Adapting evidence-based clinical practice guidelines for people with attention deficit hyperactivity disorder in Saudi Arabia: process and outputs of a national initiative.

BACKGROUND: We recently adapted the published National Institute for Health and Care Excellence (NICE) Attention deficit hyperactivity disorder (ADHD) diagnosis and management guideline to the Saudi Arabian context. It has been postulated that adaptation of evidence-based clinical practice guidelines to the local healthcare context rather than de-novo development will improve their adoption and implementation without imposing a significant burden on resources. The objective of this paper is to describe the adaptation process methodology utilized for the generation of the first national guideline for management of people with ADHD in Saudi Arabia. METHODS: We used the KSU-Modified-ADAPTE methodology for the guideline adaptation process. We describe the full process in detail including the three phases of set-up, adaptation, and finalization. The process was conducted by a multidisciplinary guideline adaptation group in addition to an external review for the clinical content and methodology. RESULTS: The group adapted ten main categories of recommendations from one source CPG (NICE). The recommendations include: (i) service organisation and training, (ii) recognition, identification and referral, (iii) diagnosis, (iv) support, (v) managing ADHD, (vi) dietary advice, (vii) medication, (viii) maintenance and monitoring, (ix) adherence to treatment, and (x) review of medication and discontinuation. Several implementation tools were compiled and developed to enhance implementability including a clinical algorithm, quality measures, coding system, medication tables, translations, patient information, and online resources. CONCLUSIONS: The finalized clinical practice guideline provides healthcare providers with applicable evidence-based guidance for the management of people with ADHD in Saudi Arabia. The project also demonstrated the effectiveness of KSU-Modified-ADAPTE, and emphasized the value of a collaborative clinical and methodological expert group for adaptation of national guidelines.

The impact of vitamin D food fortification and health outcomes in children: a systematic review and meta-regression.

OBJECTIVE: Vitamin D (vitD) deficiency is a global childhood health problem. Food fortification is a promising strategy to curb vitD deficiency. We aimed to assess the effectiveness of utilizing vitD fortification in staple foods to improve 25hydroxyvitamin D (25(OH)D) concentration and to reduce the prevalence of vitD deficiency among healthy children. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating the use of vitD fortified food products compared to no fortification among healthy children aged 1-18 years old. We searched Medline, Embase, Global Health, and Cochrane (CENTRAL) databases from database inception until May 2019. Independently, six reviewers in pairs screened titles and abstracts, assessed the full text for eligibility, and performed data extraction and quality assessment. The primary outcome is the impact of fortification on 25(OH)D concentration. The secondary outcomes included the impact of fortification on the prevalence of vitD deficiency, school performance, cognitive function, school absences, infection rate, hospital admission length, and compliance with fortified food product consumption. RESULTS: We identified 2229 articles. After assessing eligibility, 20 RCTs met the inclusion criteria. The eligible RCTs assessed the fortification of milk, cereal, juice, bread, yogurt, and cheese compared with no fortification. All RCTs, except for three, had a low risk of bias. Food fortification improved 25(OH)D concentration by a mean difference (MD) of 15.51 nmol/L (95% confidence interval (CI) 6.28, 24.74; I2 = 99%), which resulted in a mean increase of 3 nmol/l for every 100 IU of vitD, when adjusted for baseline 25(OH)D concentration and country latitude. Additionally, the prevalence of vitD deficiency decreased by a risk ratio of 0.53 (95% CI 0.41, 0.69; I2 = 95%), and cognitive function improved by a MD of 1.22 intelligence quotient (IQ) points (95% CI 0.65, 1.79; I2 = 0%). The overall evidence quality was high. CONCLUSION: VitD food fortification is an effective way to improve 25(OH)D concentration, prevent vitD deficiency, and improve IQ levels. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017057631.

The Relationship between Sleep and Cognitive Performance in Autism Spectrum Disorder (ASD): A Pilot Study.

BACKGROUND: Sleep concerns are common in children with autism spectrum disorders (ASD). The impact of poor sleep on cognitive performance in ASD children is not well-established. We investigated the possible correlation between sleep quality in ASD children and cognitive performance. The Cambridge Neuropsychological Test Automated Battery (CANTAB) was administered to examine specific components of non-verbal cognition. METHODS: The Children's Sleep Habits Questionnaire (CSHQ) and actigraphy-measured data from 18 children with diagnosis of ASD were evaluated. Motor planning task (MOT), simple reaction time task (SRT) and the intradimensional/extradimensional shift (IED) of CANTAB were administered. RESULTS: ASD good sleeper (ASD-GS) showed significant better response time for SRT task as compared to ASD poor sleeper (ASD-PS) based on CSHQ score. Parameters of bedtime resistance (r = 0.531, p = 0.023), sleep anxiety (r = 0.474, p = 0.047) from CSHQ and actigrapgy dependent (wake after sleep onset (WASO) (r = 0.430, p = 0.024) were significantly correlate with response time of SRT task. CONCLUSION: We conclude that some signs reflecting the presence of poor sleep in ASD correlate with various aspects of motor output on non-verbal performance tasks. The question is raised whether poor sleep in non-complaining persons with autism should be treated.

Correlation between Autism Treatment Evaluation Checklist (ATEC) and Childhood Autism Rating Scale (CARS) in the evaluation of autism spectrum disorder.

Identification of health issues in children with autism spectrum disorder (ASD) is paramount to provide appropriate care and interventions. The Autism Treatment Evaluation Checklist (ATEC) is the one of the few current measures that assesses ASD-associated health problems thus informing intervention decisions. However, little research has been conducted to compare ATEC with other more recognized measures such as the Childhood Autism Rating Scale (CARS). It is unclear whether these two scales can be used interchangeably or whether high scores on one scale are comparable to the other. The aim of the current study was to compare the correlation between ATEC and CARS in the evaluation of children with ASD. This prospective cross-sectional study was conducted at the Developmental and Behavioural Paediatrics Outpatient Clinic at King Saud University, King Khalid University hospital (KKUH) in Riyadh, Saudi Arabia. Forty children with a prior diagnosis of ASD seen during the period from October 2014 to August 2015 were included. Each child was assessed using ATEC and CARS independently during the same visit. The Spearman's rank correlation coefficient test was used. The overall mean CARS score was 34.125 ± 5.535 (range from 22 to 42) and the mean ATEC score was 40.95± 9.1934.1 (range from 24 to 72). The Spearman's rank correlation coefficient (rs) was 0.015, and p-value was 0.926 (> 0.05) meaning that there was no correlation between CARS and ATEC scales. No correlation between CARS and ATEC scale was found. ATEC should not be used instead of CARS to delineate co-morbid health issues. Future studies are needed to assess the validity of ATEC and its correlation with other well established scales.

Developmental regression in autism spectrum disorder.

The occurrence of developmental regression in autism spectrum disorder (ASD) is one of the most puzzling phenomena of this disorder. A little is known about the nature and mechanism of developmental regression in ASD. About one-third of young children with ASD lose some skills during the preschool period, usually speech, but sometimes also nonverbal communication, social or play skills are also affected. There is a lot of evidence suggesting that most children who demonstrate regression also had previous, subtle, developmental differences. It is difficult to predict the prognosis of autistic children with developmental regression. It seems that the earlier development of social, language, and attachment behaviors followed by regression does not predict the later recovery of skills or better developmental outcomes. The underlying mechanisms that lead to regression in autism are unknown. The role of subclinical epilepsy in the developmental regression of children with autism remains unclear.

Type 1 pleuropulmonary blastoma in a 3-year-old male with a cystic lung mass.

Pleuropulmonary blastoma (PPB) is a rare and aggressive intrathoracic malignant tumor that can be associated with cystic lung lesions in children. This neoplasm is histologically characterized by primitive blastoma and a malignant mesenchymal stroma. The authors describe a 3-year-old boy who presented with a history of fever and cough. Radiological imaging demonstrated a large cystic lesion replacing the left lower lobe. The patient underwent thoracoscopic resection of the lesion. Interestingly, the histopathology demonstrated a type 1 PPB. Type 1 lesions are usually observed in young infants, whereas older infants and children tend to present with type 2 or 3 PPB, which carry a poorer prognosis and higher risk of recurrence. Thus, the presence of large or peripherally based lung cysts should raise the suspicion of PPB. Resection is warranted for all such lesions.