A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods: This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results: Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion: The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

The impact of heat waves on children's health : a systematic review

Young children are thought to be particularly sensitive to heatwaves, but relatively less research attention has been paid to this field to date. A systematic review was conducted to elucidate the relationship between heat waves and children’s health. Literature published up to August 2012 were identified using the following MeSH terms and keywords: “heatwave”, “heat wave”, “child health”, “morbidity”, “hospital admission”, “emergency department visit”, “family practice”, “primary health care”, “death” and “mortality”. Of the 628 publications identified, 12 met the selection criteria. The existing literature does not consistently suggest that mortality among children increases significantly during heat waves, even though infants were associated with more heat-related deaths. Exposure to heat waves in the perinatal period may pose a threat to children’s health. Pediatric diseases or conditions associated with heat waves include renal disease, respiratory disease, electrolyte imbalance and fever. Future research should focus on how to develop a consistent definition of a heat wave from a children’s health perspective, identifying the best measure of children’s exposure to heat waves, exploring sensitive outcome measures to quantify the impact of heat waves on children, evaluating the possible impacts of heat waves on children’s birth outcomes, and understanding the differences in vulnerability to heat waves among children of different ages and from different income countries. Projection of the children’s disease burden caused by heat waves under climate change scenarios, and development of effective heat wave mitigation and adaptation strategies that incorporate other child protective health measures, are also strongly recommended.

The impact of heatwaves on emergency department visits in Brisbane, Australia : a time series study

Introduction The acute health effects of heatwaves in a subtropical climate and their impact on emergency departments (ED) are not well known. The purpose of this study is to examine overt heat-related presentations to EDs associated with heatwaves in Brisbane. Methods Data were obtained for the summer seasons (December to February) from 2000-2012. Heatwave events were defined as two or more successive days with daily maximum temperature >=34[degree sign]C (HWD1) or >=37[degree sign]C (HWD2). Poisson generalised additive model was used to assess the effect of heatwaves on heat-related visits (International Classification of Diseases (ICD) 10 codes T67 and X30; ICD 9 codes 992 and E900.0). Results Overall, 628 cases presented for heat-related illnesses. The presentations significantly increased on heatwave days based on HWD1 (relative risk (RR) = 4.9, 95% confidence interval (CI): 3.8, 6.3) and HWD2 (RR = 18.5, 95% CI: 12.0, 28.4). The RRs in different age groups ranged between 3-9.2 (HWD1) and 7.5-37.5 (HWD2). High acuity visits significantly increased based on HWD1 (RR = 4.7, 95% CI: 2.3, 9.6) and HWD2 (RR = 81.7, 95% CI: 21.5, 310.0). Average length of stay in ED significantly increased by >1 hour (HWD1) and >2 hours (HWD2). Conclusions Heatwaves significantly increase ED visits and workload even in a subtropical climate. The degree of impact is directly related to the extent of temperature increases and varies by socio-demographic characteristics of the patients. Heatwave action plans should be tailored according to the population needs and level of vulnerability. EDs should have plans to increase their surge capacity during heatwaves.

Setting water quality objectives for the health of freshwater fish

An important responsibility of the Environment Protection Authority, Victoria, is to set objectives for levels of environmental contaminants. To support the development of environmental objectives for water quality, a need has been identified to understand the dual impacts of concentration and duration of a contaminant on biota in freshwater streams. For suspended solids contamination, information reported by Newcombe and Jensen [ North American Journal of Fisheries Management , 16(4):693--727, 1996] study of freshwater fish and the daily suspended solids data from the United States Geological Survey stream monitoring network is utilised. The study group was requested to examine both the utility of the Newcombe and Jensen and the USA data, as well as the formulation of a procedure for use by the Environment Protection Authority Victoria that takes concentration and duration of harmful episodes into account when assessing water quality. The extent to which the impact of a toxic event on fish health could be modelled deterministically was also considered. It was found that concentration and exposure duration were the main compounding factors on the severity of effects of suspended solids on freshwater fish. A protocol for assessing the cumulative effect on fish health and a simple deterministic model, based on the biology of gill harm and recovery, was proposed. References D. W. T. Au, C. A. Pollino, R. S. S Wu, P. K. S. Shin, S. T. F. Lau, and J. Y. M. Tang. Chronic effects of suspended solids on gill structure, osmoregulation, growth, and triiodothyronine in juvenile green grouper epinephelus coioides . Marine Ecology Press Series , 266:255--264, 2004. J.C. Bezdek, S.K. Chuah, and D. Leep. Generalized k-nearest neighbor rules. Fuzzy Sets and Systems , 18:237--26, 1986. E. T. Champagne, K. L. Bett-Garber, A. M. McClung, and C. Bergman. {Sensory characteristics of diverse rice cultivars as influenced by genetic and environmental factors}. Cereal Chem. , {81}:{237--243}, {2004}. S. G. Cheung and P. K. S. Shin. Size effects of suspended particles on gill damage in green-lipped mussel perna viridis. Marine Pollution Bulletin , 51(8--12):801--810, 2005. D. H. Evans. The fish gill: site of action and model for toxic effects of environmental pollutants. Environmental Health Perspectives , 71:44--58, 1987. G. C. Grigg. The failure of oxygen transport in a fish at low levels of ambient oxygen. Comp. Biochem. Physiol. , 29:1253--1257, 1969. G. Holmes, A. Donkin, and I.H. Witten. {Weka: A machine learning workbench}. In Proceedings of the Second Australia and New Zealand Conference on Intelligent Information Systems , volume {24}, pages {357--361}, {Brisbane, Australia}, {1994}. {IEEE Computer Society}. D. D. Macdonald and C. P. Newcombe. Utility of the stress index for predicting suspended sediment effects: response to comments. North American Journal of Fisheries Management , 13:873--876, 1993. C. P. Newcombe. Suspended sediment in aquatic ecosystems: ill effects as a function of concentration and duration of exposure. Technical report, British Columbia Ministry of Environment, Lands and Parks, Habitat Protection branch, Victoria, 1994. C. P. Newcombe and J. O. T. Jensen. Channel suspended sediment and fisheries: A synthesis for quantitative assessment of risk and impact. North American Journal of Fisheries Management , 16(4):693--727, 1996. C. P. Newcombe and D. D. Macdonald. Effects of suspended sediments on aquatic ecosystems. North American Journal of Fisheries Management , 11(1):72--82, 1991. K. Schmidt-Nielsen. Scaling. Why is animal size so important? Cambridge University Press, NY, 1984. J. S. Schwartz, A. Simon, and L. Klimetz. Use of fish functional traits to associate in-stream suspended sediment transport metrics with biological impairment. Environmental Monitoring and Assessment , 179(1--4):347--369, 2011. E. Al Shaw and J. S. Richardson. Direct and indirect effects of sediment pulse duration on stream invertebrate assemb ages and rainbow trout ( Oncorhynchus mykiss ) growth and survival. Canadian Journal of Fish and Aquatic Science , 58:2213--2221, 2001. P. Tiwari and H. Hasegawa. {Demand for housing in Tokyo: A discrete choice analysis}. Regional Studies , {38}:{27--42}, {2004}. Y. Tramblay, A. Saint-Hilaire, T. B. M. J. Ouarda, F. Moatar, and B Hecht. Estimation of local extreme suspended sediment concentrations in california rivers. Science of the Total Environment , 408:4221--

The global public health issue of pharmaceutical waste : what role for pharmacists?

Purpose Pharmaceuticals have played an important role in improving the quality of life of the human population in modern times. However, it must also be acknowledged that both the production and use of pharmaceuticals have a significant, negative impact on the environment and consequently, a negative impact on the health of humans and wildlife. This negative impact is due to the embedded carbon in pharmaceuticals' manufacture and distribution and the waste generated in their manufacture, consumption and disposal. Pharmaceutical waste is comprised of contaminated waste (unwanted pharmaceuticals and their original containers) and non-contaminated waste (non-hazardous packaging waste). The paper aims to discuss these issues. Design/methodology/approach The article is a literature review. Findings The article identified a gap in the literature around pharmacist attitudes and behaviour toward the environmentally responsible handling of pharmaceutical waste. Originality/value Pharmacists, with their professional commitment to the quality use of medicines and their active participation in the medicines management pathway, already play an important role in the more sustainable use of pharmaceuticals. Even so, they have the potential to play an even greater role with the environmentally responsible disposal of pharmaceutical waste (including packaging waste) and the education of other health professionals and the general public on this topic.

Physical inactivity remains the greatest public health problem of the 21st century : evidence, improved methods and solutions using the '7 investments that work' as a framework

In 2009, BJSM's first editorial argued that ‘Physical inactivity is the greatest public health problem of the 21st century’.1 The data supporting that claim have not yet been challenged. Now, 5 years after BJSM published its first dedicated ‘Physical Activity is Medicine’ theme issue (http://bjsm.bmj.com/content/43/1.toc) we are pleased to highlight 23 new contributions from six countries. This issue contains an analysis of the cost of physical inactivity from the US Centre for Diseases Control.2 We also report the cost-effectiveness of one particular physical activity intervention for adults.3

School physical education in the post-report era : an analysis from public health

The 1996 United States Surgeon General’s report on physical activity and health represents a watershed moment in the modern history of physical activity and public health. Based on a compelling body of scientific evidence from the fields of medicine, epidemiology, physiology, and health psychology, the Surgeon General’s report proclaimed that people of all ages could improve their health and quality of life through lifelong practice of moderate physical activity (United States Department of Health and Human Services [USDHHS], 1996). Physical Activity and Health: A Report of the Surgeon General was an especially important publication for school physical education. Not only did the report acknowledge the importance of regular physical activity during childhood and adolescence, it also identified school physical education as an important vehicle for promoting healthenhancing physical activity in young people. “With evidence that success in this arena is possible, every effort should be made to encourage schools to require daily physical education in each grade and to promote physical activities that can be enjoyed throughout life” (USDHHS, 1996, p. 6). The purpose of this article is to discuss the status of school physical education since the release of the Surgeon General’s report on physical activity and health nearly a decade ago. Specifically, the article will address four questions: 1) What has been the historical role of physical education in physical activity and public health? 2) What impact, if any, has the Surgeon General’s report has had on physical education programs? 3) What impact should physical education have on public health and physical activity? 4) What should teacher education programs in physical education do to prepare physical education teachers, given the current role of physical education?

Exploring the impact of shared domain knowledge on strategic alignment in the Australian public sector

In this age of ever-increasing information technology (IT) driven environments, governments/or public sector organisations (PSOs) are expected to demonstrate the business value of the investment in IT and take advantage of the opportunities offered by technological advancements. Strategic alignment (SA) emerged as a mechanism to bridge the gap between business and IT missions, objectives, and plans in order to ensure value optimisation from investment in IT and enhance organisational performance. However, achieving and sustaining SA remains a challenge requiring even more agility nowadays to keep up with turbulent organisational environments. The shared domain knowledge (SDK) between the IT department and other diverse organisational groups is considered as one of the factors influencing the successful implementation of SA. However, SDK in PSOs has received relatively little empirical attention. This paper presents findings from a study which investigated the influence of SDK on SA within organisations in the Australian public sector. The developed research model examined the relationship of SDK between business and IT domains with SA using a survey of 56 public sector professionals and executives. A key research contribution is the empirical demonstration that increasing levels of SDK between IT and business groups leads to increased SA.

Development of a new regulatory model for occupational health and safety in the New South Wales coal industry: an issues paper for the New South Wales Department of Mineral Resources

This paper addresses the regulatory issues arising in developing a new regulatory model for the New South Wales Coal Industry. As such, it identifies the relevant literature on this subject, the options available for reform, and the experience of Australian and key international bodies responsible for the development of regulatory standards in this area. In particular it: Identifies the main shortcomings in the existing regulatory approach; Identifies the potential roles/main strengths and weaknesses of different types of standards (eg specification, performance, process and systems-based rules) and potential “best practice’ combinations of standards; Examines the appropriateness of the current regulatory regime whereby the general OHS legislation (including the general duty provisions) applies to mining in addition to the large body of regulation which is specific to mining; Identifies the importance of, and possible means of addressing, issues of worker participation within the coal mining industry; Draws on the literature on what motivates companies and individuals for the purpose of recommending key provisions for inclusion in new legislation to provide appropriate personal and organisational incentives; Draws on the literature on major hazards facilities to suggest the appropriate roles for OHS management systems and safety reports or comparable approaches (eg mine safety management plans); Draws on the United Kingdom (UK) and United States of America (USA) experience of coal mine safety and its regulation for comparative purposes, and for insights as to what sort of regulation most effectively reduces work related injury and disease in coal mining; Examines the relevant roles of International Labour Organisation (ILO) Conventions; Examines the extent to which different regulatory regimes would be appropriate to open cut and underground coal mining; and Examines options for reform. This paper is focussed specifically on the issues identified above.

The unequal distribution of road trauma in China : understanding risk factors to improve public health

The World Health Organization identifies road trauma as a major public health issue in every country; most notably among low-to-middle income countries. More than 90% of all road fatalities occur in these countries, although they have only 48% of all registered vehicles [1]. Unprecedented focus has been placed on reducing the global road trauma burden through the United Nations Decade of Action for Road Safety (2011-2020). China is rapidly transitioning from a nation of bicycle riders and pedestrians to one where car ownership and use is increasing. This transition presents important public health, mobility, and safety challenges. Rapid motorisation has resulted in an increased road trauma burden, shouldered disproportionately among the population. Vulnerable road users (bicyclists, pedestrians, and motorcyclists) are of particular concern, representing 70% of all road-related fatalities [1]. Furthermore, those at greatest risk of sustaining a crash-related disability are: male, older, less educated, and earning a lower income [2] and residing in urban areas [3], with higher fatality rates in north-western poorer provinces [3]. Speeding is a key factor in road crashes in China [1, 4] and is one of two risk factors targeted in the Bloomberg Philanthropies-funded Global Road Safety Program operating in two Chinese cities over five year [5] to which the first author has provided expert advice. However, little evidence exists to help understand the factors underpinning speeding behaviour. Previous research conducted by the authors in Beijing and Hangzhou explored personal, social, and legal factors relating to speeding to assist in better understanding the motivations for non-compliance with speed limits. Qualitative and quantitative research findings indicated that speeding is relatively common, including self-reported travel speeds of greater than 30 km/hour above posted speed limits [6], and that the road safety laws and enforcement practices may, in some circumstances, contribute to this [7]. Normative factors were also evident; the role of friends, family members and driving instructors were influential. Additionally, using social networks to attempt to avoid detection and penalty was reported, thereby potentially reinforcing community perceptions that speeding is acceptable [8, 9]. The authors established strong collaborative links with the Chinese Academy of Sciences and Zhejiang Police College to conduct this research. The first author has worked in both institutions for extended time periods and recognises that research must include an understanding of culturally-relevant issues if road safety is to improve in China. Future collaborations to assist in enhancing our understanding of such issues are welcomed. References [1] World Health Organization. (2009). Global status report on road safety: Time for action; Geneva. [2] Chen, H., Du, W., & Li, N. (2013). The socioeconomic inequality in traffic-related disability among Chinese adults: the application of concentration index. Accident Analysis & Prevention, 55(101-106). [3] Wang, S. Y., Li, Y. H., Chi, G. B., Xiao, S. Y., Ozanne-Smith, J., Stevenson, M., & Phillips, M. (2008). Injury-related fatalities in China: an under-recognised public-health problem. The Lancet (British edition), 372(9651), 1765-1773. [4] He, J., King, M. J., Watson, B., Rakotonirainy, A., & Fleiter, J. J. (2013). Speed enforcement in China: National, provincial and city initiatives and their success. Accident Analysis & Prevention, 50, 282-288. [5] Bhalla, K., Li, Q., Duan, L., Wang, Y., Bishai, D., & Hyder, A. A. (2013). The prevalence of speeding and drink driving in two cities in China: a mid project evaluation of ongoing road safety interventions. Injury, 44, 49-56. doi:10.1016/S0020-1383(13)70213-4. [6] Fleiter, J. J., Watson, B., & Lennon, A. (2013). Awareness of risky behaviour among Chinese drivers. Peer-reviewed paper presented at 23rd Canadian Multidisciplinary Road Safety Conference, Montréal, Québec. [7] Fleiter, J. J., Watson, B., Lennon, A., King, M. J., & Shi, K. (2009). Speeding in Australia and China: A comparison of the influence of legal sanctions and enforcement practices on car drivers. Peer-reviewd paper presented at Australasian Road Safety Research Policing Education Conference, Sydney. [8] Fleiter, J. J., Watson, B., Lennon, A., King, M. J., & Shi, K. (2011). Social influences on drivers in China. Journal of the Australasian College of Road Safety, 22(2), 29-36. [9] Fleiter, J. J., Watson, B., Guan, M. Q., Ding, J. Y., & Xu, C. (2013). Characteristics of Chinese Drivers Attending a Mandatory Training Course Following Licence Suspension. Peer-reviewed paper presented at Road Safety on Four Continents, Beijing, China.

The Australian prehospital pandemic risk perception study and an examination of new public health roles in pandemic response for ambulance services

This report is one of a series of products resulting from a National Health and Medical Research Council (NHMRC) Urgent Research Grant – Pandemic Influenza [No 409973]. The research targeted two key aspects of planning and preparedness for a human influenza pandemic, namely:

Growing demand for emergency department services : associated factors and perspective of patients

This thesis demonstrates how patients' perceived urgency affects their decision to use public hospital emergency departments. The findings inform public health policy solutions aimed at reducing rapid growth in emergency department utilisation which results in congestion and affects the safety, satisfaction, and the quality of care. This research identified that patients attending emergency departments did so based on the perception of their own health status and beliefs that emergency departments were the most suitable location for their care. Blaming patients as "frequent flyers" or "inappropriate users" ignores the complex and multi-factorial nature of the genuine need for urgent medical care felt by patients.

Sources of productivity growth in health services : a case study of Queensland public hospitals

Improving the performance of health sector is one of the most popular issues in Australia. This paper contributes to this important policy debate by examining the efficiency of health facilities in Queensland using the Malmquist Productivity Index (MPI). This method is selected because it is suitable for the multi-input, multi-output, and not-for-profit natures of public health services. In addition, with the availability of panel data we can decompose productivity growth into useful components, including technical efficiency changes, technological changes and scale changes. The results revealed an average of 1.6 per cent of growth in total factor productivity (TFP) among Queensland public hospitals in the study period. The main component contributing to the modest improvement of TFP during the period was catching-up at an average of 1.0 per cent. SFA estimates suggest that the number of nurses is the most influential determinant of output.