Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study

BACKGROUND

The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics.

METHODS

This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order.

RESULTS

The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy.

CONCLUSION

Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

Levetiracetam as an alternative therapy for Tourette syndrome

Tourette syndrome is a common childhood-onset neuropsychiatric disorder characterized by chronic tics and frequent comorbid conditions such as attention deficit disorder. Most currently used tic-suppressing drugs are frequently associated with serious adverse events. Thus, alternative therapeutic agents with more favorable side-effect profiles are being evaluated. New hypotheses and recent studies involving GABAergic system in the pathophysiology of Tourette syndrome suppose a reason for the evaluation of GABAergic drugs. Levetiracetam is a drug with an atypical GABAergic mechanism of action that might be expected to improve tics. Although trials performed to evaluate the efficacy of levetiracetam in the treatment of Tourette syndrome have provided conflicting results, it may be useful in some patients. The established safe profile of levetiracetam makes this drug an alternative for treatment if intolerance to currently used drugs appears, but additional evaluation with larger and longer duration controlled studies are necessary to assess the real efficacy in patients with Tourette syndrome.

[Coding in neuropediatrics based on the International Classification Diseases, 9th revision (ICD-9), 5th edition (2006)]

AIMS

To analyze International Classification Diseases, 9th revision (ICD-9) coding and adapt it, on a consensus basis, to 'reasons for medical consultation', 'diagnoses' and 'procedures' in child neurology.

MATERIALS AND METHODS

The most frequent reasons for medical consultation, diagnoses and procedures in neuropediatrics were selected and assigned the most appropriate ICD-9, Clinical Modification (5th ed.) (ICD-9-CM) codes in accordance with this system's coding rules. Disorders were grouped by sections, and allocated to the various members of the working group (13 child neurologists from 10 hospitals in Madrid and environs).

RESULTS

Available on the web www.neurologia.com/cie-9. ICD-9-CM codes were assigned to: 158 reasons for medical consultation; 886 diagnoses; 73 diagnostic procedures; and 53 therapeutic procedures. In every case, the most appropriate ICD-9 code was sought for the respective diagnosis. No codes were invented but the working group did take certain liberties with interpretation, which nevertheless showed respect for general ICD-9-CM philosophy and are described in full in the text.

CONCLUSIONS

The creation of this ICD-9 adaptation will not only enhance diagnostic coding in child neurology departments, but will also provide them with a useful tool for setting up databases to enable information to be retrospectively analyzed and shared by the different health centers.

[Treatment of Tourette syndrome and its comorbidity: experience with 17 cases]

INTRODUCTION

Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases.

MATERIAL AND METHODS

We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón.

RESULTS

Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged from 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53%), obsessive-compulsive disorder in 8 (48%) and anxiety in 7 (41%). Learning disorders were found in 7 patients (41%), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuroleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics.

CONCLUSIONS

In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening.

[The clinical semiology of attention deficit hyperactivity disorder according to age, and the effectiveness of treatments at different ages]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is the most important cause of poor academic performance and is also usually associated with behavioural, emotional and sociability disorders.

AIM

To analyse the different clinical features and the response to psychostimulant therapy, according to the age.

SUBJECTS AND METHODS

We reviewed the cases of 152 children referred to Neuropaediatrics owing to suspected ADHD over a 6-year period. Diagnosis and comorbidity were investigated by the looking at their case history, by examination and observation, as well as by interviewing the parents (DSM-IV criteria), and by applying Conners' Rating Scale for parents and teachers, in addition to neuropsychological tests. In order to improve data processing, we established four groups according to the patient's age at diagnosis and when treatment was started: G1: 3-5; G2: 6-8; G3: 9-11; and G4: 12-15 years.

RESULTS

ADHD was diagnosed in 102 of the 152 children; 53% had the combined type, 26% were of the inattentional type, and 20% were hyperactive/impulsive. Poor school performance increased with age and reached 75% in G4. The same occurred with conduct disorders: at 6 years of age, 23% were found to have oppositional defiant disorder, and from the age of 9 onwards over 60% of them had conduct disorders. Up until 12 years of age they showed some improvement with psychostimulants and later the rate of dropouts from medical clinical controls and from treatment was over 40%.

CONCLUSIONS

The older patients are and the later ADHD is attended, the more problems they have. If successful preventive measures are to be implemented, it would be advisable to begin treatment even before children start primary education (5 years old), so as to try and avoid the pedagogical and behavioural repercussions observed in these children at the age of 6.

[Variability in the treatment of headaches in visits to the Neuropaediatrics service at six Spanish hospitals]

INTRODUCTION

Headache is one of the chief reasons for visiting Neuropaediatric units. Variability in clinical practice has been defined as variations in the rates a clinical procedure is employed. The aim of this work is to study the variability in the treatment of children's headaches in six Spanish hospitals.

PATIENTS AND METHODS

We conducted a retrospective study involving patients who first visited because of a headache some time in the year 1999. Data were collected in December 2003. The following variables were analysed: type of headache, neuroimaging scans, beginning of prophylaxis, follow-up visits to clinic and number of patients who dropped out of the follow-up.

RESULTS

In all, 372 children were attended. 63.4% of the headaches were considered as being migraine-type; 43% of the patients were submitted to neuroimaging and prophylaxis was established in 36.8%. Mean follow-up time in the clinic was 10.6 months and the mean number of visits was 3. 30% had dropped out of the follow-up. In the comparative analysis, significant differences were found in all the variables studied.

CONCLUSIONS

Overall results are similar to those found in other series. The differences found between centres can be accounted for by differences in population, differences in health professionals' styles of medical practice or by the nonexistence of clear guidelines regarding a particular procedure.

[Clinical progress of neonatal non-ketotic hyperglycinemia under treatment]

INTRODUCTION

Non-ketotic hyperglycinemia is a congenital error in the breakdown of glycine. The most common type is the classical neonatal form, which begins at the age of a few days with symptoms of lethargy, hypotonia, myoclonia, convulsions, apneas and, frequently, ends in death. Survivors usually develop intractable epilepsy and mental retardation. There is no effective treatment for this condition, but trials have been carried out with a therapy that diminishes the levels of glycine, benzoate (BZ), and another that blocks the excitatory effect in N-methyl-D-aspartate receptors: dextromethorphan (DTM).

CASE REPORT

We report on the progress of a classical neonatal case, which began at the age of a few hours with hypotonia and stupor, without myoclonias or seizures, but with a suppression wave trace on the electroencephalogram (EEG). Cerebrospinal fluid (CSF) showed glycine levels of 141 micromol/L (the normal level is 6.66 +/- 2.66 micromol/L), with a CSF/plasma ratio of 0.19 (the normal ratio is < 0.02). Treatment was started on the thirteenth day with BZ and DTM, and alertness and eye fixation improved in just three days; at the same time the EEG readings become normal. The glycine level in plasma returned to normal at two months and that in CSF was considerably reduced, although with CSF/plasma levels that were still high. At present the patient is 4 years old, has never had convulsions, EEG results have always been normal, and continues with BZ, DTM, carnitine and diet. The patient has presented a high degree of hypermotoric behaviour, but is currently more attentive and more sociable, has been walking from the age of 35 months and has a quotient in the different areas of development of 40-50.

CONCLUSIONS

The clinical progress made by our patient could be said to be anything but negligible, and we therefore recommend that treatment should be started as early as possible after diagnosis.

[Growth charts for the Spanish population with neurofibromatosis type 1]

OBJECTIVE

To make the charts of stature and head circumference of Spanish pediatric patients affected with neurofibromatosis type 1 (NF1), to compare them with the ones from a healthy population and to review the possible causes of its alterations.

PATIENTS AND METHODS

We obtained the data from 251 Spanish patients (122 women and 129 men) with NF1 seen in seven hospitals between the years 2000 and 2002, with ages between 1 month and 18 years old. The calculation of the 50th centile or median was done using the method of mobile variables, and the 3rd and 97th centiles where calculated from this median.

RESULTS

Girls with NF1 have a shorter stature than the healthy ones, which becomes evident after 10 years of age. We have not found differences in the stature between boys with the disease and those without it. In regards to head circumference, in boys and girls we have observed that it is bigger throughout life in patients affected with NF1, and that the 50th centile of healthy people correlates with the 3rd centile of those affected, the 97th centile of the healthy ones with the 50th centile of those affected, being the 3rd centile of the healthy people well below the 3rd centile of the affected ones, and the 97th centile of the affected ones well above the 97th of the healthy people.

CONCLUSIONS

The short stature in postpuberal girls and the macrocephaly in both sexes at all ages, are primary characteristics in the NF1 and they are not usually related with other alterations, although they are not specific for this illness.

[Effects of corticosteroids in the management of Duchenne muscular dystrophy: our experience]

Objective To evaluate the clinical course in patients with Duchenne muscular dystrophy admitted to our department who received corticosteroid treatment and to compare their course with that in patients who did not receive corticosteroid treatment.Patients and methodsWe performed a retrospective study of 20 pediatric patients with a diagnosis of Duchenne muscular dystrophy who were offered corticosteroid treatment: 10 patients received deflazacort and 10 refused the treatment. The MRC muscular strength scale and Vignos' functional scale were used to evaluate clinical course, which was compared in both groups.ResultsUntreated patients showed progressive worsening. Corticosteroid-treated patients showed disease stabilization both in muscular strength and functional performance. In addition, muscular balance improved in 70 % of these patients, but only 2 % showed functional improvement. The positive effect of steroid treatment had a mean duration of 12 months. Loss of independent gait occurred at similar ages in both groups (10.3 vs. 10.5 years). The results of Achilles' tendon surgery were poor.ConclusionsCorticosteroids produced clinical stabilization and improved muscular strength. Functional improvement was not significant, including loss of gait, probably because this loss also depends on an increase in joint contracture. Good coordination among multiprofessional teams is essential to achieve optimal results.

[Diagnosis in severe myoclonic epilepsy in childhood: study of 13 cases]

OBJECTIVE

The purpose of this report is to describe clinical pattern, EEG, outcome and differential diagnosis in severe myoclonic epilepsy in infancy (SMEI).

MATERIAL AND METHODS

We report 13 cases initially diagnosed of SMEI and selected according to the following criteria: first seizure between 1 and 12 months of life, frequent seizures resistant to antiepileptic drugs, no previous personal history of disease, normal psychomotor development before the first seizure and normal EEG, CT scanning and laboratory analyses at the beginning. CT and/or MRI were performed in 13 cases, arteriography in 2 patients, MR spectroscopic imaging in 1 child and SPECT in 3 cases. Quantification of enzymatic activities of the mitochondrial respiratory chain was made in 5 patients.

RESULTS

Only 8 cases were finally diagnosed of SMEI according to ILAE definition. In two cases, seizures were finally controlled with antiepileptic treatment and EEG abnormalities disappeared. Three patients showed other findings: mesiotemporal sclerosis, angiitis diffusely involving CNS and mitochondrial cytopathy with deficiency of the complex IV.

CONCLUSIONS

Although diagnosis of SMEI, based on clinical manifestations, is suspected in most cases from the first year of life, final diagnosis should not be confirmed until steady state, when polymorphous seizures occur. Even then, differential diagnosis should be made with other disorders. Perhaps, further studies should be performed in order to identify and eliminate another etiology.

[Neurocutaneous melanosis]

Neurocutaneous melanosis is a sporadic neurocutaneous syndrome characterized by the presence of giant or multiple melanocytic nevi and excessive proliferation of melanotic cells in the central nervous system. Patients usually consult dermatologists because the congenital cutaneous nevi. Most neurologic symptoms appear in the first two years of life and the prognosis in such cases is poor, especially if they are caused by hydrocephalus, which is the main complication. All patients with giant or multiple melanocytic nevi should be seen frequently to detect promptly the eventual development of neurologic involvement.

[Neurocutaneous melanosis and congenital melanocytic nevi: report of 6 cases]

Six patients with congenital giant or multiple melanocytic nevi are studied retrospectively. The clinical, electroencephalographic and neuro-imaging findings for the four patients with neurocutaneous melanosis are described. The other two patients had only cutaneous melanosis. Three of the four with neurocutaneous alterations suffered seizures with flexion spasms and one had partial seizures. The seizures were treated and brought under control in three cases, whereas in the fourth untreated patient, only a single seizure was seen. Three patients have developed with lower intelligence levels and attention deficit syndrome. The other, whose intelligence is normal, suffers mild left hemiparesis secondary to porencephaly. None has developed hydrocephalus or symptoms of intracranial hypertension at the stages of follow-up reported, with ages ranging from 5 and 12 years. Contrary to previous reports, we found that the survival prognosis for patients with neurological involvement is favorable after a minimum follow-up of 5 years.

[Hereditary amyotrophic neuralgia: two new cases]

We report clinical and electrophysiologic findings for two members of a family with a history of hereditary amyotrophic neuralgia, emphasizing the early onset in both patients, the great variation in symptoms within the same family and the poor functional evolution of one patient, who suffered significant functional sequelae at the age of 17 years in spite of not having suffered recurrences since age 5, and without having experienced either clinical or neurophysiological improvement during the intervening years.

[Unilateral agenesis of the internal carotid artery in childhood: description of a case]

INTRODUCTION

Unilateral or bilateral agenesis of the internal carotid artery has not often been described in children since it is usually asymptomatic.

CLINICAL CASE

We describe a case of isolated unilateral agenesis of the internal carotid artery in a child of 20 months old who presented with two episodes of status convulsives, the first after a head injury and the second when he was febrile. The anomaly was a casual finding, diagnosed on cerebral magnetic resonance when there was no signal corresponding to carotid blood flow. It was confirmed by echography-doppler and angiographic magnetic resonance. We also describe the neuro-radiological findings which led to the diagnosis of this anomaly.

CONCLUSIONS

We consider that unilateral agenesis of the carotid artery was a casual finding in this case. The provisional diagnosis may be made when there is absence of vascular signals on conventional magnetic resonance.

[Menkes' disease: anatomo-clinical presentation of a case]

We describe a case of Menke's disease with severe neurological involvement, convulsive crises and characteristic hair anomalies (scanty, fragile, macroscopically hypopigmented and microscopically kinked) which led to rapid diagnosis. Vascular abnormalities with elongated, twisted arteries, skeletal abnormalities (more wormian cranial bones than usual, lateral spurs of metaphyses) and vesicle diverticuli. Electron microscopy of skeletal muscle showed concentrically laminated bodies, possibly of mitochondrial origin. Respiratory chain enzyme activity was normal. The patient died at the age of two and a half. On necropsy, histological abnormalities characteristics of the illness were seen (loss of neurones in the granular layer of the cerebellum, the neurones of Purkinje had thickening of the dendrites which spread out in the form of a weeping willow, reduplication and fragmentation of the internal elastic layer of muscle arteries). In the cortex of the cerebellum mega-mitochondria with electron-dense bodies, were seen on electron microscopy. This is the first case of Menke's disease described in the Spanish literature which includes pathology and electron microscope studies.