The marital and family functioning of adults with ADHD and their spouses

Little is known about the family relationships of adults with Attention-Deficit/Hyperactivity Disorder (ADHD). Thus, the marital adjustment and family functioning of 33 married adults with ADHD and their spouses was compared to 26 non-ADHD control participants and their spouses. Results revealed that married adults with ADHD reported poorer overall marital adjustment on the Dyadic Adjustment Scale (DAS; Spanier, 1989) and more family dysfunction on the Family Assessment Device (FAD; Eptein, Baldwin, & Bishop, 1983) than control adults. The spouses of adults with ADHD did not differ from control spouses in reports of overall marital adjustment and family dysfunction. A greater proportion of their marital adjustment scores, however, fell within the maladjusted range. The ADHD adults' perceptions of the health of their marriages and families were more negative than their spouses' perceptions. The way in which spouses of ADHD adults compensated for their partners' difficulties were explored through clinical interviews. The findings in this study underscore the need for assessments and treatments to address marital and family functioning of adults with ADHD.

Multiple complex developmental disorder: the "multiple and complex" evolution of the "childhood borderline syndrome" construct

OBJECTIVES

To provide an overview of the history, evolution, and nosology of the diagnostic constructs for "borderline syndrome of childhood," also known as "multiple complex developmental disorder."

METHOD

The authors synthesized information found via electronic searches of databases (MEDLINE, PsycINFO, Current Contents, Humanities Abstracts, and Social Sciences Abstracts) and bibliographic directed searches.

RESULTS

Although early publications (prior to 1980) were either highly anecdotal or lacking in scientific rigor, they were nonetheless noted for their historic value and influence on research trends. The recent publications (1990s) were characterized by more rigorous methodology and greater generalizability. Current classifications, proposals for diagnostic criteria, epidemiological data, and nosological suggestions were summarized.

CONCLUSION

The literature supports the creation of a new diagnostic label to describe a population of children whose symptoms are currently subsumed under the labels "borderline" or "multiple complex developmental disorder." A full characterization of the syndrome, including its evolution, would require prospective studies and may differ from the known evolution for personality disorders and/or pervasive developmental disorders. The authors propose a process by which a new nomenclature is derived.

Inpatient treatment of severe disruptive behaviour disorders with risperidone and milieu therapy

OBJECTIVES

To evaluate the therapeutic impact of adding risperidone to milieu therapy of latency-aged inpatients with severe disruptive disorders.

METHODS

The charts of 90 latency-aged patients consecutively admitted to a psychiatry ward were reviewed retrospectively. Fifteen of these patients received risperidone treatment, were nonpsychotic, and did not suffer from pervasive developmental disorder (12 male, 3 female; mean age 9.99 years, SD 1.76). Their scores on the Children's Global Assessment Scale (CGAS) were compared at admission, before risperidone treatment, and at discharge.

RESULTS

All subjects were diagnosed with a disruptive behavioural disorder. Ten (66.67%) had additional learning difficulties, and 13 (86.7%) had pathological personality traits. The characteristics of the sample suggested borderline pathology or multiple complex developmental disorder. Following a mean of 38 days after admission (SD 22.3), the patients received risperidone for a mean of 46 days (SD 28.2) before being discharged. The mean maintenance dose of risperidone was 1.27 mg daily (SD 0.36). Mean CGAS scores increased from admission (21.9, SD 7.0) to before risperidone treatment (26.8, SD 7.6, P < 0.0001) and to discharge (50.3, SD 5.3, P < 0.0001). Only 2 patients had documented side effects.

CONCLUSIONS

Low-dose risperidone used adjunctively to milieu therapy led to statistically and clinically significant additional improvement in the functioning of hospitalized latency-aged children with severe behavioural disorders. Low-dose risperidone is a safe and effective adjunct to milieu therapy for treating this population in inpatient settings. Prospective randomized controlled trials are needed to confirm these findings.

Characterization of the heparan sulfate and chondroitin sulfate assembly sites in CD44

Isoforms of CD44 are differentially modified by the glycosaminoglycans (GAGs) chondroitin sulfate (CS), heparan sulfate (HS), and keratan sulfate. GAG assembly occurs at serines followed by glycines (SG), but not all SG are utilized. Seven SG motifs are distributed in five CD44 exons, and in this paper we identify the HS and CS assembly sites that are utilized in CD44. Not all the CD44 SG sites are modified. The SGSG motif in CD44 exon V3 is the only HS assembly site; this site is also modified with CS. HS and CS attachment at that site was eliminated by mutation of the serines in the V3 motif to alanine (AGAG). Exon E5 is the only other CD44 exon that supports GAG assembly and is modified with CS. Using a number of recombinant CD44 protein fragments we show herein that the eight amino acids located downstream of the SGSG site in V3 are responsible for the specific addition of HS to this site. If the eight amino acids located downstream from the first SG site in CD44 exon E5 are exchanged with those located downstream of the SGSG site in exon V3, the SG site in E5 becomes modified with HS and CS. Likewise if the eight amino acids found downstream from the first SG in E5 are placed downstream from the SGSG in V3, this site is modified with CS but not HS. We also show that these sequences cannot direct the modification of CD44 with HS from a distance. Constructs containing CD44 exon V3 in which the SGSG motif was mutated to AGAG were not modified with HS even though they contained other SG motifs. Thus, a number of sequence and structural requirements that dictate GAG synthesis on CD44 have been identified.

Generation of artificial proteoglycans containing glycosaminoglycan-modified CD44. Demonstration of the interaction between rantes and chondroitin sulfate

All CD44 isoforms are modified with chondroitin sulfate (CS), while only those containing variably spliced exon V3 are modified with both CS and heparan sulfate (HS). The CS is added to a serine-glycine (SG) site in CD44 exon E5, while HS and CS are added to the SGSG site in exon V3. Site-directed mutagenesis and other molecular biology techniques were used to determine the minimal motifs responsible for the addition of CS and HS to CD44 (see accompanying paper (Greenfield, B., Wang, W.-C., Marquardt, H., Piepkorn, M., Wolff, E. A., Aruffo, A., and Bennett, K. L. (1999) J. Biol. Chem. 274, 2511-2517)). We have used this information to generate artificial proteoglycans containing the extracellular domain of the cell adhesion protein lymphocyte function-associated antigen-3 (LFA-3) (CD58) and CD44 motifs modified with CS or a combination of CS and HS. Analysis of the CD44-modified LFA-3 protein showed that it retains the ability to engage and trigger the function of its natural ligand CD2, resulting in T cell activation. In addition, the glycosaminoglycan-modified artificial proteoglycan is capable of binding the chemokine RANTES (regulated upon activation, normally T cell expressed and secreted) and delivering it to human T cells, resulting in enhanced T cell activation. These data demonstrate that artificial proteoglycans can be engineered with functional domains that have enhanced activity by codelivering glycosaminoglycan-binding molecules. The artificial proteoglycans were also used as a model system to explore the glycosaminoglycan binding properties of basic-fibroblast growth factor and the chemokine RANTES. While basic-fibroblast growth factor was shown to bind HS alone, this model revealed that RANTES binds not only HS, as has been demonstrated in the past, but also CS. Thus, artificial proteoglycans can be used for studying the glycosaminoglycan binding patterns of growth factors and chemokines and provide a means to manipulate the levels, types, and activity of glycosaminoglycan-binding proteins in vitro and in vivo.

Function of the nasal muscles in normal subjects assessed by dynamic MRI and EMG: its relevance to rhinoplasty surgery

The external nose is generally considered to have a relatively static shape. Movement of the nose and the potential for change of external shape and the internal airway have been assessed by (1) cadaver dissection and (2) dynamic studies during a standardized series of facial expressions in 13 subjects; video recording of the movement of skin markers, electromyography, and moving magnetic resonance images. A standard description of muscle anatomy is presented. The dynamic investigations indicated the following. Video analysis showed the components of muscle action: dilatation, constriction of the nostril, depression of the tip, vertical contraction in the bridge, and elevation of the alar, in different expressions. Electromyography confirmed muscle actions during expression and phonation. Magnetic resonance imaging demonstrated large changes in the external shape of the nose and nasal aperture due to muscle actions. Muscle function should be given greater consideration in aesthetic and cleft rhinoplasty.

Identification of CD44 residues important for hyaluronan binding and delineation of the binding site

CD44 is a widely distributed cell surface protein that plays a role in cell adhesion and migration. As a proteoglycan, CD44 is also implicated in growth factor and chemokine binding and presentation. The extracellular region of CD44 is variably spliced, giving rise to multiple CD44 isoforms. All isoforms contain an amino-terminal domain, which is homologous to cartilage link proteins. The cartilage link protein-like domain of CD44 is important for hyaluronan binding. The structure of the link protein domain of TSG-6 has been determined by NMR. Based on this structure, a molecular model of the link-homologous region of CD44 was constructed. This model was used to select residues for site-specific mutagenesis in an effort to identify residues important for ligand binding and to outline the hyaluronan binding site. Twenty-four point mutants were generated and characterized, and eight residues were identified as critical for binding or to support the interaction. In the model, these residues form a coherent surface the location of which approximately corresponds to the carbohydrate binding sites in two functionally unrelated calcium-dependent lectins, mannose-binding protein and E-selectin (CD62E).

Deleted in colorectal carcinoma (DCC) binds heparin via its fifth fibronectin type III domain

DCC (deleted in colorectal carcinoma) is a broadly expressed cell-surface receptor. Netrin-1 was recently identified as a DCC ligand in brain, but the possibility of other DCC ligands was suggested by the finding that an anti-DCC antibody (clone AF5) neutralized netrin-1-dependent commissural axon outgrowth without blocking DCC/netrin-1 interactions. Here we have searched for alternative cell-surface DCC ligands. A DCC-Ig fusion protein bound to neural and epithelial derived cell lines, indicating that these lines express ligand(s) for DCC. The cell-surface binding activity was mediated by the loop between beta-strands F and G of the fifth fibronectin type III repeat FNIII-D5. The loop included the sequence KNRR, which resembles heparin-binding motifs in other proteins. Heparinase and heparitinase treatment of cells reduced binding of DCC-Ig, suggesting that heparan sulfate proteoglycans are cell-surface DCC ligand(s). This was further supported by heparin blocking experiments and by binding of DCC-Ig to immobilized heparan sulfate. The interaction between DCC-Ig and heparan sulfate/heparin, both on the surface of cells and immobilized on plastic, was blocked by the same anti-DCC antibody that blocks netrin-1-dependent commissural axon outgrowth. Taken together, these findings suggest that the DCC-Ig/heparin interaction may contribute to the biological activity of DCC.

Juvenile onset bipolar disorder

This article reviews juvenile onset bipolar disorder with regard to history, diagnosis, comorbidity, differential diagnosis, prevalence, etiology, treatment, and outcome. Specifically, it deals with past and current diagnostic criteria for juvenile onset bipolar disorder, the controversy around its comorbidity with attention deficit hyperactivity disorder (ADHD), and how to differentiate it from ADHD, conduct disorder, drug and alcohol abuse, and schizophrenia, Genetic and neuroimaging studies investigating the possible etiology of this condition are also described. Treatment, both pharmacological (eg, lithium, neuroleptics, anticonvulsants, benzodiazepines, antidepressants) and psychosocial (eg, psychoeducation of child and family, school intervention, family, group and/or individual therapy) are outlined. Finally, long-term outcome and factors which may influence outcome are addressed.

Regulation of CD44 binding to hyaluronan by glycosylation of variably spliced exons

The hyaluronan (HA)-binding function (lectin function) of the leukocyte homing receptor, CD44, is tightly regulated. Herein we address possible mechanisms that regulate CD44 isoform-specific HA binding. Binding studies with melanoma transfectants expressing CD44H, CD44E, or with soluble immunoglobulin fusions of CD44H and CD44E (CD44H-Rg, CD44E-Rg) showed that although both CD44 isoforms can bind HA, CD44H binds HA more efficiently than CD44E. Using CD44-Rg fusion proteins we show that the variably spliced exons in CD44E, V8-V10, specifically reduce the lectin function of CD44, while replacement of V8-V10 by an ICAM-1 immunoglobulin domain restores binding to a level comparable to that of CD44H. Conversely, CD44 bound HA very weakly when exons V8-V10 were replaced with a CD34 mucin domain, which is heavily modified by O-linked glycans. Production of CD44E-Rg or incubation of CD44E-expressing transfectants in the presence of an O-linked glycosylation inhibitor restored HA binding to CD44H-Rg and to cell surface CD44H levels, respectively. We conclude that differential splicing provides a regulatory mechanism for CD44 lectin function and that this effect is due in part to O-linked carbohydrate moieties which are added to the Ser/Thr rich regions encoded by the variably spliced CD44 exons. Alternative splicing resulting in changes in protein glycosylation provide a novel mechanism for the regulation of lectin activity.

Short-term efficacy of interventions by a youth crisis team

OBJECTIVE

To determine the impact of an outpatient psychiatric Emergency Room Follow-up Team (ERFUT) on the hospitalization rate of youth in crisis (mostly suicidal adolescents).

METHOD

The rate of psychiatric admissions of youth to a general pediatric hospital during a year prior to the ERFUT creation was compared to that same rate after the team's creation. The proportion of patients returning to the Emergency Room (ER) 2 or more times was also compared for those same years. Deaths were identified at 3-year follow-up for the experimental group.

RESULTS

A 16% reduction in the hospitalization rate followed the team's creation, without an increase in the proportion of patients returning to the ER. Also, none of the experimental group subjects had died at 3-year follow-up.

CONCLUSION

There is a subpopulation of previously hospitalized suicidal adolescents who can be effectively cared for as outpatients when treated rapidly and intensively.

Posture in patients with shoulder overuse injuries and healthy individuals

Assessment of posture is an integral component of patient evaluation with shoulder overuse injuries. However, the professional literature contains relatively few studies that have assessed the relationship between posture, function, and injury. The purpose of this study was to determine the relationship and differences in postural variables within and between subjects with overuse injuries to the shoulder of healthy subjects. Thirty patient subjects and 30 healthy subjects matched for age and gender were recruited. Scapular protraction and rotation, forward head position, midthoracic curvature, and passive humeral elevation in the plane of the scapula were measured randomly in standing. All measurement techniques were standardized and validated. Intrarater and interrater reliability for all clinical measures were established before data collection. Forward head position was significantly greater (p < .001) in the patient group than the healthy group; humeral elevation was significantly greater (p < .001) in the healthy group than in the patient group and in the uninvolved shoulders (p < .01) than the involved shoulders within the patient group. Scapular protraction, rotation, midthoracic curvature, and scapular symmetry were not significantly different between groups. Scapula protraction and rotation were significantly related (p < .05) in the patient group. No other postural variables were related. Conclusions regarding the influence of posture to shoulder injury are inconclusive based on several confounding variables that may have affected the outcome.

Association of the eosinophilia-myalgia syndrome with the ingestion of tryptophan

We report on a series of three patients with an unusual syndrome of eosinophilia and myalgia associated with the oral ingestion of tryptophan that was recognized in New Mexico in October 1989. All three patients, who were women 37 to 44 years of age, had severe muscle pain, muscle weakness, mouth ulcers, and striking eosinophilia (more than 8 X 10(9) cells per liter). Other manifestations included fever, abdominal pain, dyspnea, skin rash, and elevated serum concentrations of aminotransferase and aldolase. The women had been taking tryptophan in doses of 1.2 to 2.4 g a day for three weeks to 2 1/2 years. The discontinuation of tryptophan and the initiation of glucocorticoid treatment resulted in improvement, but all three women were still symptomatic three to five months later. Tests for trichinosis and other parasites and for allergic and connective-tissues disorders were negative, and serum immunoglobulin concentrations and erythrocyte sedimentation rates were normal. A muscle biopsy in one patient and biopsies of the vagina, liver, and other abdominal organs in another revealed eosinophilic infiltration, as well as the extracellular deposition of eosinophil-granule major basic protein. All three patients had elevated serum and urinary levels of this protein and eosinophil-derived neurotoxin, indicative of eosinophil degranulation. The syndrome of eosinophilia and myalgia in association with the ingestion of tryptophan that was seen in these three patients is a newly recognized adverse effect of tryptophan ingestion. Our identification of this association in these patients led to the discovery of an epidemic of what is now called the eosinophilia-myalgia syndrome.

The influence of cephalostatic ear rods on the positions of the head and neck during postural recordings

This study examined the effect of cephalostatic ear rods on the positions of the head and neck. The method error was assessed for postural recordings of the head and neck position made with and without ear rods. A photographic angle was correlated with the postural angles on x-ray film. The material compared 33 dental students who were recorded with ear rods in and with ear rods out. Subjects were chosen randomly to repeat the postural recordings. The differences between the mean for each postural variable were subjected to comparative analysis, using Student's t test for paired samples. A significant difference (p less than or equal to 0.05) was found between the means of the inclination of the cervical spine to the true horizontal and the means of the photographic angle. The mean values for the remaining postural variables showed an insignificant but consistent pattern of axial extension of the cervical spine. Cephalostatic ear rods may alter head and neck position during postural recordings. The method error made for recording total head and neck position with ear rods was higher than without ear rods. The difference in the photographic angle was found to have a moderate positive correlation with the difference in the cervical inclination and the total head and neck position. These data suggest that lateral cephalostatics without ear rods may be used to record total head and neck position and the photographic technique may be used as a quick, inexpensive method for the clinician to determine head and neck positional changes before and after treatment.

Two subgroups of hyperactives as adults: correlations of outcome

This prospective study explored the association of continuing symptoms of the hyperactive syndrome with adult outcome. A fifteen year follow-up compared 61 hyperactive subjects and 41 matched controls. Outcome measures examined included continuing symptoms of the hyperactive syndrome, antisocial behaviour, substance use, and emotional difficulties. Two subgroups of the hyperactive population were identified. Those hyperactive subjects with moderate or severe continuing symptoms were characterized by significant emotional difficulties, alcohol use, and antisocial behaviour. By contrast, hyperactive subjects with none or only mild continuing symptoms at follow-up did not have other difficulties in psychosocial functioning, and were, in addition, similar to the control group in many respects. The importance of continuing symptoms in determining the adult outcome of children with a diagnosis of ADDH is discussed. Accordingly, the need for comprehensive early, and ongoing interventions is emphasized.

A rural child psychiatry day treatment centre: systemic perspective

The author presents the complexities of directing a DTC (Day Treatment Center) in a rural setting. These complexities are explored from the perspective of system's theory. The various systems contained within the DTC are in dynamic equilibrium with each other as well as with various community groups. Changes in any one system have significant impact on the groups the system impinges on. As an example, the DTC had not functioned well for a period of time prior to the author's arrival. During that period the staff communicated poorly among themselves, resulting in conflicts between the teaching and non-teaching staff. When these conflicts were resolved the well-established incompatibilities and stresses within the system of the non-teaching staff surfaced. In the process of this conflict resolution the DTC was reorganized. New groups were established to access children at primary and secondary levels of medical prevention. Rapport with other systems in the community improved. Consequently, with better communication between groups of staff and with the community, the treatment of the children could be more effective.

Acceleration of tetrazolium reduction by bacteria

Conditions were assessed which would permit more rapid recognition of bacterial growth than has been previously reported using tetrazolium salts. Microtitration trays were used. 2-(p-Iodophenyl)-3(p-nitrophenyl)-5-phenyltetrazolium chloride is rapidly reduced by respiring cells in tissue homogenates but is more toxic than other tetrazoliums when added to growing bacterial cultures. Phenazine methosulfate (PMS), an intermediate electron carrier, potentiates tetrazolium reduction. Growth was readily detected by the addition of these compounds after 3 to 4 h of incubation in Schaedler broth. The final concentration prior to addition to tray wells was 1.0 mg/ml for 2-(p-iodophenyl)-3(p-nitrophenyl)-5-phenyltetrazolium chloride and 0.06 mg/ml for PMS. Addition of 0.5 to 0.8 g of agar per liter of broth enhanced subsequent tetrazolium reduction.