The burden of otitis media

Otitis media is the most frequent reason that children go to the doctor for illness. In developing countries, where children have limited access to medical care, suppurative complications of otitis media (OM) are frequent and permanent hearing loss results. In developed countries, the most common morbidity of OM is conductive hearing loss due to middle ear effusion. Infants with severe and recurrent OM and persistent middle ear effusion are at risk for problems in behavior and development of speech, language and cognitive abilities. Parent stress is frequent. The cost of otitis media is large (>$5 billion in the United States). Selection and spread of multi-drug resistant bacterial pathogens arising from extensive use of antimicrobial agents for OM is a problem for management of all diseases due to the pathogens. The incidence and severity of OM may diminish with introduction of new bacterial and viral vaccines.

Monozygotic boys with fragile X syndrome

Monozygotic twin boys with fragile X syndrome underwent thorough genetic, psychiatric, neurological, and language evaluations at 10 years of age. They both demonstrated physical features, speech and language difficulties, social problems, and attentional deficits that characterize the behavioural phenotype of fragile X syndrome. Despite identical genetic constitutions, there were important developmental and behavioural heterogeneities. Twin A showed less social interaction and symbolic play and more speech and language dysfunction than twin B. Twin A also had significantly larger caudate volumes. It is suggested that the Xq27.3 anomaly may not be sufficient to account for all the behavioural phenotypic and neuroanatomical features of fragile X syndrome.

Patterns of neuropsychological deficits in children with medulloblastoma according to craniospatial irradiation doses

This study aimed to analyse the relationship between supratentorial irradiation dose and the intellectual outcome in 36 children (aged between 5 and 15 years) treated for medulloblastoma. The supratentorial radiation dose was reduced to 25 Gy in 23 children and given at the standard dose, 35 Gy, in 13 other children. Neuropsychological evaluation was performed at a mean of 4.3 years (SD 4.7 years) after radiotherapy. The supratentorial radiation dose was the principal risk factor associated with impaired intellectual outcome. Verbal fluency, immediate word list recall, block design, and fine motricity of the dominant hand were significantly lower in children irradiated at the standard doses than in those irradiated at reduced doses. These findings suggest that the dose of radiotherapy applied to the brain strongly influences later verbal and non-verbal skills in children with medulloblastoma. This should be taken into account in treatment planning and in rehabilitation programs.

Etiologic yield of single domain developmental delay: a prospective study

OBJECTIVE

To determine the etiologic yield in young children with single domain developmental delay (either developmental language disorder or isolated motor delay) after a specialty diagnostic evaluation.

METHODS

During an 18-month period, all children <5 years of age, who were consecutively referred to pediatric neurology or developmental pediatric clinics at a single tertiary pediatric center, were prospectively enrolled. Etiologic yield was determined after completion of clinical assessments and selected laboratory studies requested by the evaluating physician.

RESULTS

Seventy-two children (60 boys) were found to have a developmental language disorder, and 22 children (11 boys) had isolated motor delay, of whom 6 had an associated diagnosis of cerebral palsy. An etiologic diagnosis was rarely made in the children with developmental language disorder (3/72, 4.1%). Laboratory investigations (metabolic, cytogenetic, imaging), aside from audiometry, were uniformly uninformative. In those children with isolated motor delay, an etiology was apparent in more than half (13/22, 59%). Slightly more than half (7/13, 54%) of etiologies identified in this group were potentially preventable. Successful etiologic determination in children with motor delay often had an impact on recurrence risk estimation, medical management, or specific therapy offered (8/13, 62%). The presence of physical findings on initial assessment was found to be highly predictive of successful etiologic determination in children with isolated motor delay (13/17 vs 0/5, P =.002).

CONCLUSION

Etiologic yield differs substantially according to the subgroup of single domain developmental delay.

Speech recognition training for enhancing written language generation by a traumatic brain injury survivor

Impairments in motor functioning, language processing, and cognitive status may impact the written language performance of traumatic brain injury (TBI) survivors. One strategy to minimize the impact of these impairments is to use a speech recognition system. The purpose of this study was to explore the effect of mild dysarthria and mild cognitive-communication deficits secondary to TBI on a 19-year-old survivor's mastery and use of such a system-specifically, Dragon Naturally Speaking. Data included the % of the participant's words accurately perceived by the system over time, the participant's accuracy over time in using commands for navigation and error correction, and quantitative and qualitative changes in the participant's written texts generated with and without the use of the speech recognition system. Results showed that Dragon NaturallySpeaking was approximately 80% accurate in perceiving words spoken by the participant, and the participant quickly and easily mastered all navigation and error correction commands presented. Quantitatively, the participant produced a greater amount of text using traditional word processing and a standard keyboard than using the speech recognition system. Minimal qualitative differences appeared between writing samples. Discussion of factors that may have contributed to the obtained results and that may affect the generalization of the findings to other TBI survivors is provided.

Association of epilepsy with different groups of microcephaly

Sixty-six participants (33 males, 33 females) with microcephaly (MC), age range from 2 to 19 years old, were evaluated. MC was classified pathogenetically into isolated MC (IMC) and multiple MC (MMC) and classified etiologically into primary MC (PMC) and secondary MC (SMC). Both IMC and MMC were further classified. Overall prevalence of epilepsy was 40.9%. Furthermore, there was a significantly higher prevalence of epilepsy in males. Main seizure type was generalized tonic-clonic seizures. Generally, learning disability (LD) was diagnosed in 93.9% and profound LD was evident in 43.9% of participants. There was an inverse correlation between severity of epilepsy and IQ but a positive correlation between severity of epilepsy and degree of LD. Differences in the success rate between monotherapy and polytherapy or response to antiepileptic drugs were not observed. Results suggest that epilepsy may be associated with the lower cognitive ability of the participants with microcephaly. The pathogenetic classification proposed is of value in delineating the prevalence of epilepsy and LD in the different varieties of MC as compared with the etiological classification.

Incidence and outcome of poststroke urinary retention: a prospective study

OBJECTIVE

To document the incidence and outcome of poststroke urinary retention, and to determine clinical variables associated with it.

DESIGN

Cohort of 80 consecutive patients.

SETTING

Inpatient setting of a tertiary rehabilitation center.

PARTICIPANTS

Eighty patients (48 men, 32 women; mean age, 65.4 yr) with a first ischemic stroke, admitted for rehabilitation within 4 weeks of the stroke.

MAIN OUTCOME MEASURES

Patients had their postvoid residuals (PVR) assessed via a bladder scanner within 72 hours of admission. Urinary retention was defined by a PVR of more than 100mL on 2 consecutive occasions.

RESULTS

Urinary retention was present in 23 (29%) patients. Cognitive impairment, aphasia, diabetes mellitus, and cortical stroke were present in 30%, 29%, 31%, and 41% of patients, respectively. Fifteen (19%) patients developed urinary tract infection during rehabilitation. Urinary retention was significantly associated (p < .05) with cognitive impairment, diabetes mellitus, aphasia, a lower admission functional status (as measured on the modified Barthel index), and urinary tract infection, but not with the use of anticholinergic medications. On discharge, 4 patients still had urinary retention (3 were voiding spontaneously and the other used intermittent catheterization).

CONCLUSION

Urinary retention was common in patients with ischemic stroke. It should be strongly suspected in patients with aphasia, cognitive impairment, poor functional status, and diabetes mellitus.

Decline of language among women and men with Alzheimer's disease

Previous research raises the possibility that gender differences occur in language function in Alzheimer's disease, but this hypothesis has not been evaluated systematically in longitudinal studies. The authors examined the association of gender with rate of decline in language and other cognitive functions among 410 persons with Alzheimer's disease. Participants were recruited from a dementia clinic and followed for up to 5 annual evaluations. Follow-up participation among survivors exceeded 90%. Decline in a composite score based on 8 language tests was evaluated in random effects models with age, education, and race controlled. Annual decline was 0.71 standard units (95% confidence interval [CI] = 0.62-0.79) for women and 0.74 units (95% CI = 0.61-0.86) for men, not a significant difference. Decline on the individual language tests and on composite measures of memory, perception, and global cognition also indicated no significant association with gender. These results suggest that Alzheimer's disease affects language and other cognitive functions similarly in women and men.

Language and calculation within the parietal lobe: a combined cognitive, anatomical and fMRI study

We report the case of a patient (ATH) who suffered from aphasia, deep dyslexia, and acalculia, following a lesion in her left perisylvian area. She showed a severe impairment in all tasks involving numbers in a verbal format, such as reading aloud, writing to dictation, or responding verbally to questions of numerical knowledge. In contrast, her ability to manipulate non-verbal representations of numbers, i.e., Arabic numerals and quantities, was comparatively well preserved, as evidenced for instance in number comparison or number bisection tasks. This dissociated impairment of verbal and non-verbal numerical abilities entailed a differential impairment of the four arithmetic operations. ATH performed much better with subtraction and addition, that can be solved on the basis of quantity manipulation, than with multiplication and division problems, that are commonly solved by retrieving stored verbal sequences. The brain lesion affected the classical language areas, but spared a subset of the left inferior parietal lobule that was active during calculation tasks, as demonstrated with functional MRI. Finally, the relative preservation of subtraction versus multiplication may be related to the fact that subtraction activated the intact right parietal lobe, while multiplication activated predominantly left-sided areas.

Diagnostic assessment and treatment goals in logopedics: impairments, disabilities and handicaps

This study was aimed to investigate to what extent impairments, disabilities and handicaps are used as diagnostic assessments and treatment goals in logopedics. Traditionally, logopedists are mainly concerned with impairments. These days, increasing attention is demanded for disabilities and handicaps as well. A survey study was carried out on 1,567 patients in logopedic practices in the Netherlands to provide an empirical quantitative description of diagnostic assessments and treatment goals, formulated in terms of impairments, disabilities and handicaps. Results show that logopedists indeed often indicate impairments as diagnostic assessments and as treatment goals, particularly language development impairments and phonetic/phonological articulation impairments. Interestingly, also large numbers of diagnostic assessments and treatment goals were indicated at the level of disabilities and handicaps; the most important being disability in expressing communication and occupational handicap. These results demonstrate that disabilities and handicaps may serve an important function in logopedics, in that they may guide assessment as well as therapy. It is concluded that disabilities and handicaps should be considered in the future development of the profession of logopedics.

Update on childhood-onset schizophrenia

Updated findings from the ongoing National Institute of Mental Health Child Psychiatry Branch longitudinal study of childhood-onset schizophrenia (COS) are presented, along with replications from collaborators at other sites. Clinical and neurobiologic continuities of COS with poor-outcome adult-onset schizophrenia suggests that their underlying pathophysiology is the same. However, these early-onset cases appear to have more striking genetic contributions to their etiology. Updated findings involve risk factors (birth complications, cytogenic abnormalities, early language and motor problems, and familial psychopathology), treatment trials, and brain magnetic resonance imaging studies.

The relationship between event representation and linguistic skill in narratives of children and adolescents with Down syndrome

Children and adolescents with Down syndrome present with greater difficulty in expressive language than nonverbal cognitive domains. As narratives involve an understanding of the relationship(s) between events and their verbal expression, this divergence has implications for understanding narrative abilities in persons with Down syndrome. In this project, we investigated the relationship between event representation and linguistic expression in narratives of children and adolescents with Down syndrome (n = 31) and groups of typically developing children matched for mental age (n = 31), syntax comprehension (n = 28), or expressive language (n = 27). A short wordless film, the Pear Story (Chafe, 1980), was viewed individually by each participant and then each participant retold the story to an adult who (presumably) had not seen the film. Findings suggest a disparate relationship between linguistic expression and event representation in narratives of children and adolescents with Down syndrome. Participants with Down syndrome produced narratives that were significantly longer and more complex than the expressive-language-matched-group, with no differences observed in event structure when compared to the MA-matched group. Comparatively, use of linguistic devices and cohesion were poorer in the children and adolescents with Down syndrome than in the MA-matched children, with no differences observed in comparison to children matched for expressive language.

Expressive language disorder after infarction of left lentiform nucleus

A 53 year old bilingual woman presented with apraxia of speech and writing in English and German after ischaemic infarction of the left posterior lentiform nucleus. Detailed language assessment revealed impairments of articulation, verbal fluency, auditory repetition, interpretation of complex semantic relationships, formulation of definitions and verbal short-term memory. The case illustrates the role of the basal ganglia in speech planning, word retrieval and verbal short-term memory.

Persisting aphasia as the sole manifestation of partial status epilepticus

OBJECTIVES

Persisting aphasia presenting as an isolated inability to vocalize is an uncommon presentation of simple partial status epilepticus and only eight such cases have been reported over the past 40 years.

METHODS

We studied a patient with a 5-year history of recurrent episodes of inability to talk, without any other motor or cognitive impairments. Episodes lasted as long as 24 h, interictal EEGs were normal and she was diagnosed as a conversion disorder.

RESULTS

EEG recordings during one of the episodes showed continuous discharges in the right frontal and parasagital areas demonstrating the ictal nature of the deficits. During the episode the patient had no deficits of strength, or in her ability to perform skilled movements to command, imitation or manipulation of objects. Comprehension of complex verbal commands was preserved and she would make attempts to articulate words and correctly answered questions with head nodding or monosyllables, yes or no. She could hum but had no other vocalizations.

CONCLUSIONS

This is the first case of aphasic status epilepticus secondary to epileptogenic discharges of the right hemisphere. The case is also unique for the isolated involvement of production of language during the seizure.

Conceptual apraxia and semantic memory deficit in Alzheimer's disease: two sides of the same coin?

This study was designed to examine the patterns of apraxic disturbances and the relationships between action knowledge and other measures of semantic knowledge about objects in 10 well-characterized Alzheimer's disease (AD) patients. Five tasks were used to assess components of action knowledge (action-tool relationships, pantomime recognition, and sequential organization of action) and praxis execution (actual use, pantomiming) according to the cognitive model of praxis. Three tasks (verbal comprehension, naming, and a visual semantic matching task) were used to assess verbal-visual semantics. Considering patterns of apraxia first, conceptual apraxia was found in 9 out of the 10 AD patients, suggesting that it is a common feature even in the early stages of AD. Second, we found partly parallel deficits in tests of action-semantic and verbal-visual semantic knowledge in 9 AD patients. Impaired action knowledge was found only in patients with a semantic language deficit. These findings provide no evidence that "action semantics" may be separated from other semantic information. Our results support the view of a unitary semantic system, given that the representations of action-semantic and other semantic knowledge of objects are often simultaneously disrupted in AD.

Infant hearing loss: the necessity for early identification

There has been controversy in the health professions about the necessity for newborn infant hearing screening. It is well accepted that patient history or a birth that places the infant in the high-risk registry (HHR) can identify 50% of all infants born with permanent bilateral hearing loss. Two major factors which have been cited as reasons for not screening the well-baby nursery have been poor cost effectiveness and the lack of documentation as to the benefits derived from early identification and intervention. Recent technological developments and published data are presented which indicate that economical well-baby hearing screening can be done in any setting, and that the language acquisition of the infant is permanently affected if the intervention is not done in the first six months after birth.

Language and oral-motor development and disorders in infants and young toddlers with human immunodeficiency virus

There are only a few studies on the preverbal and language development of infants and toddlers with human immunodeficiency virus (HIV). However, the available literature indicates that HIV infection appears to compromise language development. No studies could be found on the oral-motor development of such children. This article reviews current research on the preverbal and language development of children with HIV from birth to 3 years of age and provides recommendations for future research. Information on several virus-related pathologies that can interfere with oral-motor integrity and development is also presented. Proper intervention to remediate language disorders and support oral-motor development of these children requires their comprehensive assessment, and a dynamic assessment strategy is recommended.

Cognitive function and language of a child with an arachnoid cyst in the left frontal fossa

The authors inspected the cognitive function of a boy with a congenital arachnoid cyst in the left frontal fossa. Neuropsychological tests described his cognition, including language, memory, and frontal functions, as mildly retarded overall. The boy's verbal ability was delayed, but his frontal function was intact. We supposed that the cyst would not affect his cognitive function. SPECT images showed low perfusion in the left temporal lobe. Dysfunction of the left temporal lobe should cause delayed language leading to learning difficulty. Neuropsychological evaluation of cognitive function concurrent with rCBF imaging was necessary not only for describing the influence of the cyst but also in discriminating its psychological aspects.

[Klinefelter syndrome in young children: possibility of diagnosis]

In one boy aged 7 years with a micropenis, and in 3 boys aged 6, 4 and 5 years with delayed speech and language development and behavioural problems, Klinefelter's syndrome was diagnosed. In the first case the diagnosis was immediately suspected because of the micropenis. The other three boys were diagnosed after long observation. One of them was suspected of having a chromosomal abnormality because of behavioural problems together with a typical, female fat distribution pattern. If a delayed speech and language development and behaviour problems are present, Klinefelter's syndrome should be considered, especially if tallness and (or) small genitals are present.

Intelligence profiles in children and adolescents with left temporal lobe epilepsy: relationship to language laterality

Pre- and postoperative IQ profiles were examined in children and adolescents with left temporal-lobe epilepsy. Participants were grouped according to their pattern of speech dominance, as indicated by the intracarotid sodium amobarbital procedure. Seven participants with typical (left hemisphere) speech representation were matched for age and sex to seven participants with atypical (bilateral or right hemisphere) speech representation. The group with atypical speech representation tended to perform worse pre- and postoperatively on several verbal and nonverbal subtests. Unlike Strauss et al.'s (1990) sample, however, the groups did not differ significantly on pre- or postoperative Performance IQ. The results suggest that when individuals are matched closely for age and sex, there may only be limited support for a nonverbal "crowding" hypothesis. Atypical speech representation in children and adolescents with early temporal-lobe epilepsy appears to be associated with lowered performance on both verbal and nonverbal IQ subtests.

[Validation of a model for the prediction of verbal semantic fluency]

INTRODUCTION

The diagnosis of dementia requires documentation of cognitive loss with respect to the patient's previous level. It would therefore be very useful to have models available which would predict the result expected in the tests normally used in the diagnosis of dementia.

OBJECTIVE

To validate a model for prediction of the results of a test of semantic verbal fluency in persons with no dementia.

PATIENTS AND METHODS

A model for the prediction of semantic verbal fluency deduced from a sample of 138 persons was applied to two other independent samples: the first of 86 persons from the same environment as the original sample and a second multicentric sample of 92 persons. The validity of the model was evaluated by residual analysis.

RESULTS

No sex differences were seen between the samples, but there were differences regarding the other variables, including the observed and predicted verbal fluency. The residuals of the samples did not differ from each other nor vary from zero, but were normally distributed.

CONCLUSION

The model proposed based on sociodemographic and clinical variables is valid and satisfactorily predicts the verbal fluency to be expected in each case.

Comparison of microembolism detected by transcranial Doppler and neuropsychological sequelae of carotid surgery and percutaneous transluminal angioplasty

BACKGROUND AND PURPOSE

Percutaneous transluminal angioplasty (PTA) is currently being assessed for the treatment of carotid stenosis. In comparison with carotid endarterectomy (CEA), there is evidence of an increased risk of cerebral microembolism during the procedure. We have sought evidence of any neuropsychological sequelae of carotid PTA and compared it with CEA to demonstrate the relative safety of the 2 treatment options.

METHODS

The neuropsychological outcomes after CEA and PTA were compared in 2 matched groups of patients with severe symptomatic carotid stenosis, 96% of whom had been randomized in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), at a single center. Transcranial Doppler insonation of the middle cerebral artery was used to measure cerebral reactivity in response to carbon dioxide inhalation before treatment and then to detect microembolization of the ipsilateral cerebral hemisphere and measure changes in blood flow velocity during the procedures. The performance on a neuropsychological test battery administered before, 6 weeks after, and 6 months after the procedure was compared in 20 patients undergoing PTA and 26 having CEA.

RESULTS

At 6 weeks, 5 patients in each group showed a similar decline in neuropsychological performance; global measures showed no significant difference between the 2 procedures, despite a significantly higher incidence of microemboli during PTA. Both groups showed a marked reduction in anxiety after treatment.

CONCLUSIONS

The findings provide some reassurance that PTA is not associated with greater cerebral complications than CEA, despite the higher embolic load recorded by transcranial Doppler ultrasonography during angioplasty.