Friday, January 29, 2010
C.A. Revives UCL Action Against Kaiser Over Autism Services
By KENNETH OFGANG, Staff Writer
Class action allegations charging Kaiser Foundation Health Plan with violating the Unfair Competition Law by denying speech and behavioral therapies to children with autism spectrum disorders were revived yesterday by this district’s Court of Appeal.
Div. Seven said the complaint raised issues that are properly resolved in a class action, and that Los Angeles Superior Court Judge Emilie Elias erred in dismissing the case on the ground that the court would be required to resolve individual issues with respect to the medical necessity of the therapies.
Britain's medical regulator finds that Dr. Andrew Wakefield, who now practices in Texas, conducted his now-discredited research on the MMR shot in an unethical and irresponsible manner.
Reporting from London - The British doctor whose suggestion of a link between the MMR shot and autism helped cause vaccination rates to plunge conducted his now-discredited research in a dishonest and irresponsible manner, medical authorities here concluded Thursday.
Sunday, January 24, 2010
Medical treatment of autism spectrum disorders.
RECENT FINDINGS: There continues to be disagreement regarding the exact prevalence and etiological significance of gastrointestinal conditions, epilepsy and other abnormal electroencephalographic findings, and sleep problems. It is not clear whether gastrointestinal conditions occur more frequently than in typically developing children, and whether there are distinct conditions that occur more often in ASD than in non-ASD populations. Abnormal electroencephalographic findings have been reported in up to 60% of children with ASD, and some believe that these abnormalities may be responsible for parts of the ASD phenotype. Sleep problems are reported more frequently than in the general population, and effective treatments are available. Future medical treatments for ASD may be directed at underlying core symptoms and have greater impact than today's symptomatic approach.
SUMMARY: Further research in these areas is needed to better guide diagnosis and treatment of a variety of medical conditions experienced by people with ASD.
Are you sure its epilepsy? Nonepileptic paroxysmal events in children are common, and may be more diverse in etiology than those seen in adults.
Nonepileptic paroxysmal events in a pediatric population.
We determined the types of nonepileptic events that are most prominent in the pediatric population, and stratified those events by age group. Ninety-four of 416 pediatric patients monitored during a 3-year period (23%) were found to have had nonepileptic events. Thirty-eight percent of these children were diagnosed with psychogenic nonepileptic seizures, and 72% of those were adolescents.
In children younger than 5 years of age, behavioral events and parasomnias were the most common mimickers of epilepsy. Other events, including stereotyped movements and myoclonus, were also diagnosed.
We suggest that children with refractory paroxysmal events should be considered for early inpatient monitoring.
Copyright © 2009 Elsevier Inc. All rights reserved.
Recent studies suggest that Attention Deficit Hyperactivity Disorder (ADHD) is a common comorbid condition in childhood epilepsy, but little is known regarding the nature, frequency and timing of associated neurobehavioural/cognitive complications or the underlying aetiology of ADHD in epilepsy. This investigation examined: (i) the prevalence of ADHD and its subtypes; (ii) the association of ADHD with abnormalities in academic, neuropsychological, behavioural and psychiatric status and (iii) the aetiology of ADHD in paediatric epilepsy. Seventy-five children (age 8-18) with new/recent onset idiopathic epilepsy and 62 healthy controls underwent structured interview (K-SADS) to identify the presence and type of DSM-IV defined ADHD, neuropsychological assessment, quantitative MR volumetrics, characterization of parent observed executive function, review of academic/educational progress and assessment of risk factors during gestation and delivery. The results indicate that ADHD is significantly more prevalent in new onset epilepsy than healthy controls (31% versus 6%), characterized predominantly by the inattentive variant, with onset antedating the diagnosis of epilepsy in the majority of children. ADHD in childhood epilepsy is associated with significantly increased rates of school based remedial services for academic underachievement, neuropsychological consequences with prominent differences in executive function, and parent-reported dysexecutive behaviours. ADHD in paediatric epilepsy is neither associated with demographic or clinical epilepsy characteristics nor potential risk factors during gestation and birth. Quantitative MRI demonstrates that ADHD in epilepsy is associated with significantly increased gray matter in distributed regions of the frontal lobe and significantly smaller brainstem volume. Overall, ADHD is a prevalent comorbidity of new onset idiopathic epilepsy associated with a diversity of salient educational, cognitive, behavioural and social complications that antedate epilepsy onset in a significant proportion of cases, and appear related to neurodevelopmental abnormalities in brain structure.
Sleep Med Clin. 2008 Mar;3(1):37-46.
Polycystic Ovary Syndrome and Obstructive Sleep Apnea.
Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL.
Polycystic ovary syndrome (PCOS), the most common endocrine disorder of pre-menopausal women, is characterized by chronic hyperandrogenism, oligoanovulation, obesity and insulin resistance. Importantly, PCOS women are at increased risk for glucose intolerance, type 2 diabetes and cardiovascular disorders. Recent reports indicate an unexpectedly high prevalence of obstructive sleep apnea (OSA) in PCOS. Alterations in sex steroids (i.e. high androgen and low estrogen levels) and increased visceral adiposity in PCOS could potentially contribute to the increased prevalence of OSA in this disorder. There is some evidence to suggest that there may be strong associations between the presence and severity of OSA and the metabolic disturbances that characterize PCOS. Causal mechanisms in the link between PCOS and OSA remain to be elucidated. Clinicians who manage PCOS patients should be aware of the high prevalence of OSA in these patients and systematically evaluate these women for sleep disturbances.
Getting To The Crux Of Bruxism
Your face hurts and you wonder why. Well, maybe the days of wondering and wandering from doctor to doctor are over. You might be, quite literally, chomping at the bit.
A survey published in "Acta Odontologica" sought to determine whether orofacial pain was associated with bruxism and insomnia symptoms. The researchers found that moderate to severe pain was significantly associated with insomnia and frequent bruxism, in addition to female gender, but negatively associated with age over 45 years....
Of course, it is reasonable to try oral splints. However, caregivers should also focus on the brain, and not just the teeth: depression and anxiety should be ruled in or out, and aggressively treated. Sleep apnea should be ruled out with a sleep study, and treated if found, as sleep apnea is known to be a cause of secondary bruxism.
Girls With ADHD at High Risk for Psychiatric Complications in Young Adulthood
January 22, 2010 — Girls with attention-deficit/hyperactivity disorder (ADHD) are at high risk for psychiatric complications in young adulthood, particularly antisocial, addictive, mood, anxiety, and eating disorders, according to a longitudinal case-control study with follow-up of 11 years.
Published online in the January 15 issue of the American Journal of Psychiatry, investigators found that the risk for 6 composite lifetime diagnostic categories was significantly higher in girls with ADHD compared with controls, with hazard ratios of 6.8 for mood disorders, 2.1 for anxiety disorders, 7.2 for antisocial disorders, 3.2 for developmental disorders, 2.7 for substance dependence disorders, and 3.5 for eating disorders.
Girls with ADHD also had significantly higher 1-year prevalence of composite mood, anxiety, antisocial, and substance dependence disorders relative to the comparison group, investigators add.
"We were not surprised for these findings at all, but the overwhelming amount of research in ADHD is in boys, and we needed to extend our research to females as there are very few studies assessing what happens to girls with ADHD," Joseph Biederman, MD, Harvard Medical School, Boston, Massachusetts, told Medscape Psychiatry.
"So even though the findings are not different from boys with ADHD, it is very important to establish that girls are at very high risk of developing the same complications as boys," he added.
For the study, investigators analyzed data on 96 girls with ADHD and 91 comparison girls from the original longitudinal sample. All girls had completed a full follow-up assessment at a mean of 11 years after enrollment.
At the 11-year follow-up reassessment, 93% of girls with ADHD had received some form of treatment for the disorder — 1% counseling alone, 21% medication alone, and 71% counseling and medication.
During the year preceding the 11-year follow-up assessment, 42% of ADHD girls were also receiving some form of treatment, whereas the rate of full or subthreshold ADHD during the interval between year 5 and year 11 was 69%. The rate of current full or subthreshold ADHD was 62%.
Girls with ADHD had a significantly higher lifetime prevalence of major depression, bipolar disorder, separation anxiety disorder, agoraphobia, social phobia, specific phobia, panic disorder, generalized anxiety disorder, oppositional defiant disorder, conduct disorder, antisocial personality disorder, Tourette or tic disorders, language disorder, enuresis, and bulimia than comparison girls.
The 1-year prevalence of eating disorders did not differ significantly between the 2 groups, but mood, anxiety, and antisocial disorders all remained significantly higher in girls with ADHD after controlling for baseline psychopathology.
Table. Adjusted 1-Year Prevalence Estimates for Psychiatric Disorders in ADHD and Comparison Subjects at 11 Years of Follow-up
|Disorder||Comparison Group (95% CI) (n = 91)||ADHD Group (95% CI) (n = 96)|
|Mood disorders||0.07 (0.03 – 0.14)||0.23 (0.15 – 0.32)|
|Anxiety disorders||0.21 (0.14 – 0.31)||0.47 (0.37 – 0.57)|
|Antisocial disorders||0.04 (0.02 – 0.11)||0.21 (0.14 – 0.31)|
|Substance dependence disorders||0.07 (0.04 – 0.15)||0.31 (0.22 – 0.41)|
|Eating disorders||0.03 (0.01 – 0.10)||0.07 (0.03 – 0.14)|
ADHD = attention-deficit/hyperactivity disorder; CI = confidence interval
Multiple Factors at Play
There may be multiple reasons girls with ADHD are so highly predisposed to developing psychiatric complications in young adulthood, said Dr. Biederman. The risk factors that produce ADHD may also lead to a wide range of complications as girls mature, he said.
"Patients with ADHD are more impulsive and reactive and more prone to experiment with drugs and then transition from experimentation to abuse and then dependence," said Dr. Biederman.
Moreover, children with ADHD typically do not do well in school, at play or even within the family, all of which may serve to demoralize and upset them, setting the stage for depression and other psychiatric disorders in later life.
Whatever the various reasons or combinations of causes, "the comorbid conditions that girls with ADHD develop in themselves are very morbid and risky, and knowing that ADHD is associated with bad outcomes may allow clinicians to very aggressively diagnose and treat it and which may have important implications for diminishing the risk of comorbidity," said Dr. Biederman.
Strength of the Study
Scott Kollins, PhD, MS, Duke University School of Medicine, Durham, North Carolina, told Medscape Psychiatry that the strength of the longitudinal study is in showing that ADHD outcomes are just as poor for girls as they are for boys and that it is "really valuable" to demonstrate this kind of impairment into adulthood.
He also agrees with investigators that girls with ADHD are less likely to be referred for diagnosis and treatment in childhood and therefore are not receiving treatment for ADHD, the result of which is a possible future "pernicious course" as shown in this study. Dr. Kollins feels that the protective effect of early treatment of ADHD against poor outcomes later in life continues to be debated.
Nevertheless, "what is clear is that if you treat the impairment in ADHD, it’s a good thing and even if you do not have a huge impact down the road, if you intervene early, there is a possibility of reducing the risk for some of these other complications later on."
Dr. Biederman has received research support, consultation fees, or speaker’s fees from Abbott, Aiza, AstraZeneca, Bristol Myers Squibb, Celltech, Cephalon, Eli Lilly, Esai, Forest, GlaxoSmithKline, Gliatech, Janssen Pharmaceuticals, McNeil, Merck, NARSAD, National Institute on Drug Abuse, National Institute of Child Health and Human Development, National Institute of Mental Health, New River, Novartis, Noven, Neurosearch, Organon, Otsuka, Pfizer, Pharmacia, Prechter Foundation, shire, Stanley Foundations, UCB Pharma, and Wyeth. Dr Kollins has disclosed no relevant financial relationships.
Am J Psychiatry. Published online January 15, 2010.