Rehabilitation outcomes for brain injured patients in Australia: functional status, length of stay and discharge destination

This study describes the rehabilitation length of stay (LOS), discharge destination and discharge functional status of 149 patients admitted with traumatic brain injury (TBI) to an Australian hospital over a 5-year period. Hospital charts of patients admitted between 1993-1998 were reviewed. Average LOS over the 5-year time period was 61.8 days and only decreased nominally over this time. Longer LOS was predicted by lower admission motor FIM scores and presence of comorbidities. Mean admission and discharge motor FIM scores were 58 and 79, which represented a gain of 21 points. Higher discharge motor FIM scores were predicted by higher admission motor FIM scores and younger age. FIM gain was predicted by cognitive status and age. Most patients, 88%, were discharged back to the community, with 30% changing their living setting or situation. Changing living status was predicted by living alone and having poorer functional status on admission.

Damages for wrongful conception : moving away from policy considerations?

The House of Lords addressed the issue of damages in a wrongful conception case, in McFarlane and Another v Tayside Health Board - decision provides a strong indication that damages will be awarded for pain and suffering associated with childbirth but not for the costs of maintaining the child until adulthood - no case involving a claim of raising a child in a wrongful birth case has yet come before the High Court of Australia.

Surgical outcomes of a randomized prospective trial involving patients with a proximal femoral fracture

Background: An orthopaedic management/patient-focused care unit (OMPFCU) involving a dedicated orthopaedic-geriatrics liaison team was established at the Royal Brisbane Hospital in 1994 in an effort to safely accelerate rehabilitation of patients with proximal femoral fractures. Methods: The surgical outcomes of the patients were monitored in order to determine whether accelerated rehabilitation had any significant adverse effects on the surgical outcomes, measured by mortality, readmission to hospital, deep wound infection, fracture union delay, mobility and the revision surgery rate. Results: No significant difference was recorded in mortality and morbidity, deep wound infection and revision surgery rates between patients in the Royal Brisbane Hospital OMPFCU and those in standard care in the orthopaedic surgery wards. Conclusion: Accelerated rehabilitation for patients with a proximal femoral fracture in a major teaching hospital can be accomplished safely.

Single institution outcomes of treatment of severe aplastic anaemia

Background: In severe aplastic anaemia, the treatment of choice for young patients with a human leucocyte antigen-matched sibling is now established as allogeneic bone marrow transplantation (BMT). In older patients and in those without a matched sibling donor, immunosuppressive therapy is the usual first option. 'Alternative' marrow donors are emerging as an option for those without a matched sibling donor. Aims: To review 10 years of local experience in treating severe aplastic anaemia with BMT and immunosuppressive therapy with emphasis on long-term outcomes. Methods: A retrospective analysis was performed of all patients with severe aplastic anaemia presenting to the Royal Brisbane and Royal Children's Hos- pitals between 1989 and 1999. Data were abstracted regarding patient demographics, pretreatment characteristics and outcome measures, including response rates, overall survival and long-term complications. Results: Twenty-seven consecutive patients were identified, 12 treated with immunosuppression alone and 15 with BMT. In these two groups, transfusion independence was attained in 25% and 100%, respectively, with overall survival being 36% and 100%, respectively. Those treated with immunosuppression were significantly older (median 41.5 versus 22 years, P = 0.008). Long-term survivors of either treatment had extremely low morbidity. Three patients carried pregnancies to term post-transplant. Three patients received alternative donor BMT with correspondingly excellent survival. Conclusions: Patients treated with allogeneic BMT for severe aplastic anaemia enjoyed extremely good long-term survival and minimal morbidity. Patients treated with immunosuppressive therapy had a poorer outcome reflecting their older age and different usage of therapies over the past decade. Optimal treatment strategies for severe aplastic anaemia remain to be determined.

Macroeconomic policy in an output-expenditure model

This paper proposes an alternative framework for examining the international macroeconomic impact of domestic monetary and fiscal policies and focuses on the distinction between national spending and national production and the reactive behavior of foreign investors to changing external account balances. It demonstrates that under a floating exchange rate regime, monetary and fiscal policies can affect aggregate expenditure and output quite differently, with important implications for the behavior of the exchange rate, the current account balance, and national income in the short run, as well as the economy's price level in the long run. In particular, this paper predicts that expansionary monetary and fiscal policies tend to depreciate the currency and only temporarily raise gross domestic product and the current account surplus, although permanently raise the domestic price level. This is a revised version of a paper presented at the Forty-Ninth International Atlantic Economic Conference, March 14–21, 2000, Munich, Germany.

Child-Pugh class, nutritional indicators and early liver transplant outcomes

Background/Aims: Patients with chronic liver disease undergoing liver transplantation have reduced body fat and muscle mass. The extent to which nutritional indicators and Child-Pugh class are predictive of postoperative outcome in adults is unclear. The aims of this study were to determine in adult patients undergoing transplant 1) the influence of preoperative Child-Pugh class and nutritional indicators on early transplant outcomes and one-year survival, 2) the relationship between nutritional indicators and Child-Pugh class and disease type. This study included 80 patients (1990-1994). Methodology: The nutritional indicators utilized were grip strength, triceps skinfold thickness and uncorrected mid-arm muscle area. Measured outcomes were ventilator time, intensive care stay, postoperative hospital stay and one-year survival. Results: Early morbidity was determined in survivors. Child-Pugh class C patients required longer ventilation and spent more time in the intensive care unit than Child-Pugh classes A and B. No significant relationships were found length of hospital stay. Relationships between the nutritional indicators (when controlled for Child-Pugh class) and early morbidity could not be determined due;to insufficient data. No relationship was established between one-year survival and Child-Pugh class or the nutritional indicators. Grip strength and mid-arm muscle area were lower in the patients in Child-Pugh:classes B and C. Parenchymal liver disease was associated with lower grip strength and mid-arm muscle area when compared to cholestatic disease. Conclusions: Child-Pugh class C is associated with greater early postoperative morbidity. Advanced Child-Pugh class is also associated with diminished muscle status and parenchymal disease.

Highlights of drought policy and related science in Australia and the USA

Patterns of water supply and use in Australia and the U.S.A. differ in many ways. This results in different perceptions concerning the nature of drought and policy approaches to its management. This paper discusses the differences and similarities and explores lessons that policy makers in both countries can learn from one another. A key difference between the two countries is that whereas drought is perceived in Australia essentially in terms of its impact on agriculture, in the U.S. both perceptions and policy are also heavily influenced by the impact of drought on urban communities. This has led to different policy emphases. In 1992 Australia established its National Drought Policy; the U.S. is presently considering the adoption of a national drought policy. These policies highlight drought being accepted as part of natural climate variability, rather than as a natural disaster. They also emphasize the protection of the natural resource base.

The Role of Non-Market Valuation in Forest Management and Recreation Policy

Forests, and particularly those where native and mixed species are gown, provide a variety of non-wood values, important among which are recreation and environmental services. Substantial progress has been made in recent years in estimating economic values on these services. A considerable amount of research on forest values has been carried out recently in tropical and sub-tropical eastern Australia, some of which is reported in the following papers. The need for estimates of non-wood forest benefits is apparent, and it is clear that further development of techniques and a greater understanding of the way these values can be integrated into public-sector decision making is required.

Survivors and victims: A case study of organisational restructuring in the public health sector

This paper examines a process of major organizational restructuring in an Australian hospital within a context of decentralization of health services and relocation of clients, brought about by changes in government policy. The change process differed from the abrupt downsizing often found in the private sector in that the organization initiated significant job losses concomitantly with the development of new facilities around the State, while attempting to deal with employee issues related to downsizing. The paper focuses on the process involved in the downsizing, from the perspective of both the "survivors" and "victims" of the change. It draws on interviews and focus groups with managers, union officials and employees, as well a survey of employees to assess the outcomes and effectiveness of the restructuring process. Using a stakeholder analysis framework, the paper examines the complex issues and perspectives raised by the downsizing process.