New insights into appetite, inflammation and the use of fish oil in hemodialysis patients

Protein-energy wasting (PEW) is commonly seen in patients with chronic kidney disease (CKD). The condition is characterised by chronic, systemic low-grade inflammation which affects nutritional status by a variety of mechanisms including reducing appetite and food intake and increasing muscle catabolism. PEW is linked with co-morbidities such as cardiovascular disease, and is associated with lower quality of life, increased hospitalisations and a 6-fold increase in risk of death1. Significant gender differences have been found in the severity and effects of several markers of PEW. There have been limited studies testing the ability of anti-inflammatory agents or nutritional interventions to reduce the effects of PEW in dialysis patients. This thesis makes a significant contribution to the understanding of PEW in dialysis patients. It advances understanding of measurement techniques for two of the key components, appetite and inflammation, and explores the effect of fish oil, an anti-inflammatory agent, on markers of PEW in dialysis patients. The first part of the thesis consists of two methodological studies conducted using baseline data. The first study aims to validate retrospective ratings of hunger, desire to eat and fullness on visual analog scales (VAS) (paper and pen and electronic) as a new method of measuring appetite in dialysis patients. The second methodological study aims to assess the ability of a variety of methods available in routine practice to detect the presence of inflammation. The second part of the thesis aims to explore the effect of 12 weeks supplementation with 2g per day of Eicosapentaenoic Acid (EPA), a longchain fatty acid found in fish oil, on markers of PEW. A combination of biomarkers and psychomarkers of appetite and inflammation are the main outcomes being explored, with nutritional status, dietary intake and quality of life included as secondary outcomes. A lead in phase of 3 months prior to baseline was used so that each person acts as their own historical control. The study also examines whether there are gender differences in response to the treatment. Being an exploratory study, an important part of the work is to test the feasibility of the intervention, thus the level of adherence and factors associated with adherence are also presented. The studies were conducted at the hemodialysis unit of the Wesley Hospital. Participants met the following criteria: adult, stage 5 CKD on hemodialysis for at least 3 months, not expected to receive a transplant or switch to another dialysis modality during the study, absence of intellectual impairment or mental illness impairing ability to follow instructions or complete the intervention. A range of intermediate, clinical and patient-centred outcome measures were collected at baseline and 12 weeks. Inflammation was measured using five biomarkers: c-reactive protein (CRP), interleukin-6 (IL6), intercellular adhesion molecule (sICAM-1), vascular cell adhesion molecule (sVCAM-1) and white cell count (WCC). Subjective appetite was measured using the first question from the Appetite and Dietary Assessment (ADAT) tool and VAS for measurements of hunger, desire to eat and fullness. A novel feature of the study was the assessment of the appetite peptides leptin, ghrelin and peptide YY as biomarkers of appetite. Nutritional status/inflammation was assessed using the Malnutrition-Inflammation Score (MIS) and the Patient-Generated Subjective Global Assessment (PG-SGA). Dietary intake was measured using 3-day records. Quality of life was measured using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF™ v1.3 © RAND University), which combines the Short-Form 36 (SF36) with a kidney-disease specific module2. A smaller range of these variables was available for analysis during the control phase (CRP, ADAT, dietary intake and nutritional status). Statistical analysis was carried out using SPSS version 14 (SPSS Inc, Chicago IL, USA). Analysis of the first part of the thesis involved descriptive and bivariate statistics, as well as Bland-Altman plots to assess agreement between methods, and sensitivity analysis/ROC curves to test the ability of methods to predict the presence of inflammation. The unadjusted (paired ttests) and adjusted (linear mixed model) change over time is presented for the main outcome variables of inflammation and appetite. Results are shown for the whole group followed by analyses according to gender and adherence to treatment. Due to the exploratory nature of the study, trends and clinical significance were considered as important as statistical significance. Twenty-eight patients (mean age 61±17y, 50% male, dialysis vintage 19.5 (4- 101) months) underwent baseline assessment. Seven out of 28 patients (25%) reported sub-optimal appetite (self-reported as fair, poor or very poor) despite all being well nourished (100% SGA A). Using the VAS, ratings of hunger, but not desire to eat or fullness, were significantly (p<0.05) associated with a range of relevant clinical variables including age (r=-0.376), comorbidities (r=-0.380) nutritional status (PG-SGA score, r=-0.451), inflammatory markers (CRP r=-0.383; sICAM-1 r=-0.387) and seven domains of quality of life. Patients expressed a preference for the paper and pen method of administering VAS. None of the tools (appetite, MIS, PG-SGA, albumin or iron) showed an acceptable ability to detect patients who are inflamed. It is recommended that CRP should be tested more frequently as a matter of course rather than seeking alternative methods of measuring inflammation. 27 patients completed the 12 week intervention. 20 patients were considered adherent based on changes in % plasma EPA, which rose from 1.3 (0.94)% to 5.2 (1.1)%, p<0.001, in this group. The major barriers to adherence were forgetting to take the tablets as well as their size. At 12 weeks, inflammatory markers remained steady apart from the white cell count which decreased (7.6(2.5) vs 7.0(2.2) x109/L, p=0.058) and sVCAM-1 which increased (1685(654) vs 2249(925) ng/mL, p=0.001). Subjective appetite using VAS increased (51mm to 57mm, +12%) and there was a trend towards reduction in peptide YY (660(31) vs 600(30) pg/mL, p=0.078). There were some gender differences apparent, with the following adjusted change between baseline and week 12: CRP (males -3% vs females +17%, p=0.19), IL6 (males +17% vs females +48%, p=0.77), sICAM-1 (males -5% vs females +11%, p=0.07), sVCAM-1 (males +54% vs females +19%, p=0.08) and hunger ratings (males 20% vs females -5%, p=0.18). On balance, males experienced a maintainence or reduction in three inflammatory markers and an improvement in hunger ratings, and therefore appeared to have responded better to the intervention. Compared to those who didn’t adhere, adherent patients maintained weight (mean(SE) change: +0.5(1.6) vs - 0.8(1.2) kg, p=0.052) and fat-free mass (-0.1 (1.6) vs -1.8 (1.8) kg, p=0.045). There was no difference in change between the intervention and control phase for CRP, appetite, nutritional status or dietary intake. The thesis makes a significant contribution to the evidence base for understanding of PEW in dialysis patients. It has advanced knowledge of methods of assessing inflammation and appetite. Retrospective ratings of hunger on a VAS appear to be a valid method of assessing appetite although samples which include patients with very poor appetite are required to confirm this. Supplementation with fish oil appeared to improve subjective appetite and dampen the inflammatory response. The effectiveness of the intervention is influenced by gender and adherence. Males appear to be more responsive to the primary outcome variables than females, and the quality of response is improved with better adherence. These results provide evidence to support future interventions aimed at reducing the effects of PEW in dialysis patients.

Development of a particle number and particle mass emissions inventory for an urban fleet : a study in South-East Queensland

Motor vehicles are a major source of gaseous and particulate matter pollution in urban areas, particularly of ultrafine sized particles (diameters < 0.1 µm). Exposure to particulate matter has been found to be associated with serious health effects, including respiratory and cardiovascular disease, and mortality. Particle emissions generated by motor vehicles span a very broad size range (from around 0.003-10 µm) and are measured as different subsets of particle mass concentrations or particle number count. However, there exist scientific challenges in analysing and interpreting the large data sets on motor vehicle emission factors, and no understanding is available of the application of different particle metrics as a basis for air quality regulation. To date a comprehensive inventory covering the broad size range of particles emitted by motor vehicles, and which includes particle number, does not exist anywhere in the world. This thesis covers research related to four important and interrelated aspects pertaining to particulate matter generated by motor vehicle fleets. These include the derivation of suitable particle emission factors for use in transport modelling and health impact assessments; quantification of motor vehicle particle emission inventories; investigation of the particle characteristic modality within particle size distributions as a potential for developing air quality regulation; and review and synthesis of current knowledge on ultrafine particles as it relates to motor vehicles; and the application of these aspects to the quantification, control and management of motor vehicle particle emissions. In order to quantify emissions in terms of a comprehensive inventory, which covers the full size range of particles emitted by motor vehicle fleets, it was necessary to derive a suitable set of particle emission factors for different vehicle and road type combinations for particle number, particle volume, PM1, PM2.5 and PM1 (mass concentration of particles with aerodynamic diameters < 1 µm, < 2.5 µm and < 10 µm respectively). The very large data set of emission factors analysed in this study were sourced from measurement studies conducted in developed countries, and hence the derived set of emission factors are suitable for preparing inventories in other urban regions of the developed world. These emission factors are particularly useful for regions with a lack of measurement data to derive emission factors, or where experimental data are available but are of insufficient scope. The comprehensive particle emissions inventory presented in this thesis is the first published inventory of tailpipe particle emissions prepared for a motor vehicle fleet, and included the quantification of particle emissions covering the full size range of particles emitted by vehicles, based on measurement data. The inventory quantified particle emissions measured in terms of particle number and different particle mass size fractions. It was developed for the urban South-East Queensland fleet in Australia, and included testing the particle emission implications of future scenarios for different passenger and freight travel demand. The thesis also presents evidence of the usefulness of examining modality within particle size distributions as a basis for developing air quality regulations; and finds evidence to support the relevance of introducing a new PM1 mass ambient air quality standard for the majority of environments worldwide. The study found that a combination of PM1 and PM10 standards are likely to be a more discerning and suitable set of ambient air quality standards for controlling particles emitted from combustion and mechanically-generated sources, such as motor vehicles, than the current mass standards of PM2.5 and PM10. The study also reviewed and synthesized existing knowledge on ultrafine particles, with a specific focus on those originating from motor vehicles. It found that motor vehicles are significant contributors to both air pollution and ultrafine particles in urban areas, and that a standardized measurement procedure is not currently available for ultrafine particles. The review found discrepancies exist between outcomes of instrumentation used to measure ultrafine particles; that few data is available on ultrafine particle chemistry and composition, long term monitoring; characterization of their spatial and temporal distribution in urban areas; and that no inventories for particle number are available for motor vehicle fleets. This knowledge is critical for epidemiological studies and exposure-response assessment. Conclusions from this review included the recommendation that ultrafine particles in populated urban areas be considered a likely target for future air quality regulation based on particle number, due to their potential impacts on the environment. The research in this PhD thesis successfully integrated the elements needed to quantify and manage motor vehicle fleet emissions, and its novelty relates to the combining of expertise from two distinctly separate disciplines - from aerosol science and transport modelling. The new knowledge and concepts developed in this PhD research provide never before available data and methods which can be used to develop comprehensive, size-resolved inventories of motor vehicle particle emissions, and air quality regulations to control particle emissions to protect the health and well-being of current and future generations.

Facial feature detection for in-car environment

Acoustically, vehicles are extremely noisy environments and as a consequence audio-only in-car voice recognition systems perform very poorly. Seeing that the visual modality is immune to acoustic noise, using the visual lip information from the driver is seen as a viable strategy in circumventing this problem. However, implementing such an approach requires a system being able to accurately locate and track the driver’s face and facial features in real-time. In this paper we present such an approach using the Viola-Jones algorithm. Using this system, we present our results which show that using the Viola-Jones approach is a suitable method of locating and tracking the driver’s lips despite the visual variability of illumination and head pose.

Multi-sensor tracking using a scalable condensation filter

Surveillance and tracking systems typically use a single colour modality for their input. These systems work well in controlled conditions but often fail with low lighting, shadowing, smoke, dust, unstable backgrounds or when the foreground object is of similar colouring to the background. With advances in technology and manufacturing techniques, sensors that allow us to see into the thermal infrared spectrum are becoming more affordable. By using modalities from both the visible and thermal infrared spectra, we are able to obtain more information from a scene and overcome the problems associated with using visible light only for surveillance and tracking. Thermal images are not affected by lighting or shadowing and are not overtly affected by smoke, dust or unstable backgrounds. We propose and evaluate three approaches for fusing visual and thermal images for person tracking. We also propose a modified condensation filter to track and aid in the fusion of the modalities. We compare the proposed fusion schemes with using the visual and thermal domains on their own, and demonstrate that significant improvements can be achieved by using multiple modalities.

Multi-spectral fusion for surveillance systems

Surveillance systems such as object tracking and abandoned object detection systems typically rely on a single modality of colour video for their input. These systems work well in controlled conditions but often fail when low lighting, shadowing, smoke, dust or unstable backgrounds are present, or when the objects of interest are a similar colour to the background. Thermal images are not affected by lighting changes or shadowing, and are not overtly affected by smoke, dust or unstable backgrounds. However, thermal images lack colour information which makes distinguishing between different people or objects of interest within the same scene difficult. ----- By using modalities from both the visible and thermal infrared spectra, we are able to obtain more information from a scene and overcome the problems associated with using either modality individually. We evaluate four approaches for fusing visual and thermal images for use in a person tracking system (two early fusion methods, one mid fusion and one late fusion method), in order to determine the most appropriate method for fusing multiple modalities. We also evaluate two of these approaches for use in abandoned object detection, and propose an abandoned object detection routine that utilises multiple modalities. To aid in the tracking and fusion of the modalities we propose a modified condensation filter that can dynamically change the particle count and features used according to the needs of the system. ----- We compare tracking and abandoned object detection performance for the proposed fusion schemes and the visual and thermal domains on their own. Testing is conducted using the OTCBVS database to evaluate object tracking, and data captured in-house to evaluate the abandoned object detection. Our results show that significant improvement can be achieved, and that a middle fusion scheme is most effective.

Lip detection for audio-visual speech recognition in-car environment

Acoustically, car cabins are extremely noisy and as a consequence audio-only, in-car voice recognition systems perform poorly. As the visual modality is immune to acoustic noise, using the visual lip information from the driver is seen as a viable strategy in circumventing this problem by using audio visual automatic speech recognition (AVASR). However, implementing AVASR requires a system being able to accurately locate and track the drivers face and lip area in real-time. In this paper we present such an approach using the Viola-Jones algorithm. Using the AVICAR [1] in-car database, we show that the Viola- Jones approach is a suitable method of locating and tracking the driver’s lips despite the visual variability of illumination and head pose for audio-visual speech recognition system.

Audio visual automatic speech recognition in vehicles

Acoustically, car cabins are extremely noisy and as a consequence, existing audio-only speech recognition systems, for voice-based control of vehicle functions such as the GPS based navigator, perform poorly. Audio-only speech recognition systems fail to make use of the visual modality of speech (eg: lip movements). As the visual modality is immune to acoustic noise, utilising this visual information in conjunction with an audio only speech recognition system has the potential to improve the accuracy of the system. The field of recognising speech using both auditory and visual inputs is known as Audio Visual Speech Recognition (AVSR). Continuous research in AVASR field has been ongoing for the past twenty-five years with notable progress being made. However, the practical deployment of AVASR systems for use in a variety of real-world applications has not yet emerged. The main reason is due to most research to date neglecting to address variabilities in the visual domain such as illumination and viewpoint in the design of the visual front-end of the AVSR system. In this paper we present an AVASR system in a real-world car environment using the AVICAR database [1], which is publicly available in-car database and we show that the use of visual speech conjunction with the audio modality is a better approach to improve the robustness and effectiveness of voice-only recognition systems in car cabin environments.

Cascading appearance-based features for visual voice activity detection

The detection of voice activity is a challenging problem, especially when the level of acoustic noise is high. Most current approaches only utilise the audio signal, making them susceptible to acoustic noise. An obvious approach to overcome this is to use the visual modality. The current state-of-the-art visual feature extraction technique is one that uses a cascade of visual features (i.e. 2D-DCT, feature mean normalisation, interstep LDA). In this paper, we investigate the effectiveness of this technique for the task of visual voice activity detection (VAD), and analyse each stage of the cascade and quantify the relative improvement in performance gained by each successive stage. The experiments were conducted on the CUAVE database and our results highlight that the dynamics of the visual modality can be used to good effect to improve visual voice activity detection performance.

Zinc supplementation at conventional doses does not improve the disturbance of taste perception in hemodialysis patients

Objective: To determine the effect of zinc supplementation on taste perception in a group of hemodialysis patients. Design and Setting: Double-blind randomized placebo-controlled study in a teaching hospital dialysis unit. Patients: Fifteen stable hemodialysis patients randomized to placebo (6 male, 2 female; median age, 67; range, 30 to 72 years) or treatment (5 male, 2 female; median age, 60; range, 31 to 76 years). Intervention: Treatment group received zinc sulfate 220 mg per day for 6 weeks, and the placebo group received an apparently identical dummy pill. Main Outcome Measures: Taste scores by visual analogue scales, normalized protein catabolic rate and plasma, whole blood and red cell zinc levels. Results: At baseline, sweet and salt tastes were identified correctly by both groups. Sour was often confused with salt. Sour solutions of different concentrations were not distinguishable. Taste scores were not different after 6 weeks for either group. There was no significant increment in zinc levels or normalized protein catabolic rate for either group. Conclusion: We found a disturbance of taste perception in hemodialysis patients, particularly for the sour modality, which was not corrected by this regimen of zinc supplementation. These results cast doubts on the conclusions of earlier studies that indicated an improvement in taste after zinc supplementation.

Multi-modal object tracking using dynamic performance metrics

Intelligent surveillance systems typically use a single visual spectrum modality for their input. These systems work well in controlled conditions, but often fail when lighting is poor, or environmental effects such as shadows, dust or smoke are present. Thermal spectrum imagery is not as susceptible to environmental effects, however thermal imaging sensors are more sensitive to noise and they are only gray scale, making distinguishing between objects difficult. Several approaches to combining the visual and thermal modalities have been proposed, however they are limited by assuming that both modalities are perfuming equally well. When one modality fails, existing approaches are unable to detect the drop in performance and disregard the under performing modality. In this paper, a novel middle fusion approach for combining visual and thermal spectrum images for object tracking is proposed. Motion and object detection is performed on each modality and the object detection results for each modality are fused base on the current performance of each modality. Modality performance is determined by comparing the number of objects tracked by the system with the number detected by each mode, with a small allowance made for objects entering and exiting the scene. The tracking performance of the proposed fusion scheme is compared with performance of the visual and thermal modes individually, and a baseline middle fusion scheme. Improvement in tracking performance using the proposed fusion approach is demonstrated. The proposed approach is also shown to be able to detect the failure of an individual modality and disregard its results, ensuring performance is not degraded in such situations.

Advice-implicative interrogatives : building 'client-centered" support in a children's helpline

Interactional research on advice giving has described advice as normative and asymmetric. In this paper we examine how these dimensions of advice are softened by counselors on a helpline for children and young people through the use of questions. Through what we term ‘‘adviceimplicative interrogatives,’’ counselors ask clients about the relevance or applicability of a possible future course of action. The allusion to this possible action by the counselor identifies it as normatively relevant, and displays the counselor’s epistemic authority in relation to dealing with a client’s problems. However, the interrogative format mitigates the normative and asymmetric dimensions typical of advice sequences by orienting to the client’s epistemic authority in relation to their own lives, and delivering advice in a way that is contingent upon the client’s accounts of their experiences, capacities, and understandings. The demonstration of the use of questions in advice sequences offers an interactional specification of the ‘‘client-centered’’ support that is characteristic of prevailing counseling practice. More specifically, it shows how the values of empowerment and child-centered practice, which underpin services such as Kids Helpline, are embodied in specific interactional devices. Detailed descriptions of this interactional practice offer fresh insights into the use of interrogatives in counseling contexts, and provide practitioners with new ways of thinking about, and discussing, their current practices.

Art in early childhood : the discourse of 'proper' teaching

This thesis is a problematisation of the teaching of art to young children. To problematise a domain of social endeavour, is, in Michel Foucault's terms, to ask how we come to believe that "something ... can and must be thought" (Foucault, 1985:7). The aim is to document what counts (i.e., what is sayable, thinkable, feelable) as proper art teaching in Queensland at this point ofhistorical time. In this sense, the thesis is a departure from more recognisable research on 'more effective' teaching, including critical studies of art teaching and early childhood teaching. It treats 'good teaching' as an effect of moral training made possible through disciplinary discourses organised around certain epistemic rules at a particular place and time. There are four key tasks accomplished within the thesis. The first is to describe an event which is not easily resolved by means of orthodox theories or explanations, either liberal-humanist or critical ones. The second is to indicate how poststructuralist understandings of the self and social practice enable fresh engagements with uneasy pedagogical moments. What follows this discussion is the documentation of an empirical investigation that was made into texts generated by early childhood teachers, artists and parents about what constitutes 'good practice' in art teaching. Twenty-two participants produced text to tell and re-tell the meaning of 'proper' art education, from different subject positions. Rather than attempting to capture 'typical' representations of art education in the early years, a pool of 'exemplary' teachers, artists and parents were chosen, using "purposeful sampling", and from this pool, three videos were filmed and later discussed by the audience of participants. The fourth aspect of the thesis involves developing a means of analysing these texts in such a way as to allow a 're-description' of the field of art teaching by attempting to foreground the epistemic rules through which such teacher-generated texts come to count as true ie, as propriety in art pedagogy. This analysis drew on Donna Haraway's (1995) understanding of 'ironic' categorisation to hold the tensions within the propositions inside the categories of analysis rather than setting these up as discursive oppositions. The analysis is therefore ironic in the sense that Richard Rorty (1989) understands the term to apply to social scientific research. Three 'ironic' categories were argued to inform the discursive construction of 'proper' art teaching. It is argued that a teacher should (a) Teach without teaching; (b) Manufacture the natural; and (c) Train for creativity. These ironic categories work to undo modernist assumptions about theory/practice gaps and finding a 'balance' between oppositional binary terms. They were produced through a discourse theoretical reading of the texts generated by the participants in the study, texts that these same individuals use as a means of discipline and self-training as they work to teach properly. In arguing the usefulness of such approaches to empirical data analysis, the thesis challenges early childhood research in arts education, in relation to its capacity to deal with ambiguity and to acknowledge contradiction in the work of teachers and in their explanations for what they do. It works as a challenge at a range of levels - at the level of theorising, of method and of analysis. In opening up thinking about normalised categories, and questioning traditional Western philosophy and the grand narratives of early childhood art pedagogy, it makes a space for re-thinking art pedagogy as "a game oftruth and error" (Foucault, 1985). In doing so, it opens up a space for thinking how art education might be otherwise.

A ‘cost-per-wear’ model based on contact lens replacement frequency

Purpose: The aim was to construct and advise on the use of a cost-per-wear model based on contact lens replacement frequency, to form an equitable basis for cost comparison. ---------- Methods: The annual cost of professional fees, contact lenses and solutions when wearing daily, two-weekly and monthly replacement contact lenses is determined in the context of the Australian market for spherical, toric and multifocal prescription types. This annual cost is divided by the number of times lenses are worn per year, resulting in a ‘cost-per-wear’. The model is presented graphically as the cost-per-wear versus the number of times lenses are worn each week for daily replacement and reusable (two-weekly and monthly replacement) lenses.---------- Results: The cost-per-wear for two-weekly and monthly replacement spherical lenses is almost identical but decreases with increasing frequency of wear. The cost-per-wear of daily replacement spherical lenses is lower than for reusable spherical lenses, when worn from one to four days per week but higher when worn six or seven days per week. The point at which the cost-per-wear is virtually the same for all three spherical lens replacement frequencies (approximately AUD$3.00) is five days of lens wear per week. A similar but upwardly displaced (higher cost) pattern is observed for toric lenses, with the cross-over point occurring between three and four days of wear per week (AUD$4.80). Multifocal lenses have the highest price, with cross-over points for daily versus two-weekly replacement lenses at between four and five days of wear per week (AUD$5.00) and for daily versus monthly replacement lenses at three days per week (AUD$5.50).---------- Conclusions: This cost-per-wear model can be used to assist practitioners and patients in making an informed decision in relation to the cost of contact lens wear as one of many considerations that must be taken into account when deciding on the most suitable lens replacement modality.

Global trends in prescribing contact lenses for extended wear

Extended wear has long been the ‘holy grail’ of contact lenses by virtue of the increased convenience and freedom of lifestyle which they accord; however, this modality enjoyed only limited market success during the last quarter of the 20th century. The introduction of silicone hydrogel materials into the market at the beginning of this century heralded the promise of successful extended wear due to the superior oxygen performance of this lens type. To assess patterns of contact lens fitting, including extended wear, over the past decade, up to 1000 survey forms were sent to contact lens fitters in Australia, Canada, Japan, the Netherlands, Norway, the UK and the USA each year between 2000 and 2009. Practitioners were asked to record data relating to the first 10 contact lens fits or refits performed after receiving the survey form. Analysis of returned forms revealed that, averaged over this period, 9% of all soft lenses prescribed were for extended wear, with national figures ranging from 2% in Japan to 17% in Norway. The trend over the past decade has been for an increase from about 5% of all soft lens fits in 2000 to a peak of between 9 and 12% between 2002 and 2007, followed by a decline to around 7% in 2009. A person receiving extended wear lenses is likely to be an older female who is being refitted with silicone hydrogel lenses for full-time wear. Although extended wear has yet again failed to fulfil the promise of being the dominant contact lens wearing modality, it is still a viable option for many people.