A comparison of methods to identify alcohol involvement in youth injury-related emergency department presentation data

Aims: To compare different methods for identifying alcohol involvement in injury-related emergency department presentation in Queensland youth, and to explore the alcohol terminology used in triage text. Methods: Emergency Department Information System data were provided for patients aged 12-24 years with an injury-related diagnosis code for a 5 year period 2006-2010 presenting to a Queensland emergency department (N=348895). Three approaches were used to estimate alcohol involvement: 1) analysis of coded data, 2) mining of triage text, and 3) estimation using an adaptation of alcohol attributable fractions (AAF). Cases were identified as ‘alcohol-involved’ by code and text, as well as AAF weighted. Results: Around 6.4% of these injury presentations overall had some documentation of alcohol involvement, with higher proportions of alcohol involvement documented for 18-24 year olds, females, indigenous youth, where presentations occurred on a Saturday or Sunday, and where presentations occurred between midnight and 5am. The most common alcohol terms identified for all subgroups were generic alcohol terms (eg. ETOH or alcohol) with almost half of the cases where alcohol involvement was documented having a generic alcohol term recorded in the triage text. Conclusions: Emergency department data is a useful source of information for identification of high risk sub-groups to target intervention opportunities, though it is not a reliable source of data for incidence or trend estimation in its current unstandardised form. Improving the accuracy and consistency of identification, documenting and coding of alcohol-involvement at the point of data capture in the emergency department is the most desirable long term approach to produce a more solid evidence base to support policy and practice in this field.

Consumer perceptions of medication warnings about driving : a comparison of French and Australian labels

OBJECTIVE Little research has examined user perceptions of medication warnings about driving. Consumer perceptions of the Australian national approach to medication warnings about driving are examined. The Australian approach to warning presentation is compared with an alternative approach used in France. Visual characteristics of the warnings and overall warning readability are investigated. Risk perceptions and behavioral intentions associated with the warnings are also examined. METHOD Surveys were conducted with 358 public hospital outpatients in Queensland, Australia. Extending this investigation is a supplementary comparison study of French hospital outpatients (n = 75). RESULTS The results suggest that the Australian warning approach of using a combination of visual characteristics is important for consumers but that the use of a pictogram could enhance effects. Significantly higher levels of risk perception were found among the sample for the French highest severity label compared to the analogous mandatory Australian warning, with a similar trend evident in the French study results. The results also indicated that the French label was associated with more cautious behavioral intentions. CONCLUSION The results are potentially important for the Australian approach to medication warnings about driving impairment. The research contributes practical findings that can be used to enhance the effectiveness of warnings and develop countermeasures in this area. Hospital pharmacy patients should include persons with the highest level of likelihood of knowledge and awareness of medication warning labeling. Even in this context it appears that a review of the Australian warning system would be useful particularly in the context of increasing evidence relating to associated driving risks. Reviewing text size and readability of messages including the addition of pictograms, as well as clarifying the importance of potential risk in a general community context, is recommended for consideration and further research.

Hospital outpatients' responses to taking medications with driving warnings

OBJECTIVE The study investigates the knowledge, intentions, and driving behavior of persons prescribed medications that display a warning about driving. It also examines their confidence that they can self-assess possible impairment, as is required by the Australian labeling system. METHOD We surveyed 358 outpatients in an Australian public hospital pharmacy, representing a well-advised group taking a range of medications including those displaying a warning label about driving. A brief telephone follow-up survey was conducted with a subgroup of the participants. RESULTS The sample had a median age of 53.2 years and was 53 percent male. Nearly three quarters (73.2%) had taken a potentially impairing class of medication and more than half (56.1%) had taken more than one such medication in the past 12 months. Knowledge of the potentially impairing effects of medication was relatively high for most items; however, participants underestimated the possibility of increased impairment from exceeding the prescribed dose and at commencing treatment. Participants' responses to the safety implications of taking drugs with the highest level of warning varied. Around two thirds (62.8%) indicated that they would consult a health practitioner for advice and around half would modify their driving in some way. However, one fifth (20.9%) would drive when the traffic was thought to be less heavy and over a third (37.7%) would modify their medication regime so that they could drive. The findings from the follow-up survey of a subsample taking target drugs at the time of the first interview were also of concern. Only just over half (51%) recalled seeing the warning label on their medications and, of this group, three quarters (78%) reported following the warning label advice. These findings indicated that there remains a large proportion of people who either did not notice or did not consider the warning when deciding whether to drive. There was a very high level of confidence in this group that they could determine whether they were personally affected by the medication, which may be a problem from a safety perspective. CONCLUSION This study involved persons who should have had a very high level of knowledge and awareness of medication warning labeling. Even in this group there was a lack of informed response to potential impairment. A review of the Australian warning system and wider dissemination of information on medication treatment effects would be useful. Clarifying the importance of potential risk in the general community context is recommended for consideration and further research.

Short-term traffic volume forecasting : a k-nearest neighbor approach enhanced by constrained linearly sewing principle component algorithm

To enhance the performance of the k-nearest neighbors approach in forecasting short-term traffic volume, this paper proposed and tested a two-step approach with the ability of forecasting multiple steps. In selecting k-nearest neighbors, a time constraint window is introduced, and then local minima of the distances between the state vectors are ranked to avoid overlappings among candidates. Moreover, to control extreme values’ undesirable impact, a novel algorithm with attractive analytical features is developed based on the principle component. The enhanced KNN method has been evaluated using the field data, and our comparison analysis shows that it outperformed the competing algorithms in most cases.

A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods: This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results: Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion: The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

Retinal nerve fibre layer thickness is associated with higher risk of foot ulceration in diabetic peripheral neuropathy

Purpose To evaluate the association between retinal nerve fibre layer (RNFL) thickness and diabetic peripheral neuropathy in people with type 2 diabetes, and specifically those at higher risk of foot ulceration. Methods RNFL thicknesses was measured globally and in four quadrants (temporal, superior, nasal and inferior) at 3.45 mm diameter around the optic nerve head using optical coherence tomography (OCT). Severity of neuropathy was assessed using the Neuropathy Disability Score (NDS). Eighty-two participants with type 2 diabetes were stratified according to NDS scores (0-10) as: none, mild, moderate, and severe neuropathy. A control group was additionally included (n=17). Individuals with NDS≥ 6 (moderate and severe neuropathy) have been shown to be at higher risk of foot ulceration. A linear regression model was used to determine the association between RNFL and severity of neuropathy. Age, disease duration and diabetic retinopathy levels were fitted in the models. Independent t-test was employed for comparison between controls and the group without neuropathy, as well as for comparison between groups with higher and lower risk of foot ulceration. Analysis of variance was used to compare across all NDS groups. Results RNFL thickness was significantly associated with NDS in the inferior quadrant (b= -1.46, p=0.03). RNFL thicknesses globally and in superior, temporal and nasal quadrants did not show significant associations with NDS (all p>0.51). These findings were independent of the effect of age, disease duration and retinopathy. RNFL was thinner for the group with NDS ≥ 6 in all quadrants but was significant only inferiorly (p<0.005). RNFL for control participants was not significantly different from the group with diabetes and no neuropathy (superior p=0.07, global and all other quadrants: p>0.23). Mean RNFL thickness was not significantly different between the four NDS groups globally and in all quadrants (p=0.08 for inferior, P>0.14 for all other comparisons). Conclusions Retinal nerve fibre layer thinning is associated with neuropathy in people with type 2 diabetes. This relationship is strongest in the inferior retina and in individuals at higher risk of foot ulceration.

Cortisol shifts financial risk preferences

Risk taking is central to human activity. Consequently, it lies at the focal point of behavioral sciences such as neuroscience, economics, and finance. Many influential models from these sciences assume that financial risk preferences form a stable trait. Is this assumption justified and, if not, what causes the appetite for risk to fluctuate? We have previously found that traders experience a sustained increase in the stress hormone cortisol when the amount of uncertainty, in the form of market volatility, increases. Here we ask whether these elevated cortisol levels shift risk preferences. Using a double-blind, placebo-controlled, cross-over protocol we raised cortisol levels in volunteers over eight days to the same extent previously observed in traders. We then tested for the utility and probability weighting functions underlying their risk taking, and found that participants became more risk averse. We also observed that the weighting of probabilities became more distorted among men relative to women. These results suggest that risk preferences are highly dynamic. Specifically, the stress response calibrates risk taking to our circumstances, reducing it in times of prolonged uncertainty, such as a financial crisis. Physiology-induced shifts in risk preferences may thus be an under-appreciated cause of market instability.

Polymorphisms in inflammation pathway genes and endometrial cancer risk

BACKGROUND Experimental and epidemiologic evidence have suggested that chronic inflammation may play a critical role in endometrial carcinogenesis. METHODS To investigate this hypothesis, a two-stage study was carried out to evaluate single-nucleotide polymorphisms (SNP) in inflammatory pathway genes in association with endometrial cancer risk. In stage I, 64 candidate pathway genes were identified and 4,542 directly genotyped or imputed SNPs were analyzed among 832 endometrial cancer cases and 2,049 controls, using data from the Shanghai Endometrial Cancer Genetics Study. Linkage disequilibrium of stage I SNPs significantly associated with endometrial cancer (P < 0.05) indicated that the majority of associations could be linked to one of 24 distinct loci. One SNP from each of the 24 loci was then selected for follow-up genotyping. Of these, 21 SNPs were successfully designed and genotyped in stage II, which consisted of 10 additional studies including 6,604 endometrial cancer cases and 8,511 controls. RESULTS Five of the 21 SNPs had significant allelic odds ratios (ORs) and 95% confidence intervals (CI) as follows: FABP1, 0.92 (0.85-0.99); CXCL3, 1.16 (1.05-1.29); IL6, 1.08 (1.00-1.17); MSR1, 0.90 (0.82-0.98); and MMP9, 0.91 (0.87-0.97). Two of these polymorphisms were independently significant in the replication sample (rs352038 in CXCL3 and rs3918249 in MMP9). The association for the MMP9 polymorphism remained significant after Bonferroni correction and showed a significant association with endometrial cancer in both Asian- and European-ancestry samples. CONCLUSIONS These findings lend support to the hypothesis that genetic polymorphisms in genes involved in the inflammatory pathway may contribute to genetic susceptibility to endometrial cancer. Impact statement: This study adds to the growing evidence that inflammation plays an important role in endometrial carcinogenesis.

Sequencing risk : the worst returns in their worst order

For the first of the baby boomers turning 65 years of age, after a decade littered with financial shocks (dot.com bubble, sub-prime, global financial crisis, sovereign debt), sequencing risk can represent a significant threat to their retirement nest eggs. This paper takes an outcomeoriented approach to the problem, to provide practical insights into how sequencing risk works and the critical dependency of retirement outcomes on sequencing risk. Our analysis challenges the conventional wisdom that it is the accumulated average of investment returns that matter. We show, instead, that it is the realised sequence of returns which largely determines the sustainability of retirement incomes.

Older driver safety and mobility : where to from here?

The older adult population (65 years and over) represents a rapid growing segment of the population in many developed countries. Unlike earlier cohorts of older drivers that included many who were familiar with public transportation, the present cohort of older drivers historically has a greater reliance on the private automobile as their main form of transportation. Recent studies of older adults’ travel patterns reported automobile to be responsible for over 80% of the total number of hours spent on all trips. While older drivers, as a group, does not demonstrate a particular road risk, the evident demographic change and the increased physical fragility and severity of crash-related injuries makes older driver safety a prevalent public health issue. This study systematically reviewed the safety and mobility outcomes of existing strategies used internationally to manage older driver safety, with a specific focus on age-based testing (ABT), license restriction and self-regulation (i.e. voluntary limiting driving in potentially hazardous situations). ABT remains the most commonly adopted strategy by licensing authorities both within Australia and internationally. Heterogeneity in the development of functional declines, and in driving behaviours within the older driver population, makes age an unreliable index of driving capacity. Given the counter-productive safety and mobility outcomes of ABT strategies, their continued popularity within both the legislative and public domains remains problematic. Self-regulation may provide greater potential for reducing older drivers’ crash risk while maintaining their mobility and independence. The current body of literature on older drivers’ self-regulation is systematically reviewed. Despite being promoted by researchers and licensing authorities as a strategy to maintain older driver safety and mobility, the proportion of older drivers who self-regulate, and exactly how they do so, remains unclear. Future research on older drivers’ adoption of self-regulation, particularly the underlying psychological factors that underlies this process, is needed in order to promote its use within the older driver community.

Towards networked governance : improving interagency communication and collaboration for disaster risk management and climate change adaptation in Australia

Major disasters, such as bushfires or floods, place significant stress on scarce public resources. Climate change is likely to exacerbate this stress. An integrated approach to disaster risk management (DRM) and climate change adaptation (CCA) could reduce the stress by encouraging the more efficient use of pooled resources and expertise. A comparative analysis of three extreme climate-related events that occurred in Australia between 2009 and 2011 indicated that a strategy to improve interagency communication and collaboration would be a key factor in this type of policy/planning integration. These findings are in accord with the concepts of Joined-up Government and Network Governance. Five key reforms are proposed: developing a shared policy vision; adopting multi-level planning; integrating legislation; networking organisations; and establishing cooperative funding. These reforms are examined with reference to the related research literature in order to identify potential problems associated with their implementation. The findings are relevant for public policy generally but are particularly useful for CCA and DRM.

A framework for conceptualising traffic safety culture

Traffic safety culture is a relatively new concept which has recently gained attention in the field of traffic safety. There is currently little known regarding the nature of the concept, nor how it should be defined. Preliminary definitions have tended to focus on specific road safety problems and the anticipated effect of a strong traffic safety culture. The literature to date has tended to emphasise how traffic safety culture might be created or shaped. However, without a better understanding of the nature and structure of traffic safety culture, discussions regarding changes to traffic safety culture are restricted. An examination of different conceptualisations and definitions of organisational safety culture provides a preliminary theoretical framework for traffic safety culture. Two high risk driving behaviours within the Australian context are compared to illustrate how key factors within this framework can be used to understand and improve road safety outcomes.

Terrorism risk, resilience and volatility : a comparison of terrorism patterns in three Southeast Asian countries

Objective This article explores patterns of terrorist activity over the period from 2000 through 2010 across three target countries: Indonesia, the Philippines and Thailand. Methods We use self-exciting point process models to create interpretable and replicable metrics for three key terrorism concepts: risk, resilience and volatility, as defined in the context of terrorist activity. Results Analysis of the data shows significant and important differences in the risk, volatility and resilience metrics over time across the three countries. For the three countries analysed, we show that risk varied on a scale from 0.005 to 1.61 “expected terrorist attacks per day”, volatility ranged from 0.820 to 0.994 “additional attacks caused by each attack”, and resilience, as measured by the number of days until risk subsides to a pre-attack level, ranged from 19 to 39 days. We find that of the three countries, Indonesia had the lowest average risk and volatility, and the highest level of resilience, indicative of the relatively sporadic nature of terrorist activity in Indonesia. The high terrorism risk and low resilience in the Philippines was a function of the more intense, less clustered pattern of terrorism than what was evident in Indonesia. Conclusions Mathematical models hold great promise for creating replicable, reliable and interpretable “metrics” to key terrorism concepts such as risk, resilience and volatility.

A dedicated retrieval and transfer service : the QUARTS project

Background The transfer and/or retrieval of a critically patient is inherently dangerous not only for the patient but for staff as well. The quality and experience of unplanned transfers can influence patient mortality and morbidity. However, international evidence suggests that dedicated transfer/retrieval teams can improve mortality and morbidity outcomes. Aims The initial aim of this paper is to describe an in-house competency-based training programme, which encompasses the STaR approach to develop members of our existing nursing team to be part of the dedicated transfer/retrieval service. The paper also presents audit data findings which examined the source of referrals, number of patients actually transferred and clinical status of those being transferred. Results Audit data illustrate that the most frequent source of referrals comes from Accident and Emergency and the Surgical Directorate with the most common presenting condition being cardio-respiratory failure or arrest. Audit data reveal that the number of patients actually transferred or retrieved is relatively small (33%) compared with the overall number of requests for assistance. However, 36% of those patients transferred had a level 2 or level 3 acuity status that necessitated the admission to a critical care area. Conclusions A number of studies have concluded that the ill-experienced and ill-equipped transfer team can place patients’ at serious risk of harm. Whether planned or unplanned, dedicated critical care transfer/retrieval teams have been shown to reduce patient mortality and morbidity.