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.

Agility : customer's perspective

In competitive environments agility is emerging as an important determinant of success. Despite the widely accepted importance of agility there has been paucity in research on this construct, especially the customer’s perspective of agility. Rise of digital natives together with growth of ubiquitous information systems has changed the way firms engage with their customers. Firms are finding it difficult to establish sustained loyalty hence the long term sustained advantage over competition. Hence, firms are increasingly investing substantial resources on dynamic Customer Relationship Management systems such as mobile-CRMS to better engage with customers to sense and respond quickly (Agility of the firm) to their demands. This paper investigates firm’s customer agility from customer’s perspective, and we propose a model to understand firm’s customer agility from customer’s point of view. The proposed model is derived based on previous conceptions of agility and the expectation confirmation theory (ECT). This paper reports the initial findings of this study obtained through a pilot test. The findings of the study demonstrate that customer’s view point on firm’s customer agility is an important determinant of achieving success through sustained competitive advantage.

The roles of Australian chairs in clinical nursing

Australian chairs in clinical nursing have been established in order to achieve more effective partnerships between academia and the health care sector in education, research and quality of nursing care. The aim of this study was to describe the goals, obstacles, supports and outcomes of such appointments. The study explored the perceptions of a purposive sample of Australian professors holding clinical chairs, stratified to ensure representation of both the geographical and clinical specialty diversity of the population. Eight professors were interviewed using semi-structured telephone interviews. The interviews covered three phases: role establishment, current foci and future developments. Qualitative analysis for common themes and areas of divergence was conducted with concurrent analysis providing the opportunity to seek confirmation for emerging themes. The participants highlighted the diversity of arrangements between university and health sector partners in establishing their respective roles. Clear communication was crucial to successful partnership arrangements. All roles included components of education, research and politics but the relative contribution of each of these areas depended to a large extent on the priorities of the employing partners. The participants felt the need to secure sustainable income sources and consolidate outcomes to ensure the continued viability of their positions. Clinical professorial nursing appointments provide one means of addressing perceived gaps in the links between the university and health care sectors, academia and clinicians, thus enhancing nursing education, research and politics. Through emphasizing common purpose and mutual respect, these positions can illuminate the crucial role nursing plays in Australian health care delivery.

Opportunities and challenges : school guidance counsellors’ perceptions of counselling students online

School guidance counsellors world-wide seek ways of providing appropriate professional assistance to all students. While young people integrate online technology into their daily lives and go online for information and to communicate with each other, school counsellors in Australia are not offering online support to students. This cross-sectional study reported on the reluctance of school counsellors to offer online counselling and the reasons for this. A survey of 210 school guidance counsellors found that there is conditional support for the introduction of online counselling into the school setting. Counsellors indicated that they would use online counselling if students accepted its use in the school setting though they question how genuine students would be in its use. Most respondents reported a lack of confidence in understanding the ethical and legal implications of online counselling. However, the majority of participants were prepared to undertake further professional development in this mode of counselling. Additionally, they sought confirmation of the effectiveness of counselling students online before committing themselves to it. The implications for school guidance practice are discussed.

A typical migraine susceptibility region localizes to chromosome 1q31

Migraine (with and without aura) is a prevalent neurovascular disease that shows strong familial aggregation, although the number of genes involved and the mode of inheritance is not clear. Some insight into the disease has been gained from genetic studies into a rare and very severe migraine subtype known as familial hemiplegic migraine (FHM). In this study, we took a family-based linkage and association approach to investigate the FHM susceptibility region on chromosome 1q31 for involvement in typical migraine susceptibility in affected Australian pedigrees. Initial multipoint ALLEGRO analysis provided strong evidence for linkage of Chrlq31 markers to typical migraine in a large multigenerational pedigree. The 1-LOD* unit support interval for suggestive linkage spanned approximately 18 cM with a maximum allele sharing LOD* score of 3.36 obtained for marker D1S2782 (P=0.00004). Subsequent analysis of an independent sample of 82 affected pedigrees added support to the initial findings with a maximum LOD* of 1.24 (P=0.008). Utilising the independent sample of 82 pedigrees, we also performed a family-based association test. Results of this analysis indicated distortion of allele transmission at marker D1S249 [global chi2 (5) of 15.00, P=0.010] in these pedigrees. These positive linkage and association results will need further confirmation by independent researchers. However, overall they provide good evidence for the existence of a typical migraine locus near these markers on Chrlq3l, and reinforce the idea that an FHM gene in this genomic region may also contribute to susceptibility to the more common forms of migraine.

Locked nucleic acid (LNA) single nucleotide polymorphism (SNP) genotype analysis and validation using real-time PCR

With an increased emphasis on genotyping of single nucleotide polymorphisms (SNPs) in disease association studies, the genotyping platform of choice is constantly evolving. In addition, the development of more specific SNP assays and appropriate genotype validation applications is becoming increasingly critical to elucidate ambiguous genotypes. In this study, we have used SNP specific Locked Nucleic Acid (LNA) hybridization probes on a real-time PCR platform to genotype an association cohort and propose three criteria to address ambiguous genotypes. Based on the kinetic properties of PCR amplification, the three criteria address PCR amplification efficiency, the net fluorescent difference between maximal and minimal fluorescent signals and the beginning of the exponential growth phase of the reaction. Initially observed SNP allelic discrimination curves were confirmed by DNA sequencing (n = 50) and application of our three genotype criteria corroborated both sequencing and observed real-time PCR results. In addition, the tested Caucasian association cohort was in Hardy-Weinberg equilibrium and observed allele frequencies were very similar to two independently tested Caucasian association cohorts for the same tested SNP. We present here a novel approach to effectively determine ambiguous genotypes generated from a real-time PCR platform. Application of our three novel criteria provides an easy to use semi-automated genotype confirmation protocol.

Dynamic simulation of a light-weight, low-drag, hybrid-electric sports coupe

The University of Queensland UltraCommuter concept is an ultra- light, low-drag, hybrid-electric sports coupe designed to minimize energy consumption and environmental impact while enhancing the performance, styling, features and convenience that motorists enjoy. This paper presents a detailed simulation study of the vehicle's performance and fuel economy using ADVISOR, including a detailed description of the component models and parameters assumed. Results from the study include predictions of a 0-100 kph acceleration time of ≺9s, and top speed of 170 kph, an electrical energy consumption of ≺67 Wh/km in ZEV mode and a petrol-equivalent fuel consumption of ≺2.5 L/100 km in charge-sustaining HEV mode. Overall, the results of the ADVISOR modelling confirm the UltraCommuter's potential to achieve high performance with high efficiency, and the authors look forward to a confirmation of these estimates following completion of the vehicle.

Stakeholder engagement and asset management : a case study of the Gold Coast airport, Queensland

One of the fastest growing industries – aviation – faces serious and compounding challenges in maintaining healthy relationships with community stakeholders. One area in aviation creating community conflict is noise pollution. However, current understandings of the factors that affect noise annoyance of the community are poorly conceptualized. More importantly, the way community needs and expectations could be incorporated in airport governance has been inadequately framed to address the issue of aircraft noise. This paper proposes the util-ity of adopting an integrated strategic asset management (ISAM) framework [1] to explore the dynamic nature of relationships between and airport and its surrounding area. The case of the Gold Coast Airport (OOL) operator and community stakeholders is used. This paper begins with an overview of the ISAM framework in the context of airport governance and sustainable development – as a way to find a balance between economic opportunities and societal concerns through stakeholder engagement. Next, an exploratory case study is adopted as a method to explore the noise-related complaints, complainants, and possible causes. Fol-lowing this, the paper reviews three approaches to community stakeholder engagement in Australia, Japan, and UK and discusses their implications in the con-text of OOL. The paper concludes with a contention that airport governance is likely to be much more effective with the adoption of ISAM framework than without it.

Dengue or Kokobera? A case report from the top end of the Northern Territory

In early April 1998, the Centre for Disease Control in Darwin was notified of a possible case of dengue which appeared to have been acquired in the Northern Territory. Because dengue is not endemic to the Northern Territory, locally acquired infection has significant public health implications, particularly for vector identification and control to limit the spread of infection. Dengue IgM serology was positive on two occasions, but the illness was eventually presumptively identified as Kokobera infection. This case illustrates the complexity of interpreting flavivirus serology. Determining the cause of infection requires consideration of the clinical illness, the incubation period, the laboratory results and vector presence. Waiting for confirmation of results, before the institution of the public health measures necessary for a true case of dengue, was ultimately justified in this case. This is a valid approach in the Northern Territory, but may not be applicable to areas of Australia with established vectors for dengue. Commun Dis Intell 1998;22:105-107.

Carbonic anhydrase IX expression, a novel surrogate marker of tumor hypoxia, is associated with a poor prognosis in non-small-cell lung cancer

Purpose To evaluate carbonic anhydrase (CA) IX as a surrogate marker of hypoxia and investigate the prognostic significance of different patterns of expression in non-small-cell lung cancer (NSCLC). Methods Standard immunohistochemical techniques were used to study CA IX expression in 175 resected NSCLC tumors. CA IX expression was determined by Western blotting in A549 cell lines grown under normoxic and hypoxic conditions. Measurements from microvessels to CA IX positivity were obtained. Results CA IX immunostaining was detected in 81.8% of patients. Membranous (m) (P = .005), cytoplasmic (c) (P = .018), and stromal (P < .001) CA IX expression correlated with the extent of tumor necrosis (TN). The mean distance from vascular endothelium to the start of tumor cell positivity was 90 μm, which equates to an oxygen pressure of 5.77 mmHg. The distance to blood vessels from individual tumor cells or tumor cell clusters was greater if they expressed mCA IX than if they did not (P < .001). Hypoxic exposure of A549 cells for 16 hours enhanced CAIX expression in the nuclear and cytosolic extracts. Perinuclear (p) CA IX (P = .035) was associated with a poor prognosis. In multivariate analysis, pCA IX (P = .004), stage (P = .001), platelet count (P = .011), sex (P = .027), and TN (P = .035) were independent poor prognostic factors. Conclusion These results add weight to the contention that mCA IX is a marker of tumor cell hypoxia. The absence of CA IX staining close to microvessels suggests that these vessels are functionally active. pCA IX expression is representative of an aggressive phenotype. © 2003 by American Society of Clinical Oncology.

Interactions between hypoxia and epidermal growth factor receptor in non-small-cell-lung cancer

Tumor hypoxia has been recognized to confer resistance to anticancer therapy since the early 20th century. More recently, its fundamental role in tumorigenesis has been established. Hypoxia-inducible factor (HIF)-1 has been identified as an important transcription factor that mediates the cellular response to hypoxia, promoting both cellular survival and apoptosis under different conditions. Increased tumor cell expression of this transcription factor promotes tumor growth In vivo and is associated with a worse prognosis in patients with non-small-cell lung cancer (NSCLC) undergoing tumor resection. The epidermal growth factor receptor (EGFR) promotes tumor cell proliferation and anglogenesis and inhibits apoptosis. Epidermal growth factor receptor expression increases in a stepwise manner during tumorigenesis and is overexpressed in > 50% of NSCLC tumors. This review discusses the reciprocal relationship between tumor cell hypoxia and EGFR. Recent studies suggest that hypoxia induces expression of EGFR and its ligands. In return, EGFR might enhance the cellular response to hypoxia by increasing expression of HIF-1α, and so act as a survival factor for hypoxic cancer cells. Immunohistochemical studies on a series of resected NSCLC tumors add weight to this contention by demonstrating a close association between expression of EGFR, HIF-1α, and:1 of HIF-1's target proteins, carbonic anhydrase IX. In this article we discuss emerging treatment strategies for NSCLC that target HIF-1, HIF-1 transcriptional targets, and EGFR.

Front-line workers as intermediaries : the changing landscape of disability and employment services in Australia

Recent welfare reform in Australia has been constructed around the now-familiar principle of paid work and willingness to work as the fundamental marker of social citizenship. Beginning with the long-term unemployed in Australia in the mid 1990s, the scope of welfare reform has now extended to include people with a disability – which is a category of income support that has been growing in Australia. From the national government’s point of view this growth is a financial concern as it seeks to move as many people as possible into paid work to support the costs of an ageing population (DEWR, 2005). In doing so, the government has changed the meaning of disability in terms of eligibility for financial support from the state, and at the same time redefined the role of people with a disability with regard to work, and the role of the state with regard to the disabled. This has been a matter of some political contention in Australia.

WATER - a series of photographs by Louise Grayson

This body of photographic work has been created to firstly, explore a new approach to practice-led research that uses an “action genre” approach to reflective practice (Lemke) and secondly, to visually explore human interaction with the fundamental item in life - water. The first of these is based on the contention that to understand the meanings inherent in photographs we cannot look merely at the end result. It is essential to keep looking at the actions of practitioners, and the influences upon them, to determine how external influences affect the meaning potential of editorial photographs (Grayson, 2012). WATER therefore, provides an ideal platform to reflect upon the actions and influences involved in creating work within the photographic genre of photojournalism. It enables this practitioner to reflect on each stage of production to gain a better understanding of how external influences impact the narrative potential within images created. There are multi-faceted influences experienced by photographers who are creating images that, in turn, are part of constructing and presenting the narrative potential of editorial photographs. There is an important relationship between professional photographers and the technical, cultural, economic and institutional forces that impinge upon all stages of production and publication. What results is a greater understanding of technical, cultural, economic and institutional forces that impinge upon all stages of production and publication. Therefore, to understand the meanings inherent in photographs within WATER, I do not look merely at the end result. It provides a case study looking at my actions in the filed, and the influences upon me, to determine how external influences affect the meaning potential of these photographs (Grayson, 2012). As a result, this project adds to the body of scholarship around the definition of Photojournalism, how it has adapted to the current media environment and provides scope for further research into emerging new genres within editorial photography, such as citizen photojournalism. Concurrently, the photographs themselves were created to visually explore how there remains a humanistic desire to interact with the natural form of water even while living a modern cosmopolitan life around it. Taking a photojournalistic approach to exploring this phenomenon, the images were created by “capturing moments as they happened” with no posing or setting up of images. This serendipitous approach to the photographic medium provides the practitioner with at least an attempt to direct the subjectivity contained explicitly in photographs. What results is a series of images that extend the visual dialogue around the role of water within modern humanistic lifestyles and how it remains an integral part of our society’s behaviors. It captures important moments that document this relationship at this time of modern development. The resulting works were exhibited and published as part of the Head On Photo Festival, Australia's largest photo festival and the world's second largest festival in Sydney 20-24 May 2013. The WATER series of images were curated by three Magnum members; Ian Berry, Eli Reed and Chris Steele-Perkins. Magnum is a highly regarded international photographic co-operative with editorial offices in New York, London, Paris and Tokyo. There was a projection of the works as part of the official festival programme, presented to both members of the public and Sydney’s photography professionals. In addition, a sample of images from the WATER series was chosen for inclusion in the Magnum-published hardcover book. References Grayson, Louise. 2012. “Editorial photographs and patterns of practice.” Journalism Practice. Accessed: http://www.tandfonline.com/doi/abs/10.1080/17512786.2012.726836#.UbZN-L--1RQ Lemke, Jay. 1995. Textual Politics: Discourse and Social Dynamics. London: Taylor & Francis.

Cross-layer design for traffic management in wireless networked control systems

Wireless networked control systems (WNCSs) have been increasingly deployed in industrial applications. As they require timely data packet transmissions, it is difficult to make efficient use of the limited channel resources, particularly in contention based wireless networks in the layered network architecture. Aiming to maintain the WNCSs under critical real-time traffic condition at which the WNCSs marginally meet the real-time requirements, a cross-layer design (CLD) approach is presented in this paper to adaptively adjust the control period to achieve improved channel utilization while still maintaining effective and timely packet transmissions. The effectiveness of the proposed approach is demonstrated through simulation studies.

The role of common but differentiated responsibility in the 2020 climate regime

The principle of common but differentiated responsibility (CBDR) will play a role in the 2020 Climate Regime. This Article starts by examining differential treatment within the international legal order, finding that it is ethically and practically difficult to implement an international climate instrument based on formal equality. There is evidence of state parties accepting differential responsibilities in a number of areas within the international legal order and the embedding of CBDR in the United Nations Framework Convention on Climate Change (UNFCCC), means that that differential commitments will lie at the heart of the 2020 climate regime. The UNFCCC applies the implementation method of differentiation, while the Kyoto Protocol applies both the obligation and implementation method of differentiation. It is suggested that the implementation model will be the differentiation model retained in the 2020 climate agreement. The Parties’ submissions under the Durban Platform are considered in order to gain an understanding of their positions on CBDR. While there are areas of contention including the role of principles in shaping obligations and the ongoing legal status of Annex I and Non-Annex I distinction, there is broad consensus among the parties in favour of differentiation by implementation with developed and major economies undertaking Quantified Emission Limitation and Reduction Objectives (economy wide targets) and developing countries that are not major economies undertaking sectoral targets.