Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : A modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist presents means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances in which nurse-administered procedural sedation and analgesia is used in the cardiac catheterisation laboratory. Methods A sequential mixed methods design was utilised. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised in accordance with responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterisation laboratory nurses. All but one of the draft recommendations met the pre-determined cut-off point for inclusion. There were a total of 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer twenty four recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Post-procedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterisation laboratory setting.

Validating a novel, low cost, automated malnutrition screening system as a predictor of nutritional risk in the Oncology Day Care Unit

Background Cancer-related malnutrition is associated with increased morbidity, poorer tolerance of treatment, decreased quality of life, increased hospital admissions, and increased health care costs (Isenring et al., 2013). This study’s aim was to determine whether a novel, automated screening system was a useful tool for nutrition screening when compared against a full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. Methods A single site, observational, cross-sectional study was conducted in an outpatient oncology day care unit within a Queensland tertiary facility, with three hundred outpatients (51.7% male, mean age 58.6 ± 13.3 years). Eligibility criteria: ≥18 years, receiving anticancer treatment, able to provide written consent. Patients completed the Malnutrition Screening Tool (MST). Nutritional status was assessed using the PG-SGA. Data for the automated screening system was extracted from the pharmacy software program Charm. This included body mass index (BMI) and weight records dating back up to six months. Results The prevalence of malnutrition was 17%. Any weight loss over three to six weeks prior to the most recent weight record as identified by the automated screening system relative to malnutrition resulted in 56.52% sensitivity, 35.43% specificity, 13.68% positive predictive value, 81.82% negative predictive value. MST score 2 or greater was a stronger predictor of nutritional risk relative to PG-SGA classified malnutrition (70.59% sensitivity, 69.48% specificity, 32.14% positive predictive value, 92.02% negative predictive value). Conclusions Both the automated screening system and the MST fell short of the accepted professional standard for sensitivity (80%) or specificity (60%) when compared to the PG-SGA. However, although the MST remains a better predictor of malnutrition in this setting, uptake of this tool in the Oncology Day Care Unit remains challenging.

Hospitalisation of Indigenous children in the Northern Territory for lower respiratory illness in the first year of life

Objective To describe the epidemiology of acute lower respiratory infection (ALRI) and bronchiectasis in Northern Territory Indigenous infants hospitalised in the first year of life. Design A historical cohort study constructed from the NT Hospital Discharge Dataset and the NT Imm(u)nisation Register. Participants and setting All NT resident Indigenous infants, born 1 January 1999 to 31 December 2004, admitted to NT public hospitals and followed up to 12 months of age. Main outcome measures Incidence of ALRI and bronchiectasis (ICD-10-AM codes) and radiologically confirmed pneumonia (World Health Organization protocol). Results Data on 9295 infants, 8498 child-years of observation and 15 948 hospitalised episodes of care were analysed. ALRI incidence was 426.7 episodes per 1000 child-years (95% Cl, 416.2-437.2). Incidence rates were two times higher (relative risk, 2.12; 95% Cl, 1.98-2.27) for infants in Central Australia compared with those in the Top End. The median age at first admission for an ALRI was 4.6 months (interquartile range, 2.6-7.3). Bronchiolitis accounted for most of the disease burden, with a rate of 227 per 1000 child-years. The incidence of first diagnosis of bronchiectasis was 1.18 per 1000 child-years (95% Cl, 0.60-2.16). One or more key comorbidities were present in 1445 of the 3227 (44.8%) episodes of care for ALRI. Conclusions Rates of ALRI and bronchiectasis in NT Indigenous infants are excessive, with early onset, frequent repeat episodes, and a high prevalence of comorbidities. These high rates of disease demand urgent attention.

The role of chemotherapy in the treatment of adult soft tissue sarcomas

Adult soft tissue sarcomas are relatively rare tumours which are curable with radical surgery. Approximately 50% of patients will develop inoperable disease or metastases for which chemotherapy may be inappropriate. Only two cytotoxic agents - doxorubicin and ifosfamide - have activity in > 20% of patients. For both these agents there is evidence of a dose-response relationship. There is currently no good evidence that combination chemotherapy confers a clinical benefit compared with single agents. Outside a clinical trial, standard first-line therapy should be with single agent doxorubicin at a dose intensity ≥ 70 mg2 every 3 weeks. Approximately 25% of patients may be expected to respond to this regimen. There is the suggestion that responses may occur to ifosfamide in patients who progress on doxorubicin. The role of chemotherapy in the adjuvant setting remains uncertain. Several trials have suggested a modest relapse-free and overall survival benefit for the use of post-operative chemotherapy and a recent overview of 14 randomised trials confirms a small though significant benefit. These benefits have to be weighed against the toxicity of chemotherapy. The importance of treating all patients with soft tissue sarcomas in clinical trials is stressed. There is an urgent need to define new active agents to treat this disease.

Cisplatin and gemcitabine in the management of metastatic penile cancer

Penile cancer is rare and receives little public attention. There are few treatment options for advanced disease. The most active regimen to date is a combination of bleomycin, methotrexate, and cisplatin. However the treatment-related mortality is 11% and hence this combination has not been adapted as a standard of care. We report two cases of advanced penile cancer where a sustained palliative response was observed with combination chemotherapy using cisplatin and gemcitabine. Our experience demonstrates that this is a well tolerated regimen active in this setting. © 2009 Elsevier Inc. All rights reserved.

Pitfalls in the use of kappa when interpreting agreement between multiple raters in reliability studies

OBJECTIVE To compare different reliability coefficients (exact agreement, and variations of the kappa (generalised, Cohen's and Prevalence Adjusted and Biased Adjusted (PABAK))) for four physiotherapists conducting visual assessments of scapulae. DESIGN Inter-therapist reliability study. SETTING Research laboratory. PARTICIPANTS 30 individuals with no history of neck or shoulder pain were recruited with no obvious significant postural abnormalities. MAIN OUTCOME MEASURES Ratings of scapular posture were recorded in multiple biomechanical planes under four test conditions (at rest, and while under three isometric conditions) by four physiotherapists. RESULTS The magnitude of discrepancy between the two therapist pairs was 0.04 to 0.76 for Cohen's kappa, and 0.00 to 0.86 for PABAK. In comparison, the generalised kappa provided a score between the two paired kappa coefficients. The difference between mean generalised kappa coefficients and mean Cohen's kappa (0.02) and between mean generalised kappa and PABAK (0.02) were negligible, but the magnitude of difference between the generalised kappa and paired kappa within each plane and condition was substantial; 0.02 to 0.57 for Cohen's kappa and 0.02 to 0.63 for PABAK, respectively. CONCLUSIONS Calculating coefficients for therapist pairs alone may result in inconsistent findings. In contrast, the generalised kappa provided a coefficient close to the mean of the paired kappa coefficients. These findings support an assertion that generalised kappa may lead to a better representation of reliability between three or more raters and that reliability studies only calculating agreement between two raters should be interpreted with caution. However, generalised kappa may mask more extreme cases of agreement (or disagreement) that paired comparisons may reveal.

Asking for it? Practices and structures that perpetuate employee silence in pursuing customised work arrangements

A component of broader scholarship addressing the social context in which individuals work, has focused on the role of ‘employee voice’ in determining flexible-work outcomes (Donnelly et al., 2012). Employee voice incorporates a spectrum of practices designed to give employees a say in organisational decisions (Dundon et al., 2004). This paper extends work on voice and workplace flexibility in two ways. First, it focuses not simply on ‘voice’ but on its antithesis, employee silence, which is defined (following Van Dyne et al., 2003) as the intentional withholding of ideas and opinions. We utilise an alternative reading of silence to the majority of literature which interprets it as a product of employee motivation, by focusing on the role of management and by adopting a framework which considers silence as a control dialectic (Donaghey et al., 2011). Second, the study examines silence with respect to preferences for customising the terms/conditions of employment beyond narrowly defined notions of ‘flexible work’ (e.g., reduced hours; home-working). The study utilises 30 telephone interviews with employees who had been previously identified as ‘discontent non-requesters’ (Skinner and Pocock, 2011: 75), that is they had expressed a desire to request flexible working provisions, but had not done so. Interviewees were asked to articulate the reasons for, and consequences of, their silence. The findings reveal nuanced workplace practices and structures that close down possibilities for employee voice and perpetuate silence on matters relating to customising work. They also illustrate a disjuncture between espoused organizational goals and everyday practices and norms encountered in workplaces.

Capability presence in the newly internationalizing firm

We investigate the enablers of early internationalization of the firm. We posit that for firms to internationalize early in their lifecycles, sets of capabilities must be present at the firm’s formative stage and that these capabilities build upon routines that the founders bring into the new firm. These capabilities are aligned to establish a platform for internationalization unencumbered by the administrative heritage often observed in well-established firms. We model this phenomenon, testing it in a cross-national setting of early internationalizing firms in Australia and the United States. To do so, we draw upon a dynamic capabilities framing, conceptualizing and measuring the dynamic capabilities that founders apply in their early internationalization activities.

An exploratory study of staff nurses' knowledge of delirium in the medical ICU: An Asian perspective

Aim The aim of this study was to establish intensive care unit nurses’ knowledge of delirium within an acute tertiary hospital within South East Asia. Background Delirium is a common, life threatening and often preventable cause of morbidity and mortality among older patients. Undetected and untreated delirium is a catalyst to increased mortality, morbidity, functional decline and results in increased requirement for nursing care, healthcare expense and hospital length of stay. However, despite effective assessment tools to identify delirium in the acute setting, there still remains an inability of ICU nurses’ to accurately identify delirium in the critically ill patient especially that of hypoactive delirium. Method A purposive sample of 53 staff nurses from a 13-bedded medical intensive care unit within an acute tertiary teaching hospital in South East Asia were asked to participate. A 40 item 5-point Likert scale questionnaire was employed to determine the participants’ knowledge of the signs and symptoms; the risk factors and negative outcomes of delirium. Results The overall positively answered mean score was 27 (67.3%) out of a possible 40 questions. Mean scores for knowledge of signs and symptoms, risk factors and negative outcomes were 9.52 (63.5%, n = 15), 11.43 (63.5%, n = 17) and 6.0 (75%, n = 8), respectively. Conclusion Whilst the results of this study are similar to others taken from a western perspective, it appeared that the ICU nurses in this study demonstrated limited knowledge of the signs and symptoms, risk factors and negative outcomes of delirium in the critically patient. The implications for practice of this are important given the outcomes of untreated delirium.

Pulmonary embolism in the emergency department : a Singaporean nursing case review

Introduction The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. Method We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats—a single case report or a series of case reports; in this case we opted to report on a single case. Discussion The gentleman in question was an ambulance admissionto the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. Conclusion We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

Lattice-based completely non-malleable public-key encryption in the standard model

An encryption scheme is non-malleable if giving an encryption of a message to an adversary does not increase its chances of producing an encryption of a related message (under a given public key). Fischlin introduced a stronger notion, known as complete non-malleability, which requires attackers to have negligible advantage, even if they are allowed to transform the public key under which the related message is encrypted. Ventre and Visconti later proposed a comparison-based definition of this security notion, which is more in line with the well-studied definitions proposed by Bellare et al. The authors also provide additional feasibility results by proposing two constructions of completely non-malleable schemes, one in the common reference string model using non-interactive zero-knowledge proofs, and another using interactive encryption schemes. Therefore, the only previously known completely non-malleable (and non-interactive) scheme in the standard model, is quite inefficient as it relies on generic NIZK approach. They left the existence of efficient schemes in the common reference string model as an open problem. Recently, two efficient public-key encryption schemes have been proposed by Libert and Yung, and Barbosa and Farshim, both of them are based on pairing identity-based encryption. At ACISP 2011, Sepahi et al. proposed a method to achieve completely non-malleable encryption in the public-key setting using lattices but there is no security proof for the proposed scheme. In this paper we review the mentioned scheme and provide its security proof in the standard model. Our study shows that Sepahi’s scheme will remain secure even for post-quantum world since there are currently no known quantum algorithms for solving lattice problems that perform significantly better than the best known classical (i.e., non-quantum) algorithms.

The once-and-for-all withdrawal of the Liverpool Care Pathway in the UK : what are the implications for Australia?

This Perspective reflects on the withdrawal of the Liverpool Care Pathway in the UK, and its implications for Australia. Integrated care pathways are documents which outline the essential steps of multidisciplinary care in addressing a specific clinical problem. They can be used to introduce best clinical practice, to ensure that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. By providing clear instructions, decision support and a framework for clinician-patient interactions, care pathways guide the systematic provision of best evidence-based care. The Liverpool Care Pathway (LCP) is an example of an integrated care pathway, designed in the 1990s to guide care for people with cancer who are in their last days of life and are expected to die in hospital. This pathway evolved out of a recognised local need to better support non-specialist palliative care providers’ care for patients dying of cancer within their inpatient units. Historically, despite the large number of people in acute care settings whose treatment intent is palliative, dying patients receiving general hospital acute care tended to lack sufficient attention from senior medical staff and nursing staff. The quality of end-of-life care was considered inadequate, therefore much could be learned from the way patients were cared for by palliative care services. The LCP was a strategy developed to improve end-of-life care in cancer patients and was based on the care received by those dying in the palliative care setting.

Architecture in the South Pacific : the Ocean of Islands

Architecture in the South Pacific: The Ocean of Islands recounts the recent developments of the South Pacific and its fascinating architecture. This volume traces the European architectural overlay onto this scattered group of islands as well as the transition of these same islands towards a regional identity that has been fashioned by the remoteness of each location, the incomparable setting, and the distinctive ethnic mix of its inhabitants. A series of themed essays present the story of architectural development in the Solomon Islands, Vanuatu, New Caledonia, Fiji, Wallis and Futuna, Tonga, the Cook Islands, Samoa and American Samoa, and French Polynesia. Recent architecture typifies the evolution of the islands as they have been subjected to the transformative waves of alien trade, religion, colonization, war and tourism, followed by post-colonialism and revived nationalism. As with the Pacific region itself, the most prominent characteristic of the architecture is its diversity. The blending of the universal and the local sets the stage for a fresh vision of the South Pacific across a wide range of building types, from spectacular mission churches to sensational resorts in paradise. This book, in full colour, will appeal to architects, armchair-tourists, students and all those for whom the South Pacific is the idyll of their dreams.

The role of autogenic halide gas in the production of metal borides

Synthesis of metal borides is typically undertaken at high temperature using direct combinations of elemental starting materials[1]. Techniques include carbothermal reduction using elemental carbon, metals, metal oxides and B2O3[2] or reaction between metal chlorides and boron sources[3]. These reactions generally require temperatures greater than 1200oC and are not readily suitable for an industrial setting nor scalable to bulk production.

An analysis of the timeliness and nature of profit warnings in the aftermath of the Global Financial Crisis

The global financial crisis (GFC) has severely impacted the financial position and performance of many companies internationally. Because of its severity and associated increase in uncertainty it challenges the effectiveness of existing disclosure regulation. Australia provides a unique environment in which to test the effects of the GFC on corporate disclosure because statutory rules mandate the timely disclosure of ‘price-sensitive’ information (ASX Rule 3.1) by listed entities. Exploiting this institutional setting we investigate the determinants and timeliness of profit warnings issued by the top 500 ASX-listed firms with profit declines in the 2009 fiscal year. Our findings show that firms behave differently with regard to the issuance of profit warnings: larger and more indebted firms are more likely to issue a profit warning and tend to be timelier; surprisingly, poorer performing firms tend to release the news more quickly and this might be attributed to an increasing threat of litigation. Our analysis of profit warning determinants shows interesting results with the presence of asset impairments hindering the early disclosure of profit warnings. Our findings are novel for two main reasons: first, we provide insights into the impact of global financial crisis on profit warning behaviour; second, we are the first to examine the differential impact of alternative features of profit warnings on disclosure timeliness. The findings have implications for regulators in determining compliance with continuous disclosure rules and more broadly, for market participants in interpreting profit warnings.