Epidemiology of autism spectrum disorders

An Analysis of the Time Required for the Diagnosis of ASD and the Factors Influencing Its Duration in a Sample of the Pediatric Population from Poland

Background/Objectives: Early diagnosis of autism spectrum disorder (ASD) is a very important factor for improving the quality of life of people on the spectrum, but it still remains a major problem in Europe, especially concerning girls. In this study, we tried to answer the question of what factors affect the age of diagnosis in Poland. Additionally, we tried to establish the time between the first visit to the mental health center (MHC) and the diagnosis in this population, and what factors affect its length. Methods: 77 children were randomly recruited among the patients who came to local MHC at the Child and Family Health Centre in Sosnowiec. All participants were tested using the ADOS-2 protocol. In addition, the study used the TAS-20 test and BDI. Results: The mean age of the first enrollment in the MHC was 9.09 years for girls and 6.42 for the boys. The time needed to obtain a diagnosis from the first visit was consecutively 2.90 years and 4.29 years, but the difference was not statistically significant (p > 0.05). Obtaining a different psychiatric diagnosis did not affect the average time to diagnosis and the age of diagnosis. Conclusions: The results of the study indicate that the diagnosis of ASD is still a significant problem both in Poland and in the world. Obtaining an accurate diagnosis requires significant time, and it frequently involves consulting multiple specialists. The diagnostic process should be flexible, and the specialist should always take into account the axial symptoms but remain aware that the "overdiagnosis" of ASD can also have harmful consequences for the child.

Prevalence of autism spectrum disorder in mainland china over the past 6 years: a systematic review and meta-analysis

BACKGROUND

Coupled with its rising prevalence, Autism spectrum disorder (ASD) has become a globally recognized public health concern. Nevertheless, large-scale, multicenter studies that analyze the epidemiology of ASD in China are relatively scarce.

METHODS

Literature searches were conducted in PubMed/Medline, Embase, the Cochrane Library, Wanfang Data Knowledge Service Platform, China Biology Medicine database (CBM), China Science and Technology Journal Database (CSTJ), and China National Knowledge Infrastructure (CNKI) to retrieve studies published before April 8, 2023, related to ASD prevalence among children aged 0 to 14 years in mainland China. Meta-analysis was conducted using RevMan 5.2 and Stata 14.0.

RESULTS

Twenty-one articles were included. The ASD prevalence among children in mainland China has been 0.7% (95% confidence interval(CI): 0.006-0.008) since 2017. The prevalence of ASD among boys was 1.0% (95% CI: 0.008-0.011), which was significantly higher than that among girls at 0.2% (95% CI: 0.002-0.003), with a statistically significant difference (OR = 3.198, 95% CI: 2.489-4.109, P = 0.000). Among the included studies, 18 reported an ASD prevalence of 0.8% (95% CI: 0.007-0.010), while 3 studies reported an autistic disorder (AD) prevalence of 0.7% (95% CI: 0.006-0.008). The prevalence of autism among urban children was 23.9% (95% CI: 0.149-0.328), and in rural areas, it was 0.7% (95% CI: 0.002-0.013), with no statistically significant difference (OR = 1.342, 95% CI: 0.258-6.975, P = 0.727). Regression analysis showed that factors such as region (P = 0.000), age (P = 0.000), study period (P = 0.000), sample size (P = 0.000), sampling method (P = 0.002), population source (P = 0.000), disease type (P = 0.000), quality score of the study (P = 0.000), and diagnostic criteria (P = 0.000) might have contributed to the heterogeneity in ASD prevalence.

CONCLUSION

The prevalence of ASD in China from 2017 to 2023 was 7/1000, showing an upward trend compared to that before 2017 (26.50/10,000). The male-to-female prevalence ratio was 5:1.The overall prevalence remained significantly lower than that reported in foreign countries.

The role of environmental trace element toxicants on autism: A medical biogeochemistry perspective

Since genetic factors alone cannot explain most cases of Autism, the environmental factors are worth investigating as they play an essential role in the development of some cases of Autism. This research is a review paper that aims to clarify the role of the macro elements (MEs), Trace elements (TEs) and ultra-trace elements (UTEs) on human health if they are greater or less than the normal range. Aluminium (Al), cadmium Cd), lead (Pb), chromium (Cr), zinc (Zn), copper (Cu), nickel (Ni), arsenic (As), mercury (Hg), manganese (Mn), and iron (Fe) have been reviewed. Exposure to toxicants has a chemical effect that may ultimately lead to autism spectrum disorder (ASD). The Cr, As and Al are found in high concentrations in the blood of an autistic child when compared to normal child reference values. The toxic metals, particularly aluminium, are primarily responsible for difficulties in socialization and language skills disabilities. Zinc and copper are important elements in regulating the gene expression of metallothioneins (MTs), and zinc deficiency may be a risk factor for ASD pathogenesis. Autistics frequently have zinc deficiency combined with copper excess; as part of the treatment protocol, it is critical to monitor zinc and copper levels in autistic people, particularly those with zinc deficiency. Zinc deficiency is linked to epileptic seizures, which are common in autistic patients. Higher serum manganese and copper significantly characterize people who have ASD. Autistic children have significantly decreased lead and cadmium in urine, whereas they have significantly higher urine Cr. A higher level of As and Hg was found in the ASD individual's blood.

Effectivity of (Personalized) Cognitive Behavioral Therapy for Insomnia in Mental Health Populations and the Elderly: An Overview

Insomnia is very prevalent in psychiatry and is considered a transdiagnostic symptom of mental disorders. Yet, it is not only a consequence of a mental condition but may also exert detrimental effects on psychiatric symptom severity and therapeutic response; thus, adequate insomnia treatment is particularly important in psychiatric populations. The first choice of intervention is cognitive behavioral therapy for insomnia (CBT-I) as it is rather effective, also in the long run without side effects. It is offered in various forms, ranging from in-person therapy to internet-delivered applications. CBT-I protocols are typically developed for individuals with insomnia disorder without co-occurring conditions. For an optimal therapeutic outcome of CBT-I in individuals with comorbid mental disorders, adaptations of the protocol to tailor the treatment might be beneficial. Based on a literature search using major search engines (Embase; Medline; APA Psych Info; and Cochrane Reviews), this paper provides an overview of the effectiveness of the different CBT-I applications in individuals with diverse comorbid mental conditions and older adults and describes the functionality of CBT-I protocols that have been personalized to specific psychiatric populations, such as depression, substance abuse, and schizophrenia spectrum disorder. Finally, we discuss urgent needs for insomnia therapy targeted to improve both sleep and psychopathologies.

Children with Autism Spectrum Disorder Spent 30 Min Less Daily Time in Moderate-to-Vigorous Physical Activity than Typically Developing Peers: a Meta-Analysis of Cross-sectional Data

It remains unclear if participation in moderate-to-vigorous physical activity (MVPA) differs between children with ASD and typically developing children (TDC). We compared daily MVPA, time spent in MVPA during physical education (PE) and recess, and odds of not meeting MVPA recommendation (60 min/day) between children with ASD and TDC. Nine studies reporting accelerometer-measured MVPA were included in the meta-analyses. MVPA was 30 min lower/day, 12% and 8% lower during PE and recess, respectively, in children with ASD, and they had 4 times higher odds of not meeting MVPA recommendation when compared to TDC. Children with ASD engage in daily MVPA less than TDC and below the guidelines. Tailored interventions to increase MVPA in children with ASD are warranted.

Vitamin D levels in children and adolescents with autism

OBJECTIVE

This study aimed to investigate the relationship between autism spectrum disorder (ASD) and vitamin D levels in children and adolescents.

METHODS

We measured serum 25-hydroxyvitamin D (25-OHD) levels in 1529 patients with ASD aged 3 to 18 years, without any additional chronic diseases. Levels of 25-OHD were compared according to sex, age (<11 or ≥11 years), and birth season. Additionally, laboratory parameters (calcium, phosphorus, alkaline phosphatase, and 25-OHD) of 100 selected patients with ASD were compared with those of the healthy control group.

RESULTS

Vitamin D deficiency or insufficiency was found in approximately 95% of all patients. Levels of 25-OHD in adolescent patients with ASD aged 11 to 18 years were significantly lower than those in patients aged younger than 11 years. In the 100 selected patients with ASD, mean serum 25-OHD levels were significantly lower and alkaline phosphatase levels were higher compared with those in healthy children.

CONCLUSION

Our study suggests a relationship between vitamin D and ASD in children. Monitoring vitamin D levels is crucial in autistic children, especially adolescents, to take protective measures and treat this condition early.

Higher Lactate Level and Lactate-to-Pyruvate Ratio in Autism Spectrum Disorder

Mitochondrial dysfunction is considered one of the pathophysiological mechanisms of autism spectrum disorder (ASD). However, previous studies of biomarkers associated with mitochondrial dysfunction in ASD have revealed inconsistent results. The objective of this study was to evaluate biochemical markers associated with mitochondrial dysfunction in subjects with ASD and their unaffected family members. Lactate and pyruvate levels, as well as the lactate-to-pyruvate ratio, were examined in the peripheral blood of probands with ASD (Affected Group, AG) and their unaffected family members (biological parents and unaffected siblings, Unaffected Group, UG). Lactate ≥22 mg/dl, pyruvate ≥1.4 mg/dl, and lactate-to-pyruvate ratio >25 were defined as abnormal. The clinical variables were compared between subjects with higher (>25) and lower (≤25) lactate-to-pyruvate ratios within the AG. The AG (n=59) had a significantly higher lactate and lactate-to-pyruvate ratio than the UG (n=136). The frequency of subjects with abnormally high lactate levels and lactate-to-pyruvate ratio was significantly higher in the AG (lactate 31.0% vs. 9.5%, ratio 25.9% vs. 7.3%, p<0.01). The relationship between lactate level and the repetitive behavior domain of the Autism Diagnostic Interview-Revised was statistically significant. These results suggest that biochemical markers related to mitochondrial dysfunction, especially higher lactate levels and lactate-to-pyruvate ratio, might be associated with the pathophysiology of ASD. Further larger studies using unrelated individuals are needed to control for the possible effects of age and sex on chemical biomarker levels.

Social brain dysfunctionality in individuals with autism spectrum disorder and their first-degree relatives: An activation likelihood estimation meta-analysis

The social brain hypothesis is regarded as a powerful theory to understand social cognition. Individuals with autism spectrum disorder (ASD) have specific deficits in social and communicative behavior, but the exact relationship between these deficits and abnormalities in the social brain remains unclear. The high heritability of this disorder makes it important to focus on the first-degree relatives of those affected. Research focusing on genetically at-risk (yet healthy) relatives of patients with ASD is critical to the study of neuroimaging endophenotypes. We conducted a voxel-wise activation likelihood estimation (ALE) meta-analysis of 9 functional neuroimaging studies published during the period from 2006 to 2018. These studies included 200 individuals with ASD, 216 unaffected family members (UF), and 235 typical development controls (TD). The voxel-wise significance threshold was p < 0.01 (uncorrected p = 0.001).The ALE meta-analyses showed hyperactivation in the inferior frontal gyrus (IFG) and superior temporal gyrus (STG) among individuals with ASD and UF, compared with TD individuals. Group comparisons showed greater likelihood of hyperactivation in the amygdala for ASD, compared with UF and TD.

Age at death and comorbidity of dementia-related disorders among individuals with autism spectrum disorder

Purpose

Autism spectrum disorder (ASD) is a lifelong disorder that requires intervention and support services for a growing geriatric population. The purpose of this paper is to examine the mean age at death of individuals with ASD and subsequent comorbidity with Alzheimer’s disease, and any form of dementia, as a whole and according to sex.

Design/methodology/approach

Data consisted of 1,754 individuals who had an ASD listed as one of the causes of deaths from the National Vital Statistics System with data from 1999 to 2015. In the current study, the authors present contradictory results with a mean age at death for individuals with ASD was 68 years by adjusting for changing prevalence rates.

Findings

Females with ASD had a higher mean age at death than males with ASD; consistent with the trend in the sex differences in the general population. The results of the current study also indicate that individuals with ASD were, in fact, less likely than the general population to have Alzheimer’s disease or a form of dementia. However, males with ASD were significantly more likely to have acquired Alzheimer’s disease or a form of dementia as compared to females with ASD.

Originality/value

Guan and Li (2017) reported a mean age at death of 36 years old for individuals with ASD, which was subsequently reported in the mass media, most notably CNN. The authors contend that this study provides a more accurate estimate mean age at death.

Differences in oxytocin and vasopressin levels in individuals suffering from the autism spectrum disorders vs general population - a systematic review

INTRODUCTION

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social interactions, communication, and the presence of stereotyped, repetitive behaviors. Oxytocin (OXT) and arginine-vasopressin are neuropeptides produced in hypothalamus and they are related to processing emotions and social behavior. In the light of a growing number of scientific reports related to this issue, the two neurohormones started to be linked with the basis of neurodevelopmental disorders, including the ASD. The aim of this study was a systematic review of previous studies regarding the differences in OXT and vasopressin levels in ASD and neurotypical persons.

MATERIALS AND METHODS

Literature review focused on publications in the last 10 years located via the MEDLINE/PubMed database as well as the Google Scholar browser. Selection was made by assumptive criteria of inclusion and exclusion.

RESULTS

From the 487 studies qualified to the initial abstract analysis, 12 met the six inclusion criteria and were included in the full-text review.

CONCLUSION

Currently, available study reports still do not provide unequivocal answers as to the differences in concentrations of those neuropeptides between children with ASD and neurotypical control. Therefore, it is necessary to continue the research taking into account necessity of proper homogenization of study groups, utilization of objective and quantifiable tools for ASD diagnosis and broadening the range of biochemical and molecular factors analyzed.

[The prevalence of autism: genuine and imaginary]

In this review, the authors analyze the causes of the high prevalence of autism spectrum disorders (ASD) in recent decades. It is shown that the expansion of the boundaries of the 'autistic spectrum' concept led to a significant spread of data on its prevalence, depending on the time, diagnostic criteria, country and region. Stability of the diagnosis of ASD is not high and depends on the age of the child. Diagnostic practice in comorbid psychiatric disorders unfairly shifted toward ASD. At the same time, the hypothesis on the uniqueness of autistic manifestations in infancy is not convincingly confirmed. The practical aspect of the problem of the epidemiology of autism does not exclude, but on the contrary, presupposes early detection of nonspecific mental disorders followed by medical-psychological-pedagogical correction.

Adverse drug event-related hospitalisation in persons with neurodevelopmental disorders: a state-wide retrospective cohort study

BACKGROUND

Little is known about the sociodemographic and clinical characteristics of adverse drug events (ADEs) in patients with neurodevelopmental disorders (NDD).

OBJECTIVE

The objective of this study was to describe and compare the demographic details of people with and without NDD hospitalised due to ADEs.

METHODS

The all-inclusive New South Wales Admitted Patient Data Collection from 2001 to 2014 was employed to identify ADE-related hospitalisations in patients with NDD using the International Classification of Diseases 10th revision Australian modification codes. We derived case sets specific to different clinical groups and patient characteristics and compared proportional differences between patients with and without intellectual disability using chi squared tests.

RESULTS

A total of 2173 patients with NDD were admitted for acute care of ADEs, accounting for 0.7% of all ADE-related hospitalisations. Hospitalised ADEs among patients with NDD increased by twofold over the 14-year study period. Psychotropic medications and opioid analgesic medications were leading causes of ADE-related hospitalisations in patients with NDD. Compared with their counterparts, patients with NDD were younger, experienced more socio-economic disadvantage and less private insurance coverage, suffered with less severe but different co-morbid clinical conditions and incurred more challenges in the acute hospital care setting.

CONCLUSION

Although the pattern of ADE-related hospitalisations in patients with NDD differed from that in patients without NDD, there is a lack of targeted healthcare programmes to meet their special needs. This study suggests the need for countermeasures in primary healthcare settings to reduce the burden of ADEs in this vulnerable group.

Brief Report: Regional Variations in Characteristics of ASD Hospitalizations in the U.S

Regional differences in ASD inpatient care remain understudied. We used the Nationwide Inpatient Sample to examine contributory causes and potential determinants associated with regional variations in ASD hospitalizations. We performed univariate and multivariate analyses to identify differences in ASD hospitalizations across four U.S. Census Bureau-defined regions. Our results revealed considerable variations in ASD hospitalizations across U.S. regions. Compared with patients in the Northeast, those in the Midwest, South, and West were less likely to be hospitalized for ASD. Significant differences were observed among regions with regard to the effect of health insurance type, hospital length of stay, hospital bed size, hospital location and teaching status on ASD hospitalizations. The region-specific analysis provides direction for further investigation.

Risk for ASD in Preterm Infants: A Three-Year Follow-Up Study

Background

The aim of this study was to examine the long-term risk for autism spectrum disorders (ASD) in individuals who are born preterm and full-term using both observational instruments and parental reports. Neonatal risk factors and developmental characteristics associated with ASD risk were also examined.

Method

Participants included 110 preterm children (born at a gestational age of ≤ 34 weeks) and 39 full-term children assessed at ages 18, 24, and 36 months. The Autism Diagnostic Observation Schedule, the Modified Checklist for Autism in Toddlers, the Autism Diagnostic Interview-Revised, the Social Communication Questionnaire, and the Mullen Scales of Early Learning were administered.

Results and Conclusions

The long-term risk for ASD was higher when parental reports were employed compared to observational instruments. At 18 and 24 months, a higher long-term risk for ASD was found for preterm children compared to full-term children. At 36 months, only one preterm child and one full-term child met the cutoff for ASD based on the ADOS, yet clinical judgment and parental reports supported an ASD diagnosis for the preterm child only. Earlier gestational age and lower general developmental abilities were associated with elevated ASD risk among preterm children.

The prevalence of autism spectrum disorders in China: a comprehensive meta-analysis

There are conflicting prevalence estimates of autism spectrum disorders (ASDs) in mainland China (China thereafter). This study is a comprehensive meta-analysis of the pooled prevalence of ASDs in the general population in China. Study investigators independently conducted a systematic literature search of the following databases: PubMed, EMBASE, PsycINFO, China National Knowledge Infrastructure, Chinese biomedical literature service system, and Wan Fang. Studies reporting prevalence of ASDs and autism in Chinese population were identified and analysed using the Comprehensive Meta-Analysis program with the random effects model. Forty-four studies were included in the meta-analysis comprising 2,337,321 subjects of whom 46.66 % were females. The mean age of subjects ranged from 1.6 to 8 years. Based on diagnostic criteria the pooled prevalence of ASDs was 39.23 per 10,000 (95% CI: 28.44-50.03 per 10,000, I2=89.2%); specifically, the prevalence of autism was 10.18 per 10,000 (95% CI: 8.46-11.89 per 10,000, I2=92.5%). Subgroup analyses revealed significant difference in the prevalence of ASDs between genders (72.77 per 10,000 in males vs. 16.45 per 10,000 in females). In conclusion, the prevalence of ASDs and autism in China was found generally lower than those reported in other countries. Further studies are needed to clarify the variation in prevalence.

Potential Sex Differences Relative to Autism Spectrum Disorder and Metals

PURPOSE OF REVIEW

This study aims to summarize the current body of literature on the relationship between various toxic metals exposures (i.e., aluminum, antimony, arsenic, beryllium, cadmium, chromium, lead, manganese, and nickel) and autism spectrum disorder (ASD), with a focus on potential sex differences in these associations.

RECENT FINDINGS

Sex differences in ASD diagnosis and mutagenic effects of toxic exposures indicate that sex differences may play a major part in the causal relationship of any potential associations seen; however, we were only able to find three studies that reported on sex differences in observed associations with toxic metals exposure and ASD. We also found several studies investigating associations between ASD and metals exposures, including 11 on aluminum, 6 on antimony, 15 on arsenic, 5 on beryllium, 17 on cadmium, 11 on chromium, 25 on lead, 14 on manganese, and 13 on nickel with markers of exposure in hair, urine, blood, teeth, fingernails, and air pollution. Results for each metal were conflicting, but studies on cadmium and lead yielded the highest proportion of studies with positive results (72% and 36%, respectively). Based on our examination of existing literature, the current evidence warrants a considerable need for evaluations of sex differences in future studies assessing the association between metals exposures and ASD. Additionally, failure to account for potential sex differences could result in bias and misinterpretation of exposure-disease relationships.

Is food refusal in autistic children related to TAS2R38 genotype?

Several studies suggest that atypical eating behaviors, in particular food selectivity, are more frequent in children with autism spectrum disorder (ASD). A link between bitter taste perception, namely PROP/PTC sensitivity and food preferences is known in healthy children. The aim of this study is to investigate whether genetic variants of the TAS2R38 taste receptor responsible for different bitter sensitivity could affect foods preferences and consequently food refusal in ASD children. We recruited 43 children with ASD and 41 with normotypic development (TD) with or without food selectivity, aged between 2 and 11 years. Children were characterized for bitter sensitivity by means of PROP strips and FACS analysis and genotyped for TAS2R38 polymorphisms. Food selectivity was assessed by a validated food preference questionnaire filled by parents. A statistically significant correlation between PROP sensitivity and food refusal was observed. Furthermore, a prevalence of the PAV-sensitive haplotype compared to the AVI-insensitive one was seen in ASD children with food selectivity. In agreement with the initial hypothesis the results show that food refusal in ASD children is mediated by bitter taste sensitivity thus suggesting that the bitter sensitivity test may be used as a device to orientate tailored food proposals for the practical management of food selectivity in ASD. Autism Res 2018, 11: 531-538. © 2017 International Society for Autism Research, Wiley Periodicals, Inc.

LAY SUMMARY

A variation of the gene TAS2R38, associated with bitter taste sensitivity, can cause a different perception of some foods. In particular, some children are hypersensitive to bitterness and show a more restricted repertoire of accepted foods. We evaluate bitter sensitivity in ASD children with or without food selectivity, through a simple bitter taste test with edible strips. The results show that food refusal in ASD children can be mediated by bitter taste sensitivity thus suggesting that the bitter sensitivity test may be used as a device to orientate tailored food proposals for the practical management of food selectivity in ASD.

From Infections to Anthropogenic Inflicted Pathologies: Involvement of Immune Balance

A temporal trend can be seen in recent human history where the dominant causes of death have shifted from infectious to chronic diseases in industrialized societies. Human influences in the current "Anthropocene" epoch are exponentially impacting the environment and consequentially health. Changing ecological niches are suggested to have created health transitions expressed as modifications of immune balance from infections inflicting pathologies in the Holocene epoch (12,000 years ago) to human behaviors inflicting pathologies beginning in the Anthropocene epoch (300 years ago). A review of human immune health and adaptations responding to environmental (biological, chemical, physical, and psychological) stresses, which are influenced by social conditions, emphasize the involvement of fluctuations in immune cell subsets affecting influential gene-environment interactions. The literature from a variety of fields (anthropological, immunological, and environmental) is incorporated to present an expanded perspective on shifts in diseases within the context of immune balance and function and environmental immunology. The influences between historical and contemporary human ecology are examined in relation to human immunity. Several examples of shifts in human physiology and immunity support the premise that increased incidences of chronic diseases are a consequence of human modification of environment and lifestyle. Although the development of better health care and a broader understanding of human health have helped with better life quality and expectancy, the transition of morbidity and mortality rates from infections to chronic diseases is a cause for concern. Combinations of environmental stressors/pollutants and human behaviors and conditions are modulating the immune-neuroendocrine network, which compromises health benefits.

Maternal Body Mass Index and Risk of Autism Spectrum Disorders in Offspring: A Meta-analysis

Controversial results of the association between maternal body mass index (BMI) and risk of autism spectrum disorder (ASD) in offspring were reported among several studies. This meta-analysis was conducted to estimate the overall association between maternal BMI and risk of ASD in offspring. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched until January 2016. Cohort and case-control studies addressing the association between maternal BMI and risk of ASD in offspring were included. We used random-effect models to estimate the summary relative risks (RRs), we also performed a dose-response meta-analysis to estimate the trend from the correlated log RR estimates across levels of BMI quantitatively. Totally, 6 cohort studies and 1 case-control study involving 8,403 cases and 509,167 participants were included for analysis. The summary RR (95% confidence interval) for ASD in offspring in relation to maternal underweight, overweight, and obesity vs. normal weight during pre-pregnancy or pregnancy, was 1.07 (0.93, 1.23), 1.28 (1.19, 1.36) and 1.36 (1.03, 1.78), respectively. A linear dose-response relationship was found, with a pooled RR of 1.16 (1.01, 1.33) for each 5 kg/m2. increment in maternal BMI. The present study suggests that excessive maternal BMI is associated with increased ASD risk in offspring.

ASD Symptom Severity in Adolescence of Individuals Diagnosed with PDD-NOS in Childhood: Stability and the Relation with Psychiatric Comorbidity and Societal Participation

The current 7-year follow-up study investigated: (1) the stability of ASD severity, and (2) associations of ASD severity in adolescence with (a) childhood and concurrent psychiatric comorbidity, and (b) concurrent societal functioning. The Autism Diagnostic Observation Schedule (ADOS) and the Diagnostic Interview Schedule for Children were administered in childhood (ages 6-12) and in adolescence (ages 12-20) to 72 individuals with a pervasive developmental disorder-not otherwise specified (PDD-NOS). ADOS calibrated severity scores showed a large stability (r = .51). Psychiatric comorbidity in childhood and adolescence were not associated with ASD severity in adolescence. Mental health care use (87 %) and special education needs were high (71 %). Reevaluation of ASD severity and psychiatric comorbidity later in life seem useful when PDD-NOS is diagnosed in childhood.

Knowledge-guided mutation in classification rules for autism treatment efficacy

Data mining methods in biomedical research might benefit by combining genetic algorithms with domain-specific knowledge. The objective of this research is to show how the evolution of treatment rules for autism might be guided. The semantic distance between two concepts in the taxonomy is measured by the number of relationships separating the concepts in the taxonomy. The hypothesis is that replacing a concept in a treatment rule will change the accuracy of the rule in direct proportion to the semantic distance between the concepts. The method uses a patient database and autism taxonomies. Treatment rules are developed with an algorithm that exploits the taxonomies. The results support the hypothesis. This research should both advance the understanding of autism data mining in particular and of knowledge-guided evolutionary search in biomedicine in general.

Prevalence of Autism Spectrum Disorders in Ecuador: A Pilot Study in Quito

This research presents the results of the first phase of the study on the prevalence of pupils with Autism Spectrum Disorder (ASD) in regular education in Quito, Ecuador. One-hundred-and-sixty-one regular schools in Quito were selected with a total of 51,453 pupils. Prevalence of ASD was assessed by an interview with the rector of the school or its delegate. Results show an extremely low prevalence of 0.11 % of pupils with any ASD diagnosis; another 0.21 % were suspected to have ASD, but were without a diagnosis. This low prevalence suggests that children and adolescents with ASD are not included in regular education in Quito. These results are discussed in the light of low diagnostic identification of ASD and low inclusion tolerance.

Paternal age bioethics

Modern genetic sequencing studies have confirmed that the sperm of older men contain a greater number of de novo germline mutations than the sperm of younger men. Although most of these mutations are neutral or of minimal phenotypic impact, a minority of them present a risk to the health of future children. If demographic trends towards later fatherhood continue, this will likely lead to a more children suffering from genetic disorders. A trend of later fatherhood will accelerate the accumulation of paternal-origin de novo mutations in the gene pool, gradually reducing human fitness in the long term. These risks suggest that paternal age is of ethical importance. Children affected by de novo mutations arising from delayed fatherhood can be said to be harmed, in the sense of 'impersonal' harm or 'non-comparative' harm. Various strategies are open at societal and individual levels towards reducing deleterious paternal age effects. Options include health education to promote earlier fatherhood, incentives for young sperm donors and state-supported universal sperm banking. The latter approach would likely be of the greatest benefit and could in principle be implemented immediately. More futuristically, human germline genetic modification offers the potential to repair heritable mutational damage.

Cochlear Implantation in Children With Autism Spectrum Disorder

OBJECTIVE

To assess the outcome of cochlear implantation in children with autism spectrum disorder (ASD).

STUDY DESIGN

Retrospective case review and survey.

SETTING

Tertiary referral center.

PATIENTS

Children who meet criteria for cochlear implantation and diagnosis of ASD.

MAIN OUTCOME MEASURES

Receptive and expressive language scores and parental survey data.

RESULTS

Fifteen patients with history of ASD and cochlear implantation were analyzed and compared with 15 patients who received cochlear implant and have no other disability. Postoperatively, more than 67% of children with ASD significantly improved their speech perception skills, and 60% significantly improved their speech expression skills, whereas all patients in the control group showed significant improvement in both aspects. The top 3 reported improvements after cochlear implantation were name recognition, response to verbal requests, and enjoyment of music. Of all behavioral aspects, the use of eye contact was the least improved. Survey results in regard to improvements in patient interaction were more subtle when compared with those related to sound and speech perception. The most improved aspects in the ASD patients' lives after cochlear implantation seemed to be attending to other people's requests and conforming to family routines. Of note, awareness of the child's environment is the most highly ranked improvement attributed to the cochlear implant.

CONCLUSION

Cochlear implants are effective and beneficial for hearing impaired members of the ASD population, although development of language may lag behind that of implanted children with no additional disabilities. Significant speech perception and overall behavior improvement are noted.

Importance and hurdles to drug discovery for neurological disease

This is a critical time in neurotherapeutics. The prevalence of neurological disease, such as dementia, stroke, and peripheral neuropathy, is large and growing consequent to the aging population. The personal and societal impact of these disorders is enormous, and the number of novel therapies in the pipeline for these disorders has been contracting. Support for the development of neurotherapies must continue from the bench to their ultimate place at the bedside. Academic medicine must continue to play a critical role, in league with industry and government, in the development of novel neurotherapies desperately needed by an ever-expanding population. Critical steps include the identification and adoption of reliable, valid, and reproducible biomarkers to serve as primary endpoints in clinical trials of neurological disease.

Autistic children exhibit decreased levels of essential Fatty acids in red blood cells

Omega-6 (n-6) and omega-3 (n-3) polyunsaturated fatty acids (PUFA) are essential nutrients for brain development and function. However, whether or not the levels of these fatty acids are altered in individuals with autism remains debatable. In this study, we compared the fatty acid contents between 121 autistic patients and 110 non-autistic, non-developmentally delayed controls, aged 3–17. Analysis of the fatty acid composition of red blood cell (RBC) membrane phospholipids showed that the percentage of total PUFA was lower in autistic patients than in controls; levels of n-6 arachidonic acid (AA) and n-3 docosahexaenoic acid (DHA) were particularly decreased (p < 0.001). In addition, plasma levels of the pro-inflammatory AA metabolite prostaglandin E2 (PGE2) were higher in a subset of the autistic participants (n = 20) compared to controls. Our study demonstrates an alteration in the PUFA profile and increased production of a PUFA-derived metabolite in autistic patients, supporting the hypothesis that abnormal lipid metabolism is implicated in autism.

Integrated analysis of whole-exome sequencing and transcriptome profiling in males with autism spectrum disorders

BACKGROUND

Autism spectrum disorders (ASD) are a group of neurodevelopmental disorders with high heritability. Recent findings support a highly heterogeneous and complex genetic etiology including rare de novo and inherited mutations or chromosomal rearrangements as well as double or multiple hits.

METHODS

We performed whole-exome sequencing (WES) and blood cell transcriptome by RNAseq in a subset of male patients with idiopathic ASD (n = 36) in order to identify causative genes, transcriptomic alterations, and susceptibility variants.

RESULTS

We detected likely monogenic causes in seven cases: five de novo (SCN2A, MED13L, KCNV1, CUL3, and PTEN) and two inherited X-linked variants (MAOA and CDKL5). Transcriptomic analyses allowed the identification of intronic causative mutations missed by the usual filtering of WES and revealed functional consequences of some rare mutations. These included aberrant transcripts (PTEN, POLR3C), deregulated expression in 1.7% of mutated genes (that is, SEMA6B, MECP2, ANK3, CREBBP), allele-specific expression (FUS, MTOR, TAF1C), and non-sense-mediated decay (RIT1, ALG9). The analysis of rare inherited variants showed enrichment in relevant pathways such as the PI3K-Akt signaling and the axon guidance.

CONCLUSIONS

Integrative analysis of WES and blood RNAseq data has proven to be an efficient strategy to identify likely monogenic forms of ASD (19% in our cohort), as well as additional rare inherited mutations that can contribute to ASD risk in a multifactorial manner. Blood transcriptomic data, besides validating 88% of expressed variants, allowed the identification of missed intronic mutations and revealed functional correlations of genetic variants, including changes in splicing, expression levels, and allelic expression.

Screening for autism spectrum disorder in very preterm infants during early childhood

AIM

The aim of the study was to screen very preterm infants for autism spectrum disorder (ASD) with comparisons to a group of term controls. The study also aimed to identify maternal and neonatal risk factors, development and behaviour associated with a positive screen in the preterm group.

METHOD

Preterm infants born ≤ 30 weeks gestation and term infants were recruited at two years of age. The mothers were posted the questionnaires and completed the Modified Checklist for Autism in Toddlers (M-CHAT), the Child Behaviour Checklist (CBCL) and the Depression, Anxiety and Stress Scales (DASS). Previously collected data from the mothers at 12 months--the Edinburgh Postnatal Depression Scales (EPDS) were analysed. The children had neurodevelopmental assessment including the Bayley-III. Infants positive on M-CHAT screen had an M-CHAT follow-up interview by phone and then were assessed by a developmental paediatrician as indicated with a diagnosis of autism being made on clinical judgement.

RESULTS

13 (13.4%) of the 97 preterm infants screened positive on the M-CHAT compared to three (3.9%) of the 77 term infants (p = 0.036). On follow-up interview, three of the preterm infants remained positive (one was diagnosed with autism) compared to none of the term infants. The preterm infants who screened positive were born to younger, non-Caucasian mothers and were of lower birth weight and had a higher incidence of being small for gestational age (SGA). The infants had lower composite scores on Bayley-III and had more internalising and externalising behaviours on the CBCL. The mothers had more emotional problems on the DASS and higher scores on the EPDS. On multivariate analysis, SGA, greater internalising behaviours and higher EPDS scores remained statistically significant.

CONCLUSIONS

A positive screen on the M-CHAT occurs more commonly in very preterm infants than those born at term. Internalising behaviours and maternal mental health are associated with a positive screen in the preterm cohort.

Summer Treatment Program Improves Behavior of Children with High-Functioning Autism Spectrum Disorder

This study evaluated the effects of a behavioral summer treatment program for children with high-functioning autism spectrum disorder (HFASD). Twenty boys (M = 9.2 years) diagnosed with HFASD participated in the 6-week program across 6 years. Detailed daily behavioral data were collected on a variety of positive and negative social behaviors. Repeated measures ANOVAs of weekly behavior frequencies indicated substantial improvements in a number of behaviors over the 6 weeks of the program, including following activity rules, contributing to a group discussion, paying attention, and less complaining/whining. Overall, results highlight the potential efficacy of treating chronic functional impairments of HFASD and associated problem behaviors in the context of an intensive behavioral summer treatment program.

A case with a ring chromosome 13 in a cohort of 203 children with non-syndromic autism and review of the cytogenetic literature

Autistic spectrum disorder (ASD) is a group of neurodevelopmental disorders characterized by impairments of social interaction, communication and restricted, repetitive and stereotyped patterns of behavior, interests and activities. Frequencies of chromosomal abnormalities in cohorts of individuals with ASD varying between 1.2 and 28.6% have been reported. In this study, we evaluated 203 Thai children who met the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), for autistic disorder or pervasive developmental disorder not otherwise specified (PDD-NOS), and who had neither major dysmorphic features nor CGG repeat expansions of the FMR1 gene. A routine G-banding chromosome analysis was performed at a minimum of ISCN 400-550 bands. A chromosomal abnormality was observed in one child (0.5%), a 41-month-old boy with a ring chromosome 13 detected by G-banding analysis and subsequently confirmed by FISH. SNP microarray analysis detected a 2.11-Mb deletion of chromosome 13q34, encompassing 23 genes. The MCF2L and UPF3A genes are among those genes that may explain the autistic features in our case. To the best of our knowledge, only one autistic case with a ring chromosome 13 has been previously reported. In this article, we also systemically reviewed 21 studies that utilized a conventional cytogenetic method to detect chromosomal abnormalities in patients with ASD. When we summed all cases with chromosomal abnormalities, including the case from our study, the frequency of chromosomal abnormalities detected by conventional cytogenetics in patients with ASD was 3.2% (118/3,712).

Food for thought: dietary changes in essential fatty acid ratios and the increase in autism spectrum disorders

The last decades have shown a spectacular and partially unexplained rise in the prevalence of autism spectrum disorders (ASD). This rise in ASD seems to parallel changes in the dietary composition of fatty acids. This change is marked by the replacement of cholesterol by omega-6 (n-6) fatty acids in many of our food products, resulting in a drastically increased ratio of omega-6/omega-3 (n-6/n-3). In this context, we review the available knowledge on the putative role of fatty acids in neurodevelopment and describe how disturbances in n-6/n-3 ratios may contribute to the emergence of ASDs. Both clinical and experimental research is discussed. We argue that a change in the ratio of n-6/n-3, especially during early life, may induce developmental changes in brain connectivity, synaptogenesis, cognition and behavior that are directly related to ASD.

Autism and nutrition: the role of the gut-brain axis

Autism spectrum disorder (ASD) is characterised by deficits in the ability to socialise, communicate and use imagination, and displays of stereotypical behaviour. It is widely accepted that ASD involves a disorder in brain development. However, the real causes of the neurodevelopmental disorders associated with ASD are not clear. In this respect, it has been found that a majority of children with ASD display gastrointestinal symptoms, and an increased intestinal permeability. Moreover, large differences in microbiotic composition between ASD patients and controls have been reported. Therefore, nutrition-related factors have been hypothesised to play a causal role in the aetiology of ASD and its symptoms. Through a review of the literature, it was found that abnormalities in carbohydrate digestion and absorption could explain some of the gastrointestinal problems observed in a subset of ASD patients, although their role in the neurological and behavioural problems remains uncertain. In addition, the relationship between an improved gut health and a reduction of symptoms in some patients was evaluated. Recent trials involving gluten-free diets, casein-free diets, and pre- and probiotic, and multivitamin supplementation show contradictive but promising results. It can be concluded that nutrition and other environmental influences might trigger an unstable base of genetic predisposition, which may lead to the development of autism, at least in a subset of ASD patients. Clear directions for further research to improve diagnosis and treatment for the different subsets of the disorder are provided.

Coherent somatic mutation in autoimmune disease

BACKGROUND

Many aspects of autoimmune disease are not well understood, including the specificities of autoimmune targets, and patterns of co-morbidity and cross-heritability across diseases. Prior work has provided evidence that somatic mutation caused by gene conversion and deletion at segmentally duplicated loci is relevant to several diseases. Simple tandem repeat (STR) sequence is highly mutable, both somatically and in the germ-line, and somatic STR mutations are observed under inflammation.

RESULTS

Protein-coding genes spanning STRs having markers of mutability, including germ-line variability, high total length, repeat count and/or repeat similarity, are evaluated in the context of autoimmunity. For the initiation of autoimmune disease, antigens whose autoantibodies are the first observed in a disease, termed primary autoantigens, are informative. Three primary autoantigens, thyroid peroxidase (TPO), phogrin (PTPRN2) and filaggrin (FLG), include STRs that are among the eleven longest STRs spanned by protein-coding genes. This association of primary autoantigens with long STR sequence is highly significant (p<3.0x10(-7)). Long STRs occur within twenty genes that are associated with sixteen common autoimmune diseases and atherosclerosis. The repeat within the TTC34 gene is an outlier in terms of length and a link with systemic lupus erythematosus is proposed.

CONCLUSIONS

The results support the hypothesis that many autoimmune diseases are triggered by immune responses to proteins whose DNA sequence mutates somatically in a coherent, consistent fashion. Other autoimmune diseases may be caused by coherent somatic mutations in immune cells. The coherent somatic mutation hypothesis has the potential to be a comprehensive explanation for the initiation of many autoimmune diseases.

Autism spectrum disorders in children of parents with inflammatory bowel disease - a nationwide cohort study in Denmark

PURPOSE

Inflammatory bowel disease (IBD) and autism spectrum disorders (ASD) may share genetic and environmental risk factors. We examined whether parental IBD is associated with an increased risk of ASD in offspring.

METHODS

We conducted a registry-based nationwide cohort study including children born alive in Denmark from January 1, 1994 to December 31, 2009, with follow-up throughout 2010. IBD in parents and ASD in offspring were identified using inpatient and outpatient hospital diagnoses. We computed risk of ASD and crude and adjusted incidence rate ratios (aIRRs) with 95% confidence intervals (CI) using Cox proportional-hazards regression. We evaluated the risk of ASD according to maternal and paternal IBD, and separately for maternal and paternal Crohn's disease (CD) and ulcerative colitis (UC). Children with parents free of IBD were the comparison cohort.

RESULTS

We identified 1,005,330 children during the study period. Among them, 11,888 (1.2%) had a parent with IBD and 8,087 (0.8%) had a diagnosis of ASD during up to 17 years of follow-up. The 10-year risks of ASD were 0.7% among children of parents with IBD and 0.9% among children of parents without IBD. The aIRR for ASD among children with parental IBD was 0.8 (95% CI: 0.6-1.0), and results were similar regardless of parent of IBD origin or whether a parent had CD or UC. The estimates were similar for different ASD subtypes.

CONCLUSION

We found no evidence of an increased risk of ASD among children born to parents with IBD.

Human serum transferrin: is there a link among autism, high oxalate levels, and iron deficiency anemia?

It has been previously suggested that large amounts of oxalate in plasma could play a role in autism by binding to the bilobal iron transport protein transferrin (hTF), thereby interfering with iron metabolism by inhibiting the delivery of iron to cells. By examining the effect of the substitution of oxalate for the physiologically utilized synergistic carbonate anion in each lobe of hTF, we sought to provide a molecular basis for or against such a role. Our work clearly shows both qualitatively (6 M urea gels) and quantitatively (kinetic analysis by stopped-flow spectrofluorimetry) that the presence of oxalate in place of carbonate in each binding site of hTF does indeed greatly interfere with the removal of iron from each lobe (in the absence and presence of the specific hTF receptor). However, we also clearly demonstrate that once the iron is bound within each lobe of hTF, neither anion can displace the other. Additionally, as verified by urea gels and electrospray mass spectrometry, formation of completely homogeneous hTF-anion complexes requires that all iron must first be removed and hTF then reloaded with iron in the presence of either carbonate or oxalate. Significantly, experiments described here show that carbonate is the preferred binding partner; i.e., even if an equal amount of each anion is available during the iron loading process, the hTF-carbonate complex is formed.

Revisiting the relationship between autism and schizophrenia: toward an integrated neurobiology

Schizophrenia and autism have been linked since their earliest descriptions. Both are disorders of cerebral specialization originating in the embryonic period. Genetic, molecular, and cytologic research highlights a variety of shared contributory mechanisms that may lead to patterns of abnormal connectivity arising from altered development and topology. Overt behavioral pathology likely emerges during or after neurosensitive periods in which resource demands overwhelm system resources and the individual's ability to compensate using interregional activation fails. We are at the threshold of being able to chart autism and schizophrenia from the inside out. In so doing, the door is opened to the consideration of new therapeutics that are developed based upon molecular, synaptic, and systems targets common to both disorders.

A review of the serotonin transporter and prenatal cortisol in the development of autism spectrum disorders

The diagnosis of autism spectrum disorder (ASD) during early childhood has a profound effect not only on young children but on their families. Aside from the physical and behavioural issues that need to be dealt with, there are significant emotional and financial costs associated with living with someone diagnosed with ASD. Understanding how autism occurs will assist in preparing families to deal with ASD, if not preventing or lessening its occurrence.

Serotonin plays a vital role in the development of the brain during the prenatal and postnatal periods, yet very little is known about the serotonergic systems that affect children with ASD. This review seeks to provide an understanding of the biochemistry and physiological actions of serotonin and its termination of action through the serotonin reuptake transporter (SERT). Epidemiological studies investigating prenatal conditions that can increase the risk of ASD describe a number of factors which elevate plasma cortisol levels causing such symptoms during pregnancy such as hypertension, gestational diabetes and depression. Because cortisol plays an important role in driving dysregulation of serotonergic signalling through elevating SERT production in the developing brain, it is also necessary to investigate the physiological functions of cortisol, its action during gestation and metabolic syndromes.

Mitochondrial dysfunction in autism

Using data of the current prevalence of autism as 200:10,000 and a 1:2000 incidence of definite mitochondrial (mt) disease, if there was no linkage of autism spectrum disorder (ASD) and mt disease, it would be expected that 1 in 110 subjects with mt disease would have ASD and 1 in 2000 individuals with ASD would have mt disease. The co-occurrence of autism and mt disease is much higher than these figures, suggesting a possible pathogenetic relationship. Such hypothesis was initially suggested by the presence of biochemical markers of abnormal mt metabolic function in patients with ASD, including elevation of lactate, pyruvate, or alanine levels in blood, cerebrospinal fluid, or brain; carnitine level in plasma; and level of organic acids in urine, and by demonstrating impaired mt fatty acid β-oxidation. More recently, mtDNA genetic mutations or deletions or mutations of nuclear genes regulating mt function have been associated with ASD in patients or in neuropathologic studies on the brains of patients with autism. In addition, the presence of dysfunction of the complexes of the mt respiratory chain or electron transport chain, indicating abnormal oxidative phosphorylation, has been reported in patients with ASD and in the autopsy samples of brains. Possible pathogenetic mechanisms linking mt dysfunction and ASD include mt activation of the immune system, abnormal mt Ca(2+) handling, and mt-induced oxidative stress. Genetic and epigenetic regulation of brain development may also be disrupted by mt dysfunction, including mt-induced oxidative stress. The role of the purinergic system linking mt dysfunction and ASD is currently under investigation. In summary, there is genetic and biochemical evidence for a mitochondria (mt) role in the pathogenesis of ASD in a subset of children. To determine the prevalence and type of genetic and biochemical mt defects in ASD, there is a need for further research using the latest genetic technology such as next-generation sequencing, microarrays, bioinformatics, and biochemical assays. Because of the availability of potential therapeutic options for mt disease, successful research results could translate into better treatment and outcome for patients with mt-associated ASD. This requires a high index of suspicion of mt disease in children with autism who are diagnosed early.

Do politics affect prevalence? An overview and the case of cerebral palsy

Many factors must be considered when assessing estimates of prevalence, including research methods and quality of the work by the research team. Broad social and political forces also influence estimates of prevalence, as seen in the case of autism and intellectual disability. Indeed, researchers themselves may be influenced by broader sociopolitical factors in ways that they do not recognize. To further explore the relationship of prevalence to sociopolitical factors, we reviewed the historical prevalence of cerebral palsy (CP) (as a proxy for physical disability) in the late 20th century. We hypothesized that increased awareness of physical impairments associated with the disability rights movement of the 1970s would increase the prevalence of CP, primarily because of changes in case definition. Although prevalence of CP did rise slightly in the 1980s, we conclude that this change is better explained by increased survival of low birth weight infants, which is only indirectly related to the disability rights movement.

Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation

OBJECTIVE

To assess long-term survival, graft function, and health-related quality of life (QOL) after visceral transplantation.

BACKGROUND

Despite continual improvement in early survival, the long-term therapeutic efficacy of visceral transplantation has yet to be defined.

METHODS

A prospective cross-sectional study was performed on 227 visceral allograft recipients who survived beyond the 5-year milestone. Clinical data were used to assess outcome including graft function and long-term survival predictors. The socioeconomic milestones and QOL measures were assessed by clinical evaluation, professional consultation, and validated QOL inventory.

RESULTS

Of 376 recipients, 227 survived beyond 5 years, with conditional survival of 75% at 10 years and 61% at 15 years. With a mean follow-up of 10 ± 4 years, 177 (92 adults, 85 children) are alive, with 118 (67%) recipients 18 years or older. Nonfunctional social support and noninclusion of the liver in the visceral allograft are the most significant survival risk factors. Nutritional autonomy was achievable in 160 (90%) survivors, with current serum albumin level of 3.7 ± 0.5 gm/dL and body mass index of 25 ± 6 kg/m(2). Despite coexistence or development of neuropsychiatric disorders, most survivors were reintegrated to society with self-sustained socioeconomic status. In parallel, most of the psychological, emotional, and social QOL measures significantly (P < 0.05) improved after transplantation. Current morbidities with potential impact on global health included dysmotility (59%), hypertension (37%), osteoporosis (22%), and diabetes (11%), with significantly (P < 0.05) higher incidence among adult recipients.

CONCLUSIONS

With new tactics to further improve long-term survival including social support measures, visceral transplantation has achieved excellent nutritional autonomy and good QOL.

Invited commentary: the 21st century epidemiologist--a need for different training?

The accompanying paper by Ogino et al. (Am J Epidemiol. 2012;176(8):659-667) cogently suggests a need for including modern approaches like molecular pathological epidemiology (MPE) in our research. However, Ogino et al. make an assumption that epidemiology has previously not included pathology or modern technologies in epidemiologic studies and that there is a unique need for the specialty of MPE. The new molecular pathology is yet another technique that can improve epidemiologic investigations. There is a long tradition of combining good pathology with epidemiologic research, especially in studies of cardiovascular disease. Large epidemiologic studies have successfully integrated specialty expertise in a collaborative and mutually beneficial approach to test specific hypotheses. The author is concerned that MPE techniques, whether they involve metabolomics, genomics, proteomics, or microarrays, will come to drive epidemiologic studies without any specific hypothesis-testing or unique population characteristics. The epidemiologist would then become little more than a collector of study subjects and a distributor of the various specimens to the laboratories.