Lower threshold for referral for psychiatric treatment for adopted adolescents.

Epidemiological data on a national sample of 3,698 adolescents, of whom 145 were adopted, indicate that adoption significantly increases the likelihood of referral for psychiatric treatment even after controlling for the fact that adoptees display more behavior problems and come from more educated families. This is accounted for by the fact that adoptees are significantly more likely to be referred when they display few problems. Thus, contrary to popular myth and clinical lore, the overrepresentation of young adoptees in clinical settings is not attributable solely to the fact that adoptees are more troubled. Rather, adoptees do display more problems but they are also referred more readily even after controlling for extent of problems.     

The need for regulatable vectors for gene therapy for Parkinson's disease

Gene therapy is now a very promising approach for the treatment of Parkinson's disease, for which there are currently few treatment options. However, gene therapy is invasive and irreversible, and its long-term effects are not yet known. Regulatable vectors allow the expression of the introduced gene to be adjusted or stopped by changing the dose of an oral inducer drug, thus adding an important safety mechanism as well as the ability to tailor the dose to an individual patient's needs. Although the use of conventional gene therapy should not be delayed until regulatable systems are available, clinical trials of regulatable gene therapies are imminent. Regulatable systems provide the best hope for safely delivering effective, flexible treatments over the long course of Parkinson's disease, and their development should be actively supported.     

Evidence for Interventions for Young Offenders

Young offenders are an issue of global concern. Despite a greater understanding of the aetiology of conduct disorder and juvenile delinquency, the research on treatments and the use of evidence-based methods of interventions has not kept pace. This review critically and selectively examined interventions for young offenders, and organises them based on levels of care. The challenge is to intervene using empirical strategies that are implemented based on our emerging understanding of aggression.     

Challenges for gene therapy for muscular dystrophy

Gene therapy for muscular dystrophy represents a promising avenue of pursuit for a disease with a limited repertoire of treatment. Recent successes in the research arena using adeno-associated viral vectors should accelerate the movement of gene-based therapeutics for muscle disorders into the clinic. Nevertheless, significant challenges remain before gene therapy can deliver on the promises avowed by early pioneers of the field. This review examines recent progress and the hurdles remaining to achieve gene-based treatment therapies for muscular dystrophy.     

Challenges for gene therapy for muscular dystrophy

Gene therapy for muscular dystrophy represents a promising avenue of pursuit for a disease with a limited repertoire of treatment. Recent successes in the research arena using adeno-associated viral vectors should accelerate the movement of gene-based therapeutics for muscle disorders into the clinic. Nevertheless, significant challenges remain before gene therapy can deliver on the promises avowed by early pioneers of the field. This review examines recent progress and the hurdles remaining to achieve gene-based treatment therapies for muscular dystrophy.     

The Scope for Psychosocial Treatments for Psychosis

The recent Australian Study on Low Prevalence Disorders (Jablensky et al., 2000) found that, whilst most Australians with a psychotic illness (91%) were taking medication, few were receiving adequate psychosocial support from mental health services; fully 47% of the sample perceived the need for a particular type of service which was not able to be accessed by them, either because of it simply not being available or not being affordable (65% and 49%, respectively, of respondents identified these as barriers). This article outlines a proposed framework that will help meet some of this deficit. The program will develop, evaluate and disseminate comprehensive modular treatment packages addressing the psychosocial needs of people with psychotic disorders. It is novel in terms of the comprehensiveness of the approach, the rigour of the evaluation (using controlled experimental design), and the extent of inter-sectoral and multidisciplinary involvement in mapping needs, developing the interventions, and dissemination.     

Genome scan for susceptibility loci for schizophrenia

OBJECTIVE: Schizophrenia is a relatively common, often chronic and debilitating mental illness. Evidence from various studies has clearly demonstrated that genetic factors contribute substantially to the etiology. The goal of this study was to identify chromosomal regions likely to contain schizophrenia susceptibility genes. METHODS: A genome-wide map of 388 microsatellite DNA markers was genotyped in 5 schizophrenia families. Nonparametric linkage analysis (Genehunter) was used to assess the pattern of allele sharing at each marker locus relative to the presence of disease. RESULTS: Nonparametric linkage scores did not reach a genome-wide level of statistical significance (p < 0.00002) or a p value suggestive of linkage (p < 0.007) for any marker; however, one p value suggested replicated linkage (p < 0.01) at chromosome 6p24 in region D6S309 (p = 0.0047). Furthermore, 11 markers resulted in p < 0.05 at chromosomes 6p, 6q, 10q, 12q and 14q. CONCLUSIONS: Despite the differences in diagnostic schemes, in markers used and methods of analyses between studies published so far, we think that our result supports the notion that there is possibly some consistent evidence for replicated linkage of a schizophrenia susceptibility locus around the region of D6S309 at chromosome 6p24.     

Need for palliative care for neurological diseases

The new concept of palliative care supports the idea of palliation as an early approach to patients affected by disabling and life-limiting disease which focuses on the patient’s quality of life along the entire course of disease. This model moves beyond the traditional concept of palliation as an approach restricted to the final stage of disease and widens the fields of intervention. There is a growing awareness of the importance of palliative care not only in oncological diseases but also in many other branches of medicine, and it appears particularly evident in the approach to many of the most frequent neurological diseases that are chronic, incurable and autonomy-impairing illnesses. The definition and implementation of palliative goals and procedures in neurology must take into account the specific features of these conditions in terms of the complexity and variability of symptoms, clinical course, disability and prognosis. The realization of an effective palliative approach to neurological diseases requires specific skills and expertise to adapt the concept of palliation to the peculiarities of these diseases; this approach should be realized through the cooperation of different services and the action of a multidisciplinary team in which the neurologist should play a central role to identify and face the patient’s needs. In this view, it is paramount for the neurologist to be trained in these issues to promote the integration of palliative care in the care of neurological patients.     

Growing Evidence for Psychodynamic Therapy for Depression

Psychodynamic therapy (PT) for depression is the least examined treatment method for depression, compared to cognitive-behavioral therapy (CBT) and interpersonal therapy. This article, consisting of five randomized clinical trials of short psychodynamic supportive psychotherapy (SPSP) conducted over the last 25 years in Amsterdam, will review the trial results to provide answers to the question about which role SPSP can play in the treatment of depression. The researchers conclude that it is justified to qualify SPSP an empirically supported therapy form of PT for depression. In particular, adding SPSP to pharmacotherapy yields better results than pharmacotherapy by itself. Adding medication to SPSP may have a significant added value, but it is not as large as in the first comparison. The results also confirm no difference in efficacy between CBT and SPSP.     

Enoxaparin for neonatal thrombosis: a call for a higher dose for neonates

Introduction

Enoxaparin is the current anticoagulant of choice for neonatal thrombosis. Present neonatal treatment guidelines of 1.5 mg/kg every 12 hours (q12 h) are extrapolated primarily from an earlier study with 9 infants less than 2 months of age. More recent studies indicate an increased dose requirement for neonates.

Materials and methods

Relevant data from articles and abstracts were identified by searching MEDLINE and pediatric and hematology conference proceedings.

Results

Publications between 1996 and 2007 included 8 papers, 4 abstracts and 1 review article with primary research documenting enoxaparin use in 240 neonates. The mean maintenance dose of enoxaparin ranged from 1.48 to 2.27 mg/kg q12 h for all infants, but was higher for preterm neonates at 1.9-2.27 mg/kg q12 h. The efficacy of enoxaparin, causing either complete or partial resolution was between 59 and 100%. Minor side effects were common and adverse events (major bleeding) occurred in 12 patients (0-19%).

Conclusions

Increased experience with enoxaparin use in neonates in the past decade has indicated higher doses to achieve accepted target anti-factor Xa values. The long-term use of indwelling catheters (Insuflon® catheter) for enoxaparin administration may need to be reevaluated in ELBW infants. Suggested starting doses of enoxaparin are 1.7 mg/kg q12 h for term neonates and 2.0 mg/kg q12 h for preterm neonates if there is no considerable bleeding risk. However, further prospective studies are needed to validate an increased initial dose of enoxaparin.     

Parents' Preferences for School- and Community-Based Services for Children at Risk for ADHD

This study used conjoint analysis, trade-off methodology employed by marketing researchers and health economists, to examine preferences of parents for school- and community-based interventions for childhood ADHD. Participants were 29 mothers (86.2% Caucasian) of boys aged 5–13 years with or at risk of ADHD. Mothers completed a conjoint survey that examined trade-offs across 15 attributes of service content (e.g., materials, resources), process (e.g., time demand, format/delivery mode), and outcome (e.g., improvement in children's behavioral functioning). Findings suggest that parents preferred services maximizing children's behavioral and social outcomes (relative to family functioning). Parents were willing to give up services with desirable delivery features (such as daily homeschool notes and child's frequent participation in therapy) for programs optimizing outcomes. Simulation analyses, forecasting tools that predict how respondents would behave in the real world, revealed that 62.1% of parents were predicted to prefer a standard, evidence-informed school-based service involving daily teacher involvement and monthly parent involvement, while 37.9% of parents were predicted to use a standard, evidence-informed community-based service involving daily parent involvement and monthly teacher involvement. Findings from this study show that parents value improved social and behavioral outcomes more than desirable service delivery features. However, results suggest that if the treatment package includes school-based services in which there is greater teacher involvement and less parent involvement, a majority of parents prefer school services, especially if they involve children's ongoing use of self-control strategies. Results suggest ways in which the delivery of effective treatments needs to be altered to make them more palatable and acceptable by parents. Other implications for school-based practitioners are discussed.     

A rapid method for mass screening for parkinsonism

Epidemiology studies of parkinsonism employ a variety of techniques for unbiased sampling of populations. No current method permits mass screening of all subjects in a population for parkinsonism by movement disorders specialists. We developed and piloted a new approach to facilitate accurate and efficient screening of large populations for diagnosis of parkinsonism and provide data on sensitivity and specificity. We evaluated 2081 welders referred for medical-legal screening. Subjects were video taped using a standardized protocol, and videos were rated on the Unified Parkinson's Disease Rating Scale motor subsection 3 (UPDRS3). A "video rater" viewed video tapes and entered ratings through a web-based database. An "in-person" examiner performed a UPDRS3 examination in a randomly selected subgroup of 48 workers drawn from the 2081. We developed quantitative diagnostic criteria for parkinsonism that established minimum diagnostic thresholds based upon UPDRS3 scores and compared these criteria with diagnosis by an in-person examiner. Specificity of these criteria compared to in-person examination was 91-100% but sensitivity was 56%. A threshold UPDRS3 score greater than nine provided 100% sensitivity and 81% specificity. Liberal criteria identified 266 (13.1%) subjects with probable parkinsonism and 220 (10.8%) subjects with definite parkinsonism. Conservative criteria identified 260 (12.8%) with probable parkinsonism and 122 (6%) with definite parkinsonism. Our screening method permits rapid assessment of parkinsonian signs. An absolute UPDRS3 score greater than nine provided the best combination of sensitivity and specificity for the diagnosis of parkinsonism, while quantitative exam-based criteria for cardinal parkinsonian signs maximized specificity. Parkinsonism as diagnosed by our criteria was common in this group of welders.     

Technique for stereotactic body radiotherapy for spinal metastases

Stereotactic body radiotherapy (SBRT) is an emerging technique for spinal tumours that is a natural succession to brain radiosurgery. The spine is an ideal site for SBRT due to its relative immobility and the potential clinical benefits of high dose delivery, particularly to optimise local control and avoid disease progression that can result in spinal cord compression. However, the proximity of the tumour to the spinal cord, with the potential for radiation myelopathy if the dose is delivered inaccurately or if the spinal cord dose limit is set too high, demands technical accuracy with radiation myelopathy a feared complication. Spine SBRT has been delivered with either a robotic-based linac system such as the Cyberknife, or with linac-based systems equipped with a multileaf collimator and image guidance system. Regardless of the technology, spine SBRT demands sophisticated treatment planning and delivery. This case-based technical review outlines the SBRT apparatus, planning and treatment delivery in use at the University of Toronto, Toronto, Canada.