Hypotonic cerebral palsy. Which treatment?

BACKGROUND: Aim of this study is to verify whether tonus neurophysiological and communicative-relational aspects in hypotonic subjects can be recovered by psychomotor therapy. METHODS: This case series includes two randomized groups of children with central hypotonia observed at the Department of Child Neuropsychiatry of the Gaslini Institute of Genova from February 1992 to December 1996. The 1st group includes 6 subjects treated in a local rehabilitation service only by kinesitherapy. The 2nd group includes 6 children undergoing psychomotor treatment in our Department, where all the 12 cases underwent periodical controls. RESULTS: Tonus physiological aspects equally improved in the two groups, whereas the improvement of the communication aspect was more marked in the second. CONCLUSIONS: The conclusion is drawn that psychomotor therapy seems more appropriate for a global recovery of the hypotonic child.     

Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus

OBJECTIVE: Using clinical practice guidelines, a registered nurse adjusted antireflux medications, evaluated esophageal biopsy reports, determined the interval between surveillance endoscopies, and provided education for patients with Barrett's esophagus. No previous reports have assessed the effectiveness or patient satisfaction associated with registered nurse-provided primary care. Because estimates of the incidence of dysplasia and adenocarcinoma vary widely, we also prospectively followed a cohort of patients with Barrett's esophagus. METHODS: Charts were reviewed to determine the frequency of variation from guidelines, the annual incidence of dysplasia and adenocarcinoma, and frequency of reflux symptoms. Patients were mailed a questionnaire to assess satisfaction with their medical care and with the nurse. RESULTS: Variation by the nurse from the guidelines on surveillance endoscopy (1.9%) and the treatment of reflux (1.3%) was rare. Most patients were very satisfied (score of 6 on 0-6-point Likert scale) with overall medical care (88%), and patient education (76%), and most patients did not think that increased physician involvement would improve their care (93%). Ninety-seven percent of patients had control of reflux symptoms. Two patients with long segment Barrett's esophagus (n = 67) developed high grade dysplasia over 323 patient-yr of follow-up (1 of 162 patient-yr for an annual incidence of 0.6%). No patients with short segment Barrett's esophagus (n = 56) developed high grade dysplasia or adenocarcinoma over 172 patient-years of follow-up. CONCLUSION: The registered nurse in our clinical setting effectively administered clinical practice guidelines for the management of Barrett's esophagus without clinically significant morbidity or patient dissatisfaction. Before these results can be generalized to other settings, further studies will need to be performed.     

A single physician or a group of specialists in a surgical ward. II. Impact on the continuity and patient satisfaction

The impact on quality of ward care provided by surgeons within two continuity schedules was assessed by explicit and implicit audit. In one schedule one surgeon provided care and in another a staff of surgeons provided care. The study included 214 consecutive inpatients. The study demonstrated that quality of ward care was unaffected by continuity schedule. In the single surgeon continuity schedule, however, nearly twice as many discharge letters were posted within four days (p < 0.001). Likewise, twice as many contained information that the patients had been informed about the diagnosis (p < 0.05). In both continuity schedules about 20% of the patients received inadequate care. Analysis of this finding demonstrated that more patients had been subject to inadequate follow-up in the single surgeon continuity schedule, whereas more patients had been subject to inadequate postoperative observation in the staff continuity schedule. In both schedules an equal number of patients had been subject to incomplete diagnoses and inadequate medical care.     

Patient satisfaction with surgical treatment of refractory epilepsy done in childhood and early adolescence

The results of a retrospective self-controlled telephone satisfaction survey of 63 patients who had undergone an earlier resection for the treatment of medically refractory epilepsy before the age of 18 years was reported. The survey items consisted of a global rating scale and a series of open-ended questions about positive and negative outcomes as a result of the surgery. Most (80%) of the patients felt the surgery had had a positive effect on their lives. The mean global score was 6.24+2.4 (scale 0-9). Strong positive correlations were found between seizure control and degree of satisfaction and between perceived postsurgical neurological deficits and dissatisfaction.     

Effects of caregiver burden and satisfaction on affect of older end-stage renal disease patients and their spouses.

We examined the extent to which a 2-factor model of affect explains how the burdens and satisfactions experienced by caregivers influence their own well-being and that of the spouses for whom they provide care. Using data from 315 older patients with end-stage renal disease and their spouses, we extended tests of Lawton et al.’s (1991) 2-factor model both longitudinally and dyadically. Multilevel modeling analyses partially support the 2-factor model. Consistent with the model, mean caregiver burden has a stronger effect on both caregiver and patient negative affect than does mean caregiver satisfaction. Contrary to the model, mean caregiver satisfaction has an effect on caregiver positive affect that is similar to that of mean caregiver burden, and it has no effect on patient positive affect. Time-varying effects of caregiver burden are consistent with the 2-factor model for caregiver but not patient negative affect. Time-varying effects of caregiver satisfaction are not consistent with the 2-factor model for either patients or caregivers. Results highlight the powerful role of caregiver burden for both caregivers and patients and suggest important new directions for conducting health-related research with late-life marital dyads. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Strabismus in children with cerebral palsy

In 48 children with cerebral palsy the characteristics of the squint and amblyopia were analyzed, also with respect to the features of cerebral palsy and to birth weight. Strabismus of congenital esotropia type was found to be common, as was also exotropia of early onset. Spontaneous alternation or an accommodative component of the squint was present only in a few cases. There was no evidence of an accumulation of any strabismus type in the different subgroups of cerebral palsy, whereas amblyopia or an obvious risk for amblyopia was found in the great majority of the cases. Some kind of amblyopia treatment was given to 34. Most of them showed improvement of the visual capacity which encourages treatment of amblyopia, even in children with cerebral palsy.     

Nutrition in children with cerebral palsy

The previously reported earlier onset of pituitary tumours in cross-bred mice inheriting a mutant Rb-1 allele paternally has been ascribed to imprinting of an Rb-1-linked gene. Here, we demonstrate that, as predicted from this mechanism, there is no effect of the parent of origin of the mutation in inbred mice.     

Cervical stenosis and dystonic cerebral palsy

We have tested the in vitro activities of eight fluoroquinolones against 160 Brucella melitensis strains. The most active was sitafloxacin (MIC at which 90% of the isolates are inhibited [MIC90], 0.12 microg/ml). In decreasing order, the activities (MIC90s) of the rest of the tested fluoroquinolones were as follows: levofloxacin, 0.5 microg/ml; ciprofloxacin, trovafloxacin, and moxifloxacin, 1 microg/ml; and ofloxacin, grepafloxacin, and gatifloxacin, 2 microg/ml.     

Parenting and social functioning of children with and without cerebral palsy.

Objective: To examine the associations between parenting dimensions and the social functioning of children with and without cerebral palsy (CP). The primary hypothesis was that controlling for cognitive ability, specific parenting dimensions would be associated with higher social functioning, including larger social networks, higher-quality friendships, and healthier social adjustment in children with and without CP. Participants: Forty-one children with cerebral palsy and 60 typically developing (TD) children, ages 6 to 12. Measures: Parenting Dimensions Inventory; Social Network Inventory for Children, Friendship Quality Questionnaire, Personality Inventory for Children-Second Edition, WISC-III Vocabulary. Results: Bivariate associations revealed that cognitive ability was associated with social functioning in both groups. In the group with CP, controlling for cognitive ability, parenting dimensions were not associated with social functioning, in contrast with findings in the TD sample. Conclusions: Findings suggest different parenting influences on the social development of children with and without CP. Theoretical and methodologic implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Working memory and articulation rate in children with spastic diplegic cerebral palsy.

A. D. Baddeley, N. Thomson, and M. Buchanan (1975) suggested that articulatory rehearsal rate determines the amount of verbal material that can be maintained in working memory. In the current study, 12 children with spastic diplegic cerebral palsy (SDCP) and 38 normal children were tested on measures of articulation rate and memory span for 1-, 2-, and 3-syllable words. Across all conditions, articulation rate for the SDCP group was significantly slower than for the normal group; nonetheless, memory span was equivalent for both groups. This finding implies that covert rehearsal proceeded normally for the SDCP group, in spite of decrements in speech rate. Thus, the relationship between overt and covert rehearsal rates differs for children with SDCP compared with normal children. Findings from the current study further suggest that normal speech rates are not necessary for development of normal covert rehearsal rates. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Association of cerebral palsy with epilepsy

Fifty patients of various types of cerebral palsy were studied to find out an association between cerebral palsy, EEG abnormalities and development quotient. Seventy-six per cent patients had spastic cerebral palsy. Hypotonic cerebral palsy was the next common type (14%). Athetosis and ataxic forms were found to be rare (2% each). Epilepsy was associated with 56% patients. Clinical types of seizures observed were: Generalised tonic-clonic (43%), myoclonic (17.9%), generalised tonic (10.7%), partial simple (10.7%) and partial complex (17.9%). The incidence of seizures was highest in hypotonic type in which 85.7% had epilepsy. Mean developmental quotient of cerebral palsy patients was 34.9% with maximum retardation in hypotonic cerebral palsy (25.14%). Sixty per cent of patients had abnormal EEG, out of these hypotonic patients had maximum (70%) chances of EEG abnormality followed by spastic patients (55%). Developmental retardation was more severe statistically in the patients with abnormal EEG than normal EEG.     

Intern call structure and patient satisfaction

Our institution has instituted "short-call" and "nightfloat" systems to reduce the number of admissions to the traditional "long-call" housestaff. However, the nightfloat system introduces increased discontinuity to patient care, and interns may spend less time with short-call patients because they are nor required to spend the night on-call. Discontinuity and less time spent with patients may result in decreased patient satisfaction. Over a 6-month period, data were collected on 145 consecutive patients admitted to a teaching Veterans Affairs Medical Center with the primary diagnoses of congestive heart failure and chronic obstructive pulmonary disease. We found that patients admitted to either short-call or nightfloat interns were significantly less satisfied with their care than patients admitted to long-call housestaff, controlling for intern gender, patient age, and patient severity of illness (p = 0.02). Residency program directors need to realize that changes in the structure of teaching environment may have an impact on patient satisfaction.     

Pathological fractures in patients with cerebral palsy

A retrospective study was made of 37 patients with 54 fractures that occurred without significant trauma. The morbidity and causes of these pathological fractures in patients with cerebral palsy were analyzed. The major causes for the fractures were long and fragile lever arms and stiffness in major joints, particularly the hips and knees. An additional factor was severe osteoporosis following a long period of postoperative immobilization. Seventy-four percent of the fractures occurred in the femoral shaft and supracondylar region. Stress fractures were rare (7%) and involved only the patella. Conservative treatment was sufficient in most cases but surgical fixation provided a good alternative for fractures of the femoral shaft. Intraarticular fractures with joint incongruity resulted in a decreased level of activity of the patient. Since osteoporosis is a major risk factor, patients with cerebral palsy should bear weight to prevent pathological fractures. Any stiffness of major joints and extended periods of immobilization should be avoided.     

Electronic fetal monitoring in predicting cerebral palsy

A 58 year old man was admitted to the accident and emergency department following an industrial accident in which he sustained a three part fracture dislocation of his right humerus. Chest radiography revealed a large mass in the right upper hemithorax and, when the patient became hypotensive, an emergency thoracotomy was performed. The mass was found to be a massive intrathoracic lipoma. This case shows how preexisting intrathoracic lesions may be mistaken for subclavian or great vessel trauma following violent shoulder girdle injury. The differential diagnosis of traumatic and non-traumatic intrathoracic mass lesions in chest radiography should be considered carefully.     

Natural history of scoliosis in spastic cerebral palsy

BACKGROUND: Although the frequent occurrence of scoliosis in patients who have spastic cerebral palsy is well known and surgical treatment has often been recommended for these patients, little is known about the natural history of scoliosis in this population. We aimed to clarify the natural history of scoliosis from childhood through to adulthood and provide objective data on proper surgical indications for such patients. METHODS: The participants were 37 institutionalised patients with severe spastic cerebral palsy and scoliosis. All the participants had a series of radiographs taken, starting at a mean age of 7.8 years; they were followed up for an average of 17.3 years. We retrospectively reviewed radiographs and assessed the effect of five factors on progression of scoliosis: sex, degree of spasticity, initial physical capability, pattern of spinal curve, and location of curve. FINDINGS: Scoliosis usually started before the age of 10 years and progressed rapidly during the growth period. In many cases, even after growth had ended, continuous progression was seen. The mean magnitude of the curves at final examination was 55 degrees (Cobb angle). In 11 (85%) of 13 patients who had a spinal curve of more than 40 degrees before age 15 years, the scoliosis progressed to more than 60 degrees by the time of the final examination. Meanwhile, in only three (13%) of 24 patients who had a curve of less than 40 degrees at age 15 years, did the scoliosis progress to more than 60 degrees. Severe scoliosis (> or = 60 degrees) developed predominantly in those who had total body involvement (67%), were bedridden (100%), or had throacolumbar curves (57%). INTERPRETATION: The risk factors for progression of scoliosis in spastic cerebral palsy are: having a spinal curve of 40 degrees before age 15 years; having total body involvement; being bedridden; and having a thoracolumbar curve. Patients with these risk factors might benefit from early surgical intervention to prevent progression to severe scoliosis.