Primary Care Management of Children with Attention-Deficit/Hyperactivity Disorder Appears More Assertive Following Brief Psychiatric Intervention Compared with Single Session Consultation.

Objectives: We examined primary care providers' (PCPs') management of attention-deficit/hyperactivity disorder (ADHD) during and following families' participation in two arms of the Children's ADHD Telemental Health Treatment Study. We hypothesized that more intensive treatment during the trial would show an "after-effect" with more assertive PCPs' management during short term follow-up. Methods: We conducted a pragmatic follow-up of PCPs' management of children with ADHD who had been randomized to two service delivery models. In the Direct Service Model, psychiatrists provided six sessions over 22 weeks of pharmacotherapy followed by behavior training. In the Consultation Model, psychiatrists provided a single-session consultation and made treatment recommendations to PCPs who implemented these recommendations at their discretion for 22 weeks. At the end of the trial, referring PCPs for both service delivery models resumed ADHD treatment for 10 weeks. We performed intent-to-treat analysis using all 223 original participants. We applied linear regression models on continuous outcomes, Poisson regression models on count outcomes, and logistic regression models to binary outcomes. Missing data were addressed through imputations. Results: Participants in the Direct Service Model had more ADHD visits than those in the Consultation Model across the full 32 weeks (mean = 7.05 visits vs. 3.36 visits; adjusted rate ratio = 2.1 [1.85-2.38]; p < 0.0001). During follow-up, participants in the DSM were more likely to be taking ADHD-related medications (82% vs. 61%; adjusted odds ratio = 2.44 [1.24-4.81], p = 0.01). At 32 weeks, participants in the Direct Service Model had higher stimulant dosages (adjusted difference = 5.64 [0.12-11.15] mg; p = 0.046). Conclusion: These results from a pragmatic follow-up of a randomized trial suggest an "after-effect" for brief intensive treatment in the Direct Service Model on the short term follow-up management of ADHD in primary care.

Recent advances in the treatment of childhood obesity.

The multidisciplinary, four-phase approach, which includes PSMF, BEM, and MPE is successful in treating mild, moderate, and severe degrees of childhood and adolescent obesity. The MPE program is appropriate for use with PSMF and BEM due to its progressive nature, variety of options, and moderate intensity level. In addition, the MPE program is of sufficient intensity, duration, and frequency to promote a significant increase in estimated aerobic capacity (VO2max) and to promote the maintenance of lean body mass and resting energy expenditure. The short-term intervention of PSMF, BEM, and MPE also results in an improvement in body composition, lipid profiles, and IGF-1 and T3 levels. The 1200-calorie balanced diet, MPE, and BEM also provide a successful method of weight maintenance in children and adolescents, as indicated by further improvement in body composition at the 26-week measure. Additional studies are needed to assess the contribution of exercise to the maintenance of lean body mass and resting energy expenditure in obese children and adolescents. In addition, it will be important to assess long-term weight maintenance in obese adolescents who effectively lose weight in this multidisciplinary program.

Hydroxyethyl starch versus albumin in cardiopulmonary bypass prime solutions.

To compare hydroxyethyl starch (HES) with 25% albumin, 20 patients undergoing aortocoronary bypass were randomized into two groups: 10 received 1,000 ml of HES and 10 received 200 ml of 25% albumin in a bloodless priming solution for cardiopulmonary bypass (CPB). Platelet aggregation, antithrombin III, reptilase time, fibrinogen, plasminogen, fluid requirements, and hemodynamics were monitored. Platelet aggregation was abnormal in both groups, being relatively poorer in the albumin group. Both groups exhibited below normal antithrombin III and plasminogen levels, with significantly lower antithrombin III levels noted in the HES group postoperatively (41.9 +/- 11.8% versus 56.6 +/- 9.9%; p = 0.006). Compared with the albumin group, the HES group had slightly, but not significantly, elevated liver function test results, total volume replacement (9,173 +/- 2,046 ml versus 8,522 +/- 1,192 ml; p = 0.057), packed red blood cell usage (227 +/- 284 ml versus 75 +/- 168 ml; p = 0.066), and chest tube drainage (599 +/- 253 ml versus 454 +/- 174 ml; p = 0.144). In the HES group, 5% albumin requirement was greater (386 +/- 466 ml versus 50 +/- 158 ml; p = 0.002) and percent increase of body weight was higher (5.2 +/- 0.8% versus 2.3 +/- 0.6%; p = 0.05) postoperatively. Postoperative weight increase and colloid requirements plus trends toward larger blood loss and blood transfusions indicate possible further evaluation. However, results suggest that HES is a safe additive to priming solutions. Compared with albumin, HES has comparable changes in coagulation variables and slightly less severe derangements in platelet aggregation.

The vessels of the stria vascularis: quantitative comparison of three rodent species.

The stria vascularis (SV) was quantitatively compared in three species commonly used in auditory research: guinea pig, mouse and gerbil. Measurements were obtained for surface area, cross-sectional area, length, width and thickness of SV. Surface area and length were proportional to the overall size of the cochlea in each species, but there was no significant difference between species in mean cross-sectional area. In guinea pig and mouse, there was no significant difference in thickness (endolymphatic surface to spiral ligament) and a similar pattern was observed for width (Reissner's membrane to spiral prominence): the width of SV increased from the apical end to a point 80% of the distance from the apex, then decreased to the basal end of SV. The thickness of gerbil SV was significantly less (P less than 0.001) and there was less of a gradient in width as compared to guinea pig and mouse. The vessels of SV were compared in terms of vascular density (vessels per unit area), rbc density (red blood cells per unit area), R/V (rbc density/vascular density), inter-vessel spacing and vessel diameter. Highly significant (P less than 0.001) differences between species were found in vascular density, RBC density and vessel diameter, but there were no differences between species for R/V or inter-vessel spacing. The results of this study may reflect differences in the metabolic requirements of SV among different species.

Neural basis for regulation of cochlear blood flow: peptidergic and adrenergic innervation of the spiral modiolar artery of the guinea pig.

The spiral modiolar artery is the terminal artery in the cochlea, and as such is expected to play a major role in the control of cochlear blood flow. In this study, we examined the distribution of adrenergic and peptidergic nerve fibres on the spiral modiolar artery of the guinea pig using histofluorescence and immunofluorescence techniques. The spiral modiolar artery was dissected from the modiolus so that the entire length of the vessel and its branches, could be observed. Noradrenaline was identified using the glyoxylic acid histofluorescence technique. The presence of the vasoactive peptides substance P, calcitonin gene-related peptide (CGRP), neuropeptide Y (NPY) and vasoactive intestinal polypeptide (VIP), was investigated using antibodies against these peptides. Each putative transmitter tested yielded labelled nerve fibres throughout the length of the spiral modiolar artery and its branches. Double-labelling experiments confirmed that CGRP and substance P are contained in the same fibres but that VIP and substance P appear to be contained in different populations of fibres. These results establish that nerve fibres containing vasoactive peptides and noradrenaline supply the spiral modiolar artery and suggest that they are involved in the regulation of cochlear blood flow.

Potentiation of noise induced threshold shifts and hair cell loss by carbon monoxide.

Previous studies have determined that severe systemic hypoxia disrupts cochlear function acutely, but have suggested that augmentation of cochlear perfusion may successfully protect cochlear function under all but the most profound hypoxic treatments. In the current study we report on the chronic effects of simultaneous exposures to noise and carbon monoxide on pure tone thresholds and hair cell survival in rats. Following initial threshold determination, rats received acute exposure to carbon monoxide, noise, or both agents concurrently. Thresholds were evaluated 2-4 and 6-8 weeks later. The data show that carbon monoxide alone does not affect either auditory thresholds or compromise hair cells at the light microscopic level. The noise exposure alone produced variable, but quite limited permanent threshold shifts which were related to the power spectrum of the broad band noise that was employed. Hair cell loss was restricted to the basal turn of the cochlea. Simultaneous exposure to carbon monoxide and noise induced large threshold shifts at all frequencies studied, but the effect was greatest at the highest test frequency; an effect not consistent with the noise power spectrum. Widespread hair cell loss persisted over fully half of the basilar membrane in the most severely affected rat. Outer hair cells appear to be particularly vulnerable. Carbon monoxide plus noise did not appear to preferentially disrupt a particular row of outer hair cells. These data complement existing evidence that hyperoxia can mitigate against noise induced injury and reinforce the view that some types of noise induced damage may result from metabolic insufficiencies.

Differences in the distribution of F-actin in outer hair cells along the organ of Corti.

There is evidence of differences in the structure, innervation and physiological responses between outer hair cells (OHCs) of the basal and apical turns of the mammalian cochlea. In this study we have used rhodamine-labelled phalloidin to investigate the differential distribution of F-actin in OHCs along the organ of Corti of the guinea pig. Isolated OHCs and surface preparations and cryosections of the organ of Corti were studied. F-actin was observed in stereocilia and the cuticular plate of all OHCs. In addition, some OHCs had a network of F-actin extending from the cuticular plate towards the nucleus. This infracuticular network was observed in most OHCs of the apical cochlear turns but was not seen in any OHCs of the basal turn. These microstructural differences between OHCs of the base and apex could be related to differences in OHC function between the apical and basal portions of the cochlea.

Species differences in the distribution of infracuticular F-actin in outer hair cells of the cochlea.

The distribution of filamentous actin (F-actin) in outer hair cells has been examined in several mammalian species using tetramethylrhodamine phalloidin, a specific marker for F-actin. The stereocilia and cuticular plates of the OHC in all species examined (pigmented guinea pig, hooded rat, chinchilla and squirrel monkey) contained F-actin; however, an infracuticular network of F-actin was present in OHC of the apical turns of the guinea pig cochlea but could not be identified in any other species examined.

Experimental cochleo-vestibular deafferentation with NaCl.

An animal experiment was performed to evaluate structural and ultrastructural changes in the inner ear as a result of placing 10-12 crystals of reagent grade sodium chloride (NaCl) in the vestibule. Chinchillas were sacrificed 8 and 24 hours after treatment and the cochlear and vestibular tissues were examined by light microscopy and scanning electron microscopy. Inner ear pathology consisted of extensive degenerative changes in morphology of all sensory structures of the inner ear. The extent of these pathological changes supports the idea of eventual total deafferentation of the inner ear.

Chemical labyrinthectomy with NaCl. Menière's disease treatment with deposition of NaCl in the vestibule.

Thirteen individuals with unilateral Menière's disease were chosen for experimental chemical labyrinthectomy. All subjects suffered from frequent attacks of disabling vertigo and had mean pure-tone thresholds greater than 50 dB in the affected ear. The surgical procedure was similar to stapedectomy; after removal of the stapes, several crystals of NaCl were placed in the vestibule which was then covered with a vein graft. Postoperative recovery was rapid, allowing patients to be discharged 4-6 days after surgery. Of the 13 subjects, all reported complete relief from vertigo. Tinnitus was cured in 7 subjects, greatly improved in 4 and unchanged in 2. Most patients complaining of aural fullness preoperatively reported relief from this symptom following surgery. To date (up to 4 years post-surgery) none of the subjects has shown any significant alteration in audiologic or vestibular function in the contralateral ear. The ease and safety of this procedure make it an attractive method when cochleovestibular deafferentation is indicated.

Development of cochlear-wall implants for electrical stimulation of the auditory nerve.

The aim of these experiments was to investigate the use of titanium implants for anchorage of stimulating electrodes or other clinical or experimental devices in the bony wall of the cochlea. Twenty-six cylindrical titanium fixtures, 0.6 mm in diameter, were inserted into holes drilled in the otic capsule in 8 ears in 5 nonhuman primates and then examined for stability after periods of 2 months to 2 years. Following sacrifice, the bone-metal interfaces were examined microscopically. Fourteen of the implants were firmly fixed in the bone, 6 were loosely fixed and 6 came out. Poor fixation was associated with infection in the middle ear. In uninfected ears, 90% of the implants were stable. The implants were not osseointegrated in the classic sense, but in stable implants, direct bone contact covering 5 to 60% of the titanium oxide surface of the implant shaft was observed.

Training of child and adolescent psychiatry fellows in autism and intellectual disability.

Patients with autism spectrum disorders and intellectual disability can be clinically complex and often have limited access to psychiatric care. Because little is known about post-graduate clinical education in autism spectrum disorder and intellectual disability, we surveyed training directors of child and adolescent psychiatry fellowship programs. On average, child and adolescent psychiatry directors reported lectures of 3 and 4 h per year in autism spectrum disorder and intellectual disability, respectively. Training directors commonly reported that trainees see 1-5 patients with autism spectrum disorder or intellectual disability per year for outpatient pharmacological management and inpatient treatment. Overall, 43% of directors endorsed the need for additional resources for training in autism spectrum disorder and intellectual disability, which, coupled with low didactic and clinical exposure, suggests that current training is inadequate.

Psychopharmacology of schizophrenia in children and adolescents.

The past 5 five years have seen major advances in the diagnosis and treatment of schizophrenia in children and adolescents. This article, reviews the clinical and diagnostic characteristics of schizophrenia in youth with an eye toward recent findings. This article also provides a more extensive review and update of the psychopharmacology of early-onset schizophrenia.

Trauma and diverse child populations.

It has been estimated that as many as two-thirds of American youth experience a potentially life-threatening event before 18 years of age and that half have experienced multiple potentially traumatic events. Race, ethnicity, and culture influence the frequency and nature of these traumas and also the ways in which children react to traumatic events. The authors discuss the varied influences of cultural background on these reactions to trauma, the varying presentations of diverse children experiencing troubling reactions, and the need to provide treatment to children and their families in a fashion that is culturally sensitive and acceptable to diverse families.

Mission statements.

With the move towards a far more business-oriented NHS, Lynne Carlisle looks at a private company whose efforts at staff communication could provide a useful lesson to health service managers.

Auditory dysfunction and cochlear vascular injury following trimethyltin exposure in the guinea pig.

Trimethyltin chloride (TMT) produces an auditory impairment in the rat due, presumably, to cochlear injury. The loss is unusual in that it persists for several weeks, but ultimately resolves at least at low to middle frequencies. Recovery of high frequency auditory loss is less predictable. Given this pattern of injury and recovery plus the known ability of TMT to impair oxidative phosphorylation, it was hypothesized that TMT would damage the stria vascularis which is the most metabolically active area and a structure containing one of the primary vascular networks in the cochlea. Trimethyltin chloride ototoxicity was evaluated in guinea pigs treated with the toxicant and then subjected to weekly tests of the auditory brainstem response evoked by tonal stimuli. A high frequency impairment was found which tended to improve within the first 2 weeks after exposure. Subjects were euthanized 6 weeks after TMT for histopathological study of the cochlea. At that time point most subjects showed full functional recovery. Subjects showed significant changes both in the number of outer hair cells and in the condition of the stria vascularis. Outer hair cell loss was observed in a restricted portion of the most basal turn of the cochlea which is responsible for encoding high frequency sound despite recovery of function in some animals. A very marked increase in the diameter of the vessels of the stria vascularis was observed along with signs of atrophy in the stria vascularis. Enlarged vessel diameters were particularly apparent in the apical and middle turns of the cochlea, which did not show significant hair cell loss. The data confirm that TMT does produce both hair cell damage and vascular pathology in the cochlea.

Endocochlear potential generation is associated with intercellular communication in the stria vascularis: structural analysis in the viable dominant spotting mouse mutant.

Deafness in the viable dominant spotting mouse mutant is due to a primary defect of the stria vascularis which results in absence of the positive endocochlear potential in scala media. Endocochlear potentials were measured and the structure of stria vascularis of mutants with potentials close to zero was compared with that in normal littermate controls by use of morphometric methods. The stria vascularis was significantly thinner in mutants. Marginal cells were not significantly different from controls in terms of volume density or intramembrane particle density but the network density of tight junctions was significantly reduced in the mutants. A virtual absence of gap junctions between basal cells and marginal or intermediate cells was observed, but intramembrane particle density and junctional complexes between adjacent basal cells were not different from controls. The volume density of basal cells was significantly greater in mutants. Intermediate cells accounted for a significantly smaller volume density of the stria vascularis in mutants and had a lower density of intramembrane particles than controls. Melanocytes were not identified in the stria vascularis of mutants. These results suggest that communication between marginal, intermediate and basal cells might be important to the normal function of the stria vascularis.