Nutritional status in Parkinson's disease patients undergoing deep-brain stimulation surgery : a pilot study

People with Parkinson’s disease (PD) are at higher risk of malnutrition due to PD symptoms and pharmacotherapy side effects. Poorer outcomes are associated with higher amounts of weight loss (>5%) and lower levels of fat free mass. When pharmacotherapy is no longer effective for symptom control, deep-brain stimulation (DBS) surgery may be considered. People with PD scheduled for DBS surgery were recruited from a Brisbane neurological clinic (n=11 out of 16). The Scale for Outcomes of Parkinson’s disease –Autonomic (SCOPA-AUT), Modified Constipation Assessment Scale (MCAS), and a 3-day food diary were mailed to participants’ homes for completion prior to hospital admission. During admission, the Patient-Generated Subjective Global Assessment (PG-SGA), weight, height and body composition were assessed. Mean(±s.d.) PD duration from diagnosis and time since occurrence of PD symptoms was 9.0(±8.0) and 12(±8.8) years, respectively. Five participants reported unintentional weight loss (average loss of 15.6%). PD duration but not years since symptom onset significantly predicted PG-SGA scores (β=4.2, t(8)=2.7, p<.05). Both were positively correlated with PG-SGA score (r = .667, r=.587). On average, participants classified as well-nourished (SGA-A) (n=4) were younger, had shorter disease durations, lower PG-SGA scores, higher body mass (BMI) and fat free mass (FFMI) indices when compared to malnourished participants (SGA-B) (n=7). They also reported fewer non-motor symptoms on the SCOPA-AUT and MCAS. Three participants had previously received dietetic advice but not in relation to PD. These findings demonstrate that malnutrition remains unrecognised and untreated in this group despite unintentional weight loss and a high prevalence of malnutrition.

Nutritional status in Parkinson’s disease patients undergoing deep brain stimulation surgery : a pilot study

Objectives: People with Parkinson’s disease (PD) are at higher risk of malnutrition due to PD symptoms and pharmacotherapy side effects. When pharmacotherapy is no longer effective for symptom control, deep-brain stimulation (DBS) surgery may be considered. The aim of this study was to assess the nutritional status of people with PD who may be at higher risk of malnutrition related to unsatisfactory symptom management with optimised medical therapy. Design: This was an observational study using a convenience sample. Setting: Participants were seen during their hospital admission for their deep brain stimulation surgery. Participants: People with PD scheduled for DBS surgery were recruited from a Brisbane neurological clinic (n=15). Measurements: The Patient-Generated Subjective Global Assessment (PG-SGA), weight, height and body composition were assessed to determine nutritional status. Results: Six participants (40%) were classified as moderately malnourished (SGA-B). Eight participants (53%) reported previous unintentional weight loss (average loss of 13.3%). On average, participants classified as well-nourished (SGA-A) were younger, had shorter disease durations, lower PG-SGA scores, higher body mass (BMI) and fat free mass indices (FFMI) when compared to malnourished participants (SGA-B). Five participants had previously received dietetic advice but only one in relation to unintentional weight loss. Conclusion: Malnutrition remains unrecognised and untreated in this group despite unintentional weight loss and presence of nutrition impact symptoms. Improving nutritional status prior to surgery may improve surgical outcomes.

The impact of litigation risk on corporate prospective disclosure : a review of the empirical literature

We review the literature on the impact of litigation risk (a form of external governance) on corporate prospective disclosure decisions as reflected in management earnings forecasts. From this analysis we identify four key areas for future research. First, litigation risk warrants more attention from researchers; currently it tends to be treated as a secondary factor impacting MEF decisions. Second, it would be informative from a governance perspective for researchers to explore why litigation risk has a differential impact on MEF decisions across countries. Third, understanding the interaction between litigation risk and forecast/firm-specific characteristics is important from management, investor and regulatory perspectives but is currently under-explored Last, research on the litigation risk and MEF attributes link is piecemeal and incomplete, requiring more integrated and expanded analysis.

Enhancing opportunities to feed forward ; developing problem solving skills using web based scenarios

Universities often struggle to satisfy students’ need for feedback. This is an area where student satisfaction with courses of study can be low. Yet it is clear that one of the properties of good teaching is giving the highest quality feedback on student work. The term ‘feedback’ though is most commonly associated with summative assessment given by a teacher after work is completed. The student can often be a passive participant in the process. This paper looks at the implementation of a web based interactive scenario completed by students prior to summative assessment. It requires students to participate actively to develop and improve their legal problem solving skills. Traditional delivery of legal education focuses on print and an instructor who conveys the meaning of the written word to students. Today, mixed modes of teaching are often preferred and they can provide enhanced opportunities for feeding forward with greater emphasis on what students do. Web based activities allow for flexible delivery; they are accessible off campus, at a time that suits the student and may be completed by students at their own pace. This paper reports on an online interactive activity which provides valuable formative feedback necessary to allow for successful completion of a final problem solving assignment. It focuses on how the online activity feeds forward and contributes to the development of legal problem solving skills. Introduction to Law is a unit designed and introduced for completion by undergraduate students from faculties other than law but is focused most particularly on students enrolled in the Bachelor of Entertainment Industries degree, a joint initiative of the faculties of Creative Industries, Business and Law at the Queensland University of Technology in Australia. The final (and major) assessment for the unit is an assignment requiring students to explain the legal consequences of particular scenarios. A number of cost effective web based interactive scenarios have been developed to support the unit’s classroom activities. The tool commences with instruction on problem solving method. Students then view the stimulus which is a narrative produced in the form of a music video clip. A series of questions are posed which guide students through the process and they can compare their responses with sample answers provided. The activity clarifies the problem solving method and expectations for the summative assessment and allows students to practise the skill. The paper reports on the approach to teaching and learning taken in the unit including the design process and implementation of the activity. It includes an evaluation of the activity with respect to its effectiveness as a tool to feed forward and reflects on the implications for the teaching of law in higher education.

Assessing Cardiovascular Risk in Regional Areas: The Healthy Hearts – Beyond City Limits Program

Background: Cardiovascular disease (CVD) is more prevalent in regional and remote Australia compared to metropolitan areas. The aim of Healthy Hearts was to determine age and sex specific CVD risk factor levels and the potential value of national risk clinics. Methods: Healthy Hearts was an observational research study conducted in four purposefully selected higher risk communities in regional Victoria, Australia. The main outcome measures were the proportion of participants with CVD risk factors with group comparisons to determine the adjusted likelihood of elevated risk factor levels. Trained personnel used a standardized protocol over four weeks per community to measure CVD risk factor levels, estimate absolute CVD risk and provide feedback and advice. Results: A total of 2125 self-selected participants were assessed (mean age 58 ± 15 years, 57% women). Overall, CVD risk factors were highly prevalent. More men than women had ≥ 2 modifiable CVD risk factors (76% vs. 68%, p < .001), pre-existing CVD (20 vs. 15%, p < .01) and a major ECG abnormality requiring follow-up (15% vs. 7%, p < .001) . Less men reported depressive symptoms compared to women (28% vs. 22%, p < .01). A higher proportion of women were obese (adjusted OR 1.36, 95% CI 1.13 to 1.63), and physically inactive (adjusted OR 1.32, 95% CI 1.07 to 1.63). Conclusions: High CVD risk factor levels were confirmed for regional Victoria. Close engagement with individuals and communities provides scope for the application of regional risk management clinics to reduce the burden of CVD risk in regional Australia.

Telehealth for nursing homes: the utilization of specialist services for residential care

Specialist care consultations were identified by two research nurses using documentation in patient records, appointment diaries, electronic billing services and on-site observations at a 441-bed long term care facility. Over a six-month period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). Most consultations were for general practice (n = 2589, 78%); these consultations were mainly on site (99%), with only 27 taking place off site. There were 744 consultations for specialities other than general practice. A total of 146 events related to an emergency or unplanned hospital admission. The remaining medical consultations (n = 598, 18%) related to 23 medical specialities. The largest number of consultations were for surgery (n = 106), podiatry (n = 100), nursing services including wound care (n = 74), imaging (n = 41) and ophthalmology (n = 40). Many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

Ambulance use is associated with higher self-rated illness seriousness : user attitudes and perceptions

Objectives The objective was to study the role and effect of patients' perceptions on reasons for using ambulance services in Queensland, Australia. Methods A cross-sectional survey was conducted of patients (n = 911) presenting via ambulance or self-transport at eight public hospital emergency departments (EDs). The survey included perceived illness severity, attitudes toward ambulance, and reasons for using ambulance. A theoretical framework was developed to inform this study. Results Ambulance users had significantly higher self-rated perceived seriousness, urgency, and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions. In compared to self-transports, likelihood of using an ambulance increased by 26% for every unit increase in perceived seriousness; and patients who had not used an ambulance in the 6 months prior to the survey were 66% less likely to arrive by ambulance. Patients who had presented via ambulance stated they considered the urgency (87%) or severity (84%) of their conditions as reasons for calling the ambulance. Other reasons included requiring special care (76%), getting higher priority at the ED (34%), not having a car (34%), and financial concerns (17%). Conclusions Understanding patients' perceptions is essential in explaining their actions and developing safe and effective health promotion programs. Individuals use ambulances for various reasons and justifications according to their beliefs, attitudes, and sociodemographic conditions. Policies to reduce and manage demand for such services need to address both general opinions and specific attitudes toward emergency health services to be effective.

Circulating tumour cells, their role in metastasis and their clinical utility in lung cancer

Circulating tumour cells (CTCs) have attracted much recent interest in cancer research as a potential biomarker and as a means of studying the process of metastasis. It has long been understood that metastasis is a hallmark of malignancy, and conceptual theories on the basis of metastasis from the nineteenth century foretold the existence of a tumour "seed" which is capable of establishing discrete tumours in the "soil" of distant organs. This prescient "seed and soil" hypothesis accurately predicted the existence of CTCs; microscopic tumour fragments in the blood, at least some of which are capable of forming metastases. However, it is only in recent years that reliable, reproducible methods of CTC detection and analysis have been developed. To date, the majority of studies have employed the CellSearch™ system (Veridex LLC), which is an immunomagnetic purification method. Other promising techniques include microfluidic filters, isolation of tumour cells by size using microporous polycarbonate filters and flow cytometry-based approaches. While many challenges still exist, the detection of CTCs in blood is becoming increasingly feasible, giving rise to some tantalizing questions about the use of CTCs as a potential biomarker. CTC enumeration has been used to guide prognosis in patients with metastatic disease, and to act as a surrogate marker for disease response during therapy. Other possible uses for CTC detection include prognostication in early stage patients, identifying patients requiring adjuvant therapy, or in surveillance, for the detection of relapsing disease. Another exciting possible use for CTC detection assays is the molecular and genetic characterization of CTCs to act as a "liquid biopsy" representative of the primary tumour. Indeed it has already been demonstrated that it is possible to detect HER2, KRAS and EGFR mutation status in breast, colon and lung cancer CTCs respectively. In the course of this review, we shall discuss the biology of CTCs and their role in metastagenesis, the most commonly used techniques for their detection and the evidence to date of their clinical utility, with particular reference to lung cancer.

Development and interrater reliability testing of a telephone interview training programme for Australian nurse interviewers

Summary Background The final phase of a three phase study analysing the implementation and impact of the nurse practitioner role in Australia (the Australian Nurse Practitioner Project or AUSPRAC) was undertaken in 2009, requiring nurse telephone interviewers to gather information about health outcomes directly from patients and their treating nurse practitioners. A team of several registered nurses was recruited and trained as telephone interviewers. The aim of this paper is to report on development and evaluation of the training process for telephone interviewers. Methods The training process involved planning the content and methods to be used in the training session; delivering the session; testing skills and understanding of interviewers post-training; collecting and analysing data to determine the degree to which the training process was successful in meeting objectives and post-training follow-up. All aspects of the training process were informed by established educational principles. Results Interrater reliability between interviewers was high for well-validated sections of the survey instrument resulting in 100% agreement between interviewers. Other sections with unvalidated questions showed lower agreement (between 75% and 90%). Overall the agreement between interviewers was 92%. Each interviewer was also measured against a specifically developed master script or gold standard and for this each interviewer achieved a percentage of correct answers of 94.7% or better. This equated to a Kappa value of 0.92 or better. Conclusion The telephone interviewer training process was very effective and achieved high interrater reliability. We argue that the high reliability was due to the use of well validated instruments and the carefully planned programme based on established educational principles. There is limited published literature on how to successfully operationalise educational principles and tailor them for specific research studies; this report addresses this knowledge gap.

Outcomes following inpatient rehabilitation : a seven year perspective

Introduction: Improving physical and cognitive functioning is a key objective of multi-disciplinary inpatient geriatric rehabilitation. Outcomes relevant to minimum functional ability required for older adults to successfully participate in the community have been reported. However, there has been little investigation reporting outcomes of older inpatients receiving multi-disciplinary rehabilitation being discharged home from geriatric rehabilitation units. This study aims to investigate characteristics and physical and cognitive outcomes of this cohort. Method: The Princess Alexandra Hospital Geriatric and Rehabilitation Unit is the largest rehabilitation unit in Queensland. Multidisciplinary health professionals enter admission and discharge functional and clinical outcomes along with demographic information into a purpose designed database for all patients. Data collected between 2005 and 2011 was analysed using descriptive statistics. Results: During the seven-year period, 4120 patients were admitted for rehabilitation; 2126 (52%) were female, mean age of 74 years (Standard Deviation 14). Primary reasons for admission were for reconditioning post medical illness or surgical admission (n = 1285, 31%), and 30% (n = 1233) admitted for orthopaedic reasons. Of these orthopaedic admissions, 6.6% (n = 82) were for elective surgery, and 46% (n = 565) were for fractured neck-of-femurs. 76% (n = 3130) of patients were discharged home, 13% (n = 552) to residential care facilities and 10% (n = 430) were discharged to an alternative hospital setting or passed away during their admission. Mean length of stay was 44 days (SD 39) Preliminary analysis of FIM outcomes shows a mean motor score of 53 (SD = 19) on admission which significantly improved to 71 (SD = 18) by discharge. There was no change on FIM cognitive score (28 (SD7) vs 29 (SD 6). Conclusion: Geriatric patients have significant functional limitations even on discharge from inpatient rehabilitation; though overall cognition is relatively intact. Orthopaedic conditions and general deconditioning from medical/surgical admissions are the main reasons for admission. The majority of people receiving rehabilitation are discharged home.

Outcomes following inpatient rehabilitation of lower limb amputees

Introduction: Lower-limb amputations are a serious adverse consequence of lifestyle related chronic conditions and a serious concern among the aging population in Australia. Lower limb amputations have severe personal, social and economic impacts on the individual, healthcare system and broader community. This study aimed to address a critical gap in the research literature by investigating the physical functioning and social characteristics of lower limb amputees at discharge from tertiary hospital inpatient rehabilitation. Method: A cohort study was implemented among patients with lower limb amputations admitted to a Geriatric Assessment and Rehabilitation Unit for rehabilitation at a tertiary hospital. Conventional descriptive statistics were used to examine patient demographic, physical functioning and social living outcomes recorded for patients admitted between 2005 and 2011. Results: A total of 423 admissions occurred during the study period, 313 (74%) were male. This sample included admissions for left (n = 189, 45%), right (n = 220, 52%) and bilateral (n = 14, 3%) lower limb amputations, with 15 (3%) patients dying whilst an inpatient. The mean (standard deviation) age was 65 (13.9) years. Amputations attributed to vascular causes accounted for 333 (78%) admissions; 65 (15%) of these had previously had an amputation. The mean (SD) length of stay in the rehabilitation unit was 56 (42) days. Prior to this admission, 123 (29%) patients were living alone, 289 (68%) were living with another and 3 (0.7%) were living in residential care. Following this amputation related admission, 89 (21%) patients did not return to their prior living situation. Of those admitted, 187 (44%) patients were discharged with a lower limb prosthesis. Conclusion: The clinical group is predominately older adults. The ratio of males to females was approximately 3:1. Over half did not return to walking and many were not able to return to their prior accommodation. However, few patients died during their admission.

Consumer guarantees and the supply of educational services by higher education providers

The higher education sector is undergoing a number of significant changes, the implications of which have yet to emerge. One such change is the increasing reliance by higher education providers on the revenue generated by full fee paying international students to fund their operating expenses. The report by the Victorian Ombudsman, Investigation into how Universities Deal with International Students ('Victorian Ombudsman's Report') tabled in the Victorian Parliament on 27 October 2011, provides evidence that Australian higher education providers may be failing to meet their legal obligations to international students. The Victorian Ombudsman's Report is the result of an investigation into four Victorian universities teaching international students with a focus on accounting and nursing schools. The report contains evidence that the universities were admitting students with scores below, or at the lower end of, the International English Language Testing System ('IELTS') score considered acceptable. Alternatively, they were relying upon their own language testing admission standards and not on an independent test like the IELTS test. While the universities provided English language support services for their international students after they had been admitted, the Ombudsman was concerned that the universities 'have not dedicated sufficient resources to meet the level of need amongst international students'.

A lawyer's duty of care : beware the failure to advise of contingencies and foreseeable risks

It is trite law that a lawyer owes their client a duty of care requiring the lawyer to take reasonable steps to avoid their client suffering foreseeable economiic loss: Hawkins v Clayton. In the context of a property transaction this will include a duty to warn the client of anything that is unusual or anything which may affect the client obtaining the full benefit of the contract entered into: Macindoe v Parbery.

Benefit cost analysis applied to behavioral and engineering safety countermeasures in San Francisco, California

The state of the practice in safety has advanced rapidly in recent years with the emergence of new tools and processes for improving selection of the most cost-effective safety countermeasures. However, many challenges prevent fair and objective comparisons of countermeasures applied across safety disciplines (e.g. engineering, emergency services, and behavioral measures). These countermeasures operate at different spatial scales, are funded often by different financial sources and agencies, and have associated costs and benefits that are difficult to estimate. This research proposes a methodology by which both behavioral and engineering safety investments are considered and compared in a specific local context. The methodology involves a multi-stage process that enables the analyst to select countermeasures that yield high benefits to costs, are targeted for a particular project, and that may involve costs and benefits that accrue over varying spatial and temporal scales. The methodology is illustrated using a case study from the Geary Boulevard Corridor in San Francisco, California. The case study illustrates that: 1) The methodology enables the identification and assessment of a wide range of safety investment types at the project level; 2) The nature of crash histories lend themselves to the selection of both behavioral and engineering investments, requiring cooperation across agencies; and 3) The results of the cost-benefit analysis are highly sensitive to cost and benefit assumptions, and thus listing and justification of all assumptions is required. It is recommended that a sensitivity analyses be conducted when there is large uncertainty surrounding cost and benefit assumptions.

Language and utilisation of emergency care in Queensland

Objective: To compare access and utilisation of EDs in Queensland public hospitals between people who speak only English at home and those who speak another language at home. Methods: A retrospective analysis of a Queensland statewide hospital ED dataset (ED Information System) from 1 January 2008 to 31 December 2010 was conducted. Access to ED care was measured by the proportion of the state’s population attending EDs. Logistic regression analyses were performed to determine the relationships between ambulance use and language, and between hospital admission and language, both after adjusting for age, sex and triage category. Results: The ED utilisation rate was highest in English only speakers (290 per 1000 population), followed by Arabic speakers (105), and lowest among German speakers (30). Compared with English speakers, there were lower rates of ambulance use in Chinese (odds ratio 0.50, 95% confidence interval, 0.47–0.54), Vietnamese (0.87, 0.79–0.95), Arabic (0.87, 0.78–0.97), Spanish (0.56, 0.50–0.62), Italian (0.88, 0.80–0.96), Hindi (0.61, 0.53–0.70) and German (0.87, 0.79–0.90) speakers. Compared with English speakers, German speakers had higher admission rates (odds ratio 1.17, 95% confidence interval, 1.02–1.34), whereas there were lower admission rates in Chinese (0.90, 0.86–0.99), Arabic (0.76, 0.67–0.85) and Spanish (0.83, 0.75–0.93) speakers. Conclusion: This study showed that there was a significant association between lower utilisation of emergency care and speaking languages other than English at home. Further researches are needed using in-depth methodology to investigate if there are language barriers in accessing emergency care in Queensland.