Thesis (Ph. D.)--University of California, San Diego, 2002. / Vita. Includes bibliographical references.

Aim: The aim of the study was to explore the lived experiences of critical care nurses with Muslim traditional practices. Methodology: A phenomenological approach was used in the study to gain the critical care nurses' perspectives of Muslim traditional illness practices. The realised sample was six participants, from intensive care units within one provincial and one private hospital. The researcher applied the principle of theoretical saturation, which was achieved at the verifying interviews of the participants. Two semi- structured interviews were conducted with each participant an initial and a verifying interview, each of which lasted 20 - 30 minutes. All interviews were recorded and transcribed. Manual data analysis was used to identify categories and themes. Findings: The participants were open-minded to the Muslim clients' belief system on healing and agreed that the clients' cultural beliefs took precedence over their own beliefs. The participants believed that Muslims relied on traditional illness practices as these provided them with hope and faith in times of despair as well as provided them with emotional and spiritual contentment. A number of methods were used by the participants to acquire knowledge about Muslim traditional illness practices. There was great support for the delivery of culturally sensitive care amongst the critical care nurses. Recommendations were suggested for nursing education, nursing practice and further research to facilitate the creation of a culturally sensitive climate in health care delivery. / Thesis (M.N.)-University of Natal, Durban, 2003.

Background Instillation of nonnal saline before suctioning is a common nursing intervention although little research supports the practice. Objectives To detennine when and how often saline is used during suctioning and to assess the knowledge of nurses and respiratory therapists of the advantages and dangers of using saline during endotracheal suctioning. Methods A survey of nurses and respiratory therapists working in adult and neonatal intensive care units was conducted in three large teaching hospitals in the UAE. Results Of the 81 respondents, 38 (47%) rarely instil saline before suctioning, whereas 20 (25%) frequently use saline. Seventy-four percent use saline to enhance retrieval of secretions, and 72% use it to stimulate cough. Nurses and respiratory therapists differ in their use and understanding of saline instillation. Most nurses (56%) rarely use saline before suctioning, whereas most respiratory therapists (37%) frequently use saline. Respiratory therapists (93%) were more aware than were nurses (61%) of the benefit of using nonnal saline to stimulate a cough. Respiratory therapists considered oxygen desaturation as a major adverse effect of saline instillation in comparison to nurses who stressed on pulmonary infection as a major side effect. Conclusion The results of the survey indicates that the practice of these professionals are not in line with most recent research results in the area and indicate a need for in-service education. / Thesis (M.Cur.)-University of Natal,Durban, 2002.

Patient safety is of particular importance within intensive care units (ICUs), where critically ill, vulnerable patients receive complex multidisciplinary care. Prior research has indicated that improving patient safety and reducing errors within healthcare requires a focus on systems and organisational culture issues. This thesis was concerned with three studies. One focused on assessing the patient safety culture and two on quality improvement initiatives within an intensive care unit (ICU) of a large teaching hospital. The first study involved a survey of ICU consultant, registrar and nursing staff regarding aspects of safety culture. This was conducted using an existing Hospital Survey on Patient Safety Culture. Of the twelve patient safety culture composites assessed, eight had scores lower than 50%, highlighting these as areas for improvement. Overall, while the survey results revealed that teamwork within the ICU was considered a strength, event reporting and patient care handovers and transitions were both considered areas with potential for improvement. The second study focused on the evaluation of a change initiative designed to improve the handover of patient clinical information in the ICU. This study involved a survey and interviews with consultant, registrar and nursing staff before and after the introduction of a Patient Management, Plan and Progress (PMPP) document. Examination of the survey responses involved both quantitative and qualitative analysis; respondent interview transcripts were analysed using thematic analysis. The results of this study revealed resistance to, and criticisms of, the introduction of the PMPP document; the initiative failed and use of the document was discontinued. The second initiative concerned an evaluation of the impact of a hospital-wide document on improving documentation of withdrawal of patient treatment within the ICU. This involved both quantitative and qualitative analysis, with a patient medical record audit of decisions to withdraw patient treatment within the ICU before and after the introduction of an Advance Care Plan (ACP) document. ICU consultant, registrar and nursing staff were interviewed regarding the process of withdrawal of patient treatment within the ICU. Interview transcripts were analysed using a modified grounded theory approach. Results revealed that the attempt to improve the documentation of withdrawal of treatment within the ICU failed, with the ACP document remaining unused in 89% of cases and incomplete in the remaining 11%. Also, documentation of decision-making and of the process within the medical records did not improve. Before-introduction findings revealed that only 26% of medical records met the pre-existing requirements for treatment withdrawal in the ICU, and after-introduction findings revealed that only 19% of medical records audited met the requirements of the ACP document. After-audit findings also revealed significant and inappropriate increases in the involvement of an ICU registrar both as primary and secondary decision-makers. In spite of an increased awareness of ICU staff concerning the importance of improving documentation, the medical record audit revealed less compliance with the standards required for documentation. Possible reasons for the document remaining essentially unused, as revealed from interviews with staff, included: previous criticisms by the coroner when they failed to complete a similar formalised document properly; perceived logistical issues associated with obtaining required staff signatures; disagreement concerning who should be involved in documenting the withdrawal of treatment process; and the existence of an ICU subculture of practice that, in one particular aspect of documentation, was not consistent with established hospital and ICU protocol and documentation requirements. The final chapter of this thesis considered implications of the results of the studies for the planning, development, implementation and evaluation of improvement programs within the ICU setting. The results were considered within the context of organisational change management theory and research, including factors that have been found to be critical in the success or failure of change programs, such as resistance to change, the involvement of key stakeholders in the change process, leadership, communication and organisational culture. It is suggested that management consultants with organisational change expertise in the planning, development, implementation and evaluation of such programs should be involved in future quality improvement initiatives. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297608 / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2007

Thesis (M.Eng. (Hons.)) -- University of Western Sydney, 2001. / Bibliography : leaves [185]-195 (v. 1).

Thesis (MNutr (Human Nutrition))--University of Stellenbosch, 2006. / INTRODUCTION: The primary objective was to determine whether acidified formulae (pH 3.5 and 4.5) decreased gastric and tracheal colonisation, as well as microbial contamination of the enteral feeding delivery system, compared with a non-acidified control formula (pH 6.8) in critically ill patients. Secondary objectives included tolerance of the trial formulae and mortality in relation to the administration of acidified formulas. DESIGN: The trial was a controlled, double-blinded, randomised clinical trial of three parallel groups at a single centre. METHOD: Sixty-seven mechanically ventilated, medical and surgical critically ill patients were randomised according to their APACHE II scores and included in the trial. Patients received either an acidified (pH 3.5 or 4.5) or control polymeric enteral formula via an 8-Fr nasogastric tube at a continuous rate. Daily samples were taken for microbiologic analyses of the enteral formulae at various stages of reconstitution and at 6-hour and 24-hour intervals during administration thereof (feeding bottle and delivery set). Daily patient samples included nasogastric and tracheal aspirates, haematological evaluation and gastro-intestinal tolerance. The trial period terminated when patients were extubated, transferred from the ICU, enteral nutrition became contraindicated, a patient died, or for a maximum of 21 days. RESULTS: Gastric pH showed no significant difference (p = 0.86) between the 3 feeding groups [pH 3.5 (n = 23), pH 4.5 (n = 23) and pH 6.8 (n = 21)] at baseline prior to the administration of enteral formulae. After initiation of feeds, the gastric pH decreased significantly (p< 0.0001) in the acidified formulae as compared to the control formula during the trial period. Patients who received acidified enteral formulae (pH 3.5 and 4.5) had significantly less (p < 0.0001) contamination from the feeding bottles and delivery systems in respect of Enterobacteriacea, and Enterococcus., The more acidified group (pH 3.5) showed significantly less gastric contamination (p = 0.029) with Enterobacteriacea, , but not for fungi. The 3.5 acidified group also had the lowest gastric growth in terms of colony counts (≤104) of these organisms, but not for fungi, when compared to the control group (≤105). Vomiting episodes were 22% and abdominal distension 12%, with a higher incidence in the control group. Adverse events occurred equally between the groups with a higher, but not significantly different incidence of 37% in the control group and 32% for the acidified groups. There was no evidence of gastro-intestinal bleeding in any patient. Overall, the mortality rate in this trial was 6%, with 6.5% for the acidified groups (n=46) and 4.8% for the control group (n=21), a statistically insignificant difference. CONCLUSION: Acidified enteral formulae significantly decrease gastric colonisation by preserving gastric acidity that decreases the growth of Enterobacteriaceaes organisms. Acidified formulae significantly decrease bacterial contamination of the enteral feeding system (bottle and delivery set) of Enterobacteriaceae and Enterococcus organisms. Acidified formulae are tolerated well in critically ill patients.

Patients in the intensive and critical care unit frequently undergo diagnostic radiology procedures such as computed tomography (CT) and X-ray imaging. As these patients often require respiratory assistance and are vulnerable to infection, it is important to understand the potential acute effects of these procedures on the lungs and immune system. The aim of this study was to determine the acute effects of a single clinically relevant low-dose X-ray exposure in order to establish baseline responses in markers of lung injury and immune function in a rodent model. Male Sprague-Dawley rats (200-250 g) were irradiated with 0, 2, 20 or 200 mGy whole-body X-rays in an XRAD 320 irradiator. Markers of lung injury and immune activation in the lungs and spleen were evaluated 0.5, 4, and 24 h post-irradiation to examine the acute stages of the physiological and immunological response. Intratrachaeal lipopolysaccharide (LPS) exposure was used as a positive control model of acute lung injury. Lung injury endpoints included respiratory mechanics, pulmonary oedema, arterial blood oxygenation, histological analysis, and cellular and proteinaceous infiltrate via bronchoalveolar lavage. Immunological measures in the spleen focused on splenocyte proliferation, using the MTS assay and differential cell counts before and after stimulation with LPS or concanavalin A (Con A), as compared to unstimulated cultures. Splenocyte proliferation in response to Con A, but not LPS, was significantly decreased after 200 mGy in vivo X-irradiation (repeated measures two-way ANOVA with LSD post-hoc, p=0.024). There was a non-significant trend towards increased lung tissue resistance after 200 mGy, with no significant effect on pulmonary oedema, cellular or proteinaceous infiltrate, nor other aspects of respiratory mechanics (two-way ANOVA with LSD post-hoc, p>0.05). A clear understanding of these immunological and physiological effects informs the responsible use of medical diagnostic procedures in modern medicine. Establishment of this model for the elucidation of acute immune effects of low-dose radiation will facilitate future work evaluating these parameters in disease models, mimicking patients in intensive care. / Thesis / Master of Science (MSc) / Diagnostic procedures such as computed tomography (CT) and X-ray imaging are a common part of intensive and critical care medicine. Some physicians are concerned that this exposure to diagnostic radiation may negatively affect the health of their patients, who are prone to infection and who often need a machine to breathe for them. In order for doctors to make informed decisions, the possible effects of these levels of radiation must be understood. To improve this understanding, this study looked at the short-term effects of X-ray doses on key organs affected by critical illness, the lungs, and the spleen, which is an important organ of the immune system that helps fight infection. Using an animal model, doses of X-rays in the range of diagnostic radiation (0-200 mGy) were examined and no significant effect on lung health was found. However, the highest dose of X-rays tested, which is greater than that expected for a single CT scan, did have an effect on cells from the spleen. Spleen cells are designed to multiply when they detect various types of infection, so that there are more immune cells to fight that infection. The cells from animals that were given the highest dose of X-rays didn’t multiply as much in response to infective stimulus as those from animals that received lower doses, or no X-rays at all. Overall, it seems that diagnostic radiation doesn’t have an effect in the lungs, but very high diagnostic doses could slightly affect a patient’s ability to fight infection. It is important to remember that patients in critical care are very sick, so doctors have good reason to use diagnostic tools available to them. Missing a diagnosis has major and immediate consequences, which must be balanced against the potential small risks of using radiation to make that diagnosis.

[Tuncated abstract] This research thesis consists of five sections. Section one provides the background information (chapter 1) and a description of characteristics of the cohort and the methods of analysis (chapter 2). The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system is one of commonly used severity of illness scoring systems in many intensive care units (ICUs). Section two of this thesis includes an assessment of the performance of the APACHE II scoring system in an Australian context. First, the performance of the APACHE II scoring system in predicting hospital mortality of critically ill patients in an ICU of a tertiary university teaching hospital in Western Australia was assessed (Chapter 3). Second, a simple modification of the traditional APACHE II scoring system, the 'admission APACHE II scoring system', generated by replacing the worst first 24-hour data by the ICU admission physiological and laboratory data was assessed (Chapter 3). Indigenous and Aboriginal Australians constitute a significant proportion of the population in Western Australia (3.2%) and have marked social disadvantage when compared to other Australians. The difference in the pattern of critical illness between indigenous and non-indigenous Australians and also whether the performance of the APACHE II scoring system was comparable between these two groups of critically ill patients in Western Australia was assessed (Chapter 4). Both discrimination and calibration are important indicators of the performance of a prognostic scoring system. ... The use of the APACHE II scoring system in patients readmitted to ICU during the same hospitalisation was evaluated and also whether incorporating events prior to the ICU readmission to the APACHE II scoring system would improve its ability to predict hospital mortality of ICU readmission was assessed in chapter 10. Whilst there have been a number of studies investigating predictors of post-ICU in-hospital mortality none have investigated whether unresolved or latent inflammation and sepsis may be an important predictor. Section four examines the role of inflammatory markers measured at ICU discharge on predicting ICU re- 4 admission (Chapter 11) and in-hospital mortality during the same hospitalisation (Chapter 12) and whether some of these inflammatory markers were more important than organ failure score and the APACHE II scoring system in predicting these outcomes. Section five describes the development of a new prognostic scoring system that can estimate median survival time and long term survival probabilities for critically ill patients (Chapter 13). An assessment of the effects of other factors such as socioeconomic status and Aboriginality on the long term survival of critically ill patients in an Australian ICU was assessed (Chapter 14). Section six provides the conclusions. Chapter 15 includes a summary and discussion of the findings of this thesis and outlines possible future directions for further research in this important aspect of intensive care medicine.

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008

Inadequate delivery of nutrition to the critically ill is common, and may adversely affect clinical outcomes, including survival. This thesis reports studies designed to characterise the gastrointestinal dysfunction underlying feed intolerance in the critically ill, as well as the pathophysiology of these dysfunctions, and investigate potential therapeutic measures. While it has been established that enteral nutrition is frequently unsuccessful in the critically ill, assessment of the success of feeding in an Australian intensive care unit (ICU) had not been performed previously. A prospective survey examined the incidence of, and risk factors for, feed intolerance in the ICU at the Royal Adelaide Hospital and demonstrated that, in 40 patients receiving enteral feeding, only about 60% of their nutritional requirements were met at the end of the first week. The main cause for this lack of success was large gastric residual volumes, indicative of delayed gastric emptying (GE). This study, accordingly, quantified the limitations of nutritional delivery in contemporary practice in a local ICU. The results suggest that a better understanding of the pathogenesis underlying this problem is warranted in order to direct research into improved therapies. Scintigraphy is the most accurate technique to measure GE, but is difficult to perform in the ICU. A simpler, more convenient, test would increase the accessibility of GE measurement for both research and clinical purposes. A study comparing a breath test technique and gastric residual volume measurement to the scintigraphic measurement of GE in 25 mechanically ventilated patients demonstrated that GE measured by a breath test technique closely correlated with that measured by scintigraphy. While the breath test had a specificity of 100% it only had a sensitivity of about 60% in the prediction of delayed GE. Similarly, gastric residual volume measurement correlated with scintigraphic measurement of GE but also lacked sensitivity. The breath test has previously been demonstrated to be highly reproducible and it represents a useful option for repeated measurement of GE in the same patient. It is therefore likely to be useful to determine changes in GE over time or in response to a therapeutic intervention. There is a lack of information about the prevalence and determinants of delayed GE in the critically ill. Previous studies have substantial limitations and scintigraphic measurement of GE has only rarely been used. A study comparing GE measured by scintigraphy in 25 patients to 14 healthy subjects demonstrated that GE was delayed in approximately 50% of the ICU patients (>10% retention at 4h) and markedly delayed in about 20% (>50% retention at 4h). Patients with trauma and sepsis appeared to have a relatively higher prevalence of delayed GE (80% and 75% respectively). In addition, the longer the patient had been in ICU the more normal the rate of GE. Quantification of delayed GE may prove useful by defining patients who may benefit from preventative or therapeutic options. The abnormalities in gastrointestinal motility underlying delayed GE in the critically ill are poorly characterised. Simultaneous manometric and gastric emptying measurements were performed in 15 mechanically ventilated patients and 10 healthy subjects. These studies demonstrated that delayed GE was associated with reduced antral activity, increased pyloric activity and increased retrograde duodenal activity in the patients. Persistent fasting motility during feeding was also frequently observed. Furthermore, the feedback response to small intestinal nutrients was enhanced. This latter observation may provide an explanation for the delayed GE and warrants further investigation. Recent studies suggest that the hormone cholecystokinin may be a mediator of increased small intestinal feedback and, if confirmed, this has clear therapeutic implications. Nutrient absorption has rarely been measured in the critically ill. GE and glucose absorption (using 3-O-methyl glucose) were measured simultaneously in 19 ICU patients and compared to 19 healthy subjects. Glucose absorption was shown to be markedly reduced in the patients. Slow GE was associated with delayed, and reduced, absorption. However, glucose absorption was also reduced in patients with normal GE suggesting that reduced glucose absorption in critical illness is only partly due to delayed GE. Accordingly, measures to improve the effectiveness of GE and thereby improve overall nutritional status may be compromised by abnormal small intestinal absorption. The mechanisms underlying this warrant further investigation. A number of therapeutic options directed at improving the delivery of nutrition were examined. In a study involving 20 mechanically ventilated patients, administration of 200mg erythromycin intravenously was shown to be superior to placebo for treating feed intolerance. The optimal dose of erythromycin, however, was unclear. In a subsequent study involving 35 ICU patients, GE was measured using a breath test technique, before and after 2 different doses of erythromycin or placebo and a ‘low’ intravenous dose (70mg) of erythromycin appeared to be as effective as a ‘moderate’ dose (200mg). Both doses were only effective in subjects who had delayed GE at baseline. Based on the outcome of these studies, low doses of erythromycin have subsequently been routinely used to treat feed intolerance in the critically ill patients at the Royal Adelaide Hospital. Animal and human studies suggested that the antibiotic, cefazolin, may have a prokinetic effect. Cefazolin, however, did not demonstrate similar prokinetic activity at a ‘low’ dose (50mg) in a critically ill cohort. The results of this study do not support the use of this agent, at this dose, as a prokinetic, in this population. If nasogastric administration of nutrition proves unsuccessful an alternative is to infuse nutrient directly into the small intestine. However, the placement of feeding tubes distal to the pylorus is technically difficult. A novel technique for postpyloric tube insertion was examined with promising results. In summary, the studies described in this thesis have provided a number of insights relevant to the management of the critically ill by quantifying the prevalence of feed intolerance and delayed GE, characterising some of the disturbances in gastrointestinal motility underlying this problem, and evaluating a number of therapeutic interventions. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1345143 / Thesis (Ph.D.) -- University of Adelaide, School of Medicine, 2008