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In a prospective randomized multi-centre study, the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general (narcotic-relaxant) anaesthesia. The 28-day mortality was 6.6% with subarachnoid, and 5.9% with general, anaesthesia. The difference was not significant (95% confidence limits: -3.5 to +4.8). At 1 year following surgery, the mortality was 20.4%. Increasing age, ischaemic heart disease, cardiac failure, preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality. A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality. Senile dementia and admission other than from the patient's own home, were factors associated with a poorer long term outcome. From the point of view of mortality, subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly.

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Neonatal meningitis is a serious problem with a high mortality and frequent neurological sequelae. The incidence of neonatal meningitis was calculated and the aetiology, clinical and laboratory features, and the treatment of cases recorded prospectively over a 7 year 8 month period was documented. It was further investigated whether secondary meningitis had occurred after lumbar puncture.The estimated incidence of bacterial, viral, and fungal meningitis was 0-25, 0-11, and 0-02 per 1000 live births respectively. There were eight cases of early onset meningitis (seven definite, one probable) and group B streptococci accounted for six (75%) of these. Blood cultures were negative in only one of seven cases of definite early bacterial meningitis. Of the 15 late onset cases, Gram negative organisms accounted for six of the seven bacterial cases. The overall mortality was 26%. Of the 11 survivors of bacterial meningitis, three (27%) had significant neurological sequelae at follow up (between three months to three years later).As in the first 48 hours after birth an initial blood culture is unlikely to be negative if bacterial meningitis is present, lumbar puncture can be deferred if the procedure might exacerbate respiratory distress. Although approximately 1880 infants had a lumbar puncture during the review period, only one case of meningitis was found where it was possible that lumbar puncture in a bacteraemic infint may have caused meningeal infection. The incidence of this potential complication must therefore be low.

At every point in the lifespan, the brain balances malleable processes representing neural plasticity that promote change with homeostatic processes that promote stability. Whether a child develops typically or with brain injury, his or her neural and behavioral outcome is constructed through transactions between plastic and homeostatic processes and the environment. In clinical research with children in whom the developing brain has been malformed or injured, behavioral outcomes provide an index of the result of plasticity, homeostasis, and environmental transactions. When should we assess outcome in relation to age at brain insult, time since brain insult, and age of the child at testing? What should we measure? Functions involving reacting to the past and predicting the future, as well as social-affective skills, are important. How should we assess outcome? Information from performance variability, direct measures and informants, overt and covert measures, and laboratory and ecological measures should be considered. In whom are we assessing outcome? Assessment should be cognizant of individual differences in gene, socio-economic status (SES), parenting, nutrition, and interpersonal supports, which are moderators that interact with other factors influencing functional outcome.

DiscussionNewborn infants of diabetic mothers are at risk of developing severe hypoglycaemia. Good control of maternal diabetes during pregnancy increases the fetal survival rate.3 Recent reports4 support the hypothesis that neonatal hypoglycaemia is due to islet-cell hyperplasia, which in turn may be caused in utero by maternal hyperglycaemia. Since perfect control of maternal blood glucose is aimed at during pregnancy, it is logical to avoid excessive stimulation of fetal insulin secretion immediately before delivery.5The combined infusion of insulin and glucose is a simple way of controlling the maternal blood glucose concentration during labour. It also permits adequate hydration of the mother and prevents starvation ketosis. At the same time the stomach may be kept empty, so that a general anaesthetic can be given without delay.Infused insulin is cleared extremely rapidly from the plasma, and by means of an insulin infusion the maternal plasma insulin concentration may be readily adjusted to achieve more-constant blood glucose concentrations. Immediately after delivery maternal insulin requirements fall, and the infusion rate of insulin may be lowered accordingly.Measurement of blood glucose with Dextrostix and the reflectance meter is simple and may be performed by nurses on capillary blood samples obtained by finger-prick at the bedside. The result is available within two minutes and compares favourably with estimations performed by a standard laboratory method. Repeated estimations may be performed without undue discomfort to the patient. (During one premature labour over 100 capillary blood samples were taken in 48 hours.)Provided that simple rules are observed and equipment is properly standardised, management of diabetes during labour with this method becomes a simple procedure suitable for all obstetric units.We thank Mr M Cameron for the obstetric care of these patients, and the labour ward staff and Sister Susan Judd and the house physicians of the medical unit for help with management of the infusions.

Diabetes, heart disease and stroke are significant risk factors for stroke or death following CEA. The risk score model identified patients at higher risk and aided in comparative audit.

Aims To ascertain how closely services for the screening and treatment of retinopathy of prematurity (ROP) were organised on a national level in 1995. Methods Questionnaires about the local arrangements for the screening and treatment of retinopathy of prematurity (ROP) were sent to the entire consultant membership (n = 648) of the Royal College of Ophthalmologists (RCOphth) and to the clinical directors (n = 259) of neonatal units and other units caring for preterm babies in the UK in 1995. Results 568/648 of UK consultants (88%) and 15 non-consultant ophthalmologists and 210/259 paediatricians (81%) and 19% paediatricians in non-neonatal units responded. Thirty-one per cent responding ophthalmologists were involved in the ROP service: of these 64% screened babies, 34% screened and treated babies, while 1% ophthalmologists treated ROP but did not screen. Ninety-six per cent units caring for preterm babies had their babies screened for ROP and for almost 95% of the screening took place in the neonatal unit. About 8200 babies were screened in 1994; 277 developed stage 3, of whom 54% received treatment. Nine per cent (n = 14) and 5% (n = 8) treated babies became blind in one and both eyes respectively. A sessional commitment was identified for 9% ophthalmologists, but for less than half this was included in the contracted work programme. Sixty-five ophthalmologists treated babies with ROP, but only 10 treated more than five babies in 1994. Training needs were identified by 71 respondents. Conclusions Several aspects of ROP screening and treatment services require improvement. Hopefully, reducing the number of identified screeners would increase skills, confidence and the ability to recognise severe disease requiring treatment, and also facilitate incorporation of this work into consultant work plans.