Pharmacotherapy of emotional and behavioral symptoms associated with autism spectrum disorder in children and adolescents.

Autism spectrum disorder (ASD) is characterized by impairment in social communication and restricted patterns of behavior. Although there is no pharmacological treatment approved by the US Food and Drug Administration (FDA) for the core symptoms of ASD, there is mounting support in the literature for the management of behavioral symptoms associated with this developmental disorder, in particular, irritability and hyperactivity. Aripiprazole and risperidone are currently approved by the FDA for the treatment of irritability in youth with ASD. Though not FDA-approved, methylphenidate and guanfacine are effective for the management of hyperactivity in children with ASD. Selective serotonin reuptake inhibitors are often used in clinical practice to target anxiety and compulsions; however, there is little evidence to support its use in this population. There is a great need for further research on the safety and efficacy of existing psychotropic medications in youth with ASD, as well as the development of new treatment modalities for the core and associated behavioral symptoms.

El trastorno del espectro autista (TEA) se caracteriza por un deterioro en la comunicación social y una restricción en los patrones conductuales. Aunque la Administración de Alimentos y Fármacos de EE.UU. (FDA) no ha aprobado un tratamiento farmacológico para los síntomas centrales del TEA, en la literatura existe un soporte creciente para el manejo de los síntomas conductuales asociados con este trastorno del desarrollo, en particular la irritabilidad y la hiperactividad. Actualmente el aripiprazol y la risperidona están aprobados por la FDA para el tratamiento de la irritabilidad en jóvenes con TEA. El metilfenidato y la guanfecina son efectivos para el manejo de la hiperactividad en niños con TEA, pero no han sido aprobados por la FDA. Los inhibidores selectivos de la recaptura de serotonina se emplean con frecuencia en la práctica clínica contra la ansiedad y las compulsiones; sin embargo, existe poca evidencia que avale su empleo en esta población. En jóvenes con TEA existe una gran necesidad de futuras investigaciones acerca de la seguridad y eficacia de los fármacos psicotrópicos, como también del desarrollo de nuevas modalidades terapéuticas para los síntomas centrales y las conductas asociadas.

Le trouble du spectre de l'autisme (TSA) se caractérise par des déficits de la communication sociale et des modes comportementaux restreints. Il n'existe pas de traitement pharmacologique approuvé par la FDA américaine (Food and Drug Administration) pour les symptômes fondamentaux du TSA, mais on trouve dans la littérature un soutien croissant en faveur de la prise en charge des symptômes comportementaux associés à ce trouble du développement, en particulier l'irritabilité et l'hyperactivité. L'aripiprazole et la rispéridone sont actuellement approuvés par la FDA pour le traitement de l'irritabilité chez les jeunes ayant un TSA. Non approuvés par la FDA, le méthylphénidate et la guanfacine sont cependant efficaces pour la prise en charge de l'hyperactivité chez les enfants ayant un TSA. Les inhibiteurs sélectifs de la recapture de la sérotonine sont souvent utilisés en pratique clinique pour cibler l'anxiété et les compulsions, mais il y a peu de données en faveur de leur utilisation dans cette population. Il faudrait d'autres études sur la sécurité d'emploi et l'efficacité des traitements psychotropes existants chez les jeunes ayant un TSA, et il faudrait développer de nouvelles modalités de traitement pour les symptômes comportementaux fondamentaux et associés.

A longitudinal study of emergency medicine residents' malpractice fear and defensive medicine.

OBJECTIVES: To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents. METHODS: Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs. RESULTS: All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (+/-SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (+/-1.1) and 2.7 (+/-1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI = -8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI = -1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%). CONCLUSIONS: Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.

Pretest probability estimates: a pitfall to the clinical utility of evidence-based medicine?

OBJECTIVES: The Bayesian application of likelihood ratios has become incorporated into evidence-based medicine (EBM). This approach uses clinicians' pretest estimates of disease along with the results of diagnostic tests to generate individualized posttest disease probabilities for a given patient. To date, there is minimum scientific validation for the clinical application of this approach. This study is designed to evaluate variability in the initial step of this process, clinicians' estimates of pretest probability of disease, to assess whether this approach can be expected to yield consistent posttest disease estimates. METHODS: This cross-sectional cohort study was conducted at an urban county teaching hospital by using a sample of emergency and internal medicine residents and faculty, as well as emergency department (ED) midlevel practitioners. Participants read clinical vignettes designed to raise consideration for common ED disorders and were asked to estimate the likelihood of the suggested diagnosis based on the history and physical examination findings alone. No information about laboratory results or imaging studies was provided. RESULTS: Mean pretest probability estimates of disease ranged from 42% (95% confidence interval [95% CI] = 36.6% to 47.4%) to 77% (95% CI = 72.9% to 81.1%). The smallest difference in pretest probability magnitude for a single vignette was 70% (range 30-100%; interquartile range [IQR] 64-80%), whereas the largest was 95% (range 3-98%; IQR 30-60%). CONCLUSIONS: Wide variability in clinicians' pretest probability estimates of disease may present a possible concern about decision-making models based on Bayes' theorem, because it may ultimately yield inconsistent posttest disease estimates.

EMS activation in a cohort of critically ill patients.

The objective of this study was to examine Emergency Medical Services (EMS) activation in a cohort of critically ill patients and to evaluate whether factors such as perceived difficulty of access to emergency care, insurance status, and educational level are associated with EMS use. Patients admitted from the emergency department to the intensive care unit (ICU) of an urban county hospital for diagnoses other than acute cardiac conditions or stroke were interviewed about EMS use. Overall EMS use was found to be 52%. Primary reasons for not activating EMS were a belief that symptoms were not serious (36%) or that self-transport was faster (25%). The only factors significantly associated with bypassing EMS were car ownership, lack of health insurance, and self-decision to go to an emergency department. Sixty-eight percent of the sample reported little difficulty in accessing emergency care. In conclusion, because of a belief that symptoms were not serious or self-transport would be faster, nearly half of the critically ill patient sample did not activate EMS. Patient education about warning sign recognition for serious illnesses and about the potential benefits derived from EMS should be improved.