The Association between Educational Attainment and Patterns of Emergency Department Utilization among Adults with Sickle Cell Disease.

PURPOSE: Patients with low educational attainment may be at increased risk for unplanned health care utilization. This study aimed to determine what factors are related to emergency department (ED) visits in hopes of guiding treatments and early interventions. METHODS: At two medical centers in the Mid-Atlantic United States, 258 adults with sickle cell disease aged 19-70 years participated in a retrospective study where we examined whether education level is independently associated with ED visits after accounting for other socioeconomic status (SES) variables, such as pain and disease severity and psychosocial functioning. RESULTS: The data showed that patients without a high school education visited the ED three times as frequently as patients with post secondary education. Controlling for poverty and employment status decreased the effect of education on ED visits by 33.24 %. Further controlling for disease severity and/or psychosocial functioning could not account for the remaining association between education and ED visits, suggesting that education is independently associated with potentially avoidable emergency care. CONCLUSIONS: Early interventions addressing disparities in academic performance, especially for those children most at risk, may lead to improved long-term health outcomes in this population.

Nonlocal neurology: beyond localization to holonomy.

The concept of local pathology has long served neurology admirably. Relevant models include self-organizing nonlinear brain dynamics, global workspace and dynamic core theories. However such models are inconsistent with certain clinical phenomena found in Charles Bonnet syndrome, disjunctive agnosia and schizophrenia, where there is disunity of content within the unity of consciousness. This is contrasted with the split-brain case where there is disunity of content and disunity of consciousnesses. The development of quantum brain theory with it nonlocal mechanisms under the law of the whole ("holonomy") offers new possibilities for explaining disintegration within unity. Dissipative quantum brain dynamics and its approach to the binding problem, memory and consciousness are presented. A nonlocal neurology armed with a holonomic understanding might see more deeply into what clinical neurology has always aspired to: the patient as a whole.

The syndrome of spontaneous intracranial hypotension.

The authors report four cases of headache and other symptomatology related to the syndrome of intracranial hypotension. They were seen in a routine clinical practice over the past 3 years. The clinical features, magnetic resonance imaging (MRI) findings, and follow-up of these patients are described. Review of the prior literature on the topic is also included. All four patients presented with orthostatic headache syndrome. Three of the four demonstrated diffuse leptomeningeal thickening and enhancement on MRI studies. One subsequently developed a subdural effusion. One patient demonstrated downward displacement of the posterior fossa initially, which resolved on follow-up MRI scanning. Possible pathophysiologies of the syndrome are discussed.

Iatrogenic bile duct injuries: avoidance, recognition, and treatment.

Common bile duct injury has potential catastrophic implications if unrecognized or inadequately managed at the time of initial surgical intervention. Every precaution necessary to avoid operative injury to the common duct should be taken, and with experience and meticulous attention to detail, this complication should rarely be encountered in the career of a well-trained general surgeon. If ever this unexpected occurrence happens, adherence to certain principles of recognition and management may preclude significant morbidity and mortality. Two patients with injured common bile ducts are discussed. One patient presented with an iatrogenic stricture due to previous operative trauma. A second patient suffered a complete transection of the common duct while undergoing a routine cholecystectomy; the transection was recognized and repaired primarily. The fundamental principles of bile duct reconstruction and biliary-enteric anastomoses are discussed. The prevention of stricture formation is explained, with specific guidelines presented to minimize this potentially lethal complication.

Aspergillosis of the nervous system.

Cerebral aspergillosis currently occurs most frequently with disseminated aspergillosis in immunocompromised hosts. Twelve patients with cerebral aspergillosis in this setting were seen over 10 years. Underlying illnesses were renal transplantation in six cases and one case each of subacute hepatic necrosis, head trauma, glioblastoma, microglioma, and esthesioneuroblastoma. All patients were receiving high dose steroid therapy except one who had ectopic ACTH syndrome. Eleven patients were receiving broad spectrum antibiotics. All patients were febrile and developed progressive pulmonary infiltrates preceding or coincident with neurologic symptoms. Sudden onset of neurologic deficits or seizures occurred in nine of 11 clinically analyzable cases. Brainstem or cerebellar signs and symptoms were a presenting feature in three cases and were eventually seen in five cases. Cranial computerized tomography in four cases showed low absorption areas with minimal enhancement and little mass effect. Neurologic deterioration was rapid with nine of 11 patients dying within 6 days of onset. Neuropathologic examination showed multiple abscess formation in 11 cases and prominent blood vessel invasion in all cases. The sudden onset of stroke-like deficits and brainstem findings in a febrile immunocompromised host with pulmonary infiltrates suggests the diagnosis of cerebral aspergillosis. Two cases of aspergillus meningitis were also seen, one postoperatively.

Malignant meningiomas: CT and histologic criteria, including a new CT sign.

Histologic features that could be correlated with malignancy were assessed by reviewing the microscopic slides of 167 meningiomas. Six tumors had shown two or more recurrences. In three having three or more recurrences, the number of mitoses counted under high power was higher than in those meningiomas showing clinically benign behavior. The radiologic and histologic features of seven meningiomas showing malignant clinical behavior and/or malignant histologic features were also evaluated and correlated. On computed tomography (CT), most of the malignant meningiomas were moderately hyperdense before contrast enhancement, but showed no or minimal calcification. Marked perifocal edema was common. Indistinct tumor margins or, occasionally, deeply extending fringes of tumor interdigitating with brain substance, marked bone destruction, or prominent pannus or tumor, extending well away from the globoid mass, termed "mushrooming," is described for the first time and seems to be the most useful correlate of histologic or clinical malignancy. This sign occurred in five of the seven cases and was absent in about 250 benign meningiomas reviewed. It was visible only at surgery in one additional case.

Computed tomography of intracranial aspergillosis.

Cranial computed tomography (CT) scans were analyzed in five patients with autopsy documented intracranial aspergillosis. All infections occurred in immunocompromised hosts. Our findings included subtle low attenuation abnormalities, minimal mass effect, and poor contrast enhancement without ring configuration, in the clinical setting of lethargy, fever, and pulmonary infection. The benign CT picture did not clearly depict the aggressive intracranial parenchymal destruction.

A microscope filter for endophotocoagulation.

We have developed a microscope filter for use during endophotocoagulation. The filter is adaptable to the standard operating microscope (Zeiss). We believe the filter improves both the comfort and safety of laser and xenon arc endophotocoagulation.

Surgical management of senile scleromalacia.

Senile scleral plaques may progress to senile scleromalacia. A patient is described who presented with a scleral defect which appeared dangerously close to perforation. Surgical management of this patient with an autologous scleral graft is discussed.

Prevention and management of traumatic endophthalmitis.

Twelve cases of traumatic culture-proven endophthalmitis were treated with intraocular antibiotics or in combination with vitrectomy. In 11 cases, the eyes were saved and in 10 the visual acuity was equal to or better than 20/200.

Bone formation in a periosteal graft.

Bone formation occurred in periosteal graft that was used to anchor a Cardona keratoprosthesis.