Reaching high-risk underserved individuals for cancer genetic counseling by video-teleconferencing.

BACKGROUND: Breast and colorectal cancers are common cancers for which genetic risk assessment and counseling are available. However, these services are often limited to metropolitan areas and are not readily accessible to underserved populations. Moreover, ethnic and racial disparities present additional obstacles to identifying and screening high-risk individuals and have a bearing on treatment outcomes. OBJECTIVE: To provide cancer genetic risk assessment and counseling through telemedicine to the remote, underserved primarily Hispanic population of the Texas-Mexico border region. METHODS: Program participants were mailed a questionnaire to assess their satisfaction with the program so that we could determine the acceptability of video-teleconferencing for cancer risk assessment. RESULTS: The overall level of satisfaction with the program was very high, demonstrating the acceptability of a cancer genetic risk assessment program that relied on telemedicine to reach and underserved minority community. LIMITATIONS: Delivery model requires the availability of and access to communication technologies; trained staff are needed at remote sites for sample collection and patient handling. CONCLUSION: Video-teleconferencing is an acceptable method of providing cancer risk assessment in a remote, underserved population.

Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway.

Attention-deficit/hyperactivity disorder (ADHD) has become a major aspect of the work of child and adolescent psychiatrists and paediatricians in the UK. In Scotland, Child and Adolescent Mental Health Services were required to address an increase in referral rates and changes in evidence-based medicine and guidelines without additional funding. In response to this, clinicians in Dundee have, over the past 15 years, pioneered the use of integrated psychiatric, paediatric, nursing, occupational therapy, dietetic and psychological care with the development of a clearly structured, evidence-based assessment and treatment pathway to provide effective therapy for children and adolescents with ADHD. The Dundee ADHD Clinical Care Pathway (DACCP) uses standard protocols for assessment, titration and routine monitoring of clinical care and treatment outcomes, with much of the clinical work being nurse led. The DACCP has received international attention and has been used as a template for service development in many countries. This review describes the four key stages of the clinical care pathway (referral and pre-assessment; assessment, diagnosis and treatment planning; initiating treatment; and continuing care) and discusses translation of the DACCP into other healthcare systems. Tools for healthcare professionals to use or adapt according to their own clinical settings are also provided.

Pharmacological treatment of attention-deficit/hyperactivity disorder: assessing outcomes.

A substantial body of evidence has supported the efficacy and safety of pharmacological treatment available for attention deficit/hyperactivity disorder (ADHD). There is increasing agreement that the important treatment outcomes for ADHD extend beyond improvement in core symptoms and that a more generic (or global) concept of remission is the overarching goal of treatment. However, there is no consensus on the best definition of remission or on how best to conceptualize and measure broader treatment outcomes. In this article, we provide an overview of the various methods and approaches to measuring treatment outcomes for ADHD with respect to symptoms, impairment, quality of life, adverse events and safety as well as cognition. We will describe the ways that they may be used within routine clinical practice and think ahead about the kinds of studies that are required to move the field forward.

Effects of methylphenidate on cognitive functions in children and adolescents with attention-deficit/hyperactivity disorder: evidence from a systematic review and a meta-analysis.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with a broad range of neuropsychological impairments. The relationship between these neuropsychological deficits and the defining symptoms of ADHD seems more complex than originally thought. Methylphenidate (MPH) is an effective treatment for ADHD symptoms, but its impact on cognition is less clearly understood. METHODS: With a common systematic search strategy and a rigorous coding and data extraction strategy across domains, we searched electronic databases to identify published placebo controlled trials that compared MPH and placebo on executive and nonexecutive memory, reaction time, reaction time variability and response inhibition in children and adolescents (5-18 years) with a formal diagnosis of ADHD. RESULTS: Sixty studies were included in the review, of which 36 contained sufficient data for meta-analysis. Methylphenidate was superior to placebo in all five meta-analyses: executive memory, standardized mean difference (SMD) .26, 95% confidence interval (CI): -.39 to -.13; non-executive memory, SMD .60, 95% CI: -.79 to -.41; reaction time, SMD .24, 95% CI: -.33 to -.15; reaction time variability, SMD .62, 95% CI: -.90 to -.34; response inhibition, SMD .41, 95% CI: -.55 to -.27. CONCLUSIONS: These data support the potentially important effects of MPH on various aspects of cognition known to be associated with ADHD. Consideration should be given to adding cognitive outcomes to the assessment of treatment outcome in ADHD, considering the complexity of the relationship between ADHD symptoms and cognition.

A comprehensive investigation of memory impairment in attention deficit hyperactivity disorder and oppositional defiant disorder.

BACKGROUND: We conducted a comprehensive and systematic assessment of memory functioning in drug-naïve boys with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). METHODS: Boys performed verbal and spatial working memory (WM) component (storage and central executive) and verbal and spatial storage load tasks, and the spatial span, spatial executive WM, spatial recognition memory and verbal recognition memory tasks from the Cambridge Neuropsychological Test Automated Battery. Groups comprised: (a) ADHD only (N = 21); (b) ADHD+ODD (N = 27); (c) ODD only (N = 21); and (d) typically developing (TYP) boys (N = 26). Groups were matched for age (M = 9.7 years) and sex (all boys). RESULTS: Confirmatory factor analyses confirmed the presence of five factors: verbal functioning, spatial functioning, WM storage, WM central executive and long-term memory (LTM). All three clinical groups demonstrated impaired memory performance. Boys with ODD and ODD+ADHD but not ADHD alone performed poorly on verbal memory tasks, whilst all three clinical groups showed impaired performance on spatial memory tasks. All three clinical groups performed poorly on the storage and central executive WM factors and the LTM factor. CONCLUSIONS: ADHD and ODD are characterised by impaired performance storage and central executive WM tasks and LTM tasks. This is, we believe, the first report of impaired WM and LTM performance in ODD. This study suggests that verbal memory difficulties are more closely associated with ODD than ADHD symptoms and that combined ADHD+ODD represents a true comorbidity. The data also support a small but growing number of suggestions in the literature of impaired LTM in ADHD.

Exploring the role of religiosity and spirituality in amniocentesis decision-making among Latinas.

Given the complex array of emotional and medical issues that may arise when making a decision about amniocentesis, women may find that their spiritual and/or religious beliefs can comfort and assist their decision-making process. Prior research has suggested that Latinas' spiritual and/or religious beliefs directly influence their amniocentesis decision. A more intimate look into whether Latinas utilize their beliefs during amniocentesis decision-making may provide an opportunity to better understand their experience. The overall goal of this study was to describe the role structured religion and spirituality plays in Latinas' daily lives and to evaluate how religiosity and spirituality influences health care decisions, specifically in prenatal diagnosis. Semi-structured interviews were conducted with eleven women who were invited to describe their religious beliefs and thoughts while considering the option of amniocentesis. All participants acknowledged the influence of religious and/or spiritual beliefs in their everyday lives. Although the women sought comfort and found validation in their beliefs and in their faith in God's will during their amniocentesis decision-making process, results suggest the risk of procedure-related complications played more of a concrete role than their beliefs.

Do the diagnostic criteria for ADHD need to change? Comments on the preliminary proposals of the DSM-5 ADHD and Disruptive Behavior Disorders Committee.

The purpose of this commentary is to discuss the recent proposals for revision of the diagnostic criteria made by the DSM-5 ADHD and Disruptive Behavior Disorders Committee. The major concerns with the current diagnostic criteria for ADHD and hence the main suggestions for change focused on the general structure and organization of subtypes, the number, content and distribution of criteria, the age of onset criteria, the ascertainment of cross-situationality and the inclusion and exclusion criteria. Suggestions for change in these areas have been made in order that these changes can be tested in field trials before being finalised. Whilst several of the proposed revisions are relatively uncontentious e.g., the elaborated symptoms criteria, the identification of ADHD as a disorder of both behavioural and cognitive functioning, the situational and developmental dependence of symptoms, the permission to diagnose ADHD in the presence of an autism spectrum disorder, clarification of the relationship between ADHD and irritable mood and the importance of getting information from teachers and other third parties. Several of the other proposed changed are more contentious and will require extensive field testing to assess their impact on validity, reliability and clinical usefulness. These include changes to the way in which individuals with inattention but no hyperactivity/impulsivity are classified, the addition of four new impulsivity symptoms, a reduction in the number of symptoms required to meet criteria for older adolescents and adults and the raising of the age of onset to 12 years of age.

Osmotic, controlled-release methylphenidate for the treatment of ADHD.

Methylphenidate (MPH) is the most commonly used and best-studied stimulant medication for attention-deficit hyperactivity disorder. However, its short duration of action usually results in a requirement to administer multiple daily doses in order to achieve optimal clinical benefit. Although a wax-matrix-based SR formulation of MPH has been available since the 1990s, it was not well accepted into clinical practice. The variable absorption profile and lack of an immediate-release component results in a slower onset of action compared with immediate-release MPH. Hence, there was a need to develop alternative longer-lasting preparations of MPH that were as efficacious as IR MPH, but which also addressed the problems inherent in multiple daily dosing. An osmotic, controlled-release (OROS) formulation of MPH HCl has been developed over the past 10 years for once-daily administration. OROS MPH has been widely accepted by clinicians and is now the most widely prescribed MPH product in North America. Clinical trials have shown OROS MPH to have a continued action over a 12-h period, to be superior to placebo and to be as effective as immediate-release MPH dosed three times daily, in reducing symptoms of attention-deficit hyperactivity disorder, with similar incidence of side effects. There have been a smaller number of trials comparing OROS MPH with non-stimulant treatments, such as atomoxetine.