Codesigning enhanced models of care for Northern Australian Aboriginal and Torres Strait Islander youth with type 2 diabetes: study protocol.

INTRODUCTION: Premature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of care. We describe the methods for the codesign, implementation and evaluation of enhanced models of care with Aboriginal and Torres Strait Islander youth living with type 2 diabetes across Northern Australia. METHODS AND ANALYSIS: Our mixed-methods approach is informed by the principles of codesign. Across eight sites in four regions, the project brings together the lived experience of Aboriginal and Torres Strait Islander young people (aged 10-25) with type 2 diabetes, their families and communities, and health professionals providing diabetes care through a structured yet flexible codesign process. Participants will help identify and collaborate in the development of a range of multifaceted improvements to current models of care. These may include addressing needs identified in our formative work such as the development of screening and management guidelines, referral pathways, peer support networks, diabetes information resources and training for health professionals in youth type 2 diabetes management. The codesign process will adopt a range of methods including qualitative interviews, focus group discussions, art-based methods and healthcare systems assessments. A developmental evaluation approach will be used to create and refine the components and principles of enhanced models of care. We anticipate that this codesign study will produce new theoretical insights and practice frameworks, resources and approaches for age-appropriate, culturally safe models of care. ETHICS AND DISSEMINATION: The study design was developed in collaboration with Aboriginal and Torres Strait Islander and non-Indigenous researchers, health professionals and health service managers and has received ethical approval across all sites. A range of outputs will be produced to disseminate findings to participants, other stakeholders and the scholarly community using creative and traditional formats.

Synthetic studies toward inducamide C.

The alkaloid inducamide C is proposed to contain a very rare benzoxazepine ring. Herein, we report that the benzoxazepine ring in inducamide C is unstable and prone to rearrangement, indicating that structural revision of the natural product may be necessary. In a first-generation synthetic approach, attempts to assemble the benzoxazepine by cyclization of 4-hydroxyinducamide A led to the regioisomeric oxepanoindole, a result of the 4-hydroxyindole (C4-OH) undergoing preferential cyclization instead of the desired chlorosalicylic acid C15-OH. A second-generation approach involved dealkylation of O-isopropylinducamide C, but the same oxepanoindole formed via rearrangement of the proposed inducamide C structure. Computational studies validate preferential formation of the oxepanoindole and the lactone in O-isopropylinducamide C is susceptible to nucleophilic attack. Thus, inducamide C is either highly unstable or in need of structural revision.

Understanding lived experiences of Aboriginal people with type 2 diabetes living in remote Kimberley communities: diabetes, it don't come and go, it stays!

This study aimed to explore the lived experiences of Kimberley Aboriginal people with type 2 diabetes managed by remote Aboriginal Community Controlled Health Services using phenomenological analysis. Semi-structured interviews formulated by Aboriginal Health Workers, researchers and other clinicians were used to obtain qualitative data from 13 adult Aboriginal patients with type 2 diabetes managed in two remote communities in the Kimberley. Together with expert opinion from local Aboriginal Health Workers and clinicians, the information was used to develop strategies to improve diabetes management. Of 915 regular adult patients in the two communities, 27% had type 2 diabetes; 83% with glycated haemoglobin A >10%. Key qualitative themes included: the need for culturally relevant education and pictorial resources; importance of continuous therapeutic relationships with healthcare staff; lifestyle management advice that takes into account local and cultural factors; and the involvement of Aboriginal community members and families in support roles. Recommendations to improve diabetes management in the remote communities have been made collaboratively with community input. This study provides a framework for culturally relevant recommendations to assist patients with diabetes, for collaborative research, and for communication among patients, Aboriginal Health Workers, community members, researchers and other clinicians. Interventions based on recommendations from this study will be the focus of further collaborative research.

Complex diabetes screening guidelines for high-risk adolescent Aboriginal Australians: a barrier to implementation in primary health care.

The aim of this study is to ascertain whether a simplified screening algorithm incorporating glycated haemoglobin (HbA1c) tests increases type 2 diabetes (T2D) screening in 10- to 14-year-old Aboriginal Australians presenting to primary healthcare (PHC) services. The study involved a 6-month pilot of a locally developed evidence-based screening algorithm in a remote Western Australian Kimberley town. A retrospective audit of electronic health records for the pilot period (27 June-26 December 2016) and a 6-month period before the screening algorithm was introduced (1 October 2015-31 March 2016) was conducted. Interviews were held with 30 PHC staff at participating PHC services, an Aboriginal Community Controlled Health Service (ACCHS) and a hospital-based general practice service. During the pilot, significantly more patients received an initial T2D screening test at the ACCHS (28/130 (22%) v. 50/139 (36%), P = 0.011), but there was no change at the hospital (0.02% v. 0.02%, P = 0.615). Staff feedback suggested measures to improve screening; these include simple guidelines, targeted screening, patient and staff education, point-of-care HbA1c tests and a whole-of-clinic approach to implementation. Implementing a screening algorithm for young-onset diabetes in Aboriginal Australians is challenging, but practical measures can be taken to improve screening.

N-Heterocyclic Carbene Catalyzed (5+1) Annulations Exploiting a Vinyl Dianion Synthon Strategy.

Direct polarity inversion of conjugate acceptors provides a valuable entry to homoenolates. N-heterocyclic carbene (NHC) catalyzed reactions, in which ß-unsubstituted conjugate acceptors undergo homoenolate formation and C-C bond formation twice, have been developed. Specifically, the all-carbon (5+1) annulations give a range of mono- and bicyclic cyclohexanones (31 examples). In the first family of annulations, ß-unsubstituted acrylates tethered to a divinyl ketone undergo cycloisomerization, providing hexahydroindenes and tetralins. In the second, partially untethered substrates undergo an intermolecular (5+1) annulation involving dimerization followed by cycloisomerization. While enantioselectivity was not possible with the former, the latter proved viable, allowing cyclohexanones to be produced with high levels of enantiopurity (most >95:5 e.r.) and exclusive diastereoselectivity (>20:1 d.r.). Derivatizations and mechanistic studies are also reported.

Enantioselective N-Heterocyclic Carbene Catalyzed Cyclopentene Synthesis via the ß-Azolium Ylide.

Herein we report the cycloisomerization of electron-poor 1,5-dienes via the ß-azolium ylide to give enantioenriched cyclopentenes. The reaction is mediated by a chiral N-heterocyclic carbene (NHC) catalyst, exploits readily available substrates, has good generality (17 examples), and displays excellent enantioselectivity (mostly >94:6). Studies demonstrating the viability of a related dynamic kinetic resolution are reported, as are those with alternate tethers and derivatizations.

Bronchiectasis in the Kimberley region of Western Australia.

OBJECTIVE: To review the work-up and inpatient management of non-cystic fibrosis bronchiectasis exacerbations against best practice guidelines in the Kimberley, a remote region of Western Australia, with the ultimate goal of improving treatment in the region.^ DESIGN: Retrospective cohort study and audit of remote adult bronchiectasis hospital admissions between 2011 and 2016. SETTING: Remote hospital inpatients. PARTICIPANTS: Thirty-two patients and 110 hospital admissions were included. Patients were ≥15 years old, had computed tomography confirmed bronchiectasis and at least one hospital admission for acute respiratory illness prior to January 2011. MAIN OUTCOMES MEASURED: The 5-year mortality and compliance to a Lung Foundation position statement on non-cystic fibrosis bronchiectasis which suggests investigating for an underlying cause at diagnosis and during exacerbations prolonged antibiotics (10-14 days) and prolonged hospital admissions (≥7 days) are required. RESULTS: The overall 5-year mortality was 21.8%, with the median age at death of 37 years (interquartile range, 27-63). The median duration of hospital admission was shorter than the recommended 3 days (interquartile range, 2-5) with 11 of 100 (11%) patients admitted for ≥7 days. The median duration of antibiotics was also shorter than the recommended 7 days (interquartile range, 4-10), with 31 of the 98 (32%) patients prescribed ≥10 days and 6 of the 98 (6%) prescribed ≥14 days of therapy. CONCLUSION: We found under-treatment and under-investigation of non-cystic fibrosis bronchiectasis in the Kimberley region. Five-year mortality was high, consistent with other rural Australian Indigenous cohorts.§ Following this audit, a strategy to improve awareness, as well as update and promote regional guidelines has been developed.

Synthesis of Inducamides A and B.

The inducamides are a family of chlorinated alkaloids featuring an amide arising from union of an l-tryptophan to a rare chlorosalicylic acid unit, the production of which is linked to a chemically induced mutation in the RNA polymerase of Streptomyces sp. (SNC-109-M3). The synthesis of inducamides A and B has been accomplished by the coupling of 6-hydroxy-3-chloro-2-methylbenzoic acid with l-6-chlorotryptophan and l-tryptophan, respectively, followed by ester hydrolysis. The spectroscopic data and optical rotation for each synthetic sample confirm the structures of these silent secondary metabolites and their biosynthesis from l-tryptophan.

The mental health literacy of rural adolescents: Emo subculture and SMS texting.

OBJECTIVE: This study sought to explore the mental health literacy of adolescents living in a rural area in Australia through in-depth, semi-structured interviews, with a view to identifying areas for further research and making recommendations for improved education programs around mental health. METHOD: Nine Year 10 students (two boys and seven girls) from a rural secondary school in South Australia read two vignettes, one portraying depression and the other schizophrenia. Semi-structured individual interviews that focussed on the vignettes were audio-taped, transcribed and analysed for thematic content. RESULTS: The data yielded a number of main themes, many of which have been previously identified in the literature. Two new findings also emerged. These were the role of Emo subculture and dealing with distress, and the value of confiding in another person through short message service (SMS) texting. CONCLUSIONS: The impact of Emo subculture and SMS texting on mental health literacy requires further exploration. It is suggested that these two findings are not confined to rural youth, but may have national and international relevance.

University rural health clubs: nurturing the future Australian rural workforce.

CONTEXT: Australian university rural health clubs (RHC) are part of a national strategy to address the rural health workforce shortage. The student members of these clubs throughout Australia comprise the National Rural Health Network (NRHN). The NRHN is a multidisciplinary body representing medical, nursing and allied health students, aiming to increase the health workforce and health outcomes for rural and remote Australians. The NRHN and its constituent clubs run a variety of activities to promote rural careers to both school-aged and university students. These have included events at local, state and national levels. ISSUES: The purpose of the present article is to describe the roles and activities of RHC and the NRHN as they aim to contribute towards developing a sustainable rural workforce. Key features of RHC and the NRHN are: (1) providing positive rural experiences; (2) peer promotion of rural health; (3) personal and professional development; (4) providing a volunteer workforce for rural health initiatives; and (5) cross-disciplinary interaction. The NRHN is currently investigating methods to quantify the impact of the RHC on the career choices of potential rural health professionals. LESSONS LEARNED: The NRHN and its constituent clubs are student-driven initiatives occupying a unique place in addressing the rural workforce shortage. Although little formal evidence exists for their success, the issues raised in this article illustrate their importance and broader benefits in this field.

Parental substance abuse, reports of chronic pain and coping in adult patients with sickle cell disease.

There is increasing interest from a social learning perspective in understanding the role of parental factors on adult health behaviors and health outcomes. Our review revealed no studies, to date, that have evaluated the effects of parental substance abuse on reports of chronic pain and coping in adult patients with sickle cell disease (SCD). We explored the effects of parental substance (alcohol or drug) abuse on reports of the sensory, affective and summary indices of pain in 67 adult patients, mean age 38.9 (13.5), with SCD. We also explored the effects of parental substance abuse on psychopathology associated with pain and active coping. Twenty-four percent of patients reported that their parent(s) abused substances. Patients whose parent(s) were characterized as substance abusers reported greater sensory (p=0.02), affective (p=0.01) and summary (VAS; p=0.02) indices of pain as compared to their counterparts, whose parent(s) were not characterized as substance abusers. Patients did not differ in average age, education or the propensity to respond in a socially acceptable manner. There was a significant trend towards patients who characterized their parents as abusers scoring higher than their counterparts on active coping. We propose a Social Learning Theory to explain the current findings and suggest a need for additional prospective research to simultaneously explore biological (genetic) and social factors that influence the interpretation, experience and reporting of chronic pain in adult patients with chronic disease.