Impact of haemodialysis hours on outcomes in older patients.

AIM: Previous studies report an association between longer haemodialysis treatment sessions and improved survival. Worldwide, there is a trend to increasing age among prevalent patients receiving haemodialysis. This analysis aimed to determine whether the mortality benefit of longer haemodialysis treatment sessions diminishes with increasing age. METHODS: This was a retrospective cohort study of people who first commenced thrice-weekly haemodialysis aged ≥65 years, reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry from 2005 to 2015, included from 90 days after dialysis start. The primary outcome was all-cause mortality. Cox regression analysis was performed with haemodialysis session duration the exposure of interest. RESULTS: Of 8224 people who commenced haemodialysis as their first treatment for kidney failure aged ≥65 years during this period, 4727 patients died. Longer dialysis hours per session was associated with a decreased risk of death in unadjusted analyses [hazard ratio, HR, for ≥5 h versus 4 to <4.5 h: 0.81 (0.75-0.88, p < .001)]. Patients having longer dialysis sessions were younger but had greater co-morbidity. In an adjusted model including age and other variables, the survival benefit of longer hours was only partially attenuated [HR for previous comparison: 0.75 (0.69-0.82, p < .001)], and no interaction between age and hours was demonstrated (p = .89). CONCLUSION: The apparent survival benefit associated with longer haemodialysis session length appears to be preserved in patients 65 years or older. In practice, the benefit of longer dialysis hours should be carefully weighed against other factors in this patient group.

Mortality After Home Hemodialysis Treatment Failure and Return to In-Center Hemodialysis.

RATIONALE & OBJECTIVE: Patients on home hemodialysis (HHD) may eventually return to in-center hemodialysis (ICHD) for clinical, technical, or psychosocial reasons. We studied the mortality of patients returning to ICHD after HHD, comparing it with the mortality experience among patients receiving HHD and patients receiving ICHD without prior treatment with HHD. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: All patients represented in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) who commenced HD during 2005-2015 and were treated for >90 days. EXPOSURE: ICHD and/or HHD, and clinical characteristics at study entry. OUTCOME: Mortality and cause of death. ANALYTICAL APPROACH: A time-varying multivariate Cox proportional hazards analysis with shared frailty was implemented to explore the association between patient treatment states and mortality. Patients were censored at the time of transplantation or change in treatment modality to peritoneal dialysis. RESULTS: A total of 19,306 patients initiated HD and were treated for >90 days. The mean age of patients was 60.8 ± 15.4 (SD) years, 62% were male, and 49% had diabetes. After HHD treatment failure, adjusted mortality was increased compared with continued HHD at 0-30 days (HR, 3.93 [95% CI, 2.09-7.40]; P < 0.001), 30-90 days (HR, 3.34 [95% CI, 1.98-5.62]; P < 0.001), and >90 days (HR, 2.29 [95% CI, 1.84-2.85]; P < 0.001). LIMITATIONS: Covariates recorded at dialysis initiation, residual confounding underlying successful initiation of HHD treatment, and observational data lacking detail on cause of HHD treatment failure. CONCLUSIONS: HHD treatment failure is associated with a significant increase in mortality compared with continued HHD. This risk was present in both the early (first 30 days and 30-90 days) and late (>90 days) periods after HHD treatment failure. Further investigation into the specific causes of treatment failure and death may highlight specific high-risk patients.

Dialysis modality utilization patterns and mortality in older persons initiating dialysis in Australia and New Zealand.

AIM: The benefits of dialysis in the older population remain highly debated, particularly for certain dialysis modalities. This study aimed to explore the dialysis modality utilization patterns between in-centre haemodialysis (ICHD), peritoneal dialysis (PD) and home haemodialysis (HHD) and their association with outcomes in older persons. METHODS: Older persons (≥75 years) initiating dialysis in Australia and New Zealand from 1999 to 2018 reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry were included. The main aim of the study was to characterize dialysis modality utilization patterns and describe individual characteristics of each pattern. Relationships between identified patterns and survival, causes of death and withdrawal were examined as secondary analyses, where the pattern was considered as the exposure. RESULTS: A total of 10 306 older persons initiated dialysis over the study period. Of these, 6776 (66%) and 1535 (15%) were exclusively treated by ICHD and PD, respectively, while 136 (1%) ever received HHD during their dialysis treatment course. The remainder received both ICHD and PD: 906 (9%) started dialysis on ICHD and 953 (9%) on PD. Different individual characteristics were seen across dialysis modality utilization patterns. Median survival time was 3.0 (95%CI 2.9-3.1) years. Differences in survival were seen across groups and varied depending on the time period following dialysis initiation. Dialysis withdrawal was an important cause of death and varied according to individual characteristics and utilization patterns. CONCLUSION: This study showed that dialysis modality utilization patterns in older persons are associated with mortality, independent of individual characteristics.

Multicenter registry analysis comparing survival on home hemodialysis and kidney transplant recipients in Australia and New Zealand.

BACKGROUND: In the era of organ shortage, home hemodialysis (HHD) has been identified as the possible preferential bridge to kidney transplantation. Data are conflicting regarding the comparability of HHD and transplantation outcomes. This study aimed to compare patient and treatment survival between HHD patients and kidney transplant recipients. METHODS: The Australia and New Zealand Dialysis and Transplant Registry was used to include incident HHD patients on Day 90 after initiation of kidney replacement therapy and first kidney-only transplant recipients in Australia and New Zealand from 1997 to 2017. Survival times were analyzed using the Kaplan-Meier product-limit method comparing HHD patients with subtypes of kidney transplant recipients using the log-rank test. Adjusted analyses were performed with multivariable Cox proportional hazards regression models for time to all-cause mortality. Time-to-treatment failure or death was assessed as a composite secondary outcome. RESULTS: The study compared 1411 HHD patients with 4960 living donor (LD) recipients, 6019 standard criteria donor (SCD) recipients and 2427 expanded criteria donor (ECD) recipients. While LD and SCD recipients had reduced risks of mortality compared with HHD patients [LD adjusted hazard ratio (HR) = 0.57, 95% confidence interval (CI) 0.46-0.71; SCD HR = 0.65 95% CI 0.52-0.79], the risk of mortality was comparable between ECD recipients and HHD patients (HR = 0.90, 95% CI 0.73-1.12). LD, SCD and ECD kidney recipients each experienced superior time-to-treatment failure or death compared with HHD patients. CONCLUSIONS: This large registry study showed that kidney transplant offers a survival benefit compared with HHD but that this advantage is not significant for ECD recipients.

Dialysis initiation in older persons across centres and over time in Australia and New Zealand.

AIM: With improved life expectancy over time, the burden of kidney failure resulting in kidney replacement therapy (KRT) in older persons is increasing. This study aimed to describe the age distribution at dialysis initiation in Australia and New Zealand (ANZ) across centres and over time. METHODS: Adults initiating dialysis as first KRT in ANZ from 1999 to 2018 reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry were included. The primary outcomes were the age distribution and the proportion of older persons (75 years and older) initiating dialysis across centres and over time. Secondary outcomes were characterization of the older population compared with younger people and differences in dialysis modality and treatment trajectories between groups. RESULTS: Over the study period, 55 382 people initiated dialysis as first KRT, including 10 306 older persons, in 100 centres. Wide variation in age distribution across states/countries was noted, although the proportion of older persons at dialysis initiation did not significantly change over time (from 13% in 1999 to 19% in 2003, then remaining stable thereafter). Older persons were less likely to be treated with home therapies compared with younger people. Older persons were mostly Caucasians; had higher socioeconomic position, more cardiovascular comorbidities and higher eGFR at baseline; and resided in major cities. Higher proportions of older persons per centre were noted in privately funded facilities. CONCLUSION: Wide variations were noted in the proportions of older persons initiating dialysis across centres and states/country, which were associated with different case-mix across regions, particularly in terms of ethnicity, remoteness and socioeconomic advantage.

Variability and trends over time and across centres in haemodialysis weekly duration in Australia and New Zealand.

AIM: Haemodialysis treatment prescription varies widely internationally. This study explored patient- and centre-level characteristics associated with weekly haemodialysis hours. METHODS: Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data were analysed. Characteristics associated with weekly duration were evaluated using mixed-effects linear regression models with patient- and centre-level covariates as fixed effects, and dialysis centre and state as random effects using the 2017 prevalent in-centre haemodialysis (ICHD) and home haemodialysis (HHD) cohorts. Evaluation of patterns of weekly duration over time analysed the 2000 to 2017 incident ICHD and HHD cohorts. RESULTS: Overall, 12 494 ICHD and 1493 HHD prevalent patients in 2017 were included. Median weekly treatment duration was 13.5 (interquartile range [IQR] 12-15) hours for ICHD and 16 (IQR 15-20) hours for HHD. Male sex, younger age, higher body mass index, arteriovenous fistula/graft use, Aboriginal and Torres Strait Islander ethnicity and longer dialysis vintage were associated with longer weekly duration for both ICHD and HHD. No centre characteristics were associated with duration. Variability in duration across centres was very limited in ICHD compared with HHD, with variation in HHD being associated with state. Duration did not vary significantly over time for ICHD, whereas longer weekly HHD treatments were reported between 2006 and 2012 compared with before and after this period. CONCLUSION: This study in the Australian and New Zealand haemodialysis population showed that weekly duration was primarily associated with patient characteristics. No centre effect was demonstrated. Practice patterns seemed to differ across states/countries, with more variability in HHD than ICHD.

Effect of Low-Sodium versus Conventional Sodium Dialysate on Left Ventricular Mass in Home and Self-Care Satellite Facility Hemodialysis Patients: A Randomized Clinical Trial.

BACKGROUND: Fluid overload in patients undergoing hemodialysis contributes to cardiovascular morbidity and mortality. There is a global trend to lower dialysate sodium with the goal of reducing fluid overload. METHODS: To investigate whether lower dialysate sodium during hemodialysis reduces left ventricular mass, we conducted a randomized trial in which patients received either low-sodium dialysate (135 mM) or conventional dialysate (140 mM) for 12 months. We included participants who were aged >18 years old, had a predialysis serum sodium ≥135 mM, and were receiving hemodialysis at home or a self-care satellite facility. Exclusion criteria included hemodialysis frequency >3.5 times per week and use of sodium profiling or hemodiafiltration. The main outcome was left ventricular mass index by cardiac magnetic resonance imaging. RESULTS: The 99 participants had a median age of 51 years old; 67 were men, 31 had diabetes mellitus, and 59 had left ventricular hypertrophy. Over 12 months of follow-up, relative to control, a dialysate sodium concentration of 135 mmol/L did not change the left ventricular mass index, despite significant reductions at 6 and 12 months in interdialytic weight gain, in extracellular fluid volume, and in plasma B-type natriuretic peptide concentration (ratio of intervention to control). The intervention increased intradialytic hypotension (odds ratio [OR], 7.5; 95% confidence interval [95% CI], 1.1 to 49.8 at 6 months and OR, 3.6; 95% CI, 0.5 to 28.8 at 12 months). Five participants in the intervention arm could not complete the trial because of hypotension. We found no effect on health-related quality of life measures, perceived thirst or xerostomia, or dietary sodium intake. CONCLUSIONS: Dialysate sodium of 135 mmol/L did not reduce left ventricular mass relative to control, despite improving fluid status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: The Australian New Zealand Clinical Trials Registry, ACTRN12611000975998.

Effect of patient- and center-level characteristics on uptake of home dialysis in Australia and New Zealand: a multicenter registry analysis.

BACKGROUND: Home-based dialysis therapies, home hemodialysis (HHD) and peritoneal dialysis (PD) are underutilized in many countries and significant variation in the uptake of home dialysis exists across dialysis centers. This study aimed to evaluate the patient- and center-level characteristics associated with uptake of home dialysis. METHODS: The Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry was used to include incident dialysis patients in Australia and New Zealand from 1997 to 2017. Uptake of home dialysis was defined as any HHD or PD treatment reported to ANZDATA within 6 months of dialysis initiation. Characteristics associated with home dialysis uptake were evaluated using mixed effects logistic regression models with patient- and center-level covariates, era as a fixed effect and dialysis center as a random effect. RESULTS: Overall, 54 773 patients were included. Uptake of home-based dialysis was reported in 24 399 (45%) patients but varied between 0 and 87% across the 76 centers. Patient-level factors associated with lower uptake included male sex, ethnicity (particularly indigenous peoples), older age, presence of comorbidities, late referral to a nephrology service, remote residence and obesity. Center-level predictors of lower uptake included small center size, smaller proportion of patients with permanent access at dialysis initiation and lower weekly facility hemodialysis hours. The variation in odds of home dialysis uptake across centers increased by 3% after adjusting for the era and patient-level characteristics but decreased by 24% after adjusting for center-level characteristics. CONCLUSION: Center-specific factors are associated with the variation in uptake of home dialysis across centers in Australia and New Zealand.

Clinical Evaluation of the Cook Advance Enforcer 35 Focal-Force PTA Balloon Catheter for Treatment of Hemodialysis Fistula Stenoses: A Feasibility Study.

PURPOSE: A prospective, single-center, single-arm feasibility study evaluated procedural and short-term performance of the Advance Enforcer 35 focal-force percutaneous transluminal angioplasty (PTA) balloon catheter in treating stenoses of mature native arteriovenous (AV) hemodialysis access circuits. MATERIALS AND METHODS: Twenty-eight patients undergoing treatment for stenosis of a mature native AV hemodialysis access circuit were enrolled at a single institution. Angiographic assessments of the study lesion were required at baseline and after the procedure. Adjunctive procedures for significant residual stenosis were permitted, and patients had clinical and imaging follow-up for as long as 6 months. RESULTS: Treatment with the study balloon was effective in reducing the average percent diameter stenosis of the treated lesion from 66.3% (range, 43.8%-93.3%) before the procedure to 23.7% (range, -6.7% to 51.4%) after the procedure. The average inflation pressure required was 12.3 atm. Only 1 patient required an adjunctive procedure, and all patients could resume normal dialysis following the study procedure. At 3 months, 62.0% of study lesions remained patent, and the 6-month patency rate was 25.1%. Two adverse events associated with the study procedure were reported: access-site hematoma and forearm pain (3.6% each). CONCLUSIONS: The results demonstrate safety of the study balloon in treating AV access stenosis. Nominal-diameter angioplasty was achieved at relatively low pressure in most study patients without the use of adjunctive procedures, and resumption of normal dialysis was achieved for all patients.

Changing ethnic and clinical trends and factors associated with successful home haemodialysis at Auckland District Health Board.

BACKGROUND: The health and diversity of the population in New Zealand (NZ) is changing under the influence of many socio-economic factors. This may have shifted the landscape of home haemodialysis (HHD). AIMS: To examine the demographic and clinical changes, determinants of HHD training and technique outcome and mortality between 2008 and 2015 at Auckland District Health Board, NZ. METHODS: We compared three incident cohorts of HHD patients between 2008 and 2015. Relevant factors, including demographic and clinical characteristics, training failure, technique failure and mortality were recorded. Factors associated with training and technique failure were examined by multivariate logistic regression. RESULTS: Of 152 patients, 133 completed training, 13 (10%) experienced technique failure and 15 (11%) died. Significant changes in ethnicity (increased: Maori 1.7-fold, Asian 1.7-fold and Pasifika 1.4-fold; decreased: NZ European 2.7-fold, P = 0.001), and major comorbidities, ≥2 major comorbidities (1.8-fold increase, P = 0.03), diabetes (2.1-fold increase, P = 0.013) and heart failure (P = 0.04) were seen. HHD as first renal replacement therapy modality increased 15-fold (P = 0.0001) and training time increased by 4.5 weeks (P = 0.004). Death and technique failure were unchanged over time. Shorter training time, employment and lower C-reactive protein were associated with 'Successful HHD'. 'Unsuccessful HHD' patient characteristics differed by ethnicity. CONCLUSIONS: The HHD population has become more representative of the NZ population, but significantly more comorbid over time. Patient training time has increased, but mortality and technique failure remain stable. 'Successful HHD' is predicted by social and clinical factors, and 'unsuccessful HHD' may have different mechanisms in different patient groups.

Survey of Core Trainees' Confidence in Electroconvulsive Therapy.

OBJECTIVES: The objective of the survey was to assess confidence in electroconvulsive therapy (ECT) in core psychiatry trainees across Scotland, looking at both theoretical and practical aspects of ECT. METHODS: A link to a 14-item electronic questionnaire was distributed to core trainees via deanery administrators. Most questions were based on the Royal College of Psychiatry's ECT guidelines. RESULTS: A total of 85 responses were analyzed from trainees at all 3 levels of core training and from all health boards across Scotland. Almost 90% of trainees felt that their ECT training was sufficient, with more senior trainees rating their training better than those in the first year of training. Trainees who had theoretical teaching before their practical sessions rated their training better than those with purely observational training. Most trainees felt confident delivering ECT under supervision, and nearly 75% of trainees felt confident preparing a patient for ECT. The areas in which trainees felt least confident were in practical aspects such as dosing protocols and electroencephalogram interpretation. CONCLUSIONS: While ECT training and trainee confidence in delivering ECT were generally good, there are variations in trainees' experience that could be addressed by having a standardized ECT training, including theoretical teaching and practical competencies, in line with current guidelines. Ideally, evidence of meeting the Royal College recommendations for ECT competencies could be made a compulsory aspect of core training in the United Kingdom.

The incidence and costs of bacteremia due to lack of gentamicin lock solutions for dialysis catheters.

The use of antibiotic lock solutions as prophylaxis for catheter-associated blood stream infection (CRBSI) has been shown to be effective in previous randomized controlled trials. However, the cost-effectiveness of this approach had not been studied. In 2012, the routine gentamicin-heparin lock solution used in Auckland City Hospital was withdrawn from the market, leading to a change to heparin-only lock. This was then replaced with gentamicin-citrate lock in 2014. This situation allowed review of the CRBSI rate and financial impact of different catheter lock solutions. A retrospective audit was performed from 1 January 2011 to 31 December 2015 to investigate the rate of culture-proven CRBSI in patients with tunneled cuffed dialysis catheters. There were 89 cases of CRBSI involving 64 patients in the 5-year period. In comparison with the heparin-only lock, both gentamicin-heparin and gentamicin-citrate locks had a significantly lower rate of bacteremia, with rate ratios of 0.46 (confidence interval 0.30-0.72) and 0.11 (confidence interval 0.05-0.22), respectively. The inpatient costs as a consequence of the CRBSI were NZ$27 792 per 1000 catheter days for heparin-only lock, NZ$10 608.56 per 1000 catheter days for gentamicin-heparin lock, and NZ$ 1898.45 per 1000 catheter days for gentamicin-citrate lock. The lack of antibiotic lock solutions led to an increase in bacteremia rates and higher financial cost for inpatient management of bacteremia. Our findings highlight the importance of consistent supply of pharmaceuticals.

Update: Rationale and design of the Sodium Lowering In Dialysate (SoLID) trial: a randomised controlled trial of low versus standard dialysate sodium concentration during hemodialysis for regression of left ventricular mass.

After the publication of our paper Dunlop et al. "Rationale and design of the Sodium Lowering In Dialysate (SoLID) trial: a randomised controlled trial of low versus standard dialysate sodium concentration during hemodialysis for regression of left ventricular mass", we became aware of further data correlating left ventricular (LV) mass index at baseline and their corresponding mass at 12 months, using cardiac magnetic resonance imaging (MRI) in patients on hemodialysis. The original published sample size for the SoLID trial of 118 was a conservative estimate, calculated using analysis of covariance and a within person Pearson's correlation for LV mass index of 0.75. New data communicated to the SoLID trial group has resulted in re-calcuation of the sample size, based upon a within person Pearson's correlation of 0.8 but otherwise unchanged assumptions. As a result, the SoLID trial will now recruit 96 participants.

Transition to schizophrenia in acute and transient psychotic disorders.

BACKGROUND: The diagnostic category of acute and transient psychotic disorders (ATPD) was introduced in ICD-10. Subsequent studies have called into question its validity and reliability. AIMS: To determine the pattern of diagnostic revision to schizophrenia in first-ever diagnosed ATPD. METHOD: Using data drawn from the Scottish Morbidity Record, we estimated incidence and diagnostic change in first-ever diagnosed ATPD in Scottish hospitals between January 1997 and December 2010 (n = 2923). RESULTS: The average incidence of ATPD was 4.1 per 100 000 population per year. Diagnostic stability was estimated at 53.9% over an average of approximately 4 years of observation. The most common diagnostic shift was to schizophrenia (12.6%), over an average of 1.7 years. Estimates of the transition risks for schizophrenia were 80% at 2.8 years and 90% at 4.6 years. Longer first admission to hospital, younger age at onset and male gender were associated with increased risk and earlier development of schizophrenia. CONCLUSIONS: Routinely collected data suggest that approximately one in eight individuals with first-ever diagnosed ATPD will develop schizophrenia within 3-5 years. Those at high risk of transition may benefit from monitoring for possible diagnostic change.

Rationale and design of the Myocardial Microinjury and Cardiac Remodeling Extension Study in the Sodium Lowering in Dialysate trial (Mac-SoLID study).

BACKGROUND: The Sodium Lowering in Dialysate (SoLID) trial is an ongoing a multi-center, prospective, randomised, single-blind (assessor), controlled, parallel assignment clinical trial, enrolling 96 home and self-care hemodialysis (HD) patients from 7 centers in New Zealand. The trial will evaluate the hypothesis that lower dialysate [Na+] during HD results in lower left ventricular (LV) mass. Since it's inception, observational evidence has suggested increased mortality risk with lower dialysate [Na+], possibly due to exacerbation of intra-dialytic hypotension and subsequent myocardial micro-injury. The Myocardial Micro-injury and Cardiac Remodeling Extension Study in the Sodium Lowering In Dialysate Trial (Mac-SoLID study) aims to determine whether lower dialysate [Na+] results in (i) increased levels of high-sensitivity Troponin T (hsTnT), a well-established marker of intra-dialytic myocardial micro-injury in HD populations, and (ii) increased fixed LV segmental wall motion abnormalities, a marker of recurrent myocardial stunning and micro-injury, and (iii) detrimental changes in LV geometry due to maladaptive homeostatic mechanisms. METHODS/DESIGN: The SoLID trial and the Mac-SoLID study are funded by the Health Research Council of New Zealand. Key exclusion criteria: patients who dialyse > 3.5 times per week, pre-dialysis serum sodium <135 mM, and maintenance haemodiafiltration. In addition, some medical conditions, treatments or participation in other dialysis trials that contraindicate the study intervention or confound its effects, will be exclusion criteria. The intervention and control groups will receive dialysate sodium 135 mM and 140 mM respectively, for 12 months. The primary outcome measure for the Mac-SOLID study is repeated measures of [hsTnT] at 0, 3, 6, 9, and 12 months. The secondary outcomes will be assessed using cardiac magnetic resonance imaging (MRI), and comprise LV segmental wall motion abnormality scores, LV mass to volume ratio and patterns of LV remodeling at 0 and 12 months. DISCUSSION: The Mac-SoLID study enhances and complements the SoLID trial. It tests whether potential gains in cardiovascular health (reduced LV mass) which low dialysate [Na+] is expected to deliver, are counteracted by deterioration in cardiovascular health through alternative mechanisms, namely repeated LV stunning and micro-injury. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number: ACTRN12611000975998.

Teaching therapeutic seizure criteria to psychiatrists.

OBJECTIVES: Following on from our previous work looking at the interrater reliability of assessing seizure adequacy for electroconvulsive therapy (ECT), we sought to examine whether a specific teaching module could improve the reliability of visual inspection of electroencephalography (EEG) recordings for specific features of seizure length, presence of polyspike, δ wave activity, and post-ictal suppression. METHODS: Twelve medical practitioners at varying levels of training and ECT experience rated 15 EEG traces after minimal training and a further set of 15 EEG traces after a more detailed training. Results were analyzed to examine the interrater reliability of the EEG features and the overall assignment of traces as meeting "old" (1995) or "new" (2005) Royal College of Psychiatrists criteria for therapeutic seizures compared with the agreed ratings of 2 experienced ECT practitioners ("standard ratings"). RESULTS: There was evidence for a specific training effect for the "old" criteria with an improvement in the interrater reliability (generalized κ, 0.590 vs 0.813) associated with a significantly better estimation of seizure length as assessed by comparison of the root mean square difference from the standard ratings (mean, 7.83 vs 4.49; P < 0.003). The interrater reliability for the new criteria did not improve (generalized κ, 0.599 vs 0.581) but was already at quite a good standard. Examination of individual features did demonstrate improvement in the rating of δ activity (generalized κ, 0.564 vs 0.655) and post-ictal suppression (generalized κ, 0.553 vs 0.611) after the training. When these 2 criteria were grouped together (δ suppression), interrater reliability was shown to be significantly improved after the training (generalized κ, 0.568 vs 0.659). Although not statistically significant, the participants reported that the training improved their confidence in using both criteria for therapeutic seizures (old: 49% vs 67%; new: 27% vs 48%). CONCLUSIONS: The reliability of assessments of seizure length, presence of δ activity, and post-ictal suppression can be measurably improved with a specific teaching module. Using the δ suppression criteria together with the accurate estimation of seizure length on EEG may have greater clinical utility when it comes to instructing trainees in ECT administration, assessment of therapeutic seizures, and developing protocols for dose adjustment.

Greater haemodialysis exposure ('quotidian haemodialysis') has different mortality associations by patient age group.

Background: Worldwide, most people requiring kidney replacement therapy receive haemodialysis (HD) three times per week. Greater HD time and/or frequency may improve survival, but implementation requires understanding potential benefits across the range of patients. Methods: Using data from the Australia and New Zealand Dialysis and Transplant Registry, we assessed whether quotidian HD (defined as >3 sessions/week and/or >5 h/session) was associated with reduced mortality in adult patients. The primary outcome of all-cause mortality was analysed by a time-varying Cox proportional hazards model with quotidian HD as the exposure of interest. Results: Of 24 138 people who received HD between 2011 and 2019, 2632 (10.9%) received quotidian HD at some stage. These patients were younger, more likely male and more likely to receive HD at home. Overall, quotidian versus standard HD was associated with a decreased risk for all-cause mortality {crude hazard ratio [HR] 0.50 [95% confidence interval (CI) 0.45-0.56]}, but an interaction between quotidian HD and age was identified (P = .005). Stratified by age groups and splitting follow-up time where proportional hazards were violated, the corresponding HR compared with standard HD was 2.43 (95% CI 1.56-3.79) for people >75 years of age in the first year of quotidian HD, 1.52 (95% CI 0.89-2.58) for 1-3 years and 0.95 (95% CI 0.51-1.78) for ≥3 years. There was no significant survival advantage in younger people. Conclusions: Although quotidian HD conferred survival benefit in crude analyses, people ≥75 years of age had greater mortality with quotidian HD than standard HD. The mortality benefit in younger people was attenuated when adjusted for known confounders.

Rationale and design of the Sodium Lowering In Dialysate (SoLID) trial: a randomised controlled trial of low versus standard dialysate sodium concentration during hemodialysis for regression of left ventricular mass.

BACKGROUND: The current literature recognises that left ventricular hypertrophy makes a key contribution to the high rate of premature cardiovascular mortality in dialysis patients. Determining how we might intervene to ameliorate left ventricular hypertrophy in dialysis populations has become a research priority. Reducing sodium exposure through lower dialysate sodium may be a promising intervention in this regard. However there is clinical equipoise around this intervention because the benefit has not yet been demonstrated in a robust prospective clinical trial, and several observational studies have suggested sodium lowering interventions may be deleterious in some dialysis patients. METHODS/DESIGN: The Sodium Lowering in Dialysate (SoLID) study is funded by the Health Research Council of New Zealand. It is a multi-centre, prospective, randomised, single-blind (outcomes assessor), controlled parallel assignment 3-year clinical trial. The SoLID study is designed to study what impact low dialysate sodium has upon cardiovascular risk in dialysis patients. The study intends to enrol 118 home hemodialysis patients from 6 sites in New Zealand over 24 months and follow up each participant over 12 months. Key exclusion criteria are: patients who dialyse more frequently than 3.5 times per week, pre-dialysis serum sodium of <135 mM, and maintenance hemodiafiltration. In addition, some medical conditions, treatments or participation in other dialysis trials, which contraindicate the SoLID study intervention or confound its effects, will be exclusion criteria. The intervention and control groups will be dialysed using dialysate sodium 135 mM and 140 mM respectively, for 12 months. The primary outcome measure is left ventricular mass index, as measured by cardiac magnetic resonance imaging, after 12 months of intervention. Eleven or more secondary outcomes will be studied in an attempt to better understand the physiologic and clinical mechanisms by which lower dialysate sodium alters the primary end point. DISCUSSION: The SoLID study is designed to clarify the effect of low dialysate sodium upon the cardiovascular outcomes of dialysis patients. The study results will provide much needed information about the efficacy of a cost effective, economically sustainable solution to a condition which is curtailing the lives of so many dialysis patients. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number: ACTRN12611000975998.

Interrater reliability of 2 definitions of seizure adequacy in electroconvulsive therapy.

OBJECTIVES: Clear evidence of a generalized seizure is regarded as an essential component of a therapeutic electroconvulsive therapy (ECT) session. Recent criteria, in particular, the Royal College of Psychiatry ECT Handbook (2005), suggest that the pattern of electroencephalographic (EEG) seizure is more important than the duration of the seizure when assessing seizure adequacy. We examined the reliability of using EEG criteria compared to simple measures of seizure duration by reviewing 100 sample EEG printouts obtained during ECT sessions in a Scottish hospital ECT unit. METHODS: The EEGs were independently assessed by 3 clinicians (a "control" ECT consultant, an experienced ECT therapist, and a less experienced trainee) blind to each other's ratings. RESULTS: While there was good interrater reliability for measures of seizure duration, kappa scores for EEG criteria were much better for the more than the less experienced rater (κ = 0.68 vs 0.50). Even greater differences were seen for individual components: polyspike activity (κ = 0.80 vs 0.55), spike and wave complexes (κ = 0.80 vs 0.38), and postictal suppression (κ = 0.63 vs 0.35). CONCLUSIONS: The implications of these finding are briefly discussed in the context of developing rational criteria for assessing ECT efficacy that rely upon the consistent and replicable delivery of standardized ECT techniques and consequent training needs of ECT practitioners.