Neuropsychological assessment, neuroimaging, and neuropsychiatric evaluation in pediatric and adult patients with sickle cell disease (SCD)

Traditionally, neuropsychological deficits due to Sickle Cell Disease (SCD) have been understudied in adults. We have begun to suspect, however, that symptomatic and asymptomatic Cerebrovascular Events (CVE) may account for an alarming number of deficits in this population. In the current brief review, we critically evaluated the pediatric and adult literatures on the neurocognitive effects of SCD. We highlighted the studies that have been published on this topic and posit that early detection of CVE via neurocognitive testing, neuropsychiatric evaluations, and neuroimaging may significantly reduce adult cognitive and functional morbidities.     

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged‐matched cohorts of children with and without otitis media with effusion

Serum IgA and IgG functional antibodies and their subclasses to Streptococcus pneumoniae capsular antigen found in two aged‐matched cohorts of children with and without otitis media with effusion The relationship between acute otitis media and otitis media with effusion (OME) is uncertain and the aetiology of OME is multifactorial. Otitis media with effusion may be an inflammatory condition; both bacteria and viral infections could play a part in this inflammation. The four bacteria Streptococcus pneumoniae, Haemophilus influenza, Staphylococcus aureus and Branhamella catarrhalis cause 60% of the infections whereas S. pneumoniae accounts for up to 35%. IgA provides the dominant surface response to polysaccharide and lipopolysaccharide antigens, of which IgA₂ is the main subclass. Once the mucosa has been breached, most protection is provided by IgG. IgG₂ acts mainly against bacterial capsular antigens. This study looked at two groups of 50 children with and without OME who were aged between 3 and 10 years. The aims were to determine if, firstly, the levels of the serum immunoglobulins were different in the two groups, secondly whether these children made the appropriate antibody response to the capsular antigen to S. pneumoniae (PCP), and finally if there was a delay in the maturity of the IgA response. The total IgG, IgA and all subclass levels were measured using radial immunodiffusion. Levels of functional IgA and IgG were measured using ELISAs (25 patients in each group). The results were analysed with non‐parametric tests. The immunoglobulin levels were within the normal levels for both groups. There were very good correlations between the IgG total anti‐PCP and the IgG₂ anti‐PCP (R > 0.9, p = 0.001). There was a good correlation between the levels of both IgG total and IgG₂ anti‐PCP against IgA total anti‐PCP in both groups (R > 0.85, p > 0.01). This confirms a normal antibody response between both groups of patients. The ages of the controls and patients (50 samples) were correlated with increasing titres of circulating functional antibodies (P = 0.001). This is highly suggestive of a normal age‐related response. In conclusion, the findings were contradictory to our original hypothesis that there is a subtle difference in surface protection between children with and without OME. We believe that a previous history of recurrent acute otitis media is unrelated to the development of OME after 3 years of age.     

Resolution of primary murine listeriosis and acquired resistance to lethal secondary infection can be mediated predominantly by Thy-1+ CD4- CD8- cells.

Mice depleted of CD4+, CD8+, Thy-1+ CD4- CD8-, or all three types of cells by appropriate monoclonal antibody treatment were tested for their ability to express resistance against a primary and secondary Listeria monocytogenes infection. It was found that mice depleted of CD8+, CD4+, or both of these subsets of T cells remained capable of controlling and then resolving both a primary infection and a secondary infection lethal for normal animals. In contrast, depleting mice of a population of Thy-1+ CD8- CD4- cells that remain after CD4+ and CD8+ T cells had been removed, rendered them incapable of resolving a sublethal primary infection or of expressing acquired immunity to a lethal secondary infection. The results point to the possibilities that Thy1+ CD4- CD8- alpha beta T cells, Thy1+ CD4- CD8- gamma delta T cells, Thy-1+ NK cells, or all three types of these host cells are involved in anti-L. monocytogenes resistance.     

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects.

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.     

An investigation of the suitability of bra fit in women referred for reduction mammaplasty.

Reduction mammaplasty is rationed in NHS plastic surgery provision, despite abundant evidence that most women who undergo this operation obtain significant improvement in their physical health and quality of life. We suspected that women seeking reduction mammaplasty often wear ill-fitting bras, which may exacerbate some of their symptoms. Therefore, we studied 103 women who attended a nurse-run pre-assessment clinic, asking them what size bra they currently wore and then measuring them to see whether their bra size was correct. We also questioned bra manufacturers, designers and shop bra fitters about bra manufacture, sizing and fitting techniques, and we reviewed these findings. Of the 102 women suitable for inclusion in the study, all wore the wrong size bra. Their mean 'claimed' back measurement was 36 inches (range: 30-42 in.) and their mean cup size was F (range: C-J). We found that all but one underestimated their back measurement (by a mean of 4 in.; range: -2-10 in.) and overestimated their cup size (by a mean of three sizes; range: one size smaller to seven sizes larger) when compared with manufacturers' fitting guidelines. Multiple regression analysis used to assess the relationships of various factors to incorrect bra sizing showed a strong link (Pearson correlation=0.54; P<0.001) between obesity and inaccurate back measurement. The reasons why women with breast hypertrophy wear incorrectly fitting bras are discussed. We conclude that obesity, breast hypertrophy, fashion and bra-fitting practices combine to make those women who most need supportive bras the least likely to get accurately fitted bras, so exacerbating the symptoms for which they seek surgery.     

Postkeratoplasty crystalline deposits mimicking bacterial infectious crystalline keratopathy

Three corneal transplant patients developed white, crystalline, anterior stromal lesions in their grafts while receiving long-term topical corticosteroid therapy. A presumed diagnosis of infectious crystalline keratopathy was made in each case. However, histologic examination of the lesions failed to show gram-positive cocci. A fungal infiltrate was present in the first two patients, and calcium deposits produced the lesion in the third patient.     

Knowledge and attitude change as predictors of metabolic improvement in diabetes education

Randomized trials of formal diabetes education have proven that education in isolation from other aspects of diabetes care has limited impact on metabolic control through the simple transfer of information. Comprehensive programme evaluation requires assessment of the process by which knowledge and attitude change affect subsequent control of diabetes. This study examined the impact of a formal diabetes education programme on diabetes-specific knowledge and attitude, and the relationship between these characteristics and metabolic control of the disease over a 15-month period. Knowledge and attitude were assessed using parallel forms of the DKN and ATT39 scales presented randomly as pre-test and post-test to 309 patients attending a 2-day diabetes education programme. Mean knowledge scores increased by 25% (P less than 0.0001) and standardized ATT scores showed a small but significant positive shift after the programme (P less than 0.01) and remained stable in a subset of 177 patients at 3-month follow-up. ATT scores showed a marked convergence towards normal during the intervention (ANOVA, P less than 0.0001). Glycosylated haemoglobin (HbAlc), a medium-term measure of blood glucose control, was recorded in 209 cases for 6 months preceding the programme, and for 15 months following, at intervals of 3 months. The mean HbAlc improvement, from 11.3 to 9.0% (P less than 0.001), was predicted by stepwise regression from initial diabetes control (57% variance) and psychosocial factors (17% variance) including attitude scores and personality characteristics. Diabetes knowledge did not predict improvement in the control of diabetes.