End-of-life checklist developed
AUSTRALIAN doctors have developed a checklist designed to identify elderly hospital patients likely to die within the next 3 months. In research published in BMJ Supportive & Palliative Care, the authors wrote that the tool was not intended to preclude access to health care for terminal elderly people, “but to provide an objective assessment and definition of the dying patient as a starting point for honest communication with patients and families, about recognising that dying is part of the life cycle”. They said the Critera for Screening and Triaging to Appropriate Alternative Care (CriSTAL) could also minimise the risk of further futile treatment. The researchers conducted a narrative literature search for papers about explicit and practical definitions of end of life and for tools or screening instruments to predict death. A checklist of 29 predictors of death was compiled, including older age (at least 65 years of age); two criteria of deterioration; at least two criteria for frailty; an early warning score of more than 4; at least one other underlying health condition; nursing home residency; cognitive impairment; previous emergency admission or intensive care treatment within the preceding year; an abnormal electrocardiographic tracing; and protein in the urine. The authors wrote that CriSTAL’s 29 predictors would be tested in a retrospective data review based on deaths reported from rapid response team (RRT) attendances in a teaching hospital during 2012–2013. “Controls will be age-sex-ward matched records of patients admitted in the same period with an RRT call but [who] did not die before or within 3 months of discharge”, they wrote. “Careful use of the CriSTAL tool care for decision-making would involve alignment with quality of care principles and patient values and preferences, and should not be driven by hospital financial pressures or need to meet health system performance indicators.”
Adenotonsillectomy improves obstructive sleep apnoea symptoms
A LARGE prospective randomised controlled trial has found significant improvements in quality of life (QoL) measures for children with obstructive sleep apnoea symptoms (OSAS) who undergo adenotonsillectomy (AT) compared with those on watchful waiting. The research, published in Pediatrics, included 453 children aged 5‒9.9 years with OSAS who were randomly assigned to undergo AT or watchful waiting with supportive care. QoL and symptom severity surveys were completed at baseline and 7 months later. The researchers found the benefits from AT were evident in both generic and disease-specific health-related QoL, with moderate to large improvements observed for most QoL and symptom measurements, including school, emotional and physical function domains, and snoring, sleepiness and inattentive/behavioural scales. “These observations have important clinical implications for the many children with OSAS who are evaluated for AT”, the researchers wrote. “The findings are of particular relevance, given the growing interest from patients, payers, and providers that QoL and symptom outcomes be highlighted in the management of chronic health conditions.” The authors did acknowledge that the short follow-up period was a limitation of the study.

Sleep position a risk factor in epilepsy death
THE prone sleeping position is a major risk factor for sudden unexpected death in epilepsy (SUDEP), particularly in patients aged 40 years and younger, research published in Neurology has found. The authors conducted a systematic review and meta-analysis of 25 publications — 14 single case reports and 11 case series — which included 253 cases of SUDEP with documented body position. Of these patients, 73.3% had died in the prone position while 26.7% died in non-prone positions. The prone position was reported in 11 patients observed in video-electroencephalogram-monitored SUDEP, the authors said. In a subgroup of 88 cases in which demographics and circumstances of death were documented, the prone position was observed in 85.7% of patients aged 40 years or younger, and in 60% of patients older than 40 years. The reason why prone position represented such a significant risk factor for younger individuals was unclear, but could be multifactorial, the authors wrote. They suggested their findings had significant implications regarding the mechanisms of SUDEP, which shared similarities to those of sudden infant death syndrome. The authors said more research was needed to develop effective measures for SUDEP prevention and recommended that information on a patient’s body position be included in all future SUDEP case reports. An accompanying editorial said the research highlighted how simple measures, such as bringing patients out of the prone position, could substantially reduce risk. However, the editorial identified several limitations of the review, including the small number of studies included and the lack of control groups.

Alcohol ads associated with increased drinking in young
TELEVISION alcohol advertising is associated with adolescents and young adults trying alcohol, binge drinking and progressing to hazardous drinking, according to a US study. The research, published in JAMA Pediatrics, included telephone and web-based surveys of 2541 adolescents aged 15‒23 years at baseline, with 1596 completing a follow-up survey 2 years later. The surveys examined participants’ recall of television advertising images for top beer and distilled spirits brands, as well as their drinking behaviour. The authors determined an alcohol receptivity score based on whether respondents had seen and liked randomly selected, deidentified advertisements, and whether they could correctly identify the brand. The authors found that underage participants were only slightly less likely than those of legal drinking age to have seen alcohol ads. The transition to binge and hazardous drinking occurred for 29% and 18% respectively of those aged 15‒17 years and for 29% and 19% respectively of 18‒20 year olds. The authors wrote that among underage participants, the alcohol advertising receptivity score independently predicted the onset of drinking, binge drinking and hazardous drinking. They wrote that their findings supported existing research that suggested alcohol advertising was a cause of youth drinking. “Current self-regulatory standards for televised alcohol advertising appear to inadequately protect underage youth from exposure to televised alcohol advertising and its probable effect on behavior”, they wrote.

Big jump in single sperm use for IVF cycles
AMONG new in vitro fertilisation (IVF) cycles in the US, intracytoplasmic sperm injection (ICSI) use has doubled since 1996, particularly for those without male factor infertility, according to research published in JAMA. However, the researchers found no evidence of improved outcomes from ICSI over conventional IVF. The authors assessed the use and reproductive outcomes of ICSI compared with conventional IVF based on data recorded in the US National Assisted Reproductive Technology Surveillance System. Of nearly 1.4 million fresh IVF cycles reported in 1996‒2012, 65.1% used ICSI and 35.8% reported male factor infertility. The authors found that among cycles with male factor infertility, ICSI use increased from 76.3% to 93.3% over the study period, while for those without male factor infertility, ICSI use rose from 15.4% to 66.9%. In cycles with male factor infertility, ICSI was associated with a lower multiple birth rate compared with conventional IVF. The authors found the likelihood of cycle cancellation between retrieval and transfer, which they described as a surrogate measure of failed fertilisation, was “markedly decreased” for cycles where ICSI was used compared with conventional IVF, “thereby confirming that ICSI increases the likelihood of fertilization in the context of male factor infertility”. However, they found that in the absence of male factor infertility, ICSI use was associated with small but statistically significant decreases in implantation, pregnancy, live birth, multiple live birth and low birthweight rates compared with conventional IVF. “Although such differences may be a function of the large sample size and thus not clinically relevant, our findings suggest that use of ICSI may improve fertilization rates but not implantation or pregnancy rates in the setting of unexplained infertility, advanced maternal age, and low oocyte yield”, the authors wrote.

Public consultation open for draft organ donation guidelines
THE National Health and Medical Research Council is inviting public comment on a draft document on organ donation released last week. Ethical guidelines for organ transplantation from deceased donors was developed with advice from an expert working group at the request of the Organ and Tissue Authority and the Transplantation Society of Australia and New Zealand.  In a media release, NHMRC CEO Professor Warwick Anderson said that because the demand for organs in Australia greatly outstripped availability, it was important that “decisions around who is eligible for organ transplantation and how to prioritise recipients are made in ethical and transparent ways”. The draft document outlines who is currently eligible for organ donation, how organs are allocated, and how the process is monitored. It then outlines principles and values which aim to support decision making so health professionals have an ethical framework to guide clinical consideration and judgement. Case studies are used to highlight ethical dilemmas that may arise. Public consultation on the draft document closes on 6 March.

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