Good nutrition for good surgery: clinical and quality of life outcomes

Undernutrition is common in patients admitted for surgery and is often unrecognised, untreated and worsens in hospital. The complex synergistic relationship between nutritional status and the physiological responses to surgery puts patients at high nutritional risk. There are clear prospective associations between inadequate nutritional status and the risk of poorer outcomes for surgical patients, including infection, complications and length of stay. However, practically and ethically evidence that nutritional interventions can significantly reduce these poor outcomes is difficult to obtain. Nevertheless health professionals have a duty of care to ensure our patients are properly fed, by whatever means, to meet their physiological requirements.

Quality of life after total laparoscopic hysterectomy versus total abdominal hysterectomy for stage I endometrial cancer (LACE) : a randomised trial

Background: The two-stage Total Laparoscopic Hysterectomy (TLH) versus Total Abdominal Hysterectomy (TAH) for stage I endometrial cancer (LACE) randomised controlled trial was initiated in 2005. The primary objective of stage 1 was to assess whether TLH results in equivalent or improved QoL up to 6 months after surgery compared to TAH. The primary objective of stage 2 was to test the hypothesis that disease-free survival at 4.5 years is equivalent for TLH and TAH. Results addressing the primary objective of stage 1 of the LACE trial are presented here. Methods: The first 361 LACE participants (TAH n= 142, TLH n=190) were enrolled in the QoL substudy at 19 centres across Australia, New Zealand and Hong Kong, and 332 completed the QoL analysis. Randomisation was performed centrally and independently from other study procedures via a computer generated, web-based system (providing concealment of the next assigned treatment) using stratified permuted blocks of 3 and 6, and assigned patients with histologically confirmed stage 1 endometrioid endometrial adenocarcinoma and ECOG performance status <2 to TLH or TAH stratified by histological grade and study centre. No blinding of patients or study personnel was attempted. QoL was measured at baseline, 1 and 4 weeks (early), and 3 and 6 months (late) after surgery using the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. The primary endpoint was the difference between the groups in QoL change from baseline at early and late time points (a 5% difference was considered clinically significant). Analysis was performed according to the intention-to-treat principle using generalized estimating equations on differences from baseline for the early and late QoL recovery. The LACE trial is registered with clinicaltrials.gov (NCT00096408) and the Australian New Zealand Clinical Trials Registry (CTRN12606000261516). Patients for both stages of the trial have now been recruited and are being followed up for disease-specific outcomes. Findings: The proportion of missing values at the 5%, 10% 15% and 20% differences in the FACT-G scale was 6% (12/190) in the TLH and 14% (20/142) in the TAH group. There were 8/332 conversions (2.4%, 7 of which were from TLH to TAH). In the early phase of recovery, patients undergoing TLH reported significantly greater improvement of QoL from baseline compared to TAH in all subscales except the emotional and social well-being subscales. Improvements in QoL up to 6 months post-surgery continued to favour TLH except for the emotional and social well-being of the FACT and the visual analogue scale of the EuroQoL five dimensions (EuroQoL-VAS). Length of operating time was significantly longer in the TLH group (138±43 mins), than in the TAH group at (109±34 mins; p=0.001). While the proportion of intraoperative adverse events was similar between the treatment groups (TAH 8/142, 5.6%; TLH 14/190, 7.4%; p=0.55), postoperatively, twice as many patients in the TAH group experienced adverse events of CTC grade 3+ than in the TLH group (33/142, 23.2% and 22/190, 11.6%, respectively; p=0.004). Postoperative serious adverse events occurred more frequently in patients who had a TAH (27/142, 19.0%) than a TLH (15/190, 7.9%) (p=0.002). Interpretation: QoL improvements from baseline during early and later phases of recovery, and the adverse event profile significantly favour TLH compared to TAH for patients treated for Stage I endometrial cancer.

Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life

Background: Impairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL. ---------- Methods: Australian women (n = 287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy- Breast questionnaire were used to assess self-reported UBF and QoL, respectively. ---------- Results: Although mean UBF improved over time, up to 41% of women revealed declines in UBF between sixand 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least twofold (p < 0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p < 0.05). ---------- Conclusions: Significant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.

Communication patterns within social networks : a case study of Australian women

Based on the perception that “individual bonds to one another is the essence of society” (Fischer, 1982a, p. 2), this paper examines contemporary networks of friends: friendworks, of adult women in an Australian sea change community. Communication patterns are examined drawing on findings from a case study of 26 women aged 35-76 years. Among the case study participants, many have undertaken a ‘sea change’ as adults, which in most cases has led to a significant reconstruction of their friendworks. Location and lifestyle are identified as impacting factors on communication patterns with friends; face-to-face interactions are by far the most frequent and preferred method of communication among the participants. The landline telephone and internet are the main communication methods used to maintain friendships with distant loved ones, while the mobile phone is reported as the communication method employed the least. The infrequency of mobile phone use can be attributed to cost issues, highlighting a discrepancy between these women’s social and communication needs and the current Australian mobile phone policy.

The Australian Palliative Care Outcomes Collaboration (PCOC) : measuring the quality and outcomes of palliative care on a routine basis

Australia is leading the way in establishing a national system (the Palliative Care Outcomes Collaboration – PCOC) to measure the outcomes and quality of specialist palliative care services and to benchmark services across the country. This article reports on analysis of data collected routinely at point-of-care on 5939 patients treated by the first fifty one services that voluntarily joined PCOC. By March 2009, 111 services have agreed to join PCOC, representing more than 70% of services and more than 80% of specialist palliative care patients nationally. All states and territories are involved in this unique process that has involved extensive consultation and infrastructure and close collaboration between health services and researchers. The challenges of dealing with wide variation in outcomes and practice and the progress achieved to date are described. PCOC is aiming to improve understanding of the reasons for variations in clinical outcomes between specialist palliative care patients and differences in service outcomes as a critical step in an ongoing process to improve both service quality and patient outcomes. What is known about the topic? Governments internationally are grappling with how best to provide care for people with life limiting illnesses and how best to measure the outcomes and quality of that care. There is little international evidence on how to measure the quality and outcomes of palliative care on a routine basis. What does this paper add? The Palliative Care Outcomes Collaboration (PCOC) is the first effort internationally to measure the outcomes and quality of specialist palliative care services and to benchmark services on a national basis through an independent third party. What are the implications for practitioners? If outcomes and quality are to be measured on a consistent national basis, standard clinical assessment tools that are used as part of everyday clinical practice are necessary.

Globalization, suburbanization, and the creative workforce : Findings from Australian suburban communities

This paper considers the changing relationship between economic prosperity and Australian suburbs, noting that what has been termed “the first suburban nation” in experiencing an intensification of suburban growth in the 2000s, in the context of economic globalization. The paper reports on a three-year Australian Research Council funded project into “Creative Suburbia”, identifying the significant percentage of the creative industries workforce who live in suburban areas. Drawing on case studies from suburbs in the Australian cities of Brisbane and Melbourne, it notes the contrasts between the experience of these workers, who are generally positive towards suburban life, and the underlying assumptions of “creative cities” policy discourse that such workers prefer to be concentrated in high density inner urban creative clusters.

Government, citizenship and cultural policy : expertise and participation in Australian media policy

The study of institutions and policy processes in the formation of culture have been a major concern of the "cultural policy debate", which has been a major debate in Australian cultural studies in the 1990s (Bennett 1992a; Cunningham 1992; O'Regan 1993; cf. McGuigan 1996). Bennett (1992) argues that culture in modern societies is defined less by a distinct series of artistic and intellectual practices, the ways of life of distinctive communities or social groups, or as a system for the structuring of meaning in a society, but rather in terms of "the specificity of the governmental tasks and programmes in which those practices come to be inscribed." (Bennett 1992a: 397) Within such a framework, policy becomes "not... an optional add-on but... central to the definition and constitution of culture" (Bennett 1992a: 397). This understanding of culture as "intrinsically governmental" has in turn been linked to an increasingly strategic role for discourses of citizenship as a basis for the engagement of cultural studies intellectuals with the political sphere...

Reference bias : presentation of extreme health states prior to EQ-VAS improves health-related quality of life scores. A randomised crossover trial.

Background: Clinical practice and clinical research has made a concerted effort to move beyond the use of clinical indicators alone and embrace patient focused care through the use of patient reported outcomes such as healthrelated quality of life. However, unless patients give consistent consideration to the health states that give meaning to measurement scales used to evaluate these constructs, longitudinal comparison of these measures may be invalid. This study aimed to investigate whether patients give consideration to a standard health state rating scale (EQ-VAS) and whether consideration of good and poor health state descriptors immediately changes their selfreport. Methods: A randomised crossover trial was implemented amongst hospitalised older adults (n = 151). Patients were asked to consider descriptions of extremely good (Description-A) and poor (Description-B) health states. The EQ-VAS was administered as a self-report at baseline, after the first descriptors (A or B), then again after the remaining descriptors (B or A respectively). At baseline patients were also asked if they had considered either EQVAS anchors. Results: Overall 106/151 (70%) participants changed their self-evaluation by ≥5 points on the 100 point VAS, with a mean (SD) change of +4.5 (12) points (p < 0.001). A total of 74/151 (49%) participants did not consider the best health VAS anchor, of the 77 who did 59 (77%) thought the good health descriptors were more extreme (better) then they had previously considered. Similarly 85/151 (66%) participants did not consider the worst health anchor of the 66 who did 63 (95%) thought the poor health descriptors were more extreme (worse) then they had previously considered. Conclusions: Health state self-reports may not be well considered. An immediate significant shift in response can be elicited by exposure to a mere description of an extreme health state despite no actual change in underlying health state occurring. Caution should be exercised in research and clinical settings when interpreting subjective patient reported outcomes that are dependent on brief anchors for meaning. Trial Registration: Australian and New Zealand Clinical Trials Registry (#ACTRN12607000606482) http://www.anzctr. org.au

Seeking a life in the literary position : the writing of Charmian Clift

An examination of the published and unpublished writing of Charmian Clift.

Intake of isoflavone and lignan phytoestrogens and associated demographic and lifestyle factors in older Australian women

The purpose was to determine intake of phytoestrogens in a sample of older Australian women, and to investigate associated lifestyle factors. Subjects were an age-stratified sample of 511 women aged 40-80 y, randomly selected from the electoral roll and participating in the Longitudinal Assessment of Ageing in Women at the Royal Brisbane and Women’s Hospital. A cross-sectional study was conducted to assess isoflavone and lignan intake over the past month from food and supplements using a 112-item phytoestrogen frequency questionnaire. Data were also collected on nutrient intakes, physical activity, smoking, alcohol, non-prescription supplements, hormone therapy, education and occupation. Logistic regression was used to evaluate associations between demographic and lifestyle variables and soy/linseed consumption while controlling for age. Isoflavone intakes were significantly higher in the younger compared to older age groups (p<0.001); there were no age-related differences in lignan intake. Forty-five percent of women consumed at least one serve of a soy and/or linseed item and were defined as a soy/linseed consumer. Median (range) intakes by consumers for isoflavones and lignans (3.9 (0-172) mg/d and 2.4 (0.1-33) mg/d) were higher than intakes by non-consumers (0.004 (0-2.6) mg/d and 1.57 (0.44-4.7) mg/d), respectively (p<0.001). Consumers had higher intakes of dietary fibre (p=0.003), energy (p=0.04) and polyunsaturated fat (p=0.004), and higher levels of physical activity (p=0.006), socio-economic position (p<0.001), education (p<0.001) and supplement use (p<0.001). Women who consumed soy or linseed foods differed in lifestyle and demographic characteristics suggesting these factors should be considered when investigating associations with chronic disease outcomes.

On location : the imagined private interior in public life

This paper reveals the interior landscapes of selected contemporary Australian films, such as The Caterpillar Wish and Bad Boy Bubby, to develop a number of thematic influences on the manner in which domestic and private lives are constructed through filmic imagination. The research uncovers the conditions that contribute to particular scenographic representations of the humble interiors that act as both backdrop and performer to subtle and often troubled narratives. Such readings are informed by the theoretical works of writer Gertrude Stein, among others, who explore the relationships between the scenographic third dimension and the fourth dimensional performance in the representation of narrative space. A further theoretical thread lies in Giuliana Bruno’s work on the tension between private and public filmic space, which is explored through the public outing of intensely private spaces generated through narratives framed by the specificities of found interiors. Beyond the interrogation of qualities of imagined filmic space is the condition whereby locations, once transformed by the event of movie making are consequently forever revised. These altered conditions subsequently reinvest the lives of those who return to the location with layered narratives of occupation. Situationally, the now reconverted interior performs as contributor to subsequent private inhabitation, even if only as imagined space. The possibility here is that the qualities of the original may be superimposed and recontextualised to invest post-produced interiors with the qualities of the other space as imagined. This reading of film space explores new theoretical design scenarios for imagined and everyday interior landscapes.

Bushfire sustainability : Strategies for reconciling bushfire and biodiversity with daily life

This exhibition and catalogue provides a visual record of student work exhibited at the Australian Institute of Architects offices in Brisbane from November 15 to 29, 2010. The exhibition features the final design outcomes of the inaugural Bushfire Sustainability unit conducted at QUT in semester two, 2010. The core objective of this unit was to develop our students’ skills in collaborative practice in design, research and presentation. The theme of ‘bushfire sustainability’ was chosen because living sustainably in bushfire prone landscapes presents a number of problems, the nature of which might only be resolved via multidisciplinary collaboration among the design disciplines. The students involved represent the disciplines of Interior Design, Landscape Architecture, Industrial Design, Architecture and Sustainability – all from within the School of Design at QUT. 55 students, mostly in their third year of study, worked in teams of five (one from each discipline) to design one of a number of homes in highly bushfire prone sites in either Western Australia or SE Queensland. This year level and the interdisciplinary mix are perhaps the best placed to resolve these problems: being unrestrained from the burdens of professional practice and technical overload they retain the potential for innovative, lateral thinking across the range of spatial scales and philosophical perspectives associated with inhabitation of bushfire prone landscapes. It is envisaged that, through the ‘vehicle’ of this design research, that the students’ work will contribute to understandings of how creative design disciplines might respond to this significant national problem, which hitherto has been attended to primarily by engineering and the sciences.

Vulnerability, insurance and policy: The learner driver's standard of care

In Cook v Cook the Australian High Court held that the standard of reasonable care owed by a learner driver to an instructor, conscious of the driver’s lack of experience, was lower than that owed to other passengers and road users. Recently, in Imbree v McNeilly, the High Court declined to follow this principle, concluding that the driver’s status or relationship with the claimant should no longer influence or alter the standard of care owed. The decision therefore provides an opportunity to re-examine the rationale and policy behind current jurisprudence governing the standard of care owed by learner drivers. In doing so, this article considers the principles relevant to determining the standard and Imbree’s implications for other areas of tort law and claimant v defendant relationships. It argues that Imbree was influenced by changing judicial perceptions concerning the vulnerability of driving instructors and the relevance of insurance to tortious liability.

The Australian story : catalysts and inhibitors in the achievement of new women professors

Women are substantially under-represented in the professoriate in Australia with a ratio of one female professor to every three male professors. This gender imbalance has been an ongoing concern with various affirmative action programs implemented in universities but to limited effect. Hence, there is a need to investigate the catalysts for and inhibitors to women’s ascent to the professoriate. This investigation focussed on women appointed to the professoriate between 2005, when a research quality assessment was first proposed, and 2008. Henceforth, these women are referred to as “New Women Professors”. The catalysts and inhibitors in these women’s careers were investigated through an electronic survey and focus group interviews. The survey was administered to new women professors (n=255) and new men professors (n=240) to enable a comparison of responses. However, only women participated in focus group discussions (n=21). An analysis of the survey and interview data revealed that the most critical catalysts for women’s advancement to the professoriate were equal employment opportunities and mentoring. Equal opportunity initiatives provided women with access to traditionally male-dominated forums. Mentoring gave women an insider perspective on the complexity of academia and the politics of the academy. The key inhibitors to women’s career advancement were negative discrimination, the culture of the boys’ club, the tension between personal and professional life, and isolation. Negative discrimination and the boys’ club are problematic because they favour men and marginalise women. The tension between personal and professional life is a particular concern for women who bear children and typically assume the major role in a family for child rearing. Isolation was a concern for both women and men with isolation appearing to increase after ascent to the professoriate. Knowledge of the significant catalysts and inhibitors provides a pragmatic way to orient universities towards redressing the gender balance in the professoriate.