The sustainability imperative and urban New Zealand : promise and paradox

'Urban sustainability' is an increasingly ubiquitous term now featuring in all manner of policy documents and promotional material. As an ambitious attempt to address social, economic and bio-physical environmental issues it appears to balance philanthropic ideals, such as social development, with environmental concern and fiscal efficiency. Yet, my research involving in-depth interviews with 35 urban practitioners in Christchurch, New Zealand, exposes much of the apparent consensus around its meaning as illusory. Though the concept's promise rests on an apparently neutral reconciliation of disparate goals and aspirations, it is conceptually paradoxical, difficult to implement and extremely political. While the orthodox tripartite promotes a combination of social, economic and environmental elements, I have found practitioners tend to emphasise bio-physical aspects of the concept. As a corollary, urban sustainability is often reified as a technical problem to be managed within certain budget constraints. The ways in which the concept is quite literally made concrete in our cities and towns naturalises certain social arrangements, such as, for example, the spatial segregation of different groups. The processes of reification also serve to legitimise particular rationalities, one of which encourages a particular reading of 'the environment' that rests on an unhelpful and possibly dangerous separation of nature and the city. In this thesis I use techniques associated with discourse analysis and symbolic interaction, informed by an eclectic literature around social geography, and urban political economy and ecology, to explore and elaborate upon these themes

Soft infrastructure for hard times: Collaborative planning for the (re)building of better homes, towns and cities

Disaster recovery involves the restoration, repair and rejuvenation of both hard and soft infrastructure. In this report we present observations from seven case studies of collaborative planning from post-earthquake Canterbury, each of which was selected as a means of better understanding ‘soft infrastructure for hard times’. Though our investigation is located within a disaster recovery context, we argue that the lessons learned are widely applicable. Our seven case studies highlighted that the nature of the planning process or journey is as important as the planning objective or destination. A focus on the journey can promote positive outcomes in and of itself through building enduring relationships, fostering diverse leaders, developing new skills and capabilities, and supporting translation and navigation. Collaborative planning depends as much upon emotional intelligence as it does technical competence, and we argue that having a collaborative attitude is more important than following prescriptive collaborative planning formulae. Being present and allowing plenty of time are also key. Although deliberation is often seen as an improvement on technocratic and expert dominated decision-making models, we suggest that the focus in the academic literature on communicative rationality and discursive democracy has led us to overlook other more active forms of planning that occur in various sites and settings. Instead, we offer an expanded understanding of what planning is, where it happens and who is involved. We also suggest more attention be given to values, particularly in terms of their role as a compass for navigating the terrain of decision-making in the collaborative planning process. We conclude with a revised model of a (collaborative) decision-making cycle that we suggest may be more appropriate when (re)building better homes, towns and cities

Reporting on the Seminar - Risk interpretation and action (RIA): Decision making under conditions of uncertainty

The paper reports on the World Social Science (WSS) Fellows seminar on Risk Interpretation and Action (RIA), undertaken in New Zealand in December, 2013. This seminar was coordinated by the WSS Fellows program of the International Social Science Council (ISSC), the RIA working group of the Integrated Research on Disaster Risk (IRDR) program, the IRDR International Center of Excellence Taipei, the International START Secretariat and the Royal Society of New Zealand. Twenty-five early career researchers from around the world were selected to review the RIA framework under the theme of \u27decision-making under conditions of uncertainty\u27, and develop novel theoretical approaches to respond to and improve this framework. Six working groups emerged during the seminar: 1. the assessment of water-related risks in megacities; 2. rethinking risk communication; 3. the embodiment of uncertainty; 4. communication in resettlement and reconstruction phases; 5. the integration of indigenous knowledge in disaster risk reduction; and 6. multi-scale policy implementation for natural hazard risk reduction. This article documents the seminar and initial outcomes from the six groups organized; and concludes with the collective views of the participants on the RIA framework

Quality indicators for patients with traumatic brain injury in European intensive care units

Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measur

Machine learning algorithms performed no better than regression models for prognostication in traumatic brain injury

Objective: We aimed to explore the added value of common machine learning (ML) algorithms for prediction of outcome for moderate and severe traumatic brain injury. Study Design and Setting: We performed logistic regression (LR), lasso regression, and ridge regression with key baseline predictors in the IMPACT-II database (15 studies, n = 11,022). ML algorithms included support vector machines, random forests, gradient boosting machines, and artificial neural networks and were trained using the same predictors. To assess generalizability of predictions, we performed internal, internal-external, and external validation on the recent CENTER-TBI study (patients with Glasgow Coma Scale <13, n = 1,554). Both calibration (calibration slope/intercept) and discrimination (area under the curve) was quantified. Results: In the IMPACT-II database, 3,332/11,022 (30%) died and 5,233(48%) had unfavorable outcome (Glasgow Outcome Scale less than 4). In the CENTER-TBI study, 348/1,554(29%) died and 651(54%) had unfavorable outcome. Discrimination and calibration varied widely between the studies and less so between the studied algorithms. The mean area under the curve was 0.82 for mortality and 0.77 for unfavorable outcomes in the CENTER-TBI study. Conclusion: ML algorithms may not outperform traditional regression approaches in a low-dimensional setting for outcome prediction after moderate or severe traumatic brain injury. Similar to regression-based prediction models, ML algorithms should be rigorously validated to ensure applicability to new populations

Exome Sequencing and the Management of Neurometabolic Disorders

BACKGROUND: Whole-exome sequencing has transformed gene discovery and diagnosis in rare diseases. Translation into disease-modifying treatments is challenging, particularly for intellectual developmental disorder. However, the exception is inborn errors of metabolism, since many of these disorders are responsive to therapy that targets pathophysiological features at the molecular or cellular level. METHODS: To uncover the genetic basis of potentially treatable inborn errors of metabolism, we combined deep clinical phenotyping (the comprehensive characterization of the discrete components of a patient's clinical and biochemical phenotype) with whole-exome sequencing analysis through a semiautomated bioinformatics pipeline in consecutively enrolled patients with intellectual developmental disorder and unexplained metabolic phenotypes. RESULTS: We performed whole-exome sequencing on samples obtained from 47 probands. Of these patients, 6 were excluded, including 1 who withdrew from the study. The remaining 41 probands had been born to predominantly nonconsanguineous parents of European descent. In 37 probands, we identified variants in 2 genes newly implicated in disease, 9 candidate genes, 22 known genes with newly identified phenotypes, and 9 genes with expected phenotypes; in most of the genes, the variants were classified as either pathogenic or probably pathogenic. Complex phenotypes of patients in five families were explained by coexisting monogenic conditions. We obtained a diagnosis in 28 of 41 probands (68%) who were evaluated. A test of a targeted intervention was performed in 18 patients (44%). CONCLUSIONS: Deep phenotyping and whole-exome sequencing in 41 probands with intellectual developmental disorder and unexplained metabolic abnormalities led to a diagnosis in 68%, the identification of 11 candidate genes newly implicated in neurometabolic disease, and a change in treatment beyond genetic counseling in 44%. (Funded by BC Children's Hospital Foundation and others.)

Frequency of fatigue and its changes in the first 6 months after traumatic brain injury: results from the CENTER-TBI study

Background: Fatigue is one of the most commonly reported subjective symptoms following traumatic brain injury (TBI). The aims were to assess frequency of fatigue over the first 6 months after TBI, and examine whether fatigue changes could be predicted by demographic characteristics, injury severity and comorbidities. Methods: Patients with acute TBI admitted to 65 trauma centers were enrolled in the study Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI). Subj

Tracheal intubation in traumatic brain injury

Background: We aimed to study the associations between pre- and in-hospital tracheal intubation and outcomes in traumatic brain injury (TBI), and whether the association varied according to injury severity. Methods: Data from the international prospective pan-European cohort study, Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI), were used (n=4509). For prehospital intubation, we excluded self-presenters. For in-hospital intubation, patients whose tracheas were intubated on-scene were excluded. The association between intubation and outcome was analysed with ordinal regression with adjustment for the International Mission for Prognosis and Analysis of Clinical Trials in TBI variables and extracranial injury. We assessed whether the effect of intubation varied by injury severity by testing the added value of an interaction term with likelihood ratio tests. Results: In the prehospital analysis, 890/3736 (24%) patients had their tracheas intubated at scene. In the in-hospital analysis, 460/2930 (16%) patients had their tracheas intubated in the emergency department. There was no adjusted overall effect on functional outcome of prehospital intubation (odds ratio=1.01; 95% confidence interval, 0.79–1.28; P=0.96), and the adjusted overall effect of in-hospital intubation was not significant (odds ratio=0.86; 95% confidence interval, 0.65–1.13; P=0.28). However, prehospital intubation was associated with better functional outcome in patients with higher thorax and abdominal Abbreviated Injury Scale scores (P=0.009 and P=0.02, respectively), whereas in-hospital intubation was associated with better outcome in patients with lower Glasgow Coma Scale scores (P=0.01): in-hospital intubation was associated with better functional outcome in patients with Glasgow Coma Scale scores of 10 or lower. Conclusion: The benefits and harms of tracheal intubation should be carefully evaluated in patients with TBI to optimise benefit. This study suggests that extracranial injury should influence the decision in the prehospital setting, and level of consciousness in the in-hospital setting. Clinical trial registration: NCT02210221

Informed consent procedures in patients with an acute inability to provide informed consent

Purpose: Enrolling traumatic brain injury (TBI) patients with an inability to provide informed consent in research is challenging. Alternatives to patient consent are not sufficiently embedded in European and national legislation, which allows procedural variation and bias. We aimed to quantify variations in informed consent policy and practice. Methods: Variation was explored in the CENTER-TBI study. Policies were reported by using a questionnaire and national legislation. Data on used informed consent procedures were available for 4498 patients from 57 centres across 17 European countries. Results: Variation in the use of informed consent procedur

Quality indicators for patients with traumatic brain injury in European intensive care units: a CENTER-TBI study

Abstract: Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measurement and improvement. Methods: Our analysis was based on 2006 adult patients admitted to 54 ICUs between 2014 and 2018, enrolled in the CENTER-TBI study. Indicator scores were calculated as percentage adherence for structure and process indicators and as event rates or median scores for outcome indicators. Feasibility was quantified by the completeness of the variables. Discriminability was determined by the between-centre variation, estimated with a random effect regression model adjusted for case-mix severity and quantified by the median odds ratio (MOR). Statistical uncertainty of outcome indicators was determined by the median number of events per centre, using a cut-off of 10. Results: A total of 26/42 indicators could be calculated from the CENTER-TBI database. Most quality indicators proved feasible to obtain with more than 70% completeness. Sub-optimal adherence was found for most quality indicators, ranging from 26 to 93% and 20 to 99% for structure and process indicators. Significant (p < 0.001) between-centre variation was found in seven process and five outcome indicators with MORs ranging from 1.51 to 4.14. Statistical uncertainty of outcome indicators was generally high; five out of seven had less than 10 events per centre. Conclusions: Overall, nine structures, five processes, but none of the outcome indicators showed potential for quality improvement purposes for TBI patients in the ICU. Future research should focus on implementation efforts and continuous reevaluation of quality indicators. Trial registration: The core study was registered with ClinicalTrials.gov, number NCT02210221, registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582)