Peripheral cord insertion is associated with adverse pregnancy outcome only when accompanied by clinically significant placental pathology.

OBJECTIVE: To examine the relationship between umbilical cord insertion site, placental pathology and adverse pregnancy outcome in a cohort of normal and complicated pregnancies. METHODS: Sonographic measurement of the cord insertion and detailed placental pathology were performed in 309 participants. Associations between cord insertion site, placental pathology and adverse pregnancy outcome (pre-eclampsia, preterm birth, small-for-gestational age) were examined. RESULTS: A total of 93 (30%) participants were identified by pathological examination to have a peripheral cord insertion site. Only 41 of the 93 (44%) peripheral cords were detected by prenatal ultrasound. Peripherally inserted cords were associated significantly (P < 0.0001) with diagnostic placental pathology (most commonly with maternal vascular malperfusion (MVM)); of which 85% had an adverse pregnancy outcome. In cases of isolated peripheral cords, without placental pathology, the incidence of adverse outcome was not statistically different when compared to those with central cord insertion and no placental pathology (31% vs 18%; P = 0.3). A peripheral cord with an abnormal umbilical artery (UA) pulsatility index (PI) corresponded to an adverse outcome in 96% of cases compared to 29% when the UA-PI was normal. CONCLUSIONS: This study demonstrates that peripheral cord insertion is often part of the spectrum of findings of MVM disease and is associated with adverse pregnancy outcome. However, adverse outcome was uncommon when there was an isolated peripheral cord insertion and no placental pathology. Therefore, additional sonographic and biochemical features of MVM should be sought when a peripheral cord is observed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Determination of fetal heart rate short-term variation from umbilical artery Doppler waveforms.

OBJECTIVE: To evaluate the feasibility of using umbilical artery (UA) Doppler waveforms to measure fetal heart rate (FHR) short-term variation (STV) across gestation. METHODS: This was a prospective longitudinal study, conducted at two study sites, of 195 pregnancies considered low risk. Pulsed-wave Doppler of the UAs was performed at 4-weekly intervals, between 14 and 40 weeks of gestation, using a standardized imaging protocol. Up to 12 consecutive UA Doppler waveforms were analyzed using offline processing software. FHR STV was calculated using average R-R intervals extracted from the waveforms and baseline corrected for FHR. RESULTS: Baseline-corrected FHR STV increased significantly with gestational age (conditional R2 = 0.37; P < 0.0001) and was correlated inversely with FHR (conditional R2 = 0.54; P < 0.0001). The STV ranged (median (interquartile range)) from 3.5 (2.9-4.1) ms at 14-20 weeks' gestation to 6.3 (4.8-7.7) ms at 34-40 weeks' gestation. The change in heart rate STV did not differ between study sites or individual sonographers. CONCLUSIONS: UA Doppler waveforms offer a robust and feasible method to derive STV of the FHR. It should be emphasized that the UA Doppler-derived STV is not interchangeable with measurements derived with computerized cardiotocography. Accordingly, further investigations are needed to validate associations with outcome, in order to determine the value of concurrent fetal cardiovascular and heart rate evaluations that are possible with the technique described here. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study.

OBJECTIVE: To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes. METHODS: A retrospective cohort study of term neonatal outcomes before (1998-2004) and after (2005-2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed. RESULTS: There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1-45.5%, RR 0.82, 95% CI 0.7-0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76-0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95-0.96). CONCLUSIONS: Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

IFPA meeting 2015 workshop report II: mechanistic role of the placenta in fetal programming; biomarkers of placental function and complications of pregnancy.

Workshops are an integral component of the annual International Federation of Placenta Association (IFPA) meeting, allowing for networking and focused discussion related to specialized topics on the placenta. At the 2015 IFPA meeting (Brisbane, Australia) twelve themed workshops were held, three of which are summarized in this report. These workshops focused on various aspects of placental function, particularly in cases of placenta-mediated disease. Collectively, these inter-connected workshops highlighted the role of the placenta in fetal programming, the use of various biomarkers to monitor placental function across pregnancy, and the clinical impact of novel diagnostic and surveillance modalities in instances of late onset fetal growth restriction (FGR).

Posterior urethral valves: Metabolic consequences in a cohort of patients.

BACKGROUND: Despite the improvements in diagnosis and management of posterior urethral valves (PUVs), about one third of patients develop chronic kidney disease (CKD). Children with PUVs might have abnormal calcium, phosphorus, vitamin D and parathyroid hormone levels, which could affect their bone growth and overall health. OBJECTIVE: The aim was to determine the relationship between kidney function, vitamin D deficiency and secondary hyperparathyroidism in children with PUVs. PATIENTS AND METHODS: Sixty-four children with PUVs were followed for a period of 3.64 ± 2.50 years after their initial presentation and management. Their laboratory parameters were compared with 20 age-, gender- and race-matched children in a control group, including: serum calcium, phosphorus, intact parathyroid hormone (iPTH), 25-hydroxyvitamin D levels, and kidney function. RESULTS: Children with PUVs had significantly lower estimated kidney function (P = 0.006) and vitamin D levels (P < 0.001) and higher iPTH levels (P = 0.042). There were no significant between-group differences in serum calcium, phosphorus, alkaline phosphatase, sodium, potassium, and bicarbonate levels. There was a strong correlation between the degree of vitamin D deficiency and hyperparathyroidism and the degree of kidney dysfunction (r = 0.52 and -0.52, respectively) in the PUV group. On a multivariate analysis, the kidney dysfunction was the only independent predictor of vitamin D deficiency (ρ = 0.271, P < 0.001), while kidney dysfunction, serum calcium and alkaline phosphatase were independent predictors for hyperparathyroidism (ρ = 0.925, P<0.001, ρ = 0.933, P<0.001 and ρ = 0.913, P < 0.001, respectively). DISCUSSION: The prevalence of CKD in children with PUVs ranges from 30 to 60%. Patients with CKD are more likely to have vitamin D deficiency and display more-prominent hyperparathyroidism. Compared with a control group with normal kidney function, the present cohort had lower 25-hydroxyvitamin D and higher iPTH serum levels. Abnormal kidney function was a major predictor for both serum levels. In this cohort, there were no significant differences in serum calcium and phosphorus between children with PUVs and the control group, and also between those with and without CKD. On the contrary, vitamin D level decreased early in the disease and progressively declined thereafter, while iPTH was the opposite. These findings were comparable to previous studies. This study had some limitations because it was a single center cross-sectional non-randomized study. However, the findings in this study can be extrapolated to children with PUVs and CKD from other origins because the unit is considered as a referral center in the Middle East region. CONCLUSION: Abnormal kidney function, vitamin D deficiency, and secondary hyperparathyroidism are prevalent in children with PUVs. Kidney function is the main determinant of vitamin D and parathyroid hormone levels. Efforts should be directed toward managing CKD, and controlling vitamin D deficiency and hyperparathyroidism in children after ablation of PUV.

Dorsal laminectomy for treatment of cervical vertebral stenotic myelopathy in an alpaca.

CASE DESCRIPTION: An 11-year-old male breeding alpaca was evaluated for a 2-day history of lowered head carriage and lethargy. CLINICAL FINDINGS: On initial examination, the alpaca had signs of lethargy and lowered carriage of the head and neck, but no specific neurologic deficits. Medical management improved the clinical signs, but 8 months later, the alpaca developed acute, progressive general proprioceptive ataxia affecting all 4 limbs and was referred for further evaluation and treatment. Magnetic resonance imaging and CT identified disruption of the normal osseous architecture of C7 and T1. Medical management was attempted, but because of a lack of improvement, the patient underwent surgery 14 months after initial examination. TREATMENT AND OUTCOME: A dorsal laminectomy of C7 and T1 via a dorsal midline approach was performed, and the spinous processes of both vertebrae were removed prior to removal of the overlying lamina. Free dorsal expansion of the spinal cord was ensured by resection of the ligamentum flavum. Six months after surgery, the alpaca had returned to successful breeding with 7 hembra bred in the first year after surgery, producing 6 crias, and 4 crias in the second year. The patient was eventually euthanized 28 months after surgery because of neurologic deterioration but was still ambulatory at that time. CONCLUSIONS AND CLINICAL RELEVANCE: A good outcome with adequate alleviation of clinical signs and breeding soundness for > 2 years following dorsal laminectomy was achieved in this camelid patient. The surgical approach was similar to that in other species and was associated with mild postoperative morbidity. Veterinarians treating camelids should be aware of the initial clinical signs and treatment options for cervical vertebral stenotic myelopathy. In acute cases, the signs of reduced cervical mobility and pain on manipulation should prompt investigation including appropriate diagnostic imaging. Timely surgical intervention should be considered in patients that respond poorly to medical treatment to avoid irreversible spinal cord injury and optimize outcome.

Maternal vitamin D supplementation during pregnancy prevents vitamin D deficiency in the newborn: an open-label randomized controlled trial.

OBJECTIVE: To determine whether maternal vitamin D supplementation, in the vitamin D deficient mother, prevents neonatal vitamin D deficiency. DESIGN: Open-label randomized controlled trial. SETTING: Metropolitan Melbourne, Australia, tertiary hospital routine antenatal outpatient clinic. PARTICIPANTS: Seventy-eight women with singleton pregnancies with vitamin D deficiency/insufficiency (serum 25-OH Vit D < 75 nmol/l) at their first antenatal appointment at 12-16-week gestation were recruited. INTERVENTION: Participants were randomized to vitamin D supplementation (2000-4000 IU cholecalciferol) orally daily until delivery or no supplementation. MAIN OUTCOME MEASURES: The primary outcome was neonatal serum 25-OH vit D concentration at delivery. The secondary outcome was maternal serum 25-OH vit D concentration at delivery. RESULTS: Baseline mean maternal serum 25-OH vit D concentrations were similar (P = 0·9) between treatment (32 nmol/l, 95% confidence interval 26-39 nmol/l) and control groups (33 nmol/l, 95% CI 26-39 nmol/l). Umbilical cord serum 25-OH vit D concentrations at delivery were higher (P < 0·0001) in neonates of treatment group mothers (81 nmol/l, 95% CI; 70-91 nmol/l) compared with neonates of control group mothers (42 nmol/l, 95% CI; 34-50 nmol/l) with a strongly positive correlation between maternal serum 25-OH Vit D and umbilical cord serum 25-OH vit D concentrations at delivery (Spearman rank correlation coefficient 0·88; P < 0·0001). Mean maternal serum 25-OH Vit D concentrations at delivery were higher (P < 0·0001) in the treatment group (71 nmol/l, 95% CI; 62-81 nmol/l) compared with the control group (36 nmol/l, 95% CI; 29-42 nmol/l). CONCLUSION: Vitamin D supplementation of vitamin D deficient pregnant women prevents neonatal vitamin D deficiency.

Stroke physician versus stroke neurologist: can anyone thrombolyse?

BACKGROUND/AIM: The aim of this study is to compare the outcomes of thrombolysis under standard clinical settings between subjects treated by a stroke neurologist versus those treated by a non-neurologist stroke physician. METHODS: Single-centre, observational cohort study of subjects thrombolysed in a calendar year, stratified according to the physician type authorising thrombolysis. Endpoints measured include proportion of subjects with symptomatic intracranial haemorrhage, door-to-needle time, change in National Institute of Health Stroke Scale and discharge destination. RESULTS: Forty-nine subjects with a mean age 76 ± 16 years underwent thrombolysis, 21 were under the care of a stroke neurologist and 28 by a non-neurologist stroke physician. No symptomatic intracranial haemorrhages were observed. There was no difference in terms of door-to-needle time, proportion of individuals with haemorrhagic transformation, mortality or discharge destination between the two groups. CONCLUSION: Due to the single-centre, observational nature of this study, the equivalent outcomes between those thrombolysed by a stroke neurologist versus those thrombolysed by a stroke physician must be interpreted with caution pending further studies. Nevertheless, in the current setting, no signal for harm has been detected. This study is unique as it is the first to our knowledge comparing outcomes between a neurologist and non-neurologist following thrombolysis.

The efficacy of a standardised product from dried leaves of Solanum glaucophyllum as source of 1,25-dihydroxycholecalciferol for poultry.

1. Chemical characterisation of an extract of Solanum glaucophyllum (SG) leaves affirmed the predominant presence of 1,25-dihydroxycholecalciferol (1,25(OH)2D3) glycosides. The compound 1-(ß-D-glucopyranosyl)-1α,25-dihydroxycholecalciferol was isolated for the first time from a natural source. 2. Vitamin D activity of the extract was confirmed by the calcaemic properties shown in a quail eggshell bioassay. The results suggested a 1,25(OH)2D3 bioavailability of approximately 15%. 3. A broiler feeding experiment replicated in time was carried out with 6 treatments. A basic control diet containing 25 µg cholecalciferol/kg was supplemented with 2.5 and 5 µg free 1,25(OH)2D3/kg, with a product based on dried SG leaves (Panbonis) providing 10 µg of 1,25(OH)2D3-glycosides/kg, with two concentrations of an SG extract providing 8.8 and 37.8 µg of 1,25(OH)2D3-glycosides/kg. 4. Tibia breaking strength and stiffness were numerically greater in all treatment groups with free 1,25(OH)2D3 and with SG products compared to controls, though the overall treatment effects only had probabilities in the range of P = 0.07 to P = 0.1. Values for both characteristics increased progressively, with additions of synthetic 1,25(OH)2D3; values with the dried SG product were similar to those with 5 µg synthetic 1,25(OH)2D3/kg. 5. Plasma calcium was mildly elevated (P < 0.05) in treatment groups. The SG extract treatment containing 37.8 µg 1,25(OH)2D3/kg gave the highest plasma calcium concentration and lowest bodyweight, signs of marginal hypervitaminosis D. Plasma 1,25(OH)2D3 concentrations were in the normal range for all treatments. 6. Tibial dyschondroplasia occurred in only one replicate. The incidences were 31% in controls but considerably lower or zero with all other treatments. 7. Bioavailability of 1,25(OH)2D3 in the SG product seemed to be higher in broiler chickens than in Japanese quails. 8. It is concluded that the inclusion of the dried SG product as a source of vitamin D3 in broiler diets at a dietary concentration of 1 g/kg, providing 10 µg 1,25(OH)2D3/kg, is safe and efficacious.

Circulating RNA coding genes regulating apoptosis in maternal blood in severe early onset fetal growth restriction and pre-eclampsia.

OBJECTIVE: To determine whether the intrinsic apoptosis pathway is differentially expressed in placenta and maternal blood in severe preterm fetal growth restriction (FGR) and pre-eclampsia (PE), and to examine whether circulating RNA in maternal blood may be potential biomarkers. STUDY DESIGN: Maternal blood samples and placental biopsies were collected from women with preterm: FGR (n=20), PE without FGR (n=8) and controls (n=20). Real-time PCR examined the expression of genes in the intrinsic apoptosis pathway in FGR and PE, stratified according to the severity of placental insufficiency. RESULT: Severe preterm FGR, with or without PE, was associated with increased expression of BCL2, BCL-XL, BIM, BAD and Survivin in both the placenta and maternal blood (1.6 to 3.3-fold, P<0.05). In preterm PE, but not FGR, there was increased placental expression of BCL-XL and BCL2 (1.6 to 2.5-fold, P<0.05), but only BCL2 was significantly increased in the maternal blood (1.8-fold, P<0.05). Increased expression of genes of the intrinsic apoptosis pathway reflected the severity of FGR as determined by deteriorations in umbilical artery Doppler velocimetry. CONCLUSION: In severe early onset FGR there was increased expression of genes regulating intrinsic apoptosis in both the placenta and maternal blood. Circulating RNA regulating placenta apoptosis may be used to develop noninvasive novel biomarkers for FGR.

First detection of 'Candidatus Mycoplasma haemolamae' infection in alpacas in England.

This is the first report of detection of Candidatus Mycoplasma haemolamae in alpacas in England. The primary case occurred in a three year-old male alpaca in the south-east of England which presented with a history of progressive weight loss, lethargy, swelling of the scrotum and pale mucous membranes. Blood smear examination revealed a moderate, regenerative anaemia, with numerous small basophilic coccoid structures consistent with Candidatus M haemolamae. To confirm the presence of Candidatus M haemolamae, a portion of the 16S rDNA gene was amplified and analysed by denaturing gradient gel electrophoresis (DGGE). 16S rDNA gene sequencing showed a 99.8 per cent homology with Candidatus M haemolamae sequences deposited in GenBank. Subsequently, a cross-sectional study was carried out to investigate the presence of Candidatus M haemolamae infection in the alpaca herd from which the primary case was detected (n=131). Blood smear examinations and PCR with DGGE were used and compared with a species-specific PCR. The prevalence of infection when PCR positive results were combined was 29 per cent. A substantial agreement between the PCR/DGGE and the species-specific PCR was found (κ=0.86). A significant association was also found between age and infection (P=0.04) while no significant association was found with sex or origin.

Placental expression of a novel primate-specific splice variant of sFlt-1 is upregulated in pregnancies complicated by severe early onset pre-eclampsia.

sFlt-1 is increased in the placenta and serum of women with pre-eclampsia. A novel primate-specific splice variant has recently been discovered, but its expression in severe pre-eclampsia has yet to be reported. We investigated placental expression of the previously described variant, sFlt-1/sFlt-i13, and the novel variant, sFlt-e15a, in pregnancies complicated by severe early onset pre-eclampsia (n = 14) and HELLP (haemolysis, elevated liver enzymes and a low platelet count) syndrome (n = 8). There was significant upregulation of both variants in pre-eclampsia and HELLP syndrome compared with normotensive term (n = 35) and preterm controls (n = 8). We conclude that the novel primate-specific splice variant of sFlt-1 is highly expressed in both severe pre-eclampsia and HELLP.

Peroxisome proliferator-activated receptors are altered in pathologies of the human placenta: gestational diabetes mellitus, intrauterine growth restriction and preeclampsia.

BACKGROUND: Common complications of pregnancy arise in part from dysfunctional placental development, and include gestational diabetes mellitus (GDM), intrauterine growth restriction (IUGR) and preeclampsia (PE). Peroxisome proliferator-activated receptors (PPARs), and their partner retinoid X receptor a (RXRalpha), mediate trophoblast differentiation and thus may offer insight into the pathophysiology of these diseases. METHODS: Human placentae were obtained from women at term with GDM and were compared to uncomplicated term placentae. Placentae from women who delivered preterm with IUGR, PE or co-existing PE and IUGR were compared to matched controls. Quantitative RT-PCR and Western blotting were used to examine mRNA and protein expression of PPARalpha, PPARdelta, PPARgamma and RXRalpha. DNA binding activity of PPAR isoforms were measured in nuclear protein extracts. RESULTS: GDM was associated with significantly lower placental PPARgamma mRNA and protein, PPARalpha protein and RXRalpha protein expression, while PPAR DNA binding activity remained unchanged. Placentae from women with PE did not demonstrate any changes in mRNA or protein expression or PPAR DNA binding activity, while IUGR/PE placenta showed significant increases in PPARalpha protein, PPARgamma mRNA and protein and RXRalpha mRNA and protein expression. Significantly elevated protein expression of PPARalpha and RXRalpha were associated with IUGR placentae. IUGR and IUGR/PE placentae had significantly higher PPARgamma DNA binding activity compared to controls. CONCLUSIONS: The data presented herein suggest that PPARs may be involved in the pathophysiology of GDM, PE and IUGR.

A QTL for osteoporosis detected in an F2 population derived from White Leghorn chicken lines divergently selected for bone index.

Osteoporosis, resulting from progressive loss of structural bone during the period of egg-laying in hens, is associated with an increased susceptibility to bone breakage. To study the genetic basis of bone strength, an F(2) cross was produced from lines of hens that had been divergently selected for bone index from a commercial pedigreed White Leghorn population. Quantitative trait loci (QTL) affecting the bone index and component traits of the index (tibiotarsal and humeral strength and keel radiographic density) were mapped using phenotypic data from 372 F(2) individuals in 32 F(1) families. Genotypes for 136 microsatellite markers in 27 linkage groups covering approximately 80% of the genome were analysed for association with phenotypes using within-family regression analyses. There was one significant QTL on chromosome 1 for bone index and the component traits of tibiotarsal and humeral breaking strength. Additive effects for tibiotarsal breaking strength represented 34% of the trait standard deviation and 7.6% of the phenotypic variance of the trait. These QTL for bone quality in poultry are directly relevant to commercial populations.

The effect of simulated hamstring shortening on gait in normal subjects.

The purpose of this study was to determine the effect of simulated hamstring shortening on gait in normal subjects. Six normal subjects wore an adjustable brace to simulate three different hamstring lengths. Evaluation of the physiological cost index (PCI) and gait analysis revealed that simulated hamstring shortening produced adverse affects in the gait of normal subjects. Significant effects were only observed when the popliteal angle exceeded 85 degrees (p<0.001) and included increased effort of walking (PCI), decreased speed, stride and step length; decreased hip flexion and increased knee flexion in stance, increased posterior pelvic tilt, decreased pelvic obliquity and rotation and premature ankle dorsi- and plantar-flexion in stance. These results emphasise the need to consider the effects of changing the length of the hamstrings on joints other than the hip and knee when assessing patients for hamstring lengthening.

Relationships between genetic, environmental and nutritional factors influencing osteoporosis in laying hens.

1. The effects upon bone quality of feeding limestone in flour or particulate form and housing type (cage or aviary) in lines of hens divergently selected for high (H) or low (L) bone strength over 7 generations were investigated. 2. As in previous generations, highly significant phenotypic differences between lines were observed in all measured bone traits at peak egg production (25 weeks) and towards the end of production (56 weeks) in both cage and aviary systems. 3. At 25 weeks there were no significant effects on bone variables of feeding particulate limestone although a significant reduction in osteoclast number was observed at this age. By 56 weeks osteoclast numbers were further reduced in hens fed particulate limestone and beneficial effects on some bone variables were observed in this treatment group. 4. The genotypic and dietary improvements upon bone quality were independent and additive at both ages. There were very few interactive effects. 5. Hens with the freedom to move in an aviary environment during the laying period had improved bone status compared to caged siblings. Environmental and genotypic effects were additive. 6. There were no effects of line on egg production although H line hens had slightly higher egg production by 56 weeks. Egg numbers were unaffected by diet. Eggshell thickness and strength were unaffected by line but hens fed particulate limestone had thicker- and stronger-shelled eggs over the production period as a whole. 7. We conclude that; (a) genetic selection is extremely effective in improving bone strength and resistance to osteoporosis; (b) allowing hens freedom to exercise can also improve bone strength but may increase the risk of keel damage if they do not have genetically-improved bone status; (c) feeding hens a particulate form of limestone from 15 weeks onwards can also increase bone strength and eggshell quality; (d) genetics, environment and nutrition all have independent and additive effects on bone status in laying hens but the relative effectiveness of these factors is genetics > environment > nutrition.

Establishment of and first 20 months of operating an outreach geriatric clinic in a regional centre.

INTRODUCTION: Providing geriatric assessments to older people residing in rural or remote areas is a challenge due to the complexities of distance and a declining medical workforce. This study aimed to develop a feasible model of service delivery in a rural area, delivering specialised falls and memory clinics similar to those available in the metropolitan area. At the end of the first 20 months we evaluated the service in terms of patient access and the satisfaction of the local health care providers. METHODS: A meeting was held with key stakeholders to identify existing service provision in the region, and to determine which services were needed. Clinic attendance and information on services provided by the clinic were collected. Questionnaires regarding clinic performance were sent to health-care providers in the region. RESULTS: The stakeholder meeting identified communication, collaboration and continuing education as the main services required of the clinic. The clinic model included a specialist geriatrician and an extended practice nurse specialising in aged care. Between May 2003 and Dec 2004, 115 people were assessed by the extended practice nurse. Interventions relating to falls and cognition were accessed by clients. Time from referral to seeing a specialist and failure to attend rates were comparable to rates seen in the metropolitan clinics. All heath-care providers who responded to the survey found the service useful. CONCLUSION: Our clinic model is a possible mechanism for delivering ambulatory aged care services to rural and remote regions. This model of care did not improve access or shorten waiting times for attendees. Future models of specialised rural care need to explore innovative workforce strategies to improve access.