35%) neonates and 56/79 (71%) children. Major hemorrhage occurred in 6% (6/99) of treated patients, including 14% (3/21 neonates, 2/15 children) with and 2% (0/17 neonates, 1/46 children) without pretreatment ICH. ACT-associated bleeds were all nonfatal, and clinical outcome was favorable in 50%, similar to the remaining patients (53%). Early follow-up imaging demonstrated thrombus propagation in 11/57 neonates (10/35 [28%] without and 1/22 [4%] with ACT [p = 0.037]) and 10/63 children (7/19 [37%] without and 3/44 [7%] with ACT [p = 0.006]). Propagation was associated with new venous infarcts in 10% neonates and 40% children and worse clinical outcome in children (p = 0.053). Recanalization occurred earlier and more completely in neonates (p = 0.002). Clinical outcome was unfavorable in 47%. INTERPRETATION: In pediatric CSVT, ACT appears safe. Nontreatment with ACT is associated with thrombus propagation, observed in (1/4) of untreated neonates and over (1/3) of children. Anticoagulants merit strong consideration in pediatric CSVT.

Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial.

BACKGROUND: Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes. OBJECTIVE: The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN. DESIGN: A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used. MEASUREMENTS: Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence. RESULTS: Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups. LIMITATIONS: Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented. CONCLUSIONS: Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Delay to diagnosis in acute pediatric arterial ischemic stroke.

BACKGROUND AND PURPOSE: For the clinician, the diagnosis of arterial ischemic stroke (AIS) in children is a challenge. Prompt diagnosis of pediatric AIS within 6 hours enables stroke-specific thrombolytic and neuroprotective strategies. METHODS: We conducted a retrospective study of prospectively enrolled consecutive cohort of children with AIS, admitted to The Hospital for Sick Children, Toronto, from January 1992 to December 2004. The data on clinical presentation, symptom onset, emergency department arrival, neuroimaging and stroke diagnosis were recorded. The putative predictors of delayed diagnosis were selected a priori for analysis. RESULTS: A total of 209 children with AIS were studied. The median interval from symptom onset to AIS diagnosis was 22.7 hours (interquartile range: 7.1 to 57.7 hours), prehospital delay (symptom onset to hospital arrival) was 1.7 hours (interquartile range: 49 minutes to 8.1 hours), and the in-hospital delay (presentation to diagnosis) was 12.7 hours (interquartile range: 4.5 to 33.5 hours). The initial assessment was completed in 16 minutes and initial neuroimaging in 8.8 hours. The diagnosis of AIS was suspected on initial assessment in 79 (38%) children and the initial neuroimaging diagnosed AIS in 47%. The parent's help seeking action, nonabrupt onset of symptoms, altered consciousness, milder stroke severity, posterior circulation infarction and lack of initial neuroimaging at a tertiary hospital were predictive delayed AIS diagnosis. CONCLUSIONS: In the diagnosis of AIS, significant prehospital and in-hospital delays exist in children. Several predictors of the delayed AIS diagnosis were identified in the present study. Efforts to target these predictors can reduce diagnostic delays and optimize the management of AIS in children.

Urgent clinical challenges in children with ischemic stroke: analysis of 1065 patients from the 1-800-NOCLOTS pediatric stroke telephone consultation service.

BACKGROUND AND PURPOSE: Clinical trials are lacking in pediatric stroke. As a result, physicians caring for children with stroke face significant challenges. The patient characteristics and specific nature of clinical challenges facing practicing clinicians can inform the design of and priorities for developing relevant clinical trials. METHODS: Physicians consulted the 1-800-NOCLOTS toll-free pediatric stroke telephone consultation service on children (birth to 18 years) with ischemic stroke. Pediatric neurologist or hematologists provided telephone consultation and documented caller and patient characteristics, antithrombotic treatments and callers' questions for entry into a computerized database. Children referred from January 1, 1995 to January 1, 2004, comprised the study cohort. RESULTS: Stroke consults were completed on 1065 children located predominantly in the United States (76%). Children had arterial ischemic stroke (AIS; 679; 64%) or cerebral sinovenous thrombosis (CSVT; 386; 36%) and were 54% male and 16% neonates. Risk factors and antithrombotic agents (none, aspirin, warfarin, and heparins) differed by stroke type. In 60% of patients, callers had not initiated antithrombotic therapy. Callers' questions for both stroke types usually concerned treatment selection (83%), but for AIS, questions more frequently (P<0.0001) concerned the selection and interpretation of etiological investigations. CONCLUSIONS: Research is urgently needed in pediatric stroke to provide direction for management in "real-life" settings. Research efforts should address the unique challenges within different stroke types and include observational studies addressing investigation of the child with AIS. For AIS and CSVT, randomized controlled trials investigating the efficacy of antithrombotic treatment are urgently needed.

The Traumatized Patient.

An irredeemable pain lies beneath some patients' nonspecific symptoms.

Connecting Hispanic Women in Baltimore to the Mercy Medical Center Sexual Assault Forensic Examiners/Forensic Nurse Examiners Program: A Preliminary Assessment of Service Utilization and Community Awareness.

Sexual violence and gender-based violence represent a major public health problem causing significant negative mental, physical, and social outcomes for victims. The rapidly growing population of Hispanic women in Baltimore are both more vulnerable to sexual assault and less able to access postassault services. In an effort to assess service utilization and community awareness of the Mercy Medical Center Sexual Assault Forensic Examiners/Forensic Nurse Examiners Program, we conducted a retrospective chart review of 2,322 women who were seen by the program between 2010 and 2013 and found that only 2.5% of the women were identified as Hispanic, about half of what Baltimore City demographic data would predict. This exploratory pilot project, augmented by key informant interviews, reveals that Hispanic women are underutilizing sexual assault services. Multiple barriers exist for Hispanic women in obtaining victim services, including lack of awareness within the community that the services exist, cultural factors, language barriers, lack of awareness of legal rights, and a fear of deportation.

Identifying advanced practice: A national survey of a nursing workforce.

BACKGROUND: The size and flexibility of the nursing workforce has positioned nursing as central to the goals of health service improvement. Nursing's response to meeting these goals has resulted in proliferation of advanced practice nursing with a confusing array of practice profiles, titles and roles. Whilst numerous models and definitions of advanced practice nursing have been developed there is scant published research of significant scope that supports these models. Consequently there is an ongoing call in the literature for clarity and stability in nomenclature, and confusion in the health industry on how to optimise the utility of advanced practice nursing. OBJECTIVES: To identify and delineate advanced practice from other levels of nursing practice through examination of a national nursing workforce. DESIGN: A cross-sectional electronic survey of nurses using the validated Advanced Practice Role Delineation tool based on the Strong Model of Advanced Practice. PARTICIPANTS: Study participants were registered nurses employed in a clinical service environment across all states and territories of Australia. METHODS: A sample of 5662 registered nurses participated in the study. Domain means for each participant were calculated then means for nursing position titles were calculated. Position titles were grouped by delineation and were compared with one-way analysis of variance on domain means. The alpha for all tests was set at 0.05. Significant effects were examined with Scheffe post hoc comparisons to control for Type 1 error. RESULTS: The survey tool was able to identify position titles where nurses were practicing at an advanced level and to delineate this cohort from other levels of nursing practice, including nurse practitioner. The results show that nurses who practice at an advanced level are characterised by high mean scores across all Domains of the Strong Model of Advanced Practice. The mean scores of advanced practice nurses were significantly different from nurse practitioners in the Direct Care Domain and significantly different from other levels of nurse across all domains. CONCLUSIONS: The study results show that the nurse practitioner, advanced practice nurse and foundation level registered nurse have different patterns of practice and the Advanced Practice Role Delineation tool has the capacity to clearly delineate and define advanced practice nursing. These findings make a significant contribution to the international debate and show that the profession can now identify what is and what is not advanced practice in nursing.

6-phosphogluconate dehydrogenase: a target for drugs in African trypanosomes.

New drugs are urgently required for Human African Trypanosomiasis (sleeping sickness), a disease which has re-emerged as a major health threat in Sub-Saharan Africa. The third enzyme of the pentose phosphate pathway, 6-phosphogluconate dehydrogenase, has been shown to be a good target for drugs. The enzyme is essential to the trypanosomes that causes sleeping sickness and structural differences when compared to its mammalian counterpart allow for selective inhibition. Three series of inhibitors have been designed, these include phosphorylated carbohydrate substrate and transition state analogues, non-carbohydrate substrate analogues and also triphenylmethane-based compounds. All have shown selective inhibition of the trypanosomal 6-phosphogluconate dehydrogenase and representatives of each have trypanocidal activity.

Systemic thromboembolism in children. Data from the 1-800-NO-CLOTS Consultation Service.

Thromboembolism (TE) has recently been recognized as a clinical entity in children. Determining the clinical characteristics of pediatric TE is an important first step in dealing with this new disorder. The paper summarizes 1776 consecutive children with systemic TE referred to 1-800-NO-CLOTS telephone consultation service. 1-800-NO-CLOTS is a free consultation service for clinicians managing pediatric TE. Patient information was collected immediately using standardized forms. In children with systemic TE, infants under one year of age (47%) including neonates (26%) represented the largest distinct pediatric age group. Age-related differences were seen in TE locations, associated conditions, and risk factors. However, venous TE was the most frequent manifestation (74%). Neonates and children with cardiac disorders were more likely to have an arterial TE than a venous TE Beyond the neonatal period, venous TE associated with a central line is more likely to occur than arterial TE. Children with ALL were 5.7 times more likely to have a venous TE than an arterial TE. TE were infrequent in otherwise healthy children with 90% of children having at least one risk factor. Central catheters were the single most common risk factor associated with TE, present in 2/3 of children. Ultrasound was most frequently employed for diagnosis of TE. Finally, there was marked heterogeneity in treatment of children with TE. In children, neonates form the largest single group with TE. TE usually occur only in the presence of one or more risk factors with catheters being the single most important factor.

Fibrinolytic response to venous occlusion is decreased in patients after Kawasaki disease.

Impaired fibrinolysis is considered a sensitive marker of endothelial dysfunction. Persistent endothelial dysfunction occurs in some patients following Kawasaki disease. The aim of the present study was to assess whether impaired fibrinolysis is present in long-term survivors of Kawasaki disease. The study included 42 children with a documented history of Kawasaki disease presenting with or without coronary lesions, and 26 healthy controls. Blood samples were collected from patients and controls prior to and following venous occlusion stress testing. Significantly decreased fibrinolytic response to venous occlusion was detected in patients compared with controls due to decreased tissue plasminogen activator. In addition, patients had significantly increased plasma concentrations of plasminogen and fibrinogen, which were related to similar increases of alpha2 -macroglobulin. Decreased fibrinolytic response was found in patients with coronary aneurysms but also in those without coronary lesions. In summary, a decreased fibrinolytic response to venous occlusion may reflect persistent endothelial damage following acute Kawasaki disease, potentially predisposing these patients to accelerated atherosclerosis and cardiovascular disease in early adult life.

Evaluating the effectiveness of an aggressive case management and home telehealth monitoring program for long-term control of A1C.

PURPOSE/OBJECTIVES: To describe and assess the effectiveness of a case management and home telemonitoring program for patients with diabetes mellitus (DM) PRIMARY PRACTICE SETTING: Case managers work in a mid-sized medical center for the Department of Veterans Affairs. Patients are veterans who participate in a home telemonitoring and case management program designed to assist with long-term control of serum glucose levels. FINDINGS/CONCLUSIONS: The home telemonitoring/case management program process is shown to be effective in helping patients with long-term control of glycosylated hemoglobin (A1C). When compared with a control group, program participants showed significantly differentiated long-term improvement in A1C levels. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: • Home telemonitoring and aggressive case management together are effective in helping patients with diabetes self-care. • Case management practices for patients with diabetes should include a strong educational component, continuing throughout the process, that addresses lifestyle and dietary changes. • Home telemonitoring may serve as a patient "demand" indicator and workload regulator for case managers. • Case management and home telemonitoring have long-term effects in diabetes self-care even after active case management and home telemonitoring come to an end.

Fundamental thermochemical properties of amino acids: gas-phase and aqueous acidities and gas-phase heats of formation.

The gas-phase acidities of the 20 L-amino acids have been predicted at the composite G3(MP2) level. A broad range of structures of the neutral and anion were studied to determine the lowest energy conformer. Excellent agreement is found with the available experimental gas-phase deprotonation enthalpies, and the calculated values are within experimental error. We predict that tyrosine is deprotonated at the CO(2)H site. Cysteine is predicted to be deprotonated at the SH but the proton on the CO(2)H is shared with the S(-) site. Self-consistent reaction field (SCRF) calculations with the COSMO parametrization were used to predict the pK(a)'s of the non-zwitterion form in aqueous solution. The differences in the non-zwitterion pK(a) values were used to estimate the free energy difference between the zwitterion and nonzwitterion forms in solution. The heats of formation of the neutral compounds were calculated from atomization energies and isodesmic reactions to provide the first reliable set of these values in the gas phase. Further calculations were performed on five rare amino acids to predict their heats of formation, acidities, and pK(a) values.

Stressed-induced TMEM135 protein is part of a conserved genetic network involved in fat storage and longevity regulation in Caenorhabditis elegans.

Disorders of mitochondrial fat metabolism lead to sudden death in infants and children. Although survival is possible, the underlying molecular mechanisms which enable this outcome have not yet been clearly identified. Here we describe a conserved genetic network linking disorders of mitochondrial fat metabolism in mice to mechanisms of fat storage and survival in Caenorhabditis elegans (C. elegans). We have previously documented a mouse model of mitochondrial very-long chain acyl-CoA dehydrogenase (VLCAD) deficiency. We originally reported that the mice survived birth, but, upon exposure to cold and fasting stresses, these mice developed cardiac dysfunction, which greatly reduced survival. We used cDNA microarrays to outline the induction of several markers of lipid metabolism in the heart at birth in surviving mice. We hypothesized that the induction of fat metabolism genes in the heart at birth is part of a regulatory feedback circuit that plays a critical role in survival. The present study uses a dual approach employing both C57BL/6 mice and the nematode, C. elegans, to focus on TMEM135, a conserved protein which we have found to be upregulated 4.3 (±0.14)-fold in VLCAD-deficient mice at birth. Our studies have demonstrated that TMEM135 is highly expressed in mitochondria and in fat-loaded tissues in the mouse. Further, when fasting and cold stresses were introduced to mice, we observed 3.25 (±0.03)- and 8.2 (±0.31)-fold increases in TMEM135 expression in the heart, respectively. Additionally, we found that deletion of the tmem135 orthologue in C. elegans caused a 41.8% (±2.8%) reduction in fat stores, a reduction in mitochondrial action potential and decreased longevity of the worm. In stark contrast, C. elegans transgenic animals overexpressing TMEM-135 exhibited increased longevity upon exposure to cold stress. Based on these results, we propose that TMEM135 integrates biological processes involving fat metabolism and energy expenditure in both the worm (invertebrates) and in mammalian organisms. The data obtained from our experiments suggest that TMEM135 is part of a regulatory circuit that plays a critical role in the survival of VLCAD-deficient mice and perhaps in other mitochondrial genetic defects of fat metabolism as well.