Attention-Deficit/Hyperactivity Disorder and comorbidity in Brazil

Abstract. Objective: The aim of this study was to compare the pattern of comorbidity in referred samples of Attention-Deficit/Hyperactivity Disorder (ADHD) patients from two different geographic areas in Brazil. Methods: The diagnoses of ADHD and comorbid conditions, according to DSM-IV criteria, were achieved in both clinics through semi-structured interview methodology, complemented by clinical interviews with the children or adolescents and their parents. Results: We assessed 343 ADHD children and adolescents in Porto Alegre (capital of the southernmost state of the country) and 78 ADHD youths in Rio de Janeiro (capital of a southestern state). Although a significant difference in the prevalence of ADHD without comorbidity was detected between the two groups (p = 0.02), no significant difference was detected in the profile of comorbidities between them. Main ADHD comorbidities in both samples were: a) Oppositional Defiant Disorder (Porto Alegre = 39.1%; Rio de Janeiro = 51.3 %); b) Anxiety Disorders (Porto Alegre = 24.2%; Rio de Janeiro = 30.8 %); c) Conduct Disorder (Porto Alegre = 13.7%; Rio de Janeiro = 17.9 %); and d) Major Depression and/or Dysthymia (Porto Alegre = 11.4%; Rio de Janeiro = 10.3 %). Conclusions: Our results from clinical samples in a developing country with a diverse culture suggest the crosscultural validity of the ADHD comorbidity profile.     

Treating individuals with eating disorders in family practice: a needs assessment

With their myriad of serious and occasionally life-threatening physical sequelae, in addition to their complex emotional issues, individuals with eating disorders can be among the most challenging a physician may see in primary practice. A two-page, 10-item survey based on a literature review of family physicians' experiences with individuals with eating disorders was distributed to a sample of 500 Manitoba family physicians. Two hundred and one surveys were returned for a province-wide return rate of 40%. Eighty percent of physicians who saw individuals with eating disorders felt there were some patients they were unable to treat for a variety of reasons including lack of physician skills, limited resources, problems with patient cooperation, the severity of the patient's illness, and a lack of time to deal with the demands of an eating disordered patient. The services most often provided by the physicians included medical management of symptoms, referral to specialized services, information on nutrition and exercise, and limited counseling. Referrals were most often made to psychiatrists, dieticians, Winnipeg's Eating Disorder Program, and community mental health workers. The strong response indicates that eating disorders are a serious concern in primary practice. The role of the family physician is very much dependent upon the individual physician's skills and degree of comfort in dealing with the disorders. Continuing education is seen as vital to improve diagnostic skills and enhance physicians' level of comfort. More support for physicians in the short term and enhanced interdisciplinary programming in the longer term are crucial in meeting patients' complex needs.     

Oppositional defiant disorder: a review of neurobiological and environmental correlates, comorbidities, treatment and prognosis

Oppositional defiant disorder (ODD) is an independent diagnostic entity but it is frequently studied in conjunction with Attention-Deficit Hyperactivity Disorder (ADHD) or Conduct Disorder (CD). The purpose of this paper is to review the extant evidence, through the PubMed database, on the neurobiological correlates of oppositional defiant disorder and also describe the familiar and school functioning, comorbidities, prognosis and therapeutic options for oppositional defiant disorder. Evidence of hormonal, genetic and neuro-functional findings in oppositional defiant disorder, correlation with the family, school relations and performance, and the association with mood and anxiety and disruptive disorders are described. The risk of an evolution to conduct disorder and of persistence of the oppositional defiant disorder symptoms is depicted. A review of the effect of Cognitive-Behavioral Therapy and medication is presented. Analysis of the available evidence shows that the impact of oppositional defiant disorder should not be ignored and it should be properly addressed. The effect of treatment for oppositional defiant disorder on the long-term outcome of patients still needs to be addressed.     

Insulin resistance and endothelial function are improved after folate and vitamin B12 therapy in patients with metabolic syndrome: relationship between homocysteine levels and hyperinsulinemia

OBJECTIVE: The purpose of this study was (a) to study whether a folate and vitamin B12 treatment, aimed at decreasing homocysteine levels, might ameliorate insulin resistance and endothelial dysfunction in patients with metabolic syndrome according to the National Cholesterol Education Program-Adult Treatment Panel-III criteria and (b) to evaluate whether, under these metabolic conditions, there is a relationship between hyperhomocysteinemia and insulin resistance. DESIGN AND METHODS: A double-blind, parallel, identical placebo-drug, randomized study was performed for 2 months in 50 patients. Patients were randomly allocated to two groups. In group 1, patients were treated with diet plus placebo for 2 months. In group 2, patients were treated with diet plus placebo for 1 month, followed by diet plus folic acid (5 mg/day) plus vitamin B12 (500 microg/day) for another month. RESULTS: In group 2, folate treatment significantly decreased homocysteine levels by 27.8% (12.2+/-1.2 vs 8.8+/-0.7 micromol/l; P<0.01). A significant decrement was observed for insulin levels (19.9+/-1.7 vs 14.8+/-1.6 microU/ml; P<0.01) accompanied by a 27% reduction in the homeostasis model assessment levels. A positive relationship was found between the decrement of homocysteine and insulin levels (r=0.60; P<0.002). In parallel, endothelial dysfunction significantly improved in the treated group, since post-ischemic maximal hyperemic vasodilation increased by 29.8% and cGMP by 13.6% while asymmetrical dimethylarginine levels decreased by 21.7%. On the contrary, in group 1 patients, treated with placebo, no changes were shown in any of the variables. CONCLUSIONS: Folate and vitamin B12 treatment improved insulin resistance and endothelial dysfunction, along with decreasing homocysteine levels, in patients with metabolic syndrome, suggesting that folic acid has several beneficial effects on cardiovascular disease risk factors.     

The italian network of primary immunodeficiencies

Primary immunodeficiencies are rare diseases, characterized by an increased susceptibility to infections. Early diagnosis and appropriate treatment are critical for reducing morbidity and mortality. Given the rarity of these diseases, the awareness of these disorders by physicians is often insufficient, leading to delayed diagnosis and inappropriate treatment which are the major causes of severe long term complications. In an attempt to address and resolve these problems an Italian Network on primary immunodeficiencies has been established with the aim to increase the awareness of these disorders among physicians and to provide the best clinical assistance to all patients on the national territory.     

Prevention and treatment of poststroke depression with mirtazapine in patients with acute stroke

BACKGROUND AND OBJECTIVE: Poststroke depression is one of the most frequent complications of stroke, affecting approximately 20% to 40% of all patients. In spite of the importance of this neuropsychiatric disorder, little attention has been given to the prevention of poststroke depression. The purpose of this study was to examine whether prophylactic treatment with the antidepressant mirtazapine in patients with acute stroke given from day 1 after the incidence prevents poststroke depression. METHOD: Patients with ischemic stroke received either 30 mg mirtazapine or no antidepressant medication from day 1 after the stroke in an open, randomized study design. Data were collected from August 2001 to December 2002. Seventy patients were enrolled in the study and were reexamined on days 7, 44, 90, 180, 270, and 360 using neurologic, functional, and depression rating scales. Those poststroke patients who developed depression (DSM-IV criteria) but had been randomly assigned to the nontreatment group were given the antidepressant mirtazapine after the diagnosis of depression had been established. RESULTS: Forty percent (14/35) of the nontreated patients and only 5.7% (2/35) of the patients who were treated with mirtazapine developed poststroke depression. Altogether, 16 patients developed poststroke depression, 15 of whom remitted after initiation of treatment with mirtazapine. CONCLUSION: Mirtazapine significantly reduced the rate of poststroke depression in patients with acute stroke. The study also demonstrated that this antidepressant was highly effective in treating poststroke depression.     

Creatine diet supplement for spinal cord injury: influences on functional recovery and tissue sparing in rats

Creatine-supplemented diet significantly attenuates cortical damage after traumatic brain injury in rodents. The protective mechanism likely involves maintenance of mitochondrial homeostasis. In the present study, we used two separate contusion spinal cord injury (SCI) instruments--the NYU device and the PSI Infinite Horizon (IH) impactor--to assess the efficacy of creatine-supplemented diets on hind limb functional recovery and tissue sparing in adult rats. Rats were fed control versus 2% creatine-supplemented chow for 4-5 weeks prior to SCI (pre-fed), after which most resumed a control diet while some remained on a 2% creatine diet (pre & post-fed). Following long-term behavioral analysis (BBB), the amount of spared spinal cord tissue among the dietary regimen groups was assessed using stereology. Comparatively, both instruments caused similar amounts of gray matter damage while the NYU device rendered a greater loss of white matter, reflected in more severe hind limb functional deficits than with the IH impactor. Relative to the control fed groups injured with either instrument, none of the creatine fed animals showed improvements in hind limb function or white matter tissue sparing. Although creatine did not attenuate gray matter loss in the NYU cohort, it significantly spared gray matter in the IH cohort with pre-fed and pre & post-fed regimens. Such selective sparing of injured spinal cord gray matter with a dietary supplement yields a promising strategy to promote neuroprotection after SCI. The relationship between the efficacy of creatine and the magnitude of the insults is discussed.     

Circadian variations in expression of the trkB receptor in adult rat hippocampus

The expression of brain-derived neurotrophic factor (BDNF) in the central nervous system (CNS) and the expression of its high-affinity trkB receptor on neuron surfaces are known to depend on neuron activity. The expression of BDNF (mRNA and protein) and trkB mRNA shows circadian oscillations in rat hippocampal homogenates. We investigated circadian variations in trkB expression in specific areas of the adult rat hippocampal formation by immunohistochemistry. In sets of two experiments performed in the spring, 39 2-month-old male Wistar rats were accustomed to a 12-h light-12-h dark cycle for 2 weeks. Three animals were then sacrificed every 4 h. Forty-micrometer-thick coronal sections of hippocampal formation were obtained and processed for trkB immunohistochemistry. Cell staining intensity was assessed by image analysis of different hippocampal areas on five sections per animal. Circadian rhythmicity was evaluated by the cosinor method. Statistically significant circadian variations in trkB expression were found in dentate gyrus, entorhinal cortex, and the CA3 and hilar regions of the hippocampus, with highest expression during the first half of the dark (activity) period. These findings suggest a relationship between trkB expression and the physiological neuronal activation of wakefulness. TrkB receptor expression in the hippocampal regions studied was continuous and changes were gradual over the 24-h cycle, suggesting that more complex regulatory mechanisms also intervened.     

Biological indices of kidney involvement in personnel exposed to sevoflurane in surgical areas

BACKGROUND: Fluoride, a main metabolite, and one degradation product of sevoflurane (SEV), called Compound A, are known to cause kidney effects in experimental animals. Other than in volunteers and patients, no research is available on exposed workers. The possible effects on the kidney in workers exposed in surgical areas were studied. METHODS: Subjects exposed to SEV and nitrous oxide (N(2)O) in surgical areas (N = 61) using open (N = 25) or semi-closed (N = 36) circuits were submitted to biological monitoring. The same biological indices were determined in 43 controls also. Sevoflurane (SEVU), nitrous oxide (N(2)OU), total urinary proteins (TUP), N-acetyl-beta-D-glucosaminidase (NAGU), and glutamine synthetase (GSU) were measured in urine. RESULTS: The mean values of environmental exposure were 31.3 ppm (range 0.9-111.6 ppm) for N(2)O and 0.28 ppm (range 0-1.88 ppm) for SEV. Exposed subjects had significantly higher excretion of TUP; a higher, not significant, excretion of GSU was also observed in subjects using open circuits. A significant correlation was found in all exposed subjects between NAGU and SEVU (r = 0.303, P < 0.05), GSU and N(2)OU (r = 0.382, P < 0.01) and, especially, GSU and SEVU (r = 0.650, P < 0.001). These correlations appeared to be influenced by the use of open circuits; infact, NAGU was well correlated to N(2)OU (r = 0.770, P < 0.001) and SEVU (r = 0.863, P < 0.001); GSU to N(2)OU (r = 0.468, P < 0.05) and SEVU (r = 0.735, P < 0.001). CONCLUSIONS: Results show that no relevant effect on the kidney is present for the levels of exposure studied. Nevertheless, correlation between dose and response urinary indices supports that SEV, other than N(2)O, may influence kidney function, especially when open circuits are used.