Diagnosis and management of ADHD: a pediatric perspective on practice and challenges in Switzerland

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders in childhood. In Switzerland, the complex diagnosis and treatment are being carried out by adolescent-/child psychiatrists, and pediatricians. Guidelines recommend a multimodal therapy for patients with ADHD. However, it has been questioned whether health professionals follow this approach or favor drug therapy. This study aims to provide insights into the practice of pediatricians in Switzerland regarding diagnosis and treatment of ADHD and their perceptions of these processes.

METHOD

An online survey (self-report) about current practices of diagnosis and management as well as challenges regarding ADHD was distributed to office-based pediatricians in Switzerland. One hundred fifty-one pediatricians participated. Results show that therapy options were almost always discussed with parents and older children. Exchange with parents (81%) and level of child's suffering (97%) were central when selecting therapy options.

RESULTS

Therapies about which pediatricians informed most often were: pharmacological therapy, psychotherapy, and multimodal therapy. Challenges voiced were the subjectivity of diagnostic criteria and dependence on third parties, low availability of psychotherapy, and a rather negative public attitude towards ADHD. Needs that were expressed were further education for all professionals, support for coordination with specialists and schools as well as improvement of information on ADHD.

CONCLUSIONS

Pediatricians do consider a multimodal approach when treating ADHD and take the families` and children's opinions into account. Improvements of the availability of child and youth psychotherapy, the strengthening of the interprofessional cooperation with therapists and schools, and efforts to increase public knowledge about ADHD are proposed.

Teachers’ mental health literacy and action competencies

Background

Teachers are very important in mental health promotion and early recognition of mental health burden (disorder, illness). Teachers’ surrogate mental health literacy (MHL) may be key to improving mental health in youth but has been little investigated. We assessed surrogate MHL in Swiss teachers and tested a measure of mental health action competencies (MHAC).

Methods

In 2020, all teaching and support staff at compulsory school level were invited to an online survey covering individual and professional characteristics, MHL (finding, understanding, critical appraisal of information) and action competencies (adapted scale Ahnert et al. 2016, range 17 - 68) personal experience with students’ MHB. Data was explored descriptively and with multivariate regression. Item response theory analyses were conducted to examine internal psychometric MHAC scale properties, and group-mean differences tested between school levels.

Results

Participation rate was 38% (N = 459). Nearly all participants had taught at least 1 mentally burdened student in the past year (average 4.7). 77% felt experienced to very experienced regarding these students. Only 32% felt they had sufficient tools and teaching resources. Participants felt it was difficult to very difficult to find (47%), understand (53%) and appraise (90%) information on students’ mental health. Kindergarden teachers and teachers without class responsibility showed significantly lower MHL. Internal psychometric properties of the MHAC measure support the use of a 1-factor scale and indicates discriminant validity with respect to age; experience and school level, median score was high (P50 48, P25 44, P75 53), but single items, e.g. on suicide signs, were rated low.

Conclusions

While overall subjective MHAC are high, teachers are insecure regarding MHL and report a lack of tools and resources. Targeted training could strengthen surrogate mental health literacy with a focus on critical appraisal and certain action competencies.

Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: A cross-sectional multicenter study

OBJECTIVE

Although lithium is widely used in current practice to treat bipolar disorder (BD) and treatment-resistant major depressive disorder (MDD) among older adults, little is known about its efficacy and tolerability in this population, which is generally excluded from randomized clinical trials. The objective of this study was to evaluate the efficacy and tolerability of long-term use of lithium among older adults with BD and MDD.

METHOD

Data from the Cohort of individuals with Schizophrenia and mood disorders Aged 55 years or more (CSA) were used. Two groups of patients with BD and MDD were compared: those who were currently receiving lithium versus those who were not. The effects of lithium on psychiatric (i.e., depressive symptoms severity, perceived clinical severity, rates of psychiatric admissions in the past-year), geriatric (overall and cognitive functioning) and physical outcomes (i.e., rates of non-psychiatric medical comorbidities and general hospital admissions in the past-year) were evaluated. All analyses were adjusted for age, sex, duration of disorder, diagnosis, smoking status, alcohol use, and use of antipsychotics, antiepileptics or antidepressants.

RESULTS

Among the 281 older participants with BD or MDD, 15.7% were taking lithium for a mean duration of 12.5(SD = 11.6) years. Lithium use was associated with lower intensity of depressive symptoms, reduced perceived clinical global severity and lower benzodiazepine use (all p < 0.05), without being linked to greater rates of medical comorbidities, except for hypothyroidism.

LIMITATIONS

Data were cross-sectional and data on lifetime history of psychotropic medications was not assessed.

CONCLUSION

Our results suggest that long-term lithium use may be efficient and relatively well-tolerated in older adults with BD or treatment-resistant MDD.

Measuring and optimizing the momentum aperture in a particle accelerator

Particle motion in storage rings is confined by various aperture limits, the size of which restricts the performance of the ring in terms of injection efficiency, lifetime, etc. Intrabeam scattering makes particles sweep a large portion of the phase space, where their motion may eventually be resonantly or chaotically excited to large amplitudes leading to collision with the vacuum chamber. We report here the studies performed at the Advanced Light Source (ALS) on the on- and off-momentum particle motion that provides a good understanding of these limitations. Using off-momentum simulations and experiments together with frequency map analysis, we could precisely correlate beam loss areas with resonance locations. The very good agreement between simulations and experiments allowed us to provide guidance for avoiding these dangerous areas. This analysis results in predictive improvements of the momentum aperture, which actually led to a lifetime increase of 25% at the ALS for very high bunch charge.

Treatment of sound errors in aphasia and apraxia of speech: Effects of phonological complexity

BACKGROUND: Recent research suggests that the complexity of treatment stimuli influences the effectiveness of treatment. However, no studies have examined the role of complexity on sound production treatment in adult individuals with sound production impairments. AIMS: This study examines effects of syllable complexity on treatment outcome in two patients with acquired sound production problems. Complexity is defined in terms of syllable structure: clusters are more complex than singletons. Using a single-subject multiple-baseline design, we address the question: Is treatment of complex syllables more effective than treatment of simple syllables? METHODS #ENTITYSTARTX00026; PROCEDURES: Two patients with aphasia and apraxia of speech were trained to produce complex or simple syllables (using modelling). Improvement was measured by percent correct on a word and nonword repetition test. OUTCOMES #ENTITYSTARTX00026; RESULTS: We found that both treatment on simple syllables and treatment on complex syllables led to improved production of simple syllables, while treatment of complex syllables also led to improvement on some complex syllables for one of the two patients. CONCLUSIONS: These results suggests that training complex items is more effective than training simple items, at least for some patients. Possible reasons for lack of stronger effects are discussed, as well as directions for future research.

Incomplete ossification of the humeral condyle in two Labrador retrievers

Incomplete ossification of the humeral condyle (IOHC) was identified in two Labrador retrievers using computed tomography. Both dogs were non-weightbearing on the affected forelimbs. The dogs were treated by means of a bone screw placed across the humeral condyle. IOHC was originally reported in spaniel and chondrodystrophic breeds. The pathogenesis of the condition remains unknown, but may be related to impaired antebrachial bone growth, similarly to the pathogeneses of elbow dysplasia and radius curvus.

Distortions in definite distance and shape perception as measured by reaching without and with haptic feedback

Psychophysical studies reveal distortions in perception of distance and shape. Are reaches calibrated to eliminate distortions? Participants reached to the front, side, or back of a target sphere. In Experiment 1, feedforward reaches yielded distortion and outward drift. In Experiment 2, haptic feedback corrected distortions and instability. In Experiment 3, feedforward reaches with only haptic experience of targets replicated the shape distortions but drifted inward. This showed that outward drift in Experiment 1 was visually driven. In Experiment 4, visually guided reaches were accurate when participants used binocular vision but when they used monocular vision, reaches were distorted. Haptic feedback corrected inaccuracy and instability of distance but did not correct monocular shape distortions. Dynamic binocular vision is representative and accurate and merits further study.

Distortions in definite distance and shape perception as measured by reaching without and with haptic feedback

Psychophysical studies reveal distortions in perception of distance and shape. Are reaches calibrated to eliminate distortions? Participants reached to the front, side, or back of a target sphere. In Experiment 1, feedforward reaches yielded distortion and outward drift. In Experiment 2, haptic feedback corrected distortions and instability. In Experiment 3, feedforward reaches with only haptic experience of targets replicated the shape distortions but drifted inward. This showed that outward drift in Experiment 1 was visually driven. In Experiment 4, visually guided reaches were accurate when participants used binocular vision but when they used monocular vision, reaches were distorted. Haptic feedback corrected inaccuracy and instability of distance but did not correct monocular shape distortions. Dynamic binocular vision is representative and accurate and merits further study.

Global dynamics of the advanced light source revealed through experimental frequency map analysis

Frequency map analysis was first used for the dynamical study of numerical simulations of physical systems (solar system, galaxies, particle accelerators). Here it is applied directly to the experimental results obtained at the Advanced Light Source. For the first time, the network of coupling resonances is clearly visible in an experiment, in a similar way as in the numerical simulation. Excellent agreement between numerical and experimental results leads us to propose this technique as a tool for improving numerical models and actual behavior of particle accelerators. Moreover, it provides a model-independent diagnostic for the evaluation of the dynamical properties of the beam.

Survival of a Pseudomonas fluorescens and Enterococcus faecalis aerosol on inert surfaces

The aim of the work presented here is to study airborne bacteria survival on three inert supports (glass, polyvinyl chloride, and stainless steel). Two Pasteur Institute bacteria were selected: Enterococcus faecalis 10.30.15 and Pseudomonas fluorescens 56.90. We have observed that bacterial aerosol lethality increased proportionally with the relative humidity of the environment, the gram-negative rod appearing more fragile than the cocci. A significant difference in survival rate is measured dependent on the supports tested, the greatest lethality being observed on the PVCs.

Subcutaneous adipose tissue expression of plasminogen activator inhibitor-1 gene during very low calorie diet in obese subjects

OBJECTIVE

To determine whether changes in subcutaneous adipose tissue plasminogen activator inhibitor-1 (PAI-1) expression influence plasma PAI-1 level during weight loss in obese humans.

DESIGN

Study of the variations of PAI-1 levels both in plasma and in subcutaneous abdominal adipose tissue in 15 volunteer non-diabetic obese subjects, body mass index (BMI) 40.4.+/-1.9 kg/m2, aged 48+/-3 y, before and after a 3 week very low calorie diet (VLCD) programme (3.9+/-0.1 MJ/day).

MEASUREMENTS

Plasma and adipose tissue PAI-1 protein levels were measured by enzyme-linked immunosorbent assay and PAI-1 mRNA levels were quantified by quantitative RT-competitive PCR.

RESULTS

VLCD induced weight loss (5.8+/-0.8 kg) and decreased plasma PAI-1 concentration (-26% (P<0. 01)). Surprisingly, PAI-1 mRNA and protein abundance in subcutaneous adipose tissue increased by 87% (P<0.05) and by 44% (P<0.01), respectively.

CONCLUSION

These data indicate thus that changes in subcutaneous adipose tissue PAI-1 expression are not involved in the decrease of plasma PAI-1 levels during VLCD in obese subjects. International Journal of Obesity (2000)24, 70-74

Peroxisome proliferator activated receptor-gamma, leptin and tumor necrosis factor-alpha mRNA expression during very low calorie diet in subcutaneous adipose tissue in obese women

BACKGROUND

PPAR gamma, leptin and TNF alpha are three major factors that play a key role in influencing adipocyte differentiation and both adipose tissue function and metabolism. However, the regulation of these three genes during a dynamic period of weight loss is unknown. We therefore investigated the concomitant regulation of the mRNA expression of PPAR gamma, leptin and TNF alpha in adipose tissue during a 21-day very low calorie diet (VLCD) in 12 non-diabetic obese women.

METHODS

The mRNA levels of PPAR gamma, leptin and TNF alpha were quantified by quantitative RT-competitive PCR in abdominal subcutaneous adipose tissue before and during VLCD (940 kcal/day).

RESULTS

VLCD induced weight loss (approximately 6 kg) and improved insulin sensitivity. Simultaneously, VLCD induced the reduction in the adipose tissue mRNA abundances of PPAR gamma (-13%, p < 0.05) and of leptin (-58%, p < 0.005), whereas TNF alpha mRNA levels increased (+78%, p < 0.005). PPAR gamma and leptin mRNA levels were correlated before (r = 0.778, p < 0.01) and after VLCD (r = 0.797, p < 0.01). Serum HDL-cholesterol concentrations were positively associated with PPAR gamma (r = 0.696, p < 0.03) and leptin (r = 0.806, p < 0.01) mRNA levels.

CONCLUSIONS

The increase in TNF alpha mRNA levels suggested that a local increased expression of this cytokine in adipose tissue might play a role in the control of the fat mass during weight loss. PPAR gamma and leptin mRNA levels were positively associated both before and after VLCD, suggesting that common regulatory mechanism(s) might control their expression. More strikingly, we found strong positive correlations between circulating HDL-cholesterol and both PPAR gamma and leptin mRNA levels, suggesting the existence of physiological links between circulating lipoprotein metabolism and adipose tissue function.

Isolation and characterization of the mouse cytosolic phosphoenolpyruvate carboxykinase (GTP) gene: evidence for tissue-specific hypersensitive sites

A 72 kilobase pair DNA fragment that contains the mouse phosphoenolpyruvate carboxykinase (PEPCK) gene locus, pck1, was isolated from a genomic bacterial artificial chromosome library. The region from approximately -5.5 to +6.6 kilobase pairs relative to the pck1 transcription start site was sequenced and exhibits a high degree of homology to the rat and human genes. Additionally, the chromatin structure of the PEPCK gene in mouse liver resembles that seen in rat. Backcross panel analysis of a microsatellite sequence confirms that the gene is located on chromosome 2. Hypersensitive site analysis was performed on nuclei isolated from the adipocyte cell line 3T3-F442A in the preadipose and adipose states. Several hypersensitive sites are present in the undifferentiated 3T3-F442A cells, before PEPCK mRNA is detected. The same sites are present after differentiation, however, the sensitivity of mHS 3 increases relative to the others. We conclude that the chromatin is open in 3T3-F442A cells and that factors are able to bind in the undifferentiated state but that something else is required for transcription.

Glucocorticoids repress induction by thiazolidinediones, fibrates, and fatty acids of phosphoenolpyruvate carboxykinase gene expression in adipocytes

Phosphoenolpyruvate carboxykinase (PEPCK) exerts a glyceroneogenic function in adipocytes in which transcription of its gene is increased by unsaturated fatty acids and fibrates. We used cultured rat adipose tissue fragments and 3T3-F442A adipocytes to show that the antidiabetic thiazolidinedione BRL 49653, a ligand and an activator of the gamma isoform of peroxisome proliferator activated receptors (PPARgamma), is a potent inducer of PEPCK mRNA. In 3T3-F442A adipocytes, the effect of BRL 49653 is rapid and concentration dependent, with a maximum reached at 1 microM and a half-maximum at 10-100 nM. PEPCK mRNA is similarly induced by the natural ligand of PPARgamma, the 15-deoxy-delta(12-14) prostaglandin J2. These observations strongly suggest that PPARgamma is a primary regulator of PEPCK gene expression in adipocytes. Dexamethasone at 10 nM repress induction of PEPCK mRNA by 1 microM BRL 49653, 0.32 mM oleate, or 1 mM clofibrate, in a cycloheximide-independent manner. The antiglucocorticoid RU 38486 prevents dexamethasone action, demonstrating involvement of the glucocorticoid receptor. Stable transfectants of 3T3-F442A adipocytes bearing -2100 to +69 base pairs of the PEPCK gene promoter fused to the chloramphenicol acetyltransferase (CAT) gene respond to 1 microM BRL 49653 or 1 mM clofibrate by a large increase in CAT activity, which is prevented by the simultaneous addition of 10 nM dexamethasone. Hence, in adipocytes, glucocorticoids act directly through the 5'-flanking region of the PEPCK gene to repress, in a dominant fashion, the stimulation of PEPCK gene transcription by thiazolidinediones and fibrates.

Transcriptional and posttranscriptional mechanisms of glucocorticoid-mediated repression of phosphoenolpyruvate carboxykinase gene expression in adipocytes

Glucocorticoids exert pleiotropic effects, among which negative regulation of transcription has been recognized as of crucial importance. While glucocorticoids induce phosphoenolpyruvate carboxykinase (PEPCK) gene expression in liver cells, it represses gene activity in adipose cells. We used the 3T3-F442A adipocytes to analyze the underlying mechanisms in these cells, the synthetic glucocorticoid dexamethasone exerts a dominant repression either on basal or on beta-agonist stimulation of PEPCK gene expression. To determine whether glucocorticoid action required protein synthesis, we employed cycloheximide, anisomycin, and puromycin, three different translation inhibitors. None of these affected induction by isoprenaline or repression by dexamethasone of isoprenaline stimulation. In contrast, dexamethasone inhibitory action on basal PEPCK mRNA was totally prevented by the three translation inhibitors. Time courses of glucocorticoid action on basal and on induction by beta-agonist were similar. Half-maximal effect of dexamethasone on isoprenaline-induced PEPCK mRNA was obtained at about 10 nM, a tenfold higher concentration than that observed for the reduction of basal mRNA. Using the transcription inhibitor DRB, we showed that dexamethasone did not alter mRNA half-life, while isoprenaline strongly stabilized mRNA. In a 3T3-F442A stable transfectant bearing -2,100 base pairs of the PEPCK promoter fused to the chloramphenicol acetyltransferase (CAT) gene, isoprenaline stimulated CAT activity, whereas dexamethasone reduced basal and isoprenaline-induced CAT expression. Hence, beta-agonists exert both transcriptional and posttranscriptional regulation, while glucocorticoid action is purely transcriptional. However, mechanisms of glucocorticoid repression of basal and of beta-agonist stimulation appear different.

[Post-traumatic temporomandibular pain dysfunction syndrome and the problems raised by its imputation]

Direct, certain and total imputability of trauma as the cause of mandibular joint dysfunction is often difficult to establish. The theoretically obligatory conditions are rarely met, making the expert's opinion quite difficult to establish. The complexity of the pathophysiology involved in mandibular joint dysfunction confirms however the reality of this sequella. By determining the precise lesional or functional origin of the syndrome and the latent or patent nature of the prior status it is possible to ascertain intermediary situations.

[Interobserver variation of the Global Assessment Scale. Study of 59 patients at admission to a general adult psychiatric unit]

In France, an analysis of the evaluation of psychiatric activity was done by a work group representing thirteen hospitals spread over the entire country. The group just recently published their final report in the form of an experimentation protocol for the description of psychiatric activity. The proposed methodology leads to some modifications of the existing data collection based on individual patient information sheets "fiche par patient", more particularly concerning new items such as the Global Assessment Scale (GAS or Axis V of DSM III-R): our first impression was that this new type of evaluation seemed to us somewhat subjective. We therefore decided to analyze the reliability of the score established by psychiatrists not familiar with its use. In the beginning the GAS score was evaluated in clinical cases (patients seen at their admission by two or three psychiatrists and scored afterwards independently), then in theoretical cases (34 cases types taken from the Health-Sickness Rating Scale of Luborsky) with the objective to improve the consensus between clinicians.

RESULTS

The clinical case studies made in an adult psychiatry pavilion permitted evaluating 59 patients at admission, of which 25 by three judges and respectively 40, 28 and 41 by pairs. The global accuracy of the score obtained with the clinical cases seems satisfactory for a discipline such as psychiatry (Kappa of Cohen's coefficient = 0.51, p < 0.001 for 25 patients by three judges--Kappa = 0.45, p < 0.001 for the 109 pairs of evaluations). The more detailed study of the classes obtained a satisfactory consensus for the scores below 40 and above 60 (K = 0.46 to 0.59) but not entirely satisfactory for the scores in the mid range of the scale between 40 and 60 (K = 0.22 to 0.29) which represents 39% of the patients in the study; this is improved by grouping into larger classes this part of the scale and it is therefore advisable to use it that way. For the 34 theoretical cases taken from the Luborsky HSRS evaluated independently by three judges the results obtained are clearly not as good (global Kappa = 0.29, p < 0.01). That is perhaps due to the fact that these "case types" don't use the descriptive patient models generally used in France. Keeping in mind that the mid range of the scale should be interpreted prudently, the GAS scale can nevertheless be credited with a certain global objectivity in the case of neutral study. Would it be the same if the GAS study could influence the allocation of resources? Taking into account all the clinical practices in mental health, the question of how all the data of this type evaluation could be recorded and updated should also examined.

Fatty acids and fibrates are potent inducers of transcription of the phosphenolpyruvate carboxykinase gene in adipocytes

Cytosolic phosphoenolpyruvate carboxykinase (PEPCK) plays a critical role in adipose tissue glyceroneogenesis. We have previously shown that transcription of the PEPCK gene was stimulated by isoprenaline and retinoic acid in 3T3-F442A adipocytes. We also showed that oleate increased PEPCK mRNA. Here, we analysed the effect that fatty acids of various chain lengths and unsaturation degrees exerted on PEPCK gene expression in 3T3-F442A adipocytes. When maintained in serum-free, glucose-free medium, differentiated cells responded to unsaturated long-chain fatty acids by a large increase in PEPCK mRNA whereas saturated fatty acids were inefficient. A maximum fivefold stimulation by oleate was attained at 4 h of treatment with 1 mM fatty acid bound to albumin in a 6:1 ratio. The poly-unsaturated very long-chain fatty acid all-cis-4,7,10,13,16,19-docosahexaenoic acid (C22:6) was even more potent and produced a tenfold increase. The expression of the genes encoding glycerol-3-phosphate dehydrogenase, hormone-sensitive lipase or actin remained unaffected by oleate exposure. A 4-h treatment by the hypolipidemic drug clofibrate, 0.5-2 mM, also produced a large (3-9-fold) increase in PEPCK mRNA. When used at non-saturating concentrations, oleate and clofibrate acted in an additive manner. At maximally effective concentrations, additivity was lost, suggesting that fatty acids and fibrates might act through similar mechanisms. Nuclear transcription experiments showed that oleate and clofibrate stimulated the transcription rate of the gene. 3T3-F442A cells were stably transfected with a plasmid containing the base pairs -2100 to +69 of the PEPCK gene promoter fused to the chloramphenicol acetyltransferase gene. These differentiated stable transfectants responded to oleate and clofibrate by a specific increase in chloramphenicol acetyltransferase activity. Adipocytes express various isoforms of peroxisome-proliferator-activated receptors that can be activated by fibrates and fatty acids. Potential recognition sequences for peroxisome-proliferator-activated receptors are present in the -2100 to +69 fragment of the PEPCK gene promoter. Thus, this gene represents an ideal molecular target for understanding the complex transcriptional control exerted by fatty acids and peroxisome proliferators.

Expression of the phosphoenolpyruvate carboxykinase gene in 3T3-F442A adipose cells: opposite effects of dexamethasone and isoprenaline on transcription

The enzyme phosphoenolpyruvate carboxykinase (PEPCK) plays a key role in gluconeogenesis in liver and in glyceroneogenesis in adipose tissue. These processes, and PEPCK, are regulated by a number of hormones, some of which have different effects on the enzyme in liver and adipose tissue. To explore this phenomenon, PEPCK gene expression was studied in 3T3-F442A adipocytes maintained in a serum-free medium. The beta-adrenergic agonist isoprenaline (isoproterenol) and a cyclic AMP analogue (8-CPT-cAMP) increased PEPCK mRNA. A maximal 3-fold induction occurred in 2 h. Dexamethasone decreased PEPCK mRNA by 80% in 4 h. Dexamethasone also counteracted the inductive effects of isoprenaline and 8-CPT-cAMP. Run-on transcription experiments showed that the isoprenaline and dexamethasone actions were, at least in part, exerted at the level of PEPCK gene transcription. These effects were further analysed by using transient and stable transfection of adipocytes with a plasmid containing bp -2100 to 69 of the PEPCK gene promoter fused to the chloramphenicol acetyltransferase (CAT) gene. In such cells isoprenaline stimulated CAT expression, an effect that was prevented if the cells were also exposed to dexamethasone.

Complications of bereavement as seen in infant anorexia and adolescent anorexia nervosa

In a certain number of cases, parents of infant and adolescent anorexics may exhibit complications of bereavement. Both infant and adolescent forms of anorexic symptoms constitute indeed two distinct pathologies. Sometimes, however, these two forms of anorexic symptoms share points in common, namely a psychopathological aspect. Making references to two clinical cases, the authors show that difficulties in the mourning process may in fact play a key role in the constitution of anorexic symptoms.