Evidence-based Risk Assessment Research Articles

SECRET: Statistical Emulation for Computational Reverse Engineering and Translation with applications in healthcare

There have been impressive advances in the physical and mathematical modelling of complex physiological systems in the last few decades, with the potential to revolutionise personalised healthcare with patient-specific evidence-based diagnosis, risk assessment and treatment decision support using digital twins. However, practical progress and genuine clinical impact hinge on successful model calibration, parameter estimation and uncertainty quantification, which calls for novel innovative adaptions and methodological extensions of contemporary state-of-the-art inference techniques from Statistics and Machine Learning. In the present study, we focus on two computational fluid-dynamics (CFD) models of the blood systemic and pulmonary circulation. We discuss state-of-the-art emulation techniques based on deep learning and Gaussian processes, which are coupled with established inference techniques based on greedy optimisation, simulated annealing, Markov Chain Monte Carlo, History Matching and rejection sampling for computationally fast inference of unknown parameters of the CFD models from blood flow and pressure data. The inference task was set as a competitive challenge which the participants had to conduct within a limited time frame representative of clinical requirements. The performance of the methods was assessed independently and objectively by the challenge organisers, based on a ground truth that was unknown to the method developers. Our results indicate that for the systemic challenge, in which an idealised case of noise-free data was considered, the relative deviation from the ground-truth in parameter space ranges from 10−5% (highest-performing method) to 3% (lowest-performing method). For the pulmonary challenge, for which noisy data was generated, the performance ranges from 0.9% to 7% deviation for the parameter posterior mean, and from 35% to 570% deviation for the parameter posterior variance.

Estimating the risk of SARS-CoV-2 infection in New Zealand border arrivals

BackgroundTravel restrictions and border controls were used extensively during the COVID-19 pandemic. However, the processes for making robust evidence-based risk assessments of source countries to inform border control policies was in many cases very limited.MethodsBetween April 2020 and February 2022, all international arrivals to New Zealand were required to spend 14 days in government-managed quarantine facilities and were tested at least twice. The infection rates among arrivals in the years 2020, 2021 and 2022 were respectively 6.3, 9.4 and 90.0 cases per thousand arrivals (487, 1064 and 1496 cases). Test results for all arrivals were linked with travel history, providing a large and comprehensive dataset on the number of SARS-CoV-2-positive and negative travellers from different countries over time. We developed a statistical model to predict the country-level infection risk based on infection rates among recent arrivals and reported cases in the country of origin. The model incorporates a country-level random effect to allow for the differences between the infection risk of the population of each country and that of travellers to New Zealand. A time dependent auto-regressive component of the model allows for short term correlation in infection rates.ResultsA model selection and checking exercise found that the model was robust and reliable for forecasting arrival risk for 2 weeks ahead. We used the model to forecast the number of infected arrivals in future weeks and categorised countries according to their risk level. The model was implemented in R and was used by the New Zealand Ministry of Health to help inform border control policy during 2021.ConclusionsA robust and practical forecasting tool was developed for forecasting infection risk among arriving passengers during a period of controlled borders during the COVID-19 pandemic. The model uses historical infection rates among arrivals and current infection rates in the source country to make separate risk predictions for arrivals from each country.

Predictive value of a novel digital risk calculator to determine early patient outcomes after major surgery: a proof-of-concept pilot study

BackgroundA structured risk assessment of patients with validated and evidence-based tools can help to identify modifiable factors before major surgeries. The Protego Maxima trial investigated the value of a new digitized risk assessment tool that combines tools which can be easily used and implemented in the clinical workflow by doctors and qualified medical staff. The hypothesis was that the structured assessment and risk-grouping is predictive of short-term surgical quality reflected by complications and overall survival.MethodsThe Protego Maxima Trial was a prospective cohort analysis of patients undergoing major surgery (visceral, thoracic, urology, vascular and gynecologic surgeries) as key inclusion criterion and the absence of an acute or acute on chronically decompensated pulmo-cardiovascular decompensation. Patients were risk-scored with the software (The Prehab App) that includes a battery of evidence-based risk assessment tools that allow a structured risk assessment. The data were grouped to predefined high and low risk groups and aggregate and individual scores. The primary outcome was to validate the predictive value of the RAI score and the TUG for overall survival in the high and low risk groups. Secondary outcomes were surgical outcomes at 90-days after surgery (overall survival, Clavien-Dindo (CD) 1–5 (all complications), and CD 3–5 (major complications)). The study was carried out in accordance with the DIN ISO 14,155, and the medical device regulation (MDR) at Frankfurt University Hospital between March 2022 and January 2023.ResultsIn total 267 patients were included in the intention to treat analysis. The mean age was 62.1 ± 12.4 years. Patients with a RAI score > 25 and/or a timed up and go (TUG) > 8 s had a higher risk for mortality at 90 days after surgery. The low-risk group predicted beneficial outcome and the high-risk group predicted adverse outcome in the ROC analysis (Area Under the Curve Receiver Operator Characteristics: AUROC > 0.800; p = 0.01). Risk groups (high vs. low) showed significant differences for 90-day survival (99.4% vs. 95.5%; p = 0.04) and major complications (16.4% vs. 32.4%; p < 0.001).ConclusionThe proof-of-concept trial showed that a risk assessment with ‘The Prehab App’ may be viable to estimate the preoperative risk for mortality and major complications before major surgeries. The overall performance in this initial set of data indicated a certain reliability of the scoring and risk grouping, especially of the RAI score and the TUG. A larger data set will be required to proof the generalizability of the risk scoring to every subgroup and may be fostered by artificial intelligence approaches.Trial registrationEthics number: 2021-483-MDR/MPDG-zuständig monocentric; The Federal Institute for Pharmaceuticals and Medical Devices/BfArM, reference number: 94.1.04-5660-13655; Eudamed: CIV-21-07-0307311; German Clinical Trial Registry: DRKS 00026985.

Groundwater Abstraction has Caused Extensive Ecological Damage to the Doñana World Heritage Site, Spain

Acreman et al. (Wetlands 42:63, 2022) reviewed evidence for ecological damage to the Doñana wetlands (UNESCO World Heritage Site [WHS] and Ramsar site), Spain, associated with intensification of groundwater use, particularly for agriculture. Acreman et al. presented a multistep methodology for evidence-based risk assessment that involves identification of conservation issues, and a systematic review of scientific evidence for ecological damage and its causes. However, they involved few local scientists, used a questionable methodology in stakeholder selection and involvement, used a flawed conceptual framework, and an incomplete literature review. We propose improvements to their methodology. They overlooked or misinterpreted key evidence, and underestimated the impacts that abstraction for irrigation for red fruits (mainly strawberries), rice and other crops has had on Doñana and its biodiversity. They reported groundwater level depletion of up to 10 m in the deep aquifer, but wrongly concluded that there is no evidence for impacts on the natural marsh ecosystem, the dune ponds or the ecotone. Groundwater drawdowns are actually up to 20 m, and have inverted the formerly ascending vertical hydraulic gradient in discharge areas. Phreatic levels have been lowered from 0.5 to 2 m in some areas. Groundwater abstraction has caused multiple ecological impacts to temporary ponds and marshes in the WHS, as well as to terrestrial vegetation, and should be urgently reduced. Furthermore, Acreman et al. focused on groundwater quantity while overlooking the importance of severe impacts on quality of both surface and groundwater, intimately connected to the use of agrochemicals for irrigated crops.

Potentials and opportunities of solar PV and wind energy sources in Saudi Arabia: Land suitability, techno-socio-economic feasibility, and future variability

Solar and wind energy sources hold significant potential to meet the escalating energy demand in Saudi Arabia sustainably. This research aims to assess the feasibility and prospects of deploying solar photovoltaic (PV) and wind energy systems in Saudi Arabia (SA). The study adopts a comprehensive approach, encompassing spatial analysis of land suitability, techno-socio-economic feasibility studies, and prediction of renewable energy (RE) resource variability and trends using machine learning techniques. Geographical Information System (GIS) spatial analysis is employed to identify suitable areas for establishing solar PV and wind farms based on multi-criteria evaluation methods. Techno-socio-economic feasibility analysis of solar PV and wind energy systems, under various configurations and scenarios, is conducted using the System Advisor Model (SAM) tool. Furthermore, a Support Vector Machine (SVM) machine learning algorithm is developed and deployed to forecast Global Horizontal Irradiation (GHI), wind speed, and influential weather parameters at different locations in SA. The projections of these variables derived from global climate models are utilized to analyze prospects and variabilities. The land suitability analysis identified four optimal locations for large-scale solar PV fields in Tabuk, Al Madinah, Makkah, and Riyadh provinces. Additionally, four promising wind farms were found in Al Madinah, Makkah, Riyadh, and Eastern provinces. The analysis also identified one location in Al Jouf province suitable for hybrid systems combining solar PV and wind energy. The techno-economic assessment revealed that wind farms performed best overall, achieving a capacity factor of 42.6 % in Al Madinah province. Although current tariffs render projects economically unviable, solar PV, wind energy, and hybrid solar PV-wind technologies are economically feasible in SA at Power Purchase Agreement (PPA) rates above $32.8/MWh, $26.1/MWh, and $50.6/MWh, respectively. The social development analysis estimated potential job creation from solar PV and wind energy deployment under different scenarios from 2020 to 2060, indicating that more ambitious climate targets could translate to millions of renewable energy jobs. The SVM model predicted solar irradiance with an R-squared value of 0.893. The CMIP6 model was then used to project the GHI for SA in 2049, suggesting an increase of approximately 19 %. Wind speed is also expected to rise roughly 5 % over the same period. The integration of GIS spatial analysis, techno-socio-economic modeling, and machine learning-based forecasting provides comprehensive insights into harnessing solar and wind energy in SA. This study facilitates evidence-based planning and risk assessment, crucial for a sustainable energy transition. The insights and roadmap derived from this research can inform policy frameworks, support the United Nations Sustainable Development Goals (UNSDGs), and attract private investments for RE development in SA. Consequently, this study establishes solar and wind energy as viable and promising solutions for meeting SA's growing energy demands sustainably, while minimizing the associated environmental impact.

P24 Penicillin allergy de labelling: a whole system approach

Abstract Background Approximately 10% of patients have a documented allergy to penicillin on their health records.1 However, when checked up to 95% are thought to be incorrect2 with side effects such as nausea, vomiting and gastrointestinal upset often being documented as allergy. Inappropriate and over labelling of penicillin allergy is detrimental to individuals and healthcare systems as alternatives to penicillins are associated with more complications, adverse events, financial costs and extended length of stay. Unnecessary use of penicillin alternatives also increases the risk of antimicrobial resistance development. Penicillin allergy de-labelling is a viable option for patients within primary care and acute settings where they meet specific criteria, leading to financial benefits for the health board and optimal treatment outcomes for the patient. NHS Tayside is the first and only Board in Scotland to adopt a whole system approach to de-labelling patients in both acute and community settings. Through the implementation of evidence-based, collaborative and systematic risk assessment processes, clinical teams are able to identify patients who may be eligible for the penicillin allergy de-labelling programme. Methods Within the acute sector, two pilot wards were identified. A Short Life Working Group (SLWG) was developed to oversee the de-labelling process and governance. Patients were identified by clinical teams and consent gained prior to carrying out the process. A single dose of oral flucloxacillin or amoxicillin was administered to the patient. The patient was monitored for any reaction as per Scottish Antimicrobial Prescribing Group (SAPG) algorithm.3 If the patient experienced no reaction, they were de-labelled, a request was sent to GP to remove the label and their details were added to a database held by the SLWG. A similar project was piloted in primary care across three Angus GP practices. The aim of the project is to identify a patient population that are labelled penicillin allergic but have received a subsequent prescription for a penicillin allowing a primary care SLWG to carry out a patient consultation with the aim of retrospectively de-labelling and updating the record. This will allow patients to receive optimal treatment options in the future. Results Within the acute setting, the pilot was initiated in May 2022. Since then, 44 patients have been recruited to the penicillin allergy de-labelling process with 98% having no immediate reaction and 67% of labels removed from patient care records at the 3 month follow-up stage. Within primary care across three GP practices, 163 patients were eligible for the pilot. A total of 85 patients (52%) were contacted via telephone and a consultation on allergy status carried out. Overall, 42 patients (50%) were successfully de-labelled and patient records were updated. Conclusions Following similar processes, there is potential for practitioners within the acute and community sectors to adopt this pilot as part of an integrated work plan across all wards and GP practices. By de-labelling patients within the community or acute sector, the patients’ records will be accurate and future treatment options can be optimized to ensure positive outcomes and minimize harm.

The risk assessment of imminent inpatient aggression: A cross-cultural validation study of the dynamic appraisal of situational aggression in Estonia.

The reason for this study was void of a data-driven imminent risk assessment instrument for aggression in psychiatry clinics in Estonia. The predictive accuracy of the observer-rated Dynamic Assessment of Situational Aggression (DASA) has been repeatedly demonstrated. However, the research gap remains regarding a deeper conceptual understanding of the underlying latent structure of the DASA. Comprehensively evaluate the psychometric properties of the Estonian DASA version for cross-cultural clinical use. We used a prospective repeated measure design and collected 6097 risk evaluations from 381 adult inpatients, 151 of whom committed 1013 aggressive incidents during the study. The Estonian DASA version has acceptable inter-rater reliability (Kendall's τ = 0.74) and is a useful instrument with excellent predictive validity (AUC = 0.86) for identifying potentially aggressive inpatients. In our sample, the DASA has a bi-factorial structure which explains 83% of the total variance. The adapted DASA has acceptable validity and reliability indices for measuring imminent aggression risk in adult inpatient units. Evidence-based risk assessment of aggression in psychiatric clinics enhances recognition of the signs of potentially aggressive behaviour in order to apply preventive actions and reduce aggression, thereby improving the quality of the care provided.

Busulfan and subsequent malignancy: An evidence-based risk assessment.

The incidence of secondary malignancies associated with busulfan exposure is considered low, but has been poorly characterized. Because this alkylating agent is increasingly utilized as conditioning prior to gene therapy in nonmalignant hematologic and related disorders, more precise characterization of busulfan's potential contribution to subsequent malignant risk is warranted. We conducted a literature-based assessment of busulfan and subsequent late effects, with emphasis on secondary malignancies, identifying publications via PubMed searches, and selecting those reporting at least 3years of follow-up. We identified eight pediatric and 13 adult publications describing long-term follow-up in 570 pediatric and 2076 adult hematopoietic cell transplant (HCT) recipients. Secondary malignancies were reported in 0.5% of pediatric HCT recipients, with no cases of myelodysplastic syndrome (MDS) or acute myelocytic leukemia (AML). Fatal secondary malignancies were reported in 0.8% of 1887 evaluable adult HCT recipients, and an overall incidence of secondary malignancies of 4.8% was reported in a subset of 389 evaluable adult patients. We also reviewed long-term results from eight publications evaluating lentiviral- and human promotor-based HSC-targeted gene therapy in 215 patients with nonmalignant conditions, in which busulfan/treosulfan monotherapy or busulfan/fludarabine was the only conditioning. Two malignancies were reported in patients with sickle cell disease (SCD), one of which was potentially busulfan-related. No additional malignancies were reported in 173 patients with follow-up of 5-12years. The incidence of busulfan-related secondary malignancies is low, and likely to be substantially less than 1% in pediatric transplant recipients, especially those receiving busulfan monotherapy for nonmalignant conditions other than SCD.

Dental extractions do not predict further use of dental general anesthesia in people with disabilities: A longitudinal analysis.

This paper describes treatments completed under dental general anesthesia (DGA) for a cohort of adults with disabilities. This patient cohort was followed up a number of years later to determine outcomes and identify factors that predict further use of DGA. A retrospective patient record review and cross-sectional survey was carried out on a convenience sample of 64 patients who had previously received dental treatment under general anesthesia. Patient record review extracted data on patient demographics and treatment provided under DGA. Cross-sectional survey a number of years post-DGA collected data on oral care habits and current oral health based on a standardized clinical examination. Statistical analysis was carried out to identify predictors of repeat DGA. Participants received extensive treatment under DGA including preventive care, restorations, extractions, and root canal treatment. At follow-up 89.1% of participants had gingival disease and 56.3% had active dental caries. The mean number of teeth present was 21.2 (SD 6.9, range 6-32). Only caries risk status was found to be a significant predictor (p=0.03) with those with a high caries risk status 6.9 times (95%CI 1.2-39.3) more likely to receive a second DGA. Dentists extract teeth for people with disabilities under DGA in the mistaken belief that this will avoid the need for further DGA. This study found that extraction of teeth does not prevent the need for repeated episodes of DGA. Therefore, dentists should stop extracting teeth for this reason. Rather, if dentists want to avoid further DGA, they should do the basics well: consistent, evidence-based caries risk assessment and risk reduction.

Neonatal early-onset sepsis calculator: Impact on antibiotic use in a level II neonatal unit in Western Australia

BackgroundOveruse of empirical intravenous antibiotics in neonates in high-income countries (HICs) is well documented. The Kaiser Permanente neonatal early-onset sepsis (EOS) calculator is an evidence-based sepsis risk assessment tool that has demonstrated potential to reduce antibiotic usage in this population. The incidence of early-onset sepsis in most HICs is 0.4–0.8 per 1000 live births. The objective was to evaluate the calculator's impact on antibiotic rates and length of stay in a regional level II Special Care Nursery. MethodsA single-centre retrospective cohort study compared antibiotic administration rates in the first 72 h in neonates ≥35 weeks gestation born during two 6-month periods in 2019 (pre-EOS calculator) and 2021 (post-EOS calculator). Electronic and paper case records were accessed to capture data. Continuous data were summarised using mean and standard deviation, and categorical data were summarized using frequency distributions. There were 951 (2019) and 1129 (2021) infants born during the study periods. ResultsFollowing implementation of the calculator, antibiotic exposure decreased from 13.7% to 4.7% of all neonates without reported negative outcomes. Mean length of stay for neonates born across the two periods decreased from 2.38 to 2.13 days. Indications for antibiotic use shifted more towards clinical condition and away from obstetric risk factors. There were no culture-proven cases of sepsis or readmissions with EOS in either period. ConclusionImplementation of the EOS calculator significantly reduced exposure to antibiotics, without adverse outcomes.

NextGEM: Next-Generation Integrated Sensing and Analytical System for Monitoring and Assessing Radiofrequency Electromagnetic Field Exposure and Health.

The evolution of emerging technologies that use Radio Frequency Electromagnetic Field (RF-EMF) has increased the interest of the scientific community and society regarding the possible adverse effects on human health and the environment. This article provides NextGEM's vision to assure safety for EU citizens when employing existing and future EMF-based telecommunication technologies. This is accomplished by generating relevant knowledge that ascertains appropriate prevention and control/actuation actions regarding RF-EMF exposure in residential, public, and occupational settings. Fulfilling this vision, NextGEM commits to the need for a healthy living and working environment under safe RF-EMF exposure conditions that can be trusted by people and be in line with the regulations and laws developed by public authorities. NextGEM provides a framework for generating health-relevant scientific knowledge and data on new scenarios of exposure to RF-EMF in multiple frequency bands and developing and validating tools for evidence-based risk assessment. Finally, NextGEM's Innovation and Knowledge Hub (NIKH) will offer a standardized way for European regulatory authorities and the scientific community to store and assess project outcomes and provide access to findable, accessible, interoperable, and reusable (FAIR) data.

Documentation of Assessments and Interventions Using a Pediatric Preoperative Risk Assessment Checklist in the Postanesthesia Care Unit: A Quality Improvement Initiative

PurposeDescribe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia. DesignProspective pre-/postdesign. MethodsPediatric perianesthesia nurses assessed 100 children preintervention according to current standard. After nurses received pediatric preoperative risk factor (PPRF) education, another 100 children were assessed postintervention using the PPRA checklist. Pre-/postpatients were unmatched for statistical purposes due to two different groups. Frequency of PACU nursing respiratory assessments/interventions was evaluated. FindingsDemographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors. ConclusionsBy identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.

The Biosafety Research Road Map: The Search for Evidence to Support Practices in the Laboratory-Shigella spp.

Shigella bacteria cause shigellosis, a gastrointestinal infection most often acquired from contaminated food or water. In this review, the general characteristics of Shigella bacteria are described, cases of laboratory-acquired infections (LAIs) are discussed, and evidence gaps in current biosafety practices are identified. LAIs are undoubtedly under-reported. Owing to the low infectious dose, rigorous biosafety level 2 practices are required to prevent LAIs resulting from sample manipulation or contact with infected surfaces. It is recommended that, before laboratory work with Shigella, an evidence-based risk assessment be conducted. Particular emphasis should be placed on personal protective equipment, handwashing, and containment practices for procedures that generate aerosols or droplets.

Management of Prostate Cancer in Older Adults.

The majority of men with prostate cancer are diagnosed when they are older than 65 years; however, clinical trial participants are disproportionately younger and more fit than the real-world population treated in typical clinical practices. It is, therefore, unknown whether the optimal approach to prostate cancer treatment is the same for older men as it is for younger and/or more fit men. Short screening tools can be used to efficiently assess frailty, functional status, life expectancy, and treatment toxicity risk. These risk assessment tools allow for targeted interventions to increase a patient's reserve and improve treatment tolerance, potentially allowing more men to experience the benefit of the significant recent treatment advances in prostate cancer. Treatment plans should also take into consideration each patient's individual goals and values considered within their overall health and social context to reduce barriers to care. In this review, we will discuss evidence-based risk assessment and decision tools for older men with prostate cancer, highlight intervention strategies to improve treatment tolerance, and contextualize these tools within the current treatment landscape for prostate cancer.

Evidence-based disaster risk assessment in Southeast Asian countries

This paper aims to provide an overview of the risks and trends of natural disasters in Southeast Asian countries and discuss necessary future countermeasures. Quantitative analysis of natural disasters was performed using data collected from EM-DAT. The disaster risk assessment for countries and disaster types was conducted using a frequency-impact risk matrix and risk ranking identification, which is a novel approach based on actual disaster data. The findings suggest that Indonesia, the Philippines, and Thailand face the highest mortality, affected population, and economic damage risks, respectively. Moreover, the study reveals that Southeast Asian countries are vulnerable to climate-related disasters. This risk assessment gives us a comprehensive understanding of natural disaster risks in Southeast Asian countries, enabling us to identify the most vulnerable countries in the region and determine the most significant disaster-type countermeasures for each country.

Real World Evidence of Wearable Smartbelt for Mitigation of Fall Impact in Older Adult Care.

Structured Abstract Falls with major injuries are a devastating occurrence for an older adult with outcomes inclusive of debility, loss of independence and increased mortality. The incidence of falls with major injuries has increased with the growth of the older adult population, and has further risen as a result of reduced physical mobility in recent years due to the Coronavirus pandemic. The standard of care in the effort to reduce major injuries from falling is provided by the CDC through an evidence-based fall risk screening, assessment and intervention initiative (STEADI: Stopping Elderly Accidents and Death Initiative) and is embedded into primary care models throughout residential and institutional settings nationwide. Though the dissemination of this practice has been successfully implemented, recent studies have shown that major injuries from falls have not been reduced. Emerging technology adapted from other industries offers adjunctive intervention in the older adult population at risk of falls and major fall injuries. Technology in the form of a wearable smartbelt that offers automatic airbag deployment to reduce impact forces to the hip region in serious hip-impacting fall scenarios was assessed in a long-term care facility. Device performance was examined in a real-world case series of residents who were identified as being at high-risk of major fall injuries within a long-term care setting. In a timeframe of almost 2 years, 35 residents wore the smartbelt, and 6 falls with airbag deployment occurred with a concomitant reduction in the overall falls with major injury rate.

Beyond chemicals: Opportunities and challenges of integrating non-chemical stressors in adverse outcome pathways.

The adverse outcome pathways (AOPs) were developed to accelerate evidence-based chemical risk assessment by leveraging data from new approach methodologies. Thanks to their stressor-agnostic approach, AOPs were seen as instrumental in other fields. Here, we present AOPs that report non-chemical stressors along with the challenges encountered for their development. Challenges regarding AOPs linked to nanomaterials include non-specific molecular initiating events, limited understanding of nanomaterial biodistribution, and needs for adaptations of the in silico modeling and testing systems. Development of AOPs for radiation face challenges in how to incorporate ionizing events type, dose rate, energy deposition, and how to account for targeting multiple macromolecules. AOPs for COVID-19 required the inclusion of SARS-CoV-2-specific replicative steps to capture the essential events driving the disease. Developing AOPs to evaluate efficacy and toxicity of cell therapies necessitates addressing the cellular nature and the therapeutic function of the stressor. Finally, addressing toxicity of emerging biological stressors like microbial pesticides can learn from COVID-19 AOPs. We further discuss that the adaptations needed to expand AOP applicability beyond chemicals are mainly at the molecular and cellular levels while downstream key events at tissue or organ level, such as inflammation, are shared by many AOPs initiated by various stressors. In conclusion, although it is challenging to integrate non-chemical stressors within AOPs, this expands opportunities to account for real-world scenarios, to identify vulnerable individuals, and to bridge knowledge on mechanisms of adversity.

Three novel bird strike likelihood modelling techniques: The case of Brisbane Airport, Australia.

The risk posed by wildlife to air transportation is of great concern worldwide. In Australia alone, 17,336 bird-strike incidents and 401 animal-strike incidents were reported to the Air Transport Safety Board (ATSB) in the period 2010-2019. Moreover, when collisions do occur, the impact can be catastrophic (loss of life, loss of aircraft) and involve significant cost to the affected airline and airport operator (estimated at globally US$1.2 billion per year). On the other side of the coin, civil aviation, and airport operations have significantly affected bird populations. There has been an increasing number of bird strikes, generally fatal to individual birds involved, reported worldwide (annual average of 12,219 reported strikes between 2008-2015 being nearly double the annual average of 6,702 strikes reported 2001-2007) (ICAO, 2018). Airport operations including construction of airport infrastructure, frequent take-offs and landings, airport noise and lights, and wildlife hazard management practices aimed at reducing risk of birdstrike, e.g., spraying to remove weeds and invertebrates, drainage, and even direct killing of individual hazard species, may result in habitat fragmentation, population decline, and rare bird extinction adjacent to airports (Kelly T, 2006; Zhao B, 2019; Steele WK, 2021). Nevertheless, there remains an imperative to continually improve wildlife hazard management methods and strategies so as to reduce the risk to aircraft and to bird populations. Current approved wildlife risk assessment techniques in Australia are limited to ranking of identified hazard species, i.e., are 'static' and, as such, do not provide a day-to-day risk/collision likelihood. The purpose of this study is to move towards a dynamic, evidence-based risk assessment model of wildlife hazards at airports. Ideally, such a model should be sufficiently sensitive and responsive to changing environmental conditions to be able to inform both short and longer term risk mitigation decisions. Challenges include the identification and quantification of contributory risk factors, and the selection and configuration of modelling technique(s) that meet the aforementioned requirements. In this article we focus on likelihood of bird strike and introduce three distinct, but complementary, assessment techniques, i.e., Algebraic, Bayesian, and Clustering (ABC) for measuring the likelihood of bird strike in the face of constantly changing environmental conditions. The ABC techniques are evaluated using environment and wildlife observations routinely collected by the Brisbane Airport Corporation (BAC) wildlife hazard management team. Results indicate that each of the techniques meet the requirements of providing dynamic, realistic collision risks in the face of changing environmental conditions.

Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews.

Workplace violence in healthcare settings is alarmingly common and represents significant financial and human cost. The aim of this scoping review was to identify and summarize evidence on strategies to prevent and/or manage workplace violence in healthcare settings. Searches were limited to evidence-based clinical practice guidelines and systematic reviews published between 2015 and 2021. Multiple databases were searched and screened. Quality of the included guidelines and reviews was also assessed. Three guidelines and 33 systematic reviews were included. Both the Occupational Safety and Health Administration 2015 and Registered Nurses' Association of Ontario 2019 guidelines provided useful recommendations for building a comprehensive prevention program. Evidence-based risk assessment, prevention and management, and education and training are all central components. Regular reassessment and adjustment is required. Included reviews (n = 33) were grouped into five main categories: violence toward nurses (n = 10); violence toward healthcare workers in general (n = 8); violence in the emergency department (n = 5); violence related to mental health (n = 5); and measurement related to workplace violence (n = 5). Multicomponent interventions were often more effective than those applied in isolation. We found consistent support for certain strategies including education and training, post-incident debriefing, multidisciplinary rapid response teams, and environmental modifications; however, the strength of evidence and certainty of conclusions were limited across reviews. This scoping review found that strong leadership that cultivates and enforces a culture of inclusivity, support, and respect is a prerequisite for a successful workplace violence prevention program. Rigorous comparative effectiveness research testing interventions are needed.

Evidence-based Risk Assessment of Ecological Damage due to Groundwater Abstraction; the Case of Doñana Natural Space, Spain

Many regions of the world are facing mounting water stress as competition increases for this vital resource that may become scarcer under future climates. More water is being allocated to our needs for food, public supply, hydro-electric power and industrial goods to support growing populations and mounting life-style expectations. To achieve this, less water is often being retained for water-dependent ecosystems. Environmental protection agencies and conservation organisations have highlighted the resulting threat to freshwater biodiversity and associated ecosystem services that support human livelihoods and well-being. Careful assessments are therefore required to advise on the optimum allocation of water and to determine the risk of developments that require redistribution of water resources.Along the northern fringes of the Guadalquivir River delta and estuary in southern Spain about 40% of all jobs derive from agriculture. The production of olives, fruit trees, rice and berries is a major component of the local economy producing large exports, but it requires significant water from local rivers and the underlying aquifers. The economy is also reliant on tourism that brings many thousands of people to the area in the summer for which groundwater abstraction is augmented. The delta is the location of the Doñana wetland complex of lagoons, marshlands, fixed and mobile dunes that was designated as a Biosphere Reserve by UNESCO in 1980, as wetland of international importance (Ramsar Site) under the Convention on Wetlands in 1982 and as a World Heritage Site by UNESCO in 1994. Fears have been expressed that increasing human water use is putting the wetlands at risk of drying out, despite efforts by the river basin authority to limit abstraction to sustainable levels.This paper reports on a methodology that analyses best available eco-hydrological scientific knowledge together with information on the likely success of abstraction control measures to determine the risk to the wetland ecosystem of current and future planned water allocation. The method was applied to Doñana by the joint UNESCO/IUCN/Ramsar Reactive Monitoring mission to in 2020. The results are also provided in the paper, which raised many important scientific and related political, legal and social issues concerning the impacts of water withdrawals on the ecology of the wetlands. The methodology has wide application to environmental water allocation assessments.