Peg Insertion Research Articles

Bimanual Coordination and Corpus Callosum Microstructure in Young Adults with Traumatic Brain Injury: A Diffusion Tensor Imaging Study

Bimanual actions are ubiquitous in daily life. Many coordinated movements of the upper extremities rely on precise timing, which requires efficient interhemispheric communication via the corpus callosum (CC). As the CC in particular is known to be vulnerable to traumatic brain injury (TBI), furthering our understanding of its structure-function association is highly valuable for TBI diagnostics and prognosis. In this study, 21 young adults with TBI and 17 controls performed object manipulation tasks (insertion of pegs with both hands and bilateral daily life activities) and cognitive control tasks (i.e., switching maneuvers during spatially and temporally coupled bimanual circular motions). The structural organization of 7 specific subregions of the CC (prefrontal, premotor/supplementary motor, primary motor, primary sensory, parietal, temporal, and occipital) was subsequently investigated in these subjects with diffusion tensor imaging (DTI). Findings revealed that bimanual coordination was impaired in TBI patients as shown by elevated movement time values during daily life activities, a decreased number of peg insertions, and slower response times during the switching task. Furthermore, the DTI analysis demonstrated a significantly decreased fractional anisotropy and increased radial diffusivity in prefrontal, primary sensory, and parietal regions in TBI patients versus controls. Finally, multiple regression analyses showed evidence of the high specificity of callosal subregions accounting for the variance associated with performance of the different bimanual coordination tasks. Whereas disruption in commissural pathways between occipital areas played a role in performance on the clinical tests of bimanual coordination, deficits in the switching task were related to disrupted interhemispheric communication in prefrontal, sensory, and parietal regions. This study provides evidence that structural alterations of several subregional callosal fibers in adults with TBI are associated with differential behavioral manifestations of bimanual motor functioning.

External validation of a prognostic scoring system for percutaneous endoscopic gastrostomy (PEG)

IntroductionThere is a significant mortality associated with PEG. The Sheffield Gastrostomy Score (SGS) was devised to try and improve outcomes following this procedure by predicting 30-day mortality. After prospectively collecting...

* Predicting outcomes in patients deferred for gastrostomy insertion using either the Sheffield gastrostomy score or the levine score

IntroductionGastrostomy insertion is widely accepted as the best means of providing medium and long term enteral nutrition. There is limited data on outcomes in patients referred for gastrostomy insertion that...

External validation of a prognostic scoring system for percutaneous endoscopic gastrostomy (PEG)

Introduction There is a significant mortality associated with PEG. The Sheffield Gastrostomy Score (SGS) was devised to try and improve outcomes following this procedure by predicting 30-day mortality. After prospectively collecting demographic, biochemical and outcome data from a cohort of patients having a new PEG inserted (Hospital A, n = 403), multivariate analysis identified that age and albumin were determinants of 30-day mortality (p 35, 25–34 and Methods Four local district general hospitals were used to externally validate the SGS. Demographic, biochemical and outcome data was obtained from all patients undergoing PEG insertion between June 2006 and June 2009. χ 2 analysis was used to compare actual 30-day mortality rates in the external cohort to the rate predicted by the SGS. Results A total of 679 new PEGs were inserted during this period in these four hospitals. Complete records were obtained from 88% (597/679) and analysed (median age 71, 322 male). The 30-day mortality for this external validation cohort was 13.6%. The main indications for PEG insertion were stroke (33.7%), oropharyngeal malignancy (32.3%) and neurodegenerative diseases (17.4%). Univariate analysis predictors of 30-day mortality in this external cohort were: increasing age, low serum albumin and stroke. There were no significant differences between the observed and the predicted mortality (p ≤ 0.05) in the external validation cohort using the SGS. Conclusion Our results suggest that the SGS can accurately stratify patients into different risk categories, with higher scores correlating with significantly lower survival. We feel that the SGS could have an important role in those patients where the benefits and risks of gastrostomy are unclear.

Predicting outcomes in patients deferred for gastrostomy insertion using either the Sheffield gastrostomy score or the Levine score

Introduction Gastrostomy insertion is widely accepted as the best means of providing medium and long term enteral nutrition. There is limited data on outcomes in patients referred for gastrostomy insertion that are either refused or do not survive until PEG insertion. Scoring systems such as the Levine score have been created to try and predict survival rates over 1 year for patients admitted acutely. The aim of this study was to determine the clinical characteristics and outcomes of patients in whom gastrostomy insertion was not felt to be appropriate on clinical grounds and the Levine score and the Sheffield gastrostomy score (SGS) applied. Methods All patients referred for gastrostomy insertion in our institute are reviewed by the gastrostomy nurse specialist and prospectively included in a database. Demographics, referral indication, biochemical profile and outcome data are also included in the database. Gastrostomy referrals from October 2003 to September 2010 were analysed and actual mortality rate was compared to the expected mortality rate predicted by the SGS and Levine score. Results 304 patients were included in the study (median age 77 years, 175 males) all of whom were referred for consideration of gastrostomy insertion but were ultimately not inserted. The 3 top reasons for non-placement were patient too ill (29.3%), oral intake restarted (18.1%) and patient died (13.5%). Overall mortality at 30 days and 1 year was 122/304 (40.1%) and 226/304 (74.3%) respectively. The highest 30 day mortality was seen in patients with cognitive impairment 12/17 (70.6%) and followed by dysphagic stroke 53/105 (50.5%). The main predictors of 30 day mortality were age >60 (OR 7.2, 3.3 – 15.8, p Conclusion The Sheffield gastrostomy score is more accurate at predicting 1 year mortality in patients deferred for gastrostomy insertion than the Levine score. This may suggest that the Sheffield PEG score could be used in the pre-assessment of patients who are being referred for PEG as a means of estimating/predicting mortality for those involved in the decision making process.

Gastrostomy complications in infants and children: a comparative study

Gastrostomy is a commonly undertaken procedure in children. Methods for gastrostomy insertion have evolved and laparoscopy is commonly used to aid its insertion. The aim of this study is to review the outcome and complications of laparoscopic-assisted gastrostomy insertion. A retrospective case note review of children undergoing gastrostomy insertion by a single surgeon from 1999 to 2007. 114 children underwent gastrostomy insertion, 68 males and 46 females, with a median age of 55 months (IQR 28-149 months). The majority were neurologically impaired. 98 underwent laparoscopic-assisted PEG (86%), 1 was converted to open procedure (0.9%) and 16 had standard PEG (14%). Median follow-up was 10.5 months with 90 children having their original gastrostomy changed to a button at a median interval of 7.4 months. Complications observed included new or deteriorating gastro-oesophageal reflux (GOR) (n = 16), infection (n = 9), granulation tissue (n = 11), tube dislodgement (n = 2) and intra-abdominal leakage of feed (n = 2). There were two gastrocolic fistulae which occurred in the standard PEG group. The inadvertent formation of a gastrocolic fistula was avoided with the use of laparoscopy to aid PEG insertion.

S1352 Comparison of Customized Versus Standardized Peripheral Parenteral Nutrition in an Asian Academic Hospital

It is Trust policy to confirm all NGT placements with a chest X-ray. We audited our practice to assess whether bridles are effective and safe. Methods: Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results: Fifty one patients were referred for bridle placement during the 27 month audit period. Median age was 72 years (range 36-90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3-8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. 1 patient required bridle replacement and only 1 experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1-32). Of these only 2 required long term PEG feeding and 21 were able to have their bridles removed as they were no longer required. 15 patients with bridles died for reasons unrelated to their bridle. An additional 147 chest X-rays had been used prior to referral whilst only 1 additional X-ray was required to confirm NGT position after bridle placement. Conclusion: Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high risk groups if patients are assessed carefully by trained staff.

PTH-057 Northern Nutrition Network regional PEG audit: third cycle: Abstract PTH-057

<h3>Introduction</h3> The Northern Nutrition Network (NNN) is a multidisciplinary group of individuals with an interest in nutrition representing 17 hospitals in the Northern Region. It meets on a regular basis to promote standards of nutrition. We have previously reported to the Society the results of a 3-month audit by members of the NNN of all PEG insertons in the 17 participating hospitals which was repeated after a 2-year interval.1 The results appeared to show a decline in the rate of PEG insertions and a decline in the 28-day mortality rate following PEG insertion. We performed a further cycle of the audit to see whether the changes had been maintained. <h3>Methods</h3> The initial audits were performed from Dec 03 to Feb 04 and Dec 05 to Feb 06. A third cycle was performed from Dec 07 to Feb 08. In order to maintain consistency for each audit the data were recorded using an identical proforma. One individual from each participating unit was responsible for ensuring that data for each PEG insertion was recorded and the Newcastle PEG team collated the data. <h3>Results</h3> See Abstract 057. <h3>Conclusion</h3> The decrease in the PEG insertion rate seen between the first and second audit and the decrease in the 28-day mortality rate were only partially maintained. The trend towards less PEG insertion in stroke patients is sustained. There is a trend towards increasing PEG insertion in patients with learning disabilities. PEG insertion rate in demented patients remains low. These prospective audits provide a useful snapshot of PEG insertion practice and trends in 17 different hospitals in the Northern Region.

CC-011 Case report: colocutaneous fistula – a rare complication of PEG tube insertion

Introduction A 69-year-old man with myotonia and history of partial gastrectomy for ulcer presented in Apr 09 with 2-wk history of diarrhoea and PEG site infection, it was noted that the discharge from the PEG tube and site was offensive. The PEG tube had been placed in 05 for swallowing difficulties with no apparent complications. Methods OGD revealed a small “hole” visible in the anterior gastric wall, surrounded by inflamed tissue. A abdominal CT showed the internal bumper and tube sited within the transverse colon. When the PEG was sited, it was placed through the transverse colon into the stomach, forming a tract. The internal bumper had eventually eroded through the stomach in 09, passing through the tract and finished in the transverse colon. This caused a faecalent discharge from the PEG. The remnant gastrocolic fistula caused the diarrhoea. Results The PEG tube was cut externally and allowed to pass through defecation. Patient was fed with a NG tube. Colocutaneous fistula remained patent. Diarrhoea had stopped, indicating closure of gastrocolic fistula. Radiological feeding tube insertion was attempted and abandoned as the transverse colon was adherent to the stomach. A PEG insertion was abandoned as trans-illumination was unsuccessful. The patient was not suitable for a surgical feeding tube insertion and he was discharged with long-term NG tube feeding. Conclusion PEG tube placement was first described in 1980.1 It is a safe technique to allow long-term feeding in patients with swallowing difficulties of various aetiologies. However, placement of PEG tubes are not without risk. Approximately 4% of patients experience major complications, such as gastric perforation, gastric bleeding, haematoma, aspiration and death. Another 13% may experience relatively minor complications, such as wound infection, tube dislodgment, aspiration, stomal leak, fever, or ileus.2 Colocutaneous fistulas are a rare complication of PEG tube insertion with only a small number of case reports cited in a Medline literature search.34 This appears to be a higher risk in patients who have undergone a partial gastrectomy, possibly due to the colon migrating into the space around the remnant stomach and/or adhesions.5

PTU-005 Neurodegeneration as a prognostic factor post gastrostomy insertion: to PEG or not to PEG?: Abstract PTU-005

Introduction Gastrostomy insertion is well-accepted as a method for medium and long-term feeding. Although gastrostomy insertion in dementia is recognised as having a poor outcome there is a paucity of data pertaining to other neurodegenerative disease (examples: motor neurone disease, Parkinson9s disease and multiple sclerosis). Methods The aim of the study was to compare the mortality of patients with neurodegenerative disease undergoing gastrostomy with other subgroups requiring the procedure. Data for all patients referred for PEG insertion at our institute are prospectively included in a database. PEG referrals from February 2004 to February 2007 were analysed. Patient demographics, indications and outcome were extracted. Group 1 acute brain injury (acute stroke, head injury, subarachnoid haemorrhage), Group 2 oropharyngeal malignancy, Group 3 neurodegenerative diseases and Group 4 other/miscellaneous (cystic fibrosis, cerebral palsy, severe pneumonia, mucopolysaccharidoses, oesophageal stricture). Results 403 gastrostomies were performed (268 males, median age 64, range 18–94). Patients with neurodegenerative diseases have a worse outcome by comparison to other disease subgroups at 1 year (with a mortality of 74%, p Conclusion This is the first study to observe that patients with neurodegenerative disease have a higher mortality at 1 year after gastrostomy insertion than other subgroups referred. This may reflect the underlying disease. This observation has implications when discussing timing of gastrostomy and obtaining informed consent.

Wearing the Wrong Size Latex Surgical Gloves Impairs Manual Dexterity

Universal precautions mandate that health care workers wear gloves when dealing with patients, often in situations requiring a high level of technical skill. Although it seems obvious that wearing the wrong size gloves could impair or prolong tasks involving manual dexterity, the issue has not been formally studied. We tested the hypothesis that wearing the wrong size gloves impairs manual dexterity. We administered a grooved pegboard test to 20 healthy, paid, volunteer health care workers. The subjects performed the test with bare hands and while wearing their preferred size of latex surgical gloves, gloves that were a full size smaller, and gloves that were a full size larger. Each subject did three runs with each size glove and three runs with bare hands. The time necessary to insert pegs was measured with a stopwatch. Peg insertion time was not affected by wearing preferred size gloves (vs. bare-handed) but was increased 7–10% by gloves that were either too small or too large (both effects: P < 0.05 vs. preferred size; both P < 0.001 vs. bare-handed). The subjects reported that the too-small gloves limited hand motion or hurt their hands, whereas the too-large gloves were clumsy but comfortable. Health care workers should wear gloves that fit properly when doing tasks that require manual dexterity. If the preferred size is unavailable, wearing gloves that are too large seems the best alternative.

Diadochokinetic movements differ between patients with Parkinson’s disease and controls

Instrumental motion assessment, i.e., peg insertion, gains importance as an addition to rating procedures to determine the efficacy of therapeutic interventions and to serve as diagnostic tool in patients with Parkinson's disease (PD). One of their motor features is disturbed execution of alternating motions. The objectives of the study were to assess pronation and supination of the forearms and peg insertion with instruments and to correlate the outcomes with rating scores in PD patients. Controls and 27 idiopathic PD patients, taken off treatment for 12 h, were scored and performed on both devices. PD patients showed a reduced maximum velocity (v), performance interval and amplitude of diadochokinetic movements than controls. V outcomes showed closer associations to rated motor behavior, in particular akinesia and rigidity, and peg insertion results than amplitude, respectively periods of diadochokinetic motion sequences. This altered performance of diadochokinetic movements corresponds to the clinical motor symptoms of PD patients and differs from healthy controls.

Attention to small details: big deal for gastrostomies

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.

Hydrophilic and hydrophobic copolymers of a polyaspartylhydrazide bearing positive charges as vector for gene therapy

AbstractBACKGROUND: The design of polymeric vectors for gene delivery provided with specific properties is one of the most critical aspects for a successful gene therapy. These polymers should be biocompatible as well as able to carry efficiently DNA to target tissues and to transfect it into cells.RESULTS: The formation of complexes of poly[(α,β‐asparthylhydrazide)–poly(ethylene glycol)] and poly[(α,β‐asparthylhydrazide)–hexadecylamine] copolymers functionalised with glycidyltrimethylammonium chloride (PAHy–PEG‐GTA and PAHy–C16‐GTA, respectively) with DNA was studied. The effects of the introduction of hydrophilic (PEG) or hydrophobic (C16) moieties on the chains of PAHy–GTA copolymers, such as the stabilising effect on the DNA structure, were evaluated. In particular, we observed a high DNA protection by PAHy–PEG‐GTA copolymers. Degradation studies led us to suppose a particular aqueous conformation of the polyionic complex of PAHy–PEG2000‐GTA in which DNA should be internalised into an inner core surrounded by a PEG hydrophilic shell; while no significant protection was detected with PAHy–C16‐GTA in which DNA should be disposed on the surface of the complex, freely exposed to DNase II action.CONCLUSION: The insertion of PEG or C16 chains into the polymeric structure of PAHy–GTA copolymers changes significantly the DNA complexing and protecting ability of the PAHy–GTA copolymers, showing that hydrophilic and hydrophobic side chains can play a crucial role in supramolecular arrangements of interpolyelectrolyte complexes between DNA and PAHy copolymers. Copyright © 2008 Society of Chemical Industry

TARGET TRACKING ROBOTIC MANIPULATION THEORIES APPLIED TO FORCE/POSITION CONTROL IN PEG-IN-HOLE ASSEMBLY TASKS

One of the most common tasks in robotic assembly processes is to insert a peg into a hole. On the surface this task seems to be simple and straight forward. However, in order to perform this process successfully it requires a complex interaction between the force and geometry of the robot and environment. Typical industrial robots have sensors at the joints and wrist to monitor the hand position and force during this interaction. Using this sensor information, many manipulation methodologies can be considered to attempt the peg insertion task. Hybrid control is one such compliant control scheme that is commonly used in industry. Nevertheless its theoretical feasibility has stirred much controversy. Recent developments in target tracking for force/position control have made it a viable alternative to hybrid control. This paper compares the performance of target tracking to the already established hybrid control schemes by assessing the outcome of case studies of several simulation experiments of peg-in-hole assembly tasks. The results indicate that the robot inserts the peg into the hole faster and with less friction force by using target tracking.

DPEJ placement in cases of PEG insertion failure

Background and study aims PEG placement is routinely used for enteral feeding; in some cases PEG is not feasible or indicated due to technical difficulties, such as gastric herniation, organ interposition, or presence of gastroparesis. In these cases, surgical gastrostomy or jejunostomy are possible alternatives; more recently, direct percutaneous jejunostomy (DPEJ) has been proposed to avoid surgical intervention. The aim of the study was to evaluate the necessity, technical feasibility and outcome of DPEJ in a group of patients consecutively proposed for PEG placement. Patients and methods In each patient proposed for PEG placement, an upper gastrointestinal endoscopy was performed, and then a pull traction removal gastrostomy tube (18–20 F) was inserted. When PEG was not feasible or contraindicated, a variable stiffness pediatric videocolonscope was used to reach the jejunum: then DPEJ was performed with the same technique and materials as PEG. In both groups enteral feeding was started 24 h after the endoscopic procedure, using an enteral feeding pump and the same nutritional schedules. Results In a 1-year period 90 patients were proposed for PEG placement; PEG could not be performed for technical reasons in 8 (gastric herniation in 1; organ interposition in 7) and gastroparesis in 1. In one patient both PEG and DPEJ were not feasible for organ interposition. The duration of the endoscopic procedure was slightly longer in DPEJ (mean 20 min versus 15 min). No complications related to the endoscopic procedure were observed in both DPEJ and PEG patients. No nutritional complication were observed in the DPEJ group. Conclusion In our experience, PEG was not feasible or contraindicated in about 10% of patients proposed for. In these patients, DPEJ was placed: the procedure resulted to be feasible and safe with the use of a pediatric videocolonscope to easily reach the jejunum. The insertion of DPEJ did not change the nutritional management of enteral feeding. However, long-term effects or complications remain to be evaluated in larger studies.

A Better Method for Preventing Infection of Percutaneous Endoscopic Gastrostomy

BackgroundPercutaneous endoscopic gastrostomy (PEG) has been widely used to maintain enteral nutrition in dysphagic patients. Local and occasional life-threatening systemic infections are still the most common complications, and the major infection source may be nosocomial flora. The effect of antibiotic prophylaxis on reducing peristomal infection is popularly accepted. However, it is accompanied with a possible risk of increasing antibiotic resistance. AimThis study attempted to determine whether 14-day discharge before PEG could reduce the rate of peristomal infection. Materials and MethodsFifty patients who had received PEG in our hospital were included in this study and followed for at least 6 months (except for those patients who died during this period). Patients were separated into two groups randomly. Twenty-five patients received PEG during in-hospitalization (group A). The other 25 patients received PEG until discharge at least for 14 days (group B). The most frequent indication for PEG insertion was the neurological condition. Risk factors for peristomal infection were analyzed statistically using logistic regression and expressed by odds ratios. Every possible factor was analyzed by chi-square test or Student’s t test. ResultOur data showed that group A had a higher peristomal infection rate than group B (32 vs 8%) (p < 0.05).Group A also showed more need of antibiotics. The risk factors related to peristomal infection were group A and lower albumin. The total rate of 30-day mortality was 4%. DiscussionWhen compared with previous data, our study showed a similar infection rate in group A, a lower infection rate in group B, and a lower 30-day mortality rate. This meant that one period of discharge could reduce the peristomal infections caused by colonized bacteria. It also decreased the need of using antibiotics and might avoid the possible adverse consequence of promoting bacterial resistance, which is an alarming and growing problem in hospital practice. ConclusionWe suggest that a 14-day grace period after discharge, before PEG insertion, may decrease peristomal infection rate, length of hospital stay after PEG, and the need for antibiotics. This is suitable for moral and ethical considerations.

SO10P A RETROSPECTIVE ANALYSIS OF WOUND INFECTION AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) IN CANCER PATIENTS

Purpose To determine infectious complications following PEG insertion with attention to the effect of chemotherapy, radiotherapy and timing of PEG insertion.Methodology A review of medical records of patients who underwent PEG insertion at a single institution between 1st July 2003 and 30th June 2005 was performed. PEG infection rate, antibiotic use, and concurrent chemotherapy and/or radiotherapy were recorded. Overall infection rate was calculated and a Quality Control Chart determined no evidence of an infectious outbreak.Results 96 PEG procedures were performed. 92.8% of patients had head and neck cancers, 90.6% had squamous cell carcinoma, 64.6% had distant disease. 71 of 96 patients were male, mean age 61.2 yrs, mean BMI 22.1 kg/m2. Median length of stay was 8 days for infected patients and 5 days for non‐infected patients; median follow‐up 21 days and 19 days respectively. 56 patients had prior chemo‐radiotherapy, 17 radiotherapy alone, 4 chemotherapy alone and 19 had no prior treatment. 14.6% patients had an infection. 21.4% of infected patients did not receive prophylactic antibiotics. Type of cancer, stage of cancer, and co‐morbidities were not predictive of infection. Chemotherapy and/or radiotherapy treatment before, during or after PEG insertion was not statistically significant for PEG infection.Conclusion An infection rate of 14.6% was found, which falls within the range outlined by other authors. Our study investigated a patient group with tumours, the majority of whom had chemo‐radiotherapy around the time of PEG insertion. There was no statistical difference in infection rate due to timing of PEG insertion and no difference with the use of chemo‐radiotherapy.

Complex movement behaviour and progression of Huntington's disease

Instrumental measurement of complex motion sequences with a peg insertion paradigm reflects impairment in patients with Huntington's disease (HD). Objectives were to study progress of HD symptoms and peg insertion results in 39 HD patients without symptomatic drug treatment over an interval of 3 years. Assessments were at baseline and 3 years later. Unified Huntington's Disease Rating Scale (UHDRS) total score, computed arm score and the specific rating outcomes for bradykinesia, chorea, dystonia and oculomotor symptoms significantly increased over a 3-year period. Motor test outcomes significantly worsened. Cognitive scores did not change significantly, but were significantly related to the peg insertion outcomes and to the various UHDRS rating results at both assessments. Peg insertion scores are nonspecific diagnostic marker for progress in HD. Peg insertion particularly reflects motor impairment and additionally higher cognitive and executive dysfunction. These higher cognitive functions are associated with frontostriatal pathology in HD. Our study results suggest that our motor test reflects these emerging deficits of higher cognitive and motor function abilities in HD. We conclude, that instrumental assessment of complex movement sequences is an additional simple method to follow impairment in HD patients in addition to clinical rating.

Complications of Sclera-Covered Enucleation Implants

To determine the incidence of complications associated with the use of donor human sclera to cover porous and nonporous enucleation implants. A retrospective case series of 207 patients receiving donor scleral-covered implants during a standardized enucleation procedure. There was a single case of exposure among the 112 patients (0.9%) receiving nonporous implants. None of the 95 porous implants (0%) demonstrated primary exposure. Conditions leading to the removal of 3 of the 207 (1.4%) implants included primary exposure (n = 1), secondary exposure after peg insertion (n = 1), and postoperative pain (n = 1). Two patients (1%) required postoperative tarsorrhaphies to control chemosis. Conjunctival granulomas developed in 2 patients (1%). Asymptomatic implant rotation was observed in 31% (5/16) of patients receiving flattened porous implants. There were no cases of implant migration or prolonged inflammation related to the covering material. Donor sclera covering of both porous and nonporous enucleation implants appears to be a successful surgical technique associated with few serious complications. The potential benefits of this technique must be balanced by the increased cost of the wrapping material and the rare but potential risk of transmitting infectious disease.