New insights into appetite, inflammation and the use of fish oil in hemodialysis patients

Protein-energy wasting (PEW) is commonly seen in patients with chronic kidney disease (CKD). The condition is characterised by chronic, systemic low-grade inflammation which affects nutritional status by a variety of mechanisms including reducing appetite and food intake and increasing muscle catabolism. PEW is linked with co-morbidities such as cardiovascular disease, and is associated with lower quality of life, increased hospitalisations and a 6-fold increase in risk of death1. Significant gender differences have been found in the severity and effects of several markers of PEW. There have been limited studies testing the ability of anti-inflammatory agents or nutritional interventions to reduce the effects of PEW in dialysis patients. This thesis makes a significant contribution to the understanding of PEW in dialysis patients. It advances understanding of measurement techniques for two of the key components, appetite and inflammation, and explores the effect of fish oil, an anti-inflammatory agent, on markers of PEW in dialysis patients. The first part of the thesis consists of two methodological studies conducted using baseline data. The first study aims to validate retrospective ratings of hunger, desire to eat and fullness on visual analog scales (VAS) (paper and pen and electronic) as a new method of measuring appetite in dialysis patients. The second methodological study aims to assess the ability of a variety of methods available in routine practice to detect the presence of inflammation. The second part of the thesis aims to explore the effect of 12 weeks supplementation with 2g per day of Eicosapentaenoic Acid (EPA), a longchain fatty acid found in fish oil, on markers of PEW. A combination of biomarkers and psychomarkers of appetite and inflammation are the main outcomes being explored, with nutritional status, dietary intake and quality of life included as secondary outcomes. A lead in phase of 3 months prior to baseline was used so that each person acts as their own historical control. The study also examines whether there are gender differences in response to the treatment. Being an exploratory study, an important part of the work is to test the feasibility of the intervention, thus the level of adherence and factors associated with adherence are also presented. The studies were conducted at the hemodialysis unit of the Wesley Hospital. Participants met the following criteria: adult, stage 5 CKD on hemodialysis for at least 3 months, not expected to receive a transplant or switch to another dialysis modality during the study, absence of intellectual impairment or mental illness impairing ability to follow instructions or complete the intervention. A range of intermediate, clinical and patient-centred outcome measures were collected at baseline and 12 weeks. Inflammation was measured using five biomarkers: c-reactive protein (CRP), interleukin-6 (IL6), intercellular adhesion molecule (sICAM-1), vascular cell adhesion molecule (sVCAM-1) and white cell count (WCC). Subjective appetite was measured using the first question from the Appetite and Dietary Assessment (ADAT) tool and VAS for measurements of hunger, desire to eat and fullness. A novel feature of the study was the assessment of the appetite peptides leptin, ghrelin and peptide YY as biomarkers of appetite. Nutritional status/inflammation was assessed using the Malnutrition-Inflammation Score (MIS) and the Patient-Generated Subjective Global Assessment (PG-SGA). Dietary intake was measured using 3-day records. Quality of life was measured using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF™ v1.3 © RAND University), which combines the Short-Form 36 (SF36) with a kidney-disease specific module2. A smaller range of these variables was available for analysis during the control phase (CRP, ADAT, dietary intake and nutritional status). Statistical analysis was carried out using SPSS version 14 (SPSS Inc, Chicago IL, USA). Analysis of the first part of the thesis involved descriptive and bivariate statistics, as well as Bland-Altman plots to assess agreement between methods, and sensitivity analysis/ROC curves to test the ability of methods to predict the presence of inflammation. The unadjusted (paired ttests) and adjusted (linear mixed model) change over time is presented for the main outcome variables of inflammation and appetite. Results are shown for the whole group followed by analyses according to gender and adherence to treatment. Due to the exploratory nature of the study, trends and clinical significance were considered as important as statistical significance. Twenty-eight patients (mean age 61±17y, 50% male, dialysis vintage 19.5 (4- 101) months) underwent baseline assessment. Seven out of 28 patients (25%) reported sub-optimal appetite (self-reported as fair, poor or very poor) despite all being well nourished (100% SGA A). Using the VAS, ratings of hunger, but not desire to eat or fullness, were significantly (p<0.05) associated with a range of relevant clinical variables including age (r=-0.376), comorbidities (r=-0.380) nutritional status (PG-SGA score, r=-0.451), inflammatory markers (CRP r=-0.383; sICAM-1 r=-0.387) and seven domains of quality of life. Patients expressed a preference for the paper and pen method of administering VAS. None of the tools (appetite, MIS, PG-SGA, albumin or iron) showed an acceptable ability to detect patients who are inflamed. It is recommended that CRP should be tested more frequently as a matter of course rather than seeking alternative methods of measuring inflammation. 27 patients completed the 12 week intervention. 20 patients were considered adherent based on changes in % plasma EPA, which rose from 1.3 (0.94)% to 5.2 (1.1)%, p<0.001, in this group. The major barriers to adherence were forgetting to take the tablets as well as their size. At 12 weeks, inflammatory markers remained steady apart from the white cell count which decreased (7.6(2.5) vs 7.0(2.2) x109/L, p=0.058) and sVCAM-1 which increased (1685(654) vs 2249(925) ng/mL, p=0.001). Subjective appetite using VAS increased (51mm to 57mm, +12%) and there was a trend towards reduction in peptide YY (660(31) vs 600(30) pg/mL, p=0.078). There were some gender differences apparent, with the following adjusted change between baseline and week 12: CRP (males -3% vs females +17%, p=0.19), IL6 (males +17% vs females +48%, p=0.77), sICAM-1 (males -5% vs females +11%, p=0.07), sVCAM-1 (males +54% vs females +19%, p=0.08) and hunger ratings (males 20% vs females -5%, p=0.18). On balance, males experienced a maintainence or reduction in three inflammatory markers and an improvement in hunger ratings, and therefore appeared to have responded better to the intervention. Compared to those who didn’t adhere, adherent patients maintained weight (mean(SE) change: +0.5(1.6) vs - 0.8(1.2) kg, p=0.052) and fat-free mass (-0.1 (1.6) vs -1.8 (1.8) kg, p=0.045). There was no difference in change between the intervention and control phase for CRP, appetite, nutritional status or dietary intake. The thesis makes a significant contribution to the evidence base for understanding of PEW in dialysis patients. It has advanced knowledge of methods of assessing inflammation and appetite. Retrospective ratings of hunger on a VAS appear to be a valid method of assessing appetite although samples which include patients with very poor appetite are required to confirm this. Supplementation with fish oil appeared to improve subjective appetite and dampen the inflammatory response. The effectiveness of the intervention is influenced by gender and adherence. Males appear to be more responsive to the primary outcome variables than females, and the quality of response is improved with better adherence. These results provide evidence to support future interventions aimed at reducing the effects of PEW in dialysis patients.

Changing the rules in use? An examination of social enterprise in local governance

As multi-stakeholder entities that explicitly inhabit both social and economic domains, social enterprises pose new challenges and possibilities for local governance. In this paper, we draw on new institutional theory to examine the ways in which locally-focused social enterprises disrupt path dependencies and rules in use within local government. Rather than examining the more commonly asked question of the influence of the state on social enterprise, our purpose here is to examine the impacts of social enterprise on governmental institutions at the local level. Our discussion is based on a mixed-methods study, including an online survey of 66 local government staff, document analysis, and in-depth interviews with 24 social enterprise practitioners and local government actors working to support social enterprise development in Victoria, Australia. We find that, in some instances, the hybrid nature of social enterprise facilitates ‘joining up’ between different functional areas of local government. Beyond organisational relationships, social enterprise also influences local governance through the reinterpretation and regeneration of institutionalised public spaces.

Elderly people's use of and attitudes towards assistive devices

People in developed countries are living longer with the help of medical advances. Literature has shown that older people prefer to stay independent and live at home for as long as possible. Therefore, it is important to find out how to best accommodate and assist them in maintaining quality of life and independence as well as easing human resources. Researchers have claimed that assistive devices assist in older people’s independence, however, only a small number of studies regarding the efficiency of assistive devices have been undertaken of which several have stated that devices are not being used. The overall aim of this research was to identify whether the disuse and ineffectiveness of assistive devices are related to change in abilities or related to the design of the devices. The objective was to gather information from the elderly; to identify what assistive devices are being used or not used and to gain an understanding on their attitudes towards assistive devices. Research was conducted in two phases. The initial phase of the research was conducted with the distribution of questionnaires to people over the age of fifty that asked general questions and specific questions on type of devices being used. Phase One was followed on by Phase Two, where participants from Phase One who had come in contact with assistive devices were invited to participate in a semi-structured interview. Questions were put forth to the interviewee on their use of and attitudes towards assistive devices. Findings indicated that the reasons for the disuse in assistive devices were mostly design related; bulkiness, reliability, performance of the device, difficulty of use. The other main reason for disuse was socially related; elderly people preferred to undertake activities on their own and only use a device as a precaution or when absolutely necessary. They would prefer not having to rely on the devices. Living situation and difference in gender did not affect the preference for the use of assistive devices over personal assistance. The majority strongly supported the idea of remaining independent for as long as possible. In conclusion, this study proposes that through these findings, product designers will have a better understanding of the requirements of an elderly user. This will enable the designers to produce assistive devices that are more practical, personalised, reliable, easy to use and tie in with the older people’s environments. Additional research with different variables is recommended to further justify these findings.

Characterisation of soils with the use of instrumental techniques : a multivariate forensic study

The value of soil evidence in the forensic discipline is well known. However, it would be advantageous if an in-situ method was available that could record responses from tyre or shoe impressions in ground soil at the crime scene. The development of optical fibres and emerging portable NIR instruments has unveiled a potential methodology which could permit such a proposal. The NIR spectral region contains rich chemical information in the form of overtone and combination bands of the fundamental infrared absorptions and low-energy electronic transitions. This region has in the past, been perceived as being too complex for interpretation and consequently was scarcely utilized. The application of NIR in the forensic discipline is virtually non-existent creating a vacancy for research in this area. NIR spectroscopy has great potential in the forensic discipline as it is simple, nondestructive and capable of rapidly providing information relating to chemical composition. The objective of this study is to investigate the ability of NIR spectroscopy combined with Chemometrics to discriminate between individual soils. A further objective is to apply the NIR process to a simulated forensic scenario where soil transfer occurs. NIR spectra were recorded from twenty-seven soils sampled from the Logan region in South-East Queensland, Australia. A series of three high quartz soils were mixed with three different kaolinites in varying ratios and NIR spectra collected. Spectra were also collected from six soils as the temperature of the soils was ramped from room temperature up to 6000C. Finally, a forensic scenario was simulated where the transferral of ground soil to shoe soles was investigated. Chemometrics methods such as the commonly known Principal Component Analysis (PCA), the less well known fuzzy clustering (FC) and ranking by means of multicriteria decision making (MCDM) methodology were employed to interpret the spectral results. All soils were characterised using Inductively Coupled Plasma Optical Emission Spectroscopy and X-Ray Diffractometry. Results were promising revealing NIR combined with Chemometrics is capable of discriminating between the various soils. Peak assignments were established by comparing the spectra of known minerals with the spectra collected from the soil samples. The temperature dependent NIR analysis confirmed the assignments of the absorptions due to adsorbed and molecular bound water. The relative intensities of the identified NIR absorptions reflected the quantitative XRD and ICP characterisation results. PCA and FC analysis of the raw soils in the initial NIR investigation revealed that the soils were primarily distinguished on the basis of their relative quartz and kaolinte contents, and to a lesser extent on the horizon from which they originated. Furthermore, PCA could distinguish between the three kaolinites used in the study, suggesting that the NIR spectral region was sensitive enough to contain information describing variation within kaolinite itself. The forensic scenario simulation PCA successfully discriminated between the ‘Backyard Soil’ and ‘Melcann® Sand’, as well as the two sampling methods employed. Further PCA exploration revealed that it was possible to distinguish between the various shoes used in the simulation. In addition, it was possible to establish association between specific sampling sites on the shoe with the corresponding site remaining in the impression. The forensic application revealed some limitations of the process relating to moisture content and homogeneity of the soil. These limitations can both be overcome by simple sampling practices and maintaining the original integrity of the soil. The results from the forensic scenario simulation proved that the concept shows great promise in the forensic discipline.

Synopolies: The use of cryptographic technologies to impede competition in multiple jurisdictions

Many jurisdictions have developed mature infrastructures, both administratively and legislatively, to promote competition. Substantial funds have been expended to monitor activities that are anticompetitive and many jurisdictions also have adopted a form of "Cartel Leniency Program", first developed by the US Federal Trade Commission, to assist in cartel detection. Further, some jurisdictions are now criminalizing cartel behaviour so that cartel participants can be held criminally liable with substantial custodial penalties imposed. Notwithstanding these multijurisdictional approaches, a new form of possibly anticompetitive behaviour is looming. Synergistic monopolies („synopolies‟) involve not competitors within a horizontal market but complimentors within separate vertical markets. Where two complimentary corporations are monopolists in their own market they can, through various technologies, assist each other to expand their respective monopolies thus creating a barrier to new entrants and/or blocking existing participants from further participation in that market. The nature of the technologies involved means that it is easy for this potentially anti-competitive activity to enter and affect the global marketplace. Competition regulators need to be aware of this potential for abuse and ensure that their respective competition frameworks appropriately address this activity. This paper discusses how new technologies can be used to create a synopoly.

Land use at privatized Australian airports : classification and analyses

In recent years the air transport industry has experienced unprecedented growth, driven by strong local and global economies. Whether this growth can continue in the face of anticipated oil crises; international economic forecasts and recent influenza outbreaks is yet to be seen. One thing is certain, airport owners and operators will continue to be faced with challenging environments in which to do business. In response, many airports recognize the value in diversifying their revenue streams through a variety of landside property developments within the airport boundary. In Australia it is the type and intended market of this development that is a point of contention between private airport corporations and their surrounding municipalities. The aim of this preliminary research is to identify and categorize on-airport development occurring at the twenty-two privatized Australian airports which are administered under the Airports Act [1996]. This new knowledge will assist airport and municipal planners in understanding the current extent and category of on-airport land use, allowing them to make better decisions when proposing development both within airport master plans and beyond the airport boundary in local town and municipal plans.

The use of high dynamic range luminance mapping in the assessment, understanding and defining of visual issues in post occupancy building assessment

The international focus on embracing daylighting for energy efficient lighting purposes and the corporate sector’s indulgence in the perception of workplace and work practice “transparency” has spurned an increase in highly glazed commercial buildings. This in turn has renewed issues of visual comfort and daylight-derived glare for occupants. In order to ascertain evidence, or predict risk, of these events; appraisals of these complex visual environments require detailed information on the luminances present in an occupant’s field of view. Conventional luminance meters are an expensive and time consuming method of achieving these results. To create a luminance map of an occupant’s visual field using such a meter requires too many individual measurements to be a practical measurement technique. The application of digital cameras as luminance measurement devices has solved this problem. With high dynamic range imaging, a single digital image can be created to provide luminances on a pixel-by-pixel level within the broad field of view afforded by a fish-eye lens: virtually replicating an occupant’s visual field and providing rapid yet detailed luminance information for the entire scene. With proper calibration, relatively inexpensive digital cameras can be successfully applied to the task of luminance measurements, placing them in the realm of tools that any lighting professional should own. This paper discusses how a digital camera can become a luminance measurement device and then presents an analysis of results obtained from post occupancy measurements from building assessments conducted by the Mobile Architecture Built Environment Laboratory (MABEL) project. This discussion leads to the important realisation that the placement of such tools in the hands of lighting professionals internationally will provide new opportunities for the lighting community in terms of research on critical issues in lighting such as daylight glare and visual quality and comfort.

Practising inspired leadership : the use of applied theatre 'prophetical' in the Executive Leadership Development Program for Queensland Health

The Executive Leadership Development Program embarked upon by Queensland Health as a part of the major reform program is discussed. The second stage of the program has begun and the main aim is to ensure leadership development across the organization.

How can flexible learning centres use social networking to improve their ongoing educational assessments?

Most online assessment systems now incorporate social networking features, and recent developments in social media spaces include protocols that allow the synchronisation and aggregation of data across multiple user profiles. In light of these advances and the concomitant fear of data sharing in secondary school education this papers provides important research findings about generic features of online social networking, which educators can use to make sound and efficient assessments in collaboration with their students and colleagues. This paper reports on a design experiment in flexible educational settings that challenges the dichotomous legacy of success and failure evident in many assessment activities for at-risk youth. Combining social networking practices with the sociology of education the paper proposes that assessment activities are best understood as a negotiable field of exchange. In this design experiment students, peers and educators engage in explicit, "front-end" assessment (Wyatt-Smith, 2008) to translate digital artefacts into institutional, and potentiality economic capital without continually referring to paper based pre-set criteria. This approach invites students and educators to use social networking functions to assess “work in progress” and final submissions in collaboration, and in doing so assessors refine their evaluative expertise and negotiate the value of student’s work from which new criteria can emerge. The mobile advantages of web-based technologies aggregate, externalise and democratise this transparent assessment model for most, if not all, student work that can be digitally represented.

Anger and depression predict hospital use among chronic heart failure patients

Costly hospital readmissions among chronic heart failure (CHF) patients are expected to increase dramatically with the ageing population. This study investigated the prognostic ability of depression, anger and anxiety, prospectively, and after adjusting for illness severity, on the number of readmissions to hospital and the total length of stay over one year. Participants comprised 175 inpatients with CHF. Depression, anger, anxiety, and illness severity were measured at baseline. One year later, the number of readmissions and length of stay for each patient were obtained from medical records. Depression and anger play a detrimental role in the health profile of CHF patients.

ePortfolio use by university students in Australia: A review of the Australian ePortfolio Project

In October 2008, the Australian Learning and Teaching Council (ALTC) released the final report for the commissioned project ePortfolio use by university students in Australia: Informing excellence in policy and practice. The Australian ePortfolio Project represented the first attempt to examine the breadth and depth of ePortfolio practice in the Australian higher education sector. The research activities included surveys of stakeholder groups in learning and teaching, academic management and human resource management, with respondents representing all Australian universities; a series of focus groups and semi-structured interviews which sought to explore key issues in greater depth; and surveys designed to capture students’ pre-course expectations and their post-course experiences of ePortfolio learning. Further qualitative data was collected through interviews with ‘mature users’ of ePortfolios. Project findings revealed that, while there was a high level of interest in the use of ePortfolios in terms of the potential to help students become reflective learners who were conscious of their personal and professional strengths and weaknesses, the state of play in Australian universities was very fragmented. The project investigation identified four individual, yet interrelated, contexts where strategies may be employed to support and foster effective ePortfolio practice in higher education: government policy, technical standards, academic policy, and learning and teaching. Four scenarios for the future were also presented with the goal of stimulating discussion about opportunities for stakeholder engagement. It is argued that the effective use of ePortfolios requires open dialogue and collaboration between the different stakeholders across this range of contexts.

Psychological predictors of young adults' use of social networking sites

Young people are increasingly using social networking sites (SNSs), like Myspace and Facebook, to engage with others. The use of SNSs can have both positive and negative effects on the individual; however, few research studies identify the types of people who frequent these Internet sites. This study sought to predict young adults’ use of SNSs and addictive tendency towards the use of SNSs from their personality characteristics and levels of self-esteem. University students (N = 201), aged 17 to 24 years, reported their use of SNSs and addictive tendencies for SNSs use, and completed the NEO Five-Factor Personality Inventory 1 and the Coopersmith Self-Esteem Inventory.2 Multiple regression analyses revealed that, as a group, the personality and self-esteem factors significantly predicted both level of SNS use and addictive tendency but did not explain a large amount of variance in either outcome measure. The findings indicated that extraverted and unconscientious individuals reported higher levels of both SNS use and addictive tendencies. Future research should attempt to identify which other psychosocial characteristics explain young people’s level of use and propensity for addictive tendencies for these popular Internet sites.