Patient expectations, outcomes and satisfaction : related, relevant or redundant?

Abstract Study design: A prospective investigation of patients undergoing lumbar spine surgery. Objective: Is there a correlation between patient’s expectations before lumbar surgery, postoperative outcomes and satisfaction levels? Methods: A prospective study of 145 patients undergoing primary, single-level surgery for degenerative lumbar conditions was conducted. Oswestry Disability Index (ODI), back visual analogue scale (VAS) and leg VAS were assessed pre-operatively and at 6 weeks and 6 months post-surgery. Patients’ expectations were measured pre-operatively by asking them to score the level of pain and disability that would be least acceptable for them to undergo surgery and be satisfied. Satisfaction was assessed six weeks post-operatively with a Likert scale. Differences in patient expectations between actual and expected improvements were quantified. Results: Most patients had a clinically relevant improvement, but only about half achieved their expectation. Satisfaction did not correlate with pre-operative pain or disability, or with patient expectation of improvement. Instead, satisfaction correlated with positive outcomes. Conclusions Patient expectations have little bearing on final outcome and satisfaction.

The impact of a model of nurse education to improve knowledge and recognition of delirium in older persons by registered nurses

Introduction: Delirium is a serious issue associated with high morbidity and mortality in older hospitalised people. Early recognition enables diagnosis and treatment of underlying cause/s, which can lead to improved patient outcomes. However, research shows knowledge and accurate nurse recognition of delirium and is poor and lack of education appears to be a key issue related to this problem. Thus, the purpose of this randomised controlled trial (RCT) was to evaluate, in a sample of registered nurses, the usability and effectiveness of a web-based learning site, designed using constructivist learning principles, to improve acute care nurse knowledge and recognition of delirium. Prior to undertaking the RCT preliminary phases involving; validation of vignettes, video-taping five of the validated vignettes, website development and pilot testing were completed. Methods: The cluster RCT involved consenting registered nurse participants (N = 175) from twelve clinical areas within three acute health care facilities in Queensland, Australia. Data were collected through a variety of measures and instruments. Primary outcomes were improved ability of nurses to recognise delirium using written validated vignettes and improved knowledge of delirium using a delirium knowledge questionnaire. The secondary outcomes were aimed at determining nurse satisfaction and usability of the website. Primary outcome measures were taken at baseline (T1), directly after the intervention (T2) and two months later (T3). The secondary outcomes were measured at T2 by participants in the intervention group. Following baseline data collection remaining participants were assigned to either the intervention (n=75) or control (n=72) group. Participants in the intervention group were given access to the learning intervention while the control group continued to work in their clinical area and at that time, did not receive access to the learning intervention. Data from the primary outcome measures were examined in mixed model analyses. Results: Overall, the effect of the online learning intervention over time comparing the intervention group and the control group were positive. The intervention groups‘ scores were higher and the change over time results were statistically significant [T3 and T1 (t=3.78 p=<0.001) and T2 and T1 baseline (t=5.83 p=<0.001)]. Statistically significant improvements were also seen for delirium recognition when comparing T2 and T1 results (t=2.58 p=0.012) between the control and intervention group but not for changes in delirium recognition scores between the two groups from T3 and T1 (t=1.80 p=0.074). The majority of the participants rated the website highly on the visual, functional and content elements. Additionally, nearly 80% of the participants liked the overall website features and there were self-reported improvements in delirium knowledge and recognition by the registered nurses in the intervention group. Discussion: Findings from this study support the concept that online learning is an effective and satisfying method of information delivery. Embedded within a constructivist learning environment the site produced a high level of satisfaction and usability for the registered nurse end-users. Additionally, the results showed that the website significantly improved delirium knowledge & recognition scores and the improvement in delirium knowledge was retained at a two month follow-up. Given the strong effect of the intervention the online delirium intervention should be utilised as a way of providing information to registered nurses. It is envisaged that this knowledge would lead to improved recognition of delirium as well as improvement in patient outcomes however; translation of this knowledge attainment into clinical practice was outside the scope of this study. A critical next step is demonstrating the effect of the intervention in changing clinical behaviour, and improving patient health outcomes.

Low SES primary school students engaging in an after-school robotics program

Recent attention in education within many western contexts has focused on improved outcomes for students, with a particular focus on closing the gap between those who come from disadvantaged backgrounds and the rest of the student population. Much of this attention has supported a set of simplistic solutions to improving scores on high stakes standardized tests. The collateral damage (Nichols & Berliner, 2007) of such responses includes a narrowing of the curriculum, plateaus in gain scores on the tests, and unproductive blame games aimed by the media and politicians at teachers and communities (Nichols & Berliner, 2007; Synder, 2008). Alternative approaches to improving the quality and equity of schooling remain as viable alternatives to these measures. As an example in a recent study of school literacy reform in low SES schools, Luke, Woods and Dooley (2011) argued for the increase of substantive content and intellectual quality of the curriculum as a necessary means to re-engaging middle school students, improving outcomes of schooling and achieving a high quality, high equity system. The MediaClub is an afterschool program for students in years 4 to 7 (9-12 year old) at a primary school in a low SES area of a large Australian city. It is run as part of an Australian Research Council funded research project. The aim of the program has been to provide an opportunity for students to gain expertise in digital technologies and media literacies in an afterschool setting. It was hypothesized that this expertise might then be used to shift the ways of being literate that these students had to call on within classroom teaching and learning events. Each term, there is a different focus on digital media, and information and communication technology (ICT) activities in the MediaClub. The work detailed in this chapter relates to a robotics program presented as one of the modules within this afterschool setting. As part of the program, the participants were challenged to find creative solutions to problems in a constructivist-learning environment.

A micro-level indexing model for assessing urban ecosystem sustainability

Purpose – As a consequence of rapid urbanisation and globalisation, cities have become the engines of population and economic growth. Hence, natural resources in and around the cities have been exposed to externalities of urban development processes. This paper introduces a new sustainability assessment approach that is tested in a pilot study. The paper aims to assist policy-makers and planners investigating the impacts of development on environmental systems, and produce effective policies for sustainable urban development. Design/methodology/approach – The paper introduces an indicator-based indexing model entitled “Indexing Model for the Assessment of Sustainable Urban Ecosystems” (ASSURE). The ASSURE indexing model produces a set of micro-level environmental sustainability indices that is aimed to be used in the evaluation and monitoring of the interaction between human activities and urban ecosystems. The model is an innovative approach designed to assess the resilience of ecosystems towards impacts of current development plans and the results serve as a guide for policymakers to take actions towards achieving sustainability. Findings – The indexing model has been tested in a pilot case study within the Gold Coast City, Queensland, Australia. This paper presents the methodology of the model and outlines the preliminary findings of the pilot study. The paper concludes with a discussion on the findings and recommendations put forward for future development and implementation of the model. Originality/value – Presently, there is a few sustainability indices developed to measure the sustainability at local, regional, national and international levels. However, due to challenges in data collection difficulties and availability of local data, there is no effective assessment model at the microlevel that the assessment of urban ecosystem sustainability accurately. The model introduced in this paper fills this gap by focusing on parcel-scale and benchmarking the environmental performance in micro-level.

Prediction of transcriptional regulatory interactions in bacteria : a comparative genomics approach

Exponential growth of genomic data in the last two decades has made manual analyses impractical for all but trial studies. As genomic analyses have become more sophisticated, and move toward comparisons across large datasets, computational approaches have become essential. One of the most important biological questions is to understand the mechanisms underlying gene regulation. Genetic regulation is commonly investigated and modelled through the use of transcriptional regulatory network (TRN) structures. These model the regulatory interactions between two key components: transcription factors (TFs) and the target genes (TGs) they regulate. Transcriptional regulatory networks have proven to be invaluable scientific tools in Bioinformatics. When used in conjunction with comparative genomics, they have provided substantial insights into the evolution of regulatory interactions. Current approaches to regulatory network inference, however, omit two additional key entities: promoters and transcription factor binding sites (TFBSs). In this study, we attempted to explore the relationships among these regulatory components in bacteria. Our primary goal was to identify relationships that can assist in reducing the high false positive rates associated with transcription factor binding site predictions and thereupon enhance the reliability of the inferred transcription regulatory networks. In our preliminary exploration of relationships between the key regulatory components in Escherichia coli transcription, we discovered a number of potentially useful features. The combination of location score and sequence dissimilarity scores increased de novo binding site prediction accuracy by 13.6%. Another important observation made was with regards to the relationship between transcription factors grouped by their regulatory role and corresponding promoter strength. Our study of E.coli ��70 promoters, found support at the 0.1 significance level for our hypothesis | that weak promoters are preferentially associated with activator binding sites to enhance gene expression, whilst strong promoters have more repressor binding sites to repress or inhibit gene transcription. Although the observations were specific to �70, they nevertheless strongly encourage additional investigations when more experimentally confirmed data are available. In our preliminary exploration of relationships between the key regulatory components in E.coli transcription, we discovered a number of potentially useful features { some of which proved successful in reducing the number of false positives when applied to re-evaluate binding site predictions. Of chief interest was the relationship observed between promoter strength and TFs with respect to their regulatory role. Based on the common assumption, where promoter homology positively correlates with transcription rate, we hypothesised that weak promoters would have more transcription factors that enhance gene expression, whilst strong promoters would have more repressor binding sites. The t-tests assessed for E.coli �70 promoters returned a p-value of 0.072, which at 0.1 significance level suggested support for our (alternative) hypothesis; albeit this trend may only be present for promoters where corresponding TFBSs are either all repressors or all activators. Nevertheless, such suggestive results strongly encourage additional investigations when more experimentally confirmed data will become available. Much of the remainder of the thesis concerns a machine learning study of binding site prediction, using the SVM and kernel methods, principally the spectrum kernel. Spectrum kernels have been successfully applied in previous studies of protein classification [91, 92], as well as the related problem of promoter predictions [59], and we have here successfully applied the technique to refining TFBS predictions. The advantages provided by the SVM classifier were best seen in `moderately'-conserved transcription factor binding sites as represented by our E.coli CRP case study. Inclusion of additional position feature attributes further increased accuracy by 9.1% but more notable was the considerable decrease in false positive rate from 0.8 to 0.5 while retaining 0.9 sensitivity. Improved prediction of transcription factor binding sites is in turn extremely valuable in improving inference of regulatory relationships, a problem notoriously prone to false positive predictions. Here, the number of false regulatory interactions inferred using the conventional two-component model was substantially reduced when we integrated de novo transcription factor binding site predictions as an additional criterion for acceptance in a case study of inference in the Fur regulon. This initial work was extended to a comparative study of the iron regulatory system across 20 Yersinia strains. This work revealed interesting, strain-specific difierences, especially between pathogenic and non-pathogenic strains. Such difierences were made clear through interactive visualisations using the TRNDifi software developed as part of this work, and would have remained undetected using conventional methods. This approach led to the nomination of the Yfe iron-uptake system as a candidate for further wet-lab experimentation due to its potential active functionality in non-pathogens and its known participation in full virulence of the bubonic plague strain. Building on this work, we introduced novel structures we have labelled as `regulatory trees', inspired by the phylogenetic tree concept. Instead of using gene or protein sequence similarity, the regulatory trees were constructed based on the number of similar regulatory interactions. While the common phylogentic trees convey information regarding changes in gene repertoire, which we might regard being analogous to `hardware', the regulatory tree informs us of the changes in regulatory circuitry, in some respects analogous to `software'. In this context, we explored the `pan-regulatory network' for the Fur system, the entire set of regulatory interactions found for the Fur transcription factor across a group of genomes. In the pan-regulatory network, emphasis is placed on how the regulatory network for each target genome is inferred from multiple sources instead of a single source, as is the common approach. The benefit of using multiple reference networks, is a more comprehensive survey of the relationships, and increased confidence in the regulatory interactions predicted. In the present study, we distinguish between relationships found across the full set of genomes as the `core-regulatory-set', and interactions found only in a subset of genomes explored as the `sub-regulatory-set'. We found nine Fur target gene clusters present across the four genomes studied, this core set potentially identifying basic regulatory processes essential for survival. Species level difierences are seen at the sub-regulatory-set level; for example the known virulence factors, YbtA and PchR were found in Y.pestis and P.aerguinosa respectively, but were not present in both E.coli and B.subtilis. Such factors and the iron-uptake systems they regulate, are ideal candidates for wet-lab investigation to determine whether or not they are pathogenic specific. In this study, we employed a broad range of approaches to address our goals and assessed these methods using the Fur regulon as our initial case study. We identified a set of promising feature attributes; demonstrated their success in increasing transcription factor binding site prediction specificity while retaining sensitivity, and showed the importance of binding site predictions in enhancing the reliability of regulatory interaction inferences. Most importantly, these outcomes led to the introduction of a range of visualisations and techniques, which are applicable across the entire bacterial spectrum and can be utilised in studies beyond the understanding of transcriptional regulatory networks.

Groundwater overuse and farm-level technical inefficiency : evidence from Sri Lanka

Extraction of groundwater for onion and other cash crop production has been increasing rapidly during the last two decades in the dry zone areas of Sri Lanka. As a result of overuse, the quantity of available groundwater is gradually declining, while water quality is deteriorating. The deteriorating water quality has a negative impact on agricultural production, especially for crops (such as onions) that are sensitive to increases in salinity levels. This issue is examined with respect to onion production in Sri Lanka. A stochastic frontier production function (SFPF) is used, in which technical efficiency and the determinants of inefficiencies are estimated simultaneously. The results show that farmers are overusing groundwater in their onion cultivation, which has resulted in decreasing yields. Factors contributing to inefficiency in production are also identified. The results have important policy implications.

Using critical incident interviews to identify the mental health knowledge, skills and attitudes of entry-level dietitians

Aim: This paper aims to explore new graduates experience working with clients with mental health issues using critical incident interviews. Methods: The qualitative research techniques were based on phenomenology. A purposive sample of 19 new graduate dietitians was drawn from a range of work settings and locations throughout Australia. Data was gathered using thirty minute Critical Incident Interviews. Audio-taped data was transcribed, coded to identify common themes, compared for congruence and then categorised into knowledge, skills and attitudes. Results: New graduates encountered a range of situations involving a variety of mental health, wellbeing, dietetic and clinical issues. Common themes highlighted the mental health knowledge, skills and attitudes required for entry-level dietitians which then informed the review of the National Competency Standards for Entry-Level Dietitians. Conclusion: New graduates encounter a variety of mental health and wellbeing issues in their everyday practice and therefore require training to address these situations competently.

Comparing the availability, price, variety and quality of fruits and vegetables across retail outlets and by area level socioeconomic position

Abstract Objective: To explore whether area-level socioeconomic position or the form of retail stream (conventional versus farmers’ market) are associated with differences in the price, availability, variety and quality of a range of fresh fruit and vegetables. Design: A multi-site cross-sectional pilot study of farmers’ markets, supermarkets and independent fruit and vegetable retailers. Each was surveyed to assess the price, availability, variety and quality of 15 fruit and 18 vegetable items. Setting: Retail outlets were located in South-East Queensland. Subjects: Fifteen retail outlets were surveyed (five of each retail stream). Results: Average basket prices were not significantly different across the socioeconomic spectrum however prices in low socioeconomic areas were cheapest. Availability, variety, and quality did not differ across levels of socioeconomic position however the areas with the most socioeconomic disadvantage scored poorest for quality and variety. Supermarkets had significantly better fruit and vegetable availability than farmers’ markets however price, variety and quality scores were not different across retail streams. Results demonstrate a trend to fruit and vegetable prices being more expensive at farmers’ markets, with the price of the Fruit basket being significantly greater at the organic farmer’s market compared with the non-organic farmers’ markets. Conclusions: Neither area-level socioeconomic position nor the form of retail stream was significantly associated with differences in the availability, price, variety and quality of fruit and vegetables, except for availability which was higher in supermarkets than farmers’ markets. Further research is needed to determine what role farmers’ markets can play in affecting fruit and vegetable intake.

In vitro primary cell culture as a physiologically relevant method for preclinical testing of human oncolytic adenovirus

Ad[I/PPT-E1A] is an oncolytic adenovirus that specifically kills prostate cells via restricted replication by a prostate-specific regulatory element. Off-target replication of oncolytic adenoviruses would have serious clinical consequences. As a proposed ex vivo test, we describe the assessment of the specificity of Ad[I/PPT-E1A] viral cytotoxicity and replication in human nonprostate primary cells. Four primary nonprostate cell types were selected to mimic the effects of potential in vivo exposure to Ad[I/PPT-E1A] virus: bronchial epithelial cells, urothelial cells, vascular endothelial cells, and hepatocytes. Primary cells were analyzed for Ad[I/PPT-E1A] viral cytotoxicity in MTS assays, and viral replication was determined by hexon titer immunostaining assays to quantify viral hexon protein. The results revealed that at an extreme multiplicity of infection of 500, unlikely to be achieved in vivo, Ad[I/PPT-E1A] virus showed no significant cytotoxic effects in the nonprostate primary cell types apart from the hepatocytes. Transmission electron microscopy studies revealed high levels of Ad[I/PPT-E1A] sequestered in the cytoplasm of these cells. Adenoviral green fluorescent protein reporter studies showed no evidence for nuclear localization, suggesting that the cytotoxic effects of Ad[I/PPT-E1A] in human primary hepatocytes are related to viral sequestration. Also, hepatocytes had increased amounts of coxsackie adenovirus receptor surface protein. Active viral replication was only observed in the permissive primary prostate cells and LNCaP prostate cell line, and was not evident in any of the other nonprostate cells types tested, confirming the specificity of Ad[I/PPT-E1A]. Thus, using a relevant panel of primary human cells provides a convenient and alternative preclinical assay for examining the specificity of conditionally replicating oncolytic adenoviruses in vivo.

Gene expression profile of primary prostate epithelial and stromal cells in response to sulforaphane or iberin exposure

BACKGROUND: Broccoli consumption has been associated with a reduced risk of prostate cancer. Isothiocyanates (ITCs) derived from glucosinolates that accumulate in broccoli are dietary compounds that may mediate these health effects. Sulforaphane (SF, 4-methylsulphinylbutyl ITC) derives from heading broccoli (calabrese) and iberin (IB, 3-methylsulphinypropyl ITC) from sprouting broccoli. While there are many studies regarding the biological activity of SF, mainly undertaken with cancerous cells, there are few studies associated with IB. METHODS: Primary epithelial and stromal cells were derived from benign prostatic hyperplasia tissue. Affymetrix U133 Plus 2.0 whole genome arrays were used to compare global gene expression between these cells, and to quantify changes in gene expression following exposure to physiologically appropriate concentrations of SF and IB. Ontology and pathway analyses were used to interpret results. Changes in expression of a subset of genes were confirmed by real-time RT-PCR. RESULTS: Global gene expression profiling identified epithelial and stromal-specific gene expression profiles. SF induced more changes in epithelial cells, whereas IB was more effective in stromal cells. Although IB and SF induced different changes in gene expression in both epithelial and stromal cells, these were associated with similar pathways, such as cell cycle and detoxification. Both ITCs increased expression of PLAGL1, a tumor suppressor gene, in stromal cells and suppressed expression of the putative tumor promoting genes IFITM1, CSPG2, and VIM in epithelial cells. CONCLUSION: These data suggest that IB and SF both alter genes associated with cancer prevention, and IB should be investigated further as a potential chemopreventative agent.

BRCA1 is an essential mediator of vinorelbine-induced apoptosis in mesothelioma

The rapeutic options for malignant pleural mesothelioma (MPM) are limited despite the increasing incidence globally. The vinca alkaloid vinorelbine exhibits clinical activity; however, to date, treatment optimization has not been achieved using biomarkers. BRCA1 regulates sensitivity to microtubule poisons; however, its role in regulating vinorelbine-induced apoptosis in mesothelioma is unknown. Here we demonstrate that BRCA1 plays an essential role in mediating vinorelbine-induced apoptosis, as evidenced by (1) the strong correlation between vinorelbine sensitivity and BRCA1 expression level; (2) induction of resistance to vinorelbine by BRCA1 using siRNA oligonucleotides; (3) dramatic down-regulation of BRCA1 following selection for vinorelbine resistance; and (4) the re-activation of vinorelbine-induced apoptosis following re-expression of BRCA1 in resistant cells. To determine whether loss of BRCA1 expression in mesothelioma was potentially relevant in vivo, BRCA1 immunohistochemistry was subsequently performed on 144 primary mesothelioma specimens. Loss of BRCA1 protein expression was identified in 38.9% of samples. Together, these data suggest that BRCA1 plays a critical role in mediating apoptosis by vinorelbine in mesothelioma, warranting its clinical evaluation as a predictive biomarker. Copyright © 2012 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Knowledge economy market development mapping study

The knowledge economy relies on the diffusion and use of knowledge as well as its creation (Houghton and Sheenan, 2000). The future success of economic activity will depend on the capacity of organisations to transform by increasing their flexibility. In particular, this transformation is dependant on a decentralised, networked and multi-skilled workforce. To help organisations transition, new strategies and structures for education are required. Education systems need to concentrate less on specialist skills and more on the development of people with broad-based problem solving skills that are adaptable, with social and inter-personal communication skills necessary for networking and communication. This paper presents the findings of a ‘Knowledge Economy Market Development Mapping Study’ conducted to identify the value of design education programs from primary through to tertiary level in Queensland, Australia. The relationship of these programs to the development of the capacities mentioned above is explored. The study includes the collection of qualitative and quantitative data consisting of a literature review, focus groups and survey. Recommendations for the future development of design education programs in Queensland, Australia are proposed, and future research opportunities are presented and discussed.

The creative citizen : understanding the value of design education programs in the knowledge economy

The knowledge economy relies on the diffusion and use of knowledge as well as its creation (Houghton and Sheenan, 2000). The future success of economic activity will depend on the capacity of organisations to transform by increasing their flexibility. In particular, this transformation is dependant on a decentralised, networked and multi-skilled workforce. To help organisations transition, new strategies and structures for education are required. Education systems need to concentrate less on specialist skills and more on the development of people with broad-based problem solving skills that are adaptable, with social and inter-personal communication skills necessary for networking and communication. This paper presents the findings of a ‘Knowledge Economy Market Development Mapping Study’ conducted to identify the value of design education programs from primary through to tertiary level in Queensland, Australia. The relationship of these programs to the development of the capacities mentioned above is explored. The study includes the collection of qualitative and quantitative data consisting of a literature review, focus groups and survey. Recommendations for the future development of design education programs in Queensland, Australia are proposed, and future research opportunities are presented and discussed.

Immigrants and the utilization of hospital emergency departments

BACKGROUND: Immigrants with language barriers are at high risk of having poor access to health care services. However, several studies have indicated that immigrants tend to use emergency departments (EDs) as their primary source of care at the expense of primary care. This may place an additional burden on already overcrowded EDs and lead to a low level of patient satisfaction with ED care. The study was to review if immigrants utilize ED care differently from host populations and to assess immigrants’ satisfaction with ED care. DATA SOURCES: Studies about immigrants' utilization of EDs in Australia and worldwide were reviewed. RESULTS: There are confl icting results in the literature about the pattern of ED care use among immigrants. Some studies have shown higher utilization by immigrants compared to host populations and others have shown lower utilization. Overall, immigrants use ED care heavily, make inappropriate visits to EDs, have a longer length of stay in EDs, and are less satisfi ed with ED care as compared to host populations. CONCLUSIONS: Immigrants might use ED care differently from host populations due to language and cultural barriers. There is sparse Australian literature regarding immigrants' access to health care including ED care. To ensure equity, further research is needed to inform policy when planning health care provision to immigrants. KEY WORDS: Emergency department; Health service; Immigrants; Language; Utilization