When parents reject interventions to reduce postnatal human immunodeficiency virus transmission.

In a recent Oregon case, the state successfully sued for custody of an infant to prevent his human immunodeficiency virus (HIV)-infected mother from breastfeeding him and to require antiretroviral prophylaxis. As more HIV-infected women give birth, pediatricians may increasingly face dilemmas when parents reject medical recommendations to forego breastfeeding and to administer antiretroviral prophylaxis to the infant. Such disagreements create ethical dilemmas because pediatricians have an obligation to both protect the infant and respect parental decision making. Pediatricians need to balance these obligations in deciding whether to ask the courts to intervene on the infant's behalf. To that end, we analyze the legal and ethical issues that arise when an HIV-infected mother refuses interventions to reduce neonatal transmission of HIV to her infant, provide an approach for addressing these disagreements, and present illustrative scenarios in which pediatricians should, may, and should not seek a court order to intervene.

Adults with ADHD. An overview.

Attention-Deficit Hyperactivity Disorder (ADHD) is a common, genetically transmitted neurological disorder, with onset in childhood, probably mediated by decreased brain dopaminergic functioning. The first author was one of the earliest to describe the persistence of symptoms into adulthood. Prevalence and natural history data suggest that of the 3 to 10% of children diagnosed with ADHD, one- to two-thirds (somewhere between 1 and 6% of the general population) continue to manifest appreciable ADHD symptoms into adult life. This paper describes how ADHD in adults can be readily diagnosed and treated, despite resembling or coexisting with other psychiatric disorders. The Wender Utah diagnostic criteria address adult characteristics of the disorder. Informant and patient interviews and rating scales are used to determine the psychiatric status of the patient as a child, make a retroactive diagnosis of childhood ADHD, and establish the current diagnosis of the adult. Stringent diagnosis is key to determining effective treatment. Dopamine agonist stimulant medications appear to be the most effective in treating ADHD. About 60% of patients receiving stimulant medication showed moderate-to-marked improvement, as compared with 10% of those receiving placebo. The core symptoms of hyperactivity, inattention, mood lability, temper, disorganization, stress sensitivity, and impulsivity have been shown to respond to treatment with stimulant medications. Non-dopaminergic medications, such as the tricyclic antidepressants and SSRIs have generally not been useful in adults with ADHD in the absence of depression or dysthymia. Pemoline is no longer approved for use in these patients, despite early favorable reports. Appropriate management of adult patients with ADHD is multimodal. Psychoeducation, counseling, supportive problem-directed therapy, behavioral intervention, coaching, cognitive remediation, and couples and family therapy are useful adjuncts to medication management. Concurrent supportive psychosocial treatment or polypharmacy may be useful in treating the adult with comorbid ADHD.

Adult ADHD. Concluding thoughts.

This concluding paper raises some final questions and issues that the authors feel should receive more emphasis in future research on ADHD in adults. One significant problem for our field is the upward extension of child-based models and approaches without proper adaptation to adults. With adults differing patterns of comorbidity and symptom heterogeneity pose new conceptual, diagnostic, and treatment challenges. As an illustration, we review ten common presenting complaints in adults and their link to the underlying core ADHD deficits of hyperkinesis, inattention, and impulsivity. While these core symptoms are often overt problems in children, in adults subtler executive dysfunction appears. Even though the growing consensus is that ADHD is a disorder of executive functions (EF), the details of the EF/ADHD connection remain unclear and may be far more complex in adults. That complexity is mirrored in the widening anatomic representation of EF, extending beyond the frontal lobes into the subcortex and other nonfrontal regions. More research will be needed to follow the developmental trajectory of executive dysfunction in ADHD over the life cycle and tie this to the developmental neuropsychology of EF. Psychosocial context and nongenetic familial influence are also critical variables that need greater consideration when characterizing and measuring ADHD symptoms in adults. Finally, until we have reached consensus on adult subject selection, we may not be able to enhance diagnostic rigor or expand our conceptual framework for understanding the underlying pathophysiology of ADHD in adults.

College students with ADHD and other hidden disabilities. Outcomes and interventions.

Nearly 25 years of special education law have enabled many qualified students with disabilities to graduate from college preparatory high school programs and enter institutes of higher education. The Americans with Disabilities Act enacted by Congress in 1990, the Individuals with Disabilities Education Act of 1975, and Section 504 of the Rehabilition Act of 1973 all mandate special education services for students with disabilities. A parallel nationwide rise is being reported in the numbers of students with disabilities on college campuses. The greatest increase is seen in students with so-called hidden disabilities such as learning disabilities, ADHD, and psychiatric disabilities. These students face a number of obstacles once they are admitted to college. Many factors, some intrinsic to the student and others extrinsic to the campus, moderate success in higher education. Overlapping or multiple diagnoses, psychological distress, poor social and interpersonal skills, persisting cognitive deficits (especially in the area of executive functioning), and alcohol abuse are important factors that must be understood as institutions of higher education strive to promote access and provide effective support services on their campuses.

Conflict-of-interest policies for investigators in clinical trials.

BACKGROUND: There is substantial concern that financial conflicts of interest on the part of investigators conducting clinical trials may compromise the well-being of research subjects. METHODS: We analyzed policies governing conflicts of interest at the 10 medical schools in the United States that receive the largest amount of research funding from the National Institutes of Health. These institutions are Baylor College of Medicine, Columbia University College of Physicians and Surgeons, Harvard Medical School, Johns Hopkins University School of Medicine, the University of Pennsylvania School of Medicine, the University of California at Los Angeles School of Medicine, the University of California at San Francisco School of Medicine, the University of Washington School of Medicine, Washington University School of Medicine at St. Louis, and Yale University School of Medicine. RESULTS: All 10 universities required that faculty members disclose financial interests to university officials. Only four required disclosure by all members of the research staff. Five universities required disclosure of all financial interests, even though federal regulations specify a threshold for disclosure. Six universities required disclosure to the institutional review board as well as to a committee on conflicts of interest or a university official. Four universities had stricter requirements for investigators conducting clinical trials than required by federal regulations. One university prohibited investigators from having stock, stock options, consulting agreements, or decision-making positions involving a company that sponsored the research. A second university prohibited researchers from trading stock or stock options in a company that sponsored the research or sold the product or device under study. Two universities ordinarily did not allow faculty members to participate in clinical research if they had what federal regulations refer to as a "significant" financial interest in the company owning the product or device being studied, but exceptions were allowed. CONCLUSIONS: Policies governing conflicts of interest at leading medical schools in the United States vary widely. We suggest that university-based investigators and research staff be prohibited from holding stock, stock options, or decision-making positions in a company that may reasonably appear to be affected by the results of their clinical research. Of the 10 medical schools we studied, only 1 had a policy that was close to this standard.

Quinolone antibiotics induce Shiga toxin-encoding bacteriophages, toxin production, and death in mice.

Shiga toxin-producing Escherichia coli (STEC) cause significant disease; treatment is supportive and antibiotic use is controversial. Ciprofloxacin but not fosfomycin causes Shiga toxin-encoding bacteriophage induction and enhanced Shiga toxin (Stx) production from E. coli O157:H7 in vitro. The potential clinical relevance of this was examined in mice colonized with E. coli O157:H7 and given either ciprofloxacin or fosfomycin. Both antibiotics caused a reduction in fecal STEC. However, animals treated with ciprofloxacin had a marked increase in free fecal Stx, associated with death in two-thirds of the mice, whereas fosfomycin did not. Experiments that used a kanamycin-marked Stx2 prophage demonstrated that ciprofloxacin, but not fosfomycin, caused enhanced intraintestinal transfer of Stx2 prophage from one E. coli to another. These observations suggest that treatment of human STEC infection with bacteriophage-inducing antibiotics, such as fluoroquinolones, may have significant adverse clinical consequences and that fluoroquinolone antibiotics may enhance the movement of virulence factors in vivo.

Peer review of teaching: instituting a program in a college of nursing.

Institutions of higher education can lose sight of the importance of teaching. Teaching, in some settings, needs to be restored to its place of primacy in the faculty role and its quality needs to be evaluated. The American Association for Higher Education (AAHE) national project, "From Idea to Prototype: The Peer Review of Teaching," is an attempt to accomplish that purpose. Involvement in the AAHE national peer review project has been the impetus for the Kent State University College of Nursing to initiate a faculty-developed program of peer review. The program has been well received primarily because it was owned and controlled by the faculty. Its voluntary nature, administrative sanction, and strong support have contributed to its success. Faculty explored many possible methods to accomplish peer review. However, the use of a task force, classroom and clinical observations, and teaching circles have been the approaches best suited to this particular departmental culture.

Extraintestinal Clostridium difficile: 10 years' experience at a tertiary-care hospital.

OBJECTIVE: To determine the clinical characteristics of patients with extraintestinal Clostridium difficile (ECD). MATERIAL AND METHODS: All cultures obtained during a 10.5-year period (from Jan. 1, 1985, to Jun. 30, 1995) at a tertiary-care hospital were retrospectively examined. The medical records of patients from whom ECD was isolated were then reviewed. RESULTS: Fourteen patients from whom ECD was cultured were identified. Thirteen of these patients (93%) had underlying systemic disease. All but one patient had recent exposure to antibiotics, and all had major bowel pathologic conditions. Nine patients had colon perforation. Of the eight patients in whom the colonic mucosa was directly inspected at operation or endoscopy, only two had evidence of pseudomembranous colitis. Five patients (36%) had documentation of recent diarrhea. ECD was isolated from intraperitoneal sites (in nine patients), blood cultures (in three), a perianal abscess, and a prosthetic hip joint. In 13 patients (93%), the infection was polymicrobial. Seven of the 13 inpatients (54%) survived to dismissal. CONCLUSION: C. difficile is a rare isolate outside of the gastrointestinal tract. ECD is found in patients with systemic illness who have been hospitalized (usually for an extended period), have intestinal pathologic conditions, and have received antibiotics. The isolation of ECD portends a poor prognosis.

Human immune response to polydimethylsiloxane (silicone): screening studies in a breast implant population.

Although initially it was thought that polydimethylsiloxane (silicone) was biologically inert, recent published studies have demonstrated varying levels of IgG antibody reactive with this structure in humans. The objective of our study was to determine whether silicone implanted in humans results in a measurable immune response directed against a 3700 mol wt hydroxyl terminated silicone molecule and whether that response could be correlated with the level of presumed silicone exposure as inferred by clinical history. In a blind study, sera from 111 patients, with and without breast implants, were sent to a laboratory using an enzyme-linked immunosorbent assay to determine specific anti-silicone IgG antibody levels. Test results showed that patients with implants demonstrated statistically significant elevation in anti-silicone antibodies compared with the unimplanted control groups. The highest anti-silicone antibody levels were measured in implanted women with either frank implant ruptures or leakage of their silicone gel implants.

The factor structure of ADHD items in DSM-III-R: internal consistency and external validation.

Previous research employing factor-analytic procedures to study the underlying dimensions of DSM-III attention deficit disorder with hyperactivity (ADDH) symptoms have consistently supported a two-factor model. Revision of the structure of the ADHD diagnosis in DSM-III-R, as well as inclusion of new items, has raised the question of comparability of the two diagnoses. To explore the significance of these changes, teacher ratings of DSM-III ADDH items and DSM-III-R ADHD items of 85 nonreferred school children were factor-analyzed to determine their underlying factor structures. A similar two-factor solution was obtained for each diagnostic scale. The factors consisted of items believed to reflect inattention and hyperactivity-impulsivity constructs. These factors were further evaluated against results of a cognitive test battery to ascertain whether objective, external validation could be demonstrated. The hyperactivity-impulsivity factor scores were related to continuous performance test measures of response inhibition, while inattention-disorganization factor scores were related to measures of attention and visual search. Implications for assessment and diagnosis of ADHD are discussed.

The dimension of focussed attention: relationship to behavior and cognitive functioning in children.

A sample of 73 nonreferred school children were administered a newly developed Visual Focussed-attention Test along with other measures of attentional, cognitive, and behavioral functioning. Internal reliability and construct validity for the test were established. Children were then divided into underfocussed (distractible, n = 6), normofocussed (n = 38), and overfocussed (n = 5) groups based upon their test scores. The three groups did not differ with regard to age, intellectual functioning, or academic achievement. However, the underfocussed and overfocussed groups contained a greater proportion of behaviorally disturbed children than the normofocussed group. Underfocussed children, as a group, were rated higher than normofocussed, but not higher than overfocussed children on the Hyperactivity factor of the Conners Teacher Questionnaire. The significance of these focussed attention deficits is reviewed in relation to the more familiar concepts of distractibility and hyperactivity.

Inattentive and noninattentive ADHD children: do they constitute a unitary group?

Teacher-rated ADHD and normal control children were administered a continuous performance test (CPT), and were then further subdivided based upon the presence or absence of objectively assessed attentional deficits. In addition, children were assessed using several measures of cognitive and behavioral functioning. Attentional deficits were significantly more prevalent among the ADHD group, but about half of the ADHD children showed no evidence of objectively assessed attentional dysfunction. Further group analyses indicated that ADHD children with objectively assessed attentional dysfunction appeared cognitively impaired, while ADHD children without objective evidence of attentional dysfunction had more conduct problems. CPT inattention was not related to the presence of cognitive impairments or conduct problems in the control group. These data must be considered preliminary because teacher ratings were the only source of diagnosis and a single measure of inattention was used. However, they suggest that two subtypes of ADHD children can be identified, one characterized by inattention and learning problems, and the other by conduct problems.

Validation of hyperactive, aggressive, and mixed hyperactive/aggressive childhood disorders: a research note.

Eighty-five non-referred school children were divided into four groups based upon the IOWA Conners Teacher's Questionnaire: pure hyperactive (HYP), pure aggressive (AGG), mixed hyperactive/aggressive (HYP/AGG), and normal controls. The groups were compared on neurobehavioral tests believed to assess inattention and impulsivity. A continuous performance test indicated that the HYP group was more inattentive than the other groups and the HYP/AGG group was most impulsive. The AGG group did not differ from controls. The data support the distinction between HYP, AGG and HYP/AGG groups of children selected by the IOWA Conners.