Hesham M. Hamoda

Association between attention-deficit/hyperactivity disorder and epilepsy in pediatric populations

There is a bidirectional relationship between attention-deficit/hyperactivity disorder (ADHD) and epilepsy. ADHD increases seizure risk, while patients with epilepsy have an increased prevalence of ADHD. The reasons explaining this association are not fully understood. Proposed mechanisms include effects of antiepileptic medications, underlying neurodevelopmental vulnerability, the effects of chronic seizures and subclinical epileptiform activity on cognitive functions and adrenergic dysfunction. There may also be a common genetic defect underlying both disorders in some families. Antiepileptics associated with ADHD-like side effects include phenobarbital, gabapentin, vigabatrin and topiramate. Methylphenidate has been studied in a double-blind setting against placebo for treatment of ADHD comorbid with epilepsy, and has a good risk–benefit ratio. Amphetamine, atomoxetine, clonidine and guanfacine only have case series to support their use and bupropion should be avoided.

The Psychopharmacology Algorithm Project at the Harvard South Shore Program : An Update on Psychotic Depression

&NA; This new version of the psychotic depression algorithm has been developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The most effective treatment modality for inpatients with severe psychotic depression is electroconvulsive therapy. The first‐line psychopharmacological treatment is a combination of an antidepressant (either a tricyclic or a selective serotonin reuptake inhibitor) and an antipsychotic. If one of these combinations has failed, consider switching to the other. If both combinations have failed, the next psychopharmacological option would be to augment the combination with lithium. Another option, though with limited evidence, is monotherapy with clozapine. If there is a good reason to avoid combination therapy with an antipsychotic, then a trial of monotherapy with a TCA or an SSRI can be supported. If that fails, adding an antipsychotic or ECT should be considered.

Variations in hospital waste quantities and generation rates

Abstract The relationship between public health and improper collection, handling, and disposal of solid wastes in general, and hospital wastes in particular, is quite clear. Hazardous and nonhazardous wastes generated from different divisions of two of the largest public hospitals (capacity of approximately 400 beds each) in Kuwait were quantified and generation rates were determined. The generation rates were related to some important factors such as the number of patients, number of beds, and the type of activity conducted in different sections of the hospitals. The relationship between the waste generation rate and the number of patients was more applicable than that expressed in terms of the number of beds. The rates observed were in the range of 4.89 to 5.4 kg/patient/day, which corresponds to 3.65 to 3.97 kg/bed/day, respectively. These generation rates were comparable with those reported in the literature for similar hospitals. Minimal waste quantities were collected in the weekends. The study indicated that the hospitals surveyed provide some segregation of hazardous and nonhazardous wastes. Hazardous wastes contributed about 53% of the total quantity of wastes generated at the hospitals.

Electroconvulsive therapy in children and adolescents.

Electroconvulsive therapy (ECT) is a recognized and effective treatment in adults for several psychiatric and neurological conditions in which the use of pharmacotherapy is ineffective, untimely or contraindicated. It has been used with success in mood and psychotic disorders, catatonia, neuroleptic malignant syndrome, Parkinson’s disease and intractable seizures. Its benefits have been recognized and its risks identified through an extensive body of research. The benefits of ECT are not limited to the adult population; research has been conducted on its use in child and adolescent populations for decades. In 2004, the American Academy of Child and Adolescent Psychiatry published practice parameters for the use of ECT in adolescent populations. However, ECT continues to be underused in cases where it is clearly indicated. In this article, we review the use of ECT in the adolescent population; its indications, administration, contraindications and risks, with emphasis on articles published after the American Academy of Child and Adolescent Psychiatry practice parameters were formulated. We also review reasons behind the underutilization of ECT in adolescents for whom this treatment modality is indicated.

Diffusion tensor imaging study of the fornix in first episode schizophrenia and in healthy controls

BACKGROUND The fornix is a compact bundle of white matter fibers that project from the hippocampus to the mamillary bodies and septal nuclei. Its association with memory, as well as with symptoms in schizophrenia, has been reported in chronic schizophrenia. The purpose of this study is to determine whether or not fornix abnormalities are evident at the onset of schizophrenia. METHODS Diffusion tensor imaging (DTI) and DT tractography were used to evaluate the fornix in 21 patients with first episode schizophrenia (16 males/5 females) and 22 healthy controls (13 males/9 females). Groups were matched on age, gender, parental socioeconomic status, education and handedness. Fractional anisotropy (FA), a measure of white matter integrity, radial diffusivity (RD), thought to reflect myelin integrity, trace, a possible marker of atrophy or cell loss, and axial diffusivity (AD), thought to reflect axonal integrity, were averaged over the entire tract extracted by means of DT tractography, and used to investigate fornix abnormalities in first episode schizophrenia compared with healthy controls. RESULTS Significant group differences were found between first episode patients and controls for FA (p=0.0001), RD (p=0.001) and trace (p=0.006). CONCLUSION These findings suggest abnormalities in the fornix in the early stages of schizophrenia, and further suggest that white matter abnormalities, which are apparent in the early course of the disease, may reflect myelin disturbances.

A competency-based model for research training during psychiatry residency.

The Institute of Medicine recently identified a critical shortage of psychiatrist-researchers and highlighted the need for competency-based curricula that promote research training during psychiatry residency as a way to address that shortage. In this article we review extant approaches to research training during psychiatry residency. We then identify five core elements necessary for promoting research training: (1) mentoring, (2) education, (3) experience, (4) time, and (5) support. We describe six interrelated domains of core research competencies that can be mastered gradually over the course of residency training: (1) research literacy, (2) content mastery of specific research topics, (3) principles of research design and methods, (4) principles of biostatistics, (5) presentation and writing skills, including grant writing, and (6) principles of responsible conduct of research. Finally, we propose a broadly applicable, developmental, competency-based framework for applying these core elements to research training during psychiatry residency.

A Roadmap for Observership Programs in Psychiatry for International Medical Graduates

ObjectiveInternational medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs.MethodThis article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs.ResultsAuthors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them.ConclusionObservership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls. Drs. Hamoda and Sacks contributed equally to this article and are hence co-1st authors.

Promoting Scholarship During Child and Adolescent Psychiatry Residency

BackgroundIn 2003, the Institute of Medicine (IOM) drew attention to the critical national shortage of psychiatrist-researchers and the need for competency-based curricula to promote research training during psychiatry residency as one way to address this shortage at the institutional level. Here, the authors report on the adaptation, implementation, and results attained with a broadly applicable, developmental, competency-based framework for promoting scholarship during child and adolescent psychiatry residency.MethodsThe authors instituted structural program changes, protecting time for all residents to engage in scholarly pursuits and a mentorship program to support residents in their scholarly interests. The authors assessed five graduating classes before and five classes after these changes were implemented, examining whether these changes sustained scholarship for residents with previous experience during general psychiatry residency and whether they promoted emergence of new scholarship among residents without such experience.ResultsThe authors observed a tenfold increase in the number of residents engaged in rigorously-defined scholarly pursuits after the program changes, which helped sustain the scholarship of more residents with previous experience and promoted the emergence of more new scholarship among residents without previous experience.ConclusionThe authors conclude that it is possible to sustain and promote scholarship during child psychiatry residency despite the relatively short duration of the program and the many requirements for graduation and certification. The changes implemented were universal in scope and required no special funding mechanisms, making this approach potentially exportable to other training programs.

Early auditory processing evoked potentials (N100) show a continuum of blunting from clinical high risk to psychosis in a pediatric sample

BACKGROUND The N100 is a negative deflection in the surface EEG approximately 100 ms after an auditory signal. It has been shown to be reduced in individuals with schizophrenia and those at clinical high risk (CHR). N100 blunting may index neural network dysfunction underlying psychotic symptoms. This phenomenon has received little attention in pediatric populations. METHOD This cross-sectional study compared the N100 response measured via the average EEG response at the left medial frontal position FC1 to 150 sinusoidal tones in participants ages 5 to 17 years with a CHR syndrome (n=29), a psychotic disorder (n=22), or healthy controls (n=17). RESULTS Linear regression analyses that considered potential covariates (age, gender, handedness, family mental health history, medication usage) revealed decreasing N100 amplitude with increasing severity of psychotic symptomatology from healthy to CHR to psychotic level. CONCLUSIONS Longitudinal assessment of the N100 in CHR children who do and do not develop psychosis will inform whether it predicts transition to psychosis and if its response to treatment predicts symptom change.

Suprathreshold fiber cluster statistics: Leveraging white matter geometry to enhance tractography statistical analysis

&NA; This work presents a suprathreshold fiber cluster (STFC) method that leverages the whole brain fiber geometry to enhance statistical group difference analyses. The proposed method consists of 1) a well‐established study‐specific data‐driven tractography parcellation to obtain white matter tract parcels and 2) a newly proposed nonparametric, permutation‐test‐based STFC method to identify significant differences between study populations. The basic idea of our method is that a white matter parcels neighborhood (nearby parcels with similar white matter anatomy) can support the parcels statistical significance when correcting for multiple comparisons. We propose an adaptive parcel neighborhood strategy to allow suprathreshold fiber cluster formation that is robust to anatomically varying inter‐parcel distances. The method is demonstrated by application to a multi‐shell diffusion MRI dataset from 59 individuals, including 30 attention deficit hyperactivity disorder patients and 29 healthy controls. Evaluations are conducted using both synthetic and in‐vivo data. The results indicate that the STFC method gives greater sensitivity in finding group differences in white matter tract parcels compared to several traditional multiple comparison correction methods. HighlightsSuprathreshold fiber cluster statistics for a whole brain WM statistical analysis.Leveraging WM geometry to correct for multiple comparisons across fiber tracts.Application to investigate group WM differences between ADHD and healthy controls.High sensitivity and specificity in identifying significant between‐group differences.