The Texas Children's Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Attention-Deficit/Hyperactivity Disorder

OBJECTIVES: Expert consensus methodology was used to develop evidence-based, consensually agreed-upon medication treatment algorithms for attention-deficit/hyperactivity disorder (ADHD) in the public mental health sector. Although treatment algorithms for adult mental disorders have been developed, this represents one of the first attempts to develop similar algorithms for childhood mental disorders. Although these algorithms were developed initially for the public sector, the goals of this approach are to increase the uniformity of treatment and improve the clinical outcomes of children and adolescents with ADHD in a variety of treatment settings. METHOD: A consensus conference of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families was convened to develop evidence-based consensus algorithms for the pharmacotherapy of childhood ADHD. After a series of presentations of current research evidence and panel discussion, the consensus panel met and drafted the algorithms along with guidelines for implementation. RESULTS: The panel developed consensually agreed-upon algorithms for ADHD with and without specific comorbid disorders. The algorithms consist of systematic strategies for psychopharmacological interventions and tactics to ensure successful implementation of the strategies. While the algorithms focused on the medication management of ADHD, the conference emphasized that psychosocial treatments are often a critical component of the overall management of ADHD. CONCLUSIONS: Medication algorithms for ADHD can be developed with consensus. A companion article will discuss the implementation of these algorithms.     

Observations on CT differentiation of pleural and peritoneal fluid

Distinguishing juxtadiaphragmatic pleural and peritoneal fluid by computed tomography (CT) is sometimes difficult. We evaluated the distribution of fluid in 50 consecutive patients with pleural effusion or ascites or both. Juxtadiaphragmatic pleural fluid was nearly always found posteromedially, whereas peritoneal fluid typically distributed lateral to the liver or spleen or both in the posterior upper abdomen. This difference in distribution is easily explained by pertinent upper abdominal peritoneal and extraperitoneal anatomy. On the basis of distribution alone, pleural and peritoneal fluid could be differentiated in 47 of 50 patients. Difficulty was encountered with loculated pleural fluid and with ascites having a large left subphrenic component; in those situations, previously reported CT signs may be helpful.     

Variability of post-void residual urine volume in the elderly

Residual urine volume, though clinically important as a diagnostic tool, is reported to be variable and unreliable. Variability was examined among 14 geriatric patients, mean age 77 years. Residual urine was measured by ultrasound at three different times of day on each of two visits separated by 2–4 weeks. Results were examined by analysis of variance. Mean residual urine was 154 ml. Between-patient variability was large [standard deviation (SD) 246 ml]. There was no significant difference between values in men and women, nor between visits. Within-patient variability was large because of a large systematic variation with time of day (SD 128 ml), with greatest volumes in the early morning. The inherent, random variability of the measurement was much smaller than this (SD 44 ml). If the physiological factors causing the temporal variation could be controlled more reproducible measurements would be possible.     

Screening for cephalosporin-resistant Streptococcus pneumoniae with the Kirby-Bauer disk susceptibility test.

Kirby-Bauer disk susceptibility tests with five standard cephalosporin disks were performed on 23 penicillin-resistant Streptococcus pneumoniae isolates for which ceftriaxone MICs were 0.125 to 4 micrograms/ml. Cefuroxime disk inhibition zone diameters distinguished clearly isolates for which ceftriaxone MICs were > or = 2 micrograms/ml from more susceptible strains, whereas cephalothin, ceftizoxime, cefotaxime, and ceftriaxone disks distinguished these isolates less clearly than the cefuroxime disk did.     

An electron microscopic study of Aujeszky's disease

Summary Sixteen calves were killed at intervals during the course of the disease from 48 h onwards after subcutaneous infection with Aujeszky's disease virus. Ultrastructural changes were evident in the spinal ganglia from 84 h post-inoculation and the intercostal nerves from 96 h post-inoculation. The cytopathic changes in the spinal ganglia consisted of neuronal degeneration, neuronophagia, Schwann cell degeneration and cellular infiltration. The neuronophagic nodule was invariably contained within an intact sheath of satellite cells. Changes in the intercostal nerves were less dramatic but cellular infiltration was frequently seen and occasional Schwann cells were degenerate. In the terminal stages of the disease demyelination was rarely observed. In the ganglion virus was invariably seen in degenerating neurons and occasionally in Schwann cells and monocytes. Satellite cells were rarely infected even when ensheathing an infected neuron. Extra-cellular virus was not observed in ganglia or nerves. Schwann cells and monocytes in the nerves were occasionally infected. Virus particles were seen in the axoplasm both in the ganglion and in the entire length of the nerve. The particles in the axoplasm varied in morphology; thus unenveloped and enveloped particles, and particles in the process of acquiring an envelope were recognised. It was concluded that the neural pathway of Aujeszky's disease virus is probablyvia the axoplasm.     

Tactile function of educable mentally retarded children.

The tactile perception ability of 29 seven-and eight-year-old educable mentally retarded children was evaluated by using the tactile perception portions of the Southern California Sensory Integration Tests. The children were also observed for tactile defensive behavior. Compared to normal children of the same age (as reported in normative data), this sample of children was significantly inferior in manual form, finger identification, graphesthesia, and perception of simultaneous stimuli, but not in the localization of single stimuli. During the testing, 62 percent showed tactile defensive behavior. The role of tactile perception in the development of symbolic communications is reviewed.