Clemente Cedro

Sleep disorders in children with Attention-Deficit/Hyperactivity Disorder (ADHD) recorded overnight by video-polysomnography

OBJECTIVE To outline specific sleep disturbances in different clinical subsets of Attention Deficit/Hyperactivity Disorder (ADHD) and to confirm, by means of nocturnal video-polysomnography (video-PSG), a variety of sleep disorders in ADHD besides the classically described periodic leg movement disorder (PLMD), restless legs syndrome (RLS) and sleep related breathing disorder (SRBD). METHODS Fifty-five ADHD children (47 M, 8F; mean age=8.9 y) were included: 16 had Inattentive and 39 Hyperactive/Impulsive or Combined ADHD subtype. Behavior assessment by Conners and SNAP-IV Scales, a structured sleep interview and a nocturnal video-PSG were administered. RESULTS Most children/parents reported disturbed, fragmentary sleep at night; complaints were motor restlessness (50%), sleep walking (47.6%), night terrors (38%), confusional arousals (28.5%), snoring (21.4%), and leg discomfort at night associated with RLS (11.9%). There is a significant difference (p value <0.05 or <0.001) in almost all the studied sleep variables between ADHD children and controls. International RLS Rating Scale scoring, Periodic Limb Movements during Sleep (PLMS) and Wake (PLMW) indexes, hyperactivity and opposition scores and ADHD subtype appear related. Different sleep disorders seem to address specific ADHD phenotypes and correlate with severity of symptoms as in sleep related movement disorders occurring in Hyperactive/Impulsive and Combined ADHD subtypes. Besides, an abnormality of the arousal process in slow wave sleep with consequent abnormal prevalence of disorders of arousal possibly enhanced by SRBD has also been detected in 52% of our sample. CONCLUSIONS This study underlines the opportunity to propose and promote the inclusion of sleep studies, possibly by video-PSG, as part of the diagnostic screening for ADHD. This strategy could address the diagnosis and treatment of different specific ADHD phenotypic expressions that might be relevant to childrens symptoms and contribute to ADHD severity.

The effect of mirtazapine augmentation of clozapine in the treatment of negative symptoms of schizophrenia: a double-blind, placebo-controlled study

The development of therapeutic strategies to effectively treat negative symptoms remains one of the primary goals in the treatment of schizophrenia. Mirtazapine is the first of a new class of dual action compounds, the noradrenergic and specific serotonergic antidepressants (NaSSa), whose activity is related to the enhancement of noradrenergic and serotonergic transmission by a presynaptic &agr;2 antagonism and postsynaptic 5-HT2 and 5-HT3 antagonism, respectively. This study was a 8-week double-blind, randomized, placebo-controlled trial of 30 mg adjunctive mirtazapine to clozapine therapy in 24 patients with DSM-IV schizophrenia. The main finding at the end of the trial was a significant reduction on the Scale for the Assessment of Negative Symptoms (SANS) total scores in the mirtazapine group compared to placebo (P<0.01) with a significant improvement on the SANS subscales avolition/apathy and anhedonia/asociality. The Brief Psychiatric Rating Scale total score at week 8 showed superiority of mirtazapine over placebo. These findings suggest a potential role for mirtazapine as an augmentation strategy in the treatment of negative symptoms of schizophrenia.

Ictal and interictal EEG abnormalities in ADHD children recorded over night by video-polysomnography

In this paper we explore the prevalence of ictal and interictal epileptiform discharges (IEDs) and sleep disorders in ADHD children referred to a sleep clinic for all night video-PSG. Forty-two ADHD outpatients (35 males and 7 females) underwent video-PSG and a behavioural/neuropsychological assessment. Spearman correlation coefficients (p<0.05 criterion level) were used to assess the association between cognitive, behavioural, clinical (co-morbidity), sleep (sleep efficiency) and EEG (seizures, IEDs, localization of IEDs foci) variables. Sleep disorders were found in 86% of ADHD children; among these, 26% had RLS. 53.1% of ADHD children had IEDs (28.2% centro-temporal spikes, 12.5% frontal spikes, 9.3% temporal-occipital spikes and 2.3% generalized S-W). Nocturnal seizures were recorded in three patients: two with atypical interictal rolandic spikes and one with left frontal slow abnormalities. A significant relationship (p<0.05) emerges between nocturnal seizures and WISC-R IQ score and visual-spatial memory test and between some cognitive variables and interictal rolandic spikes. High levels of inattention, impulsivity/hyperactivity and oppositional behaviours were related (p<0.01 or 0.05) with Restless Leg Syndrome diagnosis. In conclusion, ADHD is a condition often associated with EEG epileptiform abnormalities. Seizures/IEDs presence seems to play a role on cognitive abilities, conversely sleep disorders have a stronger impact on behavioural rather than cognitive indicators.

Olanzapine augmentation of paroxetine-refractory obsessive-compulsive disorder

The aim of the present study was to investigate the effect of adjunctive olanzapine in patients with obsessive-compulsive disorder (OCD) refractory to paroxetine. Twenty-one patients unresponsive to treatment with paroxetine, administered for at least 12 weeks at the dose of 60 mg/day, participated to a 12-week open-label, add-on trial with olanzapine (10 mg/day). The psychopathological state was evaluated by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and by Clinical Global Impression (CGI). Three patients did not complete the 12-week adjunctive treatment with olanzapine. In the 18 completers, the mean Y-BOCS score decreased significantly from 27.1+/-4.0 at baseline to 20.1+/-3.9 at final evaluation (P<.001). Seven patients (38.9%) were rated as responders at final evaluation. Steady-state plasma concentrations of paroxetine were not modified during olanzapine coadministration. The drug combination was generally well tolerated and initial sedation and weight gain were the most frequent unwanted effects. Our findings confirm the results of previous studies and indicate that the addition of olanzapine to ongoing treatment with serotonin reuptake inhibitors (SRI) may be beneficial in some patients unresponsive to SRI monotherapy.

Analysis of psychopathological comorbidity behind the common symptoms and signs of endometriosis.

OBJECTIVE The present study was aimed to investigate quality of life, negative emotions, such as anger, anxiety and depression, and possible psychopathological comorbidity in patients affected by endometriosis. STUDY DESIGN We undertook a prospective, cohort study between October 2013 and February 2014. We selected patients with histologically confirmed ovarian endometriosis (Endometriosis Group) and with other benign adnexal diseases (Control Group) who underwent laparoscopic surgery. Participants underwent a psychometric assessment using the following self-report instruments: Symptom Checklist-90-R, State-Trait Anger Expression Inventory-2, Self-Rating Anxiety Scale, Self-Rating Depression Scale, Quality of Life Index. RESULTS The Endometriosis Group was formed by 166 patients (mean age: 36±6 yrs) matched with 48 controls (mean age: 38.4±12.8 yrs). Somatization (p=0.02), depression (p=0.01), sensitivity (p=0.04) and phobic anxiety (p=0.04) were higher in Endometriosis Group than in Control Group. Endometriosis Group was further characterized by significantly higher levels of anxiety than Control Group (p=0.03) as assessed by Self-Rating Anxiety Scale. Regarding Quality of Life Index, a significant health decline in Endometriosis Group compared with Control Group (p=0.008) was found. CONCLUSION Higher levels of somatization, depression, sensitivity and anxiety were found in Endometriosis Group compared with Control Group.

Aripiprazole in Children with Tourette's Disorder and Co-morbid Attention-Deficit/Hyperactivity Disorder: A 12-Week, Open-Label, Preliminary Study

Tourettes disorder (TD) in children and adolescents is frequently co-morbid with attention-deficit/hyperactivity disorder (ADHD). Dopamine-blockers are the first line treatment for TD, whereas dopamine-agonists, such as stimulants, are the gold-standard in the treatment of ADHD. These contrasting effects supported concerns about the risk that stimulants for treating ADHD may trigger or worsen co-morbid tics. Aripiprazole, a partial dopamine agonist, acts as an antagonist at dopamine D2 receptors in hyperdopaminergic conditions and displays agonist properties under hypodopaminergic conditions. The present study describes the use of aripiprazole (10.0 ± 4.8 mg/day) in a consecutive group of 28 patients with a primary diagnosis of TD and co-morbid ADHD, combined subtype. The Yale Global Tic Severity Scale (YGTSS) and the ADHD-Rating Scale (ADHD-RS-IV) were used as primary outcome measures and both significantly improved (p<0.001) after the treatment. Global measures of severity (Clinical Global Impressions-Severity) and of functional impairment (Childrens Global Assessment Scale) also significantly improved during the treatment (p<0.001). At the YGTSS there was a reduction of 42.5%, in motor tics, of 47.9% in phonic tics (44.7% for the combined scores), and of 32.3% in tic impairment. Nineteen patients (67.9%) had a reduction of at least 50% of the YGTSS score (motor+phonic tics). The improvement at the ADHD-RS-IV score was 22.5%, 12 patients (42.8%) presented an improvement of 30%, but only 2 (7.1%) an improvement greater than 50%. Using a logistic regression model, a reduction of at least 30% in ADHD-RS-IV score was more likely to occur in the obsessive-compulsive disorder co-morbid group. Aripiprazole was well tolerated and none of the patients discontinued medication because of side effects. In summary, aripiprazole resulted in an effective treatment for TD, but it was only moderately effective on co-occurring ADHD symptomatology. Our preliminary data suggest that aripiprazole may represent a possible therapeutic option, among other possible monotherapies addressing both tics and ADHD.

Association between Burnout and Anger in Oncology versus Ophthalmology Health Care Professionals

The prevalence of burnout in oncology staff was compared with that of the ophthalmology staff, who normally present a low prevalence of burnout as described in this literature. The correlation of burnout with the emotion of anger was also investigated. Thirty-six subjects working in an oncology department and 32 working in an ophthalmology department were examined using the Maslach Burnout Inventory and the State-Trait Anger Expression Inventory. The oncology group showed higher mean scores on the MBI Emotive Exhaustion and Depersonalization scales with respect to ophthalmology staff. Correlation analysis showed that increasing burnout was associated with higher anger expressed towards the environment and loss of anger control. Anger, as a response to frustration, appears to be a feature constantly associated with the clinical expression of burnout and it should not be underestimated in theoretical and preventive contexts.

Neuropsychological findings in patients with Unverricht–Lundborg disease

The aims of this study were to clarify if patients with Unverricht-Lundborg disease (ULD) have adequate cognitive functioning and to delineate their neuropsychological profile. We evaluated 20 patients with ULD and 20 healthy, matched controls. Mean age of the patients was 35 years, and mean duration of disease, 22 years. Patients underwent a neuropsychological battery exploring intelligence, executive functions, visuospatial and verbal memory, depression, and anxiety. Eleven of 20 subjects with ULD had mild to moderate cognitive impairment. Compared with controls, patients with ULD had lower scores on all short-term memory and executive function tasks. Linear regression analysis disclosed significant associations between impaired performance on some memory tests and duration of disease and between severity of myoclonus and performance on most executive function tests. In conclusion, most patients with ULD seem to be impaired with respect to cognitive abilities. Longitudinal prospective studies are needed to confirm and further expand our findings.

Horner syndrome following thyroidectomy

Dear Editor,Horner syndrome (HS) is due to the disruption of sympa-thetic innervation of the eye anywhere along its three-neuron circuit. The typical clinical feature includes a triadof ipsilateral blepharoptosis, pupillary miosis, and facialanhydrosis. Neoplasm of lung apex (Pancoast tumor),vascular injuries, syringohydromyelia, carotid dissection orfibromuscolar dysplasia, are the most common causes [1].HS has only rarely been reported after thyroidectomy, withonly 28 cases mostly published in surgical journals [2, 3].Herein, we report a 56-year-old man exhibiting HS aftertotal thyroidectomy. Patient came at our observation40 days after surgical intervention for multinodular goiter.Histological examination on specimens from ablate thyroidtissue was negative for neoplasms. Immediately afterawakening from anesthesia, mild myosis, eyelid ptosis andenophthalmos of the right eye were evident. Patient alsoexhibited a bitonal voice. Neurological examination wasotherwise normal. Emiphacial anhydrosis was not noticedby patient. Laryngoscopy examination revealed right vocalcord paralysis. Brain MRI, chest X ray, single fiber EMGand neck CT scan were normal. At 2-month follow-up, aslight improvement of eyelid ptosis was observed.The possible causes of HS following thyroidectomyinclude post-operative hematoma compressing the cervicalsympathetic chain, ischemia-induced neural damagecaused by lateral ligature on inferior thyroid artery trunk,stretching of the cervical sympathetic chain by the retrac-tor, damage to the anastomosis between the cervical sym-pathetic chain and the recurrent laryngeal nerve during itsidentification [2]. Prognosis is usually poor with 70% ofpatients presenting permanent damage or incompleterecovery. Complete remission may occur after long time(up to 15 months). In the reported case, post-operativehematoma or adherences were ruled out by neck CT scan.Since right vocal cord paralysis, probably related to thedeficit of the inferior laryngeal nerve, was also present, weargue that mechanical damage on the anastomosis of therecurrent laryngeal nerve and sympathetic nervous bran-ches around the inferior thyroid artery, might cause HS inour patient.References

Gender Role Identity in a Sample of Italian Male Homosexuals

ABSTRACT Gender role is a multifactorial concept, as gender-related attitudes, behaviors, and personality are partially autonomous. The aim of the study was to evaluate the prevalent gender role identity in a sample of male homosexuals. One hundred male homosexuals and 50 male heterosexuals matched for age and sex, have been assessed with the Italian version of the Bem Sex-Role Inventory (BSRI; Bem, 1974). Statistically significant differences have been found between the two groups at the dimensions “Masculine” (z = 1.963; p = 0.001) and “Androgyny” (z = 2.367; p < 0.0001). The results obtained from the present study tend to confirm that homosexuals view themselves as adrogynous individuals, sharing both features of masculine and feminine gender roles.