Clinical utility of mental state screening as a predictor of intellectual outcomes 6 months after diagnosis of type 1 diabetes

Background Screening tests of basic cognitive status or ‘mental state’ have been shown to predict mortality and functional outcomes in adults. This study examined the relationship between mental state and outcomes in children with type 1 diabetes. Objective We aimed to determine whether mental state at diagnosis predicts longer term cognitive function of children with a new diagnosis of type 1 diabetes. Methods Mental state of 87 patients presenting with newly diagnosed type 1 diabetes was assessed using the School-Years Screening Test for the Evaluation of Mental Status. Cognitive abilities were assessed 1 wk and 6 months postdiagnosis using standardized tests of attention, memory, and intelligence. Results Thirty-seven children (42.5%) had reduced mental state at diagnosis. Children with impaired mental state had poorer attention and memory in the week following diagnosis, and, after controlling for possible confounding factors, significantly lower IQ at 6 months compared to those with unimpaired mental state (p < 0.05). Conclusions Cognition is impaired acutely in a significant number of children presenting with newly diagnosed type 1 diabetes. Mental state screening is an effective method of identifying children at risk of ongoing cognitive difficulties in the days and months following diagnosis. Clinicians may consider mental state screening for all newly diagnosed diabetic children to identify those at risk of cognitive sequelae.

An innovative approach to the assessment of nutrient intake in adults with type 2 diabetes : the development, trial and evaluation of a mobile phone photo/voice dietary record

Nutrition interventions in the form of both self-management education and individualised diet therapy are considered essential for the long-term management of type 2 diabetes mellitus (T2DM). The measurement of diet is essential to inform, support and evaluate nutrition interventions in the management of T2DM. Barriers inherent within health care settings and systems limit ongoing access to personnel and resources, while traditional prospective methods of assessing diet are burdensome for the individual and often result in changes in typical intake to facilitate recording. This thesis investigated the inclusion of information and communication technologies (ICT) to overcome limitations to current approaches in the nutritional management of T2DM, in particular the development, trial and evaluation of the Nutricam dietary assessment method (NuDAM) consisting of a mobile phone photo/voice application to assess nutrient intake in a free-living environment with older adults with T2DM. Study 1: Effectiveness of an automated telephone system in promoting change in dietary intake among adults with T2DM The effectiveness of an automated telephone system, Telephone-Linked Care (TLC) Diabetes, designed to deliver self-management education was evaluated in terms of promoting dietary change in adults with T2DM and sub-optimal glycaemic control. In this secondary data analysis independent of the larger randomised controlled trial, complete data was available for 95 adults (59 male; mean age(±SD)=56.8±8.1 years; mean(±SD)BMI=34.2±7.0kg/m2). The treatment effect showed a reduction in total fat of 1.4% and saturated fat of 0.9% energy intake, body weight of 0.7 kg and waist circumference of 2.0 cm. In addition, a significant increase in the nutrition self-efficacy score of 1.3 (p<0.05) was observed in the TLC group compared to the control group. The modest trends observed in this study indicate that the TLC Diabetes system does support the adoption of positive nutrition behaviours as a result of diabetes self-management education, however caution must be applied in the interpretation of results due to the inherent limitations of the dietary assessment method used. The decision to use a close-list FFQ with known bias may have influenced the accuracy of reporting dietary intake in this instance. This study provided an example of the methodological challenges experienced with measuring changes in absolute diet using a FFQ, and reaffirmed the need for novel prospective assessment methods capable of capturing natural variance in usual intakes. Study 2: The development and trial of NuDAM recording protocol The feasibility of the Nutricam mobile phone photo/voice dietary record was evaluated in 10 adults with T2DM (6 Male; age=64.7±3.8 years; BMI=33.9±7.0 kg/m2). Intake was recorded over a 3-day period using both Nutricam and a written estimated food record (EFR). Compared to the EFR, the Nutricam device was found to be acceptable among subjects, however, energy intake was under-recorded using Nutricam (-0.6±0.8 MJ/day; p<0.05). Beverages and snacks were the items most frequently not recorded using Nutricam; however forgotten meals contributed to the greatest difference in energy intake between records. In addition, the quality of dietary data recorded using Nutricam was unacceptable for just under one-third of entries. It was concluded that an additional mechanism was necessary to complement dietary information collected via Nutricam. Modifications to the method were made to allow for clarification of Nutricam entries and probing forgotten foods during a brief phone call to the subject the following morning. The revised recording protocol was evaluated in Study 4. Study 3: The development and trial of the NuDAM analysis protocol Part A explored the effect of the type of portion size estimation aid (PSEA) on the error associated with quantifying four portions of 15 single foods items contained in photographs. Seventeen dietetic students (1 male; age=24.7±9.1 years; BMI=21.1±1.9 kg/m2) estimated all food portions on two occasions: without aids and with aids (food models or reference food photographs). Overall, the use of a PSEA significantly reduced mean (±SD) group error between estimates compared to no aid (-2.5±11.5% vs. 19.0±28.8%; p<0.05). The type of PSEA (i.e. food models vs. reference food photograph) did not have a notable effect on the group estimation error (-6.7±14.9% vs. 1.4±5.9%, respectively; p=0.321). This exploratory study provided evidence that the use of aids in general, rather than the type, was more effective in reducing estimation error. Findings guided the development of the Dietary Estimation and Assessment Tool (DEAT) for use in the analysis of the Nutricam dietary record. Part B evaluated the effect of the DEAT on the error associated with the quantification of two 3-day Nutricam dietary records in a sample of 29 dietetic students (2 males; age=23.3±5.1 years; BMI=20.6±1.9 kg/m2). Subjects were randomised into two groups: Group A and Group B. For Record 1, the use of the DEAT (Group A) resulted in a smaller error compared to estimations made without the tool (Group B) (17.7±15.8%/day vs. 34.0±22.6%/day, p=0.331; respectively). In comparison, all subjects used the DEAT to estimate Record 2, with resultant error similar between Group A and B (21.2±19.2%/day vs. 25.8±13.6%/day; p=0.377 respectively). In general, the moderate estimation error associated with quantifying food items did not translate into clinically significant differences in the nutrient profile of the Nutricam dietary records, only amorphous foods were notably over-estimated in energy content without the use of the DEAT (57kJ/day vs. 274kJ/day; p<0.001). A large proportion (89.6%) of the group found the DEAT helpful when quantifying food items contained in the Nutricam dietary records. The use of the DEAT reduced quantification error, minimising any potential effect on the estimation of energy and macronutrient intake. Study 4: Evaluation of the NuDAM The accuracy and inter-rater reliability of the NuDAM to assess energy and macronutrient intake was evaluated in a sample of 10 adults (6 males; age=61.2±6.9 years; BMI=31.0±4.5 kg/m2). Intake recorded using both the NuDAM and a weighed food record (WFR) was coded by three dietitians and compared with an objective measure of total energy expenditure (TEE) obtained using the doubly labelled water technique. At the group level, energy intake (EI) was under-reported to a similar extent using both methods, with the ratio of EI:TEE was 0.76±0.20 for the NuDAM and 0.76±0.17 for the WFR. At the individual level, four subjects reported implausible levels of energy intake using the WFR method, compared to three using the NuDAM. Overall, moderate to high correlation coefficients (r=0.57-0.85) were found across energy and macronutrients except fat (r=0.24) between the two dietary measures. High agreement was observed between dietitians for estimates of energy and macronutrient derived for both the NuDAM (ICC=0.77-0.99; p<0.001) and WFR (ICC=0.82-0.99; p<0.001). All subjects preferred using the NuDAM over the WFR to record intake and were willing to use the novel method again over longer recording periods. This research program explored two novel approaches which utilised distinct technologies to aid in the nutritional management of adults with T2DM. In particular, this thesis makes a significant contribution to the evidence base surrounding the use of PhRs through the development, trial and evaluation of a novel mobile phone photo/voice dietary record. The NuDAM is an extremely promising advancement in the nutritional management of individuals with diabetes and other chronic conditions. Future applications lie in integrating the NuDAM with other technologies to facilitate practice across the remaining stages of the nutrition care process.

Secondary curve behavior in Lenke Type 1C adolescent idiopathic scoliosis after thoracoscopic selective anterior thoracic fusion

Study Design. Analysis of a case series of 24 Lenke 1C adolescent idiopathic scoliosis (AIS) patients receiving selective thoracoscopic anterior scoliosis correction. Objective. To report the behaviour of the compensatory lumbar curve in a group of Lenke IC AIS patients following thoracoscopic anterior scoliosis correction, and to compare the results of this study with previously published data. Summary of Background Data. Several prior studies have reported spontaneous lumbar curve correction for both anterior and posterior selective fusion in Lenke 1C/King-Moe II patients; however to our knowledge no previous studies have reported outcomes of thoracoscopic anterior correction for this curve type. Methods. All AIS patients with a curve classification of Lenke 1C and a minimum of 24 months follow-up were retrieved from a consecutive series of 190 AIS patients who underwent thoracoscopic anterior instrumented fusion. Cobb angles of the major curve, instrumented levels, compensatory lumbar curve, and T5-T12 kyphosis were recorded, as well as coronal spinal balance, T1 tilt angle and shoulder balance. All radiographic parameters were measured before surgery and at 2, 6, 12 and 24 months after surgery. Results. Twenty-four female patients with right thoracic curves had a mean thoracic Cobb angle of 53.0° before surgery, decreasing to 24.9° two years after surgery. The mean lumbar compensatory Cobb angle was 43.5° before surgery, spontaneously correcting to 25.4° two years after surgery, indicating balance between the thoracic and lumbar scoliotic curves. The lumbar correction achieved (41.8%) compares favourably to previous studies. Conclusions. Selective thoracoscopic anterior fusion allows spontaneous lumbar curve correction and achieves coronal balance of main thoracic and compensatory lumbar curves, good cosmesis and patient satisfaction. Correction and balance are maintained 24 months after surgery.

Solution methods for advection-diffusion-reaction equations on growing domains and subdomains, with application to modelling skin substitutes

Problems involving the solution of advection-diffusion-reaction equations on domains and subdomains whose growth affects and is affected by these equations, commonly arise in developmental biology. Here, a mathematical framework for these situations, together with methods for obtaining spatio-temporal solutions and steady states of models built from this framework, is presented. The framework and methods are applied to a recently published model of epidermal skin substitutes. Despite the use of Eulerian schemes, excellent agreement is obtained between the numerical spatio-temporal, numerical steady state, and analytical solutions of the model.

The relationship between Bayesian motor unit number estimation and histological measurements of motor neurons in wild-type and SOD1 G93A mice

Objective: To assess the relationship between Bayesian MUNE and histological motor neuron counts in wild-type mice and in an animal model of ALS. Methods: We performed Bayesian MUNE paired with histological counts of motor neurons in the lumbar spinal cord of wild-type mice and transgenic SOD1 G93A mice that show progressive weakness over time. We evaluated the number of acetylcholine endplates that were innervated by a presynaptic nerve. Results: In wild-type mice, the motor unit number in the gastrocnemius muscle estimated by Bayesian MUNE was approximately half the number of motor neurons in the region of the spinal cord that contains the cell bodies of the motor neurons supplying the hindlimb crural flexor muscles. In SOD1 G93A mice, motor neuron numbers declined over time. This was associated with motor endplate denervation at the end-stage of disease. Conclusion: The number of motor neurons in the spinal cord of wild-type mice is proportional to the number of motor units estimated by Bayesian MUNE. In SOD1 G93A mice, there is a lower number of estimated motor units compared to the number of spinal cord motor neurons at the end-stage of disease, and this is associated with disruption of the neuromuscular junction. Significance: Our finding that the Bayesian MUNE method gives estimates of motor unit numbers that are proportional to the numbers of motor neurons in the spinal cord supports the clinical use of Bayesian MUNE in monitoring motor unit loss in ALS patients. © 2012 International Federation of Clinical Neurophysiology.

A qualitative investigation into the different health experiences of people living with type II diabetes, in the rural environments

Study Rationale The objective of the study was to explore if and how rural culture influences type II diabetes management and to better understand the social processes that rural people construct in coping with diabetes and its complications. In particular, the study aimed to analyse the interface and interactions between rural people with type II diabetes and the Australian health care system. Theoretical framework and methods The research applied constructivist grounded theory methods within an interpretive interactionist framework. Data from 39 semi-structured interviews with rural and urban people with type II diabetes plus a mix of rural health care providers were analysed to develop a theoretical understanding of the social processes that define diabetes management in that context. Results The analysis suggests that although type II diabetes imposes limitations that require adjustment and adaptation these processes are actively negotiated by rural people within the environmental context to fit the salient social understandings of autonomy and self-reliance. Thus people normalised self-reliant diabetes management behaviours because this was congruent with the rural culture. Factors that informed the actions of normalisation were the relationships between participants and health care professions, support and access to individual resources. Conclusions The findings point to ways in which rural self-reliance is conceived as the primary strategy of diabetic management. People face the paradox of engaging with a health care system that at the same time maximises individual responsibility for health and minimises the social support by which individuals manage the condition. The emphasis on self-reliance gives some legitimacy to a lack of prevention and chronic care services. Success of diabetic management behaviours is contingent on relative resources. Where there is good primary care there develop a number of downstream effects including a sense of empowerment to manage difficult rural environmental circumstances. This has particular bearing on health outcomes for people with fewer resources.

More is not necessarily better. A biomechanical study on distal screw numbers in volar locking distal radius plates

INTRODUCTION: Currently available volar locking plates for the treatment of distal radius fractures incorporate at least two distal screw rows for fixation of the metaphyseal fragment and have a variable-angle locking mechanism which allows placement of the screws in various directions There is, however no evidence that these plates translate into better outcomes or have superior biomechanical properties to first generation plates, which had a single distal screw row and fixed-angle locking. The aim of our biomechanical study was to compare fixed-angle single-row plates with variable-angle multi-row plates to clarify the optimal number of locking screws. MATERIALS AND METHODS: Five different plate-screw combinations of three different manufacturers were tested, each group consisting of five synthetic fourth generation distal radius bones. An AO type C2 fracture was created and the fractures were plated according to each manufacturer's recommendations. The specimens then underwent cyclic and load-to-failure testing. An optical motion analysis system was used to detect displacement of fragments. RESULTS: No significant differences were detected after cyclic loading as well as after load-to-failure testing, neither in regard to axial deformation, implant rigidity or maximum displacement. The fixed-angle single-row plate showed the highest pre-test rigidity, least increase in post-testing rigidity and highest load-to-failure rigidity and least radial shortening. The radial shortening of plates with two distal screw rows was 3.1 and 4.3 times higher, respectively, than that of the fixed-angle single-row plate. CONCLUSION: The results of our study indicate that two distal screw rows do not add to construct rigidity and resistance against loss of reduction. Well conducted clinical studies based on the findings of biomechanical studies are necessary to determine the optimal number of screws necessary to achieve reproducibly good results in the treatment of distal radius fractures.

More men than women make mucosal IgA antibodies to human papillomavirus type 16 (HPV-16) and HPV-18: A study of oral HPV and oral HPV antibodies in a normal healthy population

Background: We have previously shown the high prevalence of oral anti-human papillomavirus type 16 (HPV-16) antibodies in women with HPV-associated cervical neoplasia. It was postulated that the HPV antibodies were initiated after HPV antigenic stimulation at the cervix via the common mucosal immune system. The present study aimed to further evaluate the effectiveness of oral fluid testing for detecting the mucosal humoral response to HPV infection and to advance our limited understanding of the immune response to HPV. Methods: The prevalence of oral HPV infection and oral antibodies to HPV types 16, 18 and 11 was determined in a normal, healthy population of children, adolescents and adults, both male and female, attending a dental clinic. HPV types in buccal cells were determined by DNA sequencing. Oral fluid was collected from the gingival crevice of the mouth by the OraSure method. HPV-16, HPV-18 and HPV-11 antibodies in oral fluid were detected by virus-like particle-based enzyme-linked immunosorbent assay. As a reference group 44 women with cervical neoplasia were included in the study. Results: Oral HPV infection was h ighest in children (9/114, 7.9%), followed by adolescents (4/78, 5.1%), and lowest in normal adults (4/116, 3.5%). The predominant HPV type found was HPV-13 (7/22, 31.8%) followed by HPV-32 (5/22, 22.7%). The prevalence of oral antibodies to HPV-16, HPV-18 and HPV-11 was low in children and increased substantially in adolescents and normal adults. Oral HPV-16 IgA was significantly more prevalent in women with cervical neoplasia (30/44, 68.2%) than the women from the dental clinic (18/69, 26.1% P = 0.0001). Significantly more adult men than women displayed oral HPV-16 IgA (30/47 compared with 18/69, OR 5.0, 95% CI 2.09-12.1, P < 0.001) and HPV-18 IgA (17/47 compared with 13/69, OR 2.4, 95% CI 0.97-6.2, P = 0.04). Conclusion: The increased prevalence of oral HPV antibodies in adolescent individuals compared with children was attributed to the onset of sexual activity. The increased prevalence of oral anti-HPV IgA in men compared with women was noteworthy considering reportedly fewer men than women make serum antibodies, and warrants further investigation. © 2006 Marais et al; licensee BioMed Central Ltd.

Randomised controlled trial of an automated, interactive telephone intervention (TLC Diabetes) to improve type 2 diabetes management : Baseline findings and six-month outcomes

Background: Effective self-management of diabetes is essential for the reduction of diabetes-related complications, as global rates of diabetes escalate. Methods: Randomised controlled trial. Adults with type 2 diabetes (n = 120), with HbA1c greater than or equal to 7.5 %, were randomly allocated (4 × 4 block randomised block design) to receive an automated, interactive telephone-delivered management intervention or usual routine care. Baseline sociodemographic, behavioural and medical history data were collected by self-administered questionnaires and biological data were obtained during hospital appointments. Health-related quality of life (HRQL) was measured using the SF-36. Results: The mean age of participants was 57.4 (SD 8.3), 63 % of whom were male. There were no differences in demographic, socioeconomic and behavioural variables between the study arms at baseline. Over the six-month period from baseline, participants receiving the Australian TLC (Telephone-Linked Care) Diabetes program showed a 0.8 % decrease in geometric mean HbA1c from 8.7 % to 7.9 %, compared with a 0.2 % HbA1c reduction (8.9 % to 8.7 %) in the usual care arm (p = 0.002). There was also a significant improvement in mental HRQL, with a mean increase of 1.9 in the intervention arm, while the usual care arm decreased by 0.8 (p = 0.007). No significant improvements in physical HRQL were observed. Conclusions: These analyses indicate the efficacy of the Australian TLC Diabetes program with clinically significant post-intervention improvements in both glycaemic control and mental HRQL. These observed improvements, if supported and maintained by an ongoing program such as this, could significantly reduce diabetes-related complications in the longer term. Given the accessibility and feasibility of this kind of program, it has strong potential for providing effective, ongoing support to many individuals with diabetes in the future.

An introduction to mixed methods research for nephrology nurses

Mixed methods research is the use of qualitative and quantitative methods in the same study to gain a more rounded and holistic understanding of the phenomena under investigation. This type of research approach is gaining popularity in the nursing literature as a way to understand the complexity of nursing care and as a means to enhance evidenced-based practice. This paper introduces nephrology nurses to mixed methods research, its terminology and application to nephrology nursing. Five common mixed methods designs will be described highlighting the purposes, strengths and weaknesses of each design. Examples of mixed methods research will be given to illustrate the wide application of mixed methods research to nursing and its usefulness in nephrology nursing research.

Child car restraints : mandating type and seating row according to age with positive effect in regional city in Queensland, Australia

Road trauma is a leading cause of child injury worldwide. In highly motorised countries, injury as a passenger represents a major proportion of all child road deaths and hospitalisations. Australia is no exception, particularly since there are high levels of private motor vehicle travel to school in most Australian states. Recently the legislation governing the type of car restraints required for children aged under 7 years has changed in Australia, aligning requirements better with accepted best practice. However, it is unclear what effect these changes have had on children’s seating positions or the types of restraints used. A mixed methods evaluation of the impact of the new legislation on compliance was conducted at three times: baseline (Time 1); after announcement that changes were going to be implemented but before enforcement began (Time 2); and after enforcement commenced (Time 3). Measures of compliance were obtained using two methods: road-side observations of vehicles with child passengers; and parental self-report (intercept interviews conducted at Time 2 and Time 3 only). Results from the observations suggested an overall positive effect. Proportions of children occupying front seats decreased overall and use of dedicated child seats increased to almost 40% of the observed children by Time 3. However, almost a quarter of the children observed still occupied front seats. These results differed from those of the interview study where almost no children were reported as usually travelling in the front seat, and reported use of dedicated restraints with children was almost 90%, over twice that of the observations.

Order conditions of stochastic Runge-Kutta methods by B-series

In this paper, general order conditions and a global convergence proof are given for stochastic Runge Kutta methods applied to stochastic ordinary differential equations ( SODEs) of Stratonovich type. This work generalizes the ideas of B-series as applied to deterministic ordinary differential equations (ODEs) to the stochastic case and allows a completely general formalism for constructing high order stochastic methods, either explicit or implicit. Some numerical results will be given to illustrate this theory.

Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes

Purpose: Type 2 diabetes is a leading cause of morbidity and mortality in midlife and older Australian women with known modifiable risk factors for type 2 diabetes including smoking, nutrition, physical activity and obesity. In Australia little research has been done to investigate the perceived barriers to healthy lifestyle activities in midlife and older women with type 2 diabetes. The primary aim of this study was to explore the level and type of perceived barriers to health promotion activities. The secondary aim was to explore the relationship of perceived barriers to smoking behaviour, fruit and vegetable intake, physical activity, and body mass index. Methods: The study was a cross sectional survey of women, aged over 45 with type 2 diabetes, attending metropolitan community health clinics (N = 41). Data was collected from self-report questionnaire and analysed using descriptive and inferential statistics. Results: Women in the study had average total barriers scores similar to those reported in the literature for women with a range of physical disabilities and illnesses. The leading barriers for this group of women were: lack of interest, concern about safety, too tired, lack of money and feeling what they do does not help. There was no association between total barriers scores and body mass index, physical activity, fruit and vegetable intake or socio-demographic variables. Conclusion: This study contributes to understanding the perceptions of midlife and older women with type 2 diabetes about the level and type of barriers to healthy lifestyle activities that they experience. Evidence from this study can be applied to inform health promotion for lifestyle risk factor reduction in women with type 2 diabetes.

Nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : a mixed methods study

The cardiac catheterisation laboratory (CCL) is a specialised medical radiology facility where both chronic-stable and life-threatening cardiovascular illness is evaluated and treated. Although there are many potential sources of discomfort and distress associated with procedures performed in the CCL, a general anaesthetic is not usually required. For this reason, an anaesthetist is not routinely assigned to the CCL. Instead, to manage pain, discomfort and anxiety during the procedure, nurses administer a combination of sedative and analgesic medications according to direction from the cardiologist performing the procedure. This practice is referred to as nurse-administered procedural sedation and analgesia (PSA). While anecdotal evidence suggested that nurse-administered PSA was commonly used in the CCL, it was clear from the limited information available that current nurse-led PSA administration and monitoring practices varied and that there was contention around some aspects of practice including the type of medications that were suitable to be used and the depth of sedation that could be safely induced without an anaesthetist present. The overall aim of the program of research presented in this thesis was to establish an evidence base for nurse-led sedation practices in the CCL context. A sequential mixed methods design was used over three phases. The objective of the first phase was to appraise the existing evidence for nurse-administered PSA in the CCL. Two studies were conducted. The first study was an integrative review of empirical research studies and clinical practice guidelines focused on nurse-administered PSA in the CCL as well as in other similar procedural settings. This was the first review to systematically appraise the available evidence supporting the use of nurse-administered PSA in the CCL. A major finding was that, overall, nurse-administered PSA in the CCL was generally deemed to be safe. However, it was concluded from the analysis of the studies and the guidelines that were included in the review, that the management of sedation in the CCL was impacted by a variety of contextual factors including local hospital policy, workforce constraints and cardiologists’ preferences for the type of sedation used. The second study in the first phase was conducted to identify a sedation scale that could be used to monitor level of sedation during nurse-administered PSA in the CCL. It involved a structured literature review and psychometric analysis of scale properties. However, only one scale was found that was developed specifically for the CCL, which had not undergone psychometric testing. Several weaknesses were identified in its item structure. Other sedation scales that were identified were developed for the ICU. Although these scales have demonstrated validity and reliability in the ICU, weaknesses in their item structure precluded their use in the CCL. As findings indicated that no existing sedation scale should be applied to practice in the CCL, recommendations for the development and psychometric testing of a new sedation scale were developed. The objective of the second phase of the program of research was to explore current practice. Three studies were conducted in this phase using both quantitative and qualitative research methods. The first was a qualitative explorative study of nurses’ perceptions of the issues and challenges associated with nurse-administered PSA in the CCL. Major themes emerged from analysis of the qualitative data regarding the lack of access to anaesthetists, the limitations of sedative medications, the barriers to effective patient monitoring and the impact that the increasing complexity of procedures has on patients' sedation requirements. The second study in Phase Two was a cross-sectional survey of nurse-administered PSA practice in Australian and New Zealand CCLs. This was the first study to quantify the frequency that nurse-administered PSA was used in the CCL setting and to characterise associated nursing practices. It was found that nearly all CCLs utilise nurse-administered PSA (94%). Of note, by characterising nurse-administered PSA in Australian and New Zealand CCLs, several strategies to improve practice, such as setting up protocols for patient monitoring and establishing comprehensive PSA education for CCL nurses, were identified. The third study in Phase Two was a matched case-control study of risk factors for impaired respiratory function during nurse-administered PSA in the CCL setting. Patients with acute illness were found to be nearly twice as likely to experience impaired respiratory function during nurse-administered PSA (OR=1.78; 95%CI=1.19-2.67; p=0.005). These significant findings can now be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered PSA in the CCL. The objective of the third and final phase of the program of research was to develop recommendations for practice. To achieve this objective, a synthesis of findings from the previous phases of the program of research informed a modified Delphi study, which was conducted to develop a set of clinical practice guidelines for nurse-administered PSA in the CCL. The clinical practice guidelines that were developed set current best practice standards for pre-procedural patient assessment and risk screening practices as well as the intra and post-procedural patient monitoring practices that nurses who administer PSA in the CCL should undertake in order to deliver safe, evidence-based and consistent care to the many patients who undergo procedures in this setting. In summary, the mixed methods approach that was used clearly enabled the research objectives to be comprehensively addressed in an informed sequential manner, and, as a consequence, this thesis has generated a substantial amount of new knowledge to inform and support nurse-led sedation practice in the CCL context. However, a limitation of the research to note is that the comprehensive appraisal of the evidence conducted, combined with the guideline development process, highlighted that there were numerous deficiencies in the evidence base. As such, rather than being based on high-level evidence, many of the recommendations for practice were produced by consensus. For this reason, further research is required in order to ascertain which specific practices result in the most optimal patient and health service outcomes. Therefore, along with necessary guideline implementation and evaluation projects, post-doctoral research is planned to follow up on the research gaps identified, which are planned to form part of a continuing program of research in this field.

Maintaining shared knowledge of acquaintance : methods people use to establish who knows whom

Acquaintance is a fundamental determinant of how people behave when interacting with one another. This article focuses on how this type of personal knowledge is an important consideration for people as social actors. Studying naturally-occurring social encounters, I describe how speakers use particular references to convey whether a recipient should be able to recognise a non-present third party. On some occasions, however, the presumption of recognisability or non-recognisability that underpins the use of a particular reference proves questionable. By exploring how recipients can challenge reference forms, and thereby reject claims of either recognisability or non-recognisability, I explain how people establish and maintain a shared understanding of who knows whom. I conclude by discussing motivations for this behaviour, and thereby contribute to understanding the commonsense reasoning that underpins orderly conduct in this aspect of social encounters.