Disordered gambling in adolescents : epidemiology,diagnosis, and treatment

Rapid expansion of legalized gambling has been associated with increased rates of gambling disorders among adults and adolescents worldwide. Epidemiologic studies suggest that, in North America, up to 6% of adults and 20% of adolescents have a gambling problem. Despite increasing prevalence rates of gambling disorders, little research is available on how to treat such disorders in adolescents. Much of what is known about how to treat adolescent problem and pathological gambling comes from research on psychosocial and psychopharmacologic treatments for adult pathological gambling. Risk factors for adolescent gambling disorders include male gender, alcohol and drug use, deviant peers, family history of gambling, and impulsive behavior. While several risk factors characterize disordered gambling among adolescents, the extent to which these characteristics are related remains to be determined. In terms of screening for adolescent problem and pathological gambling, several instruments designed to reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for pathological gambling are available. Psychosocial approaches used to treat adult pathological gambling include Gamblers Anonymous, cognitive-behavioral therapy (CBT), and motivational enhancement therapy (MET). Among adolescents, CBT as well as an eclectic therapy have been helpful in reducing problematic gambling behavior. In terms of pharmacotherapy, three classes of psychotropic drugs have been used to treat adult pathological gambling - serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers. While some of these pharmacotherapies have been efficacious in treating adult pathological gambling, additional double-blind, placebo-controlled studies are needed to determine the long-term effectiveness of these treatments. No known study has evaluated the use of psychopharmacologic agents in treating adolescent pathological gambling. Possible reasons for the lack of research on treatment for adolescent gambling disorders include lack of motivation to pursue treatment, feelings of self-control, and negative perception of therapy. Referrals from parents, teachers, and peers of adolescents, as well as community outreach programs, may be useful in successfully deriving a treatment population. Clinicians are advised to be sensitive to behavioral risk factors and to screen for disordered gambling in high risk adolescents. A combination of CBT and MET, as well as medication for any comorbid psychiatric condition, is recommended.     

Eating disorders in children and adolescents: epidemiology, diagnosis and treatment

Eating disorders such as anorexia nervosa (AN) and bulimia nervosa (BN) are increasingly prevalent among children and adolescents. Whereas AN has a peak age of onset in early to mid-adolescence, BN typically presents during or after late adolescence. There is a spectrum of eating disorders that can be categorised by the criteria in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders into AN, BN and 'eating disorder not otherwise specified (ED-NOS)'. The key clinical signs of AN are those of protein calorie malnutrition. In BN, signs of purging are also important. Despite marked physical changes, metabolic decompensation occurs late and when present is an indication for hospital admission. During refeeding, electrolyte disturbances, in particular hypophosphataemia, should be serially monitored. For females with AN, restoration of gonadotropins, oestradiol and resumption of menses is a cardinal indicator of nutritional recovery. Treatment should address the medical, nutritional and psychological needs of children and adolescents with eating disorders. No single professional can be proficient in all spheres. Children and adolescents with eating disorders are best managed by a 'team approach'. Treatment may occur in a variety of inpatient, daypatient or outpatient settings. The aims of medical treatment are to promote bodyweight gain and nutritional recovery. Psychiatric goals address the psychosocial precipitants, treat comorbid mood symptoms and assist the patient to develop alternative coping skills. The crude mortality of AN has decreased to around 6%. For children and adolescents, the morbidity from malnutrition is increased because of the biological changes that are interrupted.     

Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies

Introduction: Dysmenorrhea is the most common gynecologic complaint among adolescents/young adults. Dysmenorrhea is usually primary and is associated with normal ovulatory cycles and with no pelvic pathology. Potent prostaglandins and potent leukotrienes play an important role in generating primary dysmenorrhea symptoms. Adolescents/young adults with severe dysmenorrhea symptoms may have pelvic abnormalities, such as endometriosis or uterine anomalies (secondary dysmenorrhea).

Areas covered: This review provides an update on treatments and management strategies of dysmenorrhea in adolescents/young adults. Medical literature articles were retrieved using a Medline search on primary and secondary dysmenorrhea. Original articles from peer-reviewed journals were selected based on relevance.

Expert opinion: Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) is the preferred initial treatment for dysmenorrhea in nonsexually active adolescents/young adults. Adolescents/young adults with symptoms that do not respond to NSAIDs for three menstrual periods should be offered hormonal treatment, such as combined estrogen and progestin oral contraceptive pills (OCPs), for three menstrual cycles. If dysmenorrhea does not improve within 6 months of NSAIDs and OCPs, a laparoscopy is indicated to look for endometriosis, which is the most common reason for secondary dysmenorrhea.     

Post-traumatic stress disorder in children and adolescents: epidemiology, diagnosis and treatment options

Post-traumatic stress disorder (PTSD) is a common psychiatric condition in childhood and adolescence. Rates vary widely depending upon the type of trauma exposure. Interpersonal traumas, such as rape or physical abuse, are more likely to result in PTSD than exposure to natural or technological disaster. Clinical presentations are exceedingly complex and children with PTSD are at increased risk of having comorbid psychiatric diagnoses. Because of its complexity and frequent occurrence with other disorders, assessment of PTSD necessitates a broad-based evaluation utilizing multiple informations and structured instruments specific to the symptoms of PTSD in youth. Cognitive-behavioral therapy (CBT) is the treatment of first choice. Pharmacological agents for PTSD treatment have received little empirical investigation in childhood. Pharmacological treatment is used to target disabling symptoms of the disorder, which limit psychotherapy or life functioning, by helping children to tolerate working through distressful material in therapy and life. Pharmacological treatment should be based on a stepwise approach utilizing broad spectrum medications such as the selective serotonin reuptake inhibitors as first-line agents. Comorbid conditions should be identified and treated with appropriate medication or psychosocial interventions. Treatment algorithms are provided to guide rational medication strategies for children and adolescents with PTSD, subsyndromal PTSD, and in PTSD that is comorbid with other psychiatric conditions of childhood. Reduction in even one debilitating symptom of PTSD can improve a child's overall functioning across multiple domains.     

Social anxiety disorder in children and adolescents: epidemiology, diagnosis, and treatment

Social anxiety disorder (SOC) is characterized by marked and persistent fear of one or more social performance situations in which the person is exposed to unfamiliar people or to possible scrutiny. The person fears that she or he might act in a way that will be humiliating or embarrassing. Children and adolescents with this disorder often have great impairment in their academic performance, social skills, peer relationships, and family life. Early diagnosis is vital. Primary care providers are in a unique situation to first diagnose and treat SOC in children and adolescents. There is evidence of successful pharmacologic and psychosocial treatment in pediatric SOC. Serotonin reuptake inhibitors, which are considered first-line medications for SOC, have shown promising results in open-label and double-blind trials. Studies have demonstrated that psychosocial treatments, specifically cognitive-behavioral therapy and group therapy, are efficacious in pediatric SOC. There is some evidence that the use of combination therapy, both pharmacology and psychosocial treatment, is beneficial in the management of pediatric SOC.     

Dual diagnosis and successful participation of adolescents in substance abuse treatment.

A retrospective record review of one year of admissions to a residential adolescent substance abuse treatment program (N = 91) examined the prevalence of comorbid psychiatric disorders and factors associated with successful treatment participation. Psychiatric and substance use disorders (SUD) were diagnosed by DSM-IV criteria. Successful participation was based on multiple factors assessed by the treatment team. Consistent with prior studies, there was considerable comorbidity (63.7%) with both disruptive (Attention Deficit Hyperactivity Disorder [ADHD], 11%; Conduct Disorder [CD], 24%) and other disorders (depression, 24%; adjustment disorder, 7.7%; bipolar disorder, 3.3%). Male gender was negatively associated (OR = 0.23, P = 0.019) with successful participation in univariate analyses, as was ADHD (OR = 0.18, P = 0.007). CD (OR = 0.37, P = 0.053) approached significance. Multivariate analysis reveals ADHD was significant while having CD and being male approached significance. Psychotropic medication use and other diagnoses were not associated with successful participation. It is concluded that further research on the relationship between ADHD, CD, and substance abuse treatment is needed.     

Alcohol use disorders in adolescents: epidemiology,diagnosis, psychosocial interventions,and pharmacological treatment

Alcohol (ethanol) abuse and dependence are the most common substance use disorders among adolescents. Binge drinking occurs in up to one-third of adolescents, and alcohol use disorders occur in about 6% of this age group. Adolescents with alcohol use disorders also typically have problems with other substances and comorbid mental disorders. Validated measures are available for the clinical detection and diagnosis of adolescent alcohol use disorders and related problems. Psychosocial interventions promoting abstinence are the most common treatments for alcohol use disorders, with empirical support particularly strong for family-based approaches. Pharmacological interventions may diminish the effects of alcohol withdrawal, prevent a return to alcohol consumption, or treat comorbid mental disorders. In this population, pharmacological interventions require further investigation and, where indicated, are generally considered to be supplementary to psychosocial approaches.     

Aspergillosis: diagnosis and treatment

The incidence of invasive aspergillosis is increasing rapidly in the developed world with two Aspergillus spp., A. fumigatus and A. flavus, causing the majority of infections (85-90% and 5-10%, respectively). The major risk factors are profound neutropenia (/=400 mg daily) is a useful alternative and surgical resection may be life saving in some cases. The efficacy of the initial therapy is critical for improving mortality rates.     

Haemoglobinopathy in pregnancy: diagnosis and treatment

Haemoglobinopathies differ in geographic prevalence but together are amongst the most common genetic disorders worldwide. Despite huge diagnostic progress, therapeutic options remain limited, with many treatments still at the experimental stage, no more so than in pregnancy: not only does the presence of a fetus subject treatments to greater limitations, but also any worsening of the anaemia as pregnancy progresses results in higher fetomaternal morbidity and mortality. Anaemia weakens the response to peripartum blood loss, with the risk of postpartum complications. Until recently the standard conventional therapy for severe anaemia was (repeated) blood transfusion, with its well-known risks. Recombinant human erythropoietin (rhEPO) can induce fetal haemoglobin and is a safer, if less immediately effective, alternative for the correction of anaemia in pregnant patients with haemoglobinopathy.     

Substance dependency treatment for adolescents: practice and research

This paper reviews the more common treatment approaches that address adolescent substance abuse and the spectrum of problems which often attend involvement with drugs. The most common outpatient treatment approaches for adolescents are 12-step based programs and family-based therapies which may be used separately or in conjunction with each other. The therapeutic community is a residential approach, characterized by the use of the peer community itself to facilitate social and psychological change in individuals. Both outpatient and residential modalities have demonstrated effectiveness in working with adolescents. Ideally, the type of intervention will depend upon the young person's needs, in particular the extent and effects of his/her drug use, as well as the level of other problems. Overall, treatment must address a range of concerns of special relevance to adolescents because of their age and dependency status; for example, developmental stage, cultural issues, and gender issues.     

Migraine in children and adolescents: a guide to drug treatment

Migraine is a common disorder in children and adolescents, with a prevalence of 5 and 10%, respectively. Some patients may have recognisable factors that trigger or aggravate migraine attacks, such as flickering or bright lights, strong smells and noise, and where possible these should be avoided. It is also wise to maintain a lifestyle where children receive regular meals and get sufficient sleep. If used, acute pharmacological treatment should be given at the onset of an attack, followed by a rest or sleep. According to recent literature, paracetamol (acetaminophen) and ibuprofen can be recommended for the acute treatment of migraine attacks in children and adolescents, and sumatriptan nasal spray can be recommended for adolescents. The oral formulation of sumatriptan has not shown efficacy in paediatric patients, and the subcutaneous injection, although somewhat effective, is not an ideal formulation for this patient group. There are too few data on the efficacy of the other 'triptans' to recommend their use in children and adolescents. There are less data on the use of prophylactic drugs in paediatric patients. In systematic studies, only flunarizine, which is not available in many countries, and propranolol have been found to be effective. A pilot placebo-controlled study suggests that topiramate might also be effective. Several other agents are commonly used to prevent migraine attacks in children (e.g. amitriptyline, valproic acid [sodium valproate]) despite a lack of robust research into their efficacy.     

Polycystic ovary syndrome in adolescents: current and future treatment options

Polycystic ovary syndrome (PCOS) is a very common disorder affecting 5-10% of women of reproductive age. The pivotal endocrine abnormalities of this syndrome are insulin resistance and ovarian and, to a lesser degree, adrenal hypersensitivity to hormonal stimulation. PCOS may manifest itself as early as the first decade of life by premature pubarche or menarche. Oligoamenorrhea in the first postpubarchal years, although very common, may be an early symptom of PCOS, especially in overweight girls with hirsutism or acne. Girls with low birth weight as well as a family history of diabetes mellitus or premature cardiovascular disease are at high risk for developing PCOS. Circulating bioavailable testosterone levels are usually elevated, while total testosterone may be normal due to low levels of sex hormone-binding globulin. The typical sonographic appearance of PCOS ovaries consists of high ovarian volume (>10 mL) and the presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter. However, this finding is not specific, since it may occur in >20% of healthy girls. The therapeutic goals in adolescents with PCOS is first to restore bodyweight and menses and to reduce the signs of hyperandrogenism. The reduction of bodyweight in this young age group may require the collaboration of the pediatrician, dietitian, and psychotherapist. The adolescent should be urged to adopt a healthy lifestyle with the aim to maintain a normal body mass index throughout adolescence and adult life. The choice of medical therapy depends on the clinical presentation. Oral contraceptives are a good option when acne and hirsutism are the principal complaints. Adolescents with isolated cycle irregularity may be placed on a cyclical progestin regimen to induce withdrawal bleeding. Metformin, by decreasing insulin resistance, alleviates many of the hormonal disturbances and restores menses in a considerable proportion of patients. It may be used alone or in combination with oral contraceptives. Independently of medical treatment, restoration and maintenance of bodyweight within normal range is of paramount importance.     

铊中毒的诊断和治疗

铊为高毒性重金属,成人致死量约为12mg/kg。铊中毒的机制尚未明了,可能与竞争性抑制钾的作用、与蛋白及酶分子上巯基结合及与核黄素结合成不溶性化合物有关。铊中毒临床表现的典型特征为胃肠炎、多发性神经病及脱发三联症。胃肠道症状出现较早,如恶心、呕吐和腹痛。神经系统症状为下肢麻痛、惊厥和昏迷。脱发在中毒1～3周内出现。其他中毒体征和症状有:皮疹、肾损害、心动过速及视力障碍等。患者可死于呼吸衰竭。24h尿液铊浓度检测为评估铊中毒的最佳方法。尿铊>0.3mg/L具有诊断意义。铊中毒应与格林-巴利综合征、铅中毒和砷中毒相鉴别。口服铊中毒可用活性炭、硫酸镁和普鲁士蓝等药物处理。普鲁士蓝常用剂量为250mg/(kg.d),分4次口服。据报道,血液灌流能有效排除已吸收的铊。