Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

Development of a food frequency questionnaire for Sri Lankan adults

Abstract (provisional) Background Food Frequency Questionnaires (FFQs) are commonly used in epidemiologic studies to assess long-term nutritional exposure. Because of wide variations in dietary habits in different countries, a FFQ must be developed to suit the specific population. Sri Lanka is undergoing nutritional transition and diet-related chronic diseases are emerging as an important health problem. Currently, no FFQ has been developed for Sri Lankan adults. In this study, we developed a FFQ to assess the regular dietary intake of Sri Lankan adults. Methods A nationally representative sample of 600 adults was selected by a multi-stage random cluster sampling technique and dietary intake was assessed by random 24-h dietary recall. Nutrient analysis of the FFQ required the selection of foods, development of recipes and application of these to cooked foods to develop a nutrient database. We constructed a comprehensive food list with the units of measurement. A stepwise regression method was used to identify foods contributing to a cumulative 90% of variance to total energy and macronutrients. In addition, a series of photographs were included. Results We obtained dietary data from 482 participants and 312 different food items were recorded. Nutritionists grouped similar food items which resulted in a total of 178 items. After performing step-wise multiple regression, 93 foods explained 90% of the variance for total energy intake, carbohydrates, protein, total fat and dietary fibre. Finally, 90 food items and 12 photographs were selected. Conclusion We developed a FFQ and the related nutrient composition database for Sri Lankan adults. Culturally specific dietary tools are central to capturing the role of diet in risk for chronic disease in Sri Lanka. The next step will involve the verification of FFQ reproducibility and validity.

Talk and web searching in an early years classroom

Recent Australian early childhood policy and curriculum guidelines promoting the use of technologies invite investigations of young children’s practices in classrooms. This study examined the practices of one preparatory year classroom, to show teacher and child interactions as they engaged in Web searching. The study investigated the in situ practices of the teacher and children to show how they accomplished the Web search. The data corpus consists of eight hours of videorecorded interactions over three days where children and teachers engaged in Web searching. One episode was selected that showed a teacher and two children undertaking a Web search. The episode is shown to consist of four phases: deciding on a new search subject, inputting the search query, considering the result options, and exploring the selected result. The sociological perspectives of ethnomethodology and conversation analysis were employed as the conceptual and methodological frameworks of the study, to analyse the video-recorded teacher and child interactions as they co-constructed a Web search. Ethnomethodology is concerned with how people make ‘sense’ in everyday interactions, and conversation analysis focuses on the sequential features of interaction to show how the interaction unfolds moment by moment. This extended single case analysis showed how the Web search was accomplished over multiple turns, and how the children and teacher collaboratively engaged in talk. There are four main findings. The first was that Web searching featured sustained teacher-child interaction, requiring a particular sort of classroom organisation to enable the teacher to work in this sustained way. The second finding was that the teacher’s actions recognised the children’s interactional competence in situ, orchestrating an interactional climate where everyone was heard. The third finding was that the teacher drew upon a range of interactional resources designed to progress the activity at hand, that of accomplishing the Web search. The teacher drew upon the interactional resources of interrogatives, discourse markers, and multi-unit turns during the Web search, and these assisted the teacher and children to co-construct their discussion, decide upon and co-ordinate their future actions, and accomplish the Web search in a timely way. The fourth finding explicates how particular social and pedagogic orders are accomplished through talk, where children collaborated with each other and with the teacher to complete the Web search. The study makes three key recommendations for the field of early childhood education. The study’s first recommendation is that fine-grained transcription and analysis of interaction aids in understanding interactional practices of Web searching. This study offers material for use in professional development, such as using transcribed and videorecorded interactions to highlight how teachers strategically engage with children, that is, how talk works in classroom settings. Another strategy is to focus on the social interactions of members engaging in Web searches, which is likely to be of interest to teachers as they work to engage with children in an increasingly online environment. The second recommendation involves classroom organisation; how teachers consider and plan for extended periods of time for Web searching, and how teachers accommodate children’s prior knowledge of Web searching in their classrooms. The third recommendation is in relation to future empirical research, with suggested possible topics focusing on the social interactions of children as they engage with peers as they Web search, as well as investigations of techno-literacy skills as children use the Internet in the early years.

Health complaint commissions in Australia : time for a national approach to data collection

Health complaint statistics are important for identifying problems and bringing about improvements to health care provided by health service providers and to the wider health care system. This paper overviews complaints handling by the eight Australian state and territory health complaint entities, based on an analysis of data from their annual reports. The analysis shows considerable variation between jurisdictions in the ways complaint data are defined, collected and recorded. Complaints from the public are an important accountability mechanism and open a window on service quality. The lack of a national approach leads to fragmentation of complaint data and a lost opportunity to use national data to assist policy development and identify the main areas causing consumers to complain. We need a national approach to complaints data collection in order to better respond to patients’ concerns.

The post-illumination pupil response of melanopsin expressing intrinsically photosensitive retinal ganglion cells in diabetes

Purpose: This study investigates the clinical utility of the melanopsin expressing intrinsically photosensitive retinal ganglion cell (ipRGC) controlled post-illumination pupil response (PIPR) as a novel technique for documenting inner retinal function in patients with Type II diabetes without diabetic retinopathy. Methods: The post-illumination pupil response (PIPR) was measured in seven patients with Type II diabetes, normal retinal nerve fiber thickness and no diabetic retinopathy. A 488 nm and 610 nm, 7.15º diameter stimulus was presented in Maxwellian view to the right eye and the left consensual pupil light reflex was recorded. Results: The group data for the blue PIPR (488 nm) identified a trend of reduced ipRGC function in patients with diabetes with no retinopathy. The transient pupil constriction was lower on average in the diabetic group. The relationship between duration of diabetes and the blue PIPR amplitude was linear, suggesting that ipRGC function decreases with increasing diabetes duration. Conclusion: This is the first report to show that the ipRGC controlled post-illumination pupil response may have clinical applications as a non-invasive technique for determining progression of inner neuroretinal changes in patients with diabetes before they are ophthalmoscopically or anatomically evident. The lower transient pupil constriction amplitude indicates that outer retinal photoreceptor inputs to the pupil light reflex may also be affected in diabetes.

Learning and assessment in Australia

Camp Kilda (CK) is regarded as being a quality early childhood center, and has many features you would typically expect to see in settings across Australia. The children are busily engaged in hands-on activity, playing indoors and outdoors, in the sandpit, under the shade of a big mango tree. The learning environment is planned to offer a variety of activities, including dramatic play, climbing equipment, balls, painting, drawing, clay, books, blocks, writing materials, scissors, manipulative materials. The children are free to access all the materials, and they play either individually or in small groups. The teachers encourage and stimulate the children’s learning, through interactions and thoughtful planning. Learning and assessment at CK is embedded within the cultural and social contexts of the children and their community. Children’s learning is made visible through a rich variety of strategies, including recorded observations, work samples, photographs, and other artifacts. Parents are actively encouraged to build on these “stories” of their children. Planning is based around the teachers’ analysis of the information they gather daily as they interact with the children and their families.

Encouraging, assisting and time to EAT : improved nutritional intake for older medical patients receiving Protected Mealtimes and/or additional nursing feeding assistance

Background & Aims: Inadequate feeding assistance and mealtime interruptions during hospitalisation may contribute to malnutrition and poor nutritional intake in older people. This study aimed to implement and compare three interventions designed to specifically address mealtime barriers and improve energy intakes of medical inpatients aged ≥65 years. Methods: Pre-post study compared three mealtime assistance interventions: PM: Protected Mealtimes with multidisciplinary education; AIN: additional assistant-in-nursing (AIN) with dedicated meal role; PM+AIN: combined intervention. Dietary intake of 254 patients (pre: n=115, post: n=141; mean age 80±8) was visually estimated on a single day in the first week of hospitalisation and compared with estimated energy requirements. Assistance activities were observed and recorded. Results: Mealtime assistance levels significantly increased in all interventions (p<0.01). Post-intervention participants were more likely to achieve adequate energy intake (OR=3.4, p=0.01), with no difference noted between interventions (p=0.29). Patients with cognitive impairment or feeding dependency appeared to gain substantial benefit from mealtime assistance interventions. Conclusions: Protected Mealtimes and additional AIN assistance (implemented alone or in combination) may produce modest improvements in nutritional intake. Targeted feeding assistance for certain patient groups holds promise; however, alternative strategies are required to address the complex problem of malnutrition in this population.

Spatial and temporal analysis of Barmah Forest virus disease in Queensland, Australia

Barmah Forest virus (BFV) disease is one of the most widespread mosquito-borne diseases in Australia. The number of outbreaks and the incidence rate of BFV in Australia have attracted growing concerns about the spatio-temporal complexity and underlying risk factors of BFV disease. A large number of notifications has been recorded continuously in Queensland since 1992. Yet, little is known about the spatial and temporal characteristics of the disease. I aim to use notification data to better understand the effects of climatic, demographic, socio-economic and ecological risk factors on the spatial epidemiology of BFV disease transmission, develop predictive risk models and forecast future disease risks under climate change scenarios. Computerised data files of daily notifications of BFV disease and climatic variables in Queensland during 1992-2008 were obtained from Queensland Health and Australian Bureau of Meteorology, respectively. Projections on climate data for years 2025, 2050 and 2100 were obtained from Council of Scientific Industrial Research Organisation. Data on socio-economic, demographic and ecological factors were also obtained from relevant government departments as follows: 1) socio-economic and demographic data from Australian Bureau of Statistics; 2) wetlands data from Department of Environment and Resource Management and 3) tidal readings from Queensland Department of Transport and Main roads. Disease notifications were geocoded and spatial and temporal patterns of disease were investigated using geostatistics. Visualisation of BFV disease incidence rates through mapping reveals the presence of substantial spatio-temporal variation at statistical local areas (SLA) over time. Results reveal high incidence rates of BFV disease along coastal areas compared to the whole area of Queensland. A Mantel-Haenszel Chi-square analysis for trend reveals a statistically significant relationship between BFV disease incidence rates and age groups (ƒÓ2 = 7587, p<0.01). Semi-variogram analysis and smoothed maps created from interpolation techniques indicate that the pattern of spatial autocorrelation was not homogeneous across the state. A cluster analysis was used to detect the hot spots/clusters of BFV disease at a SLA level. Most likely spatial and space-time clusters are detected at the same locations across coastal Queensland (p<0.05). The study demonstrates heterogeneity of disease risk at a SLA level and reveals the spatial and temporal clustering of BFV disease in Queensland. Discriminant analysis was employed to establish a link between wetland classes, climate zones and BFV disease. This is because the importance of wetlands in the transmission of BFV disease remains unclear. The multivariable discriminant modelling analyses demonstrate that wetland types of saline 1, riverine and saline tidal influence were the most significant risk factors for BFV disease in all climate and buffer zones, while lacustrine, palustrine, estuarine and saline 2 and saline 3 wetlands were less important. The model accuracies were 76%, 98% and 100% for BFV risk in subtropical, tropical and temperate climate zones, respectively. This study demonstrates that BFV disease risk varied with wetland class and climate zone. The study suggests that wetlands may act as potential breeding habitats for BFV vectors. Multivariable spatial regression models were applied to assess the impact of spatial climatic, socio-economic and tidal factors on the BFV disease in Queensland. Spatial regression models were developed to account for spatial effects. Spatial regression models generated superior estimates over a traditional regression model. In the spatial regression models, BFV disease incidence shows an inverse relationship with minimum temperature, low tide and distance to coast, and positive relationship with rainfall in coastal areas whereas in whole Queensland the disease shows an inverse relationship with minimum temperature and high tide and positive relationship with rainfall. This study determines the most significant spatial risk factors for BFV disease across Queensland. Empirical models were developed to forecast the future risk of BFV disease outbreaks in coastal Queensland using existing climatic, socio-economic and tidal conditions under climate change scenarios. Logistic regression models were developed using BFV disease outbreak data for the existing period (2000-2008). The most parsimonious model had high sensitivity, specificity and accuracy and this model was used to estimate and forecast BFV disease outbreaks for years 2025, 2050 and 2100 under climate change scenarios for Australia. Important contributions arising from this research are that: (i) it is innovative to identify high-risk coastal areas by creating buffers based on grid-centroid and the use of fine-grained spatial units, i.e., mesh blocks; (ii) a spatial regression method was used to account for spatial dependence and heterogeneity of data in the study area; (iii) it determined a range of potential spatial risk factors for BFV disease; and (iv) it predicted the future risk of BFV disease outbreaks under climate change scenarios in Queensland, Australia. In conclusion, the thesis demonstrates that the distribution of BFV disease exhibits a distinct spatial and temporal variation. Such variation is influenced by a range of spatial risk factors including climatic, demographic, socio-economic, ecological and tidal variables. The thesis demonstrates that spatial regression method can be applied to better understand the transmission dynamics of BFV disease and its risk factors. The research findings show that disease notification data can be integrated with multi-factorial risk factor data to develop build-up models and forecast future potential disease risks under climate change scenarios. This thesis may have implications in BFV disease control and prevention programs in Queensland.

Regulation of land access for resource development: A coal seam gas case study from Queensland

A number of regulatory statutes provide for agreements with landowners which are given extended effect, that is, are binding upon the landowner’s successors (‘statutory agreements’). Several Queensland statutes require a project proponent to enter into a statutory agreement with a landowner before a resource development activity can be carried out on private land or by accessing private land. Provisions of Queensland’s Petroleum and Gas (Production and Safety) Act 2004 make certain types of statutory agreements binding upon successors and assigns of the landowner, but do not clearly prescribe the nature and contents of an agreement, nor require that the agreement be recorded on the land title or petroleum register. If statutory agreements are to be used for such purposes, their purpose and content should be more clearly defined by statute and they should be recorded on a searchable register.

Improvising a future in the performing arts : a new strategy to help performance studies students successfully shift between academic culture, professional culture, industry and career?

If there is one thing performance studies graduates should be good at, it is improvising – play and improvisation are central to the contemporary and cultural performance practices we teach and the methods by which we teach them. Objective, offer, acceptance, advancing, reversing, character, status, manipulation, impression management, relationship management – whether we know them from Keith Johnson’s theatre theories or Erving Goffman’s theatre theories, the processes by which we play out a story, scenario or social situation to our own benefit are familiar. We understand that identity, action, interaction and its personal, aesthetic, professional or political outcomes are unpredictable, and that we need to adapt to changeable and uncertain circumstances to achieve our aims. Intriguingly, though, in a Higher Education environment that increasingly emphasises employability, skills in play, improvisation and self-performance are never cited as critical graduate attributes. Is the ability to play, improve and produce spontaneous new self-performances learned in the academy worth articulating into an ability to play, improvise and product spontaneous new self-performances after graduates leave the academy and move into the role of a performing arts professional in industry? A study of the career paths of our performance studies graduates over the past decade suggests that addressing the challenges they face in moving between academic culture, professional culture, industry and career in terms of improvisation and play principles may be very productive. In articles on performing arts careers, graduates are typically advised to find a market for their work, and develop career self-management, management and marketing skills, together with an ability to find, make and maintain relationships and opportunities for themselves. Transitioning to career is cast as a challenging process, requiring these skills, because performing arts careers do not offer the security, status and stability of other careers. Our data confirms this. In our study, though, we found that strategies commonly used to build the resilience, self-reliance and persistence graduates require – talking about portfolio careers, parallel careers, and portable, transferable or translatable skills, for example – can engender panic as easily as they engender confidence. In this paper, I consider what happens when we re-articulate some of the skills scholars and industry stakeholders argue are critical in allowing graduates to shift successfully from academy to industry in terms of skills like improvisation, play and self-performance that are already familiar, meaningful and much-practiced amongst performance studies graduates.

Preservice teachers’ observations of their mentors’ teaching strategies for differentiated learning

Tensions exist between teacher-centred and learner-centred approaches with constructivism as being favoured for learning in the 21st Century. There is little evidence of teaching strategies being used in the field for differentiating student learning. In addition, preservice teachers need to learn about teaching strategies for which observations of their mentor teachers can provide practical applications. This study explores 16 preservice teachers’ observations of their mentors’ teaching strategies over a four-week professional experience. They provided a minimum of five written observations during this period. Findings indicated that these preservice teachers observed their mentors’ practices and recorded four key teaching strategies used to differentiate learning, namely: (1) designating facilitators for students’ learning, including teacher, peers, parents, and support staff such as teachers aides, (2) managing student groups, (3) contexts for learning, and (4) using a range of teaching aids (visual, auditory, games) and resources. Preservice teachers’ observations of their mentor teachers indicated that they can commence at early stages for identifying teaching strategies and how they work for differentiating student learning.

Duration-dependant response of mixed-method pre-cooling for intermittent-sprint exercise in the heat

This study examined the effects of pre-cooling duration on performance and neuromuscular function for self-paced intermittent-sprint shuttle running in the heat. Eight male, team-sport athletes completed two 35-min bouts of intermittent-sprint shuttle running separated by a 15-min recovery on three separate occasions (33°C, 34% relative humidity). Mixed-method pre-cooling was completed for 20 min (COOL20), 10-min (COOL10) or no cooling (CONT) and reapplied for 5-min mid-exercise. Performance was assessed via sprint times, percentage decline and shuttle-running distance covered. Maximal voluntary contractions (MVC), voluntary activation (VA) and evoked twitch properties were recorded pre- and post-intervention and mid- and post-exercise. Core temperature (T c), skin temperature, heart rate, capillary blood metabolites, sweat losses, perceptual exertion and thermal stress were monitored throughout. Venous blood draws pre- and post-exercise were analyzed for muscle damage and inflammation markers. Shuttle-running distances covered were increased 5.2 ± 3.3% following COOL20 (P < 0.05), with no differences observed between COOL10 and CONT (P > 0.05). COOL20 aided in the maintenance of mid- and post-exercise MVC (P < 0.05; d > 0.80), despite no conditional differences in VA (P > 0.05). Pre-exercise T c was reduced by 0.15 ± 0.13°C with COOL20 (P < 0.05; d > 1.10), and remained lower throughout both COOL20 and COOL10 compared to CONT (P < 0.05; d > 0.80). Pre-cooling reduced sweat losses by 0.4 ± 0.3 kg (P < 0.02; d > 1.15), with COOL20 0.2 ± 0.4 kg less than COOL10 (P = 0.19; d = 1.01). Increased pre-cooling duration lowered physiological demands during exercise heat stress and facilitated the maintenance of self-paced intermittent-sprint performance in the heat. Importantly, the dose-response interaction of pre-cooling and sustained neuromuscular responses may explain the improved exercise performance in hot conditions.

Muscle, skin and core temperature after −110°C cold air and 8°C water treatment

The aim of this investigation was to elucidate the reductions in muscle, skin and core temperature following exposure to −110°C whole body cryotherapy (WBC), and compare these to 8°C cold water immersion (CWI). Twenty active male subjects were randomly assigned to a 4-min exposure of WBC or CWI. A minimum of 7 days later subjects were exposed to the other treatment. Muscle temperature in the right vastus lateralis (n = 10); thigh skin (average, maximum and minimum) and rectal temperature (n = 10) were recorded before and 60 min after treatment. The greatest reduction (P<0.05) in muscle (mean ± SD; 1 cm: WBC, 1.6±1.2°C; CWI, 2.0±1.0°C; 2 cm: WBC, 1.2±0.7°C; CWI, 1.7±0.9°C; 3 cm: WBC, 1.6±0.6°C; CWI, 1.7±0.5°C) and rectal temperature (WBC, 0.3±0.2°C; CWI, 0.4±0.2°C) were observed 60 min after treatment. The largest reductions in average (WBC, 12.1±1.0°C; CWI, 8.4±0.7°C), minimum (WBC, 13.2±1.4°C; CWI, 8.7±0.7°C) and maximum (WBC, 8.8±2.0°C; CWI, 7.2±1.9°C) skin temperature occurred immediately after both CWI and WBC (P<0.05). Skin temperature was significantly lower (P<0.05) immediately after WBC compared to CWI. The present study demonstrates that a single WBC exposure decreases muscle and core temperature to a similar level of those experienced after CWI. Although both treatments significantly reduced skin temperature, WBC elicited a greater decrease compared to CWI. These data may provide information to clinicians and researchers attempting to optimise WBC and CWI protocols in a clinical or sporting setting.

Working with actors in open disclosure simulations

A key strategy in facilitating learning in Open Disclosure training is the use of hypothetical, interactive scenarios called ‘simulations’. According to Clapper (2010), the ‘advantages of using simulation are numerous and include the ability to help learners make meaning of complex tasks, while also developing critical thinking and cultural skills’. Simulation, in turn, functions largely through improvisation and role-play, in which participants ‘act out’ particular roles and characters according to a given scenario, without recourse to a script. To maximise efficacy in the Open Disclosure training context, role-play requires the specialist skills of professionally trained actors. Core capacities that professional actors bring to the training process include (among others) believability, an observable and teachable skill which underpins the western traditions of actor training; and flexibility, which pertains to the actor’s ability to vary performance strategies according to the changing dynamics of the learning situation. The Patient Safety and Quality Improvement Service of Queensland Health utilises professional actors as a key component of their Open Disclosure Training Program. In engaging actors in this work, it is essential that Facilitators of Open Disclosure training have a solid understanding of the acting process: what acting is; how actors work to a brief; how they improvise; and how they sustainably manage a wide range of emotional states. In the simulation context, the highly skilled actor can optimise learning outcomes by adopting or enacting – in collaboration with the Facilitator - a pedagogical function.

Emergence in interactive art

This thesis is concerned with creating and evaluating interactive art systems that facilitate emergent participant experiences. For the purposes of this research, interactive art is the computer based arts involving physical participation from the audience, while emergence is when a new form or concept appears that was not directly implied by the context from which it arose. This emergent ‘whole’ is more than a simple sum of its parts. The research aims to develop understanding of the nature of emergent experiences that might arise during participant interaction with interactive art systems. It also aims to understand the design issues surrounding the creation of these systems. The approach used is Practice-based, integrating practice, evaluation and theoretical research. Practice used methods from Reflection-in-action and Iterative design to create two interactive art systems: Glass Pond and +-now. Creation of +-now resulted in a novel method for instantiating emergent shapes. Both art works were also evaluated in exploratory studies. In addition, a main study with 30 participants was conducted on participant interaction with +-now. These sessions were video recorded and participants were interviewed about their experience. Recordings were transcribed and analysed using Grounded theory methods. Emergent participant experiences were identified and classified using a taxonomy of emergence in interactive art. This taxonomy draws on theoretical research. The outcomes of this Practice-based research are summarised as follows. Two interactive art systems, where the second work clearly facilitates emergent interaction, were created. Their creation involved the development of a novel method for instantiating emergent shapes and it informed aesthetic and design issues surrounding interactive art systems for emergence. A taxonomy of emergence in interactive art was also created. Other outcomes are the evaluation findings about participant experiences, including different types of emergence experienced and the coding schemes produced during data analysis.