Autism in context 2: Assessment,intervention and services in Australia

Continuing from part 1, part 2 of the autism spectrum disorders review explores clinical practice and service delivery aspects of autism spectrum disorders including current assessment approaches in Australia, family‐centred models of care, and key service structure and delivery issues. Treatments including behavioural interventions, established and emergent medication, and complementary and alternative therapies are discussed. The key role of paediatricians as both individual child and family care providers and advocates, as well as agents of service reform in Australia, is evident. Much still needs to be done.     

Self-injurious behaviours are associated with alterations in the somatosensory system in children with autism spectrum disorder

Children with autism spectrum disorder (ASD) frequently engage in self-injurious behaviours, often in the absence of reporting pain. Previous research suggests that altered pain sensitivity and repeated exposure to noxious stimuli are associated with morphological changes in somatosensory and limbic cortices. Further evidence from postmortem studies with self-injurious adults has indicated alterations in the structure and organization of the temporal lobes; however, the effect of self-injurious behaviour on cortical development in children with ASD has not yet been determined. Thirty children and adolescents (mean age = 10.6 ± 2.5 years; range 7–15 years; 29 males) with a clinical diagnosis of ASD and 30 typically developing children (N = 30, mean age = 10.7 ± 2.5 years; range 7–15 years, 26 males) underwent T1-weighted magnetic resonance and diffusion tensor imaging. No between-group differences were seen in cerebral volume, surface area or cortical thickness. Within the ASD group, self-injury scores negatively correlated with thickness in the right superior parietal lobule t = 6.3, p < 0.0001, bilateral primary somatosensory cortices (SI) (right: t = 4.4, p = 0.02; left: t = 4.48, p = 0.004) and the volume of the left ventroposterior (VP) nucleus of the thalamus (r = ?0.52, p = 0.008). Based on these findings, we performed an atlas-based region-of-interest diffusion tensor imaging analysis between SI and the VP nucleus and found that children who engaged in self-injury had significantly lower fractional anisotropy (r = ?0.4, p = 0.04) and higher mean diffusivity (r = 0.5, p = 0.03) values in the territory of the left posterior limb of the internal capsule. Additionally, greater incidence of self-injury was associated with increased radial diffusivity values in bilateral posterior limbs of the internal capsule (left: r = 0.5, p = 0.02; right: r = 0.5, p = 0.009) and corona radiata (left: r = 0.6, p = 0.005; right: r = 0.5, p = 0.009). Results indicate that self-injury is related to alterations in somatosensory cortical and subcortical regions and their supporting white-matter pathways. Findings could reflect use-dependent plasticity in the somatosensory system or disrupted brain development that could serve as a risk marker for self-injury.     

Smoothelin and caldesmon are reliable markers for distinguishing muscularis propria from desmoplasia: a critical distinction for accurate staging colorectal adenocarcinoma

An accurate distinction between deep muscularis propria invasion versus subserosal invasion by colonic adenocarcinoma is essential for the accurate staging of cancer and subsequent optimal patient management. However, problems may arise in pathologic staging when extensive desmoplasia blurs the junction between deep muscularis propria and subserosal fibroadipose tissue. To address this issue, forty-three (43) cases of colonic adenocarcinoma resections from 2007-2009 at The Methodist Hospital in Houston, TX were reviewed. These cases were selected to address possible challenges in differentiating deep muscularis propria invasion from superficial subserosal invasion based on H&E staining alone. Immunohistochemical staining using smooth muscle actin (SMA), smoothelin, and caldesmon were performed on 51 cases: 8 cases of pT1 tumors (used mainly as control); 12 pT2 tumors; and 31 pT3 tumors. All 51 (100%) had diffuse, strong (3+) immunoreactivity for caldesmon and smoothelin in the muscularis propria with a granular cytoplasmic staining pattern. However, the desmoplastic areas of these tumors, composed of spindled fibroblasts and myofibroblasts, showed negative immunostaining for caldesmon and smoothelin (0/35). SMA strongly stained the muscularis propria and weakly (1+) or moderately (2+) stained the spindled fibroblasts in the desmoplastic areas (the latter presumably because of myofibroblastic differentiation). Compared to SMA, caldesmon and smoothelin are more specific stains that allow better delineation of the muscularis propria from the desmoplastic stromal reaction which provides a critical aide for proper staging of colonic adenocarcinoma and subsequent patient care.