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Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine "booster" doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.

Many nursing home design models can have a negative impact on older people and these flaws have been compounded by Coronavirus Disease 2019 and related infection control failures. This article proposes that there is now an urgent need to examine these architectural design models and provide alternative and holistic models that balance infection control and quality of life at multiple spatial scales in existing and proposed settings. Moreover, this article argues that there is a convergence on many fronts between these issues and that certain design models and approaches that improve quality of life, will also benefit infection control, support greater resilience, and in turn improve overall pandemic preparedness.

Introduction Von Willebrand factor propeptide (VWF:Ag II) is proposed to be a more sensitive marker of acute endothelial activation than von Willebrand factor antigen (VWF:Ag). Simultaneous data on VWF:Ag and VWF:Ag II profiles are very limited following TIA and ischaemic stroke. Methods In this prospective, observational, case-control study, plasma VWF:Ag and VWF:Ag II levels were quantified in 164 patients ≤ 4 weeks of TIA or ischaemic stroke (baseline), and then ≥ 14 days (14d) and ≥ 90 days (90d) later, and compared with those from 27 healthy controls. TIA and stroke subtyping was performed according to the TOAST classification. The relationship between VWF:Ag and VWF:Ag II levels and platelet activation status was assessed. Results ‘Unadjusted’ VWF:Ag and VWF:Ag II levels were higher in patients at baseline, 14d and 90d than in controls (p ≤ 0.03). VWF:Ag levels remained higher in patients than controls at baseline (p ≤ 0.03), but not at 14d or 90d after controlling for differences in age or hypertension, and were higher in patients at baseline and 90d after controlling for smoking status (p ≤ 0.04). ‘Adjusted’ VWF:Ag II levels were not higher in patients than controls after controlling for age, hypertension or smoking (p ≥ 0.1). Patients with symptomatic carotid stenosis (N = 46) had higher VWF:Ag and VWF:Ag II levels than controls at all time-points (p ≤ 0.002). There was no significant correlation between platelet activation status and VWF:Ag or VWF:Ag II levels. Conclusions VWF:Ag and VWF:Ag II levels are increased in an overall TIA and ischaemic stroke population, especially in patients with recently symptomatic carotid stenosis. VWF:Ag II was not superior to VWF:Ag at detecting acute endothelial activation in this cohort and might reflect timing of blood sampling in our study.

Background Motorcyclists are vulnerable road users and are over represented in road fatality and injury statistics. We aimed to explore the trend of ageing motorcyclists, factors in older motorcyclist collisions and injury severity and fatality rates in older motorcyclists. Methods We performed a literature review of the subject using TRID , Cochrane Injuries , Medline and CINAHL . Results Internationally, there has been a disproportionate rise in injuries and fatalities involving older motorcyclists. Older motorcyclists are more likely to be admitted to hospital, have more severe injuries, require intensive care, have a longer length of stay and suffer more complications. Head and thoracic injuries are more common and injuries at all sites are more severe in older adults. Comorbidities and reduced physiologic reserve predispose older motorcyclists to higher mortality and more severe injuries. Older motorcyclists are more likely to ride motorcycles with larger capacity engines. They are more likely to crash on higher speed roadways and in rural areas. An increasing proportion of older motorcyclists are returning riders whose riding skill has likely depreciated over time but are riding on powerful machines. Conclusions Motorcyclists are getting older. The nature of motorcycling is changing and for many, especially older riders, it is primarily a leisure pursuit. In general, older motorcyclists are safer riders but in recent years, there has been an inordinate rise in fatalities and injuries affecting older motorcyclists. Training and safety initiatives for older motorcyclists and returning riders may be effective in reducing injuries and fatalities.

The development of a traffic system that is age-attuned needs to take account of both mobility and safety issues, in particular in terms of interventions which lead to a change in the relative proportion of modes of transport utilized, as has been postulated for the impact of medical screening of older drivers. Statistics for travel-related injury have been dominated by impacts between motorized vehicles and either other motorized vehicles or unprotected road users to the point of neglecting other significant forms of traffic-related injury. This review of research in two emerging areas of concern – non-collision injuries in public transport and single pedestrian accidents – confirms that both of these causes of death and injury in traffic require further research and monitoring in traffic injury prevention. Although the research base is slender, the data is consistently suggestive of significant need for both concern and further research, and to ensure that the factors underlying these accidents are addressed so as to enhance preserved safe mobility for older Europeans.

Background While medical conditions have been recognised as a minor contributing factor to road traffic crashes, clinicians and driver licencing agencies need mechanisms for promoting safe mobility for those with age-related illnesses which can impact on driving safety. Restrictive licensing has been proposed as a possible intervention for decreasing the risk of crashes associated with medical crashes, whilst not unduly affecting patient mobility. Objective To analyse how the term “restrictive licensing” is defined in the literature, and to determine the effectiveness of this mechanism in improving driver safety. Design A systematic literature review. Methods A search of the Medline and TRID databases. Results Restrictive licensing is most commonly defined as a geographical, time of day or speed restriction placed on the driver. Personal and vehicle modifications are considered by some to also be a form of restrictive licensing. Existing studies are supportive of the efficacy of restrictive licensing programs, with reduced crash rates for drivers carrying restricted licences compared to controls. Conclusion Restrictive licensing has been shown to be an effective mechanism of increasing driver safety without unduly impacting driver mobility. It has significant potential to have a positive impact on the ability of those with medical conditions to drive safely. Further research is needed to determine the optimum format and policies for advising driver restrictions for age-related disease and disability.

Background In Ireland, assessing medical fitness to drive (MFTD) is performed by general practitioners (GPs) despite not receiving training in traffic medicine. Aim To investigate current attitudes, resources and practices of GPs towards evaluating MFTD prior to the publication of comprehensive national guidelines. Design and setting Qualitative study of GPs registered with the Irish College of General Practitioners. Method We mailed a questionnaire-survey to GPs ( n= 1000) in November 2012. Results The response rate was 52%. A majority of GPs were confident (58%) or very confident (11%) in assessing MFTD. However, they were evenly divided as to whether GPs or practitioners specially trained for assessing MFTD should be primarily responsible (48%, 51%, respectively). Many (71%) expressed concern regarding the liability of such assessments. A significant minority reported pressure from patients and/or their families to reconsider decisions on MFTD. When seeking guidance for assessing MFTD, the majority were found to either use existing rudimentary Irish guidelines or refer to a consultant opinion (69%, 66%, respectively). Conclusion Although Irish GPs report high levels of confidence in assessing MFTD, as a group they express ambivalence about who should be primarily responsible for such assessments. This would indicate that some would consider deferring to a consultant opinion or at least recognize limitations of their skill set in this area. Further exploration is needed to determine which aspects of MFTD should be included in information and training for GPs, and to help address concerns regarding liability and patient/family communication issues.

Objectives The Beers (2012) criteria and the screening tool of older persons' potentially inappropriate prescriptions (STOPP) criteria are often used to identify potentially inappropriate medication (PIM) use in elderly patients. The aim of this study is to determine the prevalence of PIM use in nursing home residents (NHRs) aged ≥65 years presenting to the Emergency Department (ED); to compare the Beers and STOPP criteria and to identify the potential role of PIMs in ED attendances. Setting The ED of an urban tertiary referral hospital. Participants Acutely unwell long-term care NHRs seeking medical assistance at the ED. Design and Measurements This is a retrospective cohort study. Demographic and clinical data were retrieved from the ED electronic record system, from the clinical records, and transfer letters for all NHRs who attended the ED in 2011. Beers 2012 and STOPP criteria were used to identify PIMs. Results Of 195 NHRs identified, 165 were included. The mean age (±standard deviation) was 82.5 (±7.7) years; 110 (66.7%) were female and 157 (95.2%) were prescribed at least 1 PIM by either criterion. One hundred forty patients (84.8%) received a PIM according to STOPP criteria and 147 (89.1%) according to the Beers criteria. In the majority of patients (148; 89.7%), there was a difference in the medications Beers and STOPP identified as inappropriate. Fifty patients (30.3%) were considered to have a link between their attendance at ED and the PIM prescribed when assessed subjectively. Objective assessment using the WHO-UMC criteria found 7 (4.2%) had a ‘probable’ link and 45 (27.3%) a ‘possible’ link. Conclusions These results show a high rate of PIM prescribing in this cohort. The use of criteria such as Beers and STOPP may be a useful guide for physicians coordinating the long-term care of NHRs and may have the potential to reduce attendances at ED.

Background There has been an increasing interest in the arts in health care, with a suggestion that the arts and aesthetics can augment patient outcomes in stroke and other illnesses. Designing such programmes requires better knowledge of the artistic, aesthetic, and cultural pursuits of people affected by stroke. The aim of this study was to obtain the insights of this group about the profile of art and aesthetic activities in their lives and the influence of stroke on these aspects. Methods Patients attending a stroke service were administered questions adapted from the Irish Arts Council's 2006 questionnaire on participation in aesthetics and cultural pursuits. Information was also collected on stroke type and present functional and cognitive status. Thirty-eight patients were interviewed. Of these, 20 were inpatients in hospital at the time of the interview and 18 were interviewed in an outpatient setting. Results Popular activities included mainstream cinema, listening to music, dancing, attending plays or musicals, and being outdoors. Many patients ceased these activities after their stroke, mostly because of health issues and inaccessibility. Most of the patients valued the importance of the arts in the health-care setting. Conclusions This study gives a perspective for the first time on the aesthetic and cultural pursuits of stroke patients before their stroke. It portrays a wide variety of cultural and leisure activities and the cessation of these poststroke. It revealed the restrictions patients felt on gaining access to leisure pursuits both while in hospital and following discharge.

The ‘accuracy' of age, blood pressure, clinical features, duration and diabetes (ABCD 2 ) scoring by non-stroke specialists referring patients to a daily Rapid Access Stroke Prevention (RASP) service is unclear, as is the accuracy of ABCD 2 scoring by trainee residents. In this prospective study, referrals were classified as ‘confirmed TIAs' if the stroke specialist confirmed a clinical diagnosis of possible, probable or definite TIA, and ‘non-TIAs' if patients had a TIA mimic or completed stroke. ABCD 2 scores from referring physicians were compared with scores by experienced stroke specialists and neurology/geriatric medicine residents at a daily RASP clinic; inter-observer agreement was examined. Data from 101 referrals were analysed (mean age=60.0years, 58% male). The median interval between referral and clinic assessment was 1day. Of 101 referrals, 52 (52%) were ‘non-TIAs': 45 (86%) of 52 were ‘TIA mimics' and 7 (14%) of 52 were completed strokes. There was only ‘fair' agreement in total ABCD 2 scoring between referring physicians and stroke specialists ( κ =0.37). Agreement was ‘excellent' between residents and stroke specialists ( κ =0.91). Twenty of 29 patients scored as ‘moderate to high risk' (score 4–6) by stroke specialists were scored ‘low risk' (score 0–3) by referring physicians. ABCD 2 scoring by referring doctors is frequently inaccurate, with a tendency to underestimate stroke risk. These findings emphasise the importance of urgent specialist assessment of suspected TIA patients, and that ABCD 2 scores by non-stroke specialists cannot be relied upon in isolation to risk-stratify patients. Inter-observer agreement in ABCD 2 scoring was ‘excellent' between residents and stroke specialists, indicating short-term training may improve accuracy.

Summary Background Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic vs. asymptomatic carotid stenosis has not been comprehensively assessed. Setting University teaching hospitals. Methods This prospective, pilot observational study assessed platelet counts and platelet activation status, and the relationship between platelet activation and MES in asymptomatic vs. early (≤ 4 weeks after TIA/stroke) and late phase (≥ 3 months) symptomatic moderate or severe (≥ 50%) carotid stenosis patients. Full blood count measurements were performed, and whole blood flow cytometry was used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed for 1 h to classify patients as MES positive or MES negative. Results Data from 31 asymptomatic patients were compared with 46 symptomatic patients in the early phase, and 35 of these patients were followed up to the late phase after symptom onset. The median platelet count (211 vs. 200 × 109 L−1; P = 0.03) and the median percentage of lymphocyte-platelet complexes was higher in early symptomatic than asymptomatic patients (2.8 vs. 2.4%; P = 0.001). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic patients with ≥ 70% carotid stenosis (P = 0.0005) and symptomatic patients recruited within 7 days of symptom onset (P = 0.028). Complete TCD data were available in 25 asymptomatic, 31 early phase symptomatic and 27 late phase symptomatic patients. Twelve per cent of asymptomatic vs. 32% of early phase symptomatic (P = 0.02) and 19% of late phase symptomatic patients (P = 0.2) were MES positive. Early symptomatic MES-negative patients had a higher percentage of lymphocyte-platelet complexes than asymptomatic MES-negative patients (2.8 vs. 2.3%; P = 0.0085). Discussion Recently, symptomatic carotid stenosis patients have had higher platelet counts (potentially reflecting increased platelet production, mobilization or reduced clearance) and platelet activation status than asymptomatic patients. MES were more frequently detected in early symptomatic than asymptomatic patients, but the differences between late symptomatic and asymptomatic groups were not significant. Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis patients.

Quality of geriatric care depends on institutional resources e.g. hospitals, medical departments engaged in acute medicine, rehabilitation and long term care but especially in quality and quantity of well educated and trained specialists, i.e. “geriatricians”. This survey initiated by the Academic Board of the European Union Geriatric Medicine Society (EUGMS) aimed to give an European overview by mapping the current situation in number and geographical distribution of geriatricians in relation to national demographic data. The discussion focuses on special national aspects including information about the national training tenure circumstances as well as political and historical influences on the geriatric care situation. The need for an European consensus concerning training curriculum is clearly stated, but also the need for fostering geriatric medicine with look on the demographic background, which is very similar in European countries. Last but not least: The survey can function as a benchmark, which every country may use in it's own medical and political environment.

Background Although geriatrics is recognised as an effective strategy in the secondary care of older people, adoption of the specialty has been variable in the developed world. Information is needed on factors that affect recruitment and retention of geriatricians. Method Based on postal questionnaire survey undertaken in 2001, a largely identical survey was undertaken among all Finnish geriatricians (167 in active practice in 2008) in 2008. Items included work position, work satisfaction, and general views about delivery of care for older people. Results A total of 112 physicians returned the 2008 questionnaire (60% of active specialists). The varied working profile and views about geriatricians' status were largely similar to those in 2001. Half of all responders were employed by municipalities in primary care, 19% were employed by secondary or tertiary hospitals. The most important clinical settings for geriatricians were considered to be in memory clinics, rehabilitation and acute care. Most geriatricians ( n =84, [75%]) considered either general practitioners (GP), or GPs with specific training in geriatrics to be the best option for the management of common problems of older patients in the community. In general, geriatricians were optimistic about their work and possibilities to influence, even more so than in 2001. The biggest challenge was perceived to increase and distribute geriatric medicine knowledge and skills in health care for older people. Discussion Finnish geriatricians believe that geriatrics is a rewarding speciality. However, the incorporation of the principles and practice of geriatrics across other is viewed as a major challenge.

As a result of a significant amount of research in the last two decades, geriatricians have now a much clearer view of the assessment of driving and transport for those with dementia. The most radical underlying conceptual shifts have been: (a) a better balance between the important goals of mobility and safety, and (b) an awareness of the limitation of cognitive approaches to driving ability, and of the need to develop better approaches based on function and behaviour. Building on Comprehensive Geriatric Assessment, useful information can be determined by the multidisciplinary team, but the availability of on-road testing is critical to appropriate assessment of driving in those with dementia. The development of both present and future planning of driving and transport should be viewed as a collaborative process with patients and their families.

Background: Venous thromboembolism (VTE) is a well recognised and preventable complication of acute stroke. While graduated compression stockings reduce the risk of VTE in surgical patients their benefit in acute stroke remains uncertain. Methods: The relationship between symptomatic VTE and use of stockings using observational data from the ‘Tinzaparin in Acute Ischaemic Stroke Trial’, which compared 10 days of treatment with tinzaparin (175 IU.kg-1 or 100 IU.kg-1) with, aspirin (300 mg od), was assessed using logistic regression adjusted for known VTE risk factors and treatment. Results: Symptomatic VTE occurred in 28 patients (1.9%, DVT 18, PE 13) within 15 days of enrolment in 1,479 patients. Patients wearing one or two stockings for any period of time during the first 10 days (n=803) had a non-significant increase (odds ratio, OR 2.45, 95% confidence interval, CI 0.95 - 6.32) in the risk of symptomatic VTE. In contrast, those wearing bilateral stockings for 10 days (n=374) had a non-significant reduction in the odds of symptomatic VTE as compared to those who wore no stockings or wore them for less than 10 days (OR 0.65, 95% CI 0.26-1.65). Mild stroke and treatment with tinzaparin were associated with a reduced risk of VTE. Conclusions: Bilateral graduated compression stockings may reduce the incidence of VTE by one-third in patients with acute ischaemic stroke. However, the uncertainty in this finding, low frequency of symptomatic VTE, potential for stockings to cause harm, and cost of stockings highlight the need for a large randomised-controlled trial to examine the safety and efficacy of stockings in acute stroke.

The author presents his personal experiences of practising ergonomics in industrially developing countries (IDCs), particularly in the rural sector and within the remit of Development Aid Programmes. Some key differences between IDCs and industrially advanced countries (IACs) are outlined and their relevance to ergonomics indicated. Examples of both indigenously and exogenously generated ergonomics research and development projects in IDCs are given. Analysis of these projects indicates a considerable overlap between ergonomics and occupational health and the issues this raises are discussed. Ignorance of the comprehensive nature of ergonomics, and the benefits it can deliver, have adversely affected the progress and outputs of projects aimed at improving human health and (work) performance. It is apparent that some projects, clearly requiring an ergonomics input have not involved a qualified ergonomist in the project team. As a subject, ergonomics fits in well with the sustainable livelihood approach and is well suited to the participatory processes needed to identify appropriate interventions for the alleviation of poverty. It is concluded that ergonomics has more to offer IDCs that is currently being taken up and that ergonomists may need to become more involved with occupational health initiatives in IDCs. Relevance to Industry The contributions that ergonomics can make to the Development Aid industry, particularly in the areas of sustainable livelihoods and technology transfer are not being realised. The IAC approach to implementing ergonomics research and development projects for commercially competitive or legislative reasons may not be appropriate to IDCs. A closer involvement by ergonomists in occupational health care services, even where this is the responsibility of primary health care providers, might be more appropriate.

Objective Nursing home inhabitants represent the most vulnerable and frail group of older people. They have more complex medical backgrounds and more significant care requirements. With an ever-ageing European population, the number of people requiring nursing home care will only increase. It is important then that we optimise the medical care of older people living in nursing homes. Methods Formalized care standards are essential to optimal care but we feel that such guidelines are lacking. We decided to investigate this by means of a survey on nursing home care standards sent to the geriatric medicine societies around Europe. Results Only five of 25 (20%) health services have a requirement for specific training in geriatric medicine for doctors in nursing homes, while only three of 25 (12%) countries have written medical care standards applicable to nursing home care provided by professional organizations. Four of 25 (16%) had a nursing home doctor society and one of these, The Netherlands, provided written medical care standards for nursing homes which were also adopted by the relevant general practitioner society. Discussion The Europe-wide deficiency of documented care standards for nursing homes is alarming. It should be a prerequisite that physicians dealing with these complex patients have undertaken some level of specific training in geriatric medicine. It is important that geriatricians, old age psychiatrists and family doctors across European countries engage more formally on the development of appropriate models for both developing care standards and specifying appropriate training and support for doctors working in nursing homes.

It is clearly important that clinicians have appropriate assessment and management pathways when working in clinical settings where illnesses associated with cognitive impairment may impair both mobility and safety, such as memory clinics and medical services dealing with older people. However, in wider terms, particularly in terms of an understanding of the impact of cognitive function on the whole population of older drivers, it is critical that debate on cognitive function and driving is adequately informed by the sciences of gerontology and public health, embraces a broad definition of cognitive function which recognizes both the gains and losses of ageing, recognizes the barriers and disruptive influences which may skew scientific debate, and frames such a discourse in terms of an appropriate balance between mobility and safety.

Patients with underlying swallow deficits frequently present to the emergency department with symptoms of pneumonia. We review how these patients are assessed and managed in Irish hospitals.

Based on Finnish survey data, older (65+, n =1559) and younger (26–40, n =310) drivers’ accident rates were compared. In accordance with earlier studies, the rates were similar per driver (0.1) but there was a non-significant trend towards older drivers having more accidents per distance driven (10.8 vs. 8.3 per 1 million km). However, when the accidents-per-km comparison was made in groups matched for yearly exposure, there is no evidence for higher risk with increasing age. In both age groups, risk per km decreased with increasing yearly driving distance. We suggest that the previous perception of an age-related risk increase of accidents per distance driven arises from a failure to control for low mileage bias at all ages.

Objective To determine whether patients presenting to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD) are more likely than controls to suffer from oropharyngeal swallow disorder. Design Prospective case-controlled survey. Setting Departments of general and geriatric medicine in a university teaching hospital. Participants Forty-one consecutive admissions with a primary diagnosis of acute exacerbation of COPD were compared with 41 emergency medical admissions with primary diagnoses other than COPD or neurological disease. Measures A swallow screening test and structured neurological examination. Patients who tested positive on the swallow test were referred for formal Speech and Language therapy assessment with videofluroscopic examination if clinically indicated. Results Of 41 patients with COPD, 23 (56%) had a positive swallow test, compared to 12 of 41 controls (29%, P Conclusion A significant proportion of patients who are hospitalized with an exacerbation of chronic obstructive airways disease have coexisting oropharyngeal swallow disorder. Oropharyngeal swallow disorder may contribute to or exacerbate their illness. The majority of this sub-group may recover a functional swallow with compensatory strategies. Oropharyngeal swallow disorder may represent a possible remediable factor in the management of some patients with chronic obstructive airways disease.

Summary Background Low-molecular-weight heparins and heparinoids are superior to unfractionated heparin in the prevention and treatment of venous thromboembolism, but their safety and efficacy in acute ischaemic stroke are inadequately defined. Methods This randomised, double-blind, aspirin-controlled trial tested the safety and efficacy of treatment with highdose tinzaparin (175 anti-Xa IU/kg daily; 487 patients), medium-dose tinzaparin (100 anti-Xa IU/kg daily; 508 patients), or aspirin (300 mg daily; 491 patients) started within 48 h of acute ischaemic stroke and given for up to 10 days. Primary intracerebral haemorrhage was excluded by computed tomography. Outcome was assessed, with treatment allocation concealed, by the modified Rankin scale at 6 months (independence [scores 0–2] vs dependence or death [scores 3–6]). Findings Of 1486 randomised patients, two did not receive treatment and 46 were lost to follow-up. The proportions independent at 6 months were similar in the groups assigned high-dose tinzaparin (194/468 [41·5%]), mediumdose tinzaparin (206/486 [42·4%]), or aspirin (205/482 [42·5%]). There was no difference in effect in any predefined subgroup, including patients with presumed cardioembolic stroke. Other outcome measures were similar between the treatment groups (disability, casefatality, and neurological deterioration rates). During the inhospital treatment period no patient assigned high-dose tinzaparin developed a symptomatic deep-vein thrombosis compared with nine assigned aspirin. Conversely, seven patients assigned high-dose tinzaparin developed symptomatic intracerebral haemorrhage compared with one in the aspirin group. Interpretation Treatment with tinzaparin, at high or medium dose, within 48 h of acute ischaemic stroke did not improve functional outcome compared with aspirin. Although high-dose tinzaparin was superior in preventing deep-vein thrombosis, it was associated with a higher rate of symptomatic intracranial haemorrhage.

Background Services for stroke are poorly developed in Europe, and research into stroke is underfunded compared with heart disease or cancer. This may arise from the low profile of stroke within the public domain. Our aim was to assess the coverage of stroke compared with heart disease in a popular form of mass media, newspapers in the United Kingdom and Ireland. Methods We searched the online databases of 4 major newspapers in the United Kingdom and Ireland using the terms "stroke" and "heart" during a 1-year period from May 1, 2006, to May 1, 2007. The resulting articles were then classified by two clinicians and those relating to the clinical conditions of stroke and heart disease were selected. Results The searches were refined by hand and those articles relating to stroke were: 105 in the Irish Times , 223 in the Daily Telegraph , 22 in The Observer , and 149 in The Guardian . The number of articles relating to heart disease was: 443 in the Irish Times , 653 in the Daily Telegraph , 81 in The Observer , and 688 in The Guardian . Conclusions Newspaper coverage of stroke is underreported when compared with heart disease, despite the clinical and financial burden of this condition. Professional and advocacy organizations for those with stroke need to develop strategies to increase the profile of stroke in the public domain.

We report an outbreak of Clostridium difficile -associated disease (CDAD) in a large Dublin hospital. From January to June 1995, inclusive, 139 patients were affected; the mean age of cases was 68·8 ± 19 years. Clinical information is available for 73 cases identified during the first four months of the outbreak. The majority of patients presented with abrupt onset of watery diarrhoea; however, 19·2% presented with an unexplained pyrexia following a course of antimicrobial therapy and 5·5% presented with a surgical acute abdomen. Twenty patients (27·4%) experienced relapsing disease and seven (9·6%) patients died. Seventy-six percent of cases received a cephalosporin prior to the onset of disease, the highest relative risks occurring with third-generation agents; however, 9·6% of patients affected had not been exposed to antimicrobial therapy in the preceding eight weeks. Pyrolysis mass spectrometry identified two clusters of isolates, representing two strains of C. difficile . There was marked spatial clustering of these strains, with each confined to a separate area of the hospital. Infection control measures and an antibiotic policy were introduced. Throughout the outbreak period the use of the most frequently used cephalosporin in the hospital increased; this was accompanied paradoxically by a reduction in the number of new cases of CDAD.

The first recorded automobile fatality occurred in a small town in the Irish Midlands in 1869. Mary Ward, a celebrated microscopist, artist, astronomer and naturalist, fell from a steam carriage and died after crush injuries from its heavy iron wheels. The story of first automobile fatality characterizes the individual tragedy that is each premature death. It also illuminates the story of a remarkable Victorian scientific family. Among their many achievements was the building of a reflector telescope in the heart of rural Ireland that was the largest in the world for 74 years.

Crawford Long, Horace Wells and William Morton (Williams, 1954) could not have foretold that the elderly would become such major users of surgical and anaesthetic services. Not only will the number and proportion of elderly in society increase at an unprecedented rate, but their need for surgical intervention will grow. A cautious estimate, based on data from 1982, suggests that patients over the age of 65 require 190 surgical procedures yearly per 100 000 population, compared with 136 operations per 100 000 population for the 45-64 age-group (US Department of Health and Human Services, 1985). At least one half of these older people will require surgery at some time in their remaining life-time (Stoelting et al, 1988). With the revision of previous age-related barriers to surgical intervention and their replacement with an emphasis on physical fitness, this imbalance between age-groups will certainly grow. This change in practice is in part encouraged by, and accompanied by, a fall in mortality rates for elective procedures in the elderly (Schrader et al, 1991) to a reported low of 0.7% within 48 h of elective surgery for those older than 90 (Hosking et al, 1989). There has also been an understanding that earlier fears that general anaesthesia was a risk factor for dementia, which led Bedford to recommend in 1955 that operations in the elderly should be confined to 'unequivocally necessary cases' (Bedford, 1955), have been shown to be unfounded (Haan et al, 1991). Every general anaesthetist has become a 'gero-anaesthetist' to a certain extent, and an understanding of the social, biological and psychological changes of ageing and age-related diseases forms the basis of a positive approach to the anaesthetic care of the older patient.

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