Modern vestibular tests can accurately separate stroke and vestibular neuritis.

OBJECTIVES: To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests. METHODS: Patients were prospectively recruited from the emergency room within 72 h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed. RESULTS: There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior-inferior cerebellar artery, basilar-perforators, multi-territory and anterior-inferior cerebellar artery (41.4%, 21.1%, 14.1%, 7.8%). VN included superior, inferior and pan-neuritis (53.3%, 4.2%, and 41.5%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%). In VN, we recorded horizontal (98.5%) or vertical/torsional spontaneous nystagmus (1.5%) and in PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus. The mean slow-phase velocity of horizontal nystagmus was faster in VN than PCS (11.8 ± 7.2 and 5.2 ± 3.0°/s, p < 0.01). Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in stroke (0.47 ± 0.24, 0.92 ± 0.20, p < 0.001). Ipsilesional catch-up saccades occurred earlier, and their amplitude, prevalence, and velocity were greater in VN than PCS (p < 0.01). Ipsilesional SVH deviation > 2.5° occurred more often in VN than in stroke (97.6% and 24.3%, p < 0.01). Abnormal bone-conducted ocular-VEMP asymmetry ratio was more common in VN than PCS (50% and 14.4%, p < 0.01). Using the ten best discriminators (VNG, vHIT, SVH, and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%. CONCLUSION: Quantitative vestibular testing helps separate stroke from vestibular neuritis and, when used, could improve diagnostic accuracy in the emergency room.

Capturing vertigo in the emergency room: three tools to double the rate of diagnosis.

OBJECTIVE: Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo. METHODS: A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS). RESULTS: In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed "Quantitative-HINTS plus" (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere's Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere's 5.7 ± 5.5○/s (p < 0.01). In EPV, benign positional vertigo (BPV) was identified in 82.3% using VOG. Paroxysmal positional-nystagmus lasting < 60 s separated BPV from non-BPV with 90% sensitivity and 100% specificity. In the control group of ER patients undergoing management-as-usual (n = 115), diagnoses included BPV (38.3%) and non-specific vertigo (41.7%). Unblinded assessors reached a final diagnosis in 90.6 and 30.4% of the intervention and control groups. Blinded assessors provided with the data gathered from each group reached a diagnosis in 86.3 and 41.1%. CONCLUSION: Three tools: a structured-assessment, vHIT and VOG doubled the rate of diagnosis in the ER.

Capturing acute vertigo: A vestibular event monitor.

OBJECTIVE: To facilitate the diagnosis of vestibular disorders by patient-initiated capture of ictal nystagmus. METHODS: Adults from an Australian neurology outpatient clinic reporting recurrent vertigo were recruited prospectively and taught to self-record spontaneous and positional nystagmus at home while symptomatic, using miniature video-oculography goggles. Consenting patients with ictal videorecordings and a final unblinded clinical diagnosis of Ménière disease (MD), vestibular migraine (VM), or benign paroxysmal positional vertigo (BPPV) were included. RESULTS: Ictal eye videos of 117 patients were analyzed. Of 43 patients with MD, 40 showed high-velocity spontaneous horizontal nystagmus (median slow-phase velocity [SPV] 39.7°/s; 21 showed horizontal nystagmus reversing direction within 12 hours [24 on separate days]). In 44 of 67 patients with VM, spontaneous horizontal (n = 28, 4.9°/s), upbeating (n = 6, 15.5°/s), or downbeating nystagmus (n = 10, 5.1°/s) was observed; 16 showed positional nystagmus only, and 7 had no nystagmus. Spontaneous horizontal nystagmus with SPV >12.05°/s had a sensitivity and specificity of 95.3% and 82.1% for MD (95% confidence interval [CI] 0.84-0.99, 0.71-0.90). Nystagmus direction change within 12 hours was highly specific (95.7%) for MD (95% CI 0.85-0.99). Spontaneous vertical nystagmus was highly specific (93.0%) for VM (95% CI 0.81-0.99). In the 7 patients with BPPV, spontaneous nystagmus was absent or <3°/s. Lying affected-ear down, patients with BPPV demonstrated paroxysmal positional nystagmus. Median time for peak SPV to halve (T50) was 19.0 seconds. Patients with VM and patients with MD demonstrated persistent positional nystagmus (median T50; 93.1 seconds, 213.2 seconds). T50s <47.3 seconds had a sensitivity and specificity of 100% and 77.8% for BPPV (95% CI 0.54-1.00, 0.64-0.88). CONCLUSION: Patient-initiated vestibular event monitoring is feasible and could facilitate rapid and accurate diagnosis of episodic vestibular disorders.

Climate change and the health of older people in Australia: A scoping review on the role of mobile applications (apps) in ameliorating impact.

OBJECTIVES: Due to the impact of climate change, mobile applications (apps) providing information about the external environment have the potential to improve the health of older people. The purpose of this research was to undertake a scoping review of the evidence on the usability, feasibility and effectiveness of mobile apps to encourage access to activities outside the home in older people. METHODS: A search of databases was undertaken with relevant keywords. Selected manuscripts were judged for relevance to the inclusion criteria and assessed for quality. RESULTS: Very few published studies examined mobile apps specifically designed to prevent, or to treat, chronic disease in ageing populations, and fewer had rigorous designs. No study addressed accessing the external environment in the context of climate change. CONCLUSION: This study demonstrates that there is a gap in the evidence about the mobile apps designed for healthy ageing and, more specifically, to improve access to the external environment.

Diagnostic accuracy of clinical tests for ankle syndesmosis injury.

OBJECTIVE: Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests. DESIGN: Cross-sectional diagnostic accuracy study. SETTING: 9 clinics in two Australian cities. PARTICIPANTS: 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled. METHODS: Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests. RESULTS: The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004). CONCLUSIONS: Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific).

Validation of respiratory inductive plethysmography (LifeShirt) in obesity hypoventilation syndrome.

Validation of respiratory inductive plethysmography (LifeShirt system) (RIPLS) for tidal volume (VT), minute ventilation (V˙E), and respiratory frequency (fB) was performed among people with untreated obesity hypoventilation syndrome (OHS) and controls. Measures were obtained simultaneously from RIPLS and a spirometer during two tests, and compared using Bland Altman analysis. Among 13 OHS participants (162 paired measures), RIPLS-spirometer agreement was unacceptable for VT: mean difference (MD) 3 mL (1%); limits of agreement (LOA) -216 to 220 mL (±36%); V˙E MD 0.1 L min(-1) (2%); LOA -4.1 to 4.3 L min(-1) (±36%); and fB: MD 0.2 br min(-1) (2%); LOA -4.6 to 5.0 br min(-1) (±27%). Among 13 controls (197 paired measures), RIPLS-spirometer agreement was acceptable for fB: MD -0.1 br min(-1) (-1%); LOA -1.2 to 1.1 br min(-1) (±12%), but unacceptable for VT: MD 5 mL (1%); LOA -160 to 169 mL (±20%) and V˙E: MD 0.1 L min(-1) (1%); LOA -1.4 to 1.5 L min(-1) (±20%). RIPLS produces valid measures of fB among controls but not OHS patients, and is not valid for quantifying respiratory volumes among either group.

Predictive factors for ankle syndesmosis injury in football players: a prospective study.

OBJECTIVES: Up to 25% of all ankle injuries involve the ankle syndesmosis and factors that increase risk have yet to be investigated prospectively. This study aimed to identify predictors of ankle syndesmosis injury in football players. DESIGN: A prospective study. METHODS: Rugby Union and Australian Football League players were recruited during 2010. Rugby League and different Rugby Union players were recruited during 2011. Baseline data collection included: age, body size, flexibility, strength and balance. Bivariate correlations were performed between all predictors. Variables with r ≥ 0.7 had only one variable entered in further analysis. Remaining predictor variables were analysed for association with the presence/absence of ankle syndesmosis injury. Variables with non-significant association with injury (p>0.2) were included in a backward step-wise Cox regression model. RESULTS: 202 male participants aged 21 ± 3.3 years (mean ± SD) were recruited of whom 12 (5.9%) sustained an ankle syndesmosis injury. The overall incidence rate was 0.59/1000 h sport participation for Rugby Union and Rugby League. Australian Football League training data was not available. No significant predictors were identified; however, participants who sustained an injury during the season performed a higher vertical jump (63.6 ± 8.2 cm) and greater Star Excursion Balance Test reach (80.5 ± 5.3 cm), than participants who did not sustain an injury: 59.1 ± 7.8 cm for Vertical Jump and 77.9 ± 6.1 cm for Star Excursion Balance Test. This was normalised for height. CONCLUSIONS: Variables such as age, body size, foot posture, flexibility and muscle strength did not increase risk of ankle syndesmosis injury. Jump height and balance performance may play a role in predicting ankle syndesmosis sprains.

Prognosis of ankle syndesmosis injury.

PURPOSE: Ankle syndesmosis injury has been associated with persistent pain and prolonged recovery; however, no predictors of prolonged recovery have been identified. The aims of this study were to establish prognosis for ankle syndesmosis injury compared with a lateral ankle sprain and to explore factors associated with prolonged recovery. METHODS: Participants (n = 63) age 21 ± 3.2 yr, with acute ankle ligament injuries (diagnosed through magnetic resonance imaging), were recruited from 10 sport clubs and sports medicine and physiotherapy clinics in two Australian cities. Follow-up was until full recovery and with preinjury activity level. Time to return to play was compared between injury types using Kaplan-Meier survival curves. Secondary analysis investigated putative factors that increased risk of prolonged recovery. For this analysis, participants unrecovered at 2 wk completed the following: Fear Avoidance Beliefs Questionnaire (FABQ); Star Excursion Balance Test, weight-bearing lunge, and vertical jump (VJ). These variables were correlated with time to recovery using bivariate Pearson's r correlation coefficient. RESULTS: The median recovery time for conservatively treated ankle syndesmosis injury was 62 and 15 d for lateral sprain. The sport-specific subscale scores of the FABQ were significantly higher (P = 0.017) for the ankle syndesmosis group, whereas vertical jump height was lower for this group, (P = 0.052). No baseline variables were strong predictors (r ≥ 0.6) of recovery. Moderate correlations were found for VJ (r = -0.471, P = 0.004) and the sport-specific subscale of the FABQ (r = 0.463, P = 0.004). CONCLUSIONS: Conservatively treated ankle syndesmosis injuries took four times longer to recover than lateral ankle sprain. Tests such as VJ and FABQ may identify individuals at risk of prolonged recovery and allow health professionals to determine realistic and appropriate time to recovery.

Ocular vestibular evoked myogenic potentials: the effect of head and body tilt in the roll plane.

OBJECTIVE: To explore effects of whole-head/body tilt in the roll plane on ocular-vestibular evoked myogenic potentials (oVEMP). METHODS: Twenty healthy subjects were randomly tilted in an Eply Omniax rotator across a series of eight angles from 0° to 360° (at 45° separations) in the roll plane. At each position, oVEMPs to air-conducted (AC) and bone-conducted (BC) stimulation were recorded from unrectified infra-orbital surface electromyography during upward gaze. oVEMP amplitudes, latencies and amplitude asymmetry were compared across each angle of orientation. RESULTS: Head orientation had a significant effect on oVEMP reflex amplitudes for both AC and BC stimulation (p<0.001). For both stimuli there was a trend for lower amplitudes with increasing angular departure from the upright position. Mean amplitudes decreased by 42.6-56.8% (AC) and 23.2-25.5% (BC) when tilted 180°. Roll-plane tilt had a significant effect on amplitude asymmetry ratios recorded in response to AC stimuli (p<0.001), indicating a trend for lower amplitudes from the dependent (down) ear. Amplitude asymmetry ratios for BC stimuli were unaffected by head and body orientation. CONCLUSIONS: The results confirm an effect of head and body orientation on oVEMP reflexes recorded in response to air- and bone-conducted stimuli. SIGNIFICANCE: The upright position yields an optimal oVEMP response.

Validity of arterialised-venous P CO2, pH and bicarbonate in obesity hypoventilation syndrome.

This prospective study investigated the validity of arterialised-venous blood gases (AVBG) for estimating arterial carbon dioxide P CO2, pH and bicarbonate (HCO3(-)) in people with obesity hypoventilation syndrome (OHS). AVBGs were obtained from an upper limb vein, after heating the skin at 42-46°C. Arterial blood gas (ABG) and AVBG samples were taken simultaneously and compared using Bland Altman analysis. Between-group differences were assessed with independent t-tests or Mann-Whitney U tests. Forty-two viable paired samples were analysed, including 27 paired samples from 15 OHS participants, and 15 paired samples from 16 controls. AVBG-ABG agreement was not different between groups, or between dorsal hand, forearm and antecubital AVBG sampling sites, and was clinically acceptable for P Co2: mean difference (MD) 0.4 mmHg (0.9%), limits of agreement (LOA) -2.7-3.6 mmHg (± 6.6%); pH: MD -0.008 (-0.1%), LOA -0.023-0.008 (± 0.2%); and HCO3(-): MD -0.3 mmol L(-1) (-1.0%), LOA -1.8-1.2 mmol L(-1) (± 5.3%). AVBG provides valid measures of [Formula: see text] , pH, and HCO3(-) in OHS.

Markers of good performance in mammography depend on number of annual readings.

PURPOSE: To explore relationships between reader performance and reader characteristics in mammography for specific radiologist groupings on the basis of annual number of readings. MATERIALS AND METHODS: The institutional review board approved the study and waived the need for patient consent to use all images. Readers gave informed consent. One hundred sixteen radiologists independently reviewed 60 mammographic cases: 20 cases with cancer and 40 cases with normal findings. Readers located any visualized cancer, and levels of confidence were scored from 1 to 5. A jackknifing free response operating characteristic (JAFROC) method was used, and figures of merit along with sensitivity and specificity were correlated with reader characteristics by using Spearman techniques and standard multiple regressions. RESULTS: Reader performance was positively correlated with number of years since qualification as a radiologist (P ≤ .01), number of years reading mammograms (P ≤ .03), and number of readings per year (P ≤ .0001). The number of years since qualification as a radiologist (P ≤ .004) and number of years of reading mammograms (P ≤ .002) were negatively related to JAFROC values for radiologists with annual volumes of less than 1000 mammographic readings. For individuals with more than 5000 mammographic readings per year, JAFROC values were positively related to the number of years that the reader was qualified as a radiologist (P ≤ .01), number of years of reading mammograms (P ≤ .002), and number of hours per week of reading mammograms (P ≤ .003). Number of mammographic readings per year was positively related with JAFROC scores for readers with an annual volume between 1000 and 5000 readings (P ≤ .03). Differences in JAFROC scores appear to be more related to specificity than location sensitivity, with the former demonstrating significant relationships with four of the five characteristics analyzed, whereas no relationships were shown for the latter. CONCLUSION: Radiologists' determinants of performance are associated with annual reading volumes. Ability to recognize normal images is a discriminating factor in individuals with a high volume of mammographic readings.

Gender differences in health-related quality of life of Australian chronically-ill adults: patient and physician characteristics do matter.

BACKGROUND: The aims of this study were to explore the health-related quality of life (HRQoL) in a large sample of Australian chronically-ill patients (type 2 diabetes and/or hypertension/ischaemic heart disease), to investigate the impact of characteristics of patients and their general practitioners on their HRQoL and to examine clinically significant differences in HRQoL among males and females. METHODS: This was a cross-sectional study with 193 general practitioners and 2181 of their chronically-ill patients aged 18 years or more using the standard Short Form Health Survey (SF-12) version 2. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and general practitioners at level 2) was applied to relate PCS-12 and MCS-12 to patient and general practitioner (GP) characteristics. RESULTS: Employment was likely to have a clinically significant larger positive effect on HRQoL of males (regression coefficient (B) (PCS-12) = 7.29, P < 0.001, effect size = 1.23 and B (MCS-12) = 3.40, P < 0.01, effect size = 0.55) than that of females (B(PCS-12) = 4.05, P < 0.001, effect size = 0.78 and B (MCS-12) = 1.16, P > 0.05, effect size = 0.16). There was a clinically significant difference in HRQoL among age groups. Younger men (< 39 years) were likely to have better physical health than older men (> 59 years, B = -5.82, P < 0.05, effect size = 0.66); older women tended to have better mental health (B = 5.62, P < 0.001, effect size = 0.77) than younger women. Chronically-ill women smokers reported clinically significant (B = -3.99, P < 0.001, effect size = 0.66) poorer mental health than women who were non-smokers. Female GPs were more likely to examine female patients than male patients (33% vs. 15%, P < 0.001) and female patients attending female GPs reported better physical health (B = 1.59, P < 0.05, effect size = 0.30). CONCLUSIONS: Some of the associations between patient characteristics and SF-12 physical and/or mental component scores were different for men and women. This finding underlines the importance of considering these factors in the management of chronically-ill patients in general practice. The results suggest that chronically ill women attempting to quit smoking may need more psychological support. More quantitative studies are needed to determine the association between GP gender and patient gender in relation to HRQoL.

Under-reporting of birth registrations in New South Wales, Australia.

BACKGROUND: To determine the rates of birth registration over a five-year period in New South Wales (NSW) and explore the factors associated with the rate of registration. METHODS: This is a cross-sectional study using linked population databases. The study population included all births of NSW residents in NSW between 2001 and 2005. RESULTS: Birth registration rates in NSW were 82.66% in the year of birth, 93.19% in the first year, 94.02% in the second, 94.56% in the third and 95.08% in the fourth year after birth. The non-registration of births was mainly associated with such factors as neonatal and postneonatal death (adjusted OR = 3.84, 95% CI: 3.23-4.57); being Indigenous (adjusted OR = 3.26, 95% CI: 3.10-3.43); maternal age <25 or >39 years (adjusted OR = 2.81, 95% CI: 2.72-2.90); low birthweight (<2,500 grams) (adjusted OR = 1.79, 95% CI: 1.69-1.90); living in remote areas (adjusted OR = 1.57, 95% CI: 1.52-1.63); being born after the first quarter of year (adjusted OR = 1.08-1.56, 95% CI between 1.03-1.12 and 1.49-1.64); mother having more pregnancies (adjusted OR = 1.85-7.29, 95% CI between1.78-1.93 and 6.87-7.73). Mothers who were born overseas were more likely to register their births than those born in Australia (adjusted OR = 0.72, 95% CI: 0.69-0.75). Multiple births were more likely to be registered than singleton births (adjusted OR = 0.84, 95% CI: 0.76-0.92). About one-third of the non-registrations of births in NSW were explained by the risk factors. The reasons for the remaining non-registrations need to be investigated. CONCLUSION: Of birth in NSW, 4.92% were not registered by the fourth year after birth.

Injury trends and mortality in adult patients with major trauma in New South Wales.

OBJECTIVE: To examine trends in mechanism and outcome of major traumatic injury in adults since the implementation of the New South Wales trauma monitoring program, and to identify factors associated with mortality. DESIGN AND SETTING: Retrospective review of NSW Trauma Registry data from 1 January 2003 to 31 December 2007, including patient demographics, year of injury, and level of trauma centre where definitive treatment was provided. PARTICIPANTS: 9769 people aged ≥ 15 years hospitalised for trauma, with an injury severity score (ISS) > 15. MAIN OUTCOME MEASURES: The NSW Trauma Registry outcome measures included were overall hospital length of stay, length of stay in an intensive care unit and in ospital mortality. RESULTS: There was a decreasing trend in severe trauma presentations in the age group 16-34 years, and an increasing trend in presentations of older people, particularly those aged ≥ 75 years. Road trauma and falls were consistently the commonest injury mechanisms. There were 1328 inhospital deaths (13.6%). Year of injury, level of trauma centre, ISS, head/neck injury and age were all independent predictors of mortality. The odds of mortality was significantly higher among patients receiving definitive care at regional trauma centres compared with Level I centres (odds ratio, 1.34; 95% CI, 1.10-1.63). CONCLUSIONS: Deaths from major trauma in NSW trauma centres have declined since 2003, and definitive care at a Level 1 trauma centre was associated with a survival benefit. More comprehensive trauma data collection with timely analysis will improve injury surveillance and better inform health policy in NSW.

Prevalence and impact of chronic musculoskeletal ankle disorders in the community.

OBJECTIVE: To determine the point prevalence of chronic musculoskeletal ankle disorders in the community. DESIGN: Cross-sectional stratified (metropolitan vs regional) random sample. SETTING: General community. PARTICIPANTS: Population-based computer-aided telephone survey of people (N=2078) aged 18 to 65 years in New South Wales, Australia. Of those contacted, 751 participants provided data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Point prevalence for no history of ankle injury or chronic ankle problems (no ankle problems), history of ankle injury without residual problems, and chronic ankle disorders. Chronic musculoskeletal ankle disorders due to ankle sprain, fracture, arthritis, or other disorder compared by chi-square test for the presence of pain, weakness, giving way, swelling and instability, activity limitation, and health care use in the past year. RESULTS: There were 231 (30.8%) participants with no ankle problems, 342 (45.5%) with a history of ankle injury but no chronic problems, and 178 (23.7%) with chronic ankle disorders. The major component of chronic ankle disorders was musculoskeletal disorders (n=147, 19.6% of the total sample), most of which were due to ankle injury (n=117, 15.6% of the total). There was no difference among the arthritis, fracture, sprain, and other groups in the prevalence of the specific complaints, or health care use. Significantly more participants with arthritis had to limit activity than in the sprain group (Chi-square test, P=.035). CONCLUSIONS: Chronic musculoskeletal ankle disorders affected almost 20% of the Australian community. The majority were due to a previous ankle injury, and most people had to limit or change their physical activity because of the ankle disorder.

Vestibular evoked myogenic potentials to sound and vibration: characteristics in vestibular migraine that enable separation from Meniere's disease.

OBJECTIVES: It can be difficult to distinguish vestibular migraine (VM) from Menière's disease (MD) in its early stages. Using vestibular-evoked myogenic potentials (VEMPs), we sought to identify test parameters that would help discriminate between these two vestibular disorders. METHODS: We first recorded ocular and cervical VEMPs (oVEMP/cVEMP) to air-conducted clicks and bone-conducted vibration in 30 control participants, 30 participants with clinically definite VM and 30 participants with clinically probable VM. Results were compared with a group of 60 MD patients from a previous study. oVEMPs and cVEMPs were then recorded at octave frequencies of 250 Hz to 2000 Hz in 20 controls and 20 participants each with clinically definite VM and MD. Inter-aural amplitude asymmetry ratios and amplitude frequency ratios were compared between groups. RESULTS: For click, tendon-hammer-tap and minishaker-tap VEMPs, there were no significant differences in reflex amplitudes or symmetry between controls, definite VM and probable VM. Compared with MD patients, participants with VM had significantly fewer reflex abnormalities for click-cVEMP, click-oVEMPs and minitap-cVEMPs. The ratio of cVEMP amplitude generated by tone bursts at a frequency of 0.5 kHz to that generated by 1 kHz was significantly lower for MD affected ears than for VM or controls ears. cVEMP asymmetry ratios for 0.5 kHz tone bursts were significantly higher for MD than VM. CONCLUSIONS: The 0.5/1 kHz frequency ratio, 0.5 kHz asymmetry ratio and caloric test combined, separated MD from VM with a sensitivity of 90.0% and specificity of 70.0%.

Risk factors for in-hospital post-hip fracture mortality.

INTRODUCTION: Approximately 10% of hip fracture patients die during hospitalization; however, it is not clear what risk factors contribute to the excess mortality. This study sought to examine risk factors of, and to develop prognostic model for, predicting in-hospital mortality among hip fracture patients. METHODS: We studied outcomes among 410 men and 1094 women with a hip fracture who were admitted to a major-teaching-hospital in Sydney (Australia) between 1997 and 2007. Clinical data, including concomitant illnesses, were obtained from inpatient data. The primary outcome of the study was in-hospital mortality regardless of length of stay. A Log-binomial regression model was used to identify risk factors for in-hospital mortality. Using the identified risk factors, prognostic nomograms were developed for predicting short term risk of mortality for an individual. RESULTS: The median duration of hospitalization was 9 days. During hospitalization, the risk of mortality was higher in men (9%) than in women (4%). After adjusting for multiple risk factors, increased risk of in-hospital mortality was associated with advancing age (rate ratio [RR] for each 10-year increase in age: 1.91 95% confidence interval [CI]: 1.47 to 2.49), in men (RR 2.13; 95% CI 1.41 to 3.22), and the presence of comorbid conditions on admission (RR for one or more comorbid conditions vs. none: 2.30; 95% CI 1.52 to 3.48). Specifically, the risk of mortality was increased in patients with a pre-existing congestive heart failure (RR 3.02; 95% CI: 1.65 to 5.54), and liver disease (RR 4.75; 95% CI: 1.87 to 12.1). These factors collectively accounted for 69% of the risk for in-hospital mortality. A nomogram was developed from these risk factors to individualize the risk of in-hospital death following a hip fracture. The area under the receiver operating characteristic curve of the final model containing age, sex and comorbid conditions was 0.76. CONCLUSION: These data suggest that among hip fracture patients, advancing age, gender (men), and pre-existing concomitant diseases such as congestive heart failure and liver disease were the main risk factors for in-hospital mortality. The nomogram developed from this study can be used to convey useful prognostic information to help guide treatment decisions.

The vestibular evoked-potential profile of Ménière's disease.

OBJECTIVE: To define the ocular and cervical vestibular evoked myogenic potential (oVEMP and cVEMP) profile in Ménière's Disease (MD), we studied air-conducted (AC) sound and bone-conducted vibration (BCV)-evoked responses in 77 patients and 35 controls. METHODS: oVEMPs were recorded from unrectified infra-orbital surface electromyography (EMG) during upward gaze. cVEMPs were recorded from rectified and unrectified sternocleidomastoid EMG during head elevation against gravity. Responses to AC clicks delivered via headphones and BC forehead taps delivered with a mini-shaker (bone-conduction vibrator) and a triggered tendon-hammer were recorded. RESULTS: In clinically definite unilateral MD (n=60), the prevalence of unilateral VEMP abnormalities was 50.0%, 10.2% and 11.9% for click, minitap and tendon-hammer evoked oVEMPs, 40.0%, 22.8% and 10.7% for click, minitap and tendon-hammer evoked cVEMPs. The most commonly observed profile was abnormality to AC stimulation alone (33.3%), followed by abnormalities to both AC and BCV stimuli (26.7%). Isolated abnormalities to BCV stimuli were rare (5%) and limited to the minitap cVEMP. The prevalence of abnormalities for each of the AC VEMPs was significantly higher than for any one BCV VEMP. For click cVEMP, click oVEMP and minitap cVEMP, average Reflex Asymmetry Ratios (AR) were significantly higher in MD compared with controls. Test results for AC cVEMP, AC oVEMP, minitap cVEMP and caloric asymmetry were significantly correlated with hearing loss. CONCLUSIONS: Predominance of abnormalities in oVEMP and cVEMP responses to AC sound is characteristic of MD and indicative of saccular involvement. SIGNIFICANCE: This pattern of VEMP abnormalities may enable separation of Ménière's disease from other peripheral vestibulopathies.

Perinatal outcomes after assisted reproductive technology treatment in Australia and New Zealand: single versus double embryo transfer.

OBJECTIVE: To compare the perinatal outcomes of babies conceived by single embryo transfer (SET) with those conceived by double embryo transfer (DET). DESIGN, SETTING AND PARTICIPANTS: A retrospective population-based study of embryo transfer cycles in Australia and New Zealand between 2002 and 2006, using data from the Australia and New Zealand Assisted Reproduction Database. MAIN OUTCOME MEASURES: Proportion of SET procedures; comparison of SET and DET procedures with respect to multiple births, low birthweight (LBW), preterm birth and fetal death. RESULTS: The proportion of SET procedures has increased from 28.4% in 2002 to 32.0% in 2003, 40.5% in 2004, 48.2% in 2005 and 56.9% in 2006. The multiple birth rate for all babies conceived by SET (4.0%) was 10 times lower than for those conceived by DET (39.1%) (P < 0.01). The average birthweight for all liveborn babies conceived by SET (3290 g) was higher than for those conceived by DET (2934 g) (P < 0.01). The preterm birth rate of all DET-conceived babies (30.3%) was higher than for SET-conceived babies (12.3%) (adjusted odds ratio [AOR], 3.19 [95% CI, 3.01-3.38]). All babies conceived by DET were more likely to be stillborn than those conceived by SET (AOR, 1.49 [95% CI, 1.21-1.82]). Singletons conceived by DET were more likely to be born preterm than singletons conceived by SET (AOR, 1.13 [95% CI, 1.05-1.22]). Liveborn singletons conceived by DET were 15% more likely to have LBW than liveborn singletons conceived by SET (AOR, 1.15 [95% CI, 1.05-1.26]). There was no significant difference in fetal death rate between DET- and SET-conceived singletons. CONCLUSION: The increase in proportion of SET procedures has resulted in a lower rate of multiple births and in better perinatal outcomes in Australian and New Zealand assisted reproduction programs.

Enhancing evaluation in an undergraduate medical education program.

Approaches to evaluation of medical student teaching programs have historically incorporated a range of methods and have had variable effectiveness. Such approaches are rarely comprehensive, typically evaluating only a component rather than the whole program, and are often episodic rather than continuous. There are growing pressures for significant improvement in academic program evaluation. The authors describe an initiative that arose after a radical reorganization of the undergraduate medical education program at the University of New South Wales in part in response to feedback from the accrediting authority. The aim was to design a comprehensive, multicomponent, program-wide evaluation and improvement system. The framework envisages the quality of the program as comprising four main aspects: curriculum and resources; staff and teaching; student experience; and student and graduate outcomes. Key principles of the adopted approach include the views that both student and staff experiences provide valuable information; that measurement of student and graduate outcomes are needed; that an emphasis on action after evaluation is critical (closing the loop); that the strategies and processes need to be continual rather than episodic; and that evaluation should be used to recognize, report on, and reward excellence in teaching. In addition, an important philosophy adopted was that teachers, course coordinators, and administrators should undertake evaluation and improvement activities as an inherent part of teaching, rather than viewing evaluation as something that is externally managed. Examples of the strategy in action, which provide initial evidence of validation for this approach, are described.