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Pregnancy-associated VTE (PA-VTE) is a leading cause of maternal morbidity and mortality in the developed world.1 However, in many cases, PA-VTE is preventable using pharmacological thromboprophylaxis. In 2014, a comprehensive VTE prevention protocol was introduced at the Rotunda Hospital to streamline the identification of women at risk of VTE and promote use of risk-appropriate thromboprophylaxis in line with local guidelines. The VTE prevention protocol centred on two components; a postnatal VTE electronic risk assessment tool called ‘Thrombocalc’, and a comprehensive clinical guideline on the prevention of PA-VTE.The aim of this thesis was to explore the need for, and potential impact of, a comprehensive, systematic postpartum VTE prevention protocol. Three distinct studies were carried out to achieve this.First, in a cross-sectional study of over 21,000 postpartum women from an Irish maternity hospital, a high prevalence of VTE risk factors was observed, which in some cases was higher than other European populations. VTE risk was noted to be highly individualised and dynamic, supporting the need for systematic VTE risk assessment and an individualised approach to VTE prevention.Then, Thrombocalc’s novel risk score was validated using a cohort of over 300,000 pregnancies recorded in the Danish Medical Birth Register. At the risk threshold used in the Rotunda Hospital, the VTE risk score had a sensitivity of 67% and a specificity of 62%. Thrombocalc’s risk score demonstrated higher sensitivity when compared with previous and current risk assessment tools from the Royal College of Obstetricians and Gynaecologists in the UK.Finally, using a before and after study design, implementation of the VTE prevention protocol was shown to increased compliance with documented VTE risk assessment (2% to 98%, p < 0.001), increase prescription (67% to 91%, OR 5.05, p In conclusion, this body of research demonstrates that a comprehensive VTE prevention protocol enables systematic and individualised assessment of VTE risk and promotes the implementation risk-appropriate thromboprophylaxis in line with local guidelines. It is hypothesised that such improvements may ultimately contribute to effective prevention of postpartum VTE.

Bloodstream infections carry a high economic and health burdenand can develop into invasive life-threatening conditions such as sepsis, meningitis and infective endocarditis, characterised byaberrant thrombus formation and endothelial dysregulation. The intestinal and vaginal microflora, Streptococcus agalactiae, commonly known as Group B Streptococcus (GBS), is the mostcommonneonatalinvasive bloodstream infection pathogenin the western world. The aim of this thesis was to investigate the molecularinteractions between GBS,platelets and endothelial cells and the potential value of these interactions inGBS bloodstream infectionmanagement.Here, we demonstrate a GBS strain dependent platelet and endothelialcell interaction. GBS signal driven platelet aggregation was dependent on the bacterial strain, trypsin sensitive bacterial surface proteins and immunoglobulin G.We have delineated the functional role of the platelet receptor FcγRIIain GBS driven thrombus formation using a microfluidic physiological shear flow system coupled with real time microscopy, revealingits non-involvement in the initial platelet rolling and adhesion interaction with GBSeven as GBS was shown to interact withplatelets optimally only at low shear rate (≤ 200 s-1). GBS strain dependent endothelial cell invasion was accompanied by endothelial cell damage and necrosis as seen in our flow cytometric analysis and electron micrograph of GBS infected endothelial cells. These endothelial abnormalities coincided with an increase in endothelial permeability as seenin our FITC-dextran monolayer flux analysis.While epidemiological studies suggest an association between GBS serotype and clonal complex groups with GBS pathogenicity,our observation of GBS strain dependent platelet and endothelial dysregulation reveals that predicting disease outcome, particularly thrombotic and endothelial dysfunction, based on serotype or clonal complex group could be misleading.Our studyhas revealedthe usefulness of the flow system in studying GBS platelet-bacterial interactions andadds to theevidence of FcγRIIaas a potential target in bacterial induced thrombosis.

Prolonged outpatient waiting times are a global healthcare concern affecting most hospital specialties, including in Ireland. Improvement of waiting times is a constant battle and priority for Ireland’s health service, the Health Service Executive. The result of lengthy waiting for outpatient Holter monitor appointments can mean a delay in diagnosis and the potential consequences of delay in treatment. Patient satisfaction and trust in healthcare providers is negatively impacted by long waits. This quality improvement project plan focuses on improving waiting times for outpatient Holter monitoring. With guidance from Lean Six Sigma and the Define, Measure, Analyse, Improve, Control framework, quality improvement tools such as process flow mapping and the fishbone diagram aided in establishing root causes of the problem. While several areas for improvement are identified, an achievable, low-cost intervention around the patient process was identified. The inclusion of text message reminders sent to patients five days prior to their appointments is proposed as a strategy to reduce the amount of Did Not Attend patients, which will allow patients on the waiting list to be allocated the appointment slot and thereby provide an improvement to outpatient Holter monitor waiting lists.

Long waiting lists are continuing to be a global healthcare issue and Ireland is no exception. The World Health Organisation declared a global pandemic in early 2020 and as a consequence, waiting lists are lengthened even further. Data collection from this study revealed that in November 2019, a total of 181 patients attended the private dermatology clinic yet only 8% were new patients. The average time new patients waited for this appointment was 121.77 days. In November 2019 the practice received 48 referrals from general practitioners and similarly, patients were required to wait for an average of 121.8 days before their first appointment. Moles or lesions requiring further investigation were the most common reason for referral (56%) followed by acne (15%). Further data collection and analysis was unattainable due to the cessation of clinical placement as a result of COVID-19 at the time. However, data did show a large volume of return patients attended the clinic. The focus of this quality improvement plan is to reduce waiting times for new patients referred to a private dermatology clinic. Patients referred due to suspicious moles or lesions will be streamlined to a nonphysician led clinic, specifically an Advanced Practice Provider, to see these cohort of patients. The Lean Six Sigma Model with the use of the DMAIC framework and quality improvement tools assisted with the development of this project. This proposed plan anticipates to reduce waiting times for new patients by 50% following two years of implementation.

Pulmonary embolism (PE) is a potentially fatal condition which affects millions of people globally. Traditionally, people diagnosed with a PE are treated in hospital. However, published guidelines from the European Society of Cardiology (ESC) and British Thoracic Society (BTS) suggest that the early discharge and outpatient management of low-risk PE patients is safe and non-inferior to inpatient management. Despite the evidence and the publication of these guidelines, approximately 80% of low-risk PE patients are managed in the hospital. The practice of hospitalising all patients confirmed with a PE leads to prolonged hospital length of stay and poorer patient outcomes. Using the DMAIC (Define, measure, analyse, improve and control) framework for quality improvement (QI), this project examined the contributing factors leading to the prolonged hospital length of stay of low-risk PE patients. Through the use of various QI tools such as process flow maps, stakeholder analysis and fishbone diagrams, the root cause of prolonged hospitalisation was identified. The data collected identified a low prevalence of low-risk PE patients at the project site; however, it did reveal that hospital days could potentially be saved if these patients were managed as per the ESC and BTS guidelines. Furthermore, physician awareness of these guidelines and the use of stratification tools designed to identify low-risk PE patients was not deemed to be sufficient. The lack of a PE management pathway at the QI site was also amongst the problems identified. This QI project plan discusses several feasible options which could be implemented to overcome the identified problems. These options include increasing physician awareness of PE guidelines and PE risk stratification tools via education modalities, in combination with implementing an early discharge pathway for low-risk PE patients.

Central diabetes insipidus is a common complication of transsphenoidal pituitary surgery. Damage to the pituitary stalk during surgery results in the disruption of water homeostasis, resulting in increased thirst and the production of large volumes of dilute urine. While symptomatic central diabetes insipidus can be managed with the administration of desmopressin, it has the potential to progress to severe dehydration, hypernatremia and become a life-threatening medical emergency. This project utilised the DMAIC framework and associated quality improvement tools to structure a quality improvement plan aimed to reduce the length of stay for patients diagnosed with central diabetes insipidus post-transsphenoidal pituitary surgery by investigating the current management pathway. The results of this project revealed that (1) the median length of stay for a patient diagnosed with post-operative central diabetes insipidus increased from 15 days to 17 days and (2) there is an increased incidence of both hypernatremia and hyponatremia amongst these patients. Specific laboratory results and clinical observations are used to determine a patients eligibility to receive treatment for diabetes insipidus. The lack of an available standardised reference guide in this institution may have resulted in the inconsistencies in available results found in this project. Based upon a review of literature pertinent to this topic and the analysis of results this quality improvement project plan proposes the implementation of standardised guidelines for the inpatient management of central diabetes insipidus post-transsphenoidal pituitary surgery to maintain and promote safe and effective patient care in the future.

The clinical presentation of neurosurgical patients tends to be sporadic in nature. These patients present to healthcare settings across the country before being referred to the National Referral Centre for Neurosurgery and Neurology in Ireland. The growing demands on the healthcare sector, such as an ageing population and finite resources, has limited the luxury of in-patient pre-operative assessment days prior to surgery. The organisation in question had established a nurse-led pre-operative assessment clinic for elective neurosurgical referrals. This pre-assessment clinic improved the day of surgery admission rate by almost 50%. An additional cohort of neurosurgical patient referrals were identified, which are neither surgically elective nor emergency, but deemed ‘urgent.’ These are predominantly patients with newly diagnosed brain tumours. In October 2019, the Neurosurgery Outreach Pre-Operative Assessment Service (NeurO-PAS) was established at this organisation to pre-assess urgent brain tumour referrals from the referring hospital – prior to inter-hospital transfer. This quality improvement (QI) project aims to improve compliance with the NeurO-PAS pathway, therefore, reducing the investigation duplication rate. The Lean Six Sigma QI model was utilised to develop this project, under guidance of the DMAIC framework. QI tools, such as, stakeholder analysis, process flow maps and a fishbone diagram, were compiled to identify the root cause of duplicated investigations. Analysis of collected data portrays that duplications are associated with a lack of pathway awareness and communication breakdown. Improved compliance with the pathway could potentially reduce the rate of investigations duplicated, thus, improving the patient flow to neurosurgery.

Herpes simplex keratitis (HSK) is the commonest cause of infectious blindness in the developed world. It is caused by herpes simplex virus type 1 (HSV‐1) and is characterised by recurrent episodes of infection and immune‐mediated corneal inflammation that lead to significant loss of vision. Following transmission of HSV‐1 the virus is initially suspended in the tear film, where it encounters a multi‐pronged defence comprising enzymes, complement, immunoglobulins and crucially, a range of anti‐viral and pro‐inflammatory cytokines. HSV‐1, however, is able to overcome innate immune responses, to establish lifelong latency and to reactivate throughout susceptible individual’s lifetime with the potential of causing irreversible damage to the sight. The crucial roles of viral regulatory protein ICP0 in the pathogenesis of HSV‐1 infection is well established. ICP0 is important for the virus’s ability to cause a productive infection, to establish a latent state and to successfully reactivate. However, the molecular mechanisms behind these processes are largely unknown. The aim of this study was to investigate the interactions between ICP0 and key elements of type I IFN pathway and to identify possible targets that contribute to viral survival. Our Luciferase studies have demonstrated the ability of ICP0 to inhibit type I IFN activity downstream of TLRs 3, 4 and 7 which are known to be involved in host antiviral defences. Further co‐transfection experiments have identified IRF7, a crucial driver of IFN‐ as a potential target for ICP0. IRF7 stability experiment has confirmed that IRF7 is targeted by ICP0 for degradation in a dose dependent fashion. This finding is another step towards better understanding of the pathogenesis of herpes simplex keratitis (HSK) and may become a potential therapeutic target for HSK.

Stroke is one of the leading causes of death and disability worldwide and is a huge economic burden. The management of stroke is time dependant. Shorter times result in reduced mortality and morbidity. National Guidelines in Ireland suggest a door-to-treatment time of one hour or less from presentation to the emergency department. Despite this recommendation, delays are still occurring for patients accessing timely treatment. This quality improvement project was carried out in a busy North Dublin hospital- one of the largest acute stroke centres in Ireland. A total of nine patient journeys were followed and door-to-treatment times were documented over a three-month period. Five of these patients presented out-of-hours and four presented in-hours, whilst a specialised stroke team was on-site. The average door-to-treatment time for a stroke patient presenting out-of-hours was 72 minutes, whereas, the average door-to-treatment time for a stroke presenting in-hours was 54.25 minutes. The DMAIC framework and QI tools guided this project and recommendations were made following data analysis, to meet the aim to reduce door-to-needle times or acute ischaemic stroke patients. These included regular on-site teaching by the stroke team, improving communication with the emergency services to ensure pre-alert to an incoming FAST positive patient and the presence of a stroke crash trolley within the radiology department. Following implementation of these changes, a plan will be put in place to monitor and sustain improvements. This quality improvement plan requires a collaborative team approach to meet the national guidelines in treating this important life-threatening condition.

Numerous guidelines have been published outlining evidence-based bestpractice in secondary stroke prevention, including optimal target control of riskfactors. Despite these guidelines failure to achieve these recommendations inclinical practice is common. This study, ASPIRE-S2 is a 5-year follow-up studyof the ASPIRE-S Study (Action on Secondary Prevention Interventions andRehabilitation in Stroke). The primary aim of this study was to prospectivelyassess secondary prevention profiles of Irish ischaemic stroke patients at 5-years and compare them to that measured at 6-months. Secondary outcomesat 5-years (cognitive impairment, recurrent stroke events and mortality) andtheir association with secondary risk factors measured at 6-months post-strokeare also reported. The secondary aims of this thesis were to review bloodpressure profiles at 6-months post-stroke among the original ASPIRE-S cohort.This included examining the prevalence of inter-arm blood pressure differenceand to investigate its associated risk factors. Ambulatory blood pressure profilesand their association with cognitive impairment 6-months post-stroke was alsoreviewed.Numerous secondary risks were measured at 5-year review including bloodpressure (both clinic and ABPM), fasting risks (lipids and glucose and HBA1C indiabetics), anticoagulation control in patients on warfarin therapy, and physicalmeasurements (weight, waist circumference, height). Lifestyle risk factors(alcohol and smoking) were documented. These were compared to thosemeasured in the same patient group at 6-months. Secondary end-points at 5-years post-stroke that were reviewed included death, cognitive impairment,vulnerability and psychological wellbeing. Association of secondary risk factorsmeasured at 6-months with mortality at 5-years was analysed. Blood pressureanalysis including inter-arm blood pressure analysis in a post-stroke populationand ambulatory blood pressure patterns associated with cognitive impairmentpost-stroke included those patients from the original ASPIRE-S study withmeasurements taken at 6-months post-stroke.Results of this follow-up study revealed that secondary risk factor managementremains suboptimal among stroke survivors at 5-years post-ischaemic strokewith a substantial proportion of patients not reaching recommended targetcontrol for secondary risks, especially in relation to blood pressure control.Comparative analysis of risk factors between the two time-points (6-months and5-years post-stroke) showed an increase in the prevalence of cardiovascularrisk factors (ex: hypertension, hypercholesterolaemia, atrial fibrillation) at 5-yearreview. There was no statistically significant improvement in secondary riskfactor control (blood pressure, lipid, diabetic management) at 5-years poststrokewhen compared to that measured at 6-months. Analysis of secondaryrisk factors measured at 6-months showed that atrial fibrillation, high TC/HDLratio, cognitive impairment and vulnerability were associated with mortality at 5-years.Results from our blood pressure analysis at 6-months post-stroke showed thatthere was a high prevalence of inter-arm blood pressure difference among thispatient population. 40.3% had an intra-arm systolic blood pressure difference(IASBP) of >10mmHg and 20.6% had a difference of >15mmHg. A history ofalcohol excess was associated with an increased IASBP >15mmHg.Review of nocturnal blood pressure profiles at 6-months and their associationwith cognitive impairment was performed. A reduction in normal systolic dippingat night-time predicted the presence of cognitive decline (MOCA months post-stroke (OR 1.06 CI 1.01-1.11 p=0.02).The results from this study reveals that secondary risk factor control continuesto be suboptimal in long-term follow-up. This research aims to highlight theimportance for increased vigilance among healthcare professionals in managingsecondary cardiovascular risks in high-risk patient populations. The need forcontinued audit of clinical practise should be encouraged to ensure guidelinesare met. Public health bodies should promote healthy lifestyle advise andsecondary prevention strategies so to encourage patient involvement and tofurther the education on secondary stroke prevention.

Sildenafil, a phosphodiesterase type-5 inhibitor, is used for the treatment of infants with pulmonary hypertension (PH). Intravenous (IV) sildenafil (Revatio®) is approved for the treatment of PH in adults but is used off-label in paediatrics. The absence of compatibility data between sildenafil and other commonly used IV medications such as adrenaline, noradrenaline, vasopressin, milrinone and heparin necessitates the use of a dedicated IV line for sildenafil. In the critically unwell child, limited IV access can make the delivery of multiple IV infusions particularly problematic. The application of devices known as Y-site or multi-lumen connectors allows multiple drug infusions to converge and enter through a single venous port of entry. However these devices can only be utilised if compatibility studies are available demonstrating the drug mixture stability. Chemical incompatibilities can lead to drug-drug interactions, potentially resulting in sub-therapeutic outcomes. The overall aim of this thesis was to establish the physical and chemical compatibility of sildenafil with the commonly administered drugs in the management of PH in paediatrics. This study evaluated the Y-site and multi-lumen chemical and physical compatibility, of 42 different combinations of sildenafil with (adrenaline, noradrenaline, milrinone, vasopressin and heparin), and different diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v), in two environmental conditions frequently encountered in the Paediatric Intensive Care Unit (PICU) (room temperature 18-22°C and 37°C). Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance as outlined in Chapter 2. In first part of Chapter 3, binary drug mixtures of sildenafil were examined for physical and chemical compatibility to establish Y-site compatibility. All drugs proved to be compatible when combined with sildenafil, except the binary mixture of heparin that lead to a physical and chemical incompatibility. In the second part of Chapter 3, multiple drug combinations of four and five drugs were combined with sildenafil to establish multi-lumen compatibility. The limited and incomplete data presented in the literature for the compatibility of drugs administered via Y-site in combination with sildenafil, makes studies such as this one invaluable to clinicians. The overall aim of this work is to provide a complete compatibility chart of all five drugs identified as critical in combination with Sildenafil at RT and at 37°C. This preliminary data provides a starting point in the investigation of the compatibility of Sildenafil in combination with commonly used ICU drug infusions. This research will help inform clinical judgement to allow for the safe IV Y-site and multi-lumen drug administration in the PICU.

Background: Mobility is acknowledged in the literature as the highest predictorof pressure ulcer development, however most of clinical studies assess mobilitysubjectively. The few studies that have analysed mobility objectively usingtechnology have the limitation of not measuring small postural changes, whichare important for pressure relief. A more comprehensive analysis of mobility,including all types of movement is needed to better understand mobility andpressure ulcer development, and to further correlate it with other risk factors.Therefore, a quantitative, prospective, non-experimental study among the elderlypopulation was undertaken.Aim: The primary objective of the study was to explore how activity and mobility,along with other risk factors lead to pressure ulcer development in older personscared for in long-term facilities. The secondary objectives of the study were firstlyto report pressure ulcer incidence among the study participants using visual skinassessment and sub-epidermal moisture (SEM) measurement. Secondly, toexplore mobility in healthy volunteers using a mobility sensor in order to compareto mobility levels of older people cared for in long-term settings.Methods: Ethical approval was received. The chosen explanatory variables wereincluded as they are common to the three most widely used risk assessment tools(Waterlow, Norton and Braden), namely, mobility, activity, nutritional status andincontinence. Following statistical advice and after the results of the pilot study of48 participants, the sample size was recalculated based on the two causal factorsthat varied over the 20-day follow-up, namely mobility and activity. Therefore, atotal of 150 participants were included. The pilot study also identified the need toinclude healthy participants to better determine mobility among a healthypopulation, in order to enhance the understanding of the older participants’movements. Following ethical approval, a total of 22 healthy participants wereincluded and their mobility were assessed over a 2-night period, using the samemotion sensor employed within the main study.

Chronic kidney disease (CKD) is a growing global health concern with an age-standardized global prevalence of approximately 10%. Of those with CKD, approximately 2% will go on to require renal replacement therapy within any given 5-year period. Renal transplantation is accepted as the most clinically- and cost-effective treatment for end-stage kidney failure. In this thesis, we set out to examine the impact of common genetic variation on renal transplant function as well as a common post-transplant complication: non-melanoma skin cancer. We also aimed to examine a common form of CKD, IgA nephropathy, in a familial context using next generation sequencing techniques. We demonstrated that polygenic (but not single variant) effects of common genetic variation found in both the kidney donor and recipient impacts the function of the renal allograft in the early stages post-transplant. We also illustrated how measures of post-transplant renal outcomes do not correlate with the level of shared genetic ancestry between unrelated kidney donors and recipients in a cohort of European, deceased-donor transplants. We also showed that polygenic (but not single variant) effects of common genetic variation impacts both whether or not an individual develops post-transplant non-melanoma skin cancer but also, the speed at which they develop non-melanoma skin cancer. Finally, in our exome sequencing analysis of familial IgAN, we found that a number of Irish families carried rare, damaging and potentially disease-causing mutations in type IV collagen-related genes, known to cause kidney disease. In summary, this thesis demonstrates the impact of genetic variation on both kidney disease and transplant outcomes.

IntroductionLymphoedema is an incurable, progressive condition, which results in the swelling of a limb or limbs and impairs mobility (Lymphatic Framework, 2006). The psychosocial impact of lower limb lymphoedema is also devastating as body image and quality of life are greatly affected (Lasinski et al, 2012). Although lymphoedema is a chronic condition, it is manageable through treatment modalities which include manual lymphatic drainage, compression bandaging, compression hosiery, skin care and exercise, otherwise known as Complex Decongestive Therapy (CDT) (Todd, 2012). The area of lower limb, non-cancer related, lymphoedema is poorly resourced and poorly researched, therefore this thesis proposes to explore treatment outcomes for patients with non-cancer related lower limb lymphoedema during the intensive and maintenance phases of CDT,examine their experiences of living with lymphoedema and the challenges of lifelong self-care maintenance.Research QuestionsThe research questions for the study were as follows;1. What is the impact of Complex Decongestive Therapy (CDT) as a treatment for primary and secondary lower limb lymphoedema during the intensive and maintenance phases of CDT, in relation to;a. Quality of life?b. Limb circumferential and volumatic changes?c. Self-efficacy in managing lymphoedema self care?2. What are the patients’ experiences of living with lymphoedema?3. What are the patients’ experiences of the four elements of CDT used during the intensive and maintenance phases of treatment?Aims & ObjectivesThe aims of this study were twofold;1. To examine the impact of Complex Decongestive Therapy (CDT) as a treatment for primary and secondary, non-cancer related, lower limb lymphoedema during the intensive and maintenance phases of CDT;2. To explore the experiences of patients with primary and secondary, non-cancer related lower limb lymphoedema during the intensive and maintenance phases of CDT.The objectives of the study are as follows:1. To determine the impact of CDT on limb circumference and quality of life.2. To explore the patients’ experience of living with lymphoedema.3. To investigate the patients’ reported experience of the four elements of CDT.4. To examine the patients’ reported maintenance regimen of self-care and its resulting effect on limb volume and quality of life.MethodsA mixed methodology, using both quantitative and qualitative data in a sequential manner was used. This study was divided into 3 parts,Part 1 a quantitative approach was used to measure;a) Limb volume changes.b) Quality of Life changesc) Self-efficacyPart 2 –A qualitative approach was used to analyse data from face to face, semi-structured interviews with 18 participants exploring the experiences of patients living with lymphoedema and their experiences of Complex Decongestive Therapy.Part 3 – Descriptive analysis of 18 participant diaries was used during maintenance self-care, over a 4-month period, to examine the participants’ experiences of lymphoedema self care.ResultsA purposive sample of 20 participants were recruited to this study All participants were diagnosesd with lower limb lymphoedema, 10 participants had primary lymphoedema and 10 participants had secondary, non-cancer related lymphoedema. The study setting was a lymphoedema clinic in the Midlands of Ireland, run by the researcher who is also a Tissue Viability Nurse and Manual Lymphatic Drainage Therapist.The findings included a reduction in limb volume from baseline to week 8 during intensive therapy and then a fluctuation of oedema for 6 of the participants during the 4-month self-maintenance period. Quality of life improved for all participants from baseline to week 24. Thematic analysis of the interviews identified themes of lack of knowledge, delayed diagnosis, physical, psychosocial and financial burden of lymphoedema and positive therapeutic effect of treatment. The diary analysis identified self-care challenges that were influenced by elevated body mass index and carer support.ConclusionPrimary and secondary, non-cancer related lower limb lymphoedema is an area of lymphoedema that is poorly researched. It is also true to say that there is a sparsity of research in the area of lymphoedema self maintenance care. The aims of this research study were twofold, to explore patient outcomes with regard to limb volume, quality of life and self-efficacy during the intensive and maintenance phases of CDT and to examine the experiences of the patients living with lymphoedema, during their treatment and following on into self maintenance. The findings included reduction in limb volume during therapy, an improvement in quality of life and a fluctuation in self-efficacy that was influenced by elevated body mass index. Thematic analysis of interviews concluded that living with lymphoedema poses many challenges resulting from poor knowledge within the health professions and a lack of referral pathways and services. The success of lymphoedema self maintenance is greatly influenced by the patients physical ability and support structures, especially in the case of the patient with an elevated body mass index.

IntroductionIn Ireland, it is estimated that 10,000 people have a stroke annually. A high numberof stroke-survivors with residual deficits requiring care are discharged to their own.Informal carers are often central in homecare provision. The discharge planningprocess (DPP) is the process used to establish the requirements necessary for apatient to transition from one level of care to another, and may involve carers.Aims and ObjectivesThe aim of this study was to explore the experiences of carers of stroke-survivors inIreland, in relation to the DPP and transition of care to the home setting. Theobjectives were; to identify carers’ perceptions of being engaged in necessarydiscussions when discharge-planning. To identify experiences of the DPP thataffected planning for and impacted upon effective transition to the home setting,including perceived supports and barriers. To explore the impact of onward referral,and access to support services, on the DPP and transition of care to the home setting.MethodsThis study employed a qualitative descriptive design using semi-structuredinterviews, with carers of stroke-survivors in Ireland (n=6). The Caregiver BurdenScale (CBS) was used a thematic prompt by participants prior to conductinginterviews. Key themes emerged from data analysis, which were identified usingthematic analysis.ResultsResults of the CBS (Macera et al., 1993) identified areas where participants providedcare and areas that increased their stress. Theme one involved preparation fordischarge while in the hospital. Supports at this time, included access to aninformation-pack on aspects related to their relative’s care. Theme two related toaccess to community-services and life at home post-discharge, with access to earlysupported discharge described as beneficial.ConclusionsEffective communication of information, provision of necessary training and accessto community services upon discharge, were considered key components of effectivedischarge planning.Implications of FindingsHealth professionals must ensure that adequate information exchange and trainingoccurs with carers of stroke-survivors, to support their involvement in the DPP andensure continuity of care on discharge.

Patients with advanced chronic kidney disease (CKD) or end-stage renaldisease (ESRD) have a large burden of symptoms, with sleepdisturbance, restless legs syndrome and fatigue among the mostprevalent (1). These sleep-related symptoms are considered an absolutepriority for both treatment and research by patients and their caregivers(2). Despite this, clinicians consistently underestimate and overlook thesesymptoms in clinical encounters (3). The impact of RRT modality choiceon such symptoms is not well defined and is poorly communicated topatients choosing between modalities. In fact, communication regardingthe impact of modality choice is so poor that patients consistently reportfeeling excluded entirely from ‘shared decision-making’ (4). It is criticalthat physicans consider the impact of RRT modality on all aspects ofpatient care, including sleep, engage patients in this major decision, andcommunicate in outcomes that patients understand and value (such assymptoms and quality of life).Disturbed sleep has a major negative impact on health-related quality oflife, mood, and neurocognitive function. There is a growing body ofevidence suggesting that sleep disturbance in general, and some of thespecific sleep disorders in particular, are independent cardiovascular riskfactors (5). The American Heart Association called for promotion ofhealthy sleep along with other risk factor modifications in their 2019scientific statement (6). Patients with advanced CKD or ESRD are alreadyat high cardiovascular risk, and any modifiable element to this risk shouldbe aggressively managed.The impact of initiating a particular RRT modality or changing RRTmodality on sleep-related symptoms is not well understood, particularly inthe case of the nocturnal therapies, where alarms and anxiety maycounteract any positve effects of improved uraemia and extracellular fluidvolume control. My published, peer-reviewed, systematic review aimed toassess the impact of a change in RRT modality on sleep quality inpatients with ESRD (7). Sixteen heterogeneous studies, with a combinedtotal of 670 patients and 191 controls, were included. Meta-analysis of thesixteen studies favoured increased intensity RRT (either intensivehemodialysis (HD), automated peritoneal dialysis (APD) or transplant)over conventional RRT (conventional HD or continuous ambulatoryperitoneal dialysis (CAPD)) in terms of overall sleep quality, with statisticalsignificance. Restless legs syndrome (RLS) and sleep apnoea alsoimproved in the majority of patients following a switch to increasedintensity RRT.This cohort study assessed sleep quality in sixty patients (unselected forsleep disturbance) with advanced CKD or ESRD. There was a highprevalence of self-reported poor sleep quality (54%), RLS, (44%) andexcessive daytime sleepiness (22%). Polysomnography (PSG) andactigraphy studies identified marked sleep fragmentation and distortedsleep architecture, with longer time than usual spent in the lighter stagesof sleep, and shorter time than usual spent in the deeper, restorativestages of sleep. Sleep apnoea and abnormal periodic limb movements(PLMs) were also highly prevalent (44% and 47% respectively). Markedbenefits in terms of sleep quality, health related quality of life (HRQoL)and sleep apnoea were demonstrated post-transplant in the subgroup thatwere transplanted. Many parameters of subjective and objective sleepquality improved after either initiating dialysis from chronic kidney disease(CKD) or optimisation dialysis in those already on some form of dialysis.There was a high prevalence (44%, n=14) of sleep apnoea in the 32patients that underwent baseline PSG, with older age as an independentrisk factor. Screening tools (such as the Epworth Sleepiness Scale) andactigraphy did not accurately predict the diagnosis or obviate the need forPSG for the diagnosis. 70% of patients with an abnormal apnoeahypopnoeaindex (AHI) had subjective and / or objective improvementwith initiation of continuous positive airways pressure (CPAP) oroptimisation of RRT. As there is emerging evidence that sleep apnoea isan independent cardiovascular risk factor in ESRD, the concept of treatingsleep apnoea and potentially improving the cardiovascular risk profile isan appealing one (8).RLS and abnormal PLMs were also prevalent (45% and 47%respectively). Increased age was, again, an independent risk factor.Actigraphy did not predict an abnormal PLM index but was useful inselected cases. 73% of patients with an abnormal PLM index hadsubjective and / or objective improvement with pharmacologic therapy oroptimisation of RRT. As there is emerging evidence that PLMs areassociated with nocturnal hypertension and increased cardiovascular riskin ESRD, the concept of treating them and modifying this risk is, again,appealing (9).With regard to screening for sleep disturbance, the individualquestionnaires performed poorly in terms of predicting their specificoutcome of interest in this study cohort. However, the Pittsburgh SleepQuality Index (PSQI) proved useful in identifying those patients who hadsleep disturbance in general (rather than a specific problem). Pairedactigraphy and PSG analyses showed good agreement for sleepefficiency and time spent awake after sleep onset. The PSQI and wristactigraphy may, therefore, help to triage patients for PSG assessment injurisdictions with limited PSG access. There were no safety issues withthe 55 unattended home PSG studies and seventy actigraphy studies,including those performed during nocturnal dialysis (PD or HD).To conclude, sleep disorders are highly prevalent, easily and safelystudied with unattended home PSG and eminently modifiable in stableoutpatients with advanced CKD or ESRD. Given that the sleep disordershave such a negative impact on clinical outcomes in these patients,identification and management of sleep disorders should be a priority inNephrology clinics. With ongoing dissemination of these researchfindings, we hope to highlight the prevalence of sleep disorders in thispopulation, guide appropriate investigations, facilitate discussionsregarding modality choice, encourage patients and doctors to intensifydialysis, and ultimately contribute to improved management of sleepdisorders and patient outcomes in patients with advanced CKD or ESRD.

Objective To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke. Design Nonrandomized, single-blind controlled trial. Setting Medical rehabilitation ward of a rehabilitation hospital. Participants Sixty-eight persons receiving inpatient rehabilitation after a stroke. Interventions Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay. Main outcome measures Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later. Results Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007). Conclusions Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.

Background and Purpose. Physiotherapists' use of research evidence with clinical decision-making has interested researchers world-wide since 1980; however, little is known about such practices in Australia. The present survey sought information on Australian physiotherapists' perceptions of the importance of research, and barriers to uptake of evidence in clinical practice, when compared with an international cohort from 2001. Method. An Australian-relevant version of an English (UK) National Health Service (NHS) survey instrument was used to canvass 453 physiotherapists, randomly selected from the South Australian Physiotherapy Registration Board 2004–2005 records. The first survey was mailed in August 2005, a reminder was sent two weeks later to non-responders and a follow-up survey was sent in April 2006 to non-responders whose addresses had changed since 2005. Results. There was a 51% response rate. Of the non-responders, 12% were not contactable at their listed address, highlighting the mobility of Australian physiotherapists. Most respondents had undertaken research as students (59.5%) or as students and clinicians (11.5%). Of these, 37.1% were encouraged to embark on more research, and 20.5% were discouraged. The significant predictors of positive perceived importance of research were: previous research experience; being positive about undertaking further research; working in hospitals and holding a postgraduate degree. Clinicians working privately were significantly less likely than managers to be positive about research importance. The only significant predictor for not perceiving barriers to uptake of evidence was being positive about undertaking future research. Conclusions. The study identified constraints on uptake of evidence into practice that were related to accessing, reading and interpreting published research, and implementing findings. Found consistently across employment categories were barriers relating to lack of time, uncertainty about what the research reported, scepticism about the value of research and being isolated from peer support and literature sources. The responses indicated a positive shift towards evidence uptake since the 2001 NHS survey, suggesting an influence of increased exposure to information on evidence-based practice. A greater focus on research whilst training, the application of educational strategies for empowerment, better knowledge transfer and upskilling within the workplace, and ensuring dedicated time and organizational support for research activities are indicated. Copyright © 2007 John Wiley & Sons, Ltd.

Background and Aim: This article provides an overview of a phenomenological investigation of spirituality with six people who have experienced mental illness. The study aimed to gain a greater understanding of the phenomenon of spirituality and its relationships to occupation and the experience of mental illness. Methods and Results: Participants were interviewed and the interviews were audiotaped and transcribed verbatim. Findings emerged through multiple readings and gradually constructed meanings from the data. Spirituality was found to be: unique to each participant, a journey through life, vitally important to participants, manifested as ‘spiritual occupations’, the foundation of meaningful doing, important socially as well as individually, and was found to support participants in coping with mental illness. This article focuses on the ‘meta’, integrative theme of spirituality as life sustaining. It concludes with the notion that spirituality is essential to the participants and is a significant aspect of their occupational behaviour. Conclusion: It is recommended that occupational therapists give themselves a ‘licence’ to discuss spirituality in practice and that they commit to learning more about how spirituality is a part of the lives of their clients.

Background Obstetric brachial plexus palsy, a complication of childbirth, occurs in 1–3 per 1000 live births internationally. Traction and/or compression of the brachial plexus is thought to be the primary mechanism of injury and this may occur in utero, during the descent through the birth canal or during delivery. This results in a spectrum of injuries that vary in severity, extent of damage and functional use of the affected upper limb. Most infants receive treatment, such as conservative management (physiotherapy, occupational therapy) or surgery; however, there is controversy regarding the most appropriate form of management. To date, no synthesised evidence is available regarding the effectiveness of primary conservative management for obstetric brachial plexus palsy. Objectives The objective of this review was to systematically assess the literature and present the best available evidence that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy. Search strategy A systematic literature search was performed using 14 databases: TRIP, MEDLINE, CINAHL, AMED, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science Direct, Physiotherapy Evidence Database, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Those studies that were reported in English and published over the last decade (July 1992 to June 2003) were included in this review. Selection criteria Quantitative studies that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy were eligible for inclusion in this review. This excluded studies that solely investigated the effect of primary surgery for these infants, management of secondary deformities and the investigation of the effects of pharmacological agents, such as botulinum toxin. Data collection and analysis Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion. Studies were assessed for clinical homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format. Results Eight studies were included in the review. Most were ranked low on the Hierarchy of Evidence (no randomised controlled trials were found), and had only fair methodological quality. Conservative management was variable and could consist of active or passive exercise, splints or traction. All studies lacked a clear description of what constituted conservative management, which would not allow the treatment to be replicated in the clinical setting. A variety of outcome instruments were used, none of which had evidence of validity, reliability or sensitivity to detect change. Furthermore, less severely affected infants were selected to receive conservative management. Therefore, it is difficult to draw conclusions regarding the effectiveness of conservative management for infants with obstetric brachial plexus palsy. Conclusions There is scant, inconclusive evidence regarding the effectiveness of primary conservative intervention for infants with obstetric brachial plexus palsy. Further research should be directed to develop outcome instruments with sound psychometric properties for infants with obstetric brachial plexus palsy and their families. These outcome instruments should then be used in well-designed comparative studies.

2005 Objective. No studies to date have examined the effect on Blood pressure (BP) when pregnant women participate in aquatic physiotherapy (AP) classes; although, previous studies have indicated that there may be a detrimental outcome to the pregnant mother and fetus when there is a significant rise in the maternal BP. At least three components may contribute to BP changes: temperature, exercise, and immersion. This study examines BP changes in pregnant women attending AP classes. Method. An experimental same-subject, repeated measures design was employed. Forty-five sets of data were collected from pregnant women attending routine, existing, nonaerobic AP classes. Blood pressure measurements were taken preimmersion, 25 minutes after entering the pool, immediately following the 50 minute AP class (while immersed), and 812 minutes after exiting the water. Results. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) data were analyzed using a repeated measures analysis of variance (ANOVA). For all sets of data a highly significant difference was observed (p = 0.0000). Post-hoc Tukey test results showed BP to decrease significantly on entering the water (MAP mean difference of 10.52 mm Hg, 95% CI 8.75 to12.29), to remain at this low level postexercise while still immersed, and then return to preimmersion values 812 minutes after exiting the water. Conclusion. These results indicate that AP classes are safe for nonhypertensive pregnant women in their third trimester. The use of AP in the antenatal care of women with unstable BP or who are hypertensive needs further research.

Aims: To develop the Activity Card Sort (ACS) — Australia as a tool to measure participation in activities of daily living for older adults. Methods: Secondary data analysis of activity diaries of older Australians in Brisbane and Adelaide were utilised for item generation. Survey of older adults and cluster analysis was used for item selection and determination of domains for the ACS-Australia. Results: The final ACS-Australia is comprised of 82 activity items, falling under the three domains of household activities, social/educational activities and leisure activities. Conclusions: The ACS-Australia has robust properties, wide application and provides a culturally relevant tool to measure participation of older Australians, thus will facilitate rigorous clinical and population-based research.

PhD Doctorate The peer reviewed publications contained in this thesis provide clear evidence that the broad characteristic 'rural background' is an important independent predictor of rural practice. Rural background was explored in several ways: primary and secondary home and schooling; location of undergraduate and postgraduate training and finally partner's primary and secondary home and schooling. What influences a doctor to practice in a rural location is complex but for the 2414 GPs who are represented in this thesis we now know that rural background, special entry programs, 'place of education' and partners background were associated with rural practice. The publications are representative of the stages of the thesis. The systematic review identified factors relating to practice location explored in previous studies. The State study informed the development of the questionnaire used in the national study and the feasibility of carrying out a national study. The final stage was conducted as an observational retrospective case-control study in each state and territory (excluding the ACT) in Australia. In the publications presented in this thesis, the strength of the association between rural background and rural practice location was consistent across the factors explored and they were 2-3 times more likely to have attended a rural primary or secondary school. They were 2-3 times more likely to have a spouse/partner who had attended a rural primary or secondary school. Rural GPs were 1.6 times more likely to have experienced rural placements while at medical school and approximately 3 times more likely to have had rural postgraduate training. However, the strength of the association with postgraduate training was found to increase proportionally and when more than half of their postgraduate training was in a rural location the GP was 10 times more likely to be practising in a rural location.These findings can be applied to the broad group of Australian private practice GPs who make up the majority of the medical workforce in the primary care setting. While overseas trained medical practitioners importantly make up approximately 25% of the GP workforce in Australia, this study aimed to provide evidence to inform medical education policy in Australia. Over the last 5-10 years Australian medical schools have increased the number of rural background students studying medicine with the objective of increasing the number of graduates practising in rural locations. During this same time the opportunities for medical education to be undertaken in rural locations have also increased. This thesis supports these initiatives The future direction for workforce research now rests with prospective longitudinal research such as the Committee of Deans of Australian and New Zealand Medical Schools, Medical Schools Outcomes Database project. Following our medical students through their medical training and into their postgraduate years will allow evaluation of rural selection policies, rural programs and medical education and in time assist with medical workforce planning to increase the size of the rural medical workforce in Australia.

Problem-based learning (PBL) is a popular curricular approach in medical education. This thesis asks the question: How does PBL teach medical students about what matters in medicine using qualitative methods. The research demonstrates that PBL contributes to the on-going marginalisation of social issues in medical education. PhD Doctorate

Background Low back pain (LBP) is the most prevalent musculoskeletal condition and one the most common causes of disability in the developed nations. Anecdotally, there is a general assumption that LBP prevalence in Africa is comparatively lower than in developed countries. The aim of this review was to systematically appraise the published prevalence studies conducted on the African continent to establish the prevalence of LBP in Africa. Methods A comprehensive search was conducted in April 2006. The following databases PEDro, Psychinfo, Science Direct, SportsDiscus, PubMed, CINAHL, Biblioline Pro-African Wide NiPAD and SA ePublications were individually searched using specifically developed search strategies for epidemiological research conducted on LBP amongst the African population. Two reviewers independently evaluated the methodological quality of the studies reviewed. Results A total of 27 eligible epidemiological studies were included in this review. The majority of the studies (63%) were conducted in South Africa (37%) and Nigeria (26%). The most common population group involved workers (48%), while scholars comprised 15% of the population. 67% of the studies were found to be methodologically sound, and the LBP prevalence of these were analyzed. The mean LBP point prevalence among the adolescents was 12% and among adults was 32%. The average one year prevalence of LBP among adolescents was 33% and among adults was 50%. The average lifetime prevalence of LBP among the adolescents was 36% and among adults was 62%. Conclusion The findings support the global burden of disease of LBP, in addition to suggesting that LBP prevalence among Africans is rising and is of concern. Further research into the most effective strategies to prevent and manage LBP in Africa is warranted.

A systematic review was performed to identify studies reporting summary data (mean, standard deviation) of sonographic cross-sectional measurements of the ulnar nerve at the elbow. Comparisons of measurements were performed to determine whether statistical differences existed between groups of individuals symptomatic and asymptomatic of ulnar nerve entrapment at the elbow (UNE). Across the four studies meeting the selection criteria of the search, five sample groups were identified and compared: three asymptomatic of UNE and two symptomatic of UNE. There were significant differences between measurements of people with and without UNE ( P < .0001—.041). Significant differences also existed between the two symptomatic populations ( P < .0001—.0062) and between the three asymptomatic populations ( P < .0001—.41). This systematic review demonstrates that significant differences exist between sonographic measurements of ulnar nerve dimension between people with and without UNE, confirming that these measurements are potential discriminators of UNE. The demonstration of significant differences between measurements of ulnar nerve size within sample populations with similar symptomatic status suggests that further studies are required to confirm the effect of ulnar nerve pathologies, measurement protocols, and anthropometric factors.

Question: Which models of undergraduate/entry-level clinical education are being used internationally in allied health disciplines? What is the effect and, from the perspective of stakeholders, what are the advantages, disadvantages, and recommendations for successful implementation of different models of undergraduate/entry-level clinical education? Conclusion: There is currently no 'gold standard' model of clinical education. The perception that one model is superior to any other is based on anecdotes and historical precedents, rather than on meaningful, robust, comparative studies. Design: Systematic review with data from quantitative and qualitative studies synthesised in a narrative format. Intervention: Six broad models of clinical education: one-educator-to-one-student (1:1); one-educator-to-multiple-students (1:2); multiple-educators-to-one-student (2:1); multipleeducators-to-multiple-students (2:2); non-discipline-specific-educator and student-as-educator. Outcome measures: Models were examined for productivity; student assessment; and advantages, disadvantages, and recommendations for implementation. Participants: Undergraduates/entry-level students from five allied health disciplines undergoing clinical education. Results: The review found few experimental studies, and a large amount of descriptive research and opinion pieces. The rigour of quantitative evidence was low, however qualitative was higher. Evidence supporting one model over another was largely deficient with few comparative studies available for analysis. Each model proffered strengths and weaknesses, which were unique to the model.