Whole-body substrate metabolism is associated with disease severity in patients with non-alcoholic fatty liver disease

Objectives In non-alcoholic fatty liver disease (NAFLD), hepatic steatosis is intricately linked with a number of metabolic alterations. We studied substrate utilisation in NAFLD during basal, insulin-stimulated and exercise conditions, and correlated these outcomes with disease severity. Methods 20 patients with NAFLD (mean±SD body mass index (BMI) 34.1±6.7 kg/m2) and 15 healthy controls (BMI 23.4±2.7 kg/m2) were assessed. Respiratory quotient (RQ), whole-body fat (Fatox) and carbohydrate (CHOox) oxidation rates were determined by indirect calorimetry in three conditions: basal (resting and fasted), insulin-stimulated (hyperinsulinaemic–euglycaemic clamp) and exercise (cycling at an intensity to elicit maximal Fatox). Severity of disease and steatosis were determined by liver histology, hepatic Fatox from plasma β-hydroxybutyrate concentrations, aerobic fitness expressed as , and visceral adipose tissue (VAT) measured by computed tomography. Results Within the overweight/obese NAFLD cohort, basal RQ correlated positively with steatosis (r=0.57, p=0.01) and was higher (indicating smaller contribution of Fatox to energy expenditure) in patients with NAFLD activity score (NAS) ≥5 vs <5 (p=0.008). Both results were independent of VAT, % body fat and BMI. Compared with the lean control group, patients with NAFLD had lower basal whole-body Fatox (1.2±0.3 vs 1.5±0.4 mg/kgFFM/min, p=0.024) and lower basal hepatic Fatox (ie, β-hydroxybutyrate, p=0.004). During exercise, they achieved lower maximal Fatox (2.5±1.4 vs. 5.8±3.7 mg/kgFFM/min, p=0.002) and lower (p<0.001) than controls. Fatox during exercise was not associated with disease severity (p=0.79). Conclusions Overweight/obese patients with NAFLD had reduced hepatic Fatox and reduced whole-body Fatox under basal and exercise conditions. There was an inverse relationship between ability to oxidise fat in basal conditions and histological features of NAFLD including severity of steatosis and NAS

A framework for cost-aware process management : generation of accurate and timely management accounting cost reports

Organisations are constantly seeking efficiency improvements for their business processes in terms of time and cost. Management accounting enables reporting of detailed cost of operations for decision making purpose, although significant effort is required to gather accurate operational data. Business process management is concerned with systematically documenting, managing, automating, and optimising processes. Process mining gives valuable insight into processes through analysis of events recorded by an IT system in the form of an event log with the focus on efficient utilisation of time and resources, although its primary focus is not on cost implications. In this paper, we propose a framework to support management accounting decisions on cost control by automatically incorporating cost data with historical data from event logs for monitoring, predicting and reporting process-related costs. We also illustrate how accurate, relevant and timely management accounting style cost reports can be produced on demand by extending open-source process mining framework ProM.

Using the collaborative evidence based practice model : a systematic review and uptake of chlorhexidine-impregnated sponge dressings on central venous access devices in a tertiary cancer centre

Background: Greater research utilisation in cancer nursing practice is needed, in order to provide well-informed and effective nursing care to people affected by cancer. This paper aims to report on the implementation of evidence-based practice in a tertiary cancer centre. Methods: Using a case report design, this paper reports on the use of the Collaborative Model for Evidence Based Practice (CMEBP) in an Australian tertiary cancer centre. The clinical case is the uptake of routine application of chlorhexidine-impregnated sponge dressings for preventing centrally inserted catheter-related bloodstream infections. In this case report, a number of processes that resulted in a service-wide practice change are described. Results: This model was considered a feasible method for successful research utilisation. In this case report, chlorhexidine-impregnated sponge dressings were proposed and implemented in the tertiary cancer centre with an aim of reducing the incidence of centrally inserted catheter-related bloodstream infections and potentially improving patient health outcomes. Conclusion: The CMEBP is feasible and effective for implementing clinical evidence into cancer nursing practice. Cancer nurses and health administrators need to ensure a supportive infrastructure and environment for clinical inquiry and research utilisation exists, in order to enable successful implementation of evidence-based practice in their cancer centres.

Community-based asylum seekers’ use of primary health care services in Melbourne

Objective: To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne. Design and setting: Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006. Main outcome measures: Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals. Results: Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55–65), followed by musculoskeletal conditions (27.1; 95% CI, 24–30), and psychological problems (26.5; 95% CI, 23–30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16–21). Conclusions: The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Food insecurity among adults residing in disadvantaged urban areas : potential health and dietary consequences

Objective: Food insecurity is the limited or uncertain availability or access to nutritionally-adequate, culturally-appropriate and safe foods. Food insecurity may result in inadequate dietary intakes, overweight or obesity and the development of chronic disease. Internationally, few studies have focused on the range of potential health outcomes related to food insecurity among adults residing in disadvantaged locations and no such Australian studies exist. The objective of this study was to investigate associations between food insecurity, socio-demographic and health factors and dietary intakes among adults residing in disadvantaged urban areas. Design: Data were collected by mail survey (n= 505, 53% response rate), which ascertained information about food security status, demographic characteristics (such as age, gender, household income, education) fruit and vegetable intakes, take-away and meat consumption, general health, depression and chronic disease. Setting: Disadvantaged suburbs of Brisbane city, Australia, 2009. Subjects: Individuals aged ≥ 20 years. Results: Approximately one-in-four households (25%) were food insecure. Food insecurity was associated with lower household income, poorer general health, increased healthcare utilisation and depression. These associations remained after adjustment for age, gender and household income. Conclusion: Food insecurity is prevalent in urbanised disadvantaged areas in developed countries such as Australia. Low-income households are at high risk of experiencing food insecurity. Food insecurity may result in significant health burdens among the population, and this may be concentrated in socioeconomically-disadvantaged suburbs.

Potential health and dietary consequences of food insecurity among Australian adults residing in urbanised disadvantaged areas

Purpose: Food insecurity is the limited/uncertain availability or ability to acquire nutritionally-adequate, culturally-relevant and safe foods. Adults suffering from food insecurity are at risk of inadequate nutrient intakes or, paradoxically, overweight/obesity and the development of chronic disease. Despite the global financial crisis and rising costs of living, few studies have investigated the potential dietary and health consequences of food insecurity among the Australian population. This study examined whether food insecurity was associated with health behaviours and dietary intakes among adults residing in socioeconomically-disadvantaged urbanised areas. Methods: In this cross-sectional study, a random sample of residents (n = 1000) were selected from the most disadvantaged suburbs of Brisbane city (response rate 51%). Data were collected by postal questionnaire which ascertained information on socio-demographic information, household food security, height, weight, frequency of healthcare utilisation, presence of chronic disease and intakes of fruit, vegetables and take-away. Data were analysed using logistic regression. Results/Findings: The prevalence of food insecurity was 25%. Those reporting food insecurity were two-to-three times more likely to have seen a general practitioner or been hospitalised within the previous 6 months. Furthermore, food insecurity was associated with a three-to-six-fold increase in the likelihood of experiencing depression. Food insecurity was associated with higher intakes of some take-away foods, however was not significantly associated with weight status or intakes of fruits or vegetables among this disadvantaged sample. Conclusion: Food insecurity has potential adverse health consequences that may result in significant health burdens among the population, and this may be concentrated in socioeconomically-disadvantaged suburbs.

Universal access to ambulance does not increase overall demand for ambulance services in Queensland, Australia

Objective. To determine the impact of the introduction of universal access to ambulance services via the implementation of the Community Ambulance Cover (CAC) program in Queensland in 2003–04. Method. The study involved a 10-year (2000–01 to 2009–10) retrospective analysis of routinely collected data reported by the Queensland Ambulance Service (QAS) and by the Council of Ambulance Authorities. The data were analysed for the impact of policy changes that resulted in universal access to ambulance services in Queensland. Results. QASis a statewide, publically funded ambulance service. In Queensland, ambulance utilisation rate (AUR)per 1000 persons grew by 41% over the decade or 3.9% per annum (10-year mean = 149.8, 95% CI: 137.3–162.3). The AUR mean after CAC was significantly higher for urgent incidents than for non-urgent ones. However projection modelling demonstrates that URs after the introduction of CAC were significantly lower than the projected utilisation for the same period. Conclusions. The introduction of universal access under the Community Ambulance Cover program in Queensland has not had any significant independent long-term impact on demand overall. There has been a reduction in the long-term growth rate, which may have been contributed to by an ‘appropriate use’ public awareness program.

Emergency Health Services (EHS) : demand and service delivery models. [Monograph 2 : Queensland EHS users’ profile]

Emergency health is a critical component of Australia’s health system and one which is increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the characteristics of users of emergency health services with an aim to identify those that appear to contribute to demand growth. This study utilises data on patients treated by Emergency Departments (ED) and Queensland Ambulance Service (QAS) across Queensland. ED data was derived from the Emergency Department Information System (EDIS) for the period 2001-02 through to 2010-11. Ambulance data was extracted from the QAS’ Ambulance Information Management System (AIMS) and electronic Ambulance Report Form (eARF) for the period 2001-02 through to 2009-10. Due to discrepancies and comparability issues for ED data, this monograph compares data from the 2003-04 time period with 2010-11 data for 21 of the reporting EDs. Also a snapshot of users for the 2010-11 financial year for 31 reporting EDs is used to describe the characteristics of users and to compare those characteristics with population demographics. For QAS data, the 2002-03 and 2009-10 time periods were selected for detailed analyses to identify trends. • Demand for emergency health care services is increasing, representing both increased population and increased relative utilisation. Per capita demand for ED attention has increased by 2% per annum over the last decade and for ambulance attention by 3.7% per annum. • The growth in ED demand is prominent in more urgent triage categories with actual decline in less urgent patients. An estimated 55% of patients attend hospital EDs outside of normal working hours. There is no evidence that patients presenting out of hours are significantly different to those presenting within working hours; they have similar triage assessments and outcomes. • Patients suffering from injuries and poisoning comprise 28% of the ED workload (an increase of 65% in the study period), whilst declines of 32% in cardiovascular and circulatory conditions, and musculoskeletal problems have been observed. • 25.6% of patients attending EDs are admitted to hospital. 19% of admitted patients and 7% of patients who die in the ED are triage category 4 or 5 on arrival. • The average age of ED patients is 35.6 years. Demand has grown in all age groups and amongst both men and women. Men have higher utilisation rates for ED in all age groups. The only group where the growth rate in women has exceeded men is in the 20-29 age group; this growth is particularly in the injury and poisoning categories. • Considerable attention has been paid publicly to ED performance criteria. It is worth noting that 50% of all patients were treated within 33 minutes of arrival. • Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people appears to exceed those of European and other backgrounds. The utilisation rates for immigrant people is generally less than that of Australian born however it has not been possible to eliminate the confounding impact of different age and socioeconomic profiles. • Demand for ambulance service is also increasing at a rate that exceeds population growth. Utilisation rates have increased by an average of 5% per annum in Queensland compared to 3.6% nationally, and the utilisation rate in Queensland is 27% higher than the national average. • The growth in ambulance utilisation has also been amongst the more urgent categories of dispatch and utilisation rates are higher in rural and regional areas than in the metropolitan area. The demand for ambulance increases with age but the growth in demand for ambulance service has been more prominent in younger age groups. These findings contribute significantly to an understanding of the growth in demand for emergency health. It shows that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that the congestion of emergency health services is due to inappropriate attendees is unable to be substantiated. The consistency of the growth in demand over the last decade reflects not only the changing demographics of the Australian population but also the changes in health status, standards of acute health care and other social factors. The growth is also amongst patients with acute injury and poisoning which is inconsistent with rates of chronic disease as a fundamental driver. We have also interviewed patients in regard to their decision making choices for acute health care and the factors that influence these decisions and this will be the subject of a third Monograph and publications.

Ultimate limit states design of concrete railway sleepers

The railway industry has been slow to adopt limit states principles in the structural design of concrete sleepers for its tracks, despite the global take up of this form of design for almost every other type of structural element. Concrete sleeper design is still based on limiting stresses but is widely perceived by track engineers to lead to untapped reserves of strength in the sleepers. Limit design is a more rational philosophy, especially where it is based on the ultimate dynamic capacity of the concrete sleepers. The paper describes the development of equations and factors for a limit design methodology for concrete sleepers in flexure using a probabilistic evaluation of sleeper loading. The new method will also permit a cogent, defensible means of establishing the true capacity of the billions of concrete sleepers that are currently in-track around the world, leading to better utilisation of track infrastructure. The paper demonstrates how significant cost savings may be achieved by track owners.

Imaging affect : abstraction and the echo of the unknowable

As an artist my primary interest is in the abstract, that is in images of the imageless. I am curious about the emergence of pictorial significance and content from this unknowable space. To speak of the significance of an imageless image is also to speak of its affect. I aim to explore this both theoretically and practically. Theoretically I will explore affect through the late work of Lyotard and his notion of the affect-phrase. This is an under-examined aspect of Lyotard and demarcates a valuable way to look at the origins, impact and ramifications of affect for art. Practically I will apply these understandings to the development of my own creative work which includes both painting and digital work. My studio practice moves towards exploring the unfamiliar through the powerful and restless silence of affect.In this intense space each work or body of work 'leaks' into the next occasioning a sense of borderlessness, or of uncertainty. This interpenetration and co-mingling of conceptual and material terrains combines to present temporal and spatial slippages evident within the works themselves and their making, but it is also evident in bodies of work across the chronology of their making. Through a mapping of my own painting and digital arts practice and the utilisation of Lyotard’s notion of the affect -phrase I aim to describe the action of this ‘charged emptiness’ on creativity and explore and explain its significance on that we call image and its animation of what we call critical discourse.

Value added products from modified kaolins : new chemical routes to new markets

Chemical treatments of kaolins to produce nanocrystalline or "X-ray amorphous", stable aluminosilicates with variable - but reproducible - types of micro- and meso-porosity have been developed. These materials show cation exchange capacities and surface area values significantly higher (ranging from 10x to 100x) than kaolin and show good acid resistance to pH~3.0. The combination of these properties offers strong potential for many new applications of kaolin-derived materials in large worldwide markets such as environmental remediation and catalysis. Kaolin amorphous derivative (KAD) is well-suited to removal of many toxic metals down to ppb range from acid mine drainage. Engineering development trials of the KAD manufacturing process and the utilisation of KAD in polluted waters such as acid mine drainage indicates that scale-up from bench-scale is not a barrier to market entry.

Re-use of domain knowledge to provide confidence for adoption of off-site manufacturing for construction in Australia

Many construction industry decision-makers believe there is a lack of off-site manufacture (OSM) adoption for non-residential construction in Australia. Identification of construction business process was considered imperative in order to assist decision-makers to increase OSM utilisation. The premise that domain knowledge can be re-used to provide an intervention point in the construction process led a team of researchers to construct simple base-line process models for the complete construction process, segmented into six phases. Sixteen domain knowledge industry experts were asked to review the construction phase base-line models to answer the question “Where in the process illustrated by this base-line model phase is an OSM task?”. Through an iterative and generative process a number of off-site manufacture intervention points were identified and integrated into the process models. The re-use of industry expert domain knowledge provided suggestions for new ways to do basic tasks thus facilitating changes to current practice. It is expected that implementation of the new processes will lead to systemic industry change and thus a growth in productivity due to increased adoption of OSM.

Contribution of knowledge management activities to organisational business performance

Purpose – Within the construction industry there is a growing awareness of the need for linking knowledge management (KM) to business strategy, organisational objectives and existing performance measures. This study was undertaken within the context of construction organisations, and attempts to provide the empirical evidence about the relationships between KM activities and organisational business performance. Design/methodology/approach – A questionnaire survey was administered to a sample of construction contractors operating in Hong Kong to investigate the opinions of construction professionals regarding the intensity of KM activities and business performance within their organisations. In parallel to the survey, semi-structured interviews were undertaken to provide qualitative insights that helped to clarify and deepen understanding of the KM process within the context of the research target. Findings – The investigation shows that knowledge utilisation is the strongest contributor to general business performance. In addition, the impact of KM activities on the lagging performance indicators of the Balanced Scorecard (BSC), such as “financial performance”, is in an indirect manner, and through the leading indicators such as performance from “internal process” as well as “learning and growth” perspectives. Originality/value – The study empirically establishes the linkage between intensity of KM activities and business performance, and demonstrates that KM strategies need to be explicitly formulated and measured according to organisational business objectives.

ECMO : the clinician’s view

Background: Extra corporeal membrane oxygenation (ECMO) is a complex rescue therapy used to provide cardiac and/or respiratory support for critically ill patients who have failed maximal conventional medical management. ECMO is based on a modified cardiopulmonary bypass (CPB) circuit, and can provide cardiopulmonary support for up-to several months. It can be used in a veno venous configuration for isolated respiratory failure, (VV-ECMO), or in a veno arterial configuration (VA-ECMO) where support is necessary for cardiac +/- respiratory failure. The ECMO circuit consists of five main components: large bore cannulae (access cannulae) for drainage of the venous system, and return cannulae to either the venous (in VV-ECMO) or arterial (in VA ECMO) system. An oxygenator, with a vast surface area of hollow filaments, allows addition of oxygen and removal of carbon dioxide; a centrifugal blood pump allows propulsion of blood through the circuit at upto 10 L/minute; a control module and a thermoregulatory unit, which allows for exact temperature control of the extra corporeal blood. Methods: The first successful use of ECMO for ARDS in adults occurred in 1972, and its use has become more commonplace over the last 30 years, supported by the improvement in design and biocompatibility of the equipment, which has reduced the morbidity associated with this modality. Whilst the use of ECMO in neonatal population has been supported by numerous studies, the evidence upon which ECMO was integrated into adult practice was substantially less robust. Results: Recent data, including the CESAR study (Conventional Ventilatory Support versus Extra corporeal membrane oxygenation for Severe Respiratory failure) has added a degree of evidence to the role of ECMO in such a patient population. The CESAR study analysed 180 patients, and confirmed that ECMO was associated with an improved rate of survival. More recently, ECMO has been utilized in numerous situations within the critical care area, including support in high-risk percutaneous interventions in cardiac catheter lab; the operating room, emergency department, as well in specialized inter-hospital retrieval services. The increased understanding of the risk:benefit profile of ECMO, along with a reduction in morbidity associated with its use will doubtless lead to a substantial rise in the utilisation of this modality. As with all extra-corporeal circuits, ECMO opposes the basic premises of the mammalian inflammation and coagulation cascade where blood comes into foreign circulation, both these cascades are activated. Anti-coagulation is readily dealt with through use of agents such as heparin, but the inflammatory excess, whilst less macroscopically obvious, continues un-abated. Platelet consumption and neutrophil activation occur rapidly, and the clinician is faced with balancing the need of anticoagulation for the circuit, against haemostasis in an acutely bleeding patient. Alterations in pharmacokinetics may result in inadequate levels of disease modifying therapeutics, such as antibiotics, hence paradoxically delaying recovery from conditions such as pneumonia. Key elements of nutrition and the innate immune system maysimilarly be affected. Summary: This presentation will discuss the basic features of ECMO to the nonspecialist, and review the clinical conundrum faced by the team treating these most complex cases.

Empirical study of interactions between knowledge management activities

Purpose – Recent knowledge management (KM) literature suggests that KM activities are not independent of each other, rather they interact with each other to form a process which receives input from both external and internal business environments, and then produces new knowledge for future utilisation. The purpose of this paper is to empirically investigate the relationships between KM activities within the construction business context in order to identify and map the pattern of their interactions. Design/methodology/approach – A questionnaire survey was administered to a sample of contracting organisations operating in Hong Kong to elicit opinions of construction professionals on the intensity of KM activities currently being executed by their organisations in order to facilitate knowledge capture, sharing and utilisation. More than 150 respondents from 99 organisations responded to the survey. Additionally, a total of 15 semi-structured interviews were undertaken to provide a unique perspective on many of the challenges facing local construction organisations when dealing with KM activities. Findings – Knowledge acquisition and utilisation play paramount roles in the development of the organisational knowledge asset. The higher the intensity of these two activities, the larger the organisational knowledge pool which, in turn, demands greater knowledge dissemination capacity. This dissemination capacity enables more active and intense responses to market changes and clients' needs, thus facilitating and stimulating acquisition and utilisation of new tacit knowledge, thus improving organisational business performance. Originality/value – Interactions between KM activities were empirically investigated, from a strategic perspective, in the construction business context.