Medicine (Austin & Northern Health) - Theses
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ItemThe physical function of the elderly with rheumatoid arthritis( 1997)This thesis contains a body of work concerned with the physical function of the elderly with rheumatoid arthritis (RA). Chapter 2 reviews the relevant literature including that concerned with functional status measurement, functional outcome in RA and RA in the elderly. Chapter 3 describes a study validating the adapted Barthel Index - which is commonly used to measure personal care and mobility activities of daily living (ADL) - in a self-report format. This study was performed on a sample of geriatric day hospital attendees in Edinburgh, Scotland. Chapter 4 outlines the methods used in the main study describing the physical function of the elderly with RA (ER), as compared with that in younger people with the disease (YR) and elderly unaffected control subjects (EC). This study was also conducted in Edinburgh, between 1988 and 1989. Physical functional performance and capacity were measured using the adapted Barthel Index in its previously validated self-report format. Chapter 5 presents the results of the main study, and Chapter 6 discusses these results and a number of other important issues relating to study methodology, general health status, unmet needs and physical function. The main research objectives of this thesis were to determine: 1.the level of physical functioning of older people with RA, in terms of self-care, mobility and instrumental activities of daily living, 2.if age or the rheumatoid process has a greater influence in determining physical functional outcome in older people with RA, 3.whether older people with RA are able to perform physically at, or near their level of functional capacity, and if not why, 4.the main determinants of physical functional performance, in terms of medical, social and psychological health status measures, and if they differ in older and younger people with RA.
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ItemA prospective assessment of the total palliative care needs of patients with advanced malignancy( 1993)From Preface: This thesis is based on original work by the author who was the principal investigator of the prospective study. A proportion of patient interviews were conducted by two members of the Palliative Care Service and a State Registered Nurse. The majority of patient accrual and follow-up interviews, all data analysis and compilation of the results were completed by the principal investigator.
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ItemLife after life-support( 1998)This research project examined the 639 admissions to the intensive care unit at the Royal Melbourne Hospital between 1 July and 31 December 1993. The data were examined from a biopsychosocial perspective using both qualitative and quantitative methods. I demonstrate that the lack of commitment to provide ongoing health and social services in the community diminished the efforts made in the intensive care unit. Although the commitment to “save lives” in the intensive care unit was evident in the 90% survival rate, the failure to provide adequate follow-up care in the general wards and the community contributed to both the 10.5% readmission rate to the intensive care unit and the 101 unplanned readmissions to hospital. Six months after discharge from the intensive care unit, patients’ perceived health status, functional recovery and “quality of life” were assessed by personal interviews and self-reported questionnaires. Although 90% of the survivors were living at home, this did not always imply a “successful” outcome. While the degree of dependency varied, many patients required ongoing care in the community. The reliance on families to provide this care is located within a broader social and political ideology. In this thesis, I argue that there was a failure to recognise the integral relationship between intensive care units and other parts of the health care system. This resulted in life-saving crisis interventions in the intensive care unit without a continuity of care. To ensure that the life-saving efforts in the intensive care unit are worthwhile, the current biomedical and economic perspective needs to be complemented with a more holistic approach to health care. Recognising that patients have special needs after discharge from the intensive care unit, that the technological “fix” does not occur in isolation, and that the recovery process may be slow and long, is crucial. Continuity of care in both the general hospital wards, the rehabilitation hospital and the community makes the difference between patients thriving and merely surviving.
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ItemThe mathematical analysis of heart rate variability( 1998)This thesis examines various mathematical approaches, including conventional statistical descriptions and nonlinear mathematical methods of measuring short term heart rate variability (HRV). The observation that the heart beat is not precisely regular was made nearly 400 years ago by Dr Thomas Willis. This physiological phenomena was not fully appreciated until relatively recently when computer based methods to accurately measure the heart rate became readily available. Since the first contemporary scientific papers describing this natural fluctuation in heart rate started to appear in 1964, there has been an ever increasing number of publications evaluating the use of HRV analysis in various areas of clinical medicine. Although modern signal processing techniques provide a means of analysing beat to beat functions in heart rate there still remain many problems in developing suitable practical techniques which can be used in the clinical setting. Most commonly, HRV analysis is performed using data collected from 24-hour ambulatory electrocardiograms, however the attendant logistic and technical difficulties make long term HRV analysis impractical as a routine clinical investigation. To address this problem, short term analysis of HRV using geometric methods based on the Poincaré plot are examined in detail in this thesis. Issues relating to time series analysis including stationarity, artefact and filtering methodology are also explored. Using health volunteers and subjecting them to various autonomic perturbations it was demonstrated that the width of the Poincaré plot as quantified by SD delta RR (r-MSSD) is a measure of parasympathetic nervous system activity. The autonomic effect of various doses of captopril in patients with left ventricular dysfunction and heart failure was shown to be dose responsive with an increase in cardiac vagal activity occurring at low dose captopril (12.5 mg BD) and a reduction in vagal activity to baseline levels at the highest dose (50 mg BD). The implication of this study suggests that careful dosing of captopril is required in patients with heart failure to optimise cardiac autonomic activity. Reduced HRV has also been shown to be a consistent feature in patients with hypertension and it was demonstrated that increasing doses of enalapril result in an increase in cardiac parasympathetic nervous system activity. The implication being that increasing doses of enalapril provide beneficial autonomic changes in these patients. Mathematical models enable theoretical explorations of physiological control systems too complex for complete understanding. It is with this principle in mind that a simple mathematical model of the baroreflex loop is developed and used to generate some of the characteristic Poincaré plot patterns produced in the various studies presented in this thesis. The implications of the mathematical model have relevance to the nonlinear mathematical methods of HRV analysis and provide theoretical structure with which to interpret the nonlinear parameters used to quantify HRV.