Rural and Urban Differentials in Primary Care Management of Chronic Heart Failure: New Data from the CASE Study

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia. Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study. Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998. Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study. Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%). Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

The role of soil characteristics on temperature sensitivity of soil organic matter

The uncertainty associated with how projected climate change will affect global C cycling could have a large impact on predictions of soil C stocks. The purpose of our study was to determine how various soil decomposition and chemistry characteristics relate to soil organic matter (SOM) temperature sensitivity. We accomplished this objective using long-term soil incubations at three temperatures (15, 25, and 35°C) and pyrolysis molecular beam mass spectrometry (py-MBMS) on 12 soils from 6 sites along a mean annual temperature (MAT) gradient (2–25.6°C). The Q10 values calculated from the CO2 respired during a long-term incubation using the Q10-q method showed decomposition of the more resistant fraction to be more temperature sensitive with a Q10-q of 1.95 ± 0.08 for the labile fraction and a Q10-q of 3.33 ± 0.04 for the more resistant fraction. We compared the fit of soil respiration data using a two-pool model (active and slow) with first-order kinetics with a three-pool model and found that the two and three-pool models statistically fit the data equally well. The three-pool model changed the size and rate constant for the more resistant pool. The size of the active pool in these soils, calculated using the two-pool model, increased with incubation temperature and ranged from 0.1 to 14.0% of initial soil organic C. Sites with an intermediate MAT and lowest C/N ratio had the largest active pool. Pyrolysis molecular beam mass spectrometry showed declines in carbohydrates with conversion from grassland to wheat cultivation and a greater amount of protected carbohydrates in allophanic soils which may have lead to differences found between the total amount of CO2 respired, the size of the active pool, and the Q10-q values of the soils.

The aetiology, impact and management of cancer-related fatigue in patients with advanced cancer

Cancer-related fatigue (CRF) is a distressing symptom frequently experienced by patients with advanced cancer. While there have been some advances in the understanding of the management of fatigue associated with cancer treatment, CRF associated with advanced cancer remains a phenomenon that is not well-managed. The aetiologic factors associated with CRF, the impacts of CRF and the current management of CRF are discussed in this review article in relation to patients with advanced cancer. The paper concludes that while further research is required in the area, there are several potentially effective strategies currently available that can reduce the severity of CRF in patients with advanced cancer.

Editoral : Correspondence regarding Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. The Lancet 2011; 378: 731–39. Published 20 August 2011.

We read the excellent review of telemonitoring in chronic heart failure (CHF)1 with interest and commend the authors on the proposed classification of telemedical remote management systems according to the type of data transfer, decision ability and level of integration. However, several points require clarification in relation to our Cochrane review of telemonitoring and structured telephone support2. We included a study by Kielblock3. We corresponded directly with this study team specifically to find out whether or not this was a randomised study and were informed that it was a randomised trial, albeit by date of birth. We note in our review2 that this randomisation method carries a high risk of bias. Post-hoc metaanalyses without these data demonstrate no substantial change to the effect estimates for all cause mortality (original risk ratio (RR) 0·66 [95% CI 0·54, 0·81], p<0·0001; revised RR 0·72 [95% CI 0·57, 0·92], p=0·008), all-cause hospitalisation (original RR 0·91 [95% CI 0·84, 0·99] p=0·02; revised RR 0.92 [95% CI 0·84, 1·02], p=0·10 ) or CHF-related hospitalisation (original RR 0·79 [95% CI 0·67, 0·94] p=0·008; revised RR 0·75 [95% CI 0·60, 0·94] p=0·01). Secondly, we would classify the Tele-HF study4, 5 as structured telephone support, rather than telemonitoring. Again, inclusion of these data alters the point-estimate but not the overall result of the meta-analyses4. Finally, our review2 does not include invasive telemonitoring as the search strategy was not designed to capture these studies. Therefore direct comparison of our review findings with recent studies of these interventions is not recommended.

New Evidence for Structured Telephone Support in the Management of Patients with Heart Failure [Letter to Editor]

Letter to the Editor of New England Journal of Medicine on behalf of the Cochrane Systematic Review team.

The safety risk management of unmanned aircraft systems

The safety risk management process describes the systematic application of management policies, procedures and practices to the activities of communicating, consulting, establishing the context, and identifying, analysing, evaluating, treating, monitoring and reviewing risk. This process is undertaken to provide assurances that the risks of a particular unmanned aircraft system activity have been managed to an acceptable level. The safety risk management process and its outcomes form part of the documented safety case necessary to obtain approvals for unmanned aircraft system operations. It also guides the development of an organisation’s operations manual and is a primary component of an organisation’s safety management system. The aim of this chapter is to provide existing risk practitioners with a high level introduction to some of the unique issues and challenges in the application of the safety risk management process to unmanned aircraft systems. The scope is limited to safety risks associated with the operation of unmanned aircraft in the civil airspace system and over inhabited areas. The structure of the chapter is based on the safety risk management process as defined by the international risk management standard ISO 31000:2009 and draws on aviation safety resources provided by International Civil Aviation Organization, the Federal Aviation Administration and U.S. Department of Defense. References to relevant aviation safety regulations, programs of research and fielded systems are also provided.

External management of curriculum change

At a time of rapid curriculum reform, some schools are turning to external change agents for assistance, but what's the best way to initiate such an approach?

The relationship between parents’ self-efficacy beliefs, outcome expectations, child behaviour, and management of atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin condition, characterized by intense pruritis, with a complex aetiology comprising multiple genetic and environmental factors. It is a common chronic health problem among children, and along with other allergic conditions, is increasing in prevalence within Australia and in many countries worldwide. Successful management of childhood AD poses a significant and ongoing challenge to parents of affected children. Episodic and unpredictable, AD can have profound effects on children’s physical and psychosocial wellbeing and quality of life, and that of their caregivers and families. Where concurrent child behavioural problems and parenting difficulties exist, parents may have particular difficulty achieving adequate and consistent performance of the routine management tasks that promote the child’s health and wellbeing. Despite frequent reports of behaviour problems in children with AD, past research has neglected the importance of child behaviour to parenting confidence and competence with treatment. Parents of children with AD are also at risk of experiencing depression, anxiety, parenting stress, and parenting difficulties. Although these factors have been associated with difficulty in managing other childhood chronic health conditions, the nature of these relationships in the context of child AD management has not been reported. This study therefore examined relationships between child, parent, and family variables, and parents’ management of child AD and difficult child behaviour, using social cognitive and self-efficacy theory as a guiding framework. The study was conducted in three phases. It employed a quantitative, cross-sectional study design, accessing a community sample of 120 parents of children with AD, and a sample of 64 child-parent dyads recruited from a metropolitan paediatric tertiary referral centre. In Phase One, instruments designed to measure parents’ self-reported performance of AD management tasks (Parents’ Eczema Management Scale – PEMS) and parents’ outcome expectations of task performance (Parents’ Outcome Expectations of Eczema Management Scale – POEEMS) were adapted from the Parental Self-Efficacy with Eczema Care Index (PASECI). In Phase Two, these instruments were used to examine relationships between child, parent, and family variables, and parents’ self-efficacy, outcome expectations, and self-reported performance of AD management tasks. Relationships between child, parent, and family variables, parents’ self-efficacy for managing problem behaviours, and reported parenting practices, were also examined. This latter focus was explored further in Phase Three, in which relationships between observed child and parent behaviour, and parent-reported self-efficacy for managing both child AD and problem behaviours, were explored. Phase One demonstrated the reliability of both PEMS and POEEMS, and confirmed that PASECI was reliable and valid with modification as detailed. Factor analyses revealed two-factor structures for PEMS and PASECI alike, with both scales containing factors related to performing routine management tasks, and managing the child’s symptoms and behaviour. Factor analysis was also applied to POEEMS resulting in a three-factor structure. Factors relating to independent management of AD by the parent, involving healthcare professionals in management, and involving the child in management of AD were found. Parents’ self-efficacy and outcome expectations had a significant influence on self-reported task performance. In Phase Two, relationships emerged between parents’ self-efficacy and self-reported performance of AD management tasks, and AD severity, child behaviour difficulties, parent depression and stress, conflict over parenting issues, and parents’ relationship satisfaction. Using multiple linear regressions, significant proportions of variation in parents’ self-efficacy and self-reported performance of AD management tasks were explained by child behaviour difficulties and parents’ formal education, and self-efficacy emerged as a likely mediator for the relationships between both child behaviour and parents’ education, and performance of AD management tasks. Relationships were also found between parents’ self-efficacy for managing difficult child behaviour and use of dysfunctional parenting strategies, and child behaviour difficulties, parents’ depression and stress, conflict over parenting issues, and relationship satisfaction. While significant proportions of variation in self-efficacy for managing child behaviour were explained by both child behaviour and family income, family income was the only variable to explain a significant proportion of variation in parent-reported use of dysfunctional parenting strategies. Greater use of dysfunctional parenting strategies (both lax and authoritarian parenting) was associated with more severe AD. Parents reporting lower self-efficacy for managing AD also reported lower self-efficacy for managing difficult child behaviour; likewise, less successful self-reported performance of AD management tasks was associated with greater use of dysfunctional parenting strategies. When child and parent behaviour was directly observed in Phase Three, more aversive child behaviour was associated with lower self-efficacy, less positive outcome expectations, and poorer self-reported performance of AD management tasks by parents. Importantly, there were strong positive relationships between these variables (self-efficacy, outcome expectations, and self-reported task performance) and parents’ observed competence when providing treatment to their child. Less competent performance was also associated with greater parent-reported child behaviour difficulties, parent depression and stress, parenting conflict, and relationship dissatisfaction. Overall, this study revealed the importance of child behaviour to parents’ confidence and practices in the contexts of child AD and child behaviour management. Parents of children with concurrent AD and behavioural problems are at particular risk of having low self-efficacy for managing their child’s AD and difficult behaviour. Children with more severe AD are also at higher risk of behaviour problems, and thus represent a high-risk group of children whose parents may struggle to manage the disease successfully. As one of the first studies to examine the role and correlates of parents’ self-efficacy in child AD management, this study identified a number of potentially modifiable factors that can be targeted to enhance parents’ self-efficacy, and improve parent management of child AD. In particular, interventions should focus on child behaviour and parenting issues to support parents caring for children with AD and improve child health outcomes. In future, findings from this research will assist healthcare teams to identify parents most in need of support and intervention, and inform the development and testing of targeted multidisciplinary strategies to support parents caring for children with AD.

Organization and management of police

To understand the nature of police organisations and their management in an Australian context it is necessary to appreciate the recent history of policing at least in the last 30 years. In doing so an overall perspective is gained on the various reform efforts and organisational changes that have taken place in Australian policing. With this police reform perspective clearly in mind it then becomes possible to appreciate that the organization and management of the institution of policing in Australia is nested within the larger framework of ‘governance’. Hence, this notion of governance will be used as the key focal point around which to understand how police organizations manage their mission in the Australian context. Finally, the chapter discusses the inevitable ‘tension spaces’ that arise in policing and the need for police organizations to better manage such complexities.

Employer's management of part-time student labour

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Effect of soil parameter uncertainty on seismic response of buried segmented pipeline

Pipelines are important lifeline facilities spread over a large area and they generally encounter a range of seismic hazards and different soil conditions. The seismic response of a buried segmented pipe depends on various parameters such as the type of buried pipe material and joints, end restraint conditions, soil characteristics, burial depths, and earthquake ground motion, etc. This study highlights the effect of the variation of geotechnical properties of the surrounding soil on seismic response of a buried pipeline. The variations of the properties of the surrounding soil along the pipe are described by sampling them from predefined probability distribution. The soil-pipe interaction model is developed in OpenSEES. Nonlinear earthquake time-history analysis is performed to study the effect of soil parameters variability on the response of pipeline. Based on the results, it is found that uncertainty in soil parameters may result in significant response variability of the pipeline.

Importance of soil ecology in vegetation rehabilitation on a North Stradbroke Island sand mine

Sibelco Australia Limited (SAL), a mineral sand mining operation on North Stradbroke Island, undertakes progressive rehabilitation of mined areas. Initial investigations have found that some areas at SAL’s Yarraman Mine have failed to redevelop towards approved criteria. This study, undertaken in 2010, examined ground cover rehabilitation of different aged plots at the Yarraman Mine to determine if there was a relationship between key soil and vegetation attributes. Vegetation and soil data were collected from five plots rehabilitated in 2003, 2006, 2008, 2009 and 2010, and one unmined plot. Cluster (PATN) analysis revealed that vegetation species composition, species richness and ground cover differed between plots. Principal component analysis (PCA) extracted ten soil attributes that were then correlated with vegetation data. The attributes extracted by PCA, in order of most common variance, were: water content, pH, terrolas depth, elevation, slope angle, leaf litter depth, total organic carbon, and counts of macrofauna, fungi and bacteria. All extracted attributes differed between plots, and all except bacteria correlated with at least one vegetation attribute. Water content and pH correlated most strongly with vegetation cover suggesting an increase in soil moisture and a reduction in pH are required in order to improve vegetation rehabilitation at Yarraman Mine. Further study is recommended to confirm these results using controlled experiments and to test potential solutions, such as organic amendments.

Challenges in the context-aware management of business processes : a multiple case study

Current conceptualizations of organizational processes consider them as internally optimized yet static systems. Still, turbulences in the contextual environment of a firm often lead to adaptation requirements that these processes are unable to fulfil. Based on a multiple case study of the core processes of two large organizations, we offer an extended conceptualisation of business processes as complex adaptive systems. This conceptualization can enable firms to optimise business processes by analysing operations in different contexts and by examining the complex interaction between external, contextual elements and internal agent schemata. From this analysis, we discuss how information technology can play a vital goal in achieving this goal by providing discovery, analysis, and automation support. We detail implications for research and practice.

Proactive management of collision risks in port waters using navigational traffic conflicts

Navigational collisions are one of the major safety concerns in many seaports. To address this safety concern, a comprehensive and structured method of collision risk management is necessary. Traditionally management of port water collision risks has been relied on historical collision data. However, this collision-data-based approach is hampered by several shortcomings, such as randomness and rarity of collision occurrence leading to obtaining insufficient number of samples for a sound statistical analysis, insufficiency in explaining collision causation, and reactive approach to safety. A promising alternative approach that overcomes these shortcomings is the navigational traffic conflict technique that uses traffic conflicts as an alternative to the collision data. This paper proposes a collision risk management method by utilizing the principles of this technique. This risk management method allows safety analysts to diagnose safety deficiencies in a proactive manner, which, consequently, has great potential for managing collision risks in a fast, reliable and efficient manner.