Professor Kichu Nair

© 2019 The Author(s). Background: Despite the perceived ethical, personal and health service benefits of advance care planning (ACP), the extent to which older and seriously ill Australian inpatients have considered future health decisions remains uncertain. This study aimed to determine in a sample of older and seriously ill inpatients, the proportion who had: 1) engaged in four advance care planning (ACP) activities; 2) not engaged in ACP activities but wanted to; and 3) reasons why they had not engaged. Methods: Cross-sectional face-to-face standardised interview survey with inpatients in a tertiary referral centre who were either: aged 80+ years; aged 55+ years with progressive chronic disease(s); or judged by treating clinicians as having a life expectancy of less than 12 months. Patients indicated whether they had engaged in four ACP activities: (1) appointed medical substitute-decision-maker(s), (2) recorded end-of-life wishes in an advance directive or care plan; and talked about their end-of-life wishes with their: (3) support persons and/or (4) doctors. Patients who had not engaged in activities were asked whether they wished this to occur and reasons why. Results: One hundred eighty-six inpatients consented to the study (80% of approached). Of these, 9% (n = 16) had engaged in four ACP activities; 27% (n = 50) had not engaged in any. Half (n = 94, 52%) had appointed a medical substitute-decision-maker, 27% (n = 50) had recorded wishes in an advance directive or care plan, 51% (n = 90) had talked about their end-of-life wishes with support persons and 27% (n = 48) had talked with their doctor. Patients who wanted to, but had not, engaged in the four ACP activities were unaware they could record wishes or appoint decision-makers, or indicated providers had not initiated conversations. Conclusion: Relatively few inpatients had engaged in all four ACP activities. More inpatients had discussed end of life issues with family and appointed substitute decision makers, than completed written documents or talked with doctors. Community education and a more active role for community and hospital-based providers in supporting patients and families to collaboratively resolve end-of-life decisions may increase the probability wishes are known and followed.

Objective: To estimate the cost of resources required to deliver a program to assess international medical graduates (IMGs) in Newcastle, Australia, known as the Workplace Based Assessment (WBA) Program. Design and setting: A costing study to identify and evaluate the resources required and the overheads of delivering the program for a cohort of 15 IMGs, based on costs in 2012. Main outcome measures: Labour-related costs. Results: The total cost in 2012 for delivering the program to a typical cohort of 15 candidates was $243 384. This equated to an average of $16226 per IMG. After allowing for the fees paid by IMGs, the WBA Program had a deficit of $153384, or $10226 per candidate, which represents the contribution made by the health system. Conclusion: The cost per candidate to the health system of this intensive WBA program for IMGs is small.

In this series, we present authoritative advice on the investigation of a common clinical problem, especially commissioned for family doctors and written by members of the Royal Australasian College of Physicians.

Background: The purpose of this study was to compare apolipoprotein E e4 (Apo E e4) and apolipoprotein E e2 (Apo E e2) as predictors of cognitive and functional trajectories over 30 months. Methods: This prospective cohort study included 287 community-dwelling memory clinic patients with dementia, mild cognitive impairment, or no cognitive impairment. The Addenbrooke Cognitive Assessment, Mini-Mental State Examination, Montreal Cognitive Assessment, Delirium Index, and Nottingham Instrumental Activities of Daily Living tests were administered to each subject. Results: One hundred and nine subjects (40%) carried Apo E e4 and 48 (16.7%) carried Apo E e2. One hundred and nine e4-positive subjects differed significantly from 178 e4-negative subjects in 19/52 comparisons (36.5%), whereas 46 Apo E e2-positive subjects had 0/52 significant differences from 239 e2-negative subjects (P < 0.0001). The variables most affected by e4 were the Delirium Index and Mini-Mental State Examination. Instrumental Activities of Daily Living score and residence were unrelated to Apo E e4 or e2. Conclusion: Apo E e4 positivity predicted four cognitive scores measured every 6 months over 30 months. Apo E e2 scores predicted none of 52 comparisons. © 2013 Regal et al.

We report on an elderly lady with a large hiatus hernia presenting with presyncope and syncope associated with large meals. Though left atrial filling and mitral inflow was unimpaired, this case is interesting since the symptoms resolved with adjustment to meal size. Copyright 2013 BMJ Publishing Group. All rights reserved.