BackgroundThe incidence of chronic kidney disease (CKD) is rising and is likely to continue to do so for the foreseeable future, with the fastest growth seen among adults ≥75 years of age. Elderly patients with advanced CKD are likely to have a higher burden of comorbidity and frailty, both of which may influence their disease outcome. For these patients, treatment decisions can be complex, with the current lack of robust prognostic tools hindering the shared decision-making process. The current study aims to assess the impact of comorbidity and frailty on the outcomes of patients referred for pre-dialysis education.MethodsWe performed a single-centre study of patients (n = 283) referred for pre-dialysis education between 2010 and 2012. The Charlson Comorbidity Index (CCI) and Clinical Frailty Scale (CFS) were used to assess comorbid disease burden and frailty, respectively. Follow-up data were collected until February 2015.ResultsThe CCI and CFS scores at the time of referral to the pre-dialysis service were independent predictors of mortality. Within the study follow-up period, 76% of patients with a high CFS score at the time of pre-dialysis education had died, with 63% of these patients not commencing dialysis before death.ConclusionA relatively simple frailty scale and comorbidity score could be used to predict survival and better inform the shared decision-making process for patients with advanced kidney disease.

A lack of data on patient choices and outcomes at the time of pre-dialysis planning limits meaningful shared decision making, particularly in older frailer patients. In this large retrospective cohort study of patients aged over 70 seen by the pre-dialysis clinic (2004-2016) of a large single centre in the United Kingdom (1,216 patients), age, sex, comorbidity, poverty and frailty were used to predict choice of renal replacement therapy (RRT) over maximum conservative management (MCM). The impact of patient choice of RRT versus MCM was used to predict survival from the time of choice using multivariable Cox proportional hazards regression. Older age, female sex, greater poverty and greater frailty were associated with choosing MCM, whilst comorbidity had no significant impact on choice. At 5 years of follow up, 49% of all patients had died without receiving RRT. Over 70% of the patients choosing MCM died with better kidney function than the median level at which those starting RRT initiated treatment. Frailty and age were better predictors of survival than comorbidity and in patients with at least moderate frailty, RRT offered no survival benefit over MCM. In conclusion, analysing outcomes from the time of choice may improve shared decision making. Frailty should be routinely assessed and collected and further work may help predict which patients are unlikely to survive or progress to end stage renal disease and may not need to be burdened with making a pre-dialysis choice.

The challenge for the pre-dialysis team is to educate and involve renal patients on deciding their treatment options, which many find overwhelming. We developed an option grid that provides a summary of renal replacement therapy options. Using a ‘decision-quality measure’, we can demonstrate that patients showed a clear improvement in their knowledge of the options and a noticeable shift from being undecided to being able to make a choice. We hope that our option grid may form the basis for information that could be used more widely, across many renal units.

Sports are popular across the nation and youth sport participation is at an all-time high, yet children are quitting youth sports at an alarming rate. If this trend is going to change, several areas of concern must be addressed. The climate created on youth teams can be polarizing, having the potential for significant positive or negative developmental effects. Therefore, the authors explore achievement goals, motivational climate and personal development, and TARGET descriptions. They offer suggestions for coaches, such as creating a mastery climate or fostering a more positive environment, so this negative trend can hopefully be curbed. Creating a mastery climate presents an environment in which children feels competent and successful and could be the key important factor in their continued participation in youth sport. There is little doubt that the world is infatuated by sports. People watch them, analyze them, argue about them, spend money on them, and encourage their children to play them. Not surprisingly, youth sport is the most popular structured activity in the United States, with an estimated 45 million American children enrolled in an organized program or team in 2005 (Mahoney, Larson, Eccles, & Lord, 2005). Attention has been devoted to maximizing this access and determining effective ways to use the popularity as a tool in youth

A content analysis of the rapid email responses to a potentially controversial article published in the British Medical Journal (BMJ) on the effect of remote, retroactive intercessory prayer on a group of patients with bloodstream infection at a university hospital in Israel was performed. The content analysis revealed 12 main themes, of which the most predominant were negative and relating to methodological concerns or comments, and/or were religious in nature, often with direct reference to God. Further responses were of a satirical nature, mocking the study. It is concluded that perhaps the real strength of the paper lies not in the results of the study itself, but in the challenge to what constitutes conventional wisdom and the encouragement to readers of the BMJ to ‘Think out of the box’. Copyright © 2005 John Wiley & Sons, Ltd.