The myth of vaccination and autism spectrum

BACKGROUND

Among all of the studied potential causes of autism, vaccines have received some of the most scrutiny and have been the topic of many evidence-based studies. These efforts have led the great majority of scientists, physicians, and public health researchers to refute causation between vaccines and autism.

RATIONALE

This presumed association and concern has been a major contributor to parents' refusal to immunize their children and has become a major threat to public health in secluded populations over the last two decades, even prior to the COVID-19 pandemic. With the emergence of COVID-19 immunizations, sentiments towards this topic were addressed as a public health concern that may influence the ability to overcome the Corona virus worldwide.

SCIENTIFIC REVIEW OF DATA

Despite the overwhelming data demonstrating that there is no link between vaccines and autism, many parents are hesitant to immunize their children because of the alleged association. Other contributing factors to the myths and conspiracy theories surrounding the association between vaccines and autism include the fact that the diagnosis of autism is typically made after the age of receiving the main childhood immunizations, as well as the occasional occurrence of regression after the age of first year vaccinations. In spite of vast evidence that the main contribution to the increase in incidence is from improvement of the diagnostic process, this rapid and publicized rise in autism diagnoses feeds parental concerns regarding any medical intervention that may be associated with the health of their children.

RECOMMENDATIONS

It is plausible that with more evidence-based studies linking autism to specific etiologies the myth will diminish and disappear eventually. In an era where conspiracy theories are prevalent on social media, it is critical that evidence-based studies relating autism to specific etiologies be made public, and that information concerning autism diagnosis and causes be made more readily available through social media and parental organizations.

Expression of Cntnap2 (Caspr2) in multiple levels of sensory systems

Genome-wide association studies and copy number variation analyses have linked contactin associated protein 2 (Caspr2, gene name Cntnap2) with autism spectrum disorder (ASD). In line with these findings, mice lacking Caspr2 (Cntnap2(-/-)) were shown to have core autism-like deficits including abnormal social behavior and communication, and behavior inflexibility. However the role of Caspr2 in ASD pathogenicity remains unclear. Here we have generated a new Caspr2:tau-LacZ knock-in reporter line (Cntnap2(tlacz/tlacz)), which enabled us to monitor the neuronal circuits in the brain expressing Caspr2. We show that Caspr2 is expressed in many brain regions and produced a comprehensive report of Caspr2 expression. Moreover, we found that Caspr2 marks all sensory modalities: it is expressed in distinct brain regions involved in different sensory processings and is present in all primary sensory organs. Olfaction-based behavioral tests revealed that mice lacking Caspr2 exhibit abnormal response to sensory stimuli and lack preference for novel odors. These results suggest that loss of Caspr2 throughout the sensory system may contribute to the sensory manifestations frequently observed in ASD.

Mesenchymal Stem Cell Transplantation Promotes Neurogenesis and Ameliorates Autism Related Behaviors in BTBR Mice

Autism spectrum disorders (ASD) are characterized by social communication deficits, cognitive rigidity, and repetitive stereotyped behaviors. Mesenchymal stem cells (MSC) have a paracrine regenerative effect, and were speculated to be a potential therapy for ASD. The BTBR inbred mouse strain is a commonly used model of ASD as it demonstrates robust behavioral deficits consistent with the diagnostic criteria for ASD. BTBR mice also exhibit decreased brain-derived neurotrophic factor (BDNF) signaling and reduced hippocampal neurogenesis. In the current study, we evaluated the behavioral and molecular effects of intracerebroventricular MSC transplantation in BTBR mice. Transplantation of MSC resulted in a reduction of stereotypical behaviors, a decrease in cognitive rigidity and an improvement in social behavior. Tissue analysis revealed elevated BDNF protein levels in the hippocampus accompanied by increased hippocampal neurogenesis in the MSC-transplanted mice compared with sham treated mice. This might indicate a possible mechanism underpinning the behavioral improvement. Our study suggests a novel therapeutic approach which may be translatable to ASD patients in the future.

Coordination of sniffing and whisking depends on the mode of interaction with the environment

Smell and touch convey most of the information that nocturnal rodents collect in their natural environments, each via its own complex network of muscles, receptors and neurons. Being active senses, a critical factor determining the integration of their sensations relates to the degree of their coordination. While it has been known for nearly 50 years that sniffing and whisking can be coordinated, the dynamics of such coordination and its dependency on behavioral and environmental conditions are not yet understood. Here we introduce a novel non-invasive method to track sniffing along with whisking and locomotion using high-resolution video recordings of mice, during free exploration of an open arena. Active sensing parameters in each modality showed significant dependency on exploratory modes (“Outbound”, “Exploration” and “Inbound”) and locomotion speed. Surprisingly, the correlation between sniffing and whisking was often as high as the bilateral inter-whisker correlation. Both inter-whisker and inter-modal coordination switched between distinct high-correlation and low-correlation states. The fraction of time with high-correlation states was higher in the Outbound and Exploration modes compared with the Inbound mode. Overall, these data indicate that sniffing–whisking coordination is a complex dynamic process, likely to be controlled by multiple-level inter-modal coordinated loops of motor-sensory networks.

ErbB1–4 expression in prostate cancer patients and its correlation to patients’ ethnicity and outcome

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Background: ErbB family is involved in both cancer progression and treatment response in solid tumors. Few inconclusive studies reported on ErbB over-expression in prostate cancer. We investigated ErbB1–4 expression in prostate cancer patients and its correlation to patients ethnicity and outcome. Methods: ErbB expression was evaluated by immunohistochemistry of prostate cancer specimen using polyclonal antibody (Santa Cruz, CA). The staining was recorded as negative (0/+1), moderately positive (+2) and highly positive (+3). Kattan nomogram was used to predict 5-yr progression-free probability, assuming that all patients received external beam radiation therapy (a total dose of 78 Gy) and hormonal manipulation. Origin was counted in all 43 patients: Ashkenazic patients were defined as those who immigrated from East/West Europe or North America and Sephardic patients - from Middle East and North Africa. Results: ErbB1 (+2/+3) was over-expressed in 12 and 7 patients for a total of 19/43 (44%). ErbB2 over-expression (+2/+3) was not found in all patients. ErbB3 over-expression of +2 was seen in 2 patients and none had +3 (2/43, 5%). ErbB4 over-expression (+2/+3) was seen in 5 and 11 patients for a total of 16/43 (37%). 22 patients were Ashkenazic and 21 - Sephardic. ErbB1 over-expression in Ashkenazic and Sephardic groups was 9/22 (41%) and 10/21 (48%). ErbB4 over-expression in the two groups was 7/22 (32%) and 9/21 (43%). Kattan score of <80 was seen in 20/43 and <60 in 7/43 patients. ErbB1 over-expression was noted in 11/20 and in 4/7 patients. ErbB4 over-expression was seen in 7/20 and in 4/7 patients. In both ErbB1 and ErbB4 over-expression and Kattan nomogram of <80 and <60 the Sephardic ethnicity dominated-7/11 (64%), 3/4 (75%), 5/7 (71%) and 3/4 (75%). Conclusions: ErbB1 and ErbB4 over-expression is presented in 43% and 37% patients while ErbB3 was over-expressed in 5%; no over-expression of ErbB2 was observed. Ashkenazic and Sephardic ethnicity were evenly distributed in the over-expressed ErbB1 and ErbB4 patients. However, a tendency to a worse prognosis, based on Kattan nomogram, was seen in over-expressed ErbB1 and ErbB4 patients from Sephardic ethnicity. Further studies on ethnicity and ErbB prevalence and prognosis are warranted.

No significant financial relationships to disclose.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.

Gastro-oesophageal reflux disease in obesity: pathophysiological and therapeutic considerations

Gastro-oesophageal reflux disease (GERD) is common in obese patients. Apart from the physical discomfort and the economic burden, GERD may increase morbidity and mortality through its association with oesophageal carcinoma. The pathophysiology of GERD differs between obese and lean subjects. First, obese subjects are more sensitive to the presence of acid in the oesophagus. Second, hiatal hernia, capable of promoting GERD by several mechanisms, is more prevalent among the obese. Third, obese subjects have increased intra-abdominal pressure that displaces the lower oesophageal sphincter and increases the gastro-oesophageal gradient. Finally, vagal abnormalities associated with obesity may cause a higher output of bile and pancreatic enzymes, which makes the refluxate more toxic to the oesophageal mucosa. The altered body composition associated with obesity affects the pharmacokinetics of drugs. There are no data regarding the efficacy of any of the drugs used for GERD treatment. The dosages of cimetidine and ranitidine should be calculated according to the patient's ideal body weight, not their actual weight. Of the operative procedures used for weight loss, Roux-en-Y gastric bypass was found to be most effective for GERD, while gastric banding was associated with a high prevalence of reflux. This review outlines the pathophysiology and the treatment of GERD in obesity with emphasis on the therapeutic considerations in this population of patients.

Enalapril-induced eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare disorder of unknown etiology. We describe a case of a 63-year-old woman with chronic diarrhea and eosinophilia. Small bowel biopsy revealed eosinophils in large clusters in the lamina propria with focal infiltration of the epithelium. The patient's diarrhea and eosinophilia started shortly after enalapril was prescribed. When the patient was instructed to stop taking that drug, her diarrhea promptly ceased, and the blood eosinophil level returned to normal. This is the first reported case of eosinophilic gastroenteritis associated with an angiotensin-converting enzyme inhibitor. Eosinophilic gastroenteritis should be entertained in the differential diagnosis of patients taking angiotensin-converting enzyme inhibitors who develop diarrhea or other gastrointestinal symptoms.

Case report: Hepatic involvement in antiphospholipid syndrome

Three cases of hepatic involvement in antiphospholipid syndrome are described. One patient had catastrophic antiphospholipid syndrome with haemorrhages and necrosis in the liver parenchyma. The second patient had blood clots in the small hepatic vessels. The third patient had autoimmune hepatitis type I associated with antiphospholipid syndrome. Other possible hepatic manifestations of antiphospholipid syndrome are also discussed.

Catastrophic antiphospholipid syndrome triggered by trauma

We describe the first case of catastrophic antiphospholipid syndrome triggered by trauma. In contrast to reports that emphasize the devastating nature of the syndrome, our patient's course is less dramatic and more elusive. A possible pathophysiological explanation to the association of antiphospholipid syndrome and trauma is discussed.

[Biofeedback treatment of irritable bowel syndrome]

Irritable bowel syndrome is a group of heterogenic complaints of functional bowel disorder in the absence of organic pathology. The pathophysiology is unclear. In most cases treatment includes symptomatic remedies, antidepressants, psychotherapy and hypnotherapy. Biofeedback has recently been introduced as a therapeutic modality. Treatment also includes relaxation techniques and guided imagery, together with computer-assisted monitoring of sympathetic arousal. Biofeedback requires active participation of patients in their healing progress and leads to symptom reduction in 2/3.

Nitric oxide metabolites in decompensated liver cirrhosis

High levels of nitric oxide are thought to be the cause of some of the complications associated with decompensated end-stage liver disease. To assess nitric oxide metabolism in cirrhotic patients, we measured the levels of nitric oxide metabolites (nitrosohemoglobin, methemoglobin, nitrate, and nitrite) in normal subjects, in patients with decompensated cirrhosis, in patients with renal failure (model for impaired NO metabolites excretion), and in patients with mononitrates-treated anginal syndrome (model for exogenous nitric oxide). When compared to controls, patients with decompensated cirrhosis exhibited elevated levels of nitrate only. A significant increase of nitrate was also noted in patients receiving exogenous nitrates, whereas patients with impaired excretion had significantly elevated levels of both nitrite and nitrate. In conclusion, nitric oxide metabolism in patients with decompensated cirrhosis is similar to that of patients receiving nitric oxide from an exogenous source. Renal impairment, whether alone or associated with cirrhosis, causes a change in nitric oxide metabolism. These findings may have clinical implications for nitrates treatment in patients with decompensated cirrhosis.

Lipoamide dehydrogenase deficiency: a newly discovered cause of acute hepatitis in adults

Lipoamide dehydrogenase deficiency is a rare disease, manifested in early childhood by lactic acidemia, progressive neurological damage and death in most cases. We report a case of lipoamide dehydrogenase deficiency in a 34-year-old Ashkenazi-Jewish woman. The deficiency manifested as acute hepatitis without cognitive impairment or acidosis. The patient's brother also had lipoamide dehydrogenase deficiency, diagnosed at the age of 20, and manifested as hepatocellular damage, lactic acidemia and myoglobinuria. We assume that the trigger for this hepatocellular damage was prolonged fasting, and that otherwise the patient might have gone undiagnosed. Other cases in Ashkenazi Jews of mild lipoamide dehydrogenase deficiency with hepatocellular injury but without central nervous system involvement are reviewed.

Text-to-algorithm conversion to facilitate comparison of competing clinical guidelines

This study aimed to test the usefulness and reliability of text-to-algorithm conversion in comparing competing clinical guidelines and defining their differences. Two pairs of competing guidelines for measles immunization, published in 1989 and 1994, were analyzed and compared. Five categories of differences were detected: differences in recommendations, excluded elements, logical inconsistencies, nonspecific phrases, and approaches to contraindications. On a scale of 0-10 (where identical=10), the overall comparison scores were 6.01 for the guidelines published in 1989 and 5.54 for the guidelines published in 1994. Text-to-algorithm conversions performed by three different persons on the 1989 guidelines were compared and found similar. Text-to-algorithm conversion is an important step in facilitating comparison of competing guidelines. It has the potential to assist in making rational and systematic choices between competing guidelines before actual field testing takes place. Physicians can use it to analyze and to learn a prose clinical guideline, to critique existing guidelines, and to simulate hypothetical patients for teaching and evaluating clinical management.

Histamine-evoked acetylcholine release in sensitized tracheal preparation

The contractile response to histamine of tracheal muscle was studied in preparations from BSA-sensitized and non-sensitized guinea-pigs. Sensitization did not enhance the overall response to histamine. However, this response showed evidence of acetylcholine participation. In sensitized preparations, atropine (0.1 microM) caused a significant depression of the dose response to histamine (n = 11, p = 0.028), especially in the range 2-8 microM. Physostigmine (0.1 microM) significantly potentiated the effect of histamine (n = 8, p = 0.003), especially at greater than 4 microM histamine. The response to histamine of non-sensitized preparations was not altered by atropine (n = 11) or physostigmine (n = 8). The following agents did not discriminate between sensitized and non-sensitized preparations: Famotidine, an H2 antagonist; dimaprit, an H2 agonist; thioperamide, an H3 antagonist; alpha-methylhistamine, an H3 agonist; gallamine, an M2 antagonist, suggesting that muscarinic M2 receptor dysfunction alone is not sufficient to cause bronchial hyper-responsiveness. The results show that sensitization causes a change in the components of the contractile response to histamine rather than bronchial hyper-responsiveness to this agent.

Urticaria in idiopathic bilateral recurrent branch retinal arterial occlusion

Idiopathic bilateral recurrent branch retinal arterial occlusion (IBRBRAO) is a rare syndrome characterized by migraine headaches, tinnitus, vertigo, hearing loss, and recurrent branch retinal artery occlusion of unknown etiology. Affected patients frequently undergo a wide range of medical evaluation and have no apparent pathologic findings. We present here a case of IBRBRAO, associated with urticarial rash, not described in this syndrome in previous publications.

Clinical algorithms teach pediatric decisionmaking more effectively than prose

Despite the rapidly increasing volume of medical literature, little attention has been paid to the appropriate printed format for teaching clinical content. This study attempted to determine whether a clinical algorithm (CA) or prose is more effective for teaching clinical decisionmaking. Clerkship students, preclerkship students, and pediatric house officers in five medical centers in the USA and Israel were presented with clinical algorithms and prose describing management of fever in a child under 2 years of age, and management of meningitis in children. Knowledge of decisionmaking was measured before and after learning, using audio-taped clinical problems and learning time as measured. It was concluded that CAs are more effective and more efficient than prose for teaching clinical decisionmaking. When writing about clinical decisionmaking, the use of CAs should always be considered, especially if a series of interdependent decisions is being described.

Criteria map audit of scorpion envenomation in the Negev, Israel

A criteria map audit is a medical record audit in which quality of care is evaluated according to algorithmically arranged criteria. Thus, a particular criterion is applied to the patient record only if other criteria have been met. For example, if a stung child's condition is severe but not life threatening and if he has had a positive skin test for antivenom sensitivity then he should receive antivenom only after receiving adrenaline and hydrocortisone. We used a modified criteria map audit to determine both the clinical picture of scorpion envenomation and quality of care process in 94 children. Related outcomes of care measured included mortality, persistent morbidity, allergic reaction to scorpion antivenom and length of stay in hospital. Scorpion stings in the Negev region are usually due to the yellow scorpion, L. quinquestriatus, and usually occur in the summer months on the extremities in exposed male children under 10. The clinical picture is more severe when the scorpion is yellow, when the child is younger and when the sting is on the trunk or head. Symptoms apparently mediated by the central nervous system (2.6 findings/child) were more frequent than parasympathetic symptoms (2.3 findings/child). Treatment with antivenom and specific therapy for complications led to very low persistent morbidity and mortality in symptomatic cases, but was also accompanied by a longer hospital stay (64% equal to or greater than 3 days) than for asymptomatic cases (18% equal to or greater than 3 days). Testing for antivenom sensitivity was omitted in an unacceptably high percentage of cases (69%) and its omission led to an allergic reaction in 4 out of 40 cases (10%). Inadequacy in treatment of 7 secondary clinical problems ranged from 71% for hypertension to 29% for seizures (mean 46%). Persistent morbidity was negligible and mortality was 1.2%. We conclude that criteria map audit can be used to describe the clinical and epidemiological picture of a clinical problem while at the same time providing an audit of the process of care.

Increase in relevant data after introduction of a problem-oriented record system in primary pediatric care

We determined the effect of the problem list and standard data base components of the problem-oriented record (POR) on kibbutz clinic care. We compared quantity and type of data collected and number of problems identified before and after POR implementation at an experimental clinic with the same variables measured at a similar clinic. Family history, prenatal, natal, nutritional, immunization, environment, review of systems, psychosocial and total data collected, as well as number of chronic problems identified, increased significantly after POR implementation.

Problem-oriented record: effect on problem identification in the hospital

The problem-oriented record (POR) is a medical record format that consists of a standard data base, a problem list, problem-oriented plans and problem-oriented progress notes. It has been claimed repeatedly that the use of a POR improves medical care. The effect of the standard data base and problem list components of the POR on the process of care was determined. Process of care was defined as the quantity and type of data collected and the number of problems identified per patient, which were measured before and after introduction of the POR into the pediatric wards of a regional university hospital, using a standardized audit technique. The same measures were also made in the pediatric wards of two similar hospitals at which the POR had not been introduced. Data collection scores in the experimental hospital for both subjective and objective data increased significantly both after POR implementation and also in comparison with the two other hospitals. The type of data collected was determined by the POR forms. The number of problems identified increased, but not significantly. We conclude that the standardized data base and problem list components of the POR can increase the amount and determine the type of data collected in pediatric wards, while not significantly affecting the number of problems identified.

A required course in decision-making for preclinical medical students

Objectives, methods of instruction, and evaluation of a preclinical course in decision-making are described in this article. One set of objectives that related to learning to read and write clinical algorithms was taught by having students read a clinical algorithm about a problem, solve a patient management problem about the problem, and write an algorithm. A second set of objectives that related to learning clinical decision analysis was taught by solving problems and discussing them. Three methods used to evaluate three classes showed the following results: large increases in taped interview problem (TIP) scores after learning algorithms, high mean scores on a final examination that tested all course objectives, and high voluntary class attendance. It is concluded that preclinical medical students can be taught cognitive decision-making skills, that the TIP is a promising tool for measuring such skills, and that careful monitoring of a course in clinical decision-making may provide valuable information regarding learning and teaching technical clinical management.

Shuval automated problem-oriented record: an off-line record for a primary care clinic

An off-line system for automating the problem-oriented record implemented at Kibbutz Shuval is described. The Shuval problem-oriented record consists of acute and chronic problem lists, a preprinted data base collected by patients and nurses, problem-oriented plan flow sheets, problem-oriented progress notes and a regular record audit. The mean conversion time from a traditional record to a problem-oriented record was 17 min for a child's record and 25 min for an adult's. The automated problem-oriented record consists of three data processing forms that contain almost all data in the record. Transfer of data took, on the average, 10 min (range, 5 to 30 min) for a child's record. The following five types of analysis can be performed with the Shuval automated problem-oriented record: administrative, patient care, epidemiologic, demographic and clinical research. Coupled with the manual problem-oriented record, the Shuval automated record provides many advantages of an on-line problem-oriented record at considerably less cost.