Pre-existing Neurological Disease Research Articles

Chronic exercise preserves brain function in masters athletes when compared to sedentary counterparts

Objective: Exercise is beneficial for both the body and the mind, and it has been associated with protective neurocognitive effects, such as increased levels of brain-derived neurotrophic factor and neurogenesis. These effects are linked to the attenuation of age-related mental decline and the preservation of mental capacities in older, physically active adults. This study evaluated whether masters athletes, a highly active population, have better cognitive function compared to age-matched non-athletes based on the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) tool. Methods: Masters athletes and sedentary controls were recruited and screened for eligibility. All subjects were excluded if they had preexisting neurological diseases, psychiatric disorders, substance abuse disorders, learning disorders, and/or a history of traumatic brain injury, and in addition, control subjects were excluded if they performed >1 h/week of aerobic exercise. All participants completed a health and activity survey which includes the SF-12 and the ImPACT neurocognitive test which measures verbal and visual memory as well as reaction time. Differences between masters athletes and the control population were determined by ImPACT score composites. Results: 51 pairs of athletes and non-athletes were analyzed. Athletes had significantly higher verbal memory scores (85.9 ± 7.7 vs 79.9 ± 13.9, p = 0.01) and faster reaction times (0.71 ± 0.12 vs 0.76 ± 0.15 s, p = 0.04) on the ImPACT test. Athletes also scored significantly higher on the physical components summary score of the SF-12 (55.0 ± 3.3 vs 51.8 ± 6.7, p = 0.004). Conclusion: Masters athletes performed better on verbal memory and reaction time test, as well as on physical function as evaluated by the SF-12, compared to non-athlete controls. Chronic physical activity may preserve neurocognitive processes and increase physical health, which are protective factors for the negative effects of the aging process.

Retrospective evaluation of prognostic indicators in dogs with head trauma: 72 cases (January-March 2011).

To investigate the prognostic value of clinical and laboratory variables and scoring systems in dogs with head trauma. Retrospective study (January-March, 2011). University teaching hospital. Seventy-two client-owned dogs with a history of head trauma occurring ≤5 days prior to hospital admission. Dogs were excluded if they had an unconfirmed history of trauma, preexisting neurologic disease, or insufficient data available in the medical record. None. Data from hospital admission were collected, including vital signs; blood pressure; pulse oximetry; venous blood gases and electrolyte concentrations; plasma lactate and blood glucose concentrations; PCV; total plasma protein concentration; activated clotting time; WBC count; and serum albumin, creatinine, total bilirubin, and BUN concentrations. Modified Glasgow Coma Scale (MGCS), mentation, and animal trauma triage (ATT) scores were also calculated. Treatment with mannitol, hypertonic saline (HS), corticosteroids, benzodiazepines, or phenobarbital, and requirement for endotracheal intubation were also recorded. Outcome was classified as survival or nonsurvival to hospital discharge. Decreased pulse oximetry, pH, bicarbonate concentration, or base excess, and increased potassium concentration, lactate concentration, BUN concentration, ATT score, or mentation score were risk factors for nonsurvival. Decreased MGCS score was the strongest predictor of nonsurvival; a score ≤ 11 was 84% sensitive and 73% specific for predicting nonsurvival. Dogs were more likely to die before discharge if they required HS or endotracheal intubation. Dogs that did not survive following head trauma were more likely to have poor perfusion, severe concurrent injuries reflected by increased ATT scores, severe traumatic brain injury as evidenced by decreased MGCS or increased mentation scores, or requirement for HS administration or endotracheal intubation.

Neurology of the H1N1 pandemic in Singapore: a nationwide case series of children and adults.

Neurologic complications have long been associated with influenza. A novel strain of influenza A (H1N1) first described in humans to have outbreak potential in 2009 in Mexico went on to become the first influenza pandemic of this century. We evaluated the neurologic complications of the novel influenza A (H1N1) 2009 in children and adults admitted to all public hospitals in Singapore during the influenza A (H1N1) 2009 pandemic between May 2009 and March 2010. All patients were positive for novel H1N1 infection and presented with neurologic symptoms prior to oseltamivir treatment. Ninety-eight patients (median age 6.6 years, range 0.4-62.6) were identified; 90 % were younger than 18 years; 32 % suffered from preexisting neurological, respiratory, or cardiac disease; and 66 % presented with seizures. Of those presenting with seizures, new onset seizures were the most common manifestation (n = 40, 61.5 %), followed by breakthrough seizures (n = 18, 27.7 %) and status epilepticus (n = 7, 10.8 %). Influenza-associated encephalopathy occurred in 20 %. The majority of children (n = 88) presented with seizures (n = 63, 71.6 %), encephalopathy (n = 19, 21.6 %), and syncope (n = 4, 4.5 %). Among adults, a wider range of neurological conditions were seen, with half of them presenting with an exacerbation of their underlying neurological disease. The neurological symptoms developed at a median of 2 days after the onset of systemic symptoms. The median length of hospital stay was 3 days, and 79 % were monitored in general wards. Neurologic complications associated with the novel influenza A (H1N1) 2009 strain were generally mild and had a good outcome. They occurred more frequently in patients with underlying neurological disorders. Seizures and encephalopathy were the most common manifestations, similar to other influenza virus strains.

Regional Anesthesia in Patients With Preexisting Neurologic Disease.

Since publication of initial recommendations in 2008, there is limited new information regarding the performance of regional anesthesia in patients with preexisting neurologic diseases. However, the strength of evidence has increased since 2008 regarding (1) the concern that diabetic nerves are more sensitive to local anesthetics and perhaps more susceptible to injury and (2) the concern that performing neuraxial anesthesia and analgesia in patients with preexisting spinal canal pathology may increase the risk of new or worsening neurologic symptoms. This increased evidence reinforces our initial recommendations. In addition, since the initial recommendations in 2008, the concept of postsurgical inflammatory neuropathy has been described and is potentially a contributor to postoperative neurologic dysfunction.

Intermittent Dialysis Leading to Dialysis Disequilibrium Syndrome

Dialysis disequilibrium syndrome (DDS) is a critical and ultimately fatal condition that presents in hemodialysis patients. Serious manifestations of DDS involve impaired concentration, disorientation, and coma. Risk factors for the condition include dialysis treatment, elevated BUN, renal disease, metabolic acidosis, and pre-existing neurologic disease. There are three main theories proposed to account for the development of DDS, including a reverse urea effect, idiogenic osmoles, and paradoxical brain acidosis. Each of these theories potentiates cerebral edema, and eventually brain herniation, that leads to death. This case examines a 33-year-old Hispanic male brought to the emergency room. He was admitted to the ICU based on hospital findings and had a metabolic acidosis that persisted despite appropriate initial treatment. He was eventually placed on hemodialysis over the course of 2 weeks, and ultimately expired from DDS. This paper aims to demonstrate that hemofiltration is a superior alternative in patients where hemodialysis is indicated, so that DDS, and subsequent fatality, can be avoided. World J Nephrol Urol. 2015;4(3):247-250 doi: http://dx.doi.org/10.14740/wjnu228e

The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015.

The Second American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine updates information that was originally presented at the Society's first open forum on this subject (2005) and published in 2008. Portions of the second advisory were presented in an open forum (2012) and are herein updated, with attention to those topics subject to evolving knowledge since the first and second advisory conferences. The second advisory briefly summarizes recommendations that have not changed substantially. New to this iteration of the advisory is information related to the risk of nerve injury inherent to common orthopedic surgical procedures. Recommendations are expanded regarding the preventive role of various monitoring technologies such as ultrasound guidance and injection pressure monitoring. New clinical recommendations focus on emerging concerns including spinal stenosis and vertebral canal pathologies, blood pressure management during neuraxial anesthesia, administering blocks in anesthetized or deeply sedated patients, patients with preexisting neurologic disease, and inflammatory neuropathies. An updated diagnostic and treatment algorithm is presented.

Regional anesthesia in patients with pre-existing neurologic disease.

Regional anesthesia is controversial in patients with pre-existing neurologic disease. This study reviews the published evidence regarding the utilization and outcomes of regional anesthetics in this population. Although publications are sparse, neuraxial and peripheral regional techniques have been successfully described in patients with spinal cord injury, multiple sclerosis, Guillain-Barre disease, neurofibromatosis, diseases of the neuromuscular junction, and Charcot-Marie Tooth disease without neurologic complications. Ultrasound guidance may aid in reduction in local anesthetic dose, anatomical evaluation and avoidance of needle trauma. Regional anesthesia can be safely utilized in patients with pre-existing neurological disease and may have benefits over general anesthesia; however, a conservative approach is warranted. In addition, further publications regarding regional techniques in this population are needed.

Cerebral oxygen desaturation monitored by intraoperative near-infrared spectroscopy and incidence of post-operative cognitive dysfunction: a systematic review

Background Many advances have been made in the field of anesthesia to properly protect and monitor cerebral function and oxygenation during surgery; yet the incidence of cerebral injury, including postoperative cognitive dysfunction (POCD) remains high. Cerebral oxygen saturation measured by cerebral oximetry has the potential to decrease incidence of POCD and improve patient outcomes. Objectives To synthesize the evidence on whether there is a direct relationship between cerebral oxygen desaturation using intraoperative cerebral oximetry monitoring and the incidence of post-operative cognitive dysfunction. Inclusion criteria Types of participants This review considered all patients over the age of eight years old receiving general anesthesia for any surgical procedure, as patients younger than this age usually have different anesthetic emergence and transfer processes than patients older than eight years of age. Patients with pre-existing neurologic disease including stroke, alcohol abuse, history of psychiatric disorders and emergency cases were excluded, since a baseline neurologic test cannot be performed appropriately. Type of intervention This review considered studies that examine the use of near infrared spectroscopy or cerebral oximetry as a monitor for cerebral oxygen saturation and desaturation in patients receiving general anesthesia. Types of studies This review considered randomized controlled trials, cohort studies and case-control studies. Types of outcomes The review considered studies that include measurements of postoperative neurological deficit, or postoperative cognitive dysfunction related to cerebral oxygen desaturation as outcome measures. Search strategy The search strategy aimed to find both published and unpublished studies and papers. The search was limited to the English language, beginning with the first human reported cerebral oximetry studies using near-infrared spectroscopy in 1985 through 2013. The search was performed across: CINAHL, MEDLINE, [email protected], EMBASE, Elsevier Science Direct, Mednar and ProQuest. Methodological quality Studies were critically appraised by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data collection Data was extracted using the standardized data extraction tools from the Joanna Briggs Institute. Data synthesis Due to the heterogeneity of the data and outcome measurements, a meta-analysis was not possible; results are presented in a narrative summary. Results Ten studies were included in the review: Two randomized controlled trials (RCT) and eight cohort studies. In eight of the studies, monitoring of cerebral oxygen saturation by cerebral oximetry was supported. Two of the studies supporting this intervention were RCTs. Three of the studies conclude that cerebral oxygen desaturation increases length of hospital stay. Conclusions Based on the included literature, maintenance of cerebral oxygen saturation monitored by cerebral oximetry has the potential to reduce incidence of POCD. Avoidance of cerebral oxygen desaturation is also associated with a reduction in postoperative complications, including decreased length of hospital stay and faster recovery. Implications for practice The use of cerebral oximetry as an adjunct monitor during general anesthesia can help the anesthesia provider reduce incidence of postoperative cognitive dysfunction. This impacts practice and patients in that reduction of cognitive decline has the potential to aid patients to recover faster, allowing them to resume activities of daily living quicker and face a potentially shorter hospital stay. Implications for research The literature for this topic consists mainly of prospective observational cohort studies. Further randomized controlled trials are needed to determine if a higher threshold for minimal cerebral oxygen levels may decrease incidence of POCD. There is still some controversy regarding this monitoring device and incidence of cognitive decline, since there is no set safe threshold allowing deviation from baseline values. Further research is also needed to determine if prevention of cerebral oxygen desaturation has any implications in overall hospital costs.

Prevalence and risk factors for canine post-anesthetic aspiration pneumonia (1999–2009): a multicenter study

ObjectiveTo determine the incidence of canine post-anesthetic aspiration pneumonia (AP) and to identify anesthetic agents, procedures and management factors associated with the development of AP. Study designMulticenter, randomized, case-controlled retrospective study. AnimalsTwo hundred and forty dogs affected with AP and 488 unaffected control dogs. MethodsElectronic medical record databases at six Veterinary colleges were searched for dogs, coded for anesthesia or sedation and pneumonia from January 1999 to December 2009. The resultant 2158 records were hand-searched to determine eligibility for inclusion. Diagnosis of AP was made radiographically. Two unaffected control dogs were randomly selected for each affected dog, from a list of dogs that underwent sedation or anesthesia in the same time period and did not develop aspiration pneumonia. Fifty-seven factors were then evaluated for association with aspiration pneumonia. Data analysis was performed using univariate Chi-square or student t-tests, then multivariate logistic regression. ResultsIncidence of post-anesthetic AP was 0.17%, from 140,711 cases anesthetized or sedated over the 10 year period. Two anesthesia-related events were significantly associated with development of AP: regurgitation and administration of hydromorphone at induction. Administration of anticholinergics was not associated with AP. Procedures associated with increased odds of aspiration pneumonia included laparotomy, upper airway surgery, neurosurgery, thoracotomy and endoscopy. Orthopedic surgery, ophthalmologic surgery, dental procedures, MRI, CT, bronchoscopy, cystoscopy, tracheoscopy and neutering were not associated with development of AP. Three patient factors were associated with the development of AP: megaesophagus, and a history of pre-existing respiratory or neurologic disease. Sixty-nine% of dogs with two or more of the above independent predictive variables developed AP. Conclusion and clinical relevanceMost anesthetic agents and procedures were not associated with the development of AP. We need to devise and evaluate strategies to protect at risk patients.

Anesthesia for cesarean section in patients with preexisting neurologic diseases--10 years of practice

Regional anesthesia is considered a 'gold standard' for cesarean sections. However, it is very often contraindicated in patients with coexistent neurological diseases. This article attempts to review the specific concerns for administration of anesthesia for cesarean section posed by spinal diseases, epilepsy sclerosis multiplex and others. We present 85 cases of parturients with pre-existing neurological diseases, who received anesthesia for caesarean section at the First Clinic of Anesthesia and Intensive Care in the last 10 years. We compared those cases with the medical literature. We successfully used general as well as regional anesthesia. The decision about the anesthetic technique was based on the neurological state of each patient. No guidelines for anesthesiologist concerning the best anesthetic technique for patients with neurological diseases have been designed so far. The choice of the safest method is made individually and depends on a variety of factors.

Ceftriaxone-induced acute encephalopathy in a peritoneal dialysis patient.

Encephalopathy is a rare side effect of third and fourth generation cephalosporins. Renal failure and preexisting neurological disease are notable risk factors. Recognition is important as discontinuing the offending agent usually resolves symptoms. We present a case of acute encephalopathy in a patient with end stage renal disease (ESRD) treated with peritoneal dialysis (PD) who received intravenous ceftriaxone for peritonitis. This case illustrates the potential severe neurologic effects of cephalosporins, which are recommended by international guidelines as first-line antimicrobial therapy for spontaneous bacterial peritonitis.

The epidemiology of respiratory arrests in a teaching hospital

AimsWe aimed to characterise antecedent causes and outcomes of respiratory arrests occurring within a metropolitan tertiary teaching hospital in Melbourne, Australia. MethodsWe conducted a retrospective audit of respiratory arrests within our hospital over a 6-year period. Data were collected regarding patient characteristics, preceding clinical state, presumed causes and outcomes of arrests. We also compared outcomes of respiratory arrests to that of cardiac arrests occurring over the same period. ResultsWe identified 82 respiratory arrests, occurring at a rate of 0.57/1000 inpatient admissions. Pre-existing respiratory, neurologic and cardiac disease was common, as was multi-morbidity. Preceding clinical instability was evident in 39% of arrests, most commonly elevated respiratory rate or progressive hypoxia. Pulmonary oedema was the most common cause of respiratory arrest followed by aspiration, neurologic events, medication side-effects, and tracheostomy-tube complications. In-hospital mortality for respiratory arrests was 25.1%, compared with 74.9% for cardiac arrests (p<0.001) over the same time period. ConclusionsAlthough rare, respiratory arrests are associated with significantly lower in-hospital mortality than cardiac arrests. Further studies are needed to better predict respiratory arrests and identify interventions to reduce incidence and improve outcomes.

Orphan symptoms in advanced cancer patients followed at home

Orphan symptoms are rarely assessed, particularly at home. The aim of this multicenter prospective study was to assess the prevalence of these symptoms and eventual factors possibly associated in advanced cancer patients at admission of a home care program. A prospective study was performed at three home care programs in Italy. Patients' data were collected, including age, sex, diagnosis, and Karnofsky status. Possible contributing factors were analyzed; preexisting neurological diseases, cerebral metastases, hyperthermia, diabetes, a state of dehydration clinically evident and/or oliguria, possible biochemical parameters when available, data regarding recent chemotherapy, opioids and doses, use of neuroleptics, benzodiazepine or anticonvulsants, corticosteroids, anti-inflammatory, and antibiotics were collected. Myoclonus, hiccup, sweating, pruritus, and tenesmus, either rectal or vesical, were assessed, according to a preliminary definition, at time of home care program admission. Three hundred sixty-two patients were surveyed at the three home care programs. Globally, 48 patients presented one or more orphan symptoms in the period taken into consideration, and 7 patients presented more than 1 symptom. One patient presented occasional and diffuse myoclonus. Nineteen patients presented sweating, 13 patients presented pruritus, and 14 patients presented hiccup. Finally, nine patients presented rectal or vesical tenesmus. There was a significant correlation between sweating and transdermal fentanyl use (P = 0.044), fever (P = 0.001), hiccup (P < 0.0005), and vesical tenesmus (P = 0.028). Pruritus was not associated to any factor. Hiccup was associated with gender (males, P = 0.006) and sweating (P < 0.0005). Vesical tenesmus was associated with fever (P = 0.019) and sweating (P = 0.028). Although the symptoms examined have a low prevalence in advanced cancer patients admitted to home care, the distress for patients may be high and deserve further analyses. Given the low prevalence of these symptoms, large studies are needed to find possible associated factors.

Rise of community-onset urinary tract infection caused by extended-spectrum β-lactamase-producing Escherichia coli in children

Urinary tract infection (UTI) caused by resistant bacteria is becoming more prevalent. Few studies are available regarding community-onset UTIs caused by extended-spectrum β-lactamase (ESBL)-producing bacteria in children. During a 5-year period, hospitalized children with community-onset UTI caused by ESBL-producing Escherichia coli (case) and those with non-ESBL-producing E. coli (control) were identified. Patients with long-term care facility stay within the preceding month and those with urine cultures obtained >72 hours after admission were excluded. Clinical features and risk factors associated with the occurrence of ESBL-producing E. coli UTI were reviewed. The prevalence of UTI due to ESBL-producing E. coli increased slightly from 0.59% in 2002 to 0.96% in 2006. A total of 104 cases and 208 controls were included for comparison. The ciprofloxacin resistance of the ESBL-producing E. coli increased significantly in this period (p = 0.006). Pre-existing neurological diseases (p < 0.001), use of antibiotics in the past 3 months (p < 0.001), and recent hospitalization within 1 month (p < 0.001) were found to be potential risk factors. Moreover, previous exposure to third-generation cephalosporins (p < 0.001) and aminoglycosides (p < 0.001) was associated with the selection of ESBL-producing E. coli. Children with ESBL-producing E. coli UTIs had a longer hospital stay (p = 0.031) than those without. ESBL-producing E. coli gradually became coresistant to other broad-spectrum antibiotics, notably ciprofloxacin. UTIs caused by such resistant organisms led to a longer hospital stay and more antibiotic use. Reinforcement of infection control measures, especially hand washing in childcare settings and antibiotic stewardship, is critical to reduce the spread of ESBL-producing E. coli.

Parental management of children’s seizures at home

AimParents play an important role in the management of seizures at home. Their attitude has to be fast and efficient enough to avoid complications such as aspiration pneumonia or persistent seizures. The main goals of this study were to analyse the quality of parental management and the predictors of admission after a seizure.MethodA five-year retrospective study of children suffering from seizures at home was conducted. Data were retrieved by medical records and completed by a structured questionnaire.ResultsA total of 114 children were included in the study. Thirty-six percent of the parents turned the child in a lateral security position. Sixty-one percent of the parents did not administer intra-rectal diazepam, when the drug was indicated following the current guidelines. The reasons why diazepam was not administered were the lack of awareness of the procedure, lack of diazepam at home and impossibility to keep calm during the episode. The national emergency numbers were called within a median of 18 min after the seizure started, with a significant correlation between this delay and the total duration of seizures. The predictors of in-hospital admission were drug administration by the mobile unit (SMUR) (OR: a = 25.2; p = 0.001), a diagnosis of status epilepticus (OR: a = 23.6; p < 0.0001) and a pre-existing neurological disease (OR: a=0.19; p = 0.02).ConclusionsOur study finds a significant rate of inappropriate management of paediatric seizures at home. Improving parental education and the use of newer formulations of antiepileptic drugs are necessary to reduce morbidity associated with seizures.

International Society of Sports Nutrition position stand: energy drinks.

Position Statement: The International Society of Sports Nutrition (ISSN) bases the following position stand on a critical analysis of the literature on the safety and efficacy of the use of energy drinks (ED) or energy shots (ES). The ISSN has concluded the following. 1. Although ED and ES contain a number of nutrients that are purported to affect mental and/or physical performance, the primary ergogenic nutrients in most ED and ES appear to be carbohydrate and/or caffeine. 2. The ergogenic value of caffeine on mental and physical performance has been well-established but the potential additive benefits of other nutrients contained in ED and ES remains to be determined. 3. Consuming ED 10-60 minutes before exercise can improve mental focus, alertness, anaerobic performance, and/or endurance performance. 4. Many ED and ES contain numerous ingredients; these products in particular merit further study to demonstrate their safety and potential effects on physical and mental performance. 5. There is some limited evidence that consumption of low-calorie ED during training and/or weight loss trials may provide ergogenic benefit and/or promote a small amount of additional fat loss. However, ingestion of higher calorie ED may promote weight gain if the energy intake from consumption of ED is not carefully considered as part of the total daily energy intake. 6. Athletes should consider the impact of ingesting high glycemic load carbohydrates on metabolic health, blood glucose and insulin levels, as well as the effects of caffeine and other stimulants on motor skill performance. 7. Children and adolescents should only consider use of ED or ES with parental approval after consideration of the amount of carbohydrate, caffeine, and other nutrients contained in the ED or ES and a thorough understanding of the potential side effects. 8. Indiscriminant use of ED or ES, especially if more than one serving per day is consumed, may lead to adverse events and harmful side effects. 9. Diabetics and individuals with pre-existing cardiovascular, metabolic, hepatorenal, and neurologic disease who are taking medications that may be affected by high glycemic load foods, caffeine, and/or other stimulants should avoid use of ED and/or ES unless approved by their physician.

Pediatric idiopathic transverse myelitis presenting as an anterior cord syndrome: A case report

Describe the case of an Anterior Cord Syndrome secondary to transverse myelitis. ANTERIOR CORD SYNDROME: Anterior Cord syndrome (ACS) is characterized by a lesion that affects the anterior two thirds of the spinal cord while preserving the posterior columns. TRANSVERSE MYELITIS: Transverse myelitis (TM) is an inflammatory disorder with a heterogeneous pathogenesis affecting the spinal cord at one or more segments, resulting in motor, sensory, and autonomic dysfunction in the absence of a preexisting neurological disease or spinal cord compression. The patient was treated with methylprednisolone, IV Antibiotics, acyclovir, and inpatient rehabilitation. The patient significantly improved her function throughout inpatient rehabilitation and was discharged after achieving modified independent level with ambulation and all activities of daily living. The patient also gained independence with an intermittent catheterization program and a nightly bowel program, which included suppository and digital stimulation. This case illustrates the first documented pediatric patient with a unique case of Anterior Cord Syndrome caused by idiopathic transverse myelitis.

Mutism and Persistent Dysarthria Due to Tacrolimus-Based Immunosuppression Following Allogeneic Liver Transplantation

Tacrolimus is a potent immunosuppressant medication with a low therapeutic index. We report a case of mutism with persistent dysarthria in a patient receiving tacrolimus-based immunosuppression following allogeneic liver transplantation. A 59-year-old female patient with end-stage liver disease secondary to primary sclerosing cholangitis underwent successful allogeneic liver transplantation. The patient was started on tacrolimus for prevention of allograft rejection and subsequently developed complete mutism. Following consultation of the medical toxicology service, tacrolimus was discontinued and the patient's mutism gradually improved. However, the patient still has moderate dysarthria more than 2 years after tacrolimus discontinuation. The Naranjo probability scale revealed a probable adverse reaction of mutism and dysarthria associated with tacrolimus therapy. Mutism is an uncommon complication of calcineurin inhibitors. Both cyclosporine and tacrolimus have been associated with mutism, though mutism may be more common in patients treated with tacrolimus. The mechanism of injury has not been delineated, although liver transplant patients and patients with preexisting hepatic encephalopathy or neurologic disease may be at increased risk for this complication. The mainstay of treatment is tacrolimus dose reduction or discontinuation, although benzodiazepine therapy may be beneficial in the treatment of this disorder. Clinicians should be aware of the potential adverse effects associated with calcineurin inhibitor toxicity in transplant patients and should advocate for aggressive and rapid treatment of this serious adverse drug effect.

Medulloblastoma presenting as dialysis disequilibrium syndrome

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder that occurs during or after hemodialysis. This is caused by brain edema that manifests as neurological symptoms that include headache, emesis, nausea, blurring of vision, disturbed consciousness, tremors and seizures, and in severe cases, death. The incidence of DDS is very high among patients with preexisting neurological diseases. There has been much debate about the origin of DDS. We report a case of DDS, as presenting syndrome of a medulloblastoma in a child aged 5 years, and discuss the pathogenesis and the possible role of DDS for an earlier detection of occult brain lesions in dialyzed patients.

Anaesthetic implications of neurological disease in pregnancy

The advances in medicine mean that more women with pre-existing neurological disease, who previously may not have lived to childbearing age, are choosing to become pregnant despite the risks. Other women may coincidentally exhibit their first symptoms during pregnancy. When caring for these patients, it is important to have a comprehensive understanding of the underlying pathophysiology and recognize the potential for exacerbation during pregnancy. Neurological disease remains a significant cause of maternal morbidity and mortality with eight direct and 37 indirect deaths attributed to central nervous system (CNS) disorders in the 2003–5 CEMACH report (Table 1).