Reliability and validity of a DSM-IV based ADHD screener.

The Diagnostic Rating Scale (DRS) was completed by the parents and teachers of 82 children referred for clinical evaluations, 73 referred children seen twice, and 218 non-referred children from the community. The DRS, which uses a categorical rather than a dimensional rating approach, was 70% to 90% sensitive to diagnoses of Attention Deficit/Hyperactivity Disorder (ADHD) made by blind clinical teams. In research and clinical applications, the DRS could improve screening efficiency, especially in situations where it would be desirable to exclude all children who might have ADHD or identify all children with Hyperactive-Impulsive symptoms. Because of its objectivity and consistency with the Diagnostic and Statistical Manual (DSM)-IV criteria, the DRS could facilitate comparison of participant samples across studies.

Mother and teacher reports of ADHD symptoms: DSM-IV Questionnaire data.

OBJECTIVE: Diagnosis of attention-deficit/hyperactivity disorder (ADHD) is thought to be best accomplished by a multimodal approach. In many research and clinical settings, such extensive procedures may not be feasible. A screening instrument that could identify children meeting necessary (but not sufficient) criteria would permit selection of subgroups for more resource-intensive diagnostic procedures. METHOD: The Diagnostic Rating Scale (DRS) was completed by the mothers and teachers of 124 children referred to hospital-based clinics and 225 nonreferred children. The authors performed principal components analysis (PCA) on the questionnaire, compared the scores obtained by children from the 2 samples, and examined age and gender effects. Diagnoses derived from the DRS were not validated against structured diagnostic interviews. RESULTS: PCAs replicated the DSM-IV symptom combinations. Children from the referred sample exhibited more symptoms (p < .001) than children from the community sample. Boys were overrepresented among the children who received DRS-derived ADHD diagnoses. Girls were more likely (92%) to receive a diagnosis of ADHD, predominantly inattentive subtype, than other ADHD diagnoses. CONCLUSIONS: The results of this study provide preliminary support for the validity of the parent and teacher DRS as time- and resource-efficient screening instruments for examining symptoms associated with ADHD.

Medical marijuana.

Although many clinical studies suggest the medical utility of marijuana for some conditions, the scientific evidence is weak. Many patients in California are self-medicating with marijuana, and physicians need data to assess the risks and benefits. The only reasonable solution to this problem is to encourage research on the medical effects of marijuana. The current regulatory system should be modified to remove barriers to clinical research with marijuana. The NIH panel has identified several conditions for which there may be therapeutic benefit from marijuana use and that merit further research. Marijuana should be held to the same evaluation standards of safety and efficacy as other drugs (a major flaw in Proposition 215) but should not have to be proved better than current medications for its use to be adopted. The therapeutic window for marijuana and THC between desired effect and unpleasant side effects is narrow and is a major reason for discontinuing use. Although the inhaled route of administration has the benefit of allowing patients to self-titrate the dose, the smoking of crude plant material is problematic. The NIH panel recommended that a high priority be given to the development of a controlled inhaled form of THC. The presence of a naturally occurring cannabinoid-receptor system in the brain suggests that research on selective analogues of THC may be useful to enhance its therapeutic effects and minimize adverse effects.

An Escherichia coli chromosomal ars operon homolog is functional in arsenic detoxification and is conserved in gram-negative bacteria.

Arsenic is a known toxic metalloid, whose trivalent and pentavalent ions can inhibit many biochemical processes. Operons which encode arsenic resistance have been found in multicopy plasmids from both gram-positive and gram-negative bacteria. The resistance mechanism is encoded from a single operon which typically consists of an arsenite ion-inducible repressor that regulates expression of an arsenate reductase and inner membrane-associated arsenite export system. Using a lacZ transcriptional gene fusion library, we have identified an Escherichia coli operon whose expression is induced by cellular exposure to sodium arsenite at concentrations as low as 5 micrograms/liter. This chromosomal operon was cloned, sequenced, and found to consist of three cistrons which we named arsR, arsB, and arsC because of their strong homology to plasmid-borne ars operons. Mutants in the chromosomal ars operon were found to be approximately 10- to 100-fold more sensitive to sodium arsenate and arsenite exposure than wild-type E. coli, while wild-type E. coli that contained the operon cloned on a ColE1-based plasmid was found to be at least 2- to 10-fold more resistant to sodium arsenate and arsenite. Moreover, Southern blotting and high-stringency hybridization of this operon with chromosomal DNAs from a number of bacterial species showed homologous sequences among members of the family Enterobacteriaceae, and hybridization was detectable even in Pseudomonas aeruginosa. These results suggest that the chromosomal ars operon may be the evolutionary precursor of the plasmid-borne operon, as a multicopy plasmid location would allow the operon to be amplified and its products to confer increased resistance to this toxic metalloid.

Factors encouraging cohort maintenance in a longitudinal study.

Maintenance of the cohort is one of the primary challenges of a longitudinal study. At the end of 3 years of follow up in the Framingham Children's Study, a longitudinal study of young children and their parents, 100 of the original 106 families (94.3%) have remained in the study. A questionnaire was administered to identify factors contributing to the high rate of follow up to this point in the study. The attitudes of the staff, feedback to the subjects, the staff's handling of questions and problems, and association with the Framingham Heart Study emerged as the most important factors influencing continued participation in the study. In addition, 99% of the subjects stated that they believed the medical research to be important. We conclude that the quality of the communication with study participants and the subjects' perceived importance of the research have been the key factors in maintaining the cohort in this longitudinal epidemiologic study.

Psychiatry in a troubled world: the relation of clinical practice and social reality.

Based on studies conducted over the course of the past half-century, elements common to all forms of effective psychotherapy are reviewed. The emergence of innovative modes of therapy is noted, with special attention to the recent advent of systems-theoretical approaches to intervention. Contradictions between therapeutic goals of personal harmony and our current competitive social ethic are considered, and the mental health implications of achieving a more just society are highlighted.

Impact of adjuvant chemotherapy on cosmesis and complications in stages I and II carcinoma of the breast treated by biopsy and radiation therapy.

Cosmesis and complication rates were examined in patients with early stage carcinoma of the breast treated by biopsy and radiation therapy with and without adjuvant chemotherapy in an attempt to determine the effect of chemotherapy upon these parameters. Between April 1, 1975 and June 1, 1980, 51 patients were treated with radiation therapy and adjuvant chemotherapy (XRT + ACT) and 83 patients with radiotherapy alone (XRT). Chemotherapy usually consisted of cytoxan, methotrexate and 5-fluorouracil for 6 or 12 cycles. Minimum follow-up was 36 months. Cosmetic results deteriorated with time in both groups but to a greater extent in the XRT + ACT group. At 36 months, excellent cosmetic results were obtained in 73 of the 83 patients (88%) in the XRT group compared to 37 of 51 patients (73%) in the XRT + ACT group (p = less than .05). Comparison of the two treatment groups revealed that complication rates were significantly increased in the XRT + ACT group. Of the 51 patients in the XRT + ACT group, 21 patients (41%) suffered complications compared to 8 (10%) of the 83 patients in the XRT group (p = less than .001). This difference in complication rates resulted primarily from an increased incidence in the XRT + ACT group of wet desquamation in the electron beam portal used to treat the internal mammary lymph nodes and a trend towards a higher incidence of spontaneous nonpathologic rib fractures, myositis and arm edema. An increased incidence of nonbreast primary cancers was not seen. Our preliminary conclusions are that adjuvant chemotherapy has a negative impact upon cosmesis and complication rates in patients being treated with definitive radiotherapy. However, cosmetic results remain satisfactory and complication rates are maintained at an acceptable level. Continued close follow-up will be required before definitive conclusions can be reached as to the overall incidence and severity of the changes noted.

Systems thinking in psychiatry: some theoretical and clinical implications.

The author discusses the theoretical and pragmatic value of systems thinking in psychiatry. An awareness of the pluralistic, multifactorial origins of psychopathology broadens the psychiatrist's understanding and increases his or her therapeutic potential. The psychiatrist who thinks in systems terms is a true generalist in medicine, and to practice that way is the most effective way of treating people.

Work in progress: serial evaluation of tumor volume using computed tomography and contrast kinetics.

Computed tomography can be used to evaluate tumor volume changes after therapy. Pre- and posttreatment results are presented for nine human neoplasms. Volume changes are correlated with the behavior of intravenous diatrizoate contrast material. The five-minute diatrizoate distribution volume appears to be a potential contrast material marker for therapeutically induced tumor volume changes. Neoplasms decreasing in volume demonstrate a decrease in the diatrizoate distribution volume; those increasing in volume demonstrate an increase.

Clinical studies with ultrasound-induced hyperthermia.

Results obtained in clinical studies in which ultrasound was used for hyperthermia induction are reviewed. High intensity ultrasound has certain advantages for the induction of local hyperthermia: Well-collimated beams can be produced, which makes good localization possible; ultrasound can be focused; and absorption in tissue is proportional to frequency, hence the depth of penetration can be controlled. Limitations include the fact that ultrasound is reflected from tissue-air interfaces and thus cannot be used to heat tumors in the lung. Local "hot spots" due to impedance mismatches that result in standing wave patterns may occur near bone. During clinical treatments, this latter problem is frequently associated with a patient's complaint of pain. The temperature generated depends both on ultrasound absorption coefficients, which vary among different tissues, and dissipation of heat, which varies due to local differences in blood flow rates. Thus inhomogeneities of heating in tissue may be observed despite uniform ultrasound fields. Clinical results with ultrasound-induced hyperthermia have been reported by groups at Stanford, M.D. Anderson Hospital, and Massachusetts Institute of Technology-Harvard. Approximately 40-50% of the superficial tumors showed an objective response to ultrasound hyperthermia in the range of 43 degrees -50 degrees C. Responses to heat alone were partial and transitory. Some radiation responses appeared to be improved by concomitant ultrasound hyperthermia.