Identifying and enhancing risk thresholds in the detection of elder financial abuse: A signal detection analysis of professionals' decision making

Background: Financial abuse of elders is an under acknowledged problem and professionals' judgements contribute to both the prevalence of abuse and the ability to prevent and intervene. In the absence of a definitive "gold standard" for the judgement, it is desirable to try and bring novice professionals' judgemental risk thresholds to the level of competent professionals as quickly and effectively as possible. This study aimed to test if a training intervention was able to bring novices' risk thresholds for financial abuse in line with expert opinion. Methods: A signal detection analysis, within a randomised controlled trial of an educational intervention, was undertaken to examine the effect on the ability of novices to efficiently detect financial abuse. Novices (n = 154) and experts (n = 33) judged "certainty of risk" across 43 scenarios; whether a scenario constituted a case of financial abuse or not was a function of expert opinion. Novices (n = 154) were randomised to receive either an on-line educational intervention to improve financial abuse detection (n = 78) or a control group (no on-line educational intervention, n = 76). Both groups examined 28 scenarios of abuse (11 "signal" scenarios of risk and 17 "noise" scenarios of no risk). After the intervention group had received the on-line training, both groups then examined 15 further scenarios (5 "signal" and 10 "noise" scenarios). Results: Experts were more certain than the novices, pre (Mean 70.61 vs. 58.04) and post intervention (Mean 70.84 vs. 63.04); and more consistent. The intervention group (mean 64.64) were more certain of abuse post-intervention than the control group (mean 61.41, p = 0.02). Signal detection analysis of sensitivity (Á) and bias (C) revealed that this was due to the intervention shifting the novices' tendency towards saying "at risk" (C post intervention -.34) and away from their pre intervention levels of bias (C-.12). Receiver operating curves revealed more efficient judgments in the intervention group. Conclusion: An educational intervention can improve judgements of financial abuse amongst novice professionals.

Chromium supplementation in patients with type 2 diabetes and high risk of type 2 diabetes: a meta-analysis of randomized controlled trials

Introduction: Chromium is an essential trace mineral for carbohydrate and lipid metabolism, which is currently prescribed to control diabetes mellitus. Results of previous systematic reviews and meta-analyses of chromium supplementation and metabolic profiles in diabetes have been inconsistent. Aim: The objective of this meta-analysis was to assess the effects on metabolic profiles and safety of chromium supplementation in type 2 diabetes mellitus and cholesterol. Methods: Literature searches in PubMed, Scopus and Web of Science were made by use of related terms-keywords and randomized clinical trials during the period of 2000-2014. Results: Thirteen trials fulfilled the inclusion criteria and were included in this systematic review. Total doses of Cr supplementation and brewer's yeast ranged from 42 to 1,000 µg/day, and duration of supplementation ranged from 30 to 120 days. The analysis indicated that there was a significant effect of chromium supplementation in diabetics on fasting plasma glucose with a weighted average effect size of -29.26 mg/dL, p = 0.01, CI 95% = -52.4 to -6.09; and on total cholesterol with a weighted average effect size of -6.7 mg/dL, p = 0.01, CI 95% = -11.88 to -1.53. Conclusions: The available evidence suggests favourable effects of chromium supplementation on glycaemic control in patients with diabetes. Chromium supplementation may additionally improve total cholesterol levels.

A meta-analysis of trabecular bone score in fracture risk prediction and its relationship to FRAX

Trabecular bone score (TBS) is a grey-level textural index of bone microarchitecture derived from lumbar spine dual-energy X-ray absorptiometry (DXA) images. TBS is a BMD-independent predictor of fracture risk. The objective of this meta-analysis was to determine whether TBS predicted fracture risk independently of FRAX probability and to examine their combined performance by adjusting the FRAX probability for TBS. We utilized individual level data from 17,809 men and women in 14 prospective population-based cohorts. Baseline evaluation included TBS and the FRAX risk variables and outcomes during follow up (mean 6.7 years) comprised major osteoporotic fractures. The association between TBS, FRAX probabilities and the risk of fracture was examined using an extension of the Poisson regression model in each cohort and for each sex and expressed as the gradient of risk (GR; hazard ratio per 1SD change in risk variable in direction of increased risk). FRAX probabilities were adjusted for TBS using an adjustment factor derived from an independent cohort (the Manitoba Bone Density Cohort). Overall, the GR of TBS for major osteoporotic fracture was 1.44 (95% CI: 1.35-1.53) when adjusted for age and time since baseline and was similar in men and women (p > 0.10). When additionally adjusted for FRAX 10-year probability of major osteoporotic fracture, TBS remained a significant, independent predictor for fracture (GR 1.32, 95%CI: 1.24-1.41). The adjustment of FRAX probability for TBS resulted in a small increase in the GR (1.76, 95%CI: 1.65, 1.87 vs. 1.70, 95%CI: 1.60-1.81). A smaller change in GR for hip fracture was observed (FRAX hip fracture probability GR 2.25 vs. 2.22). TBS is a significant predictor of fracture risk independently of FRAX. The findings support the use of TBS as a potential adjustment for FRAX probability, though the impact of the adjustment remains to be determined in the context of clinical assessment guidelines.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods: Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings: All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation: Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Classification tree analysis of postal questionnaire data to identify risk of excessive gestational weight gain

OBJECTIVE: overweight/obese weight status during pregnancy increases risk of a range of adverse health outcomes for mother and child. Whereas identification of those who are overweight/obese pre-pregnancy and in early pregnancy is straightforward, prediction of who will experience excessive gestational weight gain (EGWG), and thus be at greater risk of becoming overweight or obese during pregnancy is more challenging. The present study sought to better identify those at risk of EGWG by exploring pre-pregnancy BMI as well as a range of psychosocial risk factors identified as risk factors in prior research. METHODS: 225 pregnant women completed self-reported via postal survey measures of height, weight, and psychosocial variables at 16-18 weeks gestation, and reported their weight again at 32-34 weeks to calculate GWG. Classification and regression tree analysis (CART) was used to find subgroups in the data with increased risk of EGWG based on their pre-pregnancy BMI and psychosocial risk factor scores at Time 1. FINDINGS: CART confirmed that self-reported BMI status was a strong predictor of EGWG risk for women who were overweight/obese pre-pregnancy. Normal weight women with low motivation to maintain a healthy diet and who reported lower levels of partner support were also at considerable risk of EGWG. IMPLICATIONS FOR PRACTICE: present findings offer support for inclusion of psychosocial measures (in addition to BMI) in early antenatal visits to detect risk of EGWG. However, these findings also underscore the need for further consideration of effect modifiers that place women at increased or decreased risk of EGWG. Proposed additional constructs are discussed to direct further theory-driven research.

Increasing body weight and risk of limitations in activities of daily living: a systematic review and meta-analysis

This study examined the relationship between normal weight, overweight and obesity class I and II+, and the risk of disability, which is defined as impairment in activities of daily living (ADL). Systematic searching of the literature identified eight cross-sectional studies and four longitudinal studies that were comparable for meta-analysis. An additional four cross-sectional studies and one longitudinal study were included for qualitative review. Results from the meta-analysis of cross-sectional studies revealed a graded increase in the risk of ADL limitations from overweight (1.04, 95% confidence interval [CI] 1.00-1.08), class I obesity (1.16, 95% CI 1.11-1.21) and class II+ obesity (1.76, 95% CI 1.28-2.41), relative to normal weight. Meta-analyses of longitudinal studies revealed a similar graded relationship; however, the magnitude of this relationship was slightly greater for all body mass index categories. Qualitative analysis of studies that met the inclusion criteria but were not compatible for meta-analysis supported the pooled results. No studies identified met all of the pre-defined quality criteria, and subgroup analysis was inhibited due to insufficient comparable studies. We conclude that increasing body weight increases the risk of disability in a graded manner, but also emphasize the need for additional studies using contemporary longitudinal cohorts with large numbers of obese class III individuals, a range of ages and with measured height and weight, and incident ADL questions.

The magnitude of association between overweight and obesity and the risk of diabetes: a meta-analysis of prospective cohort studies

The objectives of this meta-analysis were to examine the magnitude of the relative risk (RR) of developing type 2 diabetes for overweight and obese populations, compared to those with normal weight, and to determine causes of the variation in RR between various cohort studies. The magnitude of the RR was analyzed by combining 18 prospective cohort studies that matched defined criteria. The variance in RR between studies was explored. The overall RR of diabetes for obese persons compared to those with normal weight was 7.19, 95% CI: 5.74, 9.00 and for overweight was 2.99, 95% CI: 2.42, 3.72. The variation in RR among studies was explored and it was found that the effect of heterogeneity was highly related with sample size, method of assessment of body mass index (BMI) and method of ascertainment of type 2 diabetes. By combining only cohort studies with more than 400 cases of incident diabetes (>median), adjusted by at least three main confounding variables (age, family history of type 2 diabetes, physical activity), measured BMI, and diabetes determined by clinical diagnosis, the RR was 7.28, 95% CI: 6.47, 8.28 for obesity and 2.92, 95% CI: 2.57, 3.32 for overweight.

Gendering Security: violence and risk in Australia's night-time economies

Expanding the Gaze is a collection of important new empirical and theoretical works that demonstrate the significance of the gendered dynamics of surveillance.

Physical activity guidelines and cardiovascular risk in children: a cross sectional analysis to determine whether 60 minutes is enough

BACKGROUND: Physical activity reduces cardiovascular mortality and morbidity. The World Health Organisation (WHO) recommends children engage in 60 min daily moderate-to-vigorous physical activity (MVPA). The effect of compliance with this recommendation on childhood cardiovascular risk has not been empirically tested. To evaluate whether achieving recommendations results in reduced composite-cardiovascular risk score (CCVR) in children, and to examine if vigorous PA (VPA) has independent risk-reduction effects.

METHODS: PA was measured using accelerometry in 182 children (9-11 years). Subjects were grouped according to achievement of 60 min daily MVPA (active) or not (inactive). CCVR was calculated (sum of z-scores: DXA body fat %, blood pressure, VO2peak, flow mediated dilation, left ventricular diastolic function; CVR score ≥ 1SD indicated 'higher risk'). The cohort was further split into quintiles for VPA and odds ratios (OR) calculated for each quintile.

RESULTS: Active children (92 (53 boys)) undertook more MVPA (38 ± 11 min, P < 0.001), had greater VO2peak (4.5 ± 0.8 ml/kg/min P < 0.001), and lower fat % (3.9 ± 1.1 %, P < 0.001) than inactive. No difference were observed between active and inactive for CCVR or OR (P > 0.05). CCVR in the lowest VPA quintile was significantly greater than the highest quintile (3.9 ± 0.6, P < 0.05), and the OR was 4.7 times higher.

CONCLUSION: Achievement of current guidelines has positive effects on body composition and cardiorespiratory fitness, but not CCVR. Vigorous physical activity appears to have beneficial effects on CVD risk, independent of moderate PA, implying a more prescriptive approach may be needed for future VPA guidelines.

Rethinking the food security debate in Asia: Some missing ecological and health dimensions and solutions

Food security is a global and regional concern of rapidly increasing consequence. It is at risk of inattention because of competing crises, because of its theoretical amenability to previously effective, if temporary measures, most impressively with the so-called Green Revolution and because of the recourse to the global trade paradigm as a putative solution. We identify some missing or under-emphasised dimensions in this analysis, with particular reference to Asia, which in spite of recent growth-or in some cases because of it-faces particularly daunting food problems. Greater emphasis needs to be given to population size and distribution through more concerted family planning and enlightened migration policy; public policy to retain or encourage plant-based diets; integration of food, health and environmental approaches to create resilient regional food systems; and the incorporation of food into the broader human security agenda. While regional organisations, along with their NGO counterparts and nation states, have an over-arching role to strategise in this way, substantial progress could still be made at the community and household levels, especially with current technologies which can marshal their collective and coherent action.