Gastrointestinal Symptoms in Pediatric Patients with Anxiety Disorders and Their Relationship to Selective Serotonin Reuptake Inhibitor Treatment or Placebo.

Gastrointestinal symptoms are commonly reported as adverse effects of selective serotonin reuptake inhibitors (SSRIs), the first-line pharmacologic treatment for pediatric anxiety disorders; however, the temporal course of these symptoms during treatment, although believed to be transient, has never been prospectively evaluated. Additionally, rates of gastrointestinal symptoms and functional gastrointestinal syndromes in anxious youth are poorly understood. We examined gastrointestinal symptoms in youth with anxiety disorders during a double-blind, placebo-controlled trial of escitalopram (n = 51). Then, in a separate sample of prospectively treated children and adolescents with generalized, social and/or separation anxiety disorders (n = 56), we examined the frequency of gastrointestinal symptoms based on the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) and ROME III criteria and the association of these symptoms with clinical and demographic characteristics using logistic regression. The frequency/severity of abdominal pain, diarrhea, bloating constipation or total gastrointestinal symptoms did not differ between patients receiving placebo (n = 25) or escitalopram (n = 26). However, escitalopram-treated youth had transient changes in nausea/vomiting and total upper gastrointestinal symptoms during the first two weeks of treatment. ROME III criteria for functional gastrointestinal syndromes were present in 12/56 patients (21.4%). QPGS-related functional gastrointestinal syndromes and symptoms were unrelated to treatment, treatment type, or clinical or demographic variables. Gastrointestinal symptoms are common in youth with anxiety and SSRIs produce transient-rather than sustained-gastrointestinal symptoms. Assessing gastrointestinal symptoms prior to pharmacotherapy and discussing factors that increase (or decrease) the likelihood of transient SSRI-related symptoms in youth may decrease patient uncertainty related to side effects and decrease medication-related anxiety.

Mega-analysis methods in ENIGMA: The experience of the generalized anxiety disorder working group.

The ENIGMA group on Generalized Anxiety Disorder (ENIGMA-Anxiety/GAD) is part of a broader effort to investigate anxiety disorders using imaging and genetic data across multiple sites worldwide. The group is actively conducting a mega-analysis of a large number of brain structural scans. In this process, the group was confronted with many methodological challenges related to study planning and implementation, between-country transfer of subject-level data, quality control of a considerable amount of imaging data, and choices related to statistical methods and efficient use of resources. This report summarizes the background information and rationale for the various methodological decisions, as well as the approach taken to implement them. The goal is to document the approach and help guide other research groups working with large brain imaging data sets as they develop their own analytic pipelines for mega-analyses.

Acid-sensing T cell death associated gene-8 receptor expression in panic disorder.

BACKGROUND: While disruption of acid-base homeostasis has been pathoetiologically implicated in panic disorder (PD), the mechanism by which pH imbalance is translated to panic pathophysiology is poorly understood. Recently, in a translational rodent model of PD, we reported a role of microglial acid sensing G-protein coupled receptor, T cell death associated gene-8 (TDAG8) in panic-associated behavior and physiology. However, the clinical validity of the TDAG8 receptor has not been investigated. OBJECTIVE: To assess TDAG8 in PD, we evaluated TDAG8 receptor expression in adolescents and young adults with PD and healthy comparison subjects. METHODS: Relative expression of TDAG8 mRNA was determined in peripheral blood mononuclear cells from patients with PD, and compared to expression in healthy subjects. Linear models were utilized to evaluate the relationship between TDAG8 expression and panic disorder symptom severity scale (PDSS) score as well as other potential explanatory variables (e.g., CRP, body mass index, sex, age). Models were refined based on the estimated parameter significance, evidence of omitted variable bias and Bayesian/Akaike information criteria. RESULTS: Relative to healthy comparison subjects (n=17), expression of TDAG8 mRNA was significantly increased in patients with PD (n=15) (1.60±0.65 vs. 1.01±0.50, p=0.008). TDAG8 mRNA expression predicted PD symptom severity in a fixed effect model incorporating age and sex (p=0.003). CONCLUSIONS: Collectively, our results suggest greater TDAG8 expression in patients with PD compared to healthy subjects, and directly link TDAG8 expression and the severity of the PD symptoms. Further investigation of the TDAG8 receptor in panic pathophysiology is warranted.

The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: Signal detection and validation.

BACKGROUND: In pediatric patients with anxiety disorders, existing symptom inventories are either not freely available or require extensive time and effort to administer. We sought to evaluate a brief self-report scale-the Generalized Anxiety Disorder 7-item scale (GAD-7)-in adolescents with generalized anxiety disorder (GAD). METHODS: The Pediatric Anxiety Rating Scale (PARS) and the GAD-7 were administered to youth with GAD (confirmed by structured interview). Relationships between the measures were assessed, and sensitivity and specificity was determined with regard to a global symptom severity measure (Clinical Global Impression-Severity). RESULTS: In adolescents with GAD (N = 40; mean age, 14.8 ± 2.8), PARS and GAD-7 scores strongly correlated (R = 0.65, P ≤ .001) and a main effect for symptom severity was observed (P ≤ .001). GAD-7 scores ≥11 and ≥17 represented the optimum specificity and sensitivity for detecting moderate and severe anxiety, respectively. CONCLUSIONS: The PARS and GAD-7 similarly reflect symptom severity. The GAD-7 is associated with acceptable specificity and sensitivity for detecting clinically significant anxiety symptoms. GAD-7 scores may be used to assess anxiety symptoms and to differentiate between mild and moderate GAD in adolescents, and may be more efficient than the PARS.

The Impact of COVID-19 Infection and Characterization of Long COVID in Adolescents With Anxiety Disorders: A Prospective Longitudinal Study.

While the coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted pediatric mental health, the impact of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection on youth with anxiety disorders has not been prospectively examined. Further, there are limited prospective data on post-acute sequelae COVID-19, including symptoms that constitute the long COVID neuropsychiatric syndrome. In December 2019, we began a longitudinal study of adolescents aged 12-17 years with DSM-5 primary anxiety disorders treated with either duloxetine or escitalopram. Assessments included all items from the Generalized Anxiety Disorder-7 (GAD-7) and Quick Inventory of Depressive Symptomatology (QIDS) scales at each week and a weekly clinician-rated Clinical Global Impressions-Severity (CGI-S) scale. We examined the longitudinal course of anxiety, including following laboratory-confirmed SARS-CoV-2 infection in affected adolescents. This prospective study of the longitudinal impact of COVID-19 in pediatric anxiety disorders reveals that COVID-19 is associated with worsening anxiety symptoms and a disquieting 33% worsening in syndromic severity. Further, these data raise the possibility that, in anxious youth, COVID-19 is associated with a surfeit of neuropsychiatric symptoms.

Executive Functioning in Pediatric Anxiety and Its Relationship to Selective Serotonin Reuptake Inhibitor Treatment Response: A Double-Blind, Placebo-Controlled Trial.

Objective: To characterize executive function in adolescents with generalized anxiety disorder (GAD) and its relationship to treatment. Methods: Using data from a double-blind, placebo-controlled trial of escitalopram in adolescents (N = 51) 12-17 years of age with GAD, we used the self-report version of the Behavior Rating Inventory of Executive Function (BRIEF-SR) to assess executive function, at baseline, and examined its relationship to treatment response as measured by the Pediatric Anxiety Rating Scale (PARS). Results: For all baseline subscores of the BRIEF-SR, T-scores were significantly elevated in adolescents with GAD compared to an age- and sex-matched normative healthy sample. In escitalopram-treated patients, baseline BRIEF-SR scores for Emotional Control (ß = 0.256, 95% credibility interval [CrI]: 0.367 to 0.146, p < 0.001), Working Memory (ß = 0.204, CrI: 0.2952 to 0.1134, p < 0.001), Planning/Organizing (ß = -0.223, CrI: -0.1021 to -0.3436, p = 0.004), and Task Completion (ß = -0.152, CrI: 0.075 to 0.228, p = 0.002) predicted the trajectory of improvement in PARS score over the 8-week trial. For youth who received placebo, only the Inhibit score was significantly, but weakly, associated with response trajectory (ß = -0.081, CrI: -0.0167 to -0.1461, p = 0.015). For adolescents who had clinically significant impairment in Emotional Control, Working Memory, Planning/Organizing, and Task Completion (i.e., T-score >65), the trajectory of improvement significantly differed from patients without scores in the clinically significant range. Conclusions: Taken together, these findings point to the potential value of assessing executive function in youth with anxiety disorders as one strategy for guiding treatment selection. These data suggest that executive function may predict treatment response to psychopharmacologic treatment and point to numerous avenues for further personalizing treatment.

Pediatric anxiety and daily fine particulate matter: A longitudinal study.

Daily variations in ambient fine particulate matter (PM2.5) could contribute to the morbidity of anxiety disorders in children and adolescents, but has not yet been studied longitudinally at a daily level. We tested this association using repeated weekly measures of anxiety symptom severity in a group of 23 adolescents with generalized anxiety disorder. After estimating ambient PM2.5 concentrations using a validated model, we found that increased concentrations were significantly associated with increased anxiety symptom severity and frequency two, three, and four days later. PM2.5 may be a novel, modifiable exposure that could inform population level interventions to decrease psychiatric morbidity.

An Innovative Academic Practice Model for Clinical Nursing Education During the COVID-19 Pandemic.

In March of 2020, Columbia University School of Nursing (CUSON) Masters Direct Entry (MDE) program and New York Presbyterian Hospital (NYPH) created an innovative academic partnership to address the clinical needs of students and to help alleviate the burden of surging COVID-19 cases on nurses and the health care system. Through this partnership, students were hired as nurse technicians to assist with patient care during the first wave of the COVID-19 pandemic. As a result of this enhanced relationship, a pipeline of well-qualified graduate nurses with unique skills to adapt to a rapidly changing practice environment was created. Student participants in this opportunity developed an understanding of the organizational and leadership structures of the health care institution. The understanding of organizational and leadership structures will help transform the delivery of care.

Acute neurofunctional effects of escitalopram during emotional processing in pediatric anxiety: a double-blind, placebo-controlled trial.

Anxiety disorders are the most common mental disorders in adolescents. However, only 50% of pediatric patients with anxiety disorders respond to the first-line pharmacologic treatments-selective serotonin reuptake inhibitors (SSRIs). Thus, identifying the neurofunctional targets of SSRIs and finding pretreatment or early-treatment neurofunctional markers of SSRI treatment response in this population is clinically important. We acquired pretreatment and early-treatment (2 weeks into treatment) functional magnetic resonance imaging during a continuous processing task with emotional and neutral distractors in adolescents with generalized anxiety disorder (GAD, N = 36) randomized to 8 weeks of double-blind escitalopram or placebo. Generalized psychophysiological interaction analysis was conducted to examine the functional connectivity of the amygdala while patients viewed emotional pictures. Full-factorial analysis was used to investigate the treatment effect of escitalopram on amygdala connectivity. Correlation analyses were performed to explore whether pretreatment and early (week 2) treatment-related connectivity were associated with treatment response (improvement in anxiety) at week 8. Compared to placebo, escitalopram enhanced emotional processing speed and enhanced negative right amygdala-bilateral ventromedial prefrontal cortex (vmPFC) and positive left amygdala-right angular gyrus connectivity during emotion processing. Baseline amygdala-vmPFC connectivity and escitalopram-induced increased amygdala-angular gyrus connectivity at week 2 predicted the magnitude of subsequent improvement in anxiety symptoms. These findings suggest that amygdala connectivity to hubs of the default mode network represents a target of acute SSRI treatment. Furthermore, pretreatment and early-treatment amygdala connectivity could serve as biomarkers of SSRI treatment response in adolescents with GAD. The trial registration for the study is ClinicalTrials.gov Identifier: NCT02818751.

Bridging Anxiety and Depression: A Network Approach in Anxious Adolescents.

BACKGROUND: The phenomenology and neurobiology of depressive symptoms in anxious youth is poorly understood. METHODS: Association networks of anxiety and depressive symptoms were developed in adolescents with generalized anxiety disorder (GAD; N=52, mean age: 15.4±1.6 years) who had not yet developed major depressive disorder. Community analyses were used to create consensus clusters of depressive and anxiety symptoms and to identify "bridge" symptoms between the clusters. In a subset of this sample (n=39), correlations between cortical thickness and depressive symptom severity was examined. RESULTS: Ten symptoms clustered into an anxious community, 5 clustered into a depressive community and 5 bridged the two communities: impaired schoolwork, excessive weeping, low self-esteem, disturbed appetite, and physical symptoms of depression. Patients with more depressive cluster burden had altered cortical thickness in prefrontal, inferior and medial parietal (e.g., precuneus, supramarginal) regions and had decreases in cortical thickness-age relationships in prefrontal, temporal and parietal cortices. LIMITATIONS: Data are cross-sectional and observational. Limited sample size precluded secondary analysis of comorbidities and demographics. CONCLUSIONS: In youth with GAD, a sub-set of symptoms not directly related to anxiety bridge anxiety and depression. Youth with greater depressive cluster burden had altered cortical thickness in cortical structures within the default mode and central executive networks. These alternations in cortical thickness may represent a distinct neurostructural fingerprint in anxious youth with early depressive symptoms. Finally, youth with GAD and high depressive symptoms had reduced age-cortical thickness correlations. The emergence of depressive symptoms in early GAD and cortical development may have bidirectional, neurobiological relationships.

Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial.

Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.

Acute Neurofunctional Effects of Escitalopram in Pediatric Anxiety: A Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Amygdala-ventrolateral prefrontal cortex (VLPFC) circuitry is disrupted in pediatric anxiety disorders, yet how selective serotonin reuptake inhibitors (SSRIs) affect this circuitry is unknown. We examined the impact of the SSRI escitalopram on functional connectivity (FC) within this circuit, and whether early FC changes predicted treatment response in adolescents with generalized anxiety disorder (GAD). METHOD: Resting-state functional magnetic resonance (MR) images were acquired before and after 2 weeks of treatment in 41 adolescents with GAD (12-17 years of age) who received double-blind escitalopram or placebo for 8 weeks. Change in amygdala-based whole-brain FC and anxiety severity were analyzed. RESULTS: Controlling for age, sex, and pretreatment anxiety, escitalopram increased amygdala-VLPFC connectivity compared to placebo (F = 17.79, p = .002 FWE-corrected). This early FC change predicted 76.7% of the variability in improvement trajectory in patients who received escitalopram (p < .001) but not placebo (p = .169); the predictive power of early amygdala-VLPFC FC change significantly differed between placebo and escitalopram (p = .013). Furthermore, this FC change predicted improvement better than baseline FC or clinical/demographic characteristics. Exploratory analyses of amygdala subfields' FC revealed connectivity of left basolateral amygdala (BLA) -VLPFC (F = 19.64, p < .001 FWE-corrected) and superficial amygdala-posterior cingulate cortex (F = 22.92, p = .001 FWE-corrected) were also increased by escitalopram, but only BLA-VLPFC FC predicted improvement in anxiety over 8 weeks of treatment. CONCLUSION: In adolescents with GAD, escitalopram increased amygdala-prefrontal connectivity within the first 2 weeks of treatment, and the magnitude of this change predicted subsequent clinical improvement. Early normalization of amygdala-VLPFC circuitry might represent a useful tool for identifying future treatment responders as well as a promising biomarker for drug development. CLINICAL TRIAL REGISTRATION INFORMATION: Neurofunctional Predictors of Escitalopram Treatment Response in Adolescents With Anxiety; https://www.clinicaltrials.gov/; NCT02818751.

Cortical and subcortical brain structure in generalized anxiety disorder: findings from 28 research sites in the ENIGMA-Anxiety Working Group.

The goal of this study was to compare brain structure between individuals with generalized anxiety disorder (GAD) and healthy controls. Previous studies have generated inconsistent findings, possibly due to small sample sizes, or clinical/analytic heterogeneity. To address these concerns, we combined data from 28 research sites worldwide through the ENIGMA-Anxiety Working Group, using a single, pre-registered mega-analysis. Structural magnetic resonance imaging data from children and adults (5-90 years) were processed using FreeSurfer. The main analysis included the regional and vertex-wise cortical thickness, cortical surface area, and subcortical volume as dependent variables, and GAD, age, age-squared, sex, and their interactions as independent variables. Nuisance variables included IQ, years of education, medication use, comorbidities, and global brain measures. The main analysis (1020 individuals with GAD and 2999 healthy controls) included random slopes per site and random intercepts per scanner. A secondary analysis (1112 individuals with GAD and 3282 healthy controls) included fixed slopes and random intercepts per scanner with the same variables. The main analysis showed no effect of GAD on brain structure, nor interactions involving GAD, age, or sex. The secondary analysis showed increased volume in the right ventral diencephalon in male individuals with GAD compared to male healthy controls, whereas female individuals with GAD did not differ from female healthy controls. This mega-analysis combining worldwide data showed that differences in brain structure related to GAD are small, possibly reflecting heterogeneity or those structural alterations are not a major component of its pathophysiology.

Creating library tutorials for nursing students.

This article describes one librarian's experiences with creating, promoting, and assessing online library tutorials. Tutorials were designed to provide on-demand and accessible library instruction to nursing students at Michigan State University. Topics for tutorials were chosen based on the librarian's liaison experiences and suggestions from nursing faculty. The tutorials were created using Camtasia and required the application of several tools and techniques. Tutorials were promoted through Web pages, the ANGEL course management system, blog posts, librarian interactions, e-mails, and more. In order to assess the tutorials' perceived effectiveness, feedback was gathered using a short survey. Future plans for the nursing tutorials project are also discussed.

Escitalopram in Adolescents With Generalized Anxiety Disorder: A Double-Blind, Randomized, Placebo-Controlled Study.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat pediatric anxiety disorders, including generalized anxiety disorder (GAD); however, their efficacy and tolerability are difficult to predict. This study evaluated the efficacy and tolerability of escitalopram in adolescents with GAD (DSM-IV-TR) and the impact of variants in HTR2A and serotonin transporter (SLC6A4) genes and cytochrome P450 2C19 (CYP2C19) phenotypes on response as well as CYP2C19 phenotype on escitalopram pharmacokinetics from February 2015 through November 2018. METHODS: Patients were treated with escitalopram (forced titration to 15 mg/d, then flexible titration to 20 mg/d) (n = 26, mean ± SD age: 14.8 ± 1.7 years) or placebo (n = 25, mean ± SD age: 14.9 ± 1.6 years) for 8 weeks. Outcomes were the change in scores on the Pediatric Anxiety Rating Scale (PARS) and Clinical Global Impressions (CGI) scales as well as vital signs and adverse events. Plasma escitalopram and desmethylcitalopram area under the curve during 24 hours (AUC0-24) and maximum concentration (Cmax) were determined and compared across CYP2C19 phenotypes. RESULTS: Escitalopram was superior to placebo for mean ± SD baseline-to-endpoint change in PARS (-8.65 ± 1.3 vs -3.52 ± 1.1, P = .005) and CGI scores, and increasing CYP2C19 metabolism was associated with decreases in escitalopram Cmax (P = .07) and AUC0-24 (P < .05). Vital signs, corrected QT interval, and adverse events were similar in patients who received escitalopram and placebo. CONCLUSIONS: Escitalopram reduces anxiety symptoms, and pharmacogenetics variables influence the trajectory and magnitude of improvement. Variation in CYP2C19 metabolism accounts for significant differences in escitalopram pharmacokinetics, raising the possibility that CYP2C19 phenotype should be considered when prescribing escitalopram. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02818751.

Greater Dynamic and Lower Static Functional Brain Connectivity Prospectively Predict Placebo Response in Pediatric Generalized Anxiety Disorder.

Objectives: Placebo response is one of the most significant barriers to detecting treatment effects in pediatric (and adult) clinical trials focusing on affective and anxiety disorders. We sought to identify neurofunctional predictors of placebo response in adolescents with generalized anxiety disorder (GAD) by examining dynamic and static functional brain connectivity. Methods: Before randomization to blinded placebo, adolescents, aged 12-17 years, with GAD (N = 25) underwent resting state functional magnetic resonance imaging. Whole brain voxelwise correlation analyses were used to determine the relationship between change in anxiety symptoms from baseline to week 8 and seed-based dynamic and static functional connectivity maps of regions in the salience and ventral attention networks (amygdala, dorsal anterior cingulate cortex [dACC], and ventrolateral prefrontal cortex [VLPFC]). Results: Greater dynamic functional connectivity variability in amygdala, dACC, VLPFC, and regions within salience, default mode, and frontoparietal networks was associated with greater placebo response. Lower static functional connectivity between amygdala and dorsolateral prefrontal cortex, amygdala and medial prefrontal cortex, dACC and posterior cingulate cortex and greater static functional connectivity between VLPFC and inferior parietal lobule were associated with greater placebo response. Conclusion: Placebo response is associated with a distinct dynamic and static connectivity fingerprint characterized by "variable" dynamic but "weak" static connectivity in the salience, default mode, frontoparietal, and ventral attention networks. These data provide granular evidence of how circuit-based biotypes mechanistically relate to placebo response. Finding biosignatures that predict placebo response is critically important in clinical psychopharmacology and to improve our ability to detect medication-placebo differences in clinical trials.

Transforming nursing curricula for a global community.

With nurses and midwives providing the majority of health care globally, nursing education in all countries must prepare students for broader responsibilities to move the agenda forward for equitable care and universal health coverage. Columbia University School of Nursing developed and implemented a vibrant approach to curriculum transformation that included a new didactic course followed by a program of global clinical experiences to expand students' learning environments in global health. Program planning included defining learning objectives, mobilizing support within the school, establishing new sites, recruiting and preparing students, overseeing of students with host institutions, and evaluating the program. A total of twenty-four students were placed over five sites for a six-week credit-bearing global clinical experience. Students had varied clinical experiences with new understandings of the reality of health disparities. Host sites expressed a commitment to have students return in the next year, and all students stated that they would chose a global experience again. This innovation provides a transformative addition to nursing education with a deepened understanding of health disparities and nursing roles in different health systems. It strengthens the school's network of nursing and midwifery educators and opens doors for new exchanges.

Antidepressant Prescribing by Pediatricians: A Mixed-Methods Analysis.

Among pediatricians, perceived knowledge of efficacy, tolerability, dosing, and side effects of antidepressants represent significant sources of variability in the use of these medications in youth with depressive and anxiety disorders. Importantly, the qualitative factors that relate to varying levels of comfort with antidepressants and willingness to prescribe are poorly understood. Using a mixed-methods approach, in-depth interviews were conducted with community-based and academic medical center-based pediatricians (N = 14). Interviews were audio recorded and iteratively coded; themes were then generated using inductive thematic analysis. The relationship between demographic factors, knowledge of antidepressants, dosing, and side effects, as well as prescribing likelihood scores for depressive disorders, anxiety disorders or co-morbid anxiety and depressive disorders, were evaluated using mixed models. Pediatricians reported antidepressants to be effective and well-tolerated. However, the likelihood of individual physicians initiating an antidepressant was significantly lower for anxiety disorders relative to depressive disorders with similar functional impairment. Pediatricians considered symptom severity/functional impairment, age and the availability of psychotherapy as they considered prescribing antidepressants to individual patients. Antidepressant choice was related to the physician׳s perceived knowledge and comfort with a particular antidepressant, financial factors, and the disorder-specific evidence base for that particular medication and consultation with mental health practitioners. Pediatricians noted similar efficacy and tolerability profiles for antidepressants in youth with depressive disorders and anxiety disorders, but tended to utilize "therapy first" approaches for anxiety disorders relative to depressive disorders. Parental and family factors that influenced prescribing of antidepressants by pediatricians included parental ambivalence, family-related dysfunction and impairment secondary to the child׳s psychopathology as well as the child׳s psychosocial milieu. Pediatricians consider patient- and family-specific challenges when choosing prescribing antidepressant medications and are, in general, less likely to prescribe antidepressants for youth with anxiety disorders compared to youth with depressive disorders. The lower likelihood of prescribing antidepressants for anxious youth is not related to perception of the efficacy or tolerability, but rather to a perception that anxiety disorders are less impairing and more appropriately managed with psychotherapy.

Efficacy of a topical antimicrobial-anti-inflammatory combination in the treatment of pyotraumatic dermatitis in dogs.

Abstract The efficacy of a topical antimicrobial-corticosteroid combination for the treatment of pyotraumatic dermatitis in dogs, was investigated. An open-ended, double-blind, randomized trial design was used. Forty dogs were divided into two vehicle-treated control groups and three treatment groups. The dogs in the respective treatment groups were treated with emulsions of either neomycin, prednisolone or a neomycin-prednisolone combination. Lesions were shaved and cleaned before treatment commenced, whereafter the allocated emulsion was applied twice daily for 7 days. Lesions were evaluated for surface area and degree of pruritus and inflammation. Skin biopsy specimens for bacterial culture and histopathological examination were taken. Staphylococcus aureus was the predominant organism isolated. The antimicrobial-corticosteroid combination emulsion resulted in the quickest recovery, followed by the antimicrobial drug alone. Prednisolone alone gave significantly poorer results. Dogs in all groups, including the control groups, recovered completely within 7 days. Résumé L'efficacité d'un topique associant antimicrobien et corticoide dans le traitement de la dematite pyotraumatique du chien a étéétudiée. Une étude randomisée, ouverte, en double aveugle, a été réalisée. Quarante chiens ont été divisés en deux groupes controles traités seulement à l'aide du véhicule et trois groupes traités respectivement soit par l'émulsion de néomycine seule, de prednisolone seule ou par l'association néomycine-prednisolone. Les lésions ont été tondues et nettoyées avant la mise en place du traitement, après quoi l'émulsion a été appliquée deux fois par jour pour sept jours. Les lésions ont étéévaluées quant à leur extension et le degré de prurit et d'inflammation. Des biopsies cutanées ont été réalisées pour culture bactériologique et examen histopathologique. Le principal agent isolé est le staphyloccoque doré. L'émulsion associant antimicrobien et corticoide a entrainé la guérison la plus rapide, suivi par l'antimicrobien utilisé seul. La prednisolone utilisée seule a donné les plus mauvais résultats. Les chiens de tous les groupes, y compris les groupes controles, ont été complètement guéris en sept jours. [Schroeder, H., Swan, G. E., Berry, W. L., Pearson, J. Efficacy of a topical antimicrobial-anti-inflammatory combination in the treatment of pyotraumatic dermatitis in dogs (Efficatité d'un topique associant antimicrobien et antiinflammatoire dans le traitement de la dermatite pyotraumatique du chien). Veterinary Dermatology 1966; 7: 163-170.] Résumén Se investigó la eficacia de un preparado tópico combinado antimicrobiano-corticoesteroideo en el tratamiento de la dermatitis piotraumática canina. Se utilizó un ensayo de final abierto, doble-ciego y al azar. Cuarenta perros se dividieron en dos grupos control tratados con un vehiculador y tres grupos a los que se aplicó el tratamiento. Los perros en los respectivos grupos de tratamiento fueron tratados con emulsiónes de en neomicina o prednisolona o con una combinación de neomicina-prednisolona. Se afeitaron y lavaron las lesiones antes del inicio del tratamiento, y después se aplicó la emulsión asignada dos veces al día durante 7 días. Se evaluaron las lesiones según el área afectada y el grado de prurito e inflamación. Se tomaron biopsias cutáneas para cultivo bacteriano y examen histopatológico. Staphylococcus aureus fue el organismo que predominó en los aislamiento. La emulsión con combinación de antibiótico-corticoesteroide fue la que cursó con una recuperación más rápida, seguido del antimicrobiano solo. El tratamiento unicamente con prednisolona dio resultados significativamente peores. Los perros de todos los grupos, incluyendo los de los grupos control, se recuperaron dentro de los 7 días de tratamiento. [Schroeder, H., Swan, G. E., Berry, W. L., Pearson, J. Efficacy of a topical antimicrobial-anti-inflammatory combination in the treatment of pyotraumatic dermatitis in dogs (Eficacia de un tratamiento antimicrobiano-antiinflamatorio topico combinado en la dermatitis piotraumatica canina). Veterinary Dermatology 1966; 7: 163-170.] Zusammenfassung Die Wirksamkeit einer lokalen Antibiotikum-Kortikoid-Kombination für die Behandlung der pyotraumatischen Dermatitis des Hundes wurde untersucht. Es wurde das Modell einer offenen, randomisierten Doppelblindstudie verwendet. 40 Hunde wurden in zwei Vehikel-behandelte Kontroll-und drei Behandlungsgruppen eingeteilt. Die Hunde der drei Behandlungsgruppen wurden mit Emulsionen von Neomycin, Prednisolon oder einer Neomycin-Prednisolon-Kombination behandelt. Die Hautveränderungen wurden geschoren und gereinigt bevor die Behandlung begann. Dann wurde die entsprechende Emulsion zweimal täglich sieben Tage lang aufgetragen. Die Hautveränderungen wurden nach Größe der Oberfläche und Grad des Juckreizes und der Entzündung beurteilt. Es wurden Hautbioptate für bakteriologische Kulturen und histopathologische Untersuchungen entnommen. Als vorherrschender Keim wurde Staphylococcus aureus isoliert. Die Antibiotikum-Kortikoid-Kombination brachte die schnellste Abheilung, gefolgt von der ausschließlich antibiotischen Therapie. Prednisolon als Monotherapie ergab signifikant schlechtere Resultate. Die Hunde in alien Gruppen, einschließlich der Kontrollgruppen, gesundeten innerhalb von 7 Tagen vollständig. [Schroeder, H., Swan, G.E., Berry, W.L., Pearson, J. Efficacy of a topical antimicrobial-antiinflammatory combination in the treatment of pyotraumatic dermatitis in dogs (Wirksamkeit einer lokalen antimikrobiellen-entzündungshemmenden Kombination bei der Behandlung der pyotraumatischen Dermatitis des Hundes). Veterinary Dermatology 1996; 7: 163-170.].