Mitigating the SARS-CoV-2 Delta disease burden in Australia by non-pharmaceutical interventions and vaccinating children: a modelling analysis.

BACKGROUND: In countries with high COVID-19 vaccination rates the SARS-CoV-2 Delta variant resulted in rapidly increasing case numbers. This study evaluated the use of non-pharmaceutical interventions (NPIs) coupled with alternative vaccination strategies to determine feasible Delta mitigation strategies for Australia. We aimed to understand the potential effectiveness of high vaccine coverage levels together with NPI physical distancing activation and to establish the benefit of adding children and adolescents to the vaccination program. Border closure limited SARS-CoV-2 transmission in Australia; however, slow vaccination uptake resulted in Delta outbreaks in the two largest cities and may continue as international travel increases. METHODS: An agent-based model was used to evaluate the potential reduction in the COVID-19 health burden resulting from alternative vaccination strategies. We assumed immunity was derived from vaccination with the BNT162b2 Pfizer BioNTech vaccine. Two age-specific vaccination strategies were evaluated, ages 5 and above, and 12 and above, and the health burden determined under alternative vaccine coverages, with/without activation of NPIs. Age-specific infections generated by the model, together with recent UK data, permitted reductions in the health burden to be quantified. RESULTS: Cases, hospitalisations and deaths are shown to reduce by (i) increasing coverage to include children aged 5 to 11 years, (ii) activating moderate NPI measures and/or (iii) increasing coverage levels above 80%. At 80% coverage, vaccinating ages 12 and above without NPIs is predicted to result in 1095 additional hospitalisations per million population; adding ages 5 and above reduces this to 996 per million population. Activating moderate NPIs reduces hospitalisations to 611 for ages 12 and over, and 382 per million for ages 5 and above. Alternatively, increasing coverage to 90% for those aged 12 and above is estimated to reduce hospitalisations to 616. Combining all three measures is shown to reduce cases to 158, hospitalisations to 1 and deaths to zero, per million population. CONCLUSIONS: Delta variant outbreaks may be managed by vaccine coverage rates higher than 80% and activation of moderate NPI measures, preventing healthcare facilities from being overwhelmed. If 90% coverage cannot be achieved, including young children and adolescents in the vaccination program coupled with activation of moderate NPIs appears necessary to suppress future COVID-19 Delta-like transmission and prevent intensive care unit surge capacity from being exceeded.

A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study.

BACKGROUND: Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS: This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS: Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS: Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

Overcoming inefficiencies arising due to the impact of the modifiable areal unit problem on single-aggregation disease maps.

BACKGROUND: In disease mapping, fine-resolution spatial health data are routinely aggregated for various reasons, for example to protect privacy. Usually, such aggregation occurs only once, resulting in 'single-aggregation disease maps' whose representation of the underlying data depends on the chosen set of aggregation units. This dependence is described by the modifiable areal unit problem (MAUP). Despite an extensive literature, in practice, the MAUP is rarely acknowledged, including in disease mapping. Further, despite single-aggregation disease maps being widely relied upon to guide distribution of healthcare resources, potential inefficiencies arising due to the impact of the MAUP on such maps have not previously been investigated. RESULTS: We introduce the overlay aggregation method (OAM) for disease mapping. This method avoids dependence on any single set of aggregate-level mapping units through incorporating information from many different sets. We characterise OAM as a novel smoothing technique and show how its use results in potentially dramatic improvements in resource allocation efficiency over single-aggregation maps. We demonstrate these findings in a simulation context and through applying OAM to a real-world dataset: ischaemic stroke hospital admissions in Perth, Western Australia, in 2016. CONCLUSIONS: The ongoing, widespread lack of acknowledgement of the MAUP in disease mapping suggests that unawareness of its impact is extensive or that impact is underestimated. Routine implementation of OAM can help avoid resource allocation inefficiencies associated with this phenomenon. Our findings have immediate worldwide implications wherever single-aggregation disease maps are used to guide health policy planning and service delivery.

Reducing Bruzzi's Formula to Remove Instability in the Estimation of Population Attributable Fraction for Health Outcomes.

The aim of this study was to reconcile 3 approaches to calculating population attributable fractions and attributable burden percentage: the approach of Bruzzi et al. (Am J Epidemiol. 1985;122(5):904-914.), the maximum-likelihood method of Greenland and Drescher (Biometrics. 1993;49(3):865-872.), and the multivariable method of Tanuseputro et al. (Popul Health Metr. 2015;13:5.). Using data from a statewide point prevalence survey (Western Australian Point Prevalence Survey, 2014) linked to an administrative database, we compared estimates of attributable burden percentage obtained using the contrasting methods in 6 logistic models of health outcomes from the survey, estimating 95% confidence intervals using nonparametric and weighted bootstrap approaches. Our results show that instability can arise from the fundamental algebraic construction of Bruzzi's formula, and that this instability may substantially influence the calculation of attributable burden percentage and associated confidence intervals. These observations were confirmed in a simulation study. The algebraic reduction of Bruzzi's formula to the 2 alternative methods resulted in markedly more stable estimates for population attributable fraction and attributable burden percentage in cross-sectional studies and cohort designs with fixed follow-up time. We advocate the widespread implementation of the maximum-likelihood approach and the multivariable method.

Hospital admissions and emergency department presentations for dental conditions indicate access to hospital, rather than poor access to dental health care in the community.

High rates of dental-related potentially preventable hospitalisations are thought to reflect poor access to non-hospital dental services. The association between accessibility (geographic and financial) to non-hospital dentists and potentially preventable hospitalisations was examined in Western Australia. Areas with persistently high rates of dental-related potentially preventable hospitalisations and emergency department (ED) presentations were mapped. Statistical models examined factors associated with these events. Persistently high rates of dental-related potentially preventable hospitalisations were clustered in metropolitan areas that were socioeconomically advantaged and had more dentists per capita (RR 1.06, 95% CI 1.04-1.08) after adjusting for age, sex, socioeconomics, and Aboriginality. Persistently high rates of ED presentations were clustered in socioeconomically disadvantaged areas near metropolitan EDs and with fewer dentists per capita (RR 0.91, 0.88-0.94). A positive association between dental-related potentially preventable hospitalisations and poor (financial or geographic) access to dentists was not found. Rather, rates of such events were positively associated with socioeconomic advantage, plus greater access to hospitals and non-hospital dental services. Furthermore, ED presentations for dental conditions are inappropriate indicators of poor access to non-hospital dental services because of their relationship with hospital proximity. Health service planners and policymakers should pursue alternative indicators of dental service accessibility.

The ecological fallacy of the role of age in chronic disease and hospital demand.

OBJECTIVE: To examine the relationship between age and all-cause hospital utilization in the years preceding and following a diagnosis in hospital of heart failure, type 2 diabetes, or chronic obstructive pulmonary disease (COPD). RESEARCH DESIGN: A cohort study of all patients in Western Australia who have had a principal diagnosis of heart failure, type 2 diabetes, or COPD, upon admission to hospital. All-cause hospital utilization 6 years preceding and 4 years following cardinal events, that is, a disease-specific diagnosis upon hospital admission, where such an event has not occurred in the previous 2 years, are examined in specific age groups. RESULTS: Six years preceding a cardinal event, all-cause emergency department (ED) presentations are similar in all age groups, from under 55 to over 85 years of age, except in COPD where ED presentation rates are higher in younger groups. All-cause hospital inpatient days are transiently higher in the years preceding and following a cardinal event in older age groups, yet return to similar levels across all age cohorts after 4 years. ED presentations are significantly higher in the 4 years following cardinal events in younger compared with older groups. CONCLUSIONS: Longitudinal analysis of utilization around cardinal events overcomes the confounding effect of differences in chronic disease rates between age groups, avoiding a source of ecologic bias that erroneously attributes increasing utilization in individuals with chronic disease to age. Programs designed to reduce hospital demand in patients with chronic disease should possibly focus on younger, rather than older, individuals.

The ratchet effect: dramatic and sustained changes in health care utilization following admission to hospital with chronic disease.

OBJECTIVE: To describe the previously unexamined association between admissions to hospital with chronic disease and changes in all-cause health service utilization over time. RESEARCH DESIGN: A cohort study examining the population of Western Australia with hospitalizations for chronic disease from 2002 to 2010. A "rolling" clearance period is used to define "cardinal events," that is, a disease-specific diagnosis upon hospital admission, where such an event has not occurred in the previous 2 years. Changes in the rate of cardinal events associated with diagnoses of heart failure, type 2 diabetes, chronic obstructive pulmonary disease, cataract with diabetes, asthma, and dialysis are examined. Health service utilization (defined as inpatient days or emergency department presentations) 6 years preceding and 4 years following such events is presented. RESULTS: Cardinal events make up 40%-60% of all chronic disease admissions. A previously undescribed ratchet effect following cardinal events specifically associated with type 2 diabetes, heart failure, and chronic obstructive pulmonary disease is observed. This involves a 2- to 3-fold increase in inpatient days and emergency department presentations that are sustained for at least 4 years. CONCLUSIONS: Cardinal events represent an important reference point to understand the impact of chronic disease on health service utilization. Events that herald such a marked transition in health service demand have not been previously described.

Investigating local variation in disease rates within high-rate regions identified using smoothing.

Exploratory disease maps are designed to identify risk factors of disease and guide appropriate responses to disease and helpseeking behaviour. However, when produced using aggregatelevel administrative units, as is standard practice, disease maps may mislead users due to the Modifiable Areal Unit Problem (MAUP). Smoothed maps of fine-resolution data mitigate the MAUP but may still obscure spatial patterns and features. To investigate these issues, we mapped rates of Mental Health- Related Emergency Department (MHED) presentations in Perth, Western Australia, in 2018/19 using Australian Bureau of Statistics (ABS) Statistical Areas Level 2 (SA2) boundaries and a recent spatial smoothing technique: the Overlay Aggregation Method (OAM). Then, we investigated local variation in rates within high-rate regions delineated using both approaches. The SA2- and OAM-based maps identified two and five high-rate regions, respectively, with the latter not conforming to SA2 boundaries. Meanwhile, both sets of high-rate regions were found to comprise a select number of localised areas with exceptionally high rates. These results demonstrate how, due to the MAUP, disease maps that are produced using aggregate-level administrative units are unreliable as a basis for delineating geographic regions of interest for targeted interventions. Instead, reliance on such maps to guide responses may compromise the efficient and equitable delivery of healthcare. Detailed investigation of local variation in rates within high-rate regions identified using both administrative units and smoothing is required to improve hypothesis generation and the design of healthcare responses.

Improving the Efficiency of Geographic Target Regions for Healthcare Interventions.

Appropriate prioritisation of geographic target regions (TRs) for healthcare interventions is critical to ensure the efficient distribution of finite healthcare resources. In delineating TRs, both 'targeting efficiency', i.e., the return on intervention investment, and logistical factors, e.g., the number of TRs, are important. However, existing approaches to delineate TRs disproportionately prioritise targeting efficiency. To address this, we explored the utility of a method found within conservation planning: the software Marxan and an extension, MinPatch ('Marxan + MinPatch'), with comparison to a new method we introduce: the Spatial Targeting Algorithm (STA). Using both simulated and real-world data, we demonstrate superior performance of the STA over Marxan + MinPatch, both with respect to targeting efficiency and with respect to adequate consideration of logistical factors. For example, by design, and unlike Marxan + MinPatch, the STA allows for user-specification of a desired number of TRs. More broadly, we find that, while Marxan + MinPatch does consider logistical factors, it also suffers from several limitations, including, but not limited to, the requirement to apply two separate software tools, which is burdensome. Given these results, we suggest that the STA could reasonably be applied to help prevent inefficiencies arising due to targeting of interventions using currently available approaches.

Modelling the Relationship between Rainfall and Mental Health Using Different Spatial and Temporal Units.

Drought is thought to impact upon the mental health of agricultural communities, but studies of this relationship have reported inconsistent results. A source of inconsistency could be the aggregation of data by a single spatiotemporal unit of analysis, which induces the modifiable areal and temporal unit problems. To investigate this, mental health-related emergency department (MHED) presentations among residents of the Wheat Belt region of Western Australia, between 2002 and 2017, were examined. Average daily rainfall was used as a measure of drought. Associations between MHED presentations and rainfall were estimated based on various spatial aggregations of underlying data, at multiple temporal windows. Wide variation amongst results was observed. Despite this, two key features were found: Associations between MHED presentations and rainfall were generally positive when rainfall was measured in summer months (rate ratios up to 1.05 per 0.5 mm of daily rainfall) and generally negative when rainfall was measured in winter months (rate ratios as low as 0.96 per 0.5 mm of daily rainfall). These results demonstrate that the association between drought and mental health is quantifiable; however, the effect size is small and varies depending on the spatial and temporal arrangement of the underlying data. To improve understanding of this association, more studies should be undertaken with longer time spans and examining specific mental health outcomes, using a wide variety of spatiotemporal units.

A modelling analysis of the effectiveness of second wave COVID-19 response strategies in Australia.

There is a significant challenge in responding to second waves of COVID-19 cases, with governments being hesitant in introducing hard lockdown measures given the resulting economic impact. In addition, rising case numbers reflect an increase in coronavirus transmission some time previously, so timing of response measures is highly important. Australia experienced a second wave from June 2020 onwards, confined to greater Melbourne, with initial social distancing measures failing to reduce rapidly increasing case numbers. We conducted a detailed analysis of this outbreak, together with an evaluation of the effectiveness of alternative response strategies, to provide guidance to countries experiencing second waves of SARS-Cov-2 transmission. An individual-based transmission model was used to (1) describe a second-wave COVID-19 epidemic in Australia; (2) evaluate the impact of lockdown strategies used; and (3) evaluate effectiveness of alternative mitigation strategies. The model was calibrated using daily diagnosed case data prior to lockdown. Specific social distancing interventions were modelled by adjusting person-to-person contacts in mixing locations. Modelling earlier activation of lockdown measures are predicted to reduce total case numbers by more than 50%. Epidemic peaks and duration of the second wave were also shown to reduce. Our results suggest that activating lockdown measures when second-wave case numbers first indicated exponential growth, would have been highly effective in reducing COVID-19 cases. The model was shown to realistically predict the epidemic growth rate under the social distancing measures applied, validating the methods applied. The timing of social distancing activation is shown to be critical to their effectiveness. Data showing exponential rise in cases, doubling every 7-10 days, can be used to trigger early lockdown measures. Such measures are shown to be necessary to reduce daily and total case numbers, and the consequential health burden, so preventing health care facilities being overwhelmed. Early control of second wave resurgence potentially permits strict lockdown measures to be eased earlier.

Predicting Future Geographic Hotspots of Potentially Preventable Hospitalisations Using All Subset Model Selection and Repeated K-Fold Cross-Validation.

Long-term future prediction of geographic areas with high rates of potentially preventable hospitalisations (PPHs) among residents, or "hotspots", is critical to ensure the effective location of place-based health service interventions. This is because such interventions are typically expensive and take time to develop, implement, and take effect, and hotspots often regress to the mean. Using spatially aggregated, longitudinal administrative health data, we introduce a method to make such predictions. The proposed method combines all subset model selection with a novel formulation of repeated k-fold cross-validation in developing optimal models. We illustrate its application predicting three-year future hotspots for four PPHs in an Australian context: type II diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and "high risk foot". In these examples, optimal models are selected through maximising positive predictive value while maintaining sensitivity above a user-specified minimum threshold. We compare the model's performance to that of two alternative methods commonly used in practice, i.e., prediction of future hotspots based on either: (i) current hotspots, or (ii) past persistent hotspots. In doing so, we demonstrate favourable performance of our method, including with respect to its ability to flexibly optimise various different metrics. Accordingly, we suggest that our method might effectively be used to assist health planners predict excess future demand of health services and prioritise placement of interventions. Furthermore, it could be used to predict future hotspots of non-health events, e.g., in criminology.

Impact of the modifiable areal unit problem in assessing determinants of emergency department demand.

OBJECTIVE: To examine the impact of the modifiable areal unit problem (MAUP) in an investigation of factors associated with ED demand in Perth, Western Australia, in 2016. Furthermore, to advocate a means of avoiding this impact. METHODS: ED presentations were classified as: urgent medical, non-urgent medical, urgent trauma or non-urgent trauma. In each group, sex-stratified, age-adjusted multivariate associations with socio-economic status and distance to the nearest ED and general practitioner (GP) were estimated. Modelling was undertaken using different sets of spatial units: Australian Bureau of Statistics (ABS) Statistical Areas Level 1 (SA1s) and numerous aggregate-level zonations of SA1s (ABS SA2s and others). RESULTS: Estimates obtained using the different units often varied widely: for seven (30%) of 24 strata defined by combinations of sex, ED type and covariate, the smallest and largest effect sizes differed in terms of direction; further, for 11 (65%) of the remaining 17 strata, the largest effect size was at least twice as high as the smallest. This demonstrates the MAUP's impact and that analyses based on a single set of spatial units are unreliable. To resolve the observed variation, we highlight the SA1-level estimates. CONCLUSIONS: When formulating interventions targeting reduced ED utilisation, policy planners should be guided by evidence based on analysis of appropriate spatial units. This ideal is undermined by the widespread lack of acknowledgement of the MAUP in studies examining drivers of ED demand using spatially aggregated data. To avoid the MAUP, only estimates obtained through examining a minimal geographic unit should be relied upon.

Impact of structured education and self management on rural asthma outcomes.

BACKGROUND: This study trialled the outcome for asthma patients of a brief, nurse led, patient education session with general practice review of an Asthma Action Plan. METHODS: Prospective cohort with before-after measures conducted in six rural general practices. Outcome measures were changes over 12 months in self reported asthma control, quality of life, device use, and unscheduled general practice and emergency department visits for asthma exacerbation. RESULTS: Eighty-three patients participated. Mean asthma control score decreased but did not reach statistical significance (p=0.124). Quality of life improved for adults (Wilcoxon rank signed test for two related samples p<0.001). The proportion of patients who had one or more unscheduled visits to their general practitioner over 12 months decreased from 23% to 13% (p=0.178) and emergency department presentations decreased from 9% to 4% (p=0.102). DISCUSSION: Structured general practice based education appears to be an effective preventive health care program, with the potential to reduce expensive unscheduled use of health services.

Anxiety and alcohol in the working-age population are driving a rise in mental health-related emergency department presentations: 15 year trends in emergency department presentations in Western Australia.

OBJECTIVE: To evaluate age, gender and disease-specific trends in ED for mental health presentations over 15 years. METHODS: The study population consisted of residents of metropolitan Perth, Western Australia, presenting to Perth ED between 1 July 2002 and 30 June 2017. Population rates of mental health-related ED presentations per year were calculated. RESULTS: Rates of mental health ED presentations are significantly increasing in the working-age population for those with stress and anxiety-related diagnoses, particularly in younger females, and also for alcohol-related presentations for those aged 10-49 years, particularly in males. CONCLUSION: The present study demonstrates that increased rates of mental health-related ED presentations are driven by increased rates of presentation for stress and anxiety-related and alcohol-related presentations in both genders across the working-age population.

Burden of primary care-type emergency department presentations using clinical assessment by general practitioners: A cross-sectional study.

OBJECTIVE: To compare methods of assessment of the burden of primary care-type ED (PCTED) presentations against clinical assessment by general practitioners (GPs) in ED. METHODS: A cross-sectional study involving clinical assessment of patients presenting to four EDs in Western Australia. The GPs assessed patients who were likely to be discharged home from ED, and considered whether they could be managed in general practice. Patient presentations were defined by the GPs as: PCTED; PCTED if additional primary care resources were available; or not PCTED. RESULTS: GP researchers determined that 80% of patients assessed were PCTED presentations, with one-third of these considered PCTED presentations if additional resources were available. A high proportion of identified PCTED presentations included categories excluded by previous methods. Analysis of linked data found the cohort assessed to be of lower urgency, younger, and with a shorter length of stay than the average patient being discharged from ED. After accounting for potential bias, it is suggested that 20-40% of all ED presentations could be PCTED presentations. CONCLUSIONS: Previous methods determining the burden of PCTED presentations have not been validated. Many presentations excluded by previous methods were identified as manageable in general practice by GPs clinically assessing patients in ED. Improved validation of criteria used to identify PCTED presentations will enable appropriately designed interventions to reduce such events.

Hospital use in Aboriginal and non-Aboriginal patients with chronic disease.

OBJECTIVE: The objective of this study was to compare rates of hospital utilisation in Aboriginal and non-Aboriginal peoples before and after hospital admission for chronic obstructive pulmonary disease, heart failure and/or type 2 diabetes mellitus. METHODS: This was a longitudinal cohort study from 2002 to 2014, which was conducted in all hospitals in Western Australia. The participants of this study were Aboriginal and non-Aboriginal patients with a principal diagnosis of heart failure, type 2 diabetes or chronic obstructive pulmonary disease, on admission to hospital, where such an event had not occurred in the previous 3 years. Inpatient days and ED presentations were the main outcome measures. RESULTS: Among the patients with chronic disease, Aboriginal people have similar inpatient days for all causes compared to non-Aboriginal people. However, they have much higher ED presentations in comparison. Age of onset of cardinal events occurs 15-20 years earlier in Aboriginal patients with chronic disease. Although age has little influence on ED presentations in non-Aboriginal chronic disease patients, younger Aboriginal people with chronic disease present far more often to ED than older Aboriginal people. CONCLUSIONS: Aboriginal people use health services in a different manner when compared to non-Aboriginal people. In a subset of patients with chronic disease, high use may be reduced with better access to primary healthcare. Policy-makers and healthcare providers should examine healthcare use from primary to tertiary care among the Aboriginal population, with a particular focus on ED presentations; investigate the underlying causes driving specific patterns of health service utilisation among Aboriginal people; and develop interventions to reduce potential deleterious impacts, and enhance the potential benefits, of specific patterns of healthcare use.

A hanging drop culture method to study terminal erythroid differentiation.

OBJECTIVE: To design a culture method allowing the quantitative and qualitative analysis of terminal erythroid differentiation. METHODS: Primary erythroid progenitors derived either from mouse tissues or from human umbilical cord blood were differentiated using hanging drop cultures and compared to methylcellulose cultures. Cultured cells were analyzed by FACS to assess differentiation. RESULTS: We describe a practical culture method by adapting the previously described hanging drop culture system to conditions allowing terminal differentiation of primary erythroid progenitors. Using minimal volumes of media and small numbers of cells, we obtained quantitative terminal erythroid differentiation within two days of culture in the case of murine cells and 4 days in the case of human cells. CONCLUSIONS: The established methods for ex vivo culture of primary erythroid progenitors, such as methylcellulose-based burst-forming unit-erythroid (BFU-E) and colony-forming unit-erythroid (CFU-E) assays, allow the detection of committed erythroid progenitors but are of limited value to study terminal erythroid differentiation. We show that the application of hanging drop cultures is a practical alternative that, in combination with clonogenic assays, enables a comprehensive assessment of the behavior of primary erythroid cells ex vivo in the context of genetic and drug-induced perturbations.

Improving the implementation of an early literacy program by child health nurses through addressing local training and cultural needs.

This study evaluates the implementation of an early literacy program by child health nurses (CHNs) in Geraldton and the Midwest regions of Western Australia. Children's early preschool exposure to reading is an important step in developing literacy skills in later schooling. The program aims to improve early literacy development by supplying parents with an appropriate book and information on reading to children at the child's seven-to-nine months of age health check. This study highlights the potential role of CHNs in encouraging early literacy in regional communities. However, a barrier to the successful implementation of the program was found to be its dependence on attendance at a predetermined health check. This was especially so for the Aboriginal population, which had a significantly lower attendance rate. Dependence on personal and professional experience amongst CHNs also resulted in sub-optimal implementation of the program. Recommendations to broaden the scope of the intervention, in timing and location, and to develop appropriate training for CHNs are discussed. It is shown that the implementation of such evidence-based programs must address local community and service provider issues to reach their full potential.