Optimisation of Surgical Timing in Rheumatic Mitral Valve Disease

Rheumatic heart disease is a consequence of Group A streptococcal infections, and disproportionately affects the world’s most disadvantaged people. Whilst the disease has been essentially eradicated from nonindigenous populations in Australia, Indigenous Australians continue to have some of the highest rates of rheumatic heart disease in the world. The mortality and morbidity associated with rheumatic heart disease primarily results from complications of valvular heart disease which include heart failure and stroke. Valvular surgery can reduce the risk of these, however it comes with its own short-term increase in risk and long-term sequelae. Guidelines for the management of valvular heart disease primarily focus on North American and European populations which are generally older and with mainly single valve disease. Given the unique pathophysiology and demographics of rheumatic valvular disease, this may prove problematic. Rheumatic heart disease is epitomised by progressive mixed and multivalvular disease in children and young adults. Early intervention provides improved long-term outcomes following valvular surgery, especially in young adults. This thesis focuses on surgical delays, screening, and echocardiographic predictors as methods to reduce long-term risk in patients with rheumatic heart disease and optimise timing of tertiary intervention. Chapter 1 reviews the current management of rheumatic heart disease and the pitfalls of existing international guidelines in patients with rheumatic heart disease including current evidence for timing and replacement of valves. Chapter 2 reports on current surgical management of rheumatic heart disease in Australia and compares that to current guidelines. Given most patients come from remote communities, it further looks at delayed referrals and further, delayed surgery for those referred. It illustrates that there are many patients with guideline indications for surgery who fail to be referred or have surgery performed. Chapter 3 examines the prevalence of rheumatic heart disease in Indigenous populations across different regions of South Australia. This provides guidance to the tailoring of screening programs as well as defining the prevalence of echocardiographic confirmed RHD in South Australia. This study shows the prevalence of RHD in remote areas are significantly higher than metropolitan or rural areas. Chapter 4 quantifies sonographer sensitivity and accuracy using the World Heart Federation rheumatic heart disease echocardiographic screening criteria, as well as examining sonographer views of the echocardiographic parameters to enable further refinement of existing criteria. It confirms that sonographers have an extremely high sensitivity and reasonable specificity for RHD screening. Chapter 5 demonstrates the potential role of the left atrium in the management of rheumatic mitral valve disease. It finds that left atrial ejection fraction is the strongest and most reliable predictor for developing a guideline indication for valve intervention in the subsequent two-years. Finally, the insights gained in current management, screening, and echocardiographic assessment are placed in the context of previous literature in Chapter 6, before possible directions for future studies on optimising surgical outcomes and longevity of patients with rheumatic heart disease are discussed in Chapter 7.Thesis (Ph.D.) -- University of Adelaide, Adelaide Medical School, 202

2016 Grizzly Football Yearbook

Annual yearbook of the University of Montana’s Athletics Department. This volume covers the period from fall 2016 through spring 2017.https://scholarworks.umt.edu/grizzlyfootball_yearbooks/1066/thumbnail.jp

2017 Annual report town of Rindge, New Hampshire for the year ending December 31, 2017.

This is an annual report containing vital statistics for a town/city in the state of New Hampshire

Workplace Bullying: An exploratory study in Australian academia

Workplace bullying is a behaviour which adversely affects individuals, organisations and the community at large. While substantial research has been conducted on workplace bullying in different work settings, limited research exists on this behaviour at universities; no comprehensive studies have to date been conducted in the context of Australian academia. This study therefore contributes through breaking new ground by exploring bullying within the increasingly corporatised and competitive Australian higher education sector. New Public Management (NPM) practices, diminished government funding, and limited resources risk transforming this sector into a full-fledged industry focused on corporate objectives to achieve operational profitability. Universities’ primary commitment to further higher education and quality research may also be overshadowed by the bids to achieve revenue maximisation. The resultant competitive workplaces staffed by a more contingent workforce may also influence bullying experienced by both academic and professional staff in universities. While prior research has shown that competitive work environments can facilitate workplace bullying, no known previous study explored the bullying experiences of academic and professional staff in the Australian higher education sector. This study’s primary aim was therefore to explore the nature, influencing factors and consequences of workplace bullying for both academic and professional staff within Australian academia. Being an exploratory study, this research adopted a qualitative approach to gather a rich description of bullying experienced by both these distinct workstreams in universities. Individual accounts of being bullied at work were gathered by interviewing academic and professional staff from four Western Australian public universities. Thematic analysis of these confidential semi-structured interviews provided insights into the interplay of various underlying factors which enable workplace bullying. While many of this study’s findings resonate with the established literature on the subject, others are unique to the two-tiered context of Australian higher education sector. This study’s participants, explicitly as well as implicitly, linked bullying behaviours in their workplaces to the volatile economic environment of the Australian higher education sector, and increased competition amongst its workforce. As the sector’s changing employment patterns have moved towards a more contingent workforce, the sense of insecurity amongst university employees has developed to a point where many may prefer to endure bullying rather than reporting it formally. One strong theme emerging from this study’s data was the role that organisational and individuals’ culture(s) played in the occurrence of workplace bullying. Participants identified their universities’ work culture as one which tolerated workplace bullying, despite the considerable impact on individual victims. Some participants also noted the differences in individuals’ cultural backgrounds as triggers for bullying. In light of this study’s findings, measures to ameliorate workplace bullying may include steps to spread awareness and respect about cultural differences amongst the universities’ workforce. Universities might also consider explicitly addressing these issues in its anti-bullying policies. This study’ findings also underlined the lack of consistently implemented, robust anti-bullying policies in universities to safeguard employees’ wellbeing. On an individual level, power was found to be at the core of bullying. The power differentials between the victims and the alleged perpetrators stemmed from the hierarchical organisational structures existing in the universities. Although hierarchies are set in universities to accomplish its objectives, these structures often result in power being concentrated with certain individuals who may misuse it to bully others. In some cases, it appeared that bullying was being used to counter a perceived threat that high performing individuals posed to the alleged perpetrators’ established power and organisational status. Data analysis also highlighted the adverse consequences of bullying for both individuals and organisations. Workplace bullying was found to have harmful effects on an individual’s psychological and physical health; its negative impacts extended beyond the workplace to victims’ home life with their family and friends. On an organisational level, workplace bullying resulted in lower levels of staff productivity and engagement, while increasing universities’ employee turnover and damaging institutional reputations. This study, therefore, highlights how the adverse consequences of bullying experienced by academic and professional staff may prove particularly detrimental to their universities. While the productivity losses due to workplace bullying may be less obvious in universities than in other organisations, they can impair the intellectual contribution these academic institutions make to society. Such contribution can be in the form of the quality of teaching and research outputs, as well as the provision of support services for the students and staff at these institutions. Since this study incorporated the inputs of both academic and professional staff, its findings may represent the views held by the larger workforce in the Australian higher education sector. This study also provides a base for further qualitative and quantitative studies of workplace bullying within and beyond Australian academia