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Monaro S. What have we learned from two trials comparing open surgery and endovascular revascularization in patients with chronic limb threatening ischemia? JOURNAL OF VASCULAR NURSING 2023; 41:248-249. [PMID: 38072581 DOI: 10.1016/j.jvn.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Susan Monaro
- Susan Wakil School of Nursing & Midwifery, University of Sydney, New South Wales, Australia.
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Qato K, Bahroloomi D, Conway A, Lu E, Pamoukian V, Giangola G, Carroccio A. Contemporary outcomes of initial treatment strategy of endovascular intervention or bypass in patients with critical limb ischemia. Vascular 2023; 31:1117-1123. [PMID: 35698916 DOI: 10.1177/17085381221107749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The optimal management for revascularization after critical limb ischemia (CLI) is controversial due to limited studies comparing long-term results of endovascular and open techniques. This study compares long-term outcomes after initial management of CLI via lower extremity bypass (LEB) and percutaneous vascular intervention (PVI). METHODS This retrospective cohort study investigates outcomes of patients who underwent endovascular or open surgical management for CLI at a single institution from 2013-2018. All patients with diagnosis of CLI were included and separated based on initial therapy of PVI or LEB. Demographic, procedural, and follow-up data were assessed. Primary endpoints included major adverse limb events (MALE), specifically the need for major amputation and reintervention. Secondary endpoints included mortality at 30 days and one year. A multivariable Cox Proportional Hazard regression model was used to assess the relationship between Surgery group and time to MALE/death while controlling for confounding variables. RESULTS This study identified 338 patients with an initial diagnosis of CLI who underwent either LEB (n = 108, 32%) or PVI (n = 230, 68%). The average age was 71.4, 54.4% were male, 30% were African American, 53.6% were diabetic, and 93.2% had hypertension. Patients who underwent LEB were more predominantly smokers (p = .003) and less predominantly on dialysis at time of surgery (p = .01). Re-intervention rates in the bypass group (11%) were not significantly different than the PVI group (9%; p = .95). In the bypass group, 20 (19%) patients had a major amputation with a median time of 189.5 days compared to 23 (10%) patients at a median time of 113 days in the PVI group; however, this difference was not significant (p = .16). There was no significant difference in 1-year mortality between the LEB (2%) and PVI group (4%; p = .2). The cumulative incidence of MALE/death at 30 days was 4.0% in the bypass group and 3.7% in the PVI group (p = .2). Incidences of MALE/death were 21.1% and 48.5% in the bypass group and 19.7 and 45.9% in the PVI group at one and 2 years, respectively. Intervention type was not found to be significantly associated with MALE/death after controlling for possible confounders (HR = 0.82, p = .43). CONCLUSIONS In the initial management of CLI, there is no significant difference in long-term outcomes in terms of major amputation, need for reintervention, limb-salvage, and 1-year mortality.
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Affiliation(s)
- Khalil Qato
- Division of Vascular Surgery, Northwell Health, Glen Cove, NY, USA
| | - Donna Bahroloomi
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Allan Conway
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Eileen Lu
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Vicken Pamoukian
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Gary Giangola
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Alfio Carroccio
- Division of Vascular Surgery, Lenox Hill Hospital, New York, NY, USA
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Monaro S, West S, Gullick J. Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse. J Clin Nurs 2023; 32:6559-6573. [PMID: 36788640 DOI: 10.1111/jocn.16644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/14/2023] [Accepted: 01/23/2023] [Indexed: 02/16/2023]
Abstract
AIMS AND OBJECTIVES To explore the notion of Being-with and authentic discourse for people making decisions about major amputation. BACKGROUND Chronic limb-threatening ischaemia is a devastating disease with a high burden of pain and complex wounds. Patients may deteriorate suddenly after multiple revascularisation procedures and, amputation is offered when further reperfusion is considered futile. Delayed decisions about amputation have negative consequences for patients, families and health systems, yet little attention is given to training clinicians for the sophisticated communication required. Clinicians need to engage in authentic discourse about amputation to create shared meaning and facilitate decision-making. DESIGN Qualitative study using hermeneutic Heideggerian phenomenology. METHODS Twelve patients offered major amputation, and 13 family participants from three vascular units in Australia engaged in 42 semi-structured interviews, representing 19 cases of chronic limb-threatening ischaemia. Hermeneutic phenomenology using the Heideggerian tenet of Being-with as an analytic framework, a philosophically based understanding of Being-with and Discourse related to treatment discussions and decisions was derived. The research was reported in accordance with the COREQ checklist. FINDINGS Effective discourse between the person and family was hampered by changed circumstances of Being-with, characterised by guilt, and a retreat from discourse through deficient discourse and filtering information. Clinician Being-with was hampered by discourse that was deficient, poorly delivered, discordant and disconnected through a lack of empathetic listening. There were also examples of enhanced clinician Being-with that made room for more constructive discourse and more timely decisions about amputation. CONCLUSIONS Heidegger's construct of Being-with provides a useful framework to reveal the role of authentic discourse in improving patient and family experience and decisions about treatment. NO PATIENT OR PUBLIC CONTRIBUTION This study did not engage consumers other than as patient and carer participants. RELEVANCE TO CLINICAL PRACTICE Decisions about amputation are often difficult for patients or family members who may be substitute decision-makers. A better understanding of the experience may assist clinicians in their interactions with patients and families.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Sandra West
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
| | - Janice Gullick
- Faculty of Medicine and Health, Sydney Nursing School, University of Sydney, Sydney, New South Wales, Australia
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Choy OS, Manewell S, Rajendran S, Aitken SJ. Variation in treatment and outcomes for patients with chronic limb-threatening ischaemia in New South Wales, Australia. ANZ J Surg 2021; 91:1211-1219. [PMID: 33908162 DOI: 10.1111/ans.16886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/26/2021] [Accepted: 04/07/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic limb-threatening ischaemia (CLTI) carries significant amputation and mortality risks. Australian population-based outcomes for CLTI are inadequately known. This study aimed to distinguish factors associated with outcomes in the first 2 years after CLTI surgery. METHODS By linking routinely collected health administrative and mortality data from New South Wales, this population-based cohort study identified patients with ischaemic rest pain, gangrene or ulceration undergoing vascular surgery in public hospitals between 2010 and 2012. The primary outcome was 2-year amputation-free survival (AFS), and secondary outcomes included readmission and reoperation rates. Multivariable regression analysis identified prognostic factors adjusted for patient, hospital and geographic factors. RESULTS Primary CLTI surgery was performed on 4898 patients. Almost half the cohort had minor amputations without concurrent revascularization (2398, 49%), and the remaining patients had open (652, 13%) or endovascular (1848, 38%) surgery. At 2-years, the AFS rate was 72%. Significant disparity was seen between age groups, with the 2-year AFS 71% in patients aged 75 years or older, compared to 95% in patients aged less than 75 years (P < 0.001). Place of residence or hospital training status did not significantly influence AFS or readmission, but non-training hospitals had higher rates of reoperation. CONCLUSION This population-based cohort study demonstrated variable outcomes for patients with CLTI, particularly with respect to older age, admission acuity and comorbidity. Results may guide service improvements however further research is needed into how population-wide health initiatives can address age-related disparities in CLTI.
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Affiliation(s)
- Oh Sung Choy
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Nepean Hospital, Sydney, New South Wales, Australia
| | - Sarah Manewell
- Podiatry Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Saissan Rajendran
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord Institute of Academic Surgery, Vascular Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Sarah J Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord Institute of Academic Surgery, Vascular Department, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Sun KP, Xu N, Huang ST, Cao H, Chen Q. Health-Related Quality of Life in Children and Adolescents with Simple Congenital Heart Defects before and after Transcatheter Intervention Therapy: A Single-Center Study. Ann Thorac Cardiovasc Surg 2021; 27:105-111. [PMID: 32893225 PMCID: PMC8058546 DOI: 10.5761/atcs.oa.20-00078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To explore the health-related quality of life (HRQoL) of children and adolescents with simple congenital heart defects before and after the transcatheter intervention. Methods: The Pediatric Quality of Life Inventory 4.0 scale was used to assess the quality of life of 78 children and adolescents before and after the transcatheter intervention and to evaluate the parents’ perception of their children’s quality of life. Results: In all, 76 patients were completed the study. The results showed that the scores of the four dimensions and the total score for the quality of life of the patients significantly improved 1 month after the intervention. At 6 months after treatment, the scores in all dimensions continued to improve. From the parents’ perspective, the scores of the patients in all dimensions improved significantly at 1 month and 6 months after treatment. In terms of the quality of life assessment, the self-assessment results of the patients were more positive than those of their parents. Conclusions: The results showed that the quality of life of children and adolescents with simple congenital heart defects can be positively affected by the transcatheter intervention. Moreover, this improvement is not transient and seems to increase over time.
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Affiliation(s)
- Kai-Peng Sun
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Ning Xu
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China.,Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Guzelhan Y, Oztas DM, Conkbayir C, Rodoplu O, Erdinc I, Canbay C, Ugurlucan M, Alpagut U, Bozbuga N. Assessment of anxiety and health-related quality of life in patients with lower extremity peripheral arterial occlusive disease. Arch Med Sci Atheroscler Dis 2020; 5:e212-e218. [PMID: 32832723 PMCID: PMC7433785 DOI: 10.5114/amsad.2020.97728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The aim of this study was to investigate the effect of chronic occlusive vascular disease on anxiety with adverse outcome with health-related quality of life (HRQoL). MATERIAL AND METHODS Three hundred and thirty-five patients who were treated for peripheral arterial occlusive disease were enrolled in this study. 187 patients who had undergone percutaneous transluminal angioplasty and 148 patients who had one or more surgical revascularizations enrolled in the study. Mean age of the patients was 62.6 ±10 years. Two hundred and eighty-nine patients were male, 46 patients were female. Physical and mental domains of quality of life were measured using the 36-item Medical Outcomes Short-Form Health Survey (SF-36) self-administered questionnaire and anxiety symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI). At baseline 335 patients filled out the SF-36 and STAI, and 304 patients (90.7 % of the series) filled them out at 6-month follow-up. RESULTS There was no mortality and no significant morbidity after vascular interventions in the series. Significant improvement was found in two of eight health domains. The score of social functioning increased to 60.4 from 52.6 (p < 0.03) and general health perception increased to 75.1 from 60.5 (p < 0.04) at 6-month follow-up. The two STAI sub-scores, the State Anxiety Inventory (STAI-S) and the Trait Anxiety Inventory (STAI-T) were found high (≥ 40) both preoperatively and 6 months postoperatively. Postoperatively there was no significant decrease of the levels of anxiety. CONCLUSIONS This study suggests that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and prediction of functional status in patients suffering from lower extremity peripheral arterial occlusive disease.
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Affiliation(s)
- Yalcin Guzelhan
- Department of Psychiatry, Istanbul Education and Research Hospital, Istanbul, Turkey
| | - Didem Melis Oztas
- Cardiovascular Surgery Clinic, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Cenk Conkbayir
- Department of Cardiology, Near East University, Nicosia, Cyprus
| | - Orhan Rodoplu
- Cardiovascular Surgery Clinic, Kadikoy Medicana Hospital, Istanbul, Turkey
| | - Ibrahim Erdinc
- Cardiovascular Surgery Clinic, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Cagla Canbay
- Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ufuk Alpagut
- Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Nilgun Bozbuga
- Department of Cardiovascular Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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Monaro S, West S, Gullick J. The body with chronic limb‐threatening ischaemia: A phenomenologically derived understanding. J Clin Nurs 2020; 29:1276-1289. [DOI: 10.1111/jocn.15151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/31/2019] [Accepted: 11/24/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital Concord NSW Australia
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
| | - Sandra West
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
| | - Janice Gullick
- Faculty of Medicine and Health Sydney Nursing School University of Sydney Camperdown NSW Australia
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Vitamin D as A Protector of Arterial Health: Potential Role in Peripheral Arterial Disease Formation. Int J Mol Sci 2019; 20:ijms20194907. [PMID: 31623356 PMCID: PMC6801787 DOI: 10.3390/ijms20194907] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 12/14/2022] Open
Abstract
Atherosclerotic occlusive diseases and aneurysms that affect large and medium-sized arteries outside the cardiac and cerebral circulation are collectively known as peripheral arterial disease (PAD). With a rise in the rate of aging population worldwide, the number of people diagnosed with PAD is rapidly increasing. The micronutrient vitamin D is an important steroid hormone that acts on many crucial cellular mechanisms. Experimental studies suggest that optimal levels of vitamin D have beneficial effects on the heart and blood vessels; however, high vitamin D concentrations have been implicated in promoting vascular calcification and arterial stiffness. Observations from various clinical studies shows that deficiency of vitamin D has been associated with a greater risk of PAD. Epidemiological studies have often reported an inverse relation between circulating vitamin D status measured in terms of 25-hydroxivitamin D [25(OH)D] levels and increased cardiovascular disease risk; however, randomized controlled trials did not show a consistent positive effect of vitamin D supplementation on cardiovascular disease risk or events. Even though PAD shares all the major risk factors with cardiovascular diseases, the effect of vitamin D deficiency in PAD is not clear. Current evidence suggests a strong role of vitamin D in promoting genomic and epigenomic changes. This review summarises the current literature that supports the notion that vitamin D deficiency may promote PAD formation. A better understanding of underlying pathological mechanisms will open up new therapeutic possibilities which is the main unmet need in PAD management. Furthermore, epigenetic evidence shows that a more holistic approach towards PAD prevention that incorporates a healthy lifestyle, adequate exercise and optimal nutrition may be more effective in protecting the genome and maintaining a healthy vasculature.
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Duff S, Mafilios MS, Bhounsule P, Hasegawa JT. The burden of critical limb ischemia: a review of recent literature. Vasc Health Risk Manag 2019; 15:187-208. [PMID: 31308682 PMCID: PMC6617560 DOI: 10.2147/vhrm.s209241] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/07/2019] [Indexed: 01/15/2023] Open
Abstract
Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains—epidemiologic, clinical, humanistic, and economic—focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient’s physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden—a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.
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Affiliation(s)
- Steve Duff
- Veritas Health Economics Consulting , Carlsbad, CA, USA
| | | | - Prajakta Bhounsule
- Health Economics and Reimbursement, Abbott Vascular, Santa Clara, CA, USA
| | - James T Hasegawa
- Health Economics and Reimbursement, Abbott Vascular, Santa Clara, CA, USA
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Monaro S, West S, Pinkova J, Gullick J. The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation. J Clin Nurs 2018; 27:3530-3543. [PMID: 29776002 DOI: 10.1111/jocn.14536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/10/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023]
Abstract
AIMS AND OBJECTIVES To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI). BACKGROUND CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning. DESIGN Longitudinal qualitative study using Heideggerian phenomenology. METHODS Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed. RESULTS Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity). CONCLUSIONS Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy. RELEVANCE TO CLINICAL PRACTICE A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Sandra West
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Janice Gullick
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
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