Pediatric Annals

Trend Watch 

Trend Watch

Abstract

Researchers at the National Institutes of Health have proposed diagnostic criteria for a broadened syndrome of acute onset obsessive-compulsive disorder to eliminate etiological factors and to clarify initial clinical presentation from another similar acute condition.

According to National Institute of Mental Health (NIMH) Pediatric and Development Neuroscience Branch Chief Susan E. Swedo, MD, and colleagues, pediatric acute-onset neuropsychiatric syndrome (PANS) would be differentiated from what is currently known as pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS).

Three potential diagnostic criteria have been developed by the researchers for PANS:

The person must present with an abrupt, dramatic onset of obsessive-compulsive behavior (OCD) or severely restricted food intake.

The person must have a concurrent presence of at least two additional neuropsychiatric symptoms with similarly severe and acute onset. The symptoms can be anxiety, mood swings and depression, aggression, irritability and oppositional behaviors, developmental regression, sudden abnormalities, somatic signs and symptoms.

Symptoms cannot be explained by a known neurologic or medical disorder.

The proposed PANS criteria were developed after a July 2010 PANDAS workshop at the NIH. Researchers, clinicians, and advocates considered all cases of acute-onset OCD, regardless of potential cause. According to Swedo, PANS will likely include a number of related disorders with different causes that share a common presentation.

“Defining the syndrome by the presenting clinical symptoms will allow physicians to make a diagnosis at the time of initial evaluation, without having to wait for laboratory studies,” Swedo told Pediatric Annals. “Further, by removing the requirement that strep infections play a role in the onset of symptoms (as PANDAS requires), the spectrum of cases has been broadened to include all acute-onset cases.” Swedo also said she hopes the criteria will lead to a better understanding of how acute-onset neuropsychiatric symptoms are triggered and will “increase our knowledge about specific types of the disorder, such as PANDAS and infection-triggered (syndromes).”

“As the field moves toward agreement on this broadened syndrome, affected youth will be more likely to receive appropriate care, regardless of whether they are seen by a neurologist, pediatrician or child psychiatrist,” said Thomas R. Insel, MD, NIMH director.

In a separate NIH study now underway, Swedo and colleagues are investigating the effectiveness of intravenous immunoglobulin (IVIG) for reducing OCD symptoms in children with PANDAS.

According to Swedo, the IVIG trial is a replication of a previous trial conducted at NIMH by Perlmutter and colleagues. “The current double-blind, multi-site, placebo-controlled study will look at IVIG, a medication derived from normal antibodies that neutralizes harmful antibodies, as it has shown promise in a pilot study with people who have PANDAS,” said Swedo, who added that the clinical ratings are being done by investigators at Yale University to keep investigators blind to the nature of the study drug infusion.

“We expect to show that IVIG is vastly superior to placebo in reducing severity of the obsessive-compulsive symptoms and other neuropsychiatric symptoms present in children with acute, severe PANDAS,” Swedo told Pediatric Annals.

Swedo, SE. Pediatr Therapeut. 2012; doi:10.4172/2161-0665.1000113 [CrossRef] . Disclosure: The researchers report no relevant financial disclosures. Dr. James Leckman, a researcher on the NIH study, has received research funding from Talecris (Grifols).

The incidence of cutaneous melanoma is rising among those aged younger than 40 years according to a Mayo Clinic study. The use of indoor tanning beds is a main culprit, especially among women, the researchers wrote.

Despite an overall decrease in mortality rates, attributed to early detection and improved medical care, the study found that the incidence of melanoma increased eightfold among women and fourfold among men from 1970 to 2009.

The study confirmed that the incidence of…

New Diagnostic Criteria Proposed for Sudden-Onset OCD in Children

Researchers at the National Institutes of Health have proposed diagnostic criteria for a broadened syndrome of acute onset obsessive-compulsive disorder to eliminate etiological factors and to clarify initial clinical presentation from another similar acute condition.

According to National Institute of Mental Health (NIMH) Pediatric and Development Neuroscience Branch Chief Susan E. Swedo, MD, and colleagues, pediatric acute-onset neuropsychiatric syndrome (PANS) would be differentiated from what is currently known as pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS).

Three potential diagnostic criteria have been developed by the researchers for PANS:

  1. The person must present with an abrupt, dramatic onset of obsessive-compulsive behavior (OCD) or severely restricted food intake.

  2. The person must have a concurrent presence of at least two additional neuropsychiatric symptoms with similarly severe and acute onset. The symptoms can be anxiety, mood swings and depression, aggression, irritability and oppositional behaviors, developmental regression, sudden abnormalities, somatic signs and symptoms.

  3. Symptoms cannot be explained by a known neurologic or medical disorder.

The proposed PANS criteria were developed after a July 2010 PANDAS workshop at the NIH. Researchers, clinicians, and advocates considered all cases of acute-onset OCD, regardless of potential cause. According to Swedo, PANS will likely include a number of related disorders with different causes that share a common presentation.

“Defining the syndrome by the presenting clinical symptoms will allow physicians to make a diagnosis at the time of initial evaluation, without having to wait for laboratory studies,” Swedo told Pediatric Annals. “Further, by removing the requirement that strep infections play a role in the onset of symptoms (as PANDAS requires), the spectrum of cases has been broadened to include all acute-onset cases.” Swedo also said she hopes the criteria will lead to a better understanding of how acute-onset neuropsychiatric symptoms are triggered and will “increase our knowledge about specific types of the disorder, such as PANDAS and infection-triggered (syndromes).”

“As the field moves toward agreement on this broadened syndrome, affected youth will be more likely to receive appropriate care, regardless of whether they are seen by a neurologist, pediatrician or child psychiatrist,” said Thomas R. Insel, MD, NIMH director.

In a separate NIH study now underway, Swedo and colleagues are investigating the effectiveness of intravenous immunoglobulin (IVIG) for reducing OCD symptoms in children with PANDAS.

According to Swedo, the IVIG trial is a replication of a previous trial conducted at NIMH by Perlmutter and colleagues. “The current double-blind, multi-site, placebo-controlled study will look at IVIG, a medication derived from normal antibodies that neutralizes harmful antibodies, as it has shown promise in a pilot study with people who have PANDAS,” said Swedo, who added that the clinical ratings are being done by investigators at Yale University to keep investigators blind to the nature of the study drug infusion.

“We expect to show that IVIG is vastly superior to placebo in reducing severity of the obsessive-compulsive symptoms and other neuropsychiatric symptoms present in children with acute, severe PANDAS,” Swedo told Pediatric Annals.

Swedo, SE. Pediatr Therapeut. 2012; doi:10.4172/2161-0665.1000113 [CrossRef] . Disclosure: The researchers report no relevant financial disclosures. Dr. James Leckman, a researcher on the NIH study, has received research funding from Talecris (Grifols).

Tanning Beds Linked to Increase in Melanoma Cases in Young Adults

The incidence of cutaneous melanoma is rising among those aged younger than 40 years according to a Mayo Clinic study. The use of indoor tanning beds is a main culprit, especially among women, the researchers wrote.

Despite an overall decrease in mortality rates, attributed to early detection and improved medical care, the study found that the incidence of melanoma increased eightfold among women and fourfold among men from 1970 to 2009.

The study confirmed that the incidence of cutaneous melanoma is increasing among young adults, particularly women in their 20s and 30s, researchers wrote.

Reed, KB: Mayo Clin Proc. 2012; 87:328–334. Disclosure: Funding was received by the National Institutes of Health. The researchers have no financial relationships relevant to this article to disclose.

Reduced Medication Use May Be Tied to Insurance Cost-Share Policies

Health insurers’ cost-sharing policies for privately insured families may be to blame for a dip in necessary medication use by children with asthma, according to a recent study.

Pinar Karaca-Mandic, PhD, and colleagues of the Division of Health Policy and Management at the School of Public Health at the University of Minnesota in Minneapolis performed a retrospective study of insurance claims of 8,334 US children between 1997 and 2007 from 37 employers. Children were divided into two age groups: children aged younger than 5 years and children aged 5 to 18 years. The researchers measured asthma medication use, asthma-related hospitalizations and ED visits during a 1-year follow-up.

The data indicated that older children had less drug coverage than younger children and, consequently, had more hospitalizations. Although the researchers acknowledged several limitations of the study, they “suggest that greater prescription cost-sharing among children with asthma may lead to small reductions in use of important medications with unintended consequences of more frequent asthma-related hospitalizations.”

This finding contrasts established studies on the effects of cost-sharing on adults, who forgo prescription medications at a greater rate.

In a related editorial, Wendy J. Unger, PhD, said there were other study limitations, suggesting that due to “low observed rates of hospitalizations and emergency department visits … this was a relatively healthy cohort.” An alternative explanation for the slightly reduced use of medication may be that parents make their children’s medication purchases a higher priority than their own. Unger urged value-based insurance designs as possible solutions to the decreases in medication use.

“Recognizing that fully covering services and interventions that promote child health may deter or prevent serious or chronic diseases in the adult years is perhaps the best form of value in drug policy reform,” she wrote.

Karaca-Mandic, P. JAMA. 2012;307:1284–1291. Disclosure: Some researchers reported financial ties to Bristol-Myers Squibb, Novartis, Pfizer and Precision Health Economics.

Delays in Post-Concussion Physical Response Time Continue, Even After Symptoms Subside

Median “motor evoked potential” tests after an acute concussion showed delays in physical response time for up to 10 days, as opposed to improved self-reported symptoms and improved neurocognitive functions, according to recent data. These data may suggest the involvement of apparently different recovery patterns post-concussion.

The study included 18 college men and women athletes. A nine-person control group was compared with nine participants who exhibited clinically acute concussion symptoms as a result of a sports-related traumatic force to the head, either directly or through transmission. Participants with an injury were matched with a control participant for age, gender, sport, position played, prior concussion history, and history of learning disability or attention-deficit hyperactivity disorder (ADHD).

Each concussed participant was screened and tested within 24 hours of the injury and on days 3, 5, and 10. An accepted head injury scale (HIS) questionnaire and neuropsychological testing were administered.

Both self-reported symptoms and neurocognitive deficits were highest in the first 24 to 72 hours before beginning to improve. Although not all participants were symptom-free on day 10, HIS scores improved by this time. Concussion Resolution Index (CRI) scores also improved by day 10. These results were compared with motor evoked potential (MEP) test results obtained during the same time period.

MEPs were measured using transcranial magnetic stimulation and were recorded from the upper extremities using parameters set by the study. Ulnar amplitude decreased on day 3, significantly increased on day 5 and decreased only slightly by day 10. Median MEP response time continued to slow through day 10. Delays in response time continued up to day 10, even as the athletes’ symptoms decreased and cognitive functioning improved.

The apparent differential rates of recovery most likely indicate different pathophysiological processes occurring in the immediate post-concussion period, the researchers wrote.

“Further investigation of MEPs in concussed athletes is needed, especially to assess how long the disturbances in physiological functioning continue after those initial 10 days post-injury,” Scott C. Livingston, PhD, of the University of Kentucky, and colleagues wrote in their study. “But in the meantime, sports medicine personnel caring for concussed athletes should be cautious about relying solely on self-reported symptoms and neurocognitive test performances when making return-to-play decisions.”

Livingston, SC. J Clin Neurophysiol. 2012;29: 23–32. Disclosures: Funding was received from the National Operating Committee on the Standards of Athletic Equipment and the National Athletic Trainers’ Association Research and Education Foundation.

Number of US-Born Twins on the Rise

One in every 30 babies born in the US in 2009 was a twin, compared with one in every 53 in 1980, according to Barbara Luke, ScD, MPH, professor in the Department of Obstetrics, Gynecology and Reproductive Biology at the College of Human Medicine at Michigan State University, who presented the findings at the 14th Congress of the International Society of Twin Studies in Florence, Italy.

“Since the 1980s, there has been a dramatic rise in multiple births in the US and other nations,” Luke said in a press release. She noted that before 1980, the proportion of twin births was relatively stable at about 2%, but a dramatic increase has occurred in the last 30 years.

Luke attributed this rise to a number of factors, including delayed childbearing, divorce and remarriage, and increased use of fertility-enhancing therapies.

“Older maternal age accounts for about one-third of the rise, and two-thirds is due to the increased use of fertility treatments,” she said in a press release. According to Luke, multiple births have potential immediate and long-term adverse health effects for the mother and her children, with gestational diabetes, preeclampsia, low birthweight, and preterm delivery as the most important potential risks.

Check List ☑

Updated Field Triage Guidelines

Earlier this year, the AAP endorsed the CDC’s updated field triage guidelines. Need-to-know pediatric pointers endorsed by the AAP include:

  • ☑ Children 15 years and younger who fall 10 or more feet, or at least two times’ their height should be transported to a trauma center.

  • ☑ The lower normal respiratory rate limit for infants aged 1 year and younger is about 20 breaths per minute. Higher than that reflects risk of more severe injury, possibly necessitating higher triage.

  • ☑ Systolic blood pressure criterion remains the same as the 2005–2006 guidelines: <90 mmHg for children. The CDC guidelines noted that transporting an infant with this systolic blood pressure to a trauma center (preferably a pediatric one) was considered over-triage.

Sasser, SM et al. MMWR. 2012. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/.rr6101a1.htm. Accessed March 13, 2012.

Authors
Written by Suzanne Bryla, Rob Volansky, and Colleen Zacharyczuk

10.3928/00904481-20120426-02

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