Creating a therapeutic environment : a non-randomised controlled trial of a quiet time intervention for patients in acute care

Background: Noise is a significant barrier to sleep for acute care hospital patients, and sleep has been shown to be therapeutic for health, healing and recovery. Scheduled quiet time interventions to promote inpatient rest and sleep have been successfully trialled in critical care but not in acute care settings. Objectives: The study aim was to evaluate as cheduled quiet time intervention in an acute care setting. The study measured the effect of a scheduled quiet time on noise levels, inpatients’ rest and sleep behaviour, and wellbeing. The study also examined the impact of the intervention on patients’, visitors’ and health professionals’ satisfaction, and organisational functioning. Design: The study was a multi-centred non-randomised parallel group trial. Settings: The research was conducted in the acute orthopaedic wards of two major urban public hospitals in Brisbane, Australia. Participants: All patientsadmitted to the two wards in the5-month period of the study were invited to participate, withafinalsample of 299 participants recruited. This sample produced an effect size of 0.89 for an increase in the number of patients asleep during the quiet time. Methods: Demographic data were collected to enable comparison between groups. Data for noise level, sleep status, sleepiness and well being were collected using previously validated instruments: a Castle Model 824 digital sound level indicator; a three point sleep status scale; the Epworth Sleepiness Scale; and the SF12 V2 questionnaire. The staff, patient and visitor surveys on the experimental ward were adapted from published instruments. Results: Significant differences were found between the two groups in mean decibel level and numbers of patients awake and asleep. The difference in mean measured noise levels between the two environments corresponded to a ‘perceived’ difference of 2 to 1. There were significant correlations between average decibel level and number of patients awake and asleep in the experimental group, and between average decibel level and number of patients awake in the control group. Overall, patients, visitors and health professionals were satisfied with the quiet time intervention. Conclusions: The findings show that a quiet time intervention on an acute care hospital ward can affect noise level and patient sleep/wake patterns during the intervention period. The overall strongly positive response from surveys suggests that scheduled quiet time would be a positively perceived intervention with therapeutic benefit.

Clinical whole-body skin examination reduces the incidence of thick melanomas

Survival from melanoma is strongly related to tumour thickness, thus earlier diagnosis has the potential to reduce mortality from this disease. However, in the absence of conclusive evidence that clinical skin examination reduces mortality, evidence-based assessments do not recommend population screening. We aimed to assess whether clinical whole-body skin examination is associated with a reduced incidence of thick melanoma and also whether screening is associated with an increased incidence of thin lesions (possible overdiagnosis). A population-based case-control study of all Queensland residents aged 20-75 years with a histologically confirmed first primary invasive cutaneous melanoma diagnosed between January 2000 and December 2003. Telephone interviews were completed by 3,762 eligible cases (78.0%) and 3,824 eligible controls (50.4%) Whole-body clinical skin examination in the three years before diagnosis was associated with a 14% lower risk of being diagnosed with a thick melanoma (>0.75mm) (OR= 0.86, 95% CI=0.75, 0.98). Risk decreased for melanomas of increasing thickness: the risk of being diagnosed with a melanoma 0.76-1.49mm was reduced by 7% (OR=0.93, 95% CI 0.79, 1.10), by 17% for melanomas 1.50-2.99mm (OR=0.83, 95% CI=0.65, 1.05) and by 40% for melanomas ≥3mm (OR=0.60, 95% CI=0.43, 0.83). Screening was associated with a 38% higher risk of being diagnosed with a thin invasive melanoma (≤0.75mm) (OR=1.38, 95% CI=1.22, 1.56). This is the strongest evidence to date that whole-body clinical skin examination reduces the incidence of thick melanoma. Because survival from melanoma is strongly related to tumour thickness, these results suggest that screening would reduce melanoma mortality.

Combined marrow stromal cell-sheet techniques and high-strength biodegradable composite scaffolds for engineered functional bone grafts

In this study, cell sheets comprising multilayered porcine bone marrow stromal cells (BMSC) were assembled with fully interconnected scaffolds made from medical-grade polycaprolactone–calcium phosphate (mPCL–CaP), for the engineering of structural and functional bone grafts. The BMSC sheets were harvested from culture flasks and wrapped around pre-seeded composite scaffolds. The layered cell sheets integrated well with the scaffold/cell construct and remained viable, with mineralized nodules visible both inside and outside the scaffold for up to 8 weeks culture. Cells within the constructs underwent classical in vitro osteogenic differentiation with the associated elevation of alkaline phosphatase activity and bone-related protein expression. In vivo, two sets of cell-sheet-scaffold/cell constructs were transplanted under the skin of nude rats. The first set of constructs (554mm3) were assembled with BMSC sheets and cultured for 8 weeks before implantation. The second set of constructs (10104mm3) was implanted immediately after assembly with BMSC sheets, with no further in vitro culture. For both groups, neo cortical and well-vascularised cancellous bone were formed within the constructs with up to 40% bone volume. Histological and immunohistochemical examination revealed that neo bone tissue formed from the pool of seeded BMSC and the bone formation followed predominantly an endochondral pathway, with woven bone matrix subsequently maturing into fully mineralized compact bone; exhibiting the histological markers of native bone. These findings demonstrate that large bone tissues similar to native bone can be regenerated utilizing BMSC sheet techniques in conjunction with composite scaffolds whose structures are optimized from a mechanical, nutrient transport and vascularization perspective.

Laser doppler imaging in a paediatric burns population

Objective Laser Doppler imaging (LDI) was compared to wound outcomes in children's burns, to determine if the technology could be used to predict these outcomes. Methods Forty-eight patients with a total of 85 burns were included in the study. Patient median age was 4 years 10 months and scans were taken 0–186 h post-burn using the fast, low-resolution setting on the Moor LDI2 laser Doppler imager. Wounds were managed by standard practice, without taking into account the scan results. Time until complete re-epithelialisation and whether or not grafting and scar management were required were recorded for each wound. If wounds were treated with Silvazine™ or Acticoat™ prior to the scan, this was also recorded. Results The predominant colour of the scan was found to be significantly related to the re-epithelialisation, grafting and scar management outcomes and could be used to predict those outcomes. The prior use of Acticoat™ did not affect the scan relationship to outcomes, however, the use of Silvazine™ did complicate the relationship for light blue and green scanned partial thickness wounds. Scans taken within the 24-h window after-burn also appeared to be accurate predictors of wound outcome. Conclusion Laser Doppler imaging is accurate and effective in a paediatric population with a low-resolution fast-scan.

From go to woe : how a not-for-profit managed the change to accrual accounting

Purpose – The aim of this paper is to examine the process of change in an Australian not-for-profit organization, from a cash-based to an accrual-based accounting system. Its particular focus is the relationship between the image portrayed by accrual accounting adoption and the technical realities of the new system. Design/methodology/approach – Data were gathered from interviews, documents and meetings, and were contextualized and interpreted using institutional theory. Findings – The decision to change to accrual accounting was made at the top of the organizational hierarchy in response to institutional pressure to present a corporate image. The implementation of the new system was poorly conceived, inadequately resourced, and hampered by an authoritarian structure that effectively ignored the technical incompetence and training needs of many accounting staff. This resulted in an accounting system half way between cash and accrual, and very different from the system as it had been promoted. The process caused conflict at all levels of the organizational hierarchy. Research limitations/implications – Accounting in not-for-profit organizations is an under-researched area offering potential for fruitful research in a changing institutional landscape. This institutional approach, while offering just one interpretation of the qualitative data gathered in this project, provides valuable insights about the process of change. Practical implications – Not-for-profit organizations play a vital economic and social role, and need carefully to assess their responses to ongoing institutional pressures. In implementing change, they face the challenge of balancing the promotion of an institutionally acceptable image and the need for technical efficiencies. Originality/value – The examination of change in an organization provides a rich context for the exploration of the dynamic, problematic process by which a new accounting practice is embedded and institutionalized. Keywords Institutional theory, Not-for-profit organizations, Accrual accounting, Change process, Qualitative research, Change management, Decision making, Training needs, Australia Paper type Research paper

Transition to intensive care nursing: A state-wide, workplace centred program-12 years on

In November 1999, the Queensland Health (QH) Transition to Practice Nurse Education Program - Intensive Care (TPNEP-IC) was initiated in QH Intensive Care Units (ICUs) across Queensland. This 12-month, state-wide, workplace based education program has set minimum standards for intensive care nursing education and therefore minimum standards for intensive care nursing practice in QH. In the 12 years of operation, 824 nurses have completed TPNEP-IC, 761 achieving academic credit status and 453 utilising this academic credit status to undertake postgraduate study in critical/intensive care nursing at three Queensland universities. These outcomes were achieved through the appointment of nurse educators within ICUs who, through a united and strong commitment to this state-wide approach formed collaborative professional networks, which resulted in the development, implementation and maintenance of the program. Furthermore, these networks enabled a framework of support for discussion and dissemination of evidence based practice, to endorse quality processes for TPNEP-IC and to nurture leadership potential among educators. Challenges to overcome included obtaining adequate resources to support all aspects of the program, gaining local management and administrative support, and embedding TPNEP-IC within ICU culture. The 12 years of operation of the program have demonstrated its long term sustainability. The program is being launched through a new blended learning approach utilising e-learning strategies. To capitalise on the current success, a strong commitment by all stakeholders will be required to ensure the ongoing sustainability of the program.

Shear tests of lipped channel beams with stiffened web openings

Cold-formed steel lipped channel beams (LCB) are used extensively in residential, industrial and commercial buildings as load bearing structural elements. Their shear strengths are considerably reduced when web openings are included for the purpose of locating building services. Past research has shown that the shear capacities of LCBs were reduced by up to 70% due to the inclusion of these web openings. Hence there is a need to improve the shear capacities of LCBs with web openings. A cost effective way of eliminating the detrimental effects of large web openings is to attach suitable stiffeners around the web openings and restore the original shear strength and stiffness of the LCBs. Hence detailed experimental studies were undertaken to investigate the shear behaviour and strength of LCBs with stiffened web openings. Both plate and stud stiffeners with varying sizes and thicknesses were attached to the web elements of LCBs using different screw-fastening arrangements. Simply supported test specimens of LCBs with aspect ratios of 1.0 and 1.5 were loaded at mid-span until failure. Test results showed that the plate stiffeners established using AISI recommendations are inadequate to restore the shear strengths of LCBs with web openings. Hence new stiffener arrangements have been proposed for LCBs based on experimental results. This paper presents the details of this experimental study on the shear strength of lipped channel beams with stiffened web openings, and the results.

Does preoperative oral carbohydrate reduce hospital stay?

Background Carbohydrate-rich fluids are used to improve postoperative recovery but the effectiveness of the product for reducing length of hospital stay is uncertain. Objective To assess the effectiveness of preoperative loading with carbohydrates on postoperative outcomes. Participants Forty six patients booked for elective colorectal surgery. Methods Participants were allocated to a Carbohydrate-rich fluid group or Usual Care group during their pre-admission clinic visit. The primary outcome was ‘Time to readiness for discharge’. Results Patients in the control group spent on average 4.3 days (95% confidence interval 3.2 to 5.7) and the Carbohydrate-rich fluid group spent 4.1 days (95% confidence interval 3.2 to 5.4) until the primary outcome was met (p=0.824). Conclusion The safety of preoperative high carbohydrate fluids is supported but we were unable to confirm or refute the benefit of CHO for shorter hospital stay following elective colorectal surgery.

Pharmacokinetics-based elucidation on disparity in clinical effectiveness between varieties of Zhi Zhu Wan, a traditional Chinese medical formula

AIM: Zhi Zhu Wan (ZZW) is a classical Chinese medical formulation used for the treatment of functional dyspepsia that attributed to Spleen-deficiency Syndrome. ZZW contains Atractylodes Rhizome and Fructus Citrus Immaturus, the later originates from both Citrus aurantium L. (BZZW) and Citrus sinensis Osbeck (RZZW). The present study is designed to elucidate disparities in the clinical efficacy of two ZZW varieties based on the pharmacokinetics of naringenin and hesperetin. MEHTOD: After oral administration of ZZWs, blood sample was collected from healthy volunteers at designed time points. Naringenin and hesperetin were detected in plasma by RP-HPLC, pharmacokinetic parameters were processed using mode-independent methods with WINNONLIN. RESULTS: After oral administration of BZZW, both naringenin and hesperetin were detected in plasma, and demonstrated similar pharmacokinetic parameters. Ka was 0.384+/-0.165 and 0.401+/-0.159, T(1/2(ke))(h) was 5.491+/-3.926 and 5.824+/-3.067, the AUC (mg/Lh) was 34.886+/-22.199 and 39.407+/-19.535 for naringenin and hesperetin, respectively. However, in the case of RZZW, only hesperetin was found in plasma, but the pharmacokinetic properties for hesperetin in RZZW was different from that in BZZW. T(max) for hesperetin in RZZW is about 8.515h, and its C(max) is much larger than that of BZZW. Moreover, it was eliminated slowly as it possessed a much larger AUC value. CONCLUSION: The distinct therapeutic orientations of the Chinese medical formula ZZWs with different Fructus Citrus Immaturus could be elucidated based on the pharmacokinetic parameters of constituents after oral administration.

Genome-wide association study identifies new multiple sclerosis susceptibility loci on chromosomes 12 and 20

To identify multiple sclerosis (MS) susceptibility loci, we conducted a genome-wide association study (GWAS) in 1,618 cases and used shared data for 3,413 controls. We performed replication in an independent set of 2,256 cases and 2,310 controls, for a total of 3,874 cases and 5,723 controls. We identified risk-associated SNPs on chromosome 12q13-14 (rs703842, P = 5.4 x 10(-11); rs10876994, P = 2.7 x 10(-10); rs12368653, P = 1.0 x 10(-7)) and upstream of CD40 on chromosome 20q13 (rs6074022, P = 1.3 x 10(-7); rs1569723, P = 2.9 x 10(-7)). Both loci are also associated with other autoimmune diseases. We also replicated several known MS associations (HLA-DR15, P = 7.0 x 10(-184); CD58, P = 9.6 x 10(-8); EVI5-RPL5, P = 2.5 x 10(-6); IL2RA, P = 7.4 x 10(-6); CLEC16A, P = 1.1 x 10(-4); IL7R, P = 1.3 x 10(-3); TYK2, P = 3.5 x 10(-3)) and observed a statistical interaction between SNPs in EVI5-RPL5 and HLA-DR15 (P = 0.001).

Pre-crash traffic flow trend analysis on motorways

Crashes on motorway contribute to a significant proportion (40-50%) of non-recurrent motorway congestions. Hence reduce crashes will help address congestion issues (Meyer, 2008). Crash likelihood estimation studies commonly focus on traffic conditions in a Short time window around the time of crash while longer-term pre-crash traffic flow trends are neglected. In this paper we will show, through data mining techniques, that a relationship between pre-crash traffic flow patterns and crash occurrence on motorways exists, and that this knowledge has the potential to improve the accuracy of existing models and opens the path for new development approaches. The data for the analysis was extracted from records collected between 2007 and 2009 on the Shibuya and Shinjuku lines of the Tokyo Metropolitan Expressway in Japan. The dataset includes a total of 824 rear-end and sideswipe crashes that have been matched with traffic flow data of one hour prior to the crash using an incident detection algorithm. Traffic flow trends (traffic speed/occupancy time series) revealed that crashes could be clustered with regards of the dominant traffic flow pattern prior to the crash. Using the k-means clustering method allowed the crashes to be clustered based on their flow trends rather than their distance. Four major trends have been found in the clustering results. Based on these findings, crash likelihood estimation algorithms can be fine-tuned based on the monitored traffic flow conditions with a sliding window of 60 minutes to increase accuracy of the results and minimize false alarms.

Pre-crash and non-crash traffic flow trends analysis on motorways

Crashes that occur on motorways contribute to a significant proportion (40-50%) of non-recurrent motorway congestions. Hence, reducing the frequency of crashes assists in addressing congestion issues (Meyer, 2008). Crash likelihood estimation studies commonly focus on traffic conditions in a short time window around the time of a crash while longer-term pre-crash traffic flow trends are neglected. In this paper we will show, through data mining techniques that a relationship between pre-crash traffic flow patterns and crash occurrence on motorways exists. We will compare them with normal traffic trends and show this knowledge has the potential to improve the accuracy of existing models and opens the path for new development approaches. The data for the analysis was extracted from records collected between 2007 and 2009 on the Shibuya and Shinjuku lines of the Tokyo Metropolitan Expressway in Japan. The dataset includes a total of 824 rear-end and sideswipe crashes that have been matched with crashes corresponding to traffic flow data using an incident detection algorithm. Traffic trends (traffic speed time series) revealed that crashes can be clustered with regards to the dominant traffic patterns prior to the crash. Using the K-Means clustering method with Euclidean distance function allowed the crashes to be clustered. Then, normal situation data was extracted based on the time distribution of crashes and were clustered to compare with the “high risk” clusters. Five major trends have been found in the clustering results for both high risk and normal conditions. The study discovered traffic regimes had differences in the speed trends. Based on these findings, crash likelihood estimation models can be fine-tuned based on the monitored traffic conditions with a sliding window of 30 minutes to increase accuracy of the results and minimize false alarms.

Does project culture matter? A comparative study of two major hospital projects

Purpose - Cultural issues in the construction industry have attracted growing attention from both practitioners and academia. However, there are few studies on culture issues at the project level. The influence of project culture has not traditionally been on the research radar. This research aims to investigate the impacts of project culture on the performance of construction projects. Design/methodology/approach - A case study approach, utilising questionnaire surveys, in-depth interviews and review of project documents, was employed to investigate project culture and its associated impacts in two major hospital projects. Findings - The results indicated that project culture played an important role in achieving harmonious relationships between project participants and better project outcomes in terms of schedule, functionality, satisfaction with the process, satisfaction with the relationships, environmental issues addressed commercial success, further business opportunities and overall performance. Case 1 outperformed Case 2 in these performance indicators. Similarly, it became clear that the project’s culture should be developed from the outset and sustained during the project period. Furthermore, it was also highlighted that the project culture should be translated to all levels of the supply chain i.e. sub-contractors and suppliers. Practical implications – The findings enabled the client to understand the role of project culture and actively commit towards the development and maintenance of the project culture from very early on. It also helps project teams to understand how to deal with cultural issues at the project level. Originality/value- This study is one of limited empirical studies that offer in-depth insights of how project culture affects the performance of construction projects. It is also the first study of hospital projects on the research topic.

Traffic safety risks trends and patterns analysis on motorways

Crashes that occur on motorways contribute to a significant proportion (40-50%) of non-recurrent motorway congestion. Hence, reducing the frequency of crashes assist in addressing congestion issues (Meyer, 2008). Analysing traffic conditions and discovering risky traffic trends and patterns are essential basics in crash likelihood estimations studies and still require more attention and investigation. In this paper we will show, through data mining techniques, that there is a relationship between pre-crash traffic flow patterns and crash occurrence on motorways, compare them with normal traffic trends, and that this knowledge has the potentiality to improve the accuracy of existing crash likelihood estimation models, and opens the path for new development approaches. The data for the analysis was extracted from records collected between 2007 and 2009 on the Shibuya and Shinjuku lines of the Tokyo Metropolitan Expressway in Japan. The dataset includes a total of 824 rear-end and sideswipe crashes that have been matched with crashes corresponding traffic flow data using an incident detection algorithm. Traffic trends (traffic speed time series) revealed that crashes can be clustered with regards to the dominant traffic patterns prior to the crash occurrence. K-Means clustering algorithm applied to determine dominant pre-crash traffic patterns. In the first phase of this research, traffic regimes identified by analysing crashes and normal traffic situations using half an hour speed in upstream locations of crashes. Then, the second phase investigated the different combination of speed risk indicators to distinguish crashes from normal traffic situations more precisely. Five major trends have been found in the first phase of this paper for both high risk and normal conditions. The study discovered traffic regimes had differences in the speed trends. Moreover, the second phase explains that spatiotemporal difference of speed is a better risk indicator among different combinations of speed related risk indicators. Based on these findings, crash likelihood estimation models can be fine-tuned to increase accuracy of estimations and minimize false alarms.

Water heating and dehumidification with heat pump utilizing solar, ambient and waste heat

The low temperature operation of a heat pump makes it an excellent match for the use of solar energy. At the National University of Singapore, a solar assisted heat pump system has been designed, fabricated and installed to provide water heating and drying. The system also utilizes the air con waste heat, which would normally be released to atmosphere adding to global warming. Experimental results show that the twophase unglazed solar evaporator-collector, instead of losing energy to the ambient, gained a significant amount due to low operating temperature of the collector. As a result, the collector efficiency attains a value greater than 1, when conventional collector equations are used. With this evaporator-collector, the system can be operated even in the absence of solar irradiation. The waste heat was collected from an air-con system, which maintained a room at 20-22 oC. In the condenser side, water at 60 oC was produced at a rate of 3 liter/minute and the drying capacity was 2.2kg/hour. Maximum COP of the system was found to be about 5.5.