Natural history of cognitive deficits and their relationship to MRI T2-hyperintensities in NF1

BACKGROUND

Cognitive impairment is the most common complication of neurofibromatosis type 1 (NF1) in childhood. Current research suggests a strong relationship between cognitive deficits and brain T2-hyperintensities. The majority of these lesions disappear as the child ages. Cross-sectional data suggest that there also are improvements in intellect.

OBJECTIVE

To determine the natural history of cognitive functioning and MRI T2-hyperintensities from childhood into adulthood, and whether changes in MRI T2-hyperintensities over time are predictive of changes in cognitive functioning.

METHODS

The authors conducted a prospective longitudinal study of a cohort of 32 patients with NF1 and 11 unaffected sibling controls. All patients underwent neuropsychological assessments and 27 children underwent MRI examinations. The patients were then reassessed after an 8-year period.

RESULTS

and

CONCLUSIONS

There was no improvement in cognitive ability as the children with NF1 developed into adulthood compared with controls. Despite significant decreases in the number, size, and intensity of the T2-hyperintensities over the 8-year period, these changes were not associated with changes in cognitive ability. T2-hyperintensities in the cortex or subcortical or deep white matter are more frequent with age and these lesions are likely to have a different pathology than basal ganglia lesions. The best predictor of cognitive dysfunction in adulthood was the presence of T2-hyperintensities in childhood, rather than current lesion status. There is a limited time window (<18 years) in which the presence of T2-hyperintensities can be used as biologic markers of cognitive dysfunction.

Congenital adrenal hyperplasia: preliminary observations of the urethra in 9 cases

PURPOSE

Congenital adrenal hyperplasia is the most common cause of androgen mediated virilization of the genitourinary tract in females. In our study relative lengths of the internal genital duct structure were compared with the degree of virilization of the external genitalia.

MATERIALS AND METHODS

The records of 9 consecutive female patients with a median age of 2.6 years with congenital adrenal hyperplasia were studied. There were 4 normal females with a median age of 7.4 months who had a voiding cystourethrogram for urinary tract infection used as controls. The patients with congenital adrenal hyperplasia were stratified into groups as having mild, moderate or severe virilization based on preoperative photographs of external genitalia. By lateral voiding cystourethrograms the length of the proximal urethra, vagina and urogenital sinus was measured and standardized against the femoral metaphysis. The relative length of these internal genital structures was compared to the degree of virilization of the external genitalia.

RESULTS

There were 4 cases classified as normal, and 2 mildly, 4 moderately and 3 severely virilized. The urogenital sinus appeared to lengthen, with increasing virilization of the external genitalia. There was no trend for the proximal urethra to shorten with increasing virilization. The vagina also seemed to shorten with increasing virilization.

CONCLUSIONS

Our results suggest that the vagina enters the urogenital sinus at a fixed distance from the bladder neck. With increasing virilization, the majority of urethral lengthening occurs primarily distal to the vaginal opening, that is urogenital sinus lengthening.

Congenital fibrosis of the extraocular muscles associated with cortical dysplasia and maldevelopment of the basal ganglia

BACKGROUND

Congenital fibrosis of the extraocular muscles (CFEOM) is a rare condition that has been traditionally regarded as a primary eye muscle disease. Recent studies, however, suggest that CFEOM may be the result of a primary neuropathy with secondary myopathic changes.

PURPOSE

To describe a previously unrecognized association between congenital fibrosis of the extraocular muscles and structural abnormalities of the brain.

DESIGN

Small case series.

METHODS

Detailed clinical examinations and neuroradiologic studies were performed on the three affected family members. In addition, genetic analysis of the family was performed.

RESULTS

The three affected family members, mother and two children, have the ocular features of 'classic' congenital fibrosis of the extraocular muscles. All showed dilation of the left lateral ventricle secondary to hypoplasia of the body and tail of the ipsilateral caudate nucleus. There was fusion of an enlarged caudate nucleus head with the underlying putamen. Both children showed widespread bilateral cortical dysplasia. Genetic analysis of the family was inconclusive but consistent with linkage to the CFEOM1 locus on chromosome 12. Chromosomal analysis of the affected individuals did not show evidence of a deletion of chromosome 12 and haplotype analysis was not suggestive of a microdeletion.

CONCLUSIONS

Cerebral cortical and basal ganglia maldevelopment can be found in individuals with CFEOM. This suggests that neuroimaging should be considered in the initial diagnostic evaluation of these patients, particularly if there is developmental delay.

Facial fractures in children

OBJECTIVE

To determine the pattern of injury of facial fractures in children, the relative contribution of plain radiography and CT scanning in the diagnosis of these injuries, and factors leading to delayed diagnosis.

DESIGN

Retrospective case note review.

PARTICIPANTS

All children with facial fractures identified using the trauma and medical record databases at our institution.

RESULTS

Forty-six children with 59 facial fractures presented over a 4-year, 2-month period from November 1995 to December 1999. The median age was 10 years, with a range from 1 to 14. There was a 2-to-1 male-to-female sex ratio. A motor vehicle accident (MVA) involving a child as passenger, pedestrian, or cyclist accounted for 63% of cases. In seven of these, the child was either a front seat passenger or inappropriately restrained for their age and size. In all but one case, the presence of a fracture was associated with an overlying laceration, abrasion, or significant soft tissue edema. Initial examination and plain radiologic assessment by a pediatric clinician led to diagnostic delay in nine children. Facial CT was performed in 38 children, and all results were positive. Twenty-six patients required operative intervention for their facial fracture. Associated injuries, particularly of the head and limbs, were present in all but six patients.

CONCLUSIONS

Facial fractures were uncommon overall but occurred more frequently in children with major trauma. Plain facial radiographs provided limited additional diagnostic information to careful clinical examination and often fail to detect or clearly define a facial fracture in children. In the correct clinical setting, a facial CT scan allows accurate diagnosis of the injury and can reveal previously unsuspected additional fractures.

Constraint-induced motor relearning after stroke: a naturalistic case report

Constraint-induced movement therapy (CIMT) is a promising approach to promoting recovery of functional arm movement after stroke. However, controlled studies have been limited to persons who sustained strokes at least 1 year before beginning the treatment protocol. This case study documents the neurologic history and motor recovery of a woman whose natural circumstances lend support to the principles of CIMT. The patient sustained a right midpontine vascular infarct and fell simultaneously, fracturing her right humerus. Orthopedic intervention for the fracture mirrored the protocol suggested by proponents of CIMT by immobilizing her right arm. Her significant recovery of left arm use over a 1-year period was more extensive than what would be typically expected after the type of cerebral infarct she incurred. Her case provides the first evidence in the literature that supports the principles of CIMT when it is applied immediately poststroke.

Parental values in the decision about cochlear implantation

Parents of children who are deaf are required to make decisions shortly after diagnosis that will affect the child's method of communication and educational placement. This study examines the role of parental values and preferences in this decision making process. Twenty families with a deaf child participated in this study. Parents from 19 of these families completed a multi-attribute preference study, which assesses their preference for different outcomes in four domains, i.e. academic achievement, social life, communication, and emotional well being. In ten of these families, the child had received a cochlear implant. Results indicate wide variability in parental preferences, which do not appear to correlate with the parents' decisions to choose cochlear implantation. Interview data from the study provides some insight into the parents' motivations. The small size of the study limits further analysis of factors that influence parents' choices and suggests further study with larger numbers of families.

A haplotype relative risk study of the dopamine D4 receptor (DRD4) exon III repeat polymorphism and attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is a developmental syndrome expressed along three domains: inattention, hyperactive-impulsive, and combined type. Several investigations have recently examined the role of the dopamine DRD4 exon III repeat polymorphism in ADHD. The long 7 repeat allele of this receptor was shown in three family-based studies, but not in one case control design, to be a risk factor for this disorder. We now report an additional family-based study of DRD4 exon III repeat region and ADHD. However, in the current study we fail to observe preferential transmission of the DRD4 exon III long 7 repeat allele, chi(2) = 0. 142, P < 0.1, df = 1. Nor was any preferential transmission observed when genotypes were compared, chi(2) = 0.180, P > 0.1, df = 1. Possible reasons are discussed, especially lack of sufficient power in analying more refined phenotypes, why the current results in contrast to previous findings fail to support a role for the long form of the DRD4 receptor as a putative risk factor for ADHD.

Evaluation of a workshop to teach clinical bioethics in the clinical setting

That the teaching of medical ethics must extend into the clinical years in order for medical students to effectively acquire the knowledge and skills required for dealing with clinical bioethical issues has been widely recognized. A limiting factor has been the lack of physicians able to teach bioethics in the clinical setting. This paper describes the structure and evaluation of a workshop for teaching clinicians how to teach bioethics in the clinical setting. 80 physicians participated in 4 workshops in which they were provided with the ethical principles needed to deal with clinical bioethical issues and appropriate teaching methods. Methods such as paper cases, videotaped standardized patient interactions and live standardized patients were presented. The workshops have been highly evaluated. Post workshop evaluation showed that a significant number of physicians taught ethical issues during rounds and seminars. The frequency of teaching ranged from once per month to one or more times per week.

Longitudinal changes in attitudes of offspring concerning life-sustaining measures for their terminally ill parents

OBJECTIVES

To define longitudinal changes in the attitudes of offspring concerning life-sustaining measures for their older, terminally ill parents and to determine whether experience of a "life event" influences such decisions.

DESIGN

An attitudinal survey of three groups.

SETTING

The geriatric department of a university-affiliated general hospital.

PARTICIPANTS

Fifty-one subjects who had been interviewed regarding life-sustaining treatment for their terminally ill parents were reinterviewed 6 years later. In addition, a control group composed of 116 participants was generated from patients visiting hospital outpatient clinics. The control group had no prior experience involving hospitalization of a first-degree relative as a result of a life-threatening situation.

INTERVENTIONS

Each subject took part in a personal interview.

MAIN OUTCOME MEASURES

Attitudes regarding life-sustaining measures were assessed, and the subjects' sociodemographic and religious characteristics were noted.

RESULTS

The attitudes of offspring in the acute phase situation and after the passage of 6 years were strikingly consistent. Twenty-one percent had requested the initiation of resuscitation in the acute phase ("real time"), and 27.4% said the same 6 years later. The provision of nutrition and medication was requested by approximately 70% of participants both at the acute phase and 6 years later. When comparing each individual's personal views at the interviews with all others, consistency in attitude was found among answers to most questions. When comparing the acute phase group with the control group, a significantly higher percentage of the former requested the initiation of resuscitation (48.3% vs 25%), whereas a smaller percentage preferred that the decision be made by the physician (3.5% vs 21.3%). Active euthanasia was requested by 6.5% of the acute phase group and 12.9% of the control group.

CONCLUSIONS

The decisions made by offspring regarding life-sustaining measures for their terminally ill parent at real time remain unchanged 6 years after the event. Exposure to a life event significantly affects the decision-making of the offspring of a terminally ill parent. However, the subject's attitude toward extreme solutions--opposing active euthanasia and requesting the administration of nutrition and medication--was not influenced by the fact that the subject had undergone a life event.

Haplotype relative risk study of catechol-O-methyltransferase (COMT) and attention deficit hyperactivity disorder (ADHD): association of the high-enzyme activity Val allele with ADHD impulsive-hyperactive phenotype

Attention deficit hyperactivity disorder (ADHD) is a developmental syndrome expressed along three domains: inattention, hyperactive-impulsive, and combined type. Both environmental and genetic factors contribute to the etiology of this complex disease. In the current investigation, a catechol-O-methyltransferase (COMT) polymorphism that codes for a high versus low enzyme COMT activity was examined using family-based methods for a role in ADHD. Using a haplotype relative risk design and a parent-to-proband allele transmission test with 48 ADHD triads, we found an association between COMT and illness (chi(2) = 4.72, p = 0.03, df = 1). In particular, the impulsive-hyperactive type of ADHD (excluding inattention) ascertained by Diagnostic and Statistical Manual of Mental Disorders (DSM IV) criteria (chi(2) = 8.34, p = 0.004, df = 1), by the Conners Teaching Rating Hyperactivity scale (Pearson chi(2) = 5.32, p = 0.02, df = 1) as well as by the Continuous Performance Test False Alarm scale (chi(2) = 2.78, p = 0.096, df = 1) were associated with the high enzyme activity COMT val allele. Similar results were obtained if genotype frequencies were compared. It should be noted that the association between the high-enzyme activity COMT val allele that increases CNS dopamine (and norepinephrine) clearance is consistent with the use of methylphenidate, an agent that increases dopamine (and norepinephrine) turnover, in the treatment of this disorder. These provisional findings suggest that newly developed COMT inhibitors such as tolcapone, applied in Parkinson's disease, might in due time be considered in the treatment of ADHD.

The influence of medical and legal authorities on deaths facilitated by physicians

This study investigated whether two widely publicized cases of deaths facilitated by physicians were followed by significant peaks in mortality. In March, 1991, Timothy Quill, MD, published a controversial editorial describing the physician-assisted suicide (PAS) of his 45-year-old, female leukemia patient. In a landmark decision in December 1990, the Missouri Supreme Court allowed removal of life support for Nancy Cruzan, a comatose accident victim. Correcting for trends and seasonal fluctuations, the authors examined: (1) U.S. leukemia mortality in the period centered on Quill's editorial, and (2) mortality from accident/coma combinations in the period centered on the Missouri Supreme Court's decision on Cruzan. Female leukemia deaths rose 11.3% above the expected rate (p < .01) just after Quill's article was published. The more closely the decedent matched Quill's patient, the greater the peak, with the largest peak (33.9%) evident for female leukemia patients in their 40s, who were long-term residents of smaller communities (p < .05). Five possible explanations for the findings were assessed, leading to the conclusion that Quill's editorial elicited an increase in mortality. The involvement of physicians in this increase is supported by analysis of the Cruzan case. This showed a mortality peak of 57% for accident/coma patients following the court decision.

Decision-making and the role of surrogacy in withdrawal or withholding of therapy in neonates

Ideally, decisions to forego life-sustaining treatments in neonates should be arrived at by a team of expert physicians, nurses, and social workers, together with both parents. Surrogates, however, may occasionally have other considerations than the best interest of the ill neonate, and sometimes the postpartum mother may be temporarily incompetent to make such grave decisions. Therefore, a careful assessment of the parents' decision is required. Physical help in the caring for the child, psychologic family counseling, educational and vocational assistance, and even quality institutionalization must be provided if the parents are unable to fully care for the child.

Somatosensory functioning in children with attention deficit hyperactivity disorder

In order to test the hypothesis that attention deficit hyperactivity disorder (ADHD) is related to deficits in somatosensory processing, 49 ADHD male children and 49 matched controls were tested on a wide range of tactile tasks, and somatosensory evoked potentials (SEP) were also recorded. In addition, parents' and teachers' ratings on the children's typical responses to tactile stimuli were obtained. The results show that the ADHD children were less skilled on suprathreshold, but not on threshold tasks than were the controls. Further, a larger percentage of ADHD children were 'tactile defensive'. Finally, the ADHD children showed larger-than-normal amplitudes of late, but not early components of the SEP. These data suggest that some aspects of somatosensory processing by ADHD children are deficient.

Levels of L-methionine S-adenosyltransferase activity in erythrocytes and concentrations of S-adenosylmethionine and S-adenosylhomocysteine in whole blood of patients with Parkinson's disease

In the present study, levels of S-adenosylmethionine (SAM) and S-adenosylhomocysteine (SAH) in whole blood as well as L-methionine S-adenosyltransferase (MAT) activity in erythrocytes were assayed in a series of 20 patients with Parkinson's disease and 12 healthy control subjects. A significant difference was found with regard to SAM levels between patients and controls, with the detected levels being 383.1 +/- 41.5 nM for the parkinsonian patients and 680.6 +/- 30.9 nM for the controls. With regard to SAH, we found no difference between the groups. The catalytic activity of MAT was increased by 30% in patients compared to controls, with the Vmax for methionine being 17.9 +/- 3.7 and 13.9 +/- 2.2 pmol/mg/h, respectively.

Mitochondrial encephalomyopathy associated with a novel mutation in the mitochondrial tRNA(leu)(UUR) gene (A3243T)

We report a new mutation, an A-->T transition at nt 3243 in the mitochondrial tRNA(leu)(UUR) gene, in a 9-year-old girl who presented with muscle weakness of 3 years duration complicated by rapidly progressive encephalopathy. In muscle, the activity of the mitochondrial respiratory chain complexes I, III, and IV was markedly reduced. The mutation, involving a highly conserved base pair in the dihydrouridine loop, was heteroplasmic in muscle (81.4%), skin (69.3%), and blood (13.8%) and was not present in blood of 50 healthy individuals. The mitochondrial 3243 base is a "hot spot" for mutations; an A-->G transition at this position is found in a high proportion in most MELAS patients. Since the A-->T transition creates a new recognition site for the restriction enzyme TspRI, both ApaI and TspRI should be used to exclude a mutation at nt 3243.

Is the patient's right to die evolving into a duty to die?: Medical decision making and ethical evaluations in health care

When patient or family requests for continued life-sustaining treatments conflict with doctor recommendations, different conclusions as to what is beneficial for the patient may arise. Past practices usually accepted patient or family requests based on the principle of autonomy or that the doctor's primary responsibility is to the individual patient. Many patients die in intensive care units after doctors forego life-prolonging interventions. Health care changes and cost containment have led to a change in the classical ethical model of the patient-doctor relationship such that concerns for societal requirements increasingly overrule those for individual patient needs. The ability to keep patients alive with little likelihood of recovery and the recognition of escalating health costs have led to calls for the needs of society and distributive justice to be taken into account. A tendency to justify a duty to die for these patients has arisen. Recent legal decisions in cases with conflicts between families and health care providers and institutions over foregoing life-sustaining therapies have decided for the families against doctors and hospitals, compelling institutions and their staff to act contrary to their ethical views. Value judgments of doctors are sometimes confused with medical indications for therapy. Doctors have defined therapies as futile or non-beneficial based on their own values and even withdrawn life-sustaining treatments without patient or family input. In some cases, the right to die is leading to the duty to die even against patient or surrogate wishes. Such observations indicate the need for rigorous analyses of medical decision making in this context and for ethical evaluations in health care in general.