Unveiling what is absent within: illustrating anesthetic considerations in a patient with hydranencephaly - a case report.

BACKGROUND: Hydranencephaly is a rare and debilitating congenital condition in which most anesthesiologists are unfamiliar. Primary surgical treatment involves CSF diversion, though other palliative procedures requiring anesthesia are often required. With medical advancements and a resulting prolonged life expectancy, caring for these patients is becoming more routine. CASE PRESENTATION: We follow an infant with hydranencephaly over three different procedures requiring anesthesia from 5 months of age to 2 years, highlighting the various anesthetic considerations. CONCLUSIONS: Anticipation of difficult positioning, deliberate airway management, and attention to anesthetic recovery were all necessary to safely care for this patient. An understanding of the challenges this particular condition poses will help anesthesiologists provide the most safe and effective care when encountering these patients.

Hitting the Nail on the Head: A Case Report Demonstrating the Importance of a Multidisciplinary Approach to an Unusual Penetrating Intracranial Injury.

A 28-year-old man presented with a penetrating injury by a nail gun to the head. Imaging revealed a nail abutting the superior sagittal sinus without active extravasation. An anesthesia-led multidisciplinary team devised a detailed perioperative plan including conception of a complex decision tree, coordination of care, and resource utilization. In the operating room, the nail was removed under general anesthesia, with blood products and equipment for craniotomy readily available, and imaging modalities reserved for immediate use. This case highlights the importance of a multidisciplinary approach to challenging penetrating head injuries and the crucial role anesthesiologists have as leaders in perioperative care.

Temporal reward discounting in children, adolescents, and emerging adults during an experiential task.

The goal of this study was to examine age effects on the ability/willingness to wait for large rewards in a real temporal reward discounting task from childhood to adulthood. Therefore, a real temporal discounting (TD) task was administered to children aged 6-12 (n = 39), adolescents aged 13-17 (n = 28), and young adults aged 18-19 (n = 55). Findings indicated that the cross-sectional development of TD followed a quadratic pattern across age groups, with adolescents choosing more often than children and adults to wait for the large delayed reward, resulting in reward-maximization. Various interpretations of this finding were offered, including a focus on reward maximization despite an immature ability to exert self-control, and flexible self-control which was high during this task as a result of strong motivation to maximize financial gains.

Steep temporal reward discounting in ADHD-Combined type: acting upon feelings.

Difficulty waiting plays a primary role in symptoms of attention-deficit/hyperactivity disorder (ADHD), in particular, impulsivity. Current theories suggest that relatively strong preferences for small immediate rewards as observed in ADHD-Combined type are the result of delay-related negative feelings. However, the measurement of difficulty waiting is typically limited to objective choices between small immediate and large delayed rewards. This study aimed at extending the measurement of difficulty waiting in ADHD-Combined type with ratings about subjective feelings. Children and adolescents (ages 6-17) with ADHD-Combined type (n=25), ADHD-Inattentive type (n=20) and matched typically developing participants (n=37) performed temporal reward discounting tasks, and completed a Visual Analogue Scale of subjectively experienced ease/difficulty waiting. Although those with ADHD-Combined type demonstrated relatively steep temporal reward discounting, as reported elsewhere (Scheres et al., 2010), there were no group differences for subjectively experienced ease/difficulty waiting. Additionally, correlations between subjective and objective measures of difficulty waiting were significantly higher in the ADHD-Combined type group than in the control group. These findings suggest that (a) those with ADHD-Combined type do not choose impulsively because they have more negative feelings about waiting than controls; (b) choices in the ADHD-Combined type group are more in accordance with/driven by their feelings than choices made by participants in the control group.

Studying the relation between temporal reward discounting tasks used in populations with ADHD: a factor analysis.

BACKGROUND: This study aimed at investigating the relationship between tasks that have been used in attention deficit hyperactivity disorder (ADHD) to measure choices between smaller immediate and larger delayed rewards: real and hypothetical temporal discounting tasks, and single-choice paradigms. METHODS: Participants were 55 undergraduate psychology students. Tasks included a real and hypothetical version of a temporal discounting (TD) task with choices between a large reward (10 cents) after delays up to 60 seconds, and smaller immediate rewards (2-8 cents); two versions of a hypothetical temporal discounting task with choices between a large reward ($100) after delays up to 120 months, and smaller immediate rewards ($1-$95); a Choice Delay Task with choices between one point now and two points after 30 seconds (one point is worth five cents). RESULTS: Correlation analyses showed that the real and the hypothetical TD tasks with 10 cents were very strongly associated. However, the hypothetical TD tasks with $100 did not correlate with either the real or the hypothetical TD task with 10 cents. Principal component analysis extracted two components: one for small amounts and short delays, and a second one for large rewards and long delays. CONCLUSIONS: Temporal reward discounting is not a uniform construct. Functional brain imaging research could shed more light on unique brain activation patterns associated with different forms of temporal reward discounting.

Temporal reward discounting in attention-deficit/hyperactivity disorder: the contribution of symptom domains, reward magnitude, and session length.

BACKGROUND: Theoretical models have hypothesized that one core problem in attention-deficit/hyperactivity disorder (ADHD) is abnormal reward processing. Temporal reward discounting (decreases in subjective reward value due to prereward delay) is of interest because of its relation with a key symptom of ADHD-impulsivity. This study investigated 1) whether steep temporal reward discounting (TD) is associated with ADHD-combined type (ADHD-C)/symptoms of hyperactivity-impulsivity specifically; 2) the role of reward magnitude in TD in ADHD-C/participants with symptoms of hyperactivity-impulsivity; and 3) whether steep TD in ADHD-C/participants with symptoms of hyperactivity-impulsivity is affected by session length. METHODS: Three TD tasks were administered to children and adolescents (aged 6-17) with ADHD-C (n = 25), ADHD-inattentive type (ADHD-I; n = 20), and matched typically developing participants (n = 37). Reward magnitude and session length were varied. RESULTS: Steep TD was observed in participants with ADHD-C but not in those with ADHD-I, independent of reward magnitude and session length. Dimensional analyses revealed that steep TD was associated with hyperactivity-impulsivity (transcending the arbitrary cutoff for ADHD subtypes), especially when reward magnitude at the trial level was small. CONCLUSIONS: These findings suggest that steep TD in ADHD is best thought of as a correlate of the symptom dimension of hyperactivity/impulsivity. Additionally, steep TD in ADHD is the result of a trade-off between delay and reward magnitude, with all factors contributing to choice preferences. These findings may help refine the delay aversion theory of ADHD, and provide evidence for the notion that unique reward processing is one mechanism associated with symptoms of hyperactivity-impulsivity.