Interventions to control nosocomial infections : study designs and statistical issues

There is a wide range of potential study designs for intervention studies to decrease nosocomial infections in hospitals. The analysis is complex due to competing events, clustering, multiple timescales and time-dependent period and intervention variables. This review considers the popular pre-post quasi-experimental design and compares it with randomized designs. Randomization can be done in several ways: randomization of the cluster [intensive care unit (ICU) or hospital] in a parallel design; randomization of the sequence in a cross-over design; and randomization of the time of intervention in a stepped-wedge design. We introduce each design in the context of nosocomial infections and discuss the designs with respect to the following key points: bias, control for nonintervention factors, and generalizability. Statistical issues are discussed. A pre-post-intervention design is often the only choice that will be informative for a retrospective analysis of an outbreak setting. It can be seen as a pilot study with further, more rigorous designs needed to establish causality. To yield internally valid results, randomization is needed. Generally, the first choice in terms of the internal validity should be a parallel cluster randomized trial. However, generalizability might be stronger in a stepped-wedge design because a wider range of ICU clinicians may be convinced to participate, especially if there are pilot studies with promising results. For analysis, the use of extended competing risk models is recommended.

Increasing stochastic perturbations enhances acquisition and learning of complex sport movements

Traditionally, the aquisition of skills and sport movement has been characterised by numerous repetitions of presumed model movement pattern to be acquired by learners. This approach has been questioned by research identifying the presence of individualised movement patterns and the low probability of occurrence of two identical movements within and between individuals. In contrast, the differential learning approach claims advantage for incurring variability in the learning process by adding stochastic perturbations during practice. These ideas are exemplified by data from a high jump experiment which compared the effectiveness of classical and a differential training approach with pre-post test design. Results showed clear advantages for the group with additional stochastic perturbation during the aquisition phase in comparison to classically trained athletes. Analogies to similar phenomenological effects in the neurobiological literature are discussed.

Resorbable composite scaffolds for bone tissue engineering

Bone loss associated with trauma osteo-degenerative diseases and tumors has tremendous socioeconomic impact related to personal and occupation disability and health care costs. Bone grafting is often critical to surgical therapies. Autogenous bone is presently the preferred grafting material; however, this holds several disadvantages such as donor site morbidity. In the present climate of increasing life expectancy with an ensuing increase in bone-related injuries, orthopaedic surgery is undergoing a paradigm shift from bone-grafting to bone engineering, where a scaffold is implanted to provide adequate load bearing and enhance tissue regeneration. Our group at Queensland University of Technology (QUT) have developed, characterised and tested polycaprolactone/ tricalcium phosphate (PCL/TCP) composite scaffolds for low load-bearing bone defects. These scaffolds are being further developed for application in higher load bearing sites. Our approach emphasizes the importance of the biomaterials’ structural design, the scaffold architecture and structural and nutritional requirements for cell culture. These first-generation scaffolds made from medical grade PCL (mPCL) have been studied for more than 5 years within a clinical setting 1. This paper describes the application of second-generation scaffolds in small and large animal bone defect models and the ensuing bone regeneration as shown by histology and µCT.

The effects of muscle fatigue on knee function during landing

The human knee acts as a sophisticated shock absorber during landing movements. The ability of the knee to perform this function in the real world is remarkable given that the context of the landing movement may vary widely between performances. For this reason, humans must be capable of rapidly adjusting the mechanical properties of the knee under impact load in order to satisfy many competing demands. However, the processes involved in regulating these properties in response to changing constraints remain poorly understood. In particular, the effects of muscle fatigue on knee function during step landing are yet to be fully explored. Fatigue of the knee muscles is significant for 2 reasons. First, it is thought to have detrimental effects on the ability of the knee to act as a shock absorber and is considered a risk factor for knee injury. Second, fatigue of knee muscles provides a unique opportunity to examine the mechanisms by which healthy individuals alter knee function. A review of the literature revealed that the effect of fatigue on knee function during landing has been assessed by comparing pre and postfatigue measurements, with fatigue induced by a voluntary exercise protocol. The information is limited by inconsistent results with key measures, such as knee stiffness, showing varying results following fatigue, including increased stiffness, decreased stiffness or failure to detect any change in some experiments. Further consideration of the literature questions the validity of the models used to induce and measure fatigue, as well as the pre-post study design, which may explain the lack of consensus in the results. These limitations cast doubt on the usefulness of the available information and identify a need to investigate alternative approaches. Based on the results of this review, the aims of this thesis were to: • evaluate the methodological procedures used in validation of a fatigue model • investigate the adaptation and regulation of post-impact knee mechanics during repeated step landings • use this new information to test the effects of fatigue on knee function during a step-landing task. To address the aims of the thesis, 3 related experiments were conducted that collected kinetic, kinematic and electromyographic data from 3 separate samples of healthy male participants. The methodologies involved optoelectronic motion capture (VICON), isokinetic dynamometry (System3 Pro, BIODEX) and wireless surface electromyography (Zerowire, Aurion, Italy). Fatigue indicators and knee function measures used in each experiment were derived from the data. Study 1 compared the validity and reliability of repetitive stepping and isokinetic contractions with respect to fatigue of the quadriceps and hamstrings. Fifteen participants performed 50 repetitions of each exercise twice in randomised order, over 4 sessions. Sessions were separated by a minimum of 1 week’s rest, to ensure full recovery. Validity and reliability depended on a complex interaction between the exercise protocol, the fatigue indicator, the individual and the muscle of interest. Nevertheless, differences between exercise protocols indicated that stepping was less effective in eliciting valid and reliable changes in peak power and spectral compression, compared with isokinetic exercise. A key finding was that fatigue progressed in a biphasic pattern during both exercises. The point separating the 2 phases, known as the transition point, demonstrated superior between-test reliability during the isokinetic protocol, compared with stepping. However, a correction factor should be used to accurately apply this technique to the study of fatigue during landing. Study 2 examined alterations in knee function during repeated landings, with a different sample (N =12) performing 60 consecutive step landing trials. Each landing trial was separated by 1-minute rest periods. The results provided new information in relation to the pre-post study design in the context of detecting adjustments in knee function during landing. First, participants significantly increased or decreased pre-impact muscle activity or post-impact mechanics despite environmental and task constraints remaining unchanged. This is the 1st study to demonstrate this effect in healthy individuals without external feedback on performance. Second, single-subject analysis was more effective in detecting alterations in knee function compared to group-level analysis. Finally, repeated landing trials did not reduce inter-trial variability of knee function in some participants, contrary to assumptions underpinning previous studies. The results of studies 1 and 2 were used to modify the design of Study 3 relative to previous research. These alterations included a modified isokinetic fatigue protocol, multiple pre-fatigue measurements and singlesubject analysis to detect fatigue-related changes in knee function. The study design incorporated new analytical approaches to investigate fatiguerelated alterations in knee function during landing. Participants (N = 16) were measured during multiple pre-fatigue baseline trial blocks prior to the fatigue model. A final block of landing trials was recorded once the participant met the operational fatigue definition that was identified in Study 1. The analysis revealed that the effects of fatigue in this context are heavily dependent on the compensatory response of the individual. A continuum of responses was observed within the sample for each knee function measure. Overall, preimpact preparation and post-impact mechanics of the knee were altered with highly individualised patterns. Moreover, participants used a range of active or passive pre-impact strategies to adapt post-impact mechanics in response to quadriceps fatigue. The unique patterns identified in the data represented an optimisation of knee function based on priorities of the individual. The findings of these studies explain the lack of consensus within the literature regarding the effects of fatigue on knee function during landing. First, functional fatigue protocols lack validity in inducing fatigue-related changes in mechanical output and spectral compression of surface electromyography (sEMG) signals, compared with isokinetic exercise. Second, fatigue-related changes in knee function during landing are confounded by inter-individual variation, which limits the sensitivity of group-level analysis. By addressing these limitations, the 3rd study demonstrated the efficacies of new experimental and analytical approaches to observe fatigue-related alterations in knee function during landing. Consequently, this thesis provides new perspectives into the effects of fatigue in knee function during landing. In conclusion: • The effects of fatigue on knee function during landing depend on the response of the individual, with considerable variation present between study participants, despite similar physical characteristics. • In healthy males, adaptation of pre-impact muscle activity and postimpact knee mechanics is unique to the individual and reflects their own optimisation of demands such as energy expenditure, joint stability, sensory information and loading of knee structures. • The results of these studies should guide future exploration of adaptations in knee function to fatigue. However, research in this area should continue with reduced emphasis on the directional response of the population and a greater focus on individual adaptations of knee function.

Developing a framework for planning healthy communities : the Logan Beaudesert health decision support system

In the last few decades, the focus on building healthy communities has grown significantly (Ashton, 2009). There is growing evidence that new approaches to planning are required to address the challenges faced by contemporary communities. These approaches need to be based on timely access to local information and collaborative planning processes (Murray, 2006; Scotch & Parmanto, 2006; Ashton, 2009; Kazda et al., 2009). However, there is little research to inform the methods that can support this type of responsive, local, collaborative and consultative health planning (Northridge et al., 2003). Some research justifies the use of decision support systems (DSS) as a tool to support planning for healthy communities. DSS have been found to increase collaboration between stakeholders and communities, improve the accuracy and quality of the decision-making process, and improve the availability of data and information for health decision-makers (Nobre et al., 1997; Cromley & McLafferty, 2002; Waring et al., 2005). Geographic information systems (GIS) have been suggested as an innovative method by which to implement DSS because they promote new ways of thinking about evidence and facilitate a broader understanding of communities. Furthermore, literature has indicated that online environments can have a positive impact on decision-making by enabling access to information by a broader audience (Kingston et al., 2001). However, only limited research has examined the implementation and impact of online DSS in the health planning field. Previous studies have emphasised the lack of effective information management systems and an absence of frameworks to guide the way in which information is used to promote informed decisions in health planning. It has become imperative to develop innovative approaches, frameworks and methods to support health planning. Thus, to address these identified gaps in the knowledge, this study aims to develop a conceptual planning framework for creating healthy communities and examine the impact of DSS in the Logan Beaudesert area. Specifically, the study aims to identify the key elements and domains of information that are needed to develop healthy communities, to develop a conceptual planning framework for creating healthy communities, to collaboratively develop and implement an online GIS-based Health DSS (i.e., HDSS), and to examine the impact of the HDSS on local decision-making processes. The study is based on a real-world case study of a community-based initiative that was established to improve public health outcomes and promote new ways of addressing chronic disease. The study involved the development of an online GIS-based health decision support system (HDSS), which was applied in the Logan Beaudesert region of Queensland, Australia. A planning framework was developed to account for the way in which information could be organised to contribute to a healthy community. The decision support system was developed within a unique settings-based initiative Logan Beaudesert Health Coalition (LBHC) designed to plan and improve the health capacity of Logan Beaudesert area in Queensland, Australia. This setting provided a suitable platform to apply a participatory research design to the development and implementation of the HDSS. Therefore, the HDSS was a pilot study examined the impact of this collaborative process, and the subsequent implementation of the HDSS on the way decision-making was perceived across the LBHC. As for the method, based on a systematic literature review, a comprehensive planning framework for creating healthy communities has been developed. This was followed by using a mixed method design, data were collected through both qualitative and quantitative methods. Specifically, data were collected by adopting a participatory action research (PAR) approach (i.e., PAR intervention) that informed the development and conceptualisation of the HDSS. A pre- and post-design was then used to determine the impact of the HDSS on decision-making. The findings of this study revealed a meaningful framework for organising information to guide planning for healthy communities. This conceptual framework provided a comprehensive system within which to organise existing data. The PAR process was useful in engaging stakeholders and decision-making in the development and implementation of the online GIS-based DSS. Through three PAR cycles, this study resulted in heightened awareness of online GIS-based DSS and openness to its implementation. It resulted in the development of a tailored system (i.e., HDSS) that addressed the local information and planning needs of the LBHC. In addition, the implementation of the DSS resulted in improved decision- making and greater satisfaction with decisions within the LBHC. For example, the study illustrated the culture in which decisions were made before and after the PAR intervention and what improvements have been observed after the application of the HDSS. In general, the findings indicated that decision-making processes are not merely informed (consequent of using the HDSS tool), but they also enhance the overall sense of ‗collaboration‘ in the health planning practice. For example, it was found that PAR intervention had a positive impact on the way decisions were made. The study revealed important features of the HDSS development and implementation process that will contribute to future research. Thus, the overall findings suggest that the HDSS is an effective tool, which would play an important role in the future for significantly improving the health planning practice.

Finite element modelling of load bearing steel stud walls under real building fires

Fire safety has become an important part in structural design due to the ever increasing loss of properties and lives during fires. Conventionally the fire rating of load bearing wall systems made of Light gauge Steel Frames (LSF) is determined using fire tests based on the standard time-temperature curve given in ISO 834 (ISO, 1999). The standard time-temperature curve given in ISO 834 (ISO, 1999) originated from the application of wood burning furnaces in the early 1900s. However, modern commercial and residential buildings make use of thermoplastic materials, which mean considerably high fuel loads. Hence a detailed fire research study into the performance of LSF walls was undertaken using the developed real fire curves based on Eurocode parametric curves (ECS, 2002) and Barnett’s BFD curves (Barnett, 2002) using both full scale fire tests and numerical studies. It included LSF walls without any insulation, and the recently developed externally insulated composite panel system. This paper presents the details of the numerical studies and the results. It also includes brief details of the development of real building fire curves and experimental studies.

Fire tests of load bearing steel stud walls exposed to real building fires

Abstract. Fire resistance has become an important part in structural design due to the ever increasing loss of properties and lives every year. Conventionally the fire rating of load bearing Light gauge Steel Frame (LSF) walls is determined using standard fire tests based on the time-temperature curve given in ISO 834 [1]. Full scale fire testing based on this standard time-temperature curve originated from the application of wood burning furnaces in the early 1900s and it is questionable whether it truly represents the fuel loads in modern buildings. Hence a detailed fire research study into the performance of LSF walls was undertaken using real design fires based on Eurocode parametric curves [2] and Barnett’s ‘BFD’ curves [3]. This paper presents the development of these real fire curves and the results of full scale experimental study into the structural and fire behaviour of load bearing LSF stud wall systems.

Numerical modelling and full scale testing of load bearing steel walls under real fires

Fire safety has become an important part in structural design due to the ever increasing loss of properties and lives during fires. Fire rating of load bearing wall systems made of Light gauge Steel Frames (LSF) is determined using fire tests based on the standard time-temperature curve given in ISO 834. However, modern residential buildings make use of thermoplastic materials, which mean considerably high fuel loads. Hence a detailed fire research study into the performance of load bearing LSF walls was undertaken using a series of realistic design fire curves developed based on Eurocode parametric curves and Barnett’s BFD curves. It included both full scale fire tests and numerical studies of LSF walls without any insulation, and the recently developed externally insulated composite panels. This paper presents the details of fire tests first, and then the numerical models of tested LSF wall studs. It shows that suitable finite element models can be developed to predict the fire rating of load bearing walls under real fire conditions. The paper also describes the structural and fire performances of externally insulated LSF walls in comparison to the non-insulated walls under real fires, and highlights the effects of standard and real fire curves on fire performance of LSF walls.

Pull-through failures of crest-fixed steel claddings initiated by transverse splitting

Crest-fixed steel claddings made of thin, high strength steel often suffer from local pull-through failures at their screw connections during high wind events such as storms and hurricanes. Currently there aren't any adequate design provisions for these cladding systems except for the expensive testing provisions. Since the local pull-through failures in the less ductile steel claddings are initiated by transverse splitting at the fastener hole, analytical studies have not been able to determine the pull-through failure loads. Analytical studies could be used if a reliable splitting criterion is available. Therefore a series of two-span cladding tests was conducted on a range of crest-fixed steel cladding systems under simulated wind uplift loads. The strains in the sheeting around the critical fastener holes were measured until the pull-through failure. This paper presents the details of the experimental investigation and the results including a strain criterion for the local pull-through failure.

Loading of a very tall building in a simulated downburst wind field

Thunderstorm downbursts are important for wind engineers as they have been shown to produce the design wind speeds for mid to high return periods in many regions of Australia [1]. In structural design codes (e.g. AS/NZS1170.02-02) an atmospheric boundary layer (ABL) is assumed, and a vertical profile is interpolated from recorded 10 m wind speeds. The ABL assumption is however inaccurate when considering the complex structure of a thunderstorm outflow, and its effects on engineered structures. Several researchers have shown that the downburst, close to its point of divergence is better represented by an impinging wall jet profile than the traditional ABL. Physical modelling is the generally accepted approach to estimate wind loads on structures and it is therefore important to physically model the thunderstorm downburst so that its effects on engineered structures may be studied. An advancement on the simple impinging jet theory, addressed here is the addition of a pulsing mechanism to the jet which allows not only the divergent characteristics of a downburst to be produced, but also it allows the associated leading ring vortex to be developed. The ring vortex modelling is considered very important for structural design as it is within the horizontal vortex that the largest velocities occur [2]. This paper discusses the flow field produced by a pulsed wall jet, and also discusses the induced pressures that this type of flow has on a scaled tall building.

High mobility diketopyrrolopyrrole (DPP)-based organic semiconductor materials for organic thin film transistors and photovoltaics

In recent years, the electron-accepting diketopyrrolopyrrole (DPP) moiety has been receiving considerable attention for constructing donor-acceptor (D-A) type organic semiconductors for a variety of applications, particularly for organic thin film transistors (OTFTs) and organic photovoltaics (OPVs). Through association of the DPP unit with appropriate electron donating building blocks, the resulting D-A molecules interact strongly in the solid state through intermolecular D-A and π-π interactions, leading to highly ordered structures at the molecular and microscopic levels. The closely packed molecules and crystalline domains are beneficial for intermolecular and interdomain (or intergranular) charge transport. Furthermore, the energy levels can be readily adjusted, affording p-type, n-type, or ambipolar organic semiconductors with highly efficient charge transport properties in OTFTs. In the past few years, a number of DPP-based small molecular and polymeric semiconductors have been reported to show mobility close to or greater than 1 cm2 V -1 s-1. DPP-based polymer semiconductors have achieved record high mobility values for p-type (hole mobility: 10.5 cm2 V-1 s-1), n-type (electron mobility: 3 cm2 V-1 s-1), and ambipolar (hole/electron mobilities: 1.18/1.86 cm2 V-1 s-1) OTFTs among the known polymer semiconductors. Many DPP-based organic semiconductors have favourable energy levels and band gaps along with high hole mobility, which enable them as promising donor materials for OPVs. Power conversion efficiencies (PCE) of up to 6.05% were achieved for OPVs using DPP-based polymers, demonstrating their potential usefulness for the organic solar cell technology. This article provides an overview of the recent exciting progress made in DPP-containing polymers and small molecules that have shown high charge carrier mobility, around 0.1 cm2 V-1 s-1 or greater. It focuses on the structural design, optoelectronic properties, molecular organization, morphology, as well as performances in OTFTs and OPVs of these high mobility DPP-based materials.

Minimising the failure of rail joints through managing the localised condition of track

To effectively address the high rate of failure of Insulated Rail Joints (IRJs) in the heavy haul lines, a research plan was designed and implemented with particular attention to understand their mechanical behaviour and deterioration process. In this paper, part of this ongoing research is described. During the past decades many studies have tried to improve the service life of IRJs by introducing a new structural design or material for IRJ components. This paper looks into this problem from a different perspective highlighting the significance of localised condition of track to the loads and responses of the IRJs. Results from a series of field measurements conducted in a rail track within the Australian Rail Track Corporation (ARTC) network are discussed. The interactive effects of IRJ responses and localised track condition are further investigated using the results obtained from numerical simulations. The field measurements and the simulation results provide valuable insight on the influence of track condition to the behaviour of IRJs.

Reduced withdrawal and failure rates of accelerated nursing students enrolled in pharmacology is associated with a supportive intervention

Background To reduce nursing shortages, accelerated nursing programs are available for domestic and international students. However, the withdrawal and failure rates from these programs may be different than for the traditional programs. The main aim of our study was to improve the retention and experience of accelerated nursing students. Methods The academic background, age, withdrawal and failure rates of the accelerated and traditional students were determined. Data from 2009 and 2010 were collected prior to intervention. In an attempt to reduce the withdrawal of accelerated students, we set up an intervention, which was available to all students. The assessment of the intervention was a pre-post-test design with non-equivalent groups (the traditional and the accelerated students). The elements of the intervention were a) a formative website activity of some basic concepts in anatomy, physiology and pharmacology, b) a workshop addressing study skills and online resources, and c) resource lectures in anatomy/physiology and microbiology. The formative website and workshop was evaluated using questionnaires. Results The accelerated nursing students were five years older than the traditional students (p < 0.0001). The withdrawal rates from a pharmacology course are higher for accelerated nursing students, than for traditional students who have undertaken first year courses in anatomy and physiology (p = 0.04 in 2010). The withdrawing students were predominantly the domestic students with non-university qualifications or equivalent experience. The failure rates were also higher for this group, compared to the traditional students (p = 0.05 in 2009 and 0.03 in 2010). In contrast, the withdrawal rates for the international and domestic graduate accelerated students were very low. After the intervention, the withdrawal and failure rates in pharmacology for domestic accelerated students with non-university qualifications were not significantly different than those of traditional students. Conclusions The accelerated international and domestic graduate nursing students have low withdrawal rates and high success rates in a pharmacology course. However, domestic students with non-university qualifications have higher withdrawal and failure rates than other nursing students and may be underprepared for university study in pharmacology in nursing programs. The introduction of an intervention was associated with reduced withdrawal and failure rates for these students in the pharmacology course.

A pilot education on heart failure self-management and introduction of the teach-back method to cardiac nurses in Vietnam

It is recognised that patients with chronic disease are unable to remembercorrectly information provided by health care profesionals. The teach-back method is acknowledgedas a technique to improve patients’ understanding. Yet it is not used in nursing practice in Vietnam. Objectives This study sought to examine knowledge background of heart failure among cardiac nurses, introduce a education about heart failure self-management and the teach-back method to assist teaching patients on self-care. The study also wanted to explore if a short education could benefit nurses’ knowledge so they would be qualified to deliver education to patients. Methods A pre/post-test design was employed. Cardiac nurses from 3 hospitals (Vietnam National Heart Institute, E Hospital, Huu Nghi Hospital) were invited to attend a six-hour educational session which covered both the teach-back method and heart failure self-management. Role-play with scenarios were used to reinforce educational contents. The Dutch Heart Failure Knowledge Scale was used to assess nurses’ knowledge of heart failure at baseline and after the educational session. Results 20 nurses from3 selected hospitals participated. Average age was 34.5±7.9 years and years of nursing experience was 11.6±8.3. Heart failure knowledge score at the baseline was 12.7±1.2 and post education was 13.8±1.0. There was deficiency of nurses knowledge regarding fluid restriction among heart failure people, causes of worsening heart failure. Heart failure knowledge improved significantly following the workshop (p < 0.001). All nurses achieved an overall adequate knowledge score (≥11 of the maximum 15) at the end. 100% of nurses agreed that the teach-back method was effective and could be used to educate patients about heart failure self-management. Conclusions The results of this study have shown the effectiveness of the piloteducaiton in increasing nurses’ knowledge of heart failure. The teach-back method is accepted for Vietnamese nurses to use in routine cardiac practice.