Detecting cognitive dysfunction in a busy multiple sclerosis clinical setting: a computer generated approach.

BACKGROUND AND PURPOSE: This study aims to explore the effectiveness of a brief, computerized battery of tests in detecting cognitive differences between clinically isolated syndromes (CIS), relapsing-remitting multiple sclerosis (RRMS), primary progressive multiple sclerosis (PPMS) and secondary progressive multiple sclerosis (SPMS) patients. METHODS: Four groups of patients between the ages of 18 and 63 were enrolled from two hospital-based multiple sclerosis clinics: CIS (n = 42), RRMS (n = 44), PPMS (n = 15) and SPMS (n = 37). All subjects were administered a validated battery of five computerized cognitive tests: the STROOP Color-Word Test, the Computerized Symbol Digit Modalities Test, the Paced Visual Serial Addition Test (PVSAT) 4 s and 2 s trials, and a speed of cognition index obtained by subtracting simple reaction time from choice reaction time. Results were recorded by the test administrator. RESULTS: Significant between-group differences in cognition were evident on all tests (P < 0.01) with the exception of the PVSAT 2 s trial. CIS patients were the least impaired, SPMS the most. RRMS and PPMS patients generally had a similar cognitive profile, more impaired than the CIS patients but less so than the SPMS patients. These differences persisted after controlling for the effects of age and education. CONCLUSIONS: The ability of this computerized cognitive battery to distinguish the progression of cognitive deficits across the entire multiple sclerosis disease spectrum from CIS through to SPMS enhances its construct validity. This finding, coupled with the battery's brevity (20 min) and ease of administration, highlights its potential utility in a busy clinic setting.

Traumatic cranial injury sustained from a fall on the rigid external distraction device.

Distraction osteogenesis has become a popular treatment of congenital maxillocraniofacial anomalies. Many ingenious internal and external devices have been developed and used. The rigid external distraction system based on systems previously used in correction of maxillary retrusion offers postoperative adjustment in two dimensions. Figueroa and Polley reported the use of this device with minimal morbidity in children as young as 5 years of age. They reported no problems with infection, bleeding, pain, loosening of the intraoral splint, dental injury, or wear problems in a series of 14 consecutive cleft patients. Recent modification of the system, rigid external distraction II, has allowed it to be applied to more complex craniofacial deformities that require a LeFort III osteotomy. A review of the neurosurgery and orthopedic literature revealed that halo complications relate primarily to the skull pins. In most cases, these complications can be prevented if the device is carefully applied and monitored. Early recognition and prompt treatment of complications are important. After experience with this system for advancement at the LeFort III level, six patients with various syndromes involving the craniofacial skeleton have undergone LeFort III level distraction osteogenesis with the rigid external distraction device in combination with a planned and stabilized frontosupraorbital advancement. In one of these cases, a 7-year-old child fell on the device after discharge from the hospital and sustained a compound depressed skull fracture that required debridement and repair.

A case of atypical McCune-Albright syndrome requiring optic nerve decompression.

McCune-Albright syndrome (MAS) is a disease of noninheritable, genetic origin defined by the triad of café-au-lait pigmentation of the skin, precocious puberty, and polyostotic fibrous dysplasia. This syndrome, which affects young girls primarily, has also been reported with other endocrinopathies, and rarely with acromegaly and hyperprolactinemia. The fibrous dysplasia in MAS is of the polyostotic type and, apart from the characteristic sites such as the proximal aspects of the femur and the pelvis, the craniofacial region is frequently involved. A male patient with MAS presented with juvenile gigantism, precocious puberty, pituitary adenoma-secreting growth hormone and prolactin, hypothalamic pituitary gonadal and thyroid dysfunction, and polyostotic fibrous dysplasia causing optic nerve compression. Visual deterioration and its surgical management are presented.

Assessment and treatment of facial deformity resulting from radiation to the orbital area in childhood.

Children who receive radiation for malignant tumors in the orbital area frequently develop widespread craniofacial deformities. These affect the skull, orbit, maxilla, and mandible. When these patients seek treatment at a later age, they require careful assessment using cephalometrics and three-dimensional imaging. It is recommended that the four levels of skeletal deformity be corrected in a single procedure, that is frontotemporal expansion with repositioning of the skull base area, orbital expansion and repositioning together with maxillary and mandibular surgery. Bone grafts should be inlay rather than onlay and soft tissue should be supplied by free-tissue transfer. This counteracts any residual ischemia related to the previous radiation therapy. The second surgical stage is designed to reconstruct the socket and the eyelids to allow more satisfactory rehabilitation with an ocular prosthesis. In patients who have a globe present, the usual enophthalmos can be corrected by repositioning of the eye as part of the first procedure by reducing the anteroposterior dimensions of the socket. In bilateral cases, the deformity is hourglass in nature and requires correction in the frontal and temporal area with lateral displacement of the orbits. A bimaxillary procedure is also indicated. It is emphasized that to formulate a satisfactory operative plan an in-depth three-dimensional analysis of the deformity is mandatory.

Extradural dead space following cranial bone advancement.

The extradural dead space produced after enlargement of the intracranial space or after reduction of the volume of the intracranial contents persists for an unknown period of time. To investigate this further, an extradural dead space was surgically created by advancement of parietal bones in 9 adult rabbits. By design, there was no connection with the paranasal sinuses. To determine outcome of the dead space, three-dimensional computed tomographic and histological studies were performed. The brain volume decreased in the first 3 months after surgery and remained constant for up to 9 months. The extradural volume increased in the first 4 weeks postoperatively, gradually decreasing in size with time. The brain failed to eliminate the extradural dead space by rearrangement or expansion. An osseous cavity filled with fluid and connective tissue was formed within the dead space. The fluid within it remained, even 9 months after surgery. This could be a potential environment for bacterial invasion if there was a connection with the nasopharynx.

"Side table assembly"--an adjuvant to craniofacial reconstruction.

Plates and screws are used extensively in craniofacial surgery; they have increased the speed of this surgery, but this can be made even more efficient. Utilising an adjacent instrument table, the rearrangement and reassembly of bone segments resulting from osteotomy or fracture can be performed by a second surgical team using plates and screws. At the conclusion of the operation, the reassembled bony reconstruction can rapidly be placed in position with a minimum of additional screws. This technique has been found to be technically easier and to afford a considerable saving of operating time.

Intraoperative cranial nerve monitoring during posterior skull base surgery.

Intraoperative monitoring of neurophysiologic function is rapidly evolving as an important adjunct during skull base surgery to reduce the incidence of neurologic deficit. Facial nerve monitoring is an excellent model, since electrical and mechanical evoked potentials can be directly presented to the surgeon in real-time through an acoustic loudspeaker display. The lower cranial nerves may also be monitored using similar electromyographic techniques. Auditory system monitoring is more difficult due to the low amplitude response that requires averaging and filtering to extract the evoked potential. In conjunction with auditory monitoring, improved hearing preservation may be further enhanced by concomitant facial nerve monitoring, since the surgeon is alerted to traumatic manipulations that may affect both facial and cochlear nerves. Techniques and interpretative issues are presented to maximize the efficacy and safety of cranial nerve monitoring.

[Determining a level of immigration for Quebec: why and how?]. / Determiner un niveau d'immigration pour le Quebec: pourquoi, comment?

PIP: In the late 1960s, Quebec demonstrated its willingness to influence migration by creating a Ministry of Immigration. The goal of the Ministry changed over the course of a decade from assuring harmonious integration of immigrants to obtaining a greater role in recruitment and selection as well as in reception and establishment. In the early 1970s the Canadian government undertook a significant revision of its immigration policies. The most significant change was probably the requirement of an annual estimate of the number of immigrants judged opportune to admit during a particular time period. to be preceded by consultations with the provinces concerning demographic needs and the labor market. A 1978 agreement between Quebec and the Canadian government gave Quebec a greater role in immigrant selection and recruitment, and in effect allowed it to develop its own immigration policy. Ability to absorb potential immigrants became the primary criterion in setting quotas for Quebec. The approach of the federal government has not changed greatly since the new policy came into use. The extent of annual net immigration judged desirable has changed from about 75,000 persons initially to about 55,000 more recently. The federal government has always viewed immigration as a possible solution to labor market problems, but estimates of manpower needs became very volatile in the late 1970s with the general rise in rates of unemployment, and survey results lost importance as a source of guidance. The government estimated that 20 to 25 thousand immigrants selected to fill specific manpower needs could be accomodated annually in the 1980s, but the collapse of the labor market following the economic crisis caused a downward revision in estimates for 1982-83 to 8000 to 10,000 workers with jobs already in hand. In order to participate in planning of immigration, Quebec had to develop a research program desinged to identify its capacity to absorb immigrants each year. The 1st step was to try to measure the impact of immigration using a framework of demoeconomic projections aided by a behavior model. 3 levels of immigration ranging from 15,000 to 30,000 annually were compared to a control case of no immigration in order to detect impact. Growth contributed by immigration is not expected to help solve the 3 major demographic problems expected over the next 20 years: the fertility decline, aging of the population, and emigration. Immigration does however exacerbate unemployment although it does not cause it. Economic constraints on immigration in the early 1980s are due more to poor prospects of growth than to the impact of immigration on growth. The suggested numbers of immigrants of 15,200 in 1983, 16,000 in 1984, and 17,000 in 1985 almost constitute minima given the probable immigration of family members and refugees.^ieng