Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol

Objective Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Methods Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final score (Emergency Department Assessment of Chest pain Score [EDACS]). EDACS was combined with electrocardiogram results and troponin results at 0 and 2 h to develop an ADP (EDACS-ADP). The score and EDACS-ADP were validated and tested for reproducibility in separate cohorts of patients. Results In the derivation (n = 1974) and validation (n = 608) cohorts, the EDACS-ADP classified 42.2% (sensitivity 99.0%, specificity 49.9%) and 51.3% (sensitivity 100.0%, specificity 59.0%) as low risk of major adverse cardiac events, respectively. The intra-class correlation coefficient for categorisation of patients as low risk was 0.87. Conclusion The EDACS-ADP identified approximately half of the patients presenting to the ED with possible cardiac chest pain as having low risk of short-term major adverse cardiac events, with high sensitivity. This is a significant improvement on similar, previously reported protocols. The EDACS-ADP is reproducible and has the potential to make considerable cost reductions to health systems.

Performance assessment in a heat exchanger tube fitted with double counter twisted tape inserts

The present study explored the effects of the double counter twisted tapes on heat transfer and fluid friction characteristics in a heat exchanger tube. The double counter twisted tapes were used as counter-swirl flow generators in the test section. The experiments were performed with double counter twisted tapes of four different twist ratios (y = 1.95, 3.85, 5.92 and 7.75) using air as the testing fluid in a circular tube turbulent flow regime where the Reynolds number was varied from 6950 to 50,050. The experimental results demonstrated that the Nusselt number, friction factor and thermal enhancement efficiency were increased with decreasing twist ratio. The results also revealed that the heat transfer rate in the tube fitted with double counter twisted tape was significantly increased with corresponding increase in pressure drop. In the range of the present work, heat transfer rate and friction factor were obtained to be around 60 to 240% and 91 to 286% higher than those of the plain tube values, respectively. The maximum thermal enhancement efficiency of 1.34 was achieved by the use of double counter twisted tapes at constant blower power. In addition, the empirical correlations for the Nusselt number, friction factor and thermal enhancement efficiency were also developed, based on the experimental data.

The literacy curriculum: A critical review

This is a critical review of the scope of the literacy curriculum in the twenty-first century, uncovering the strengths, controversies, and silences that have divided literacy researchers and educators. It conceptualizes the literacy curriculum as a particular set of socially organized symbolic practices that are always selective, and which are inextricably connected to the function and organization of schooling. We trace the political, historical, and ideological antecedents of literacy curriculum and schooling as a form of cultural apparatus of the nation-state, before tracing some of the major interpretive paradigms that have influenced the shape of the literacy curriculum in many parts of the world. These include debates about skills-based approaches, whole language, systemic functional grammar, and critical literacy. It then draws attention to noteworthy advances and shifts in the field over recent decades: debates about the role of orality in the literacy curriculum, home-school community literacy practices, teacher and student knowledge of language and grammar, and the role of curriculum area literacies. It anticipates the future of the literacy curriculum in online textual environments and the changing sensorial and material nature of literacy practices, while acknowledging that curriculum innovation is always limited in complex ways by historically established pedagogic discourses of schooling.

Probabilistic assessment of herbicide runoff from Japanese rice paddies: The effects of local meteorological conditions and site-specific water management

Uncertainty assessments of herbicide losses from rice paddies in Japan associated with local meteorological conditions and water management practices were performed using a pesticide fate and transport model, PCPF-1, under the Monte Carlo (MC) simulation scheme. First, MC simulations were conducted for five different cities with a prescribed water management scenario and a 10-year meteorological dataset of each city. The effectiveness of water management was observed regarding the reduction of pesticide runoff. However, a greater potential of pesticide runoff remained in Western Japan. Secondly, an extended analysis was attempted to evaluate the effects of local water management and meteorological conditions between the Chikugo River basin and the Sakura River basin using uncertainty inputs processed from observed water management data. The results showed that because of more severe rainfall events, significant pesticide runoff occurred in the Chikugo River basin even when appropriate irrigation practices were implemented. © Pesticide Science Society of Japan.

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.

Pesticide exposure assessment in rice paddy areas: A Japanese perspective

This chapter provides an overview of the Japanese regulatory issues regarding pesticide use in rice paddies and an introduction of the new pesticide registration program. In addition, the experience of the environmental monitoring of pesticides and the modeling approaches used for the calculation of predicted environmental concentrations (PECs) in surface water and ground water systems adjacent to rice paddies in Japan are also discussed. Japan has been one of the major pesticide users in the world. Although having a long history in rice cultivation, the pesticide exposure assessment for paddy rice production received less attention compared with EU and US. Applications of up-to-date techniques and the development of realistic assessment procedures under specific climatic conditions as well as mitigation management practices for controlling pesticide contamination are important for an environmental-friendly rice production. Through the international cooperation and research exchanges, advances in pesticide risk assessment for rice paddies in Asian region and other rice-growing areas in the world would contribute to sustainable rice production. Transplanting of rice seedlings grows almost all rice paddies in Japan. The land preparation starts around April and June, and the harvest season lasts from August to October depending on the region and the rice varieties. Most of the rice paddies are treated with herbicides and other crop protection products, such as fungicides and insecticides that are applied during the crop season accordingly. Newly developed insecticides and fungicides are also applied during seedbed preparation.

Modeling approaches for pesticide exposure assessment in rice paddies

Pesticide use in paddy rice production may contribute to adverse ecological effects in surface waters. Risk assessments conducted for regulatory purposes depend on the use of simulation models to determine predicted environment concentrations (PEC) of pesticides. Often tiered approaches are used, in which assessments at lower tiers are based on relatively simple models with conservative scenarios, while those at higher tiers have more realistic representations of physical and biochemical processes. This chapter reviews models commonly used for predicting the environmental fate of pesticides in rice paddies. Theoretical considerations, unique features, and applications are discussed. This review is expected to provide information to guide model selection for pesticide registration, regulation, and mitigation in rice production areas.

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.

Assessment of body composition in Sri Lankan children: Validation of a bioelectrical impedance prediction equation

Objective: To develop bioelectrical impedance analysis (BIA) equations to predict total body water (TBW) and fat-free mass (FFM) of Sri Lankan children. Subjects/Methods: Data were collected from 5- to 15-year-old healthy children. They were randomly assigned to validation (M/F: 105/83) and cross-validation (M/F: 53/41) groups. Height, weight and BIA were measured. TBW was assessed using isotope dilution method (D2 O). Multiple regression analysis was used to develop preliminary equations and cross-validated on an independent group. Final prediction equation was constructed combining the two groups and validated by PRESS (prediction of sum of squares) statistics. Impedance index (height2/impedance; cm2/Ω), weight and sex code (male = 1; female = 0) were used as variables. Results: Independent variables of the final prediction equation for TBW were able to predict 86.3% of variance with root means-squared error (RMSE) of 2.1l. PRESS statistics was 2.1l with press residuals of 1.2l. Independent variables were able to predict 86.9% of variance of FFM with RMSE of 2.7 kg. PRESS statistics was 2.8 kg with press residuals of 1.4 kg. Bland Altman technique showed that the majority of the residuals were within mean bias±1.96 s.d. Conclusions: Results of this study provide BIA equation for the prediction of TBW and FFM in Sri Lankan children. To the best of our knowledge there are no published BIA prediction equations validated on South Asian populations. Results of this study need to be affirmed by more studies on other closely related populations by using multi-component body composition assessment.

Impact of ethnicity upon body composition assessment in Sri Lankan Australian children

Objectives: Obesity is a disease with excess body fat where health is adversely affected. Therefore it is prudent to make the diagnosis of obesity based on the measure of percentage body fat. Body composition of a group of Australian children of Sri Lankan origin were studied to evaluate the applicability of some bedside techniques in the measurement of percentage body fat. Methods: Height (H) and weight (W) was measured and BMI (W/H2) calculated. Bioelectrical impedance analysis (BIA) was measured using tetra polar technique with an 800 μA current of 50 Hz frequency. Total body water was used as a reference method and was determined by deuterium dilution and fat free mass and hence fat mass (FM) derived using age and gender specific constants. Percentage FM was estimated using four predictive equations, which used BIA and anthropometric measurements. Results: Twenty-seven boys and 15 girls were studied with mean ages being 9.1 years and 9.6 years, respectively. Girls had a significantly higher FM compared to boys. The mean percentage FM of boys (22.9 ± 8.7%) was higher than the limit for obesity and for girls (29.0 ± 6.0%) it was just below the cut-off. BMI was comparatively low. All but BIA equation in boys under estimated the percentage FM. The impedance index and weight showed a strong association with total body water (r 2 = 0.96, P < 0.001). Except for BIA in boys all other techniques under diagnosed obesity. Conclusions: Sri Lankan Australian children appear to have a high percentage of fat with a low BMI and some of the available indirect techniques are not helpful in the assessment of body composition. Therefore ethnic and/or population specific predictive equations have to be developed for the assessment of body composition, especially in a multicultural society using indirect methods such as BIA or anthropometry.

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.

Sustainability at the Australian local government level: Is there room for Strategic Environmental Assessment (SEA)?

Recent calls in Australia have addressed the need for better integration of planning processes. The consequent effort made by government has been, and still is, reshaping the way urban and regional planning and sustainability are managed. Focusing on planning practices at the local and regional levels, we investigate how environmental sustainability is pursued from an institutional perspective. Specifically, we analyse the way that planning in Australian cities aims to achieve sustainable strategies and reflect on the relationship with ‘Strategic Environmental Assessment’. This paper has four goals. First, sustainable planning practices at the local and regional levels are analysed considering the legislative and organizational frameworks of each state. The goal is to identify through an analysis of planning documents how much discretion is given to local councils to address sustainable strategies. Second, we focus on two regional and four cities in Queensland, to outline strengths and weaknesses of current legislative and practical frameworks. We use analytical criteria from the SEA literature to investigate these plans in more detail. Third, we examine the relationship between strategic and statutory plans, to see how sustainability is actually implemented. Finally we compare emerging issues about sustainable planning in Australia with countries overseas with different planning and SEA traditions. Considering that SEA is evolving and there are considerable international experiences, we offer recommendations on how Australia might achieve a more integrated and sustainable approach to planning.

Organisational driving safety systems analysis: Fleet safety situational issues and system gaps

The identification of safety hazards and risks and their associated control measures provides the foundation for any safety program and essentially determines the scope, content and complexity of an effective occupational health and safety management system. In the case of work-related road safety (WRRS), there is a gap within current knowledge, research and practice regarding the holistic assessment of WRRS safety systems and practice. In order to mitigate this gap, a multi-level process tool for assessing WRRS safety systems was developed from extensive consultation, practice and informed by theoretical models and frameworks. Data collection for the Organisational Driving Safety Systems Analysis (ODSSA) tool utilised a case study methodology and included multiple information sources: such as documents, archival records, interviews, direct observations, participant observations, and physical artefacts. Previous trials and application of the ODSSA has indicated that the tool is applicable to a wide range of organisational fleet environments and settings. This paper reports on the research results and effectiveness of the ODSSA tool to assess WRRS systems across a large organisation that recently underwent considerable organisational change, including amalgamation of multiple organisations. The outcomes of this project identified considerable differences in the degree by which the organisation addressed WRRS across their vehicle fleet operations and provided guidelines for improving organisations’ WRRS systems. The ODSSA tool was pivotal in determining WRRS system deficiencies and provided a platform to inform mitigation and improvement strategies.

Health Assessment and Physical Examination, 2nd Edition

Health Assessment and Physical Examination is designed to teach students to assess a patient’s physical, psychological, cultural and emotional dimensions of health as a foundation of nursing care. The skills of interviewing, inspection, percussion, palpation, auscultation, and documentation are refined to help students to make clinical judgements and promote healthy patient outcomes. A strong emphasis on science encompasses all the technical aspects of anatomy, physiology, and assessment, while highlighting clinically relevant information. Emphasis on caring is displayed through themes of assessment of the whole person, which also encourages nurses to think about care for themselves as well as patients.

Assessment of carotid plaque vulnerability using structural and geometrical determinants

Background Because many acute cerebral ischemic events are caused by rupture of vulnerable carotid atheroma and subsequent thrombosis, the present study used both idealized and patient-specific carotid atheromatous plaque models to evaluate the effect of structural determinants on stress distributions within plaque. Methods and Results Using a finite element method, structural analysis was performed using models derived from in vivo high-resolution magnetic resonance imaging (MRI) of carotid atheroma in 40 non-consecutive patients (20 symptomatic, 20 asymptomatic). Plaque components were modeled as hyper-elastic materials. The effects of varying fibrous cap thickness, lipid core size and lumen curvature on plaque stress distributions were examined. Lumen curvature and fibrous cap thickness were found to be major determinants of plaque stress. The size of the lipid core did not alter plaque stress significantly when the fibrous cap was relatively thick. The correlation between plaque stress and lumen curvature was significant for both symptomatic (p = 0.01; correlation coefficient: 0.689) and asymptomatic patients (p = 0.01; correlation coefficient: 0.862). Lumen curvature in plaques of symptomatic patients was significantly larger than those of asymptomatic patients (1.50±1.0mm-1 vs 1.25±0.75 mm-1; p = 0.01). Conclusion Specific plaque morphology (large lumen curvature and thin fibrous cap) is closely related to plaque vulnerability. Structural analysis using high-resolution MRI of carotid atheroma may help in detecting vulnerable atheromatous plaque and aid the risk stratification of patients with carotid disease.