bluuebunny/crossref_metadata_2025 huggingface dataset:
A Real Options Approach to Watchful Waiting: Theory and an Illustration
Authors: Driffield Tarn , Smith Peter C.
Published: April 2007

Watchful waiting is a form of clinical management under which immediate curative treatment is not given. Instead, the patient undergoes a period of observation during which periodic tests monitor the progression of the illness. Hitherto, little attention has been given to how such patient management should be modeled from an economic perspective. Watchful waiting preserves an “option” to start treatment some time in the future, and evaluating a watchful waiting regime therefore has close analogies with pricing a financial option in the derivatives market. This article demonstrates how the methods used to price financial options can be used to decide when to pursue a watchful waiting strategy for a particular patient. The principles of option pricing are illustrated with the example of abdominal aortic aneurysm. A simple trinomial model of disease progression is used, in which patients are periodically monitored, and their health state can remain unchanged, deteriorate, or improve. Backward induction is used to solve the model at each period, with optimal treatment recommendations depending on the current health state. At very low levels of expected net benefits, the patient is discharged. At high levels, the patient is treated immediately. At intermediate levels, watchful waiting continues. The authors argue that option pricing methods offer important insights into the evaluation of a watchful waiting strategy. The methods also have potential applications in other domains of medical care. Key words: watchful waiting; option pricing; cost-effectiveness analysis. (Med Decis Making 2007;27:178—188)
Patients Derogate Physicians Who Use a Computer-Assisted Diagnostic Aid
Authors: Arkes Hal R. , Shaffer Victoria A. , Medow Mitchell A.
Published: April 2007

Objective . To ascertain whether a physician who uses a computer-assisted diagnostic support system (DSS) would be rated less capable than a physician who does not. Method . Students assumed the role of a patient with a possible ankle fracture (experiment 1) or a possible deep vein thrombosis (experiment 2). They read a scenario that described an interaction with a physician who used no DSS, one who used an unspecified DSS, or one who used a DSS developed at a prestigious medical center. Participants were then asked to rate the interaction on 5 criteria, the most important of which was the diagnostic ability of the physician. In experiment 3, 74 patients in the waiting room of a clinic were randomly assigned to the same 3 types of groups as used in experiment 1. In experiment 4, 131 3rd- and 4th-year medical students read a scenario of a physician-patient interaction and were randomly assigned to 1 of 4 groups: the physician used no DSS, heeded the recommendation of a DSS, defied a recommendation of a DSS by treating in a less aggressive manner, or defied a recommendation of a DSS by treating in a more aggressive manner . Results . The participants always deemed the physician who used no decision aid to have the highest diagnostic ability. Conclusion . Patients may surmise that a physician who uses a DSS is not as capable as a physician who makes the diagnosis with no assistance from a DSS. Key words: decision support techniques; diagnosis computer assisted; patient satisfaction. (Med Decis Making 2007; 27: 189—202)
Decision to Implant a Cardioverter Defibrillator after Myocardial Infarction: The Role of Ejection Fraction v. Other Risk Factor Markers
Authors: Bailey James J. , Hodges Morrison , Church Timothy R.
Published: April 2007

Background . The Multicenter Automatic Defibrillator Implantation Trial showed that in post—myocardial infarction patients with a left ventricular ejection fraction (EF) ≤ 0.30, an implantable cardioverter defibrillator (ICD) resulted in a 31% relative reduction in the risk of death when compared with a conventional therapy group. Whether further refinement in risk estimation could be achieved with additional clinical testing to qualify patients for primary prevention with ICDs remains problematic. Methods . The authors analyzed Cardiac Arrhythmia Suppression Trial registry data to estimate sensitivity and specificity of EF, ventricular premature frequency, and nonsustained ventricular tachycardia for predicting death. They combined the results with similar data from the literature and used summarizing receiver operating characteristic (meta-ROC) curves to estimate overall operational values for sensitivity and specificity for each clinical test. They estimated aggregate values for prior probability to project risks when tests were used singly and in combination. Results . The authors used arrhythmia markers and heart rate variability to further stratify low-EF patients (prior risk = 20.3%); proportionately, 20.4% were predicted at high risk (> 30%) and 40.5% at low risk (< 10%). When heart rate variability is normal, those at high risk reduced proportionately to 9.2%, and those at low risk increased to 51.6%. Conclusions . The combined use of noninvasive markers for arrhythmia substrate and altered autonomic tone can improve risk stratification in low EF without optimal beta-block therapy, whereas for those with optimal beta-block therapy, markers for arrhythmia substrate alone work. Ancillary use of electrophysiologic stimulation can improve results.
Value of Information on Preference Heterogeneity and Individualized Care
Authors: Basu Anirban , Meltzer David
Published: April 2007

Background . Cost-effectiveness analysis traditionally focuses on identifying when treatments are cost-effective based on their average benefits and costs in the population. However, there may be considerable value in identifying when treatments are cost-effective for individual patients given their preferences or other personal attributes. Objectives . To present a theoretical framework to assess the potential value of identifying cost-effective treatments for individual patients given their preferences and to compare the value of individualized treatment decisions with the value of treatment decisions based on traditional population-level cost-effectiveness analysis. Methods . The authors calculate the expected value of individualized care (EVIC), which represents the potential value of providing physicians information on the preferences of individual patients, such as quality-of-life (QOL) weights, so as to make individualized treatment decisions. They also show how EVIC varies with insurance structures that do not internalize relative costs of treatments. They illustrate this theory using an example in which physicians make treatment choices for 65-year-old prostate cancer patients. Results . The value of identifying cost-effective treatments at the individual level for 65-year-old prostate cancer patients in the United States is about $70 million annually. This is more than 100 times the $0.7 million annual value of identifying the cost-effective treatment on average for this population. However, failure to internalize costs almost eliminates the value of individualized care. Conclusions . The value of individualizing care can be far greater than the value of improved decision making at the group level. However, this can vary immensely with insurance. EVIC can provide a guide as to when the high value of individualized care may make population-level decision making especially at risk of providing poor guidance for coverage decisions. Future studies of the value of individualized care should also consider baseline levels of individualization of care. Key words: preferences; value of information; individualization of care; quality of life; prostate cancer. (Med Decis Making 2007; 27: 112—127)
Limitations of Acceptability Curves for Presenting Uncertainty in Cost-Effectiveness Analysis
Authors: Groot Koerkamp Bas , Hunink M.G. Myriam , Stijnen Theo , Hammitt James K. , Kuntz Karen M. , Weinstein Milton C.
Published: April 2007

Clinical journals increasingly illustrate uncertainty about the cost and effect of health care interventions using cost-effectiveness acceptability curves (CEACs). CEACs present the probability that each competing alternative is optimal for a range of values of the cost-effectiveness threshold. The objective of this article is to demonstrate the limitations of CEACs for presenting uncertainty in cost-effectiveness analyses. These limitations arise because the CEAC is unable to distinguish dramatically different joint distributions of incremental cost and effect. A CEAC is not sensitive to any change of the incremental joint distribution in the upper left and lower right quadrants of the cost-effectiveness plane; neither is it sensitive to radial shift of the incremental joint distribution in the upper right and lower left quadrants. As a result, CEACs are ambiguous to risk-averse policy makers, inhibit integration with risk attitude, hamper synthesis with other evidence or opinions, and are unhelpful to assess the need for more research. Moreover, CEACs may mislead policy makers and can incorrectly suggest medical importance. Both for guiding immediate decisions and for prioritizing future research, these considerable drawbacks of CEACs should make us rethink their use in communicating uncertainty. As opposed to CEACs, confidence and credible intervals do not conflate magnitude and precision of the net benefit of health care interventions. Therefore, they allow (in)formal synthesis of study results with risk attitude and other evidence or opinions. Presenting the value of information in addition to these intervals allows policy makers to evaluate the need for more empirical research.
Efficiency, Equity, and Budgetary Policies
Authors: Epstein David M. , Chalabi Zaid , Claxton Karl , Sculpher Mark
Published: April 2007

The standard decision rules of cost-effectiveness analysis either require the decision maker to set a threshold willingness to pay for additional health care or to set an overall fixed budget. In practice, neither are generally taken, but instead an arbitrary decision rule is followed that may not be consistent with the overall budget, lead to an allocation of resources that is less than optimal, and is unable to identify the program that should be displaced at the margin. Recent work has shown how mathematical programming can be used as a generalization of the standard decision rules. The authors extend the use of mathematical programming, first to incorporate more complex budgetary rules about when expenditure can be incurred, and show the opportunity loss, in terms of health benefit forgone, of each budgetary policy. Second, the authors demonstrate that indivisibility in a patient population can be regarded as essentially a concern for horizontal equity and represent this and other equity concerns as constraints in the program. Third, the authors estimate the different opportunity costs of a range of equity concerns applied to particular patient populations, and when imposed on all patient populations. They apply this framework of analysis to a realistic and policy-relevant problem. Key words: cost-effectiveness analysis; cost-benefit analysis; mathematical programming; resource allocation. (Med Decis Making 2007;27:128—137)
The Influence of Irrelevant Anchors on the Judgments and Choices of Doctors and Patients
Authors: Brewer Noel T. , Chapman Gretchen B. , Schwartz Janet A. , Bergus George R.
Published: April 2007

Background. Little research has examined how anchor numbers affect choice, despite several decades of research showing that judgments typically and robustly assimilate toward irrelevant anchors. Methods. In one experiment, HIV-positive patients (N = 99) judged the chances that sexual partners would become infected with HIV after sex using a defective condom and then indicated their choices of remedial action. In a second experiment, Iowa physicians (N = 191) rated the chances that hypothetical patients had a pulmonary embolism and then formulated a treatment plan. Results. Irrelevant anchor numbers dramatically affected judgments by HIV-infected patients of the chances of HIV infection after a condom broke during sex (43% v. 64% in the low- and high-anchor conditions, respectively) and judgments by doctors of the chances of pulmonary embolism (23% v. 53%, respectively). Despite large anchoring effects in judgement, treatment choices did not differ between low-and high-anchor conditions. Accountability did not reduce the anchoring bias in the doctors' judgments. Discussion. The practical implications of anchoring for risk judgments are potentially large, but the bias may be less relevant to treatment choices. The findings suggest that the theoretical underpinnings of the anchoring bias may be more complex than previously thought. Key words: anchoring bias; assimilation effect; contrast effect; risk perception. (Med Decis Making 2007; 27: 203—211)
Comparison of Preseason, Midseason, and Postseason Neurocognitive Scores in Uninjured Collegiate Football Players
Authors: Miller Jennifer R. , Adamson Gregory J. , Pink Marilyn M. , Sweet John C.
Published: April 2007

Background

College football players sustain an average of 3 subconcussive blows to the head per game. Concussions correlate with decreases in standardized neurocognitive test scores. It is not known whether repetitive, subconcussive microtrauma associated with participation in a full season of collision sport affects neurocognitive test scores.

Hypothesis

No difference exists between preseason, midseason, and postseason Standardized Assessment of Concussion (SAC) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores when collegiate football players sustain subconcussive microtrauma from forceful, repetitive contact activity.

Study Design

Case series; Level of evidence, 4.

Methods

Fifty-eight members of a Division III collegiate football team who had no known concussion during the season voluntarily completed the SAC and ImPACT instruments preseason, midseason, and postseason. A repeated measures analysis of variance was used to compare the scores at the 3 time intervals (P < .05).

Results

No statistically significant decreases were found in overall SAC or ImPACT scores or in any of the domains or composites of the tests (P < .05) when preseason, midseason, and postseason scores were evaluated.

Conclusions

ImPACT and SAC neurocognitive test scores are not significantly altered by a season of repetitive contact in collegiate football athletes who have not sustained a concussion.

Clinical Relevance

A diminution in SAC or ImPACT scores in concert with clinical symptoms and findings should be interpreted as evidence of a postconcussive event.
Importance of Sports in Cartilage Regeneration after Autologous Chondrocyte Implantation
Authors: Kreuz Peter Cornelius , Steinwachs Matthias , Erggelet Christoph , Lahm Andreas , Krause Stefanie , Ossendorf Christian , Meier Dirk , Ghanem Nadir , Uhl Markus
Published: April 2007

Background

There have been no data in the literature reporting the influence of sports on the outcome of autologous chondrocyte implantation in chondral defects of the knee.

Hypothesis

Sports can improve the result of autologous chondrocyte implantation in postoperative follow-up.

Study Design

Cohort study; Level of evidence, 2.

Methods

Between 1997 and 2003, 118 patients with symptomatic isolated chondral lesions of the knee underwent autologous chondrocyte implantation. According to the sports activity level before the start of symptoms, patients were assigned to 2 groups: group II with no or rare sports involvement (1-3 times/month); group I with regular (1-3 times/week) or competitive sports (4-7 times/week). All patients underwent clinical and magnetic resonance imaging evaluation preoperative and 6, 18, and 36 months after autologous chondrocyte implantation.

Results

Group I patients showed significantly better results (<.01) in the International Cartilage Repair Society and Cincinnati scores than group II patients. Preoperative evaluation revealed no correlation between the sports activity levels and the clinical scores (P > .05). However, from the sixth month on, correlation was statistically significant, increasing from 6 to 18 months, and from 18 to 36 months postoperatively.

Conclusion

Physical training improves long-term results after autologous chondrocyte implantation of the knee and should be carried out for at least 2 years after surgery.
Community Participation in Urban Sanitation
Authors: Nance Earthea , Ortolano Leonard
Published: April 2007

This article explores how well community participation explains variations in the performance of sanitation projects in Brazilian cities. Case studies of condominial sewers in Recife and Natal, Brazil, reveal a variety of activities that we categorize into four forms of participation: mobilizing, decision making, construction, and maintenance. Mobilizing and decision making were associated with performance in the cases we examined. Our results suggest that participation form as well as community influence are important. The hypothesis that increased participation enhances performance is an oversimplification for condominial sewers.
Remaking Minnie Street
Authors: Day Kristen , Anderson Craig , Powe Michael , McMillan Tracy , Winn Diane
Published: April 2007

Urban design is frequently identified as a tool to reduce crime and improve traffic safety in urban neighborhoods. In this “before” and “after” evaluation, we assess a major urban revitalization in the Minnie Street neighborhood in Santa Ana, California, in terms of its impacts on crime and pedestrian safety. Conclusions suggest that urban design can help to improve crime and traffic safety in poor urban neighborhoods but that other factors must also be considered.
Food Deserts, Oases, or Mirages?
Authors: Short Anne , Guthman Julie , Raskin Samuel
Published: April 2007

In light of claims that many low-income urban neighborhoods are “food deserts,” this article reports on pilot research to assess whether and how small, full-service food retailers contribute to urban food security. It demonstrates that such stores meet many of the criteria for community food security by providing a wide variety of relatively low-cost foods. At the same time, their geographic unevenness, tendency to target particular ethnic clienteles, and inability to address affordability in an absolute sense place some caveats on the conclusions and suggest the need for more fine-grained research regarding how the unique economic development histories and cultural politics of neighborhoods affect food availability.
Bridging Community Differences through Informal Processes
Authors: Hou Jeffrey , Kinoshita Isami
Published: April 2007

Participatory planning today faces a dual challenge—the growing diversity and differences at the community level and the limitations of institutionalized participation. By comparing two cases of community planning in Seattle, Washington, and Matsudo, Japan, this article examines the role of informal processes in overcoming institutional and social barriers and negotiating differences of identities, values, and interests. The article argues that, through animated interactions, building of trust, experiential learning, and spontaneity, informal activities and processes can serve as important vehicles for creating meanings, social relationships, and collective actions and enable planners to navigate the cultural and political terrain of community differences.
The Status of Teaching on Voluntary Methods of Land Use Control in Planning Curricula
Authors: Merrill Samuel B. , Lapping Mark
Published: April 2007

Given the pace of land conservation in North America, the increasing complexity of land protection transactions, the charged social and political scenarios that often attend restriction of development rights, and the impacts of land conservation on local taxation, it is clear that municipal planners should be conversant about methods for and implications of voluntary land conservation planning and practice. To evaluate the nature of teaching on these issues, we conducted a survey of accredited planning degree programs. Results suggest that among accredited planning education degree programs, there is significant room for improvement in quality and quantity of teaching about voluntary land conservation. Recommendations include making some currently elective courses required and introducing more varied and participatory teaching methods in current and new courses that cover these topic areas.
Geographies of Opportunity for Whom?
Authors: Harwood Stacy
Published: April 2007

Local governments claim that neighborhood improvement programs develop grassroots leadership capacity, raise the importance of neighborhood issues on the citywide political agenda, and empower residents to solve neighborhood-level problems. This article argues that neighborhood improvement programs also jeopardize the geography of opportunity, particularly women's neighborhood activism. Drawing from interviews with neighborhood activists and local government officials from one municipality in Southern California, this study illuminates the ways in which local government efforts regulate and contain neighborhood activism.
Neuronal Intranuclear Hyaline Inclusion Disease With Rapidly Progressive Neurological Symptoms
Authors: Mano T. , Takizawa S. , Mohri I. , Okinaga T. , Shimono K. , Imai K. , Taniike M. , Ozono K. , Fujimura H.
Published: April 2007

This report describes a male patient who presented with symptoms suggestive of spinocerebellar degeneration and who died of respiratory failure at the age of 7 years but was diagnosed, at autopsy, as having neuronal intranuclear hyaline inclusion disease. Neuronal intranuclear hyaline inclusion disease is a progressive and degenerative disease; diagnosis is possible only by neuropathological analysis. This is a rare disorder; few cases with early childhood onset and rapidly progressive neurologic symptoms have been documented. According to previous reports, most neurons in the central nervous system exhibited intranuclear eosinophilic inclusion bodies; neuronal depletion appeared to be restricted to the cerebellar cortex and the medullary inferior olivary nuclei, consistent with the fact that clinical deficit appears to correspond to the site of neuronal depletion and not to where eosinophilic bodies are detected. Immunohistochemical analysis revealed that these inclusions were positive for ubiquitin. The case presented herein clearly indicates that neuronal intranuclear hyaline inclusion disease should be considered as a differential diagnosis of cases involving spinocerebellar degeneration with childhood onset.
Spastic Cerebral Palsy: Clinical Magnetic Resonance Imaging Correlation of 129 Children
Authors: Kułak Wojciech , Sobaniec Wojciech , Kubas Bozena , Walecki Jerzy , Smigielska-Kuzia Joanna , Bockowski Leszek , Artemowicz Barbara , Sendrowski Krzysztof
Published: April 2007

A prospective study was undertaken of 129 children with spastic cerebral palsy to clarify the relationship between magnetic resonance imaging (MRI) findings and clinical features of cerebral palsy. Low birth weight, asphyxia, prematurity, seizures, mental development, Gross Motor Function Classification System, and MRI findings were analyzed. Significant abnormalities relevant to the cerebral palsy were evident on imaging in 123 (95.3%). A similar percentage of MRI abnormalities were detected in the groups, 45 (100%) in patients with tetraplegic cerebral palsy, 37 (92.5%) in children with diplegic cerebral palsy, and 42 (95.4%) with hemiplegic cerebral palsy. Periventricular leukomalacia was detected more frequently in the children with spastic diplegia than in the patients with tetraplegia or hemiplegia. Cerebral atrophy was found more often in the tetraplegic group compared to the diplegic patients. Porencephalic cysts were detected more frequently in children with spastic hemiplegia. Congenital brain anomalies were found in a higher proportion in tetraplegic children. Significant correlations between the MRI findings and Gross Motor Function Classification System in the diplegic and tetraplegic patients were found. No correlations between the MRI results and risk factors for cerebral palsy in the tetraplegic patients were noted. Early detection of brain abnormalities in children with cerebral palsy may help in the prognosis and in the initiation of appropriate therapy
Neonatal Spinal Muscular Atrophy Type 1 With Bone Fractures and Heart Defect
Authors: Vaidla Eve , Talvik Inga , Kulla Andres , Sibul Hiljar , Maasalu Katre , Metsvaht Tuuli , Piirsoo Andres , Talvik Tiina
Published: April 2007

The authors present the case of an infant girl with severe generalized weakness, multiple bone fractures, and heart defect. She needed mechanical ventilation from birth. Radiographs showed mid-diaphyseal fractures of both humeri and of the right femur as well as generalized osteopenia. Electroneuromyography showed spontaneous fibrillations at rest with no active movements. Motor response to a stimulus could not be registered. A systolic heart murmur was detected, and echocardiography showed a large atrial septal defect and an additional membrane in the left atrium. DNA analysis confirmed the diagnosis of spinal muscular atrophy on the third day of life. Histology of the muscle showed both hypertrophic and atrophic fibers. Degenerating swollen neurons were found in the ventral horns of the spinal cord and also in the mesencephalic red nucleus, which has not been described before. Humeral bone showed only partly formed cortical bone. The spectrum of spinal muscular atrophy is very diverse, and atypical clinical findings do not always rule out 5q spinal muscular atrophy. The SMN1 gene should still be investigated.
Accuracy of ICD-9 Codes for Identifying Children With Cerebral Sinovenous Thrombosis
Authors: Golomb Meredith R. , Garg Bhuwan P. , Williams Linda S.
Published: April 2007

Childhood sinovenous thrombosis is rare, making it difficult to study; International Classification of Diseases, ninth revision ( ICD-9), code searches across multiple hospitals would permit the identification of large numbers of children with sinovenous thrombosis. However, the accuracy of these codes for identifying childhood sinovenous thrombosis has not been established. We performed a retrospective search of admissions records for Riley Hospital for Children in Indianapolis, Indiana, from January 1999 to June 2005 using ICD-9 codes 325 (cerebral sinovenous thrombosis, excluding nonpyogenic cases and cases associated with pregnancy and the puerperium), 437.6 (cerebral venous thrombosis of nonpyogenic origin), and 671.5 (cerebral venous thrombosis in pregnancy or the puerperium) in any position. During this period, there were 47 042 admissions. ICD-9 code 325 identified 61 admissions on 56 children. Only 13% were of pyogenic origin. Fifty-two (92.9%) had “possible, probable, or definite” sinovenous thrombosis, but only 76.9% of those had “probable or definite” sinovenous thrombosis. Uncertainty in diagnoses stemmed from limitations in imaging and disagreement over interpretation of imaging studies. ICD-9 code 325 in the primary position identified 7 children; all had possible ( n = 1), probable ( n = 1), or definite ( n = 5) sinovenous thrombosis. ICD-9 code 437.6 identified a single admission on a single case of probable cerebral venous thrombosis; it was unclear whether this case was ``nonpyogenic.'' ICD-9 code 671.5 did not identify any children. ICD-9 code 325 is useful for identifying children likely to have sinovenous thrombosis, but it is not useful for differentiating pyogenic and nonpyogenic cases, and uncertainty in clinical diagnosis makes it difficult to gauge the true accuracy. Furthermore, it is important to search for the code in any position as limiting searches to the primary position misses most cases.
Intractable Epilepsy in Hemimegalencephaly and Tuberous Sclerosis Complex
Authors: Guerra Maria P. , Cavalleri Francesca , Migone Nicola , Lugli Licia , Delalande Olivier , Cavazzuti Giovanni B. , Ferrari Fabrizio
Published: April 2007

Hemimegalencephaly is a rare brain malformation consisting of the enlargement of 1 hemisphere, often associated with abnormal cortical gyration, thick cortex, large neurons, and increased astrocytes. Cranial asymmetry is the first clinical sign usually present at birth; in the most severe cases, hemimegalencephaly may be evident during pregnancy. Hemiparesis, intractable epilepsy, and developmental delay are the typical clinical manifestations. Tuberous Sclerosis Complex is an autosomal dominant disorder affecting about 1 in 6000 live births; the number of spontaneous mutations is remarkable. It is characterized by the development of hamartias, or nongrowing lesions, and hamartomas, which grow as benign tumors and rarely progress to malignancy. These lesions most frequently involve the brain, skin, kidneys, eyes, and heart. The rare association of hemimegalencephaly and tuberous sclerosis complex has been reported in a few cases. The authors report the case of a 4-year-old boy with left hemimegalencephaly, tuberous sclerosis complex genetically confirmed, and intractable epilepsy originating from the nonhemimegalencephalic hemisphere.
Transient Peripheral Leukocytosis in Children With Afebrile Seizures
Authors: Aydogan Metin , Aydogan Aysen , Kara Bulent , Erdogan Sarper , Basim Berkant , Sarper Nazan
Published: April 2007

The purpose of this study was (1) to demonstrate whether peripheral blood leukocytosis accompanies first afebrile seizures without bacterial infection, (2) to investigate the duration of leukocytosis, and (3) to assess the relationship between peripheral blood leukocytosis and seizure characteristics. Complete blood count was routinely obtained from all the patients. Blood and urine cultures were obtained from patients with leukocytosis. On the 24th hour of admission, a second complete blood count was obtained from patients with initial leukocytosis. Sixty-two children aged 4.0 ± 3.6 years (range, 6 months—13 years)—31 boys (50%) and 31 girls (50%)—enrolled in the study. The findings showed that peripheral blood leukocytosis was found in 8% of afebrile children without status epilepticus and 41.6% of afebrile children with status epilepticus. An interesting finding of the study was that peripheral blood leukocytosis accompanied by afebrile seizures subsided in 24 hours. Transient leukocytosis could be found in children with afebrile seizures without bacterial infection.
Acute Intermittent Porphyria, Rasmussen Encephalitis, or Both?
Authors: Tziperman Barak , Garty Ben-Zion , Schoenfeld Nili , Hoffer Vered , Watemberg Nathan , Lev Dorit , Ganor Yonathan , Levite Mia , Lerman-Sagie Tally
Published: April 2007

A case of a young woman who suffers from refractory epilepsy in the form of Rasmussen encephalitis and acute intermittent porphyria is presented. The patient developed refractory partial seizures with progressive hemispheric atrophy in the first decade. Both her serum and cerebrospinal fluid contained significantly elevated levels of anti-GluR3B antibodies. Her serum also contained anti-NR2A antibodies (directed against the N-methyl-D-aspartate receptor). Seven years later, acute intermittent porphyria was diagnosed as she developed an acute episode of abdominal pain, dark urine, and hyponatremia. For several years, all attempts to discontinue porphyrinogenic antiepileptic drugs such as phenobarbital and valproate resulted in seizure worsening. During a major acute intermittent porphyria crisis, brain edema and coma developed, allowing the discontinuation of phenobarbital. On recovery, atrophy of the right hemisphere ensued. Several etiologic hypotheses are presented. Double insults, porphyria, and an autoimmune process are suggested for the development of Rasmussen encephalitis in this patient. The authors recommend testing for porphyria in cases of Rasmussen encephalitis and other intractable seizures.
Reinvestigation and Reduction of Polytherapy in Children With Chronic Seizures
Authors: Chen Chu-Chin , Chiu Pao-Chin , Chen Mei-Tsen
Published: April 2007

From October 2001 to October 2003, the authors reviewed all patients with chronic seizures taking antiepileptic drugs for more than 2 years with follow-up at the pediatric neurological clinic. They identified 31 patients who were using 3 or more drugs. Twenty-nine patients agreed to undergo a drug reduction and readjustment. The authors spent a mean period of 14.1 months to either purely reduce the numbers of drugs or introduce a new drug (rational polytherapy) plus removal of some drugs to achieve the end goal of a maximum of 2 or 3 drugs (if necessary). Seizure control in 96.6% of patients (28 of 29 patients) did not worsen after the readjustment and reduction of the antiepileptic drugs. Instead, 65.5% (19 of 29 patients) got better, and 37.9% (11 of 29) were seizure free. The number of antiepileptic drugs before and after adjusting was 3.6 (range, 3-6) to 1.9 (4 monotherapy, 22 duotheray, and 2 triple drugs). The most common combined therapies were sodium valproate/lamotrigine (n = 10) and carbamazepine/ topiramate (n = 5). Although the results could be possibly attributed to the spontaneous remission of the seizures, it was still shown that those patients were overtreated. Serial addition to 3 or more antiepileptic drugs is less likely to lead to seizure freedom for patients with difficult-to-treat epilepsy. On the contrary, polytherapy and some antiepileptic drugs could aggravate seizures. Certain combinations of antiepileptic drugs (rational polytherapy) offer better efficacy to control seizures.
The Effects of Methylphenidate on the Classroom Behavior of Elementary School—Age Children With Cerebral Palsy: A Preliminary Observational Analysis
Authors: Symons Frank J. , Tervo Raymond C. , Kim Ockjean , Hoch John
Published: April 2007

High- and low-dose methylphenidate administration was evaluated prospectively for 3 elementary school—age children with cerebral palsy, cognitive impairments, and attention-deficit hyperactivity disorder (ADHD) symptoms using single-case, randomized, double-blind, placebo-controlled designs. An observational time sampling protocol was used to directly measure and quantify classroom behavior. Summary level analysis showed that (1) low-dose (0.3 mg/kg/dose) administration was associated with clinically significant (>50%) reductions in stereotyped and disruptive behavior relative to baseline and placebo conditions, (2) high-dose (0.5 mg/kg/dose) administration was associated with exacerbated amounts of stereotyped and disruptive behavior, and (3) no changes were directly observed for task-related behavior at either dose. Results are discussed with respect to previous research with methylphenidate administration and cerebral palsy, and the suggestion is made that further work using larger, randomly selected study samples with complementary measures of behavior and performance appears warranted.
Muscle Myostatin Expression in Children With Muscle Diseases
Authors: Castro-Gago Manuel , Gómez-Lado Carmen , Eiris-Puñal Jesús , Carneiro Isabel , Arce Víctor Manuel , Devesa Jesús
Published: April 2007

The demonstration that myostatin may negatively regulate muscle mass in adult individuals has raised the possibility of targeting the myostatin pathway to increase muscle growth in a variety of muscle-degenerative and -wasting conditions. To gain further insight into the possible role of myostatin in primary muscle diseases, the authors investigated the expression of muscle myostatin in children with congenital fiber type 1 disproportion, in others with neurogenic muscular atrophy, in others with myotonia congenita, in others with infantile glycogenosis type II, in others with Prader-Willi syndrome, and in 4 age-matched controls. No differences in the pattern of myostatin expression were found in any case, even in those patients with prominent muscular atrophy or hypertrophy. These findings suggest that muscle alterations that can be observed in primary muscle diseases do not depend on changes in myostatin expression.
Is Hospitalization Really Necessary During the Introduction of the Ketogenic Diet?
Authors: Rizzutti Sueli , Figueiredo Ramos Ana Maria , Muszkat Mauro , Gabbai Alberto Alain
Published: April 2007

The ketogenic diet is traditionally introduced with an initial period of fasting. This study compares the efficacy and tolerability of the introduction of a prediet (2:1 ratio of fat:protein + carbohydrates) before hospitalization with the aim at reducing the time of same and the period of fasting necessary to reach ketosis. For a minimum period of 1 year, adverse effects, metabolic profile, and linear growth were prospectively evaluated in 46 children. Twenty-three children received a prediet for a period of 10 days, and in the other 23 children, the ketogenic diet was introduced by hospitalization regimen after a fasting period. The use of the prediet led to a shorter fasting period of a mean 18.3 hours compared with the group without prediet, in which the fasting period was 41.3 hours ( P = .001). At the end, there was no difference in the adverse effects between the groups. In those submitted to the prediet, a better adaptation to the diet and acceptance to the proposal of introducing the ketogenic diet were observed.
Muscle Phosphofructokinase Deficiency With Neonatal Seizures and Nonprogressive Course
Authors: Al-Hassnan Zuhair N. , Mustafa Al Budhaim  , Al-Owain Mohammed , Lach Boleslaw , Al-Dhalaan Hesham
Published: April 2007

Muscle phosphofructokinase deficiency is known to cause childhood-onset exercise intolerance, muscle cramps, and myoglobinuria. Rarely, phosphofructokinase deficiency manifests in infancy as congenital myopathy and arthrogryposis with fatal outcome. Here, the authors report the case of a 2-year-old boy with infantile phosphofructokinase deficiency who presented on the third day of life with intractable seizures. Two of his sisters died in infancy with hypotonia, developmental delay, and seizure disorder of unclear etiology. On follow-up, he has had hypotonia and mild developmental delay. However, he continues to gain developmental milestones, and his seizures are now well controlled on carbamazepine. This presentation suggests expanding the phenotype of muscle phosphofructokinase deficiency to include early-onset neonatal seizures. It is also unusual in the relatively milder course of the infantile form of this disorder. The authors propose that this form of glycogen storage disease be considered in the differential diagnosis of neonatal seizures and early infantile nonprogressive muscle weakness.
Miller Fisher Syndrome and Escherichia coli Infection: Is It a Novel Association?
Authors: Blasetti Annalisa , Cerruto Marina , Cutarella Rocco , Tocco Annamaria , Caporale Maria Cristina , Chiarelli Francesco , Verrotti Alberto
Published: April 2007

Miller Fisher syndrome is characterized by ataxia, ophthalmoplegia, and reduced or absent tendon reflexes. Generally, it is considered an acute postinfectious paralytic illness caused by a wide variety of infections including Campylobacter jejuni. The authors report the case of a 10-year-old girl with Miller Fisher syndrome who had a previous infection of Escherichia coli. If confirmed by other reports, this report could disclose a new association of Miller Fisher syndrome with E coli infection.
Organizing Logopedic Therapy for Babies With Unilateral and Bilateral Brain Lesion in the Prespeech Period
Authors: Gec Vida
Published: April 2007

The goal of the research was to point out the importance of early prespeech therapy for babies suffering from at-birth-acquired unilateral or bilateral lesion in the prespeech period of development. On the basis of existing studies and experience in the field, a protocol and methodology for the observation of the phonological development of infants in the period between 6 and 24 months were established. Mothers made notes of the changes in the child's development in a diary specially prepared for the research. The data from the diary and the babies' reaction to the therapy in the logopedic office were inserted into the protocol. The research itself involved an experimental and a control group. The control group consisted of 60 babies without brain lesion, while the experimental group was composed of 30 babies suffering from brain lesion obtained at birth as a result of hemorrhaging, hypoxia, and asphyxia. The phonological development of the babies was observed through the ages of 6, 9, 12, and 24 months. This article demonstrates the significant differences in phonological development between the experimental and the control group. The results of the research show that phonological development in the first 6, 9, 12, and 24 months does indeed exist in the experimental group (despite the differences when compared with the control group) and can be enhanced with early monitoring and logopedic rehabilitation in the case of babies with brain lesion.
Treatment Leading to Dramatic Recovery in Acute Hemorrhagic Leukoencephalitis
Authors: Payne Eric T. , Rutka James T. , Ho Tommy K. , Halliday William C. , Banwell Brenda L.
Published: April 2007

The clinical course, neuroimaging, neuropathological features, and management of a 7-year-old girl with acute hemorrhagic leukoencephalitis are reported. Treatment with subtotal bifrontal craniectomies for symptoms of imminent uncal herniation followed by high-dose corticosteroid therapy was associated with dramatic clinical recovery. This report highlights the utility of aggressive intervention in acute hemorrhagic leukoencephalitis, an otherwise fatal disorder.
Computerized Tomography Scan of the Brain in a Community Study of Neurological Impairment in Kenya
Authors: Njuguna P.W. , Mungala-Odera V. , Chong W.K. , Meehan R.A. , Newton C.R.J.C.
Published: April 2007

Neurological impairment is common in resource-poor countries, but its causes are not clear. Computerized tomography (CT) of the brain has been used to determine the cause of brain insults that may manifest as neurological impairments. The authors conducted a community survey in Kilifi of 10 218 children aged 6 to 9 years to detect neurological impairment. From this survey, 34 children were identified, of whom 16 had motor deficits, 11 complex partial seizures, 4 microcephaly or macrocephaly, and 3 severe developmental delay. These children were assessed with elicitation of history, physical examination, and CT scan of the brain. Sixteen (47%) of the scans showed abnormalities: cerebral atrophy (n = 9), schizencephaly (n = 3), periventricular leukomalacia (n = 2), porencephalic cyst (n = 1), and agenesis of the corpus callosum (n = 1). The minimum prevalence of abnormalities on the CT scan of the brain is 1.56 of 1000, and the prevalence of schizencephaly is 0.29 of 1000. Motor impairments were more likely to show abnormality than the other indications. CT abnormalities are common in children with neurological impairment in Kenya, but the appearances did not identify a major cause.
Levetiracetam for the Treatment of Neonatal Seizures
Authors: Shoemaker Michael T. , Rotenberg Joshua S.
Published: April 2007

Seizures are a common occurrence in the neonatal intensive care unit, especially among low-birth-weight infants. The efficacy and safety of standard anticonvulsants have not been evaluated extensively in the neonate. In addition, there is concern for the adverse effects of phenobarbital on long-term development. Levetiracetam has been a commonly prescribed oral anticonvulsant for the use of adjunctive therapy for partial seizures in adults with favorable tolerability, and it has been recently approved for children older than age 4 years. There are no published studies regarding the safety and efficacy of this medication in the infant population. This report describes the initiation of levetiracetam in 3 infants, aged 2 days to 3 months, for refractory seizures or intolerance to other anticonvulsants. Each patient was without seizure on levetiracetam monotherapy, and there were no adverse effects.
Hemispherectomy in Early Infantile Epileptic Encephalopathy
Authors: Hamiwka Lorie , Duchowny Michael , Alfonso Israel , Liu Edward
Published: April 2007

The authors report the successful surgical treatment of early infantile epileptic encephalopathy and suppression burst in 2 children with hemispheric dysplasia. At surgical evaluation, focal epileptic patterns were recorded from the abnormal hemisphere, and ictal single-photon emission computed tomography demonstrated ipsilateral regional hyperperfusion. Functional hemispherectomy was performed after electrocorticography revealed near-continuous spike and slow-wave discharges over the affected hemisphere. Histopathology revealed Taylor-type cortical dysplasia. Postoperatively, both patients are seizure free on antiepileptic drug monotherapy and have shown improved developmental status. Their favorable outcome demonstrates that children with early infantile epileptic encephalopathy due to unilateral malformations of cortical development may benefit from early surgical intervention.
Botulinum Toxin Type B Improves the Speed of Reaching in Children With Cerebral Palsy and Arm Dystonia: An Open-Label, Dose-Escalation Pilot Study
Authors: Sanger Terence D. , Kukke Sahana N. , Sherman-Levine Sara
Published: April 2007

Seven children between 2 and 15 years of age with cerebral palsy and upper extremity dystonia were enrolled in an open-label, dose-escalation pilot clinical trial of botulinum toxin type B (Myobloc), injected into the biceps and brachioradialis muscles of 1 or both arms. The primary outcome measure was the change in maximum speed of hand movement during attempted forward reaching. Escalating doses of 12.5, 25, and 50 U/kg per muscle were injected at each of 3 visits. Reaching speed improved in response to injection, and dystonia scores on the Burke-Fahn-Marsden dystonia scale, the Unified Dystonia Rating Scale, and the Unified Parkinson's Disease Rating Scale improved. There was not a dose-related effect on efficacy. There were no serious adverse events. Two children reported transient weakness. These results support the use of botulinum toxin type B as a safe and effective treatment for upper extremity dystonia in children with cerebral palsy. Larger controlled trials are needed to confirm these results.
Ethnic Differences in Decisional Balance and Stages of Mammography Adoption
Authors: Otero-Sabogal Regina , Stewart Susan , Shema Sarah J. , Pasick Rena J.
Published: April 2007

Behavioral theories developed through research with mainstream, English-speaking populations have been applied to ethnically diverse and underserved communities in the effort to eliminate disparities in early breast cancer detection. This study tests the validity of the transtheoretical model (TTM) decisional balance measure and the application of the TTM stages of change in a multiethnic, multilingual sample. A random sample of 1,463 Filipino, Latino, African American, Chinese, and White women aged 40 to 74 completed a phone survey of mammography beliefs and practices. Consistent with the TTM and independent of ethnicity, decisional balance was associated with mammography stage in all five ethnic groups when controlling for socioeconomic and other factors. In addition, having private insurance and a regular physician and being a long-time resident in the United States were positively associated with mammography maintenance. The application of the TTM for mammography is supported in a multiethnic and multilingual sample.