d-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study

Objective To investigate the efficacy of using a rapid plasma d-dimer test as an adjunct to compression ultrasound for diagnosing clinically suspected deep vein thrombosis.

Community college adjunct policies and practices: Incumbents' perspectives and congruence with learning organization tenets

The primary research question was: What is the nature and degree of alignment between the tenets of learning organizations and the policies and practices of a community college concerning adjunct instructors? I investigated the employment experiences of 8 adjunct instructors at a large community college in the Southeastern U.S. to (a) describe and explain the perspectives of the adjuncts, (b) describe and explain my own adjunct employment experience at the same college, (c) determine how the adjunct policies and practices collectively encountered were congruent with or at variance with the tenets of learning organizations, and (d) to use this framework to support recommendations that may help the college achieve more favorable alignment with these tenets. ^ Data on perceived adjunct policies and practices were reduced into 11 categories and, using matrices, were compared with 5 major categories of learning organization tenets. The 5 categories of tenets were: (a) inputs, (b) information flow/communication, (c) employee inclusion/value, (d) teamwork, and (e) facilitation of change. The 11 categories of the college's policies and practices were (a) becoming an adjunct, (b) full-time employment aspirations, (c) salary, (d) benefits, (e) job security and predictability, (f) job satisfaction, (g) respect, (h) support services, (i) professional development, (j) institutional inclusion, and (k) future role of adjuncts. The reflective journal component relied on a 5-year (1995–2000) personal and professional journal maintained by me during employment with the same college as the participants. ^ Findings indicate that the college's adjunct policies and practices were most incongruent with 25 of the 70 learning organization tenets. These incongruencies spanned the 5 categories, although most occurred in the Employee/Inclusion/Value category. Adjunct instructors wanted inclusion, respect, value, trust, and empowerment in decision making processes that affect adjunct policies and practices of the college, but did not perceive this to be a part of the present situation. ^

The socialization of adjunct faculty into the academic culture of a public community college campus

This study investigated the socialization of adjunct faculty into the academic culture of a community college campus. Because of the increased utilization of adjunct faculty, the need to socialize them to effectively function within the organizational culture has become more acute. A review of the literature revealed that when employees are socialized, they are more committed to the goals and welfare of the organization, are less likely to leave the organization, and are more productive and innovative. Therefore, it is important that administrators have programs and practices in place that would help to integrate adjunct faculty into the academic culture. The model of organizational socialization (Chao, O'Leary-Kelly, Wolf, Klein, & Gardner, 1994) formed the framework for this study, which was guided by the following research questions: How do adjunct faculty members describe their socialization into the culture of their college campus? How do administrators describe their roles and that of the organization in the socialization of adjunct faculty members? What organizational programs and activities are in place for the socialization of adjunct faculty? The North Campus of Miami Dade College was the site for this study, as it is a campus with a long history of utilizing adjunct faculty members and one that has a clearly-stated mission of adjunct faculty socialization. A qualitative case study method was used, and data collection included interviews and the review and analysis of institutional documents. The participants included 11 adjunct faculty members, 4 department chairpersons, the campus president, and the college training and development coordinator. The study revealed that there were structured and consistent professional development programs, but these conflicted with the schedules of adjunct faculty. Overall, adjunct faculty found support from the leadership; however, they revealed a need for more mentoring, more interactions with full-time faculty, and more input in decision making concerning textbooks and curricula. Implications and recommendations for practice include making professional development more accessible and relevant to adjunct faculty, developing a formal mentoring program where full-time faculty and veteran adjunct faculty mentor novice adjunct faculty, and involving adjuncts in decisions regarding curriculum and textbook selection.

Career technical education adjunct faculty teacher readiness: An investigation of teacher excellence and variables of preparedness

The purpose of this research was to examine the relationship between teaching readiness and teaching excellence with three variables of preparedness of adjunct professors teaching career technical education courses through student surveys using a correlational design of two statistical techniques; least-squares regression and one-way analysis of variance. That is, the research tested the relationship between teacher readiness and teacher excellence with the number of years teaching, the number of years of experience in the professional field and exposure to teaching related professional development, referred to as variables of preparedness.^ The results of the research provided insight to the relationship between the variables of preparedness and student assessment of their adjunct professors. Concerning the years of teaching experience, this research found a negative inverse relationship with how students rated their professors' teaching readiness and excellence. The research also found no relationship between years of professional experience and the students' assessment. Lastly, the research found a significant positive relationship between the amount of teaching related professional development taken by an adjunct professor and the students' assessment in teaching readiness and excellence.^ This research suggests that policies and practices at colleges should address the professional development needs of adjunct professors. Also, to design a model that meets the practices of inclusion for adjunct faculty and to make professional development a priority within the organization. Lastly, implement that model over time to prepare adjuncts in readiness and excellence. ^

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

© 2014, Canadian Anesthesiologists' Society.Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.

Angiomatoid fibrous histiocytoma: comparison of fluorescence in situ hybridization and reverse transcription polymerase chain reaction as adjunct diagnostic modalities

Angiomatoid fibrous histiocytoma (AFH) is a rare soft tissue neoplasm of intermediate biologic potential and uncertain differentiation, most often arising in the extremities of children and young adults. Although it has characteristic histologic features of a lymphoid cuff surrounding nodules of ovoid cells with blood-filled cystic cavities, diagnosis is often difficult due to its morphologic heterogeneity and lack of specific immunoprofile. Angiomatoid fibrous histiocytoma is associated with recurrent chromosomal translocations, leading to characteristic EWSR1-CREB1, EWSR1-ATF1, and, rarely, FUS-ATF1 gene fusions; fluorescence in situ hybridization (FISH), detecting EWSR1 or FUS rearrangements, and reverse transcription-polymerase chain reaction (RT-PCR) for EWSR1-CREB1 and EWSR1-ATF1 fusion transcripts have become routine ancillary tools. We present a large comparative series of FISH and RT-PCR for AFH. Seventeen neoplasms (from 16 patients) histologically diagnosed as AFH were assessed for EWSR1 rearrangements or EWSR1-CREB1 and EWSR1-ATF1 fusion transcripts. All 17 were positive for either FISH or RT-PCR or both. Of 16, 14 (87.5%) had detectable EWSR1-CREB1 or EWSR1-ATF1 fusion transcripts by RT-PCR, whereas 13 (76.5%) of 17 had positive EWSR1 rearrangement with FISH. All 13 of 13 non-AFH control neoplasms failed to show EWSR1-CREB1 or EWSR1-ATF1 fusion transcripts, whereas EWSR1 rearrangement was present in 2 of these 13 cases (which were histopathologically myoepithelial neoplasms). This study shows that EWSR1-CREB1 or EWSR1-ATF1 fusions predominate in AFH (supporting previous reports that FUS rearrangement is rare in AFH) and that RT-PCR has a comparable detection rate to FISH for AFH. Importantly, cases of AFH can be missed if RT-PCR is not performed in conjunction with FISH, and RT-PCR has the added advantage of specificity, which is crucial, as EWSR1 rearrangements are present in a variety of neoplasms in the histologic differential diagnosis of AFH, that differ in behavior and treatment.

Effect of galactose metabolising and non-metabolising strains of Streptococcus thermophilus as a starter culture adjunct on the properties of Cheddar cheese made with low or high pH at whey drainage

Cheddar cheese was made using control culture (Lactococcus lactis subsp. lactis), or with control culture plus a galactose-metabolising (Gal+) or galactose-non-metabolising (Gal-) Streptococcus thermophilus adjunct; for each culture type, the pH at whey drainage was either low (pH 6.15) or high (pH 6.45). Sc. thermophilus affected the levels of residual lactose and galactose, and the volatile compound profile and sensory properties of the mature cheese (270 d) to an extent dependent on the drain pH and phenotype (Gal+ or Gal-). For all culture systems, reducing drain pH resulted in lower levels of moisture and lactic acid, a higher concentration of free amino acids, and higher firmness. The results indicate that Sc. thermophilus may be used to diversify the sensory properties of Cheddar cheese, for example from a fruity buttery odour and creamy flavour to a more acid taste, rancid odour, and a sweaty cheese flavour at high drain pH.

The acquisition of adjunct control: grammar and processing

This dissertation uses children’s acquisition of adjunct control as a case study to investigate grammatical and performance accounts of language acquisition. In previous research, children have consistently exhibited non-adultlike behavior for sentences with adjunct control. To explain children’s behavior, several different grammatical accounts have been proposed, but evidence for these accounts has been inconclusive. In this dissertation, I take two approaches to account for children’s errors. First, I spell out the predictions of previous grammatical accounts, and test these predictions after accounting for some methodological concerns that might have influenced children’s behavior in previous studies. While I reproduce the non-adultlike behavior observed in previous studies, the predictions of previous grammatical accounts are not borne out, suggesting that extragrammatical factors are needed to explain children’s behavior. Next, I consider the role of two different types of extragrammatical factors in predicting children’s non-adultlike behavior. With a new task designed to address the task demands in previous studies, children exhibit significantly higher accuracy than with previous tasks. This suggests that children’s behavior has been influenced by task- specific processing factors. In addition to the task, I also test the predictions of a similarity-based interference account, which links children’s errors to the same memory mechanisms involved in sentence processing difficulties observed in adults. These predictions are borne out, supporting a more continuous developmental trajectory as children’s processing mechanisms become more resistant to interference. Finally, I consider how children’s errors might influence their acquisition of adjunct control, given the distribution in the linguistic input. I discuss the results of a corpus analysis, including the possibility that adjunct control could be learned from the input. The kinds of information that could be useful to a learner become much more limited, however, after considering the processing limitations that would interfere with the representations available to the learner.

Career Technical Education Adjunct Faculty Teacher Readiness: An Investigation of Teacher Excellence and Variables of Preparedness

The purpose of this research was to examine the relationship between teaching readiness and teaching excellence with three variables of preparedness of adjunct professors teaching career technical education courses through student surveys using a correlational design of two statistical techniques; least-squares regression and one-way analysis of variance. That is, the research tested the relationship between teacher readiness and teacher excellence with the number of years teaching, the number of years of experience in the professional field and exposure to teaching related professional development, referred to as variables of preparedness. The results of the research provided insight to the relationship between the variables of preparedness and student assessment of their adjunct professors. Concerning the years of teaching experience, this research found a negative inverse relationship with how students rated their professors’ teaching readiness and excellence. The research also found no relationship between years of professional experience and the students’ assessment. Lastly, the research found a significant positive relationship between the amount of teaching related professional development taken by an adjunct professor and the students’ assessment in teaching readiness and excellence. This research suggests that policies and practices at colleges should address the professional development needs of adjunct professors. Also, to design a model that meets the practices of inclusion for adjunct faculty and to make professional development a priority within the organization. Lastly, implement that model over time to prepare adjuncts in readiness and excellence.

Cholesterol-lowering management of stroke : inconsistencies of evidence and practice

Cholesterol-lowering treatment by statins is an important and costly issue; however, its role in stroke has not been well documented. The aim of the present study was to review literature and current practice regarding cholesterol-lowering treatment for stroke patients. A literature review was conducted on lipids in stroke and their management with both statins and diet, including the cost-effectiveness of medical nutrition therapy. Qualifying criteria and prescription procedures of the Pharmaceutical Benefits Scheme (PBS) were also reviewed. Data on lipid levels and statin prescriptions were analysed for 468 patients admitted to a stroke unit. The literature shows that management with both medication and diet can be effective, especially when combined; however, 60% of patients with an ischaemic event had fasting total cholesterol measures ≥4 mmol/L (n = 231), with only 52% prescribed statins on discharge (n = 120). Hypercholesterolaemia is an underdiagnosed and undertreated risk factor within the stroke population. It appears that the PBS has not kept pace with advances in the evidence in terms of statin use in the stroke population, and review is needed. The present review should address the qualifying criteria for the stroke population and recommendations on referral to dietitians for dietary advice. Cholesterol-lowering treatment for both stroke patients and the wider population is an area that needs awareness raising and review by the PBS, medical practitioners and dietitians. The role of dietary and pharmacological treatments needs to be clearly defined, including adjunct therapy, and the cost-effectiveness of medical nutrition therapy realised.

Changing motorcycle rider safety attitudes and motives for risk taking : process evaluation of a rider training intervention

Risk-taking behaviour by motorcyclists has been shown to contribute to a substantial proportion of road crashes in Australia and abroad. Concern has been expressed that traditional motorcycle licence training programs do not sufficiently address such behaviour. Accordingly, the Three Steps to Safer Riding program was developed to address risk taking behaviour by riders as an adjunct to existing skills-based rider training. The program was designed to be delivered in a one hour classroom session at the start of training, with a 20 minute debrief to revise the key concepts at the end of training. This paper reports on the key training concepts, methodology and implementation of the pilot program with a major rider training organisation in Queensland and presents findings from a process evaluation. The Three Steps to Safer Riding intervention pilot was delivered to 518 learner riders over a three month period. Follow-up focus groups and one interview with intervention participants (N=18) five to eight months after completion of the program suggest that new riders (absolute novices) embraced and internalised many of the intervention concepts. However, some riders who had previous riding experience prior to training stated these issues were common sense, yet still expressed riding styles that were contrary to some of the key intervention messages. This is discussed in terms of raising awareness of risk issues for motorcyclists versus behaviour change. Additionally, interviews conducted with riding instructors are discussed regarding logistical challenges of implementation, training consistency, skills required to deliver the program, support for the program, and student engagement.

When and how to treat pulmonary non-tuberculous mycobacterial diseases

Nontuberculous mycobacteria are ubiquitous environmental organisms that have been recognised as a cause of pulmonary infection for over 50 years. Traditionally patients have had underlying risk factors for development of disease; however the proportion of apparently immunocompetent patients involved appears to be rising. Not all patients culture-positive for mycobacteria will have progressive disease, making the diagnosis difficult, though criteria to aid in this process are available. The two main forms of disease are cavitary disease (usually involving the upper lobes) and fibronodular bronchiectasis (predominantly middle and lingular lobes). For patients with disease, combination antibiotic therapy for 12-24 months is generally required for successful treatment, and this may be accompanied by drug intolerances and side effects. Published success rates range from 30-82%. As the progression of disease is variable, for some patients, attention to pulmonary hygiene and underlying diseases without immediate antimycobacterial therapy may be more appropriate. Surgery can be a useful adjunct, though is associated with risks. Randomised controlled trials in well described patients would provide stronger evidence-based data to guide therapy of NTM lung diseases, and thus are much needed.

The efficacy of an augmented virtual reality system to alleviate pain in children undergoing burns dressing changes : a randomised controlled trial

In children, the pain and anxiety associated with acute burn dressing changes can be severe, with drug treatment alone frequently proving to be inadequate. Virtual reality (VR) systems have been successfully trialled in limited numbers of adult and paediatric burn patients. Augmented reality (AR) differs from VR in that it overlays virtual images onto the physical world, instead of creating a complete virtual world. This prospective randomised controlled trial investigated the use of AR as an adjunct to analgesia and sedation in children with acute burns. Forty-two children (30 male and 12 female), with an age range of 3–14 years (median age 9 years) and a total burn surface area ranging from 1 to 16% were randomised into a treatment (AR) arm and a control (basic cognitive therapy) arm after administration of analgesia and/or sedation. Pain scores, pulse rates (PR), respiratory rates (RR) and oxygen saturations (SaO2) were recorded pre-procedurally, at 10 min intervals and post-procedurally. Parents were also asked to grade their child's overall pain score for the dressing change. Mean pain scores were significantly lower (p = 0.0060) in the AR group compared to the control group, as were parental pain assessment scores (p = 0.015). Respiratory and pulse rates showed significant changes over time within groups, however, these were not significantly different between the two study groups. Oxygen saturation did not differ significantly over time or between the two study groups. This trial shows that augmented reality is a useful adjunct to pharmacological analgesia.

Max Dupain and the photography of Australian architecture

This thesis considers Max Dupain (1911-1992) and his contribution to the development of architectural photography in Australia. Through his continuous and prolific output over six decades of professional photography Dupain greatly stimulated awareness of and interest in Australian architecture. Before Dupain began specialising in the field, little consistent professional architectural photography had been practised in Australia. He and some of his close associates subsequently developed architectural photography as both a specialised branch of photography and - perhaps more significantly - as a necessary adjunct to architectural practice. In achieving these dual accomplishments, Dupain and like-minded practitioners succeeded in elevating architectural photography to the status of a discipline in its own right. They also gave Australians generally a deeper understanding of the heritage represented by the nation's built environment. At the same time, some of the photographic images he created became firmly fixed in the public imagination as historical icons within the development of a distinctive Australian tradition in the visual arts. Within his chosen field Dupain was the dominant Australian figure of his time. He was instrumental in breaking the link with Pictorialism by bringing Modernist and Documentary perspectives to Australian architectural photography. He was an innovator in the earlier decades of his professional career, however, his photographic techniques and practice did not develop beyond that. By the end of the 1980s he had largely lost touch with the technology and techniques of contemporary practice. Dupain's reputation, which has continued growing since his death in 1992, therefore arises from reasons other than his photographic images alone. It reflects his accomplishment in raising his fellow citizens' awareness of a worthwhile home-grown artistic tradition.

Crosstalk between developmental and tumour-specific signalling pathways : kallikrein-related serine peptidases and nodal in prostrate cancer

Prostate cancer is an important male health issue. The strategies used to diagnose and treat prostate cancer underscore the cell and molecular interactions that promote disease progression. Prostate cancer is histologically defined by increasingly undifferentiated tumour cells and therapeutically targeted by androgen ablation. Even as the normal glandular architecture of the adult prostate is lost, prostate cancer cells remain dependent on the androgen receptor (AR) for growth and survival. This project focused on androgen-regulated gene expression, altered cellular differentiation, and the nexus between these two concepts. The AR controls prostate development, homeostasis and cancer progression by regulating the expression of downstream genes. Kallikrein-related serine peptidases are prominent transcriptional targets of AR in the adult prostate. Kallikrein 3 (KLK3), which is commonly referred to as prostate-specific antigen, is the current serum biomarker for prostate cancer. Other kallikreins are potential adjunct biomarkers. As secreted proteases, kallikreins act through enzyme cascades that may modulate the prostate cancer microenvironment. Both as a panel of biomarkers and cascade of proteases, the roles of kallikreins are interconnected. Yet the expression and regulation of different kallikreins in prostate cancer has not been compared. In this study, a spectrum of prostate cell lines was used to evaluate the expression profile of all 15 members of the kallikrein family. A cluster of genes was co-ordinately expressed in androgenresponsive cell lines. This group of kallikreins included KLK2, 3, 4 and 15, which are located adjacent to one another at the centromeric end of the kallikrein locus. KLK14 was also of interest, because it was ubiquitously expressed among the prostate cell lines. Immunohistochemistry showed that these 5 kallikreins are co-expressed in benign and malignant prostate tissue. The androgen-regulated expression of KLK2 and KLK3 is well-characterised, but has not been compared with other kallikreins. Therefore, KLK2, 3, 4, 14 and 15 expression were all measured in time course and dose response experiments with androgens, AR-antagonist treatments, hormone deprivation experiments and cells transfected with AR siRNA. Collectively, these experiments demonstrated that prostatic kallikreins are specifically and directly regulated by the AR. The data also revealed that kallikrein genes are differentially regulated by androgens; KLK2 and KLK3 were strongly up-regulated, KLK4 and KLK15 were modestly up-regulated, and KLK14 was repressed. Notably, KLK14 is located at the telomeric end of the kallikrein locus, far away from the centromeric cluster of kallikreins that are stimulated by androgens. These results show that the expression of KLK2, 3, 4, 14 and 15 is maintained in prostate cancer, but that these genes exhibit different responses to androgens. This makes the kallikrein locus an ideal model to investigate AR signalling. The increasingly dedifferentiated phenotype of aggressive prostate cancer cells is accompanied by the re-expression of signalling molecules that are usually expressed during embryogenesis and foetal tissue development. The Wnt pathway is one developmental cascade that is reactivated in prostate cancer. The canonical Wnt cascade regulates the intracellular levels of β-catenin, a potent transcriptional co-activator of T-cell factor (TCF) transcription factors. Notably, β-catenin can also bind to the AR and synergistically stimulate androgen-mediated gene expression. This is at the expense of typical Wnt/TCF target genes, because the AR:β-catenin and TCF:β-catenin interactions are mutually exclusive. The effect of β-catenin on kallikrein expression was examined to further investigate the role of β-catenin in prostate cancer. Stable knockdown of β-catenin in LNCaP prostate cancer cells attenuated the androgen-regulated expression of KLK2, 3, 4 and 15, but not KLK14. To test whether KLK14 is instead a TCF:β-catenin target gene, the endogenous levels of β-catenin were increased by inhibiting its degradation. Although KLK14 expression was up-regulated by these treatments, siRNA knockdown of β-catenin demonstrated that this effect was independent of β-catenin. These results show that β-catenin is required for maximal expression of KLK2, 3, 4 and 15, but not KLK14. Developmental cells and tumour cells express a similar repertoire of signalling molecules, which means that these different cell types are responsive to one another. Previous reports have shown that stem cells and foetal tissues can reprogram aggressive cancer cells to less aggressive phenotypes by restoring the balance to developmental signalling pathways that are highly dysregulated in cancer. To investigate this phenomenon in prostate cancer, DU145 and PC-3 prostate cancer cells were cultured on matrices pre-conditioned with human embryonic stem cells (hESCs). Soft agar assays showed that prostate cancer cells exposed to hESC conditioned matrices had reduced clonogenicity compared with cells harvested from control matrices. A recent study demonstrated that this effect was partially due to hESC-derived Lefty, an antagonist of Nodal. A member of the transforming growth factor β (TGFβ) superfamily, Nodal regulates embryogenesis and is re-expressed in cancer. The role of Nodal in prostate cancer has not previously been reported. Therefore, the expression and function of the Nodal signalling pathway in prostate cancer was investigated. Western blots confirmed that Nodal is expressed in DU145 and PC-3 cells. Immunohistochemistry revealed greater expression of Nodal in malignant versus benign glands. Notably, the Nodal inhibitor, Lefty, was not expressed at the mRNA level in any prostate cell lines tested. The Nodal signalling pathway is functionally active in prostate cancer cells. Recombinant Nodal treatments triggered downstream phosphorylation of Smad2 in DU145 and LNCaP cells, and stably-transfected Nodal increased the clonogencity of LNCaP cells. Nodal was also found to modulate AR signalling. Nodal reduced the activity of an androgen-regulated KLK3 promoter construct in luciferase assays and attenuated the endogenous expression of AR target genes including prostatic kallikreins. These results demonstrate that Nodal is a novel example of a developmental signalling molecule that is reexpressed in prostate cancer and may have a functional role in prostate cancer progression. In summary, this project clarifies the role of androgens and changing cellular differentiation in prostate cancer by characterising the expression and function of the downstream genes encoding kallikrein-related serine proteases and Nodal. Furthermore, this study emphasises the similarities between prostate cancer and early development, and the crosstalk between developmental signalling pathways and the AR axis. The outcomes of this project also affirm the utility of the kallikrein locus as a model system to monitor tumour progression and the phenotype of prostate cancer cells.