Estimating disease likelihood: a case of rubbery figures

In diagnosis and prognosis, we should avoid intuitive “guesstimates” and seek a validated numerical aid

Spatial, temporal, and human dimensions of air pollution in Brisbane

Arriving in Brisbane some six years ago, I could not help being impressed by what may be prosaically described as its atmospheric amenity resources. Perhaps this in part was due to my recent experiences in major urban centres in North America, but since that time, that sparkling quality and the blue skies seem to have progressively diminished. Unfortunately, there is also objective evidence available to suggest that this apparent deterioration is not merely the result of habituation of the senses. Air pollution data for the city show trends of increasing concentrations of those very substances that have destroyed the attractiveness of major population centres elsewhere, with climates initially as salubrious. Indeed, present figures indicate that photochemical smog in unacceptably high concentrations is rapidly becoming endemic also over Brisbane. These regrettable developments should come as no surprise. The society at large has not been inclined to respond purposefully to warnings of impending environmental problems, despite the experiences and publicity from overseas and even from other cities within Australia. Nor, up to the present, have certain politicians and government officials displayed stances beyond those necessary for the maintenance of a decorum of concern. At this stage, there still exists the possibility for meaningful government action without the embarrassment of losing political favour with the electorate. To the contrary, there is every chance that such action may be turned to advantage with increased public enlightenment. It would be more than a pity to miss perhaps the final remaining opportunity: Queensland is one of the few remaining places in the world with sufficient resources to permit both rational development and high environmental quality. The choice appears to be one of making a relatively minor investment now for a large financial and social gain the near future, or, permitting Brisbane to degenerate gradually into just another stagnated Los Angeles or Sydney. The present monograph attempts to introduce the problem by reviewing the available research on air quality in the Brisbane area. It also tries to elucidate some seemingly obvious, but so far unapplied management approaches. By necessity, such a broad treatment needs to make inroads into extensive ranges of subject areas, including political and legal practices to public perceptions, scientific measurement and statistical analysis to dynamics of air flow. Clearly, it does not pretend to be definitive in any of these fields, but it does try to emphasize those adjustable facets of the human use system of natural resources, too often neglected in favour of air pollution control technology. The crossing of disciplinary boundaries, however, needs no apology: air quality problems are ubiquitous, touching upon space, time and human interaction.

The Rural Clinical Division: a student journey to rural medicine

Background: The University of Queensland has through an Australian Government initiative, established a Rural Clinical Division (RCD) at four regional sites in the southern and central Queensland. Over the fi rst four years of the existence of the RCD, an integrated package of innovative medical education has been developed. Method: The integrated aspects of the RCD program include: The Rural Medical Rotation: Every medical student undertakes an eight week rural rotation in Year 3. Year 3 and 4 MBBS - 100 students are currently spending one to two years in the rural school and demand is increasing. Interprofessional Education - Medical and Allied Health students attend lectures, seminars and workshops together and often share the same rural clinical placement. Rural health projects - allow students to undertake a project of benefi t to the rural community. Information Technology (IT) - the Clinical Discussion Board (CDB) and Personal Digital Assistants (PDA) demonstrate the importance of IT to medical students in the 21st century. Changing the Model of Medical Education - The Leichhardt Community Attachment Placement (LCAP), is a pilot study that resulted in the addition of three interns to the rural workforce. All aspects of the RCD are evaluated with surveys using both qualitative and quantitative free response questions, completed by all students regularly throughout the academic year. Results: Measures of impact include: Student satisfaction and quality of teaching surveys – 86-91% of students improved their clinical skills and understanding across all rotations. Academic results and progress – RCD students out-perform their urban colleagues. Intent to work in rural areas – 90% of students reported a greater interest in rural medicine. Intern numbers – rural / regional intern placements are increasing. Conclusions: The RCD proves to be a site for innovations all designed to help reach our primary goal of fostering increased recruitment of a rural medical workforce.

Polytomous item response theory models

Polytomous Item Response Theory Models provides a unified, comprehensive introduction to the range of polytomous models available within item response theory (IRT). It begins by outlining the primary structural distinction between the two major types of polytomous IRT models. This focuses on the two types of response probability that are unique to polytomous models and their associated response functions, which are modeled differently by the different types of IRT model. It describes, both conceptually and mathematically, the major specific polytomous models, including the Nominal Response Model, the Partial Credit Model, the Rating Scale model, and the Graded Response Model. Important variations, such as the Generalized Partial Credit Model are also described as are less common variations, such as the Rating Scale version of the Graded Response Model. Relationships among the models are also investigated and the operation of measurement information is described for each major model. Practical examples of major models using real data are provided, as is a chapter on choosing an appropriate model. Figures are used throughout to illustrate important elements as they are described.

Historic Bridge Photographs: The Lahey Collection

Romeo Watkins Lahey (1887-1968) was a distinguished Queensland engineer. He graduated in engineering from the University of Sydney in 1914 and served in World War I from 1915 to 1918 with The Royal Australian Engineers. Following the war, he accepted an offer to remain for a period in England and studied town planning at the University of London. He visited Europe and collected a remarkable set of historic bridge photographs. In the course of this visit, he met Paul Sejourne, a distinguished French bridge engineer, the designer of at Ieast one of the bridges (at Fontpedrouse, pages 25-27) included in this set. When Lahey died, his wife Sybil and daughter Ann took steps to give this remarkable set of 58 historic bridge photographs to The University of Queensland. More recently, Lahey's daughters Ann Neale and Alison Drake have given a set of lantern plates collected by their father, many of which also have photographs of bridges. This volume is divided into three parts: (a) a biography of Romeo Watkins Lahey, written by his daughter, Ann Neale; (b) copies of the original set of 58 bridge photographs, and (c) copies taken from 32 lantern plates. To these have been added captions. Many of the original photographs carried titles; where these are available they have been printed in italics. Further work has been done to identify bridges and where possible the captions include the completion date, major dimensions, locations, and references to published works. Plates 8.1-10 are copies of drawings used as Figures in a book. These drawings have not been copied and the source has not been identified. Two lists of photographs and plates are included - the first in the order of the original collections and a second with bridges listed in the order of material, structural form and date. The collection is of remarkable value to any bridge historian, and is recommended for study by students.

A mathematical model of HIV transmission in NSW prisons

A mathematical model was developed to estimate HIV incidence in NSW prisons. Data included: duration of imprisonment; number of inmates using each needle; lower and higher number of shared injections per IDU per week; proportion of IDUs using bleach; efficacy of bleach; HIV prevalence and probability of infection. HIV prevalence in IDUs in prison was estimated to have risen from 0.8 to 5.7% (12.2%) over 180 weeks when using lower (and higher) values for frequency of shared injections. The estimated minimum (and maximum) number of IDU inmates infected with HIV in NSW prisons was 38 (and 152) in 1993 according to the model. These figures require confirmation by seroincidence studies. (C) 1998 Published by Elsevier Science Ireland Ltd. All rights reserved.

Suicide and recency of health care contacts - A systematic review

Background Many countries have set targets for suicide reduction, and suggested that mental health care providers and general practitioners have a key role to play. Method Asystematic review of the literature. Results Among those in the general population who commit suicide, up to 41% may have contact with psychiatric inpatient care in the year prior to death and up-to 9% may commit suicide within one day of discharge. The corresponding figures are I I and 4% for community-based psychiatric care and 83 and 20% for general practitioners. Conclusions Among those who die by suicide. contact with health services is common before death. This is a necessary but not sufficient condition for clinicians to intervene. More work is needed to determine whether these people show characteristic patterns of care and/or particular risk factors which would enable a targeted approach to be developed to assist clinicians in detecting and managing high-risk patients.

Predictors of local recurrence after treatment of ductal carcinoma in situ - A meta-analysis

lBACKGROUND. Management of patients with ductal carcinoma in situ (DCIS) is a dilemma, as mastectomy provides nearly a 100% cure rate but at the expense of physical and psychologic morbidity. It would be helpful if we could predict which patients with DCIS are at sufficiently high risk of local recurrence after conservative surgery (CS) alone to warrant postoperative radiotherapy (RT) and which patients are at sufficient risk of local recurrence after CS + RT to warrant mastectomy. The authors reviewed the published studies and identified the factors that may be predictive of local recurrence after management by mastectomy, CS alone, or CS + RT. METHODS. The authors examined patient, tumor, and treatment factors as potential predictors for local recurrence and estimated the risks of recurrence based on a review of published studies. They examined the effects of patient factors (age at diagnosis and family history), tumor factors (sub-type of DCIS, grade, tumor size, necrosis, and margins), and treatment (mastectomy, CS alone, and CS + RT). The 95% confidence intervals (CI) of the recurrence rates for each of the studies were calculated for subtype, grade, and necrosis, using the exact binomial; the summary recurrence rate and 95% CI for each treatment category were calculated by quantitative meta-analysis using the fixed and random effects models applied to proportions. RESULTS, Meta-analysis yielded a summary recurrence rate of 22.5% (95% CI = 16.9-28.2) for studies employing CS alone, 8.9% (95% CI = 6.8-11.0) for CS + RT, and 1.4% (95% CI = 0.7-2.1) for studies involving mastectomy alone. These summary figures indicate a clear and statistically significant separation, and therefore outcome, between the recurrence rates of each treatment category, despite the likelihood that the patients who underwent CS alone were likely to have had smaller, possibly low grade lesions with clear margins. The patients with risk factors of presence of necrosis, high grade cytologic features, or comedo subtype were found to derive the greatest improvement in local control with the addition of RT to CS. Local recurrence among patients treated by CS alone is approximately 20%, and one-half of the recurrences are invasive cancers. For most patients, RT reduces the risk of recurrence after CS alone by at least 50%. The differences in local recurrence between CS alone and CS + RT are most apparent for those patients with high grade tumors or DCIS with necrosis, or of the comedo subtype, or DCIS with close or positive surgical margins. CONCLUSIONS, The authors recommend that radiation be added to CS if patients with DCIS who also have the risk factors for local recurrence choose breast conservation over mastectomy. The patients who may be suitable for CS alone outside of a clinical trial may be those who have low grade lesions with little or no necrosis, and with clear surgical margins. Use of the summary statistics when discussing outcomes with patients may help the patient make treatment decisions. Cancer 1999;85:616-28. (C) 1999 American Cancer Society.

Cost-effectiveness analysis of humanitarian relief interventions: visceral leishmaniasis treatment in the Sudan

Spending by aid agencies on emergencies has quadrupled over the last decade, to over US$ 6 billion. To date, cost-effectiveness has seldom been considered in the prioritization and evaluation of emergency interventions. The sheer volume of resources spent on humanitarian aid and the chronicity of many humanitarian interventions call for more attention to be paid to the issue of 'value for money'. In this paper we present data from a major humanitarian crisis, an epidemic of visceral leishmaniasis (VL) in war-torn Sudan. The special circumstances provided us, in retrospect, with unusually accurate data on excess mortality, costs of the intervention and its effects, thus allowing us to express cost-effectiveness as the cost per Disability Adjusted Life Year (DALY) averted. The cost-effectiveness ratio, of US$ 18.40 per DALY (uncertainty range between US$ 13.53 and US$ 27.63), places the treatment of VL in Sudan among health interventions considered 'very flood value for money' (interventions of less than US$ 25 per DALY). We discuss the usefulness of this analysis to the internal management of the VL programme, the procurement of funds for the programme, and more generally, to priority setting in humanitarian relief interventions. We feel that in evaluations of emergency interventions attempts could be made more often to perform cost-effectiveness analyses, including the use of DALYs, provided that the outcomes of these analyses are seen in the broad context of the emergency situation and its consequences on the affected population. This paper provides a first contribution to what is hoped to become an international database of cost-effectiveness studies of health outcome such as the DALY.

Strategic research partnerships: Empirical evidence from Asia

This paper evaluates the role Strategic Research Partnerships (SRPs) play in Asia. Specific Asian institutional settings influence the roles of SRPs. Japan is regarded as a forerunner in the practice of SRPs. In Japan, lack of spillover channels, limited opportunities for mergers and acquisitions, weak university research and pressure for internal diversification motivate firms to form SRPs. In Korea, SRPs are regarded as a means to promote large-scale research projects. In Taiwan, SRPs are formed to facilitate technological diffusion. Empirical findings on SRPs, focusing on government-sponsored R&D consortia in Japan, are summarized. Issues regarding SRP formation, their effect on R&D spending of participating firms, and productivity, are examined. Reference is made to alternative forms of measurement of SRPs and their potential application to Asian countries is assessed. Enhancing the capacity of policy-makers to assess the extent and contribution of SRPs is considered to be a priority.

Investment prioritization based on broadscale spatial budgeting to meet downstream targets for suspended sediment loads

On the basis of a spatially distributed sediment budget across a large basin, costs of achieving certain sediment reduction targets in rivers were estimated. A range of investment prioritization scenarios were tested to identify the most cost-effective strategy to control suspended sediment loads. The scenarios were based on successively introducing more information from the sediment budget. The relationship between spatial heterogeneity of contributing sediment sources on cost effectiveness of prioritization was investigated. Cost effectiveness was shown to increase with sequential introduction of sediment budget terms. The solution which most decreased cost was achieved by including spatial information linking sediment sources to the downstream target location. This solution produced cost curves similar to those derived using a genetic algorithm formulation. Appropriate investment prioritization can offer large cost savings because the magnitude of the costs can vary by several times depending on what type of erosion source or sediment delivery mechanism is targeted. Target settings which only consider the erosion source rates can potentially result in spending more money than random management intervention for achieving downstream targets. Coherent spatial patterns of contributing sediment emerge from the budget model and its many inputs. The heterogeneity in these patterns can be summarized in a succinct form. This summary was shown to be consistent with the cost difference between local and regional prioritization for three of four test catchments. To explain the effect for the fourth catchment, the detail of the individual sediment sources needed to be taken into account.

Pathology reporting of breast cancer: trends in 1989-1999, following the introduction of mammographic screening in Western Australia

Background: A survey of pathology reporting of breast cancer in Western Australia in 1989 highlighted the need for improvement. The current study documents (1) changes in pathology reporting from 1989 to 1999 and (2) changes in patterns of histopathological prognostic indicators for breast cancer following introduction of mammographic screening in 1989. Methods: Data concerning all breast cancer cases reported in Western Australia in 1989, 1994 and 1999 were retrieved using the State Cancer Registry, Hospital Morbidity data system, and pathology laboratory records. Results: Pathology reports improved in quality during the decade surveyed. For invasive carcinoma, tumour size was not recorded in 1.2% of pathology reports in 1999 compared with 16.1% in 1989 (rho<0.001). Corresponding figures for other prognostic factors were: tumour grade 3.3% and 51.6% (rho<0.001), tumour type 0.2% and 4.1% (rho<0.001), vascular invasion 3.7% and 70.9% (rho<0.001), and lymph node status 1.9% and 4.5% (rho=0.023). In 1999, 5.9% of reports were not in a synoptic/checklist format, whereas all reports were descriptive in 1989 (rho<0.001). For the population as a whole, the proportion of invasive carcinomas <1 cm was 20.9% in 1999 compared with 14.5% in 1989 (rho<0.001); for tumours <2 cm the corresponding figures were 65.4% and 59.7% (rho=0.013). In 1999, 30.5% of tumours were histologically well-differentiated compared with 10.6% in 1989 (rho<0.001), and 61.7% were lymph node negative in 1999 compared with 57.1% in 1989 (rho=0.006). Pure ductal carcinoma in situ (DCIS) constituted 10.9% and 7.9% of total cases of breast carcinoma in 1999 and 1989, respectively (rho=0.01). Conclusions: Quality of pathology reporting improved markedly over the period, in parallel with adoption of stanclardised synoptic pathology reports. By 1999, recording of important prognostic information was almost complete. Frequency of favourable prognostic factors generally increased over time, reflecting expected effects of mammographic screening.