Security protection for critical infrastructure

Understanding and managing information infrastructure (II) security risks is a priority to most organizations dealing with information technology and information warfare (IW) scenarios today (Libicki, 2000). Traditional security risk analysis (SRA) was well suited to these tasks within the paradigm of computer security, where the focus was on securing tangible items such as computing and communications equipment (NCS,1996; Cramer, 1998). With the growth of information interchange and reliance on information infrastructure, the ability to understand where vulnerabilities lie within an organization, regardless of size, has become extremely difficult (NIPC, 1996). To place a value on the information that is owned and used by an organization is virtually an impossible task. The suitability of risk analysis to assist in managing IW and information infrastructure-related security risks is unqualified, however studies have been undertaken to build frameworks and methodologies for modeling information warfare attacks (Molander, Riddile, & Wilson, 1996; Johnson, 1997; Hutchinson & Warren, 2001) which will assist greatly in applying risk analysis concepts and methodologies to the burgeoning information technology security paradigm, information warfare.

The effects of time pressure and experience on nurses' risk assessment decisions : a signal detection analysis

Background: Time pressure and, occasionally, suboptimal assessment decisions are features of nursing in acute care.

Objectives: To explore the effect of generic and specialist clinical experience on the ability to detect the need to take action in acute care and the impact of time pressure on nurses' decision-making performance.

Methods: Experienced acute care registered nurses (n = 241) were presented with 50 vignettes of real clinical risk assessments. Each vignette contained seven information cues. In response to these vignettes, nurses had to decide whether to intervene or not. The 26 vignettes were time limited and mixed randomly into the 50 cases. Signal detection analysis was used to establish nurses' performance, personal decision thresholds ([beta]), and their abilities (d') to distinguish a signal of clinical risk from the clinical noise of noncontributory information.

Results: Nurses had significantly lower d' and were significantly less likely to indicate intervening under time pressure. For ability-but not threshold-there was a significant interaction of time pressure and years of experience in acute care. With no time pressure, d' increased in line with years of experience. Under time pressure, there was no effect.

Discussion: Time pressure reduced nurses' ability to detect the need and the tendency to report intervening. Thus, there were more failures to report appropriate intervention under time pressure, and the positive effects of clinical experience were negated under time pressure. More and larger scale research on the effect on clinical outcomes of time pressured nursing choices is required.

Texture and mechanical anisotropy in three extruded magnesium alloys

One ZM61 alloy (6·2%Zn, 1·2%Mn) and two magnesium alloys containing nominally 3% of neodymium and yttrium respectively have been prepared in the form of hot extruded flat strips. Their textures and microstructures have been quantified and series of mechanical tests were carried out to determine plane stress yield loci in both the solution treated and aged conditions. The ZM61 alloy had a sharp texture and marked anisotropy of strength that could be rationalised in terms of deformation by basal <a> slip and {1012}<1011> twinning. This material was much weaker in compression than in tension. Precipitation hardening on aging caused a greater impedance to twinning than to slip with the result that the anisotropy was somewhat reduced. The Mg–3Nd alloy had a very weak and different texture but nevertheless demonstrated a pronounced anisotropy of strength. Aging increased the yield stress by about 80% and also inhibited twinning to some extent although the degree of anisotropy remained almost unaffected. The Mg–3Y alloy which showed a texture of intermediate strength was different in type from either of the others. Its strength behaviour was close to isotropic; in particular, no difference existed between tensile and compressive loading, and aging produced only a marginal increase in strength. Twins were relatively infrequent in the deformed Mg–3Y alloy but its mechanical behaviour could not be rationalised according to simple models.

Nurses' critical event risk assessments : a judgement analysis

Aims. To explore and explain nurses' use of readily available clinical information when deciding whether a patient is at risk of a critical event.

Background. Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing-knowledge 'basics' such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses' responses to abnormal signs result in delays of between one and three hours.

Methods. A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, 'at-risk' status, and whether they would intervene in response to 50 computer-presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients.

Results. Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as 'at risk' and deciding to intervene. Nurses' weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non-linear ways that contributed little to decisional accuracy. The low-moderate achievement (Ra) statistics suggests that nurses' assessments of risk were largely inaccurate; these assessments were applied consistently among 'patients' (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene.

Conclusion. Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use.

Relevance to clinical practice. Practice developers and educators need to pay attention to the quality of nurses' clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes' rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of 'holism' and 'expertise' from the science of predictive validity, accuracy and competence in judgement and decision making.

Implementation of a medication guideline to improve medication safety for patients

Although the incidence of medication error remains unknown, in Australian hospitals, they are thought to occur in 5-20 % of drug administrations 1. Not surprisingly, international debate has focused on the mechanisms to improve the safety of patients. Thus a new National Inpatient Medication Chart (NIMC) was endorsed to improve communication and reduce medication errors 2. This study aimed to investigate the documentation practices of clinicians following the implementation of a medication guideline and NIMC.
A pre and post-test design was used to evaluate the adoption of and adherence to the medication guideline at Western Health, an 850 bed healthcare network in Australia. Audits of inpatient medication charts (N=265) were conducted at 3 months prior to and repeated 4 months (N=290) after implementation. The pre-test data was used to formulate an interdisciplinary organizational strategy that included mandatory education for all clinical staff, practice reminders, decision prompts, a telephone hotline for support, an intranet information website and electronically distributed Frequently Asked Questions.
Pre and post implementation audits highlighted areas of potential medication error. The post-test showed an overall trend towards improvement in documentation. There were significant improvements in 4 critical practices: Drug name clear (p=0.0003); Drug dose clear (p=0.0002); Prescribed frequency equals documented frequency (p=0) and; No signature by administrator (p=0).
The majority of documentation errors showed poor attention to detail and would be considered a slip or lapse in skill based judgment 3. Although this study was designed to evaluate documentation practices, future research should include observation methods to increase our understanding of the context behind the judgments such as work place interruptions, skill mix and knowledge levels. While evidence based guidelines enable work, they are not the actual work or substance of patient care. Organisational systems can assist in preventing unconscious aberrations that lead to error.

Quantification of urbanization in relation to chronic diseases in developing countries : a systematic review

During and beyond the twentieth century, urbanization has represented a major demographic shift particularly in the developed world. The rapid urbanization experienced in the developing world brings increased mortality from lifestyle diseases such as cancer and cardiovascular disease. We set out to understand how urbanization has been measured in studies which examined chronic disease as an outcome. Following a pilot search of PUBMED, a full search strategy was developed to identify papers reporting the effect of urbanization in relation to chronic disease in the developing world. Full searches were conducted in MEDLINE, EMBASE, CINAHL, and GLOBAL HEALTH. Of the 868 titles identified in the initial search, nine studies met the final inclusion criteria. Five of these studies used demographic measures (such as population density) at an area level to measure urbanization. Four studies used more complicated summary measures of individual and area level data (such as distance from a city, occupation, home and land ownership) to define urbanization. The papers reviewed were limited by using simple area level summary measures (e.g., urban rural dichotomy) or having to rely on preexisting data at the individual level. Further work is needed to develop a measure of urbanization that treats urbanization as a process and which is sensitive enough to track changes in “urbanicity” and subsequent emergence of chronic disease risk factors and mortality.

Life-change events and participation in physical activity : a systematic review

Physical inactivity and related diseases are of global public health concern. In many developing countries, levels of health promoting physical activity (PA) are falling despite government initiatives. Previous work has identified that periods of transition across a life course, or ‘life-change events’ have implications for drop out from PA. As yet, there has been little work to understand the life course as a whole and to furnish a complete list of possible life changes that might affect participation in PA. Our paper presents a review of the published literature in which life events have been studied in relation to their effect on participation in PA. A literature search was conducted for papers published between 1977 and April 2007 and referenced in Pubmed. Papers were reviewed if they; reported the effect of a life-change event; had PA as an outcome; reported results in English; and reported results from observational studies. The references for studies identified during this first phase were searched for further papers. Eighty-seven papers were identified as potentially relevant on the basis of title, of which 19 papers met the inclusion criteria on the basis of full text. Five life changes were identified; change in employment status; change in residence; change in physical status; change in relationships; and change in family structure. It was noted that few longitudinal studies examined PA both before and after a life event. A list of possible life events which might effect participation in PA is presented. This paper represents a first step towards a detailed programme of work on life-change events and PA.

Beating the blues after cancer : randomised control trial of a tele-based psychological intervention for high distress patients and carers

Background : The diagnosis and treatment of cancer is a major life stress such that approximately 35% of patients experience persistent clinically significant distress and carers often experience even higher distress than patients. This paper presents the design of a two arm randomised controlled trial with patients and carers who have elevated psychological distress comparing minimal contact self management vs. an individualised tele-based cognitive behavioural intervention.

Methods/design : 140 patients and 140 carers per condition (560 participants in total) will been recruited after being identified as high distress through caller screening at two community-based cancer helplines and randomised to 1) a single 30-minute telephone support and education session with a nurse counsellor with self management materials 2) a tele-based psychologist delivered five session individualised cognitive behavioural intervention. Session components will include stress reduction, problem-solving, cognitive challenging and enhancing relationship support and will be delivered weekly. Participants will be assessed at baseline and 3, 6 and 12 months after recruitment. Outcome measures include: anxiety and depression, cancer specific distress, unmet psychological supportive care needs, positive adjustment, overall Quality of life.

Discussion : The study will provide recommendations about the efficacy and potential economic value of minimal contact self management vs. tele-based psychologist delivered cognitive behavioural intervention to facilitate better psychosocial adjustment and mental health for people with cancer and their carers.

Knowledge-in-practice in the caring professions : multidisciplinary perspectives

Contents:  Ideas of knowledge in practice / Struan Jacobs -- Information, knowledge, and wisdom in medical practice / P. B. Greenberg -- The practice of the psychiatrist / Alex Holmes -- Social work knowledge-in-practice / Heather D'Cruz -- Disability : a personal approach / Lisa Chaffey -- Knowledge in the making : an analytical psychology perspective / Joy Norton -- Knowledge to action in the practice of nursing / Alison Hutchinson, Tracey Bucknall -- The risky business of birth / Frances Sheean and Jennifer M. Cameron -- Skills for person-centred care : health professionals supporting chronic condition prevention and self-management / Sharon Lawn and Malcolm Battersby -- Knowledge and reasoning in practice : an example from physiotherapy and occupational therapy / Megan Smith ... [et al.] -- Using knowledge in the practice of dealing with addiction : an ideal worth aiming for / Peter Miller.

Healthy cities

Healthy Cities is a worldwide movement developed by the European office of the World Health Organization. It has been implemented formally through WHO in many cities, and others have adopted the model. Grounded in 11 qualities that range from housing to economy and social characteristics such as a supportive community, Healthy Cities goes well beyond the definition of health as an absence of disease. This entry looks at its development and implementation around the world.

Steroidogenesis in cultured mammalian glial cells

A protocol for culturing mammalian type 1 astrocytic cells, using female post-natal rat cerebral cortical tissue, was established and refined for use in steroidogenic metabolic studies incorporating progestin radioisotopes. Cultures were characterised for homogeneity using standard morphological and immunostaining techniques. Qualitative and quantitative studies were conducted to characterise the progesterone (P) metabolic pathways present in astrocytes in vitro. Of particular interest was the formation of the P metabolite, 5á-pregnan-3á-ol-20-one (THP). THP is a GABA(A) receptor agonist, believed to play a vital role in neural functioning and CNS homeostasis. One aim of this study was to observe any modulatory effects selected neuroactive ligands have on the conversion of P into THP, in an attempt to link astrocytic steroidogenesis with neuronal control. In qualitative studies, chromatographic procedures were used to establish the progestin profile of cerebral cortical astrocytes. Tritiated P, DHP (5á-pregnan-3,20-dione) and THP incurbates were preliminary fractionated by either normal phase (NP) or reverse phase (RP) high performance liquid chromatography (HPLC). The radiometabolites associated with each fraction were further chromatographed, before and/or after chemical derivatistation, by the aforemention HPLC procedures and thin layer chromatography (TLC). Steroid radiometabolites were tentatively identified by comparing their chromatographic mobility with authentic steroids. The identity of the main putative 5á-reduced P metabolities, DHP, THP and 5á-pregnan-3á,20á-diol (20áOH-THP) were further confirmed by isotopic dilution analysis. Their conclusive identification, along with the tentative identification of 20á-hydroxypreg-4-en-3-one (20áOH-P) and 20á-hydroxy-5á-pregnan-3-one (20áOH-DHP), verify the localisation of 5á-reductase, 3á-hydroxy steroif oxidoreductase (HSOR), and 20á-HSOR activity in the cultured astrocytes utilised in this study programme. Other minor metabolites detected were tentatively identified, including 5á-pregnan-3á,21-diol-20-one (THDoc), indicating the presence of 21-hydroxylase enzymatic activity. THDoc, like THP, is a GABA(A) receptor agonist. The chemical and physical characterisation of several yet unidentified progestin metabolites, associated with a highly polar RP HPLC fraction (designated RP peak 1*), indicate the presence of one or more extra hydroxylase enzymes. Quantitative analysis included a preliminary study. In this study, the percentage yields of radiometabolites formed in cultures incubated with increasing substrate concentrations of (3)H-P for 24 hours were determined. At the lower concentrations examined (ie 0.5 to 50nM), the metabolites associated with the polar RP HPLC fraction (RP peak 1*) collectively have the highest percentage yield. They are subsequently considered metabolic end products of degradative catabolic P pathways. The percentage yield of THP peaks in the medium concentration ranges (ie 5 to 500nM), whereas DHP remains fairly static at a low level with increasing concentration. Both DHP and THP are considered metabolic pathway intermediates. The percentage yield of 20áOH-THP continues to increase with increasing concentration over 5nM, superseding THP approaching the highest concentration examined (5000nM). This indicated the formation of 20áOH-THP does not occur entirely via THP. 20áOH-THP also possibly serves as the direct intermediate in the formation of the main radiometabolites associated with RP peak 1*. A time/yield study incorporating incubation times from one to 24 hours was also conducted. The full array of radiometabolites (individually or in groups) formed in astrocyte cultures incubated with 50nM tritiated P, DHP of THP, were assayed. Cultures were observed to rapidly convert any DHP into THP, showing astrocytic 3á-HSOR activity is very high. The study also showed 5á-reduction (ie the conversation of P into DHP) is the rate limiting reaction in the two step conversion of P into THP. 5á-Reduction also appears to be a rate limiting step in the formation of 20á-hydroxylated metabolites in astrocytes. Cultures incubated with the tritiated 5á-reduced pregnanes from one to four hours form greater quantities to 20á-hydroxylated radiometabolites compared to cultures incubated with (3)H-P. The time yield/studies also provided further evidence the unidentified polar radiometabolites associated with RP peak 1* are metabolic end products. For the P and DHP incubates, the collective formation of the aforementioned polar radiometabolites initially lags behind the formation of THP. As the formation of the latter begins to plateau with increasing time between four to 24 hours, the net yield of radiometabolites associated with RP peak 1* continues to rise. The time/yield studies also indicate 5á-reduction and perhaps 3á-hydroxylation are pre-requisite steps in the formation of the polar metabolites. Cultures incubated with the 5á-reduced progestins from one to four hours form higher yields of the radiometabolites associated with RP peak 1* compared to cultures incubated with P as substrate. The net yields of the radiometabolites associated with RP peak 1* for cultures incubated with THP were substantially higher compared to cultures incubated with DHP after equivalent times. The effect selected neuroligands have on the yield of radiometabolites formed by cultured astrocytes incubated with 50nM (3)H-P was also examined. Dibutyryl cyclic adenosine monophosphate (DBcAMP), not actually a neuroligand per se, but an analog of the intracellular secondary messenger cAMP, was also utilised in these studies. The inhibitory neurotransmitter ă-amino-nbutyric acid (GABA), DBcAMP and isoproterenol (a â-adrenergic receptor agonist) all quickly induce a transient but substantial increase in 20á-HSOR activity in cultured astrocytes. Cultures pretreated with these three compounds (10, 20 and 1µM respectively) form substantially higher yields of 20á-hydroxylated metabolites, including 20áOH-THP (between 200 to 580% greater), when incubated with 50nM (3)H-P for one to four hours. These increases also coincide with increases in the net yield of metabolites formed (by 16 to 48%). The same pre-treated cultures form significantly lower yields of THP, by 25 to 41%, after one hour. This is most likely due to the increased metabolism of any formed THP into 20áOH-THP. Octopamine (an á-adrenergic agonist) only induces a slight increase in 20á-HSOR activity, having relatively little effect on the yield of 20áOH-THP formed. Pretreatment with octopamine induces a significant increase in the yield of THP for cultures incubated with (3)H-P for four hours (by 24%). The increase in THP formation appears to be due to an increase in 3á-HSOR activity, as judged by the concomitant drop in the yield of the 5á-reduced, 3-keto substrates. An increase in 5á-reductase activity cannot be excluded however. Isoproterenol appears to induce an increase in 5á-reductase activity as isoproterenol appears to induce an increase in 5á-reductase activity as isoproterenol one and four hour incubates have higher yields of DHP. This is in contrast to the other three incubates. After 12 hours, all incubates have higher yields of THP (15-30%).