Psychopharmacologic Treatment of Schizophrenia in Adolescents and Children.

An increasing number of antipsychotic medications have demonstrated efficacy in randomized placebo-controlled trials in the treatment of children and adolescents with schizophrenia. This review summarizes and synthesizes relevant antipsychotic medication studies, with particular emphasis on second-generation agents, and discusses other clinical considerations that may influence medication selection. With the exception of clozapine demonstrating superior efficacy in the improvement of psychotic symptoms in treatment-resistant patients, many antipsychotic agents have been shown to be similarly efficacious, including first-generation medications. Consideration of the side-effect profile, which can differ substantially from medication to medication, is essential when choosing treatment options.

A Focused Review on the Treatment of Pediatric Patients with Atypical Antipsychotics.

OBJECTIVES: The use of atypical antipsychotic medications in pediatric patients has become more prevalent in recent years. The purpose of this review is to provide a clinically relevant update of recent selected key publications regarding the use of atypical antipsychotics in this population. METHODS: Studies reviewed included randomized, double-blind, placebo-controlled medication trials conducted within the past 5 years. A PubMed search was conducted for each of the 11 second-generation antipsychotic medications currently approved by the Food and Drug Administration for use in the United States: clozapine, risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, paliperidone, asenapine, iloperidone, lurasidone, and cariprazine. Trials published in English with subjects 18 years of age and younger were included in this review. Additional studies, chosen for their significance to clinical practice, were also included at the discretion of the authors. RESULTS: This review demonstrates that more empiric data are available regarding both the acute efficacy and, to a lesser extent, the longer-term efficacy and tolerability for several of the considered antipsychotic medications. The clinical conditions for which these medications have been studied include schizophrenia, bipolar disorder, Tourette's disorder, and autism spectrum disorder. They have also been used as an adjunctive treatment for disruptive behavior disorders with aggression, which have not responded to treatment with stimulants. CONCLUSION: Evidence regarding the efficacy and tolerability of antipsychotic medications for mental health disorders in children and adolescents has expanded exponentially in recent years. However, more information is needed so that evidence-based comparisons between medications can be made. In the future, data enabling the selection of medications based upon individual patient characteristics could potentially lead to greater efficacy and efficiency in treating what are frequently debilitating medical conditions. Maladaptive aggression in children, often treated with antipsychotics, is one such area in which there is a dearth of actual information available to the clinician. It is to be hoped that additional, longer-term studies of these medications will further inform evidence-based practice in clinical settings.

The role of media in preventing student suicides: A Hong Kong experience.

INTRODUCTION: In view of the surge of student suicides in March 2016, a large-scale media involvement was engaged to minimize copycat effects and to extensively spread more preventive information. METHODS: Trend differences between student suicides in overall as well as youth suicides between 2003 and 2016 were examined. Impacts of media involvement were examined as to the changes of their intensities in reporting student suicides in different manners. Local polynomial smoothing method was used to estimate the intensities throughout the study period. RESULTS: The intensity of students' suicides has been slowly increasing since 2006, which was in contrast to the decreasing trend of overall suicide intensity. After our engagement with the media, acute descriptive-reporting in student suicide news has sharply dropped and remained low since then, whereas preventive-reporting has increased sharply in March and April 2016, but dropped back to normal afterwards. The higher intensity of preventive-reporting seemed to have a protective effect on student suicide. LIMITATIONS: Data of student suicides in 2016 were substantially extracted from the local news, which may not contain complete information. The analyses suggested, but could not confirm, a causal relationship between the changes of student suicide news-reporting and the incidents of suicides themselves. CONCLUSIONS: The recent surge of student suicides in Hong Kong was statistically abnormal. Media engagement has changed local suicide news-reporting to become more preventive, which could have contributed to the drop of student suicides. It is essential to sustain the media's coverage of preventive reporting to maintain its enduring effect.

Suicide by gassing in Hong Kong 2005-2013: Emerging trends and characteristics of suicide by helium inhalation.

BACKGROUND: Increased use of lethal suicide methods can have a profound impact on overall suicide incidence; the epidemic of suicide by barbecue charcoal gas poisoning in some East Asian countries is a recent example. There have been concerns about recent rises in suicide using gases in some Western countries. METHODS: We investigated suicide by gassing in Hong Kong (2005-2013) using Coroner's files data. The characteristics were compared between suicide by helium inhalation, charcoal gas poisoning, and other methods. RESULTS: About one sixth (1407/8445, 16.7%) of all suicides used gases. Charcoal-burning suicides constituted the majority (97.5%) of them but showed a reduction over the 9-year period (-33%). Helium suicide was not recorded in 2005-2010 but increased from one in 2011 to three in 2012 and 11 in 2013, accounting for 1.2% of all suicides in 2013. Similar to the profile of charcoal-burning suicides, helium suicides were younger and more likely to have debt problem and less likely to receive psychiatric treatment than other suicides. Internet involvement related to the method was found in one third of cases of helium suicide. LIMITATIONS: The small number of helium suicides (n=15) limits the power to examine their characteristics. CONCLUSION: Suicide by charcoal burning showed a downward trend whilst there was an alarming increase in helium suicide in Hong Kong. Public health measures to prevent an epidemic of helium suicide similar to that of charcoal-burning suicide may include close monitoring of trend, responsible media reporting, and restricting online information about and access to this method.

"Geography of suicide in Hong Kong: spatial patterning, and socioeconomic correlates and inequalities".

Past urban research on Western nations tends to show high suicide rates in inner city and socioeconomically deprived areas. However, little is known about geographic variations in suicide in non-Western cities. We used Bayesian hierarchical models to estimate smoothed standardised mortality ratios (2005-2010) for suicide in people aged 10 years or above in each geographic unit in Hong Kong at two levels, i.e. large street block (n = 1639; median population = 1860) and small tertiary planning unit group (n = 204; median population = 14,850). We further analysed their associations with a range of area socioeconomic characteristics and a deprivation index. The "city centre" of Hong Kong, a generally non-deprived area, showed mostly below average suicide rates. However, there were high rates concentrating in some socioeconomically deprived, densely populated areas, including some inner city areas, across the city. Males had greater geographic variations in rates than females, except the elderly group. The use of smaller geographic units revealed finer detailed suicide distribution than the use of larger units, and showed that suicide rates were associated with indicators of socioeconomic deprivation (population with non-professional jobs and low median household income), and social fragmentation (proportions of unmarried adults and divorced/separated adults), but not with Gini coefficient. Sex/age groups had different associations with suicide rates. Areas in the most deprived quintile had a suicide rate more than two times higher than the least deprived. The association between suicide and deprivation was stronger in males than females and more marked in the younger populations compared to the elderly. The spatial distribution of suicide in Hong Kong showed distinct patterning and a stronger association with income compared to findings from Western countries. Suicide prevention strategies should consider tackling the marked socioeconomic gradient in suicide and high risk in young and middle-aged males living in deprived areas.

The perichondrium in auricular melanomas: implications for surgical management.

OBJECTIVE: Auricular melanomas are now considered less aggressive than originally thought, but those located on the conchal bowl and posterior ear can create particular challenges for reconstruction. Given the paucity of cases, no standardized recommendations exist for tumor resection. In this study, we provide a pathologic basis in support of conservative tumor resection along the perichondrial plane. STUDY DESIGN: Case series with review of pathology and medical records. SETTING: Academic tertiary referral center. SUBJECTS AND METHODS: We retrospectively reviewed all ear melanomas from the archives of Yale Dermatopathology and Surgical Pathology laboratories between 1987 and 2009. Cases of melanoma in situ or malignant melanoma of the earlobe were excluded. RESULTS: Fifty-one cases were included in the study. Patients' age ranged from 26 to 94 years, with a mean (SD) of 58.9 (17.5) years. The male to female ratio was of 5.4:1. Melanomas were distributed similarly between right and left ears, at 52% and 48%, respectively. The most common location was the helix (74.5%). The Breslow depth ranged from 0.19 to 11 mm, with a mean (SD) of 1.64 (1.6) mm. The lesion-perichondrium distance ranged from 0 to 8.12 mm, with a mean (SD) of 1.11 (1.1) mm. Notably, the perichondrium was not invaded in any of the cases. CONCLUSION: Based on the histopathologic characteristics of our cases, the perichondrium can be considered an effective barrier and therefore a biological plane for wide local resection in some cases of auricular melanomas, allowing surgeons to achieve negative margins without necessarily sacrificing underlying cartilage.

'Bovine' aortic arch - a marker for thoracic aortic disease.

OBJECTIVES: Very few studies have addressed the clinical significance of 'bovine' aortic arch (BA). We sought to determine whether BA is associated with thoracic aortic disease, including thoracic aortic aneurysm, aortic dissection, aortic rupture, and accelerated aortic growth rate. METHODS: We retrospectively reviewed CT and/or MRI scans of 612 patients with thoracic aortic disease and 844 patients without thoracic aortic disease to determine BA prevalence. In patients with thoracic aortic disease, we reviewed hospital records to determine growth rate, prevalence of dissection and rupture, and accuracy of radiology reports in citing BA. RESULTS: 26.3% of the patients with thoracic aortic disease had concomitant BA, compared to 16.4% of the patients without thoracic aortic disease (p < 0.001). There was no association between BA and prevalence of dissection or rupture (p = 0.38 and p = 0.56, respectively). The aortic expansion rate was 0.29 cm/year in the BA group and 0.09 cm/year in the non-BA group (p = 0.004). Radiology reports cited BA in only 16.1% of the affected patients. CONCLUSIONS: (1) BA is significantly more common in patients with thoracic aortic disease than in the general population. (2) Aortas expand more rapidly in the setting of BA. (3) Radiology reports often overlook BA. (4) BA should not be considered a 'normal' anatomic variant.

Evaluation of liver fibrosis by investigation of hepatic parenchymal perfusion using contrast-enhanced ultrasound: an animal study.

PURPOSE: To investigate the value of assessing the hepatic parenchymal perfusion in contrast-enhanced ultrasound (CEUS) for evaluating liver fibrosis, using an animal model. METHODS: Seventy Sprague-Dawley rats were divided into experimental (n = 35) and control (n = 35) groups. In the experimental group, liver fibrosis was induced by intraperitoneal injection of carbon tetrachloride. CEUS of the liver was performed at a 2-week interval for 14 weeks. Signal intensity of liver parenchyma was analyzed with time-intensity curves. Histologic examination of liver specimens of the animals was performed to assess the fibrosis stage. RESULTS: The peak signal intensity of hepatic parenchymal perfusion in stage 2-3 fibrosis was significantly lower than that in stage 0-1. The time to peak intensity of hepatic parenchymal perfusion was significantly longer in the experimental group than the control group, and in the stage 3 fibrosis than in stages 0-2 fibrosis. Using time to peak intensity of hepatic parenchymal perfusion to distinguish stage 3 fibrosis and stages 0-2 fibrosis, the optimum cutoff was 75,000 milliseconds with the sensitivity and specificity of 67% and 78%, respectively. CONCLUSIONS: This animal study showed that CEUS has the potential to be a complementary imaging tool in the evaluation of liver fibrosis.

Vertically oval corneas in a child with holoprosencephaly.

Vertically oval-shaped corneas are an uncommon ophthalmic finding. The normal human cornea has an oval shape, but is wider in the horizontal dimension. The etiology of vertically oval corneas is unclear. This report presents a case of bilateral vertical oval corneas in a male infant with semilobar holoprosencephaly.

An analysis of national target groups for monovalent 2009 pandemic influenza vaccine and trivalent seasonal influenza vaccines in 2009-10 and 2010-11.

BACKGROUND: Vaccination is generally considered to be the best primary prevention measure against influenza virus infection. Many countries encourage specific target groups of people to undertake vaccination, often with financial subsidies or a priority list. To understand differential patterns of national target groups for influenza vaccination before, during and after the 2009 influenza pandemic, we reviewed and analyzed the country-specific policies in the corresponding time periods. METHODS: Information on prioritized groups targeted to receive seasonal and pandemic influenza vaccines was derived from a multi-step internet search of official health department websites, press releases, media sources and academic journal articles. We assessed the frequency and consistency of targeting 20 different groups within populations which are associated with age, underlying medical conditions, role or occupations among different countries and vaccines. Information on subsidies provided to specific target groups was also extracted. RESULTS: We analyzed target groups for 33 (seasonal 2009 and 2009-10 vaccines), 72 (monovalent pandemic 2009-10 vaccine) and 34 (seasonal 2010 and 2010-11 vaccines) countries. In 2009-10, the elderly, those with chronic illness and health care workers were common targets for the seasonal vaccine. Comparatively, the elderly, care home residents and workers, animal contacts and close contacts were less frequently targeted to receive the pandemic vaccine. Pregnant women, obese persons, essential community workers and health care workers, however, were more commonly targeted. After the pandemic, pregnant women, obese persons, health care and care home workers, and close contacts were more commonly targeted to receive the seasonal vaccine compared to 2009-10, showing continued influence from the pandemic. Many of the countries provided free vaccines, partial subsidies, reimbursements or national health insurance coverage to specific target groups and over one-third of the countries offered universal subsidy regarding the pandemic vaccine. There was also some inconsistency between countries in target groups. CONCLUSIONS: Differences in target groups between countries may reflect variable objectives as well as uncertainties regarding the transmission dynamics, severity and age-specific immunity against influenza viruses before and after vaccination. Clarification on these points is essential to elucidate optimal and object-oriented vaccination strategies.

A semi-quantitative approach to compare high-sensitivity power Doppler sonography and conventional power Doppler sonography in the assessment of thyroid vascularity.

BACKGROUND: Ultrasound is a useful imaging tool in the assessment of thyroid glands, and Doppler ultrasound helps in the evaluation of thyroid vascularity. This study was undertaken to evaluate the difference in the thyroid vascularity demonstrated on the state-of-the-art high-sensitivity power Doppler sonography (HSPDS) and the conventional power Doppler sonography (PDS), and to investigate the feasibility of using a customized algorithm with image-processing software for semi-quantitative assessment of thyroid vascularity. METHODS: A total of 25 healthy volunteers were included in the study, and each subject had two thyroid ultrasound examinations with HSPDS and PDS, respectively. High sensitivity and conventional power Doppler sonograms of the thyroid glands were taken and recorded. To evaluate the vascularity of thyroid lobes quantitatively, a customized algorithm using the software Matlab was developed and used to analyze the ultrasound images. The vascularity of thyroid lobe (i.e., region of interest, ROI) was expressed as the vascular index (VI), which is the ratio of the number of color pixels to the total number of pixels within the ROI. RESULTS: Results showed that thyroid vascularity was detected in all thyroid lobes on both HSPDS and PDS. The mean VI of the thyroid lobes on HSPDS (right lobe, 0.31 +/- 0.08; left lobe, 0.32 +/- 0.07) was significantly higher than on PDS (right lobe, 0.18 +/- 0.09; left lobe, 0.16 +/- 0.08) (p < 0.05). There was no significant difference in the VI between the right and left thyroid lobes (p >0.05). On HSPDS, 96% of the thyroid lobes showed a VI <0.5, while 96% of thyroid lobes had a VI <0.3 on PDS. CONCLUSIONS: HSPDS is more sensitive than PDS in the detection of thyroid vascularity. The developed algorithm can quantify the color pixels on power Doppler sonograms, which is useful for objective assessment of thyroid vascularity.

The miR-200 family inhibits epithelial-mesenchymal transition and cancer cell migration by direct targeting of E-cadherin transcriptional repressors ZEB1 and ZEB2.

MicroRNAs are small non-coding RNA molecules that can regulate gene expression by interacting with multiple mRNAs and inducing either translation suppression or degradation of mRNA. Recently, several miRNAs were identified as either promoters or suppressors of metastasis. However, it is unclear in which step(s) of the multistep metastatic cascade these miRNAs play a defined functional role. To study the functional importance of miRNAs in epithelial-mesenchymal transition (EMT), a process thought to initiate metastasis by enhancing the motility of tumor cells, we used a well established in vitro EMT assay: transforming growth factor-beta-induced EMT in NMuMG murine mammary epithelial cells. We found that members of the miR-200 family, organized as two clusters in the genome, were repressed during EMT. Overexpression of each miRNA individually or as clusters in NMuMG cells hindered EMT by enhancing E-cadherin expression through direct targeting of ZEB1 and ZEB2, which encode transcriptional repressors of E-cadherin. In the 4TO7 mouse carcinoma cell line, which expresses low levels of endogenous E-cadherin and displays a mesenchymal phenotype, ectopic expression of the miR-200 family miRNAs significantly increased E-cadherin expression and altered cell morphology to an epithelial phenotype. Furthermore, ectopic expression of each miR-200 miRNA cluster significantly reduced the in vitro motility of 4TO7 cells in migration assays. These results suggested that loss of expression of the miR-200 family members may play a critical role in the repression of E-cadherin by ZEB1 and ZEB2 during EMT, thereby enhancing migration and invasion during cancer progression.