Altered gray matter organization in children and adolescents with ADHD: a structural covariance connectome study.

Although multiple studies have reported structural deficits in multiple brain regions in attention-deficit hyperactivity disorder (ADHD), we do not yet know if these deficits reflect a more systematic disruption to the anatomical organization of large-scale brain networks. Here we used a graph theoretical approach to quantify anatomical organization in children and adolescents with ADHD. We generated anatomical networks based on covariance of gray matter volumes from 92 regions across the brain in children and adolescents with ADHD (n=34) and age- and sex-matched healthy controls (n=28). Using graph theory, we computed metrics that characterize both the global organization of anatomical networks (interconnectivity (clustering), integration (path length) and balance of global integration and localized segregation (small-worldness)) and their local nodal measures (participation (degree) and interaction (betweenness) within a network). Relative to Controls, ADHD participants exhibited altered global organization reflected in more clustering or network segregation. Locally, nodal degree and betweenness were increased in the subcortical amygdalae in ADHD, but reduced in cortical nodes in the anterior cingulate, posterior cingulate, mid temporal pole and rolandic operculum. In ADHD, anatomical networks were disrupted and reflected an emphasis on subcortical local connections centered around the amygdala, at the expense of cortical organization. Brains of children and adolescents with ADHD may be anatomically configured to respond impulsively to the automatic significance of stimulus input without having the neural organization to regulate and inhibit these responses. These findings provide a novel addition to our current understanding of the ADHD connectome.

Two-year outcomes of an adjunctive telephone coaching and electronic contact intervention for adolescent weight-loss maintenance: the Loozit randomized controlled trial.

This paper reports the final 24-month outcomes of a randomized controlled trial evaluating the effect of additional therapeutic contact (ATC) as an adjunct to a community-based weight-management program for overweight and obese 13-16-year-olds. ATC involved telephone coaching or short-message-service and/or email communication once per fortnight. Adolescents were randomized to receive the Loozit group program-a two-phase behavioral lifestyle intervention with (n=73), or without (n=78), ATC in Phase 2. Adolescents/parents separately attended seven weekly group sessions (Phase 1), followed by quarterly adolescent sessions (Phase 2). Assessor-blinded, 24-month changes in anthropometry and metabolic health included primary outcomes body mass index (BMI) z-score and waist:height ratio (WHtR). Secondary outcomes were self-reported psychosocial and lifestyle changes. By 24 months, 17 adolescents had formally withdrawn. Relative to the Loozit program alone, ATC largely had no impact on outcomes. Secondary pre-post assessment of the Loozit group program showed mean (95% CI) reductions in BMI z-score (-0.13 (-0.20, -0.06)) and WHtR (-0.02 (-0.03, -0.01)) in both arms, with several metabolic and psychosocial improvements. Adjunctive ATC did not provide further benefits to the Loozit group program. We recommend that further work is needed to optimize technological support for adolescents in weight-loss maintenance. Australian New Zealand Clinical Trials Registry Number ACTRNO12606000175572.

Attention deficit disorder: not just for children.

Abstract Attention deficit/hyperactivity disorder (ADHD) has long been described in children who demonstrate developmentally inappropriate symptoms of inattention, impulsivity and motor restlessness. In adults, symptoms are known to persist and the validity of adult ADHD as an entity is now recognized. There is an associated high proportion of other serious psychiatric comorbidities, especially substance abuse, mood and anxiety disorders. Advances have been made into the aetiology and management of ADHD. Many of these focus on the dopamine and noradrenaline pathways.

Cardiac arrest and delirium: presentations of the refeeding syndrome in severely malnourished adolescents with anorexia nervosa.

AIM: To describe the clinical presentation of the refeeding syndrome and highlight the dangers of performing nutritional rehabilitation too rapidly in a severely malnourished patient. DESIGN: Retrospective case review of adolescents admitted with anorexia nervosa who developed the refeeding syndrome. RESULTS: Between July 1993 and July 1994, 3 of 48 adolescent females developed the refeeding syndrome. While the cardiac complications occurred in the first week of refeeding, the delirium characteristic of this syndrome occurred later and was more variably related to hypophosphatemia. OBSERVATIONS: Refeeding malnourished patients with anorexia nervosa can be associated with hypophosphatemia, cardiac arrhythmia and delirium. Refeeding patients with anorexia nervosa who are < 70% of ideal body weight should proceed with caution, and the caloric prescription should be increased gradually. Supplemental phosphorus should be commenced early and serum levels maintained above 3.0 mg/dL. Cardiac and neurologic events associated with refeeding are most likely to occur within the first weeks, justifying close monitoring of electrolyte and cardiac status.

Chronic illness perception in adolescence: implications for the doctor-patient relationship.

OBJECTIVE: To describe the inter-relationship of chronic illness severity as perceived by adolescents with both psychosocial well-being and objective measures of illness severity. Additionally to compared the adolescents' perception of illness severity with how their physicians believe that the adolescents perceive their illness severity. METHODS: The psychological well-being of 48 adolescents with either cystic fibrosis (CF) or insulin-dependent diabetes mellitus (IDDM) was measured by four standardized questionnaires. The adolescents' perception of severity of illness was measured using an original instrument (PSCI), and this measure was compared to their physicians' estimates of how the adolescents perceived the severity of their illness and clinical illness. RESULTS: There were 24 patients in both the CF and IDDM groups. Both groups were found to function well psychosocially; although, there were more patients with low self image compared to normative values. Depression and low self image were associated with a greater adolescent perception of illness severity. For both chronic illness groups, physicians' assessment of assumed adolescent perception of disease severity correlated with clinical indices of disease severity and was higher than the perception of illness severity reported by the adolescents. For adolescents with CF, but not with IDDM, perception of severity of chronic illness correlated with clinical indices. CONCLUSIONS: For adolescents with chronic illness, their perception of illness severity is an important indicator of psychosocial well-being. Physicians do not accurately infer their patients' perception of illness severity.

Directly observed preventive therapy. Turning the tide against tuberculosis.

OBJECTIVE: To compare compliance between directly observed preventive therapy and daily treatment for students with inactive (class II) tuberculosis. DESIGN: Cohort analytic study and cost-effectiveness analysis. Students found to be positive for purified protein derivative and having no abnormal chest x-ray films on mandated screening were advised to have prophylactic treatment with isoniazid. Treatment was either directly observed in the school health clinic or provided as daily therapy by the Department of Health. Treatment completion, age, sex, ethnicity, and recent immigration were compared between the 2 treatment groups. SETTING: A school-based clinic at an inner-city New York, NY, high school. RESULTS: In 1993, 864 students were screened. The positive purified protein derivative rate was 19.3%. All 161 students had negative findings on chest x-ray films. Of the students, 105 (65.2%) were enrolled in the school-based clinic directly observed preventive therapy program, 22 were referred to the Department of Health for daily therapy, and 34 excluded from the study before treatment. The 2 treatment groups did not differ in composition. Completion of therapy in the directly observed preventive therapy group (87.6%) was significantly greater than that in the daily therapy group (50%) (P = 0.001, X2 = 11.8) and that reported in the literature for programs other than directly observed preventive therapy (30%-70%). Directly observed preventive therapy was administered by existing personnel without additional expenditure. CONCLUSION: Directly observed preventive therapy is an effective strategy that should be used in the school clinic setting to increase compliance with prophylactic treatment for tuberculosis.

Reversibility of cerebral ventricular enlargement in anorexia nervosa, demonstrated by quantitative magnetic resonance imaging.

OBJECTIVE: To determine the reversibility of the loss of brain parenchyma and ventricular enlargement in patients with anorexia nervosa after refeeding. STUDY DESIGN: Quantitative magnetic resonance imaging was performed on three groups of subjects: (1) 12 female adolescents hospitalized with anorexia nervosa, (2) the same 12 patients after nutritional rehabilitation, a mean of 11.1 months later, and (3) 12 healthy age-matched control subjects. Sixty-four contiguous coronal magnetic resonance images, 3.1 mm thick, were obtained. With a computerized morphometry system, lateral and third ventricular volumes were measured by a single observer unaware of the status of the patient. RESULTS: On admission, patients were malnourished and had lost an average of 11.7 kg (body mass index, 14.3 +/- 2.0 kg/m2). After refeeding, they gained an average of 9.7 kg (body mass index, 17.9 +/- 1.5 kg/m2). Total ventricular volume decreased from 17.1 +/- 5.5 cm3 on admission to 12.4 +/- 3.0 cm3 after refeeding (p < 0.01) and returned to the normal range. The degree of enlargement of the third ventricle was greater than that of the lateral ventricles. There was a significant inverse relationship between body mass index and total ventricular volume (r = -0.63; p < 0.05). CONCLUSION: In patients with anorexia nervosa, cerebral ventricular enlargement correlates with the degree of malnutrition and is reversible with weight gain during long-term follow-up.

Blood ordering for haematemesis.

The blood ordering practices for acute upper gastrointestinal bleeding were assessed in 162 consecutive patients presenting with haematemesis admitted via the Accident and Emergency Centre. The patients were classified according to their estimated blood loss and haemoglobin level at the time of admission, and the amounts of blood ordered and given in the next 24 h were determined. The crossmatch: transfusion (CT) ratio was very high in one group (14.9), although the overall ratio of 2.4 was acceptable. There were marked variations in the ordering pattern of different medical officers, possibly because of the absence of clear guidelines. From the data obtained, a set of guidelines for ordering blood in this clinical condition was developed. It was estimated that if these guidelines had been used, there would have been a reduction of one-third of all units crossmatched, and that the overall CT ratio would have been reduced to 1.6.

Gastroschisis and exomphalos: recent trends and factors influencing survival.

The present study examined the treatment and survival of patients with gastroschisis and exomphalos in the 5-year period January 1982-December 1987, at the Prince of Wales Children's Hospital. There were 15 cases of gastroschisis and 17 cases of exomphalos. The influences of temperature on arrival, birthweight, method of repair and associated anomalies on survival were examined. More patients presenting with gastroschisis survived than those with exomphalos (14 of 15 compared with 10 of 17, respectively). Of all the factors examined, the presence and nature of associated anomalies is the most important in determining survival.