Dr Karen Mate

Background: It is recommended that anticholinergic medication is avoided in older people, especially those with cognitive impairment. Objective: To investigate anticholinergic load (ACL) over time in older primary care patients with and without cognitive impairment. Methods: Community-dwelling general practice patients at baseline (n = 1768), at year one (n = 1373) and a restricted cohort (with possible or definite cognitive impairment) at year two (n = 370) had medication regimens documented by a research nurse during a home visit. Anticholinergic medicines were categorized as levels 1-3 (low-high potency) and summed for each participant as a measure of their ACL. Results: Most participants had no change in ACL over time, but there was some turnover in the anticholinergic medications used. The mean change in ACL was 0.012 ± 0.99 from baseline to 12 months and -0.04 ± 1.3 from baseline to 24 months. Cardiovascular drugs were the most commonly used level 1 anticholinergics, followed by antidepressants and opioids. Antidepressants and urologicals were the most commonly used level 3 anticholinergics. The rate of anticholinergic deprescribing was equivalent to the rate of anticholinergic initiation, and commonly involved the level 1 drugs warfarin, furosemide and temazepam, and the level 3 drugs amitriptyline and oxybutynin. People with dementia had a higher ACL at baseline and year one compared with other participants. Conclusion: ACL of community-dwelling older people was very stable over time. This may represent lost opportunities for deprescribing as well as potentially inappropriate prescribing, particularly in those with cognitive impairment.

Objective: General practitioners (GPs) fail to identify more than 50% of dementia cases using the existing passive case-finding approach. Using data from the ¿Ageing in General Practice¿ study, we sought to establish the additional benefit of screening all patients over the age of 75 for dementia beyond those patients already identified by passive case-finding. Method: Patients were classified as ¿case-finding¿ (n = 425) or ¿screening¿ (n = 1006) based on their answers to four subjective memory related questions or their GP's clinical judgement of their dementia status. Cognitive status of each patient was formally assessed by a research nurse using the Cambridge Cognition Examination (CAMCOG-R). Patients then attended their usual GP for administration of the GP assessment of Cognition (GPCOG) dementia screening instrument, and follow-up care and/or referral as necessary in light of the outcome. Results: The prevalence of dementia was significantly higher in the case-finding group (13.6%) compared to the screening group (4.6%; p < 0.01). The GPCOG had a positive predictive value (PPV) of 61% in the case-finding group and 39% in the screening group; negative predictive value was >95% in both groups. GPs and their patients both found the GPCOG to be an acceptable cognitive assessment tool. The dementia cases missed via case-finding were younger (p = 0.024) and less cognitively impaired (p = 0.020) than those detected. Conclusion: There is a very limited benefit of screening for dementia, as most people with dementia could be detected using a case-finding approach, and considerable potential for social and economic harm because of the low PPV associated with screening.

Background/Aims: The General Practitioner Assessment of Cognition (GPCOG) is a brief cognitive test. This study compared the GPCOG to the Mini-Mental State Examination (MMSE), the most widely used test, in terms of their ability to detect likely dementia in primary care. Methods: General practitioners across three states in Australia recruited 2,028 elderly patients from the community. A research nurse administered the GPCOG and the MMSE, as well as the Cambridge Examination for Mental Disorders of the Elderly Cognitive Scale-Revised that we used to define likely dementia. Results: Overall, the GPCOG and the MMSE were similarly effective at detecting likely dementia. The GPCOG, however, had a higher sensitivity than the MMSE when using published cutpoints. Conclusion: The GPCOG is an effective screening tool for dementia in primary care. It appears to be a viable alternative to the MMSE, whilst also requiring less time to administer.

What is known and objectives: Adverse clinical outcomes have been associated with cumulative anticholinergic burden (to which low-potency as well as high-potency anticholinergic medicines contribute). The clinical indications for which anticholinergic medicines are prescribed (and thus the ¿phenotype¿ of patients with anticholinergic burden) have not been established. We sought to establish the overall prevalence of prescribing of anticholinergic medicines, the prevalence of prescribing of low-, medium- and high-potency anticholinergic medicines, and the clinical indications for which the medicines were prescribed in an older primary care population. Methods: This was a cross-sectional analysis of a cohort study of Australian early-career general practitioners¿ (GPs¿) clinical consultations ¿ the Registrar Clinical Encounters in Training (ReCEnT) study. In ReCEnT, GPs collect detailed data (including medicines prescribed and their clinical indication) for 60 consecutive patients, on up to three occasions 6 months apart. Anticholinergic medicines were categorized as levels 1 (low-potency) to 3 (high-potency) using the Anticholinergic Drug Scale (ADS). Results: During 2010¿2014, 879 early-career GPs (across five of Australia's six states) conducted 20 555 consultations with patients aged 65 years or older, representing 35 506 problems/diagnoses. Anticholinergic medicines were prescribed in 10·4% [95% CIs 9·5¿10·5] of consultations. Of the total anticholinergic load of prescribed medicines (¿community anticholinergic load¿) 72·7% [95% CIs 71·0¿74·3] was contributed by Level 1 medicines, 0·8% [95% CIs 0·5¿1·3] by Level 2 medicines and 26·5% [95% CIs 24·8¿28·1] by Level 3 medicines. Cardiac (40·0%), Musculoskeletal (16·9%) and Respiratory (10·6%) were the most common indications associated with Level 1 anticholinergic prescription. For Level 2 and 3 medicines (combined data), Psychological (16·1%), Neurological (16·1%), Musculoskeletal (15·7%) and Urological (11·1%) indications were most common. What is new and conclusion: Anticholinergic medicines are frequently prescribed in Australian general practice, and the majority of the ¿community¿ anticholinergic burden is contributed by ¿low¿-anticholinergic potency medicines whose anticholinergic effects may be largely ¿invisible¿ to prescribing GPs. Furthermore, the clinical ¿phenotype¿ of the patient with high anticholinergic burden may be very different to common stereotypes (patients with urological, psychological or neurological problems), potentially making recognition of risk of anticholinergic adverse effects additionally problematic for GPs.

A sound understanding of bioscience and an ability to use that knowledge in solving complex problems is required for the development of proficient health practitioners. This paper describes the continuing development of a bioscience course designed specifically for this purpose; it uses a problem based approach to teach the skill of applying knowledge of basic scientific concepts to clinical case scenarios. Face to face teaching hours were divided equally between lectures (to introduce inexperienced learners to the material) and problem based interactive tutorials (to model and practice the skill of applying basic knowledge to clinical case scenarios). The difficulty of finding sufficient teaching staff with a strong scientific and clinical background was addressed by using a large group interactive format for tutorials, along with the use of an electronic audience response system. This approach resulted in an increase of both academic performance and student satisfaction, with no diminution of the perceived level of support provided to students.

The effective communication of science through language, including reading, writing, listening, speaking, and visual representation, is an essential part of scientific learning, understanding, and practice. Language is the medium by which scientific reasoning occurs, whether be it formal language or symbolic representations of scientific phenomena. Sustainable Language Support Practices in Science Education: Technologies and Solutions presents cases on the results of a study done in Australia on first-year university students and the impact of new techniques of language acquisition on science education. The project covered biology, chemistry, and physics. Nearly 3,400 students were involved in the project, drawn from the University of Canberra, the University of Technology-Sydney, the University of Sydney, the University of Tasmania, and the University of Newcastle in Australia. This book serves as the latest research available on meta-cognitive assessment and language needs for a diverse student body; it is a vital resource for academics and practitioners designing and implementing science education around the world today. © 2012 by IGI Global. All rights reserved.

Oviduct epithelial cell (OEC) monolayers were prepared from the isthmic and ampullary parts of the oviducts of FSH-primed tammar wallabies. Co-culture experiments found that 50-60% of wallaby spermatozoa attached immediately to OEC monolayers, tracheal cell monolayer controls, and the surface of culture dishes with and without Matrigel coating. Spermatozoa were considered to be attached if they remained on the culture surface after rapidly pipetting the co-culture medium five times. The percentages of attached and unattached spermatozoa were calculated from the number of spermatozoa recovered in the agitated supernatant. After 2 h co-culture the percentage of attached spermatozoa rose to 60-80%. After 6 h co-culture the number of spermatozoa attached to OEC monolayers derived from the oviductal isthmus remained high and only a small percentage were recovered in the agitated supernatant (unattached spermatozoa 3.85 ± 0.76%, P = 0.67). However, after 6 h co-culture of spermatozoa with OEC monolayers derived from the ampulla and with the controls the percentage of attached spermatozoa declined significantly (unattached spermatozoa: ampullary monolayer 23.08 ± 4.80%, P < 0.01; tracheal monolayer 23.23 ± 5.18%, P < 0.01; Matrigel 27.23 ± 7.76%, P < 0.01; plastic surface 28.19 ± 5.30%, P < 0.01). After 6 h co-culture with ampullary and isthmic OEC monolayers, the percentage motility of both attached and unattached spermatozoa was maintained at 64.00 ± 1.90% and 56.66 ± 3.18% and 62.00 ± 3.11% and 52.00 ± 2.43%, respectively, and was then maintained at = 35% after 24 h incubation. In the controls, that is, tracheal monolayer and Matrigel, the motility of attached spermatozoa declined rapidly to 48.66 ± 2.15% and 33.63 ± 8.66%, respectively, at 6 h, and all spermatozoa were immotile after 24 h incubation. However, the motility of unattached spermatozoa in the controls (tracheal monolayer and Matrigel) was maintained at 57.33 ± 3.00% and 34.54 ± 9.27%, respectively, until 6 h and then declined rapidly, and all spermatozoa were immotile after 24 h incubation. Co-culture of wallaby spermatozoa with OEC monolayers also induced acrosomal modifications that were followed by acrosomal loss. At 6 h incubation 38.92 ± 3.98% of spermatozoa on ampullary OEC monolayers and 36.50 ± 3.81% spermatozoa on isthmic OEC monolayers had shed their acrosome. Acrosomal loss during co-culture with both isthmic and ampullary OEC monolayers was significantly (P < 0.01) greater than that observed on tracheal epithelial monolayer (24.42 ± 1.90%, P < 0.01), Matrigel (20.70 ± 2.71%, P < 0.01) and plastic (15.54 ± 2.49%, P < 0.01). Co-culturing spermatozoa with OEC monolayers also induced a transformation from streamlined orientation of sperm head and tail to T-shaped (thumbtack) orientation in a small number (10-15%) of motile spermatozoa after 6 h incubation (data not shown). The significance of these results in relation to the role of the oviduct in sperm capacitation is discussed.