Emergency department models of care in the context of care quality and cost: A systematic review

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Discovering future disaster management capability needs using scenario planning

In recent years disaster risk reduction efforts have focused on disturbances ranging from climate variability, seismic hazards, geo-political instability and public and animal health crises. These factors combined with uncertainty derived from inter-dependencies within and across systems of critical infrastructure create significant problems of governance for the private and public sector alike. The potential for rapid spread of impacts, geographically and virtually, can render a comprehensive understanding of disaster response and recovery needs and risk mitigation issues beyond the grasp of competent authority. Because of such cascading effects communities and governments at local and state-levels are unlikely to face single incidents but rather series of systemic impacts: often appearing concurrently. A further point to note is that both natural and technological hazards can act directly on socio-technical systems as well as being propagated by them: as network events. Such events have been categorised as ‘outside of the box,’ ‘too fast,’ and ‘too strange’ (Lagadec, 2004). Emergent complexities in linked systems can make disaster effects difficult to anticipate and recovery efforts difficult to plan for. Beyond the uncertainties of real world disasters, that might be called familiar or even regular, can we safely assume that the generic capability we use now will suit future disaster contexts? This paper presents initial scoping of research funded by the Bushfire and Natural Hazards Cooperative Research Centre seeking to define future capability needs of disaster management organisations. It explores challenges to anticipating the needs of representative agencies and groups active in before, during and after phases of emergency and disaster situations using capability deficit assessments and scenario assessment.

Variable phenotype in 16p duplication within a family

Background More individuals are now being identified with very rare genetic syndromes. We present a family with an inherited duplication of 16p11.2 to 16q12.1 in ring formation. Three of the four children, (aged 15 months to 10 years), mother, uncle, and grandmother are affected. Our aim was to provide preliminary evidence of possible phenotypic patterns of learning and behaviour associated with this chromosome anomaly. Method Psychometric assessments were undertaken with all four children. The mother and uncle also agreed to participate in the study. Measures of development (Bayley or Mullen), intellectual ability (WISC-IV or WAIS-III), academic achievement (WIAT-II), adaptive behaviour (Vinelands), and other relevant aspects of functioning (e.g., Children’s Memory Scale) were administered. Results. The first-born child is the only one who is unaffected. Her intellectual ability was assessed as being within the superior range. The second child experienced early difficulties with speech and motor skills. Although his intelligence is average, he has learning difficulties and significant auditory memory problems. The third child’s speech and motor milestones were markedly delayed. He has a complex medical history that includes a vitamin B12 deficiency. On the Mullen Scales at age 4 his scores ranged from average to very low. The development of the youngest child (aged 15 months), who also had a B12 deficiency but was treated early, was assessed as being within typical limits. Conclusions There is considerable developmental variability among the three children with this inherited 16p duplication. We discuss the intriguing similarities and differences, considering common features that may reflect phenotypic patterns and speculating about possible explanations for the variable presentations.

Geography and international assessment: Opportunity or distraction

Assessments of students in primary and secondary education are debated among practitioners, policy-makers, and parents. In some countries, assessment scores serve a criterion for passage between levels of education, for example, from secondary school to post-secondary education. Those practices are often traditions and while they come under criticism, they are a long-accepted part of the educational practices within a country. In those countries, the students’ assessment and examination scores are posted in public places or published in local news media. In other countries, assessments are used for the periodic checks on individual student progress. The results of assessments may be used for rating schools, and in some cases, they are used for evaluating the performance of teachers. Assessments are used less often to analyze student performance and make judgments regarding the performance of the curriculum. Even less often, assessments serve to critically establish strategies for the improvement of student learning and educational practices. The ends on the continuum of the assessment debate often focus on the opportunities that assessments present to improve education on one end. The other end is that assessments serve as a major distraction from the important work of teachers by removing classroom room time from instruction. The debate on those issues continues.

Prior and posterior linear pooling for combining expert opinions: Uses and impact on Bayesian Networks

The use of expert knowledge to quantify a Bayesian Network (BN) is necessary when data is not available. This however raises questions regarding how opinions from multiple experts can be used in a BN. Linear pooling is a popular method for combining probability assessments from multiple experts. In particular, Prior Linear Pooling (PrLP), which pools opinions then places them into the BN is a common method. This paper firstly proposes an alternative pooling method, Posterior Linear Pooling (PoLP). This method constructs a BN for each expert, then pools the resulting probabilities at the nodes of interest. Secondly, it investigates the advantages and disadvantages of using these pooling methods to combine the opinions of multiple experts. Finally, the methods are applied to an existing BN, the Wayfinding Bayesian Network Model, to investigate the behaviour of different groups of people and how these different methods may be able to capture such differences. The paper focusses on 6 nodes Human Factors, Environmental Factors, Wayfinding, Communication, Visual Elements of Communication and Navigation Pathway, and three subgroups Gender (female, male),Travel Experience (experienced, inexperienced), and Travel Purpose (business, personal) and finds that different behaviors can indeed be captured by the different methods.

Appendix 8: Quantifying the effects of environmental factors on catch rates in South-East fisheries: 1986-2006

The collection of basic environmental data by industry members was successful and offers a way of overcoming the problems associated with differences in scale between the environment and fisheries datasets. A simple method of collecting environmental data was developed that was only a small time burden on skippers, yet has the potential to provide very useful information on the same scale as the catch and effort data recorded in the logbooks. The success of this trial was aided by the natural interest of fishers to learn more about the environment in which they fish. The archival temperature-depth tags chosen proved robust, reliable and easy to use. While the use of large scale environmental data may not yield significant improvements in stock assessments for most SESSF species, fine-scale data collected from selected vessels using methods developed during this project may, in the longer term, be useful for incorporation into CPUE standardisations in the future...

Cortisol and dehydroepiandrosterone-sulphate levels correlate with symptom severity in first-episode psychosis

Dehydroepiandrosterone (DHEA) and its sulphate form (DHEA) are neuroactive steroids with antiglucocorticoid properties. An imbalance in the ratio of cortisol to DHEA(S) has been implicated in the pathophysiology of stress-related psychiatric disorders. This study prospectively investigated circulating cortisol, DHEAS and their ratio in first-episode psychosis (FEP) patients compared to healthy controls, and their relationship to perceived stress, psychotic, negative and mood symptoms. METHODS: Blood cortisol and DHEAS levels were obtained in 39 neuroleptic-naïve or minimally-treated FEP patients and 25 controls. Twenty-three patients and 15 controls received repeat assessments after 12 weeks. Perceived stress was assessed using the Perceived Stress Scale and symptoms were assessed in patients using standard rating scales. RESULTS: At baseline, no differences were observed in cortisol, DHEAS or the cortisol/DHEAS ratio between patients and controls. There were also no group differences in the change in these biological variables during the study period. Within FEP patients, decreases in cortisol and the cortisol/DHEAS ratio over time were directly related to the improvement in depression (r = 0.45; p = 0.031, r = 0.52; p = 0.01), negative (r = 0.51; p = 0.006, r = 0.55; p = 0.008) and psychotic symptoms (cortisol only, r = 0.53; p = 0.01). Perceived stress significantly correlated with DHEAS (r = 0.51; p = 0.019) and the cortisol/DHEAS ratio (r = -0.49; p = 0.024) in controls, but not patients, possibly reflecting an impaired hormonal response to stress in FEP patients. CONCLUSIONS: These findings further support the involvement of the stress system in the pathophysiology of psychotic disorders, with implications for treatment strategies that modulate these neurosteroids.

Measuring the regional availability of biomass for biofuels and the potential for microalgae

Biomass is an important energy resource for producing bioenergy and growing the global economy whilst minimising greenhouse gas emissions. Many countries, like Australia have a huge amount of biomass with the potential for bioenergy, but non-edible feedstock resources are significantly under-exploited. Hence it is essential to map the availability of these feedstocks to identify the most appropriate bioenergy solution for each region and develop supply chains for biorefineries. Using Australia as a case study,we present the spatial availability and opportunities for second and third generation feedstocks. Considerations included current land use, the presence of existing biomass industries and climatic conditions. Detailed information on the regional availability of biomass was collected from government statistics, technical reports and energy assessments as well as from academic literature. Second generation biofuels have the largest opportunity in New South Wales, Queensland and Victoria (NSW, QLD and VIC) and the regions with the highest potential for microalgae are Western Australia and Northern Territory (WA, NT), based on land use opportunity cost and climate. The approach can be used in other countries with a similar climate. More research is needed to overcome key technical and economic hurdles.

Indoor air: Contemporary sources, exposures and global implications

Recent 'Global Burden of Disease' studies have provided quantitative evidence of the significant role air pollution plays as a human health risk factor (Lim et al., The Lancet, 380: 2224–2260, 2012). Tobacco smoke, including second hand smoke, household air pollution from solid fuels and ambient particulate matter are among the top risks, leading to lower life expectancy around the world. Indoor air constitutes an environment particularly rich in different types of pollutants, originating from indoor sources, as well as penetrating from outdoors, mixing, interacting or growing (when considering microbes) under the protective enclosure of the building envelope. Therefore, it is not a simple task to follow the dynamics of the processes occurring there, or to quantify the outcomes of the processes in terms of pollutant concentrations and other characteristics. This is further complicated by limitations such as building access for the purpose of air quality monitoring, or the instrumentation which can be used indoors, because of their possible interference with the occupants comfort (due to their large size, noise generated or amount of air drawn). European studies apportioned contributions of indoor versus outdoor sources of indoor air contaminants in 26 European countries and quantified IAQ associated DALYs (Disability-Adjusted Life Years) in those countries (Jantunen et al., Promoting actions for healthy indoor air (IAIAQ), European Commission Directorate General for Health and Consumers, Luxembourg, 2011). At the same time, there has been an increase in research efforts around the world to better understand the sources, composition, dynamics and impacts of indoor air pollution. Particular focus has been directed towards the contemporary sources, novel pollutants and new detection methods. The importance of exposure assessment and personal exposure, the majority of which occurs in various indoor micro¬environments, has also been realized. Overall, this emerging knowledge has been providing input for global assessments of indoor environments, the impact of indoor pollutants and their science based management and control. It was a major outcome of recent international conferences that interdisciplinarity and especially a better colla¬boration between exposure and indoor sciences would be of high benefit for the health related evaluation of environmental stress factors and pollutants. A very good example is the combination of biomonitoring and indoor air, particle and dust analysis to study the exposure routes of semi volatile organic compounds (SVOCs). We have adopted the idea of combining the forces of exposure and indoor sciences for this Special Issue, identified new and challenging topics and have attracted colleagues who are top researchers in their field to provide their inputs. The Special Issue includes papers, which collectively present advances in current research topics and in our view, build the bridge between indoor and exposure sciences.

Randomized clinical trial of the timing it right stroke family support program: Research protocol

Background Family caregivers provide invaluable support to stroke survivors during their recovery, rehabilitation, and community re-integration. Unfortunately, it is not standard clinical practice to prepare and support caregivers in this role and, as a result, many experience stress and poor health that can compromise stroke survivor recovery and threaten the sustainability of keeping the stroke survivor at home. We developed the Timing it Right Stroke Family Support Program (TIRSFSP) to guide the timing of delivering specific types of education and support to meet caregivers' evolving needs. The objective of this multi-site randomized controlled trial is to determine if delivering the TIRSFSP across the stroke care continuum improves caregivers' sense of being supported and emotional well-being. Methods/design Our multi-site single-blinded randomized controlled trial will recruit 300 family caregivers of stroke survivors from urban and rural acute care hospitals. After completing a baseline assessment, participants will be randomly allocated to one of three groups: 1) TIRSFSP guided by a stroke support person (health care professional with stroke care experience), delivered in-person during acute care and by telephone for approximately the first six to 12 months post-stroke; 2) caregiver self-directed TIRSFSP with an initial introduction to the program by a stroke support person, or; 3) standard care receiving the educational resource "Let's Talk about Stroke" prepared by the Heart and Stroke Foundation. Participants will complete three follow-up quantitative assessments 3, 6, and 12-months post-stroke. These include assessments of depression, social support, psychological well-being, stroke knowledge, mastery (sense of control over life), caregiving assistance provided, caregiving impact on everyday life, and indicators of stroke severity and disability. Qualitative methods will also be used to obtain information about caregivers' experiences with the education and support received and the impact on caregivers' perception of being supported and emotional well-being. Discussion This research will determine if the TIRSFSP benefits family caregivers by improving their perception of being supported and emotional well-being. If proven effective, it could be recommended as a model of stroke family education and support that meets the Canadian Stroke Best Practice Guideline recommendation for providing timely education and support to families through transitions.

The YOU CALL-WE CALL randomized clinical trial: Impact of a multimodal support intervention after a mild stroke

Background Comparison of a multimodal intervention WE CALL (study initiated phone support/information provision) versus a passive intervention YOU CALL (participant can contact a resource person) in individuals with first mild stroke. Methods and Results This study is a single-blinded randomized clinical trial. Primary outcome includes unplanned use of health services (participant diaries) for adverse events and quality of life (Euroquol-5D, Quality of Life Index). Secondary outcomes include planned use of health services (diaries), mood (Beck Depression Inventory II), and participation (Assessment of Life Habits [LIFE-H]). Blind assessments were done at baseline, 6, and 12 months. A mixed model approach for statistical analysis on an intention-to-treat basis was used where the group factor was intervention type and occasion factor time, with a significance level of 0.01. We enrolled 186 patients (WE=92; YOU=94) with a mean age of 62.5±12.5 years, and 42.5% were women. No significant differences were seen between groups at 6 months for any outcomes with both groups improving from baseline on all measures (effect sizes ranged from 0.25 to 0.7). The only significant change for both groups from 6 months to 1 year (n=139) was in the social domains of the LIFE-H (increment in score, 0.4/9±1.3 [95% confidence interval, 0.1–0.7]; effect size, 0.3). Qualitatively, the WE CALL intervention was perceived as reassuring, increased insight, and problem solving while decreasing anxiety. Only 6 of 94 (6.4%) YOU CALL participants availed themselves of the intervention. Conclusions Although the 2 groups improved equally over time, WE CALL intervention was perceived as helpful, whereas YOU CALL intervention was not used.

Treatment of proximal interphalangeal joint flexion contracture: Combined static and dynamic orthotic intervention compared with other therapy intervention: randomized controlled trial

Purpose To test the effectiveness of static and dynamic orthoses using them as an exclusive treatment for proximal interphalangeal (PIP) joint flexion contracture compared with other hand therapy conservative treatments described in the literature. Methods 60 patients who used orthoses were compared with a control group that received other hand therapy treatments. Clinical assessments were measured before the experiment and 3 months after and included active PIP joint extension and function. Results A significant improvement in the extension active range of motion at the PIP joint in the second measurement was found in both groups, but it was significantly greater in the experimental group. Improvement in function (Disabilities of the Arm, Shoulder, and Hand score) between the first and second assessment was similar in the control and experimental groups. Conclusions Using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension, but the improvement did not correlate with increased function as perceived by the patient.

Development of a new ultrasound-based system for tracking motion of the human lumbar spine: Reliability, stability and repeatability during forward bending movement trials

The aim of this study was to develop a new method for quantifying intersegmental motion of the spine in an instrumented motion segment L4–L5 model using ultrasound image post-processing combined with an electromagnetic device. A prospective test–retest design was employed, combined with an evaluation of stability and within- and between-day intra-tester reliability during forward bending by 15 healthy male patients. The accuracy of the measurement system using the model was calculated to be ± 0.9° (standard deviation = 0.43) over a 40° range and ± 0.4 cm (standard deviation = 0.28) over 1.5 cm. The mean composite range of forward bending was 15.5 ± 2.04° during a single trial (standard error of the mean = 0.54, coefficient of variation = 4.18). Reliability (intra-class correlation coefficient = 2.1) was found to be excellent for both within-day measures (0.995–0.999) and between-day measures (0.996–0.999). Further work is necessary to explore the use of this approach in the evaluation of biomechanics, clinical assessments and interventions.

A kinematic analysis of the hand function

Background The evaluation of the hand function is an essential element within the clinical practice. The usual assessments are focus on the ability to perform activities of daily life. The inclusion of instruments to measure kinematic variables provides a new approach to the assessment. Inertial sensors adapted to the hand could be used as a complementary instrument to the traditional assessment. Material: clinimetric assessment (Upper Limb Functional Index, Quick Dash), antrophometric variables (eight and weight), dynamometry (palm preasure) was taken. Functional analysis was made with Acceleglove system for the right hand and computer system. The glove has six acceleration sensor, one on each finger and another one on the reverse palm. Method Analytic, transversal approach. Ten healthy subject made six task on evaluation table (tripod pinch, lateral pinch and tip pinch, extension grip, spherical grip and power grip). Each task was made and measure three times, the second one was analyze for the results section. A Matlab script was created for the analysis of each movement and detection phase based on module vector. Results The module acceleration vector offers useful information of the hand function. The data analysis obtained during the performance of functional gestures allows to identify five different phases within the movement, three static phase and tow dynamic, each module vector was allied to one task. Conclusion Module vector variables could be used for the analysis of the different task made by the hand. Inertial sensor could be use as a complement for the traditional assessment system.

SOTrain: A new program for training supervisors and operators in Australian sugar factories

The provision of effective training of supervisors and operators is essential if sugar factories are to operate profitably and in an environmentally sustainable and safe manner. The benefits of having supervisor and operator staff with a high level of operational skills are reduced stoppages, increased recovery, improved sugar quality, reduced damage to equipment, and reduced OH&S and environmental impacts. Training of new operators and supervisors in factories has traditionally relied on on-the-job training of the new or inexperienced staff by experienced supervisors and operators, supplemented by courses conducted by contractors such as Sugar Research Institute (SRI). However there is clearly a need for staff to be able to undertake training at any time, drawing on the content of online courses as required. An improved methodology for the training of factory supervisors and operators has been developed by QUT on behalf of a syndicate of mills. The new methodology provides ‘at factory’ learning via self-paced modules. Importantly, the training resources for each module are designed to support the training programs within sugar factories, thereby establishing a benchmark for training across the sugar industry. The modules include notes, training guides and session plans, guidelines for walkthrough tours of the stations, learning activities, resources such as videos, animations, job aids and competency assessments. The materials are available on the web for registered users in Australian Mills and many activities are best undertaken online. Apart from a few interactive online resources, the materials for each module can also be downloaded. The acronym SOTrain (Supervisor and Operator Training) has been applied to the new training program.