David A. Richardson

Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial

Abstract Objective: To determine the effectiveness of multifactorial intervention after a fall in older patients with cognitive impairment and dementia attending the accident and emergency department. Design: Randomised controlled trial. Participants: 274 cognitively impaired older people (aged 65 or over) presenting to the accident and emergency department after a fall: 130 were randomised to assessment and intervention and 144 were randomised to assessment followed by conventional care (control group). Setting: Two accident and emergency departments, Newcastle upon Tyne. Main outcome measures: Primary outcome was number of participants who fell in year after intervention. Secondary outcomes were number of falls (corrected for diary returns), time to first fall, injury rates, fall related attendances at accident and emergency department, fall related hospital admissions, and mortality. Results: Intention to treat analysis showed no significant difference between intervention and control groups in proportion of patients who fell during 1 years follow up (74% (96/130) and 80% (115/144), relative risk ratio 0.92, 95% confidence interval 0.81 to 1.05). No significant differences were found between groups for secondary outcome measures. Conclusions: Multifactorial intervention was not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall. What is already known on this topic Multifactorial intervention prevents falls in cognitively normal older people living in the community and in those who present to the accident and emergency department after a fall Fall prevention strategies have not been tested by controlled trials in patients with cognitive impairment and dementia who fall What this study adds No benefit was shown from multifactorial assessment and intervention after a fall in patients with cognitive impairment and dementia presenting to the accident and emergency department The intervention was less effective in these patients than in cognitively normal older people

Carotid Sinus Syndrome: A Modifiable Risk Factor for Nonaccidental Falls in Older Adults (SAFE PACE)

OBJECTIVES The aim of the study was to determine whether cardiac pacing reduces falls in older adults with cardioinhibitory carotid sinus hypersensitivity (CSH). BACKGROUND Cardioinhibitory carotid sinus syndrome causes syncope, and symptoms respond to cardiac pacing. There is circumstantial evidence for an association between falls and the syndrome. METHODS A randomized controlled trial was done of consecutive older patients (>50 years) attending an accident and emergency facility because of a non-accidental fall. Patients were randomized to dual-chamber pacemaker implant (paced patients) or standard treatment (controls). The primary outcome was the number of falls during one year of follow-up. RESULTS One hundred seventy-five eligible patients (mean age 73 +/- 10 years; 60% women) were randomized to the trial: pacemaker 87; controls 88. Falls (without loss of consciousness) were reduced by two-thirds: controls reported 669 falls (mean 9.3; range 0 to 89), and paced patients 216 falls (mean 4.1; range 0 to 29). Thus, paced patients were significantly less likely to fall (odds ratio 0.42; 95% confidence interval: 0.23, 0.75) than were controls. Syncopal events were also reduced during the follow-up period, but there were much fewer syncopal events than falls-28 episodes in paced patients and 47 in controls. Injurious events were reduced by 70% (202 in controls compared to 61 in paced patients). CONCLUSIONS There is a strong association between non-accidental falls and cardioinhibitory CSH. These patients would not usually be referred for cardiovascular assessment. Carotid sinus hypersensitivity should be considered in all older adults who have non-accidental falls.

Prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity in Patients 50 Years or over Presenting to the Accident and Emergency Department with “Unexplained” or “Recurrent” Falls

To study the prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity (CICSH) in patients 50 years or over presenting to casualty with “unexplained” or “recurrent” falls. The prospective study was from October 1, 1995 to April 30, 1996 in the Inner City Accident and Emergency Departments, Newcastle Upon Tyne, U.K. Ten thousand four hundred forty‐three patients 50 years and over presented, of which 4,051 (39%) were fallers. Fallers were excluded if they lived over 15 miles from the hospital (81), were registered blind (17), were unable to speak English (22), were unable to previously walk (27), if there was a history of only one accidental fall (1,659) or were cognitively impaired (776: Mini Mental State Examination < 24 [30]) or if there was a clear attributable medical diagnosis for the fall (871). Five hundred ninety‐eight “unexplained” or “recurrent” fallers (defined as three or more falls in the previous 12 months) were assessed for carotid sinus massage (CSM). One hundred forty‐five patients declined CSM (24%), 70 (12%) had relative contraindications to CSM and 13 already had pacemakers in situ (2%). Two hundred seventy‐nine underwent CSM, of whom 65 had CICSH (23%), which might be amenable to treatment with pacemakers. The prevalence of CICSH (a potentially treatable condition) in “unexplained” or “recurrent” fallers who present to the accident and emergency department is 23%. A randomized control study to assess benefit from pacemaker intervention in these patients is underway.

Location and removal of non-palpable Implanon ® implants with the aid of ultrasound guidance

Background Implanon® insertion appears to be an easy procedure, but in a small minority of cases difficulties have been encountered with removal if the rod is impalpable. Methods Patients were referred to the contraceptive and sexual health service with non-palpable Implanon. Following a clinical assessment and examination of the arm where the implant had been inserted, an ultrasound examination was carried out to identify and locate the implant. These implants were subsequently removed, some under general anaesthesia and others under local anaesthesia. Results Twenty-seven patients were referred to the unit with impalpable Implanon rods. In four cases the rods were palpable and were removed in the clinic setting without the need for further intervention. Positive identification of the implants was achieved in 21 of the remaining 23 cases using ultrasound. No implant was detected in two cases and etonogestrel was not demonstrated serologically in either woman, suggesting non-insertion. All 21 Implanon rods identified by ultrasound were successfully removed. In just over 52% of women a previous attempt at removal had been undertaken prior to referral. Conclusions It is possible to identify and locate impalpable Implanon rods with the aid of ultrasound, facilitating their subsequent safe removal. Although previous reports have identified the position of ‘lost’ implants using ultrasound, this is the first case series to discuss measuring the skin/implant depth. This parameter, together with the precise position of the implant (in muscle or fat), aids removal. All health professionals inserting and removing contraceptive implants should have been appropriately trained.

High likelihood of malignancy in young patients presenting with a thyroid nodule in Northern England.

Dear Editors, Thyroid nodules are rare in children and adolescents with prevalence figures ranging from 0 05–1 8%. Nodules are more likely to be malignant in the young, and the incidence of thyroid cancer may be rising in the north of England in this age group. We have undertaken a regional survey of children and adolescents (<18 years) presenting with a thyroid nodule (>5 mm on ultrasound examination) referred to our regional unit (1996– 2010). The unit covers North-East England and North Cumbria (North-East England, population 2 6 million and North Cumbria excluding Barrow in Furness, population 0 4 million). Young people with thyroid nodules or suspected thyroid cancer are referred to this unit where the regional paediatric endocrinology and oncology teams are based. We aimed to assess the clinical features, investigations, diagnosis and management of children with this problem as well as the age-standardized incidence rate (ASR). ASR per million persons per year was calculated using yearly mid-year population estimates for the study region obtained from the Office for National Statistics and based on a standard world population. Subjects were excluded if they had a family history of multiple endocrine neoplasia. Patients were identified through paediatric endocrine department records, multidisciplinary team records and radiology data (neck ultrasound examinations). In more than 90% of cases, the ultrasound examination (US) and fineneedle biopsy were performed by the same radiologist (DR). A nodule was defined as a mass on clinical examination which was within or related to the thyroid and >5 mm in diameter. The ultrasound images were reviewed (DR) to establish the precise dimensions (n = 18). Features that are known to be associated with an increased likelihood of malignancy include microcalcification, but we could not collect detailed information retrospectively on other parameters such as margin definition, capsular invasion, low echogenicity and central abnormal blood flow on Doppler. Chi-squared test was used to assess the differences between categorical binary variables. Twenty eight patients presented with a clinically apparent mass to primary or secondary care and were all clinically and biochemically euthyroid at presentation. All patients underwent a thyroid US except two who underwent neck exploration without imaging (Table 1). Twenty four patients underwent fine-needle biopsy (FNB). This indicated an unsatisfactory sample or benign lesion in eight cases (29% of total), an equivocal or follicular lesion in 12 (43%) cases and a lesion that was suspicious of malignancy in four (14%). Four cases did not undergo FNB. One of these four patients had an infective process on USS, two patients had lesions with features associated with malignancy on USS (including calcification) and did not want to undergo biopsy, and one patient underwent surgery because of a suspected thyroglossal cyst. Histological examination of excised thyroid tissue (hemior total thyroid gland) demonstrated 11 malignant and 12 benign lesions. In four of the benign cases, thyroidectomy was undertaken for cosmetic reasons, and three cases underwent thyroidectomy without a preceding biopsy. Malignant lesions were either papillary (6) or follicular carcinomas (5). The remaining 17 lesions were either a benign neoplasm (1) or non-neoplastic lesions (16) including multinodular goitre, colloid nodules and infective thyroiditis. Of patients Table 1. Clinical, radiological and cytology characteristics of patients presenting with benign and malignant thyroid nodules