Dysgraphia in Alzheimer's disease: a review for clinical and research purposes.

PURPOSE: This article presents a critical review of literature on dysgraphia associated with Alzheimer's disease (AD). Research presented includes discussions of central and peripheral spelling impairments as well as the impact of general, nonlinguistic cognitive functions on dysgraphia associated with AD. METHOD: The studies critically reviewed were from a variety of disciplines, with emphasis on seminal work, recent literature, and the first author's research. CONCLUSIONS: Studies have shown that writing impairment is heterogeneous within the AD population; however, there are certain aspects of the writing process that are more vulnerable than others and may serve as diagnostic signs. Identifying patterns of writing impairment at different stages of AD may help to chart disease progression and assist in the development of appropriate interventions.     

Laryngectomy clinical pathway: development and review.

OBJECTIVE: The goal of the study is to determine if the implementation of a protocol for the preoperative and postoperative care of patients receiving a laryngectomy for cancer of the larynx or hypopharynx (i.e., laryngectomy clinical pathway) reduced length and cost of hospital stay without increasing complication rates. DESIGN: This study is a comparison of the perioperative course of two groups of laryngectomy patients. Data were collected retrospectively from the records of patients operated on before the implementation of the clinical pathway as the institutional historical control. Comparison was made with data collected prospectively on patients operated on after the implementation of the clinical pathway. SETTING: The study was performed at a mid-sized teaching hospital associated with two regional cancer centres. All surgeries were performed by one of two otolaryngology-head and neck surgeons and residents under their supervision. METHODS: The demographic, patient, tumour, treatment, dietary, and complication data were analyzed. Fisher's exact (two-tailed) statistical test was used for parametric data and Wilcoxon scores for nonparametric data. MAIN OUTCOME MEASURE: The principal outcome measure was the length of postoperative inpatient stay. Secondary outcome measures were readmissions and postoperative complications. RESULTS: There was a statistically significant decrease of 6.7 days in the mean length of hospitalization in the clinical pathway group even when taking postoperative readmissions into account. There was no concomitant increase in surgical complications. The mean reduction in hospital cost per case was calculated to be $3,420 (Can). CONCLUSIONS: Application of a clinical pathway for patients receiving laryngectomy is both feasible and effective.     

Tutorials in clinical research: part III. Selecting a research approach to best answer a clinical question

OBJECTIVE: This is the third in a series of sequential "Tutorials in Clinical Research." The objectives of this specific report are to enable the reader to rapidly dissect a clinical question or article to efficiently determine what critical mass of information is required to answer the question and what study design is likely to produce the answer. STUDY DESIGN: Tutorial. METHODS: The authors met weekly for 3 months exploring clinical problems and systematically recording the logic and procedural pathways from multiple clinical questions to the selection of proper research approaches. The basic elements required to understand the processes of selection were catalogued and field tested, and a report was produced to define and explain these elements. RESULTS: Fundamental to a research approach is the assembly of subjects and the allocation of exposures. An algorithm leading to the selection of an approach is presented. The report is organized into three parts. The tables serve as a rapid reference section. The initial two-part narrative explains the process of approach selection. The examples section illustrates the application of the selection algorithm. CONCLUSIONS: Selecting the proper research approach has six steps: the question, logic and ethics,identification of variables, data display considerations, original data source considerations, and selection of prototypical approaches for assembly of subjects. Field tests of this approach consistently demonstrated its utility.     

The need for clinical awareness of polymorphous low-grade adenocarcinoma: a review.

Adenocarcinomas of the salivary glands are a heterogeneous group both in terms of histomorphology and clinical course. One recently described adenocarcinoma, polymorphous low-grade adenocarcinoma (solely of minor salivary gland occurrence), is appropriately named. This neoplasm has a wide spectrum of histology and can resemble tumors such as pleomorphic adenoma and adenoid cystic carcinoma; both aspects can lead to diagnostic problems for the pathologist. As well, despite an infiltrative growth pattern, which frequently results in perineural invasion, this tumor has a low local recurrence rate and a remarkable infrequency of local or distant metastasis. In order to provide appropriate therapy for polymorphous low-grade adenocarcinoma, oral and head and neck surgeons must be familiar with this neoplasm.     

Hereditary angioedema: a clinical review for the otolaryngologist

Hereditary angioedema (HAE) is a relatively rare genetic disorder that is usually characterized by either low levels of C1 esterase inhibitor (C1-INH) or the presence of dysfunctional C1-INH. It can present with relatively mild and self-limiting symptoms, but it is also potentially fatal; the most common cause of death is asphyxiation secondary to edema of the upper airway. The diagnosis of HAE, especially in the emergency situation, is not straightforward. HAE must be distinguished from several other types of angioedema that require different management approaches. Management approaches include trigger avoidance and pharmacologic therapy; the latter has traditionally involved the administration of attenuated androgens and antifibrinolytics. Recently, a new class of agent-C1-INH-has been introduced in the United States. This article provides an update on the pathophysiology, clinical picture, diagnosis, prophylaxis, and acute treatment of HAE. We must keep HAE in mind as a possible diagnosis whenever we are faced with a case of unexplained angioedema if we are to take advantage of the effective and more specific therapies that are becoming available.     

Ludwig's angina: a clinical review

Ludwig's angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by a brawny induration of the floor and suprahyoid region (bilaterally), with an elevation of the tongue potentially obstructing the airway. In the pre-antibiotic era, Ludwig's angina was frequently fatal; however, antibiotics and aggressive surgical intervention have significantly reduced mortality. We reviewed nine patients with Ludwig's angina between July 1996 and June 2002, all of whom presented with fever, neck swelling, bilateral submandibular swelling and elevation of the tongue. In eight patients (89%) a dental infection appeared to be the underlying cause. High-dosage intravenous antibiotics directed towards the suspected causative microorganisms were given to all of the patients: two were treated successfully with conservative medical management, while seven underwent surgical drainage (a tracheotomy was necessary in one patient). Routine aerobic cultures were done on samples of drained material and the predominant microorganisms were Streptococcus species in two patients; there were none in the other five. Two patients had post-operative complications, but all recovered.     

Scaffolds and biomaterials for tissue engineering: a review of clinical applications

Tissue engineering is a multidisciplinary area of research aimed at regeneration of tissues and restoration of organ function. This is achieved through implantation of cells/tissues grown outside the body or by stimulating cells to grow into an implanted matrix. In this short review, we discuss the use of biomaterials, in the form of scaffolds, for tissue engineering and review clinical applications to otorhinolaryngology-head and neck surgery.     

Clinicoanatomic studies in dysarthria: review, critique, and directions for research.

More than 30 years ago, Darley, Aronson, and Brown (1969) proposed clinicoanatomic correlations for seven perceptual types of dysarthria. These correlations have not been systematically re-examined even though imaging technologies developed in recent years provide the means to do so. This review considers data from published imaging studies as well as data from selected medical interventions to evaluate the current state of knowledge that relates lesion site to the nature of a speech disturbance. Although the extant data are not sufficient to allow a complete evaluation of the seven types of dysarthria described by Darley et al., relevant information has been reported on lesions of the pyramidal pathway, extrapyramidal pathway, and cerebellum. In general, the results are best explained by an equivalence mode of brain-behavior relationship in which a type of dysarthria is associated with a lesion in one of two or more brain structures. Criteria also are proposed for future studies of clinicoanatomic relationships in neurogenic communication disorders.     

Imitation and language development: issues and clinical implications.

The relationship between imitation and language learning is of both theoretical and clinical interest. While current psycholinguistic accounts give imitation only a limited role in language learning, learning theorists and others continue to refer to imitation as a major factor in the child's acquisition of language. Clinicians deal with imitation in modeling procedures as well as in counseling parents about how to promote children's language development. A review of theory and research on the nature and development of imitation reveals wide variation in terminology, definitions, and explanations. The clinical use of imitation procedures have greater significance for the acquisition of communication skills than for the development of linguistic structure.     

Cognitive neuroscience in tinnitus research: a current review

Advances in methods of examining the human brain have led to a dramatic increase in specific knowledge about the origins of tinnitus. Neural modeling, behavioral measurements of hearing performance and psychological state, neuro-morphology, metabolic measurements of neural activity, electromagnetic recordings of synaptic potentials, and optical measurements of action potentials are all modalities that have provided insights or the promise of new information about the pathophysiology of tinnitus. This review examines these techniques and their contributions to knowledge about tinnitus.     

Stuttering: a review of research findings and theories circa 1982

The research literature on stuttering is extensive, spanning etiology, natural history, phenomenology, and treatment. In this review, existing empirical knowledge is distilled by attending only to replicated findings. These are designated as "facts." Facts concerning the natural history of idiopathic stuttering highlight early childhood onset, probability of recovery, and importance of a positive family history of stuttering. Corroborated evidence on stutterer-nonstutterer differences concerns intelligence distribution, speech development, central auditory function, and sensory-motor response. Predictable changes in stuttering frequency, and even total elimination of stuttering, occur under a remarkable variety of conditions. Review of therapies revealed two that satisfied the most stringent criteria for good treatment. Various theoretical positions are examined for their fit with the established facts. A model of stuttering as a genetically determined reduction in central capacity for efficient sensory-motor integration is preferred, provided acquisition of secondary symptoms is attributed to instrumental learning.