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.

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.

Children's exposure assessment: a review of factors influencing Children's exposure, and the data available to characterize and assess that exposure.

We review the factors influencing children's exposure to environmental contaminants and the data available to characterize and assess that exposure. Children's activity pattern data requirements are demonstrated in the context of the algorithms used to estimate exposure by inhalation, dermal contact, and ingestion. Currently, data on children's exposures and activities are insufficient to adequately assess multimedia exposures to environmental contaminants. As a result, regulators use a series of default assumptions and exposure factors when conducting exposure assessments. Data to reduce uncertainty in the assumptions and exposure estimates are needed to ensure chemicals are regulated appropriately to protect children's health. To improve the database, advancement in the following general areas of research is required: identification of appropriate age/developmental benchmarks for categorizing children in exposure assessment; development and improvement of methods for monitoring children's exposures and activities; collection of activity pattern data for children (especially young children) required to assess exposure by all routes; collection of data on concentrations of environmental contaminants, biomarkers, and transfer coefficients that can be used as inputs to aggregate exposure models.

Pesticide exposure and creatinine variation among young children.

Pesticide exposure may differentially impact young children; they live closer to the ground and take in greater amounts of food relative to body mass than older children or adults. We are using an organophosphate (OP) urinary biomarker screen (gas chromatography with flame photometric detection, GC/FPD) to evaluate pesticide exposure among 154 children < or = 6 years of age living in a heavily farmed border (US-Mexico) community. The screen detects diethylphosphates (DEPs) and dimethylphosphates (DMPs) above a reference range of 1000 non-occupationally exposed individuals (DL=25 microg/g creatinine, Cr). At least one metabolite was detected for 33% of the subjects; many samples contained multiple biomarkers. DEP was detected in 5% of the subjects. DMP and DMTP were frequently measured (25% and 26%, respectively). Biomarker concentrations are adjusted by the body's metabolism of Cr as an indicator of urine dilution. Cr concentrations were examined separately to evaluate their effect on internal dose measures. Cr concentrations were significantly different by season (K-W=0.83, P=0.022). Significant differences exist between the autumn:spring (P=0.038) Cr concentrations and between summer:autumn (P=0.041) Cr concentrations based on Mann-Whitney U=1070.5, z=-2.041, (P=0.041). Our analysis of NHANES III data did not reflect seasonal Cr differences for 6 year olds. No younger children were included. Absorbed daily dose (ADD) estimates were calculated for children with the highest concentrations of metabolite. Calculations are theoretical values assuming that the entirety of a given metabolite was metabolized from a single pesticide. Several class appropriate pesticides were evaluated. For the children with the highest levels, almost all estimated ADDs exceeded the RfD. Although the actual metabolite concentrations dropped appreciably, ADD were still exceeded RfDs at the 95th percentile. The urinary OP screen was effective in identifying subjects with atypical internal doses. Daily Cr yield is a critical component in ADD calculations. Cr variability produces differences in internal dose measurement and estimates of ADD independent of exposure. Cr variability among young children needs to be examined, and caution should be applied when evaluating Cr adjusted internal doses for children.

Responses to the region 5 NHEXAS time/activity diary. National Human Exposure Assessment Survey.

The time/activity diary developed for use in the National Human Exposure Assessment Survey (NHEXAS) was completed by 249 participants in the Research Triangle Institute/Environmental and Occupational Health Sciences Institute (RTI/EOHSI) NHEXAS population-based pilot project conducted in the upper Midwest (EPA Region 5). The majority of participants successfully completed the diary during the 6-day study period. Participant responses showed internal consistency between related questions within the diary and between instruments used within the study. Comparison of response rates with the National Human Activity Pattern Survey, a nationwide population-based study, found consistent results when the same questions were used in both studies. Several questions identified age-specific activities. The value of the 6-day diary over 1-day surveys was apparent in discriminating between episodic and regularly conducted activities and in identifying subpopulations whose behavior may contribute to exposure to environmental pollutants.

Hygiene- and food-related behaviors associated with blood lead levels of young children from lead-contaminated homes.

Exposures associated with blood lead levels greater than 40 micrograms/dL in young children who live in lead-contaminated homes have been well documented. As the action level for lead is reduced, activities that contribute to lower levels of lead exposure must be identified. A child's eating habits and related hygiene behaviors are major hand-to-mouth activities that have been largely overlooked in the study of activities contributing to lead ingestion. To examine this subject, a survey questionnaire for caretakers of young children was developed. The objective of the questionnaire was to characterize food-related activities of young children and to identify behavioral indicators of lead exposure. The association between food- and hygiene-related behaviors and blood lead levels among 60 children between 13 and 36 months old with low-to-moderate blood lead levels was examined in homes that had been identified as containing lead in paint and house dust. The participants were enrolled in the Children's Lead Exposure and Reduction Study in Jersey City, New Jersey. Blood lead levels of children 13-24 months old did not differ significantly from those of children 25-36 months of age (10.1 and 11.3 micrograms/dL, respectively). Differences in eating habits and hygiene behaviors were found for the two age groups. Bivariate analyses found that the primary behavioral indicators of blood lead levels were determined by whether the child prepared his/her own food and whether the child ate food that had been on the floor. This factor was dependent on age. Children 13-24 months old had significantly elevated blood lead levels if these behaviors exhibited. No significant differences were found, however, for children 25-36 months old. Several food-related habits were also associated with blood lead levels. Eating hamburgers, doughnuts, peanut butter and jelly sandwiches, and cold cuts were associated with elevated blood lead levels in 13-24-month-old children, while eating vitamins, raw vegetables, and yogurt were associated with lower blood lead levels in this age group. For children 25-36 months old, eating hamburgers and peanut butter and jelly sandwiches was associated with elevated blood lead levels, while yogurt consumption was associated with lower blood lead levels.

Population-based exposure measurements in EPA region 5: a phase I field study in support of the National Human Exposure Assessment Survey.

The National Human Exposure Assessment Survey (NHEXAS) Phase I study is designed to be part of the total NHEXAS framework developed from a series of scientific discussions and workshops conducted by the U.S. Environmental Protection Agency (EPA) during 1992 and 1993. NHEXAS examines total human exposure and is structured to include: Phase I, scoping studies; Phase II, a full national exposure survey; and Phase III, a series of highly focused characterization modules. Our research program examines the scientific issues important to Phase II, including statistical sampling, methods evaluation, media concentration measurements, formulating quality assurance goals, and identification of important pathways leading to exposure. To determine the feasibility of NHEXAS in characterizing human exposure for a representative population, a hypothesis-driven design is used to answer important questions about human exposure to specific environmental contaminants. This paper describes: (1) hypotheses to be tested; (2) contaminants selected for study; (3) strategies for measuring exposure; (4) study area and population; (5) population sampling design; (6) media sampling and analysis procedures; and (7) data analysis. The contaminants of concern in this Phase I study include selected metals and volatile organic compounds. From these classes the first-tier contaminants to be measured are lead, arsenic, benzene, chloroform, perchloroethylene, and trichloroethylene. Contaminants selected for examination may potentially be found in many media (personal-nonoccupational, personal-occupational, indoor, and outdoor residential air; dust; potable water; food/beverages; soil; blood; hair; and urine) and exposures may occur by multiple routes (inhalation, ingestion, dermal). The central hypothesis of our field study is to discover whether individual and population exposures determined by modeled or extant data are/are not significantly different from those determined directly from multipathway and multimedia measurements. In addition, there are a series of subhypotheses ranging from pollutant-specific exposure measurement and body burden hypotheses to the optimization of exposure models. In keeping with the NHEXAS framework, a probability-based population sample for total exposure and the field study will be conducted in counties located throughout EPA Region 5 (Minnesota, Wisconsin, Illinois, Indiana, Ohio, and Michigan). Sampling units will be households and an individual residing within each household. Environmental, exposure, and biological media sample collection will be performed by this consortium. Analyses of the external media and biological media samples will be completed by this consortium or Federal laboratories of the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), or EPA. The protocols and analytical techniques selected for use represent the best available for total exposure assessment at this time.

Functional assessment of colonic interposition with 99Tcm-labeled milk.

A prospective study was performed to evaluate the use of radionuclide imaging in the assessment of patients who have undergone esophageal reconstruction. Dynamic radionuclide imaging was performed on ten patients aged 11 months to 11 years who had undergone colon interposition via the normal esophageal route for esophageal atresia. Patients were considered clinically unsatisfactory if at the time of imaging feeding was troubled, or if weight gain had fallen to below the third centile before operation and remained below after operation. Each patient underwent erect imaging with a small milk feed labeled with 10 to 20 MBq (250 to 500 muCi) 99Tcm DTPA adjusted according to body surface area; supine studies were subsequently performed on five patients. All five clinically unsatisfactory patients showed conduit emptying delayed beyond 45 minutes and/or spontaneous reflux, significantly different from the clinically satisfactory patients (X2 = 6.4, P less than .02). Conduit complications were subsequently identified in three of the five clinically unsatisfactory patients. Radionuclide imaging with radiolabeled milk was found to be well tolerated, and obtained results that were clinically useful. These results suggest that dynamic radionuclide imaging can be more widely applied in the assessment of esophageal substitutes.