Self-Harm in Children and Adolescents Who Presented at Emergency Units During the COVID-19 Pandemic: An International Retrospective Cohort Study

OBJECTIVE

To compare psychiatric emergencies and self-harm at emergency departments (EDs) 1 year into the pandemic, to early pandemic and pre-pandemic, and to examine the changes in the characteristics of self-harm presentations.

METHOD

This retrospective cohort study expanded on the Pandemic-Related Emergency Psychiatric Presentations (PREP-kids) study. Routine record data in March to April of 2019, 2020, and 2021 from 62 EDs in 25 countries were included. ED presentations made by children and adolescents for any mental health reasons were analyzed.

RESULTS

Altogether, 8,174 psychiatric presentations were recorded (63.5% female; mean [SD] age, 14.3 [2.6] years), 3,742 of which were self-harm presentations. Rate of psychiatric ED presentations in March to April 2021 was twice as high as in March to April 2020 (incidence rate ratio [IRR], 1.93; 95% CI, 1.60-2.33), and 50% higher than in March to April 2019 (IRR, 1.51; 95% CI, 1.25-1.81). Rate of self-harm presentations doubled between March to April 2020 and March to April 2021 (IRR, 1.98; 95% CI, 1.68-2.34), and was overall 1.7 times higher than in March to April 2019 (IRR, 1.70; 95% CI, 1.44-2.00). Comparing self-harm characteristics in March to April 2021 with March to April 2019, self-harm contributed to a higher proportion of all psychiatric presentations (odds ratio [OR], 1.30; 95% CI, 1.05-1.62), whereas female representation in self-harm presentations doubled (OR, 1.98; 95% CI, 1.45-2.72) and follow-up appointments were offered 4 times as often (OR, 4.46; 95% CI, 2.32-8.58).

CONCLUSION

Increased pediatric ED visits for both self-harm and psychiatric reasons were observed, suggesting potential deterioration in child mental health. Self-harm in girls possibly increased and needs to be prioritized. Clinical services should continue using follow-up appointments to support discharge from EDs.

DIVERSITY & INCLUSION STATEMENT

One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. While citing references scientifically relevant for this work, we also actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our reference list. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Cognitive functioning and clinical characteristics of children with non-syndromic orofacial clefts: A case-control study

Introduction

The higher rate of neuropsychiatric disorders in individuals with non-syndromic orofacial clefts has been well documented by previous studies. Our goal was to identify children with non-syndromic orofacial clefts that are at risk for abnormal neurodevelopment by assessing their developmental history and present cognitive functioning.

Materials and methods

A single-center, case-controlled study was carried out at the Department of Pediatrics of the University of Pécs in Hungary. The study consisted of three phases including questionnaires to collect retrospective clinical data and psychometric tools to assess IQ and executive functioning.

Results

Forty children with non-syndromic oral clefts and 44 age-matched controls participated in the study. Apgar score at 5 min was lower for the cleft group, in addition to delays observed for potty-training and speech development. Psychiatric disorders were more common in the cleft group (15%) than in controls (4.5%), although not statistically significant with small effect size. The cleft group scored lower on the Continuous Performance Test. Subgroup analysis revealed significant associations between higher parental socio-economic status, academic, and cognitive performance in children with non-syndromic orofacial clefts. Analyzes additionally revealed significant associations between early speech and language interventions and higher scores on the Verbal Comprehension Index of the WISC-IV in these children.

Discussion

Children with non-syndromic orofacial clefts seem to be at risk for deficits involving the attention domain of the executive system. These children additionally present with difficulties that affect cognitive and speech development. Children with non-syndromic orofacial clefts show significant skill development and present with similar cognitive strengths as their peers. Longitudinal studies with larger sample sizes are needed to provide more conclusive evidence on cognitive deficits in children with non-syndromic orofacial clefts at risk for neurodevelopmental difficulties.

The Brain in Oral Clefting: A Systematic Review With Meta-Analyses

Background

Neuroimaging of individuals with non-syndromic oral clefts have revealed subtle brain structural differences compared to matched controls. Previous studies strongly suggest a unified primary dysfunction of normal brain and face development which could explain these neuroanatomical differences and the neuropsychiatric issues frequently observed in these individuals. Currently there are no studies that have assessed the overall empirical evidence of the association between oral clefts and brain structure. Our aim was to summarize the available evidence on potential brain structural differences in individuals with non-syndromic oral clefts and their matched controls.

Methods

MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Web of Science and Embase were systematically searched in September 2020 for case-control studies that reported structural brain MRI in individuals with non-syndromic oral clefts and healthy controls. Studies of syndromic oral clefts were excluded. Two review authors independently screened studies for eligibility, extracted data and assessed risk of bias with the Newcastle-Ottawa Scale. Random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals (95% CI) were performed in order to compare global and regional brain MRI volumes.

Results

Ten studies from 18 records were included in the review. A total of 741 participants were analyzed. A moderate to high risk of bias was determined for the included studies. The cerebellum (MD: -12.46 cm³, 95% CI: -18.26, -6.67, n = 3 studies, 354 participants), occipital lobes (MD: -7.39, 95% CI: -12.80, -1.99, n = 2 studies, 120 participants), temporal lobes (MD: -10.53 cm³, 95% CI: -18.23, -2.82, n = 2 studies, 120 participants) and total gray matter (MD: -41.14 cm³; 95% CI: -57.36 to -24.92, n = 2 studies, 172 participants) were significantly smaller in the cleft group compared to controls.

Discussion

There may be structural brain differences between individuals with non-syndromic oral clefts and controls based on the available evidence. Improvement in study design, size, methodology and participant selection could allow a more thorough analysis and decrease study heterogeneity.

The brain in oral clefting: preliminary results of a systematic review with meta-analyses

Introduction

Previous neuroimaging studies of individuals with nonsyndromic oral clefts have revealed subtle brain structural differences compared to matched controls. Additional studies strongly suggest that the higher incidence of neuropsychiatric issues observed in these individuals may be explained by these neuroanatomical differences. Currently there are no studies that have assessed the overall empirical evidence of the effect of oral clefts on the brain.

Objectives

Our aim was to summarize available evidence on potential brain structure differences in individuals with nonsyndromic oral clefts and their matched controls. In the current presentation, we discuss the results of regional brain structural differences.

Methods

Five databases were systematically searched in September 2020 for case-control studies that reported neuroimaging in healthy individuals and individuals with nonsyndromic oral clefts. Duplicate study selection, data extraction, random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals were performed in order to compare regional brain MRI volumes.

Results

We have identified 245 records following the database searches, from which 12 records met the inclusion criteria. Quantitative data on brain structure were available in three studies.The cerebellum, occipital and temporal lobes were significantly smaller in the cleft group compared to controls (MD: -12.46, 95% CI: -18.26, -6.67, n=3 studies; MD:-7.39, 95% CI: -12.80, -1.99, n=2 studies; MD: -10.53, 95% CI: -18.23, -2.82, n=2 studies, respectively).

Conclusions

There may be structural brain differences between individuals with nonsyndromic oral clefts and their controls based on the available evidence.

Disclosure

No significant relationships.

Anti-Neuronal Autoantibodies (Cell Surface and Onconeural) and Their Association With Natural Autoantibodies in Synthetic Cannabinoid-Induced Psychosis

Patients suffering from encephalitis may present psychiatric symptoms; however, the clinical relevance of anti-neuronal antibodies in patients experiencing a psychotic episode without encephalitis is still unclear. In this study, we examined the presence of anti-neuronal cell surface autoantibodies and onconeural autoantibodies in serum samples of 22 synthetic cannabinoid users presenting with psychosis. We found only two positive cases; however, seven patients had borderline results. Nonetheless, we found no significant correlation between anti-neuronal autoantibodies and the intensity of psychosis indicated by the Positive and Negative Syndrome Scale (PANSS) scores. The length of drug use and the combination of other drugs with synthetic cannabinoids have no significant effect on anti-neuronal autoantibody positivity. Nonetheless, the ratio of anti-citrate synthase (anti-CS) IgM and IgG natural autoantibodies was significantly lower (p = 0.036) in the anti-neuronal autoantibody-positive/borderline samples, than in the negative group. Interestingly, anti-CS IgM/IgG showed a significant negative correlation with PANSS-positive score (p = 0.04, r = -0.464). Our results demonstrated that anti-neuronal autoantibody positivity occurs in synthetic cannabinoid users, and the alteration of anti-CS IgM/IgG natural autoantibody levels points to immunological dysfunctions in these cases.

Increased Prevalence of Minor Physical Anomalies Among the Healthy First-Degree Relatives of Bipolar I Patients - Results With the Méhes Scale

Minor physical anomalies are somatic markers of aberrant neurodevelopment, so the higher prevalence of these signs among the relatives of bipolar I patients can confirm minor physical anomalies as endophenotypes. The aim of the study was to evaluate the prevalence of minor physical anomalies in first-degree healthy relatives of patients with bipolar I disorder compared to normal control subjects. Using a list of 57 minor physical anomalies (the Méhes Scale), 20 first-degree unaffected relatives of patients with the diagnosis of bipolar I disorder and as a comparison 20 matched normal control subjects were examined. Minor physical anomalies were more common in the ear, head, mouth and trunk regions among the relatives of bipolar I patients compared to normal controls. By the differentiation of minor malformations and phenogenetic variants, we have found that both minor malformations and phenogenetic variants were more common among the relatives of bipolar I patients compared to the control group, while individual analyses showed, that one minor malformation (sole crease) and one phenogenetic variant (high arched palate) were more prevalent in the relative group. This is the first report in literature on the increased prevalence of minor physical anomalies among the first-degree unaffected relatives of bipolar I patients. The study support the concept, that minor physical anomalies can be endophenotypic markers of bipolar I affective disorder.

[Catatonia in childhood and adolescence - a brief review and case report]

The authors overview the clinical, epidemiological, pathophysiological and therapeutic aspects of catatonia in childhood and adolescence. They deal with the recent changes of the nosological position of the phenomenon, and emphasize the importance of specific therapeutic interventions.

Adaptation and validation of the Hungarian version of the Yale Food Addiction Scale for Children

Background Childhood obesity proves to be an important public health issue, since it serves as a potential risk factor for multiple diseases. Food addiction could also serve as an important etiological factor. As childhood obesity plays a serious issue also in Hungary, we aimed to adapt and validate the Hungarian version of the Yale Food Addiction Scale for Children (H-YFAS-C). Methods A total of 191 children were assessed with the H-YFAS-C and the Eating Disorder Inventory (EDI). The following psychometric properties were analyzed: internal consistency, construct validity, convergent, and discriminant validity. Results A good construct validity was revealed by confirmatory factor analysis (RMSEA = 0.0528, CFI = 0.896, χ² value = 279.06). Question 25 proved to have no significant effect on its group and was removed from further analyses. The Kuder-Richardson 20 coefficient indicated good internal consistency (K20 = 0.82). With the use of the eight EDI subscales, a good convergent and discriminant validity could be determined. Food addiction was diagnosed in 8.9% of children. The mean symptom count was 1.7 ± 1.2 (range: 0-7). Females were more often diagnosed with food addiction than males (p = .016; OR = 3.6, 95% CI: 1.2-10.6). BMI percentiles were significantly higher in children with diagnosed food addiction (p = .003). There proved to be no correlation between age and the occurrence of food addiction. Discussion and conclusion Our results show that H-YFAS-C is a good and reliable tool for addictive-like behavior assessment.

Minor physical anomalies and dermatoglyphic signs in affective disorders: A systematic review

The increased prevalence of minor physical anomalies (MPAs) and the abnormalities of dermatoglyphic patterns may be physical manifestations of neurodevelopmental disruption in affective disorders. This paper aims to review the current state of knowledge on the frequency of MPAs and dermatoglyphic abnormalities in mood disorders. A MEDLINE, PsychInfo and Web of Science search was carried out to collect all publications on the frequency of MPAs and on dermatoglyphic traits in bipolar disorder and unipolar depression. 24 studies on MPAs, 19 on dermatoglyphics, and 5 dealing with both were found with discrepant findings. The relative contribution of neurodevelopmental retardation to the aetiology of affective disorders remains undetermined, the field is open for further research. Increased recognition of neurodevelopmental processes in the origin of affective disorders may allow for earlier and more effective intervention and prevention.

Minor physical anomalies are more common among the first-degree unaffected relatives of schizophrenia patients - Results with the Méhes Scale

Minor physical anomalies are external markers of abnormal brain development,so the more common appearance of these signs among the relatives of schizophrenia patients can confirm minor physical anomalies as intermediate phenotypes. The aim of the present study was to investigate the rate and topological profile of minor physical anomalies in the first-degree unaffected relatives of patients with schizophrenia compared to matched normal control subjects. Using a list of 57 minor physical anomalies (the Méhes Scale), 20 relatives of patients with the diagnosis of schizophrenia and as a comparison 20 matched normal control subjects were examined. Minor physical anomalies were more common in the head and mouth regions among the relatives of schizophrenia patients compared to normal controls. By the differentiation of minor malformations and phenogenetic variants, we have found that only phenogenetic variants were more common in the relatives of schizophrenia patients compared to the control group, however individual analyses showed, that one minor malformation (flat forehead) was more prevalent in the relative group. The results can promote the concept, that minor physical anomalies can be endophenotypic markers of the illness.

[Yale Food Addiction Scale - review of literature]

INTRODUCTION

Food addiction is a condition presenting with a similar symptomatology to that of drug addiction, with an underlying individual sensitivity and special adaptation to certain foods, being consumed regularly. The concept of food addiction created one of the central issues in addiction research, owing to the pandemic spreading of obesity causing serious public health concerns. Development of an objective, standardized measuring tool of food addiction has become markedly necessary for both research and public health purposes.

METHODS

Literature overview in the fields of food addiction and Yale Food Addiction Scale (1956-2016).

RESULTS

For the establishment of food addiction diagnosis, the Yale Food Addiction Scale has become the most widely used method. It is an English questionnaire consisting of 25 questions, having been developed according to the 7 substance use disorder criteria in DSM-IV. The scale provides the possibility of diagnosis establishment, as well as measurement of food addiction severity. Development of the scale has given way to a number of new scientific results. The mean prevalence of food addiction is 19.7%, being more common in women, obese individuals, people >35 years and patients with already established eating disorders (binge eating disorder, bulimia). The most common symptom is the 'persistent desire or repeated unsuccessful attempts to quit'. A positive association has been recognized between food addiction symptomcount and the reward system dysfunction.

CONCLUSION

The Yale Food Addiction Scale is a psychometrically valid, objective and standardized tool, being not only useful in addiction research but also helping in diagnosis establishment in clinical practice.

Minor physical anomalies are more common in schizophrenia patients with the history of homicide

Minor physical anomalies may be external markers of abnormal brain development, so the more common appearance of these signs in homicidal schizophrenia might suggest the possibility of a more seriously aberrant neurodevelopment in this subgroup. The aim of the present study was to investigate the rate and topological profile of minor physical anomalies in patients with schizophrenia with the history of committed or attempted homicide comparing them to patients with schizophrenia without homicide in their history and to normal control subjects. Using a list of 57 minor physical anomalies, 44 patients with the diagnosis of schizophrenia were examined with the history of committed or attempted homicide, as a comparison 22 patients with the diagnosis of schizophrenia without the history of any kind of homicide and violence and 21 normal control subjects were examined. Minor physical anomalies are more common in homicidal schizophrenia patients compared to non-homicidal schizophrenia patients and normal controls, which could support a stronger neurodevelopmental component of etiology in this subgroup of schizophrenia. The higher rate of minor physical anomalies found predominantly in the head and mouth regions in homicidal schizophrenia patients might suggest the possibility of a more seriously aberrant brain development in the case of homicidal schizophrenia.

Genetic testing of hereditary spastic paraplegia

Introduction: Hereditary spastic paraplegia is the overall term for clinically and genetically diverse disorders characterized with progressive and variable severe lower extremity spasticity. The most common causes of autosomal dominantly inherited hereditary spastic paraplegias are different mutations of the spastin gene with variable incidence in different ethnic groups, ranging between 15–40%. Mutations in the spastin gene lead to loss of spastins function, causing progressive neuronal failure, which results in axon degeneration finally. Aim: The molecular testing of spastin gene is available in the institution of the authors since January, 2014. The experience gained with the examination of the first eleven patients is described in this article. Method: After polymerase chain reaction, Sanger sequencing was performed to examine the 17 exons of the spastin gene. Multiplex ligation-dependent probe amplification was performed to detect greater rearrangements in the spastin gene. Eight of the patients were examined in the genetic counseling clinic of the authors and after detailed phenotype assessment spastin gene testing was obtained. The other three patients were referred to the laboratory from different outpatient clinics. Results: Out of the 11 examined patients, four different pathogenic mutations were found in 5 patients. Conclusions: The first Hungarian data, gained with the examination of spastin gene are presented in this article. The five patients, in whom mutations were detected, represent 45.5% of all tested patients with hereditary spastic paraplegia, which is similar to those published in the international literature. Molecular testing and subsequent detailed genotype-phenotype correlations of the Hungarian patients may serve valuable new information about the disease, which later on may influence our therapeutic possibilities and decisions. Orv. Hetil., 2015, 156(3), 113–117.

[Anti-N-methyl-D aspartate receptor encephalitis - guideline to the challenges of diagnosis and therapy]

OBJECTIVE

Anti-N-methyl-D-Aspartate encephalitis is a recently diagnosed autoimmune disorder with increasing significance. During this disease antibodies are produced against the subunit of the NMDA receptor, which cause different symptoms, both psychiatric and neurological. The aim of this publication is to introduce this disease, to facilitate the diagnosis and to recommend therapeutical guideline.

MATERIALS AND METHODS

In this review we summarized the relevant literature published between 2007 and 2015 giving emphasis on etiopathogenesis, diagnosis, differential diagnosis, treatment and prognosis.

RESULTS

In the etiology an underlying tumor or a viral agent should be considered. During the disease we can discern 3 periods: first prodromal viral infections-like symptoms can be seen, 1-2 weeks later psychiatric symptoms, such as aggression, sleep and behavior disturbances appear. After that neurological symptoms (tonic-clonic convulsions, aphasia, catatonia, orofacial dyskinesia, autonom lability, altered mental state) are typical, and the patient's condition deteriorates. For the correct diagnosis it is necessary to detect antibodies against the NMDA receptor from the serum and the liquor. Steroids, immunoglobulins and plasmaheresis are the first-line therapies. If the disease is unresponsive, then as a second-line therapy anti-CD 20 (Rituximab) and cyclophosphamid can be useful. Most of the patients are improving without any neurological sequale with prompt detection and appropriate therapy.

CONCLUSION

It is important to be familiar with the symptoms, diagnosis and therapy of this disease as a practicing clinician, especially as a psychiatrist or neurologist. 75 percentage of the patients are admitted to psychiatric departments first because of the leading symptoms. Autoimmune NMDA encephalitis is a reversible disease after early diagnosis and treatment.

[Minor physical anomalies in the relatives of schizophrenia patients. A systematic review of the literature]

Minor physical anomalies are mild, clinically and cosmetically insignificant errors of morphogenesis which have a prenatal origin and may bear major informational value for diagnostic, prognostic and epidemiological purposes. Since both the central nervous system and the skin are derived from the same ectodermal tissue in utero, minor physical anomalies can be external markers of abnormal brain development and they appear more commonly in neurodevelopmental disorders. Recently studies were published on the prevalence of minor physical anomalies in the relatives of patients with schizophrenia. In a systematic review of literature 11 studies were identified with mixed results. We suppose that the differentiation of minor malformations and phenogenetic variants can help to clarify the minor anomaly profile as a potential endophenotype in schizophrenia.

[Minor physical anomalies in autism]

BACKGROUND AND PURPOSE

Minor physical anomalies are mild, clinically and cosmetically insignificant errors of morphogenesis which have a prenatal origin and may bear major informational value for diagnostic, prognostic and epidemiological purposes. Since both the central nervous system and the skin are derived from the same ectodermal tissue in utero, minor physical anomalies can be external markers of abnormal brain development and they appear more commonly in neurodevelopmental disorders. In a recently published meta-analysis Ozgen et al. have published the results of seven studies--all have used the Waldrop Scale which contains 18 minor physical anomalies--and reported on the higher prevalence of minor physical anomalies among patients with autism. There are only a very few data on the individual analysis of the prevalence of minor physical anomalies in autism.

METHODS

In our study we have studied the prevalence of 57 minor physical anomalies in 20 patients with autism and in 20 matched control subjects by the use of the Méhes Scale.

RESULTS

The prevalence of minor physical anomalies was significantly higher in the autism group (p < 0.001). The individual analysis of the 57 minor physical anomalies showed the significantly more frequent apperance of four signs (primitive shape of ear p = 0.047, abnormal philtrum p = 0.001, clinodactylia p = 0.002, wide distance between toes 1 and 2 p = 0.003). No correlation was found between the four significantly more common minor physical anomalies.

CONCLUSION

The higher prevalence of minor physical anomalies in autism supports the neurodevelopmental hypothesis of the disorder and the individual analysis of minor physical anomalies can help to understand the nature of the neurodevelopmental defect.

Relation between biomarkers and clinical severity in patients with Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS), a multiple congenital anomaly with severe mental retardation, is caused by decreased activity of 7-dehydrocholesterol reductase. Fifteen Hungarian patients were diagnosed with SLOS on the basis of clinical symptoms, serum cholesterol, 7-dehydrocholesterol, and molecular genetic testing. Their age at the time of diagnosis in mild SLOS (n = 4, clinical score <20) was 0.5-18 years, cholesterol was 2.37 ± 0.8 mmol/L, and 7DHC was 0.38 ± 0.14 mmol/L. In the group of typical SLOS (n = 7, score 20-50), the diagnosis was set up earlier (age of 0.1-7 years); t-cholesterol was 1.47 ± 0.7 mmol/L, and 7DHC was 0.53 ± 0.20 mmol/L. Patients with severe SLOS (n = 4, clinical score > 50) died as newborns and had the lowest t-cholesterol (0.66 ± 0.27 mmol/L), and 7DHC was 0.47 ± 0.14 mmol/L. Correlation coefficient with clinical severity was 0.74 for initial t-cholesterol and 0.669 for Cho/7DHC. Statistically significant difference was between the initial t-cholesterol of mild and severe SLOS (p = 0.01), and between the Cho/7DHC ratios of groups (p = 0.004). In severe SLOS, the percentage of α-lipoprotein was significantly lower than in typical (p = 0.003) and mild SLOS (p = 0.004). Although serum albumin, total bilirubin, and hemostasis parameters remained in the reference range during cholesterol supplementation (n = 10) combined with statin therapy (n = 9), increase of aspartate aminotransferase and alanine aminotransferase in 50 % of the patients probably refers to a reversible alteration of liver function; therefore, statin therapy was suspended.

CONCLUSION

life expectancy is fundamentally determined by the initial t-cholesterol, but dehydrocholesterol and α-lipoprotein have prognostic value. Accumulation of hepatotoxic DHC may inhibit the synthesis of α-lipoproteins, decreasing the reverse cholesterol transport. During statin therapy, we suggest monitoring of lipid parameters and liver function.

Mutational spectrum of smith-lemli-opitz syndrome patients in hungary

Smith-Lemli-Opitz (SLO) syndrome is an autosomal recessive disorder characterized by multiple congenital abnormalities and mental retardation. The condition is caused by the deficiency of 7-dehydrocholesterol reductase (DHCR7) which catalyzes the final step in cholesterol biosynthesis. Biochemical diagnosis is based on increased concentration of 7-dehydrocholesterol (7-DHC) in the patient serum. Both life expectancy and quality of life are severely affected by the disease. The estimated prevalence of SLO syndrome ranges between 1:20,000 and 1:40,000 among Caucasians. Although the mutational spectrum of the disease is wide, approximately 10 mutations are responsible for more than 80% of the cases. These mutations show a large interethnic variability. There are no mutation distribution data from Hungary to date. Thirteen patients were diagnosed with SLO syndrome in our laboratory. As first-line tests, serum 7-DHC and total cholesterol were measured and, in positive cases, molecular genetic analysis of the DHCR7 gene was performed. Complete genetic background of the disease could be identified in 12 cases. In 1 case only 1 mutation was detected in a heterozygote form. One patient was homozygous for the common splice site mutation c.964-1G>C, while all other patients were compound heterozygotes. One novel missense mutation, c.374A>G (p.Tyr125Cys) was identified.

Effects of prenatal fish-oil and 5-methyltetrahydrofolate supplementation on cognitive development of children at 6.5 y of age

BACKGROUND

The influence of prenatal long-chain polyunsaturated fatty acids (LC-PUFAs) and folate on neurologic development remains controversial.

OBJECTIVE

The objective was to assess the long-term effects of n-3 (omega-3) LC-PUFA supplementation, 5-methyltetrahydrofolate (5-MTHF) supplementation, or both in pregnant women on cognitive development of offspring at 6.5 y of age.

DESIGN

This was a follow-up study of the NUHEAL (Nutraceuticals for a Healthier Life) cohort. Healthy pregnant women in 3 European centers were randomly assigned to 4 intervention groups. From the 20th week of pregnancy until delivery, they received a daily supplement of 500 mg docosahexaenoic acid (DHA) + 150 mg eicosapentaenoic acid [fish oil (FO)], 400 μg 5-MTHF, or both or a placebo. Infants received formula containing 0.5% DHA and 0.4% arachidonic acid (AA) if they were born to mothers receiving FO supplements or were virtually free of DHA and AA until the age of 6 mo if they belonged to the groups that were not supplemented with FO. Fatty acids and folate concentrations were determined in maternal blood at weeks 20 and 30 of pregnancy, at delivery, and in cord blood. Cognitive function was assessed at 6.5 y of age with the Kaufman Assessment Battery for Children (K-ABC).

RESULTS

We observed no significant differences in K-ABC scores between intervention groups. Higher DHA in maternal erythrocytes at delivery was associated with a Mental Processing Composite Score higher than the 50th percentile in the offspring.

CONCLUSION

We observed no significant effect of supplementation on the cognitive function of children, but maternal DHA status may be related to later cognitive function in children. This trial was registered at clinicaltrials.gov as NCT01180933.

Prenatal DHA status and neurological outcome in children at age 5.5 years are positively associated

Beneficial effects of perinatal DHA supply on later neurological development have been reported. We assessed the effects of maternal DHA supplementation on the neurological development of their children. Healthy pregnant women from Spain, Germany, and Hungary were randomly assigned to a dietary supplement consisting of either fish oil (FO) (500 mg/d DHA + 150 mg/d EPA), 400 μg/d 5-methyltetrahydrofolate, both, or placebo from wk 20 of gestation until delivery. Fatty acids in plasma and erythrocyte phospholipids (PL) were determined in maternal blood at gestational wk 20 and 30 and in cord and maternal blood at delivery. Neurological development was assessed with the Hempel examination at the age of 4 y and the Touwen examination at 5.5 y. Minor neurological dysfunction, neurological optimality score (NOS), and fluency score did not differ between groups at either age, but the odds of children with the maximal NOS score increased with every unit increment in cord blood DHA level at delivery in plasma PL (95% CI: 1.094-2.262), erythrocyte phosphatidylethanolamine (95% CI: 1.091-2.417), and erythrocyte phosphatidylcholine (95% CI: 1.003-2.643). We conclude that higher DHA levels in cord blood may be related to a better neurological outcome at 5.5 y of age.

[Anti-NMDA-receptor encephalitis: description of the syndrome in connection with the first Hungarian patient]

In the majority of cases, anti-NMDA (N-methyl-D-aspartate) receptor encephalitis is a severe, but treatable disorder, therefore early diagnosis and adequate therapy are very important. It should be suspected in children and young women, who develop acute psychiatric symptoms and seizures. During the course of the disease severe encephalopathy, agitation, hallucinations, orofacial dyskinesias, prolonged cognitive disturbance, autonomic symptoms can be observed and akinetic mutism develops. EEG shows diffuse slowing. Brain MRI is normal or unspecific. Elevated protein, pleiocytosis and oligoclonal bands can be present in the CSF Detection of NMDA-receptor antibodies in sera or CSF confirms diagnosis. We present the case of a 15-year-old girl, who fully recovered within two months after steroid treatment and repeated plasma exchange. Ovarian teratoma has not been detected.

Transverse myelitis as a rare, serious complication of Mycoplasma pneumoniae infection

We report on the first published case of a Mycoplasma pneumoniae-associated transverse myelitis appearing in childhood and leading to persistent paraplegia and bowel and bladder dysfunctions. Magnetic resonance imaging of the spinal cord indicated extensive transverse myelitis extending from T(5)-T(12). A repeated scan established spinal cord atrophy in the affected area. Various therapies (methylprednisolone pulse therapy, plasmapheresis, and roxythromycine) produced no clinical effect.

Minor physical anomalies in affective disorders. A review of the literature

BACKGROUND

The increased frequency of MPAs may be external markers of abnormal brain development in affective disorders.

METHODS

A MEDLINE, psychInfo and Web of Science search was evaluated to collect all publications on the prevalence of minor physical anomalies in bipolar affective disorder and unipolar major depression.

AIMS

As reports on the prevalence of MPAs in affective disorders were controversial, were based on highly different number of patients and were evaluated by the use of scales with different sensitivities, we considered as important to review the current state of knowledge and to recommend directions to further research.

RESULTS

14 publications on 12 studies were found after a careful literature search. 5 studies have dealt with the prevalence of MPAs in bipolar affective disorder, 3 have reported on examinations among patients with unipolar major depression, while 5 publications on 3 studies combined patients with bipolar affective disorder, schizoaffective disorder and unipolar major depression. 1 study was published on the prevalence of MPAs among mood disorders, without the differentiation of the data of patients with bipolar affective disorder and unipolar major depression.

LIMITATIONS

Few studies with relatively small size were published, there is no data on the distinction between bipolar I and bipolar II disorders.

CONCLUSION

The reviewed data suggest a higher probability of the role of an aberrant neurodevelopment in bipolar affective disorder and a smaller in unipolar major depression.

The decoding of the flouting of the Gricean relevance maxim is impaired in mental retardation caused by perinatal hypoxia. A brief report

The authors examined the decoding of the flouting of the Gricean relevance maxim among children with mental retardation compared to a mental age matched control group with average intellectual capacities, where the cause of mental retardation was perinatal hypoxia. They have investigated the decoding deficit by five short "question and answer" conversation vignettes, where the flouting of the relevance maxim was presented. They have found significant deficit in the mental retardation group in their capacity to decode properly the flouting of the Gricean relevance maxim. These data are the first that point at a pragmatic language use deficit in mental retardation caused by perinatal hypoxia.

[Mental retardation in childhood. The prevalence of informative morphogenetic variants]

The authors observed the prevalence of informative morphogenetic variants among mentally retarded children. In their retrospective examination of a 4-years period, they included 135 hospitalized children and analysed their clinical epidemiological and dysmorphic profiles. In their descriptive analysis they found ear abnormalities and abnormal head circumference as the most common dysmorphic sings among mentally retarded children, and they emphasize the highly different importance and predictive-diagnostic value of minor malformations and phenogenetic variants.

[Behavioral phenotypes and cognitive characteristics in mental retardation]

The authors in a review article deal with characteristic cognitive and behavioral features appearing in mental retardations, which later are referred as behavioral phenotypes. Nyhan (1972) introduced the term "behavioral phenotype" to describe outwardly observable behavior so characteristic of children with genetic disorders that its presence suggests the underlying genetic condition. The behavioral phenotype is a characteristic pattern of motor, cognitive, linguistic and social abnormalities that is consistently associated with a biological/neurodevelopmental disorder. This does not mean that the behavior is present in all instances but that the probability of its occurrence is increased. In the future, more may be learned about brain mechanisms and gene-brain interactions by comparing those with behavioral involvement with others with the same syndrome but without the behavioral features.

Minor physical anomalies in non-familial unipolar recurrent major depression

BACKGROUND

The prevalence of minor physical anomalies (MPAs) was evaluated in patients with unipolar recurrent major depression to get indirect data on the possible role of aberrant neurodevelopment in the aetiology of major depression. One published study [Lohr et al., Am. J. Geriatr. Psychiatry 5 (1997) 318] on the MPA prevalence in unipolar depression, evaluated by the recently widely criticized Waldrop-scale, reports on a significantly higher MPA rate among patients.

METHODS

A scale developed by Méhes [Prog. Clin. Biol. Res. 163 (1985) 45] was used to detect the presence or absence of 57 MPAs in 30 patients with major depression and in 30 matched controls.

RESULTS

The depressive sample did not differ significantly from the control group (P=0.200). By comparing each MPA individually we could not find any significant differences between the depressive and the control sample.

LIMITATIONS

Patients and control subjects had a negative family history in connection with affective disorders; a high-risk population should give significant positive results.

CONCLUSIONS

The results do not support the role of an 'early neurodevelopmental origin' in unipolar depression.

Minor physical anomalies in schizophrenia and bipolar affective disorder

OBJECTIVE

The prevalence of minor physical anomalies (MPAs) (prenatal errors of morphogenesis) was evaluated in patients with schizophrenia and bipolar affective disorder.

METHOD

A new modification of the Waldrop-scale was used to detect the presence or absence of 57 MPAs in 30 patients with schizophrenia, 30 with bipolar disorder, and in 30 matched normal controls.

RESULTS

Patients with schizophrenia compared to normal controls had significantly higher rates of three minor malformations (furrowed tongue, flat occiput, primitive shape of ears) and those of one phenogenetic variant (wide distance between toes 1 and 2), and they also had a significantly higher rate of one minor malformation (primitive shape of ears), as compared to patients with bipolar disorder. In patients with bipolar disorder, furrowed tongue was significantly more common than in controls.

CONCLUSIONS

These results support an 'early' neuro-developmental model of schizophrenia.

Polyunsaturated fatty acids in plasma lipids of obese children with and without metabolic cardiovascular syndrome

Previously we reported significantly higher values of gamma-linolenic acid (GLA, 18:3n-6), dihomo-gamma-linolenic acid (DHGLA, 20:3n-6), and arachidonic acid (20:4n-6) in plasma lipid classes in obese children than in nonobese controls. In the present study, fatty acid composition of plasma phospholipids (PL) and sterol esters (STE) was determined by high-resolution capillary gas-liquid chromatography in obese children with and without metabolic cardiovascular syndrome [MCS: defined as simultaneous presence of (i) dyslipidemia, (ii) hyperinsulinemia, (iii) hypertension, and.(iv) impaired glucose tolerance] and in nonobese controls. Fatty acid composition of PL and STE lipids did not differ between obese children without MCS and controls. Obese children with MCS exhibited significantly lower linoleic acid (LA, 18:2n-6) values in PL (17.43 [2.36], % wt/wt, median [range from the first to the third quartile]) than obese children without MCS (19.14 [3.49]) and controls (20.28 13.80]). In contrast, PL GLA values were significantly higher in obese children with (0.13 [0.08]) than in those without MCS (0.08 [0.04]), whereas STE GLA values were higher in obese children with MCS (1.04 [0.72]) than in controls (0.62 [0.48]). DHGLA values in PL were significantly higher in obese children with MCS (4.06 [0.74]) than in controls (2.69 [1.60]). The GLA/LA ratio was significantly higher, whereas the AA/DHGLA ratio was significantly lower in obese children with MCS than in obese children without MCS and in controls. In this study, LA metabolism was affected only in obese children with but not in those without MCS. In obese children with MCS, delta6-desaturase activity appeared to be stimulated, whereas delta5-desaturase activity appeared to be inhibited. Disturbances in LA metabolism may represent an additional health hazard within the multifaceted clinical picture of MCS.

Depressive symptoms among obese children

The authors compare the appearance of depressive symptoms in 30 obese children in outpatient care and 30 normal-weight controls. The Montgomery-Asberg Depression Rating Scale showed a significantly higher rate of depression in the obese children (p < 0.01). The results are interpreted in the light of the partially contradictory views in the literature. Reference is also made to the therapeutic aspects of the problem.

Antipsychotics and breast-feeding: a review of the literature

Many women with mental illnesses would like to breast feed their infants. In light of the limited but rapidly growing data, it seems that in some cases the possible physiological and psychological benefits may outweigh putative risks. All antipsychotics are secreted into breast milk but the concentrations and effects vary. There is a subgroup of mothers with mental illnesses who want to breast feed their infants and who are receiving a single established antipsychotic drug (principally, haloperidol or chlorpromazine) at the lowest possible clinically effective dose. As a tentative conclusion, this group could experience benefits from being able to nurse which would outweigh the risk of exposing their babies to very small amounts of antipsychotic drugs. However, larger study groups with longer follow-up periods would be required to confirm this tentative conclusion. Those mothers who require 2 or more antipsychotic drugs simultaneously and those taking one drug, but at the upper end of the recommended dose range, should not be advised to breast feed. Safety considerations suggest that women taking atypical antipsychotics would be advised not to breast feed because of the limited experience with these agents. When mothers taking antipsychotic drugs do nurse, it is desirable to monitor drug concentrations in breast milk and in the infants themselves. Close monitoring of the infant is essential.

Presence of metabolic cardiovascular syndrome in obese children

The aim of the present study was to investigate the aggregation of cardiovascular risk factors (hyperinsulinaemia, impaired glucose tolerance, dyslipidaemia, and hypertension) in 180 (77 female, 103 male) obese and 239 control children. Blood glucose, serum insulin and lipid levels were determined from blood samples taken after an overnight fast. Oral glucose tolerance tests were performed and blood glucose concentrations were monitored. The body mass index, body fat (on the basis of skinfold measurements), lean body mass and waist/hip ratio were calculated and blood pressure was measured five times in all subjects. It was shown that only 14.4% of obese children were free from any risk factors, in contrast to 79.1% of the control children. Four risk factors (metabolic cardiovascular syndrome) were found in 8.9% of the obese children (8.7% in males and 9.1% in females) while none could be detected in controls. Considerable differences were also detected in the prevalence of one, two or three risk factors between control and obese children. Patients with the metabolic cardiovascular syndrome could not be characterized by any of the investigated anthropometric characteristics, but the duration of obesity was significantly longer in these children.

CONCLUSION

Potential risk factors for cardiovascular diseases already tend to cluster in childhood and they are strongly associated with obesity. Our observations suggest that the development of the metabolic cardiovascular syndrome has its origin in childhood.

Informative morphogenetic variants in patients with schizophrenia and alcohol-dependent patients: beyond the Waldrop Scale

OBJECTIVE

The authors evaluated the presence or absence of informative morphogenetic variants in patients with schizophrenia compared with alcohol-dependent patients.

METHODS

Taking into consideration the criticisms of the Waldrop Scale, which was widely used until recently to define the presence of informative morphogenetic variants, the authors evaluated the presence or absence of 56 informative morphogenetic variants in 50 consecutively admitted patients with schizophrenia and 50 consecutively admitted alcohol-dependent patients. They made a distinction between minor malformations (those developing during organogenesis) and phenogenetic variants (those developing after organogenesis). A kappa index above 75% was considered reliable.

RESULTS

Thirty-four of the 56 informative morphogenetic variants met the authors' reliability criterion. Patients with schizophrenia had significantly higher rates of three minor malformations (furrowed tongue, multiple buccal frenula, and hemangioma) and two phenogenetic variants (protruding auricle and large tongue).

CONCLUSIONS

The results suggest that using finer distinction in the evaluation of informative morphogenetic variants in schizophrenia may open new perspectives in the research of the neurodevelopmental background of schizophrenia.

Urinary sodium excretion: association with hyperinsulinaemia, hypertension and sympathetic nervous system activity in obese and control children

The aim of the present study was to evaluate the association between 24 h urinary excretion of sodium and blood pressure, fasting plasma insulin, renin, aldosterone and serum norepinephrine concentrations in 45 obese and 15 control children. Urinary sodium excretion was significantly lower in obese subjects (1.3 +/- 0.6 mmol/kg/24 h, P < 0.01) than in controls (2.8 +/- 1.3 mmol/kg/24 h). Hyperinsulinaemia did not affect sodium excretion of obese children. Plasma renin and aldosterone levels did not correlate with sodium excretion and were significantly higher in overweight children. Serum norepinephrine levels were also significantly higher in the obese group (0.66 +/- 0.89 microgram/100 ml) as compared to the controls (0.11 +/- 0.03 microgram/100 ml, P < 0.01) and showed significant negative correlation with urinary sodium excretion (r = 0.43, P < 0.05).

CONCLUSION

Hyperinsulinaemia and the consequently increased sympathetic nervous system activity might be involved in the development of high blood pressure in obese children by decreasing urinary sodium excretion.

[Multi-metabolic syndrome in obese children]

The occurrence of multimetabolic syndrome was studied in 114 (63 boys, 51 girls) obese children. From the blood sample taken after on overnight fast blood sugar, serum insulin, and lipid levels were determined. During oral glucose tolerance test blood sugar concentrations were followed. Body mass index, body fat (on the basis of skinfold measurements), lean body mass and waist/hip ratio were calculated and blood pressure was measured 6 times in all subjects. Multimetabolic syndrome was found in 16% of boys and 19.6% of girls. No significant sex difference in the frequency of multimetabolic syndrome was found. Patients with multimetabolic syndrome could not be characterized by high waist/hip ratio any other antropometric parameter. The duration of obesity was significantly higher in subjects with multimetabolic syndrome than in those not suffering from the syndrome. This finding supports the hypothesis that the development of the multimetabolic syndrome is a process. The authors emphasize the significance of this problem and the importance of early recognition and prevention.