Risk of serious NSAID-related gastrointestinal events during long-term exposure: a systematic review

Objective: Exposure to non-steroidal anti-inflammatory drugs (NSAIDs) is associated wit increased risk of serious gastrointestinal (GI) events compared with non-exposure. We investigated whether that risk is sustained over time. Data sources: Cochrane Controlled Trials Register (to 2002); MEDLINE, EMBASE, Derwent Drug File and Current Contents (1999-2002); manual searching of reviews (1999-2002). Study selection: From 479 search results reviewed and 221 articles retrieved, seven studies of patients exposed to prescription non-selective NSAIDs for more than 6 months and reporting time-dependent serious GI event rates were selected for quantitative data synthesis. These were stratified into two groups by study design. Data extraction: Incidence of GI events and number of patients at specific time points were extracted. Data synthesis: Meta-regression analyses were performed. Change in risk was evaluated by testing whether the slope of the regression line declined over time. Four randomised controlled trials (RCTs) provided evaluable data from five NSAID arms (aspirin, naproxen, two ibuprofen arms, and diclofenac). When the RCT data were combined, a small significant decline in annualised risk was seen: -0.005% (95% Cl, -0.008% to -0.001%) per month. Sensitivity analyses were conducted because there was disparity within the RCT data. The pooled estimate from three cohort studies showed no significant decline in annualised risk over periods up to 2 years: -0.003% (95% Cl, -0.008% to 0.003%) per month. Conclusions: Small decreases in risk over time were observed; these were of negligible clinical importance. For patients who need long-term (> 6 months) treatment, precautionary measures should be considered to reduce the net probability of serious GI events over the anticipated treatment duration. The effect of intermittent versus regular daily therapy on long-term risk needs further investigation.

Using intervention time series analyses to assess the effects of imperfectly identifiable natural events: A general method and example

BACKGROUND: Intervention time series analysis (ITSA) is an important method for analysing the effect of sudden events on time series data. ITSA methods are quasi-experimental in nature and the validity of modelling with these methods depends upon assumptions about the timing of the intervention and the response of the process to it. METHOD: This paper describes how to apply ITSA to analyse the impact of unplanned events on time series when the timing of the event is not accurately known, and so the problems of ITSA methods are magnified by uncertainty in the point of onset of the unplanned intervention. RESULTS: The methods are illustrated using the example of the Australian Heroin Shortage of 2001, which provided an opportunity to study the health and social consequences of an abrupt change in heroin availability in an environment of widespread harm reduction measures. CONCLUSION: Application of these methods enables valuable insights about the consequences of unplanned and poorly identified interventions while minimising the risk of spurious results.

Investigation of dyslexia and SLI risk variants in reading- and language-impaired subjects

Dyslexia (or reading disability) and specific language impairment (or SLI) are common childhood disorders that show considerable co-morbidity and diagnostic overlaps and have been suggested to share some genetic aetiology. Recently, genetic risk variants have been identified for SLI and dyslexia enabling the direct evaluation of possible shared genetic influences between these disorders. In this study we investigate the role of variants in these genes (namely MRPL19/C20RF3, ROBO1, DCDC2, KIAA0319, DYX1C1, CNTNAP2, ATP2C2 and CMIP) in the aetiology of SLI and dyslexia. We perform case–control and quantitative association analyses using measures of oral and written language skills in samples of SLI and dyslexic families and cases. We replicate association between KIAA0319 and DCDC2 and dyslexia and provide evidence to support a role for KIAA0319 in oral language ability. In addition, we find association between reading-related measures and variants in CNTNAP2 and CMIP in the SLI families.

People, technology, processes and risk knowledge sharing

The present global economic crisis creates doubts about the good use of accumulated experience and knowledge in managing risk in financial services. Typically, risk management practice does not use knowledge management (KM) to improve and to develop new answers to the threats. A key reason is that it is not clear how to break down the “organizational silos” view of risk management (RM) that is commonly taken. As a result, there has been relatively little work on finding the relationships between RM and KM. We have been doing research for the last couple of years on the identification of relationships between these two disciplines. At ECKM 2007 we presented a general review of the literature(s) and some hypotheses for starting research on KM and its relationship to the perceived value of enterprise risk management. This article presents findings based on our preliminary analyses, concentrating on those factors affecting the perceived quality of risk knowledge sharing. These come from a questionnaire survey of RM employees in organisations in the financial services sector, which yielded 121 responses. We have included five explanatory variables for the perceived quality of risk knowledge sharing. These comprised two variables relating to people (organizational capacity for work coordination and perceived quality of communication among groups), one relating to process (perceived quality of risk control) and two related to technology (web channel functionality and RM information system functionality). Our findings so far are that four of these five variables have a significant positive association with the perceived quality of risk knowledge sharing: contrary to expectations, web channel functionality did not have a significant association. Indeed, in some of our exploratory regression studies its coefficient (although not significant) was negative. In stepwise regression, the variable organizational capacity for work coordination accounted for by far the largest part of the variation in the dependent variable perceived quality of risk knowledge sharing. The “people” variables thus appear to have the greatest influence on the perceived quality of risk knowledge sharing, even in a sector that relies heavily on technology and on quantitative approaches to decision making. We have also found similar results with the dependent variable perceived value of Enterprise Risk Management (ERM) implementation.

Establishing a framework for dynamic risk management in 'intelligent' aero-engine control

The behaviour of control functions in safety critical software systems is typically bounded to prevent the occurrence of known system level hazards. These bounds are typically derived through safety analyses and can be implemented through the use of necessary design features. However, the unpredictability of real world problems can result in changes in the operating context that may invalidate the behavioural bounds themselves, for example, unexpected hazardous operating contexts as a result of failures or degradation. For highly complex problems it may be infeasible to determine the precise desired behavioural bounds of a function that addresses or minimises risk for hazardous operation cases prior to deployment. This paper presents an overview of the safety challenges associated with such a problem and how such problems might be addressed. A self-management framework is proposed that performs on-line risk management. The features of the framework are shown in context of employing intelligent adaptive controllers operating within complex and highly dynamic problem domains such as Gas-Turbine Aero Engine control. Safety assurance arguments enabled by the framework necessary for certification are also outlined.

Bottom-up risk regulation? How nanotechnology risk knowledge gaps challenge federal and state environmental agencies

Nanotechnologies have been called the "Next Industrial Revolution." At the same time, scientists are raising concerns about the potential health and environmental risks related to the nano-sized materials used in nanotechnologies. Analyses suggest that current U.S. federal regulatory structures are not likely to adequately address these risks in a proactive manner. Given these trends, the premise of this paper is that state and local-level agencies will likely deal with many "end-of-pipe" issues as nanomaterials enter environmental media without prior toxicity testing, federal standards, or emissions controls. In this paper we (1) briefly describe potential environmental risks and benefits related to emerging nanotechnologies; (2) outline the capacities of the Toxic Substances Control Act, the Clean Air Act, the Clean Water Act, and the Resources Conservation and Recovery Act to address potential nanotechnology risks, and how risk data gaps challenge these regulations; (3) outline some of the key data gaps that challenge state-level regulatory capacities to address nanotechnologies' potential risks, using Wisconsin as a case study; and (4) discuss advantages and disadvantages of state versus federal approaches to nanotechnology risk regulation. In summary, we suggest some ways government agencies can be better prepared to address nanotechnology risk knowledge gaps and risk management.

Comparative risk of microalbuminuria and proteinuria in UK residents of south Asian and white European ethnic background with type 2 diabetes:a report from UKADS

Objective - This study investigated and compared the prevalence of microalbuminuria and overt proteinuria and their determinants in a cohort of UK resident patients of white European or south Asian ethnicity with type 2 diabetes mellitus. Research design and methods - A total of 1978 patients, comprising 1486 of south Asian and 492 of white European ethnicity, in 25 general practices in Coventry and Birmingham inner city areas in England were studied in a cross-sectional study. Demographic and risk factor data were collected and presence of microalbuminuria and overt proteinuria assessed. Main outcome measures - Prevalences of microalbuminuria and overt proteinuria. Results - Urinary albumin:creatinine measurements were available for 1852 (94%) patients. The south Asian group had a lower prevalence of microalbuminuria, 19% vs. 23% and a higher prevalence of overt proteinuria, 8% vs. 3%, X2?=?15.85, 2df, P?=?0.0004. In multiple logistic regression models, adjusted for confounding factors, significantly increased risk for the south Asian vs. white European patients for overt proteinuria was shown; OR (95% CI) 2.17 (1.05, 4.49), P?=?0.0365. For microalbuminuria, an interaction effect for ethnicity and duration of diabetes suggested that risk for south Asian patients was lower in early years following diagnosis; OR for SA vs. WH at durations 0 and 1 year were 0.56 (0.37, 0.86) and 0.59 (0.39, 0.89) respectively. After 20 years’ duration, OR?=?1.40 (0.63, 3.08). Limitations - Comparability of ethnicity defined groups; statistical methods controlled for differences between groups, but residual confounding may remain. Analyses are based on a single measure of albumin:creatinine ratio. Conclusions - There were significant differences between ethnicity groups in risk factor profiles and microalbuminuria and overt proteinuria outcomes. Whilst south Asian patients had no excess risk of microalbuminuria, the risk of overt proteinuria was elevated significantly, which might be explained by faster progression of renal dysfunction in patients of south Asian ethnicity.

Reducing the risk of sexually transmitted infections in genitourinary medicine clinic patients:A systematic review and meta-analysis of behavioural interventions

Objectives: Are behavioural interventions effective in reducing the rate of sexually transmitted infections (STIs) among genitourinary medicine (GUM) clinic patients? Design: Systematic review and meta-analysis of published articles. Data sources: Medline, CINAHL, Embase, PsychINFO, Applied Social Sciences Index and Abstracts, Cochrane Library Controlled Clinical Trials Register, National Research Register (1966 to January 2004). Review methods: Randomised controlled trials of behavioural interventions in sexual health clinic patients were included if they reported change to STI rates or self reported sexual behaviour. Trial quality was assessed using the Jadad score and results pooled using random effects meta-analyses where outcomes were consistent across studies. Results: 14 trials were included; 12 based in the United States. Experimental interventions were heterogeneous and most control interventions were more structured than typical UK care. Eight trials reported data on laboratory confirmed infections, of which four observed a greater reduction in their intervention groups (in two cases this result was statistically significant, p<0.05). Seven trials reported consistent condom use, of which six observed a greater increase among their intervention subjects. Results for other measures of sexual behaviour were inconsistent. Success in reducing STIs was related to trial quality, use of social cognition models, and formative research in the target population. However, effectiveness was not related to intervention format or length. Conclusions: While results were heterogeneous, several trials observed reductions in STI rates. The most effective interventions were developed through extensive formative research. These findings should encourage further research in the United Kingdom where new approaches to preventing STIs are urgently required.

A comparison of the local authority adoption of risk management in England and Australia

This paper analyses the context and use of risk management in local authorities in England and Australia. The basic structures of risk management were found to be common across all four local authorities in both countries. However, substantial differences were found in the national context in which risk management was used. The national context in each country was compared, and a large and small local authority in each country was used for illustrative purposes. The research findings were tested against institutional, contingency, resource dependence, and political perspectives. The research finding is that each theory was necessary but not sufficient and a pluralist approach was formulated to explain the similarities and differences in risk management in local authorities across two countries.

The core executive's approach to regulation:from 'better regulation' to 'risk-tolerant deregulation'

This article examines changes in the New Labour core executive’s approach to regulation and its relationship with risk, through analysing documentary, legislative and press sources concerning approaches to regulatory decision-making. It claims that an initial commitment to ‘better regulation’ has gradually been replaced by explicit support for deregulation. A reduction in the scope of regulation was also promoted by the Thatcher and Major governments. The New Labour core executive shares previous (Conservative) administrations’ concern to include business in deregulatory decision-making. However, the article claims that there is one significant difference in the New Labour deregulatory approach: a new toleration of risk. Deregulation is, now, described as a corrective to regulators’ over-reactions to perceived risks, which, it is claimed, are holding back economic and technological progress. However, this new approach excludes competing views concerning how risk should be regulated. In particular, it does not engage with widespread popular views that governments should continue to protect against risk.

The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt

BACKGROUND: Suicide prevention can be improved by knowing which variables physicians take into account when considering hospitalization or discharge of patients who have attempted suicide. AIMS: To test whether suicide risk is an adequate explanatory variable for predicting admission to a psychiatric unit after a suicide attempt. METHODS: Analyses of 840 clinical records of patients who had attempted suicide (66.3% women) at four public general hospitals in Madrid (Spain). RESULTS: 180 (21.4%) patients were admitted to psychiatric units. Logistic regression analyses showed that explanatory variables predicting admission were: male gender; previous psychiatric hospitalization; psychiatric disorder; not having a substance-related disorder; use of a lethal method; delay until discovery of more than one hour; previous attempts; suicidal ideation; high suicidal planning; and lack of verbalization of adequate criticism of the attempt. CONCLUSIONS: Suicide risk appears to be an adequate explanatory variable for predicting the decision to admit a patient to a psychiatric ward after a suicide attempt, although the introduction of other variables improves the model. These results provide additional information regarding factors involved in everyday medical practice in emergency settings.

Increased risk of diabetes mellitus among persons with psychotic symptoms:results from the WHO World Health Survey

OBJECTIVE: To analyze with a symptom-based approach the relationship between psychosis and diabetes mellitus in the general population. METHOD: Nationally representative samples from the World Health Organization (WHO) World Health Survey, totaling 224,743 randomly selected adults 18 years and older from 52 countries worldwide, were interviewed to establish the presence of psychotic symptoms and diabetes mellitus. Presence of psychotic symptoms was established using questions pertaining to positive symptoms from the psychosis screening module of the Composite International Diagnostic Interview. Presence of diabetes was established with a response of "yes" to the question, "Have you ever been diagnosed with diabetes (high blood sugar)?" The World Health Survey was conducted between 2002 and 2004. RESULTS: An increasing number of psychotic symptoms was related to increasing likelihood of diabetes mellitus (OR = 1.27; 95% CI, 1.24-1.30). As compared to no symptoms, at least 1 psychotic symptom substantially elevated the risk (OR = 1.71; 95% CI, 1.61-1.81). In people with a lifetime diagnosis of schizophrenia or psychosis, the prevalence of diabetes was higher in those with current psychotic symptoms (7.3% vs 5.2%; OR = 1.65; 95% CI, 1.21-2.26), suggesting that the persistence of symptoms over time could play a central role. After controlling for different potential confounders, there was a clear increase in the probability of having diabetes as the number of psychotic symptoms increased. The relationship between psychotic symptoms and diabetes was tested with multiple mediation models and path analyses for categorical outcomes. Only body mass index appeared as a relevant mediator in a model with a good fit (ie, χ21 = 3.2, P = .0742; comparative fit index = 0.999). CONCLUSIONS: Psychotic symptoms are related to increased rates of diabetes mellitus in nonclinical samples, independent of several potential confounders-including a clinical diagnosis of psychosis or schizophrenia, previous antipsychotic treatment, depression, lifestyle, and individual or country socioeconomic status. The findings highlight the worldwide relevance of the problem and the importance of identifying the specific paths of this association.

Biztosítók kockázatdiverzifikációja (Risk diversification of insurers)

A biztosítók működését általában több homogén részállományból összetevődő heterogén biztosítási állomány jellemzi. A részállományok alkotta biztosítási portfólió esetében a kockázatdiverzifikáció vizsgálható a teljes állományra, illetve a részállományokra összesített kockázatok különbségeként, és elemezhető a kockázat és hozam kapcsolata alapján is. A biztosítók működésének főbb sajátosságait tartalmazó modellben azt mutatjuk meg, hogy a biztosítási portfólió esetében tapasztalható kockázatdiverzifikációs hatások milyen mértékben hasonlítanak a klasszikusnak számító, befektetésekkel foglalkozó Markowitz-féle portfólióelmélet által leírtakra. Modellünk alapján megállapítható: számos hasonlóságon túl a biztosító működési sajátosságai következtében a hatékony biztosítási portfóliók, illetve az optimális befektetési arányok meghatározása egyedi tulajdonságokkal jellemezhető. / === / Insurance is generally characterized by a heterogeneous insurance population made up of several (homogeneous) sub-populations. Risk diversification in the "insurance portfolio" containing these sub-populations can appear as a difference between the risk of the total population and the sum of the risks of the separate sub-populations, and it can also be analysed based on the relation of risk and return. Examining these aspects of risk diversification with a model covering the main features of insurance activity, the study analyses how far the risk diversification effects of the insurance portfolio resemble the results of classical Markowitz portfolio theory. Based on the results from the study's theoretical model, it appears that alongside several similarities, there are some individual features in the determination of "efficient insurance portfolios" and optimal investment weights.

Környezeti kockázatok felmérése. Paraméterek bizonytalanságának hatása a kockázatkezelési döntéshozatalra = Assessment of environmental risks – effects of parameter uncertainty to the risk management decisions

A környezeti kockázatok megfelelő felmérése és kezelése napjaink egyik legfontosabb kérdése, nemcsak a szakmai, hanem a széles értelemben vett közvélemény számára. A szerző cikkében azt vizsgálja, hogy a környezeti kockázatok felmérésének milyen megközelítései vannak. Kulcskérdésként pedig arra koncentrál, hogy a kockázatkezelési döntéseket hogyan befolyásolja a becslések bizonytalansága. Először a környezeti kockázat definícióját adja meg, majd azt mutatja be, hogy a környezeti kockázatok kezelésére vonatkozó megközelítések milyen párhuzamban állnak a pénzügyi rendszerrel, mint komplex rendszerre vonatkozó megközelítésekkel. Végül a jelenleg legnagyobb kockázatoknak tartott környezeti kockázatokat ismerteti röviden. A cikk második részében kockázatkezelési alternatívákat mutat be, és azt, hogy a kockázatkezelési lépések kiválasztását befolyásolja a bizonytalanság. Ezt illusztrálandó Brouwer-Blois (2008) modelljét használva a soklépéses szimulációt és alternatív döntési kritériumot – a kritikus (extrém) költség-hatás mutatót – alkalmazza. _____________ Adequate assessment and management of environmental risks is a key question nowadays also for professional experts and also for the overall public. In this article the author examines the different approaches concerning environmental risks. He concentrates as a key question the influence on risk management decisions of uncertainties raised by our estimations. First he analyses the definition of environmental risks, and he shows the similarities and differences between approaches concerning environmental risks and risks threatening financial system, and finally he gives short overview on the most current environmental risks. In the second part of the paper he presents risk management alternatives and analyses the influential power of uncertainty on risk management decisions. In order to illustrate this phenomenon the author applies the model of Brouwer-Blois (2008) with multistep simulation and an alternative decisive criterion, the ranking based on critical (extreme) cost to effect measure.

Biztosítási és pénzügyi kockázat együttes hatása a biztosítók szolvencia-számításánál (Common effect of insurance and financial risk in the solvency calculation of insurers)

A Szolvencia II néven említett új irányelv elfogadása az Európai Unióban új helyzetet teremt a biztosítók tőkeszükséglet-számításánál. A tanulmány a biztosítók működését modellezve azt elemzi, hogyan hatnak a biztosítók állományának egyes jellemzői a tőkeszükséglet értékére egy olyan elméleti modellben, amelyben a tőkeszükséglet-értékek a Szolvencia II szabályok alapján számolhatók. A modellben biztosítási illetve pénzügyi kockázati "modul" figyelembevételére kerül sor külön-külön számolással, illetve a két kockázatfajta közös modellben való együttes figyelembevételével (a Szolvencia II eredményekkel való összehasonlításhoz). Az elméleti eredmények alapján megállapítható, hogy a tőkeszükségletre vonatkozóan számolható értékek eltérhetnek e két esetben. Az eredmények alapján lehetőség van az eltérések hátterében álló tényezők tanulmányozására is. ____ The new Solvency II directive results in a new environment for calculating the solvency capital requirement of insurance companies in the European Union. By modelling insurance companies the study analyses the impact of certain characteristics of insurance population on the solvency capital based on Solvency II rules. The model includes insurance and financial risk module by calculating solvency capital for the given risk types separately and together, respectively. Based on the theoretical results the difference between these two approaches can be observed. Based on the results the analysis of factors in°uencing the differences is also possible.