Causes of injuries resulting in hospitalisation in Australia : assessing coder agreement on external causes

Objective: To assess extent of coder agreement for external causes of injury using ICD-10-AM for injury-related hospitalisations in Australian public hospitals. Methods: A random sample of 4850 discharges from 2002 to 2004 was obtained from a stratified random sample of 50 hospitals across four states in Australia. On-site medical record reviews were conducted and external cause codes were assigned blinded to the original coded data. Code agreement levels were grouped into the following agreement categories: block level, 3-character level, 4-character level, 5th-character level, and complete code level. Results: At a broad block level, code agreement was found in over 90% of cases for most mechanisms (eg, transport, fall). Percentage disagreement was 26.0% at the 3-character level; agreement for the complete external cause code was 67.6%. For activity codes, the percentage of disagreement at the 3-character level was 7.3% and agreement for the complete activity code was 68.0%. For place of occurrence codes, the percentage of disagreement at the 4-character level was 22.0%; agreement for the complete place code was 75.4%. Conclusions: With 68% agreement for complete codes and 74% agreement for 3-character codes, as well as variability in agreement levels across different code blocks, place and activity codes, researchers need to be aware of the reliability of their specific data of interest when they wish to undertake trend analyses or case selection for specific causes of interest.

Non-alcoholic fatty liver disease : can ultrasound assist in early diagnosis of prediabetes and delay progression to type2 diabetes mellitus

Non Alcoholic Fatty Liver Disease (NAFLD) is a condition that is frequently seen but seldom investigated. Until recently, NAFLD was considered benign, self-limiting and unworthy of further investigation. This opinion is based on retrospective studies with relatively small numbers and scant follow-up of histology data. (1) The prevalence for adults, in the USA is, 30%, and NAFLD is recognized as a common and increasing form of liver disease in the paediatric population (1). Australian data, from New South Wales, suggests the prevalence of NAFLD in “healthy” 15 year olds as being 10%.(2) Non-alcoholic fatty liver disease is a condition where fat progressively invades the liver parenchyma. The degree of infiltration ranges from simple steatosis (fat only) to steatohepatitis (fat and inflammation) steatohepatitis plus fibrosis (fat, inflammation and fibrosis) to cirrhosis (replacement of liver texture by scarred, fibrotic and non functioning tissue).Non-alcoholic fatty liver is diagnosed by exclusion rather than inclusion. None of the currently available diagnostic techniques -liver biopsy, liver function tests (LFT) or Imaging; ultrasound, Computerised tomography (CT) or Magnetic Resonance Imaging (MRI) are specific for non-alcoholic fatty liver. An association exists between NAFLD, Non Alcoholic Steatosis Hepatitis (NASH) and irreversible liver damage, cirrhosis and hepatoma. However, a more pervasive aspect of NAFLD is the association with Metabolic Syndrome. This Syndrome is categorised by increased insulin resistance (IR) and NAFLD is thought to be the hepatic representation. Those with NAFLD have an increased risk of death (3) and it is an independent predictor of atherosclerosis and cardiovascular disease (1). Liver biopsy is considered the gold standard for diagnosis, (4), and grading and staging, of non-alcoholic fatty liver disease. Fatty-liver is diagnosed when there is macrovesicular steatosis with displacement of the nucleus to the edge of the cell and at least 5% of the hepatocytes are seen to contain fat (4).Steatosis represents fat accumulation in liver tissue without inflammation. However, it is only called non-alcoholic fatty liver disease when alcohol - >20gms-30gms per day (5), has been excluded from the diet. Both non-alcoholic and alcoholic fatty liver are identical on histology. (4).LFT’s are indicative, not diagnostic. They indicate that a condition may be present but they are unable to diagnosis what the condition is. When a patient presents with raised fasting blood glucose, low HDL (high density lipoprotein), and elevated fasting triacylglycerols they are likely to have NAFLD. (6) Of the imaging techniques MRI is the least variable and the most reproducible. With CT scanning liver fat content can be semi quantitatively estimated. With increasing hepatic steatosis, liver attenuation values decrease by 1.6 Hounsfield units for every milligram of triglyceride deposited per gram of liver tissue (7). Ultrasound permits early detection of fatty liver, often in the preclinical stages before symptoms are present and serum alterations occur. Earlier, accurate reporting of this condition will allow appropriate intervention resulting in better patient health outcomes. References 1. Chalasami N. Does fat alone cause significant liver disease: It remains unclear whether simple steatosis is truly benign. American Gastroenterological Association Perspectives, February/March 2008 www.gastro.org/wmspage.cfm?parm1=5097 Viewed 20th October, 2008 2. Booth, M. George, J.Denney-Wilson, E: The population prevalence of adverse concentrations with adiposity of liver tests among Australian adolescents. Journal of Paediatrics and Child Health.2008 November 3. Catalano, D, Trovato, GM, Martines, GF, Randazzo, M, Tonzuso, A. Bright liver, body composition and insulin resistance changes with nutritional intervention: a follow-up study .Liver Int.2008; February 1280-9 4. Choudhury, J, Sanysl, A. Clinical aspects of Fatty Liver Disease. Semin in Liver Dis. 2004:24 (4):349-62 5. Dionysus Study Group. Drinking factors as cofactors of risk for alcohol induced liver change. Gut. 1997; 41 845-50 6. Preiss, D, Sattar, N. Non-alcoholic fatty liver disease: an overview of prevalence, diagnosis, pathogenesis and treatment considerations. Clin Sci.2008; 115 141-50 7. American Gastroenterological Association. Technical review on nonalcoholic fatty liver disease. Gastroenterology.2002; 123: 1705-25

SELinux policy management framework for HIS

Health Information Systems (HIS) make extensive use of Information and Communication Technologies (ICT). The use of ICT aids in improving the quality and efficiency of healthcare services by making healthcare information available at the point of care (Goldstein, Groen, Ponkshe, and Wine, 2007). The increasing availability of healthcare data presents security and privacy issues which have not yet been fully addressed (Liu, Caelli, May, and Croll, 2008a). Healthcare organisations have to comply with the security and privacy requirements stated in laws, regulations and ethical standards, while managing healthcare information. Protecting the security and privacy of healthcare information is a very complex task (Liu, May, Caelli and Croll, 2008b). In order to simplify the complexity of providing security and privacy in HIS, appropriate information security services and mechanisms have to be implemented. Solutions at the application layer have already been implemented in HIS such as those existing in healthcare web services (Weaver et al., 2003). In addition, Discretionary Access Control (DAC) is the most commonly implemented access control model to restrict access to resources at the OS layer (Liu, Caelli, May, Croll and Henricksen, 2007a). Nevertheless, the combination of application security mechanisms and DAC at the OS layer has been stated to be insufficient in satisfying security requirements in computer systems (Loscocco et al., 1998). This thesis investigates the feasibility of implementing Security Enhanced Linux (SELinux) to enforce a Role-Based Access Control (RBAC) policy to help protect resources at the Operating System (OS) layer. SELinux provides Mandatory Access Control (MAC) mechanisms at the OS layer. These mechanisms can contain the damage from compromised applications and restrict access to resources according to the security policy implemented. The main contribution of this research is to provide a modern framework to implement and manage SELinux in HIS. The proposed framework introduces SELinux Profiles to restrict access permissions over the system resources to authorised users. The feasibility of using SELinux profiles in HIS was demonstrated through the creation of a prototype, which was submitted to various attack scenarios. The prototype was also subjected to testing during emergency scenarios, where changes to the security policies had to be made on the spot. Attack scenarios were based on vulnerabilities common at the application layer. SELinux demonstrated that it could effectively contain attacks at the application layer and provide adequate flexibility during emergency situations. However, even with the use of current tools, the development of SELinux policies can be very complex. Further research has to be made in order to simplify the management of SELinux policies and access permissions. In addition, SELinux related technologies, such as the Policy Management Server by Tresys Technologies, need to be researched in order to provide solutions at different layers of protection.

Supporting fathers in the transition to parenthood

Knowledge of the experience of parenthood is usually from a woman’s perspective. The resulting outcome is that knowledge about the experience of fatherhood has been limited. Fathers are starting to change this situation by sharing their experience as is evidenced by the overall response of 267 fathers to this study. This paper focuses on the exploration of 22 men’s feelings and beliefs about fatherhood; and their expectations and views about parenting. The paper will also investigate how fathers’ antenatal expectations matched the reality of early family life including emotional well-being, attitudes to parenting, adjustment to family life and sources of support. The quantitative and qualitative data of the 22 fathers who responded to both the antenatal and postnatal questionnaires used within this paper are drawn from a larger Queensland survey of women and men during the antenatal and postnatal period.

The NOURISH randomised control trial : positive feeding practices and food preferences in early childhood - a primary prevention program for childhood obesity

Background Primary prevention of childhood overweight is an international priority. In Australia 20-25% of 2-8 year olds are already overweight. These children are at substantially increased the risk of becoming overweight adults, with attendant increased risk of morbidity and mortality. Early feeding practices determine infant exposure to food (type, amount, frequency) and include responses (eg coercion) to infant feeding behaviour (eg. food refusal). There is correlational evidence linking parenting style and early feeding practices to child eating behaviour and weight status. A focus on early feeding is consistent with the national focus on early childhood as the foundation for life-long health and well being. The NOURISH trial aims to implement and evaluate a community-based intervention to promote early feeding practices that will foster healthy food preferences and intake and preserve the innate capacity to self-regulate food intake in young children. Methods/Design This randomised controlled trial (RCT) aims to recruit 820 first-time mothers and their healthy term infants. A consecutive sample of eligible mothers will be approached postnatally at major maternity hospitals in Brisbane and Adelaide. Initial consent will be for re-contact for full enrolment when the infants are 4-7 months old. Individual mother- infant dyads will be randomised to usual care or the intervention. The intervention will provide anticipatory guidance via two modules of six fortnightly parent education and peer support group sessions, each followed by six months of regular maintenance contact. The modules will commence when the infants are aged 4-7 and 13-16 months to coincide with establishment of solid feeding, and autonomy and independence, respectively. Outcome measures will be assessed at baseline, with follow up at nine and 18 months. These will include infant intake (type and amount of foods), food preferences, feeding behaviour and growth and self-reported maternal feeding practices and parenting practices and efficacy. Covariates will include sociodemographics, infant feeding mode and temperament, maternal weight status and weight concern and child care exposure. Discussion Despite the strong rationale to focus on parents’ early feeding practices as a key determinant of child food preferences, intake and self-regulatory capacity, prospective longitudinal and intervention studies are rare. This trial will be amongst to provide Level II evidence regarding the impact of an intervention (commencing prior to age 12 months) on children’s eating patterns and behaviours. Trial Registration: ACTRN12608000056392

Tackling the burden of injury in Australasia : developing a binational trauma registry

Existing trauma registries in Australia and New Zealand play an important role in monitoring the management of injured patients. Over the past decade, such monitoring has been translated into changes in clinical processes and practices. Monitoring and changes have been ad hoc, as there are currently no Australasian benchmarks for “optimal” injury management. A binational trauma registry is urgently needed to benchmark injury management to improve outcomes for injured patients.

The use of narrative text for injury surveillance research : a systematic review

Objective: To summarise the extent to which narrative text fields in administrative health data are used to gather information about the event resulting in presentation to a health care provider for treatment of an injury, and to highlight best practise approaches to conducting narrative text interrogation for injury surveillance purposes.----- Design: Systematic review----- Data sources: Electronic databases searched included CINAHL, Google Scholar, Medline, Proquest, PubMed and PubMed Central.. Snowballing strategies were employed by searching the bibliographies of retrieved references to identify relevant associated articles.----- Selection criteria: Papers were selected if the study used a health-related database and if the study objectives were to a) use text field to identify injury cases or use text fields to extract additional information on injury circumstances not available from coded data or b) use text fields to assess accuracy of coded data fields for injury-related cases or c) describe methods/approaches for extracting injury information from text fields.----- Methods: The papers identified through the search were independently screened by two authors for inclusion, resulting in 41 papers selected for review. Due to heterogeneity between studies metaanalysis was not performed.----- Results: The majority of papers reviewed focused on describing injury epidemiology trends using coded data and text fields to supplement coded data (28 papers), with these studies demonstrating the value of text data for providing more specific information beyond what had been coded to enable case selection or provide circumstantial information. Caveats were expressed in terms of the consistency and completeness of recording of text information resulting in underestimates when using these data. Four coding validation papers were reviewed with these studies showing the utility of text data for validating and checking the accuracy of coded data. Seven studies (9 papers) described methods for interrogating injury text fields for systematic extraction of information, with a combination of manual and semi-automated methods used to refine and develop algorithms for extraction and classification of coded data from text. Quality assurance approaches to assessing the robustness of the methods for extracting text data was only discussed in 8 of the epidemiology papers, and 1 of the coding validation papers. All of the text interrogation methodology papers described systematic approaches to ensuring the quality of the approach.----- Conclusions: Manual review and coding approaches, text search methods, and statistical tools have been utilised to extract data from narrative text and translate it into useable, detailed injury event information. These techniques can and have been applied to administrative datasets to identify specific injury types and add value to previously coded injury datasets. Only a few studies thoroughly described the methods which were used for text mining and less than half of the studies which were reviewed used/described quality assurance methods for ensuring the robustness of the approach. New techniques utilising semi-automated computerised approaches and Bayesian/clustering statistical methods offer the potential to further develop and standardise the analysis of narrative text for injury surveillance.

Emergency department triage revisited

Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.

Injury bulletin 105 : skateboard injury

Summary of findings: QISU estimates that approximately 1,000 skateboard-associated injuries are seen at emergency departments each year in Queensland. 10-14 year old males are the most likely group to present to a QISU ED with a skateboard related injury. The peak time for skateboard injuries to occur is on the weekend and in the late afternoon. Only 19% of skateboard injuries occur at skate park facilities, with the remainder oc-curring in non-skate parks, on roads and footpaths. Risk factors associated with more severe injuries are, age less than 10 years and involvement in a motor vehicle crash The most common types of injuries are fractures and sprains of the upper limbs. Isolated head injuries represent approximately 5% of skateboarding injuries, but 60% of serious injuries requiring resuscitation. These injuries may be minimized or pre-vented with helmet use.

Pram and stroller related injury in Queensland children under 5 years of age

An estimated 200 Queensland children under 5 years of age are injured every year in incidents involving prams or strollers. The majority of injuries are due to falls from or falls with the pram or stroller Nineteen children were identified as having been caught in the pram or stroller mechanism (13 sustained finger injuries). Stairs and escalators were a factor in nearly 10 percent of pram or stroller fall injuries, with children being tipped out of the pram or stroller, or rolling down the stairs in the device. Roll away injuries accounted for eight percent of all pram or stroller fall injuries (some also involving stairs) Roll away injuries could be prevented by a default brake system similar to airport trolleys. Pram or stroller failure was identified in 2% of injuries

It's time to be more serious about activating youngsters : lessons for childhood obesity

The epidemic of obesity is impacting an increasing proportion of children, adolescents and adults with a common feature being low levels of physical activity (PA). Despite having more knowledge than ever before about the benefits of PA for health and the growth and development of youngsters, we are only paying lip-service to the development of motor skills in children. Fun, enjoyment and basic skills are the essential underpinnings of meaningful participation in PA. A concurrent problem is the reported increase in sitting time with the most common sedentary behaviors being TV viewing and other screen-based games. Limitations of time have contributed to a displacement of active behaviors with inactive pursuits, which has contributed to reductions in activity energy expenditure. To redress the energy imbalance in overweight and obese children, we urgently need out-of-the-box multisectoral solutions. There is little to be gained from a shame and blame mentality where individuals, their parents, teachers and other groups are singled out as causes of the problem. Such an approach does little more than shift attention from the main game of prevention and management of the condition, which requires a concerted, whole-of-government approach (in each country). The failure to support and encourage all young people to participate in regular PA will increase the chance that our children will live shorter and less healthy lives than their parents. In short, we need novel environmental approaches to foster a systematic increase in PA. This paper provides examples of opportunities and challenges for PA strategies to prevent obesity with a particular emphasis on the school and home settings.

Nature's experiment? Handedness and early childhood development

In recent years a large body of research has investigated the various factors affecting child development and the consequent impact of child development on future educational and labour market outcomes. In this article we contribute to this literature by investigating the effect of handedness on a child and given recent research demonstrating that child development strongly affects adult outcomes. Using a large nationally representative sample of young children we find that the probability of a child being left-handed is not significantly related to child health at birth, family composition, parental employment or household income. We also find robust evidence that left-handed (and mixed handed) children perform significantly worse in nearly all measures of development than right-handed children with the relative disadvantage being larger for boys than girls. Importantly these differentials cannot be explained by different socioeconomic characteristics of the household, parental attitudes or investments in learning resources.