The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BACKGROUND

Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.

METHODS

This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.

RESULTS

340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.

CONCLUSION

Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.

TRIAL REGISTRATION

NCT04872933. Registered 5th May 2021.

Identifying stressor criteria that hinder or challenge junior clinical medical student learning

INTRODUCTION

What makes something a stressor within clinical students' education is unclear. Medical students moving from a predominantly protected classroom environment to a situated-work environment provided an ideal transition point to explore the criteria that might make a learning experience a stressor and whether these stressors hinder or challenge learning.

METHOD

Data on the stressors associated with learning experiences in clinical education were collected from New Zealand undergraduate medical students. Free text comments, in a survey-based questionnaire were supplemented by focus group data. Using inductive thematic analysis with grounded theory, themes were generated about the characteristics of stressors; referred to here as stressor criteria. These stressor criteria were then classified according to their impact on perceived learning.

RESULTS

Under the broad headings of the nature of the learning task, external factors, internal factors, and social interaction; 12 stressor criteria groupings were defined. Some of these criteria were a positive challenge to learning (e.g. legitimacy of the task, novelty of the learning, social interactions) and others a hindrance.

DISCUSSION

Not all stressors hinder learning. Instead, and depending on their nature, many result in perceived assistance to learning. Stressors hindering learning need to be recognised by the teacher, especially those that can be converted from a hindrance to an assistance.

Microbiome-derived antimicrobial peptides offer therapeutic solutions for the treatment of Pseudomonas aeruginosa infections

Microbiomes are rife for biotechnological exploitation, particularly the rumen microbiome, due to their complexicity and diversity. In this study, antimicrobial peptides (AMPs) from the rumen microbiome (Lynronne 1, 2, 3 and P15s) were assessed for their therapeutic potential against seven clinical strains of Pseudomonas aeruginosa. All AMPs exhibited antimicrobial activity against all strains, with minimum inhibitory concentrations (MICs) ranging from 4–512 µg/mL. Time-kill kinetics of all AMPs at 3× MIC values against strains PAO1 and LES431 showed complete kill within 10 min to 4 h, although P15s was not bactericidal against PAO1. All AMPs significantly inhibited biofilm formation by strains PAO1 and LES431, and induction of resistance assays showed no decrease in activity against these strains. AMP cytotoxicity against human lung cells was also minimal. In terms of mechanism of action, the AMPs showed affinity towards PAO1 and LES431 bacterial membrane lipids, efficiently permeabilising the P. aeruginosa membrane. Transcriptome and metabolome analysis revealed increased catalytic activity at the cell membrane and promotion of β-oxidation of fatty acids. Finally, tests performed with the Galleria mellonella infection model showed that Lynronne 1 and 2 were efficacious in vivo, with a 100% survival rate following treatment at 32 mg/kg and 128 mg/kg, respectively. This study illustrates the therapeutic potential of microbiome-derived AMPs against P. aeruginosa infections.

Modulation of Rumen Microbes Through Extracellular Vesicle Released by the Rumen Fluke Calicophoron daubneyi

Parasite derived extracellular vesicles (EVs) have been proposed to play key roles in the establishment and maintenance of infection. Calicophoron daubneyi is a newly emerging parasite of livestock with many aspects of its underpinning biology yet to be resolved. This research is the first in-depth investigation of EVs released by adult C. daubneyi. EVs were successfully isolated using both differential centrifugation and size exclusion chromatography (SEC), and morphologically characterized though transmission electron microscopy (TEM). EV protein components were characterized using a GeLC approach allowing the elucidation of comprehensive proteomic profiles for both their soluble protein cargo and surface membrane bound proteins yielding a total of 378 soluble proteins identified. Notably, EVs contained Sigma-class GST and cathepsin L and B proteases, which have previously been described in immune modulation and successful establishment of parasitic flatworm infections. SEC purified C. daubneyi EVs were observed to modulate rumen bacterial populations by likely increasing microbial species diversity via antimicrobial activity. This data indicates EVs released from adult C. daubneyi have a role in establishment within the rumen through the regulation of microbial populations offering new routes to control rumen fluke infection and to develop molecular strategies to improve rumen efficiency.

Relationships among perceived learning, challenge and affect in a clinical context

BACKGROUND

Challenge, sometimes perceived as stress, may be beneficial or detrimental to learning but the circumstances when it may be beneficial are not clear. This study looks at the association of challenge with perceived learning and how this might be influenced by affect, context or the type of learning.

METHOD

The participants, medical students in their first years of experiential clinical exposure, rated specified learning episodes (LEs) on the perceived learning (low to high), challenge (low to high) and affect (feeling positive to negative). Such learning episodes were self-identified or identified by course organisers. Correlations, using Kendall's tau-b test, were conducted to explore the associations among learning, challenge and affect. In the second stage the types of LEs were then thematically classified in order to determine those that were positive for learning and challenging and/or associated with positive affect.

RESULT

There were positive correlations between perceived learning and challenge, and between perceived learning and affect for both types of LEs. The circumstances in which challenge (stress) promoted learning were authentic environments, authentic tasks and simulated clinical activities; most requiring a degree of social interaction.

CONCLUSION

Challenge and positive affect are beneficial in the perception of discrete learning, but are two separate constructs. Ideally both challenge and affect need to operate alongside authentic supportive clinical activities, that by their nature involve others, to maximise perceived learning.

Symptom-burden in people living with frailty and chronic kidney disease

Background

Frailty is independently associated with worse health-related quality of life (HRQOL) in chronic kidney disease (CKD). However, the relationship between frailty and symptom experience is not well described in people living with CKD. This study’s aim was to evaluate the relationship between frailty and symptom-burden in CKD.

Methods

This study is a secondary analysis of a cross-sectional observational study, the QCKD study (ISRCTN87066351), in which participants completed physical activity, cardiopulmonary fitness, symptom-burden and HRQOL questionnaires. A modified version of the Frailty Phenotype, comprising 3 self-report components, was created to assess frailty status. Multiple linear regression was performed to assess the association between symptom-burden/HRQOL and frailty. Logistic regression was performed to assess the association between experiencing symptoms frequently and frailty. Principal Component Analysis was used to assess the experienced symptom clusters.

Results

A total of 353 patients with CKD were recruited with 225 (64%) participants categorised as frail. Frail participants reported more symptoms, had higher symptom scores and worse HRQOL scores. Frailty was independently associated with higher total symptom score and lower HRQOL scores. Frailty was also independently associated with higher odds of frequently experiencing 9 out of 12 reported symptoms. Finally, frail participants experienced an additional symptom cluster that included loss of appetite, tiredness, feeling cold and poor concentration.

Conclusions

Frailty is independently associated with high symptom-burden and poor HRQOL in CKD. Moreover, people living with frailty and CKD have a distinctive symptom experience. Proactive interventions are needed that can effectively identify and address problematic symptoms to mitigate their impact on HRQOL.

Student belief about the value of challenge

BACKGROUND

The undergraduate curriculum tends to focus on how individuals can cope with stress especially when transitioning from the classroom to the clinical workplace environment. Often this carries the message that stress is bad, yet little attention has been paid to the influence of one's belief regarding the value of stress for learning. Because stress is often perceived as bad, we chose to use the term 'challenge' in exploring the associations amongst belief of the value of challenge, the challenge experienced, the perceived learning, affect and staff support.

METHODS

At the end of each clinical module within a medical curriculum, medical students rated the perceived learning, degree of challenge, affect, support and the value of challenge for learning. The value and associations amongst these variables were analysed.

RESULTS

The challenge for students varied according to the type of module. Students generally considered that challenge promoted rather than hindered learning. The level of challenge experienced may influence the perception of the value of challenge for learning. However, when challenge was regarded as beneficial, this was strongly, positively associated with perceived learning, positive affect and support.

DISCUSSION

Students who believe challenge is positive also perceive that such challenges promote learning. Likewise students who regard challenge as negative are less likely to learn from such challenges. The positive relationship between the belief of the value of challenge with affect and support may have positive implications for well-being. It is contended that curriculum planners should acknowledge the potential positive influence of stressors in clinical education and that challenge can be seen as valuable when there is student support and measures associated with maintaining a positive affect.

The importance of extracellular vesicle purification for downstream analysis: A comparison of differential centrifugation and size exclusion chromatography for helminth pathogens

BACKGROUND

Robust protocols for the isolation of extracellular vesicles (EVs) from the rest of their excretory-secretory products are necessary for downstream studies and application development. The most widely used purification method of EVs for helminth pathogens is currently differential centrifugation (DC). In contrast, size exclusion chromatography (SEC) has been included in the purification pipeline for EVs from other pathogens, highlighting there is not an agreed research community 'gold standard' for EV isolation. In this case study, Fasciola hepatica from natural populations were cultured in order to collect EVs from culture media and evaluate a SEC or DC approach to pathogen helminth EV purification.

METHODOLOGY/PRINCIPAL FINDINGS

Transmission electron and atomic force microscopy demonstrated that EVs prepared by SEC were both smaller in size and less diverse than EV resolved by DC. Protein quantification and Western blotting further demonstrated that SEC purification realised a higher EV purity to free excretory-secretory protein (ESP) yield ratio compared to DC approaches as evident by the reduction of soluble free cathepsin L proteases in SEC EV preparations. Proteomic analysis further highlighted DC contamination from ESP as shown by an increased diversity of protein identifications and unique peptide hits in DC EVs as compared to SEC EVs. In addition, SEC purified EVs contained less tegumental based proteins than DC purified EVs.

CONCLUSIONS/SIGNIFICANCE

The data suggests that DC and SEC purification methods do not isolate equivalent EV population profiles and caution should be taken in the choice of EV purification utilised, with certain protocols for DC preparations including more free ES proteins and tegumental artefacts. We propose that SEC methods should be used for EV purification prior to downstream studies.

Using 'Omic Approaches to Compare Temporal Bacterial Colonization of Lolium perenne, Lotus corniculatus, and Trifolium pratense in the Rumen

Understanding rumen plant-microbe interactions is central for development of novel methodologies allowing improvements in ruminant nutrient use efficiency. This study investigated rumen bacterial colonization of fresh plant material and changes in plant chemistry over a period of 24 h period using three different fresh forages: Lolium perenne (perennial ryegrass; PRG), Lotus corniculatus (bird's foot trefoil; BFT) and Trifolium pratense (red clover; RC). We show using 16S rRNA gene ion torrent sequencing that plant epiphytic populations present pre-incubation (0 h) were substantially different to those attached post incubations in the presence of rumen fluid on all forages. Thereafter primary and secondary colonization events were evident as defined by changes in relative abundances of attached bacteria and changes in plant chemistry, as assessed using Fourier transform infrared (FTIR) spectroscopy. For PRG colonization, primary colonization occurred for up to 4 h and secondary colonization from 4 h onward. The changes from primary to secondary colonization occurred significantly later with BFT and RC, with primary colonization being up to 6 h and secondary colonization post 6 h of incubation. Across all 3 forages the main colonizing bacteria present at all time points post-incubation were Prevotella, Pseudobutyrivibrio, Ruminococcus, Olsenella, Butyrivibrio, and Anaeroplasma (14.2, 5.4, 1.9, 2.7, 1.8, and 2.0% on average respectively), with Pseudobutyrivibrio and Anaeroplasma having a higher relative abundance during secondary colonization. Using CowPI, we predict differences between bacterial metabolic function during primary and secondary colonization. Specifically, our results infer an increase in carbohydrate metabolism in the bacteria attached during secondary colonization, irrespective of forage type. The CowPI data coupled with the FTIR plant chemistry data suggest that attached bacterial function is similar irrespective of forage type, with the main changes occurring between primary and secondary colonization. These data suggest that the sward composition of pasture may have major implications for the temporal availability of nutrients for animal.

CowPI: A Rumen Microbiome Focussed Version of the PICRUSt Functional Inference Software

Metataxonomic 16S rDNA based studies are a commonplace and useful tool in the research of the microbiome, but they do not provide the full investigative power of metagenomics and metatranscriptomics for revealing the functional potential of microbial communities. However, the use of metagenomic and metatranscriptomic technologies is hindered by high costs and skills barrier necessary to generate and interpret the data. To address this, a tool for Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) was developed for inferring the functional potential of an observed microbiome profile, based on 16S data. This allows functional inferences to be made from metataxonomic 16S rDNA studies with little extra work or cost, but its accuracy relies on the availability of completely sequenced genomes of representative organisms from the community being investigated. The rumen microbiome is an example of a community traditionally underrepresented in genome and sequence databases, but recent efforts by projects such as the Global Rumen Census and Hungate 1000 have resulted in a wide sampling of 16S rDNA profiles and almost 500 fully sequenced microbial genomes from this environment. Using this information, we have developed “CowPI,” a focused version of the PICRUSt tool provided for use by the wider scientific community in the study of the rumen microbiome. We evaluated the accuracy of CowPI and PICRUSt using two 16S datasets from the rumen microbiome: one generated from rDNA and the other from rRNA where corresponding metagenomic and metatranscriptomic data was also available. We show that the functional profiles predicted by CowPI better match estimates for both the meta-genomic and transcriptomic datasets than PICRUSt, and capture the higher degree of genetic variation and larger pangenomes of rumen organisms. Nonetheless, whilst being closer in terms of predictive power for the rumen microbiome, there were differences when compared to both the metagenomic and metatranscriptome data and so we recommend, where possible, functional inferences from 16S data should not replace metagenomic and metatranscriptomic approaches. The tool can be accessed at http://www.cowpi.org and is provided to the wider scientific community for use in the study of the rumen microbiome.

The anti-fecundity effect of 5-azacytidine (5-AzaC) on Schistosoma mansoni is linked to dis-regulated transcription, translation and stem cell activities

Uncontrolled host immunological reactions directed against tissue-trapped eggs precipitate a potentially lethal, pathological cascade responsible for schistosomiasis. Blocking schistosome egg production, therefore, presents a strategy for simultaneously reducing immunopathology as well as limiting disease transmission in endemic or emerging areas. We recently demonstrated that the ribonucleoside analogue 5-azacytidine (5-AzaC) inhibited Schistosoma mansoni oviposition, egg maturation and ovarian development. While these anti-fecundity effects were associated with a loss of DNA methylation, other molecular processes affected by 5-AzaC were not examined at the time. By comparing the transcriptomes of 5-AzaC-treated females to controls, we provide evidence that this ribonucleoside analogue also modulates other crucial aspects of schistosome egg-laying biology. For example, S. mansoni gene products associated with amino acid-, carbohydrate-, fatty acid-, nucleotide- and tricarboxylic acid (TCA)- homeostasis are all dysregulated in 5-AzaC treated females. To validate the metabolic pathway most significantly affected by 5-AzaC, amino acid metabolism, nascent protein synthesis was subsequently quantified in adult schistosomes. Here, 5-AzaC inhibited this process by 68% ±16.7% (SEM) in male- and 81% ±4.8% (SEM) in female-schistosomes. Furthermore, the transcriptome data indicated that adult female stem cells were also affected by 5-AzaC. For instance, 40% of transcripts associated with proliferating schistosome cells were significantly down-regulated by 5-AzaC. This finding correlated with a considerable reduction (95%) in the number of 5-ethynyl-2'-deoxyuridine (EdU) positive cells found in 5-AzaC-treated females. In addition to protein coding genes, the effect that 5-AzaC had on repetitive element expression was also assessed. Here, 46 repeats were found differentially transcribed between 5-AzaC-treated and control females with long terminal repeat (LTR) and DNA transposon classes being amongst the most significant. This study demonstrates that the anti-fecundity activity of 5-AzaC affects more than just DNA methylation in schistosome parasites. Further characterisation of these processes may reveal novel targets for schistosomiasis control.

The rumen microbiome: an underexplored resource for novel antimicrobial discovery

Antimicrobial peptides (AMPs) are promising drug candidates to target multi-drug resistant bacteria. The rumen microbiome presents an underexplored resource for the discovery of novel microbial enzymes and metabolites, including AMPs. Using functional screening and computational approaches, we identified 181 potentially novel AMPs from a rumen bacterial metagenome. Here, we show that three of the selected AMPs (Lynronne-1, Lynronne-2 and Lynronne-3) were effective against numerous bacterial pathogens, including methicillin-resistant Staphylococcus aureus (MRSA). No decrease in MRSA susceptibility was observed after 25 days of sub-lethal exposure to these AMPs. The AMPs bound preferentially to bacterial membrane lipids and induced membrane permeability leading to cytoplasmic leakage. Topical administration of Lynronne-1 (10% w/v) to a mouse model of MRSA wound infection elicited a significant reduction in bacterial counts, which was comparable to treatment with 2% mupirocin ointment. Our findings indicate that the rumen microbiome may provide viable alternative antimicrobials for future therapeutic application.

Anti-microbial molecules made by microbes in the gut of ruminant animals could become new weapons against antibiotic-resistant infections. An international team of researchers led by Sharon Huws at Queen’s University Belfast, UK, identified three anti-microbial peptides in the rumen of animals such as cattle, sheep and goats. The peptides—short proteins—were highly active in laboratory trials against several clinically important drug-resistant infections. These included methicillin resistant Staphylococcus aureus (MRSA), a notorious cause of life-threatening infections, especially in patients with weakened immunity. There is growing interest in using peptides as alternatives to existing antibiotics. The findings, initiated by examining a ‘library’ of molecular data, suggest that the rumen is an under-explored resource that may harbor many medically useful antimicrobials. The possibilities should be investigated further, with promising molecules being tested in clinical conditions.

Characterization of the Microbiome along the Gastrointestinal Tract of Growing Turkeys

The turkey microbiome is largely understudied, despite its relationship with bird health and growth, and the prevalence of human pathogens such as Campylobacter spp. In this study we investigated the microbiome within the small intestine (SI), caeca (C), large intestine (LI), and cloaca (CL) of turkeys at 6, 10, and 16 weeks of age. Eight turkeys were dissected within each age category and the contents of the SI, C, LI, and CL were harvested. 16S rDNA based QPCR was performed on all samples and samples for the four locations within three birds/age group were sequenced using ion torrent-based sequencing of the 16S rDNA. Sequencing data showed on a genus level, an abundance of Lactobacillus, Streptococcus, and Clostridium XI (38.2, 28.1, and 13.0% respectively) irrespective of location and age. The caeca exhibited the greatest microbiome diversity throughout the development of the turkey. PICRUSt data predicted an array of bacterial function, with most differences being apparent in the caeca of the turkeys as they matured. QPCR revealed that the caeca within 10 week old birds, contained the most Campylobacter spp. Understanding the microbial ecology of the turkey gastrointestinal tract is essential in terms of understanding production efficiency and in order to develop novel strategies for targeting Campylobacter spp.

Temporal Metagenomic and Metabolomic Characterization of Fresh Perennial Ryegrass Degradation by Rumen Bacteria

Understanding the relationship between ingested plant material and the attached microbiome is essential for developing methodologies to improve ruminant nutrient use efficiency. We have previously shown that perennial ryegrass (PRG) rumen bacterial colonization events follow a primary (up to 4 h) and secondary (after 4 h) pattern based on the differences in diversity of the attached bacteria. In this study, we investigated temporal niche specialization of primary and secondary populations of attached rumen microbiota using metagenomic shotgun sequencing as well as monitoring changes in the plant chemistry using mid-infrared spectroscopy (FT-IR). Metagenomic Rapid Annotation using Subsystem Technology (MG-RAST) taxonomical analysis of shotgun metagenomic sequences showed that the genera Butyrivibrio, Clostridium, Eubacterium, Prevotella, and Selenomonas dominated the attached microbiome irrespective of time. MG-RAST also showed that Acidaminococcus, Bacillus, Butyrivibrio, and Prevotella rDNA increased in read abundance during secondary colonization, whilst Blautia decreased in read abundance. MG-RAST Clusters of Orthologous Groups (COG) functional analysis also showed that the primary function of the attached microbiome was categorized broadly within “metabolism;” predominantly amino acid, carbohydrate, and lipid metabolism and transport. Most sequence read abundances (51.6, 43.8, and 50.0% of COG families pertaining to amino acid, carbohydrate and lipid metabolism, respectively) within these categories were higher in abundance during secondary colonization. Kyoto encyclopedia of genes and genomes (KEGG) pathways analysis confirmed that the PRG-attached microbiota present at 1 and 4 h of rumen incubation possess a similar functional capacity, with only a few pathways being uniquely found in only one incubation time point only. FT-IR data for the plant residues also showed that the main changes in plant chemistry between primary and secondary colonization was due to increased carbohydrate, amino acid, and lipid metabolism. This study confirmed primary and secondary colonization events and supported the hypothesis that functional changes occurred as a consequence of taxonomical changes. Sequences within the carbohydrate metabolism COG families contained only 3.2% of cellulose activities, on average across both incubation times (1 and 4 h), suggesting that degradation of the plant cell walls may be a key rate-limiting factor in ensuring the bioavailability of intra-plant nutrients in a timely manner to the microbes and ultimately the animal. This suggests that a future focus for improving ruminant nutrient use efficiency should be altering the recalcitrant plant cell wall components and/or improving the cellulolytic capacity of the rumen microbiota.

Exploring and Expanding the Fatty-Acid-Binding Protein Superfamily in Fasciola Species

The liver flukes Fasciola hepatica and F. gigantica infect livestock worldwide and threaten food security with climate change and problematic control measures spreading disease. Fascioliasis is also a foodborne disease with up to 17 million humans infected. In the absence of vaccines, treatment depends on triclabendazole (TCBZ), and overuse has led to widespread resistance, compromising future TCBZ control. Reductionist biology from many laboratories has predicted new therapeutic targets. To this end, the fatty-acid-binding protein (FABP) superfamily has proposed multifunctional roles, including functions intersecting vaccine and drug therapy, such as immune modulation and anthelmintic sequestration. Research is hindered by a lack of understanding of the full FABP superfamily complement. Although discovery studies predicted FABPs as promising vaccine candidates, it is unclear if uncharacterized FABPs are more relevant for vaccine formulations. We have coupled genome, transcriptome, and EST data mining with proteomics and phylogenetics to reveal a liver fluke FABP superfamily of seven clades: previously identified clades I-III and newly identified clades IV-VII. All new clade FABPs were analyzed using bioinformatics and cloned from both liver flukes. The extended FABP data set will provide new study tools to research the role of FABPs in parasite biology and as therapy targets.

Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates

BACKGROUND

Warfarin-related intracerebral haemorrhage (WRICH) has high mortality. Haematoma expansion is prolonged in WRICH and independently predicts worse outcomes. Guidelines recommend prompt reversal of the warfarin coagulopathy, but evidence of benefit is lacking.

AIMS

To determine whether the introduction of a WRICH reversal protocol (late 2008), which includes prothrombin complex concentrates (PCC), improves outcomes

METHODS

All patients presenting with WRICH between January 2004 and July 2010 were included. Retrospective case note and radiology review was performed, collecting data on intracerebral haemorrhage (ICH) severity, degree and timeliness of reversal, and patient outcomes. Cox's proportional hazards analysis was used to compare outcomes associated with and without PCC after controlling for ICH severity.

RESULTS

Eighty-eight patients were included (27 treated palliatively). Mean international normalised ratio was 2.9. Vitamin K, PCC and fresh frozen plasma were given alone or in combination to 68, 23 and 44 patients, and mean time from computed tomography scanning to administration was 2.2, 3.3 and 3.1 h respectively. Four patients received PCC pre-protocol (none before 2007), two during development and seventeen patients post-protocol. Those who received PCC had improved survival (P < 0.001). After controlling for ICH score, hazard ratio for death was 0.27 (P < 0.01) for use of PCC. Survival tended to be greater with earlier administration of PCC (P = 0.053). Despite improved survival, discharge domicile and function were not significantly worse.

CONCLUSIONS

PCC reversal was associated with improved survival without worsened disability. Delays in administration may have reduced the potential benefits.

Genetic diversity of the feminising microsporidian parasite Dictyocoela: new insights into host-specificity, sex and phylogeography

Microsporidia of the genus Dictyocoela are parasites of gammarid amphipod Crustacea. They typically exhibit low virulence and efficient vertical transmission and at least some strains are capable of feminising their hosts. Sequencing of a region of the 16S rDNA of Dictyocoela spp. from various gammarid host species and localities in Europe and northern Asia indicates that Dictyocoela is genetically diverse and that different strains predominate in different host species. However, the presence of intermediate sequences casts doubt upon previous attempts to describe Dictyocoela spp. on the basis of rDNA divergence alone. Phylogenetic analysis provides little support for coevolution between gammarids and Dictyocoela. Furthermore, observations of heavily infected individuals, together with genetic evidence of recombination, suggest that some strains of Dictyocoela may be horizontally transmitted and are sexually reproducing. These findings suggest that Dictyocoela may be phenotypically, as well as genotypically, diverse, with the potential to exhibit a range of different interactions with its host populations.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

BACKGROUND

Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1-year period and predictors of early 'failed' home discharges. Stability of discharge domicile and survival over 5 years was also reviewed.

METHODS

A 6-month cohort of all discharges was followed for 5 years. Changes in domicile, including entry into institutional care, were recorded out to 5 years or until death. Predictors of early (3 months) and later (1 year) discharge stability were assessed.

RESULTS

There were 142 discharges. Fifty-eight (76%) of those who returned home were still at home 12 months later. In contrast, there was a high mortality of dependent patients who were discharged to high dependency care (9 (29%) and 13 (42%) at 3 and 12 months, respectively). The chance of an early failed discharge was associated with lower functional ability on discharge (P= 0.012). Lower function on discharge was also independently associated with death in the next 12 months (P < 0.0001). At 5 years the mortality for the whole sample was 55% (78 of 141) and 38 (61%) of the survivors still lived in the community whereas 24 (39%) resided in institutional care.

CONCLUSION

Functional ability on discharge is a key predictor of ability to remain at home as well as survival and therefore every effort should be made to maximize function.

Developing the accredited postgraduate assessment program for Fellowship of the Australian College of Rural and Remote Medicine

INTRODUCTION

Accreditation of the Australian College of Rural and Remote Medicine (ACRRM) as a standards and training provider, by the Australian Medical Council (AMC) in 2007, is the first time in the world that a peak professional organisation for rural and remote medical education has been formally recognised. As a consequence, the Australian Government provided rural and remote medicine with formal recognition under Medicare as a generalist discipline. This accreditation was based on the ability of ACRRM to meet the AMC's guidelines for its training and assessment program.

METHODS

The methodology was a six-step process that included: developing an assessment blueprint and a classification scheme; identifying an assessment model; choosing innovative summative and formative assessment methods that met the needs of rural and remote located medical practitioner candidates; 21 rural doctors and academics developing the assessment items as part of a week-long writing workshop; investigating the feasibility of purchasing assessment items; and 48 rural candidates piloting three of the assessment items to ensure they would meet the guidelines for national accreditation.

RESULTS

The project resulted in an innovative formative and summative assessment program that occurs throughout 4 years of vocational training, using innovative, reliable, valid and acceptable methods with educational impact. The piloting process occurred for 3 of the 6 assessment tools. Structured Assessment Using Multiple Patient Scenarios (StAMPS) is a new assessment method developed as part of this project. The StAMPS pilot found that it was reliable, with a generalisability coefficient of >0.76 and was a valid, acceptable and feasible assessment tool with desired educational impact. The multiple choice question (MCQ) examination pilot found that the applied clinical nature of the questions and their wide range of scenarios proved a very acceptable examination to the profession. The web based in-training assessment examination pilot revealed that it would serve well as a formative process until ACRRM can further develop their MCQ database.

CONCLUSIONS

The ACRRM assessment program breaks new ground for assessing rural and remote doctors in Australia, and provides new evidence regarding how a comprehensive and contemporary assessment system can work within a postgraduate medical setting.

Assessment of clinical performance: gathering evidence

The focus of assessment of clinical performance has moved from over-reliance on individual tools to constructing a coherent assessment programme. The purpose of such an assessment programme is to gather high-quality evidence to make well-informed decisions. This requires clarity on the decisions to be made and an ability to gather a sufficient amount of high-quality data. The assessment programme should be aligned to doing the job well so that a successful assessment result reflects what is valued. A variety of assessments over a variety of times, matched against the areas of interest and value, enhances both reliability and validity. Workplace-based assessment tools can complement centralized assessment tools. Multiple snapshots, even if some are not totally in focus, give a better picture than one poorly aimed photograph.

The risk of recurrent stroke after intracerebral haemorrhage

BACKGROUND AND AIM

The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed.

PATIENTS AND METHODS

All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke.

RESULTS

Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type.

CONCLUSION

The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Identification of recently handled materials by analysis of latent human fingerprints using infrared spectromicroscopy

Analysis of fingerprints has predominantly focused on matching the pattern of ridges to a specific person as a form of identification. The present work focuses on identifying extrinsic materials that are left within a person's fingerprint after recent handling of such materials. Specifically, we employed infrared spectromicroscopy to locate and positively identify microscopic particles from a mixture of common materials in the latent human fingerprints of volunteer subjects. We were able to find and correctly identify all test substances based on their unique infrared spectral signatures. Spectral imaging is demonstrated as a method for automating recognition of specific substances in a fingerprint. We also demonstrate the use of attenuated total reflectance (ATR) and synchrotron-based infrared spectromicroscopy for obtaining high-quality spectra from particles that were too thick or too small, respectively, for reflection/absorption measurements. We believe the application of this rapid, nondestructive analytical technique to the forensic study of latent human fingerprints has the potential to add a new layer of information available to investigators. Using fingerprints to not only identify who was present at a crime scene, but also to link who was handling key materials, will be a powerful investigative tool.

The validity of surgical clips as a radiographic surrogate for the lumpectomy cavity in image-guided accelerated partial breast irradiation

PURPOSE

We hypothesize that surgical clips placed in the biopsy cavity during lumpectomy can be used as radiographic markers to facilitate image-guided external beam accelerated partial breast irradiation.

METHODS AND MATERIALS

We evaluated 28 patients with surgically placed clips in the lumpectomy cavity and two CT scans on different days. To establish whether the clips remain predictive of the lumpectomy cavity throughout therapy, we analyzed the motion of both cavities with repeat volumetric CT scans. The three-dimensional (3D) locations of each lumpectomy cavity and the associated clips were defined as individual regions of interest (ROIs). A single point of interest (POI) was defined for each ROI. The calculated movements of the lumpectomy cavity POIs between different scans were compared to those of the clip POIs. The second CT data set was then moved in accordance to the calculated clip POI's movement. The volume of the (second) lumpectomy cavity associated with the second scan outside of the (first) cavity of the first scan was measured. In addition, the required amount of a radial margin expansion around the first lumpectomy cavity to ensure coverage of the second lumpectomy cavity both before and after moving the second lumpectomy according to the clip POI movement was calculated.

RESULTS

The two CT scans were obtained on average 27 days apart, and the mean lumpectomy size decreased from 35 to 16 cc. The clip and lumpectomy cavity POIs moved a mean of 3 mm along the three principal Cartesian axes. In moving the second lumpectomy cavity according to the clip POI displacement from its original position, the volume of the second lumpectomy cavity outside of the volume of the first decreased from 2.6 cc to 1.0 cc after correction, and the required radial margin on the first lumpectomy cavity to include the second lumpectomy cavity decreased from 5.5 mm vs. 3.8 mm.

CONCLUSION

The surgically placed clips after lumpectomy are strong radiographic surrogates for the biopsy cavity. If the clips were used to guide accelerated partial breast irradiation, a planning target volume margin of the order of 5 mm could be used, significantly smaller than the 10-mm margin currently employed.

Secondary prevention of fractures in older people: evaluation of a protocol for the investigation and treatment of osteoporosis

It has been found previously that the investigation and treatment of osteoporosis following a fracture is poor, with only 9% of older people after a fracture being on effective osteoporosis treatment. To improve this aspect of post-fracture care in older people, a protocol has been instituted on an orthogeriatric rehabilitation ward in Christchurch, New Zealand. An audit was performed to assess the efficacy of this protocol in improving the investigation and treatment of osteoporosis (n = 193). Compliance with the investigation protocol was assessed and the pharmacological therapy initiated was requested from the general practitioner. All recommended blood-test investigations were requested in 62.8% of cases. Compared to a pre-protocol population, there was a marked increase in the measurement of bone mineral density (BMD; 93 vs 11%, P < 0.01) and vitamin D (95 vs 12%, P < 0.01). Vitamin D levels were low/-borderline in 95.6% of cases. BMD was performed in 77.7% of cases and showed osteoporosis and osteopenia to be present in 78.6 and 14.0%, respectively. For the 60 patients with BMD-confirmed osteoporosis whose therapy was obtained, 13.3% had no pharmacological therapy prescribed. Calcium, vitamin D or both were prescribed in 85.0%, bisphosphonates in 50.0% and hormone replacement therapy in 1.7% of patients. Vitamin D deficiency and osteoporosis on the basis of the BMD result are very common. The institution of a protocol has shown a significant improvement in the management of osteoporosis following a fracture. Some of the multifactorial barriers to full implementation of the guidelines are described.

Evaluation of a warfarin initiation protocol for older people

A protocol for initiation of warfarin therapy, targeted specifically for older people and based on individual responses to initial warfarin doses, was evaluated in a case-control study. People within the protocol group: (i) received higher initial doses of warfarin, (ii) reached an international normalized ratio (INR) of 2 more quickly, (iii) spent more time with INR of 2-3 in the first week and (iv) were less likely to be over-anticoagulated. However, the proportion of people who reached an INR of 2 too quickly (in <4 days) was no greater. The protocol correctly predicted the maintenance dose range of warfarin in over 70% of cases.

What is the prognosis of mild normocytic anaemia in older people?

BACKGROUND

There is reduced survival for people with all types of anaemia and it has been shown that there is a low yield from investigations for older people with normocytic anaemia. However, the longer-term outcomes of people with mild normocytic anaemia are not known.

AIMS

To determine the 5-year prognosis of older people with mild normocytic anaemia, compared with non-anaemic controls.

METHODS

This was a prospective cohort study, with some retrospective data collection, comparing 52 people aged > or =65 years (haemoglobin 100-119 g/L; mean cell volume 80-99 fL) without an obvious cause at presentation with 52 non-anaemic controls. The incidence of death, new malignancies and significant illnesses was compared between the two groups, 5 years later.

RESULTS

Anaemic patients were less likely to be living at home at baseline. Although survival was lower for the anaemic group at all follow-up times, these differences were not significantly different. Over 5 years, there were no significant differences between groups in the types of problems that developed.

CONCLUSIONS

A mild normocytic anaemia in older people, in the absence of an obvious cause, is not associated with significant differences in outcomes but is associated with poorer independence and a trend to lower survival. We suggest it may therefore be a marker of frailty in older people.

The use of portfolios for assessment of the competence and performance of doctors in practice

BACKGROUND

The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system.

RESULTS

To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes.

CONCLUSION

Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general.

Linking assessment to learning: a new route to quality assurance in medical practice

BACKGROUND

If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues.

OBJECTIVES

In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action.

METHOD

To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess.

CONCLUSIONS

We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.

Standard setting in an objective structured clinical examination: use of global ratings of borderline performance to determine the passing score

BACKGROUND

Objective structured clinical examination (OSCE) standard-setting procedures are not well developed and are often time-consuming and complex. We report an evaluation of a simple 'contrasting groups' method, applied to an OSCE conducted simultaneously in three separate schools.

SUBJECTS

Medical students undertaking an end-of-fifth year multidisciplinary OSCE.

METHODS

Using structured marking sheets, pairs of examiners independently scored student performance at each OSCE station. Examiners also provided a global rating of overall performance. The actual scores of any borderline candidates at each station were averaged to provide a passing score for each station. The passing scores for all stations were combined to become the passing score for the whole exam. Validity was determined by making comparisons with performance on other fifth-year assessments. Reliability measures comprised interschool agreement, interexaminer agreement and interstation variability.

RESULTS

The approach was simple and had face validity. There was a stronger association between the performance of borderline candidates on the OSCE and their in-course assessments than with their performance on the written exam, giving a weak measure of construct validity in the absence of a better 'gold standard'. There was good agreement between examiners in identifying borderline candidates. There were significant differences between schools in the borderline score for some stations, which disappeared when more than three stations were aggregated.

CONCLUSION

This practical method provided a valid and reliable competence-based pass mark. Combining marks from all stations before determining the pass mark was more reliable than making decisions based on individual stations.

Hip fracture mortality and morbidity--can we do better?

AIMS

To determine the mortality and morbidity from fractures of the neck of femur in Christchurch Hospital and to determine the extent that hip fracture patients are investigated and treated for osteoporosis.

METHODS

All patients treated for a fractured hip at Christchurch Hospitals between May 1998 and April 1999 were identified. Their radiographs were reviewed and each fracture was classified. Dates of death were recorded where applicable. Surviving patients were contacted at least twelve months after their fracture and asked questions relating to functional outcome following surgery. The numbers of patients who had ever had a bone density scan, treatment for osteoporosis and/or a measurement of vitamin D were recorded.

RESULTS

There were 331 fractures among 329 patients (242 women, 87 men), mean age of 79.7 (standard deviation 10.5) years. Twelve-month mortality was 26%. Men had a higher mortality rate than women for all fracture types that was independent of age. Follow up of the 231 surviving patients 12-24 months later revealed 27% still had pain and 60% had worsened mobility that they attributed to the fracture. Worsened mobility affected people living at home more than people living in institutional care. 32 people (15%) had had a vitamin D concentration measured and in 22 of these (69%) levels were below the reference range.

CONCLUSIONS

The mortality and morbidity after hip fracture is high, especially in men. There were few significant correlates with greater morbidity except for fixation by hemi arthroplasty. More attention to hip fracture prevention is needed. Few subjects were on any therapy for osteoporosis other than calcium supplements. Vitamin D deficiency is an important but under-recognised condition.

Patterns of alcohol use and misuse among elderly rest home residents in Christchurch

AIMS

To determine the prevalence of alcohol use and misuse among elderly rest home residents in Christchurch.

METHODS

A cross-sectional prevalence survey was conducted among 175 residents aged 65 years and over, randomly selected from 30 rest homes in Christchurch, in 1998. Hazardous patterns of alcohol consumption in the past twelve months were determined by the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and alcohol dependence in the past 12-months and lifetime was determined by a strctured clinical interview using DSM-IV criteria.

RESULTS

Of 246 eligible participants, 175 (71.1%) residents were interviewed, 115 women and 60 men, mean age, 82.6 years (SD=7.8) compared with 83.2 years (SD=6.3) for non-participants. The prevalence of hazardous patterns of alcohol consumption in the past twelve months by the AUDIT (cut-off score 8) was 5.1% (95% CI = 1.8-8.4). According to DSM-IV criteria, the prevalence of lifetime alcohol dependence was 20.5% (95% CI = 13.5-27.6) and for the past twelve months was 0.5% (95% CI = 0-1.7). The prevalence of lifetime alcohol dependence was significantly higher in men 36.7% (95% CI = 23.2-50.1) than women 12.2% (95% CI = 5.6-18.8) (p = 0.0001).

CONCLUSIONS

In spite of advanced age, a small proportion of elderly rest home residents consumed quantities of alcohol that put them at risk of future damage to physical or mental health. Lifetime prevalence of alcohol dependence was comparable to the general population estimates and was higher in men than women.

Development of a three-centre simultaneous objective structured clinical examination

OBJECTIVE

To describe the development, organization, implementation and evaluation of a yearly multicentre, identical and simultaneous objective structured clinical examination (OSCE).

SUBJECTS

All fifth-year medical students in a 6-year undergraduate medical programme.

SETTING

The Christchurch, Dunedin and Wellington Schools of Medicine of the University of Otago, New Zealand.

METHOD

One practice and two full 18-station OSCEs have been completed over 2 years, for up to 72 students per centre, in three centres. The process of development and logistics is described. Data are presented on validity, reliability and fairness.

RESULTS

Face and content validity were established. Internal consistency was 0.83-0. 86 and interexaminer reliability, as assessed by the coefficient of correlation, averaged 0.78. Students rated the OSCE highly on relevance. Of the total variance in total OSCE marks, the schools contributed 6.9%, and the students 93.1%, in the first year. In the second year the schools contributed 6.2% and the students 93.8%.

CONCLUSION

Implementation of a psychometrically sound, multicentre, simultaneous and identical OSCE is possible with a low level of interschool variation.

Stroke patients' views on stroke outcomes: death versus disability

AIMS

To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls.

PARTICIPANTS AND SETTING

Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sex-matched control patients from the same hospital who had never had a stroke or transient ischaemic attack.

METHODS

Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome.

RESULTS

There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11).

CONCLUSIONS

Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.

Is thiamine deficiency in elderly people related to age or co-morbidity?

OBJECTIVES

to compare erythrocyte thiamine pyrophosphate concentrations in elderly people with those in healthy younger people; to determine if any differences can be attributed to age or to co-morbidities.

DESIGN

cross-sectional and 3-year longitudinal surveys.

SETTING

primary care.

PATIENTS

100 volunteer blood donors and 222 elderly people from a general practice register.

MEASUREMENTS

thiamine pyrophosphate concentrations using high performance liquid chromatography; physical examination, medical and medication history; grip strength, body mass index and plasma albumin.

RESULTS

the mean [95% confidence interval (CI)] thiamine pyrophosphate concentration was 152 nmol/l (147-158) in the elderly group and 224 (213-235) nmol/l in the younger group (P < 0.001). Ninety-six (43.4%) of the elderly subjects had thiamine pyrophosphate concentrations below the fifth percentile of the younger subjects (140 nmol/l). Over 3 years thiamine pyrophosphate concentrations fell in the elderly cohort by 20% (95% CI: 14.5-24.5%; P < 0.01). Thiamine pyrophosphate concentrations in 39 healthy older people were no different from those in elderly people with co-morbidity but were significantly lower than those in the younger people. Elderly people with absent vibration sense in their feet had a lower thiamine pyrophosphate concentration than the rest of the group [129 (117-142)nmol/l compared with 156 (150-162)nmol/l; P < 0.01)]. Thiamine pyrophosphate concentrations were not related to prevalent diseases, common medications, body mass index, grip strength or plasma albumin.

CONCLUSION

lower thiamine pyrophosphate concentrations in elderly people appear to be related more to age itself than to co-existent illnesses.

Enantioselective syntheses of 2-alkyl- and 2,6-dialkylpiperidine alkaloids: preparations of the hydrochlorides of (-)-coniine, (-)-solenopsin A, and (-)-dihydropinidine

[reaction: see text] Sequences of lithiation-substitution, enantioselective hydrogenation, and diastereoselective lithiation-substitution provide efficient highly enantioselective syntheses of 2-substituted and cis and trans 2,6-disubstituted piperidines. The methodology is demonstrated by syntheses of (-)-coniine, (-)-solenopsin A, and (-)-dihydropinidine as their hydrochlorides.

Incidence and risk factors for hyponatraemia following treatment with fluoxetine or paroxetine in elderly people

AIMS

To establish the incidence, time course and risk factors of hyponatraemia complicating treatment with fluoxetine or paroxetine in an elderly population.

METHODS

Retrospective descriptive and case control study in an inpatient/outpatient assessment and rehabilitation service for people aged 65 years and over. Fourteen elderly patients with hyponatraemia complicating treatment with fluoxetine or paroxetine, matched with 56 controls drawn from 845 patients treated with fluoxetine or paroxetine over 3.5 years. No other SSRI antidepressants were used over the study period.

RESULTS

The incidence of hyponatraemia was 4.7/1000 people treated/year (6.3/1000 for fluoxetine and 3.5/1000 for paroxetine). Hyponatraemia was detected at a median 13.5 (mean 18.6, range 4-64) days after commencing the drug. Mean (95% confidence intervals) body weights were lower in cases at 53.0 (95% CI 46.5-59.5) kg compared with controls at 64.5 (95% CI 60.1-68.4) kg (P<0.01). 71% of cases were women compared with 45% of controls (P=0.07) but the effect of gender was confounded by body weight. There were trends for cases to be older (odds ratio 1.10: 95% CI 0.99, 1.23) and lighter (odds ratio 0.92, 95% CI 0.86, 0.99).

CONCLUSIONS

Approximately 1 in 200 elderly people treated per year with fluoxetine or paroxetine developed complicating hyponatraemia. Low body weight was a particular risk factor. Most cases occurred within 3 weeks of treatment.

The association between mortality, morbidity and age in New Zealand's oldest old

People aged eighty-five years and over (the oldest old) will form an increasing proportion of the population of New Zealand and many other countries. Because of their smaller numbers and relative inaccessibility, their health status has sometimes been extrapolated from populations of people aged sixty-five to eighty-four years. For people aged sixty-five to eighty-four years an exponential relationship is seen between age and morbidity and mortality. We explore if this exponential relationship extends to people aged ninety years and over. We analyzed data from the New Zealand 1991 Census and 1992 hospital discharge records and, for people aged sixty to eighty-nine years, confirmed an exponential relationship between age and mortality, inactivity, hospital utilization, and occupation of residential institutions. This exponential trend did not continue for people aged ninety years and over for whom mortality rates and indicators of morbidity were considerably lower than expected, and conclude that the actual health status of people aged ninety years and over is better than the status extrapolated from that of people aged sixty to eighty-nine years.

A census-based comparison of centenarians in New Zealand with those in the United States

OBJECTIVE

To describe the characteristics of New Zealand's centenarians, as given in the 1991 census, and to compare these characteristics with those of centenarians from the United States.

DESIGN

A census-based descriptive study.

SETTING

The complete national population as defined by the 1991 New Zealand census.

RESULTS

In 1991, there were 246 female and 51 male centenarians in New Zealand. Fifty-one percent of the men and 29% of the women lived at home; 16% lived at home with someone else (55% with children). People who were widowed were more likely to be living in a residential institution (69%) than people who were married (40%). Forty-three percent of men and 39% of women earned less than NZ$10,000 per year. Most had no formal educational qualification. Fourteen percent of men and 35% of women living at home did housework in the previous week. Compared with the United States, there are fewer New Zealand centenarians per number of population. People of European race were overrepresented in the New Zealand centenarian population, whereas African Americans were overrepresented in the United States centenarian population.

CONCLUSIONS

Our data have shown the heterogeneity associated with extreme ageing and can be used as a basis for comparison with other countries.

The effect of hospital admission on the opinions and knowledge of elderly patients regarding cardiopulmonary resuscitation

OBJECTIVE

to determine (i) if the opinions of elderly people, regarding their wish for cardiopulmonary resuscitation (CPR), change after staying in hospital, (ii) how much elderly people wish to be involved in making decisions about CPR and (iii) the degree of knowledge they use to make their decisions.

DESIGN

consecutive sample survey.

SETTING

assessment, treatment and rehabilitation unit.

PATIENTS

95 elderly inpatients (63% of all admissions) without a terminal illness who could give informed consent, interviewed after hospital admission. Sixty-seven were interviewed again at hospital discharge and three were interviewed 16-35 days after admission.

INTERVENTION

patient education and semi-structured questionnaire.

OUTCOME MEASURES

patients' knowledge and opinions on basic knowledge of CPR, preference for CPR, who should decide and how this should be documented.

RESULTS

knowledge improved after intervention, although patients persistently overestimated the success rate of CPR. Eighty percent on admission and 69% following a hospital stay wished to have CPR if necessary. Men were more likely to want CPR. On admission, 74% stated the patient should make the decision regarding CPR. This rose to 84% after a hospital stay. Only 57% wished to have their preference recorded in the hospital record and only 43% wanted their general practitioner notified of their wishes. Ninety-four percent felt comfortable with the interview.

CONCLUSIONS

elderly people wish to be consulted about CPR but many do not wish their preference to be committed to paper. Most older patients want CPR but these wishes may change with time. It is important that any recorded directive from a patient is updated frequently.