Banding the world together; the global growth of control banding and qualitative occupational risk management

Control Banding (CB) strategies to prevent work-related illness and injury for 2.5 billion workers without access to health and safety professionals has grown exponentially this last decade. CB originates from the pharmaceutical industry to control active pharmaceutical ingredients without a complete toxicological basis and therefore no occupational exposure limits. CB applications have broadened into chemicals in general - including new emerging risks like nanomaterials and recently into ergonomics and injury prevention. CB is an action-oriented qualitative risk assessment strategy offering solutions and control measures to users through "toolkits". Chemical CB toolkits are user-friendly approaches used to achieve workplace controls in the absence of firm toxicological and quantitative exposure information. The model (technical) validation of these toolkits is well described, however firm operational analyses (implementation aspects) are lacking. Consequentially, it is often not known if toolkit use leads to successful interventions at individual workplaces. This might lead to virtual safe workplaces without knowing if workers are truly protected. Upcoming international strategies from the World Health Organization Collaborating Centers request assistance in developing and evaluating action-oriented procedures for workplace risk assessment and control. It is expected that to fulfill this strategy's goals, CB approaches will continue its important growth in protecting workers.

COVID-19 and oil price risk exposure

This study investigates oil price risk exposure of financial and non-financial industries around the world during the COVID-19 pandemic. The empirical results show that oil supply industries benefit from positive shocks to oil price risk in general, whereas oil user industries and financial industries react negatively to positive oil price shocks. The COVID-19 outbreak appears to moderate the oil price risk exposure of both financial and non-financial industries. This brings important implications in risk management of energy risk during the pandemic.

Influencing factors of cardiorespiratory fitness in allogeneic stem cell transplant candidates prior to transplantation

PURPOSE

Cardiorespiratory fitness (CRF) seems to be prognostic prior to allogeneic stem cell transplantation (allo-HSCT). Influencing factors of CRF in allo-HSCT candidates have not been studied so far. Aim was to identify potentially influencing factors on CRF.

METHODS

To assess CRF, a maximal cardiopulmonary exercise test (CPET) was performed on average 2.6 ± 7.2 days prior to admission. A regression analysis was conducted, with the following predictors: gender, age, body mass index (BMI), time between last therapy and allo-HSCT (t_Therapies), number of cardiotoxic therapies (n_Cardiotox), number of transplantations (n_Transplantations), comorbidity index (HCT-CI), hemoglobin level of the last 3 months (area under the curve), and physical activity.

RESULTS

A total of 194 patients performed a CPET. VO_2peak was significantly reduced compared with reference data. In total, VO_2peak was 21.4 ml/min/kg (- 27.5%, p < 0.05). Men showed a significant larger percentage difference from reference value (- 29.1%, p < 0.05) than women (- 24.4%). VO_2peak was significantly (p < 0.05) influenced by age (β = - 0.11), female gender (β = - 3.01), BMI (β = - 0.44), n_Cardiotox (β = - 0.73), hemoglobin level (β = 0.56), and physical activity prior to diagnosis (β = 0.10).

CONCLUSIONS

Our study demonstrates a decreased CRF indicating the potential need of prehabilitative exercise. We revealed some influencing factors on CRF. Those patients could benefit the most from exercise.

Health risk assessment of heavy metal and its mitigation by glomalin-related soil protein in sediments along the South China coast

Knowledge regarding the exposure risk of heavy metals in estuarine wetland is important for people (especially fishermen and consumers of local fish) living in the coastal area and the coastal reclamation. Here, we assessed the ecological and human health risks of sediment-associated metals in the large-scale estuary area based on different sediment textures (Mud, Mud-Sand, and Sand). To investigate the potential impact of terrestrial material on the contamination risks, glomalin-related soil protein (GRSP), a recalcitrant soil protein fraction, was used. Results showed that the estuarine sediment texture played a rather important role in the heavy metal distribution, risk assessment, and the metal sequestration capacity of the land-derived GRSP fraction. We found arsenic, Pb, Cd, and Cr had the highest enrichment in the estuarine wetlands by calculating multiple contamination indices, and that confirmed similar findings of heavy metal contents, except Cd. The average pollution load index (PLI) was 1.67 in all the estuarine sediments, indicating multi-element contamination, with the Muddy sediments (PLI = 2.07) significantly higher than the Mud-Sand mixed sediments (PLI = 1.85), and the lowest (0.78 < 1) in the Sandy sediments. The health risk assessment suggested that the potential cancer risk occurred (>1.00E-6) but no obvious non-carcinogenic effects occurred (<1). Arsenic was found to be the primary contributor to non-carcinogenic risk, accounting for 44.2% of hazard index, while Ni is the primary control metal for carcinogenic risk (except arsenic in the Sandy sediments). As a proxy of terrestrial organic matter, GRSP fraction possessed a high sequestration capacity for heavy metal, especially in the Sandy sediments, and it was significantly associated with the mitigation of ecological and health risks, which may provide new insights into the in situ remediation of anoxic estuarine wetlands.

Stakeholder Perceptions of Risk in Construction

Safety management in construction is an integral effort and its success requires inputs from all stakeholders across design and construction phases. Effective risk mitigation relies on the concordance of all stakeholders' risk perceptions. Many researchers have noticed the discordance of risk perceptions among critical stakeholders in safe construction work, however few have provided quantifiable evidence describing them. In an effort to fill this perception gap, this research performs an experiment that investigates stakeholder perceptions of risk in construction. Data analysis confirms the existence of such discordance, and indicates a trend in risk likelihood estimation. With risk perceptions from low to high, the stakeholders are architects, contractors/safety professionals, and engineers. Including prior studies, results also suggest that designers have improved their knowledge in building construction safety, but compared to builders they present more difficultly in reaching a consensus of perception. Findings of this research are intended to be used by risk management and decision makers to reassess stakeholders' varying judgments when considering injury prevention and hazard assessment.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BACKGROUND

We examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.

METHODS

This study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.

RESULTS

In total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).

CONCLUSIONS

Pre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

The changing face of nanomaterials: Risk assessment challenges along the value chain

Risk assessment (RA) of manufactured nanomaterials (MNM) is essential for regulatory purposes and risk management activities. Similar to RA of "classical" chemicals, MNM RA requires knowledge about exposure as well as of hazard potential and dose response relationships. What makes MNM RA especially challenging is the multitude of materials (which is expected to increase substantially in the future), the complexity of MNM value chains and life cycles, the accompanying possible changes in material properties over time and in contact with various environmental and organismal milieus, and the difficulties to obtain proper exposure data and to consider the proper dose metric. This article discusses these challenges and also critically overviews the current state of the art regarding MNM RA approaches.

Residual risk of infection with blood-borne viruses in potential organ donors at increased risk of infection: systematic review and meta-analysis

OBJECTIVE

To estimate the prevalence and incidence of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) among people at increased risk of infection in Australia; to estimate the residual risk of infection among potential solid organ donors in these groups when their antibody and nucleic acid test results are negative.

STUDY DESIGN

Systematic review and meta-analysis of reports of the incidence and prevalence of HIV, HCV, and HBV in groups at increased risk of infection in Australia.

DATA SOURCES

MEDLINE, government and agency reports, Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine conference abstracts, the Australian New Zealand Clinical Trial Registry, and National Health and Medical Research Council grants published 1 January 2000 - 14 February 2019; personal communications.

DATA SYNTHESIS

Residual risk of HIV infection was highest among men who have sex with men (4.8 [95% CI, 2.7-6.9] per 10 000 antibody-negative persons; 1.5 [95% CI, 0.9-2.2] per 10 000 persons who are both antibody- and nucleic acid-negative). Residual risk of HCV infection was highest among injecting drug users (289 [95% CI, 191-385] per 10 000 antibody-negative persons; 20.9 [95% CI, 13.8-28.0] per 10 000 antibody- and nucleic acid-negative persons). Residual risk for HBV infection was highest among injecting drug users (98.6 [95% CI, 36.4-213] per 10 000 antibody-negative people; 49.4 [95% CI, 18.2-107] per 10 000 persons who were also nucleic acid-negative).

CONCLUSIONS

Absolute risks of window period viral infections are low in people from Australian groups at increased risk but with negative viral test results. Accepting organ donations by people at increased risk of infection but with negative viral test results could be considered as a strategy for expanding the donor pool.

REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), CRD42017069820.

Risk assessment's insensitive toxicity testing may cause it to fail

BACKGROUND

Risk assessment of chemicals and other agents must be accurate to protect health. We analyse the determinants of a sensitive chronic toxicity study, risk assessment's most important test. Manufacturers originally generate data on the properties of a molecule, and if government approval is needed to market it, laws globally require toxicity data to be generated using Test Guidelines (TG), i.e. test methods of the Organisation for Economic Cooperation and Development (OECD), or their equivalent. TGs have advantages, but they test close-to-poisonous doses for chronic exposures and have other insensitivities, such as not testing disease latency. This and the fact that academic investigators will not be constrained by such artificial methods, created a de facto total ban of academia's diverse and sensitive toxicity tests from most risk assessment.

OBJECTIVE

To start and sustain a dialogue between regulatory agencies and academic scientists (secondarily, industry and NGOs) whose goals would be to (1) agree on the determinants of accurate toxicity tests and (2) implement them (via the OECD).

DISCUSSION

We analyse the quality of the data produced by these incompatible paradigms: regulatory and academic toxicology; analyse the criteria used to designate data quality in risk assessment; and discuss accurate chronic toxicity test methods.

CONCLUSION

There are abundant modern experimental methods (and rigorous epidemiology), and an existing systematic review system, to at long last allow academia's toxicity studies to be used in most risk assessments.

Different Nuss procedures and risk management for pectus excavatum after surgery for congenital heart disease

PURPOSE

In Nuss procedure for pectus excavatum (PE) after surgery for congenital heart disease (CHD), retrosternal adhesion may increase the risk of cardiac injury. This study aimed to explore different Nuss procedures and their implications for reducing the incidence of serious complications and improving surgical safety.

METHODS

We retrospectively reviewed 49 cases (29 male and 20 female) of Nuss procedures for PE after surgery for CHD that were performed between April 2003 and December 2016. The median age was 5.8 years (range, 3.0-17.9), and the median Haller index was 4.6 (3.2-17.7). All patients were evaluated on their cardiac function and severity of PE by echocardiography and computed tomography scan, respectively. Three surgical procedures were used. Perioperative conditions were analyzed, including CHD type, interval between two operations, blood loss, operation time, hospital stay, complications, and postoperative results.

RESULTS

All 49 cases were completed successfully. Fourteen cases (28.6%) involved the standard three-incision thoracoscopic Nuss procedure, 30 cases (61.2%) involved the Nuss procedure assisted by a median sternum incision, and 5 cases (10.2%) involved the Nuss procedure with sternal suspension. The median interval between the CHD surgery and Nuss procedure was 4.0 years (0.5-12.0). The median blood loss was 2.0 mL (1.0-150.0 mL). The median operation time was 45.0 min (27.0-230.0), and the median hospital stay was 6.0 days (5.0-9.0). Three patients (6.1%) experienced severe surgical complications: 2 experienced a rupture of the right atrium and 1 had pericardial injury. Patients were followed up for 7-120 months after surgery. The postoperative results were excellent in 46 cases (93.9%) and good in 3 (6.1%). Twenty-four of the 49 patients have had their bars removed. The median time for bar removal was 36.0 months (24.0-47.0). The outcome after bar removal surgery was excellent in 20 cases and good in 4.

CONCLUSIONS

Patients may develop PE or worsening of preexisting PE after open heart surgery for CHD. Surgery for PE can still be performed by the standard Nuss technique without increasing the risk of cardiac injury for the patients that have had interventional cardiology procedures for CHD previously. However, the risk of cardiac injury during the Nuss procedure dramatically increases due to retrosternal adhesions that develop after open heart surgery for CHD. In our experience, the Nuss procedure is safe and feasible after open heart surgery for CHD when performed by an experienced pectus surgeon using an individualized surgical plan for each patient.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level IV.

Does age matter in predicting musculoskeletal disorder risk? An analysis of workplace predictors over 4 years

BACKGROUND

Musculoskeletal disorders (MSDs) are a major workplace issue. With increasing pressure to extend working lives, predictors of MSD risk across all age groups require accurate identification to inform risk reduction strategies.

METHODS

In 2005 and 2009, a survey was conducted in a Finnish food processing company (N = 734). Data on workplace physical and psychosocial hazards, work ability, job satisfaction and lifestyle-related variables were collected, and MSD risk was measured through assessment of work-related strain in four body areas. Predictors of MSD risk across three age groups (20-35, 36-49, 50+) were assessed with linear regression analysis.

RESULTS

Physical hazards and MSD risk were related differently for each age group. The relationship between psychosocial hazards and MSD risk was less clear. For younger workers, physical hazards were not associated with MSD risk. In contrast, for those aged 36-49, repetitive movements (B = 1.76, p < 0.001) and awkward postures (B = 1.30, p = 0.02) were associated with increased MSD risk. For older workers, environmental hazards were positively associated with MSD risk (B = 0.37, p = 0.04). Predictors of MSD risk changed differently for each age group during 4 years of follow-up. For younger workers, change in environment and repetitive movements, for middle age team support and for older workers change in awkward posture were significant predictors of MSD risk.

CONCLUSIONS

These results support the need for workplace-specific hazard surveillance data. This will ensure that all contributing factors to MSD risk can be accurately identified and controlled independent of age.

Technology Acceptance of a Machine Learning Algorithm Predicting Delirium in a Clinical Setting: a Mixed-Methods Study

Early identification of patients with life-threatening risks such as delirium is crucial in order to initiate preventive actions as quickly as possible. Despite intense research on machine learning for the prediction of clinical outcomes, the acceptance of the integration of such complex models in clinical routine remains unclear. The aim of this study was to evaluate user acceptance of an already implemented machine learning-based application predicting the risk of delirium for in-patients. We applied a mixed methods design to collect opinions and concerns from health care professionals including physicians and nurses who regularly used the application. The evaluation was framed by the Technology Acceptance Model assessing perceived ease of use, perceived usefulness, actual system use and output quality of the application. Questionnaire results from 47 nurses and physicians as well as qualitative results of four expert group meetings rated the overall usefulness of the delirium prediction positively. For healthcare professionals, the visualization and presented information was understandable, the application was easy to use and the additional information for delirium management was appreciated. The application did not increase their workload, but the actual system use was still low during the pilot study. Our study provides insights into the user acceptance of a machine learning-based application supporting delirium management in hospitals. In order to improve quality and safety in healthcare, computerized decision support should predict actionable events and be highly accepted by users.

Early detection of diving-related cognitive impairment of different nitrogen-oxygen gas mixtures using critical flicker fusion frequency

INTRODUCTION

Cognitive impairment related to inert gas narcosis (IGN) is a threat to diving safety and operations at depth that might be reduced by using enriched air nitrox (EANx) mixtures. Using critical flicker fusion frequency (CFFF), a possible early detection of cognitive abilities/cerebral arousal impairment when breathing different oxygen (O2) fractions was investigated.

METHODS

Eight male volunteers performed, in random order, two dry chamber dives breathing either air or EANx40 (40% O₂-60% nitrogen) for 20 minutes (min) at 0.4 MPa. Cognition and arousal were assessed before the dive; upon arrival at 0.4 MPa; after 15 min exposure at 0.4 MPa; on surfacing and 30 min post-dive using behavioural computer-based testing psychology experiment building language (PEBL) and by CFFF while continuously recording brain oxygenation with near-infrared spectroscopy.

RESULTS

In both breathing conditions, CFFF and PEBL demonstrated a significant inverse correlation (Pearson r of -0.90, P < 0.0001), improved cognitive abilities/cerebral arousal occurred upon arrival at 0.4 MPa followed by a progressive deterioration. Initial brain activation was associated with a significant increase in oxyhaemoglobin (HbO2) and a simultaneous decrease of deoxyhaemoglobin (HHb). The magnitude of the changes was significantly greater under EANx (P = 0.038).

CONCLUSIONS

Since changes were not related to haemodynamic variables, HbO₂ and HHb values indicate a significant, O₂-dependent activation in the prefrontal cortex. Owing to the correlation with some tests from the PEBL, CFFF could be a convenient measure of cognitive performance/ability in extreme environments, likely under the direct influence of oxygen partial pressure, a potent modulator of IGN symptoms.

Emergency Management in a Dental Clinic During the Coronavirus Disease 2019 (COVID-19) Epidemic in Beijing

BACKGROUND

In mid-March 2020, the World Health Organization declared that COVID-19 was to be characterised as a pandemic. The purpose of this article is to recommend emergency management procedures for dental clinics during this public health emergency.

MATERIALS AND METHODS

We have implemented a series of emergency management measures to prevent cross-infection in our dental clinic during the COVID-19 pandemic, including personnel scheduling, division of the clinic into functional areas, limitation or delay of non-emergency patients, staff protection and infection controls, clinical environmental disinfection, and the use of online consultation services, among others.

RESULTS

Due to public health policy and dental emergency management, the number of dental visitors to our clinic dropped sharply, and no COVID-19 suspected cases or high-risk patients received treatment. There have been no reports of infection of dental staff or patients during dental treatment in China to date.

CONCLUSION

These public health policies and dental emergency management measures were effective in controlling cross-infection of COVID-19 in the dental clinic.

PRACTICAL IMPLICATIONS

We share control measures for COVID-19, and hope that they will be helpful for dental professionals worldwide to continue to provide dental care in a safe and orderly manner.

Risk assessment in Finland: theory and practice

The Finnish risk assessment practice is based on the Occupational Safety and Health (OSH) Act aiming to improve working conditions in order maintain the employees' work ability, and to prevent occupational accidents and diseases. In practice there are hundreds of risk assessment methods in use. A simple method is used in small and medium sized enterprises and more complex risk evaluation methods in larger work places. Does the risk management function in the work places in Finland? According to our experience something more is needed. That is, understanding of common and company related benefits of risk management. The wider conclusion is that commitment for risk assessment in Finland is high enough. However, in those enterprises where OSH management was at an acceptable level or above it, there were also more varied and more successfully accomplished actions to remove or reduce the risks than in enterprises, where OSH management was in lower level. In risk assessment it is important to process active technical prevention and exact communication, increase work place attraction and increase job satisfaction and motivation. Investments in OSH are also good business. Low absenteeism due to illness or accidents increases directly the production results by improved quality and quantity of the product. In general Finnish studies have consistently shown that the return of an invested euro is three to seven-old. In national level, according to our calculations the savings could be even 20% of our gross national product.

Occurrence and Trend of Hepatitis A Virus in Bivalve Molluscs Production Areas Following a Contamination Event

The aim of this study was to assess the trend of hepatitis A virus (HAV) in a coastal zone impacted by a contamination event, providing data for the development of management strategies. A total of 352 samples, including four bivalve mollusc species (Mytilus galloprovincialis, Solen vagina, Venus gallina and Donax trunculus), were taken over a period of 6 months from 27 production areas of the coast and analysis were performed according to ISO/TS 15216-1:2013. HAV presence was detected in 77 samples from 11 production areas and all positive results were related to samples collected in the first 3 months of the surveillance, during which HAV prevalence was 39.9% and values as high as 5096 genome copies/g were detected. A progressive reduction of viral contamination was evident during the first trimester of the monitoring, with prevalence decreasing from 78.8% in the first month, to 37.8% in the second and 3.9% in the third and quantitative levels reduced from an average value of 672 genome copies/g to 255 genome copies/g over a period of 4 weeks (virus half-life: 21.5 days). A regression analysis showed that, during the decreasing phase of the contamination, the data fitted a reciprocal quadratic model (Ra² = 0.921) and, based on the model, a residual presence of HAV could be estimated after negativization of the production areas. The statistical analysis of the results per shellfish species and per production area showed that there were limited differences in contamination prevalence and levels among diverse bivalve species, while a statistically significant difference was present in quantitative levels of one production area. These data could be useful for the development of both risk assessment models and code of practice for the management of viral contamination in primary production.

Sigma Metrics Across the Total Testing Process

Laboratory quality control has been developed for several decades to ensure patients' safety, from a statistical quality control focus on the analytical phase to total laboratory processes. The sigma concept provides a convenient way to quantify the number of errors in extra-analytical and analytical phases through the defect per million and sigma metric equation. Participation in a sigma verification program can be a convenient way to monitor analytical performance continuous quality improvement. Improvement of sigma-scale performance has been shown from our data. New tools and techniques for integration are needed.

Harmonizing science and management options to reduce risks of cyanobacteria

Management of cyanobacteria has become an increasingly complex venture. Cyanobacteria risks have amplified as society moves forward in an era of accelerated global changes. The cyanobacteria management "pendulum" has progressively shifted from prevention to mitigation, with management considerations often put forth after bloom formation. A universal system (i.e., one-size-fits-all management) fails to provide a management path forward due to the inherent complexities of each lake. A tailored management plan is needed: the right species at the right time in the right place (i.e., the three Rs). The three Rs represent a customizable management strategy that is flexible and informed by advances in scientific understanding to lower cyanobacteria-associated risks. Identifying thresholds in risk tolerance, where thresholds are defined by community collectives, is essential to frame cyanobacteria management targets and to decide on what management interventions are warranted.

Horizontal infection prevention measures and a risk-managed approach to vancomycin-resistant enterococci: An evaluation

BACKGROUND

The use of infection control measures in the management of vancomycin-resistant enterococci (VRE) is hotly debated. A risk-managed approach to VRE control after the introduction of 2 horizontal infection prevention measures-an environmental cleaning (EC) and an antimicrobial stewardship (AMS) program-was assessed.

METHODS

Routine screening for VRE was discontinued 6 and 4 months after introduction of the EC and AMS programs, respectively. Only 4 units (intensive care, burns-trauma, solid organ transplant, and bone marrow transplant units) where patients were deemed to be at increased risk for VRE infection continued screening and contact precautions. Cost avoidance and value-added benefits were monitored by the hospital finance department. VRE monitoring on these high-risk units and facility-wide comprehensive bacteremia surveillance continued as per established protocols. Surveillance for methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile infection (CDI) remained unchanged.

RESULTS

VRE bacteremia rates did not increase with the change to the VRE risk-managed approach. The number of patients requiring VRE isolation in all areas of the hospital decreased from an average of 32 to 6 beds per day. Statistically significant reductions in CDI and MRSA rates were observed possibly related to the aggressive decluttering, equipment cleaning, and AMS program elements.

CONCLUSION

A risk-managed approach to VRE can be implemented without adverse consequences and potentially with significant benefits to a facility.

Harnessing landscape heterogeneity for managing future disturbance risks in forest ecosystems

In order to prevent irreversible impacts of climate change on the biosphere it is imperative to phase out the use of fossil fuels. Consequently, the provisioning of renewable resources such as timber and biomass from forests is an ecosystem service of increasing importance. However, risk factors such as changing disturbance regimes are challenging the continuous provisioning of ecosystem services, and are thus a key concern in forest management. We here used simulation modeling to study different risk management strategies in the context of timber production under changing climate and disturbance regimes, focusing on a 8127 ha forest landscape in the Northern Front Range of the Alps in Austria. We show that under a continuation of historical management, disturbances from wind and bark beetles increase by +39.5% on average over 200 years in response to future climate change. Promoting mixed forests and climate-adapted tree species as well as increasing management intensity effectively reduced future disturbance risk. Analyzing the spatial patterns of disturbance on the landscape, we found a highly uneven distribution of risk among stands (Gini coefficients up to 0.466), but also a spatially variable effectiveness of silvicultural risk reduction measures. This spatial variability in the contribution to and control of risk can be used to inform disturbance management: Stands which have a high leverage on overall risk and for which risks can effectively be reduced (24.4% of the stands in our simulations) should be a priority for risk mitigation measures. In contrast, management should embrace natural disturbances for their beneficial effects on biodiversity in areas which neither contribute strongly to landscape-scale risk nor respond positively to risk mitigation measures (16.9% of stands). We here illustrate how spatial heterogeneity in forest landscapes can be harnessed to address both positive and negative effects of changing natural disturbance regimes in ecosystem management.

Testing the performance of one and two box models as tools for risk assessment of particle exposure during packing of inorganic fertilizer

Modelling of particle exposure is a useful tool for preliminary exposure assessment in workplaces with low and high exposure concentrations. However, actual exposure measurements are needed to assess models reliability. Worker exposure was monitored during packing of an inorganic granulate fertilizer at industrial scale using small and big bags. Particle concentrations were modelled with one and two box models, where the emission source was estimated with the fertilizer's dustiness index. The exposure levels were used to calculate inhaled dose rates and test accuracy of the exposure modellings. The particle number concentrations were measured from worker area by using a mobility and optical particle sizer which were used to calculate surface area and mass concentrations. The concentrations in the worker area during pre-activity ranged 63,797-81,073 cm^-3, 4.6 × 10⁶ to 7.5 × 10⁶ μm² cm^-3, and 354 to 634 μg m^-3 (respirable mass fraction) and during packing 50,300 to 85,949 cm^-3, 4.3 × 10⁶ to 7.6 × 10⁶ μm² cm^-3, and 279 to 668 μg m^-3 (respirable mass fraction). Thus, the packing process did not significantly increase the exposure levels. Chemical exposure was also under control based on REACH standards. The particle surface area deposition rate in respiratory tract was up to 7.6 × 10⁶ μm² min^-1 during packing, with 52%-61% of deposition occurring in the alveolar region. Ratios of the modelled and measured concentrations were 0.98 ± 0.19 and 0.84 ± 0.12 for small and big bags, respectively, when using the one box model, and 0.88 ± 0.25 and 0.82 ± 0.12, when using the two box model. The modelling precision improved for both models when outdoor particle concentrations were included. This study shows that exposure concentrations in a low emission industrial scenario, e.g. during packing of a fertilizer, can be predicted with a reasonable accuracy by using the concept of dustiness and mass balance models.

Clinical applications of AI in MSK imaging: a liability perspective

Artificial intelligence (AI) applications have been gaining traction across the radiology space, promising to redefine its workflow and delivery. However, they enter into an uncertain legal environment. This piece examines the nature, exposure, and theories of liability relevant to musculoskeletal radiologist practice. More specifically, it explores the negligence, vicarious liability, and product liability frameworks by way of illustrative vignettes.

The effect of electronic reminders on risk management among diabetic patients in low resourced settings

BACKGROUND

Information technology has potential to improve health care delivery particularly among individuals with chronic diseases such as diabetes in low and middle-income countries (LMIC). Research on the usefulness of information technology to manage persons living with chronic diseases is scarce in LMIC. We sought to evaluate the effect of an electronic reminder system on cardiovascular risk factors (blood pressure, heart rate, and fasting plasma glucose) and adherence to clinical appointments among persons living with diabetes.

RESEARCH DESIGN AND METHODS

A randomized controlled design was used to recruit 200 diabetic patients (intervention n=100, control n=100) from the National Diabetes Management Research Centre, Accra. All patients received usual diabetes care. The intervention group was given electronic reminders for their clinical appointments and their physicians were prompted with abnormal laboratory results for six months.

RESULTS

Baseline characteristics were largely similar for both groups. At six months follow up, the mean reductions of all the cardiovascular risk factors in the intervention group were significantly greater than in the control group: -1.7 kg/m(2) versus -1.1 kg/m(2)(p=0.002) for BMI; -4.7 mmHg versus -2.8 mmHg (p=0.002) for SBP; -5.3 mmH versus -3.1 mmHg (p=0.001) for DBP; -1.7 bpm versus -0.1 bpm (p=0.001) for heart rate and -2.3 mmol/L versus -1.6 mmol/L (p=0.001) for fasting plasma glucose, respectively. Adherence to appointment schedules was also significantly higher in the intervention group compared with the control group (97.8% versus 89.4%, p=0.010).

CONCLUSIONS

Locally developed electronic initiatives such as this resulted in improved cardiovascular risk factors and effective compliance to clinical practices and improved quality of care for persons living with diabetes.

Enhancing phytoextraction of potentially toxic elements in a polluted floodplain soil using sulfur-impregnated organoclay

Enhancing metals phytoextraction using gentile mobilizing agents might be an appropriate approach to increase the phytoextraction efficiency and to shorten the phytoremediation duration. The effect of sulfur-impregnated organoclay (SIOC) on the redistribution of potentially toxic elements (PTEs) among their geochemical fractions in soils and their plant uptake has not yet been studied. Therefore, our aim is to investigate the role of different SIOC application doses (1%, 3% and 5%) on operationally defined geochemical fractions (soluble + exchangeable; bound to carbonate; manganese oxide; organic matter; sulfide; poorly- and well-crystalline Fe oxide; and residual fraction) of Cd, Cr, Cu, Ni, Pb, and Zn, and their accumulation by pea (Pisum sativum) and corn (Zea mays) in a greenhouse pot experiment using a polluted floodplain soil. The SIOC caused a significant decrease in soil pH, and an increase in organic carbon and total sulfur content in the soil. The addition of SIOC increased significantly the soluble + exchangeable fraction and bioavailability of the metals. The SIOC leads to a transformation of the residual, organic, and Fe-Mn oxide fractions of Cd, Cu, Ni, and Zn to the soluble + exchangeable fraction. The SIOC addition increased the potential mobile (non-residual) fraction of Cr and Pb. The SIOC increased the sulfide fraction of Cr, Ni, and Zn, while it decreased the same fraction for Cd, Cu, and Pb. The effect of SIOC on the redistribution of metal fractions increased with enhancing application dosages. Pea accumulated more metals than corn with greater accumulation in the roots than shoots. Application of the higher dose of SIOC promoted the metals accumulation by roots and their translocation to shoots of pea and corn. Our results suggest the potential suitability of SIOC for enhancing the phytomanagement of PTEs polluted soils and reducing the environmental risk of these pollutants.

Comparison of drug-related problem risk assessment tools for older adults: a systematic review

PURPOSE

This study aims to systematically review studies describing screening tools that assess the risk for drug-related problems (DRPs) in older adults (≥ 60 years). The focus of the review is to compare DRP risks listed in different tools and describe their development methods and validation.

METHODS

The systematic search was conducted using evidence-based medicine, Medline Ovid, Scopus, and Web of Science databases from January 1, 1985, to April 7, 2016. Publications describing general DRP risk assessment tools for older adults written in English were included. Disease, therapy, and drug-specific tools were excluded. Outcome measures included an assessment tool's content, development methods, and validation assessment.

RESULTS

The search produced 15 publications describing 11 DRP risk assessment tools. Three major categories of risks for DRPs included (1) patient or caregiver related risks; (2) pharmacotherapy-related risks; and (3) medication use process-related risks. Of all the risks included in the tools only 8 criteria appeared in at least 4 of the tools, problems remembering to take the medication being the most common (n=7). Validation assessments varied and content validation was the most commonly conducted (n = 9). Reliability assessment was conducted for 6 tools, most commonly by calculating internal consistency (n = 3) and inter-rater reliability (n = 2).

CONCLUSIONS

The considerable variety between the contents of the tools indicates that there is no consensus on the risk factors for DRPs that should be screened in older adults taking multiple medicines. Further research is needed to improve the accuracy and timeliness of the DRP risk assessment tools.