Malnutrition and pressure ulcer risk in adults in Australian health care facilities

Aims To determine the effect of nutritional status on the presence and severity of pressure ulcers in statewide? public healthcare facilities, in Queensland, Australia. Research Methods A multicentre, cross sectional audit of nutritional status of a convenience sample of subjects was carried out as part of a large audit of pressure ulcers in a sample of state based public healthcare facilities in 2002 and 2003. Dietitians in 20 hospitals and six residential aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment. The effect of nutritional status on the presence, highest stage and number of pressure ulcers was determined by logistic regression in a model controlling for age, gender, medical specialty and facility location. The potential clustering effect of facility was accounted for in the model using an analysis of correlated data approach. Results Subjects with malnutrition had an adjusted odds risk of 2.6 (95% CI 1.8-3.5, p<0.001) of having a pressure ulcer in acute facilities and 2.0 (95% CI 1.5-2.7, p<0.001) for residential aged care facilities. There was also increased odds risk of having a pressure ulcer, having a higher stage pressure ulcer and a higher number of pressure ulcers with increased severity of malnutrition. Conclusion Malnutrition was associated with at least twice the odds risk of having a pressure ulcer of in public healthcare facilities in Queensland. Action must be taken to identify, prevent and treat malnutrition, especially in patients at risk of pressure ulcer.

Damage assessment in structures using vibration characteristics

Changes in load characteristics, deterioration with age, environmental influences and random actions may cause local or global damage in structures, especially in bridges, which are designed for long life spans. Continuous health monitoring of structures will enable the early identification of distress and allow appropriate retrofitting in order to avoid failure or collapse of the structures. In recent times, structural health monitoring (SHM) has attracted much attention in both research and development. Local and global methods of damage assessment using the monitored information are an integral part of SHM techniques. In the local case, the assessment of the state of a structure is done either by direct visual inspection or using experimental techniques such as acoustic emission, ultrasonic, magnetic particle inspection, radiography and eddy current. A characteristic of all these techniques is that their application requires a prior localization of the damaged zones. The limitations of the local methodologies can be overcome by using vibration-based methods, which give a global damage assessment. The vibration-based damage detection methods use measured changes in dynamic characteristics to evaluate changes in physical properties that may indicate structural damage or degradation. The basic idea is that modal parameters (notably frequencies, mode shapes, and modal damping) are functions of the physical properties of the structure (mass, damping, and stiffness). Changes in the physical properties will therefore cause changes in the modal properties. Any reduction in structural stiffness and increase in damping in the structure may indicate structural damage. This research uses the variations in vibration parameters to develop a multi-criteria method for damage assessment. It incorporates the changes in natural frequencies, modal flexibility and modal strain energy to locate damage in the main load bearing elements in bridge structures such as beams, slabs and trusses and simple bridges involving these elements. Dynamic computer simulation techniques are used to develop and apply the multi-criteria procedure under different damage scenarios. The effectiveness of the procedure is demonstrated through numerical examples. Results show that the proposed method incorporating modal flexibility and modal strain energy changes is competent in damage assessment in the structures treated herein.

Assessment of tear film surface quality using dynamic-area high-speed videokeratoscopy

A new method for noninvasive assessment of tear film surface quality (TFSQ) is proposed. The method is based on high-speed videokeratoscopy in which the corneal area for the analysis is dynamically estimated in a manner that removes videokeratoscopy interference from the shadows of eyelashes but not that related to the poor quality of the precorneal tear film that is of interest. The separation between the two types of seemingly similar videokeratoscopy interference is achieved by region-based classification in which the overall noise is first separated from the useful signal (unaltered videokeratoscopy pattern), followed by a dedicated interference classification algorithm that distinguishes between the two considered interferences. The proposed technique provides a much wider corneal area for the analysis of TFSQ than the previously reported techniques. A preliminary study with the proposed technique, carried out for a range of anterior eye conditions, showed an effective behavior in terms of noise to signal separation, interference classification, as well as consistent TFSQ results. Subsequently, the method proved to be able to not only discriminate between the bare eye and the lens on eye conditions but also to have the potential to discriminate between the two types of contact lenses.

Validation of the Australian Propensity for Angry Driving Scale (Aus-PADS)

The present study used a university sample to assess the test-retest reliability and validity of the Australian Propensity for Angry Driving Scale (Aus-PADS). The scale has stability over time, and convergent validity was established, as Aus-PADS scores correlated significantly with established anger and impulsivity measures. Discriminant validity was also established, as Aus-PADS scores did not correlate with Venturesomeness scores. The Aus-PADS has demonstrated criterion validity, as scores were correlated with behavioural measures, such as yelling at other drivers, gesturing at other drivers, and feeling angry but not doing anything. Aus-PADS scores reliably predicted the frequency of these behaviours over and above other study variables. No significant relationship between aggressive driving and crash involvement was observed. It was concluded that the Aus-PADS is a reliable and valid tool appropriate for use in Australian research, and that the potential relationship between aggressive driving and crash involvement warrants further investigation with a more representative (and diverse) driver sample.

The development and evaluation of an innovative nursing practice model to improve undergraduate nursing students' competence in paediatric physical assessment

Introduction The purpose of this study was to develop, implement and evaluate the impact of an educational intervention, comprising an innovative model of clinical decisionmaking and educational delivery strategy for facilitating nursing students‘ learning and development of competence in paediatric physical assessment practices. Background of the study Nursing students have an undergraduate education that aims to produce graduates of a generalist nature who demonstrate entry level competence for providing nursing care in a variety of health settings. Consistent with population morbidity and health care roles, paediatric nursing concepts typically form a comparatively small part of undergraduate curricula and students‘ exposure to paediatric physical assessment concepts and principles are brief. However, the nursing shortage has changed traditional nursing employment patterns and new graduates form the majority of the recruitment pool for paediatric nursing speciality staff. Paediatric nursing is a popular career choice for graduates and anecdotal evidence suggests that nursing students who select a clinical placement in their final year intend to seek employment in paediatrics upon graduation. Although concepts of paediatric nursing are included within undergraduate curriculum, students‘ ability to develop the required habits of mind to practice in what is still regarded as a speciality area of practice is somewhat limited. One of the areas of practice where this particularly impacts is in paediatric nursing physical assessment. Physical assessment is a fundamental component of nursing practice and competence in this area of practice is central to nursing students‘ development of clinical capability for practice as a registered nurse. Timely recognition of physiologic deterioration of patients is a key outcome of nurses‘ competent use of physical assessment strategies, regardless of the practice context. In paediatric nursing contexts children‘s physical assessment practices must specifically accommodate the child‘s different physiological composition, function and pattern of clinical deterioration (Hockenberry & Barrera, 2007). Thus, to effectively manage physical assessment of patients within the paediatric practice setting nursing students need to integrate paediatric nursing theory into their practice. This requires significant information processing and it is in this process where students are frequently challenged. The provision of rules or models can guide practice and assist novice-level nurses to develop their capabilities (Benner, 1984; Benner, Hooper-Kyriakidis & Stannard, 1999). Nursing practice models are cognitive tools that represent simplified patterns of expert analysis employing concepts that suit the limited reasoning of the inexperienced, and can represent the =rules‘ referred to by Benner (1984). Without a practice model of physical assessment students are likely to be uncertain about how to proceed with data collection, the interpretation of paediatric clinical findings and the appraisal of findings. These circumstances can result in ad hoc and unreliable nursing physical assessment that forms a poor basis for nursing decisions. The educational intervention developed as part of this study sought to resolve this problem and support nursing students‘ development of competence in paediatric physical assessment. Methods This study utilised the Context Input Process Product (CIPP) Model by Stufflebeam (2004) as the theoretical framework that underpinned the research design and evaluation methodology. Each of the four elements in the CIPP model were utilised to guide discrete stages of this study. The Context element informed design of the clinical decision-making process, the Paediatric Nursing Physical Assessment model. The Input element was utilised in appraising relevant literature, identifying an appropriate instructional methodology to facilitate learning and educational intervention delivery to undergraduate nursing students, and development of program content (the CD-ROM kit). Study One employed the Process element and used expert panel approaches to review and refine instructional methods, identifying potential barriers to obtaining an effective evaluation outcome. The Product element guided design and implementation of Study Two, which was conducted in two phases. Phase One employed a quasiexperimental between-subjects methodology to evaluate the impact of the educational intervention on nursing students‘ clinical performance and selfappraisal of practices in paediatric physical assessment. Phase Two employed a thematic analysis and explored the experiences and perspectives of a sample subgroup of nursing students who used the PNPA CD-ROM kit as preparation for paediatric clinical placement. Results Results from the Process review in Study One indicated that the prototype CDROM kit containing the PNPA model met the predetermined benchmarks for face validity and the impact evaluation instrumentation had adequate content validity in comparison with predetermined benchmarks. In the first phase of Study Two the educational intervention did not result in statistically significant differences in measures of student performance or self-appraisal of practice. However, in Phase Two qualitative commentary from students, and from the expert panel who reviewed the prototype CD-ROM kit (Study One, Phase One), strongly endorsed the quality of the intervention and its potential for supporting learning. This raises questions regarding transfer of learning and it is likely that, within this study, several factors have influenced students‘ transfer of learning from the educational intervention to the clinical practice environment, where outcomes were measured. Conclusion In summary, the educational intervention employed in this study provides insights into the potential e-learning approaches offer for delivering authentic learning experiences to undergraduate nursing students. Findings in this study raise important questions regarding possible pedagogical influences on learning outcomes, issues within the transfer of theory to practice and factors that may have influenced findings within the context of this study. This study makes a unique contribution to nursing education, specifically with respect to progressing an understanding of the challenges faced in employing instructive methods to impact upon nursing students‘ development of competence. The important contribution transfer of learning processes make to students‘ transition into the professional practice context and to their development of competence within the context of speciality practice is also highlighted. This study contributes to a greater awareness of the complexity of translating theoretical learning at undergraduate level into clinical practice, particularly within speciality contexts.

Context-Based Modelling of Interferometric Signals for the Assessment of Tear-Film Suface Quality

Modelling of interferometric signals related to tear film surface quality is considered. In the context of tear film surface quality estimation in normal healthy eyes, two clinical parameters are of interest: the build-up time, and the average interblink surface quality. The former is closely related to the signal derivative while the latter to the signal itself. Polynomial signal models, chosen for a particular set of noisy interferometric measurements, can be optimally selected, in some sense, with a range of information criteria such as AIC, MDL, Cp, and CME. Those criteria, however, do not always guarantee that the true derivative of the signal is accurately represented and they often overestimate it. Here, a practical method for judicious selection of model order in a polynomial fitting to a signal is proposed so that the derivative of the signal is adequately represented. The paper highlights the importance of context-based signal modelling in model order selection.

Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

The oral health of critically ill children

Introduction. In adults, oral health has been shown to worsen during critical illness as well as influence systemic health. There is a paucity of paediatric critical care research in the area of oral health; hence the purpose of the Critically ill Children’s Oral Health (CCOH) study is to describe the status of oral health of critically ill children over time spent in the paediatric intensive care unit (PICU). The study will also examine the relationship between poor oral health and a variety of patient characteristics and PICU therapies and explore the relationship between dysfunctional oral health and PICU related Healthcare-Associated Infections (HAI). Method. An observational study was undertaken at a single tertiary-referral PICU. Oral health was measured using the Oral Assessment Scale (OAS) and culturing oropharyngeal flora. Information was also collected surrounding the use of supportive therapies, clinical characteristics of the children and the occurrence of PICU related HAI. Results. Forty-six participants were consecutively recruited to the CCOH study. Of the participants 63% (n=32) had oral dysfunction while 41% (n=19) demonstrated pathogenic oropharyngeal colonisation during their critical illness. The potential systemic pathogens isolated from the oropharynx and included Candida sp., Staphylococcus aureus, Haemophilus influenzae, Enterococcus sp. and Pseudomonas aeruginosa. The severity of critical illness had a significant positive relationship (p=0.046) with pathogenic and absent colonisation of the oropharynx. Sixty-three percent of PICU-related HAI involved the preceding or simultaneous colonisation of the oropharynx by the causative pathogen. Conclusion. Given the prevalence of poor oral health during childhood critical illness and the subsequent potential systemic consequences, evidence based oral hygiene practices should be developed and validated to guide clinicians when nursing critically ill children.

Infrastructure Sustainability : Damage Assessment in Multiple-Girder Composite Bridges Using Vibration Characteristics

Assessing the structural health state of urban infrastructure is crucial in terms of infrastructure sustainability. This chapter uses dynamic computer simulation techniques to apply a procedure using vibration-based methods for damage assessment in multiple-girder composite bridges. In addition to changes in natural frequencies, this multi-criteria procedure incorporates two methods, namely, the modal flexibility and the modal strain energy method. Using the numerically simulated modal data obtained through finite element analysis software, algorithms based on modal flexibility and modal strain energy change, before and after damage, are obtained and used as the indices for the assessment of structural health state. The feasibility and capability of the approach is demonstrated through numerical studies of a proposed structure with six damage scenarios. It is concluded that the modal strain energy method is capable of application to multiple-girder composite bridges, as evidenced through the example treated in this chapter.

25th anniversary of BUA for the assessment of osteoporosis : time for a new paradigm?

The measurement of broadband ultrasonic attenuation (BUA) in cancellous bone at the calcaneus for the assessment of osteoporosis was first described within this journal 25 years ago. It was recognized in 2006 by Universities UK as being one of the ‘100 discoveries and developments in UK Universities that have changed the world’ over the past 50 years. In 2008, the UK's Department of Health also recognized BUA assessment of osteoporosis in a publication highlighting 11 projects that have contributed to ‘60 years of NHS research benefiting patients’. The BUA technique has been extensively clinically validated and is utilized worldwide, with at least seven commercial systems currently providing calcaneal BUA measurement. However, there is still no fundamental understanding of the dependence of BUA upon the material and structural properties of cancellous bone. This review aims to provide an ‘engineering in medicine’ perspective and proposes a new paradigm based upon phase cancellation due to variation in propagation transit time across the receive transducer face to explain the non-linear relationship between BUA and bone volume fraction in cancellous bone.

Design and evaluation of an MRI compatible axial compression device for 3D assessment of spinal deformity and flexibility

Magnetic Resonance Imaging (MRI) offers a valuable research tool for the assessment of 3D spinal deformity in AIS, however the horizontal patient position imposed by conventional scanners removes the axial compressive loading on the spine which is an important determinant of deformity shape and magnitude in standing scoliosis patients. The objective of this study was to design, construct and test an MRI compatible compression device for research into the effect of axial loading on spinal deformity using supine MRI scans. The compression device was designed and constructed, consisting of a vest worn by the patient, which was attached via straps to a pneumatically actuated footplate. An applied load of 0.5 x bodyweight was remotely controlled by a unit in the scanner operator’s console. The entire device was constructed using non-metallic components for MRI compatibility. The device was evaluated by performing unloaded and loaded supine MRI scans on a series of 10 AIS patients. The study concluded that an MRI compatible compression device had been successfully designed and constructed, providing a research tool for studies into the effect of axial loading on 3D spinal deformity in scoliosis. The 3D axially loaded MR imaging capability developed in this study will allow future research investigations of the effect of axial loading on spinal rotation, and for imaging the response of scoliotic spinal tissues to axial loading.

Emotional and behavioural reaction to intrusive thoughts

A self-report measure of the emotional and behavioural reactions to intrusive thoughts was developed. The paper presents data that confirm the stability, reliability and validity of the new 7-item measure. Emotional and behavioural reactions to intrusions emerged as separate factors on the Emotional and Behavioural Reactions to Intrusions Questionnaire (EBRIQ), a finding confirmed by an independent stress study. Test retest reliability over 30-70 days was good. Expected relationships with other constructs were significant. Stronger negative responses to intrusions were associated with lower mindfulness scores and higher ratings of experiential avoidance, thought suppression and intensity and frequency of craving. The EBRIQ will help explore differences in reactions to intrusive thoughts in clinical and non clinical populations, and across different emotional and behavioural states. It will also be useful in assessing the effects of therapeutic approaches such as mindfulness.

Implications of faecal indicator bacteria for the microbiological assessment of roof harvested rainwater quality in Southeast Queensland, Australia

The study aimed to evaluate the suitability of Escherichia coli, enterococci and C. perfringens to assess the microbiological quality of roof harvested rainwater, and to assess whether the concentrations of these faecal indicators can be used to predict the presence or absence of specific zoonotic bacterial or protozoan pathogens. From a total of 100 samples tested, respectively 58%, 83% and 46% of samples were found to be positive for E. coli, enterococci and C. perfringens spores, as determined by traditional culture based methods. Additionally, in the samples tested, 7%, 19%, 1%, 8%, 17%, and 15% were PCR positive for A. hydrophila lip, C. coli ceuE, C. jejuni mapA, L. pneumophila mip, Salmonella invA, and G. lamblia β-giardin genes. However, none of the samples was positive for E. coli O157 LPS, VT1, VT2 and C. parvum COWP genes. The presence or absence of these potential pathogens did not correlate with any of the faecal indicator bacterial concentrations as determined by a binary logistic regression model. The roof-harvested rainwater samples tested in this study appear to be of poor microbiological quality and no significant correlation was found between the concentration of faecal indicators and pathogenic microorganisms. The use of faecal indicator bacteria raises questions regarding their reliability in assessing the microbiological quality of water and particularly their poor correlation with pathogenic microorganisms. The presence of one or more zoonotic pathogens suggests that the microbiological analysis of water should be performed, and appropriate treatment measures should be undertaken especially in tanks where the water is used for drinking.

Does quality of life among breast cancer survivors one year after diagnosis differ depending on urban and non-urban residence? A comparative study

Background: This study examined the quality of life (QOL), measured by the Functional Assessment of Cancer Therapy (FACT) questionnaire, among urban (n=277) and non-urban (n=323) breast cancer survivors and women from the general population (n=1140) in Queensland, Australia. ---------- Methods: Population-based samples of breast cancer survivors aged <75 years who were 12 months post-diagnosis and similarly-aged women from the general population were recruited between 2002 and 2007. ---------- Results: Age-adjusted QOL among urban and non-urban breast cancer survivors was similar, although QOL related to breast cancer concerns was the weakest domain and was lower among non-urban survivors than their urban counterparts (36.8 versus 40.4, P<0.01). Irrespective of residence, breast cancer survivors, on average, reported comparable scores on most QOL scales as their general population peers, although physical well-being was significantly lower among non-urban survivors (versus the general population, P<0.01). Overall, around 20%-33% of survivors experienced lower QOL than peers without the disease. The odds of reporting QOL below normative levels were increased more than two-fold for those who experienced complications following surgery, reported upper-body problems, had higher perceived stress levels and/or a poor perception of handling stress (P<0.01 for all). ---------- Conclusions: Results can be used to identify subgroups of women at risk of low QOL and to inform components of tailored recovery interventions to optimize QOL for these women following cancer treatment.