The Role of Cognitive Factors in Predicting Balance and Fall Risk in a Neuro-Rehabilitation Setting.

INTRODUCTION: There is a consistent body of evidence supporting the role of cognitive functions, particularly executive function, in the elderly and in neurological conditions which become more frequent with ageing. The aim of our study was to assess the role of different domains of cognitive functions to predict balance and fall risk in a sample of adults with various neurological conditions in a rehabilitation setting. METHODS: This was a prospective, cohort study conducted in a single centre in the UK. 114 participants consecutively admitted to a Neuro-Rehabilitation Unit were prospectively assessed for fall accidents. Baseline assessment included a measure of balance (Berg Balance Scale) and a battery of standard cognitive tests measuring executive function, speed of information processing, verbal and visual memory, visual perception and intellectual function. The outcomes of interest were the risk of becoming a faller, balance and fall rate. RESULTS: Two tests of executive function were significantly associated with fall risk, the Stroop Colour Word Test (IRR 1.01, 95% CI 1.00-1.03) and the number of errors on part B of the Trail Making Test (IRR 1.23, 95% CI 1.03-1.49). Composite scores of executive function, speed of information processing and visual memory domains resulted in 2 to 3 times increased likelihood of having better balance (OR 2.74 95% CI 1.08 to 6.94, OR 2.72 95% CI 1.16 to 6.36 and OR 2.44 95% CI 1.11 to 5.35 respectively). CONCLUSIONS: Our results show that specific subcomponents of executive functions are able to predict fall risk, while a more global cognitive dysfunction is associated with poorer balance.

Safety guideline: skin antisepsis for central neuraxial blockade.

Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade. The Working Party specifically considered the concentration of antiseptic agent to use and its method of application. The advice presented is based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents.

Curative surgical management of isolated adrenal recurrence of oesophageal adenocarcinoma.

Adrenal metastases of oesophageal adenocarcinoma are rarely detected in the clinical setting, more frequently being found as an incidental postmortem finding in the presence of widespread metastases. With improvements in the sensitivity of radiological diagnostic modalities, the incidence of adrenal tumour detection is on the rise. We report herein a particularly rare case of primary operative management by adrenalectomy for an isolated right-sided adrenal metastasis secondary to oesophageal adenocarcinoma, with a long-term survival.

Enhanced trabeculectomy in a UK district general hospital setting: is selective use of 5-fluorouracil all that is required?

To determine whether primary trabeculectomies performed in a UK district general hospital, specifically without making use of mitomycin-C augmentation but with selective use of the low potency anti-metabolite 5-fluorouracil, produce an acceptable long-term intraocular pressure (IOP)-lowering effect for an unselected patient group. Retrospective analysis of the outcomes of all the trabeculectomies (53 eyes) performed by a single surgeon in a UK district hospital with or without 5-fluorouracil enhancement. The mean follow-up period was 5.04 years. Mean IOP preoperatively was 26.4 mm Hg while postoperatively the mean was ≤14.9 at all the time periods examined. Intraoperative complications occurred in two eyes (3.8 %) including one suprachoroidal haemorrhage and one hyphema. Postoperative complications that occurred during the follow-up period included choroidal effusions in seven patients (13 %), early postoperative bleb leak in four patients (8 %) and immediate postoperative hypotony not requiring intervention in 18 patients (34 %). Five patients (9 %) developed postoperative hyphema (all <30 % anterior chamber height) and one patient (1.9 %) developed blebitis and endophthalmitis. None of our patients developed hypotony maculopathy. When trabeculectomy is performed on unselected patients attending a UK district general hospital, selective 5-fluorouracil augmentation is probably all that is required to obtain acceptable surgical outcomes.

The national pediatric epidural audit.

BACKGROUND: This paper describes a prospective audit of children receiving epidural infusion analgesia (EIA) in Great Britain and Ireland. The aim was to quantify the risks associated with this technique. METHODS: In order to obtain sufficient data on the number of pediatric epidurals performed and the incidence of unwanted events, a decision was taken, at an Annual Meeting of Great Britain and Ireland Paediatric Pain Services, to establish a national audit of EIA practice in these centers. Each site sent a monthly return of the numbers of EIA performed to the coordinating center. If an incident occurred then the referring site completed a more detailed form and the child was followed up for 1 year if possible. Incidents were graded by severity 13, serious to minor. These data were collected over the 5-year period (2001-2005). RESULTS: (i) Ninety six incidents were reported in 10 633 epidurals performed. (ii) Fifty six were associated with the insertion or maintenance of EIA; most were of low severity (1 : 189). (iii) Five incidents were graded as 1 (serious) (approximately 1 : 2000). (iv) Nine incidents were graded as 2 (approximately 1 : 1100). (v) Only one child has residual effects from a grade 1 incident 12 months after surgery (approximately 1 : 10 000). (vi) Forty incidents were also reported that were felt to be associated with the use of EIA; 33 of these incidents were the development of pressures sores. Four incidents of compartment syndrome were reported, in each of these cases the presence of EIA did not mask the condition. CONCLUSIONS: Epidural infusion analgesia in children does have risks associated with the technique. The occurrence of compartment syndrome does not appear to be masked by the presence of working EIA. As a result of this audit we can now provide parents with better information, thereby improving the process of informed consent.

Enquiry about childcare responsibility should become routine in the assessment of the older patient.

BACKGROUND: Currently elderly relatives are being asked to assist with informal childcare more frequently. This role can lead to an increase in stress and fatigue. In someone with cognitive impairment it can put both adult and child at risk. METHODS: Two hundred people attending the Carew day hospital were asked if they had supervised children in the previous 12 months. People were excluded if they had cared for children >12 years of age, had a Mini Mental State Exam (MMSE) of <10 or were resident in a nursing home. RESULTS: Thirty-two (16%, 25 female) had looked after children. Average age 79 years. Seven had a short-term memory of 0/3. Five looked after them on a daily basis, two with an MMSE <24. Five looked after them longer than a 10-h period/overnight, one with an MMSE <24. CONCLUSION: Members of the multidisciplinary team who participate in the assessment of older people need to be aware of their increasing role in childcare. As a result of our findings we propose that the time has come to include a question about childcare as part of routine assessment of the older patient.

Anaesthesia for insertion of bone-anchored hearing aids in children: a 7-year audit.

Forty-three children, aged 23 months to 14 years, received 102 anaesthetics for insertion of bone-anchored hearing aids, each lasting approximately 30-60 min. Forty of the children had a recognised syndrome involving the head and neck, including Goldenhar's and Treacher Collin's syndrome. The incidence of congenital heart disease was 19%. Pre-existing conditions, anaesthetic technique, grade of intubation, complications and discharge were audited. Sixteen of the patients were classified as Grade 3 or 4 intubations. Over the 7 years, laryngeal mask airway usage increased for airway maintenance rather than tracheal intubation, as did the use of propofol for induction rather than inhalational methods. Intra-operative complications (5.9%) were related to the airway, and postoperative ones (17.6%) mainly to nausea and vomiting. Surgery was performed as a day case in 71% of the patients despite some long-distance travel.

Pharyngeal abscess presenting with upper airway obstruction and atlanto-axial subluxation in a small infant.

We describe an infant who presented with a combination of upper airway obstruction and atlanto-axial subluxation, secondary to a pharyngeal abscess resulting from cosmetic ear piercing. This combination posed a number of difficulties for the anasthetist and a detailed plan was formulated to prepare the child for anasthesia.

Targeted deletion of the tub mouse obesity gene reveals that tubby is a loss-of-function mutation.

The mouse tubby phenotype is characterized by maturity-onset obesity accompanied by retinal and cochlear degeneration. A positional cloning effort to find the gene responsible for this phenotype led to the identification of tub, a member of a novel gene family of unknown function. A splice defect mutation in the 3' end of the tub gene, predicted to disrupt the C terminus of the Tub protein, has been implicated in the genesis of the tubby phenotype. It is not clear, however, whether the Tub mutant protein retains any biological activity, or perhaps has some dominant function, nor is it established that the tubby mutation is itself responsible for all of the observed tubby phenotypes. To address these questions, we generated tub-deficient mice and compared their phenotype to that of tubby mice. Our results demonstrate that tubby is a loss-of-function mutation of the tub gene and that loss of the tub gene is sufficient to give rise to the full spectrum of tubby phenotypes. We also demonstrate that loss of photoreceptors in the retina of tubby and tub-deficient mice occurs by apoptosis. In addition, we show that Tub protein expression is not significantly altered in the ob, db, or melanocortin 4 receptor-deficient mouse model of obesity.

Remifentanil infusion for major abdominal surgery in small infants.

Neonates are known to be sensitive to volatile anaesthetic agents which may lead to prolonged recovery. In this study, a remifentanil infusion was used in conjunction with an infusion of epidural ropivacaine and isoflurane anaesthesia for major abdominal surgery in small infants. This led to a short recovery time for infants aged 7 days to 3 months but a prolonged recovery in those under the age of 7 days. Good perioperative analgesia was achieved.

Postoperative extradural infusions in children: preliminary data from a comparison of bupivacaine/diamorphine with plain ropivacaine.

To try to decrease the incidence of side-effects associated with postoperative extradural infusions of local anaesthetics in combination with opioids, we have used plain ropivacaine solutions in 200 children. The first 72 children received an infusion of bupivacaine 0.125% + diamorphine 20 microg x ml-1, then 200 children received plain ropivacaine solutions. The children who received ropivacaine were found to have lower incidences of nausea, pruritus, urinary retention, and were less sedated, despite comparable analgesia. The management of plain ropivacaine for extradural analgesia is discussed.

Tyrosine phosphorylation of tub and its association with Src homology 2 domain-containing proteins implicate tub in intracellular signaling by insulin.

A mutation in the tub gene leads to maturity-onset obesity, insulin resistance, and progressive retinal and cochlear degeneration in mice. tub is a member of a growing family of genes that encode proteins of unknown function that are remarkably conserved across species. The absence of obvious transmembrane domain(s) or signal sequence peptide motif(s) suggests that Tub is an intracellular protein. Additional sequence analysis revealed the presence of putative tyrosine phosphorylation motifs and Src homology 2 (SH2)-binding sites. Here we demonstrate that in CHO-IR cells, transfected Tub is phosphorylated on tyrosine in response to insulin and insulin-like growth factor-1 and that in PC12 cells, insulin but not EGF induced tyrosine phosphorylation of endogenous Tub. In vitro, Tub is phosphorylated by purified insulin receptor kinase as well as by Abl and JAK 2 but not by epidermal growth factor receptor and Src kinases. Furthermore, upon tyrosine phosphorylation, Tub associated selectively with the SH2 domains of Abl, Lck, and the C-terminal SH2 domain of phospholipase Cgamma and insulin enhanced the association of Tub with endogenous phospholipase Cgamma in CHO-IR cells. These data suggest that Tub may function as an adaptor protein linking the insulin receptor, and possibly other protein-tyrosine kinases, to SH2-containing proteins.