Being on the edge of a shipwreck in planning decision-making: design as an anchor and future maker

This paper investigates recent attempts to Masterplan tourism planning and landscape development of the town of Port Campbell based on the concept of community-driven tourism planning. The Masterplan process generally sought to upgrade tourism facilities and to re-plan a core part of the Great Ocean Road corridor the proposed scheme little engendered community confidence nor encouraged the use of local community public resources of the Masterplan proposed outcomes. While analyzing broad range of aspects of the township and the national park, this design thesis attempted to identify the possible initiatives and landscape development models and also applied landscape narrative theory to focus on tourism experience making and landscape with layers of content embedded such as local history, environmental stories that would enrich the experience. The need for this paper is to articulate an alternate and more robust approach to designing on the fragile coastal edge whilst engendering community engagement and ensuring their aspirations are addressed. It is main contribution is both offering an alternate process but also demonstrating the use of design as a vehicle to reach this outcome. The research gap addressed is to challenge a conventional planning practice that was very much constrained by upper-level Melbourne-based parochial and managerial imperatives than lower-level community aspirations and perspectives.

Effects of low- versus high-fidelity simulations on the cognitive burden and performance of entry-level paramedicine students: a mixed-methods comparison trial using eye-tracking, continuous heart rate, difficulty rating scales, video observation and inte

INTRODUCTION: High-fidelity simulation-based training is often avoided for early-stage students because of the assumption that while practicing newly learned skills, they are ill suited to processing multiple demands, which can lead to "cognitive overload" and poorer learning outcomes. We tested this assumption using a mixed-methods experimental design manipulating psychological immersion. METHODS: Thirty-nine randomly assigned first-year paramedicine students completed low- or high-environmental fidelity simulations [low-environmental fidelity simulations (LFenS) vs. high-environmental fidelity simulation (HFenS)] involving a manikin with obstructed airway (SimMan3G). Psychological immersion and cognitive burden were determined via continuous heart rate, eye tracking, self-report questionnaire (National Aeronautics and Space Administration Task Load Index), independent observation, and postsimulation interviews. Performance was assessed by successful location of obstruction and time-to-termination. RESULTS: Eye tracking confirmed that students attended to multiple, concurrent stimuli in HFenS and interviews consistently suggested that they experienced greater psychological immersion and cognitive burden than their LFenS counterparts. This was confirmed by significantly higher mean heart rate (P < 0.001) and National Aeronautics and Space Administration Task Load Index mental demand (P < 0.05). Although group allocation did not influence the proportion of students who ultimately revived the patient (58% vs. 30%, P < 0.10), the HFenS students did so significantly more quickly (P < 0.01). The LFenS students had low immersion resulting in greater assessment anxiety. CONCLUSIONS: High-environmental fidelity simulation engendered immersion and a sense of urgency in students, whereas LFenS created assessment anxiety and slower performance. We conclude that once early-stage students have learned the basics of a clinical skill, throwing them in the "deep end" of high-fidelity simulation creates significant additional cognitive burden but this has considerable educational merit.

Abstraction versus case based:A comparative study of two approaches to support Parametric Design

We describe an experimental study testing the reuse of design knowledge as a method to support learning and use of parametric design in architecture.The use of parametric design systems and programming environments offer architects new opportunities, providing a powerful means to create geometries and allowing dynamic design exploration, but it can also impose substantial challenges.The proposition tested in this study is that the reuse of design knowledge can improve architects’ ability to use parametric modelling, and reduce the barriers to using programming in a design context.The paper explores and compares two approaches as a means of accessing and reusing existing design solutions: the reuse of abstract parametric ‘Design Patterns’ [1]; and secondly the reuse of parametric solutions from specific design cases (Case- Based Design).This paper outlines the principles and methods of ‘abstract’ versus ‘case-based’ approaches to reuse parametric solutions; and focuses on the results of their practical implementation through the statistical analysis of a comparative study involving 126 designers. In conclusion, it is proposed the outcomes from this study can be applied to inform the methodology for introducing parametric design in architecture and design disciplines.

Effects of a free school breakfast programme on school attendance, achievement, psychosocial function, and nutrition: a stepped wedge cluster randomised trial

BACKGROUND: Approximately 55,000 children in New Zealand do not eat breakfast on any given day. Regular breakfast skipping has been associated with poor diets, higher body mass index, and adverse effects on children's behaviour and academic performance. Research suggests that regular breakfast consumption can improve academic performance, nutrition and behaviour. This paper describes the protocol for a stepped wedge cluster randomised trial of a free school breakfast programme. The aim of the trial is to determine the effects of the breakfast intervention on school attendance, achievement, psychosocial function, dietary habits and food security.

METHODS/DESIGN: Sixteen primary schools in the North Island of New Zealand will be randomised in a sequential stepped wedge design to a free before-school breakfast programme consisting of non-sugar coated breakfast cereal, milk products, and/or toast and spreads. Four hundred children aged 5-13 years (approximately 25 per school) will be recruited. Data collection will be undertaken once each school term over the 2010 school year (February to December). The primary trial outcome is school attendance, defined as the proportion of students achieving an attendance rate of 95% or higher. Secondary outcomes are academic achievement (literacy, numeracy, self-reported grades), sense of belonging at school, psychosocial function, dietary habits, and food security. A concurrent process evaluation seeks information on parents', schools' and providers' perspectives of the breakfast programme.

DISCUSSION: This randomised controlled trial will provide robust evidence of the effects of a school breakfast programme on students' attendance, achievement and nutrition. Furthermore the study provides an excellent example of the feasibility and value of the stepped wedge trial design in evaluating pragmatic public health intervention programmes.

How technology shapes assessment design: findings from a study of university teachers

A wide range of technologies has been developed to enhance assessment, but adoption has been inconsistent. This is despite assessment being critical to student learning and certification. To understand why this is the case and how it can be addressed, we need to explore the perspectives of academics responsible for designing and implementing technology-supported assessment strategies. This paper reports on the experience of designing technology-supported assessment based on interviews with 33 Australian university teachers. The findings reveal the desire to achieve greater efficiencies and to be contemporary and innovative as key drivers of technology adoption for assessment. Participants sought to shape student behaviors through their designs and made adaptations in response to positive feedback and undesirable outcomes. Many designs required modification because of a lack of appropriate support, leading to compromise and, in some cases, abandonment. These findings highlight the challenges to effective technology-supported assessment design and demonstrate the difficulties university teachers face when attempting to negotiate mixed messages within institutions and the demands of design work. We use these findings to suggest opportunities to improve support by offering pedagogical guidance and technical help at critical stages of the design process and encouraging an iterative approach to design.

The maximum tolerated dose of walking for people with severe osteoarthritis of the knee: a phase I trial

OBJECTIVE: To determine how much physical activity, in the form of walking, can be safely and feasibly tolerated for people with severe knee osteoarthritis (OA). DESIGN: Phase I dose response trial with escalating walking doses of 10, 20, 35, 50, 70, and 95 min over 1 week, were prescribed non-randomly to people with severe knee OA. The primary stopping rule was a substantial increase in knee pain. The primary outcomes were an estimation of the maximum tolerated dose of walking; and the proportion of people who did not complete the dose for feasibility reasons. The secondary outcomes were pain, stiffness and activity limitation Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: Twenty-four participants (13 women) aged 53-83 years, and average body mass index (BMI) of 34 kg/m(2) (SD 9) were recruited. Three participants were assigned to each dose between 10 and 70 min, and nine participants assigned to the 95-min dose. The trial was stopped at 95 min due to the maximum number of adverse events occurring at this dose. Therefore, the maximum tolerated dose was 70 min. No participant stopped due to reasons related to feasibility. There was a moderate association between dose and increased activity (linear R(2) = 0.31, cubic R(2) = 0.69) and reduced stiffness (linear R(2) = 0.20, cubic R(2) = 0.52), with increased benefits at moderate to higher doses. CONCLUSIONS: There is preliminary evidence that 70 min per week of moderate intensity supervised walking was safe and feasible for people with severe OA of the knee; for higher doses there was a risk of exacerbating knee pain levels.

The diagnosis of attention-deficit/hyperactivity disorder in Australian children: current paediatric practice and parent perspective

Aims In a sample of newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD), the aims were to examine (1) paediatrician assessment and management practices; (2) previous assessments and interventions; (3) correspondence between parent-report and paediatrician identification of comorbidities; and (4) parent agreement with diagnosis of ADHD. Methods Design: cross-sectional, multi-site practice audit with questionnaires completed by paediatricians and parents at the point of ADHD diagnosis. Setting: private/public paediatric practices in Western Australia and Victoria, Australia. Main outcome measures: paediatricians: elements of assessment and management were indicated on a study-designed data form. Parents: ADHD symptoms and comorbidities were measured using the Conners 3 ADHD Index and Strengths and Difficulties Questionnaire, respectively. Sleep problems, previous assessments and interventions, and agreement with ADHD diagnosis were measured by questionnaire. Results Twenty-four paediatricians participated, providing data on 137 patients (77% men, mean age 8.1 years). Parent and teacher questionnaires were used in 88% and 85% of assessments, respectively. Medication was prescribed in 75% of cases. Comorbidities were commonly diagnosed (70%); however, the proportion of patients identified by paediatricians with internalising problems (18%), externalising problems (15%) and sleep problems (4%) was less than by parent report (51%, 66% and 39%). One in seven parents did not agree with the diagnosis of ADHD. Conclusions Australian paediatric practice in relation to ADHD assessment is generally consistent with best practice guidelines; however, improvements are needed in relation to the routine use of questionnaires and the identification of comorbidities. A proportion of parents do not agree with the diagnosis of ADHD made by their paediatrician.

Effect of adjunctive raloxifene therapy on severity of refractory schizophrenia in women: a randomized clinical trial

IMPORTANCE: A substantial proportion of women with schizophrenia experience debilitating treatment-refractory symptoms. The efficacy of estrogen in modulating brain function in schizophrenia has to be balanced against excess exposure of peripheral tissue. Raloxifene hydrochloride is a selective estrogen receptor modulator (mixed estrogen agonist/antagonist) with potential psychoprotective effects and fewer estrogenic adverse effects. OBJECTIVE: To determine whether adjunctive raloxifene therapy reduces illness severity in women with refractory schizophrenia. DESIGN, SETTING, AND PARTICIPANTS: This 12-week, double-blind, placebo-controlled, randomized clinical trial with fortnightly assessments was performed at an urban tertiary referral center and a regional center from January 1, 2006, to December 31, 2014. Participants included 56 women with schizophrenia or schizoaffective disorder and marked symptom severity despite substantial and stable antipsychotic doses. Data were analyzed using intention to treat as the basis. INTERVENTIONS: Adjunctive raloxifene hydrochloride, 120 mg/d, or placebo for 12 weeks. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in the Positive and Negative Syndrome Scale (PANSS) total score. Clinical response (defined as a ≥20% decrease in PANSS total score from baseline) and change in PANSS subscale scores, mood, cognition, reproductive hormone levels, and adverse events were also assessed. RESULTS: Of the 56 participants (mean [SD] age, 53 [7.7] years; age range, 40-70 years; mean [SD] duration of psychotic illness, 24 [11] years), 26 were randomized to raloxifene and 30 were randomized to placebo. Raloxifene produced a greater reduction in the PANSS total score relative to placebo (β = -6.37; 95% CI, -11.64 to -1.10; P = .02) and resulted in an increased probability of a clinical response (hazard ratio, 5.79; 95% CI, 1.46 to 22.97; P = .01). A significant reduction was found in the PANSS general symptom scores for the raloxifene compared with the placebo (β = -3.72; 95% CI, -6.83 to -0.61; P = .02) groups. For patients who completed the full 12-week trial, there was not a statistically significant treatment effect on PANSS positive symptom scores (β for change in raloxifene vs placebo, -1.92; 95% CI, -3.83 to 0.00; P = .05). Change in mood, cognition, and reproductive hormone levels and the rate of adverse events did not differ between groups. CONCLUSIONS AND RELEVANCE: Raloxifene hydrochloride, 120 mg/d, reduces illness severity and increases the probability of a clinical response in women with refractory schizophrenia. This large trial of raloxifene in this patient population offers a promising, well-tolerated agent that has potential application in clinical practice. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00361543.

Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units : a register study over 10 years

Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants. Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups. Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants). Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

Discharge patterns of human tensor palatini motor units during sleep onset

Study Objectives: Upper airway muscles such as genioglossus (GG) and tensor palatini (TP) reduce activity at sleep onset. In GG reduced muscle activity is primarily due to inspiratory modulated motor units becoming silent, suggesting reduced respiratory pattern generator (RPG) output. However, unlike GG, TP shows minimal respiratory modulation and presumably has few inspiratory modulated motor units and minimal input from the RPG. Thus, we investigated the mechanism by which TP reduces activity at sleep onset.

Design: The activity of TP motor units were studied during relaxed wakefulness and over the transition from wakefulness to sleep.

Setting: Sleep laboratory.

Participants: Nine young (21.4 ± 3.4 years) males were studied on a total of 11 nights.

Intervention: Sleep onset.

Measurements and Results: Two TP EMGs (thin, hooked wire electrodes), and sleep and respiratory measures were recorded. One hundred twenty-one sleep onsets were identified (13.4 ± 7.2/subject), resulting in 128 motor units (14.3 ± 13.0/subject); 29% of units were tonic, 43% inspiratory modulated (inspiratory phasic 18%, inspiratory tonic 25%), and 28% expiratory modulated (expiratory phasic 21%, expiratory tonic 7%). There was a reduction in both expiratory and inspiratory modulated units, but not tonic units, at sleep onset. Reduced TP activity was almost entirely due to de-recruitment.

Conclusions: TP showed a similar distribution of motor units as other airway muscles. However, a greater proportion of expiratory modulated motor units were active in TP and these expiratory units, along with inspiratory units, tended to become silent over sleep onset. The data suggest that both expiratory and inspiratory drive components from the RPG are reduced at sleep onset in TP.

Health care-associated native valve endocarditis: importance of non-nosocomial acquisition.

BACKGROUND: The clinical profile and outcome of nosocomial and non-nosocomial health care-associated native valve endocarditis are not well defined. OBJECTIVE: To compare the characteristics and outcomes of community-associated and nosocomial and non-nosocomial health care-associated native valve endocarditis. DESIGN: Prospective cohort study. SETTING: 61 hospitals in 28 countries. PATIENTS: Patients with definite native valve endocarditis and no history of injection drug use who were enrolled in the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) from June 2000 to August 2005. MEASUREMENTS: Clinical and echocardiographic findings, microbiology, complications, and mortality. RESULTS: Health care-associated native valve endocarditis was present in 557 (34%) of 1622 patients (303 with nosocomial infection [54%] and 254 with non-nosocomial infection [46%]). Staphylococcus aureus was the most common cause of health care-associated infection (nosocomial, 47%; non-nosocomial, 42%; P = 0.30); a high proportion of patients had methicillin-resistant S. aureus (nosocomial, 57%; non-nosocomial, 41%; P = 0.014). Fewer patients with health care-associated native valve endocarditis had cardiac surgery (41% vs. 51% of community-associated cases; P < 0.001), but more of the former patients died (25% vs. 13%; P < 0.001). Multivariable analysis confirmed greater mortality associated with health care-associated native valve endocarditis (incidence risk ratio, 1.28 [95% CI, 1.02 to 1.59]). LIMITATIONS: Patients were treated at hospitals with cardiac surgery programs. The results may not be generalizable to patients receiving care in other types of facilities or to those with prosthetic valves or past injection drug use. CONCLUSION: More than one third of cases of native valve endocarditis in non-injection drug users involve contact with health care, and non-nosocomial infection is common, especially in the United States. Clinicians should recognize that outpatients with extensive out-of-hospital health care contacts who develop endocarditis have clinical characteristics and outcomes similar to those of patients with nosocomial infection. PRIMARY FUNDING SOURCE: None.

Evaluation of process capability indices of linear profiles

Purpose: In profile monitoring, which is a growing research area in the field of statistical process control, the relationship between response and explanatory variables is monitored over time. The purpose of this paper is to focus on the process capability analysis of linear profiles. Process capability indices give a quick indication of the capability of a manufacturing process. Design/methodology/approach: In this paper, the proportion of the non-conformance criteria is employed to estimate process capability index. The paper has considered the cases where specification limits is constant or is a function of explanatory variable X. Moreover, cases where both equal and random design schemes in profile data acquisition is required (as the explanatory variable) is considered. Profiles with the assumption of deterministic design points are usually used in the calibration applications. However, there are other applications where design points within a profile would be i.i.d. random variables from a given distribution. Findings: Simulation studies using simple linear profile processes for both fixed and random explanatory variable with constant and functional specification limits are considered to assess the efficacy of the proposed method. Originality/value: There are many cases in industries such as semiconductor industries where quality characteristics are in form of profiles. There is no method in the literature to analyze process capability for theses processes, however recently quite a few methods have been presented in monitoring profiles. Proposed methods provide a framework for quality engineers and production engineers to evaluate and analyze capability of the profile processes. © Emerald Group Publishing Limited.

When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures

OBJECTIVE: Minimal trauma fractures may be the first indication of osteoporosis. Our aim was to determine the proportion of patients who underwent bone density testing for osteoporosis of those with a minimal trauma wrist fracture treated in the emergency department (ED).

DESIGN: This observational retrospective cohort study used explicit medical record review and scripted telephone interviews.

SETTING: EDs of three metropolitan hospitals in Melbourne in 2006.

PARTICIPANTS: Patients aged 50 years and over who were treated for wrist fracture due to minimal trauma. Data collected included demographic details, fracture details, causes of injury, any bone density testing and any osteoporosis-related medication change.

MAIN OUTCOME MEASURE: The proportion of patients who underwent bone density testing in the follow-up period.

RESULTS: 131 patients were studied; 83% were female, and the median age was 71 years. No patient was referred by an ED or fracture clinic for bone density testing (95% CI, 0-3.5%). Telephone follow-up data were obtained from 91 patients. Of these, 28 reported having bone density testing after their fracture, of whom 14 (50%; 95% CI, 32%-67%) were found to have osteoporosis. Seven were treated with a bisphosphonate and one with a selective oestrogen-receptor modulator.

CONCLUSION: Follow-up of patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve the identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided.

Computation and fabrication of scaled prototypes

The formal, functional, and material attributes of design are routinely investigated through the construction of physical models and scaled prototypes. With the increasing adoption of computational workflows, the digital to physical translation process is central to the construction of scaled prototypes. However, the choice of methods, tools and materials for computational prototyping is a developing area. Therefore a systematic body of knowledge on the benefits and costs of multiple methods of computational prototyping for the construction of physical prototypes need to be identified. This paper addresses the prototyping process through the comparison of three computational methods of fabrication through the modelling, analysis and construction of a Gaussian Vault. It reports on the process of digital to physical construction using additive manufacturing, surface fabrication and structural component models. The Gaussian Vault offers a unique set of geometric, structural and physical characteristics for testing all three methods of prototyping. The size, shape and proportion of vault prototypes are rapidly generated and tested. The design geometry, material properties and physical construction of the Gaussian Vault are realised using commonly used practice workflows comprising parametric modelling and analysis of geometry, model rationalisation with material characteristics and finally the use of digital fabrication methods. Comparison of the results identifies the characteristics, benefits and limitations of the three approaches. Finally the paper discusses the digital to physical translation processes and summarises the characteristics, benefits and issues encountered in each.

An exploration of treatment burden and patient capacity in people with stroke

Background and aims: Advances in modern medicine have led to improved outcomes after stroke, yet an increased treatment burden has been placed on patients. Treatment burden is the workload of health care for people with chronic illness and the impact that this has on functioning and well-being. Those with comorbidities are likely to be particularly burdened. Excessive treatment burden can negatively affect outcomes. Individuals are likely to differ in their ability to manage health problems and follow treatments, defined as patient capacity. The aim of this thesis was to explore the experience of treatment burden for people who have had a stroke and the factors that influence patient capacity. Methods: There were four phases of research. 1) A systematic review of the qualitative literature that explored the experience of treatment burden for those with stroke. Data were analysed using framework synthesis, underpinned by Normalisation Process Theory (NPT). 2) A cross-sectional study of 1,424,378 participants >18 years, demographically representative of the Scottish population. Binary logistic regression was used to analyse the relationship between stroke and the presence of comorbidities and prescribed medications. 3) Interviews with twenty-nine individuals with stroke, fifteen analysed by framework analysis underpinned by NPT and fourteen by thematic analysis. The experience of treatment burden was explored in depth along with factors that influence patient capacity. 4) Integration of findings in order to create a conceptual model of treatment burden and patient capacity in stroke. Results: Phase 1) A taxonomy of treatment burden in stroke was created. The following broad areas of treatment burden were identified: making sense of stroke management and planning care; interacting with others including health professionals, family and other stroke patients; enacting management strategies; and reflecting on management. Phase 2) 35,690 people (2.5%) had a diagnosis of stroke and of the 39 co-morbidities examined, 35 were significantly more common in those with stroke. The proportion of those with stroke that had >1 additional morbidities present (94.2%) was almost twice that of controls (48%) (odds ratio (OR) adjusted for age, gender and socioeconomic deprivation; 95% confidence interval: 5.18; 4.95-5.43) and 34.5% had 4-6 comorbidities compared to 7.2% of controls (8.59; 8.17-9.04). In the stroke group, 12.6% of people had a record of >11 repeat prescriptions compared to only 1.5% of the control group (OR adjusted for age, gender, deprivation and morbidity count: 15.84; 14.86-16.88). Phase 3) The taxonomy of treatment burden from Phase 1 was verified and expanded. Additionally, treatment burdens were identified as arising from either: the workload of healthcare; or the endurance of care deficiencies. A taxonomy of patient capacity was created. Six factors were identified that influence patient capacity: personal attributes and skills; physical and cognitive abilities; support network; financial status; life workload, and environment. A conceptual model of treatment burden was created. Healthcare workload and the presence of care deficiencies can influence and be influenced by patient capacity. The quality and configuration of health and social care services influences healthcare workload, care deficiencies and patient capacity. Conclusions: This thesis provides important insights into the considerable treatment burden experienced by people who have had a stroke and the factors that affect their capacity to manage health. Multimorbidity and polypharmacy are common in those with stroke and levels of these are high. Findings have important implications for the design of clinical guidelines and healthcare delivery, for example co-ordination of care should be improved, shared decision-making enhanced, and patients better supported following discharge from hospital.