Tele-colleaguography - Adjunct to Intraoperative Time Out for Safe Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is a common surgical procedure, and strategies for preventing biliovascular injury include intraoperative time-out and intraoperative cholangiography. However, the feasibility of intraoperative cholangiography is limited in certain regions due to cost and training constraints. This article introduces the concept of "Tele-colleaguography" as an adjunct to intraoperative time-out during laparoscopic cholecystectomy, particularly in low-resource settings. Telecolleaguography, a term coined to signify remote consultation with senior surgeons using video applications like WhatsApp and Viber, presents a potential solution to prevent bile duct injuries. The viewpoint discusses the potential benefits of Telecolleaguography, and the role of modern technology such as 5G, and references key studies that support this approach.

Celiac Plexus Denudation in Triangle Dissection in Pancreatico Duodenectomy: Perioperative Anesthetic Implications.

This is a case report of inadvertent right celiac plexus denudation during triangle dissection during the surgery for carcinoma of pancreas under combined general epidural anaesthesia. Operative removal of the ganglia has its own autonomic effects, which are important to observe for anesthesiologists and perioperative critical care physicians alike.

Initiating advanced laparoscopic surgery in a medical college hospital with basic laparoscopic set up: is it feasible and safe?

BACKGROUND: Laparoscopic surgery involves performing surgery through small incisions in abdominal wall to get access. Primary goal of this procedure is to achieve good cosmetic outcome, reduced post operative pain, early recovery and reduced hospital admission. OBJECTIVE: The main objective of this study is to see the feasibility and benefit of performing advance laparoscopic surgery in a place where basic laparoscopic surgery is done and to share my experience while performing it. MATERIALS AND METHODS: A retrospective study of case sheets and discharge summary from 1st May 2008 till 1st August 2009 was done. Altogether eight patients underwent different advanced laparoscopic procedure. Cases done for the fi rst time in the institute and those done by himself were only included. Technical feasibility, use of devices like harmonic scalpel, need for incision extension, operative time, blood product requirement, ambulation and enteral feed, post operative hospital stay and patients satisfaction regarding minimal scars were assessed. RESULT: Total eight patients underwent advance laparoscopic surgery. There were two common bile duct (CBD) exploration of which one was transcystic exploration, one total laparoscopic abdominoperineal resection (APR) for rectal cancer, one laparoscopic assisted right hemicolectomy for carcinoma ceacum, one laparoscopic assisted sigmoid colectomy for recurrent sigmoid volvulus, two laparoscopic right nephrectomy for non functioning right kidney, one retroperitoneal pyelolithotomy and one laparoscopic assisted splenectomy for massive splenomegaly with haemolytic anaemia. All procedures were technically feasible with basic laparoscopic instruments. However harmonic scalpel was required for splenectomy due to difficult hilum dissection. Ureteroscope was used as a choledochoscope in CBD exploration. Blood transfusion was required only in patient with low preoperative haemoglobin. Early ambulation and enteral feed was done within 24 hours in all and within 48 hours in patients who had bowel anastomosis. Post operative hospital stay was 5-8 days. Cosmetic scar was appreciated by all. Although long term oncological outcome is yet to come in malignancy case, biopsy report of laparoscopic APR identified 13 nodes which shows complete nodal dissection on oncological principal basis. CONCLUSION: Advanced laparoscopy is feasible, safe and effective in the hand of surgeons performing basic laparoscopic surgeries with guidance from surgeons who have long experience on same procedures but by open method.

Hospital based analytic study of peptic ulcer disease in patients with dyspeptic symptoms.

BACKGROUND: Peptic ulcer disease is one of the most common diseases prevalent in developing country like Nepal and with availability of endoscopy there have been increase in diagnosis and therapeutic use of endoscopy. OBJECTIVE: The aim of this study is to investigate the prevalence of peptic ulcer disease in patient who came for upper gastrointestinal endoscopy in Kathmandu Medical College Teaching Hospital. MATERIALS AND METHODS: All patients who were referred to department of endoscopy from outpatient department (OPD) and inpatient department with symptoms like dyspepsia, upper GI bleeding were included from August 2004 to August 2008. RESULTS: A total of 2761 patient were evaluated, with mean age group of 40.57 years (range 8- 95 years) and with sex distribution of male 1353 (49%) and female 1408 (51%) and racial difference into Aryan 2050 (74.2%) and Mongoloid 771 (25.8%). There were 983 patients (35.60%) with peptic disease which includes erosive gastritis, non erosive gastritis, duodenitis and gastroduodenitis without obvious ulcer. The prevalence of peptic disease with or without ulcer was more common in age group of 20- 49 years (n= 764, 27.67 %) with 70 patient with gastric ulcer (2.5%) and 50 patient with duodenal ulcer (1.8%). There was no significant racial difference among incidence of peptic ulcer (P value= 0.527). CONCLUSIONS: Peptic ulcer disease is a significant cause of morbidity in urban population of Nepal with more prevalent of erosive diseases in productive age group (20-49 years). However both male and female have equal incidence of peptic ulcer disease and there was no significant racial difference in its incidence.

Influence of duration of symptoms over perioperative outcomes during emergency laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is a gold standard treatment for gall stone diseases. Early surgical intervention in acute calculus cholecystitis is feasible and duration of onset of symptoms does not influence the conversion rate. OBJECTIVE: To compare the safety and feasibility between urgent and delayed laparoscopic cholecystectomy in patients with acute calculus cholecystitis. MATERIALS AND METHODS: This is a comparative study conducted in Department of Surgery, Kathmandu Medical College, during the period of January 2006 to January 2008. Alltogether, 436 patients were analysed out of which 55 were selected as urgent laparoscopic cholecystectomy and were included in the study. Among 55 patients presented with acute calculus cholecystitis were divided into two groups. Group 1 underwent laparoscopic cholecystectomy within 72 hours of onset of pain abdomen and Group 2 after 72 hours of onset of pain abdomen. RESULTS: Conversion rate in Group 1 was 19.44% whereas it was 263% in Group 2 (p = .693). There was no statistically significant difference in mean operating time (p = .412), total hospital stay (p = .626), bile duct injury and postoperative complications. CONCLUSION: Urgent laparoscopic cholecystectomy is safe and duration of onset of pain abdomen does not influence conversion rate.

Predicting difficulties during laparoscopic cholecystectomy by preoperative ultrasound.

BACKGROUND: The aim of this study was to determine whether the preoperative USG finding can predict the risk of conversion or difficulty during the laparoscopic cholecystectomy. MATERIALS AND METHODS: 200 patients undergoing Laparoscopic cholecystectomy at Kathmandu Medical College Teaching Hospital were included. Sonographic parameters like size of gall bladder, wall thickness, distance between hepaticoduodenal ligament and Hartmann's pouch and the size of stone were taken into consideration and difficulties in terms of adhesions around gall bladder, anatomy of calot's triangle and difficulty in peeling off gall bladder from the bed and retrieval were analyzed. RESULT: In 8 of 200 patients (4%), LC was converted to open procedure. In univariate analysis all the sonographic parameters we had included in this study were statically significant (p value <0.05). CONCLUSION: Preoperative sonographic signs can predict the difficulty in laparoscopic cholecystectomy.

Use of percutaneous thread loop to hold the vermiform appendix during laparoscopic appendectomy.

INTRODUCTION: Laparoscopic appendectomy, although not as widely performed as laparoscopic cholecystectomy, it has got definite advantage over the conventional open procedure. Controversy exists regarding the closure of stump. Our institute practices intracorporeal knot tying using 3 ports. Difficulties are observed in three port technique to hold the appendix during knot tying. We use a percutaneous thread loop. Advantage of the use of loop was evaluated. PATIENTS AND METHOD: Prospective study was carried out during 18 months. Total cases were randomly divided in non-loop and with loop group. Operative procedure was same. Cases were compared in terms of operating time, post-operative hospital stay and complications. RESULTS: Total patients were 66. Thirty two in non-loop group and 34 in with loop group. Mean age was 27.89 yrs. Most of the cases were females (62%). Mean operating time was less in loop group although statistically not significant. There was no difference in post operative hospital stay. Use of loop was not associated with added complications. CONCLUSION: Use of percutaneous loop to hold the appendix reduces the operating time and replaces the need of fourth port. It is safe and effective without any increased morbidity. Key words: Laparoscopic appendectomy, Intracorporeal knot, Percutaneous loop.

Effectiveness of 0.2% Glyceryl Trinitrate and 0.5% Nifedipine in the Treatment of Chronic Anal Fissure.

INTRODUCTION: Anal fissure is an ischemic ulcer caused by combination of spasm of internal anal sphincter and poor blood supply to the posterior midline of anal canal. This study aimed to assess the efficacy of Glyceryl Trinitrate and Nifedipine in the treatment of chronic anal fissure. METHODS: Ninety patients with symptomatic anal fissure in Kathmandu Medical College Teaching Hospital are allocated for study in two groups of 45 each from March 2013 to April 2014. The patients are assigned alternatively to GTN group and Nifedipine group. All patients were assessed every week till 8 weeks in regards to headache, compliance, healing and recurrence. The patients who had complete healing in 8 weeks were further followed up for 6 weeks to detect recurrence. RESULTS: Patients in the two groups were comparable in regard to demographic data (age and sex) as well as clinical factors. Headache was main complaint of patients using GTN in high percentage (16.6%) than complained by patients using topical Nifedipine (6.9%). This factor led to poor compliance with GTN compared with Nifedipine. Nifedipine showed better healing rate 82.5% compared with GTN 60%. Recurrence was comparable among the two groups. CONCLUSIONS: Nifedipine ointment showed better results than GTN ointment in chronic anal fissure regarding headache, compliance, healing and recurrence in 6 weeks of follow up period after complete healing of fissure in 8 weeks.

Laparoscopic Approach for Management of Hydatid Cyst of Liver.

BACKGROUND: Laparoscopy surgery trials are small and unconvincing at present and are limited to higher centers. The objective of the study is to determine the clinical features, prevalence of site of hydatid cyst and complications of this modality of this treatment. METHODS: A cross sectional study was carried out in all patients with one or two hepatic hydatid cyst who underwent laparoscopic management in KMCTH from January 2013 to March 2015 were included in the study. Aspiration, deroofing and evacuation of the hydatid cyst were done. RESULTS: Twenty six patients underwent laparoscopic management for liver hydatid cysts. Males were seven (65.38%) and females were 9(34.61%).The mean age was 35.5±13.1 years (range 21-55years.) The commonest complaint was pain and discomfort in 13(50%) patients and lump in 6(13.06%) patients. Twenty four (92.3%) patients were successfully treated with laparoscopic approach. Two (7.69%) patients had to be converted to laparotomy because of dense adhesions and bleeding. Mean operation time was 43.6±10.6 minutes. Two (7.69%) patients had port site infection. One (3.84%) patient had bile leak and no recurrence and mortality in our series. CONCLUSIONS: Laparoscopic management of liver hydatid cyst was safe and effective in selective group of patients in equipped hospital.

Systemic Inflammatory Response Syndrome following Gastrointestinal Surgery.

INTRODUCTION: Systemic inflammatory response syndrome symptoms immediately after surgery have lately been regarded as potential warnings of impending post-operative complications and multiple organ failure. This study was conducted to find out the clinical significance of systemic inflammatory response syndrome in postoperative patients and to investigate the relationship between the duration of post-operative systemic inflammatory response syndrome and the post-operative morbidity and mortality. METHODS: Total 30 patients who received different gastrointestinal surgery and fulfilled the diagnostic criteria for systemic inflammatory response syndrome between 2006 and 2008 at Kathmandu Medical College Teaching Hospital were included. Patients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of systemic inflammatory response syndrome, complications, and end-organ dysfunction. RESULTS: Duration of systemic inflammatory response syndrome or positive criteria's number of systemic inflammatory response syndrome after surgery significantly correlated with surgical stress parameters (blood loss/body weight and operation time). Septic complications and prolongation of systemic inflammatory response syndrome were associated with multiple organ dysfunction syndrome and increased mortality. CONCLUSIONS: Systemic inflammatory response syndrome is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from systemic inflammatory response syndrome may arrest the progression of organ dysfunction, thus reducing the mortality.

Removal of central venous catheter fragment embolus in a young male.

A 22 years male admitted with severe pancreatitis with central venous catheter implanted for central venous pressure monitoring and for providing total parental nutrition developed catheter fragment embolus due to accidental fracture of the same while manipulating it. Non surgical retrieval of the same was done by radiological intervention without any complication.

Antipsychotics and the risk of sudden cardiac death.

BACKGROUND: Case reports link antipsychotic drugs with sudden cardiac deaths, which is consistent with dose-related electrophysiologic effects. Because this association has not been confirmed in controlled studies, we conducted a retrospective cohort study in Tennessee Medicaid enrollees, which included many antipsychotic users; there were also computer files describing medication use and comorbidity. The study was conducted before the introduction of risperidone and, thus, did not include the newer atypical agents. METHODS: The cohort included 481,744 persons with 1,282,996 person-years of follow-up. This included 26,749 person-years for current moderate-dose antipsychotic use (>100-mg thioridazine equivalents), 31,864 person-years for current low-dose antipsychotic use, 37,881 person-years for use in the past year only, and 1 186,501 person-years for no use. The cohort had 1487 confirmed sudden cardiac deaths; from these, we calculated multivariate rate ratios adjusted for potential confounding factors. RESULTS: When current moderate-dose antipsychotic use was compared with nonuse, the multivariate rate ratio was 2.39 (95% confidence interval, 1.77-3.22; P<.001). This was greater than that for current low-dose (rate ratio, 1.30; 95% confidence interval, 0.98-1.72; P=.003) and former (rate ratio, 1.20; 95% confidence interval, 0.91-1.58; P<.001) use. Among cohort members with severe cardiovascular disease, current moderate-dose users had a 3.53-fold (95% confidence interval, 1.66-7.51) increased rate relative to comparable nonusers ( P<.001), resulting in 367 additional deaths per 10,000 person-years of follow-up. CONCLUSIONS: Patients prescribed moderate doses of antipsychotics had large relative and absolute increases in the risk of sudden cardiac death. Although the study data cannot demonstrate causality, they suggest that the potential adverse cardiac effects of antipsychotics should be considered in clinical practice, particularly for patients with cardiovascular disease.

Visualisation of Rouviere's Sulcus during Laparoscopic Cholecystectomy.

INTRODUCTION: Safe dissection of Calot's Triangle is important during the performance of laparascopic cholucystectomy. The purpose of the study is to determine the frequency of demonstrable Rouviere's sulcus in patients with symptomatic gall stones and its role in safe dissection in Calot's triangle. METHODS: This is a prospective descriptive study design done in Department of surgery, Kathmandu Medical College Teaching Hospital from Jan 2013 to Jan 2015. Patients who were posted for laparoscopic cholecystectomy were included. During laparoscopy, Rouviere's sulcus was noted in the operative note and classified according to following: Type I: Open type was defined as a cleft in which the right hepatic pedicle was visualized and the sulcus was opened throughout its length. Type II: if the sulcus was open only at its lateral end. Type III If the sulcus was open only at its medial end. Type IV: Fused type was defined as one in which the pedicle was not visualized. RESULTS:  A total of 200 patients underwent laparoscopic cholecystectomy during period of 2 years. Out of which Rouviere's sulcus was visualized in 150 patients (75 %).Type I (open type) was commoner in 54%, type II in 12%, Type III in 9% and type IV (fused type) in 25%. CONCLUSION: Rouviere's Sulcus is an important extra biliary land mark for safe dissection of Calot's triangle during laparoscopic cholecystectomy.  KEYWORDS: Rouviere's Sulcus, Laparoscopic cholecystectomy, Bile duct injury.

Risk factors for delayed immunization in a random sample of 1163 children from Oregon and Washington.

Despite extensive study of vaccine safety and decades of effort to immunize infants and toddlers, little is known about the comprehensiveness of vaccine coverage in US children younger than 2 years of age. Provider and parent data from a population-based sample of 1163 children from two states were analyzed to assess coverage rates at three ages and to evaluate characteristics of children and their families that predict failure to immunize on schedule. Overall, 78% of the children had received their first dose of diphtheria and tetanus toxoids with pertussis vaccine (DTP) and their first dose of oral poliovirus (OPV) by 92 days of age. Similarly, 77% had received their third dose of DTP and their second dose of OPV by their first birthday. However, by their second birthday only 60% had received the full series of four doses of DTP, three doses of OPV, and one dose of the measles, mumps, and rubella vaccines. When considered singly, several variables including child birth order, family income, maternal education, and marital status significantly predicted failure to immunize on schedule. In multivariate logistic models, only birth order and maternal education consistently predicted vaccine status at each of the three ages. Compared with first-born children, those who were later-born were 1.7 times more likely to be incompletely immunized at 2 years of age (95% confidence interval: 1.2, 2.3). Children of more educated mothers were significantly less likely to be underimmunized at all ages.(ABSTRACT TRUNCATED AT 250 WORDS)

Benzodiazepines and the risk of falls in nursing home residents.

CONTEXT: For nursing home residents who require a benzodiazepine, short-acting agents are recommended, primarily to avoid increased risk of falls and other injuries associated with the long-acting agents. However, much of the data for the clinical outcomes of falls and injuries comes from community-dwelling older people. OBJECTIVE: To quantify the rate of falls among nursing home residents taking benzodiazepines and how this varies with drug elimination half-life. DESIGN: Historical cohort study. POPULATION: A total of 2510 residents of 53 Tennessee nursing homes, classified according to benzodiazepine use on each day of follow-up. OUTCOME MEASURES: Falls occurring during study follow-up. RESULTS: After adjustment for differences in resident characteristics, benzodiazepine users had a 44% increased rate of falls (adjusted rate ratio 1.44 [95% confidence interval, 1.33-1.56]). The adjusted rate ratio increased from 1.30 (1.12-1.52) for a dose equivalent to < or = 2 mg of diazepam, to 2.21 (1.89-2.60, P < .001) for a dose of > 8 mg. The rate of falls was greatest in the 7 days after the benzodiazepine was started (rate ratio of 2.96 [2.33-3.75]) but remained elevated (1.30 [1.17-1.44]) after the first 30 days of therapy. Drugs with elimination half-lives of <12, 12-23, and > or = 24 hours had adjusted rate ratios of 1.15 (0.94-1.40), 1.45 (1.33-1.59), and 1.73 (1.40-2.14), respectively. Users of hypnotics with elimination half-lives <12 hours had an increased rate of falls occurring during the night (adjusted rate ratio 2.82 [2.02-3.94]). CONCLUSIONS: Although the risk of falls among nursing home residents receiving short-acting benzodiazepines is less than that for the long-acting agents, these drugs are associated with a materially increased risk of nocturnal falls.

Predictors of antipsychotic withdrawal or dose reduction in a randomized controlled trial of provider education.

OBJECTIVES: To evaluate the effects of an educational program to reduce antipsychotic use in nursing homes that had high use rates post-OBRA-87 and to identify factors that predicted antipsychotic withdrawal or 50% or greater dose reduction. DESIGN/SETTING: A randomized controlled trial (RCT) of the educational program (nursing home the unit of randomization and analysis) was conducted in 12 Tennessee nursing homes (6 education/6 control). Cohort analysis in baseline antipsychotic users identified factors predicting withdrawal or dose reduction. SUBJECTS: The RCT analysis included 1152 patients in the homes at baseline and 6 months. The cohort analysis included 133 baseline antipsychotic users in the five education homes able to implement the recommendations of the educational program. OUTCOME MEASURES: Change in days of antipsychotic use per 100 days of nursing home residence, withdrawal from antipsychotics, reduction in antipsychotic dose by 50% or more. RESULTS: Following the educational intervention, use of antipsychotics in the six education homes decreased from 25.3 days per 100 at baseline to 19.7 days per 100 by month 6, a 23% reduction relative to control homes (P = .014). In the withdrawal analysis, 44 (33%) of 133 baseline antipsychotic users were withdrawn. Factors at baseline predicting successful withdrawal were low antipsychotic dose, no use of benzodiazepines or antidepressants, and behavioral symptoms score below the median. However, although an additional 22 patients had dose reductions > or = 50%, none of the predictors of withdrawal were associated with dose reductions. CONCLUSIONS: Focused provider education programs may facilitate antipsychotic reduction above and beyond that attributable to regulatory changes. Patients who are poor candidates for total antipsychotic withdrawal may tolerate substantial dose reductions, which should reduce their risk of adverse antipsychotic effects.

Comparison of clinical and biomechanical measures of balance and mobility in elderly nursing home residents.

OBJECTIVE: To compare biomechanics force platform measurements of postural sway with clinical measures of balance and mobility, in frail elderly residents of community nursing homes, in terms of feasibility, correlation with other known risk factors for falls, and intercorrelation with each other. DESIGN: Cross-sectional study. SETTING: Twelve Tennessee community nursing homes. SUBJECTS: Of 1315 residents 360 (> or = 65) could stand independently (> or = 10 seconds). Of these eligible subjects, 303 (84%) provided informed consent and were assessed. MEASUREMENTS: The biomechanics force platform measurements were postural sway during quiet standing characterized as elliptical area and mean velocity. The clinical measures were functional reach, mobility maneuvers (adapted from Tinetti's Mobility Index), timed chair stands, and 10-foot walk. Resident characteristics and function were also obtained. RESULTS: Balance measurements were obtained on most (100% for postural sway to 67% for chair stand) consenting residents and were reliable on test-retest (intraclass correlation from .56 to .98). Performance in both groups of balance measures deteriorated with increasing musculoskeletal disability. Functional reach and mobility maneuvers correlated with height, and mobility maneuvers with depressive symptoms. Elliptical area correlated with mean velocity of postural sway (Pearson's r = 0.72; P < 0.001), and the clinical measures of balance (functional reach, mobility maneuvers, timed chair stands and walk) were modestly intercorrelated (r from 0.35 to 0.65; all P values < or = 0.05). However, the biomechanical measures were not correlated with the clinical measures. CONCLUSIONS: Standard measures of balance were obtained reliably from nursing home residents who could stand independently for > or = 10 seconds. However, in this group, further research is needed to determine which measures best predict falls. Further research is also needed to identify predictors of falls in the majority of residents who were too frail to undergo these standard assessments.

Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors.

OBJECTIVE: To determine the circumstances of, incidence of, and risk factors for falls resulting in serious injuries in nonambulatory nursing home residents compared with those for ambulatory residents. DESIGN: Prospective cohort study with 1-year follow-up. SETTING: Twelve community nursing homes in Tennessee. SUBJECTS: A total of 1228 residents, 65 years of age or older, of whom 725 (59%) were nonambulatory and 503 (41%) were ambulatory. MEASUREMENTS: Baseline data were obtained for potential risk factors for injurious falls. These included demographic characteristics, mental and physical function, vision, hearing, incontinence, and use of mechanical restraints and psychotropic drugs. Data were obtained from direct resident assessment, care provider interview, and the nursing home Minimum Data Set (MDS) (validated in a sample of residents). OUTCOME: There were 111 first falls resulting in serious injury (head injury with altered consciousness, fracture, joint dislocation or sprain, or sutured laceration) that received medical treatment (hospitalization, emergency room visit, physician visit, or on-site radiological examination), ascertained from facility incident reports and nursing home charts. RESULTS: Nonambulatory residents had a substantially greater prevalence of mental and physical impairment. Circumstances of injurious falls in nonambulatory (n = 39 falls) and ambulatory (n = 72 falls) residents differed; those in the former groups were more likely to involve equipment (87% vs 45%, P < .0001), occur while seated or during transferring (82% vs 21%, P < .0001), and from a chair/bed level (54% vs 6%, P < .0001). The incidence of injurious falls in nonambulatory residents (6.7 per 100 person-years) was less than half that in ambulatory residents (17.0 per 100 person-years, P < .0001). After controlling for other factors, the nonambulatory residents at highest risk were those not bed-bound and with capacity for independent transfer (incidence density ratio (IDR) = 2.02, 95% CI = 1.07-7.99); the ambulatory residents at highest risk were baseline users of psychotropic drugs (IDR = 2.49, 95% CI = 1.43-4.33). CONCLUSIONS: In the study cohort, nonambulatory residents had 35% of injurious falls. Because the circumstances and risk factors of these events were substantially different from those for ambulatory residents, separate prevention strategies may be needed for this group. These data suggest that increasing the safety of transferring and of equipment are appropriate targets for interventions.

Effects of antipsychotic withdrawal in elderly nursing home residents.

OBJECTIVE: To study the effects of antipsychotic withdrawal in elderly nursing home residents. DESIGN: Longitudinal prospective study. SETTING: 12 community nursing homes that participated in a randomized controlled trial of an educational program designed to reduce antipsychotic use. SUBJECTS: 271 residents receiving antipsychotics at baseline and remaining in the home for approximately 6 months thereafter. These were placed into two groups: those with continued use of antipsychotics at follow-up (n = 207) and those with drug discontinued (n = 64). MEASUREMENTS: Change between baseline and follow-up for several standard measurements. These included behavior problems, as reported by both regular care providers (Nursing Home Behavior Problem Scale) or a blinded study rater (items from the Brief Psychiatric Rating Scale), observer-rated psychiatric symptoms (subset of the Brief Psychiatric Rating Scale), and other standard tests of function (Activities of Daily Living, Mini-Mental State Examination, Geriatric Depression Scale, and Abnormal Involuntary Movements Scale). RESULTS: The frequency of behavior problems did not increase in residents with antipsychotics discontinued. For these residents, observer-rated psychiatric symptoms decreased by 21% (P = 0.003), which resulted from a 27% decrease in adverse affective symptoms (P = 0.0002). Residents with drug discontinued had no deterioration in any of the measures of function. CONCLUSION: In this sample, nursing home residents whose antipsychotics were discontinued had significantly improved affect and no discernable adverse effects.

Clinical and biomechanical measures of balance as fall predictors in ambulatory nursing home residents.

BACKGROUND: We evaluated the capacity of biomechanical and clinical measures of balance to predict future risk of recurrent falls in a cohort of frail, elderly ambulatory residents of 12 Tennessee community nursing homes. METHODS: Baseline measurements of balance and other potential fall risk factors were obtained in 303 ambulatory nursing home residents. Balance measures included biomechanics force platform measurements of postural sway (area ellipse and mean velocity) and clinical measures, which included functional reach, Tinetti balance subscale (adapted from Tinetti's Performance Oriented Mobility Index), timed chair stands, and 10-foot walk. Residents who fell two or more times during follow-up (mean of 11 months) were identified from nursing home incident reports and nursing notes. The predictive value of the balance measures was evaluated by the incidence density ratio (IDR) estimated from proportional hazards models. RESULTS: There were 118 recurrent fallers (54.2 per 100 person-years). Rates of recurrent falls increased with increasing quintiles of both the biomechanical and clinical measures of balance, with unadjusted IDRs (95% CI) per quintile change of 1.22 (1.07-1.39) for area ellipse, 1.12 (0.98-1.27) for mean velocity of postural sway, 1.29 (1.13-1.47) for the Tinetti balance subscale, 1.24 (1.08-1.41) for timed walk, 1.24 (1.09-1.42) for timed chair stands, and 1.12 (0.98-1.28) for functional reach. Controlling for age, gender, height, and weight did not materially affect the linear relationship between the balance measure quintiles and subsequent recurrent falls. However, after controlling for additional fall risk factors, only area ellipse of postural sway and the Tinetti balance subscale remained independently predictive of subsequent recurrent fall rates, with IDRs of 1.16 (1.02-1.36) and 1.17 (1.01-1.34), respectively. In an analysis where subjects were stratified by tertiles of each of these two measures, each measure appeared to independently predict future rates of recurrent falls. The independent predictive capacity of each measure persisted after controlling for other fall risk factors in a multivariate analysis with IDRs of 1.15 (1.00-1.32) for area ellipse and 1.15 (1.00-1.32) for the Tinetti balance subscale. Inclusion of both balance measures in a model with other fall risk factors to evaluate their relationship did not materially alter IDR point estimates of these risk factors. CONCLUSIONS: In this cohort of frail, nursing home residents, both area ellipse of postural sway and the Tinetti balance subscale independently predicted risk of future recurrent falls. However, the predictive value of other independent fall risk factors on risk of future recurrent falls persisted and was not explained by these two measures. Thus, assessment of patient fall risk based on surrogate endpoints, for either research or clinical practice, may need to include multiple measurements.