The aged care workforce in Australia

Discussion Pape

A model for measuring the health burden of classic congenital adrenal hyperplasia in adults

This is the author accepted manuscript. The final version is available from the publisher via the DOI in this record.Aim: Patients with classic Congenital Adrenal Hyperplasia (CAH) have poor health outcomes. In the absence of a comprehensive observational study, this manuscript provides a model to estimate the lifetime disease burden of adults with classic CAH. Methods: The model, built in Excel, comprises sub-domains addressing the health consequences of CAH, and synthesises evidence from clinical and epidemiological studies on health outcomes. Results: The model estimates that adults with classic CAH will implement “sick day rules” (doubling or tripling glucocorticoid and/or use of parenteral therapy) 171 times over their lifetime, and attend hospital for adrenal crisis on 11 occasions. In a population of 1,000, over 200 will die of a condition complicated by adrenal crisis resulting, on average, in a loss of 7 years of life. CAH patients may also suffer from excess CVD events. Treatment with glucocorticoids almost doubles the risk of bone fractures in CAH patients compared to the general population, leading on average to an additional 0.8 fractures per CAH patient over their lifetime. Conclusions: The disease burden model highlights gaps in evidence, particularly regarding intensity of care and adrenal crisis, and the relationship between control of CAH and risks of CVD, osteoporosis, diabetes and infertility. The model can be used for research on the impact of new clinical pathways and therapeutic interventions in terms of clinical events and cost.Funded by: European Commission under the Framework 7 programme. Grant Number: HEALTH-F5-2011-281654Diurnal Limited (UK

Enhancing seedling survival on former floodplain grazing land in the Capertee Valley, Australia

© 2017 Ecological Society of Australia and John Wiley & Sons Australia, Ltd Active revegetation is an essential component of biodiversity conservation for fragmented ecosystems and the species that depend on them. However, key knowledge gaps exist around the most cost-effective revegetation strategies to employ in different contexts. This article reports on a revegetation trial undertaken in the Capertee Valley of New South Wales, Australia, to assist the conservation of the critically endangered bird, the Regent Honeyeater (Anthochaera phrygia). Seven treatments were compared to assess their cost-effectiveness for enhancing plant survival at a floodplain site with a history of grazing on introduced pastures. While overall survival rates were low, treatments involving tree guards had higher survival rates and were more cost-effective than treatments without guards. Weed growth, animal activity and water stress all appeared to play a role in the low survival rates at this site, with enhanced weed control emerging as a priority for future trials at similar sites

Revising ethical guidance for the evaluation of programmes and interventions not initiated by researchers

Public health and service delivery programmes, interventions and policies (collectively, “programmes)” are typically developed and implemented for the primary purpose of effecting change rather than generating knowledge. Nonetheless, evaluations of these programmes may produce valuable learning that helps to determine effectiveness and costs as well as informing design and implementation of future programmes. Such studies might be termed “opportunistic evaluations”, since they are responsive to emergent opportunities rather than being studies of interventions that are initiated or designed by researchers. However, current ethical guidance and registration procedures make little allowance for scenarios where researchers have played no role in the development or implementation of a programme, but nevertheless plan to conduct a prospective evaluation. We explore the limitations of the guidance and procedures with respect to opportunistic evaluations, providing a number of examples. We propose that the key missing distinction in current guidance is that moral responsibility: researchers can only be held accountable for those aspects of a study over which they have control. We argue that requiring researchers to justify an intervention, programme or policy that would occur regardless of their involvement prevents or hinders research in the public interest without providing any further protections to research participants. We recommend that trial consent and ethics procedures allow for a clear separation of responsibilities for the intervention and the evaluation.SIW and RJL are funded by the NIHR Global Health Research Unit on Improving Health in Slums. CT, PJC and RJL are also supported by the National Institute for Health Research (NIHR) Collaboration for Leadership for Applied Health Research Care (CLAHRC) West Midlands initiative. EBW and ELD are employed by Partners In Health. MD-W is supported by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies (THIS) Institute. THIS Institute is supported by the Health Foundation - an independent charity committed to bringing about better health and health care for people in the UK. This work was also supported by MDW’s Wellcome Trust Investigator award WT09789. MDW is a National Institute for Health Research (NIHR) Senior Investigator. This paper presents independent research and the views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Healt

The environmental security debate and its significance for climate change

Policymakers, military strategists and academics all increasingly hail climate change as a security issue. This article revisits the (comparatively) long-standing “environmental security debate” and asks what lessons that earlier debate holds for the push towards making climate change a security issue. Two important claims are made. First, the emerging climate security debate is in many ways a re-run of the earlier dispute. It features many of the same proponents and many of the same disagreements. These disagreements concern, amongst other things, the nature of the threat, the referent object of security and the appropriate policy responses. Second, given its many different interpretations, from an environmentalist perspective, securitisation of the climate is not necessarily a positive development

Hospital-acquired sinusitis is a common cause of fever of unknown origin in orotracheally intubated critically ill patients

INTRODUCTION: Sinusitis is a well recognised but insufficiently understood complication of critical illness. It has been linked to nasotracheal intubation, but its occurrence after orotracheal intubation is less clear. We studied the incidence of sinusitis in patients with fever of unknown origin (FUO) in our intensive care unit with the aim of establishing a protocol that would be applicable in everyday clinical practice. METHODS: Sinus X-rays (SXRs) were performed in all patients with fever for which an initial screening (physical examination, microbiological cultures and chest X-ray) revealed no obvious cause. All patients were followed with a predefined protocol, including antral drainage in all patients with abnormal or equivocal results on their SXR. RESULTS: Initial screening revealed probable causes of fever in 153 of 351 patients (43.6%). SXRs were taken in the other 198 patients (56.4%); 129 had obvious or equivocal abnormalities. Sinus drainage revealed purulent material and positive cultures (predominantly Pseudomonas and Klebsiella species) in 84 patients. Final diagnosis for the cause of fever in all 351 patients based on X-ray results, microbiological cultures, and clinical response to sinus drainage indicated sinusitis as the sole cause of fever in 57 (16.2%) and as contributing factor in 48 (13.8%) patients with FUO. This will underestimate the actual incidence because SXR and drainage were not performed in all patients. CONCLUSION: Physicians treating critically ill patients should be aware of the high risk of sinusitis and take appropriate preventive measures, including the removal of nasogastric tubes in patients requiring long-term mechanical ventilation. Routine investigation of FUO should include computed tomography scan, SXR or sinus ultrasonography, and drainage should be performed if any abnormalities are found

Synthesis, Structure and Stereodynamics of Atropisomeric <em>N</em>‑Chloroamides

Atropisomeric N-chloroamides were efficiently accessed by electrophilic halogenation of ortho-substituted secondary anilides. The stereodynamics of atropisomerism in these novel scaffolds was interrogated by detailed experimental and computational studies, revealing that racemization is correlated with amide isomerization. The stereoelectronic nature of the amide was shown to significantly influence racemization rates, with potentially important implications for other C-N atropisomeric scaffolds

Optimality-based Analysis of XCSF Compaction in Discrete Reinforcement Learning

Learning classifier systems (LCSs) are population-based predictive systems that were originally envisioned as agents to act in reinforcement learning (RL) environments. These systems can suffer from population bloat and so are amenable to compaction techniques that try to strike a balance between population size and performance. A well-studied LCS architecture is XCSF, which in the RL setting acts as a Q-function approximator. We apply XCSF to a deterministic and stochastic variant of the FrozenLake8x8 environment from OpenAI Gym, with its performance compared in terms of function approximation error and policy accuracy to the optimal Q-functions and policies produced by solving the environments via dynamic programming. We then introduce a novel compaction algorithm (Greedy Niche Mass Compaction - GNMC) and study its operation on XCSF's trained populations. Results show that given a suitable parametrisation, GNMC preserves or even slightly improves function approximation error while yielding a significant reduction in population size. Reasonable preservation of policy accuracy also occurs, and we link this metric to the commonly used steps-to-goal metric in maze-like environments, illustrating how the metrics are complementary rather than competitive

Denitrification as a source of nitric oxide emissions from incubated soil cores from a UK grassland

Agricultural soils are a major source of nitric oxide (NO) and nitrous oxide (N2O), which are produced and consumed by biotic and abiotic soil processes. The dominant sources of NO and N2O are microbial nitrification and denitrification. While N2O emissions have been attributed to both processes, depending on the environmental conditions such as substrate availability, pH and water filled pore space (WFPS), NO emissions are thought to predominantly derive from nitrification. Although attributing gaseous emissions to specific processes is still difficult, recent findings challenge the latter of those assumptions. Using the gas-flow-soil-core method, i.e soil cores incubated under a He/O2 atmosphere at constant surface gas flow, combined with 15N labelled isotopic techniques, the present study investigated the role of denitrification on NO, N2O and N2 emissions in a UK grassland soil under high soil moisture and an aerobic headspace atmosphere. With the application of KNO3 and glucose to support denitrification, denitrification was the source of N loss of between 0.61 and 0.67% of the added N via NO emissions, 1.60–1.68% via N2O and 0.03–0.05% via N2 emissions. Overall, our study showed that denitrification has been overlooked as a source of NO emissions