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Objective To examine whether tic severity, comorbid disorders, or both are associated with illness morbidity in youths with Tourette's disorder (TD). Method Subjects were 156 consecutively referred youths (aged 5-20 years) who met DSM-III-R criteria for Tourette's disorder at a major academic medical center. All subjects were evaluated with a clinical interview by a child and adolescent psychiatrist and an assessment battery that included the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic version. Statistical analysis used χ 2 and multivariate logistic regression. Results Nineteen (12%) of the 156 youths with TD required psychiatric hospitalization. Current age, TD severity, TD duration, obsessive-compulsive disorder, psychosis, major depression, bipolar disorder, panic disorder, and overanxious disorder were significant univariate predictors of psychiatric hospitalization ( p p p p Conclusion The findings indicate that comorbid mood disorders are strongly associated with illness morbidity in youths with TD, highlighting the importance of attention to comorbidity in patients with TD.

The rheological properties of two complex mixtures of short-chain triglycerides were experimentally determined. Dynamic or absolute viscosities of the mixtures were measured for shear rates of 0.32 to 64.69 s−1 at temperatures between 25 and 80°C. The compositions of the mixtures were based on the oil of the plant species Cuphea viscosissima VS-320, a natural source of short-chain triglycerides. The dynamic viscosities of these mixtures were compared to those of a traditional vegetable oil (peanut oil) and diesel fuel. The results of this comparison were used to make estimates of the performance of such triglyceride mixtures as diesel fuel substitutes, since viscosity can be a key indicator of fuel performance for possible substitute diesel fuels. The crystallization temperatures of these two mixtures were also determined experimentally, and the effects of crystallization on fuel performance were projected. Additionally, the dynamic viscosities of pure triglycerides from C6∶0 to C18∶0 at 75°C were plotted vs. chain length. These viscosities were measured at high shear rates (>6 s−1) where dynamic viscosity is shear-independent. An obvious trend in the relationship between triglyceride chain length and viscosity was observed. A second-order regression was used to obtain an equation for this relationship. This equation was used as a model for composition dependence of viscosity. This model was applied to the viscosities of the triglyceride mixtures examined here. There was good agreement between the model and the actual, measured viscosity values determined in this study.

The relationship between dyadic power balances and the onset of war is a principal element in realist theories of international politics. The influence of the status quo orientation of the belligerents has also been specified in power transition theory as a factor which impacts on the patterns of conflict. However, despite this theoretical underpinning, the question of the probabilistic identity of war initiators constitutes a gap in the understanding of factors associated with international conflict. This study examines the identity of war initiators as it relates to both power balances and status quo orientation for a set of nation-dyads that have formed long-term rivalries. The results of the analysis indicate that for rival dyads: (1) status quo challengers rather than defenders are the most probable war initiators; (2) status quo challengers are equally likely to initiate wars whether they are superior or inferior in capabilities to their rivals; and (3) status quo defenders initiate wars almost solely under unstable military balances. This last pattern suggests that stable military balances of either preponderance or parity are generally interpreted by status quo defenders as supportive of deterrence, whereas unstable balances producing capability shifts or transitions are deemed dangerous enough to provoke preemptive military action. The distribution is such that it approximates a necessary condition for the initiation of war by the status quo defender in an enduring rivalry. All three of the above findings are consistent with A.F.K. Organski's original formulation of power transition theory.

The objective of this study was to assess the extent of referral bias by comparing children and adolescents with Obsessive Compulsive Disorder (OCD) ascertained through a specialized pediatric OCD and a general child psychiatry clinic. Subjects were juveniles meeting DSM-III-R and DSM IV criteria for OCD referred to a general pediatric psychopharmacology clinic and to a specialized OCD clinic within the same academic medical center. Subjects were evaluated clinically and with structured diagnostic interviews using the Kiddie SADS-E. OCD was identified in 8.6% of the general psychiatry clinic subjects. The only differences between ascertainment sources in clinical or sociodemographic characteristics of OCD subjects were higher rates of social phobia and ADHD in the non-specialized clinic, while specialty clinic subjects had a greater lifetime severity of OCD and were more likely to have received treatment of their OCD. Because we found limited evidence for referral biases, our results suggest that findings from studies using either of these sources may generalize to the other. It also suggests that pooling subjects from the two sources is justified. Nevertheless, because some group differences did emerge, researchers should acknowledge referral bias as a potential limitation of their work.

In two published reports using monoclonal antibodies (MAbs) generated against whole cells, Olsen et al. showed that strain-specific antigens on the surface of cultured cells of Sinorhizobium meliloti were diminished or absent in the endophytic cells (bacteroids) recovered from alfalfa nodules, whereas two common antigens were not affected by bacterial differentiation (P. Olsen, M. Collins, and W. Rice, Can. J. Microbiol. 38:506–509, 1992; P. Olsen, S. Wright, M. Collins, and W. Rice, Appl. Environ. Microbiol. 60:654–661, 1994). The nature of the antigens (i.e., the MAb epitopes), however, were not determined in those studies. For this report, the epitopes for five of the anti- S. meliloti MAbs were identified by polyacrylamide gel electrophoresis-immunoblot analyses of the polysaccharides extracted from S. meliloti and Sinorhizobium fredii . This showed that the strain-specific MAbs recognized K antigens, whereas the strain-cross-reactive MAbs recognized the lipopolysaccharide (LPS) core. The MAbs were then used in the analysis of the LPS and K antigens extracted from S. meliloti bacteroids, which had been recovered from the root nodules of alfalfa, and the results supported the findings of Olsen et al. The size range of the K antigens from bacteroids of S. meliloti NRG247 on polyacrylamide gels was altered, and the epitope was greatly diminished in abundance compared to those from the cultured cells, and no K antigens were detected in the S. meliloti NRG185 bacteroid extract. In contrast to the K antigens, the LPS core appeared to be similar in both cultured cells and bacteroids, although a higher proportion of the LPS fractionated into the organic phase during the phenol-water extraction of the bacteroid polysaccharides. Importantly, immunoblot analysis with an anti-LPS MAb showed that smooth LPS production was modified in the bacteroids.

Objectives The aim of this multicenter outpatient study was to assess the therapeutic benefits, response patterns, and safety of sertraline in adolescent major depressive disorder (MDD). Method Fifty-three adolescent outpatients with MDD were treated in an open-label, 10-week, acute-phase trial with sertraline and, if responders, for an additional 12-week continuation phase. Diagnostic and response assessments included the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), 17-item K-SADS-derived depression severity score, Hamilton Depression Rating Scale, Beck Depression Inventory, and Clinical Global Impression Scale. Results By 2 weeks, when analyzed as continuous variables, all severity scores showed significant differences from baseline. This pattern persisted through 10 weeks, with a significantly greater response occurring when treatment was extended from 6 to 10 weeks. Both clinician- and patient-rated improvement was maintained during continuation treatment. Response rates varied considerably when depression rating scales were analyzed categorically. Sertraline was generally well tolerated and did not induce manic symptoms. Conclusions: In open treatment of adolescent MDD with sertraline, significant improvement occurred early on and was maintained for 22 weeks. Absolute response rates varied depending on the rating scales used, definition of response, and length of treatment. Maximal response rates were obtained by clinician-defined ratings after 10 weeks of treatment.

A process for the rapid screening of alternative diesel fuel performance was applied to analogues of genetically modified vegetable oils and a mixture with no. 2 diesel fuel. The oils examined contained 60 to 80% of low molecular weight, short-chain, saturated triglycerides compared to the 1 to 2% found in traditional vegetable oils. These oils have relatively low viscosity that is predicted to enhance their performance as alternative diesel fuels. The screening process utilizes an engine “torque test” sequence that accelerates the tendency of diesel fuels to coke fuel injectors, a key indicator of fuel performance. The results of the tests were evaluated using a computer vision system for the rapid quantification of injector coking. The results of the screen were compared to those using no. 2 diesel fuel as a baseline. Coke deposition from the modified vegetable oil analogues was not found to be significantly different than deposition from diesel fuel. Suggestions are made to guide further modification of vegetable oil biosynthesis for the production of alternative diesel fuel.

Objective: To identify similarities and differences in neuropsychiatric correlates in children with Tourette's syndrome (TS) and those with ADHD. Method: The sample consisted of children with Tourette's syndrome with ADHD(N=79), children with Tourette's syndrome without ADHD (N=18), children with ADHD (N=563), psychiatrically referred children (N=212), and healthy controls (N=140). Results: Disorders specifically associated with Tourette's syndrome were obsessive compulsive disorder (OCD) and simple phobias. Rates of other disorders, including other disruptive behavioral, mood, and anxiety disorders, neuropsychologic correlates, and social and school functioning were indistinguishable in children with Tourette's and ADHD. However, children with Tourette's syndrome plus ADHD had more additional comorbid disorders overall and lower psychosocial function than children with ADHD. Conclusions: These findings confirm previously noted associations between Tourette's syndrome and OCDbut suggest that disruptive behavioral, mood, and anxiety disorders as well as cognitive dysfunctions may be accounted for by comorbidity with ADHD. However, Tourette's syndrome plus ADHD appears to be a more severe condition than ADHD alone.

Exposure-based cognitive-behavioral therapy and serotonin reuptake inhibitor medications are efficacious treatment options for the management of pediatric obsessive-compulsive disorder. Despite established efficacy, many youths receiving either therapy remain symptomatic after acute treatment. Regardless of the rationale for persistent symptoms, a clear need emerges for treatment options that restore functioning efficiently to symptomatic youths. One innovative approach builds upon the identified role of NMDA receptors in the fear extinction process. Instead of breaking existing connections during fear extinction, new associations develop that eventually predominate over prior associations. Recent investigations have explored augmenting exposure-based cognitive-behavioral therapy with the NMDA partial agonist d-cycloserine, with preliminary results demonstrating expedited treatment gains and moderately larger effects above exposure and response prevention therapy alone. A large randomized clinical trial is underway to evaluate the efficacy and efficiency of this therapeutic combination in pediatric obsessive–compulsive disorder. Results from this trial may translate into improved management practices.

The direct estimation of heritability from genome-wide common variant data as implemented in the program Genome-wide Complex Trait Analysis (GCTA) has provided a means to quantify heritability attributable to all interrogated variants. We have quantified the variance in liability to disease explained by all SNPs for two phenotypically-related neurobehavioral disorders, obsessive-compulsive disorder (OCD) and Tourette Syndrome (TS), using GCTA. Our analysis yielded a heritability point estimate of 0.58 (se = 0.09, p = 5.64e-12) for TS, and 0.37 (se = 0.07, p = 1.5e-07) for OCD. In addition, we conducted multiple genomic partitioning analyses to identify genomic elements that concentrate this heritability. We examined genomic architectures of TS and OCD by chromosome, MAF bin, and functional annotations. In addition, we assessed heritability for early onset and adult onset OCD. Among other notable results, we found that SNPs with a minor allele frequency of less than 5% accounted for 21% of the TS heritability and 0% of the OCD heritability. Additionally, we identified a significant contribution to TS and OCD heritability by variants significantly associated with gene expression in two regions of the brain (parietal cortex and cerebellum) for which we had available expression quantitative trait loci (eQTLs). Finally we analyzed the genetic correlation between TS and OCD, revealing a genetic correlation of 0.41 (se = 0.15, p = 0.002). These results are very close to previous heritability estimates for TS and OCD based on twin and family studies, suggesting that very little, if any, heritability is truly missing (i.e., unassayed) from TS and OCD GWAS studies of common variation. The results also indicate that there is some genetic overlap between these two phenotypically-related neuropsychiatric disorders, but suggest that the two disorders have distinct genetic architectures., Author Summary Family and twin studies have shown that genetic risk factors are important in the development of Tourette Syndrome (TS) and obsessive compulsive disorder (OCD). However, efforts to identify the individual genetic risk factors involved in these two neuropsychiatric disorders have been largely unsuccessful. One possible explanation for this is that many genetic variations scattered throughout the genome each contribute a small amount to the overall risk. For TS and OCD, the genetic architecture (characterized by the number, frequency, and distribution of genetic risk factors) is presently unknown. This study examined the genetic architecture of TS and OCD in a variety of ways. We found that rare genetic changes account for more genetic risk in TS than in OCD; certain chromosomes contribute to OCD risk more than others; and variants that influence the level of genes expressed in two regions of the brain can account for a significant amount of risk for both TS and OCD. Results from this study might help in determining where, and what kind of variants are individual risk factors for TS and OCD and where they might be located in the human genome.

Objective To examine the full spectrum of psychiatric comorbidity in juvenile obsessive-compulsive disorder (OCD) in a naturalistic manner when no exclusionary criteria are used for sample selection. Method Consecutive referrals to a specialized pediatric OCD clinic were evaluated by means of structured diagnostic interviews and rating scales. No exclusionary criteria were used for sample selection. Findings were compared with those of previously published reports of juvenile OCD. Results Compared with previous studies, our sample of juveniles with OCD had high rates of comorbidity not only with tic, mood, and anxiety disorders but also with disruptive behavior disorders. Conclusions Our findings indicate that in the naturalistic setting, juvenile OCD is heavily comorbid with both internalizing and externalizing disorders. The presence of such a complex comorbid state has important clinical and research implications and stresses the relevance of limiting exclusionary criteria in studies of juvenile OCD.

Objective : Despite the increasing awareness of attention deficit hyperactivity disorder (ADHD) in adults, there are a limited number of controlled pharmacologic studies of this disorder ; most of the trials have focused on the psychostimulants. Because the tricyclic antidepressant desipramine has been found to be effective in treating ADHD in pediatric groups, the authors tested its efficacy in adults with ADHD. Method : The authors conducted a randomized, 6-week, placebo-controlled, parallel-design study of desipramine at a target daily dose of 200 mg in 41 adult patients with DSM-III-R ADHD. They used standardized structured psychiatric instruments for diagnosis and, as the dependent variables (outcome), used separate assessments of ADHD, depressive, and anxiety symptoms at baseline and at each biweekly visit. Results : There were highly significant differences in the reduction of ADHD symptoms between adults receiving desipramine and placeho. Within the desipramine-treated group, there were clinically and statistically significant differences between baseline and the week 6 end point for 1) reduction of 12 of 14 symptoms of ADHD and 2) decreases in the broad categories of hyperactivity, impulsivity, and inattentivenes. In contrast, placebo-treated patients showed no differences between baseline and end point for any of the A DHD symptoms assessed. According to strict, predefined criteria for response, 68% of desipramine-treated subjects and no subjects in the placebo group were considered positive responders. Response to desipramine was independent of dose, level of impairment, gender, or lifetime psychiatric comorbidity with anxiety or depressive disorders. Conclusions : These results, similar to findings in children and adolescents with ADHD, indicate that desipramine is effective in the treatment of ADHD in adults.

Date Presented 4/8/2016 Mirror therapy (MT) is used in practice; however, no studies have compared the two MT protocols for upper-limb recovery. This pilot study is an important step in deciphering the superiority of the available protocols and furthers our knowledge regarding best practice for the use of MT in recovery poststroke. Primary Author and Speaker: Daniel Geller Contributing Authors: Dawn Nilsen, Glen Gillen, Steve Vanlew, Matthew Bernardo

Importance Cognitive behavior therapy (CBT) among youth with obsessive-compulsive disorder (OCD) is effective, but many patients remain symptomatic after intervention.d-cycloserine, a partial agonist at theN-methyl-d-aspartate receptor in the amygdala, has been associated with enhanced CBT outcome for OCD among adults but requires evaluation among youth. Objectives To examine the relative efficacy of weight-adjustedd-cycloserine (25 or 50 mg) vs placebo augmentation of CBT for youth with OCD and to assess if concomitant antidepressant medication moderated effects. Design, Setting, and Participants In a placebo-controlled randomized clinical trial, 142 youths (age range, 7-17 years) enrolled between June 1, 2011, and January 30, 2015, at 2 academic health science centers (University of South Florida and Massachusetts General Hospital) with a primary diagnosis of OCD were randomized in a double-blind fashion tod-cycloserine plus CBT or placebo plus CBT. Intent-to-treat analysis was performed. Interventions Patients were randomly assigned in a 1:1 ratio to either 10 sessions ofd-cycloserine plus CBT or placebo plus CBT.d-cycloserine (25 or 50 mg) or placebo was taken 1 hour before sessions 4 through 10. Main Outcomes and Measures Children’s Yale-Brown Obsessive Compulsive Scale at randomization, biweekly, midtreatment, and posttreatment. Secondary outcomes included the Clinical Global Impressions–Severity or Clinical Global Impressions–Improvement, remission status, Children’s Depression Rating Scale, Multidimensional Anxiety Scale for Children, and Children’s Obsessive-Compulsive Impact Scale–Parent Version. Results The study cohort comprised 142 participants. Their mean (SD) age was 12.7 (2.9) years, and 53.5% (76 of 142) were female. A mixed-effects model using all available data indicated significant declines in the Children’s Yale-Brown Obsessive Compulsive Scale total score and Clinical Global Impressions–Severity. No significant interaction between treatment group and changes in the Children’s Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions–Severity indicated that thed-cycloserine plus CBT group and the placebo plus CBT group declined at similar rates per assessment point on the Children’s Yale-Brown Obsessive Compulsive Scale total score (estimate, −2.31, 95% CI, −2.79 to −1.83 and estimate, −2.03, 95% CI, −2.47 to −1.58, respectively) and Clinical Global Impressions–Severity (estimate, −0.29, 95% CI, −0.35 to −0.22 and estimate, −0.23, 95% CI, −0.29 to −0.17, respectively). No group differences in secondary outcomes were present. Antidepressant medication use at baseline did not moderate changes for either group. Conclusions and Relevance d-cycloserine augmentation of CBT did not confer additional benefit relative to placebo among youth with OCD. Other augmentation approaches should be examined to enhance outcome. Trial Registration clinicaltrials.gov Identifier:NCT00864123

Objective Obsessive-compulsive disorder (OCD) is a relatively common disorder that frequently has its onset in childhood and is associated with substantial morbidity and dysfunction despite availability of new treatments. However, antiobsessional agents have not been systematically evaluated in young children and their effectiveness beyond the short term has not been well studied. The purpose of this study was to evaluate the usefulness of fluoxetine in the long-term treatment of both children and adolescents with OCD. Method All pediatric patients with a DSM-III-R diagnosis of OCD who were treated with fluoxetine were ascertained from retrospective chart reviews of a pediatric psychopharmacology clinic. Response to treatment was evaluated by experienced clinicians using the Clinical Global Impression Scale. Results Of 38 identified patients, 28 (74%) showed moderate to marked improvement of OCD symptoms on doses averaging 50 mg/day (1.0 mg/kg per day) over an average follow-up period of 19 months. Similar effects were observed in children and adolescents. Conclusion : Although limited by their retrospective nature, these findings indicate that fluoxetine may be effective in prepubertal children and that the effect can be sustained over time.

Laparoscopic liver resections are being performed with increasing frequency, with several groups having reported minimally invasive approaches for major anatomic hepatic resections. Some surgeons favor a pure laparoscopic approach, while others prefer a hand-assisted approach for major laparoscopic liver resections. There are clear advantages and disadvantages to a hand-assisted technique. The purpose of this study is to summarize the literature comparing pure laparoscopic and hand-assisted approaches for minimally invasive hepatic resection, and to describe our approach in 432 laparoscopic liver resections.

Background: The extant literature supports an association between psychological trauma and development of OCD in adults, and this link is a plausible mediator for environment–gene interactions leading to phenotypic expression of OCD. Objective: To explore the relationship between OCD and traumatic life events in children and adolescents. Methods: We examined the prevalence of traumatic life events and PTSD in a large sample of systematically assessed children with OCD. OCD symptoms and severity were assessed using the Children's Yale Brown Obsessive Compulsive Scale (CY-BOCS) in those with and without concurrent PTSD. Results: Rate of PTSD and trauma exposure was higher in children with OCD than in a comparable control group of non-OCD youth matched for age, gender and SES. Children with concurrent PTSD had more intrusive fears and distress and less control over their rituals than children with OCD but without PTSD. Total CY-BOCS scores were higher in those with concurrent PTSD. Specific type of OCD symptoms was not altered by a PTSD diagnosis. Conclusions: A history of psychologically traumatic events may be over-represented in children with OCD. Given the need to search for non-genetic factors that may lead to onset of OCD, better and more systematic methods to obtain and quantify psychologically traumatic life events are needed in clinical populations.

With the aging population, more elderly patients are being considered for hepatic resection. We investigated whether advanced age was associated with higher rate and severity of postoperative complications. A total of 75 patients aged ≥70 years (group E) were matched with 75 patients aged

Theories of international politics and war are generally formulated at the state, dyad, or system level of analysis. Systemic theories focus on structural attributes of the international system such as the distribution of capabilities. Alternatively, state‐level theories tend to emphasize national attributes, whereas dyadic theories concentrate on relational qualities between paired sets of states. This study presents an analysis of war at these analytic levels and explores the possibilities of synergistic empirical linkage. The results of a simple statistical experiment demonstrate that the two higher levels of aggregation are not separate and independent: The interaction of system and dyad‐level power dynamics is associated with patterns of international conflict, and the integration of shifting capability distributions at these levels produces a more adequate explanation of the sources of major power war.

Most theories of war and lesser forms of international conflict rest on assumptions of rational choice. Moreover, many of these explanations explicitly incorporate decision maker estimates of relative power among competitors. However, a major theory of great power war-power transition theory-postulates initiation by the weaker contender. This study demonstrates that among the strongest states an interactive relationship exists between the static power balance, differential growth rates in capabilities, and conflict initiation: initiation patterns are associated with changes in a state's relative military/economic power and power potential. The findings are consistent with the inherent logic of power transition theory and are consonant with an assumption of rational calculation in decisions involving conflict initiation. The results may be interpreted as reinforcing the realist contention that a shifting power balance is of critical significance among the causes of war and peace.

This article describes the results of a computer-assisted instruction (CAI) demonstration project that was conducted in 10 Job Corps centers nationwide. The demonstration used classical experimental methods to determine the effectiveness of CAI, with students randomly assigned to a treatment group in which they spent about one fourth to one third of their class time on the computer as a supplement to the regular self-paced education program or to a control group in which CAI was not available in their education classes. The results indicate that the effects of CAI on learning gains after about 60 hours of classroom instruction are very small on average and not significantly different from zero at conventional levels. However, there is some evidence that centers that allowed their experimental students to have sufficient access to CAI and students that used CAI more intensively did experience additional learning gains relative to the control group. Qualitative information obtained from students, teachers, and education supervisors suggest that CAI may be useful in motivating students and supports the potential educational benefits of CAI.

Introduction: Although obsessions and compulsions comprise the main features of obsessive-compulsive disorder (OCD), many patients report that their compulsions are preceded by a sense of “incompleteness” or other unpleasant feelings such as premonitory urges or a need perform actions until feeling “just right.” These manifestations have been characterized as Sensory Phenomena (SP). The current study presents initial psychometric data for a new scale designed to measure SP.Methods: Seventy-six adult OCD subjects were probed twice. Patients were assessed with an open clinical interview (considered as the “gold standard”) and with the following standardized instruments: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders, Yale-Brown Obsessive-Compulsive Scale, Dimensional Yale-Brown Obsessive-Compulsive Scale, Yale Global Tic Severity Scale, Beck Anxiety Inventory, and Beck Depression Inventory.Results: SP were present in 51 OCD patients (67.1%). Tics were present in 16 (21.1%) of the overall sample. The presence of SP was significantly higher in early-onset OCD patients. There were no significant differences in the presence of SP according to comorbidity with tics or gender. The comparison between the results from the open clinical interviews and the University of São Paulo Sensory Phenomena Scale (USP-SPS) showed an excellent concordance between them, with no significant differences between interviewers. The inter-rater reliability between the expert raters for the USP-SPS was high, with K=.92. The Pearson correlation coefficient between the SP severity scores given by the two raters was .89.Conclusion: Preliminary results suggest that the USP-SPS is a valid and reliable instrument for assessing the presence and severity of SP in OCD subjects.

Pyrolytic bio-oils have great potential as diesel fuel extenders. However, most bio-oils are not readily miscible in petroleum diesel fuel due to their high water content and abundance of hydrophilic components. This prevents their direct use as a component in diesel fuel blends. This study sought to develop inexpensive methods to upgrade bio-oil and utilize its components as a diesel fuel extender.

To examine whether adverse perinatal experiences of children are associated with obsessive compulsive disorder (OCD) in youth.Subjects were 130 children and adolescents with OCD recruited from a family genetic study of pediatric OCD and 49 matched controls from a contemporaneous family case-control study of attention-deficit/hyperactivity disorder (ADHD). Subjects were comprehensively assessed in multiple domains of function. A systematic history of pregnancy, delivery, and infancy complications was obtained.Compared to normal controls, children with OCD had mothers with significantly higher rates of illness during pregnancy requiring medical care (chi(2) +/- 8.61, p +/- 0.003) and more birth difficulties (induced labor, forceps delivery, nuchal cord, or prolonged labor) (chi(2) +/- 7.51, p +/- 0.006). Among the OCD-affected children, we found several significant associations between adverse perinatal experiences and earlier age at onset, increased OCD severity, and increased risk for comorbid ADHD, chronic tic disorder, anxiety disorder, and major depressive disorder.Although exploratory, our analyses found that children with OCD had higher rates of several adverse perinatal experiences compared with controls. Among OCD-affected children, comorbid psychopathology was predicted by specific perinatal risk factors. Prospective studies of perinatal adverse events that minimize potential recall bias and type I errors are needed.

Perinatal risk factors and obsessive-compulsive spectrum disorders in patients with rheumatic fever Aline S. Sampaio, M.D.⁎, Euripedes C. Miguel, M.D., Ph.D., Sonia Borcato, B.S., Marcelo Batistuzzo, B.S., Victor Fossaluza, M.Sh., Daniel A. Geller, M.D., Ph.D., Ana G. Hounie, M.D., Ph.D. Department and Institute of Psychiatry, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Received 8 June 2008; accepted 11 August 2008

The effect of the possession of nuclear weapons on patterns of international conflict is the subject of an extensive but generally impressionistic body of work. Assumptions in this area determine one's confidence in superpower deterrence and fuel the debate over the proper expenditure of military allocations. This study presents an analysis of escalation patterns in interstate disputes among nations with both identical and different levels of weapons technology. The results demonstrate that the distribution of nuclear capabilities does impact the patterns of escalation in serious international conflicts. The findings are supportive of the thesis of competitive risk taking in disputes between nuclear powers but also indicate that the possession of nuclear weapons has no apparent inhibitory effect on the escalatory propensities of nonnuclear opponents. The principal policy implication of this analysis is that nuclear weapons cannot be relied upon to impede escalatory dispute behavior by either nuclear or nonnuclear antagonists.

Objective: Research suggests 25% to 35% of children with attention-deficit/hyperactivity disorder (ADHD) have comorbid anxiety disorders. This double-blind study compared atomoxetine with placebo for treating pediatric ADHD with comorbid anxiety, as measured by the ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHDRS-IV-PI) and the Pediatric Anxiety Rating Scale (PARS). Method: Patients (ages 8-17 years) meeting DSM-IV criteria for ADHD and generalized anxiety disorder, separation anxiety disorder, and/or social phobia were randomized to 12 weeks of atomoxetine ( n = 87) or placebo ( n = 89). ADHDRS-IV-PI and PARS total scores were analyzed using analysis of covariance last observation carried forward and repeated-measures analyses. Results: Sixty-six patients in each group completed the study. Mean ADHDRS-IV-PI total score improved significantly for atomoxetine ( n = 55; −10.5, SD 10.6) relative to placebo ( n = 58; −1.4, SD 8.3; p n = 55; −5.5, SD 4.8) relative to placebo ( n = 58; −3.2, SD 5.0; p = .011). Conclusions: Atomoxetine was efficacious in reducing ADHD symptoms in patients who have ADHD with comorbid anxiety and was well tolerated. There was also a significant reduction in independently assessed anxiety symptoms using both clinician-rated and self-rated measures, which merits further investigation. Results support consideration of atomoxetine for the treatment of ADHD in youths who have ADHD with comorbid anxiety disorder. Clinical trial registration information: The LYBP study, on which this article is based, was not registered at clinicaltrials.gov because the last patient visit occurred before July 1, 2005. Results, however, are publicly posted at lillytrials.com and clinicalstudyresults.org. The unique study ID at both sites is 6477a.

Hepatocellular carcinoma (HCC) is estimated to be responsible for 250,000 deaths worldwide yearly. Aggressive surgical resection or liver transplantation still remain the only viable curative options for patients suffering the disease despite the multitude of emerging therapies for HCC. However, even with the most aggressive surgical intervention, survival varies widely within each particular stage of HCC. In order to improve utilization of available therapeutic modalities, a number of outcome prognostic models have been developed. This manuscript reviews the prognostic models most commonly utilized in clinical practice and the statistical methodologies on which these models are based. A multitude of statistical and mathematical techniques can be used for prognostic model development. The most common methodologies used for HCC prognostic model development can be generally divided into four groups: survival, artificial neural networks, analysis of variance, and cluster analysis. Survival methodologies (such as Cox proportional hazard model) are commonly employed for estimation of relative significance of risk factors for patient survival or cancer recurrence. Artificial neural networks (such as back-propagation network) can be supreme approximation tools for any continuous or binary function, and as such can be employed for prognostication of HCC recurrence (death). Analysis of variance and cluster analysis are the most common statistical tools of recently evolved microarrays technology, which, in turn, is one of the most promising tools available to the cancer researcher.

OBJECTIVE. The Functional Upper Extremity Levels (FUEL) is a new classification tool to assess a person’s upper-extremity functional and physical performance after sustaining a stroke. The aim of this preliminary study was to develop the tool and determine its content validity and interrater reliability. METHOD. Forty-four licensed occupational therapists ranging in years of experience from 6 mo to 16 yr participated in this study. A two-phase study was conducted: (1) constructing the FUEL and determining its content validity and (2) ascertaining its interrater reliability. RESULTS. We found that the FUEL had initial content validity and substantial interrater reliability (Fleiss κ = .754). CONCLUSION. The FUEL can be a useful clinical and research tool in occupational therapy for the assessment and classification of upper-extremity function for people after stroke. Further studies with larger samples and comparison studies with other similar tools are required to support the tool’s reliability and validity.

Although attention-deficit/hyperactivity disorder (ADHD) is frequently comorbid with Tourette's disorder (TD), it is unclear whether they have a common genetic etiology. Familial relationships between DSM-IV ADHD and TD are studied in TD+ADHD, TD-only (TD-ADHD), ADHD-only (ADHD-TD), and control groups.Case-control, direct-interview family study of 692 relatives of 75 TD+ADHD, 74 TD-only, 41 ADHD-only, and 49 control probands collected between 1999 and 2004. Age-corrected prevalence rates, odds ratios, and predictors of TD, ADHD, and OCD among relatives are estimated from blinded best-estimate diagnoses using survival Kaplan-Meier and generalized estimating equation regression analyses.In relatives of the TD-only group, although ADHD exceeded control rates (p=.03), ADHD-TD (p=.51) rates were not increased. In the ADHD-only group, TD was increased (p=.004) but TD-ADHD rates were not increased (p=.18). Comorbid ADHD+TD diagnoses in relatives were elevated in all case groups (por=.03). TD in relatives predicted comorbid ADHD (p.001), and ADHD in relatives predicted comorbid TD (p.001). OCD in relatives predicted both ADHD (p=.002) and TD (p.001) in relatives.TD and ADHD are not alternate phenotypes of a single underlying genetic cause. There is an increased risk of comorbid ADHD and TD in affected families, possibly reflecting some overlapping neurobiology or pathophysiology.

Obsessive-compulsive disorder (OCD) has a broadly diverse clinical expression that may reflect etiologic heterogeneity. Several adult studies have identified consistent symptom dimensions of OCD. The purpose of this study was to conduct an exploratory principal components analysis of obsessive-compulsive (OC) symptoms in children and adolescents with OCD to identify improved phenotypes for future studies.This study examined lifetime occurrence of OC symptoms included in the 13 symptom categories of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS). Principal components analysis with promax rotation was performed on 231 children and adolescents with OCD and compared with results of similar adult studies.A four-factor solution emerged explaining 59.8% of symptom variance characterized by 1) symmetry/ordering/repeating/checking; 2) contamination/cleaning/aggressive/somatic; 3) hoarding; and 4) sexual/religious symptoms. All factors included core symptoms that have been consistently observed in adult studies of OCD.In children and adolescents, OCD is a multidimensional disorder. Symptom dimensions are predominantly congruent with those described in similar studies of adults with OCD, suggesting fairly consistent covariation of OCD symptoms through the developmental course. Future work is required to understand changes in specific symptom dimensions observed across the life span.

To examine the relationship between obsessive compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) in children and adolescents using familial risk analysis.We assessed for ADHD and OCD in the 1057 first-degree relatives of three groups of index children: those with OCD and ADHD, those with OCD but no ADHD and matched controls with neither disorder.The age-corrected risk for OCD was similarly elevated in families of OCD youth with (14.8%) and without ADHD (17.5%) (p=.78), and both groups had significantly higher rates of OCD compared with controls (.5%) (p.001). In contrast, the risk for ADHD was significantly elevated only among relatives of youth who had ADHD (15.3%) compared with controls (4.6%) (p.001). Relatives affected with ADHD also had a significantly elevated risk for OCD compared to relatives unaffected by ADHD (20% vs. 4.9%, hazard ratio 4.8) (p.001) and the two disorders occurred together with higher than expected frequency in affected relatives of OCD+ADHD probands (p. 001) suggesting co-segregation between these two disorders. There was no evidence of nonrandom mating between OCD- and ADHD-affected spouses.These results extend previous findings regarding the familiality of both OCD and ADHD and provide further evidence of a familial relationship between ADHD and pediatric OCD which best fit the hypothesis of a unique familial subtype.

Background: Recent studies reported ADHD-like symptoms and cognitive deficits in pervasive developmental disorder (PDD). Because work in dementia documents improvement in executive function deficits with the acetylcholinesterase inhibitor donepezil, the authors reason that similar benefits could be obtained in PDD. Method: The authors describe eight cases of PDD youth ages 10 to 17 treated with donepezil targeting ADHD-like symptoms associated with PDD. Results: Most participants improve ADHD-like symptomatology. In addition, improvement in communication and socialization is noted. Conclusion: Donepezil may have a role in treating ADHD-like symptoms in children with PDD.

To use family study methodology to examine the relationship between obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.We assessed for ADHD and OCD in the 1533 first-degree relatives of three groups of index children: those with ADHD and OCD, those with ADHD but no OCD, and matched controls with neither disorder.The risk for ADHD was similarly elevated in families of ADHD youth with (18.9%) and without OCD (20.1%; p = .91), and both groups had significantly higher rates of ADHD compared with controls (4.6%; por = .001), which was consistent with previous research showing a strong familial risk for ADHD. The risk for OCD was significantly elevated only among relatives of youth with ADHD plus comorbid OCD (13.0%) compared with controls (.5%; por = .001) and was consistent with previous research showing a strong familial risk for OCD. Relatives affected with ADHD had a significantly elevated risk for OCD compared with relatives unaffected by ADHD (7.4% vs. 1.3%; p.001), suggestive of co-segregation between these disorders. There was no evidence of nonrandom mating between ADHD- and OCD-affected spouses.These results extend previously reported findings regarding the heritability of both ADHD and OCD and provide new evidence of a familial relationship between ADHD and pediatric OCD that best fits the hypothesis of a unique familial subtype.

Objective: This study examines changes in severity of tics and ADHD during atomoxetine treatment in ADHD patients with Tourette syndrome (TS). Method: Subjects (7-17 years old) with ADHD ( Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) and TS were randomly assigned to double-blind treatment with placebo ( n = 56) or atomoxetine (0.5-1.5 mg/kg/day, n = 61) for approximately 18 weeks. Results: Atomoxetine subjects showed significantly greater improvement on ADHD symptom measures. Treatment was also associated with significantly greater reduction of tic severity on two of three measures. Significant increases were seen in mean pulse rate and rates of treatment-emergent nausea, decreased appetite, and decreased body weight. No other clinically relevant treatment differences were observed in any other vital sign, adverse event, laboratory parameter, or electrocardiographic measure. Conclusion: Atomoxetine is efficacious for treatment of ADHD and its use appears well tolerated in ADHD patients with comorbid TS. (J. of Att. Dis. 2008; 11(4) 470-481)

The aim of this study was to study agreement between clinician-rated measures and self-report measures previously used in epidemiologic studies to identify obsessive-compulsive disorder (OCD) in youth and to determine the adequacy of self-report measures as screening instruments.Leyton Obsessional Inventory-Child Version (LOI-CV) survey form self-report and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) clinician-report measures were compared in a sample of 81 OCD-affected youths diagnosed using structured diagnostic interviews and the best-estimate method. Sensitivities and agreement between tests are determined for different cutoff scores.The LOI-CV survey form total (item+interference) score is correlated with KSADS-E OCD severity (r=0.37, p=0.001) but not clinician-rated GAF scores (r=-0.18, p=0.12). LOI-CV survey form sensitivities at cutoff scores of 15, 20, 25, and 30 are 55%, 36%, 28%, and 19%, respectively. CY-BOCS scores are correlated with subject-rated interview severity (p0.001) and clinician-rated GAF scores (por=0.05). CY-BOCS sensitivities at cutoff scores of 8, 10, 12, and 14 are 100%, 99%, 98%, and 90%. The cutoff scores required for greater than 95% sensitivity of the LOI-CV survey form and the CY-BOCS, respectively, are 2 and 12. LOI-CV survey form total scores do not correlate with CY-BOCS total or obsession subscores (por=0.03), but correlate with the CY-BOCS compulsion subscore.The clinician-rated CY-BOCS measure using parent and child reporting performs superiorly to the subject-rated LOI-CV measure using child reporting to identify pediatric OCD in a clinically referred population. Because self-report measures have been used in epidemiological studies, youth OCD prevalence rates may be higher than previously reported.