Neurocognitive functioning in preschool children with sickle cell disease.

BACKGROUND: Children with sickle cell disease (SCD) experience neurodevelopmental delays; however, there is limited research with preschool-age children. This study examined neurocognitive risk and protective factors in preschoolers with SCD. PROCEDURE: Sixty-two patients with SCD (60% HbSS/HbSß0 -thalassemia; 40% HbSC/HbSß+ -thalassemia) between the ages of 3 and 6 years (mean = 4.77 years) received a neuropsychological evaluation as routine systematic surveillance. Patients were not selected for disease severity, prior central nervous system findings, or existing cognitive concerns. Thirty-four patients (82% HbSS/HbSß0 -thalassemia) were prescribed hydroxyurea (HU) at the time of their neuropsychological evaluation. On average, these patients had been prescribed HU at 2.15 (standard deviation = 1.45) years of age. The average dose was 28.8 mg/kg/day. Besides genotype, there were no group differences in medical or demographic factors based on HU treatment status. RESULTS: Patients with HbSS/HbSß0 -thalassemia scored below normative expectations on measures of intelligence, verbal comprehension, and school readiness (false discovery rate-adjusted p-value [pFDR ] < .05). Age, sickle genotype, and HU treatment exposure were not associated with measured neurocognitive outcomes (pFDR  > .05). Greater social vulnerability at the community level was associated with poorer performance on measures of intellectual functioning, verbal comprehension, visuomotor control, and school readiness, as well as parent report of executive dysfunction (pFDR  < .05). Greater household socioeconomic status was positively associated with academic readiness. CONCLUSIONS: Preschoolers with severe SCD (HbSS/HbSß0 -thalassemia) perform below age expectations on measures of intelligence and academic readiness. Sociodemographic factors were stronger drivers of neurocognitive performance than disease severity or disease-modifying treatment. Neurodevelopmental interventions targeting the home and broader community environment are needed.

Pet loss and continuing bonds in children and adolescents.

There is little research available regarding the impact of pet loss on children. In the current mixed-methods study, we explored the different ways that children use continuing bonds (CB) to cope following the death of a pet. We studied 32 children (5-18 years) and their parents. Children answered four questionnaires and the Continuing Bonds Interview. Parents answered a demographic questionnaire. Results suggest that all children utilize CB while grieving the loss of a pet, although CB expression varies depending on the age of the child, the level of grief following the loss, and the strength of attachment to the pet.

Mohs Micrographic Surgery: Past, Present, and Future.

BACKGROUND: Mohs micrographic surgery (MMS) is a frequently used technique that provides total margin visualization for treatment of skin neoplasms. OBJECTIVE: To provide a comprehensive review of MMS literature, focusing on its origins, evidence behind present-day uses of MMS, and future directions. METHODS: A literature search was conducted using PubMed to identify articles pertaining to MMS. RESULTS: The fresh frozen technique led to widespread use of MMS in the 1970s. One randomized controlled trial and several large prospective studies have demonstrated low recurrence rates for treatment of nonmelanoma skin cancer (NMSC). MMS, when compared with surgical excision, also achieved a statistically significant higher cure rate for treatment of recurrent NMSC. Studies have demonstrated low recurrence for the treatment of melanoma and melanoma in situ with MMS. MMS has also been shown to effectively treat several rare cutaneous neoplasms. The future of MMS is likely to include the adoption of noninvasive imaging, immunostaining, and digital technology. CONCLUSION: Mohs micrographic surgery is an effective treatment modality for numerous cutaneous neoplasms. It has achieved statistically significant superiority to surgical excision for the treatment of recurrent and high-risk NMSC. The future is likely to see increased use of noninvasive imaging, immunostaining, and digital technology.

Use of a novel 589-nm solid-state laser for treatment of facial erythema.

OBJECTIVE: To evaluate the efficacy and safety associated with use of a 589-nm solid-state laser for treatment of facial erythema. METHODS: A prospective, IRB-approved study was conducted. Participants who were interested in treatment for facial erythema were recruited. They received four monthly treatments with the 589-nm laser. Erythema of the right and left face was graded on a scale of 0-4, 4 being most severe, by both investigators and participants prior to each treatment and at follow-up. Safety was assessed by any reported side effects. RESULTS: Twenty-four participants enrolled in the study, 16 women (67%) and 8 men (33%), with an average age of 51.1 years. Investigator grades showed a statistically significant improvement in erythema of 31% for both the right and left face. Participant grades showed a statistically significant improvement in erythema of 23.2% for the right face and 22.8% for the left face. Side effects were limited to transient erythema posttreatment. CONCLUSION: A 589-nm solid-state laser achieved a modest improvement in facial erythema when evaluating results 1 month after four monthly treatments. No major safety issues were reported.

Photodynamic Therapy for Non-Melanoma Skin Cancers.

Non-melanoma skin cancer (NMSC) is traditionally treated with surgical excision. Nonsurgical methods such as cryotherapy and topical chemotherapeutics, amongst other treatments, are other options. Actinic keratosis (AKs) are considered precancerous lesions that eventually may progress to squamous cell carcinoma (SCC). Photodynamic therapy (PDT) offers an effective treatment for AKs, and is also effective for superficial basal cell carcinoma (BCC). Nodular BCC and Bowen's disease (SCC in situ) have shown acceptable response rates with PDT, although recurrence rates are higher for these two NMSC subtypes. Methylaminolevulinate (MAL) PDT is a more effective treatment option than 5-aminolevulinic acid (ALA) PDT for nodular BCC. Several studies have shown that PDT results in superior cosmetic outcomes compared to surgical treatment. PDT is overall well-tolerated, with pain being the most common side effect.

[Respect for autonomy. How much do patients want to know in order to make decisions?]. / El respeto por la autonomía. Cuánta información desean conocer los pacientes para tomar decisiones?

Informed consent should be the expression of active participation of patients in the decision-making process. It is an application of the ethical principle of respect for patient autonomy. However, there are some concerns about the direct extrapolation of the Anglo-saxon concept of autonomy into other societies which could impose an unwanted level of patient participation. The objective of this study was to explore the quantity and quality of information that Argentine patients want to receive before making a decision about a surgical procedure. Among 200 patients possibly scheduled for elective surgery, more than 80% preferred to know all the possible alternatives of treatment and all the advantages and disadvantages of each alternative. Less than 20% considered that the patients themselves should make the decision regarding surgery after learning about all the risks and benefits. Seventy one percent of patients preferred to receive the information with their families in order to make a joint decision with them. Seventeen percent of patients preferred not knowing if there was a possibility they could die during surgery. These results suggest that in the current medical environment, one previously dominated in Argentina by a tendency towards beneficient paternalism on the part of physicians and surgeons, patients want to be extensively informed about risks, benefits, and procedural alternatives before electing to undergo a surgical procedure. Patient preferences regarding how family members should be involved in the decision-making should be elicited. Careful consideration is warranted, however, in the way health care providers might address risks of procedure-related death so that subjects who do not want to know about this risk can be identified.

Obtaining informed consent and other ethical dilemmas.

In the extracts from the discussion presented below, Prof Macklin (RM) and Dr Guerrero-Cohen (DG-C) respond to researchers' queries. Some of the dilemmas that the researchers describe were faced in their own work. Others, based on questions raised by the institutional ethics committee of the Anusandhan Trust, were summarised from the IEC's report.

El respeto por la autonomía: ¿Cuánta información desean conocer los pacientes para tomar decisiones? / Respect for autonomy: How much do patients want to know in order to make decisions?

El consentimiento informado debería ser la expresión de la participación activa de los pacientes en la toma de decisiones como resultado del respeto hacia la autonomía. Sin embargo, existen temores de que la extrapolación directa de una manera de entender la autonomía desde la cultura anglosajona pueda imponer forzadamente un modelo de participación activa de los pacientes. El objetivo del presente estudio fue explorar qué cantidad y calidad de información desean recibir los pacientes que van a ser sometidos a un procedimiento quirúrgico. De los 200 pacientes en preparación para una intervención quirúrgica, más del 80% prefirieron saber todas las posibles alternativas existentes al tratamiento ofrecido y que les fueran explicadas todas las ventajas y desventajas de cada alternativa. Menos del 20% de los pacientes consideró que, conociendo los riesgos y beneficios, la persona que debería decidir cuáles riesgos son aceptables, es el mismo paciente. El 71.5% de los pacientes prefirió que el médico le comunicara la decisión a él y a su familia para que tomaran juntos la decisión. Un 17.5% de los pacientes expresaron que preferían no saber si podían morir durante la cirugía. Esos pacientes tuvieron una mayor edad pero en un análisis multivariado no fue posible predecir quiénes preferían saber si podían morir durante la cirugía. Nuestros hallazgos sugieren la necesidad de informar extensamente a los pacientes antes de un procedimiento quirúrgico, de identificar los sujetos que no querrán conocer su riesgo de morir y de incluir al paciente y su familia en la toma de decisiones.

Informed consent should be the expression of active participation of patients in the decision-making process. It is an application of the ethical principle of respect for patient autonomy. However, there are some concerns about the direct extrapolation of the Anglo-saxon concept of autonomy into other societies which could impose an unwanted level of patient participation. The objective of this study was to explore the quantity and quality of information that Argentine patients want to receive before making a decision about a surgical procedure. Among 200 patients possibly scheduled for elective surgery, more than 80% preferred to know all the possible alternatives of treatment and all the advantages and disadvantages of each alternative. Less than 20% considered that the patients themselves should make the decision regarding surgery after learning about all the risks and benefits. Seventy one percent of patients preferred to receive the information with their families in order to make a joint decision with them. Seventeen percent of patients preferred not knowing if there was a possibility they could die during surgery. These results suggest that in the current medical environment, one previously dominated in Argentina by a tendency towards beneficient paternalism on the part of physicians and surgeons, patients want to be extensively informed about risks, benefits, and procedural alternatives before electing to undergo a surgical procedure. Patient preferences regarding how family members should be involved in the decision-making should be elicited. Careful consideration is warranted, however, in the way health care providers might address risks of procedure-related death so that subjects who do not want to know about this risk can be identified.

Con las mejores intenciones: consideraciones acerca de la autonomía y la beneficencia frente a conductas suicidas / With the best intentions: considerations on autonomy and beneficense in front of suicidal behavior

Me propongo examinar la validez del concepto de atonomía en el ámbito de la medicina, cuando el profesional sanitario debe afrontar casos de intentos de suicidio. En esas cirscuntancias, pareciera a veces que dicho principio debe ceder su lugar a la beneficencia, la que se manifiesta, entre otras, en las actitudes paternalistas. Mientras que una de las formas que asume que paternalismo-intervenir en las decisiones de personas consideradas incompetentes- es por lo general aceptada sin discusión, una segunda forma, aquella que autoriza la intervención en individuos considerados transitoriamente no autónomos, genera discusiones. A continuación, presentaré dos casos, cada uno de los cuales ilustra una forma de paternalismo. En el segundo narra la historia de una paciente competente que solicita que la dejen morir, se señalan algunos de los problemas que se suscitan cuando se defiende un paternalismo a ultranza. Gran parte de los mismos versan en torno a si existe un derecho moral a terminar con la propia vida. Finalmente, sostendré que dicha defensa exacerbada responde a un modelo médico cuestionable

Con las mejores intenciones: consideraciones acerca de la autonomía y la beneficencia frente a conductas suicidas / With the best intentions: considerations on autonomy and beneficense in front of suicidal behavior

Me propongo examinar la validez del concepto de atonomía en el ámbito de la medicina, cuando el profesional sanitario debe afrontar casos de intentos de suicidio. En esas cirscuntancias, pareciera a veces que dicho principio debe ceder su lugar a la beneficencia, la que se manifiesta, entre otras, en las actitudes paternalistas. Mientras que una de las formas que asume que paternalismo-intervenir en las decisiones de personas consideradas incompetentes- es por lo general aceptada sin discusión, una segunda forma, aquella que autoriza la intervención en individuos considerados transitoriamente no autónomos, genera discusiones. A continuación, presentaré dos casos, cada uno de los cuales ilustra una forma de paternalismo. En el segundo narra la historia de una paciente competente que solicita que la dejen morir, se señalan algunos de los problemas que se suscitan cuando se defiende un paternalismo a ultranza. Gran parte de los mismos versan en torno a si existe un derecho moral a terminar con la propia vida. Finalmente, sostendré que dicha defensa exacerbada responde a un modelo médico cuestionable (AU)

Analise de funcao: um modelo de elaboracao

O nosso objetivo foi elaborar u modelo de analise de funcao que respondesse as necessidades especificas da problematica de atendimento da reabilitacao profissional no INPS. Para cumprir com esta finalidade, foi necessaria uma abordagem particular e minuciosa dos itens da analise de funcao. Necessario, tambem, foi definir conceitual e operacionalmente cada uma das variaveis que compoem esses itens, tanto para possibilitar uma objetividade maior para o grupo de psicologos dos tecnicos de diversas categorias profissionais que a consultam. Ao lado desse carater particular, dado que as informacoes a respeito de analise de funcao se encontram extremamente dispersas na bibliografia afim, julgamos ser este modelo de utilidade para quem tambem lida com a materia.