Cognitive-behavioural therapy in medication-treated adults with attention-deficit/hyperactivity disorder and co-morbid psychopathology: a randomized controlled trial using multi-level analysis.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by high rates of co-morbid psychopathology. Randomized controlled trials of multimodal interventions, combining pharmacological and psychological treatments, have shown a robust treatment effect for ADHD symptoms but outcomes for co-morbid symptoms have been mixed. This may be accounted for by the type of intervention selected and/or by methodological problems including lack of follow-up and low power. The current study addressed these limitations in a parallel-group randomized controlled trial conducted in Iceland. METHOD: A total of 95 adult ADHD patients who were already being treated with medication (MED) were randomly assigned to receive treatment as usual (TAU/MED) or 15 sessions of cognitive-behavioural therapy (CBT/MED) using the R&R2ADHD intervention which employs both group and individual modalities. Primary measures of ADHD symptoms and severity of illness, and secondary measures of anxiety, depression and quality of life were given at baseline, end of treatment and 3-month follow-up. Primary outcomes were rated by clinicians blind to treatment condition assignment. RESULTS: CBT/MED showed overall (combined outcome at end of treatment and 3-month follow-up) significantly greater reduction in primary outcomes for clinician-rated and self-rated ADHD symptoms. Treatment effect of primary outcomes was maintained at follow-up, which suggests robust and lasting findings. In contrast to the primary outcomes, the secondary outcomes showed significant improvement over time. CONCLUSIONS: The study provides evidence for the effectiveness of R&R2ADHD and demonstrates that there are differential effects over time for ADHD symptoms versus co-morbid problems, the latter taking longer to show positive effects.

[Medication use and treatment characteristics of children referred to the outpatient ADHD-clinic at the Department of Child and Adolescent Psychiatry, the National University Hospital.].

MATERIAL AND METHODS: Data was accumulated by retrospectively looking at the records of 102 children of both sexes between 3 and 15 years of age, referred to the ADHD outpatient clinic during the period June 1, 1998 - May 31, 1999. A semi-structured diagnostic parent interview was used to assess childhood psychiatric disorders according to ICD-10. The ADHD Rating Scale- IV, the Home Situations Questionnaire and the Child Behavior Checklist were completed by the parents. Teachers filled out the ADHD Rating Scale and the Teacher Report Form as well as a form evaluating the child's academic progress. To assess intellectual functioning, WISC-III or WPPSI-R were administered. Medical evaluation was performed and drug treatment recorded. RESULTS: Seventy-two children fulfilled ICD-10 diagnostic criteria of hyperkinetic disorder. High rates of other behavioural disorders, especially oppositional defiant disorder and a significant frequency of emotional disorders were recorded. Nearly two-thirds of the children had been started on medication prior to referral, most often amytryptiline and methylphenidate. Eleven children received combined pharmacotherapy but 35% had not received any drug treatment. Psychopharmacotherapy for most of the children was started between the age of four and eight years. Behaviour management counselling and parent training was recommended in most cases. CONCLUSIONS: Thirty children did not meet full hyperkinetic disorder diagnostic criteria, but these children may nonetheless have manifested high levels of symptoms. Most of the children were started on tricyclic antidepressants rather than stimulants which is unusual compared with international research and practice. The reason is unclear but may reflect the high rate of comorbidity but also doctors' preferences.

[Hyperkinetic disorder. A review.].

Attention-deficit/hyperactivity disorder or hyperkinetic disorder is a clinically defined syndrome characterised by age inappropriate deficits in sustained attention, impulsivity and overactivity. Despite extensive investigation, a specific neuroanatomical, physiological, biochemical, or psychological origin has not been identified. Diagnosis is based on detailed medical and developmental history, symptom rating scales, psychological assessment and medical evaluation. Increases in diagnosis and treatment of the disorder have elicited public and professional concern. The main focus in this article is on this disorder in children and adolescents and includes practical information on assessment and treatment. Other disorders, which may be either comorbid with or mistaken for hyperkinetic disorder, are reviewed in less detail.

[External otitis in school children after an intensive swimming course.].

OBJECTIVE: This study reports an outbrake of external otitis in boarding school children after they had participated in an intensive swimming course. The infective agent isolated was P. aeruginosa. The question is raised whether the outbrake was caused by water contaminated by bacteria or intensive bathing. MATERIAL AND METHODS: Twenty-seven children from a rural boarding school, aged 10 to 14 years participated in an obligatory swimming course for two weeks. As the outbrake became evident all the children were examined by two doctors with an otomicroscope. Bacterial culture was taken from the external acoustic meatus (EAM) on both sides and a tympanogram was performed on all. Subjective evaluation of symptoms was achieved by using a questionnaire. Eight weeks after the swimming course ended all participants were investigated again with an ear microscope and control bacterial culture was taken from the EAM for appreciation of the outcome. RESULTS: Seventeen (63%) of the 27 children had symptoms of external otitis on the first visit. Microscopic investigation of those infected revealed seven (41.2%) children with mild, four (23.5%) with mode notrate and six (35.3%) with severe inflammation of the EAM. Of those children affected 12 (70.6%) had infection in both ears. P. aeruginosa was isolated from 11(64,7%) of those affected and from two of those who had no symptoms. The mean onset of symptoms was 2.1 days (standard error 0.5) after the swimming course had ended. The mean time for symptom relief was 11.4 days (standard error 2.2). CONCLUSIONS: Intensive swimming courses in pools where the quality of the water is checked sporadically is not advised. If intensive swimming courses are necessary the concentration of chlorine should be carefully monitored as well as checked for growth of both Cloriform bacteria and P. aeruginosa.

[The effects of different settings on outcome when screening for high blood pressure.].

INTRODUCTION: It has become increasingly popular to offer blood pressure measurements under circumstances that differ from the usual setting, for example measurements in supermarkets, pharmacies, at exhibitions etc. It is well known that environmental factors as well as doctor and patient relationship can affect blood pressure measurement. This must be considered in the diagnosis and treatment of hypertension. The aim of this study was to evaluate some of these phenomena. MATERIAL AND METHODS: Subjects attending local supermarket in a rural community were offered blood pressure measurement two Friday afternoons. All measurements were done in a sitting position with a fully automatic blood pressure recorder, AND UA-767. Hypertension was diagnosed if blood pres notsure exceeded 140 mm Hg systolic and/or 90 mmHg diastolic (according to WHO standards). Those who had hypertension were followed by two office and six home measurements. For the statistical analysis, a t-test for paired data was used. RESULTS are reported as means. RESULTS: Total of 125 subjects had their blood pressure measured. By the WHO criteria 64 (51.2%) of the subjects had hypertension. Mean blood pressure was significantly higher in the supermarket compared to office both for systolic, 17.1 (C.I:12.8-21.4)mmHg, and diastolic, 5.2 (0.1:2.7-7.7) mmHg, blood pressure. Eighty per cent of the subjects had normal blood pressure at home. Compared to supermarket the mean blood pressure reduction was 29.3 (0.1:24.7-33.9) mmHg for systolic and 10.1 (0.1:7.2-13.0) mmHg for diastolic. A "white coat effect" (office vs. home BP) was present. Mean blood pressure reduction 12.9 mmHg (0.1:10.1-15.7) mmHg for systolic and 5.0 mmHg (0.1:3.4-6.6) for diastolic. CONCLUSIONS: This unconventional approach to blood pressure screening seems to be both cheap and acceptable for the public. Blood pressure measurements under these circumstances on the other hand are not directly comparable to the standard values given by WHO and should be looked on as reflecting the blood pressure each given time. Environmental factors therefore influence the blood pressure measurement greatly. The interaction between the physician and the patient seems to be a major factor in the office vs. home blood pressure difference, the so called white coat effect. On the other hand there must be another explanation for the difference between blood pressure measurement in supermarket "and at home. Different circumstances and their effect on reference values when offering blood pressure measurements must be taken into consideration. This should be kept in mind when diagnosing hypertension.

[DNA flow cytometry is a useful prognostic guide in the treatment of breast cancer.].

It is widely agreed that the presence or absence of axillary lymph-node involvement (N) is the most reliable predictor of relapse or survival in breast cancer, together with tumor size (T) and the presence or absence of distant metastasis (M). These prognostic factors are the cornerstones of the TNM staging system. The aim of the present study was to ascertain, in all patients diagnosed with invasive primary breast cancer in Iceland during the years 1981-84 (n=347), whether flow cytometric DNA analysis of ploidy status and fraction of cells in the S-phase contribute prognostic information, addi nottional to that obtained with TNM staging variables. Paraffin fixed tumor material was available from 340 patients (98%) and DNA ploidy and S-phase fraction was assessed with flow cytometry. DNA ploidy could be analysed in 98% of tumor samples (n=334), of which 114 (34%) were diploid and 220 (66%) non-diploid. S-phase fraction could be analysed in 97% of the tumor samples (n=329), the median S-phase value was 7.0%, and was higher in non-diploid than diploid tumors (p<0.0001, 9.3% vs. 2.7%). Median duration of patient follow-up was 7.5 years. The disease-free survival at that point of time was 15% higher in patients with diploid tumors than non-diploid ones (p=0.004, 69% vs 54%). Similar survival comparison in relation to S-phase fraction was 30% when the median S-phase value was used as cut-off point (p<0.0001, S-phase<7.0% being 74% vs. S-phase ;7.0% being 44%). Multivariate analyses with regard to breast cancer survival and disease-free survival, which included both ploidy status and S-phase categories adjusting for age, tumor size and lymph node involvement, showed the S-phase value categories to be independent prognostic variables (p<0.0001). Patients with high S-phase tumors had a three-fold higher risk of recurrence than patients with low S-phase tumors. Ploidy status was not an independent prognostic variable, if however the S-phase categories were excluded from analysis, ploidy status was on the borderline of being an independent variable (p=0.09). In node-negative patients the S-phase fraction was the only useful variable in determining prognosis. We conclude that the S-phase value is a useful prognostic guide for the clinician and will be used for this purpose in the treatment of breast cancer in Iceland.

[Thrombolytic therapy in Egilsstaethir district. Five cases in a two year period.].

Egilsstadir is a rural district in Iceland with a population of 3100 people. In 1993 prehospital thrombolytic therapy started in Egilsstaethir district. A protocol was made and used as a therapeutic guide. In a period of two years five patients have been treated. Four of them got thrombolytic therapy started within four hours since beginning of symptoms. Two of the patients had successful reperfusion of the coronary arteries and two more had positive results. All of the cases were treated successfully without complications and then transferred to a special cardiology unit. Our experience is that prehospital thrombolytic therapy can easily be done in a rural setting. We consider the time gain in starting thrombolytic therapy before transferal to hospital critical to prevent morbidity and save lives. Our experience is positive to encourage continuation of prehospital thrombolytic therapy in rural settings.

[Prognosis in patients having irritable bowel syndrome.].

Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders. In this survey, the prognosis of patients diagnosed with IBS was examined. In 1982, 81 (2.9%) of the inhabitants in Egilsstaethir health care district had diagnosed IBS on their medical records (ICCH 558). Twelve years later, in 1994, the health records of those patients were examined. Information was gathered through a questionnaire, which 76% answered. Of those who answered 28% had no longer any symptoms, but 38% experienced symptoms once a month or more frequently. The medical records of 11 patients who died were checked, revealing that two had had a confirmed gastrointestinal disease, but not in the colon.

Tumours in Iceland. 14. Malignant tumours of soft tissues. Histological classification and epidemiological considerations.

All malignant tumours of soft tissues diagnosed in Iceland between 1955 and 1988 were reviewed histologically. Of a total of 155 tumours, 129 were, on review, soft tissue sarcomas, while 26 had been erroneously diagnosed and were excluded from the study. In 25% of the tumours the original sarcoma diagnosis was changed to another sarcoma type. Malignant fibrous histiocytoma, liposarcoma and leiomyosarcoma together comprise more than half of all tumours diagnosed. Contrary to previous estimations, according to this study, the age-standardized incidence of soft tissue sarcoma in Iceland is 1.8 per 1000,000 for males and 1.6 per 100,000 per females, which is similar to incidence rates in the other Nordic countries. The majority of sarcomas were of relatively high grade. The tumours were graded using both three and four grades of malignancy. Both systems yielded prognostic information although it was not possible to detect significant differences in survival for grade I and grade II tumours when the four grade system was used. The results of this study show that the epidemiology of soft tissue sarcoma in Iceland is similar to that found in other Western countries.

Soft tissue sarcomas in Iceland 1955-1988. Analysis of survival and prognostic factors.

From 1955 to 1988 a total of 129 cases (69 males and 60 females) of soft tissue sarcomas were diagnosed in Iceland, four at autopsy. The median age was 55 years (0-91). All the cases have been reviewed clinically and histopathologically and graded on both a three- and a four-point scale. The average age-standardized incidence was 1.8/100,000 for males and 1.6 for females. The tumour was most often localized in the thigh and retroperitoneal space. The most common histologic subtypes were malignant fibrous histiocytoma (22.5%), liposarcoma (18.6%) and leiomyosarcoma (16.3%). The 5- and 10-year survival rates (n = 125) were 38% and 29% respectively. Cox's multivariate analysis was performed on the following prognostic factors: age, sex, tumour localization, histopathologic subtype, tumour size, malignancy grade and year of diagnosis. The strongest prognostic factor was malignancy grade (IV vs I; p less than 0.001 and RR = 5.35 and III vs I; p = 0.017 and RR = 2.01) followed by tumour size (pT2 vs pT1; p less than 0.001 and RR = 3.09 and pT3 vs pT1; p = 0.002 and RR = 3.40) and year of diagnosis (p = 0.003 and RR = 0.96; corresponding to a 54% reduction in mortality risk during a 20-year period).

Prognostic significance of lymph node status in stage III breast cancer.

Case histories of 103 patients with locally advanced (stage III) breast cancer have been reviewed. Ninety of the patients were judged operable. The median follow-up time was 52 months. The 5-year survival rate for the whole group was 54%. The 5-year relapse-free survival rates for the pN0, pN1 and pN2-3 were 91, 50 and 19% respectively and the 5-year survival rates for the groups were 86, 53 and 30% respectively. These results underline the heterogeneity and the very different prognoses for the different subgroups in stage III breast cancer patients. A reevaluation of the staging system is therefore suggested.

Temporomandibular joint symptoms in patients with midfrequency sensorineural hearing loss.

It was hypothesized that a correlation exists between a specific form of sensorineural hearing loss and temporomandibular joint dysfunction and/or parafunction, with the audiometric configuration of the loss showing a notch (poorest threshold) at 1000 or 2000 Hz in the range from 250 through 4000 Hz. Fifty patients at audiology clinics who showed this audiometric configuration were compared with 50 control patients, matched for age, sex, and severity of loss. The midfrequency notch group reported more symptoms of temporomandibular joint dysfunction (p less than 0.005), including more temporomandibular joint pain (p less than 0.0001), tenderness (p less than 0.025), and jaw noises (p less than 0.05). The notch group also reported significantly more bruxism (p less than 0.001) and clenching (p less than 0.001). Patients found having this midfrequency notch have been predominantly female (64% in this study), the percentage who are female increasing with age. The findings demonstrate a relationship between the form of sensorineural hearing loss studied and symptoms of temporomandibular joint dysfunction.