Non-alcoholic fatty liver disease : can ultrasound assist in early diagnosis of prediabetes and delay progression to type2 diabetes mellitus

Non Alcoholic Fatty Liver Disease (NAFLD) is a condition that is frequently seen but seldom investigated. Until recently, NAFLD was considered benign, self-limiting and unworthy of further investigation. This opinion is based on retrospective studies with relatively small numbers and scant follow-up of histology data. (1) The prevalence for adults, in the USA is, 30%, and NAFLD is recognized as a common and increasing form of liver disease in the paediatric population (1). Australian data, from New South Wales, suggests the prevalence of NAFLD in “healthy” 15 year olds as being 10%.(2) Non-alcoholic fatty liver disease is a condition where fat progressively invades the liver parenchyma. The degree of infiltration ranges from simple steatosis (fat only) to steatohepatitis (fat and inflammation) steatohepatitis plus fibrosis (fat, inflammation and fibrosis) to cirrhosis (replacement of liver texture by scarred, fibrotic and non functioning tissue).Non-alcoholic fatty liver is diagnosed by exclusion rather than inclusion. None of the currently available diagnostic techniques -liver biopsy, liver function tests (LFT) or Imaging; ultrasound, Computerised tomography (CT) or Magnetic Resonance Imaging (MRI) are specific for non-alcoholic fatty liver. An association exists between NAFLD, Non Alcoholic Steatosis Hepatitis (NASH) and irreversible liver damage, cirrhosis and hepatoma. However, a more pervasive aspect of NAFLD is the association with Metabolic Syndrome. This Syndrome is categorised by increased insulin resistance (IR) and NAFLD is thought to be the hepatic representation. Those with NAFLD have an increased risk of death (3) and it is an independent predictor of atherosclerosis and cardiovascular disease (1). Liver biopsy is considered the gold standard for diagnosis, (4), and grading and staging, of non-alcoholic fatty liver disease. Fatty-liver is diagnosed when there is macrovesicular steatosis with displacement of the nucleus to the edge of the cell and at least 5% of the hepatocytes are seen to contain fat (4).Steatosis represents fat accumulation in liver tissue without inflammation. However, it is only called non-alcoholic fatty liver disease when alcohol - >20gms-30gms per day (5), has been excluded from the diet. Both non-alcoholic and alcoholic fatty liver are identical on histology. (4).LFT’s are indicative, not diagnostic. They indicate that a condition may be present but they are unable to diagnosis what the condition is. When a patient presents with raised fasting blood glucose, low HDL (high density lipoprotein), and elevated fasting triacylglycerols they are likely to have NAFLD. (6) Of the imaging techniques MRI is the least variable and the most reproducible. With CT scanning liver fat content can be semi quantitatively estimated. With increasing hepatic steatosis, liver attenuation values decrease by 1.6 Hounsfield units for every milligram of triglyceride deposited per gram of liver tissue (7). Ultrasound permits early detection of fatty liver, often in the preclinical stages before symptoms are present and serum alterations occur. Earlier, accurate reporting of this condition will allow appropriate intervention resulting in better patient health outcomes. References 1. Chalasami N. Does fat alone cause significant liver disease: It remains unclear whether simple steatosis is truly benign. American Gastroenterological Association Perspectives, February/March 2008 www.gastro.org/wmspage.cfm?parm1=5097 Viewed 20th October, 2008 2. Booth, M. George, J.Denney-Wilson, E: The population prevalence of adverse concentrations with adiposity of liver tests among Australian adolescents. Journal of Paediatrics and Child Health.2008 November 3. Catalano, D, Trovato, GM, Martines, GF, Randazzo, M, Tonzuso, A. Bright liver, body composition and insulin resistance changes with nutritional intervention: a follow-up study .Liver Int.2008; February 1280-9 4. Choudhury, J, Sanysl, A. Clinical aspects of Fatty Liver Disease. Semin in Liver Dis. 2004:24 (4):349-62 5. Dionysus Study Group. Drinking factors as cofactors of risk for alcohol induced liver change. Gut. 1997; 41 845-50 6. Preiss, D, Sattar, N. Non-alcoholic fatty liver disease: an overview of prevalence, diagnosis, pathogenesis and treatment considerations. Clin Sci.2008; 115 141-50 7. American Gastroenterological Association. Technical review on nonalcoholic fatty liver disease. Gastroenterology.2002; 123: 1705-25

Report to the Government 2.0 Taskforce : Project 4 - Copyright Law and Intellectual Property

This report is the primary output of Project 4: Copyright and Intellectual Property, the aim of which was to produce a report considering how greater access to and use of government information could be achieved within the scope of the current copyright law. In our submission for Project 4, we undertook to address: •the policy rationales underlying copyright and how they apply in the context of materials owned, held and used by government; • the recommendations of the Copyright Law Review Committee (CLRC) in its 2005 report on Crown copyright; • the legislative and regulatory barriers to information sharing in key domains, including where legal impediments such as copyright have been relied upon (whether rightly or wrongly) to justify a refusal to provide access to government data; • copyright licensing models appropriate to government materials and examples of licensing initiatives in Australia and other relevant jurisdictions; and • issues specific to the galleries, libraries, archives and museums (“GLAM”) sector, including management of copyright in legacy materials and “orphan” works. In addressing these areas, we analysed the submissions received in response to the Government 2.0 Taskforce Issues Paper, consulted with members of the Task Force as well as several key stakeholders and considered the comments posted on the Task Force’s blog. This Project Report sets out our findings on the above issues. It puts forward recommendations for consideration by the Government 2.0 Task Force on steps that can be taken to ensure that copyright and intellectual property promote access to and use of government information.

Teaching crabs to walk straight : is there a place for ethics education in Malaysian accountancy courses?

Recent releases from the International Federation of Accountants (IFAC) highlight the importance of ethics education. Academic institutions employ varying methods of teaching ethics and place varying levels of emphasis on ethics teaching during a business/accounting degree. This paper attempts to evaluate whether teaching ethics to final year accountancy students is beneficial. At the commencement of a semester 85 final year accounting students were given five ethical scenarios on which to make an ethical decision. During the semester they were subject to two different methods of teaching ethics, a traditional lecture/tutorial process and a group assignment. ----- After a significant gap, students were re-presented with the ethical scenarios and asked what action they now considered appropriate. In all five instances students offered a more ethical response the second time. When asked to evaluate the methodologies the students considered both training methods to have a positive effect on their ethical thinking. The results suggest it is beneficial to include ethics teaching in accountancy courses, if the profession’s goal of ethical practitioners is to be achieved.

Rejoinder to James Hamilton

Hamilton (2001) makes a number of comments on our paper (Harding and Pagan, 2002b). The objectives of this rejoinder are, firstly, to note the areas in which we agree; secondly, to define with greater clarity the areas in which we disagree; and, thirdly, to point to other papers, including a longer version of this response, where we have dealt with some of the issues that he raises. The core of our debate with him is whether one should use an algorithm with a specified set of rules for determining the turning points in economic activity or whether one should use a parametric model that features latent states. Hamilton begins his criticism by stating that there is a philosophical distinction between the two methods for dating cycles and concludes that the method we use “leaves vague and intuitive exactly what this algorithm is intended to measure”. Nothing is further from the truth. When seeking ways to decide on whether a turning point has occurred it is always useful to ask the question, what is a recession? Common usage suggests that it is a decline in the level of economic activity that lasts for some time. For this reason it has become standard to describe a recession as a decline in GDP that lasts for more than two quarters. Finding periods in which quarterly GDP declined for two periods is exactly what our approach does. What is vague about this?

The inherent equitable jurisdiction and the plenary power of the Supreme Court of New South Wales to order the winding up of companies

Not all companies in Australia are amenable to a winding up order pursuant to the Corporations Act 2001 (Cth). The Supreme Court of New South Wales has previously dealt with such winding up applications by apparently focusing on the inherent jurisdiction of the court to consider whether the court has jurisdiction to firstly consider the winding up application. This article proposes an original alternative paradigm: the plenary power provided to the court by s 23 of the Supreme Court Act 1970 (NSW) can be utilised to initially attract the jurisdiction of the court and subsequently the inherent jurisdiction specifically utilising the equitable “just and equitable” ground is available to the court to consider and make such a winding up order if appropriate. Variation of such a paradigm may also be available to the court when considering the inherent jurisdiction in relation to corporation matters more generally.

Is length of experience an appropriate criterion to identify level of expertise?

Clinical experience plays an important role in the development of expertise, particularly when coupled with reflection on practice. There is debate, however, regarding the amount of clinical experience that is required to become an expert. Various lengths of practice have been suggested as suitable for determining expertise, ranging from five years to 15 years. This study aimed to investigate the association between length of experience and therapists’ level of expertise in the field of cerebral palsy with upper limb hypertonicity using an empirical procedure named Cochrane–Weiss–Shanteau (CWS). The methodology involved re-analysis of quantitative data collected in two previous studies. In Study 1, 18 experienced occupational therapists made hypothetical clinical decisions related to 110 case vignettes, while in Study 2, 29 therapists considered 60 case vignettes drawn randomly from those used in Study 1. A CWS index was calculated for each participant's case decisions. Then, in each study, Spearman's rho was calculated to identify the correlations between the duration of experience and level of expertise. There was no significant association between these two variables in both studies. These analyses corroborated previous findings of no association between length of experience and judgemental performance. Therefore, length of experience may not be an appropriate criterion for determining level of expertise in relation to cerebral palsy practice.

An investigation of a process for environmental banking appropriate to Queensland

This thesis examines the advanced North American environmental mitigation schemes for their applicability to Queensland. Compensatory wetland mitigation banking, in particular, is concerned with in-perpetuity management and protection - the basic concerns of the Queensland public about its unique environment. The process has actively engaged the North American market and become a thriving industry that (for the most part) effectively designs, creates and builds (or enhances) environmental habitat. A methodology was designed to undertake a comprehensive review of the history, evolution and concepts of the North American wetland mitigation banking system - before and after the implementation of a significant new compensatory wetland mitigation banking regulation in 2008. The Delphi technique was then used to determine the principles and working components of wetland mitigation banking. Results were then applied to formulate a questionnaire to review Australian marketbased instruments (including offsetting policies) against these North American principles. Following this, two case studies established guiding principles for implementation based on two components of the North American wetland mitigation banking program. The subsequent outcomes confirmed that environmental banking is a workable concept in North America and that it is worth applying in Queensland. The majority of offsetting policies in Australia have adopted some principles of the North American mitigation programs. Examination reveals that however, they fail to provide adequate incentives for private landowners to participate because the essential trading mechanisms are not employed. Much can thus be learnt from the North American situation - where private enterprise has devised appropriate free market concepts. The consequent environmental banking process (as adapted from the North American programs) should be implemented in Queensland. It can then focus here on engaging the private sector, where the majority of naturally productive lands are managed.

The constitutional power to make war: domestic legal issues raised by Australia's action in Iraq

The legal power to declare war has traditionally been a part of a prerogative to be exercised solely on advice that passed from the King to the Governor-General no later than 1942. In 2003, the Governor- General was not involved in the decision by the Prime Minister and Cabinet to commit Australian troops to the invasion of Iraq. The authors explore the alternative legal means by which Australia can go to war - means the government in fact used in 2003 - and the constitutional basis of those means. While the prerogative power can be regulated and/or devolved by legislation, and just possibly by practice, there does not seem to be a sound legal basis to assert that the power has been devolved to any other person. It appears that in 2003 the Defence Minister used his legal powers under the Defence Act 1903 (Cth) (as amended in 1975) to give instructions to the service head(s). A powerful argument could be made that the relevant sections of the Defence Act were not intended to be used for the decision to go to war, and that such instructions are for peacetime or in bello decisions. If so, the power to make war remains within the prerogative to be exercised on advice. Interviews with the then Governor-General indicate that Prime Minister Howard had planned to take the matter to the Federal Executive Council 'for noting', but did not do so after the Governor-General sought the views of the then Attorney-General about relevant issues of international law. The exchange raises many issues, but those of interest concern the kinds of questions the Governor-General could and should ask about proposed international action and whether they in any way mirror the assurances that are uncontroversially required for domestic action. In 2003, the Governor-General's scrutiny was the only independent scrutiny available because the legality of the decision to go to war was not a matter that could be determined in the High Court, and the federal government had taken action in March 2002 that effectively prevented the matter coming before the International Court of Justice

A Delphi study to validate an advanced practice nursing tool

Aim This paper is a report of a study conducted to validate an instrument for measuring advanced practice nursing role delineation in an international contemporary health service context using the Delphi technique. Background Although most countries now have clear definitions and competency standards for nurse practitioners, no such clarity exists for many advanced practice nurse roles, leaving healthcare providers uncertain whether their service needs can or should be met by an advanced practice nurse or a nurse practitioner. The validation of a tool depicting advanced practice nursing is essential for the appropriate deployment of advanced practice nurses. This paper is the second in a three-phase study to develop an operational framework for assigning advanced practice nursing roles. Method An expert panel was established to review the activities in the Strong Model of Advanced Practice Role Delineation tool. Using the Delphi technique, data were collected via an on-line survey through a series of iterative rounds in 2008. Feedback and statistical summaries of responses were distributed to the panel until the 75% consensus cut-off was obtained. Results After three rounds and modification of five activities, consensus was obtained for validation of the content of this tool. Conclusion The Strong Model of Advanced Practice Role Delineation tool is valid for depicting the dimensions of practice of the advanced practice role in an international contemporary health service context thereby having the potential to optimize the utilization of the advanced practice nursing workforce.

Adherence to medicines in the older-aged with chronic conditions : does an intervention concerning adherence by an allied health professional help?

Adherence to medicines is a major determinant of the effectiveness of medicines. However, estimates of non-adherence in the older-aged with chronic conditions vary from 40 to 75%. The problems caused by non-adherence in the older-aged include residential care and hospital admissions, progression of the disease, and increased costs to society. The reasons for non-adherence in the older-aged include items related to the medicine (e.g. cost, number of medicines, adverse effects) and those related to person (e.g. cognition, vision, depression). It is also known that there are many ways adherence can be increased (e.g. use of blister packs, cues). It is assumed that interventions by allied health professions, including a discussion of adherence, will improve adherence to medicines in the older aged but the evidence for this has not been reviewed. There is some evidence that telephone counselling about adherence by a nurse or pharmacist does improve adherence, short- and long-term. However, face-to-face intervention counselling at the pharmacy, or during a home visit by a pharmacist, has shown variable results with some studies showing improved adherence and some not. Education programs during hospital stays have not been shown to improve adherence on discharge, but education programs for subjects with hypertension have been shown to improve adherence. In combination with an education program, both counselling and a medicine review program have been shown to improve adherence short-term in the older-aged. Thus, there are many unanswered questions about the most effective interventions to promote adherence. More studies are needed to determine the most appropriate interventions by allied health professions, and these need to consider the disease state, demographics, and socio-economic status of the older-aged subject, and the intensity and duration of intervention needed.

How I became the first Aboriginal person in Australia to lead a national education organisation

In this paper, Bronwyn Fredericks reflects on how, in 1997, she became the National President of the Council of Australian Postgraduate Associations Inc. (CAPA). The paper describes the election process faced by Fredericks, and identifies some of her key achievements during her time as National President. In becoming the National President, Bronwyn became the first Aboriginal person in Australia to lead a national education organisation. The story within this paper is told from the author’s autobiographical memory, drawing on the cultural, social and political context in which the story and the author were (and are) situated (Wojecki 2007). In this way the story teller reveals story lines which have not previously been articulated (Wojecki 2007). Throughout this paper, Fredericks ‘re-stories’ her experiences of leadership.