Post-operative Complications Following Emergency Operations Performed by Trainee Surgeons: A Retrospective Analysis of Surgical Deaths.

BACKGROUND: Adequate surgical care of patients and concurrent training of residents is achieved in elective procedures through careful case selection and adequate supervision. Whether this applies when trainees are involved in emergency operations remains equivocal. The aim of this study was therefore to compare the risk of post-operative complications following emergency procedures performed by senior operators compared with supervised trainees. METHODS: This is a retrospective cohort study examining in-hospital deaths of patients across all surgical specialties who underwent emergency surgery in Australian public hospitals reported to the national surgical mortality audit between 2009 and 2015. Multivariable logistic regression was used to explore whether there was an association between the level of operator experience (senior operator vs trainee) and the occurrence of post-operative surgical complications following an emergency procedure. RESULTS: Our population consisted of 6920 patients. There were notable differences between the trainees and senior operator groups; trainees more often operated on patients aged over 80 years, with cardiovascular and neurological risk factors. Senior operators more often operated on very young and obese patients with advanced malignancy and hepatic disease. Supervised trainees had a lower rate of post-operative complications compared with senior operators; 18% (n = 396) and 25% (n = 1210), respectively (p < 0.05). Operations performed by trainees were associated with an 18% decrease (95% CI 5-29%; p < 0.05) in odds of post-operative complications compared with senior operators, adjusting for potential confounders. CONCLUSIONS: Contrary to popular belief, our results suggest that supervised trainees safely perform emergency operations, provided that cases are judiciously selected.

Sleep-Related Infant Deaths in Victoria: A Retrospective Case Series Study.

BACKGROUND: There is general agreement that in some circumstances, sharing a sleep surface of any kind with an infant increases the risk of sudden unexpected death in infancy. There is a paucity of research conducted in Australia examining this issue. This study examines the frequency and distribution of sleep-related infant deaths in a defined population, and reports the proportion that occurred in the context of bed-sharing. METHODS: A retrospective population-based case series study was conducted of infants (≤365 days) who died in a sleeping context during the period 1 January 2008 to 31 December 2010 in the state of Victoria, Australia. Information about the infant, caregiver, sleeping environment and bed-sharing was collected from a review of the coroner's death investigation record. RESULTS: During the 3-year study period, 72 infant deaths occurred in a sleeping context. Of these, 33 (45.8 %) occurred in the context of bed-sharing: n = 7 in 2008; n = 11 in 2009; and n = 15 in 2010. Further analysis of the 33 deaths occurring in the context of bed-sharing showed that in this group, bed-sharing was largely intentional, habitual and most often involved the mother as one of the parties. CONCLUSIONS: Given the case series nature of the study design, a causal relationship between bed-sharing and infant death could not be inferred. However the fact that nearly half of all sleep-related deaths occurred in the context of bed-sharing, provides strong support for the need to undertake definitive analytic studies in Australia so that evidence-based advice can be provided to families regarding the safety of bed-sharing practices.

Identifying clusters of falls-related hospital admissions to inform population targets for prioritising falls prevention programmes.

BACKGROUND: There has been limited research investigating the relationship between injurious falls and hospital resource use. The aims of this study were to identify clusters of community-dwelling older people in the general population who are at increased risk of being admitted to hospital following a fall and how those clusters differed in their use of hospital resources. METHODS: Analysis of routinely collected hospital admissions data relating to 45 374 fall-related admissions in Victorian community-dwelling older adults aged ≥65 years that occurred during 2008/2009 to 2010/2011. Fall-related admission episodes were identified based on being admitted from a private residence to hospital with a principal diagnosis of injury (International Classification of Diseases (ICD)-10-AM codes S00 to T75) and having a first external cause of a fall (ICD-10-AM codes W00 to W19). A cluster analysis was performed to identify homogeneous groups using demographic details of patients and information on the presence of comorbidities. Hospital length of stay (LOS) was compared across clusters using competing risks regression. RESULTS: Clusters based on area of residence, demographic factors (age, gender, marital status, country of birth) and the presence of comorbidities were identified. Clusters representing hospitalised fallers with comorbidities were associated with longer LOS compared with other cluster groups. Clusters delineated by demographic factors were also associated with increased LOS. CONCLUSIONS: All patients with comorbidity, and older women without comorbidities, stay in hospital longer following a fall and hence consume a disproportionate share of hospital resources. These findings have important implications for the targeting of falls prevention interventions for community-dwelling older people.

Personality, perceptions and behavior: A study of speeding amongst drivers in Victoria, Australia.

INTRODUCTION: Road crashes present a serious public health issue. Many people are seriously or fatally injured every year in avoidable crashes. While these crashes can have multiple contributing factors, including road design and condition, vehicle design and condition, the environment and human error, the performance of illegal driving behavior, including speeding, may also play a role. The current study aimed to examine the mediating influence that four potential deterrents (perceptions towards enforcement, crash risk, social norms and disapproval, and negative personal/emotional affect) have between the Big Five personality traits (conscientiousness; extraversion; agreeableness; neuroticism; openness) and expectations to speed. METHODS: A total of 5,108 drivers in Victoria, Australia completed an online survey in 2019. A mediated regression analysis was used to examine pathways in a conceptual model developed for the study. RESULTS: The results showed that perceptions towards the four potential deterrents examined did mediate the relationship (either completely or partially) between personality and expectations to speed. CONCLUSIONS: The results of this study suggest that if interventions to deter illegal driving behavior are to be successful, one factor that could be taken into account is the personality traits of drivers who may be at greatest risk of the performance of illegal driving behaviors.

Review of injuries over a one year period among 87,134 adults studying at an open university in Thailand.

Countries need epidemiological information about population injury statistics to devise preventive strategies. To generate such information we estimated the one-year incidence and distribution of injury in a group of 87,134 adult Sukhothai Thammathirat Open University distance-learning students residing throughout Thailand. Those who participated joined the study by filling out a baseline questionnaire in 2005 which included a one-year recall of injuries serious enough to interfere with daily activities and/or require medical treatment. The more serious injuries were categorised by location, mechanism and intentionality. We collected sociodemographic information about the participants. Nearly 22% of participants reported at least one injury during the previous 12 months. Males, those with lower income and the less educated, had higher injury rates. Home injuries were more common among females. Sports, road and workplace injuries were more common among males. Transport injuries decreased with age and falls increased with age. Most injuries were unintentional. Injury rates among Thai adults are high. We identified at risk groups by injury mechanism and setting. Before interventions can be devised more research is needed regarding exposure and vulnerability in at risk socio-demographic groups.

Traffic offending and deterrence: An examination of recidivism amongst drivers in Victoria, Australia born prior to 1975.

To deter the performance of illegal driving behaviours, traffic infringement notices may be issued. Whilst there is a substantial body of research that has examined rates of reoffending following a traffic infringement, there have been few studies examining the length of time to next traffic offence. Where this research has been conducted, the findings do not provide current understandings, given the substantial changes in traffic sanctioning over time. The aim of this study was to address this gap, by examining risk factors for recidivism following a driver receiving a traffic infringement notice, as well as the time to next traffic offence. Licensing and infringements data held in the Driver Licensing System (DLS), maintained by the road authority in Victoria, Australia were used. All drivers included in the study were born prior to 1975, and received their first Victorian drivers licence between 1994 and 2016. Data from 203,620 drivers were used. Cox proportional hazards modelling was undertaken to examine factors associated with recidivism within 12 months of receiving a traffic infringement. 131,691 (64.7%) drivers had received at least one traffic infringement in Victoria, Australia since receiving their Victorian driver's licence. Factors found to be associated with longer time to further traffic offending in the year that followed the first infringement included being female; receiving a first Victorian driver's licence when aged 45+ years; and being licenced 10+ years. Traffic infringements deter some groups of Victorian drivers, but not others. If drivers are to be deterred from further illegal driving behaviour, it is important other countermeasures are developed and trialled.

A simulator study of driving behavior and mental workload in mixed-use arterial road environments.

Objectives: Mixed-use urban environments, such as arterial roads with adjacent commercial land uses, represent crash locations with the highest risk. These locations are often characterized by high volumes of motor vehicle traffic, on-street parking, and interactions with multiple road user groups such as pedestrians, cyclists, and public transportation. The objective of this study was to investigate previously identified crash risk factors for mixed-use urban environments and assess how parking occupancy, center medians, and cyclist volume influence performance and workload in a driving simulator study. Methods: Thirty participants were recruited for the study. Participants completed 6 drives that presented different combinations of cyclist volume, median condition, and parking occupancy. Incorporated into the simulator drives was a secondary peripheral detection task (PDT) designed to measure mental workload. Participants provided subjective assessments of workload using the Rating Scale Mental Effort (RSME). Results: Mean lateral lane position was found to significantly vary across the 3 independent variables of parking occupancy, cyclist volume, and median conditions. No significant changes were identified for mean speed across the conditions. Subjective and objective measures of workload identified changes due to the presence of cyclists with slower reaction times for the PDT task when cyclists were present. Conclusion: The findings provide insight into the interaction of road design elements in mixed-use urban road environments and demonstrate that increasingly complex environments increase driver demand. This has important road design implications for mixed-use arterial roads, which are often characterized by complex interactions between multiple road user groups.

Rural centres do not have a higher prevalence of post-operative complications than urban centres: a retrospective analysis of a mortality audit.

BACKGROUND: The trend towards centralization of surgical care from rural to high-volume centres is based on studies showing better outcomes for patients requiring complex surgical procedures. However, evidence that this also applies to less complex procedures is lacking. This study therefore aimed to determine whether there was a relationship between geographic location (rural versus urban) of surgical procedures of varying complexity and post-operative complications. METHODS: This was a retrospective cohort study examining all in-hospital deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2009 and 2016. Multivariable logistic regression was used to ascertain interactive effects of location and complexity of surgical procedures on post-operative complications, adjusted for potential confounders. RESULTS: There was no interactive effect of hospital location and operation complexity on the occurrence of post-operative complications. Post-operative complications were reported in 2160 of 6963 (31%) patients who died post-surgery. Patients operated on in rural centres had lower risk profiles: younger, with lower American Society of Anesthesiologists grades and less likely to present with injury and circulatory diseases. Nonetheless, risk of post-operative complications did not differ between procedures performed in rural compared with urban hospitals. CONCLUSION: Results of this study suggest that a wide range of procedures may be safely performed in rural centres. Further prospective studies of unfiltered cohorts are warranted to validate these findings.

Clozapine-associated myocarditis: a review of 116 cases of suspected myocarditis associated with the use of clozapine in Australia during 1993-2003.

BACKGROUND: Clozapine is an antipsychotic medication associated with a lower suicide rate compared with other antipsychotic agents. Clozapine is used specifically in patients for whom previous therapy was inadequate or not tolerated, and is the only antipsychotic agent associated with the development of myocarditis. OBJECTIVE: To retrospectively review all adverse drug reaction reports voluntarily submitted to the Australian Adverse Drug Reactions Unit mentioning suspected myocarditis in clozapine-treated patients. PATIENTS AND METHODS: We accessed all electronic database entries and case reports citing suspected myocarditis associated with clozapine therapy from January 1993 through to December 2003, inclusive. RESULTS: 116 case reports of suspected myocarditis amongst clozapine-treated patients were identified during the specified time frame (incidence between 0.7% and 1.2% of treated patients). Median patient age for these cases was 30 years (SD 11.1 years) compared with 37 years from the Clopine registry. The condition developed within a median 16 days (mean 19.8 days; SD 17.3 days) of commencing clozapine for the bulk of patients developing myocarditis within 6 months (n=93, 80.2%). For all cases with known treatment commencement and cessation dates (n=106), the condition developed within a median 17 days (mean 171.7 days, SD 530.9 days). Over nine-tenths of cases were prescribed clozapine within the dose range of 100 mg/day to 450 mg/day. Sixty patients (51.8%) recovered from their episode when reported or during follow-up reports, whereas 17 patients (14.7%) had not yet recovered: 27 patients (23.3%) had unknown outcome when reported and the remaining 12 patients (10.3%) died. CONCLUSION: Clozapine is uncommonly but importantly related to myocarditis, often fatal or near fatal and sometimes in relatively young patients with early onset after treatment initiation. The most striking feature about this condition is the wide diversity of nonspecific symptoms that occur in afflicted patients. Additional pharmacovigilance, improved reporting systems and further investigation of mechanisms of drug-induced myocarditis and related cardiovascular conditions (such as heart failure) are clearly warranted. A case-control study would be suitable for investigation of baseline predictors.

Traffic signal phasing at intersections to improve safety for alcohol-affected pedestrians.

Alcohol-affected pedestrians are among the highest-risk groups involved in pedestrian casualty crashes. This paper investigates the opportunities to use a modified form of traffic signal operation during high-risk periods and at high-risk locations to reduce alcohol-affected pedestrian crashes and the severity of injuries that might otherwise occur. The 'Dwell-on-Red' treatment involves displaying a red traffic signal to all vehicle directions during periods when no vehicular traffic is detected, so that drivers approach high-risk intersections at a lower speed than if a green signal were displayed. Vehicle speed data were collected before and after treatment activation at both a control and treatment site. Speed data were collected both 30 m prior to and at the intersection stop line. The treatment was associated with a reduction in mean vehicle speeds of 3.9 kph (9%) and 11.0 kph (28%) at 30 m and stop line collection points, respectively, and substantial reductions in the proportion of vehicles travelling at threatening speeds with regard to the severity of pedestrian injury. Other important road safety concerns may also benefit from this form of traffic signal modification, and it is recommended that other areas of application be explored, including the other severe trauma categories typically concentrated around signalised intersections.

In the eye of the beholder: A simulator study of the impact of Google Glass on driving performance.

This study examined whether, and to what extent, driving is affected by reading text on Google Glass. Reading text requires a high level of visual resources and can interfere with safe driving. However, it is currently unclear if the impact of reading text on a head-mounted display, such as Google Glass (Glass), will differ from that found with more traditional head-down electronic devices, such as a dash-mounted smartphone. A total of 20 drivers (22-48 years) completed the Lane Change Test while driving undistracted and while reading text on Glass and on a smartphone. Measures of lateral vehicle control and event detection were examined along with subjective workload and secondary task performance. Results revealed that drivers' lane keeping ability was significantly impaired by reading text on both Glass and the smartphone. When using Glass, drivers also failed to detect a greater number of lane change signs compared to when using the phone or driving undistracted. In terms of subjective workload, drivers rated reading on Glass as subjectively easier than on the smartphone, which may possibly encourage greater use of this device while driving. Overall, the results suggest that, despite Glass allowing drivers to better maintain their visual attention on the forward scene, drivers are still not able to effectively divide their cognitive attention across the Glass display and the road environment, resulting in impaired driving performance.

Characteristics of the road and surrounding environment in metropolitan shopping strips: association with the frequency and severity of single-vehicle crashes.

OBJECTIVES: Modeling crash risk in urban areas is more complicated than in rural areas due to the complexity of the environment and the difficulty obtaining data to fully characterize the road and surrounding environment. Knowledge of factors that impact crash risk and severity in urban areas can be used for countermeasure development and the design of risk assessment tools for practitioners. This research aimed to identify the characteristics of the road and roadside, surrounding environment, and sociodemographic factors associated with single-vehicle crash (SVC) frequency and severity in complex urban environments, namely, strip shopping center road segments. METHODS: A comprehensive evidence-based list of data required for measuring the influence of the road, roadside, and other factors on crash risk was developed. The data included a broader range of factors than those traditionally considered in accident prediction models. One hundred and forty-two strip shopping segments located on arterial roads in metropolitan Melbourne, Australia, were identified. Police-reported casualty data were used to determine how many SVC occurred on the segments between 2005 and 2009. Data describing segment characteristics were collected from a diverse range of sources; for example, administrative government databases (traffic volume, speed limit, pavement condition, sociodemographic data, liquor licensing), detailed maps, on-line image sources, and digital images of arterial roads collected for the Victorian state road authority. Regression models for count data were used to identify factors associated with SVC frequency. Logistic regression was used to determine factors associated with serious and fatal outcomes. RESULTS: One hundred and seventy SVC occurred on the 142 selected road segments during the 5-year study period. A range of factors including traffic exposure, road cross section (curves, presence of median), road type, requirement for sharing the road with other vehicle types (trams and bicycles), roadside poles, and local amenities were associated with SVC frequency. A different set of risk factors was associated with the odds of a crash leading to a severe outcome: segment length, road cross section (curves, carriageway width), pavement condition, local amenities and vehicle, and driver factors. The presence of curves was the only factor associated with both SVC frequency and severity. CONCLUSIONS: A range of risk factors were associated with SVC frequency and severity in complex urban areas (metropolitan shopping strips), including traditionally studied characteristics such as traffic density and road design but also less commonly studied characteristics such as local amenities. Future behavioral research is needed to further investigate how and why these factors change the risk and severity of crashes before effective countermeasures can be developed.

Raised crosswalks on entrance to the roundabout-a case study on effectiveness of treatment on pedestrian safety and convenience.

OBJECTIVE: A common concern in the use of a roundabout is providing adequately for the pedestrian. This unique roundabout layout, which introduces raised crosswalks directly at the roundabout entrance, as opposed to at a car length back, aims at improving safety and convenience for pedestrians at roundabouts. METHODS: A preliminary evaluation of the layout was undertaken to establish its effectiveness in meeting study objectives. A quasi-experimental before-and-after study design was used to compare speeds on approach and immediately prior to the crossing to ascertain potential impact speed and implications for pedestrian safety. Compliance to crossing and crossing time were also compared in relation to safety and convenience outcomes. A questionnaire assessed pedestrian perception of the safety and convenience at the roundabout before and after treatment. RESULTS: Results from this case study indicate that mean approach speeds (free speeds 30 m from crossing) reduced from 32.7 to 30.7 km/h and immediately prior to crossing, mean speeds reduced from 19.1 to 16.3 km/h. There was also a marked reduction in proportions of vehicles traveling at speeds that could elevate risk to pedestrians. Total crossing time after treatment reduced by around 4 s, and crossing compliance increased from approximately half to approximately 90 percent. Survey of pedestrians indicated positive response to the perceived safety and convenience posttreatment. CONCLUSIONS: Preliminary results of the case study suggest positive safety and convenience outcomes. Implications for pedestrian safety include less exposure to traffic and lower risk of serious injury, particularly for elderly pedestrians; convenience outcomes include shorter waiting times to cross and greater compliance to the crossing. A larger study is required to substantiate the findings.

Distribution of transport injury and related risk behaviours in a large national cohort of Thai adults.

BACKGROUND: A major barrier to addressing the problem of transport injury in low to middle-income countries is the lack of information regarding the incidence of traffic crashes and the demographic, behavioural and socio-economic determinants of crash-related injury. This study aimed to determine the baseline frequency and distribution of transport injury and the prevalence of various road safety behaviours in a newly recruited cohort of Thai adults. METHODS: The Thai Health-Risk Transition Study includes an ongoing population-based cohort study of 87,134 adult students residing across Thailand. Baseline survey data from 2005 includes data on self-reported transport injury within the previous 12 months and demographic, behavioural and transportation factors that could be linked to Thailand's transport risks. RESULTS: Overall, 7279 (8.4% or 8354 per 100,000) of respondents reported that their most serious injury in the 12 months prior to recruitment in the cohort was transport-related, with risk being higher for males and those aged 15-19 years. Most transport injuries occurred while using motorcycles. A much higher proportion of males reported driving after three or more glasses of alcohol at least once in the previous year compared to females. The prevalence of motorcycle helmet and seat belt wearing in this sample were higher than previously reported for Thailand. CONCLUSIONS: The reported data provide the basis for monitoring changes in traffic crash risks and risk behaviours in a cohort of adults in the context of ongoing implementation of policy and programs that are currently being introduced to address the problem of transport-related injury in Thailand.

Reliability of ICD-10 external cause of death codes in the National Coroners Information System.

Availability of ICD-10 cause of death codes in the National Coroners Information System (NCIS) strengthens its value as a public health surveillance tool. This study quantified the completeness of external cause ICD-10 codes in the NCIS for Victorian deaths (as assigned by the Australian Bureau of Statistics (ABS) in the yearly Cause of Death data). It also examined the concordance between external cause ICD-10 codes contained in the NCIS and a re-code of the same deaths conducted by an independent coder. Of 7,400 NCIS external cause deaths included in this study, 961 (13.0%) did not contain an ABS assigned ICD-10 code and 225 (3.0%) contained only a natural cause code. Where an ABS assigned external cause ICD-10 code was present (n=6,214), 4,397 (70.8%) matched exactly with the independently assigned ICD-10 code. Coding disparity primarily related to differences in assignment of intent and specificity. However, in a small number of deaths (n=49, 0.8%) there was coding disparity for both intent and external cause category. NCIS users should be aware of the limitations of relying only on ICD-10 codes contained within the NCIS for deaths prior to 2007 and consider using these in combination with the other NCIS data fields and code sets to ensure optimum case identification.

Learning and retention of associations between auditory icons and denotative referents: implications for the design of auditory warnings.

OBJECTIVE: This study examined the way in which the type and preexisting strength of association between an auditory icon and a warning event affects the ease with which the icon/event pairing can be learned and retained. BACKGROUND: To be effective, an auditory warning must be audible, identifiable, interpretable, and heeded. Warnings consisting of familiar environmental sounds, or auditory icons, have potential to facilitate identification and interpretation. The ease with which pairings between auditory icons and warning events can be learned and retained is likely to depend on the type and strength of the preexisting icon/event association. METHOD: Sixty-three participants each learned eight auditory-icon/denotative-referent pairings and attempted to recall them 4 weeks later. Three icon/denotative-referent association types (direct, related, and unrelated) were employed. Participants rated the strength of the association for each pairing on a 7-point scale. RESULTS: The number of errors made while learning pairings was greater for unrelated than for either related or direct associations, whereas the number of errors made while attempting to recall pairings 4 weeks later was greater for unrelated than for related associations and for related than for direct associations. Irrespective of association type, both learning and retention performance remained at very high levels, provided the strength of the association was rated greater than 5. CONCLUSION: This suggests that strong preexisting associations are used to facilitate learning and retention of icon/denotative-referent pairings. APPLICATION: The practical implication of this study is that auditory icons having either direct or strong, indirect associations with warning events should be preferred.