A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital

OBJECTIVES: Report the use of an objective tool, UK Gold Standards Framework (GSF) criteria, to describe the prevalence, recognition and outcomes of patients with palliative care needs in an Australian acute health setting. The rationale for this is to enable hospital doctors to identify patients who should have a patient-centred discussion about goals of care in hospital.

DESIGN: Prospective, observational, cohort study.

PARTICIPANTS: Adult in-patients during two separate 24 h periods.

MAIN OUTCOME MEASURES: Prevalence of in-patients with GSF criteria, documentation of treatment limitations, hospital and 1 year survival, admission and discharge destination and multivariate regression analysis of factors associated with the presence of hospital treatment limitations and 1 year survival.

RESULTS: Of 626 in-patients reviewed, 171 (27.3%) had at least one GSF criterion, with documentation of a treatment limitation discussion in 60 (30.5%) of those patients who had GSF criteria. Hospital mortality was 9.9%, 1 year mortality 50.3% and 3-year mortality 70.2% in patients with GSF criteria. One-year mortality was highest in patients with GSF cancer (73%), renal failure (67%) and heart failure (60%) criteria. Multivariate analysis revealed age, hospital length of stay and presence of the GSF chronic obstructive pulmonary disease criteria were independently associated with the likelihood of an in-hospital treatment limitation. Non-survivors at 3 years were more likely to have a GSF cancer (25% vs 6%, p=0.004), neurological (10% vs 3%, p=0.04), or frailty (45% vs 3%, p=0.04) criteria. After multivariate logistic regression GSF cancer criteria, renal failure criteria and the presence of two or more GSF clinical criteria were independently associated with increased risk of death at 3 years. Patients returning home to live reduced from 69% (preadmission) to 27% after discharge.

CONCLUSIONS: The use of an objective clinical tool identifies a high prevalence of patients with palliative care needs in the acute tertiary Australian hospital setting, with a high 1 year mortality and poor return to independence in this population. The low rate of documentation of discussions about treatment limitations in this population suggests palliative care needs are not recognised and discussed in the majority of patients.

TRIAL REGISTRATION NUMBER: 11/121.

Retrospective clinical audit of outcomes for patients admitted to an inpatient palliative care unit for restorative care

Background Restorative care in palliative care is a subset of rehabilitation that aims to improve quality of life through restoration or maintenance of physical functions. Outcomes for restorative care programmes delivered by palliative care units have not adequately been assessed.

Objectives The objectives are to examine the outcomes of a restorative care programme in an inpatient palliative care unit, including discharge destination, performance status changes and length of stay.

Methods Retrospective clinical audit of consecutive patients admitted to Calvary Health Care Bethlehem in Melbourne, Australia, principally for restorative care from July 2010 to December 2011.

Results 79 admissions met inclusion criteria. Mean age was 76.5 years (SD=11.14) and 43 (54%) were men. 75 (95%) patients had a malignant diagnosis; of these, the majority had lung cancer (24%). 16 patients (20%) were discharged home, 51 (65%) died and 12 (15%) were transferred. Of the patients discharged home, only 6 (38% of those discharged home) improved their performance status. Those discharged home had a significantly shorter length of stay (17 days compared to 39 days; p<0.05). Patients discharged home also had significantly better Australia-modified Karnofsky Performance Status (AKPS) and Resource Utilisation Groups-Activities of Daily Living (RUG-ADL) scores on admission than others (both p<0.05).

Conclusions The majority of patients referred for restorative care died during admission, with only a minority discharged home. Patients discharged most commonly experienced maintenance and not improvement in performance status. A successful discharge home following restorative care was associated with a shorter length of stay. Implications and recommendations for successful restorative care will be discussed.

Exploring the travel behaviors of inbound tourists to Hong Kong using geotagged photos

Insight into tourist travel behaviors is crucial for managers engaged in strategic planning and decision making to create a sustainable tourism industry. However, they continue to face significant challenges in fully capturing and understanding the behavior of international tourists. The challenges are primarily due to the inefficient data collection approaches currently in use. In this paper, we present a new approach to this task by exploiting the socially generated and user-contributed geotagged photos now made publicly available on the Internet. Our case study focuses on Hong Kong inbound tourism using 29,443 photos collected from 2100 tourists. We demonstrate how a dataset constructed from such geotagged photos can help address such challenges as well as provide useful practical implications for destination development, transportation planning, and impact management. This study has the potential to benefit tourism researchers worldwide from better understanding travel behavior and developing sustainable tourism industries.

An efficient detection mechanism against packet faking attack in opportunistic networks

Security is a major challenge in Opportunistic Networks (OppNets) because of its characteristics, such as open medium, dynamic topology, no centralized management and absent clear lines of defense. A packet dropping attack is one of the major security threats in OppNets since neither source nodes nor destination nodes have the knowledge of where or when the packet will be dropped. In our previous novel attack (Packet Faking Attack [1]) we presented a special type of packet dropping where the malicious node drops one or more packets and then injects new fake packets instead. In this paper, we present an efficient detection mechanism against this type of attack where each node can detect the attack instead of the destination node. Our detection mechanism is very powerful and has very high accuracy. It relies on a very simple yet powerful idea, that is, the packet creation time of each packet. Simulation results show this robust mechanism achieves a very high accuracy, detection rate and good network traffic reduction.

Catabolism attack and anabolism defense: a novel attack and traceback mechanism in opportunistic networks

Security is a major challenge in Opportunistic Networks (OppNets) because of its characteristics, such as open medium, dynamic topology, no centralized management and absent clear lines of defense.A packet dropping attack is one of the major security threats in OppNets since neither source nodes nor destination nodes have the knowledge of where or when the packet will be dropped. In this paper, we present a novel attack and traceback mechanism against a special type of packet dropping where the malicious node drops one or more packets and then injects new fake packets instead. We call this novel attack a Catabolism Attack and we call our novel traceback mechanism against this attack Anabolism Defense. Our novel detection and traceback mechanism is very powerful and has very high accuracy. Each node can detect and then traceback the malicious nodes based on a solid and powerful idea that is, hash chain techniques. In our defense techniques we have two stages. The first stage is to detect the attack, and the second stage is to find the malicious nodes. Simulation results show this robust mechanism achieves a very high accuracy and detection rate.

Malicious node traceback in opportunistic networks using merkle trees

Security is a major challenge in Opportunistic Networks because of its characteristics, such as open medium, dynamic topology, no centralized management and absent clear lines of defense. A packet dropping attack is one of the major security threats in OppNets since neither source nodes nor destination nodes have the knowledge of where or when the packet will be dropped. In this paper, we present a malicious nodes detection mechanism against a special type of packet dropping attack where the malicious node drops one or more packets and then injects new fake packets instead. Our novel detection and traceback mechanism is very powerful and has very high accuracy. Each node can detect and then traceback the malicious nodes based on a solid and powerful idea that is, Merkle tree hashing technique. In our defense techniques we have two stages. The first stage is to detect the attack, and the second stage is to find the malicious nodes. We have compared our approach with the acknowledgement based mechanisms and the networks coding based mechanism which are well known approaches in the literature. Simulation results show this robust mechanism achieves a very high accuracy and detection rate.

Establishing trust relationships in OppNets using Merkle trees

Opportunistic Networks (OppNets) are exposed to a variety of attacks, among them are packet dropping attacks. The security challenges in OppNets is to effectively and securely forward data and guarantee their delivery without any loss. Security and trust in OppNets have gained popularity in research because of their inherent features, including frequent partitions, long delays and intermittent connectivity. This paper presents an efficient malicious path and malicious node detection technique against selective packet dropping attacks. In our algorithm we have developed a solid detection mechanism using the Merkle tree hashing technique. The result of malicious path detection is used to build trust by destination nodes for each path, the built trust value of nodes is then used to detect malicious nodes. Simulation results show that the technique accurately detects malicious paths. The results also show that with the increase of simulation time, node detection accuracy also increases as intermediate nodes have more time to establish trust with destination nodes.