Adolescent Pediatric Decision-Making: A Critical Reconsideration in the Light of the Data

Adolescents present a puzzle. There are foundational unclarities about how they should be regarded as decision-makers. Although superficially adolescents may appear to have mature decisional capacity, their decision-making is in many ways unlike that of adults. Despite this seemingly obvious fact, a concern for the claims of autonomy has led to the development of the legal doctrine of the mature minor. This legal construct considers adolescents, as far as possible, as equivalent to adults for the purpose of medical decision-making. The movement to support independent decision-making by adolescents through providing information to them and securing their consent apart from their parents is encouraged by those legal understandings that hold that unemancipated minors should generally be considered as possessing effective decisional capacity. Such legal structures, however, do not adequately take account of the wide variations in adolescent capacities, the immaturity of most adolescent decision-makers, or the important contributions made by parents to the development of their adolescents through parental partnering in the adolescent’s decision-making. The data available indicate that in general adolescents should be regarded as apprentice decision-makers who should make decisions in collaboration with their parents until at least the age of 18. Steps should not be taken pre-emptively to isolate adolescents from the guidance of their parents. As a general rule, what Piker has referred to as “collaborative paternalism” appears most likely both to protect adolescents from their own untoward choices, while also very importantly helping them with parental guidance to develop into mature decision-makers with the capacity to make medical choices on their own.     

Automated whole‐brain N‐acetylaspartate proton MRS quantification

Concentration of the neuronal marker, N‐acetylaspartate (NAA), a quantitative metric for the health and density of neurons, is currently obtained by integration of the manually defined peak in whole‐head proton (¹H)‐MRS. Our goal was to develop a full spectral modeling approach for the automatic estimation of the whole‐brain NAA concentration (WBNAA) and to compare the performance of this approach with a manual frequency‐range peak integration approach previously employed. MRI and whole‐head ¹H‐MRS from 18 healthy young adults were examined. Non‐localized, whole‐head ¹H‐MRS obtained at 3 T yielded the NAA peak area through both manually defined frequency‐range integration and the new, full spectral simulation. The NAA peak area was converted into an absolute amount with phantom replacement and normalized for brain volume (segmented from T₁‐weighted MRI) to yield WBNAA. A paired‐sample t test was used to compare the means of the WBNAA paradigms and a likelihood ratio test used to compare their coefficients of variation. While the between‐subject WBNAA means were nearly identical (12.8 ± 2.5 mm for integration, 12.8 ± 1.4 mm for spectral modeling), the latter's standard deviation was significantly smaller (by ~50%, p = 0.026). The within‐subject variability was 11.7% (±1.3 mm ) for integration versus 7.0% (±0.8 mm ) for spectral modeling, i.e., a 40% improvement. The (quantifiable) quality of the modeling approach was high, as reflected by Cramer–Rao lower bounds below 0.1% and vanishingly small (experimental ‐ fitted) residuals. Modeling of the whole‐head ¹H‐MRS increases WBNAA quantification reliability by reducing its variability, its susceptibility to operator bias and baseline roll, and by providing quality‐control feedback. Together, these enhance the usefulness of the technique for monitoring the diffuse progression and treatment response of neurological disorders. Copyright © 2014 John Wiley & Sons, Ltd.     

MRI assessment of temporomandibular disc position among various mandibular positions: a pilot study

Purpose: The aim of this pilot study was to assess temporomandibular joint disc movement relative to the condyle among centric relation (CR), physiologic rest position (PRP), and maximal intercuspation position (MIP) in healthy patients without signs or symptoms of any temporomandibular disorder. The hypothesis was that as the condyle rotated clockwise or translated anteriorly, the disc would also move in an anterior direction. Material and methods: Magnetic resonance images were obtained on 20 volunteers in CR, physiologic rest, and MIP. Three investigators measured the location of the disc among the different mandibular positions. Results: Disc location differences between CR and PRP exhibited the widest range of measurement. The largest amount of disc protrusion relative to the condyle was found between CR and PRP on the right side. The largest amount of disc retrusion relative to the condyle was found between CR and MIP on the right side. The hypothesis was not supported by the results. Conclusions: According to the results of this pilot study, the direction of movement of the temporomandibular disc does not correlate with the rotational movement of the condyle in hinge positions. Clinical implications: Increased knowledge of temporomandibular disc movement among various mandibular positions in asymptomatic patients may help clinicians recognize deviations in symptomatic patients.     

Normative Clinical Relationships Between Orientation and Memory: Age as an Important Moderator Variable

The present study examined the relationship between memory and orientation to time, place, and personal and general information, as moderated by age, education, and simple attentional ability. A heterogeneous sample of 312 clinical referrals was divided into four groups, according to delayed memory functioning. Patients with globally good, globally poor, poor visual, and poor auditory memory were at differential risk of being disoriented, with the globally poor memory patients having the greatest risk. Overall, poorly oriented patients were older and less educated, with worse recall of digits backward. Discriminant Function Analysis selected visual and auditory memory and age as predictors of orientation. Normative tables stratified by age and memory performance are presented.