Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital

Objective: Healthcare faces the continual challenge of improving outcome whilst aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway. Design:  Discrete event simulation was used to model and analyse cost and resource utilisation with an activity based costing approach. Data for a full comparison before the process change was unavailable so we utilised a modelling approach, comparing a Virtual Fracture Clinic (VFC) to a simulated Traditional Fracture Clinic (TFC). Setting:  The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study. Outcome measures: Our study focused exclusively on non-operative trauma patients attending Emergency Department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries in association with activity costs from the models.ResultsPatients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p=<0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI: 21.74, 23.92) per patient compared with £36.81 (95% CI: 35.65, 37.97) for the TFC pathway.  Conclusions:  Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional face-to-face clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings

Service re-design in healthcare : the impact of innovative methods to compare costs and benefits

This article describes research conducted by University of Strathclyde academics that has successfully impacted upon policy implementation. Specifically, we describe the innovative application of Discrete Event Simulation (DES) in an action research framework to develop bottom-up micro costing models to determine the cost effectiveness of a radically new ‘virtual clinic’ pathway for orthopaedic trauma patients. The use of DES allowed stakeholders to compare the costs of the new approach (virtual fracture clinic) against the baseline (traditional fracture clinic) in sufficient detail. The insights generated from this research enabled health policy stakeholders to build a convincing case for the diffusion and reliable implementation of virtual pathways for orthopaedic trauma patients in other hospitals in Scotland and well beyond. Wider dissemination of this work has seen continued government funding for the use of DES for cost effectiveness studies in other healthcare settings, as well as training and capacity building in DES-supported service redesign amongst healthcare professionals throughout NHS Scotland

Cluster-randomized, crossover trial of head positioning in acute stroke

The role of supine positioning after acute stroke in improving cerebral blood flow and the countervailing risk of aspiration pneumonia have led to variation in head positioning in clinical practice. We wanted to determine whether outcomes in patients with acute ischemic stroke could be improved by positioning the patient to be lying flat (i.e., fully supine with the back horizontal and the face upwards) during treatment to increase cerebral perfusion. METHODS In a pragmatic, cluster-randomized, crossover trial conducted in nine countries, we assigned 11,093 patients with acute stroke (85% of the strokes were ischemic) to receive care in either a lying-flat position or a sitting-up position with the head elevated to at least 30 degrees, according to the randomization assignment of the hospital to which they were admitted; the designated position was initiated soon after hospital admission and was maintained for 24 hours. The primary outcome was degree of disability at 90 days, as assessed with the use of the modified Rankin scale (scores range from 0 to 6, with higher scores indicating greater disability and a score of 6 indicating death). RESULTS The median interval between the onset of stroke symptoms and the initiation of the assigned position was 14 hours (interquartile range, 5 to 35). Patients in the lying-flat group were less likely than patients in the sitting-up group to maintain the position for 24 hours (87% vs. 95%, P\u3c0.001). In a proportional-odds model, there was no significant shift in the distribution of 90-day disability outcomes on the global modified Rankin scale between patients in the lying-flat group and patients in the sitting-up group (unadjusted odds ratio for a difference in the distribution of scores on the modified Rankin scale in the lying-flat group, 1.01; 95% confidence interval, 0.92 to 1.10; P = 0.84). Mortality within 90 days was 7.3% among the patients in the lying-flat group and 7.4% among the patients in the sitting-up group (P = 0.83). There were no significant betweengroup differences in the rates of serious adverse events, including pneumonia. CONCLUSIONS Disability outcomes after acute stroke did not differ significantly between patients assigned to a lying-flat position for 24 hours and patients assigned to a sitting-up position with the head elevated to at least 30 degrees for 24 hours

Cataclysmic Variables from SDSS II. The Second Year

The first full year of operation following the commissioning year of the Sloan Digital Sky Survey has revealed a wide variety of newly discovered cataclysmic variables. We show the SDSS spectra of forty-two cataclysmic variables observed in 2002, of which thirty-five are new classifications, four are known dwarf novae (CT Hya, RZ Leo, T Leo and BZ UMa), one is a known CV identified from a previous quasar survey (Aqr1) and two are known ROSAT or FIRST discovered CVs (RX J09445+0357, FIRST J102347.6+003841). The SDSS positions, colors and spectra of all forty-two systems are presented. In addition, the results of follow-up studies of several of these objects identify the orbital periods, velocity curves and polarization that provide the system geometry and accretion properties. While most of the SDSS discovered systems are faint (>18th mag) with low accretion rates (as implied from their spectral characteristics), there are also a few bright objects which may have escaped previous surveys due to changes in the mass transfer rate.Comment: Accepted for publication in The Astronomical Journal, Vol. 126, Sep. 2003, 44 pages, 25 figures (now with adjacent captions), AASTeX v5.

A Survey of z>5.7 Quasars in the Sloan Digital Sky Survey II: Discovery of Three Additional Quasars at z>6

We present the discovery of three new quasars at z>6 in 1300 deg^2 of SDSS imaging data, J114816.64+525150.3 (z=6.43), J104845.05+463718.3 (z=6.23) and J163033.90+401209.6 (z=6.05). The first two objects have weak Ly alpha emission lines; their redshifts are determined from the positions of the Lyman break. They are only accurate to 0.05 and could be affected by the presence of broad absorption line systems. The last object has a Ly alpha strength more typical of lower redshift quasars. Based on a sample of six quasars at z>5.7 that cover 2870 deg^2 presented in this paper and in Paper I, we estimate the comoving density of luminous quasars at z 6 and M_{1450} < -26.8 to be (8 +/- 3)x10^{-10} Mpc^{-3} (for H_0 = 50 km/s/Mpc, Omega = 1). HST imaging of two z>5.7 quasars and high-resolution ground-based images (seeing 0.4'') of three additional z>5.7 quasars show that none of them is gravitationally lensed. The luminosity distribution of the high-redshfit quasar sample suggests the bright end slope of the quasar luminosity function at z 6 is shallower than Psi L^{-3.5} (2-sigma), consistent with the absence of strongly lensed objects.Comment: AJ in press (Apr 2003), 26 pages, 9 figure

High-Redshift Quasars Found in Sloan Digital Sky Survey Commissioning Data IV: Luminosity Function from the Fall Equatorial Stripe Sampl

This is the fourth paper in a series aimed at finding high-redshift quasars from five-color imaging data taken along the Celestial Equator by the SDSS. during its commissioning phase. In this paper, we use the color-selected sample of 39 luminous high-redshift quasars presented in Paper III to derive the evolution of the quasar luminosity function over the range of 3.6<z<5.0, and -27.5<M_1450<-25.5 (Omega=1, H_0=50 km s^-1 Mpc^-1). We use the selection function derived in Paper III to correct for sample incompleteness. The luminosity function is estimated using three different methods: (1) the 1/V_a estimator; (2) a maximum likelihood solution, assuming that the density of quasars depends exponentially on redshift and as a power law in luminosity and (3) Lynden-Bell's non-parametric C^- estimator. All three methods give consistent results. The luminous quasar density decreases by a factor of ~ 6 from z=3.5 to z=5.0, consistent with the decline seen from several previous optical surveys at z<4.5. The luminosity function follows psi(L) ~ L^{-2.5} for z~4 at the bright end, significantly flatter than the bright end luminosity function psi(L) \propto L^{-3.5} found in previous studies for z<3, suggesting that the shape of the quasar luminosity function evolves with redshift as well, and that the quasar evolution from z=2 to 5 cannot be described as pure luminosity evolution. Possible selection biases and the effect of dust extinction on the redshift evolution of the quasar density are also discussed.Comment: AJ accepted, with minor change

Evaluating intervention strategies in controlling coronavirus disease 2019 (COVID-19) spread in care homes : An agent-based model - Corrigendum

In the above article1, the author names should appear as follows: Le Khanh Ngan Nguyen, Susan Howick, Dennis McLafferty, Gillian H. Anderson, Sahaya J. Pravinkumar, Robert Van Der Meer and Itamar Megiddo

Optical and Radio Properties of Extragalactic Sources Observed by the FIRST and SDSS Surveys

We discuss the optical and radio properties of 30,000 FIRST sources positionally associated with an SDSS source in 1230 deg$^2$ of sky. The majority (83%) of the FIRST sources identified with an SDSS source brighter than r=21 are optically resolved. We estimate an upper limit of 5% for the fraction of quasars with broad-band optical colors indistinguishable from those of stars. The distribution of quasars in the radio flux -- optical flux plane supports the existence of the "quasar radio-dichotomy"; 8% of all quasars with i<18.5 are radio-loud and this fraction seems independent of redshift and optical luminosity. The radio-loud quasars have a redder median color by 0.08 mag, and a 3 times larger fraction of objects with red colors. FIRST galaxies represent 5% of all SDSS galaxies with r<17.5, and 1% for r<20, and are dominated by red galaxies. Magnitude and redshift limited samples show that radio galaxies have a different optical luminosity distribution than non-radio galaxies selected by the same criteria; when galaxies are further separated by their colors, this result remains valid for both blue and red galaxies. The distributions of radio-to-optical flux ratio are similar for blue and red galaxies in redshift-limited samples; this similarity implies that the difference in their luminosity functions, and resulting selection effects, are the dominant cause for the preponderance of red radio galaxies in flux-limited samples. We confirm that the AGN-to-starburst galaxy number ratio increases with radio flux, and find that radio emission from AGNs is more concentrated than radio emission from starburst galaxies (abridged).Comment: submitted to AJ, color gif figures, PS figures available from [email protected]

Retinoic Acid Signalling and the Control of Meiotic Entry in the Human Fetal Gonad

The development of mammalian fetal germ cells along oogenic or spermatogenic fate trajectories is dictated by signals from the surrounding gonadal environment. Germ cells in the fetal testis enter mitotic arrest, whilst those in the fetal ovary undergo sex-specific entry into meiosis, the initiation of which is thought to be mediated by selective exposure of fetal ovarian germ cells to mesonephros-derived retinoic acid (RA). Aspects of this model are hard to reconcile with the spatiotemporal pattern of germ cell differentiation in the human fetal ovary, however. We have therefore examined the expression of components of the RA synthesis, metabolism and signalling pathways, and their downstream effectors and inhibitors in germ cells around the time of the initiation of meiosis in the human fetal gonad. Expression of the three RA-synthesising enzymes, ALDH1A1, 2 and 3 in the fetal ovary and testis was equal to or greater than that in the mesonephros at 8–9 weeks gestation, indicating an intrinsic capacity within the gonad to synthesise RA. Using immunohistochemistry to detect RA receptors RARα, β and RXRα, we find germ cells to be the predominant target of RA signalling in the fetal human ovary, but also reveal widespread receptor nuclear localization indicative of signalling in the testis, suggesting that human fetal testicular germ cells are not efficiently shielded from RA by the action of the RA-metabolising enzyme CYP26B1. Consistent with this, expression of CYP26B1 was greater in the human fetal ovary than testis, although the sexually-dimorphic expression patterns of the germ cell-intrinsic regulators of meiotic initiation, STRA8 and NANOS2, appear conserved. Finally, we demonstrate that RA induces a two-fold increase in STRA8 expression in cultures of human fetal testis, but is not sufficient to cause widespread meiosis-associated gene expression. Together, these data indicate that while local production of RA within the fetal ovary may be important in regulating the onset of meiosis in the human fetal ovary, mechanisms other than CYP26B1-mediated metabolism of RA may exist to inhibit the entry of germ cells into meiosis in the human fetal testis

An Initial Survey of White Dwarfs in the Sloan Digital Sky Survey

An initial assessment is made of white dwarf and hot subdwarf stars observed in the Sloan Digital Sky Survey. In a small area of sky (190 square degrees), observed much like the full survey will be, 269 white dwarfs and 56 hot subdwarfs are identified spectroscopically where only 44 white dwarfs and 5 hot subdwarfs were known previously. Most are ordinary DA (hydrogen atmosphere) and DB (helium) types. In addition, in the full survey to date, a number of WDs have been found with uncommon spectral types. Among these are blue DQ stars displaying lines of atomic carbon; red DQ stars showing molecular bands of C_2 with a wide variety of strengths; DZ stars where Ca and occasionally Mg, Na, and/or Fe lines are detected; and magnetic WDs with a wide range of magnetic field strengths in DA, DB, DQ, and (probably) DZ spectral types. Photometry alone allows identification of stars hotter than 12000 K, and the density of these stars for 15<g<20 is found to be ~2.2 deg^{-2} at Galactic latitudes 29-62 deg. Spectra are obtained for roughly half of these hot stars. The spectra show that, for 15<g<17, 40% of hot stars are WDs and the fraction of WDs rises to ~90% at g=20. The remainder are hot sdB and sdO stars.Comment: Accepted for AJ; 43 pages, including 12 figures and 5 table