Evidence Based Practice Roger Hawcroft July 2011
Objectives <ul><li>To  </li></ul><ul><li>Provide an overview of EBP  </li></ul><ul><li>Outline some resources from which y...
INTRODUCTION
What is Evidence Based Practice? “ using the best research  evidence  available, along with clinical  expertise  and  pati...
Evidence-Based Practice CLINICAL  SKILLS & EXPERIENCE PATIENT PREFERENCES,  VALUES & CIRCUMSTANCES EVIDENCE EBP
The Aims of EBP <ul><li>To produce guidelines for practice using the most current and comprehensive research </li></ul><ul...
The role of EBP <ul><li>EBP is about USING research, not DOING research </li></ul><ul><li>Researchers   Practitioners dire...
Another way to think about it... <ul><li>The Practitioner  </li></ul><ul><li>Considers </li></ul><ul><li>Person  / Problem...
STEPS IN EBP
(Adapted from: Bennett & Bennett, 2000; Sackett et al, 2000) Steps in EBP... <ul><li>QUESTION: Convert the need for inform...
Focus of this session <ul><li>Step 1 - The Question </li></ul><ul><li>Step 2 - Searching for Evidence </li></ul>
STEP 1 – THE QUESTION
The Question <ul><li>Formulate a searchable question: </li></ul><ul><ul><li>Mind Map </li></ul></ul><ul><ul><ul><li>–  par...
Why spend time on the question? <ul><li>Clarifies the issue or problem </li></ul><ul><li>Helps focus your ideas  </li></ul...
A clinical problem or question arises out of the care of the patient so start here. A 45 year old male with alcohol issues...
PICO  <ul><li>Translates a clinical question into a searchable format </li></ul><ul><ul><li>P atient </li></ul></ul><ul><u...
PICO <ul><li>P opulation or patient  </li></ul><ul><li>Who are the relevant patients? – Generalise. </li></ul><ul><li>I nt...
Translate the following question into PICO format A 45 year old male presents after his third relapse following GP counsel...
PICO Patient: 45 yr old Male Alcoholic Intervention: Cognitive Behaviour Therapy Comparison: Counselling Outcome: Abstinence
Practice makes perfect  <ul><li>Think of a clinical situation / problem and translate it into a searchable question using ...
Clinical Questions <ul><li>Does cognitive behaviour therapy improve function in adults with chronic fatigue syndrome more ...
Step 2 – Finding the evidence <ul><ul><li>50 new randomised trials published per day - 2000 per year </li></ul></ul><ul><u...
What are you aiming to find? Clinical Relevance High Low Validity Low High Vast bulk scientist to scientist - not YET so r...
Levels of evidence (4S & 5S) Clinical Evidence Up-To-Date Cochrane Library EBMR Medline PsychInfo Systems Synopses Synthes...
Where to search - 1 <ul><li>Decision Support / Point of Care </li></ul><ul><li>. </li></ul><ul><ul><li>Match information f...
Where to search - 2 <ul><li>Summaries   </li></ul><ul><li>–  Clinical evidence  database </li></ul><ul><li>- Evidence base...
Where to search - 3 <ul><li>Synopses </li></ul><ul><ul><li>Evidence based journal abstracts eg.  Evidence-based mental hea...
Where to search - 4 <ul><li>Syntheses & Meta-analyses </li></ul><ul><li>Cochrane Library </li></ul><ul><li>Evidence Based ...
Where to search - 5 <ul><li>Studies –  (Original journal articles ) </li></ul><ul><li>Medline - Medical perspective </li><...
STEP 2. - FINDING THE EVIDENCE
Keyword Searching <ul><li>Seaches on the word or words entered: </li></ul><ul><li>Automated i.e. no human intervention </l...
Keyword Searching - 2 <ul><li>The resulting of using the “Bipolar disorder” search term might thus include: </li></ul><ul>...
Attributes of Keyword searching <ul><li>Will find articles whether relevant or not because it does not consider the concep...
Subject searching <ul><li>Searches using pre-defined subject headings:   </li></ul><ul><li>Has prior mediation because exp...
Attributes of Subject Heading searching <ul><li>Finds relevant material because the source material will only be found if ...
Framing the search
Boolean operators <ul><li>Boolean operators are named after George Boole, a mathematician.  </li></ul><ul><li>The operator...
Using Boolean operators All source material in the database on  Rehabilitation All source material In the database On Cogn...
Boolean operator: AND Rehabilitation  AND  Cognitive Behaviour Therapy FINDS Rehabilitation Cognitive Behviour Therapy
Boolean operator: OR Rehabilitation  OR  Cognitive Behaviour Therapy Rehabilitation Cognitive Behviour Therapy FINDS
Boolean operator: NOT Rehabilitation  NOT  Cognitive Behaviour Therapy FINDS Rehabilitation Cognitive Behviour Therapy
Sources
(Some) Sources for articles … GENERAL MENTAL HEALTH NURSING & ALLIED HEALTH PHARMACOLOGICAL Medline PsychInfo CINAHL Austr...
(Some) Sources for clinical evidence… Available via CKN Cochrane PubMed Systematic Reviews PubMed Clinical Queries DARE Cl...
Access to QH Databases <ul><li>Access to search databases and online journals in QH is via CKN (the Clinicians Knowledge N...
Next steps … <ul><li>Question </li></ul><ul><li>Find the evidence </li></ul><ul><li>Appraise the evidence critically </li>...
STEP 3. CRITICAL APPRAISAL
Critiquing the evidence <ul><li>What level of evidence do you want / need?   </li></ul><ul><ul><li>Systematic reviewes of ...
Critiquing the evidence - 3 <ul><li>Do you want : </li></ul><ul><ul><li>Qualitative </li></ul></ul><ul><ul><li>Or </li></u...
Organising for a critical appraisal <ul><li>Use simple summary tables to record your observations </li></ul>A tabular form...
STEP 4. INTEGRATE WITH PRACTICE
PUTTING IT INTO PRACTICE <ul><li>The first two stages in the EBP process have  considered what other have done and what is...
Applying the evidence <ul><li>What is possible or appropriate will depend on individual circumstances.  Three factors are ...
Attributes of a good clinical guideline <ul><li>Developed by a representative team </li></ul><ul><li>Valid </li></ul><ul><...
Promoting enthusiasm <ul><li>A Journal Club </li></ul><ul><li>A journal club is a good way to promote discussion and engen...
Research <ul><li>Undertaking research is a more demanding way in which to contribute to improved practice but if you are i...
FURTHER INFORMATION <ul><li>For further information please contact the Clinical Library Service on 07-4616-5563 or by emai...
<ul><li>THANK YOU FOR YOUR INTEREST </li></ul><ul><li>Roger Hawcroft </li></ul><ul><li>[email_address] </li></ul><ul><li>0...
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Ebp rh-july2011g

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A brief summary of Evidence-based practice as it applies in health. Includes worked-through case study example and search hints and techniques.

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  • Outcomes for the total HAU EBP and Clinical Standards Project
  • 3 prong approach Each prong is equally important and as clinicians we must consider all.
  • EBP is about AHPs USING research, not DOING research! However although it is about USING research the gaps that are identified through this process of using the literature may inform research and motivate clinician’s towards research. This cycle ultimately leads to more effective and evidence based practice.
  • There are 5 steps to consider in EBP. Discuss briefly the 5 steps. We will be discussing in more detail today Step 1. – converting the need for information into an answerable question.
  • This is probably THE most important part of the process and therefore it is important to spend some time getting the question as best as we possible can. Focusing on the question will help us to focus our ideas, determine exactly what it is we wish to know about. It can also contribute to a more efficient and effective search if we have asked the right question.
  • This is probably THE most important part of the process and therefore it is important to spend some time getting the question as best as we possible can. Focusing on the question will help us to focus our ideas, determine exactly what it is we wish to know about. It can also contribute to a more efficient and effective search if we have asked the right question.
  • Discuss this patient scenario. Highlight that clinical questions start with a patient or clinical problem pertinent to a group of patients.
  • So when designing your answerable question it is useful to structure your question into 4 parts. Highlight the four aspects of a PICO question (discussed in more detail next slide) Note that there is not always a comparator or sometimes the comparator may be standard or usual practice. This term in itself is a poor choice as what is standard or usual practice at PAH may be different to standard or usual practice in Atherton or Longreach etc. so this term does need to be used with care. It is possible to have your clinical question with not all the 4 parts.
  • Discuss the four parts of a PICO question
  • Discuss this patient scenario. Highlight that clinical questions start with a patient or clinical problem pertinent to a group of patients.
  • So when designing your answerable question it is useful to structure your question into 4 parts. Highlight the four aspects of a PICO question (discussed in more detail next slide) Note that there is not always a comparator or sometimes the comparator may be standard or usual practice. This term in itself is a poor choice as what is standard or usual practice at PAH may be different to standard or usual practice in Atherton or Longreach etc. so this term does need to be used with care. It is possible to have your clinical question with not all the 4 parts.
  • Have a series of clinical questions relevant to a few disciplines.
  • This is probably THE most important part of the process and therefore it is important to spend some time getting the question as best as we possible can. Focusing on the question will help us to focus our ideas, determine exactly what it is we wish to know about. It can also contribute to a more efficient and effective search if we have asked the right question.
  • Ebp rh-july2011g

    1. 1. Evidence Based Practice Roger Hawcroft July 2011
    2. 2. Objectives <ul><li>To </li></ul><ul><li>Provide an overview of EBP </li></ul><ul><li>Outline some resources from which you can extract available evidence </li></ul><ul><li>Provide a basis from which to develop skills in searching for evidence </li></ul>
    3. 3. INTRODUCTION
    4. 4. What is Evidence Based Practice? “ using the best research evidence available, along with clinical expertise and patient values to inform decisions regarding clinical practice” (Sackett, 2000)
    5. 5. Evidence-Based Practice CLINICAL SKILLS & EXPERIENCE PATIENT PREFERENCES, VALUES & CIRCUMSTANCES EVIDENCE EBP
    6. 6. The Aims of EBP <ul><li>To produce guidelines for practice using the most current and comprehensive research </li></ul><ul><li>Minimise inappropriate variability in practice </li></ul><ul><li>Identify strengths and weaknesses in existing research </li></ul><ul><li>Guide potential research </li></ul><ul><li>To improve the quality and safety of clinical decisions </li></ul>
    7. 7. The role of EBP <ul><li>EBP is about USING research, not DOING research </li></ul><ul><li>Researchers Practitioners direct </li></ul><ul><li>publish or research by </li></ul><ul><li>disseminate identifying areas </li></ul><ul><li>research of need, and providing </li></ul><ul><li>evidence feedback regarding </li></ul><ul><li> effectiveness of </li></ul><ul><li> research evidence. </li></ul>Those doing research Those using research Effective practice
    8. 8. Another way to think about it... <ul><li>The Practitioner </li></ul><ul><li>Considers </li></ul><ul><li>Person / Problem / Environment / Evidence </li></ul><ul><li>Applies </li></ul><ul><li>Clinical Reasoning, Judgement and Experience </li></ul><ul><li>Decides </li></ul><ul><li>Action / Treatment which will most effectively produce the desired outcomes for the patient </li></ul>
    9. 9. STEPS IN EBP
    10. 10. (Adapted from: Bennett & Bennett, 2000; Sackett et al, 2000) Steps in EBP... <ul><li>QUESTION: Convert the need for information into an answerable question. </li></ul><ul><li>FIND: Search for the best evidence </li></ul><ul><li>APPRAISE: Critically appraise the evidence. Consider: validity; results; applicability. </li></ul><ul><li>INTEGRATE: Integrate evidence with clinical expertise with patient attributes and APPLY to practice. </li></ul><ul><li>EVALUATE: your effectiveness and efficiency in executing steps 1-4. How could you improve your performance? </li></ul>
    11. 11. Focus of this session <ul><li>Step 1 - The Question </li></ul><ul><li>Step 2 - Searching for Evidence </li></ul>
    12. 12. STEP 1 – THE QUESTION
    13. 13. The Question <ul><li>Formulate a searchable question: </li></ul><ul><ul><li>Mind Map </li></ul></ul><ul><ul><ul><li>– particularly useful for study and survey type questions </li></ul></ul></ul><ul><ul><li>PICO </li></ul></ul><ul><ul><ul><li>- particularly useful for clinical questions arising directly from patient care </li></ul></ul></ul>
    14. 14. Why spend time on the question? <ul><li>Clarifies the issue or problem </li></ul><ul><li>Helps focus your ideas </li></ul><ul><li>Identifies key concepts & relationships </li></ul><ul><li>Provides key search terms </li></ul><ul><li>Gives you a starting point </li></ul><ul><li>Often indicates a search strategy </li></ul><ul><li>Shortens search time and improves chance of obtaining appropriate results </li></ul>
    15. 15. A clinical problem or question arises out of the care of the patient so start here. A 45 year old male with alcohol issues presents after his third relapse following GP counselling on a monthly basis. He has heard about cognitive and behavioural therapy and asks you whether this is a treatment option that decreases the likelihood of relapse. Consider How can this clinica problem be translated into a searchable format?
    16. 16. PICO <ul><li>Translates a clinical question into a searchable format </li></ul><ul><ul><li>P atient </li></ul></ul><ul><ul><li>I ntervention </li></ul></ul><ul><ul><li>C omparison </li></ul></ul><ul><ul><li>O utcome </li></ul></ul>
    17. 17. PICO <ul><li>P opulation or patient </li></ul><ul><li>Who are the relevant patients? – Generalise. </li></ul><ul><li>I ntervention or Indicator </li></ul><ul><li>What is the management strategy, diagnostic test or exposure that you are interested in? ( eg. cognitive therapy, surgical procedure, diagnostic test, medication, etc.) </li></ul><ul><li>C omparison </li></ul><ul><li>What is the control or alternative management strategy, test or exposure with which you will compare your intervention? </li></ul><ul><li>O utcome </li></ul><ul><li>What are the patient-relevant consequences of the exposure in which you are interested? – What do you want to happen? </li></ul>
    18. 18. Translate the following question into PICO format A 45 year old male presents after his third relapse following GP counselling on a monthly basis for alcoholism. He has read about cognitive and behavioural therapy and asks you whether this is a treatment option that decreases the likelihood of relapse.
    19. 19. PICO Patient: 45 yr old Male Alcoholic Intervention: Cognitive Behaviour Therapy Comparison: Counselling Outcome: Abstinence
    20. 20. Practice makes perfect <ul><li>Think of a clinical situation / problem and translate it into a searchable question using PICO. </li></ul>Activity
    21. 21. Clinical Questions <ul><li>Does cognitive behaviour therapy improve function in adults with chronic fatigue syndrome more effectively than bed rest? </li></ul><ul><li>Does having arthritis affect an elderly person’s quality of life? </li></ul>
    22. 22. Step 2 – Finding the evidence <ul><ul><li>50 new randomised trials published per day - 2000 per year </li></ul></ul><ul><ul><li>1000 new publications added to MEDLINE per day </li></ul></ul><ul><ul><li> - 5000 new articles published per day </li></ul></ul><ul><ul><li>an estimated 2 million new articles published each year. </li></ul></ul><ul><ul><ul><li>(MEDLINE comprises approximately 20% of the world biomedical literature) </li></ul></ul></ul>
    23. 23. What are you aiming to find? Clinical Relevance High Low Validity Low High Vast bulk scientist to scientist - not YET so relevant to clinicians High quality relevant studies
    24. 24. Levels of evidence (4S & 5S) Clinical Evidence Up-To-Date Cochrane Library EBMR Medline PsychInfo Systems Synopses Syntheses Studies Computerised Decision Support Systems Evidence-based journal abstracts Systematic Reviews Original journal articles Evidence-based mental health Summaries Evidence-based textbooks
    25. 25. Where to search - 1 <ul><li>Decision Support / Point of Care </li></ul><ul><li>. </li></ul><ul><ul><li>Match information from individual patients with the best evidence from the research that applies. </li></ul></ul><ul><ul><li>Rare – would use an electronic patient record matched to a knowledge-base </li></ul></ul>
    26. 26. Where to search - 2 <ul><li>Summaries </li></ul><ul><li>– Clinical evidence database </li></ul><ul><li>- Evidence based textbooks </li></ul>. Integrate best evidence from the lower layers, also drawing on systematic reviews to provide a full range of management options for a given health problem.
    27. 27. Where to search - 3 <ul><li>Synopses </li></ul><ul><ul><li>Evidence based journal abstracts eg. Evidence-based mental health journal </li></ul></ul>Succinct descriptions of an individual study or systematic review
    28. 28. Where to search - 4 <ul><li>Syntheses & Meta-analyses </li></ul><ul><li>Cochrane Library </li></ul><ul><li>Evidence Based Medicine Reviews (EBMR) </li></ul><ul><li>Database of Abstracts of Reviews of Effects </li></ul>Provide reliable and up-to-date information on the effects of interventions in health care and rigour of studies reviewed. Usually consider only 1 aspect of management, i.e. a single drug.
    29. 29. Where to search - 5 <ul><li>Studies – (Original journal articles ) </li></ul><ul><li>Medline - Medical perspective </li></ul><ul><li>Cinahl - Nursing perspective </li></ul><ul><li>Psychinfo - Psychological literature </li></ul>Provide reliable and up-to-date information on the effects of interventions in health care and rigour of studies reviewed.
    30. 30. STEP 2. - FINDING THE EVIDENCE
    31. 31. Keyword Searching <ul><li>Seaches on the word or words entered: </li></ul><ul><li>Automated i.e. no human intervention </li></ul><ul><li>Searches for a TEXT match between the search term and the same TEXT within the source material </li></ul><ul><li>Eg. </li></ul><ul><li>Search term = “ Bipolar disorder ” </li></ul><ul><li>Result = Includes any source which includes the TEXT “ Bipolar ” & the TEXT “ disorder ” </li></ul>
    32. 32. Keyword Searching - 2 <ul><li>The resulting of using the “Bipolar disorder” search term might thus include: </li></ul><ul><ul><li>Bipolar : case studies and clinical trials </li></ul></ul><ul><ul><li>Bipolar disorder : treatment & diagnosis </li></ul></ul><ul><ul><li>Clinical diagnosis of respiratory disorder s </li></ul></ul><ul><ul><li>Disorder – a history of civil disobedience </li></ul></ul>
    33. 33. Attributes of Keyword searching <ul><li>Will find articles whether relevant or not because it does not consider the concepts involved – only the text. </li></ul><ul><li>Often produces an impractically large result set </li></ul><ul><li>Can be useful if multiple terms are correctly combined on specific field searches </li></ul><ul><li>Is most effective when searching for precise and unique names, for example “Efexor” </li></ul>
    34. 34. Subject searching <ul><li>Searches using pre-defined subject headings: </li></ul><ul><li>Has prior mediation because expert indexers read and evaluate source materials and then allocate appropriate subject headings according to the concepts discussed in the source material. </li></ul><ul><li>Subject headings are consistently applied by use of approved headings contained in an index, such as MeSH [Medical Subject Headings] </li></ul>
    35. 35. Attributes of Subject Heading searching <ul><li>Finds relevant material because the source material will only be found if it has been allocated the relevant subject-heading because it discusses that concept. </li></ul><ul><li>Is more precise because the subject-headings are controlled terms which effectively collect together materials of a similar nature </li></ul><ul><li>The use of a controlled index allows display of a term within hierarchical and relational context </li></ul>
    36. 36. Framing the search
    37. 37. Boolean operators <ul><li>Boolean operators are named after George Boole, a mathematician. </li></ul><ul><li>The operators call for a case to be true or false </li></ul><ul><li>The operators dictate how items are to be combined and are: </li></ul><ul><ul><ul><li>AND </li></ul></ul></ul><ul><ul><ul><li>OR </li></ul></ul></ul><ul><ul><ul><li>NOT </li></ul></ul></ul>
    38. 38. Using Boolean operators All source material in the database on Rehabilitation All source material In the database On Cognitive Behaviour Therapy
    39. 39. Boolean operator: AND Rehabilitation AND Cognitive Behaviour Therapy FINDS Rehabilitation Cognitive Behviour Therapy
    40. 40. Boolean operator: OR Rehabilitation OR Cognitive Behaviour Therapy Rehabilitation Cognitive Behviour Therapy FINDS
    41. 41. Boolean operator: NOT Rehabilitation NOT Cognitive Behaviour Therapy FINDS Rehabilitation Cognitive Behviour Therapy
    42. 42. Sources
    43. 43. (Some) Sources for articles … GENERAL MENTAL HEALTH NURSING & ALLIED HEALTH PHARMACOLOGICAL Medline PsychInfo CINAHL Australian Medicines Handbook Embase PsychiatryOnline Medline Embase MD Consult Medline MD Consult Therapeutic Guidelines CINAHL MD Consult MIMS Harrisons CINAHL Medline MD Consult
    44. 44. (Some) Sources for clinical evidence… Available via CKN Cochrane PubMed Systematic Reviews PubMed Clinical Queries DARE Clinical Evidence Up To Date
    45. 45. Access to QH Databases <ul><li>Access to search databases and online journals in QH is via CKN (the Clinicians Knowledge Network) </li></ul><ul><ul><li>On QHEPS, CKN is at the far right of the Main Menu Bar </li></ul></ul><ul><ul><li>From any Internet connection, go to: </li></ul></ul><ul><li>http://ckn.health.qld.gov.au </li></ul>
    46. 46. Next steps … <ul><li>Question </li></ul><ul><li>Find the evidence </li></ul><ul><li>Appraise the evidence critically </li></ul><ul><li>Integrate & Apply the evidence to practice </li></ul><ul><li>Evaluate the outcomes </li></ul><ul><ul><li>Feed back into the process </li></ul></ul>
    47. 47. STEP 3. CRITICAL APPRAISAL
    48. 48. Critiquing the evidence <ul><li>What level of evidence do you want / need? </li></ul><ul><ul><li>Systematic reviewes of Randomised Controlled Trials </li></ul></ul><ul><ul><li>At least one Randomised Controlled Trial </li></ul></ul><ul><ul><li>Controlled non-randomised trial </li></ul></ul><ul><ul><li>Comparative studies with concurrent control </li></ul></ul><ul><ul><li>Comparison studies with historical control </li></ul></ul><ul><ul><li>Case study series </li></ul></ul>
    49. 49. Critiquing the evidence - 3 <ul><li>Do you want : </li></ul><ul><ul><li>Qualitative </li></ul></ul><ul><ul><li>Or </li></ul></ul><ul><ul><li>Quantitative </li></ul></ul><ul><ul><ul><ul><li>Evidence? </li></ul></ul></ul></ul>
    50. 50. Organising for a critical appraisal <ul><li>Use simple summary tables to record your observations </li></ul>A tabular format assists in comparing studies and in comprehension of the information – pin each one to its paper Source Sample Method Outcome Conclusions Study Design Results Comment Title Authority Design Purpose Population Intervention Outcome Results Level of evidence Other issues
    51. 51. STEP 4. INTEGRATE WITH PRACTICE
    52. 52. PUTTING IT INTO PRACTICE <ul><li>The first two stages in the EBP process have considered what other have done and what is indicated by synthesis of their collective findings … </li></ul><ul><li>The next stage is to integrate this knowledge with practice through such measures as: </li></ul><ul><ul><li>Developing clinical guidelines </li></ul></ul><ul><ul><li>Formulating a plan to change practice </li></ul></ul><ul><ul><li>Undertaking further research </li></ul></ul>
    53. 53. Applying the evidence <ul><li>What is possible or appropriate will depend on individual circumstances. Three factors are known to be critical: </li></ul><ul><ul><li>The CONTEXT in which the change is made </li></ul></ul><ul><ul><li>The nature of the EVIDENCE available </li></ul></ul><ul><ul><li>The provision of sound FACILITATION </li></ul></ul>
    54. 54. Attributes of a good clinical guideline <ul><li>Developed by a representative team </li></ul><ul><li>Valid </li></ul><ul><li>Reproducible </li></ul><ul><li>Cost effective </li></ul><ul><li>Clinically applicable </li></ul><ul><li>Flexible </li></ul><ul><li>Clearly written </li></ul><ul><li>Can be clinically audited </li></ul><ul><li>Is reviewable </li></ul>
    55. 55. Promoting enthusiasm <ul><li>A Journal Club </li></ul><ul><li>A journal club is a good way to promote discussion and engender enthusiasm for a project as well as assisting participants to understand and interpret information. </li></ul><ul><li>Clinical Library Services can assist in setting up this process. </li></ul>
    56. 56. Research <ul><li>Undertaking research is a more demanding way in which to contribute to improved practice but if you are interested in this avenue then please don’t dismiss the possibility. </li></ul><ul><li>A great deal of help and advice is available for those who do wish to pursue this course. A good start may be to contact the Human Research & Ethics Committee Coordinator. </li></ul>
    57. 57. FURTHER INFORMATION <ul><li>For further information please contact the Clinical Library Service on 07-4616-5563 or by email to: THSDLIBS@health.qld.gov </li></ul>
    58. 58. <ul><li>THANK YOU FOR YOUR INTEREST </li></ul><ul><li>Roger Hawcroft </li></ul><ul><li>[email_address] </li></ul><ul><li>07-4699-8770 </li></ul>

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