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Bernstein GA, Khan MH, Freese RL, Manko C, Silverman M, Ahmed S, Farhadian B, Ma M, Thienemann M, Murphy TK, Frankovich J. Psychometric Properties of the PANS 31-Item Symptom Rating Scale. J Child Adolesc Psychopharmacol 2024; 34:157-162. [PMID: 38536004 PMCID: PMC11040192 DOI: 10.1089/cap.2023.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by sudden onset of obsessive-compulsive disorder and/or eating restriction with associated neuropsychiatric symptoms from at least two of seven categories. The PANS 31-Item Symptom Rating Scale (PANS Rating Scale) was developed to identify and measure the severity of PANS symptoms. The objective of this study was to define the psychometric properties of the PANS Rating Scale. Methods: Children with PANS (N = 135) and their parents participated. Parents completed the PANS Rating Scale and other scales on Research Electronic Data Capture. The PANS Rating Scale includes 31 items that are rated on a Likert scale from 0 = none to 4 = extreme. Pearson's correlations were run between the PANS Total score and scores on the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), Yale Global Tic Severity Scale (YGTSS), Modified Overt Aggression Scale (MOAS), Columbia Impairment Scale (CIS), PANS Global Impairment Score (GIS), and Children's Global Assessment Scale (CGAS). Results: Convergent validity was supported by significant correlations between the PANS Total and scores on the CY-BOCS, YGTSS, MOAS, CIS, GIS, and CGAS. The largest correlations were with measures of functional impairment: PANS Total and CIS (r = 0.81) and PANS Total and GIS (r = 0.74). Cronbach's alpha was 0.89 which demonstrates strong internal consistency of the 31 items. PANS Total score was significantly higher in children in a flare of their neuropsychiatric symptoms compared to children who were not in a flare. Conclusions: This study provides preliminary support for the PANS Rating Scale as a valid research instrument with good internal consistency. The PANS Rating Scale appears to be a useful measure for assessing children with PANS.
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Affiliation(s)
- Gail A. Bernstein
- Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Maroof H. Khan
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rebecca L. Freese
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cindy Manko
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Meiqian Ma
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida, St Petersburg, Florida, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Immune Behavioral Health Program, Stanford University School of Medicine, Palo Alto, California, USA
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Calaprice-Whitty D, Tang A, Tona J. Factors Associated with Symptom Persistence in PANS: Part I-Access to Care. J Child Adolesc Psychopharmacol 2023; 33:356-364. [PMID: 37902790 DOI: 10.1089/cap.2023.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Objective: Pediatric acute-onset neuropsychiatric syndrome (PANS) presents with abrupt neuropsychiatric symptoms, often after an immunologic trigger. A 2017 survey of 698 subjects found diagnostic delays to be associated with recurrences, suggesting that timely care impacts course. This secondary analysis explores the impact of barriers to care on symptom persistence. Methods: A 146-question online survey gathered history, symptomatology, intervention, and outcome data from subjects with PANS. Multivariate analyses examined associations between symptom persistence over the entire reported disease course, measured as % days symptom-free over reporting periods averaging approximately 4 years, and access-to-care history, reflected in availability of medical expertise and affordability of care. The impacts of time from symptom onset to treatment and effectiveness of initial antibiotics were also examined. Results: Among the 646 subjects analyzed, greater symptom persistence was associated with longer intervals between symptom onset and treatment (F = 4.43, p = 0.002). Thirty-four percent of subjects with the least symptom persistence (>75% symptom-free days), versus 13% of those with the most (symptoms every day), had been diagnosed by the first practitioner seen (likelihood ratio [L-R] χ2 = 36.55, p < 0.0001, for comparison across all groups). Diagnosis and treatment had not been impeded by lack of access to expertise for 52% of subjects with the least persistent symptoms, versus 22% of those with the most (L-R χ2 = 22.47, p < 0.0001). Affordability had not impacted diagnosis and treatment for 76% of subjects with the least persistent symptoms, versus 42% of those with the most (L-R χ2 = 27.83, p < 0.0001). The subjects whose PANS symptoms resolved with antibiotic treatment of the inciting infection experienced less symptom persistence than others (χ2 = 23.27, p = 0.0001). More persistently symptomatic subjects were more likely to have discontinued intravenous immunoglobulin (IVIG) treatment for access-to-care reasons. Conclusions: Unimpeded access to care for PANS is associated with more symptom-free days over reporting periods averaging approximately 4 years. Difficulty reaching expert providers, missed opportunities for diagnoses, and financial limitations may worsen outcomes. Practitioners, particularly primary providers, should adhere to published diagnostic and treatment guidelines promptly upon presentation.
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Affiliation(s)
- Denise Calaprice-Whitty
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
- Brain Inflammation Collaborative, Delafield, Wisconsin, USA
| | - Angela Tang
- Division of Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York, USA
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Vreeland A, Calaprice D, Or-Geva N, Frye RE, Agalliu D, Lachman HM, Pittenger C, Pallanti S, Williams K, Ma M, Thienemann M, Gagliano A, Mellins E, Frankovich J. Postinfectious Inflammation, Autoimmunity, and Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection, and Pediatric Acute-Onset Neuropsychiatric Disorder. Dev Neurosci 2023; 45:361-374. [PMID: 37742615 DOI: 10.1159/000534261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/14/2023] [Indexed: 09/26/2023] Open
Abstract
Postinfectious neuroinflammation has been implicated in multiple models of acute-onset obsessive-compulsive disorder including Sydenham chorea (SC), pediatric acute-onset neuropsychiatric syndrome (PANS), and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS). These conditions are associated with a range of autoantibodies which are thought to be triggered by infections, most notably group A streptococci (GAS). Based on animal models using huma sera, these autoantibodies are thought to cross-react with neural antigens in the basal ganglia and modulate neuronal activity and behavior. As is true for many childhood neuroinflammatory diseases and rheumatological diseases, SC, PANS, and PANDAS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. In this review article, we outline the accumulating evidence supporting the role neuroinflammation plays in these disorders. We describe work with animal models including patient-derived anti-neuronal autoantibodies, and we outline imaging studies that show alterations in the basal ganglia. In addition, we present research on metabolites, which are helpful in deciphering functional phenotypes, and on the implication of sleep in these disorders. Finally, we encourage future researchers to collaborate across medical specialties (e.g., pediatrics, psychiatry, rheumatology, immunology, and infectious disease) in order to further research on clinical syndromes presenting with neuropsychiatric manifestations.
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Affiliation(s)
- Allison Vreeland
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Noga Or-Geva
- Interdepartmental Program in Immunology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California, USA
| | - Richard E Frye
- Autism Discovery and Treatment Foundation, Phoenix, Arizona, USA
| | - Dritan Agalliu
- Department of Neurology, Pathology and Cell Biology, Columbia University Irving School of Medicine, New York, New York, USA
| | - Herbert M Lachman
- Departments of Psychiatry, Medicine, Genetics, and Neuroscience, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Christopher Pittenger
- Departments of Psychiatry and Psychology, Child Study Center and Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Kyle Williams
- Department of Psychiatry Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meiqian Ma
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Palo Alto, California, USA
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Pediatric Department of Policlinico G. Matino, University of Messina, Messina, Italy
| | - Elizabeth Mellins
- Department of Pediatrics, Program in Immunology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Gagliano A, Carta A, Tanca MG, Sotgiu S. Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatr Dis Treat 2023; 19:1221-1250. [PMID: 37251418 PMCID: PMC10225150 DOI: 10.2147/ndt.s362202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) features a heterogeneous constellation of acute obsessive-compulsive disorder (OCD), eating restriction, cognitive, behavioral and/or affective symptoms, often followed by a chronic course with cognitive deterioration. An immune-mediated etiology is advocated in which the CNS is hit by different pathogen-driven (auto)immune responses. This narrative review focused on recent clinical (ie, diagnostic criteria, pre-existing neurodevelopmental disorders, neuroimaging) and pathophysiological (ie, CSF, serum, genetic and autoimmune findings) aspects of PANS. We also summarized recent points to facilitate practitioners with the disease management. Relevant literature was obtained from PubMed database which included only English-written, full-text clinical studies, case reports, and reviews. Among a total of 1005 articles, 205 were pertinent to study inclusion. Expert opinions are converging on PANS as the effect of post-infectious events or stressors leading to "brain inflammation", as it is well-established for anti-neuronal psychosis. Interestingly, differentiating PANS from either autoimmune encephalitides and Sydenham's chorea or from alleged "pure" psychiatric disorders (OCD, tics, Tourette's syndrome), reveals several overlaps and more analogies than differences. Our review highlights the need for a comprehensive algorithm to help both patients during their acute distressing phase and physicians during their treatment decision. A full agreement on the hierarchy of each therapeutical intervention is missing owing to the limited number of randomized controlled trials. The current approach to PANS treatment emphasizes immunomodulation/anti-inflammatory treatments in association with both psychotropic and cognitive-behavioral therapies, while antibiotics are suggested when an active bacterial infection is established. A dimensional view, taking into account the multifactorial origin of psychiatric disorders, should suggest neuro-inflammation as a possible shared substrate of different psychiatric phenotypes. Hence, PANS and PANS-related disorders should be considered as a conceptual framework describing the etiological and phenotypical complexity of many psychiatric disorders.
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Affiliation(s)
- Antonella Gagliano
- Department of Health Science, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Alessandra Carta
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
| | - Marcello G Tanca
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Stefano Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
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Vreeland A, Thienemann M, Cunningham M, Muscal E, Pittenger C, Frankovich J. Neuroinflammation in Obsessive-Compulsive Disorder: Sydenham Chorea, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, and Pediatric Acute Onset Neuropsychiatric Syndrome. Psychiatr Clin North Am 2023; 46:69-88. [PMID: 36740356 DOI: 10.1016/j.psc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Sydenham chorea (SC), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS) are postinfectious neuroinflammatory diseases that involve the basal ganglia and have obsessive-compulsive disorder as a major manifestation. As is true for many childhood rheumatological diseases and neuroinflammatory diseases, SC, PANDAS and PANS lack clinically available, rigorous diagnostic biomarkers and randomized clinical trials. Research on the treatment of these disorders depend on three complementary modes of intervention including: treating the symptoms, treating the source of inflammation, and treating disturbances of the immune system. Future studies should aim to integrate neuroimaging, inflammation, immunogenetic, and clinical data (noting the stage in the clinical course) to increase our understanding and treatment of SC, PANDAS, PANS, and all other postinfectious/immune-mediated behavioral disorders.
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Affiliation(s)
- Allison Vreeland
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA.
| | - Margo Thienemann
- Division of Child and Adolescent Psychiatry and Child Development, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA; Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA
| | - Madeleine Cunningham
- Department of Microbiology and Immunology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Eyal Muscal
- Department of Rheumatology, Texas Children's Hospital, Houston, TX, USA
| | | | - Jennifer Frankovich
- Stanford Children's Health, PANS Clinic and Research Program, Stanford University School of Medicine, Stanford, CA, USA; Division of Pediatrics, Department of Allergy, Immunology, Rheumatology, Stanford University School of Medicine, Stanford, CA, USA
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Berloffa S, Salvati A, Pantalone G, Falcioni L, Rizzi MM, Naldini F, Masi G, Gagliano A. Steroid treatment response to post SARS-CoV-2 PANS symptoms: Case series. Front Neurol 2023; 14:1085948. [PMID: 36864920 PMCID: PMC9972432 DOI: 10.3389/fneur.2023.1085948] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/16/2023] [Indexed: 02/16/2023] Open
Abstract
Background Pediatric acute-onset neuropsychiatric syndrome (PANS) is characterized by a wide spectrum of symptoms, including the onset of obsessive-compulsive disorder and/or severely restricted food intake, associated with emotional symptoms, behavioral symptoms, developmental regression, and somatic symptoms. Among the possible triggering agents, infectious agents have been extensively explored. More recently, sporadic case reports describe a possible association between PANS and SARS-CoV-2 infection but data on clinical presentation and treatment are still scarce. Methods We describe a case series (10 children) with acute onset or relapse of PANS symptoms after SARS-CoV-2 infection. Standardized measures (CBCL, CPRS, C-GAS, CGI-S, Y-BOCS, PANSS, and YGTSS) were used to describe the clinical picture. The efficacy of a pulse treatment with steroids for three consecutive months was assessed. Results Our data suggest that the clinical presentation of the COVID-19-triggered PANS is largely similar to that reported in typical PANS, including acute onset, with OCD and/or eating disorders, and associated symptoms. Our data suggest that treatment with corticosteroids may be beneficial for both global clinical severity and global functioning. No serious adverse effects were observed. Both OCD symptoms and tics consistently improved. Among psychiatric symptoms, affective and oppositional symptoms appeared more sensitive to the steroid treatment than the other symptoms. Conclusion Our study confirms that COVID-19 infection in children and adolescents could trigger acute-onset neuropsychiatric symptoms. Thus, in children and adolescents with COVID-19, a specific neuropsychiatric follow-up should be routinely included. Even if a small sample size and a follow-up with only two points (baseline and endpoint, after 8 weeks) limit the conclusions, it seems that steroid treatment in the acute phase may be beneficial and well tolerated.
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Affiliation(s)
- Stefano Berloffa
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Pisa, Italy
| | - Andrea Salvati
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gloria Pantalone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ludovica Falcioni
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari & “A. Cao” Pediatric Hospital, Brotzu Hospital Trust, Cagliari, Italy
| | - Micaela M. Rizzi
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari & “A. Cao” Pediatric Hospital, Brotzu Hospital Trust, Cagliari, Italy
| | - Francesca Naldini
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari & “A. Cao” Pediatric Hospital, Brotzu Hospital Trust, Cagliari, Italy
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Pisa, Italy
| | - Antonella Gagliano
- Child and Adolescent Neuropsychiatry Unit, Department of Biomedical Science, University of Cagliari & “A. Cao” Pediatric Hospital, Brotzu Hospital Trust, Cagliari, Italy,Neurology Unit, Department of Neurology of Health Science, Magna Graecia University of Catanzaro, Catanzaro, Italy,*Correspondence: Antonella Gagliano ✉
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Dabbah-Assadi F, Handel R, Shamir A. What we know about the role of corticosteroids in psychiatric disorders; evidence from animal and clinical studies. J Psychiatr Res 2022; 155:363-370. [PMID: 36182765 DOI: 10.1016/j.jpsychires.2022.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/01/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022]
Abstract
Corticosteroids, often known as steroids, are anti-inflammatory medicine prescribed for various conditions. There is accumulating evidence of immune dysregulation in major psychiatric disorders. Significant changes in concentrations of inflammatory biomarkers (i.e., IL-6 and TNF-a) have been previously reported in individuals with schizophrenia, autistic individuals, and depressive patients. Thus, systemic corticosteroids can be used as an adjuvant treatment to reduce inflammation in major psychiatric disorders. However, despite their well-known potent anti-inflammatory and immunosuppressant properties, this treatment is often associated with increased severity of several psychiatric symptoms and relapse. This article reviews the available literature on psychiatric and cognitive changes during corticosteroid therapy. Specifically, we will provide data on the good and the bad of corticosteroid therapy in autism, schizophrenia, mood disorders, and PTSD. This review will summarize the vital role of corticosteroid therapy in social and cognitive behavior.
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Affiliation(s)
- Fadwa Dabbah-Assadi
- Psychobiology Research Laboratory, Mazor Mental Health Center, Akko, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ran Handel
- Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Alon Shamir
- Psychobiology Research Laboratory, Mazor Mental Health Center, Akko, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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Gao J, Chan A, Willett T, Farhadian B, Silverman M, Tran P, Ahmed S, Thienemann M, Frankovich J. Sex and Aggression Characteristics in a Cohort of Patients with Pediatric Acute-Onset Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol 2022; 32:444-452. [PMID: 35998241 PMCID: PMC9603278 DOI: 10.1089/cap.2021.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective: This study describes for the first time the characteristics by sex of patients with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), including clinical phenotype, treatment, and psychosocial aspects of disease. Methods: This cross-sectional study included 205 consecutive community patients evaluated between January 1, 2012 and March 30, 2019 and compared 87 females with 118 males. Our primary hypothesis was that males would display more aggression, as measured by the Modified Overt Aggression Scale (MOAS) and would be treated with immunotherapy earlier than females. The MOAS began to be administered 5 years into the study period, and 57 of the 205 families completed the MOAS for this study. Results: Our analysis revealed that males had a higher median MOAS score in the first year of clinic when compared with females (median 11, interquartile range [IQR] [4-24] vs. median 3, IQR [1-9]; p = 0.03) and a higher median subscore for physical aggression (median 4, IQR [0-12] vs. median 0, IQR [0-8]; p = 0.05). The median time from PANS symptom onset to first administration of immunotherapy, which did not include nonsteroidal anti-inflammatory drugs or short bursts of oral steroids, was 6.9 years for females and 3.7 years for males (p = 0.20). The two groups did not differ significantly in age of PANS onset, time from onset to clinic entry, other psychiatric symptom measures, or laboratory markers of inflammation. Conclusion: Among patients with PANS, males exhibit more aggressive behavior when compared with females, which may advance the decision to treat with immunotherapy. Scores that capture a more global level of functioning show that despite there being a higher level of aggression in males, female patients with PANS have similar levels of overall impairment.
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Affiliation(s)
- Jaynelle Gao
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Avis Chan
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Theresa Willett
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Bahare Farhadian
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Melissa Silverman
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Paula Tran
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Sana Ahmed
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA
| | - Margo Thienemann
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer Frankovich
- Department of Pediatrics, Stanford University of Medicine, Stanford, California, USA.,Address correspondence to: Jennifer Frankovich, MD, MS, Department of Pediatrics, Stanford University of Medicine, 700 Welch Road, Stanford, CA 94305, USA
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Hoffman KL, Cano-Ramírez H. Pediatric neuropsychiatric syndromes associated with infection and microbiome alterations: clinical findings, possible role of the mucosal epithelium, and strategies for the development of new animal models. Expert Opin Drug Discov 2022; 17:717-731. [PMID: 35543072 DOI: 10.1080/17460441.2022.2074396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Subsets of pediatric obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD) respectively have been associated with respiratory tract infections and alterations in the intestinal microbiome. Pediatric Acute-onset Neuropsychiatric Syndromes (PANS) refers to the sudden onset of neuropsychiatric symptoms that are triggered by several different infectious and non-infectious factors. Clinical studies and animal modeling are consistent with the proposal that inflammation plays an important etiological role in PANS, as well as in ASD associated with gut dysbiosis. AREAS COVERED The authors provide an overview of clinical studies of PANS and ASD associated with gastrointestinal symptoms, as well as the current strategies for studying these syndromes in rodent models. Finally, the authors highlight similarities between these syndromes that may provide clues to common etiological mechanisms. EXPERT OPINION Although data from existing animal models are consistent with an important role for anti-neuronal antibodies in PANS triggered by GAS infection, we lack models for identifying pathophysiological mechanisms of PANS associated with other infectious and non-infectious triggers. The authors propose a strategy for developing such models that incorporates known vulnerability and triggering factors for PANS into the modeling process. This novel strategy should expand our understanding of the pathophysiology of PANS, as well as facilitate the development of new pharmacological treatments for PANS and related syndromes.
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Affiliation(s)
- Kurt Leroy Hoffman
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
| | - Hugo Cano-Ramírez
- Centro de Investigación en Reproducción Animal Dr. Carlos Beyer Flores (CIRA), Universidad Autónoma de Tlaxcala - Centro de Investigación de Estudios Avanzados del Instituto Politécnico Nacional (CINVESTAV-IPN)
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Cocuzza S, Maniaci A, La Mantia I, Nocera F, Caruso D, Caruso S, Iannella G, Vicini C, Privitera E, Lechien JR, Pavone P. Obsessive-Compulsive Disorder in PANS/PANDAS in Children: In Search of a Qualified Treatment-A Systematic Review and Metanalysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020155. [PMID: 35204876 PMCID: PMC8869780 DOI: 10.3390/children9020155] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/18/2022] [Indexed: 12/05/2022]
Abstract
Background: Several treatment options have been proposed for pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANS/PANDAS). Still, no clear therapeutic protocol has been recognized to prevent these neuropsychiatric diseases. The study aims to report on the literature evidence and different treatment strategies related to these disorders. Methods: We analyzed the last 20 years’ English language literature and performed a comprehensive review of the PANS/PANDAS treatment, including studies reporting OCD outcomes post-treatment follow-up. Results: We covered 11 articles in our systematic literature review for a total of 473 patients, of which four studies included 129 surgical subjects and seven papers with 326 medically treated patients. Pooled outcomes analysis, surgical and medical treatment reported an OCD reduction, but no statistical significance was obtained (p < 0.05 for both). Conclusions: Surgical therapy in selected patients can lead to promising results, although further evidence is needed. On the other hand, the role of medical therapy remains controversial, often due to the lack of univocal curative protocols and variable responses depending on the drug used and the timing of administration. Therefore, further investigations are necessary to clarify the most appropriate therapeutic procedure.
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Affiliation(s)
- Salvatore Cocuzza
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Antonino Maniaci
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Ignazio La Mantia
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Francesco Nocera
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Daniela Caruso
- Unit of Clinical Pediatrics, A.O.U. “Policlinico”, P.O. “G. Rodolico”, University of Catania, 95123 Catania, Italy;
| | - Sebastiano Caruso
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Giannicola Iannella
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, 47121 Forlì, Italy; (G.I.); (C.V.)
- Department of Sensory Organs, Sapienza University of Rome, 00194 Rome, Italy
| | - Claudio Vicini
- Department of Head-Neck Surgery, Otolaryngology, Head-Neck and Oral Surgery Unit, Morgagni Pierantoni Hospital, 47121 Forlì, Italy; (G.I.); (C.V.)
| | - Elio Privitera
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, ENT Section, University of Catania, 95123 Catania, Italy; (S.C.); (A.M.); (I.L.M.); (F.N.); (S.C.); (E.P.)
| | - Jerome Rene Lechien
- Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), 7000 Mons, Belgium;
| | - Piero Pavone
- Unit of Clinical Pediatrics, A.O.U. “Policlinico”, P.O. “G. Rodolico”, University of Catania, 95123 Catania, Italy;
- Correspondence:
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11
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Owji M, Naser Moghadasi A, Gholamian F, Mousavi SY. Obsessive compulsive disorder as a presenting symptom of COVID-19: A case-series from Iran. CASPIAN JOURNAL OF INTERNAL MEDICINE 2022; 13:259-263. [PMID: 35872671 PMCID: PMC9272957 DOI: 10.22088/cjim.13.0.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/01/2021] [Accepted: 08/14/2021] [Indexed: 11/12/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) involves different organs and clinical presentations varying from respiratory symptoms to gastrointestinal symptoms and neurological symptoms. Another group of symptoms are psychiatric symptoms and according to a study, 53.8% of participants reported various degrees of these symptoms. Case Presentation In this study, we presented six cases with sudden onset OCD or exacerbation of the previously controlled OCD concomitant with COVID-19 symptoms. Result Obsessive compulsive symptoms can be the presenting manifestation of COVID-19. Conclusion The neuropsychiatric manifestations may be resulted from central nervous system (CNS) infiltration, and dysregulation of inflammatory factors autoimmune responses.
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Affiliation(s)
- Mahsa Owji
- Multiple Sclerosis Research Center, Neuroscience institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Faezeh Gholamian
- Department of Psychiatry, Roozbeh Psychiatric Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Yaser Mousavi
- Department of Psychiatry, Children’s Medical center, Tehran University of Medical Sciences, Tehran, Iran,Correspondence: Seyed Yaser Mousavi, Psychiatric Research Center, Children’s Medical center, Tehran University of Medical Sciences, No 63, Gharib Ave, Keshavarz Blv, Tehran, 1419733151, Iran. E-mail: , Tel: 0098 2166929234, Fax: 0098 2166930024
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12
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McMahon AW, Quinto K, Abernethy A, Corrigan-Curay J. Summary of Literature on Pediatric Real-world Evidence and Effectiveness. JAMA Pediatr 2021; 175:1077-1079. [PMID: 34251405 PMCID: PMC8276122 DOI: 10.1001/jamapediatrics.2021.2149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cross-sectional study investigates the use of real-world data and real-world evidence in informing medicine efficacy in pediatric literature.
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Affiliation(s)
- Ann W. McMahon
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland
| | - Kenneth Quinto
- Office of Medical Policy, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Amy Abernethy
- Office of the Commissioner, Food and Drug Administration, Silver Spring, Maryland
| | - Jacqueline Corrigan-Curay
- Office of Medical Policy, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
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13
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Johnson M, Ehlers S, Fernell E, Hajjari P, Wartenberg C, Wallerstedt SM. Anti-inflammatory, antibacterial and immunomodulatory treatment in children with symptoms corresponding to the research condition PANS (Pediatric Acute-onset Neuropsychiatric Syndrome): A systematic review. PLoS One 2021; 16:e0253844. [PMID: 34197525 PMCID: PMC8248649 DOI: 10.1371/journal.pone.0253844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 06/15/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To assess effects of treatment against a hypothesized neuroinflammation in children with symptoms corresponding to the research condition Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) which is not included in current diagnostic systems. METHODS Systematic literature searches were performed (1998 to June 2020) in PubMed, Embase, the Cochrane Library, CINAHL, PsycInfo, and HTA databases. Inclusion criteria: patients (P) were children (<18 years) with PANS; intervention (I)/comparison (C) was use of, versus no use of, anti-inflammatory, antibacterial or immunomodulating treatments; outcomes (O) were health-related quality of life (HRQL), level of functioning, symptom change, and complications. RESULTS Four randomised controlled trials (RCTs) and three non-RCTs, including 23 to 98 patients, fulfilled the PICO. HRQL was not investigated in any study. Regarding level of functioning, two RCTs investigated antibiotics (penicillin V, azithromycin) and one RCT investigated immunomodulating treatments (intravenous immunoglobulins (IVIG), plasma exchange). Regarding symptoms, two non-RCTs investigated anti-inflammatory treatment (cyclooxygenase (COX) inhibitors, corticosteroids), two RCTs and one non-RCT investigated antibiotics (penicillin V, azithromycin), and two RCTs investigated immunomodulating treatments (IVIG, plasma exchange). Complications, reported in five studies, were consistent with those listed in the summary of products characteristics (SPC). All studies were assessed to have some or major problems regarding directness, the absence of an established diagnosis contributing to clinical diversity in the studied populations. All studies were assessed to have major risk of bias, including selection and detection biases. Due to clinical and methodological diversity, meta-analyses were not performed. CONCLUSION This systematic review reveals very low certainty of evidence of beneficial effects, and moderate certainty of evidence of adverse effects, of anti-inflammatory, antibacterial or immunomodulating treatments in patients with symptoms corresponding to the research condition PANS. Available evidence neither supports nor excludes potential beneficial effects, but supports that such treatment can result in adverse effects. REGISTRATION PROSPERO (CRD42020155714).
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Affiliation(s)
- Mats Johnson
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stephan Ehlers
- Regional Knowledge Center for Mental Health, Gothenburg, Sweden
| | - Elisabeth Fernell
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Constanze Wartenberg
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Susanna M. Wallerstedt
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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14
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Moni MA, Lin PI, Quinn JMW, Eapen V. COVID-19 patient transcriptomic and genomic profiling reveals comorbidity interactions with psychiatric disorders. Transl Psychiatry 2021; 11:160. [PMID: 33723208 PMCID: PMC7957287 DOI: 10.1038/s41398-020-01151-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 12/16/2022] Open
Abstract
Psychiatric symptoms are seen in some COVID-19 patients, as direct or indirect sequelae, but it is unclear whether SARS-CoV-2 infection interacts with underlying neuronal or psychiatric susceptibilities. Such interactions might arise from COVID-19 immune responses, from infection of neurons themselves or may reflect social-psychological causes. To clarify this we sought the key gene expression pathways altered in COVID-19 also affected in bipolar disorder, post-traumatic stress disorder (PTSD) and schizophrenia, since this may identify pathways of interaction that could be treatment targets. We performed large scale comparisons of whole transcriptome data and immune factor transcript data in peripheral blood mononuclear cells (PBMC) from COVID-19 patients and patients with psychiatric disorders. We also analysed genome-wide association study (GWAS) data for symptomatic COVID-19 patients, comparing GWAS and whole-genome sequence data from patients with bipolar disorder, PTSD and schizophrenia patients. These studies revealed altered signalling and ontology pathways shared by COVID-19 patients and the three psychiatric disorders. Finally, co-expression and network analyses identified gene clusters common to the conditions. COVID-19 patients had peripheral blood immune system profiles that overlapped with those of patients with psychiatric conditions. From the pathways identified, PTSD profiles were the most highly correlated with COVID-19, perhaps consistent with stress-immune system interactions seen in PTSD. We also revealed common inflammatory pathways that may exacerbate psychiatric disorders, which may support the usage of anti-inflammatory medications in these patients. It also highlights the potential clinical application of multi-level dataset studies in difficult-to-treat psychiatric disorders in this COVID-19 pandemic.
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Affiliation(s)
- Mohammad Ali Moni
- Faculty of Medicine, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Ping-I Lin
- Faculty of Medicine, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia
- South Western Sydney Area Health Service, Sydney, NSW, 2170, Australia
| | - Julian M W Quinn
- The Garvan Institute of Medical Research, Healthy Ageing Theme, Darlinghurst, NSW, 2010, Australia
- Division of Surgery and Anesthesia, Royal North Shore Hospital SERT Institute, St Leonards, NSW, 2065, Australia
| | - Valsamma Eapen
- Faculty of Medicine, School of Psychiatry, University of New South Wales, Sydney, NSW, 2052, Australia.
- South Western Sydney Area Health Service, Sydney, NSW, 2170, Australia.
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15
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Harris EC, Conelea CA, Shyne MT, Bernstein GA. Predictors and Prospective Course of PANS: A Pilot Study Using Electronic Platforms for Data Collection. J Child Adolesc Psychopharmacol 2021; 31:102-108. [PMID: 33395354 PMCID: PMC8670571 DOI: 10.1089/cap.2020.0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Little is known about the longitudinal course of pediatric acute-onset neuropsychiatric syndrome (PANS) because existing literature is primarily cross-sectional. To begin to address this gap, two digital platforms were used to prospectively monitor neuropsychiatric symptoms in children with PANS. The aim was to identify baseline clinical characteristics that would predict the course of neuropsychiatric symptoms over 12 weeks. We compared relative compliance between two electronic data acquisition platforms and evaluated agreement between parent-child ratings of symptoms. Methods: For 12 weeks, 20 children with PANS and their parents completed weekly rating scales of neuropsychiatric symptoms on Research Electronic Data Capture (REDCap) and concurrently parents completed tri-weekly ratings on My Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Chart, a symptom monitoring website. Longitudinal data were analyzed by using regression analyses. Results: Greater duration of time between onset of PANS and study enrollment was associated with worsening of parent-rated neuropsychiatric symptoms over 12 weeks (p = 0.05). Higher scores on parents' Caregiver Burden Inventory at baseline predicted that children would report more severe symptoms over the 12-week period (p = 0.01). Compliance rates for parents were 86.3% for the weekly REDCap PANS Symptoms Rating Scale compared with 53.8% for the tri-weekly My PANDAS Chart ratings. There was moderate agreement between children and parents on the PANS Symptom Rating Scale (r = 0.55, p < 0.0001). Conclusion: Our study highlights the utility of electronic methods for tracking longitudinal symptoms in children with PANS and suggests that particular baseline characteristics (e.g., delay in identification and treatment of PANS, greater caregiver burden) may be indicative of a differential trajectory of PANS course, with more severe symptoms over the short term. clinicaltrials.gov NCT04382716.
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Affiliation(s)
- Elizabeth C. Harris
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Christine A. Conelea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael T. Shyne
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gail A. Bernstein
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA.,Address correspondence to: Gail A. Bernstein, MD, Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota, F282/2A West, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
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16
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Lopez Pineda A, Pourshafeie A, Ioannidis A, Leibold CM, Chan AL, Bustamante CD, Frankovich J, Wojcik GL. Discovering prescription patterns in pediatric acute-onset neuropsychiatric syndrome patients. J Biomed Inform 2020; 113:103664. [PMID: 33359113 DOI: 10.1016/j.jbi.2020.103664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 10/28/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pediatric acute-onset neuropsychiatric syndrome (PANS) is a complex neuropsychiatric syndrome characterized by an abrupt onset of obsessive-compulsive symptoms and/or severe eating restrictions, along with at least two concomitant debilitating cognitive, behavioral, or neurological symptoms. A wide range of pharmacological interventions along with behavioral and environmental modifications, and psychotherapies have been adopted to treat symptoms and underlying etiologies. Our goal was to develop a data-driven approach to identify treatment patterns in this cohort. MATERIALS AND METHODS In this cohort study, we extracted medical prescription histories from electronic health records. We developed a modified dynamic programming approach to perform global alignment of those medication histories. Our approach is unique since it considers time gaps in prescription patterns as part of the similarity strategy. RESULTS This study included 43 consecutive new-onset pre-pubertal patients who had at least 3 clinic visits. Our algorithm identified six clusters with distinct medication usage history which may represent clinician's practice of treating PANS of different severities and etiologies i.e., two most severe groups requiring high dose intravenous steroids; two arthritic or inflammatory groups requiring prolonged nonsteroidal anti-inflammatory drug (NSAID); and two mild relapsing/remitting group treated with a short course of NSAID. The psychometric scores as outcomes in each cluster generally improved within the first two years. DISCUSSION AND CONCLUSION Our algorithm shows potential to improve our knowledge of treatment patterns in the PANS cohort, while helping clinicians understand how patients respond to a combination of drugs.
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Affiliation(s)
- Arturo Lopez Pineda
- Department of Biomedical Data Science, Stanford University, CA, USA; Department of Data Science, Amphora Health, Morelia, Mexico
| | - Armin Pourshafeie
- Department of Biomedical Data Science, Stanford University, CA, USA; Department of Physics, Stanford University, CA, USA
| | | | - Collin McCloskey Leibold
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Stanford University, CA, USA; Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Avis L Chan
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Stanford University, CA, USA
| | - Carlos D Bustamante
- Department of Biomedical Data Science, Stanford University, CA, USA; Department of Genetics, Stanford University, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA.
| | - Jennifer Frankovich
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Stanford University, CA, USA.
| | - Genevieve L Wojcik
- Department of Biomedical Data Science, Stanford University, CA, USA; Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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17
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Ghasemi H, Nomani H, Sahebkar A, Mohammadpour AH. Anti-inflammatory Augmentation Therapy in Obsessive-compulsive Disorder: A Review. LETT DRUG DES DISCOV 2020. [DOI: 10.2174/1570180817999200520122910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Obsessive-Compulsive Disorder (OCD) is considered as a serious disabling
psychiatric disorder, influencing 2-3% of the total general population, with an unknown etiology.
Methods:
A comprehensive literature search in electronic databases was performed to investigate
treatments targeting inflammation in patients suffering from OCD.
Results:
Recent studies display that inflammation processes and the dysfunction of the immune system
are likely to play a role in the pathophysiology of OCD, indicating that the disturbances in neurotransmitters
such as serotonin and dopamine cannot be alone involved in the development of
OCD. Therefore, it seems that medications with anti-inflammatory effects have the potential to be
evaluated as a new therapeutic strategy for OCD. However, this issue can be studied closely if OCD
etiological factors are thoroughly understood. The present review study aims at gathering all obtained
results concerning new treatments targeting inflammation in OCD patients. Reviewing the
conducted studies shows that the use of agents with anti-inflammatory properties, including some
NSAIDs, Minocycline and Atorvastatin, could lead to promising and intriguing results in the treatment
of OCD. Curcumin also showed good efficacy in the reduction of OCD-like behavior when it
has been used in an animal model. However, there is still no definitive and conclusive evidence for
any of the medications proposed.
Conclusion:
More future studies are needed to investigate anti-inflammatory treatment strategies for
OCD and its other subtypes such as Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS), and
Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection
(PANDAS).
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Affiliation(s)
- Hanie Ghasemi
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Homa Nomani
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Amir Hooshang Mohammadpour
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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18
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Gromark C, Harris RA, Wickström R, Horne A, Silverberg-Mörse M, Serlachius E, Mataix-Cols D. Establishing a Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic: Baseline Clinical Features of the Pediatric Acute-Onset Neuropsychiatric Syndrome Cohort at Karolinska Institutet. J Child Adolesc Psychopharmacol 2019; 29:625-633. [PMID: 31170007 PMCID: PMC6786340 DOI: 10.1089/cap.2018.0127] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) is a descriptive clinical entity defined by the abrupt onset of psychiatric and somatic symptoms leading to significant loss of function. Data on well-characterized PANS patients are limited, biomarkers have yet to be identified, and a solid evidence base to guide treatment is lacking. In this study, we present our experience of a systematic evaluation of the first 45 patients included in a Swedish cohort. Methods: During the period 2014-2018, our clinic received 100 referrals regarding suspected PANS. All patients underwent a standardized psychiatric/medical evaluation by a child/adolescent psychiatrist and a clinical psychologist or a nurse. Those with severe symptoms were also assessed by a pediatric neurologist and a pediatric rheumatologist. Laboratory tests were obtained at different time points in an attempt to capture an active disease state. Results: Of the 100 referrals, 45 met strict PANS criteria and consented to participate in a long-term follow-up study. The median age at intake was 7.2 years (range 3.0-13.1) and 56% were male. Ninety-three percent fulfilled both criteria for acute/atypical onset of PANS symptoms and having had an infection in relation to onset. Sixteen percent had an onset of an autoimmune or inflammatory disorder in temporal relation to the onset of PANS-related symptoms. The most common onset symptoms were obsessive-compulsive disorder (89%), anxiety (78%), and emotional lability (71%). Twenty-four percent had a preexisting autoimmune disease (AD) and 18% a preexisting psychiatric/neuropsychiatric diagnosis. Sixty-four percent of biological relatives had at least one psychiatric disorder and 76% at least one AD or inflammatory disorder. Complement activation (37%), leukopenia (20%), positive antinuclear antibodies (17%), and elevated thyroid antibodies (11%) were the most common laboratory findings. Conclusions: In our PANS cohort, there was a strong indication of an association with AD. Further work is needed to establish whether any of the potential biomarkers identified will be clinically useful. Long-term follow-up of these patients using the Swedish national registers will enable a deeper understanding of the course of this patient group.
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Affiliation(s)
- Caroline Gromark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Robert A. Harris
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Neurology, Karolinska University Hospital, Solna, Sweden
| | - AnnaCarin Horne
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Rheumatology, Karolinska University Hospital, Solna, Sweden
| | - Maria Silverberg-Mörse
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- BUP OCD and Related Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
- Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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19
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Abstract
This review and commentary is the product of an invited lecture called "Autoimmunity: PANS/PANDAS" presented at the 2018 Neurobiology of Diseases in Children Symposium in Chicago, IL. The talk addressed clinical and scientific questions and recently published data. At this time, among highly experienced and respected clinicians and researchers spanning relevant disciplines, there is substantial controversy regarding a role for inflammation in producing tics and obsessive-compulsive disorder. This commentary summarizes these controversies, discusses reasons for opposing views on best clinical practices, and concludes with suggestions for pathways forward.
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Affiliation(s)
- Donald L. Gilbert
- Division of Neurology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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20
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Hesselmark E, Bejerot S. Clinical features of paediatric acute-onset neuropsychiatric syndrome: findings from a case- control study. BJPsych Open 2019; 5:e25. [PMID: 31068234 PMCID: PMC6401534 DOI: 10.1192/bjo.2019.10] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Paediatric acute-onset neuropsychiatric syndrome (PANS), an umbrella term that includes PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is suggested to be a psychiatric disorder of autoimmune aetiology. PANS is characterised by an acute onset of obsessive-compulsive disorder or restricted eating with multiple comorbid symptoms. The specificity of the PANS criteria is not fully understood.AimsTo describe a cohort of patients with PANS and to determine if PANS features relating to symptoms, onset and course are more common in PANS than in other psychiatric conditions. METHOD A case-control study comparing patients with interview-confirmed PANS with patients with suspected PANS and patients with a psychiatric condition but with no suspicion of PANS. Validated and non-validated measures of symptoms, onset and episodic course were used. RESULTS Illness in patients with interview-confirmed PANS featured an episodic course and multiple symptoms present at onset compared with the psychiatric controls. However, individuals with interview-confirmed PANS did not present a specific symptom profile. CONCLUSIONS PANS may be a distinct clinical entity featuring an acute onset, an episodic course and multiple symptoms at onset.Declaration of interestNone.
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Affiliation(s)
- Eva Hesselmark
- PhD Student, Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet; and Stockholm Health Care Services, Stockholm County Council, Sweden
| | - Susanne Bejerot
- Professor, School of Medical Sciences, Örebro University; University Health Care Research Center, Faculty of Medicine and Health, Örebro University; and Department of Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institutet, Sweden
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21
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Wilbur C, Bitnun A, Kronenberg S, Laxer RM, Levy DM, Logan WJ, Shouldice M, Yeh EA. PANDAS/PANS in childhood: Controversies and evidence. Paediatr Child Health 2018; 24:85-91. [PMID: 30996598 DOI: 10.1093/pch/pxy145] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022] Open
Abstract
Since first defined in 1998, paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and its later, broader iteration, paediatric acute-onset neuropsychiatric syndrome (PANS), have garnered significant attention and controversy. The role of streptococcal infection in children with explosive onset obsessive-compulsive disorder and new onset tics, the natural history of this entity, and the role of symptomatic and disease-modifying therapies, including antibiotics, immunotherapy, and psychoactive drugs, are all issues that have yet to be definitively addressed. While definitive proof of the autoimmune hypothesis of PANDAS is lacking, given the heightened attention to this entity and apparent rise in use of this diagnostic category, addressing questions around diagnosis, treatment, and etiology is imperative. In this paper, we review current working definitions of PANDAS/PANS, discuss published evidence for interventions related to this entity, and propose a clinical approach to children presenting with acute symptoms satisfying criteria for PANDAS/PANS.
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Affiliation(s)
- Colin Wilbur
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sefi Kronenberg
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Ronald M Laxer
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah M Levy
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - William J Logan
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Shouldice
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Rosa JS, Hernandez JD, Sherr JA, Smith BM, Brown KD, Farhadian B, Mahony T, McGhee SA, Lewis DB, Thienemann M, Frankovich JD. Allergic Diseases and Immune-Mediated Food Disorders in Pediatric Acute-Onset Neuropsychiatric Syndrome. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2018; 31:158-165. [PMID: 30283713 DOI: 10.1089/ped.2018.0888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/26/2018] [Indexed: 12/26/2022]
Abstract
Background: The prevalence and impact of allergic and immune-mediated food disorders in pediatric acute-onset neuropsychiatric syndrome (PANS) are mostly unknown. Objective: We sought to explore the prevalence of atopic dermatitis (AD), asthma, allergic rhinitis (AR), IgE-mediated food allergies (FAs), and other immune-mediated food disorders requiring food avoidance in patients with PANS. In addition, to further understand the extent of food restriction in this population, we investigated the empiric use of dietary measures to improve PANS symptoms. Methods: Pediatric patients in a PANS Clinic and Research Program were given surveys regarding their caregiver burdens, allergic and food-related medical history, and whether food elimination resulted in perception of improvement of PANS symptoms. A review of health records was conducted to confirm that all responses in the survey were concordant with documentation of each patient's medical chart. Results: Sixty-nine (ages 4-20 years) of 80 subjects who fulfilled PANS criteria completed the surveys. Thirteen (18.8%) had AD, 11 (15.9%) asthma, 33 (47.8%) AR, 11 (15.9%) FA, 1 (1.4%) eosinophilic gastrointestinal disorders, 1 (1.4%) food protein-induced enterocolitis syndrome, 3 (4.3%) milk protein-induced proctocolitis syndrome, and 3 (4.3%) celiac disease. Thirty subjects (43.5%) avoided foods due to PANS; elimination of gluten and dairy was most common and was associated with perceived improvement of PANS symptoms (by parents). This perceived improvement was not confirmed with objective data. Conclusions: The prevalence of allergic and immune-mediated food disorders in PANS is similar to the general population as reported in the literature, with the exception of AR that appears to be more prevalent in our PANS cohort. More research will be required to establish whether diet or allergies influence PANS symptoms.
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Affiliation(s)
- Jaime S Rosa
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Joseph D Hernandez
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Janell A Sherr
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Bridget M Smith
- Mary Ann and J. Milburn Smith Child Health Research Program, Department of Pediatrics, Northwestern University Feinberg School of Medicine and Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Center of Innovation for Complex Chronic Healthcare, Hines Veterans Affairs Hospital, Hines, Illinois
| | - Kayla D Brown
- PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Bahare Farhadian
- PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Talia Mahony
- PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Sean A McGhee
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David B Lewis
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Margo Thienemann
- PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
| | - Jennifer D Frankovich
- Division of Immunology, Allergy and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,PANS Clinic and Research Program, Stanford Children's Health, Palo Alto, California
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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24
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Brown KD, Farmer C, Freeman GM, Spartz EJ, Farhadian B, Thienemann M, Frankovich J. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol 2017; 27:619-628. [PMID: 28696786 PMCID: PMC5749580 DOI: 10.1089/cap.2016.0193] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is characterized by the sudden onset of severe obsessive-compulsive symptoms and/or eating restriction along with at least two coinciding neuropsychiatric symptoms. When associated with group A Streptococcus, the syndrome is labeled Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections (PANDAS). An abnormal immune response to infection and subsequent neuroinflammation is postulated to play an etiologic role. We evaluated the impact of nonsteroidal anti-inflammatory drug (NSAID) treatment on flare duration in PANS/PANDAS. METHODS Patient inclusion criteria: Patients were included if they had at least one neuropsychiatric deterioration ("flare") that met strict PANS/PANDAS research criteria and for which flare duration could be assessed. Flare inclusion criteria: Any flare that started before October 15, 2016 was included and followed until the flare resolved or until the end of our data collection (November 1, 2016). Flare exclusion criteria: Flares were excluded if they were incompletely resolved, treated with aggressive immunomodulation, or treated with NSAIDs late (>30 days of flare onset). Ninety-five patients met study inclusion criteria and collectively experienced 390 flares that met flare criteria. Data were analyzed using multilevel linear models, adjusting for demographics, disease, and treatment covariates. RESULTS NSAID use was associated with a significantly shorter flare duration. Flares not treated with NSAIDs had a mean duration of approximately 12.2 weeks (95% CI: 9.3-15.1). Flares that occurred while the child was on NSAID maintenance therapy were approximately 4 weeks shorter than flares not managed with NSAIDs (95% CI: 1.85-6.24; p < 0.0001). Flares treated with NSAIDs within 30 days of flare onset were approximately 2.6 weeks shorter than flares not managed with NSAIDs (95% CI: 0.43-4.68; p = 0.02). Flares treated prophylactically and those treated early with NSAIDs did not differ in duration (p = 0.26). Among the flares that received NSAID treatment within the first 30 days, earlier intervention was modestly associated with shorter flare durations (i.e., for each day that NSAID treatment was delayed, flare duration increased by 0.18 weeks; 95% CI: 0.03-0.33; p = 0.02), though it was not statistically significant after controlling for covariates (p = 0.06). CONCLUSION NSAIDs given prophylactically or within 30 days of flare onset may shorten neuropsychiatric symptom duration in patients with new-onset and relapsing/remitting PANS and PANDAS. A randomized placebo-control clinical trial of NSAIDs in PANS is warranted to formally assess treatment efficacy.
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Affiliation(s)
- Kayla D. Brown
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Cristan Farmer
- Intramural Research Program, National Institute of Mental Health, Bethesda, Maryland
| | - G. Mark Freeman
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Ellen J. Spartz
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Bahare Farhadian
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
- Child & Adolescent Psychiatry, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Frankovich
- Division of Pediatrics, Department of Allergy, Immunology, & Rheumatology, Stanford University School of Medicine, Palo Alto, California
- Stanford PANS Clinic and Research Program, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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25
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Thienemann M, Murphy T, Leckman J, Shaw R, Williams K, Kapphahn C, Frankovich J, Geller D, Bernstein G, Chang K, Elia J, Swedo S. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part I-Psychiatric and Behavioral Interventions. J Child Adolesc Psychopharmacol 2017; 27:566-573. [PMID: 28722481 PMCID: PMC5610394 DOI: 10.1089/cap.2016.0145] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This article outlines the consensus guidelines for symptomatic treatment for children with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS). METHODS Extant literature on behavioral, psychotherapeutic, and psychopharmacologic treatments for PANS and PANDAS was reviewed. Members of the PANS Research Consortium pooled their clinical experiences to find agreement on treatment of PANS and PANDAS symptoms. RESULTS Current guidelines result from consensus among the Consortium members. CONCLUSION While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention. Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness. In general, typical evidence-based interventions are appropriate for the varied symptoms of PANS and PANDAS. Individual differences in expected response to psychotropic medication may require marked reduction of initial treatment dose. Antimicrobials and immunomodulatory therapies may be indicated, as discussed in Parts 2 and 3 of this guideline series.
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Affiliation(s)
| | - Tanya Murphy
- University of South Florida, St. Petersburg, Florida
| | | | | | - Kyle Williams
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | | | - Kiki Chang
- Stanford University, Stanford, California
| | - Josephine Elia
- Nemours, Alfred I duPont Hospital for Children, Wilmington, Delaware
| | - Susan Swedo
- National Institute of Mental Health, Bethesda, Maryland
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