Potential disturbance of methylphenidate of gonadal hormones or pubescent development in patients with attention-deficit/hyperactivity disorder: A twelve-month follow-up study

Several animal or case reports have demonstrated that methylphenidate (MPH) disrupts endogenous gonadal hormones and interferes with the pubescent development of children with attention-deficit/hyperactivity disorder (ADHD). Therefore, this prospective study examined the changes in gonadal hormones and pubescent development in children with ADHD undergoing 12-month MPH treatment. We recruited 146 patients with ADHD (mean age: 8.9 years, 76.7% males) and 70 healthy controls (mean age: 9.2 years, 65.7% males). Blood samples were obtained to measure the serum levels of sex hormone-binding globulin (SHBG), follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, testosterone, free testosterone, and prolactin in each child. The sex maturation of ADHD patients was evaluated using the Tanner Stage. Patients with ADHD (107 received MPH treatment and 39 were under natural observation) were followed up for 12 months, and we re-examined hormone levels and Tanner Stage at the endpoint. During a 12-month follow-up for all ADHD patients, the serum levels of SHBG and progesterone significantly decreased, while LH, FSH, and free-testosterone levels significantly increased. However, the duration, drug formulations, and doses of the MPH treatment did not significantly influence gonadal hormone trends or changes of Tanner Stage. This study provides evidence about gonadal hormone trends and pubescent development in children with ADHD who receive long-term MPH treatment in natural settings. We suggest that MPH treatment at usual doses does not significantly alter gonadal function trends in ADHD patients over the course of one year.

Validity of Visual and Auditory Attention Tests for Detecting ADHD

Objective: This investigation examines the discriminative validity of visual and auditory attention tests for differentiating patients with ADHD from healthy control participants. Method: A total of 107 ADHD patients and 58 healthy control participants were recruited. Visual and auditory attention profiles were obtained using the Conners' Continuous Performance Test 3rd Edition (CPT3) and Conners' Continuous Auditory Test of Attention (CATA), respectively. Results: We found that ADHD patients underperformed healthy controls on all CPT3 and CATA indexes, except Response Style and Hit Reaction Time. The CPT3, CATA, and CPT3 plus CATA all significantly differentiate ADHD patients and controls. CPT3 plus CATA had a greater sensitivity (82.6%), specificity (76%), positive predictive value (88.8%), negative predictive value (65.5%), and overall correct classification rate (80.6%) than CPT3 or CATA alone. Conclusion: Neuropsychological tests CPT3 and CATA provide objective information about cases of ADHD and should be used routinely for clinical assessment.

Gut microbiota and dietary patterns in children with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, but the underlying pathophysiological mechanisms of ADHD remain unclear. Gut microbiota has been recognized to influence brain function and behaviors. Therefore, this study aimed to determine whether imbalanced gut microbiomes identified by a 16S rRNA sequencing approach are involved in the pathophysiology of ADHD. We recruited a total of 30 children with ADHD (mean age: 8.4 years) and a total of 30 healthy controls (mean age: 9.3 years) for this study. The dietary patterns of all participants were assessed with the food frequency questionnaire. The microbiota of fecal samples were investigated using 16S rRNA V3V4 amplicon sequencing, followed by bioinformatics and statistical analyses. We found that the gut microbiota communities in ADHD patients showed a significantly higher Shannon index and Chao index than the control subjects. Furthermore, the linear discriminant analysis effect size (LEfSe) analysis was used to identify differentially enriched bacteria between ADHD patients and healthy controls. The relative abundance of Bacteroides coprocola (B. coprocola) was decreased, while the relative abundance of Bacteroides uniformis (B. uniformis), Bacteroides ovatus (B. ovatus), and Sutterella stercoricanis (S. stercoricanis) were increased in the ADHD group. Of all participants, S. stercoricanis demonstrated a significant association with the intake of dairy, nuts/seeds/legumes, ferritin and magnesium. B. ovatus and S. stercoricanis were positively correlated to ADHD symptoms. In conclusion, we suggest that the gut microbiome community is associated with dietary patterns, and linked to the susceptibility to ADHD.

Dehydroepiandrosterone sulfate, free testosterone, and sex hormone-binding globulin on susceptibility to attention-deficit/hyperactivity disorder

The neuroendocrine system may affect the pathophysiology of gender differences in attention deficit/hyperactivity disorder (ADHD). This study examines whether the relationships among dehydroepiandrosterone sulfate (DHEA-S), free testosterone, or sex hormone-binding globulin (SHBG) and ADHD presentations exhibit gender differences. A total of 113 boys and 35 girls with ADHD (all drug naïve) and 46 and 26 healthy control boys and girls, respectively, were recruited. Blood samples were obtained to measure the serum levels of DHEA-S, free testosterone, and SHBG in each child. The Swanson, Nolan, and Pelham Scale for ADHD Version IV (SNAP-IV) was used to evaluate behavioral symptoms and the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) and the Conners' Continuous Performance Test (CPT) were utilized to assess neurocognitive functions. Patients with ADHD had lower DHEA-S levels than male and female healthy control subjects, and no significant differences were observed in free testosterone and SHBG levels between the patients and the controls. DHEA-S levels were negatively correlated with children's impulsivity performance in the CPT. SHBG levels were negatively correlated with ADHD behavior symptoms among boys. Free testosterone levels were not significantly correlated with either ADHD clinical symptoms or neuropsychological functions. We propose that DHEA-S serves as a potential biomarker of ADHD and is consistently involved in the pathogenesis of ADHD in both boys and girls. SHBG may be involved in behaviors associated with ADHD in boys. Additional studies with basic scientific measures are warranted to elucidate the relationship between androgen hormones and clinical presentations of ADHD.

Dietary and nutrient status of children with attention-deficit/ hyperactivity disorder: a case-control study

BACKGROUND AND OBJECTIVES

Nutritional and dietary habits may affect children's behaviors and learning. The etiology of attention-deficit/hyperactivity disorder (ADHD), a common neurodevelopmental disorder in children, may be associated with unhealthy diets or nutrients deficiencies. The purpose of this study was to examine whether children with ADHD exhibited different dietary habits or nutrient profiles from healthy control subjects.

METHODS AND STUDY DESIGN

We recruited 42 patients with ADHD (mean age: 8.1 years) and 36 healthy children as the control group (mean age: 9.8 years). We adopted the ADHD Rating Scale and the Swanson, Nolan, and Pelham Version IV Scale to interview both the ADHD patients and the control subjects and then evaluated participants' dietary intake with a food frequency questionnaire. Logistic regression models were utilized to produce a composite dietary/nutrient score, while receiver operating characteristic (ROC) was adopted to differentiate between the two participant groups.

RESULTS

Compared to the control children, children with ADHD demonstrated a higher intake proportion of refined grains (p=0.026) and a lower proportion of dairy (p=0.013), calcium (p=0.043), and vitamin B-2 (p=0.024). We observed that the composite score of dietary and nutrient could significantly distinguish patients with ADHD from healthy controls (p<0.001). The composite dietary/nutrient score demonstrated a significant correlation with the severity of ADHD clinical symptoms (p<0.05).

CONCLUSIONS

ADHD children and healthy controls have different dietary patterns and that dietary and nutrient factors may play a role in the pathophysiology of ADHD. Clinicians should consider dietary habits and specific nutrients in the routine assessment of children with ADHD.

Impact of Drug Adherence on Oppositional Defiant Disorder and Conduct Disorder Among Patients With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) may be a predecessor of oppositional defiant disorder (ODD) and conduct disorder (CD), and medication is an effective treatment option for ADHD. This study aims to examine whether adherence to medication treatment is associated with developing ODD and CD among youths with ADHD.

METHODS

A total of 33,835 youths (4 years ≤ age of diagnosis ≤ 18 years) with ADHD (ICD-9-CM code 314.X) undergoing medication treatment for at least 90 days were selected from Taiwan's National Health Insurance Research Database during the period of January 2000 through December 2009. Patients' medical records were monitored through December 31, 2011, or until they had a diagnosis of ODD or CD. We categorized participants as compliant or noncompliant on the basis of a medication possession ratio (MPR) of 50%.

RESULTS

The patients with better drug adherence (MPR ≥ 50%) exhibited a significantly decreased probability of developing ODD (53% reduction, P < .001) or CD (58% reduction, P < .001) when compared to the patients with poor drug adherence (MPR < 50%). The results in our sensitivity analyses showed that good drug adherence consistently exerted protective effects on ODD or CD, irrespective of patients' characteristics. Moreover, the patients with the best drug adherence (MPR ≥ 75%) had the lowest risks of developing ODD or CD.

CONCLUSION

Among patients with ADHD undergoing drug therapy, a better drug adherence is associated with a lower likelihood of their developing ODD or CD in later life.

Prenatal and perinatal risk factors and the clinical implications on autism spectrum disorder

Prenatal and perinatal factors may increase the risk of autism spectrum disorder. However, little is known about whether unaffected siblings of probands with autism spectrum disorder also share the phenomenon and whether the prenatal/perinatal factors are related to the clinical severity of autistic symptoms. We compared the frequency of prenatal and perinatal factors among 323 probands with autism spectrum disorder (mean age ± standard deviation, 10.7 ± 3.5 years; males, 91.0%), 257 unaffected siblings (11.7 ± 4.5; 42.8%), and 1504 typically developing controls (8.9 ± 1.6 years; 53.1%); and investigated their effects on the severity of autistic symptoms. We found that probands with autism spectrum disorder and their unaffected siblings had more prenatal/perinatal events than typically developing controls with higher numbers of prenatal/perinatal factors in probands than in unaffected siblings. The prenatal/perinatal events were associated with greater stereotyped behaviors, social-emotional problems, socio-communication deficits, and overall severity. We also found that six prenatal/perinatal factors (i.e. preeclampsia, polyhydramnios, oligoamnios, placenta previa, umbilical cord knot, and gestational diabetes) were associated with the severity of autistic symptoms, particularly stereotyped behaviors and socio-communication deficits. Our findings suggest that prenatal and perinatal factors may potentially moderate the clinical expression of autism spectrum disorder. The underlying mechanism warrants further research.

Symptoms of ADHD Affect Intrasubject Variability in Youths with Autism Spectrum Disorder: An Ex-Gaussian Analysis

Increased intrasubject variability in reaction times (RT-ISV) is frequently found in individuals with autism spectrum disorder (ASD). However, how dimensional attention deficit/hyperactivity disorder (ADHD) symptoms impact RT-ISV in individuals with ASD remains elusive. We assessed 97 high-functioning youths with co-occurring ASD and ADHD (ASD+ADHD), 124 high-functioning youths with ASD only, 98 youths with ADHD only, and 249 typically developing youths, 8-18 years of age, using the Conners Continuous Performance Test (CCPT). We compared the conventional CCPT parameters (omission errors, commission errors, mean RT and RT standard error (RTSE) as well as the ex-Gaussian parameters of RT (mu, sigma, and tau) across the four groups. We also conducted regression analyses to assess the relationships between RT indices and symptoms of ADHD and ASD in the ASD group (i.e., the ASD+ADHD and ASD-only groups). The ASD+ADHD and ADHD-only groups had higher RT-ISV than the other two groups. RT-ISV, specifically RTSE and tau, was significantly associated with ADHD symptoms rather than autistic traits in the ASD group. Regression models also revealed that sex partly accounted for RT-ISV variance in the ASD group. A post hoc analysis showed girls with ASD had higher tau and RTSE values than their male counterparts. Our results suggest that RT-ISV is primarily associated with co-occurring ADHD symptoms/diagnosis in children and adolescents with ASD. These results do not support the hypothesis of response variability as a transdiagnostic phenotype for ASD and ADHD and warrant further validation at a neural level.

Social adjustment and family function after drug switch from IR-methylphenidate to OROS-methylphenidate in patients with attention-deficit/hyperactivity disorder

PURPOSE

This prospective, single-arm, open-label, 8-week, multicenter study investigated the effectiveness of switching from immediate-release methylphenidate (IR-MPH) to osmotic controlled-release methylphenidate (OROS-MPH) in patients with attention-deficit/hyperactivity disorder (ADHD).

PATIENTS AND METHODS

Overall, 296 patients with ADHD (mean age: 9.5 years) already on IR-MPH treatment were enrolled. Upon enrollment, a flexible dose of OROS-MPH was administered, replacing IR-MPH. Patients were assessed at baseline and weeks 2, 4, and 8 using the Swanson, Nolan, and Pelham version IV scale (SNAP-IV) and the Clinical Global Impression for ADHD symptoms. The Social Adjustment Inventory for Children and Adolescents assessed social functions, and the Chinese Health Questionnaire (CHQ) and Family Adaptation, Partnership, Growth, Affection, and Resolve evaluated parental and family functions.

RESULTS

Switching from IR-MPH to OROS-MPH yielded significant improvements in all ADHD symptoms, as rated by parents, teachers (SNAP-IV), and study investigators (Clinical Global Impression). CHQ scores and all Social Adjustment Inventory for Children and Adolescents subscores except spare time scores improved significantly. Patients with poor IR-MPH adherence had greater improvements in teacher-rated SNAP-IV and mothers' mental health (CHQ) after switching.

CONCLUSION

Switching from IR-MPH to OROS-MPH improved patients' behavioral ADHD symptoms and social adjustment, and mental health of patients' mothers. This was most evident in patients who previously exhibited poor IR-MPH adherence.

Blood-Bourne MicroRNA Biomarker Evaluation in Attention-Deficit/Hyperactivity Disorder of Han Chinese Individuals: An Exploratory Study

Background: Attention-deficit/hyperactivity disorder (ADHD) is a highly genetic neurodevelopmental disorder, and its dysregulation of gene expression involves microRNAs (miRNAs). The purpose of this study was to identify potential miRNAs biomarkers and then use these biomarkers to establish a diagnostic panel for ADHD. Design and methods: RNA samples from white blood cells (WBCs) of five ADHD patients and five healthy controls were combined to create one pooled patient library and one control library. We identified 20 candidate miRNAs with the next-generation sequencing (NGS) technique (Illumina). Blood samples were then collected from a Training Set (68 patients and 54 controls) and a Testing Set (20 patients and 20 controls) to identify the expression profiles of these miRNAs with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). We used receiver operating characteristic (ROC) curves and the area under the curve (AUC) to evaluate both the specificity and sensitivity of the probability score yielded by the support vector machine (SVM) model. Results: We identified 13 miRNAs as potential ADHD biomarkers. The ΔCt values of these miRNAs in the Training Set were integrated to create a biomarker model using the SVM algorithm, which demonstrated good validity in differentiating ADHD patients from control subjects (sensitivity: 86.8%, specificity: 88.9%, AUC: 0.94, p < 0.001). The results of the blind testing showed that 85% of the subjects in the Testing Set were correctly classified using the SVM model alignment (AUC: 0.91, p < 0.001). The discriminative validity is not influenced by patients' age or gender, indicating both the robustness and the reliability of the SVM classification model. Conclusion: As measured in peripheral blood, miRNA-based biomarkers can aid in the differentiation of ADHD in clinical settings. Additional studies are needed in the future to clarify the ADHD-associated gene functions and biological mechanisms modulated by miRNAs.

ADHD-related symptoms and attention profiles in the unaffected siblings of probands with autism spectrum disorder: focus on the subtypes of autism and Asperger's disorder

BACKGROUND

The presence of attention-deficit/hyperactive disorder (ADHD) symptoms and impaired attention performance are commonly noted in individuals with autism spectrum disorder (ASD). However, little is known about attention performance in their unaffected siblings. This study aimed to investigate the ADHD-related traits and attention performance in unaffected siblings of probands with autism and Asperger syndrome (AS), as well as the clinical correlates of ADHD-related traits.

METHODS

We assessed the intention, hyperactivity-impulsivity, and oppositional symptoms, and attention profiles of 199 probands with a diagnosis of ASD (122 autism, 77 AS), their unaffected siblings, and 196 typically developing controls (TD) by their parents' reports on the ADHD-related symptoms and the Connors' Continuous Performance Test (CCPT), respectively.

RESULTS

Compared to TD, unaffected siblings of ASD probands were more hyperactive/impulsive and oppositional, particularly unaffected siblings of AS probands. In CCPT, unaffected siblings of AS have intermediate levels of performance between probands with AS and TD on focused attention and sustained attention but were not statistically different from AS probands or TD in these attention profiles. In contrast, unaffected siblings of autism probands have significantly better CCPT performance when compared to autism probands but not to TD. In addition, stereotyped behaviors predicted ADHD-related traits in both sibling groups, but distinctive patterns of other correlates for ADHD-related traits were found between the two sibling groups.

CONCLUSIONS

This work suggested that unaffected siblings of AS, but not autism, have more hyperactive/impulsive traits and a trend of pervasive attention deficits assessed by CCPT which might serve as potential endophenotypes for genetic studies in AS.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01582256.

Does Methylphenidate Reduce Testosterone Levels in Humans? A Prospective Study in Children with Attention-Deficit/Hyperactivity Disorder

Background

Animal studies and case reports have suggested that methylphenidate exerts adverse effects on gonadal hormones. This study aimed to determine whether methylphenidate alters testosterone levels in children with attention-deficit/hyperactivity disorder through comparison of those with or without methylphenidate treatment.

Methods

This 4-week, nonrandomized, prospective study conducted in Taiwan included 203 attention-deficit/hyperactivity disorder patients with a mean age of 8.7 years (boys: 75.8%). After the initial recruitment, 137 received daily methylphenidate treatment (medicated group) and 66 were assessed through naturalistic observation (nonmedicated group). The saliva samples of attention-deficit/hyperactivity disorder patients were used to quantify testosterone levels at baseline and the endpoint by using the chemiluminescence immunoassay. At the 4th week, 86 patients in the medicated group and 46 patients in the nonmedicated group were eligible for statistical analyses.

Results

During the study period, salivary testosterone levels did not significantly change in the medicated group (P=.389) or in the nonmedicated group (P=.488). After correction for the potential confounding effects of age and sex, salivary testosterone levels still remained unchanged in the medicated and nonmedicated groups during the 4-week follow-up. In the medicated group, changes in salivary testosterone levels over 4 weeks were not significantly correlated with the methylphenidate daily dose (mean daily dose: 18.1 mg).

Conclusions

Findings suggest that short-term treatment with methylphenidate at usual doses does not significantly alter salivary testosterone levels in attention-deficit/hyperactivity disorder patients. Future studies should clarify whether long-term methylphenidate treatment disrupts testosterone production as well as the function of the reproductive system.

Potential role of pre- and postnatal testosterone levels in attention-deficit/hyperactivity disorder: is there a sex difference?

OBJECTIVE

Both prenatal testosterone (T) exposure and postnatal T levels have been associated with developing neural circuitry and behavioral systems. This study examined the potential correlation between pre- and postnatal T levels and behavioral and neurocognitive profiles of children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Two hundred ADHD patients with a mean age of 8.7±2.0 years (158 boys and 42 girls) were recruited. The ratio of the length of the right index finger (2D) to that of the right ring finger (4D) (2D/4D ratio) served as a surrogate of prenatal T exposure, and postnatal T was determined using salivary T concentration. Behavioral symptoms were evaluated using the Swanson, Nolan, and Pelham - Version IV Scale for ADHD (SNAP-IV). Neurocognitive function was assessed using the Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) and Conners' Continuous Performance Test (CPT).

RESULTS

Lower 2D/4D ratios were associated with comorbid disruptive behavior disorders (t=2.15, P=0.033) in all participants. Among the boys with ADHD, neither 2D/4D ratios nor salivary T levels were associated with behavioral symptoms or neurocognitive function. Among the girls with ADHD, the salivary T level was positively correlated with the Perceptual Reasoning Index of the WISC-IV (r=0.48, P=0.001) and the Confidence Index (r=0.37, P=0.017) and Omission Errors of the CPT (r=0.62, P<0.001).

CONCLUSION

Findings suggest that a higher prenatal T exposure is associated with a greater risk of developing disruptive behavior disorders, and T may exert differential neurocognitive effects between boys and girls with ADHD. However, the neurobiological mechanisms of T involved in the pathogenesis of ADHD warrant further investigation.

The Effectiveness of Aripiprazole for Tics, Social Adjustment, and Parental Stress in Children and Adolescents with Tourette's Disorder

OBJECTIVE

Tourette's syndrome (TS) frequently results in a negative impact on multiple functional domains. This prospective open-label study investigated the potential effectiveness of aripiprazole for tics, social adjustment, and parental stress in children and adolescents with TS.

METHODS

Study participants consisted of 26 patients (mean age 10.4 ± 3.0 years; 22 boys and 4 girls) who were prescribed aripiprazole, with each dose ranging from 2.5 to 15 mg/day. At baseline and 2, 4, and 8 weeks from baseline, tic symptoms, social adjustment, and parenting stress were assessed using the Yale Global Tic Severity Scale (YGTSS), the Social Adjustment Inventory for Children and Adolescents (SAICA), and the Parenting Stress Index (PSI). Aripiprazole could be optionally titrated from 2.5 to 30 mg/day at each visit.

RESULTS

Of the 26 patients at the initial visit, 22 (84.6%) completed the study. The mean dose of aripiprazole at the endpoint was 8.0 ± 4.0 mg/day. During the 8-week aripiprazole treatment period, motor tics, phonic tics, and impairment on the YGTSS all showed significant improvement. Home behaviors on the SAICA and child domain on the PSI also showed significant improvement. Patients' phonic tics, but not motor tics, showed a positive correlation with their school function and peer relationships. The child domain on the PSI was positively correlated with motor tics, phonic tics, and impairment, as measured by the YGTSS.

CONCLUSIONS

An 8-week aripiprazole treatment program for children and adolescents with TS was beneficial to their tic symptoms, behaviors at home, and caregivers' stress with regard to fulfilling parenting roles. A long-term placebo-controlled trial with larger samples is warranted to confirm the effectiveness of aripiprazole for social adjustment and parental stress.

Genome-Wide Association Study for Autism Spectrum Disorder in Taiwanese Han Population

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with strong genetic components. Several recent genome-wide association (GWA) studies in Caucasian samples have reported a number of gene regions and loci correlated with the risk of ASD--albeit with very little consensus across studies.

METHODS

A two-stage GWA study was employed to identify common genetic variants for ASD in the Taiwanese Han population. The discovery stage included 315 patients with ASD and 1,115 healthy controls, using the Affymetrix SNP array 6.0 platform for genotyping. Several gene regions were then selected for fine-mapping and top markers were examined in extended samples. Single marker, haplotype, gene-based, and pathway analyses were conducted for associations.

RESULTS

Seven SNPs had p-values ranging from 3.4~9.9*10-6, but none reached the genome-wide significant level. Five of them were mapped to three known genes (OR2M4, STYK1, and MNT) with significant empirical gene-based p-values in OR2M4 (p = 3.4*10(-5)) and MNT (p = 0.0008). Results of the fine-mapping study showed single-marker associations in the GLIS1 (rs12082358 and rs12080993) and NAALADL2 (rs3914502 and rs2222447) genes, and gene-based associations for the OR2M3-OR2T5 (olfactory receptor genes, p = 0.02), and GLIPR1/KRR1 gene regions (p = 0.015). Pathway analyses revealed important pathways for ASD, such as olfactory and G protein-coupled receptors signaling pathways.

CONCLUSIONS

We reported Taiwanese Han specific susceptibility genes and variants for ASD. However, further replication in other Asian populations is warranted to validate our findings. Investigation in the biological functions of our reported genetic variants might also allow for better understanding on the underlying pathogenesis of autism.

Neurocognitive effects of aripiprazole in adolescents and young adults with schizophrenia

BACKGROUND

The use of aripiprazole has been associated with a positive influence on mood and improved cognitive skills and social interactions; however, studies of its effects on young schizophrenic patients have been limited to active symptoms.

AIMS

This prospective, open-label study investigated the neurocognitive effects of aripiprazole in adolescents and young adults with first and repeated episodes of schizophrenia.

METHODS

Twenty-three of 42 schizophrenic outpatients aged 12-26 completed a trial of aripiprazole, and its efficacy was determined using the Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions Severity (CGI-S) and WHO Quality of Life (WHOQOL) scales. Cognitive function was measured with the Cognitive Performance Test (CPT) and Wisconsin Card Sorting Test (WCST) at 4, 12 and 24 weeks of treatment.

RESULTS

Results showed statistically significant improvements in BPRS, CGI-S and WHOQOL scores in certain (but not all) subcategories of cognitive measures including CPT detectability and total errors and perseverative errors on the WCST. There were few adverse side-effects.

CONCLUSIONS

Psychotic symptoms and cognitive skills improved during treatment with aripiprazole in adolescents and young adults with schizophrenia. Patients with first psychotic episodes did better than did those with repeat episodes.

Trends in anxiolytic-hypnotic use and polypharmacy in Taiwan, 2002-2009: a nationwide, population-based survey

OBJECTIVES

Use of anxiolytics-hypnotics, including benzodiazepines and "z" hypnotics, is a public health concern. This study aimed to investigate the trends in prevalence of anxiolytic-hypnotic drug use and polypharmacy (simultaneous use of two or more anxiolytics-hypnotics) in Taiwan.

METHODS

A dynamic sample of one million individuals who were randomly selected from the National Health Insurance database was used to detect populationwide trends in the use of anxiolytics-hypnotics in Taiwan between 2002 and 2009. The analyses included drugs that are administered orally, intravenously, or intramuscularly as well as single or compound drugs. The authors identified the number of individuals who used the drugs, the sum of days of reported drug use for all individuals (person-days), and the distribution of anxiolytic-hypnotic polypharmacy for all claims for ambulatory, pharmacy, and hospital care.

RESULTS

Annual prevalence of any anxiolytic-hypnotic use in Taiwan was higher than 20%. The number of person-days greatly increased from 2002 (4.0%) to 2009 (6.6%). The increases in use between 2002 and 2009 were greatest for clonazepam (prevalence, 7% versus 1.8%; person-days, .2% versus .6%) and zolpidem (prevalence, 2.4% versus 4.2%; person-days, .5% versus 1.5%). Polypharmacy accounted for almost 70% of all person-days of anxiolytic-hypnotic use.

CONCLUSIONS

This nationwide, population-based survey presents real-world epidemiological evidence about anxiolytic-hypnotic use. The adverse effects of the long-term use of anxiolytics-hypnotics have been established, and unnecessary use of these drugs, particularly in polypharmacy regimens, should be avoided.

Chromosomal abnormalities in patients with autism spectrum disorders from Taiwan

Autism spectrum disorders (ASD) are childhood-onset neurodevelopmental disorders characterized by verbal communication impairments, social reciprocity deficits, and the presence of restricted interests and stereotyped behaviors. Genetic factors contribute to the incidence of ASD evidently. However, the genetic spectrum of ASD is highly heterogeneous. Chromosomal abnormalities contribute significantly to the genetic deficits of syndromic and non-syndromic ASD. In this study, we conducted karyotyping analysis in a sample of 500 patients (447 males, 53 females) with ASD from Taiwan, the largest cohort in Asia, to the best of our knowledge. We found three patients having sex chromosome aneuploidy, including two cases of 47, XXY and one case of 47, XYY. In addition, we detected a novel reciprocal chromosomal translocation between long arms of chromosomes 4 and 14, designated t(4;14)(q31.3;q24.1), in a patient with Asperger's disorder. This translocation was inherited from his unaffected father, suggesting it might not be pathogenic or it needs further hits to become pathogenic. In line with other studies, our study revealed that subjects with sex chromosomal aneuploidy are liable to neurodevelopmental disorders, including ASD, and conventional karyotyping analysis is still a useful tool in detecting chromosomal translocation in patients with ASD, given that array-based comparative genomic hybridization technology can provide better resolution in detecting copy number variations of genomic DNA.

Effectiveness of aripiprazole in adolescents and young adults with schizophrenia spectrum disorders: comparison of first-episode to recurrent psychosis

AIMS

The study aims to determine the clinical outcomes of aripiprazole treatment in adolescents and young adults with schizophrenia spectrum disorders.

METHODS

This was a 24-week, observational, prospective study. Patients with schizophrenia spectrum disorders were prescribed a daily dose of 5 mg to 30 mg of aripiprazole. Effectiveness was assessed by the change from baseline in psychotic symptoms and quality of life.

RESULTS

Forty-two patients with a mean age of 18.1 ± 3.7 years were recruited. Eighteen were experiencing the first episode of psychosis (FEP), whereas the remaining 24 were non-FEP. Psychotic symptoms, but not quality of life, improved globally from baseline scores by the endpoint of the study (effect size = 0.44). Compared with non-FEP patients, FEP patients had greater improvements (effect size = 0.45) in some clinical outcome dimensions during the 24-week aripiprazole treatment.

CONCLUSION

We observed significant improvements of medium effect sizes in psychotic symptoms of patients with schizophrenia spectrum disorders within a naturalistic clinical setting, especially for FEP patients.

Psychometric properties of the Chinese version of the Autism Spectrum Quotient (AQ)

The Autism Spectrum Quotient (AQ) has been widely used for measuring autistic characteristics in parents of children with autism spectrum disorders (ASD). Nonetheless, its psychometric validity is yet to be justified. This study tested the factor structure of the AQ by means of principal component analysis and confirmatory factor analysis using, for the first time, data from 4192 Taiwanese parents (1208 with ASD children and 2984 with typically developing children). Results yielded a 35-item, 5-dimensional factor solution that had favorable psychometric characteristics (RMSEA = .054; NNFI = .962; CFI = .969) than any of the previously-published AQ factor solutions. Subscales of this new AQ-Chinese model were statistically and semantically coherent, namely: Socialness, Mindreading, Patterns, Attention to Details and Attention Switching. The psychometric properties of the AQ-Chinese did not change between clinic-based and community-based data suggesting good fitting for a continuum of autistic expression. Furthermore, the considerable overlap between the AQ-Chinese and the AQ factor structures derived previously using student samples indicated consistency in the manifestation of the autistic profile across different cultures and age groups. Group differences in the AQ-Chinese scores were in line with previous studies, i.e. males generally scored radically higher than females except in Attention to Details. Interestingly, mothers of ASD children reported lower total AQ scores than community mothers yet no significant group difference for the fathers. Important research and clinical implications pertinent to parents with children with ASD and the utility of the AQ were drawn.

Determinants of maternal satisfaction with diagnosis disclosure of autism

BACKGROUND/PURPOSE

Diagnosis disclosure is an important clinical issue in developmental disabilities, which may influence parents' ability to cope with their child's conditions. This paper presents the content and patterns of diagnosis-informed counseling for mothers of children with autism and investigates the determinants for maternal satisfaction with this counseling, in order to improve clinical practice.

METHODS

Mothers of 151 children, aged 3-12 years, with DSM-IV autistic disorder, confirmed by the Chinese version of the Autism Diagnostic Interview-Revised, were assessed. We collected information about the mothers' experience with diagnosis-informed counseling, their personality characteristics, and the extent to which they were satisfied with the counseling.

RESULTS

Satisfaction with diagnosis-informed counseling was related more to the context of the counseling, including the attitude of the counselors and the timing and duration of counseling, than to its content. Parents' social desirability, educational level, and employment status were negatively associated with their satisfaction with counseling. However, immediate emotion, neuroticism, and extroversion did not have a significant effect on the satisfaction with counseling. Approximately 60% of the mothers preferred to be informed of having an autistic child after the diagnosis had been confirmed.

CONCLUSION

Our findings suggest that more efforts are needed to improve the quality of diagnosis-informed counseling in autism, particularly in the context of breaking the news to mothers of children with autism. Future study could further examine the moderating effect of diagnostic subtype of autism spectrum disorders, treatment response, or social support on maternal satisfaction with diagnosis-informed counseling (ClinicalTrials.gov number, NCT00494754).

Neurocognitive effects of aripiprazole in adolescents and young adults with bipolar disorder

BACKGROUND

Patients with bipolar disorder have neurocognitive impairments, which are associated with poor functional outcomes.

AIMS

This study evaluated the neurocognitive effects of aripiprazole in adolescents and young adults with bipolar disorder.

METHODS

This was a 24-week, observational, prospective study performed in Taiwan. Participants in the study were clinically diagnosed as having bipolar disorder according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). In total, 28 patients participated and were administered aripiprazole. Neurocognitive function was assessed as a change from baseline in the Continuous Performance Test (CPT) and the Wisconsin Card Sorting Test (WCST).

RESULTS

The 28 patients had a mean age of 18.5 ± 3.3 years. During the 24-week aripiprazole treatment, these patients had significant improvements in omission score (χ(2) = 7.83, P = 0.050) and detectability scores (χ(2) = 13.79, P = 0.003) in the CPT, and perseverative errors (χ(2) = 17.42, P = 0.001) in the WCST. The WCST perseverative errors scores were significantly associated with general symptom scores in Brief Psychiatric Rating Scale (BPRS) (β = - 1.34, P = 0.024). No significant differences were found between the neurocognitive functions of patients with manic, depressive and mixed episodes from baseline to week 24.

CONCLUSIONS

Adolescents and young adults with bipolar disorder experienced significant neurocognitive function improvements after treatment with aripiprazole. A randomized, controlled design is warranted to determine whether these improvements are associated with aripiprazole or the course of bipolar disorder.

Remission in children and adolescents diagnosed with attention-deficit/hyperactivity disorder via an effective and tolerable titration scheme for osmotic release oral system methylphenidate

OBJECTIVES

The purpose of this study was to identify the optimal dose of osmotic release oral system methylphenidate (OROS-MPH) using a dosage forced-titration scheme to achieve symptomatic remission in children with attention- deficit/hyperactivity disorder (ADHD). We also evaluated the efficacy and safety of, and patient and parent satisfaction with, the change in therapy from immediate-release methylphenidate (IR-MPH) to OROS-MPH over 10 weeks.

METHOD

We recruited 521 children and adolescents aged 6-18 years with an American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnosis of ADHD, who had received IR-MPH treatments (<70 mg/day) for at least 1 month. The treatment, switched from IR-MPH to OROS-MPH according to a conversion scheme, started with a 6-week forced-titration phase of OROS-MPH to achieve symptomatic remission (defined as a score of 0 or 1 for each of the first 18 ADHD items in the Chinese version of the Swanson, Nolan, and Pelham, Version IV [SNAP-IV]), followed by a 4-week maintenance phase. The global ADHD severity and drug side effects of the participants were evaluated. Parents completed the ratings scales for the ADHD-related symptoms. Patient and parent satisfaction for the OROS-MPH treatment was also assessed.

RESULTS

Among the 439 participants with ADHD who completed the trial, 290 participants (66.1%) achieved symptomatic remission. The mean dose of OROS-MPH among participants in remission was 36.7 mg (1.08 mg/kg) per day. Increased efficacy, superior satisfaction, and safety equivalent to that of IR-MPH were demonstrated in intra-individual comparisons from the baseline to the end of study. Determinants for remission included less severe ADHD symptoms (SNAP-IV score < 40), no family history of ADHD, and an appropriate dosage of medication according to the patient's weight.

CONCLUSIONS

The findings suggest remission as a treatment goal for ADHD therapy by providing an optimal dosage of medication for children and adolescents with ADHD through using an effective and tolerable forced-titration scheme.

Induction of plasminogen activators in pregnant women with Toxoplasma gondii infection

OBJECTIVE

To determine whether plasminogen activators (PAs) are involved in the pathologic process of toxoplasmosis.

MATERIALS AND METHODS

Out of 220 pregnant women the study included 26 with a diagnosis of toxoplasmosis: six based on seropositivity for Toxoplasma gondii IgM and 20 based on seropositivity for T. gondii IgG. We measured serum activities and protein levels of PAs by casein zymography and Western blotting, respectively.

RESULTS

Serum PAs were higher in healthy pregnant women than in their healthy nonpregnant counterparts. Furthermore, serum PAs were significantly higher in pregnant women infected with T. gondii than in their healthy counterparts.

CONCLUSION

PAs participate in the pathogenesis of toxoplasmosis in pregnant women and may be useful markers of T. gondii infection.

Long-term effectiveness of aripiprazole in adolescents and young adults with bipolar disorder: A naturalistic study

Abstract Objective. The purpose of this study was to investigate the long-term effectiveness of aripiprazole in Taiwanese samples of adolescents and young adults with bipolar disorders. Methods. This investigation comprises a 24-week, observational, prospective study. A total of 28 patients with bipolar I disorder, diagnosed using the Mini International Neuropsychiatric Interview, were administered aripiprazole. Effectiveness was assessed by the change from the baseline in Clinical Global Impression Scale (CGI), Brief Psychiatric Rating Scale (BPRS) and The World Health Organization Quality of Life questionnaire (WHOQOL). Results. The sample comprised 19 males and nine females with a mean (SD) age of 18.5 (3.3) years. The diagnosis was bipolar I disorder with manic (n = 8), depressive (n = 6) and mixed (n = 14) episodes. Eighteen patients (64.3%) discontinued aripiprazole prematurely. The CGI severity, BPRS total score improved significantly from the baseline to the endpoint. Conclusion. Aripiprazole led to clinically meaningful improvement of global symptoms in adolescents and young adults with bipolar disorder. However, discontinuation of medication within 6 months was high. Whether aripiparzole benefits patients with manic episodes more than those with depressive or mixed episodes warrants further investigation.

Varying postprandial abdominovagal and cardiovagal activity in normal subjects

BACKGROUND

Several studies have supported the hypothesis of different presentations in the autonomic nervous system (ANS) between cardiac and gastric vagal activity. Due to the regionality of the ANS, different responses among different organ systems to the same stimulation (such as a meal) are quite possible.

METHODS

In this study we monitored the postprandial changes of heart rate variability (HRV) and gastrointestinal (GI) hormones to determine whether both responded in a similar pattern. Twenty-two healthy volunteers (6 males and 16 females) were enrolled. After recording a baseline ECG rhythm, further recordings were made at 20 min intervals for 120 min after a test meal. Serum human pancreatic polypeptide (PP), leptin, and total and active ghrelin levels were measured.

KEY RESULTS

After the meal, HR increased significantly from baseline at each time point, except for 20 min after the meal. The high frequency (HF) power decreased significantly from 40 min to 120 min after the meal. In addition, the low frequency (LF) power also decreased significantly from 60 min to 120 min. However, the LF:HF ratio increased significantly from 20 min to 120 min. There was a marked increase (>2 fold) of PP at 20 min after the meal, and the increase was sustained throughout the test period.

CONCLUSIONS & INFERENCES

These findings suggest that HRV reflects cardiac, but not equivalently, abdominovagal activity. Therefore, HRV as an abdominovagal activity measurement in patients with GI functional problems should be used with caution, and other markers such as PP should be included.

Better efficacy for the osmotic release oral system methylphenidate among poor adherents to immediate-release methylphenidate in the three ADHD subtypes

AIMS

To determine factors for switching to osmotic release oral system methylphenidate (OROS-MPH) among poor adherents to immediate-release methylphenidate (IR-MPH); and to compare the efficacy of OROS-MPH on the three attention-deficit/hyperactivity disorder (ADHD) subtypes in a multi-site prospective observational study in Taiwan.

METHODS

The sample included 240 children with ADHD, aged 6-16 years, who were poor adherents to IR-MPH, 137 of whom were switched to OROS-MPH. The child psychiatrists diagnosed the Diagnostic Statistical Manual of Mental Disorders (4th edition) ADHD subtypes and assessed the medical history, adherence, side-effects, global ADHD severity, and family/school effectiveness. Parents reported their child's behavioral symptoms.

RESULTS

The determinants for an OROS-MPH switch were higher dosage, shorter treatment and thrice-daily administration of IR-MPH, and more severe inattention symptoms. Hyperactivity and oppositional symptoms were greater in the ADHD combined and hyperactive-impulsive subtypes than the inattentive subtype. Switching to OROS-MPH significantly improved behavioral symptoms and family/school measures, and this was most evident in the ADHD-combined group, followed by the ADHD-inattentive group. Inattention influenced not only academic performance, but also overall classroom behaviors and the parent-child relationship, with the latter two also influenced by oppositional symptoms.

CONCLUSIONS

This study suggests better efficacy for the OROS-MPH among poor adherents to IR-MPH; however, its effectiveness varied across the three ADHD subtypes (ClinicalTrials.gov number NCT00460720).

National survey of adherence, efficacy, and side effects of methylphenidate in children with attention-deficit/hyperactivity disorder in Taiwan

OBJECTIVES

To identify the determinants of adherence to immediate-release (IR) methylphenidate in children and adolescents with attention-deficit/hyperactivity disorder (ADHD); to examine the impact of adherence on ADHD-related symptoms; and to compare the efficacy, adherence, and side effects of IR methylphenidate and osmotic release oral system (OROS) methylphenidate.

METHOD

This national survey, involving 12 hospitals, consisted of 2 phases of assessment. Treatment adherence in 240 (39.5%) of the 607 children aged 5 to 16 years with a clinical diagnosis of DSM-IV ADHD enrolled in the study was poor (defined as missing >or= 1 dose of ADHD medication a day and on 2 days or more during school days). Children with poor adherence at phase 1 were able to switch to OROS methylphenidate, while adherents remained on the IR variant. We reassessed 124 poor adherents who switched to OROS methylphenidate. The global ADHD severity, parent-child interaction, classroom behavior, academic performance, and side effects of the child subjects were evaluated by investigators. Parents completed the rating scales about the ADHD-related symptoms. The study began in April 2005 and was completed in February 2006.

RESULTS

Determinants for poor adherence included older age, later onset of ADHD, family history of ADHD, higher paternal education level, and multi-dose administration. Mental retardation and treatment at medical centers were inversely related to poor adherence. Overall, poor adherence was associated with more severe ADHD-related symptoms by comparison to good adherence. Similar side effect profile, superior adherence, and improved efficacy were demonstrated in intra-individual comparison of the OROS and IR methylphenidate forms.

CONCLUSION

Given that poor adherence to medication may be an important reason for suboptimal outcome in ADHD treatment, physicians should ensure adherence with therapy before adjusting dosage or switching medication.

TRIAL REGISTRATION

clinicaltrials.gov Identifier NCT00460720.

Thallium-201 SPECT predicts response to intensity-modulated radiation therapy for recurrent oral squamous cell carcinoma

The aim of this study was designed to investigate the usefulness of thallium-201 single photon emission computed tomography (SPECT) in predicting response of intensity-modulated radiation therapy (IMRT) for recurrent oral squamous cell carcinoma (OSCC).

PATIENTS, METHODS

Thirty-one patients with histologically proven recurrent OSCC were recruited. Before IMRT, all patients underwent SPECT at 15 min and 120 min after intravenous injection 111 MBq of thallous chloride ((201)Tl). Tumour uptake was measured with the semiquantitative early ratio (ER), delayed ratio (DR), and retention index (RI). The patients were classified into responder (complete response and partial response) and non-responder (stable disease and progressive disease) groups according to the tumour response evaluated by the Response Evaluation Criteria in Solid Tumors guidelines.

RESULTS

As comparing DR and RI between the two groups, both parameters were significantly higher in the responder group. When a DR of 1.75 was used as a cutoff value for the responders, the receiver operating characteristic (ROC) analyses revealed sensitivity and specificity of 79% and 75%, respectively. At a cutoff value for the responders of a RI of 78.5%, the ROC analyses showed sensitivity and specificity of 95% and 83%, respectively.

CONCLUSION

Our results suggest that (201)Tl-SPECT, as measured by the DR or RI has clinical potential in predicting response of IMRT for patients with recurrent OSCC. The ROC curve analyses further suggest that RI may be superior to DR in distinguishing responders from non-responders.

Are the local blood oxygen level-dependent (BOLD) signals caused by neural stimulation response dependent on global BOLD signals induced by hypercapnia in the functional MR imaging experiment? Experiments of long-duration hypercapnia and multilevel carbon dioxide concentration

BACKGROUND AND PURPOSE

The relationship between the local blood oxygen level-dependent (BOLD) signals caused by neural stimulation (fBOLD) and the global BOLD signals induced by hypercapnia (hBOLD) has not been fully investigated. In this study, we examine whether fBOLD is modulated by hBOLD signals, by means of experiments using a relatively wide range of inhaled carbon dioxide (CO(2)) for a long duration of 5 minutes.

MATERIALS AND METHODS

Ten healthy volunteers were recruited, each undergoing 6 separate experiments by inhaling gas mixtures with different fractions of CO(2) (room air, 3%-7%). Each experiment contained 3 phases, prehypercapnic, hypercapnic, and posthypercapnic, during which boxcar visual stimulus was given. The local fBOLD signals were measured from areas showing activation patterns highly correlated with the visual stimulus paradigm, whereas the global hBOLD signals were measured from areas showing no visual activations. Percentage changes in fBOLD during transient-state hypercapnia and steady-state hypercapnia were both investigated in response to varying degrees of hypercapnic perturbations.

RESULTS

The hBOLD signals increased with increase of inhaled CO(2) fractions. The duration for the hBOLD signals to reach steady state prolonged with increase of inhaled CO(2) fractions. Normalized fBOLD ratio was inversely related to the inhaled CO(2) during steady-state hypercapnia but showed positive association with hBOLD during transient-state hypercapnia.

CONCLUSION

Our study concludes that the steady-state fBOLD signal intensity is dependent on and inversely related to the hBOLD signals. Previous reports documenting independent and additive relationships between hBOLD and fBOLD may likely be due to transient-state observations.

A randomized, double-blind, placebo-controlled clinical trial on once-daily atomoxetine in Taiwanese children and adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

The aim of this study was to assess the efficacy and safety of the once-daily atomoxetine compared with placebo in pediatric patients with attention-deficit/hyperactivity disorder (ADHD) in Taiwan.

METHOD

The study sample included 106 patients aged 6-16 years who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria of ADHD randomly assigned to atomoxetine once daily (n = 72) and placebo once daily (n = 34) in a double-blind, 6-week treatment study. The primary efficacy measure was the total score of the ADHD Rating Scale-IV Parents Version: Investigator Administered and Scored. The secondary efficacy measures included the Clinical Global Impressions--ADHD--Severity and Chinese Conner's Parent and Teacher Rating Scale--Revised: Short Form. Data were analyzed on an intent-to-treat basis and a last-observation-carried-forward approach.

RESULTS

The two treatment groups did not differ in demographics and baseline measures. Compared to the placebo group, the atomoxetine group showed significantly greater reductions in ADHD-related symptoms according to the ratings of investigators, parents, and teachers. The treatment effect size of the primary efficacy measure was 0.70 at the end of study. Adverse events reported significantly more frequently with atomoxetine were decreased appetite (36.1%) and nausea (16.6%). No drug-related serious adverse event was observed.

CONCLUSIONS

Once-daily atomoxetine is an effective, well-tolerable, and safe treatment for children and adolescents with ADHD in Taiwan.

Thallium-201 scan in evaluating thyroid nodules following equivocal fine-needle aspiration cytology

The AIM of this prospective study was to evaluate the usefulness of the thallium-201 ( (201) Tl) thyroid scan in the detection of malignancy in cold thyroid nodules whose status was equivocal following palpation fine-needle aspiration cytology (FNAC).

PATIENTS, METHODS

Fifty-one patients with clinically palpable solitary cold thyroid nodules classified as non-diagnostic or suspicious following biopsy underwent (201) Tl thyroid scans. Each scan was performed 15 min (early scan) and 3 h (delayed scan) after an intravenous administration of 74 MBq (201) Tl. Thallium uptake in the nodules was visually assessed and scored on a three point scale, with a grade of three defining malignancy. All patients underwent surgery and the histopathology of nodule tissues were compared with results of the scans.

RESULTS

Fifty-one nodules were examined. Forty were benign and 11 were malignant. For early scans, the diagnostically relevant parameters were: sensitivity (100%), specificity (75%), and accuracy (80%). Corresponding findings for the delayed scan were: 91%, 98%, and 96%.

CONCLUSION

The (201) Tl scan is useful for detecting malignancy in cold thyroid nodules classified as nondiagnostic or suspicious lesions by FNAC.

Oral administration of paclitaxel affects the distribution and metabolism of 2-aminofluorene in various tissues of Sprague-Dawley rats

To evaluate the question of whether or not paclitaxel affects the distribution and metabolism of chemical carcinogens such as 2-aminofluorene (AF) on Sprague-Dawley rats were examined. The AF, acetylated AF and AF metabolites were determined and examined by using high performance liquid chromatography. After having received AF only, AF with paclitaxel at the same time and paclitaxel pretreated for 24 h then treated with AF for 24 h, urine, stool and tissues such as liver, kidneys, stomach, colon, bladder and blood were collected and assayed for AF and its metabolites. Compared to the control group, paclitaxel caused an increase of the metabolites excreted in urine and stool. The major metabolite excreted in urine and stool was 9-OH-AAF. The liver is the major metabolism center and the major residual metabolite of AF in the liver was also 9-OH-AAF.

Tamoxifen inhibits arylamine N-acetyltransferase activity and DNA-2-aminofluorene adduct in human leukemia HL-60 cells

Genetic regulation of acetyl coenzyme A-dependent N-acetyltransferase (NAT)and O-acetyltransferase (OAT) activities may play an important role in the metabolic activation of arylamine chemicals and carcinogens. N-acetylation is thought to be the first step in arylamine metabolism. The enzyme responsible for N-acetylation is called NAT. In this study, synthetic non-steroidal antiestrogen tamoxifen was selected for determining the inhibition of arylamine NAT activity, gene expression (NAT mRNA) and DNA-2-aminofluorene adduct formation in human leukemia HL-60 cell line. The results demonstrated that tamoxifen did not affect the level of NAT mRNA in HL-60 cells. But the results also showed that NAT activity and 2-Aminofluorene-DNA adduct formation in HL-60 cells were inhibited and decreased by tamoxifen in a dose-dependent manner when the doses of tamoxifen up to 100 micro M. We also examined the standard steady-state kinetic analysis, and the data showed that tamoxifen may be an uncompetitive inhibitor to NAT activity in cytosols based on the decrease apparent values of Km and Vmax. This report is the first finding that tamoxifen inhibited human leukemia HL-60 cells NAT activity and DNA-2-aminofluorene on adduct formation.

Needlescopic thoracic sympathetic block by clipping for craniofacial hyperhidrosis: an analysis of 28 cases

BACKGROUND

Endoscopic thoracic sympathectomy or sympathicotomy of the lower part of the stellate ganglion is an efficient method for the treatment of craniofacial hyperhidrosis, but postoperative compensatory sweating may be troublesome in some patients. Needlescopic thoracic sympathetic block by clipping may achieve a similar effect as well as providing a possible reverse operation for patients who suffer from intolerable postoperative compensatory sweating.

METHODS

Between January 1998 and June 2000, we collected a total of 28 patients with craniofacial hyperhidrosis. There were 15 men and 13 women with a mean age of 39.2 years (ranges, 19-50). All patients were placed under single-lumen intubated anesthesia in a semisitting position. Two ports were needed. We used a 2-mm 0 degrees thoracoscope and endo clips to perform a sympathetic block by clipping the lower third of the stellate ganglion at the second intercostal space.

RESULTS

The operation was usually accomplished within 20 min (ranges, 15-30). All patients were discharged within 4 h after the operation. There were no surgical complications or surgical mortality cases. All patients achieved improvement of craniofacial hyperhidrosis without recurrent symptoms after a mean of 25.3 months (range, 12-41) of follow-up. Twenty-five patients (85.7%) developed compensatory sweating of the trunk and lower limbs. One of these patients could not tolerate this postoperative sweating; he therefore underwent a reverse operation and obtained improvement of the compensatory sweating 18 days after removal of the endo clips.

CONCLUSION

Needlescopic thoracic sympathetic block by clipping is a safe and effective method for the treatment of craniofacial hyperhidrosis; compensatory sweating may be improved after a reverse operation and removal of the endo clips.

The effect of paclitaxel on gene expression and activity of arylamine N-acetyltransferase and DNA-2-aminofluorene adduct formation in human leukemia HL-60 cells

N-Acetylation is recognized as the first step in arylamine metabolism. The enzyme responsible for N-acetylation is called arylamine N-acetyltransferase (NAT),which uses acetyl coenzyme A as the acetyl group donor. Paclitaxel has been shown to exhibit antineoplastic and anticancer activity. In this study, paclitaxel was selected to determine the inhibition of arylamine N-acetyltransferase activity, gene expression (NAT mRNA) and DNA-2-aminofluorene adduct formation in human leukemia HL-60 cell line. Paclitaxel (0.01-l microM) did decrease the level of NAT mRNA in a dose-dependent manner. The results demonstrated that paclitaxel inhibited NAT activity and DNA-2-aminofluorene adduct formation in human leukemia HL-60 cells in a dose-dependent manner. Using standard steady-state kinetic analysis, it was demonstrated that paclitaxel was a possible uncompetitive inhibitor to NAT activity in cytosols based on the decrease in apparent values of K(m) and V(max). This report is the first demonstration that paclitaxel affected human leukemia HL-60 cells NAT activity and DNA-2-aminofluorene adduct formation.

Diversity in death certification: a case vignette approach

Previous studies have revealed high rates of errors in death certification, but few have discussed the nature of these errors. To explore the diversity among physicians in death certification and its relationship with the complexity of the causal sequence of death, we asked 145 physicians attending a continuing medical education course to complete the cause-of-death section on dummy death certificates of four case vignettes. The difficulty in determining the causal sequence of death varied from relatively simple to complex. Variations in death certification were classified according to wording, diagnostic semantics, combinations of expressions, correctness of certification format, and concordance with the referent underlying cause of death (UCOD). Given the same case history information, physicians showed great variation in wording and diagnostic semantics in death certification. The rates of correct certification format and concordance with referent UCOD varied with the level of complexity of the causal sequence of death. The greatest source of diversity was choosing between an acute condition of a chronic disease and the chronic disease itself, and between competing prominent comorbidities. Experience in death certification was significantly associated with correct certification format but not with concordance with referent UCOD. Knowledge of death certification was not associated with correct certification format or concordance with referent UCOD. Our findings indicate that the traditional concept of UCOD tabulation and using a single standard ICD code in evaluating the quality of death certification oversimplifies a complex situation. Variations in death certification, especially the selection of UCOD, were due to differences in interpreting the information rather than differences in knowledge of death certification.

Association of risk-taking behaviors with adolescent childbearing

BACKGROUND AND PURPOSE

Risk-taking behavior has been shown to be associated with adolescent pregnancy or childbearing. However, the specific risk-taking behavioral factors and the extent to which they are associated with adolescent childbearing is less clear. The purpose of this study was to determine the risk-taking behavioral factors associated with adolescent childbearing.

METHODS

In this case-control study, 198 mothers aged from 16 to 19 years with first-born infants born in Taichung City in 1997 were enrolled. The controls were adolescents with no history of childbearing or pregnancy matched for age and residential neighborhood of each case. A self-administered structured questionnaire inquiring about a variety of risk-taking factors was used to gather relevant information. The logistic regression model was used for univariate, combination of variables, and multivariate analysis.

RESULTS

Compared to controls, childbearing adolescents were more likely to have risk-taking behaviors including smoking, drinking, use of illegal substances, working at bars or nightclubs, and lack of use of contraception at first sexual intercourse. Logistic regression analysis for various combinations of risk-taking behaviors revealed that the more items of risk-taking behaviors adolescents had, the higher their risk of childbearing. Multiple logistic regression analysis showed that use of alcohol (adjusted OR = 1.9, 95% CI 1.1-3.1), working at sex-related workplace (adjusted OR = 4.7, 95% CI 2.4-9.3), and no use of contraceptive device at first intercourse (adjusted OR = 3.1, 95% CI 1.3-7.2), were significant risk factors for adolescent childbearing in subjects with previous sexual intercourse.

CONCLUSION

Adolescent females who used alcohol, worked at bars or nightclubs or used no contraception at first intercourse were more prone to adolescent childbearing, and a combination of risk-taking behaviors could increase the risk of childbearing. These risk-taking factors should be taken into consideration in the development of prevention programs.

Standing localized cluster in a continuum traffic model

We study the emergence of standing localized cluster in a continuum traffic model. The local-density profile, local velocity profile, and the phase boundary are obtained. The effect of the on ramp is discussed. The indication of the boundary induced phase transition is also discussed.

Factors associated with errors in death certificate completion. A national study in Taiwan

To identify characteristics of certifying physicians and the deceased that are associated with errors in death certificate completion in Taiwan, we retrospectively reviewed 4123 systematically sampled death certificates issued in 1994. Multivariate analyses were used to assess the associations of various characteristics of the certifying physicians and the deceased with four types of error. Of the 4123 death certificates reviewed, 2525 (61%) were completed correctly. In 289 (7%), only the mechanism(s) of death was given (Major Error 1); in 146 (4%), multiple causal sequences were given in part I (Major Error 2); in 800 (19%), a single causal sequence was given but was not specific enough (Minor Error 1); and in 363 (9%), a single causal sequence was given but the order was incorrect (Minor Error 2). Multiple logistic regression analyses revealed that the probability of error in death certification increased as the age of the deceased increased, the age of the certifier decreased, and the level of the hospital decreased. These findings suggest that training in death certificate completion should focus on younger certifiers and those working at lower level teaching hospitals and nonteaching hospitals. Given the high rate of Minor Error 1, physicians should be reminded to state information as specifically as possible to render cause-of-death statistics more informative.

Whole body 18F-2-deoxyglucose positron emission tomography to restage non-small cell lung cancer

The helpfulness of 18F-2-deoxyglucose positron emission tomography (FDG-PET) in restaging non-small cell lung cancer (NSCLC) has not been extensively evaluated. A total of 156 patients referred for restaging of NSCLC were retrospectively evaluated. According to the classification of American Joint Committee on Cancer, stages I and II were defined as conventionally resectable, stage IIIA as locally advanced but resectable, stage IIIB as locally advanced but unresectable, and stage IV as absolutely unresectable. Compared to initial staging by chest computed tomographic findings, FDG-PET down-staged 45/156 (29%) and up-staged 52/156 (33%) NSCLCs. In addition, 37/156 (23%) patients were reclassified from resectable to unresectable and 22/156 (14%) patients were reclassified from unresectable to resectable. Our results prove the helpfulness of whole body FDG-PET for restaging NSCLC.

Accuracy of cause-of-death coding in Taiwan: types of miscoding and effects on mortality statistics

BACKGROUND

The objectives of this study were to assess the accuracy of cause-of-death coding, determine the extent to which coders follow the selection rules of coding set out in the International Classification of Diseases, 9th Revision (ICD-9), and the effects of miscoding on mortality statistics in Taiwan.

METHOD

A systematic sample of 5621 death certificates was reviewed. The underlying cause of death (UCD) selected by the reviewer for each death certificate was compared with that selected by the original coder. The UCD was selected according to ACME (Automated Classification of Medical Entities) Decision Tables.

RESULTS

The overall agreement rates between the reviewer and coders according to the three-digit and two-digit categories of ICD-9 were 80.9% and 83.9%, respectively. Good agreement was found for malignant neoplasms (kappa = 0.94) and injuries and poisoning (kappa = 0.97), but there was poor agreement for nephrotic diseases (kappa = 0.74), hypertension-related diseases (kappa = 0.74), and cerebral infarction (kappa = 0.77). Reasons for disagreements included disagreement in nomenclature (42.8%), inappropriate judgement of causal relationships (41.5%), and incorrect interpretation of Selection Rule 3 and Modification Rules (15.7%).

CONCLUSION

This study showed various levels of agreement for different diseases between the reviewer and the original coders in selection of the UCD. Owing to the 'compensatory effect of errors', the national mortality statistics were not affected significantly. The national administration should undertake routine internal studies to control the quality of UCD coding practices.

Regional mortality from motor vehicle traffic injury: relationships among place-of-occurrence, place-of-death, and place-of-residence

Regional mortality data, which are compiled according to place-of-residence of the decedent, are an important reference for regional health planning and resource allocation. However, it would be inappropriate to apply these data to studies of environmental risk factors if a large proportion of fatal motor vehicle traffic injuries (MVTI) in fact occur outside the resident county. The aim of this study was to determine the proportion and characteristics of residents of a rural area of Taiwan who died from MVTIs that occurred outside the county of residence. We also explored the relationships among the place-of-occurrence, place-of-death, and place-of-residence of these decedents. The families or neighbors of residents of Huatung Area (eastern Taiwan) who died from MVTIs in 1994 or 1995 were interviewed to identify the place-of-occurrence of the MVTI. Of the 882 Huatung Area residents who died as a result of an MVTI during the study period and for whom relevant data were available, the MVTI occurred outside the resident county in 207 (23%) cases. Residents whose MVTI occurred outside the county of residence were more likely to be youths (aged 15-24) or young adults (aged 25-44) and driving automobiles or trucks. Of the 866 cases in which the exact place was known, the place-of-occurrence and the place-of-death (recorded on the death certificate) were in the same county in 849 (98%). Because a high proportion of fatal MVTIs occurred outside the resident county, the mortality rate calculated according to place-of-residence does not accurately reflect the environmental risk factors in this area. The finding that the characteristics of those whose MVTI occurred outside the county differed from those decedents whose MVTI occurred within the county indicates that there are two target groups for prevention programs. In addition, at least in Huatung Area, the place-of-death recorded on the death certificate could serve as a surrogate for the place-of-occurrence in epidemiologic studies.

Relationship between pterygium/pinguecula and sunlight exposure among postmen in central Taiwan

BACKGROUND

The purpose of this study was to investigate outdoor hazards and their relationship to conjunctival disorders experienced by postmen.

METHODS

Three hundred and ninety-four employees (248 postmen and 146 officers) working in 11 post offices in central Taiwan were recruited and participated in the 1994 annual labor health examination. Pinguecula and pterygium were diagnosed by an ophthalmologist. Meanwhile, detailed personal and occupational information was obtained using a structured questionnaire. The cumulative occupational sunlight exposure was calculated for each postman by considering the duration of their employment as postmen, the average working hours per day and their spectacle use (sunglasses and eyeglasses). A logistic regression was used to analyze the relationship between cumulative occupational sunlight exposure and pinguecula.

RESULTS

Among the postmen, the prevalences of pinguecula and pterygium were 62.9% and 7.3%, respectively. The outdoor nature of postal work was significantly associated with the occurrence of pinguecula as well as pterygium (p < 0.05). When the cumulative occupational sunlight exposure increased by one unit (one year x hour/day), the risks of developing pinguecula and pterygium were raised by 2.1% and 0.8%, respectively.

CONCLUSIONS

The results indicate that conjunctival disorders were associated with the cumulative occupational sunlight exposure of postmen working outdoors. This study reinforces the importance of ocular protection from sunlight.

Demographic characteristics of fathers of infants born to adolescent mothers in Taiwan

It has been well accepted that effective programs for prevention of adolescent pregnancy should involve adolescent women and their partners. Using data from certificates of live births in Taichung County, Taiwan, in 1994, the demographic characteristics of fathers whose infants were born to adolescent women were compared with a matched group fathers whose infants were born to women aged > or =20 years. Most of the fathers of infants born to adolescent women were adults: 57% of the fathers of infants born to women aged < or =15 years were > or =30 years of age. Fathers of infants born to adolescent women had a lower educational level than that of matched fathers. These demographic characteristics of fathers should be carefully interpreted and taken into consideration in developing intervention programs.

Seasonal variation of chickenpox, mumps and rubella in Taiwanese children estimated by pediatric clinics

To determine the seasonal variation of childhood infectious diseases in Taiwan, the incidence rates of chickenpox, mumps and rubella were studied by analyzing patient's records collected from pediatric clinics in northern, central, southern and eastern Taiwan from January 1, 1993 to December 31, 1993. The study revealed that a chickenpox outbreak was most likely to occur in autumn, followed by a second peak in spring, and the lowest rate in summer. In this study, the highest monthly incidence of chickenpox was 540 cases per 100,000 population. The highest incidence of mumps occurred in the spring, the second highest in autumn, and the lowest during summer. Cases of rubella occurred in the spring, summer and autumn, but not in the winter. The data on chickenpox from this study revealed a similar seasonal pattern every year to that of the Department of Health of the National Quarantine Service on Taiwan. The chickenpox virus is known to be relatively sensitive to elevations in ambient temperature and is characterized by its occurrence mainly in slightly humid seasons.

Association of parental characteristics with adverse outcomes of adolescent pregnancy

BACKGROUND

It is well-known that pregnancy in adolescence has an increased risk of adverse reproductive outcomes. It remains unclear whether this association is due mainly to the unfavourable sociodemographic status or due solely to biological immaturity of pregnant adolescents.

OBJECTIVE

The purpose of this study was to determine the association of parental sociodemographic characteristics with the adverse outcomes of adolescent pregnancy.

METHOD

Data from certificates of live births in Taichung County, Taiwan in 1994 of 7994 singleton, first-born babies whose mothers were 15-34 years of age were analysed. The relative risk of having adverse pregnancy outcomes for adolescent subgroups was obtained as compared with that among mothers 20-34 years of age with the same characteristics. The adjusted relative risk of having adverse pregnancy outcomes for each covariate was calculated by a multiple logistic regression analysis.

RESULTS

Of 7994 babies born to mothers of 15-34 years of age, 8.3% were born to adolescent mothers. In all age groups, the younger adolescent mothers (15-17 years of age) had the highest percentage of both infants with low birth weight (10.6%) and preterm births (7.1 %). Younger adolescent mothers in almost all sociodemographic categories had higher risks of having both low-birth-weight and preterm births than those of older adolescent mothers. Multiple logistic regression analysis showed that a younger maternal age is the only significant risk factor for having infants with low birth weight (adjusted RR = 2.5, 95% Cl 1.8-4.5 and adjusted RR = 1.7, 95% Cl 1.2-2.6 for younger and older adolescent mothers, respectively) or preterm birth (adjusted RR = 1.9, 95% Cl 1.1-3.4 and adjusted RR = 1.5, 95% Cl 1.0-2.3 for younger and older adolescent mothers, respectively).

CONCLUSIONS

Adolescent pregnancy carries an increased risk of having low-birth-weight and preterm births, and a younger maternal age is causally implicated.

Trends in injury mortality among adolescents in Taiwan, 1965-94

OBJECTIVES

To describe trends in injury mortality among adolescents in Taiwan for prioritising preventive interventions.

METHODS

Adolescent injury mortality data for Taiwan were derived from official publications of vital statistics from 1965 to 1994 to determine trends by sex and cause of death. Simple linear regression was used to test the trends.

RESULTS

The number of deaths due to injury among adolescents aged 10-19 years in Taiwan increased from 983 in 1965 to 1783 in 1994, an 81% increase. The injury mortality rate increased 42%, from 32.2 per 100,000 in 1965 to 45.6 per 100,000 in 1994. The proportion of injury deaths also increased, from 45.3% in 1965 to 72.8% in 1994. The trends in mortality from motor vehicle injury (MVI) among four demographic groups were all significantly positive (p < 0.001). The proportion of deaths due to MVI among injury was 14% in 1965 and increased to 63% in 1994.

CONCLUSIONS

The increase in injury mortality rates among adolescents over the past three decades appears to be due largely to the increase in MVI mortality rates with males aged 15-19 years accounting for most of this increase. Priorities for adolescents in Taiwan are MVI (especially motorcyclists) and drownings.

Factors related to adolescents' perceptions of treatment outcomes in an adolescent health clinic

To determine factors related to adolescents' perceived treatment outcomes of their health problems in an adolescent health clinic located at a college hospital, 246 adolescent patients between the ages of 11 and 21 who visited the clinic twice or more during the period January 1994 to December 1995 were included in this study. Information concerning adolescents' sociodemographic characteristics, family function, office visits and health problems of first visits was collected by reviewing subjects' medical and other clinic-related records. In addition, a structured questionnaire was mailed to assess subjects' satisfaction with physicians and the environment and services provided by the clinic as well as their perceived treatment outcomes. 148 patients completed the questionnaire, a response rate of 60.2%. Most of the respondents were in late-stage adolescence (71.0%) and were in school (71.0%). About half of respondents had normal family function, while the other half had moderate or severe family dysfunction. Most of the health problems of respondents were acute (64.2%) and were biological (76.4%) conditions. Most of the respondents were satisfied with the various characteristics of physicians except confidentiality emphasized by the physicians, while many fewer respondents were satisfied with the environment and services provided by the clinic. Family function, physicians' respect toward the adolescents, and the adolescents' satisfaction with the services provided in general were the factors significantly related to adolescents' perceived treatment outcomes based on a stepwise, multiple logistic regression analysis. We conclude that efforts to provided could result in better adolescent perceived treatment outcomes.