INTRODUCTION: Research on 5-HT-functioning in adult patients and healthy subjects using rapid tryptophan depletion (RTD) has indicated weak but stable effects on mood ratings. Altered mood in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) can confound the differential diagnosis between severe ADHD and mood disorders such as pediatric bipolar disorder. The present study investigated the effects of RTD induced lowered central nervous 5-HT-levels on mood self-ratings in children with ADHD. METHODS: Seventeen boys with ADHD participated in the study in a double-blind within-subject crossover-design. They were administered RTD within an amino acid drink lacking tryptophan, thus lowering central nervous 5-HT-synthesis. On another day they received a placebo. Self-rated mood was assessed on both days at baseline conditions and at three different post-drink time-points. RESULTS: RTD had no clear effect on mood within the whole sample. Low scorers on venturesomeness were more strongly affected by RTD in terms of feelings of inactivity and negative feelings compared to high venture patients. CONCLUSIONS: Our data did not show a significant effect of RTD on mood self-ratings. However, the findings must be considered as preliminary and require further replication, in particular as they could be due to sampling bias. Copyright (c) 2009 John Wiley & Sons, Ltd.

OBJECTIVE:: Clinical experience suggests that some (but not all) patients with attention-deficit/hyperactivity disorder (ADHD) are highly responsive to the nonstimulant atomoxetine. We conducted a retrospective analysis of randomized controlled trials (RCTs) to identify potential baseline (moderator) and on-treatment (mediator) predictors of responses. METHOD:: Data from 6 U.S. RCTs among patients aged 6 to 18 years were pooled (N = 1,069; subjects treated with atomoxetine, n = 618). Subjects were categorized as much improved (>/=40% decrease in ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored total score), minimally improved (25%-<40% decline), or nonresponders (<25% decrease). Logistic regression, analyses of variance, and repeated-measures analyses were used to explore associations between baseline and on-treatment variables, achieving a much improved response at trial endpoint (6-9 weeks). RESULTS:: Forty-seven percent of patients showed a much improved clinical response, and 40% did not respond. Only 13% of the patients had a minimal response. No baseline characteristics predicted achieving a much improved clinical response; the only predictor of achieving this response was being at least minimally improved by treatment week 4 (sensitivity = 81%, specificity = 72%, positive predictive value = 75%, and negative predictive value = 79%). CONCLUSIONS:: Clinical response to atomoxetine was bimodal, with most subjects being either responders who were much improved or nonresponders. There were no demographic or clinical predictors of response. However, subjects who ultimately achieved a much improved response were likely to be at least minimal responders by week 4. The recommendation to consider either augmenting or switching treatment in patients who do not achieve at least this level of response to atomoxetine by 4 weeks offers a method for limiting the extended duration of titration to subjects who are most likely to benefit further, while minimizing the duration of exposure in those less likely to achieve an excellent response.Clinical trials registration information-Evaluation of Continuous Symptom Treatment of ADHD: A Placebo-Controlled Double-Blind Assessment of Morning-Dosed or Evening-Dosed Strattera. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00486122. Results of the other studies analyzed in the Integrated Data Exploratory Analysis study are posted at www.clinicalstudyresults.org, ID numbers 5670, 7972, 2746, 1585, 1586, and 3468, and www.lillytrials.com.

OBJECTIVE:: To assess the utility and tolerability of higher than standard atomoxetine doses to treat attention-deficit/hyperactivity disorder (ADHD). METHOD:: Two randomized, double-blind trials of atomoxetine nonresponders ages 6 to 16 years were conducted comparing continued treatment with same-dose atomoxetine to treatment using greater than standard efficacious doses (study 1: up to 3.0 mg . kg . day; study 2: up to 2.4 mg . kg . day). RESULTS:: The primary outcome measure for both studies was mean ADHD Rating Scale (ADHD RS) total score. For study 1 (N = 122), decreases in ADHD RS total scores were not significantly different between treatment groups (mean change [SD]: continued same dose,-8.9 [11.2]; high dose,-9.8 [13.1]; p =.595). Likewise, for study 2 (N = 125), treatment groups did not differ (mean change [SD]: continued same dose,-6.2 [12.2]; high dose,-8.9 [10.0], p =.110). Tolerability was not significantly different between the continued same-dose and high-dose groups. CONCLUSIONS:: These studies provide evidence that current dose recommendations are appropriate for most patients, suggesting no systematic advantage to increasing atomoxetine doses beyond current guidelines. In both studies, continued treatment, whether at a higher dose or the previous dose, was associated with improved outcomes in patients who demonstrated incomplete/inadequate response to acute ADHD treatment, although without a placebo arm, we cannot rule out the possibility that expectancy played a role in symptom improvement.

Abstract Objective: This study compared the methylphenidate (MPH) dose-response profiles of children with the Predominantly Inattentive (PI) and Combined (CB) subtypes of attention-deficit/hyperactivity disorder (ADHD). It is the first such study to enroll a sample comprised exclusively of children, all but one of whom had no prior exposure to ADHD medications. Method: The design was a double-blind crossover with 1-week exposures to placebo and low, medium, and high, fixed, three times daily (t.i.d.) dosage regimens of immediate-release MPH, administered in random order. Parents and teachers completed weekly behavioral questionnaires (Conners, Swanson, Kotkin, Agler, M-Flynn and Pelham Scale [SKAMP]) and a child psychiatrist provided weekly ratings of symptom severity (ADHD Rating Scale [ADHD-RS]), side effects (Side Effects Rating Scale), and a Clinical Global Impressions-Severity (CGI-S). In addition, laboratory measures of vigilance (Continuous Performance Test [CPT]) and resistance to cognitive interference (Stroop) were administered weekly. Results: Twenty-five children (15 CB, 10 PI), who met rigorous diagnostic criteria for their ADHD subtype, completed the study. Groups did not differ on demographic variables or severity at baseline. Behavioral questionnaires and clinical ratings indicated significant improvement on MPH for both subtypes but no differences in response profiles of the two groups. Drug effects were predominantly linear for both subtypes. Effects of MPH were significant for the CPT, but not the Stroop, instrument with no differences between ADHD subtypes. Conclusions: Results support the clinical utility of MPH in the treatment of the PI subtype and provide no evidence of differences in response between the subtypes.

The Brooklyn Traffic Real-Time Ambient Pollutant Penetration and Environmental Dispersion (B-TRAPPED) field study examined indoor and outdoor exposure to traffic-generated air pollution by studying the individual processes of generation of traffic emissions, transport and dispersion of air contaminants along a roadway, and infiltration of the contaminants into a residence. Real-time instrumentation was used to obtain highly resolved time-series concentration profiles for a number of air pollutants. The B-TRAPPED field study was conducted in the residential Sunset Park neighborhood of Brooklyn, NY, USA, in May 2005. The neighborhood contained the Gowanus Expressway (Interstate 278), a major arterial road (4(th) Avenue), and residential side streets running perpendicular to the Gowanus Expressway and 4(th) Avenue. Synchronized measurements were obtained inside a test house, just outside the test house façade, and along the urban residential street canyon on which the house was located. A trailer containing Federal Reference Method (FRM) and real-time monitors was located next to the Gowanus Expressway to assess the source. Ultrafine particulate matter (PM), PM(2.5), nitrogen oxides (NO(x)), sulfur dioxide (SO(2)), carbon monoxide (CO), carbon dioxide (CO(2)), temperature, relative humidity, and wind speed and direction were monitored. Different sampling schemes were devised to focus on dispersion along the street canyon or infiltration into the test house. Results were obtained for ultrafine PM, PM(2.5), criteria gases, and wind conditions from sampling schemes focused on street canyon dispersion and infiltration. For comparison, the ultrafine PM and PM(2.5) results were compared with an existing data set from the Los Angeles area, and the criteria gas data were compared with measurements from a Vancouver epidemiologic study. Measured ultrafine PM and PM(2.5) concentration levels along the residential urban street canyon and at the test house façade in Sunset Park were demonstrated to be comparable to traffic levels at an arterial road and slightly higher than those in a residential area of Los Angeles. Indoor ultrafine PM levels were roughly 3-10 times lower than outdoor levels, depending on the monitor location. CO, NO(2), and SO(2) levels were shown to be similar to values that produced increased risk of chronic obstructive pulmonary disease hospitalizations in the Vancouver studies.

BACKGROUND: Flebogamma(R) 10% DIF represents an evolution of intravenous immune globulin from the previous 5% product to be administered at higher rates and with smaller infusion volumes. Pathogen safety is enhanced by the combination of multiple methods with different mechanisms of action. OBJECTIVE: The objective of this study as to evaluate the efficacy, pharmacokinetics, and safety of Flebogamma(R) 10% DIF for immunoglobulin replacement therapy in primary immunodeficiency diseases (PIDD). METHODS: Flebogamma(R) 10% DIF was administered to 46 subjects with well-defined PIDD at a dose of 300-600 mg/kg every 21-28 days for 12 months. RESULTS: Serious bacterial infection rate was 0.025/subject/year. Half-life in serum of the administered IgG was approximately 35 days. No serious treatment-related adverse event (AE) occurred in any patient. Most of the potentially treatment-related AEs occurred during the infusion, accounting for 20% of the 601 infusions administered. CONCLUSIONS: Flebogamma(R) 10% DIF is efficacious and safe, has adequate pharmacokinetic properties, and is well-tolerated for the treatment of PIDD.

OBJECTIVE: This was an exploratory study to examine the use of atypical antipsychotics in an attention-deficit/hyperactivity disorder (ADHD) clinic. METHOD: A total of 194 patients was examined to compare those receiving atypical or second-generation antipsychotics (atypicals) from those who were not. A sample of 27 children on atypicals received laboratory investigation for indicators of possible metabolic effects. RESULTS: In all, 19.1% of the patients in the clinic were receiving atypicals with a mean duration of 313 days; 36 of 37 patients on atypicals had received risperidone, with a mean dose of 0.62 mg. Children receiving atypicals were statistically more likely to have a severe co-morbid disorder, a lower Children's Global Assessment Scale score, a greater total score on the teacher Strengths and Difficulties Questionnaire, and greater difficulty with parent-rated symptoms of being touchy, worried, rages, and explosive outbursts. There were no differences found in measures of functioning, adaptive skills, quality of life, or ADHD symptoms. In the subset of children studied for potential metabolic effects, 68.0% had a waist circumference > or =90(th) percentile that was independent of weight gain, 18.5% had impaired fasting glucose, 12.5% had elevated blood pressure, 11.1% had elevated triglycerides, and 16.7% met full criteria for metabolic syndrome. CONCLUSION: Clinical implementation of the efficacy studies of risperidone for disruptive behavior disorders has led to a significant change in practice. Almost 1 in 5 patients are now receiving atypical neuroleptics, typically to treat severe co-morbid disorders and symptoms other than ADHD per se. Despite these children receiving low doses, concomitant stimulants, and low body mass index z-scores, a significant proportion of children demonstrated either one or more components or the full criteria for metabolic syndrome.

OBJECTIVE:: Understanding placebo response is a prerequisite to improving clinical trial methodology. Data from placebo-controlled trials of atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD) were analyzed to identify demographic and clinical characteristics that might predict placebo response in future clinical trials. METHOD:: Data were pooled across 731 placebo-treated pediatric patients who participated in 10 acute, randomized, placebo-controlled trials. Responder status was based on empirically derived thresholds of change on the total score of the ADHD Rating Scale with minimal and robust response defined as 25% or greater and 40% or greater decrease, respectively. Study design characteristics, including randomization ratio, dose, and titration strategy, and patient demographic and clinical characteristics were examined as potential predictors of placebo response. RESULTS:: Inattentive subtype, lack of previous stimulant treatment, presence of comorbid tics and nonwhite ethnicity were associated with robust placebo response. A subset analysis of patients completing 6 weeks of treatment (to eliminate the effects of early dropout) identified inattentive subtype and lack of previous stimulant experience as significant predictors of robust placebo response. CONCLUSIONS:: Placebo response is less likely in subjects with combined-subtype ADHD who are not stimulant-naive. Limiting ADHD clinical trials to this more restricted subject group is likely to maximize treatment differences. However, because this is not always possible or desirable, identifying other methods of mitigating placebo response is essential.Clinical trials registration information-Evaluation of Continuous Symptom Treatment of ADHD: A Placebo-Controlled Double-Blind Assessment of Morning-Dosed or Evening-Dosed Strattera. URL: http://clinicaltrials.gov. Unique identifier: NCT00486122. Results of the other studies are posted at www.clinicalstudyresults.org, ID numbers 1585, 1586, 3468, 4908, 2746, 5004, 5670, 5831, and 6477, and www.lillytrials.com.

Abstract Objective: To evaluate the impact of methylphenidate transdermal system (MTS) on health-related quality of life (HRQL) and medication satisfaction in children with attention-deficit/hyperactivity disorder (ADHD) as well as to identify potential moderators of HRQL and medication satisfaction. Research design and methods: Children aged 6-12 years diagnosed with ADHD were enrolled (N = 128) and 115 children completed the study. MTS dose was optimized over 5 weeks using 10-, 15-, 20-, or 30-mg patches worn for 9 hours. The efficacy of 4- and 6-hour wear times was then assessed in an analog classroom setting in a randomized, placebo-controlled, double-blind, three-way crossover design study. Main outcome measures: The ADHD Impact Module-Children (AIM-C), a validated HRQL instrument, was used to assess the impact of ADHD symptoms on children and their families. Satisfaction with MTS use was assessed via a Medication Satisfaction Survey (MSS). A parent or legally appointed representative (LAR) completed the measures. Tolerability was monitored by spontaneous adverse event reporting. Results: Mean scores on AIM-C child and family HRQL scales improved from baseline to endpoint across all MTS doses and the magnitude of improvement increased with time from baseline. Improvement was noted for behavior, missed doses, worry, and economic impact AIM-C scores. Overall, parents/LARs indicated a high level of satisfaction with their child's use of MTS (Visit 7 [92.1%]; Visit 10 [89.1%]). Most treatment-emergent adverse events (TEAEs) were mild to moderate. The most frequent TEAEs included decreased appetite (28%), headache (21%), insomnia (20%), and abdominal pain (12%). Conclusions: At study endpoint, MTS treatment of ADHD was associated with robust improvement in child and family HRQL, key economic impact items, and overall medication satisfaction with the effectiveness and ease of use of MTS as an ADHD treatment. Also, the majority of MTS TEAEs were mild to moderate in severity. Limitations of this study included the potential for a significant halo effect when measuring HRQL and medication satisfaction as well as the uncertainty regarding whether the improvements seen over this relatively short study duration would be sustainable long term. Clinical trial registration:#NCT00151970.

BACKGROUND:: There is no effective second-line systemic chemotherapy for patients with disease progression after cisplatin-based chemotherapy. A phase 2 trial of sorafenib was performed to determine the activity and toxicity of this agent in a multi-institutional setting in patients previously treated with 1 prior chemotherapy regimen. METHODS:: Twenty-seven patients with advanced urothelial carcinoma were treated with sorafenib 400 mg orally twice daily continuously until progression or unacceptable toxicity. RESULTS:: There were no objective responses observed. The 4-month progression-free survival (PFS) rate was 9.5%; median overall survival of the group was 6.8 months. There were no therapy-related deaths, and common grade 3 toxicities included fatigue and hand-foot syndrome. CONCLUSIONS:: Although sorafenib as a single agent has minimal activity in patients with advanced urothelial cancer in the second-line setting, further investigation of tyrosine kinase inhibitors using different trial designs with PFS endpoints is warranted. Cancer 2009.(c) 2009 American Cancer Society.

OBJECTIVES:: To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). METHOD:: Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. RESULTS:: In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. CONCLUSIONS:: Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.Clinical trial registration information-Multimodal Treatment Study of Children With Attention Deficit and Hyperactivity Disorder. URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00000388.

Neurodegenerative diseases are relatively common and usually occur in older patients. In young adulthood, neurodegeneration is less common and more frequent due to underlying inborn errors of metabolism (IEMs) that typically have a wide range of clinical presentations. In the following overview, we present a case of SSPE and NBIA. The main differential diagnoses, cardinal symptoms, diagnosis and treatment options of neurodegenerative-like disesase in young adults are presented.

PURPOSE: The pharmacology, pharmacokinetics, indications, clinical efficacy, adverse effects, drug interactions, dosage, and administration of lisdexamfetamine are reviewed. SUMMARY: Lisdexamfetamine is the first prodrug formulation of the stimulant dextroamphetamine. It is approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children age 6-12 years and adults. Due to the need for enzymatic hydrolysis, there is a decreased liability for misuse and diversion with lisdexamfetamine. Moreover, due to the rate-limiting nature of hydrolysis, the toxicity potential and chances of overdose with lisdexamfetamine are reduced. The recommended starting dosage of lisdexamfetamine is 30 mg orally daily, which can be adjusted to a maximum dosage of 70 mg daily. Clinical trials in children age 6-12 years with ADHD found significant reductions in the ADHD symptoms with lisdexamfetamine compared with placebo. However, clinical studies in adolescents have not been conducted. The efficacy and safety of lisdexamfetamine in children with ADHD and comorbid psychiatric disorders also remain to be assessed. A controlled trial in adults similarly showed significant improvements in ADHD symptoms in all treatment groups. Long-term clinical trials and head-to-head comparison trials with existing stimulant formulations are necessary. The most common adverse effects include decreased appetite, insomnia, irritability, dizziness, and weight loss. CONCLUSION: Clinical trials in children age 6-12 years and adults with ADHD have shown lisdexamfetamine to be safe and effective, with significant improvement of ADHD-related rating scores. However, the efficacy and safety of lisdexamfetamine in children with ADHD and comorbid psychiatric disorders have not been assessed.

BACKGROUND: Dexmethylphenidate is a single-isomer stimulant medication approved for the treatment of attention deficit hyperactivity disorder (ADHD). Single-isomer drugs have the potential for decreased undesired effects and improved therapeutic efficacy. Stimulant medications have been the mainstay treatments for ADHD for fifty years, and ability to reduce their adverse effects would be useful in promoting patient compliance with treatment. OBJECTIVE: To review the literature on the safety and efficacy of dexmethylphenidate. METHODS: MedLine, PubMed search of dexmethylphenidate research. RESULTS/CONCLUSIONS: Dexmethylphenidate is a safe and effective treatment for ADHD. Its overall safety and tolerability profile is similar to other members of the psychostimulant class.

This article reviews sleep characteristics of children and adolescents who have attention-deficit/hyperactivity disorder (ADHD). Research on sleep disturbances in individuals who have ADHD without comorbid conditions, measured both objectively and subjectively, is first presented. The impact of primary sleep disorders associated with ADHD is then discussed. The effects of psychiatric comorbidities on the sleep patterns of children and adolescents who have ADHD are then reviewed, and sleep alterations associated with medications used to treat ADHD and comorbid conditions are addressed.

Objective: To examine the prevalence of comorbid Axis I (current and lifetime) and II disorders in adult men and women with attention-deficit hyperactivity disorder (ADHD). Method: Adult patients (n = 447; 266 men, 181 women) received comprehensive assessments for ADHD and Axis I and II disorders. Adults were aged between 17 and 74 years. Among the patients diagnosed with ADHD (n = 335), there were those with ADHD inattentive subtype (ADHD-I)(n = 199), hyperactive-impulsive subtype (ADHD-H)(n = 24), or combined ADHD subtype (ADHD-C)(n = 112). Chi-square and logistic regression analyses were performed to examine associations between adults with and without ADHD on Axis I and II disorders. Results: Adults with ADHD, compared with those without ADHD, had higher rates of Axis I (46.9% and 27.31%) and Axis II (50.7% and 38.2%) disorders. Adults with ADHD-C were more likely to have mood disorder, anxiety, conduct disorder, and substance use disorder as well as obsessive-compulsive personality disorder, passive-aggressive personality disorder, depressive personality disorder, narcissistic personality disorder, and borderline personality disorder (BPD). Men with ADHD were more likely to have antisocial personality disorder and had higher rates of current drug abuse than women with ADHD. Women with ADHD had higher rates of past and current panic disorder, and past anorexia and bulimia. Women with ADHD were more likely to have BPD than men with ADHD. Conclusions: Adults with ADHD have very high rates of comorbid Axis I and II disorders, with differences found between men and women on certain comorbid disorders.

Attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) are separately common mental health conditions that can have an adverse effect on a patient's quality of life if left untreated. These disorders frequently co-occur with one another, which can lead to increased patient suffering and diagnostic challenges for the treating clinician. In the United States adult population, epidemiological data show that the prevalence rate for MDD is 6.7%, while the ADHD prevalence rate in US adults is 4.4%. This epidemiological data represents the general population and likely underestimates the prevalence rates in clinic or practice patients. Examining the concurrent comorbid rate, if a patient has MDD, the likelihood of that patient also having ADHD is 18.6%; if the patient has ADHD, the likelihood of that patient having comorbid MDD is 9.4%. If the patient has dysthymia, the comorbid rate of ADHD is 12.8%, while those adults with ADHD have a comorbid rate of dysthymia of 22.6%.

In examining the challenges in treating comorbid attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), there are a number of issues regarding misinformation and misconception that exist for clinicians. Like other ADHD comorbidities, there is a lack of screening, particularly among adult clinical populations who have the psychiatric comorbidity or, for patients with SUDs, there is the issue of prioritization, which condition to treat first, and determining the place of medication managementparticularly stimulant medicationparamount in treatment planning.

Based on available literature, this article reviews the challenges associated with diagnosing pediatric bipolar disorder. The article also reviews and provides discussion on the assessment tools, complex mood cycling, and clinical symptoms of pediatric bipolar disorder. The challenge of differentiating common comorbid disorders like attention deficit hyperactivity disorder and conduct disorder from pediatric bipolar disorder is presented and discussed. A discussion of the validity of diagnosis in longitudinal studies is also provided.