The contribution of major depression to the global burden of ischemic heart disease : a comparative risk assessment

Background Cardiovascular disease and mental health both hold enormous public health importance, both ranking highly in results of the recent Global Burden of Disease Study 2010 (GBD 2010). For the first time, the GBD 2010 has systematically and quantitatively assessed major depression as an independent risk factor for the development of ischemic heart disease (IHD) using comparative risk assessment methodology. Methods A pooled relative risk (RR) was calculated from studies identified through a systematic review with strict inclusion criteria designed to provide evidence of independent risk factor status. Accepted case definitions of depression include diagnosis by a clinician or by non-clinician raters adhering to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) classifications. We therefore refer to the exposure in this paper as major depression as opposed to the DSM-IV category of major depressive disorder (MDD). The population attributable fraction (PAF) was calculated using the pooled RR estimate. Attributable burden was calculated by multiplying the PAF by the underlying burden of IHD estimated as part of GBD 2010. Results The pooled relative risk of developing IHD in those with major depression was 1.56 (95% CI 1.30 to 1.87). Globally there were almost 4 million estimated IHD disability-adjusted life years (DALYs), which can be attributed to major depression in 2010; 3.5 million years of life lost and 250,000 years of life lived with a disability. These findings highlight a previously underestimated mortality component of the burden of major depression. As a proportion of overall IHD burden, 2.95% (95% CI 1.48 to 4.46%) of IHD DALYs were estimated to be attributable to MDD in 2010. Eastern Europe and North Africa/Middle East demonstrate the highest proportion with Asia Pacific, high income representing the lowest. Conclusions The present work comprises the most robust systematic review of its kind to date. The key finding that major depression may be responsible for approximately 3% of global IHD DALYs warrants assessment for depression in patients at high risk of developing IHD or at risk of a repeat IHD event.

The challenge of developing a fleet driving risk assessment tool: What can be learned from the process?

One of the riskiest activities in the course of a person's work is driving. By developing and testing a new work driving risk assessment measurement tool for use by organisations this research will contribute to the safety of those who drive for work purposes. The research results highlighted limitations associated with current self-report measures and provided evidence that the work driving environment is extremely complex and involves constant interactions between humans, vehicles, the road environment, and the organisational context.

Too much knowledge for a nurse? Use of physical assessment by final-semester nursing students

There is debate around the scope of physical assessment skills that should be taught in undergraduate nursing programs. Yet this debate is largely uninformed by evidence on what is learned and practiced by nursing students. This study examined the pattern and correlates of physical assessment skill utilization by 208 graduating nursing students at an Australian university, including measures of knowledge, frequency of use and perceived barriers to physical assessment skills during clinical practice. Of the 126 skills surveyed, on average only five were used every time students practiced. Core skills reflected inspection or general observation of the patient; none involved complex palpation, percussion or auscultation. Skill utilization was also shaped by specialty area. Most skills (70%) were, on average, never performed or learned and students perceived nursing physical assessment was marginalized in both university and workplace contexts. Lack of confidence was thus a significant barrier to use of skills. Based on these findings we argue that the current debate must shift to how we might best support students to integrate comprehensive physical assessment into nursing practice.

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. METHODS We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. FINDINGS In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. INTERPRETATION Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.

Environmental health risk assessment of dioxin in foods and the sustainability of public health interventions at severe dioxin hot spots in Vietnam

This study assessed environmental health risk from dioxin in foods and sustainability of risk reduction programs at two heavily contaminated former military sites in Vietnam. The study involved 1000 household surveys, analysis of food samples and in-depth discussions with residents and officials. The findings indicate that more than 40 years after the war, local residents still experience high exposure to dioxin if they consume local high risk foods. Public health intervention programs were rated moderately to well sustained. Internal migration, and lack of clear, official guidance and sensitivity regarding dioxin issues were the main challenges for sustainability of prevention programs.

Mobile medical applications for melanoma risk assessment: False assurance or valuable tool?

With the smartphone revolution, consumer-focused mobile medical applications (apps) have flooded the market without restriction. We searched the market for commercially available apps on all mobile platforms that could provide automated risk analysis of the most serious skin cancer, melanoma. We tested 5 relevant apps against 15 images of previously excised skin lesions and compared the apps' risk grades to the known histopathologic diagnosis of the lesions. Two of the apps did not identify any of the melanomas. The remaining 3 apps obtained 80% sensitivity for melanoma risk identification; specificities for the 5 apps ranged from 20%-100%. Each app provided its own grading and recommendation scale and included a disclaimer recommending regular dermatologist evaluation regardless of the analysis outcome. The results indicate that autonomous lesion analysis is not yet ready for use as a triage tool. More concerning is the lack of restrictions and regulations for these applications.

Current research: Neurocognitive risk assessment

The current research began from the starting point that what we are grappling with when we are dealing with violent extremists by and large is essentially ‘normal people’. What follows in this third major section of this research paper is the theoretical and conceptual search for making researchable the following question: ‘How do you assess someone who is normal?’

Exposure risk assessment and evaluation of the best management practice for controlling pesticide runoff from paddy fields. Part 2: Model simulation for the herbicide pretilachlor

BACKGROUND: Monitoring studies revealed high concentrations of pesticides in the drainage canal of paddy fields. It is important to have a way to predict these concentrations in different management scenarios as an assessment tool. A simulation model for predicting the pesticide concentration in a paddy block (PCPF-B) was evaluated and then used to assess the effect of water management practices for controlling pesticide runoff from paddy fields. RESULTS: The PCPF-B model achieved an acceptable performance. The model was applied to a constrained probabilistic approach using the Monte Carlo technique to evaluate the best management practices for reducing runoff of pretilachlor into the canal. The probabilistic model predictions using actual data of pesticide use and hydrological data in the canal showed that the water holding period (WHP) and the excess water storage depth (EWSD) effectively reduced the loss and concentration of pretilachlor from paddy fields to the drainage canal. The WHP also reduced the timespan of pesticide exposure in the drainage canal. CONCLUSIONS: It is recommended that: (1) the WHP be applied for as long as possible, but for at least 7 days, depending on the pesticide and field conditions; (2) an EWSD greater than 2 cm be maintained to store substantial rainfall in order to prevent paddy runoff, especially during the WHP.

Environmental health risk assessment of dioxin in foods at the two most severe dioxin hot spots in Vietnam

Background Bien Hoa and Da Nang airbases were bulk storages for Agent Orange during the Vietnam War and currently are the two most severe dioxin hot spots. Objectives This study assesses the health risk of exposure to dioxin through foods for local residents living in seven wards surrounding these airbases. Methods This study follows the Australian Environmental Health Risk Assessment Framework to assess the health risk of exposure to dioxin in foods. Forty-six pooled samples of commonly consumed local foods were collected and analyzed for dioxin/furans. A food frequency and Knowledge–Attitude–Practice survey was also undertaken at 1000 local households, various stakeholders were involved and related publications were reviewed. Results Total dioxin/furan concentrations in samples of local “high-risk” foods (e.g. free range chicken meat and eggs, ducks, freshwater fish, snail and beef) ranged from 3.8 pg TEQ/g to 95 pg TEQ/g, while in “low-risk” foods (e.g. caged chicken meat and eggs, seafoods, pork, leafy vegetables, fruits, and rice) concentrations ranged from 0.03 pg TEQ/g to 6.1 pg TEQ/g. Estimated daily intake of dioxin if people who did not consume local high risk foods ranged from 3.2 pg TEQ/kg bw/day to 6.2 pg TEQ/kg bw/day (Bien Hoa) and from 1.2 pg TEQ/kg bw/day to 4.3 pg TEQ/kg bw/day (Da Nang). Consumption of local high risk foods resulted in extremely high dioxin daily intakes (60.4–102.8 pg TEQ/kg bw/day in Bien Hoa; 27.0–148.0 pg TEQ/kg bw/day in Da Nang). Conclusions Consumption of local “high-risk” foods increases dioxin daily intakes far above the WHO recommended TDI (1–4 pg TEQ/kg bw/day). Practicing appropriate preventive measures is necessary to significantly reduce exposure and health risk.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

An analysis of assessment outcomes from eight years' operation of the Australian border weed risk assessment system

The majority of Australian weeds are exotic plant species that were intentionally introduced for a variety of horticultural and agricultural purposes. A border weed risk assessment system (WRA) was implemented in 1997 in order to reduce the high economic costs and massive environmental damage associated with introducing serious weeds. We review the behaviour of this system with regard to eight years of data collected from the assessment of species proposed for importation or held within genetic resource centres in Australia. From a taxonomic perspective, species from the Chenopodiaceae and Poaceae were most likely to be rejected and those from the Arecaceae and Flacourtiaceae were most likely to be accepted. Dendrogram analysis and classification and regression tree (TREE) models were also used to analyse the data. The latter revealed that a small subset of the 35 variables assessed was highly associated with the outcome of the original assessment. The TREE model examining all of the data contained just five variables: unintentional human dispersal, congeneric weed, weed elsewhere, tolerates or benefits from mutilation, cultivation or fire, and reproduction by vegetative propagation. It gave the same outcome as the full WRA model for 71% of species. Weed elsewhere was not the first splitting variable in this model, indicating that the WRA has a capacity for capturing species that have no history of weediness. A reduced TREE model (in which human-mediated variables had been removed) contained four variables: broad climate suitability, reproduction in less or than equal to 1 year, self-fertilisation, and tolerates and benefits from mutilation, cultivation or fire. It yielded the same outcome as the full WRA model for 65% of species. Data inconsistencies and the relative importance of questions are discussed, with some recommendations made for improving the use of the system.

The role of fruit traits of bird-dispersed plants in invasiveness and weed risk assessment

Aim: Birds play a major role in the dispersal of seeds of many fleshy-fruited invasive plants. The fruits that birds choose to consume are influenced by fruit traits. However, little is known of how the traits of invasive plant fruits contribute to invasiveness or to their use by frugivores. We aim to gain a greater understanding of these relationships to improve invasive plant management. Location: South-east Queensland, Australia. Methods: We measure a variety of fruit morphology, pulp nutrient and phenology traits of a suite of bird-dispersed alien plants. Frugivore richness of these aliens was derived from the literature. Using regressions and multivariate methods, we investigate relationships between fruit traits, frugivore richness and invasiveness. Results: Plant invasiveness was negatively correlated to fruit size, and all highly invasive species had quite similar fruit morphology [smaller fruits, seeds of intermediate size and few (<10) seeds per fruit]. Lower pulp water was the only pulp nutrient trait associated with invasiveness. There were strong positive relationships between the diversity of bird frugivores and plant invasiveness, and in the diversity of bird frugivores in the study region and another part of the plants' alien range. Main conclusions: Our results suggest that weed risk assessments (WRA) and predictions of invasive success for bird-dispersed plants can be improved. Scoring criteria for WRA regarding fruit size would need to be system-specific, depending on the fruit-processing capabilities of local frugivores. Frugivore richness could be quantified in the plant's natural range, its invasive range elsewhere, or predictions made based on functionally similar fruits.

Guidance for addressing the Australian Weed Risk Assessment questions

This paper provides guidance on how to address the 49 questions of the Australian Weed Risk Assessment (WRA) system. The WRA was developed in Australia in 1999, and has since been widely adapted for different regions. As interest in implementation and results comparison has increased, the issue of consistency in answering and scoring the questions has become important. As a result, this guidance was developed during the 2007 International WRA Workshop. Suggestions on search methods, data sources and examples are also provided.