A rational approach to the medical assessment of the child with attention-deficit/hyperactivity disorder

A comprehensive medical assessment is needed to evaluate children with behaviors suggestive of ADHD. This assessment assists in confirming the diagnosis of ADHD or identifies other conditions that mimic it. The article discusses several approaches to an assessment, which typically includes a detailed history, a comprehensive physical examination, a functional neurodevelopmental assessment, and the performance of a selection of tests from a wide variety of biomedical procedures.

[Helicobacter heilmannii: anatomo-clinical study of 14 new cases]

INTRODUCTION

Helicobacter pylori is one of the most common causes of human gastritis. Recently, a new agent has been isolated, which also causes a gastritis. It has been initially named Gastrospirillum hominis and renamed Helicobacter heilmannii (Hh). Hh is extremely rare. In spite of the rarity it is important to recognize and diagnose it, as it requires a proper therapy, different from Hp therapy. Clinical presentation and serological results of Hh are superimposable to those of HP. Therefore differential diagnosis resides on histological grounds. PURPOSE of the present paper is to report 14 new cases of Hh gastritis, which constitutes the first italian series.

RESULTS

Cases constituted 0.01% of all gastric biopsies seen in the period 1994-1998. Nine patients were male and five were female; age ranged from 32 to 76 years (50 years on average). All patients presented a mild to moderate gastritis. Hh is a spiral bacterium, being about 10 micra in length, localized in single or small groups in the glandular mucus. Two cases were associated with Hp. One case was associated with gastric adenocarcinoma. Two cases were diagnosed during the follow-up of duodenal ulcer. In CONCLUSION, the incidence of Hh gastritis in the present series seems consistent with that from other European countries. In all cases the presence of Hh was associated with features of gastritis. This confirms the pathogenetic role of Hh.

Soluble complement receptor type 1 (sCR1) in chronic liver diseases: serum levels at different stages of liver diseases

Complement receptor type 1 (CR1) is an integral membrane protein of many haematopoietic cells and plays an important role in the clearance of complement-associated immune complexes, favouring their transport to liver and spleen macrophages. A small amount of soluble CR1 (sCR1) is also found in plasma and might originate directly from release of leucocytes and other circulating cells. In previous studies, an increase in serum sCR1 level has been observed in liver cirrhosis and end-stage renal failure. High levels have also been found in patients with some haematologic malignancies. sCR1 serum levels were measured using a specific double sandwich ELISA assay. The present study demonstrates the correlation between mean serum sCR1 concentrations and disease severity in patients with chronic liver disease. In patients with liver cirrhosis, grouped according to the Child-Pugh classification, sCR1 rose as liver function decreased. The presence of neoplastic growth in the liver apparently does not play a role in the increase of sCR1. Serum sCR1 was not elevated in other solid malignancies. Since sCR1 accumulates in liver diseases, evaluation of its serum levels could be useful as a liver function test.

Maternally reported fetal activity levels and developmental diagnoses

Retrospective maternal report of fetal activity level was compared with developmental diagnosis in 608 consecutively referred children. Maternal history of fetal activity level was also obtained from 140 unmatched well children in a general pediatric clinic. Fetal hyperactivity was positively associated with a diagnosis of child hyperactivity, and fetal hypoactivity was positively associated with a diagnosis of mental retardation in the children. Maternal histories of fetal activity level in the control group weakened the strength of the association between fetal hyperactivity and child hyperactivity but did not affect the association between fetal hypoactivity and mental retardation in children.

Binding of human complement component C4b-binding protein (C4BP) to Streptococcus pyogenes involves the C4b-binding site

A key step in the elimination of invading pathogens from the body is the covalent binding of complement proteins C3b and C4b to their surface. However, many pathogens have evolved mechanisms to avoid the complement system of the host. Understanding how these mechanisms work may lead to more efficacious forms of therapy. Here we provide an insight into the molecular basis of how Streptococcus pyogenes binds human plasma C4b-binding protein (hC4BP), a complement regulatory molecule that may decrease C3b and C4b deposition on the streptococcal surface. We show that streptococcal surface molecules bind to a site on hC4BP that is indistinguishable from the C4b binding site. This site involves multiple binding surfaces that span short consensus repeats 1 to 3 of the alpha-chain of hC4BP. We propose that hC4BP is bound to the bacterial surface because the streptococcal surface molecules involved in the interaction mimic human C4b epitopes.

Binding of human complement component C4b-binding protein (C4BP) to Streptococcus pyogenes involves the C4b-binding site

A key step in the elimination of invading pathogens from the body is the covalent binding of complement proteins C3b and C4b to their surface. However, many pathogens have evolved mechanisms to avoid the complement system of the host. Understanding how these mechanisms work may lead to more efficacious forms of therapy. Here we provide an insight into the molecular basis of how Streptococcus pyogenes binds human plasma C4b-binding protein (hC4BP), a complement regulatory molecule that may decrease C3b and C4b deposition on the streptococcal surface. We show that streptococcal surface molecules bind to a site on hC4BP that is indistinguishable from the C4b binding site. This site involves multiple binding surfaces that span short consensus repeats 1 to 3 of the alpha-chain of hC4BP. We propose that hC4BP is bound to the bacterial surface because the streptococcal surface molecules involved in the interaction mimic human C4b epitopes.

Polymorphism of the complement components in human pathology

The complement system is an important part of non clonal or innate immunity that collaborates with acquired immunity to kill pathogens and to facilitate the clearance of immune complexes. The complement is made up of 20 distinct plasma proteins and 9 different membrane proteins. Three components, factor B, C2 and C4 (with 2 isotypes), are coded by polymorphic HLA-linked genes and are sometimes referred to as class III antigens, inherited as compact units called complotypes. The C4 genes are the most polymorphic, including a common null allele (Q0) at both the C4A and C4B loci. Other polymorphic complement factors (not linked to HLA) are C3 (2 common alleles), C6 and C7 (closely linked, with 3 and 2 alleles, respectively). A certain degree of polymorphism has also been described for complement receptors and membrane control proteins. No differences in functional activity are usually detected among different alleles. Immune-mediated diseases are associated with C4Q0, in particular: systemic lupus erythematosus and discoid-systemic lupus erythematosus, insulin-dependent diabetes mellitus, liver cirrhosis, celiac disease and IgA/IgG4 deficiency. Even if optimal HLA markers do become available, genetic counselling is usually not the ultimate goal for dealing with most of the HLA-associated common diseases, although their study could help to better delineate disease pathogenesis.

Toe walking and language development

Neurodevelopmental markers that are present early in childhood may identify children at risk for later developmental disabilities. This paper attempts to clarify the relationship between one such proposed marker, toe walking, and language development in a general pediatric population. One hundred sixty-three children being seen for well-child visits were included in the study. Information from each child's caretaker was obtained for language development and a history of toe walking; observation of toe walking during the visit was also included. The frequency of toe walking was 24%. Language quotients were calculated and compared for toe walkers (n = 39) and non-toe walkers (n = 127). The mean language quotient for toe walkers tended to be consistently lower than that for non-toe walkers. The specificity of toe walking for low language scores was 85% but had a sensitivity of only 32%. Although an association between toe walking and language delay is supported by the present data, the association does not appear to be clinically significant.

The learning-disabled medical student

Developmental pediatricians are being consulted by medical school promotion committees with regard to the course of action to be taken with learning-disabled medical students experiencing academic difficulties. Faculty attitude, a difficulty understanding the nature of learning disabilities, appears to be a major contributor to poor medical school performance on the part of learning-disabled adults. Utilizing the sequential-simultaneous information processing model as a simplified introduction to learning disability patterns, the authors argue that recommending intensive remediation of rote spelling and writing skills in students engaged in graduate education represents both a waste of time and a further emotional trauma to these young professionals.

Excessive water drinking. A marker of caretaker interaction disturbance

In children examined at a child development clinic the incidence of excessive water drinking was almost exclusively confined to the foster care population. A series of 11 patients is compared with other reports of excessive water drinking as a marker for parent-child problems and inadequate nurturance. The parent-child interaction patterns were characterized as rejecting and both overprotective and overindulgent. The family adaptational styles tended to be chaotic and rigid, and the family cohesion styles disengaged or separated. Excessive water drinking can be considered a marker for problems in parenting.

Toe walking. A marker for language disorders in the developmentally disabled

Toe walking unassociated with an autistic disorder or cerebral palsy generally has been considered a normal infant gait. The incidence of toe walking in various diagnostic subgroups of 799 developmentally disabled children presenting to a tertiary-level multidisciplinary assessment clinic was reviewed to investigate the authors' clinical impression that toe walking may be a marker for language dysfunction. Toe walking was found to be more frequent in those diagnostic subgroups with more severe language disorders. Toe walking also correlated with lower IQ scores (p less than 0.0001). The sensitivities, specificities, predictive validities and odds ratios all supported the hypothesized association between toe walking and language disorders. Further prospective studies of the neurodevelopmental outcome of children with toe walking are needed to determine whether this behavior can identify children at risk for language disorders.

Acute leukemia. Learning disabilities following CNS irradiation

Thirteen elementary school age children with acute leukemia who had received cranial irradiation with dosages between 1,800 and 4,800 rads a mean of 6.3 years earlier were evaluated for the presence of learning disorders. The authors utilized both psychometric and educational tests. The results were analyzed according to a graduated regressed standard score procedure and yielded the following diagnoses: mental retardation, two (15%); learning disability in reading and mathematics, two (15%); learning disability in mathematics, five (39%); no psychoeducational diagnosis, four (31%). Of the nine children (69%) who qualified for a specific psychoeducational diagnosis, only three were receiving any special educational services. The failure of a previous assessment of this same group of children at our center and of other research reports to uncover a similarly high incidence of neurodevelopmental pathology may be due to the specific tests employed or to the later onset of measurable difficulties in these patients.

Autism and plumbism. A possible association

Six cases of inner city black children with both infantile autism and lead poisoning are reviewed. In three cases, developmental deviance seems to have been present before the possible impact of lead toxicity. In two cases the lead poisoning may have contributed to the onset or acceleration of developmental symptomatology. In one case the temporal sequence remains unclear. Possible patterns of interaction and the implications for clinical practice are discussed.

Emotional symptoms in Prader-Willi syndrome adolescents

Clinical observations and parental reports on the behavior of Prader-Willi syndrome (PWS) patients suggest the development of a wide variety of psychiatric disorders as the PWS child enters adolescence. Documentation of these emotional disorders remains unsystematic. Here we describe the results of administering the Survey Diagnostic Instrument (SDI) to the parents of 35 PWS adolescents. The questionnaire data were supplemented by additional selected demographic and clinical data. The SDI is a 134 item questionnaire filled out by one parent. It screens for the DSM-III criterion-based diagnostic categories of neurosis (dysphoric, compulsive, anxious), somatization, conduct disorder (antisocial, violent), and hyperactivity. The following diagnostic pattern resulted: neurosis, dysphoric, (1 probable); neurosis, compulsive, 3 (6 probable); neurosis, anxious, 4 (and 10 probable); somatization, 0; conduct disorder, violent 0; conduct disorder, antisocial, 0; hyperactivity, 1 (and 1 probable). An odds ratio algorithm is used to uncover possible predisposing factors, and the results are discussed in the context of organic versus psychiatric causes.

Mentally retarded parents in the community: identification method and needs assessment survey

Mentally retarded parents in the community represent a relatively new and increasing population. Due to the parents' limitations, the children are at significant risk for medical, emotional, and cognitive delays and neglect. An estimate of the size of this population that comes to agency attention is needed in order to program supportive services. The methodology and results of a community-based survey to determine the size of this population receiving agency services in a large metropolitan area are described as are the results of a survey interview with a subset of these parents and their children to determine services needed from the parents' perspective.

Pirenzepine in non-ulcer dyspepsia. A double-blind, placebo controlled trial

Fifty patients (with non-ulcer dyspepsia) were admitted to a double-blind, placebo-controlled trial to study the effects of pirenzepine (100 mg/daily) on non-ulcer dyspepsia. Ten patients did not complete the trial. After 4 weeks of treatment, statistically significant improvement (P less than 0.001) was observed endoscopically in the pirenzepine group. The relief of dyspepsia was significantly greater in the pirenzepine-treated group. The tolerability of pirenzepine was good.