Emergency Health Services (EHS) : demand and service delivery models. [Monograph 2 : Queensland EHS users’ profile]

Emergency health is a critical component of Australia’s health system and one which is increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the characteristics of users of emergency health services with an aim to identify those that appear to contribute to demand growth. This study utilises data on patients treated by Emergency Departments (ED) and Queensland Ambulance Service (QAS) across Queensland. ED data was derived from the Emergency Department Information System (EDIS) for the period 2001-02 through to 2010-11. Ambulance data was extracted from the QAS’ Ambulance Information Management System (AIMS) and electronic Ambulance Report Form (eARF) for the period 2001-02 through to 2009-10. Due to discrepancies and comparability issues for ED data, this monograph compares data from the 2003-04 time period with 2010-11 data for 21 of the reporting EDs. Also a snapshot of users for the 2010-11 financial year for 31 reporting EDs is used to describe the characteristics of users and to compare those characteristics with population demographics. For QAS data, the 2002-03 and 2009-10 time periods were selected for detailed analyses to identify trends. • Demand for emergency health care services is increasing, representing both increased population and increased relative utilisation. Per capita demand for ED attention has increased by 2% per annum over the last decade and for ambulance attention by 3.7% per annum. • The growth in ED demand is prominent in more urgent triage categories with actual decline in less urgent patients. An estimated 55% of patients attend hospital EDs outside of normal working hours. There is no evidence that patients presenting out of hours are significantly different to those presenting within working hours; they have similar triage assessments and outcomes. • Patients suffering from injuries and poisoning comprise 28% of the ED workload (an increase of 65% in the study period), whilst declines of 32% in cardiovascular and circulatory conditions, and musculoskeletal problems have been observed. • 25.6% of patients attending EDs are admitted to hospital. 19% of admitted patients and 7% of patients who die in the ED are triage category 4 or 5 on arrival. • The average age of ED patients is 35.6 years. Demand has grown in all age groups and amongst both men and women. Men have higher utilisation rates for ED in all age groups. The only group where the growth rate in women has exceeded men is in the 20-29 age group; this growth is particularly in the injury and poisoning categories. • Considerable attention has been paid publicly to ED performance criteria. It is worth noting that 50% of all patients were treated within 33 minutes of arrival. • Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people appears to exceed those of European and other backgrounds. The utilisation rates for immigrant people is generally less than that of Australian born however it has not been possible to eliminate the confounding impact of different age and socioeconomic profiles. • Demand for ambulance service is also increasing at a rate that exceeds population growth. Utilisation rates have increased by an average of 5% per annum in Queensland compared to 3.6% nationally, and the utilisation rate in Queensland is 27% higher than the national average. • The growth in ambulance utilisation has also been amongst the more urgent categories of dispatch and utilisation rates are higher in rural and regional areas than in the metropolitan area. The demand for ambulance increases with age but the growth in demand for ambulance service has been more prominent in younger age groups. These findings contribute significantly to an understanding of the growth in demand for emergency health. It shows that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that the congestion of emergency health services is due to inappropriate attendees is unable to be substantiated. The consistency of the growth in demand over the last decade reflects not only the changing demographics of the Australian population but also the changes in health status, standards of acute health care and other social factors. The growth is also amongst patients with acute injury and poisoning which is inconsistent with rates of chronic disease as a fundamental driver. We have also interviewed patients in regard to their decision making choices for acute health care and the factors that influence these decisions and this will be the subject of a third Monograph and publications.

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.

The impact of organisational culture in project selection process : case of public infrastructure project in Indonesia

The thesis develops an Organisational Culture (OC) based framework for potentially improving the current practice of the infrastructure project selection process (PSP) in Indonesia, particularly for regional road projects. This framework is developed to address the suggestion emanating from the research that there is a need for strengthening the relevant organisational culture dimensions and making changes to current organisational culture profiles to support the effectiveness of the decision-making process of the current PSP. The findings not only benefit existing knowledge but also provide practical contributions for those decision-makers within the Indonesian regional government that are involved in PSP, i.e. by raising the awareness of the influence and the role of organisational culture.

Poisoned GOOSE : exploiting the GOOSE protocol

This paper presents a vulnerability within the generic object oriented substation event (GOOSE) communication protocol. It describes an exploit of the vulnerability and proposes a number of attack variants. The attacks sends GOOSE frames containing higher status numbers to the receiving intelligent electronic device (IED). This prevents legitimate GOOSE frames from being processed and effectively causes a hijacking of the communication channel, which can be used to implement a denial–of–service (DoS) or manipulate the subscriber (unless a status number roll-over occurs). The authors refer to this attack as a poisoning of the subscriber. A number of GOOSE poisoning attacks are evaluated experimentally on a test bed and demonstrated to be successful.

Innovation & workplace culture in the Australian interactive entertainment industry : the Halfbrick story

A recent success story of the Australian videogames industry is Brisbane based Halfbrick Studios, developer of the hit game for mobile devices, Fruit Ninja. Halfbrick not only survived the global financial crisis and an associated downturn in the Australian industry, but grew strongly, moving rapidly from developing licensed properties for platforms such as Game Boy Advance, Nintendo DS, and Playstation Portable (PSP) to becoming an independent developer and publisher of in-house titles, generating revenue both through App downloads and merchandise sales. Amongst the reasons for Halfbrick’s success is their ability to adaptively transform by addressing different technical platforms, user dynamics, business models and market conditions. Our ongoing case-study research from 2010 into Halfbrick’s innovation processes, culminating with some 10 semi-structured interviews with senior managers and developers, has identified a strong focus on workplace organisational culture, with staff reflecting that the company is a flat, team-based organisation devolving as much control as possible to the development teams directly, and encouraging a work-life balance in which creativity can thrive. The success of this strategy is evidenced through Halfbrick’s low staff turnover; amongst our interviewees most of the developers had been with the company for a number of years, with all speaking positively of the workplace culture and sense of creative autonomy they enjoyed. Interviews with the CEO, Shainiel Deo, and team leaders highlighted the autonomy afforded to each team and the organisation and management of the projects on which they work. Deo and team leaders emphasised the collaboration and communication skills they require in the developers that they employ, and that these characteristics were considered just as significant in hiring decisions as technical skills. Halfbrick’s developers celebrate their workplace culture and insist it has contributed to their capacity for innovation and to their commercial success with titles such as Fruit Ninja. This model of organisational management is reflected in both Stark’s (2009) idea of heterarchy, and Neff’s (2012) concept of venture labour, and provides a different perspective on the industry than the traditional political economy critique of precarious labour exploited by gaming conglomerates. Nevertheless, throughout many of the interviews and in our informal discussions with Halfbrick developers there is also a sense that this rewarding culture is quite tenuous and precarious in the context of a rapidly changing and uncertain global videogames industry. Whether such a workplace culture represents the future of the games industry, or is merely a ‘Prague Spring’ before companies such as Halfbrick are swallowed by traditional players’ remains to be seen. However, as the process of rapid and uncertain transformation plays out across the videogames industry, it is important to pay attention to emerging modes of organisation and workplace culture, even whilst they remain at the margins of the industry. In this paper we investigate Halfbrick’s workplace culture and ask how sustainable is this kind of rewarding and creative workplace?

Catalytic role of pre-adsorbed CO in platinum-based catalysts : the reduction of SO 2 by CO on Pt l Au m (CO) n

Using density functional theory, we have investigated the catalytic properties of bimetallic complex catalysts PtlAum(CO)n (l + m = 2, n = 1–3) in the reduction of SO2 by CO. Due to the strong coupling between the C-2p and metal 5d orbitals, pre-adsorption of CO molecules on the PtlAum is found to be very effective in not only reducing the activation energy, but also preventing poisoning by sulfur. As result of the coupling, the metal 5d band is broadened and down-shifted, and charge is transferred from the CO molecules to the PtlAum. As SO2 is adsorbed on the catalyst, partial charge moves to the anti-σ bonding orbitals between S and O in SO2, weakening the S–O bond strength. This effect is enhanced by pre-adsorbing up to three CO molecules, therefore the S–O bonds become vulnerable. Our results revealed the mechanism of the excellent catalytic properties of the bimetallic complex catalysts.

Catalytic reduction of SO2 by CO over Pt l Au m (CO) n: a first-principles investigation

The catalytic activities, to the reduction of SO2 by CO, of clusters PtlAum (l + m = 2) with or without preadsorbing CO molecules are investigated using first-principles density functional theory. We find that the PtAu(CO)n (n = 1–3) clusters show more excellent catalytic properties than either pure metallic catalysts. Preadsorption of CO to the catalysts could effectively avoid platinum-based catalyst sulfur poisoning; as more CO molecules preadsorbed to the catalysts, the energy barriers for the carbonyl sulfide (COS) molecule’s desorption from the catalyst are remarkably decreased. We propose an ideal catalytic cycle to simultaneously get rid of SO2 and CO over the catalysts PtAu(CO)3.

The cytochrome P-450 isoenzyme CYP2E1 in the biological processing of industrial chemicals : consequences for occupational and environmental medicine

The importance of the isoform CYP2E1 of the human cytochrome P-450 superfamily of enzymes for occupational and environmental medicine is derived from its unique substrate spectrum that includes a number of highly important high-production chemicals, such as aliphatic and aromatic hydrocarbons, solvents and industrial monomers (i.a. alkanes, alkenes, aromatic and halogenated hydrocarbons). Many polymorphic genes, such as CYP2E1, show considerable differences in allelic distribution between different human populations. The polymorphic nature of the human CYP2E1 gene is significant for inter-individual differences in toxicity of its substrates. Since the substrate spectrum of CYP2E1 includes many compounds of basic relevance to industrial toxicology, a rationale for metabolic interactions of different CYP2E1 substrates is provided. In-depth research into the inter-individual phenotypic differences of human CYP2E1 enzyme activities was enabled by the recognition that the 6-hydroxylation of the drug chlorzoxazone is mediated by CYP2E1. Studies on CYP2E1 phenotyping have pointed to inter-individual variations in enzyme activities. There are consistent ethnic differences in CYP2E1 enzyme expression, mostly demonstrated between European and Japanese populations, which point to a major impact of genetic factors. The most frequently studied genetic polymorphisms are the restriction fragment length polymorphisms PstI/RsaI (mutant allele: CYP2E1*5B) located in the 5′-flanking region of the gene, as well as the DraI polymorphism (mutant allele: CYP2E1*6) located in intron 6. These polymorphisms are partly related, as they form the common allele designated CYP2E1*5A. Striking inter-ethnic differences between Europeans and Asians appear with respect to the frequencies of the CYP2E1*5A allele (only approximately 5% of Europeans are heterozygous, but 37% of Asians are, whilst 6% of Asians are homozygous). Available studies indicate a wide variation in human CYP2E1 expression, which are very likely based on complex gene-environment interactions. Major inter-ethnic differences are apparent on the genotyping and the phenotyping levels. Selected cases are presented where inter-ethnic variations of CYP2E1 may provide likely explanations for unexplained findings concerning industrial chemicals that are CYP2E1 substrates. Possible consequences of differential inter-individual and inter-ethnic susceptibilities are related to individual expressions of clinical symptoms of chemical toxicity, to results of biological monitoring of exposed workers, and to the interpretation of results of epidemiological or molecular-epidemiological studies.

Species differences in acrylonitrile metabolism and toxicity between experimental animals and humans based on observations in human accidental poisonings

The high acute toxicity of acrylonitrile may be a result of its intrinsic biological reactivity or of its metabolite cyanide. Intravenous N-acetylcysteine has been recommended for treatment of accidental intoxications in acrylonitrile workers, but such recommendations vary internationally. Acrylonitrile is metabolized in humans and experimental animals via two competing pathways; the glutathione-dependent pathway is considered to represent an avenue of detoxication whilst the oxidative pathway leads to a genotoxic epoxide, cyanoethylene oxide, and to elimination of cyanide. Cases of acute acrylonitrile overexposure or intoxication have occurred within persons having industrial contact with acrylonitrile; the route of exposure was by inhalation and/or by skin contact. The combined observations lead to the conclusion of a much higher impact of the oxidative metabolism of acrylonitrile in humans than in rodents. This is confirmed by differences in the clinical picture of acute life-threatening intoxications in both species, as well as by differential efficacies of antidotes. A combination of N-acetylcysteine with sodium thiosulfate seems an appropriate measure for antidote therapy of acute acrylonitrile intoxications. Clinical observations also highlight the practical importance of human individual susceptibility differences. Furthermore, differential adduct monitoring, assessing protein adducts with different rates of decay, enables the development of more elaborated biological monitoring strategies for the surveillance of workers with potential acrylonitrile contact.

Estimating the burden of disease attributable to lead exposure in South Africa in 2000

Objectives To estimate the burden of disease attributable to lead exposure in South Africa in 2000. Design World Health Organization comparative risk assessment (CRA) methodology was followed. Recent community studies were used to derive mean blood lead concentrations in adults and children in urban and rural areas. Population-attributable fractions were calculated and applied to revised burden of disease estimates for the relevant disease categories for South Africa in the year 2000. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis. Setting South Africa. Subjects Children under 5 and adults 30 years and older. Outcome measures Cardiovascular mortality and disability-adjusted life years (DALYs) in adults 30 years and older and mild mental disability DALYs in children under 5 years. Results Lead exposure was estimated to cause 1 428 deaths (95% uncertainty interval 1 086-1 772) or 0.27% (95% uncertainty interval: 0.21 - 0.34%) of all deaths in South Africa in 2000. Burden of disease attributed to lead exposure was dominated by mild mental disability in young children, accounting for 75% of the total 58 939 (95% uncertainty interval 55 413 - 62 500) attributable DALYs. Cardiovascular disease in adults accounted for the remainder of the burden. Conclusions Even with the phasing out of leaded petrol, exposure to lead from its ongoing addition to paint, paraoccupational exposure and its use in backyard 'cottage industries' will continue to be an important public health hazard in South Africa for decades. Young children, especially those from disadvantaged communities, remain particularly vulnerable to lead exposure and poisoning.

Testing and modifying a tool to measure nurses’ beliefs about aromatherapy

Aromatherapy has been found to have some effectiveness in treating conditions such as postoperative nausea and vomiting, however unless clinicians are aware of and convinced by this evidence, it is unlikely they will choose to use it with their patients. The aim of this study was to test and modify an existing tool, Martin and Furnham’s Beliefs About Aromatherapy Scale in order to make it relevant and meaningful for use with a population of nurses and midwives working in an acute hospital setting. A Delphi process was used to modify the tool and then it was tested in a population of nurses and midwives, then exploratory factor analysis was conducted. The modified tool is reliable and valid for measuring beliefs about aromatherapy in this population.

Mid-Holocene Aboriginal occupation of offshore islands in northern Australia? A reassessment of Wurdukanhan, Mornington Island, southern Gulf of Carpentaria, Australia

Claims for mid-Holocene Aboriginal occupation at the shell matrix site of Wurdukanhan, Mornington Island, Gulf of Carpentaria, Australia, are reassessed through an analysis of the excavated assemblage coupled with new surveys and an extensive dating program. Memmott et al. (2006, pp. 38, 39) reported basal ages of c.5000–5500 years from Wurdukanhan as 'the oldest date yet obtained for any archaeological site on the coast of the southern Gulf of Carpentaria' and used these dates to argue for 'a relatively lengthy occupation since at least the mid-Holocene'. If substantiated, with the exception of western Torres Strait, these claims make Mornington Island the only offshore island used across northern Australia in the mid-Holocene where it is conventionally thought that Aboriginal people only (re)colonised islands after sea-level maximum was achieved after the mid-Holocene. Our analysis of Wurdukanhan demonstrates high shellfish taxa diversity, high rates of natural shell predation and high densities of foraminifera throughout the deposit demonstrating a natural origin for the assemblage. Results are considered in the context of other dated shell matrix sites in the area and a geomorphological model for landscape development of the Sandalwood River catchment.

Genetic evidence for natural hybridization between Red Snow Crab (Chionoecetes japonicus) and Snow Crab (Chionoecetes opilio) in Korea

Both red snow crab (Chionoecetes japonicus Rathbun, 1932) and snow crab (Chionoecetes opilio Fabricius, 1788) are commercially important species in Korea. The geographical ranges of the two species overlap in the East Sea, where both species are fished commercially. Morphological identification of the two species and putative hybrids can be difficult because of their overlapping morphological characteristics. The presence of putative hybrids can affect the total allowable catch (TAC) of C. japonicus and C. opilio, and causes problems managing C. japonicus and C. opilio wild resources. To date, however, no natural hybridization has been reported between C. japonicus and C. opilio, despite their overlapping distributions along the coast of the East Sea. In this study, the internal transcribed spacer (ITS) region of major ribosomal RNA genes from the nuclear genome and the cytochrome oxidase I (CO I) gene from the mitochondrial genome were sequenced to determine whether natural hybridization occurs between the two species. Our results revealed that all putative hybrids identified using morphological traits had two distinct types of ITS sequences corresponding to those of both parental species. Mitochondrial CO I gene sequencing showed that all putative hybrids had sequences identical to C. japonicus. A genotyping assay based on single nucleotide polymorphisms in the ITS1 region and the CO I gene produced the most efficient and accurate identification of all hybrid individuals. Molecular data clearly demonstrate that natural hybridization does occur between C. japonicus and C. opilio, but only with C. japonicus as the maternal parent.

Molecular and functional characterizations of a Kunitz-type serine protease inhibitor FcKuSPI of the shrimp Fenneropenaeus chinensis

Serine proteinase inhibitors play important and diverse roles in biological processes such as coagulation, defense mechanisms, and immune responses. Here, we identified and characterized a Kunitz-type proteinase inhibitor, designated FcKuSPI, of the BPTI/Kunitz family of serine proteinase inhibitors from the hemocyte cDNA library of the shrimp Fenneropenaeus chinensis. The deduced amino acid sequence of FcKuSPI comprises 80 residues with a putative signal peptide of 15 amino acids. The predicted molecular weight of the mature peptide is 7.66 kDa and its predicted isoelectric point is 8.84. FcKuSPI includes a Kunitz domain containing six conserved cysteine residues that are predicted to form three disulfide bonds. FcKuSPI shares 44e53% homology with BPTI/Kunitz family members from other species. FcKuSPI mRNAwas expressed highly in the hemocytes and moderately in muscle in healthy shrimp. Recombinant FcKuSPI protein demonstrated anti-protease activity against trypsin and anticoagulant activity against citrated human plasma in a dose-dependent manner in in vitro assays.

Maternal pregravid body mass index and child hospital admissions in the first 5 years of life: results from an Australian birth cohort

Objectives: To examine the association of maternal pregravid body mass index (BMI) and child offspring, all-cause hospitalisations in the first 5 years of life. Methods: Prospective birth cohort study. From 2006 to 2011, 2779 pregnant women (2807 children) were enrolled in the Environments for Healthy Living: Griffith birth cohort study in South-East Queensland, Australia. Hospital delivery record and self-report baseline survey of maternal, household and demographic factors during pregnancy were linked to the Queensland Hospital Admitted Patients Data Collection from 1 November 2006 to 30 June 2012, for child admissions. Maternal pregravid BMI was classified as underweight (<18.5 kg m−2), normal weight (18.5–24.9 kg m−2), overweight (25.0–29.9 kg m−2) or obese (30 kg m−2). Main outcomes were the total number of child hospital admissions and ICD-10-AM diagnostic groupings in the first 5 years of life. Negative binomial regression models were calculated, adjusting for follow-up duration, demographic and health factors. The cohort comprised 8397.9 person years (PYs) follow-up. Results: Children of mothers who were classified as obese had an increased risk of all-cause hospital admissions in the first 5 years of life than the children of mothers with a normal BMI (adjusted rate ratio (RR) =1.48, 95% confidence interval 1.10–1.98). Conditions of the nervous system, infections, metabolic conditions, perinatal conditions, injuries and respiratory conditions were excessive, in both absolute and relative terms, for children of obese mothers, with RRs ranging from 1.3–4.0 (PYs adjusted). Children of mothers who were underweight were 1.8 times more likely to sustain an injury or poisoning than children of normal-weight mothers (PYs adjusted). Conclusion: Results suggest that if the intergenerational impact of maternal obesity (and similarly issues related to underweight) could be addressed, a significant reduction in child health care use, costs and public health burden would be likely.