Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12-month analysis.

Fracture liaison service linked to an emergency department database effectively identifies patients with OP, improves best practice care, reduces recurrent fractures, and improves quality of life (QoL). The next step is to establish cost-effectiveness. This should be seen as the standard model of care. INTRODUCTION: The Western Australian Osteoporosis Model of Care recommends implementation of a fracture liaison service (FLS) to manage patients with minimal trauma fractures (MTFs). This study evaluates the efficacy of a FLS linked to a tertiary hospital emergency department information system (EDIS) in reducing recurrent fractures. METHODS: Patients aged ≥ 50 years with MTF identified from EDIS were invited to the FLS. Patient outcomes were compared to routine care (retrospective group-same hospital, and prospective group-other hospital) at 3- and 12-month follow-up. RESULTS: Two hundred forty-one of 376 (64.1%) eligible patients participated in the FLS with 12 months of follow-up. Absolute risk of recurrent MTF at 12 months was reduced by 9.2 and 10.2% compared with the prospective and retrospective controls, respectively. After age/sex adjustment, FLS participants had less MTF at 12 months vs. the retrospective controls, OR 0.38 (95%CI 0.18-0.79), but not the prospective controls, OR 0.40 (95%CI 0.16-1.01). FLS patients were more likely to receive the 'best practice' care, i.e. awareness of osteoporosis, investigations, and treatment (all p < 0.05). 'Fallers' (OR 0.48 (95%CI 0.24, 0.96)) and fall rates were lower in the FLS (p = 0.001) compared to the prospective control. FLS experienced the largest improvement in QoL from 3 to 12 months as measured by the EuroQoL 5-domain (EQ-5D) UK weighted score (+ 15 vs. - 11 vs. - 16%, p < 0.001) and EQ-5D Health State visual analogue scale (+ 29 vs. - 2 vs. + 1%, p < 0.001). CONCLUSION: Patients managed in a linked EDIS-FLS were more likely to receive the 'best practice' care and had lower recurrent MTF and improved QoL.

Elastic properties of organ of Corti tissues from point-stiffness measurement and inverse analysis.

We describe a method to use point-stiffness (PtSt) measurements, i.e., indentation measurements, to obtain elastic moduli of different organ of Corti (OC) tissues. A detailed finite element (FE) model of the OC is used to account for geometric effects in the indentation measurements. We also present a sensitivity analysis, performed within a Bayesian estimation framework, that can be used to improve experimental design. The sensitivity analysis shows that the basilar membrane (BM) PtSt is most sensitive to changes in the BM properties and to changes in the pillar cells (PC) properties. This result suggests that the BM and the PC dominate the macromechanics of the OC. The most likely values of the Young׳s modulus predicted for the middle turn for the BM arcuate, BM pectinate, and the PC are found to be 935 KPa (range 640-1360 KPa), 300 KPa (range 190-460 KPa), and 3 GPa (range 1-9 GPa), respectively.

Suppression of the 2010 Alexandrium fundyense bloom by changes in physical, biological, and chemical properties of the Gulf of Maine.

For the period 2005-2009, the abundance of resting cysts in bottom sediments from the preceding fall was a first-order predictor of the overall severity of spring-summer blooms of Alexandrium fundyense in the western Gulf of Maine and southern New England. Cyst abundance off mid-coast Maine was significantly higher in fall 2009 than it was preceding a major regional bloom in 2005. A seasonal ensemble forecast was computed using a range of forcing conditions for the period 2004-2009, suggesting that a large bloom was likely in the western Gulf of Maine in 2010. This did not materialize, perhaps because environmental conditions in spring-summer 2010 were not favorable for growth of A.fundyense. Water mass anomalies indicate a regional-scale change in circulation with direct influence on A. fundyense's niche. Specifically, near-surface waters were warmer, fresher, more stratified, and had lower nutrients than during the period of observations used to construct the ensemble forecast. Moreover, a weaker-than-normal coastal current lessened A. fundyense transport into the western Gulf of Maine and Massachusetts Bay. Satellite ocean color observations indicate the 2010 spring phytoplankton bloom was more intense than usual. Early-season nutrient depletion may have caused a temporal mismatch with A. fundyense's endogenous clock that regulates the timing of cyst germination. These findings highlight the difficulties of ecological forecasting in a changing oceanographic environment, and underscore the need for a sustained observational network to drive such forecasts.

An observational study of the impact of a rehabilitation admission on readmission data.

BACKGROUND AND AIM: Specialist psychiatric rehabilitation services are changing in response to overall redesign of psychiatric services. The assumed therapeutic gains of these services have not been established or quantified, and their role in contemporary practice has not been formally articulated. The aim of this observational study is to examine the impact of an admission to psychiatric rehabilitation wards at the Royal Edinburgh Hospital on readmission data post-discharge. METHOD: Thirty-five admissions were included in the sample. Simple measures of outcome were used: the number of days spent in hospital; number of Mental Health Act uses; number of admissions. This information was obtained from case notes and from data collected routinely on the Patient Information Management System. These measures were examined in the two-year periods before and after a rehabilitation admission. RESULTS: In the two-year period following the index admission there was a significant reduction in all these measures compared to the two-year period before the index admission: mean number of bed days (p < 0.001); number of uses of the Mental Health Act (p < 0.001); number of readmissions (p < 0.01). CONCLUSION: There was an improvement in patient outcome measures following a rehabilitation admission.

Longitudinal coupling in the basilar membrane.

A systematic and detailed study of the longitudinal coupling exhibited by the basilar membrane (BM) was performed in the excised gerbil cochlea. Contrary to the notion that the adjacent regions of the BM are decoupled from each other, the data indicate that: (a) the BM exhibits longitudinal coupling; (b) the length of the coupled region increases from base to apex of the cochlea; and (c) the cells of the organ of Corti (OC) increase the overall coupling exhibited by the BM. Modeling results show that, at a given location, longitudinal coupling increases the effective stiffness of the OC near the characteristic frequency. Therefore, the effect of longitudinal coupling cannot be neglected in the region of the peak of the traveling wave.

Sensing scenes with silicon.

Scene analysis, the process of converting sensory information from peripheral receptors into a representation of objects in the external world, is central to our human experience of perception. Through our efforts to design systems for object recognition and for robot navigation, we have come to appreciate that a number of common themes apply across the sensory modalities of vision, audition, and olfaction; and many apply across species ranging from invertebrates to mammals. These themes include the need for adaptation in the periphery and trade-offs between selectivity for frequency or molecular structure with resolution in time or space. In addition, neural mechanisms involving coincidence detection are found in many different subsystems that appear to implement cross-correlation or autocorrelation computations.

Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time.

OBJECTIVE: To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department. DESIGN: A comparative observational study using prospectively collected data. SETTING: Coronary care unit and emergency department of an Australian teaching hospital. PARTICIPANTS: 89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998. INTERVENTIONS: From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department. MAIN OUTCOME MEASURE: Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality. RESULTS: Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit. CONCLUSIONS: With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents.

Effects of acoustic trauma on acoustic enhancement of electrically evoked otoacoustic emissions.

Moderate acoustic trauma results in decreased cochlear sensitivity and frequency selectivity. This decrease is believed to be caused by damage to the cochlear amplifier that is associated with outer hair cells (OHCs) and their nonlinear electromechanical characteristics. A consequence of OHC nonlinearity is the acoustic enhancement effect, in which low-frequency electrically evoked otoacoustic emissions are enhanced by a simultaneous tone. The present study found that acoustic trauma reduced the acoustic enhancement effect and this reduction is correlated with the N1 threshold at the electrode site. This result is consistent with the theory that trauma affects the mechanoelectric transduction process, thus affecting cochlear mechanical nonlinearity. Acoustic trauma also reduced the cochlear microphonic in a way that suggests that the number of functioning tension-gated channels and the stiffness of the gating springs were decreased. In some cases, the electromechanical transduction process was also found to be affected by acoustic trauma.

Using clinical indicators in emergency medicine: documenting performance improvements to justify increased resource allocation.

OBJECTIVES: To demonstrate how emergency department triage scale and thrombolysis indicator data can be used to document the impact of a substantial increase in resource allocation. METHODS: Descriptive study in an emergency department of an adult tertiary hospital in Perth, Australia during similar periods of the year both before and after a substantial increase in emergency department staff, equipment, and system resources. The study group comprised a total of 11,048 emergency department attendances and all cases of emergency department initiated thrombolysis or acute angioplasty. Outcome was measured using numbers seen and percentage seen within indicator threshold time together with admission rates in each of the five triage categories as well as by using time from presentation to initiation of reperfusion treatment in acute myocardial infarction. RESULTS: The proportion of patients seen within the prescribed indicator time increased by 16.4% (95% confidence interval 14.4% to 18.2%). The increase was most pronounced in triage category 2 (32.7%). Median time to thrombolysis fell by 30 minutes to 37 minutes (p = 0.0002). CONCLUSIONS: Use of the Australasian national triage scale and time to thrombolysis clinical indicator data allows a quantitative assessment of the impact of increased emergency department resource allocation.

Re-engineering an Australian emergency department: can we measure success?

In 1996, in response to perceived deficiencies of the Emergency Department, Sir Charles Gairdner Hospital made emergency medicine a key strategic initiative. Major staffing and functional changes occurred as a result, including creation of the first Chair in Emergency Medicine in Australasia. We present a before and after study, using a range of measured variables, including the accepted Australian Council on Healthcare Standards emergency medicine clinical indicators. Clinically, there were great improvements in waiting times, time to thrombolysis in acute myocardial infarction, complaint rate, and misdiagnosed fracture rate. Increased throughput of short stay patients in a re-opened observation ward greatly shortened average length of stay for patients with a range of acute conditions. Data also indicated significant improvements in teaching and research. We conclude that with firm commitment from hospital management, re-engineering an emergency department can be shown to improve the quality-of-care.

Multiple modes of inner hair cell stimulation.

Most current theories of cochlear mechanics assume that the pattern of cochlear partition vibration is simple, similar to that of a bending beam. Recent evidence suggests, however, that the vibration of the organ of Corti can be complex and that multiple vibrational modes may play an important role in cochlear transduction. Inner hair cell (IHC) and auditory nerve responses to pure tones can exhibit large phase shifts and complex response waveforms with increasing stimulus level. In contrast, the comparable basilar membrane (BM) responses are much less complex, exhibiting only small phase shifts and relatively sinusoidal waveforms. To reconcile the differences observed between the published BM data and the IHC data, we have recorded receptor potentials from IHCs and compared these waveform data to the output of two computational models: a traditional linear model where IHC excitation depends only on BM displacement and a new model that assumes that outer hair cell (OHC) force production provides the major mechanical input to the IHC along with two additional mechanical components. Comparisons of the output of the two models with the experimental data show that the new model is capable of reproducing the very complex voltage responses of the IHC recorded in vivo whereas the traditional model performed poorly.

Organophosphate poisoning in Perth, Western Australia, 1987-1996.

This study aimed to review the presentation and management of patients with organophosphate poisoning admitted to the four tertiary teaching hospitals in Perth, Western Australia, over a 10-year period. The case notes of all 69 patients admitted with a discharge diagnosis of organophosphate poisoning were reviewed. Twenty-two of 25 patients (88%) attempting suicide were admitted to Intensive Care Units (ICUs), with a mean stay of 7 days (range 1-25 days). All but one were men, and two died. The 44 patients with accidental exposure were mainly children and had a mean stay of 2 days, with only seven going to the ICU. All survived. Complications overall included respiratory failure, convulsions, and aspiration pneumonia. Intubation and ventilation were required in 11 patients (16%), with a mean ventilation duration of 6 days (range 1-25 days). We conclude that deliberate ingestion of organophosphates is considerably more toxic than accidental exposure. Men aged 30-50 years were the most likely to attempt suicide with these agents and had prolonged ICU admissions with significant complications and mortality.

Measurements of the stiffness map challenge a basic tenet of cochlear theories.

The cochlear frequency map is believed to depend on the progressive decrease in partition stiffness from base to apex. Measurements on cochleae from human cadavers by von Békésy (1960) suggested that the elasticity of the partition increases by a factor of 100 from the stapes to the helicotrema. However, conventional models require a factor of nearly 10,000 to support the frequency range of normal hearing if entirely determined by partition stiffness. To test this assumption, we measured point stiffness along the width and length of the partition in the gerbil cochlea. Two major findings result from this study: (1) contrary to von Békésy's results, both cellular and extracellular elements of the sensory epithelium exhibit stiffness gradients; and (2) the stiffness changes by only a factor of 100 over the whole cochlea. Our results imply that present ideas regarding partition vibration need to be significantly revised.

Nonlinear characteristics of electrically evoked otoacoustic emissions.

To further our knowledge of outer hair cell nonlinearities, we measured the dependence of the electrically-evoked otoacoustic emissions (EEOEs) on current level for a wide range of electrical frequencies. Alternating electrical current was delivered into the scala media of the gerbil cochlea while the EEOE was measured with a probe-tube microphone. While the EEOE scaled linearly with current level for many frequencies and current levels, notable exceptions occurred. For frequencies below 300 Hz and currents above 20-30 microA(peak), the gain (primary EEOE magnitude divided by the current level) increased abruptly. For higher frequencies, the gain often increased slightly with increasing current of up to 30-50 microA(peak), but decreased at even higher current levels. We also investigated the enhancement of the EEOE due to simultaneous acoustic stimulation. The enhancement of the EEOE was relatively insensitive to current level with little change in enhancement for current levels up to 20 microA(peak). For current levels above approximately 40 microA(peak), the enhancement decreased slightly.

The response of aggregate production to fertility-induced changes in population age distribution.

PIP: With a particular focus upon long-term supply effects, the authors explored the implications of different population age distributions for the productive capacity of an economy. A multilevel aggregate production process was specified, plausible values assigned to its parameters, and steady-state solutions obtained under a range of alternative fertility assumptions. The theoretical model was calibrated to conform with Canadian data and published estimates of age-sex substitution elasticities. The study found productive capacity to be related to age distribution, although the output effects exceed 8%, regardless of the structure of the economy, only when total fertility rate is less than 1.6 or well above 3.0; within the range of variation, productive capacity and output per capita are lower for both younger and older populations; altering the elasticity of substitution between different tasks has negligible effects upon the sensitivity of the economy to changes in age distribution; altering the elasticity of substitution between different age-sex groups for a given task has a markedly greater effect; introducing either increasing or decreasing returns to scale has only a minor effect upon the sensitivity of the economy to changes in age distribution; and marginal products are quite sensitive to changes in age distribution for both younger and older workers, but far less sensitive for middle-aged workers.^ieng