Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms include the ...stimulants methylphenidate and amphetamine; nonstimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics.
To assess the effects of pharmacological treatments for ADHD on ADHD symptoms and tic severity in children with ADHD and comorbid tic disorders.
We searched CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009), CINAHL (1982 to July 2009), PsycINFO (1806 to July Week 4 2009) and BIOSIS Previews (1985 to July 2009). Dissertation Abstracts (searched via Dissertaation Express), and the metaRegister of Controlled Trials were searched (30 July 2009).
We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel group and cross-over study designs.
Two authors independently extracted data using standardized forms.
We included a total of eight randomized controlled studies in the review but were unable to combine any of these in meta-analysis. Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. All treatments, with the exception of deprenyl, were efficacious in treating symptoms of ADHD. Tic symptoms improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and the combination of methylphenidate and clonidine. Fear of worsening tics limited dose increases of methylphenidate in one study. High dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited.
Methylphenidate, clonidine, guanfacine, desipramine and atomoxetine appear to reduce ADHD symptoms in children with tics. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may nonetheless exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine is effective for both tics and ADHD in children, safety concerns will likely continue to limit its use in this population.
Prévalence et incidence de la démence à corps de Lewy : revue systématique du sujet.
Contexte:
Les études de population sur sa prévalence et son incidence sont essentielles à la compréhension du ...fardeau social de la démence à corps de Lewy (DCL).
Méthodologie:
Nous avons identifié les publications sur l’incidence et/ou la prévalence de la DCL dans les bases de données MEDLINE et EMBASE. Nous avons recherché des études supplémentaires dans les articles et les revues systématiques antérieures cités à titre de références. Deux évaluateurs ont examiné tous les résumés et les évaluations de textes intégraux et l’extraction des données, et ils ont évalué la qualité des publications.
Résultats:
Vingt-deux études ont été incluses. Les taux d’incidence allaient de 0,5 à 1,6 par 1 000 personnes-années. La DCL constituait 3,2 à 7,1% de tous les cas de démence dans les études sur l’incidence. Les estimés de prévalence ponctuelle et par période allaient de 0,02 à 63,5 par 1 000 personnes. Des taux croissants de prévalence étaient rapportés en association avec l’augmentation de l’âge des sujets. La DCL était responsable de 0,3 à 24,4% de tous les cas de démence dans les études de prévalence.
Conclusions:
La DCL est plus fréquente avec l’âge et constitue environ 5% de tous les cas de démence dans les populations plus âgées.
This clinical guideline provides recommendations for nonpharmacological treatments for tic disorders. We conducted a systematic literature search for clinical trials on the treatment of tics. One ...evidence-based review (including 30 studies) and 3 studies on behavioural interventions, 3 studies on deep brain stimulation (DBS), and 3 studies on transcranial magnetic stimulation (TMS) met our inclusion criteria. Based on this evidence, we have made strong recommendations for the use of habit reversal therapy and exposure and response prevention, preferably embedded within a supportive, psychoeducational program, and with the option to combine either of these approaches with pharmacotherapy. Although evidence exists for the effcacy of DBS, the quality of this evidence is poor and the risks and burdens of the procedure are fnely balanced with the perceived benefts. Our recommendation is that this intervention continues to be considered an experimental treatment for severe, medically refractory tics that have imposed severe limitations on quality of life. We recommend that the procedure should only be performed within the context of research studies and by physicians expert in DBS programming and in the management of tics. There is no evidence to support the use of TMS in the treatment of tics. However, the procedure is associated with a low rate of known complications and could continue to be evaluated within research protocols. The recommendations we provide are based on current knowledge, and further studies may result in their revision in future.
Abstract
Background
Mild behavioral impairment (MBI) is a syndrome characterized by later life onset, persistent neuropsychiatric symptoms (NPS) in non‐demented older adults. MBI can co‐occur with ...Mild Cognitive Impairment (MCI) and has a range of neurodegenerative etiologies including Alzheimer’s disease (AD), Cerebrovascular Disease (CVD), and Parkinson’s disease (PD). MBI is associated with poorer cognitive and psychosocial function and an increased risk of developing dementia. Thus, we aimed to explore the structural neural correlates of MBI, specifically in the regions known to be associated with cognitive impairment (i.e., corticolimbic and frontal‐executive circuits), across multiple neurodegenerative diagnoses from the Ontario Neurodegenerative Disease Research Initiative (ONDRI).
Method
We assessed the association between MBI and brain structural alterations via T1‐weighted imaging in three groups with Montreal Cognitive Assessment scores ³19: individuals with MCI (due to AD; n = 37), CVD (n = 129), and PD (n = 127). NPS scores were derived from the Neuropsychiatric Inventory (NPI‐Q) domains, and categorized as NPS+ (i.e., NPI score>0); and NPS‐ (NPI score = 0). We selected regions of interest from the corticolimbic and frontal‐executive circuits to measure brain structure using cortical thickness and subcortical volume. Partial correlation, corrected for age, sex, and education was used to assess the association between MBI and brain structural alterations.
Result
Overall, apathy, depression, and anxiety, which map to the decreased motivation and emotional dysregulation MBI domains, had a high prevalence across all the groups. In the brain‐MBI association analysis, apathy was associated with decreased thickness of the l‐rostral middle frontal, r‐superior temporal, and frontal pole in the PD and CVD (but not MCI) groups. Anxiety was associated with decreased volume of the right hippocampus and amygdala in the MCI group, but not CVD or PD (FDR p< 0.05). No structural correlates were found for depression.
Conclusion
Our findings provide evidence of a specific association between apathy and reduced efficiency of the frontal‐executive system in individuals with PD and CVD. In addition, the well‐established AD corticolimbic atrophy patterns (e.g., hippocampus and amygdala) seen in MCI are prominent in the presence of anxiety. Overall, the relatively distinct brain‐MBI associations across neurodegenerative disorders suggest that pathological substrates may alter MBI neural correlates.
Phosphodiesterase type 5 (PDE 5) inhibitors are widely used in the treatment of erectile dysfunction. However, the results on the cerebral vasculature are unknown. Several cases of intraparenchymal ...hemorrhage in the setting of PDE 5 inhibitor use have been reported. The effect of these agents on the risk of arteriovenous malformation (AVM) hemorrhage is speculative. This report illustrates a possible association between tadalafil (Cialis, Lilly ICOS, Indianapolis, IN), a new long-acting PDE 5 inhibitor, and AVM hemorrhage during coitus. A 59-year-old male suffered a coital intraparenchymal hemorrhage after premedication with tadalafil. Angiography and magnetic resonance imaging demonstrated an underlying right temporoparital AVM. The AVM was excised, and the patient made an uneventful recovery. AVMs are felt to be dynamic lesions that evolve in response to changes in blood flow. Repeated use of PDE 5 inhibitors could induce changes in an AVM that would make it more likely to hemorrhage, particularly in the setting of additional stress from coitus and elevated blood pressure. The potential for risk of devastating neurovascular complications related to PDE 5 inhibitors should be monitored.
INTRODUCTION
Cerebral small vessel disease (SVD) is common in patients with cognitive impairment and neurodegenerative diseases such as Alzheimer's and Parkinson's. This study investigated the burden ...of magnetic resonance imaging (MRI)‐based markers of SVD in patients with neurodegenerative diseases as a function of rare genetic variant carrier status.
METHODS
The Ontario Neurodegenerative Disease Research Initiative study included 520 participants, recruited from 14 tertiary care centers, diagnosed with various neurodegenerative diseases and determined the carrier status of rare non‐synonymous variants in five genes (ABCC6, COL4A1/COL4A2, NOTCH3/HTRA1).
RESULTS
NOTCH3/HTRA1 were found to significantly influence SVD neuroimaging outcomes; however, the mechanisms by which these variants contribute to disease progression or worsen clinical correlates are not yet understood.
DISCUSSION
Further studies are needed to develop genetic and imaging neurovascular markers to enhance our understanding of their potential contribution to neurodegenerative diseases.
Purpose The purpose of this study is to determine the effect of a 3- vs. 1-day antibiotic regimen on the rate of surgical site infection (SSI) in patients undergoing orthognathic surgery at the ...Department of Oral and Maxillofacial Surgery in Halifax, Nova Scotia, Canada. Patients and Methods A prospective, randomized controlled trial (RCT) was conducted. All patients received 1 day of intravenous (IV) antibiotics following surgery. The patients were then randomly distributed into groups that received 2 days of additional antibiotics (Group A) or placebo (Group B). The primary outcome measured was the presence of SSI. The operating surgeon; concomitant extraction of teeth; surgical procedures performed; duration of intermaxillary fixation (IMF) and length of hospital stay were analyzed for an effect on SSI. Patients were followed for 1 year following surgery to identify SSIs that may have been diagnosed outside of our hospital. Results The trial started with 288 patients, and 117 patients were lost to follow-up. Statistical analyses were ultimately performed on those 171 patients who were adherent to the study medication regimen. Group A (n=86) and B (n=85) SSI rates were 7.0 and 17.6% (p=0.04; NNT=10), respectively. The mandible/bilateral sagittal split osteotomy (BSSO) was involved in 71% of SSIs. Intra- and post-operative surgical variables did not have a significant effect on the SSI rate. Patients were followed for 1 year following surgery, where Group A (n=46) and Group B (n=44) had an SSI rate of 4 and 25% (p<0.05), respectively. Conclusions Three days of post-operative cefazolin/cephalexin significantly reduces SSI rates compared with 1 day. However, the NNT of 10 suggests that the benefits of the extended regimen may not outweigh the risks. The high prevalence of SSIs at the mandibular/BSSO incisions may be caused by contamination with more saliva and reception of a lower blood supply than maxillary/Le Fort I incisions. Mandibular osteotomies may benefit from an extended antibiotic regimen to minimize SSI and associated complications. Other surgical variables may not require special consideration for antibiotic therapy.
Background Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms ...include the stimulants methylphenidate and amphetamine; nonstimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics. Objectives To assess the effects of pharmacological treatments for ADHD on ADHD symptoms and tic severity in children with ADHD and comorbid tic disorders. Search methods We searched CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009), CINAHL (1982 to July 2009), PsycINFO (1806 to July Week 4 2009) and BIOSIS Previews (1985 to July 2009). Dissertation Abstracts (searched via Dissertaation Express), and the metaRegister of Controlled Trials were searched (30 July 2009). Selection criteria We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel group and cross-over study designs. Data collection and analysis Two authors independently extracted data using standardized forms. Main results We included a total of eight randomized controlled studies in the review but were unable to combine any of these in meta-analysis. Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. All treatments, with the exception of deprenyl, were efficacious in treating symptoms of ADHD. Tic symptoms improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and the combination of methylphenidate and clonidine. Fear of worsening tics limited dose increases of methylphenidate in one study. High dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited. Authors' conclusions Methylphenidate, clonidine, guanfacine, desipramine and atomoxetine appear to reduce ADHD symptoms in children with tics. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may nonetheless exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine is effective for both tics and ADHD in children, safety concerns will likely continue to limit its use in this population. Plain Language Summary Medications for Attention Deficit Hyperactivity Disorder in children with tics As many as half of all children with tic disorders also have Attention Deficit Hyperactivity Disorder (ADHD). Symptoms of ADHD are often more disabling for children than their tics. Historically, the reported ability of stimulant medications to worsen tics has limited their use in children who have both a chronic tic disorder and ADHD. To evaluate evidence for this reported phenomenon we searched for clinical trials of medications for ADHD used specifically in children with tic disorders. The trials indicate that a number of stimulant and non-stimulant medications are safe and effective treatments for ADHD symptoms and do not worsen tics. High dose stimulants may transiently worsen tics in some children, and worsening tics may limit dose increases of stimulants in some children, but in the majority of children both tics and ADHD symptoms improve with use of stimulant medications. PUBLICATION ABSTRACT
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