Adults with cerebral palsy: a workshop to define the challenges of treating and preventing secondary musculoskeletal and neuromuscular complications in this rapidly growing population

Although the neurological injury associated with cerebral palsy (CP) is non-progressive, adults with the disorder often develop musculoskeletal and neurological symptoms, such as severe pain, chronic fatigue, and a premature decline in mobility and function, as they age. Little is known about how to manage, much less prevent, these symptoms. This paper summarizes the findings of a multi-disciplinary workshop, sponsored by the Cerebral Palsy International Research Foundation, the American Academy for Cerebral Palsy and Developmental Medicine, and Reaching for the Stars, convened to review current knowledge and begin to develop a blueprint for future research. The goals of the workshop were to (1) define the current incidence and prevalence of CP, (2) review the known complications for persons aging with CP, (3) review current understanding of physiological processes that may contribute to loss of function and premature aging in CP, (4) evaluate current treatment interventions in terms of long-term outcomes, (5) identify cutting-edge technologies in neurorehabilitation that may help prevent or treat the effects of accelerated aging for persons diagnosed with CP, and (6) identify strategies to ensure that individuals with CP receive evidence-based care as they transition from pediatric to adult-care services.     

Diagnosing the ''strange'' child

The diagnosis of children with a spectrum of autistic features, who do not qualify for the diagnosis of classical autism, has increased during the past decade. A case is reported of an 8-year-old child originally diagnosed as learning disabled with attention disorders and hyperactivity, who was later diagnosed as having an autistic spectrum disorder when abnormalities of social interaction and play activity became more obvious. The frequency of learning and attention problems in school-age children may obscure more significant psychiatric pathologies, such as autistic disorders. Improved awareness of disorders of social functioning and play activity in the school-age child and use of screening tools may lead to earlier detection, definitive diagnosis and treatment for these children. In addition, assessments from multiple sources, i.e. the school, the home and the clinic, are needed in the diagnostic process. Periodic re-evaluations of the school-age child with problem behaviour are necessary to insure that more significant pathologies, which were not clear on initial evaluation, are diagnosed at the earliest opportunity.     

Nonthoracotomy Implantation of Cardioverter Defibrillators: Preliminary Experience with a Defibrillation Lead Placed at the Right Ventricular Outflow Tract

Although morbidity and mortality associated with defibrillator implantation using a nonthoracotomy approach have decreased as compared with a thoracotomy approach, dfifihrillation thresholds have been higher and fewer patients satisfied implan t criteria. It may be possible to improve on the success of nonthoracotomy defibrillator implantation by the placement of a right ventricular (HV) outflow defibrillation lead. Implnntable car-dioverter defibrillator implantation data of 30 consecutive patients with clinical VT or VF were reviewed. Three defibrillation leads were routinely used. When either pacing threshold at the RV apex ivas inadequate (n - 2) or 18-J shocks were not successful in terminating VF in 3 of 4 trials (n = 8). the RV apex lead was positioned to the HV outflow tract attaching to the septum. Defibrillation testing was first performed with the RV apex lead in combination with CS, SVC. and/or subcutaneous leads. Twenty patients satisfied implant criteria with a defibrillation threshold of 13.5 ± 3.6 J. In 7 of the 10 patients, whose RV lead was repositioned to the RV outflow tract, this lead in combination with SVC, CS, or subcutaneous leads produced successful defibrillation at < 18 J or in 3 of 4 trials. This approach improved the overall success of nonthoracotomy implantation of defibrillators from 69% to 90%, After a follow-up of 27 ± 6 months, there was no dislodgment of the HV outflow tract defibrillation leads. Conclusions: This article reports the preliminary observation that placement of defibrillation leads to the RV outflow tract in humans was possible and without dislodgment. RV outflow tract offers an alternative for placement of defibrillation leads, which may improve on the success of nonthoracotomy defibrillator implantation.