A model for integrating clinical care and basic science research, and pitfalls of performing complex research projects for addressing a clinical challenge

The collaboration of clinicians with basic science researchers is crucial for addressing clinically relevant research questions. In order to initiate such mutually beneficial relationships, we propose a model where early career clinicians spend a designated time embedded in established basic science research groups, in order to pursue a postgraduate qualification. During this time, clinicians become integral members of the research team, fostering long term relationships and opening up opportunities for continuing collaboration. However, for these collaborations to be successful there are pitfalls to be avoided. Limited time and funding can lead to attempts to answer clinical challenges with highly complex research projects characterised by a large number of "clinical" factors being introduced in the hope that the research outcomes will be more clinically relevant. As a result, the complexity of such studies and variability of its outcomes may lead to difficulties in drawing scientifically justified and clinically useful conclusions. Consequently, we stress that it is the basic science researcher and the clinician's obligation to be mindful of the limitations and challenges of such multi-factorial research projects. A systematic step-by-step approach to address clinical research questions with limited, but highly targeted and well defined research projects provides the solid foundation which may lead to the development of a longer term research program for addressing more challenging clinical problems. Ultimately, we believe that it is such models, encouraging the vital collaboration between clinicians and researchers for the work on targeted, well defined research projects, which will result in answers to the important clinical challenges of today.

News produsage in a pro-am mediasphere : why citizen journalism matters

The rise to prominence of citizen journalism is usually described as a paradigm shift in the relationship between news organizations and their audiences – ‘citizen’ or ‘amateur’ journalists are positioned as inherently different from, and possibly in competition with, ‘professional’ journalists. Some journalists in the industry have taken up this theme, and are at pains to distinguish their professional, supposedly objective and accountable practices from what they describe as the opinionated and partisan ‘armchair journalism’ of amateurs, while some citizen journalists, in turn, give as good at they get and describe the professionals as lackeys of their corporate masters who (willingly or unwittingly) fall prey to political and commercial spin. In fact, the very terminology we use to describe both sides creates the impression that professionals are not also citizens, and that citizen journalists are incapable of having professional skills and knowledges; in reality, of course, the lines between them are much less clear.

The 'Dirty Work' of the Lie

The panel "Duplicity/Complicity: Performing and Misperforming Lies" at PSi #15 in Croatia in July 2009 examined the half-truths, hidden assumptions and power relations embedded in every act of performance through an analysis of the way bodies, buildings, personae and communities perform and misperform lies. It was a collection of new academic voices from Australia and Croatia, intersecting and colliding and, at times, outright lying, with each other and with commentary from Alan Read. Inspired by this successful adventure in collaborative academic mis-performance, "The ‘Dirty Work’ of the Lie" takes the challenge set by the Prelude Panel at PSI #15 and subjects the ideas emerging from this panel to "friendly fire" in order to build a multi authored response to 'performance that lies', with reference to the work of A Chorus of Women, disabled artists Bill Shannon, Aaron Williamson and Kathryn Araneillo, US dance performer Ann Liv Young and US theatre and festival director Peter Sellars. In doing so, "The 'Dirty Work' of the Lie" provides a reflexive response to the duplicity inherent in the performances, and also in our own academic analyses. With Alan Read acting as interlocutor, each contributor will creatively respond to a paper presented by another, developing the key intersecting issues that emerged through the formation of the panel. These issues include impression management, self-belief and performers who are 'taken in by their own act', the dirty work of taking others in with an act, the guerrilla dimension of lying, the productivity of the lie, and questions of audience engagement and ethics. As a result, this new paper tests how the 'misperformance' of lies across different cultural sites, be it deliberate or accidental, can become a productive – and, indeed, politicised – aspect of cultural performance, betraying accepted attitudes, ideas and structures of authority and offering alternative visions. Through it’s distinctively multi vocal texture, "The 'Dirty Work' of the Lie" also interrogates the modes of analysis available to us, questioning the 'duplicity' in our reflecting, responding and listening to each other as well as the work.

The effectiveness of a short-term group music therapy intervention for parents who have a child with a disability

Background The relationship between positive parent-child interactions and optimal child development is well established. Families with a child with a disability may face additional challenges to establishing positive parent-child relationships. There are limited studies addressing the effectiveness of interventions which seek to address these issues with parents and young children with a disability. In particular, prior studies of music therapy with this group have been limited by small sample sizes and the use of measures of limited reliability and validity. Objective This study investigates the effectiveness of a short-term group music therapy intervention for parents who have a child with a disability and explores the factors associated with higher outcomes for participating families. Methods The participants were 201 mother-child dyads, where the child had a disability. Pre and post intervention parental questionnaires and clinician observation measures were taken on a range of parental wellbeing, parenting behaviours and child developmental factors. Descriptive data, t-tests for repeated measures and a predictive model tested via logistic regression are presented. Results Significant improvements pre to post were found for parent mental health, child communication and social skills, parenting sensitivity, parental engagement with child and acceptance of child, child responsiveness to parent, and child interest and participation in program activities. There was also evidence that parents were very satisfied with the program and that it brought social benefits to families. Reliable change on six or more indicators of parent or child functioning was predicted by attendance and parent education. Conclusions This study provides positive evidence for the effectiveness of group music therapy in promoting improved parental mental health, positive parenting and key child developmental areas. Whilst several limitations are discussed, the study does address some of the gaps in the music therapy evidence base in this area.

Cancer-related symptom clusters for symptom management in outpatients after commencing adjuvant chemotherapy, at 6 months, and 12 months

Goals of work: The aim of this secondary data analysis was to investigate symptom clusters over time for symptom management of a patient group after commencing adjuvant chemotherapy. Materials and methods: A prospective longitudinal study of 219 cancer outpatients conducted within 1 month of commencing chemotherapy (T1), 6 months (T2), and 12 months (T3) later. Patients' distress levels were assessed for 42 physical symptoms on a clinician-modified Rotterdam Symptom Checklist. Symptom clusters were identified in exploratory factor analyses at each time. Symptom inclusion in clusters was determined from structure coefficients. Symptoms could be associated with multiple clusters. Stability over time was determined from symptom cluster composition and the proportion of symptoms in the initial symptom clusters replicated at later times. Main results Fatigue and daytime sleepiness were the most prevalent distressing symptoms over time. The median number of concurrent distressing symptoms approximated 7, over time. Five consistent clusters were identified at T1, 2, and T3. An additional two clusters were identified at 12 months, possibly due to less variation in distress levels. Weakness and fatigue were each associated with two, four, and five symptom clusters at T1, T2, and T3, respectively, potentially suggesting different causal mechanisms. Conclusion: Stability is a necessary attribute of symptom clusters, but definitional clarification is required. We propose that a core set of concurrent symptoms identifies each symptom cluster, signifying a common cause. Additional related symptoms may be included over time. Further longitudinal investigation is required to identify symptom clusters and the underlying causes.

AITPM national newsletter president's report April 2010

Well, it has been Clem 7 month here in Brisbane and my impression is “so far, so good!” For those of you who know Brisbane, the four lane twin Clem Jones Tunnel (M7) is approximately 4.5km long, and connects Ipswich Road (A7) at the Princess Alexandra Hospital on the south side with Bowen Bridge Road (A3) at the Royal Brisbane Hospital on the north side. There are also south access ramps to the Pacific Motorway and east access ramps to Shafston Avenue (headed to/from Wynnum). Brisbanites have been enjoying a three week no-toll taste test, and I paced through it one evening with minimal fuss. The tunnel seems to have eased the congestion at the Stanley Street on-ramp to the Pacific Motorway quite a bit, and Ipswich Road – Main Street through the ‘Gabba. One must watch the signage carefully, but once we get used to the infrastructure, this will not likely be problematic. It will be interesting to see how traffic behaves when the system settles after tolling, which has likely commenced by the time you’re reading. I believe a passenger car toll is about $4.20 one way but saves about 24 signalised intersection pass-throughs.

Everything is child abuse

In 2008, the Australian federal Senate held an Inquiry into the Sexualisation of Children in the Contemporary Media Environment. I made a submission to this Inquiry, noting that in public debate about this topic a number of quite distinct issues, with distinct aetiologies, were collapsed together. These included: child pornography; children being targeted by any form of marketing; young people becoming sexually active; sexual abuse of children; raunch culture; protecting children from any sexualised material in the media; and body image disorders. I suggested that commentators had collapsed these issues together because the image of the helpless child is a powerful one for critics to challenge undesirable aspects of contemporary culture. The result of many different ideological viewpoints all using the same argument - that the forms of culture they didn't like were damaging children - gives the impression that there is no element of culture today that isn't (somebody claims) causing harm to children: everything is child abuse. The danger of such discourses is that they draw attention away from the real harm that is being caused to children by sexual and other forms of maltreatment - which overwhelmingly occur within families, and for reasons ignored in these debates.

Application of an optimisation algorithm to configure an internal fixation device

Fractures of long bones are sometimes treated using various types of fracture fixation devices including internal plate fixators. These are specialised plates which are used to bridge the fracture gap(s) whilst anatomically aligning the bone fragments. The plate is secured in position by screws. The aim of such a device is to support and promote the natural healing of the bone. When using an internal fixation device, it is necessary for the clinician to decide upon many parameters, for example, the type of plate and where to position it; how many and where to position the screws. While there have been a number of experimental and computational studies conducted regarding the configuration of screws in the literature, there is still inadequate information available concerning the influence of screw configuration on fracture healing. Because screw configuration influences the amount of flexibility at the area of fracture, it has a direct influence on the fracture healing process. Therefore, it is important that the chosen screw configuration does not inhibit the healing process. In addition to the impact on the fracture healing process, screw configuration plays an important role in the distribution of stresses in the plate due to the applied loads. A plate that experiences high stresses is prone to early failure. Hence, the screw configuration used should not encourage the occurrence of high stresses. This project develops a computational program in Fortran programming language to perform mathematical optimisation to determine the screw configuration of an internal fixation device within constraints of interfragmentary movement by minimising the corresponding stress in the plate. Thus, the optimal solution suggests the positioning and number of screws which satisfies the predefined constraints of interfragmentary movements. For a set of screw configurations the interfragmentary displacement and the stress occurring in the plate were calculated by the Finite Element Method. The screw configurations were iteratively changed and each time the corresponding interfragmentary displacements were compared with predefined constraints. Additionally, the corresponding stress was compared with the previously calculated stress value to determine if there was a reduction. These processes were continued until an optimal solution was achieved. The optimisation program has been shown to successfully predict the optimal screw configuration in two cases. The first case was a simplified bone construct whereby the screw configuration solution was comparable with those recommended in biomechanical literature. The second case was a femoral construct, of which the resultant screw configuration was shown to be similar to those used in clinical cases. The optimisation method and programming developed in this study has shown that it has potential to be used for further investigations with the improvement of optimisation criteria and the efficiency of the program.

Development and evaluation of an integrated clinical learning model to inform continuing education for acute care nurses

Background Significant ongoing learning needs for nurses have occurred as a direct result of the continuous introduction of technological innovations and research developments in the healthcare environment. Despite an increased worldwide emphasis on the importance of continuing education, there continues to be an absence of empirical evidence of program and session effectiveness. Few studies determine whether continuing education enhances or develops practice and the relative cost benefits of health professionals’ participation in professional development. The implications for future clinical practice and associated educational approaches to meet the needs of an increasingly diverse multigenerational and multicultural workforce are also not well documented. There is minimal research confirming that continuing education programs contribute to improved patient outcomes, nurses’ earlier detection of patient deterioration or that standards of continuing competence are maintained. Crucially, evidence-based practice is demonstrated and international quality and safety benchmarks are adhered to. An integrated clinical learning model was developed to inform ongoing education for acute care nurses. Educational strategies included the use of integrated learning approaches, interactive teaching concepts and learner-centred pedagogies. A Respiratory Skills Update education (ReSKU) program was used as the content for the educational intervention to inform surgical nurses’ clinical practice in the area of respiratory assessment. The aim of the research was to evaluate the effectiveness of implementing the ReSKU program using teaching and learning strategies, in the context of organisational utility, on improving surgical nurses’ practice in the area of respiratory assessment. The education program aimed to facilitate better awareness, knowledge and understanding of respiratory dysfunction in the postoperative clinical environment. This research was guided by the work of Forneris (2004), who developed a theoretical framework to operationalise a critical thinking process incorporating the complexities of the clinical context. The framework used educational strategies that are learner-centred and participatory. These strategies aimed to engage the clinician in dynamic thinking processes in clinical practice situations guided by coaches and educators. Methods A quasi experimental pre test, post test non–equivalent control group design was used to evaluate the impact of the ReSKU program on the clinical practice of surgical nurses. The research tested the hypothesis that participation in the ReSKU program improves the reported beliefs and attitudes of surgical nurses, increases their knowledge and reported use of respiratory assessment skills. The study was conducted in a 400 bed regional referral public hospital, the central hub of three smaller hospitals, in a health district servicing the coastal and hinterland areas north of Brisbane. The sample included 90 nurses working in the three surgical wards eligible for inclusion in the study. The experimental group consisted of 36 surgical nurses who had chosen to attend the ReSKU program and consented to be part of the study intervention group. The comparison group included the 39 surgical nurses who elected not to attend the ReSKU program, but agreed to participate in the study. Findings One of the most notable findings was that nurses choosing not to participate were older, more experienced and less well educated. The data demonstrated that there was a barrier for training which impacted on educational strategies as this mature aged cohort was less likely to take up educational opportunities. The study demonstrated statistically significant differences between groups regarding reported use of respiratory skills, three months after ReSKU program attendance. Between group data analysis indicated that the intervention group’s reported beliefs and attitudes pertaining to subscale descriptors showed statistically significant differences in three of the six subscales following attendance at the ReSKU program. These subscales included influence on nursing care, educational preparation and clinical development. Findings suggest that the use of an integrated educational model underpinned by a robust theoretical framework is a strong factor in some perceptions of the ReSKU program relating to attitudes and behaviour. There were minimal differences in knowledge between groups across time. Conclusions This study was consistent with contemporary educational approaches using multi-modal, interactive teaching strategies and a robust overarching theoretical framework to support study concepts. The construct of critical thinking in the clinical context, combined with clinical reasoning and purposeful and collective reflection, was a powerful educational strategy to enhance competency and capability in clinicians.

Utility of routine data sources for feedback on the quality of cancer care: an assessment based on clinical practice guidelines

Background Not all cancer patients receive state-of-the-art care and providing regular feedback to clinicians might reduce this problem. The purpose of this study was to assess the utility of various data sources in providing feedback on the quality of cancer care. Methods Published clinical practice guidelines were used to obtain a list of processes-of-care of interest to clinicians. These were assigned to one of four data categories according to their availability and the marginal cost of using them for feedback. Results Only 8 (3%) of 243 processes-of-care could be measured using population-based registry or administrative inpatient data (lowest cost). A further 119 (49%) could be measured using a core clinical registry, which contains information on important prognostic factors (e.g., clinical stage, physiological reserve, hormone-receptor status). Another 88 (36%) required an expanded clinical registry or medical record review; mainly because they concerned long-term management of disease progression (recurrences and metastases) and 28 (11.5%) required patient interview or audio-taping of consultations because they involved information sharing between clinician and patient. Conclusion The advantages of population-based cancer registries and administrative inpatient data are wide coverage and low cost. The disadvantage is that they currently contain information on only a few processes-of-care. In most jurisdictions, clinical cancer registries, which can be used to report on many more processes-of-care, do not cover smaller hospitals. If we are to provide feedback about all patients, not just those in larger academic hospitals with the most developed data systems, then we need to develop sustainable population-based data systems that capture information on prognostic factors at the time of initial diagnosis and information on management of disease progression.

A Multifaceted Strategy for Implementation of the Ottawa Ankle Rules in Two Emergency Departments

Problem Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design Before and after study. Background and setting Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.” Effects of change Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747). Lessons learnt Assessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.

A natural model for architecture

In John Frazer's seminal book An Evolutionary Architecture (1995), from which this essay is extracted, a fundamental approach is established for have natural systems can unfold mechanisms for negotiating the complex design space inherent in architectural systems. In this essay, which forms a critical part of the book, Frazer draws both correlations and distinctions from natural processes as emulated in design processes and form as active manifestations within natural systems. Form is seen as an evolving agent generated via the rules of descriptive genetic coding, functioning as a part of a metabolic environment. Frazer's process-model establishes the realm in which computation must manoeuvre to produce a valid solution space, including the operations of self-organisation, complexity and emergent behaviour. Addressing design as an authored practice, he extends the transference of 'creativity' from the explicit impression into form, to the investment of though, organisation and strategy in the computational processes which produce form. Frazer's text concentrates astutely on the practising of the evolutionary paradigm, the output of which postulates an architecture born of the relationships to dynamic environmental and socio-economic contexts, and realised through morphogenetic materialisation.

Where do they come from? Prevalence and characteristics of nascent entrepreneurs

This paper reports on a unique study of a large, random sample of business start-ups that were identified prior to the actual, commercial launch of the ventures. The purpose of this paper is two-fold. First, to present frequencies on the involvement of the Swedish population in the small business sector (particularly in start-ups of firms) and to compare these with estimates from Norway and the USA, which are based on studies using a similar research design. The authors also discuss the possible reasons for the differences that emerge between countries. Second, the characteristics of nascent entrepreneurs (i.e. individuals trying to start an independent business) are analysed and compared for sub-groups within the sample and with characteristics of business founders as they appear in theoretical accounts or retrospective empirical studies of surviving all firms. In order to get a representative sample from the working age population, respondents (n = 30,427) were randomly selected and interviewed by telephone. It was found that 2.0% of the Swedish population at the time of the interview were trying to start an independent business. Sweden had a significantly lower prevalence rate of nascent entrepreneurs compared to Norway and the USA. Nascent entrepreneurs were then compared to a control group of people not trying to start a business. The results confirmed findings from previous studies of business founders pointing to the importance of role models and the impression of self-employment obtained through these, employment status, age, education and experience. Marital status, the number of children in the household, and length of employment experience were unrelated to the probability of becoming a nascent entrepreneur. The gender of the respondent was the strongest distinguishing factor. Importantly, the results suggest that while one has a reasonably good understanding of the characteristics associated with men going into business for themselves, the type of variables investigated here have very limited ability to predict nascent entrepreneur status for women.

Self-presentation and underachievement among young adolescents identified as gifted

Academically gifted students are recognised as possessing considerable achievement potential. Yet many gifted students fail to perform at a level commensurate with their ability. This phenomenon is known as underachievement and may have far-reaching personal and social costs. Underachievement is particularly prevalent during early adolescence, between the ages of 10 to 14 years, when declining levels of academic achievement are often apparent. Grouping for instructional purposes is advocated as a means of reducing underachievement for gifted students by providing opportunities for like-minded and like-ability individuals to learn together. Despite this, some gifted students continue to underachieve. For some, underachievement appears to be a deliberate choice making them a population of learners at-risk. This multiple case study examines the relationship between self-presentation and underachievement as experienced by three gifted adolescents. It reveals how students perceived and explained the discrepancy between their ability and performance. Further, the study identifies those self-presentation strategies adopted in response to underachievement. Findings may assist parents and educators to provide greater support for gifted adolescents.

Impressions of China : Zhang Yimou's outdoor theme productions

This thesis examines contemporary mediated spectacles used in regional tourism strategies. In recent years there has been growing occurrence of ‘formatted entertainment models’ in China. With this in mind, this thesis explores the ways in which traditional cultural resources are being converted to generate diverse, hybrid commodities. The unique business model of Zhang Yimou, known as the Impression Series provides the case study. The thesis examines multilayered representations of products which continuously form, and are formatted, under the logic of the cultural market. The case study highlights the revival of traditional Chinese culture, a new branding of the Chinese national image and rising ‘soft power’. Primarily, the thesis argues that personal celebrity endorsement is replacing political propaganda heroes in promoting an alternative image of China. Zhang Yimou and Impression West Lake function as a dual branding mechanism that combines ‘people marketing’ and ‘place marketing’ for the development of a ‘created in China’ cultural commodity as well as for the generation of positive economic outcomes. Secondly, the thesis identifies how natural resources linked with a local tourism industry are articulated into cultural products and how this is experienced by visitors. Culture is a core component of China’s ‘soft power.’ Cultural experience’ strategies such as Impression combine global marketing and local cultural forces. The thesis argues that a creative entrepreneur has more advantages in promoting ‘soft power’ than governmental propaganda strategies. Thirdly, Impression West Lake encapsulates the rise of the creative entrepreneur with the help of local government authorities. Even though government cultural policy-makers can facilitate the cultural infrastructure, they ultimately rely on the entrepreneur’s creative vision and understanding of the market. Finally, based on the study of Impression West Lake, the thesis outlines future opportunities for social, cultural and economic reform in China.