Cardiac ARIA Index: Measuring Accessibility to Cardiovascular Services in Rural and Remote Australia via Applied Geographic Spatial Technology

Cardiovascular disease (CVD) continues to impose a heavy burden in terms of cost, disability and death in Australia. Evidence suggests that increasing remoteness, where cardiac services are scarce, is linked to an increased risk of dying from CVD. Fatal CVD events are reported to be between 20% and 50% higher in rural areas compared to major cities. The Cardiac ARIA project, with its extensive use of geographic Information Systems (GIS), ranks each of Australia’s 20,387 urban, rural and remote population centres by accessibility to essential services or resources for the management of a cardiac event. This unique, innovative and highly collaborative project delivers a powerful tool to highlight and combat the burden imposed by cardiovascular disease (CVD) in Australia. Cardiac ARIA is innovative. It is a model that could be applied internationally and to other acute and chronic conditions such as mental health, midwifery, cancer, respiratory, diabetes and burns services. Cardiac ARIA was designed to: 1. Determine by expert panel, what were the minimal services and resources required for the management of a cardiac event in any urban, rural or remote population locations in Australia using a single patient pathway to access care. 2. Derive a classification using GIS accessibility modelling for each of Australia’s 20,387 urban, rural and remote population locations. 3. Compare the Cardiac ARIA categories and population locations with census derived population characteristics. Key findings are as follows: • In the event of a cardiac emergency, the majority of Australians had very good access to cardiac services. Approximately 71% or 13.9 million people lived within one hour of a category one hospital. • 68% of older Australians lived within one hour of a category one hospital (Principal Referral Hospital with access to Cardiac Catheterisation). • Only 40% of indigenous people lived within one hour of the category one hospital. • 16% (74000) of indigenous people lived more than one hour from a hospital. • 3% (91,000) of people 65 years of age or older lived more than one hour from any hospital or clinic. • Approximately 96%, or 19 million, of people lived within one hour of the four key services to support cardiac rehabilitation and secondary prevention. • 75% of indigenous people lived within one hour of the four cardiac rehabilitation services to support cardiac rehabilitation and secondary prevention. Fourteen percent (64,000 persons) indigenous people had poor access to the four key services to support cardiac rehabilitation and secondary prevention. • 12% (56,000) of indigenous people were more than one hour from a hospital and only had access one the four key services (usually a medical service) to support cardiac rehabilitation and secondary prevention.

Thomas Young’s investigations in gradient-index optics

Purpose: James Clerk Maxwell is usually recognized as being the first, in 1854, to consider using inhomogeneous media in optical systems. However, some fifty years earlier Thomas Young, stimulated by his interest in the optics of the eye and accommodation, had already modeled some applications of gradient-index optics. These applications included using an axial gradient to provide spherical aberration-free optics and a spherical gradient to describe the optics of the atmosphere and the eye lens. We evaluated Young’s contributions. Method: We attempted to derive Young’s equations for axial and spherical refractive index gradients. Raytracing was used to confirm accuracy of formula. Results: We did not confirm Young’s equation for the axial gradient to provide aberration-free optics, but derived a slightly different equation. We confirmed the correctness of his equations for deviation of rays in a spherical gradient index and for the focal length of a lens with a nucleus of fixed index surrounded by a cortex of reducing index towards the edge. Young claimed that the equation for focal length applied to a lens with part of the constant index nucleus of the sphere removed, such that the loss of focal length was a quarter of the thickness removed, but this is not strictly correct. Conclusion: Young’s theoretical work in gradient-index optics received no acknowledgement from either his contemporaries or later authors. While his model of the eye lens is not an accurate physiological description of the human lens, with the index reducing least quickly at the edge, it represented a bold attempt to approximate the characteristics of the lens. Thomas Young’s work deserves wider recognition.

Can the Cardiac ARIA Index Improve Cardiac Care for Australia's Indigenous Population?

Background: Timely access to appropriate cardiac care is critical for optimising outcomes. Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services for Australia's 20,387 population locations. Methods: An expert panel defined a single patient care pathway. Using geographic information systems (GIS) the numeric/alpha index was modelled in two phases. The acute phase index (numeric) ranged from 1 (access to tertiary centre with PCI ≤1 h) to 8 (no ambulance service, >3 h to medical facility, air transport required). The aftercare index was modelled into 5 alphabetic categories; A (Access to general practitioner, pharmacy, cardiac rehabilitation, pathology ≤1 h) to E (no services available within 1 h). Results: Approximately 70% or 13.9 million people lived within a CardiacARIAindex category 1A location. Disparity continues in access to category 1A cardiac services for 5.8 million (30%) of all Australians, 60% of Aboriginal and Torres Strait Islander people and 32% of people over 65 years of age. In a cardiac emergency only 40% of the Indigenous population reside within one hour of category 1 hospital. Approximately 30% (81,491 Indigenous persons) are more than one to three hours from basic cardiac services. Conclusion: Geographically, the majority of Australian's have timely access for survival of a cardiac event. The CardiacARIAindex objectively demonstrates that the healthcare system may not be providing for the needs of 60% of Indigenous people residing outside the 1A geographic radius. Innovative clinical practice maybe required to address these disparities.

Where not to have a Heart Attack in Australia!: The Cardiac ARIA Index

Background/aims: Access to appropriate health care following an acute cardiac event is important for positive outcomes. The aim of the Cardiac ARIA index was to derive an objective, comparable, geographic measure reflecting access to cardiac services across Australia. Methods: Geographic Information Systems (GIS) were used to model a numeric-alpha index based on acute management from onset of symptoms to return to the community. Acute time frames have been calculated to include time for ambulance to arrive, assess and load patient, and travel to facility by road 40–80 kph. Results: The acute phase of the index was modelled into five categories: 1 [24/7 percutaneous cardiac intervention (PCI) ≤1 h]; 2 [24/7 PCI 1–3 h, and PCI less than an additional hour to nearest accident and emergency room (A&E)]: 3 [Nearest A&E ≤3 h (no 24/7 PCI within an extra hour)]: 4 [Nearest A&E 3–12 h (no 24/7 PCI within an extra hour)]: 5 [Nearest A&E 12–24 h (no 24/7 PCI within an extra hour)]. Discharge care was modelled into three categories based on time to a cardiac rehabilitation program, retail pharmacy, pathology services, hospital, GP or remote clinic: (A) all services ≤30 min; (B) >30 min and ≤60 min; (C) >60 min. Examples of the index indicate that the majority of population locations within capital cities were category 1A; Alice Springs and Byron Bay were 3A; and the Northern Territory town of Maningrida had minimal access to cardiac services with an index ranking of 5C. Conclusion: The Cardiac ARIA index provides an invaluable tool to inform appropriate strategies for the use of scarce cardiac resources.

Monte Carlo evaluation of collapsed-cone convolution calculations in head and neck radiotherapy treatment plans

The presence of air and bone interfaces makes the dose distribution for head and neck cancer treatments difficult to accurately predict. This study compared planning system dose calculations using the collapsed-cone convolution algorithm with EGSnrcMonte Carlo simulation results obtained using the Monte Carlo DICOMToolKit software, for one oropharynx, two paranasal sinus and three nodal treatment plans. The difference between median doses obtained from the treatment planning and Monte Carlo calculations was found to be greatest in two bilateral treatments: 4.8%for a retropharyngeal node irradiation and 6.7% for an ethmoid paranasal sinus treatment. These deviations in median dose were smaller for two unilateral treatments: 0.8% for an infraclavicular node irradiation and 2.8% for a cervical node treatment. Examination of isodose distributions indicated that the largest deviations between Monte Carlo simulation and collapsed-cone convolution calculations were seen in the bilateral treatments, where the increase in calculated dose beyond air cavities was most significant.

Dynamics of rod and cone photoreceptor interactions under mesopic light levels

Visual adaptation regulates contrast sensitivity during dynamically changing light conditions (Crawford, 1947; Hecht, Haig & Chase, 1937). These adaptation dynamics are unknown under dim (mesopic) light levels when the rod (R) and long (L), medium (M) and short (S) wavelength cone photoreceptor classes contribute to vision via interactions in shared non-opponent Magnocellular (MC), chromatically opponent Parvocellular (PC) and Koniocellular (KC) visual pathways (Dacey, 2000). This study investigated the time-course of adaptation and post-receptoral pathways mediating receptor specific rod and cone interactions under mesopic illumination. A four-primary photostimulator (Pokorny, Smithson & Quinlan, 2004) was used to independently control the activity of the four photoreceptor classes and their post-receptoral visual athways in human observers. In the first experiment, the contrast sensitivity and time-course of visual adaptation under mesopic illumination were measured for receptoral (L, S, R) and post-receptoral (LMS, LMSR, L-M) stimuli. An incremental (Rapid-ON) sawtooth conditioning pulse biased detection to ON-cells within the visual pathways and sensitivity was assayed relative to pulse onset using a briefly presented incremental probe that did not alter adaptation. Cone.Cone interactions with luminance stimuli (L cone, LMS, LMSR) reduced sensitivity by 15% and the time course of recovery was 25± 5ms-1 (μ ± SEM). PC mediated (+L-M) chromatic stimuli sensitivity loss was less (8%) than for luminance and recovery was slower (μ = 2.95 ± 0.05 ms-1), with KC mediated (S cone) chromatic stimuli showing a high sensitivity loss (38%) and the slowest recovery time (1.6 ± 0.2 ms-1). Rod-Rod interactions increased sensitivity by 20% and the time course of recovery was 0.7 ± 0.2 ms-1 (μ ± SD). Compared to these interaction types, Rod-Cone interactions reduced sensitivity to a lesser degree (5%) and showed the fastest recovery (μ = 43 ± 7 ms-1). In the second experiment, rod contribution to the magnocellular, parvocellular and koniocellular post-receptoral pathways under mesopic illumination was determined as a function of incremental stimulus duration and waveform (rectangular; sawtooth) using a rod colour match procedure (Cao, Pokorny & Smith, 2005; Cao, Pokorny, Smith & Zele, 2008a). For a 30% rod increment, a cone match required a decrease in [L/(L+M)] and an increase in [L+M] and [S/(L+M)], giving a greenish-blue and brighter appearance for probe durations of 75 ms or longer. Probe durations less than 75 ms showed an increase in [L+M] and no change in chromaticity [L/(L+M) or S/(L+M)], uggesting mediation by the MC pathway only for short duration rod stimuli. s We advance previous studies by determining the time-course and nature of photoreceptor specific retinal interactions in the three post-receptoral pathways under mesopic illumination. In the first experiment, the time-course of adaptation for ON cell processing was determined, revealing opponent cell facilitation in chromatic PC and KC pathways. The Rod-Rod and Rod-Cone data identify previously unknown interaction types that act to maintain contrast sensitivity during dynamically changing light conditions and improve the speed of light adaptation under mesopic light levels. The second experiment determined the degree of rod contribution to the inferred post-eceptoral pathways as a function of the temporal properties of the rod signal. r The understanding of the mechanisms underlying interactions between photoreceptors under mesopic illumination has implications for the study of retinal disease. Visual function has been shown to be reduced in persons with age-related maculopathy (ARM) risk genotypes prior to clinical signs of the disease (Feigl, Cao, Morris & Zele, 2011) and disturbances in rod-mediated adaptation have been shown in early phases of ARM (Dimitrov, Guymer, Zele, Anderson & Vingrys, 2008; Feigl, Brown, Lovie-Kitchin & Swann, 2005). Also, the understanding of retinal networks controlling vision enables the development of international lighting standards to optimise visual performance nder dim light levels (e.g. work-place environments, transportation).

An improved method to detect damage using modal strain energy based damage index

This paper presents two novel concepts to enhance the accuracy of damage detection using the Modal Strain Energy based Damage Index (MSEDI) with the presence of noise in the mode shape data. Firstly, the paper presents a sequential curve fitting technique that reduces the effect of noise on the calculation process of the MSEDI, more effectively than the two commonly used curve fitting techniques; namely, polynomial and Fourier’s series. Secondly, a probability based Generalized Damage Localization Index (GDLI) is proposed as a viable improvement to the damage detection process. The study uses a validated ABAQUS finite-element model of a reinforced concrete beam to obtain mode shape data in the undamaged and damaged states. Noise is simulated by adding three levels of random noise (1%, 3%, and 5%) to the mode shape data. Results show that damage detection is enhanced with increased number of modes and samples used with the GDLI.

Managing distraction and attention in diverse cohorts : 21st century challenges to law student engagement

It is imperative that we consider the use of current and emerging technologies in terms of the nature of our learners, the physical environment of the lecture theatre, and how technology may help to support appropriate pedagogies that facilitate the capturing of student attention in active engaging learning experiences. It is argued that a re-evaluation of pedagogy is required to address the tech-savy traits of the 21st century learner and the extent to which their mobile devices are capable of not only distracting them from learning but also enhancing face-to-face learning experiences.

The health and cost implications of high body mass index in Australian Defence Force personnel.

BACKGROUND: Frequent illness and injury among workers with high body mass index (BMI) can raise the costs of employee healthcare and reduce workforce maintenance and productivity. These issues are particularly important in vocational settings such as the military, which require good physical health, regular attendance and teamwork to operate efficiently. The purpose of this study was to compare the incidence of injury and illness, absenteeism, productivity, healthcare usage and administrative outcomes among Australian Defence Force personnel with varying BMI. METHODS: Personnel were grouped into cohorts according to the following ranges for (BMI): normal (18.5-24.9 kg/m²; n = 197), overweight (25-29.9 kg/m²; n = 154) and obese (≥30 kg/m²) with restricted body fat (≤28 % for females, ≤24 % for males) (n = 148) and with no restriction on body fat (n = 180). Medical records for each individual were audited retrospectively to record the incidence of injury and illness, absenteeism, productivity, healthcare usage (i.e., consultation with medical specialists, hospital stays, medical investigations, prescriptions) and administrative outcomes (e.g., discharge from service) over one year. These data were then grouped and compared between the cohorts. RESULTS: The prevalence of injury and illness, cost of medical specialist consultations and cost of medical scans were all higher (p <0.05) in both obese cohorts compared with the normal cohort. The estimated productivity losses from restricted work days were also higher (p <0.05) in the obese cohort with no restriction on body fat compared with the normal cohort. Within the obese cohort, the prevalence of injury and illness, healthcare usage and productivity were not significantly greater in the obese cohort with no restriction on body fat compared with the cohort with restricted body fat. The number of restricted work days, the rate of re-classification of Medical Employment Classification and the rate of discharge from service were similar between all four cohorts. CONCLUSIONS: High BMI in the military increases healthcare usage, but does not disrupt workforce maintenance. The greater prevalence of injury and illness, greater healthcare usage and lower productivity in obese Australian Defence Force personnel is not related to higher levels of body fat.

Mesopic rod and S-cone interactions revealed by modulation thresholds

We analyzed mesopic rod and S-cone interactions in terms of their contributions to the blue-yellow opponent pathway. Stimuli were generated using a 4-primary colorimeter. Mixed rod and S-cone modulation thresholds (constant L-, M-cone excitation) were measured as a function of their phase difference. Modulation amplitude was equated using threshold units and contrast ratios. This study identified three interaction types: (1) A linear and antagonistic rod:S-cone interaction, (2) probability summation (3) and a previously unidentified mutual nonlinear reinforcement. Linear rod:S-cone interactions occur within the blue-yellow opponent pathway. Probability summation involves signaling by different post-receptoral pathways. The origin of the nonlinear reinforcement is possibly at the photoreceptors.

Analysis of Cone-Beam CT using prior information

Treatment plans for conformal radiotherapy are based on an initial CT scan. The aim is to deliver the prescribed dose to the tumour, while minimising exposure to nearby organs. Recent advances make it possible to also obtain a Cone-Beam CT (CBCT) scan, once the patient has been positioned for treatment. A statistical model will be developed to compare these CBCT scans with the initial CT scan. Changes in the size, shape and position of the tumour and organs will be detected and quantified. Some progress has already been made in segmentation of prostate CBCT scans [1],[2],[3]. However, none of the existing approaches have taken full advantage of the prior information that is available. The planning CT scan is expertly annotated with contours of the tumour and nearby sensitive objects. This data is specific to the individual patient and can be viewed as a snapshot of spatial information at a point in time. There is an abundance of studies in the radiotherapy literature that describe the amount of variation in the relevant organs between treatments. The findings from these studies can form a basis for estimating the degree of uncertainty. All of this information can be incorporated as an informative prior into a Bayesian statistical model. This model will be developed using scans of CT phantoms, which are objects with known geometry. Thus, the accuracy of the model can be evaluated objectively. This will also enable comparison between alternative models.