Pharmacological treatment for Tourette syndrome in children and adults: What is the quality of the evidence? A systematic review

BACKGROUND

Tourette syndrome (TS) is a neurodevelopmental disorder characterised by involuntary muscle movements manifesting as motor and vocal tics. In the majority, tics are manageable without medication. Where tics cause discomfort or impair function, behavioural or pharmaceutical treatments may be considered.

AIMS

To provide a meticulous examination of the quality of evidence for the current pharmacological treatments for TS.

METHODS

PubMed and Google Scholar were searched to identify randomised, placebo-controlled trials (RCTs) of aripiprazole, risperidone, clonidine, guanfacine, haloperidol, pimozide, tiapride and sulpiride for the treatment of tics in children and adults with TS. Quality of reporting and risk of bias were assessed against the CONSORT checklist and Cochrane risk of bias criteria, respectively.

RESULTS

Seventeen RCTs were identified. Response rates reached 88.6% for aripiprazole, 68.9% for clonidine, 62.5% for risperidone and 19% for guanfacine. Statistically significant improvements were reported for all medications compared to placebo in at least one study and for at least one measure of tic severity. Most studies predated the CONSORT and Cochrane criteria and did not score highly when assessed on these measures.

CONCLUSIONS

There are relatively few placebo-controlled trials of commonly prescribed medications. Studies are often of poor quality and short duration. There is evidence for the efficacy of each medication, but no drug is clearly superior. Clonidine and guanfacine are better tolerated than antipsychotics, but less effective. There is too little evidence to determine whether adults respond differently from children.

Relaxation capacity of cartilage is a critical factor in rate- and integrity-dependent fracture

Articular cartilage heals poorly but experiences mechanically induced damage across a broad range of loading rates and matrix integrity. Because loading rates and matrix integrity affect cartilage mechanical responses due to poroviscoelastic relaxation mechanisms, their effects on cartilage failure are important for assessing and preventing failure. This paper investigated rate- and integrity-dependent crack nucleation in cartilage from pre- to post-relaxation timescales. Rate-dependent crack nucleation and relaxation responses were obtained as a function of matrix integrity through microindentation. Total work for crack nucleation increased with decreased matrix integrity, and with decreased loading rates. Critical energy release rate of intact cartilage was estimated as 2.39 ± 1.39 to 2.48 ± 1.26 kJ m-2 in a pre-relaxation timescale. These findings showed that crack nucleation is delayed when cartilage can accommodate localized loading through poroviscoelastic relaxation mechanisms before fracture at a given loading rate and integrity state.

Service innovations

Aims and Method

Young people attending the Maudsley obsessive–compulsive disorder (OCD) children's clinic had expressed an interest in meeting other similar young people with OCD. A group was set up comprising 6-weekly sessions focusing on psycho-education and support.

Results

Seven young people (mean age: 14 years 4 months; age range: 11 years 11 months to 16 years 6 months) took part. Feedback questionnaires showed that all the participants found the group helpful and enjoy-able. They felt less isolated and more confident about dealing with OCD.

Clinical Implications

Establishment of groups may be a valuable way of increasing awareness and knowledge on aspects of OCD, as well as providing much-needed psycho-social support to patients.

Cognitive Behaviour Therapy Versus a Counselling Intervention for Anxiety in Young People with High-Functioning Autism Spectrum Disorders: A Pilot Randomised Controlled Trial

The use of cognitive-behavioural therapy (CBT) as a treatment for children and adolescents with autism spectrum disorder (ASD) has been explored in a number of trials. Whilst CBT appears superior to no treatment or treatment as usual, few studies have assessed CBT against a control group receiving an alternative therapy. Our randomised controlled trial compared use of CBT against person-centred counselling for anxiety in 36 young people with ASD, ages 12-18. Outcome measures included parent- teacher- and self-reports of anxiety and social disability. Whilst each therapy produced improvements in participants, neither therapy was superior to the other to a significant degree on any measure. This is consistent with findings for adults.

Dark Matter Search Results from the PICO-60 C_{3}F_{8} Bubble Chamber

New results are reported from the operation of the PICO-60 dark matter detector, a bubble chamber filled with 52 kg of C_{3}F_{8} located in the SNOLAB underground laboratory. As in previous PICO bubble chambers, PICO-60 C_{3}F_{8} exhibits excellent electron recoil and alpha decay rejection, and the observed multiple-scattering neutron rate indicates a single-scatter neutron background of less than one event per month. A blind analysis of an efficiency-corrected 1167-kg day exposure at a 3.3-keV thermodynamic threshold reveals no single-scattering nuclear recoil candidates, consistent with the predicted background. These results set the most stringent direct-detection constraint to date on the weakly interacting massive particle (WIMP)-proton spin-dependent cross section at 3.4×10^{-41}  cm^{2} for a 30-GeV c^{-2} WIMP, more than 1 order of magnitude improvement from previous PICO results.

In-trap spectroscopy of charge-bred radioactive ions

In this Letter, we introduce the concept of in-trap nuclear decay spectroscopy of highly charged radioactive ions and describe its successful application as a novel spectroscopic tool. This is demonstrated by a measurement of the decay properties of radioactive mass A=124 ions (here, ^{124}In and ^{124}Cs) in the electron-beam ion trap of the TITAN facility at TRIUMF. By subjecting the trapped ions to an intense electron beam, the ions are charge bred to high charge states (i.e., equivalent to the removal of N-shell electrons), and an increase of storage times to the level of minutes without significant ion losses is achieved. The present technique opens the venue for precision spectroscopy of low branching ratios and is being developed in the context of measuring electron-capture branching ratios needed for determining the nuclear ground-state properties of the intermediate odd-odd nuclei in double-beta (ββ) decay.

Breakdown of the isobaric multiplet mass equation for the A = 20 and 21 multiplets

Using the Penning trap mass spectrometer TITAN, we performed the first direct mass measurements of (20,21)Mg, isotopes that are the most proton-rich members of the A = 20 and A = 21 isospin multiplets. These measurements were possible through the use of a unique ion-guide laser ion source, a development that suppressed isobaric contamination by 6 orders of magnitude. Compared to the latest atomic mass evaluation, we find that the mass of (21)Mg is in good agreement but that the mass of (20)Mg deviates by 3 σ. These measurements reduce the uncertainties in the masses of (20,21)Mg by 15 and 22 times, respectively, resulting in a significant departure from the expected behavior of the isobaric multiplet mass equation in both the A = 20 and A = 21 multiplets. This presents a challenge to shell model calculations using either the isospin nonconserving universal sd USDA and USDB Hamiltonians or isospin nonconserving interactions based on chiral two- and three-nucleon forces.

Take note of the fuss: selective eating and autistic spectrum disorders

Selective eating in children can be a huge concern for parents. In most cases the problem is self-limiting and it can be associated with a developmental disorder. This article presents observations from two case studies from a child and adolescent mental health service (CAMHS) in the south east of England that link selective eating with autistic spectrum disorders (ASD). It concludes with recommendations to consider ASD, alongside dietetic advice, when a child is presenting with selective eating.

New precision mass measurements of neutron-rich calcium and potassium isotopes and three-nucleon forces

We present precision Penning trap mass measurements of neutron-rich calcium and potassium isotopes in the vicinity of neutron number N=32. Using the TITAN system, the mass of 51K was measured for the first time, and the precision of the (51,52)Ca mass values were improved significantly. The new mass values show a dramatic increase of the binding energy compared to those reported in the atomic mass evaluation. In particular, 52Ca is more bound by 1.74 MeV, and the behavior with neutron number deviates substantially from the tabulated values. An increased binding was predicted recently based on calculations that include three-nucleon (3N) forces. We present a comparison to improved calculations, which agree remarkably with the evolution of masses with neutron number, making neutron-rich calcium isotopes an exciting region to probe 3N forces.

The on-line charge breeding program at TRIUMF's Ion Trap For Atomic and Nuclear Science for precision mass measurements

TRIUMF's Ion Trap for Atomic and Nuclear science (TITAN) constitutes the only high precision mass measurement setup coupled to a rare isotope facility capable of increasing the charge state of short-lived nuclides prior to the actual mass determination in a Penning trap. Recent developments around TITAN's charge breeder, the electron beam ion trap, form the basis for several successful experiments on radioactive isotopes with half-lives as low as 65 ms and in charge states as high as 22+.

First use of high charge states for mass measurements of short-lived nuclides in a Penning trap

Penning trap mass measurements of short-lived nuclides have been performed for the first time with highly charged ions, using the TITAN facility at TRIUMF. Compared to singly charged ions, this provides an improvement in experimental precision that scales with the charge state q. Neutron-deficient Rb isotopes have been charge bred in an electron beam ion trap to q=8-12+ prior to injection into the Penning trap. In combination with the Ramsey excitation scheme, this unique setup creating low energy, highly charged ions at a radioactive beam facility opens the door to unrivaled precision with gains of 1-2 orders of magnitude. The method is particularly suited for short-lived nuclides such as the superallowed β emitter 74Rb (T(1/2)=65  ms). The determination of its atomic mass and an improved Q(EC) value are presented.

Post-traumatic stress disorder in children and adolescents

Post-traumatic stress disorder (PTSD) is a syndrome defined by the intrusive re-experiencing of trauma, avoidance of reminders of the trauma and increased hyperarousal. Although the condition is well established in adults, there is little research into PTSD in children and adolescents. The available research shows that young people experience similar symptoms to adults. Risk factors include family dysfunction, peer problems, greater exposure to the trauma and the presence of pre-existing psychiatric disorder such as anxiety. Protective factors include good coping skills, good relationship with a parent and support from others in the community. This article reviews treatment approaches to PTSD in young people in particular the use of cognitive behavioural therapy (CBT).

Autistic spectrum disorders 2: diagnosis and management

As many as six in every 1000 children may be affected by an autistic spectrum disorder. The previous article of this two-part series discussed the distinction between autism, Asperger's syndrome and pervasive developmental disorder, and examined the assessment process. This article looks at potential differential diagnoses that must be considered, as well as conditions associated with autism. Many theories about the causes of autism have been suggested, including the MMR vaccine. Recent research has suggested that there is no link between the vaccine and autism. There is no cure for autism, but intervention and management techniques should be aimed at educating parents and carers about the disorder and behavioural interventions to aid the child's skills development.

Autistic spectrum disorders. 1: Presentation and assessment

As many as six in every 1000 children may be affected by an autistic spectrum disorder. Characterised by a triad of social communication difficulties, these children exhibit impairment in communication and socialisation, and restricted and repetitive interests, movements and activities. This article will discuss the distinction between autism, Asperger's syndrome and pervasive developmental disorder. Assessment should include a history of the child's development, observation, school report and a profile of the child's strengths and weaknesses. However, it is important that potential differential diagnoses as well as conditions associated with autism are also considered. Differential diagnoses, management and possible causes of autistic spectrum disorders will be discussed in more detail in next month's Clinical Updates.

Functional neuroimaging in early-onset anorexia nervosa

Previous neuroimaging studies in early-onset anorexia nervosa provide evidence of limbic system dysfunction. The current study adds support to the possibility by revealing a significant association between unilateral reduction of blood flow in the temporal region and impaired visuospatial ability, impaired visual memory, and enhanced speed of information processing.

ADHD: assessment and intervention

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common psychiatric disorders of childhood. Although there is a lot of debate and controversy over the recognition of ADHD, it is generally accepted nowadays as a clinical disorder that may warrant treatment Children with ADHD are pervasively overactive, fidgety and disruptive. They have impaired attention and concentration and are impulsive. These symptoms have serious implications for the child's relationships with parents, siblings and peers. It is important that community practitioners, school nurses, health visitors and other health professionals are able to recognise the condition and be able to make an informed clinical assessment and refer and manage accordingly. The assessment should include a clear history from parents, a school report and an individual interview with the child. An assessment of parental management is essential to avoid the child being wrongly diagnosed with the condition. The successful intervention should be aimed at educating the child and family about the disorder and psychosocial interventions that may help the family and school cope with the child. In some cases introduction of medication may be necessary.

The developmental, dimensional and diagnostic interview (3di): a novel computerized assessment for autism spectrum disorders

OBJECTIVE

Autism is a diagnostic spectrum of variable severity, with significant comorbidity. No existing standardized interview measures autistic features dimensionally. The authors aimed to develop a parental autism interview that could be administered to unselected clinical and general population samples that measures both symptom intensity and comorbidity across the full range of the autistic spectrum.

METHOD

A computerized procedure was devised for administration by trained interviewers that generates symptom and diagnostic profiles for both autism and non-autistic conditions. Test-retest reliability and interrater reliability were assessed in unselected clinical (n = 50) and nonclinical (n = 30) populations. Concurrent validity (n = 120), discriminant validity (n = 120), and criterion validity (n = 29) were evaluated in autistic spectrum and non-autistic patients.

RESULTS

Test-retest and interrater reliabilities were excellent (most intraclass correlation coefficients > 0.9). Concurrent validity (agreement with independent clinician formulation) was very good (mean kappa = 0.74). Criterion validity, a comparison with the Autism Diagnostic Interview, was excellent. Discrimination between autistic spectrum versus non-autistic subjects was almost perfect (sensitivity 1.0; specificity > 0.97).

CONCLUSIONS

The Developmental, Dimensional and Diagnostic Interview (3di) provides an efficient and accurate means of assessing, in dimensional terms, the presence of autistic symptoms in both clinical and normal populations. It offers novel opportunities for those engaged in research and clinical practice.

Early-onset anorexia nervosa: is there evidence of limbic system imbalance?

OBJECTIVE

This study, part of a continuing effort to understand the pathophysiology of the brain in early-onset anorexia nervosa, attempts to validate findings from an earlier study of regional cerebral blood flow and to correlate any abnormalities in blood flow with eating disorder psychopathology.

METHOD

Fifteen newly referred children and adolescents with a diagnosis of anorexia nervosa (AN) underwent regional cerebral blood flow (rCBF) examination using single-photon computerized tomography (SPECT) and the Eating Disorders Examination (EDE) for children.

RESULTS

Mean age was 14 years 11 months (SD = 1.35). Mean weight for height ratio was 82.79 % (SD = 10.66). SPECT findings showed that 11 (73%) had asymmetry (hypoperfusion) of blood flow in at least one area. Regions of the brain showing hypoperfusion included the temporal lobe (n = 9), parietal lobe (n = 5), frontal lobe (n = 3), thalamus (n = 3), and the caudate nuclei (n = 1). The median EDE subscale scores were high for all four subscales. Those patients with hypoperfusion had higher median EDE subscale scores than those without hypoperfusion, although the differences were not statistically significant.

CONCLUSIONS

Most patients in our study had abnormal rCBF, predominantly affecting the temporal lobe, confirming our previous findings. There was no association with the EDE scores. The findings support earlier suggestions of an imbalance in neural pathways or circuits, possibly within the limbic system. This hypothesis is considered within the context of current knowledge and suggestions made with regard to how it might be tested.

Clinical implications of brain imaging in eating disorders

Imaging studies have greatly improved the understanding of the pathology and physiology of psychiatric disorders, such as schizophrenia, affective disorders, obsessive-compulsive disorder, and Tourette syndrome. In the past few years, several neuroimaging studies have concentrated on patients with eating disorders. Although the number of studies is small compared with studies of other psychiatric disorders, the results are beginning to highlight potential areas in the brain that may lead to a better understanding of these disorders. Much research still is needed, and replication of results across centers is needed. The brain is an extremely complex organ; that eating disorders are a result of abnormalities in one specific area of the brain is unlikely. More likely is that several components of the brain have a role, including cortex and subcortical regions and involvement of several neurochemical pathways and circuits within the brain. Further studies are needed in this exciting development of research about eating disorders.

Genetic association studies of schizophrenia using the 8p21-22 genes: prepronociceptin (PNOC), neuronal nicotinic cholinergic receptor alpha polypeptide 2 (CHRNA2) and arylamine N-acetyltransferase 1 (NAT1)

Schizophrenia is a common, genetically heterogeneous disorder with a lifetime prevalence of approximately 1% in the general population. Linkage studies of affected families have now strongly implicated a susceptibility locus on chromosome 8p21-22. Tests of allelic association with markers on 8p21-22 should be able to localise any quantitative trait nucleotides (QTN's) or susceptibility mutations to within a few hundred kilobases. Three brain expressed candidate susceptibility genes, prepronociceptin (PNOC), neuronal cholinergic receptor, nicotinic, alpha polypeptide 2 (CHRNA2) and arylamine N-acetyltransferase 1 (NAT1) have been mapped to chromosome 8p21-22. A case-control, allelic association study was performed using a novel highly polymorphic dinucleotide repeat, D8S2611 near the PNOC gene, two previously characterised dinucleotide repeats, D8S131 and D8S131P at the CHRNA2 locus and an RFLP at the 3'UTR of the arylamine N-acetyltransferase 1 (NAT1) gene. No differences were found in allele frequencies between the patient and control groups. DNA variations or mutations at or near the three genes under study are unlikely to increase susceptibility to schizophrenia in our population sample.

Gastrin inhibits cholangiocarcinoma growth through increased apoptosis by activation of Ca2+-dependent protein kinase C-alpha

BACKGROUND/AIMS

We determined the role of gastrin in the regulation of cholangiocarcinoma growth.

METHODS

We evaluated for the functional presence of cholecystokinin (CCK)-B/gastrin receptors in the cholangiocarcinoma cell lines, Mz-ChA-1, HuH-28 and TFK-1. We determined the effect of gastrin on the growth of Mz-ChA-1, HuH-28 and TFK-1 cells. We evaluated the effect of gastrin on growth and apoptosis of Mz-ChA-1 in the absence or presence of inhibitors for CCK-A (L-364, 718) and CCK-B/gastrin (L-365, 260) receptors, the intracellular Ca2+ chelator (BAPTA/AM), and the protein kinase C (PKC)-alpha inhibitor, H7. We evaluated if gastrin effects on Mz-ChA-1 growth and apoptosis are associated with membrane translocation of PKC-alpha.

RESULTS

Gastrin inhibited DNA synthesis of Mz-ChA-1, HuH-28 and TFK-1 cells in a dose- and time-dependent fashion. The antiproliferative effect of gastrin on Mz-ChA-1 cells was inhibited by L-365, 260, H7 and BAPTA/AM but not L-364, 718. Gastrin induced membrane translocation of PKC-alpha. The inhibition of growth of Mz-ChA-1 cells by gastrin was associated with increased apoptosis through a PKC-dependent mechanism.

CONCLUSIONS

Gastrin inhibits the growth of Mz-ChA-1, HuH-28 and TFK-1 cells. Gastrin inhibits growth and induces apoptosis in Mz-ChA-1 cells through the Ca2+-dependent PKC-alpha. The data suggest a therapeutic role for gastrin in the modulation of cholangiocarcinoma growth.

A microarray enzyme-linked immunosorbent assay for autoimmune diagnostics

In order to quantify autoantibodies in the sera of patients with autoimmune disease, we have created a microarray-based immunoassay that allows the simultaneous analysis of 18 known autoantigens. The microarrays contain serial dilutions of the various antigens, thereby allowing accurate determination of autoantibody titer using minimal amounts of serum. The assay is very sensitive and highly specific: as little as 40 fg of a known protein standard can be detected with little or no cross-reactivity to nonspecific proteins. The signal intensities observed from serial dilutions of immobilized antigen correlate well with serial dilutions of autoimmune sera. Miniaturized and highly parallelized immunoassays like these will reduce costs by decreasing reagent consumption and improve efficiency by greatly increasing the number of assays that can be performed with a single serum sample. This system will significantly facilitate and accelerate the diagnostics of autoimmune diseases and can be adapted easily to any other kind of immunoassay.

Chemical and pharmacological evaluation of different ayurvedic preparations of iron

Ayurvedic preparations of metallic iron commonly categorised as different 'putas' of 'Louha Bhasma' was chemically analysed and pharmacologically investigated in iron deficiency anemia. Atomic absorption spectral (AAS) study of different putas of Louha Bhasma revealed the presence of various proportions of important metals along with varied concentration of iron in it. The effect of a representative puta viz. 50 puta of Louha Bhasma in the management of agar gel diet and phlebotomy induced iron deficiency anemia in animal model was found to be statistically highly significant (P < 0.001) in comparison to the control and standard drug Fefol treated groups.

Valve replacement in the young patient with rheumatic heart disease. Review of a twenty-year experience

During a 20-year period 303 young subjects between 9 and 20 years of age (mean, 16.2 +/- 2.72 years) with rapid and relentlessly progressive valvular disease from rheumatic fever underwent valve replacements. The Starr-Edwards ball valve prosthesis remains the device of choice, although other valves have been implanted. The overall hospital mortality rate was 9.6% in the mitral valve, 3.5% in the aortic valve, and 4.2% in the double valve replacement groups. Actuarial survival at 10, 15, and 20 years was 78.4% (+/- 3.3%), 70.0% (+/- 5.8%), and 59.3% (+/- 11.1%), respectively, for patients with mitral valve replacement. The rates for aortic valve replacement were 85.9% (+/- 4.6%) at 10 and 15 years and 72.7% (12.8%) at 20 years. In the double valve replacement group the survival rates after 5 and 10 years were 79.9% (+/- 5.1%). The incidence of thromboembolism was 0.41, 0.59, and 1.04 per 100 patient-years for the mitral, aortic, and double-valve prostheses, respectively. The prospect of childbearing seems promising in those young women who were subsequently married. Our favorable and gratifying experience in this review bears testimony to the physiologic advantages of the Starr-Edwards valve as the device of choice in the rehabilitation of patients with advanced and severe valvular disease after rheumatic fever.