Background: Clinically significant attention-deficit/hyperactivity disorder (ADHD) symptoms are common and impairing in children and youth with autism spectrum disorder(ASD). The aim of this systematic review and metaanalysis was to (a) evaluate the efficacy and safety of pharmacotherapy for the treatment of ADHD symptoms in ASD and (b) distil findings for clinical translation. Methods: We searched electronic databases and clinical trial registries (1992 onwards). We selected randomized controlled trials conducted in participants <25 years of age, diagnosed with ASD that evaluated ADHD outcomes (hyperactivity/impulsivity and inattention) following treatment with stimulants (methylphenidate or amphetamines), atomoxetine, alpha-2 adrenergic receptor agonists, antipsychotics, tricyclic antidepressants, bupropion, modafinil, venlafaxine, or a combination, in comparison with placebo, any of the listed medications, or behavioral therapies. Data were pooled using a random-effects model. Results: Twenty-five studies (4 methylphenidate, 4 atomoxetine, 1 guanfacine, 14 antipsychotic, 1 venlafaxine, and 1 tianeptine) were included. Methylphenidate reduced hyperactivity (parent-rated: standardized mean difference [SMD] = À.63, 95% CI = À.95,À.30; teacher-rated: SMD = À.81, 95%CI = À1.43,À.19) and inattention (parent-rated: SMD = À.36, 95%CI = À.64,À.07; teacher-rated: SMD = À.30, 95%CI = À.49,À.11). Atomoxetine reduced inattention (parentrated: SMD = À.54, 95%CI = À.98,À.09; teacher/investigator-rated: SMD = À0.38, 95%CI = À0.75, À0.01) and parent-rated hyperactivity (parent-rated: SMD = À.49, 95%CI = À.76,À.23; teacher-rated: SMD = À.43, 95% CI = À.92, .06). Indirect evidence for significant reductions in hyperactivity with second-generation antipsychotics was also found. Quality of evidence for all interventions was low/very low. Methylphenidate was associated with a nonsignificant elevated risk of dropout due to adverse events. Conclusions: Direct pooled evidence supports the efficacy and tolerability of methylphenidate or atomoxetine for treatment of ADHD symptoms in children and youth with ASD. The current review highlights the efficacy of standard ADHD pharmacotherapy for treatment of ADHD symptoms in children and youth with ASD. Consideration of the benefits weighed against the limitations of safety/ efficacy data and lack of data evaluating long-term continuation is undertaken to help guide clinical decision-making regarding treatment of co-occurring ADHD symptoms in children and youth with ASD.
A 45-year-old transgender man presented to a gynecologist with a 2-year history of dysfunctional uterine bleeding. Vaginal bleeding had been occurring daily, small to moderate in volume, with periods of heavier irregular bleeding occurring without precipitating or alleviating factors. Additional symptoms included suprapubic discomfort managed with acetaminophen. The patient had attributed the cause of the persistent bleed to previous exogenous testosterone used for his hormonal gender confirmation, which he had stopped 18 months before presentation. Constitutional symptoms included a weight loss of 4.5 kg in the 4 months before initial assessment. The patient had been told that he did not require screening for cervical cancer because he had never had penetrative sexual intercourse with a male. He had never been pregnant.Pertinent medical history included a surgery for a double mastectomy. A hysterectomy had been planned 1 year before presentation because of a uterine fibroid (3 cm in diameter) that was identified on ultrasonography; however, the patient decided not to undergo the procedure.A speculum examination showed an abnormal mass located at the cervix that easily bled. A Papanicolaou smear confirmed a high-grade squamous intraepithelial lesion suspicious for invasion. A mass in the bladder (2.2 × 2.1 × 2.1 cm 3 in size) was identified on ultrasonography. Examination under anesthesia with cystoscopy showed an abnormal mass in the bladder at the trigone that was obstructing the right ureter. Gynecologic examination showed a friable mass (4 cm in diameter) in maximal dimension that had entirely replaced the normal cervical tissue. Biopsies of the bladder mass, endometrium and cervix confirmed squamous cell cervical carcinoma. The patient was referred to a regional cancer centre for further management.Staging investigations included a computed tomography scan of the chest, abdomen and pelvis, which did not identify regional adenopathy or metastatic disease. There was severe right-sided hydronephrosis secondary to ureteric obstruction. Magnetic resonance imaging of the pelvis confirmed a cervical mass (3.4 × 3.3 × 2.4 cm 3 in size) with indistinct margins, parametrial involvement and invasion into the right posterior wall of the bladder (Figures 1 and 2). The mass abutted but did not invade the anterior rectal wall. Final disease staging was International Federation of Gynecology and Obstetrics stage IVA cervical cancer.We started curative intent treatment with external beam radiotherapy and concurrent weekly radiosensitizing cisplatin chemotherapy, followed by high-dose-rate intracavitary brachytherapy. After chemoradiotherapy, there was an excellent local response with no evidence of residual tumour. Our patient remains disease-free 6 months posttreatment with five years of surveillance planned. DiscussionPap smears represent a major public health advancement for the detection of gynecologic neoplasia; increased participation in screening has resulted in a drastic decline in the incidence of and mortality from...
Aim There is limited evidence examining admissions in early psychosis. We sought to estimate the proportion of people with a psychiatric admission within 2 years of the first diagnosis of psychosis, and to identify associated risk factors. Method We constructed a cohort of incident non‐affective psychosis cases using health administrative data and identified the first psychiatric hospitalization after psychosis onset. We compared hospitalization rates across sociodemographic, clinical and service‐use factors. Results One in three patients had an admission within 2 years of first diagnosis. Younger age, migrant status, diagnosis of psychosis not otherwise specified, and prior substance use were associated with increased hospitalization rates, whereas family physician involvement in diagnosis was protective. Conclusions Adolescents, immigrants and people presenting with diagnostic instability or prior substance use issues may benefit from interventions aimed at reducing hospitalization risk. Increasing primary care access and utilization among youth with early psychosis may also reduce hospitalization rates.
Prescription opioid use has historically been a regular component of the management of chronic nonmalignant pain in Canada. However, the economic implications of high rates of addiction and abuse have motivated consideration of more cost-effective management strategies for chronic pain. The economic burden imposed by prescription opioid use relates in part to lost workplace productivity, increased addiction treatment program costs, and increased overall healthcare expenditure for these patients. In this article, we present research on the economic implications of the current rates of opioid prescription, and report on the specific economic advantages realized in alternative therapeutic approaches to pain management.
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