Expanding Emergency Department capacity : a multisite study

Objectives: To i) identify predictors of admission, and ii) describe outcomes for patients who arrived via ambulance to three Australian public Emergency Departments (EDs), before and after the opening of 41 additional ED beds within the area. Methods: A retrospective, comparative, cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (ED LOS), admission requirement, access block, hospital length of stay and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission. Results: One third of all 286,037 ED presentations were via ambulance (n= 79,196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED length of stay (ED LOS), admission requirement, access block, hospital length of stay did not improve. Strong predictors of admission before and after increased capacity included: age over 65 years, Australian Triage Scale (ATS) category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS > 4 hours. With additional capacity the odds ratios for these predictors increased for age >65 and ED LOS > 4 hours and decreased for triage category and ED diagnoses. Conclusions: Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing/decreasing) ED bed numbers, the whole healthcare system needs to be considered.

What aspects of demographic, personality, attitudes, and perceptions of law enforcement influence self-reported likelihood of drink driving?

The aim of the current study was to examine the associations between a number of individual factors (demographic factors (age and gender), personality factors, risk-taking propensity, attitudes towards drink driving, and perceived legitimacy of drink driving enforcement) and how they influence the self-reported likelihood of drink driving. The second aim of this study was to examine the potential of attitudes mediating the relationship between risk-taking and self-reported likelihood of drink driving. In total, 293 Queensland drivers volunteered to participate in an online survey that assessed their self-reported likelihood to drink drive in the next month, demographics, traffic-related demographics, personality factors, risk-taking propensity, attitudes towards drink driving, and perceived legitimacy of drink driving enforcement. An ordered logistic regression analysis was utilised to evaluate the first aim of the study; at the first step the demographic variables were entered; at step two the personality and risk-taking were entered; at the third step, the attitudes and perceptions of legitimacy variables were entered. Being a younger driver and having a high risk-taking propensity were related to self-reported likelihood of drink driving. However, when the attitudes variable was entered, these individual factors were no longer significant; with attitudes being the most important predictor of self-reported drink driving likelihood. A significant mediation model was found with the second aim of the study, such that attitudes mediated the relationship between risk-taking and self-reported likelihood of drink driving. Considerable effort and resources are utilised by traffic authorities to reducing drink driving on the Australian road network. Notwithstanding these efforts, some participants still had some positive attitudes towards drink driving and reported that they were likely to drink drive in the future. These findings suggest that more work is needed to address attitudes regarding the dangerousness of drink driving.

Commitment to internationalisation : an extension of the internationalisation process model

Notwithstanding the interest over many years by scholars in modeling the internationalization of the firm, the initial transition for the firm from domestic to international operations remains under-researched. We identify the behavioral factors that are important at the pre-internationalization state and discuss how they may interrelate to influence a decision to commit to internationalization through export commencement. We study export commitment by proposing and constructing an index that incorporates the factors that influence a firm’s propensity to commit to export activities. Utilizing the items from this index in a logistic regression analysis, we distinguish between the pre-internationalization characteristics of exporting and non-exporting firms to better understand the key influences in export commitment. Implications are discussed.

Resilience of water supply systems in meeting the challenges posed by climate change and population growth

This research project provides a scientifically robust approach for assessing the resilience of water supply systems, which are critical infrastructure, to impacts of climate change and population growth. An approach for the identification of trigger points that allows timely and appropriate management actions to be taken to avoid catastrophic system failure is an important outcome of this project. In the current absence of a formal method to evaluate the resilience of a water supply system, the approach developed in this study was based on the characterisation of resilience of a water supply system to a range of surrogate measures. Accordingly, a set of indicators are proposed to evaluate system behaviour and logistic regression analysis was used to assess system behaviour under predicted rainfall, storage and demand conditions.

The influence of family history of hypertension on disease prevalence and associated metabolic risk factors among Sri Lankan adults

Background Hypertension is a major contributor to the global non-communicable disease burden. Family history is an important non-modifiable risk factor for hypertension. The present study aims to describe the influence of family history (FH) on hypertension prevalence and associated metabolic risk factors in a large cohort of South Asian adults, from a nationally representative sample from Sri Lanka. Methods A cross-sectional survey among 5,000 Sri Lankan adults, evaluating FH at the levels of parents, grandparents, siblings and children. A binary logistic regression analysis was performed in all patients with ‘presence of hypertension’ as dichotomous dependent variable and using family history in parents, grandparents, siblings and children as binary independent variables. The adjusted odds ratio controlling for confounders (age, gender, body mass index, diabetes, hyperlipidemia and physical activity) are presented below. Results In all adults the prevalence of hypertension was significantly higher in patients with a FH (29.3 %, n = 572/1951) than those without (24.4 %, n = 616/2530) (p < 0.001). Presence of a FH significantly increased the risk of hypertension (OR:1.29; 95 % CI:1.13-1.47), obesity (OR:1.36; 95 % CI: 1.27–1.45), central obesity (OR:1.30; 95 % CI 1.22–1.40) and metabolic syndrome (OR:1.19; 95 % CI: 1.08–1.30). In all adults presence of family history in parents (OR:1.28; 95 % CI: 1.12–1.48), grandparents (OR:1.34; 95 % CI: 1.20–1.50) and siblings (OR:1.27; 95 % CI: 1.21–1.33) all were associated with significantly increased risk of developing hypertension. Conclusions Our results show that the prevalence of hypertension was significantly higher in those with a FH of hypertension. FH of hypertension was also associated with the prevalence of obesity, central obesity and metabolic syndrome. Individuals with a FH of hypertension form an easily identifiable group who may benefit from targeted interventions.

Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients

BACKGROUND After general surgery, the lower limb experiences some of the highest complication rates. However, little is known about contributing factors to surgical site failure in the lower limb dermatological surgery population. OBJECTIVE To determine the incidence of lower limb surgical site failure and to explore the predictors that contribute to surgical site failure. METHODS A prospective observational study design was used to collect data from 73 participants, from July 2010, to March 2012. Incidence was determined as a percentage of surgical site failure from the total population. Predictors were determined by the use of a binary logistic regression model. RESULTS The surgical site failure rate was 53.4%. Split-skin grafting had a higher failure rate than primary closures, 66% versus 26.1%. Predictors of lower limb surgical site failure were identified as increasing age (p = .04) and the presence of postoperative hematoma (p = .01), with all patients who developed surgical site infection experiencing surgical site failure (p = .01). CONCLUSION Findings from this study confirmed that the lower limb is at high risk of surgical site failure. Two predictors of surgical site failure from this cohort were determined. However, to understand this phenomenon and make recommendations to assist and reduce surgical site complications, further research in this field is required.

Association of STAT3 and TNFRSF1A with ankylosing spondylitis in Han Chinese

Objectives: Recent association studies by the Australo-Anglo-American Spondyloarthritis Consortium (TASC) in Caucasian European populations from Australia, North America and the UK have identified a number of genes as being associated with ankylosing spondylitis (AS). A candidate gene study in a Han Chinese population was performed based on these findings to identify associated genes in this population. Methods: A case-control study was performed in a Han Chinese population of patients with AS (n=775) and controls (n=1587) from Shanghai and Nanjing. All patients met the modified New York criteria for AS. The cases and controls were genotyped for 115 single nucleotide polymorphisms (SNPs) tagging IL23R, ERAP1, STAT3, JAK2, TNFRSF1A and TRADD, as well as other confirmation SNPs from the TASC study, using the Sequenom iPlex and the ABI OpenArray platforms. Statistical analysis of genotyped SNPs was performed using the Cochran - Armitage test for trend and meta-analysis was performed using METAL. SNPs in AS-associated genes in this study were then imputed using MaCH, and association with AS tested by logistic regression. Results: SNPs in TNFRSF1A (rs4149577, p=8.2×10-4), STAT3 (rs2293152, p=0.0015; rs1053005, p=0.017) and ERAP1 (rs27038, p=0.0091; rs27037, p=0.0092) were significantly associated with AS in Han Chinese. Association was also observed between AS and the intergenic region 2p15 (rs10865331, p=0.023). The lack of association between AS and IL23R in Han Chinese was confirmed (all SNPs p>0.1). Conclusions: The study results demonstrate for the first time that genetic polymorphisms in STAT3, TNFRSF1A and 2p15 are associated with AS in Han Chinese, suggesting common pathogenic mechanisms for the disease in Chinese and Caucasian European populations. Furthermore, previous findings demonstrating that ERAP1, but not IL23R, is associated with AS in Chinese patients were confirmed.

Cardiovascular disease is increased prior to onset of rheumatoid arthritis but not osteoarthritis: The population-based Nord-Trøndelag health study (HUNT)

Introduction: Patients with rheumatoid arthritis (RA) have increased risk of cardiovascular (CV) events. We sought to test the hypothesis that due to increased inflammation, CV disease and risk factors are associated with increased risk of future RA development. Methods: The population-based Nord-Trøndelag health surveys (HUNT) were conducted among the entire adult population of Nord-Trøndelag, Norway. All inhabitants 20 years or older were invited, and information was collected through comprehensive questionnaires, a clinical examination, and blood samples. In a cohort design, data from HUNT2 (1995-1997, baseline) and HUNT3 (2006-2008, follow-up) were obtained to study participants with RA (n = 786) or osteoarthritis (n = 3,586) at HUNT3 alone, in comparison with individuals without RA or osteoarthritis at both times (n = 33,567). Results: Female gender, age, smoking, body mass index, and history of previous CV disease were associated with self-reported incident RA (previous CV disease: odds ratio 1.52 (95% confidence interval 1.11-2.07). The findings regarding previous CV disease were confirmed in sensitivity analyses excluding participants with psoriasis (odds ratio (OR) 1.70 (1.23-2.36)) or restricting the analysis to cases with a hospital diagnosis of RA (OR 1.90 (1.10-3.27)) or carriers of the shared epitope (OR 1.76 (1.13-2.74)). History of previous CV disease was not associated with increased risk of osteoarthritis (OR 1.04 (0.86-1.27)). Conclusion: A history of previous CV disease was associated with increased risk of incident RA but not osteoarthritis.

Prevalence of retinopathy among adults with self-reported diabetes mellitus: the Sri Lanka diabetes and Cardiovascular Study

Background: At present there are no large scale nationally-representative studies from Sri Lanka on the prevalence and associations of Diabetic Retinopathy (DR). The present study aims to evaluate the prevalence and risk factors for DR in a community-based nationally-representative sample of adults with self-reported diabetes mellitus from Sri Lanka. Methods: A cross-sectional community-based national study among 5,000 adults (≥18 years) was conducted in Sri Lanka, using a multi-stage stratified cluster sampling technique. An interviewer-administered questionnaire was used to collect data. Ophthalmological evaluation of patients with ‘known’ diabetes (previously diagnosed at a government hospital or by a registered medical practitioner) was done using indirect ophthalmoscopy. A binary-logistic regression analysis was performed with ‘presence of DR’ as the dichotomous dependent variable and other independent covariates. Results: Crude prevalence of diabetes was 12.0%(n=536),of which 344 were patients with ‘known’ diabetes.Mean age was 56.4 ± 10.9 years and 37.3% were males. Prevalence of any degree of DR was 27.4% (Males-30.5%, Females-25.6%; p = 0.41). In patients with DR, majority had NPDR (93.4%), while 5.3% had maculopathy. Patients with DR had a significantly longer duration of diabetes than those without. In the binary-logistic regression analysis in all adults duration of diabetes (OR:1.07), current smoking (OR:1.67) and peripheral neuropathy (OR:1.72)all were significantly associated with DR. Conclusions: Nearly 1/3rd of Sri Lankan adults with self-reported diabetes are having retinopathy. DR was associated with diabetes duration, cigarette smoking and peripheral neuropathy. However, further prospective follow up studies are required to establish causality for identified risk factors

Triaging older major trauma patients in the emergency department: An observational study

Background The objective of this study was to compare the triage category assigned to older trauma patients with younger trauma patients upon arrival to the emergency department. The focus was to examine whether older major trauma patients were less likely to be assigned an emergency triage category on arrival to the emergency department after controlling for relevant demographics, injury characteristics and injury severity. Methods This was an observational study using data from the Queensland Trauma Registry. All trauma patients aged 15 years and older who presented to contributing hospitals between 1 January 2005 and 31 December 2009 with an Injury Severity Score (ISS)>15 were included. Logistic regression analysis examined the odds of assignment to emergency (Australasian Triage Scale (ATS) 1 or 2) versus urgent (ATS 3–5) treatment for patients across various age categories after adjustment for relevant demographics, injury characteristics and injury severity. Results The study used data on 6923 patients with a median (IQR) age of 43 (26–62) years and a mortality of 11.4% (95% CI 10.7% to 12.2%). Compared with individuals aged 15–34, the adjusted odds of being assigned an ATS category 1 or 2 were 30% lower (OR=0.68, 95% CI 0.57 to 0.81) for individuals aged 55–75 years and were 50% lower (OR=0.46, 95% CI 0.37 to 0.56) for individuals aged 75 years or older. Conclusions Among patients with an ISS>15, older major trauma patients were less likely to be assigned an emergency triage category compared with younger patients. This suggests that the elderly may be undertriaged and provides a potential area of study for reducing mortality and morbidity in older

The prevalence, predictors and associations of hypertension in Sri Lanka: A cross-sectional population based national survey

We studied the community prevalence, patterns and predictors of hypertension in a large sub-population of South Asian adults with a view of identifying differential risk factors. Data were collected between years 2005-2006 and 5000 adults were invited for the study. The sample size was 4485, and about 39.5% were males. Mean systolic and diastolic blood pressures were 127.1 ± 19.8 mmHg and 75.4 ± 11.3 mmHg, respectively. Age-adjusted prevalence in all adults, males and females was 23.7%, 23.4% and 23.8%, respectively. Urban adults had a significantly higher prevalence of hypertension than rural adults. In the binary logistic-regression analysis, male gender (OR: 1.2), increasing age, Sri Lankan Moor ethnicity (OR: 1.6), physical inactivity (OR: 1.7), presence of diabetes (OR: 2.2) and central obesity (OR: 2.3) all were significantly associated with hypertension. In conclusion, nearly one-third of the Sri Lankan adult population is hypertensive. Hence, public health initiatives should encourage healthier lifestyles with emphasis on preventing obesity and increasing physical activity.

Changing travel patterns and journeys to health services in Great Britain 1985-2012: An examination health service utilisation using the National Travel Survey

Background This paper examines changing patterns in the utilisation and geographic access to health services in Great Britain using National Travel Survey data (1985-2012). The National Travel Survey (NTS) is a series of household surveys designed to provide data on personal travel and monitor changes in travel behaviour over time. The utilisation rate was derived using the proportion of journeys made to access health services. Geographic access was analysed by separating the concept into its accessibility and mobility dimensions. Methods Variables from the PSU, households, and individuals datasets were used as explanatory variables. Whereas, variables extracted from the journeys dataset were used as dependent variables to identify patterns of utilisation i.e. the proportion of journeys made by different groups to access health facilities in a particular journey distance or time band or by mode of transport; and geographic access to health services. A binary logistic regression analysis was conducted to identify the utilisation rate over the different time periods between different groups. This analysis shows the Odds Ratios (ORs) for different groups making a trip to utilise health services compared to their respective counterparts. Linear multiple regression analyses were conducted to then identify patterns of change in the accessibility and mobility level. Results Analysis of the data has shown that that journey distances to health facilities were signi fi cantly shorter and also gradually reduced over the period in question for Londoners, females, those without a car or on low incomes, and older people. Although rates of utilisation of health services we re Oral Abstracts / Journal of Transport & Health 2 (2015) S5 – S63 S43 signi fi cantly lower because of longer journey times. These fi ndings indicate that the rate of utilisation of health services largely depends on mobility level although previous research studies have traditionally overlooked the mobility dimension. Conclusions This fi nding, therefore, suggests the need to improve geographic access to services together with an enhanced mobility option for disadvantaged groups in order for them to have improved levels of access to health facilities. This research has also found that the volume of car trips to health services also increased steadily over the period 1985-2012 while all other modes accounted for a smaller number of trips. However, it is dif fi cult to conclude from this research whether this increase in the volume of car trips was due to a lack of alternative transport or due to an increase in the level of car-ownership.

The relationship between the determinants of rental housing satisfaction and considering moving in Finland

Purpose The purpose of this paper is to discuss the relation between dissatisfaction with housing conditions and considering moving among residents of Finnish rental multifamily buildings. The paper examines physical attributes, socioeconomic factors, and subjective opinions related to housing conditions and satisfaction with housing. Design/methodology/approach Logistic regression analysis is used to examine survey data to analyse which factors contribute to dissatisfaction with the housing unit and the apartment building and whether dissatisfaction is related to consideration of moving. Findings The findings indicate that dissatisfaction with the building and individual housing unit are associated with greater probability of considering moving. Satisfaction with kitchen, living room, storage, and building age are the most important indicators of satisfaction with the housing unit, and satisfaction with living room, bathroom, storage, and building age are associated with satisfaction with the apartment building. These are the areas in which landlords could invest in renovations to increase satisfaction in an attempt to reduce turnover. Research limitations/implications The study is conducted with Finnish data only. The sample is not a representative sample of the Finnish population. A longitudinal study would be needed to determine whether dissatisfied residents indending to move actually change residence. Originality/value This study is the first of its kind in the Finnish housing market. It tests a general model that has been suggested to be customized to local conditions. In addition, much of the research on this topic is more than 20 years old. Examination of the model under current housing and socioeconomic conditions is necessary to determine if relationships have changed over time.

No influence of 5-HTTLPR gene polymorphism on migraine symptomatology, comorbid depression, and chronification

BACKGROUND: The serotonergic system is thought to play an important role for mediating susceptibility to migraine and depression, which is frequently found comorbid in migraine. The functional polymorphism in the serotonin transporter gene linked polymorphic region (5-HTTLPR/SLC6A4) was previously associated with attack frequency and, thus, possibly with chronification. OBJECTIVE: We hypothesized that patients with the "s" allele have higher attack frequency and, paralleling results in depression research, higher scores of depression. METHODS: Genetic analysis of the SLC6A4 44 bp insertion/deletion polymorphism (5-HTTLPR) was performed in 293 patients with migraine with and without aura. Self-rating questionnaires were used for assessment of depression. RESULTS: Multinomial logistic regression analysis found no evidence for association of the 5-HTTLPR polymorphism with either depression or migraine attack frequency. CONCLUSION: We were not able to demonstrate any influence of the serotonin transporter 5-HTTLPR polymorphism on migraine phenomenology (attack frequency or comorbid depression), thereby excluding this variant to be a common genetic denominator for chronic migraine and depression.

Impact of malnutrition on 12-month mortality following acute hip fracture

Background Studies investigating the relationship between malnutrition and post-discharge mortality following acute hip fracture yield conflicting results. This study aimed to determine whether malnutrition independently predicted 12-month post-fracture mortality after adjusting for clinically relevant covariates. Methods An ethics approved, prospective, consecutive audit was undertaken for all surgically treated hip fracture inpatients admitted to a dedicated orthogeriatric unit (November 2010–October 2011). The 12-month mortality data were obtained by a dual search of the mortality registry and Queensland Health database. Malnutrition was evaluated using the Subjective Global Assessment. Demographic (age, gender, admission residence) and clinical covariates included fracture type, time to surgery, anaesthesia type, type of surgery, post-surgery time to mobilize and post-operative complications (delirium, pulmonary and deep vein thrombosis, cardiac complications, infections). The Charlson Comorbidity Index was retrospectively applied. All diagnoses were confirmed by the treating orthogeriatrician. Results A total of 322 of 346 patients were available for audit. Increased age (P = 0.004), admission from residential care (P < 0.001), Charlson Comorbidity Index (P = 0.007), malnutrition (P < 0.001), time to mobilize >48 h (P < 0.001), delirium (P = 0.003), pulmonary embolism (P = 0.029) and cardiovascular complication (P = 0.04) were associated with 12-month mortality. Logistic regression analysis demonstrated that malnutrition (odds ratio (OR) 2.4 (95% confidence interval (CI) 1.3–4.7, P = 0.007)), in addition to admission from residential care (OR 2.6 (95% CI 1.3–5.3, P = 0.005)) and pulmonary embolism (OR 11.0 (95% CI 1.5–78.7, P = 0.017)), independently predicted 12-month mortality. Conclusions Findings substantiate malnutrition as an independent predictor of 12-month mortality in a representative sample of hip fracture inpatients. Effective strategies to identify and treat malnutrition in hip fracture should be prioritized.