This document provides an overview of a presentation on new concepts in the epidemiology, diagnosis, and treatment of ADHD in children, adolescents, and adults. It begins with disclosures from the presenter, Louis B. Cady, MD, of past and current financial relationships. The presentation then covers topics such as the increasing prevalence of ADHD diagnosis, diagnostic criteria and symptoms, course and long-term outcomes without treatment, and an overview of treatment options including stimulant medications, atomoxetine, and alpha-2 agonists.
In his fourth and concluding lecture of the IMMH Conference in San Antonio, 2014, Dr. Cady reviews the statistics, epidemiology, biological nature and pharmacologic treatment of ADHD. The first part of the presentation was absolutely conventional allopathic psychiatry, inclusive of brain imaging.
The second part of the presentation considered: "If we are thinking about biological, psychological, and behavioral interventions for a 'psychiatric' patient, shouldn't we be considering the TWO biological levels?" The most normal biological level that "biologically trained psychiatrists" consider is medications and medication effectiveness. However, sometimes even the most vigorous, precise, and heroic efforts do not work. The potential confound it the underlying physiological, hormonal, nutrient, antioxidant, PUFA-rich state associated with optimal health and well being.
In the final analysis, shouldn't we make sure that we have BOTH of these biological foundations right?
We hope that you enjoy this provocative slide presentation.
Russell A. Barkley.
Clinical Professor of Psychiatry Medical University of South Carolina, Charleston SC, and Research Professor, Departament of Psychiatry Suny Upstate Medical University Syracuse, NY.
Dr Chris Kingswood, UK, presented at the 2007 ATSS Conference - Advances in Tuberous Sclerosis: From Pathway to Therapy.
Reviews key clinical manifestations of TSC and recommended treatment and management guidelines.
Provides detailed information and images on kidney involvement in Tuberous Sclerosis.
In his fourth and concluding lecture of the IMMH Conference in San Antonio, 2014, Dr. Cady reviews the statistics, epidemiology, biological nature and pharmacologic treatment of ADHD. The first part of the presentation was absolutely conventional allopathic psychiatry, inclusive of brain imaging.
The second part of the presentation considered: "If we are thinking about biological, psychological, and behavioral interventions for a 'psychiatric' patient, shouldn't we be considering the TWO biological levels?" The most normal biological level that "biologically trained psychiatrists" consider is medications and medication effectiveness. However, sometimes even the most vigorous, precise, and heroic efforts do not work. The potential confound it the underlying physiological, hormonal, nutrient, antioxidant, PUFA-rich state associated with optimal health and well being.
In the final analysis, shouldn't we make sure that we have BOTH of these biological foundations right?
We hope that you enjoy this provocative slide presentation.
Russell A. Barkley.
Clinical Professor of Psychiatry Medical University of South Carolina, Charleston SC, and Research Professor, Departament of Psychiatry Suny Upstate Medical University Syracuse, NY.
Dr Chris Kingswood, UK, presented at the 2007 ATSS Conference - Advances in Tuberous Sclerosis: From Pathway to Therapy.
Reviews key clinical manifestations of TSC and recommended treatment and management guidelines.
Provides detailed information and images on kidney involvement in Tuberous Sclerosis.
KEYNOTE presentation (June 2015), ESCAP Expert Paper (July 2015), TV interview and abstract by professor Beate Herpertz-Dahlmann (Aachen University) on new developments in the diagnostics and treatment of adolescent eating disorders
Presentatie autisme escap 2015m4 madrid how_malleable_is_autism_escap_postUtrecht
KEYNOTE abstract by professor Sally Rogers (UC Davis MIND Institute, Sacramento) titled 'How malleable is autism? Outcome studies from the youngest children with ASD', held at the ESCAP 2015 Congress in Madrid, Monday June 22nd 2015
KEYNOTE presentation by professor Celso Arango (Hospital General Universitario Gregorio Marañón. IiSGM, Universidad Complutense, CIBERSAM. Madrid, Spain) on developmental trajectories in early-onset psychoses, held at the ESCAP 2015 Congress in Madrid, Monday June 22nd 2015
Information on finding basic or introductory information about Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD). A pathfinder for user services at a public library.
Health Related Quality of Life with Children of Autism Spectrum Disorder in B...farhana safa
Research done by Dr. Farhana Safa about Autism Spectrum Disorder in Bangladesh. This was done during my MPH program under the course no.: MPH5040 at American International University, Bangladesh (AIUB).
KEYNOTE presentation (June 2015), ESCAP Expert Paper (July 2015), TV interview and abstract by professor Beate Herpertz-Dahlmann (Aachen University) on new developments in the diagnostics and treatment of adolescent eating disorders
Presentatie autisme escap 2015m4 madrid how_malleable_is_autism_escap_postUtrecht
KEYNOTE abstract by professor Sally Rogers (UC Davis MIND Institute, Sacramento) titled 'How malleable is autism? Outcome studies from the youngest children with ASD', held at the ESCAP 2015 Congress in Madrid, Monday June 22nd 2015
KEYNOTE presentation by professor Celso Arango (Hospital General Universitario Gregorio Marañón. IiSGM, Universidad Complutense, CIBERSAM. Madrid, Spain) on developmental trajectories in early-onset psychoses, held at the ESCAP 2015 Congress in Madrid, Monday June 22nd 2015
Information on finding basic or introductory information about Attention Deficit Disorder (ADD) or Attention Deficit Hyperactive Disorder (ADHD). A pathfinder for user services at a public library.
Health Related Quality of Life with Children of Autism Spectrum Disorder in B...farhana safa
Research done by Dr. Farhana Safa about Autism Spectrum Disorder in Bangladesh. This was done during my MPH program under the course no.: MPH5040 at American International University, Bangladesh (AIUB).
What is Attention-Deficit/Hyperactivity Disorder?
Inattentive, hyperactive & impulsive to excessive degree compared with their peers.
For more info, download the presentation.
Babatunde Idowu Ogundipe M.D. M.P.H.
Comprehensive Clinical Services P.C.
October 7 2011
This program is part of a comprehensive School Mental Health and High School Curriculum Guide.
Find out more about the guide by visiting:
teenmentalhealth.org
This poster was presented to highlight the following mental health conditions in adolescent patients: attention deficit/hyperactivity disorder (ADD/ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).
Mental Health is a very important aspect of public health. Although mental health assessment is vital within all populations, it is especially vital to assess mental health within our vulnerable populations (e.g. adolescents)
Natural Treatments for ADHD (TADH) in Sao Paulo, Brazil, for Laboratorio Grea...Louis Cady, MD
In this presentation, given at UNIP (Campus Paraiso - Sao Paulo, SP Brazo) for the 2019 Congresso de Saude Mental (Conference on Mental Health), Dr. Cady reviewed the prevalence, inheritability, and social ramifications of ADHD (TADH in Brazil). He specifically reviewed multiple holistic interventions, including limiting "electric screen time,"good quality diet with adequate amounts of essential fatty acids and critically important trace elements, and the use of pharmacogenomic testing as well as functional, integrative medicine testing, all to better characterize logical and reeasonmable points for holistic intervention.
This presentation was simultaneously translated into Portugue for the attendees, but unfortunately the slides were not available in translated form.
For further information in Brazil on this topic, or to order a video/audio recording of the conference (in Portuguese),contact Luiz Dias of Laboratorio Great Plains in Brazil.
Natural Treatments for ADHD - April 11, 2018Louis Cady, MD
This presentation will be delivered April 11, 2018 on recorded webinar for the Autism Global Conference. It was my pleasure to prepare and present this lecture (in webinar form), outlining a coherent philosophy of finding biological underpinnings that can cause or contribute to, or exacerbate, mental dysfunction. In the case of this presentation, the question is "How much of ADHD symptomatology is caused by a lack of a good medication, or, rather, lack of a coherent strategy for finding and fixing underlying biological abnormalities?"
Those biological abnormalities in this presentation include MTHFR polymorphisms, COMT polymorphisms, elemental deficiencies (lithium, magnesium, zinc, iron, and copper), essential fatty acid deficiencies, the confound of high fructose corn syrup, and many others.
Rational strategies for nutraceutical intervention are reviewed.
Similar to New Concepts in the Epidemiology, Diagnosis and Precision Treatment of ADHD in Children, Adolescents, and Adults (20)
SEND IN THE SHRINKS - 2009 Oliver CME seminarLouis Cady, MD
This one was fun.
I was invited by Dr. Randalll Oliver, MD, Founder of the Oliver Heachache and Pain Clinic in Evansville, to present to an audience of primary care practitioners about how to use pysychiatric mediations ("psychopharmacology") in clinical practice.
Along the way, I covered, ADHD and treatments, depression, anxiety, erectile dysfunction, hypoadrenia, and even touched on hypothyroidism. Although this presentation was in 2009, all of the drugs covered are stills in use, and, at times.... stupidly.
This presentation deconstructs the intricacies of selecting and antidepressant, particularly in the SSRI class.
What is the nature of QUALITY in medicine -for ASQ 11 14 2023.pptLouis Cady, MD
In this presentation, Dr. Cady deconstructs the tensions and stressors on both patients and health care providers in today's system.
This presentation reviews checklists foe liminating mistakes, the actual number of mistakes that are being made in medical practice, and what patients and their loved ones can do for self protection.
This isn't a "bash the doctor" presentation. It's a thoughtful, careful exploration of stresses and ramifications to the current US healthcare system.
This was a Grand Rounds program for St. Marys Hospital (now Ascension St. Vincent) in Evansville delivered on April 2, 2014. It is uploaded to my slideshare site as a public service to patients and mental health practitioners.
We are actually no longer using TMS at Cady Wellness, having transitioned to the attempting maximum stabilization of our patients with nutraceuticals, hormones, and the latest advance in psychopharmacology. This includes intramuscularly administered ketamine, which has been transformative in many of our patients.
Hormones and Mental Health - Thyroid and Testosterone.pptxLouis Cady, MD
In this presentation for the Psychiatry Redefined program, Dr.
Cady breaks down and deconstructs the accepted, unthinking, "practice guideline based" notions of thyroid and tesotsterone, with there seemingly "normal" levels and dosing, versus what the actual peer reviewed medical literature says. In this presentation, do use of all forms of thyroid, and all forms of testosterone are reviewed. The idiocy of "T4 only treatment" is covered. The use of T4, T3, a combination of T4 and T3, and all of the porcine and compounded products is review.
In terms of testosterone, dr. Katie reviews the concept of "do you want to be optimal or do you want to be normal." He notes that it is "normal" for oil in cars to deteriorate and break down with age. It's also "normal" for men's and women's testosterone (as well as thyroid) to go down with age. The question is, "do we want to do anything about it?"
Logical ways of intervening in both the thyroid and female and male gonadal axes are covered. There is scrupulous attention paid to the thyroid hormone pathways, and the relevance of reverse T3 versus free T3. Similarly, in terms of women, the downstream effect of estradiol coming from testosterone is also reviewed.
The Moral Imperative of Integrative Medicine 2022.pptLouis Cady, MD
Presented to Psychiatry Redefined Meeting - September 10, 2022
Three cases are reviewed - two with MTHFR deficiencies and pharmcotherapy challenges; one case with schizophrenia solidly treated with clozapine but also with additional antidepressant (vortioxetine) and functional, integrative medicine techniques.
CORONOFOBIA - Passos práticos para equilibrar as defesas do corpo e da menteLouis Cady, MD
Esta palestra, apresentada em 29 de maio de 2021 para o Congresso de Medicina Integrativa para a Saúde Mental 2020, promovido pelo Laboratório Great Plains no Brasil, enfocou coisas simples e de bom senso que os pacientes (e seus médicos) podem fazer para se manter seguros e viver durante o Pandemia do covid.
Os seguintes conceitos holísticos foram revisados:
- sono adequado e por que é tão importante;
- o uso de melatonina, cientificamente validada como tendo atividade antiviral (referências citadas);
- a importância de diminuir o estresse e técnicas para fazê-lo;
- a necessidade de "comer frutas e vegetais" como sua mãe e sua avó ensinaram devido à ingestão de carotenóides e antioxidantes ((referências citadas);
- o uso adequado de suplementos vitamínicos / nutricionais (referências citadas).
O foco desta apresentação não foram medidas heróicas para salvar vidas na unidade de terapia intensiva para pacientes gravemente enfermos com COVID, mas, sim, técnicas de bom senso, práticas, baratas e (em alguns casos) GRATUITAS para melhorar você e seus pacientes 'saúde e resistência às doenças.
THE MORAL IMPERATIVE OF INTEGRATIVE MEDICINE - O IMPERATIVO MORAL DA MEDICINA...Louis Cady, MD
Neste programa, o Dr. Cady baseia-se em uma série de casos clínicos para ilustrar a necessidade absoluta e moral do tratamento de precisão de nossos pacientes com todas as ferramentas disponíveis para uso por meio da medicina integrativa.
O uso de testes de polimorfismo MTHFR, testes convencionais e laboratoriais e testes farmacogenômicos foram revisados.
Os casos apresentados ilustram a trágica dificuldade de um menino com deficiência de MTHFR que estava prestes a desviar sua vida; um paciente esquizofrênico com vários problemas de medicina funcional que precisavam ser resolvidos (levedura, glúten, sensibilidade alimentar de IgG); uma estudante universitária a quem foi dito "não há nada de errado com você; seus laboratórios estão bem", embora ela tenha manifestado todos os sintomas relevantes de hipotireoidismo; e um CEO do sexo masculino de 42 anos que estava "tão cansado que parecia morrer" e que, na verdade, estava funcionalmente com pouco testosterona. O último caso revisado foi de um adorável garotinho que tinha autismo e foi recuperado por meio de uma abordagem focada e intensa de medicina integrativa.
Dr. Cady deconstructs some the medical literature about the use of nutrients - and the evidence of what happens in the presence of their insufficiency. Everything for decreased viral replication to decrease brain shrinkage is covered. The role of antioxidant and carotenoids, measured by the Pharmanex Biophotonic Scanner, is reviewed.
Please note - there is no representation that any nutrient or supplement can treat, prevent, mitigate, or cure any medical condition. It does seem, however, upon reflecting on the medical literature, that there seems to be a lot of evidence for therapeutic effect in the presence of good levels of nutrient, and harm to patients if they have insufficient levels.
Subtitle: The Moral Imperative of Integrative Medicine
This presentation, two hours in length, was delivered to the A4m MMI Audience in their Frontiers of Neurology - Module 3.
The following topics are reviewed:
- ADHD, Autism, Depression, Schizophrenia
- the impact of neuroinflammation on all of these.
- confounding factors and the ways to mitigate them: Omega6/Omega 3 imbalance in the Western diet, MTHFR polymorphism, the use of elemental lithium, the presence of intestinal dysbiosis and the role of gluten/dairy IgG Food allergies.
- pharmacogenomic testing
The Moral Imperative of Integrative Medicine - IMMH 2020Louis Cady, MD
IN this presentation, Dr. Cady reviews several of the handful of functional, integrative medicine techniques required for a holistic and comprehensive management of psychiatric issues. MTHFR, hormone balance, diagnosis and treating intestinal dysbiosis, need for trace elements, and hormones (including thyroid, testosterone and estradiol) are reviewed.
This brief webinar, a gift to the local Jewish community and Temple Adath B'Nai Israel here in Evansville, IN, reviews the tradition of mindfulness and the interdigitation of Buddhist practices with some Jewish traditions. Dr. Cady reviews the downstream effects of stress, how meditation and mindfulness are useful tools and techniques, and actually how to practice it. Multiple references without being complicated or overdone are provided.
Webinar 5: Designing Your Future: WHAT'S COMING NEXT?Louis Cady, MD
In this capstone webinar presentation, closing out Dr. Cady's series on dealing with COVID 19, he turns his attention to a nunmber of interesting thems:
- what's the REAL case fatality rate of COVID 19
- How is it likely that society will reopen?
- What's going to happen in education and medicine?
- What's going to happen when the robots and AI arrive?
- What's the future going to be out 500 years?
HOW TO SAVE MONEY ON YOUR HEALTHCARE: An Integrative Medicine ApproachLouis Cady, MD
In this webinar, the fourth in a series of five from Dr. Louis Cady and the Cady Wellness Institute, we focus on the actual dollars and cents of health care expenditures, and the societal and PERSONAL costs of poor health maintenance behavior. We examine the essentially passive US medical system, that would rather drug a symptom than fix the underlying problem.
Great attention is paid on not shaming the patient or the doctors as they exist in the current system. Both groups "do not know what they do not know." Confirmation bias is rampant.
This webinar points the way to living a more vital, energetic life, with a minimum of cost, grief, and misery.
The Do It To Yourself Treatment of Depression - Webinar #3Louis Cady, MD
This is the third in a series of five webinars. The first was on staying alive by boosting your immunity during COVID 19. The second was on not screwing yourself up inside your head. This third one encompasses a romp through the peer reviewed medical literature looking for supplements and nutrients that you could use to self treat depression at home, CAREFULLY. Numerous cautions and warnings are included.
The driving impetus to this program is that many people - due to social isolation and their mental health care, or medical practitioners' offices being closed down - have not been able to get help or succeed in optimizing their treatment for depression. There are multiple useful nutrients for both depression and anxiety in nature's abundant pharmacopeia, and this webinar touches on just a few of them.
I hope you enjoy it.
HOW TO COPE WITH THE PSYCHOLOGICAL IMPACT OF COVID 19 AND SOCIAL DISTANCINGis...Louis Cady, MD
In this presentation, Dr. Cady will review:
- What did Sparky learn about not being an emotional support animal?
- "Do it to yourself psychotherapy." Learn the following:
- What are the wrong - and the RIGHT ways of any sort of "behavioral therapy"?
- How to use a journal to think RATIONALLY and “get out of your head.”
- How to get out of your HEAD and into your LIFE.
- We'll cover all 10 of David Burns’ cognitive distortions, customized and gift-wrapped for dealing with COVID 19.
- We will cover actionable examples of how to reprogram yourself.
We will review What are the 3 P's of Positive Psychology and Learned Optimism?
The Cady 5 "5P’s” and “How to shrink yourself."
Can we find the GOOD in COVID?
This presentation is meant to be provocative and to challenge you mentally, intellectually, and emotionally. Some of the great thinkers and exemplars of human performance and possibility are featured.
BOOSTING YOUR IMMUNITY During the COVID 19 PandemicLouis Cady, MD
In this presentation, presented as a live webinar on Monday, April 27th, Dr. Louis Cady of the Cady Wellness Institute reviewed practical, common-sense things that can be done to boost your immunity, with documentation from the peer-reviewed medical literature. Dr. Cady also reviews supplements and nutrients that are established in the peer-reviewed medical literature as having antiviral capabilities. These include Vitamins C,D, and E, Zinc, carotenoids and antioxidants, probiotics, the reishi mushroom, elderberry, cannabidiol (CBD - not marijuana or weed!).
Points presented are scrupulously documented from the medical literature. This presentation does not guarantee or represent that using ANY of these nutrients will "keep you from getting infected or dying" from COVID 19. They are presented for your thoughtful consideration.
Tratamento holistica de ezschizophrenia - São Paulo, Brazil April 20, 2019Louis Cady, MD
Esta é a versão em inglês da apresentação do Dr. Cady feita na UNIP (Campus Paraiso - São Paulo, SP Brasil) para o Congresso de Saúde Mental de 2019 (Conferência sobre Saúde Mental). Foi entregue em 20 de abril de 2019.
Nesta apresentação, o Dr. Cady analisa brevemente a história da esquizofrenia, a falha do bloqueio do receptor de dopamina D2 como uma cura universal na esquizofrenia, e várias intervenções holísticas que podem impactar forte e positivamente os sintomas da esquizofrenia. Incluídos na pesquisa do Dr. Cady estavam o papel dos ácidos graxos essenciais, deficiências nutricionais (particularmente vitaminas do complexo B), o perigo de supercrescimento da cândida, testes farmacogenômicos, polimorfismos da MTHFR e muito mais.
Foi uma honra e um privilégio entregar esta apresentação em
São Paulo.
Para mais informações no Brasil sobre este tema, ou para solicitar uma gravação em vídeo / áudio da conferência, entre em contato com Luiz Dias do Laboratório Grandes Planícies no Brasil.
Slides, até o apêndice, são traduzidos por Luiz Dias.
The integrative treatment of schizophrenia brazil 2019Louis Cady, MD
This is the English language version of Dr. Cady's presentation given at UNIP (Campus Paraiso - Sao Paulo, SP Brazil) for the 2019 Congresso de Saude Mental (Conference on Mental Health). It was delivered April 20, 2019.
This presentation also includes extra slides in the appendix that were not presented, and, unfortunately, these slides of the appendix have not been translated in the Portuguse version of this presentation.
In this presentation (Portuguese presentation will also be posted next), Dr. Cady briefly reviews the history of schizophrenia, the failure of the dopamine D2 receptor blockage as a universal cure-all in schizophrenia, and various holistic interventions which can strongly and positively impact symptoms of schizophrenia. Included in Dr. Cady's survey were the role of essential fatty acids, nutrient deficiencies (particularly B vitamins), the danger of overgrowth of candida , pharmacogenomic testing, MTHFR polymorphisms, and more.
It was an honor and a privilege to deliver this presentation in
São Paulo,.
For further information in Brazil on this topic, or to order a video/audio recording of the conference (in Portuguese),contact Luiz Dias of Laboratorio Great Plains in Brazil.
Thyroid, Adrenals, and Sex Steroids - A Balancing ActLouis Cady, MD
This was the second presentation gibven on MZarch 29, 2019 at the Manlove Psychiagtric Group and Brain Injury Institute spring conference in Rapid City, SD.
In this presentation, Dr. Cady carefully goes over the necessity of integrating and overview and awareness of hormones and their levels in the elucidation of what truly is going on with the patient.
This was an overview lecture only. Dr. Cady will be presenting a 16 hour CME program in Austin Texas on June 22 and 23 for the National Procedures Institute, and will explore all aspects of all relevant hormones and what can be done to manage and optimize them.
This lecture was presented on March 29, 2019 in Rapid Citry, South Dakota, for the conference co-sponsored by the Manlove Psychiatric Group and the Brain Injury Center.
It reviews the uptick in diagnosis of ADHD, the raiontale for its concern, causative factors, and how it can be worked up holistically and in a balanced, not necessarily medication-oriented way.
Use of high dose fish oil, iron supplementation, and how to overrcome nutritional deficiencies are discussed.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ocular injury ppt Upendra pal optometrist upums saifai etawah
New Concepts in the Epidemiology, Diagnosis and Precision Treatment of ADHD in Children, Adolescents, and Adults
1. New Concepts in the Epidemiology, Diagnosis and
Precision Treatment of ADHD in Children,
Adolescents, and Adults
(Slideshare users: this is an updated cover slide)
Grand Rounds – Saint Mary’s Hospital February 5,
2014
Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Clinical Lecturer – Indiana University School of Medicine
Department of Psychiatry
Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana
2. Continuing Medical Education Commercial Disclosure Requirement
for Louis B. Cady, M.D.
I, Louis B. Cady, MD, have the following commercial relationships to
disclose:
•Speaker honoraria received from:
• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX
•Speaker’s bureaus (active) for:
• Forest Pharmaceuticals, Sunovion
•Historical data – speaker’s bureau for Bristol-Myers Squibb,
Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil,
Pfizer-Roerig, Sanofi!~aventis, Sepracor, Shire, McNeil, Takeda,
Janssen, Searle, Shire, Takeda, Wyeth-Ayerst
This CME presentation is not being underwritten by any
pharmaceutical company, and Dr. Cady is not receiving a
fee or honorarium for presenting it.
3. This is where to follow along
on your tablets and smart
phones, or access the
presentation slides later…
www.slideshare.net/lcady
md
Note – the 7 True/False “Q & A” for CME
documentation of learning are attached at the end
of this presentation with the correct answer
indicated.
9. Increased methylphenidate usage for
attention deficit disorder in the 1990’s.
Safer DJ et al. Pediatrics. 1996 Dec; 98(6 Pt 1):1084-8}
• 2.5 X increase in MPH tx between 1990 and 1995
– 2.8% (1.5 million) US youths aged 5-18 received this
medication in mid-1995
• “The increase in methylphenidate…appears
largely related to
– an increased duration of treatment;
– More girls, adolescents and inattentive youths on the
medication
– And a recent improved public image of medication
treatment.”
10. Prevalence data of parent report of ADHD
“CURRENT Dx” by provider
2007
2011
IL
4.8%
7.2%
IN
9.3%
13.0%
KY 10.2% 14.8%
Rates of ADHD diagnosis increased an average of 3% per
year from 1997 to 2006 (CDC Vital & Health Statistics)
http://www.cdc.gov/ncbddd/adhd/prevalence.html accessed 01 26 2014
11. ADHD Stats at 317 years of age.
• 5 million children
(9% for this age
group)
– Boys 12%
– Girls 5%
• Children with fair/poor
health status 2½ X
more likely to have dx.
(8% vs 21%)
12. What does it ―look like‖?
A section for kinesthetic and
visual learners…
13.
14.
15. ADHD – not concentrating
Inferior Orbital pre-frontal cortex
Images courtesy of Daniel Amen, MD – Amen Clinics, Inc.,
Newport Beach, CA
20. DIAGNOSIS: FOUR FLAVORS OF
ADHD
314.00 ADHD Predominantly Inattentive
Type*
314.01 ADHD Predominant HyperactiveImpulsive Type*
314.04 ADHD, Combined Type
314.9 ADHD – Not Otherwise Specified
6 of 9 symptoms required for 314.00 &
314.01
21. PATIENT NAME: ___________________________
DATE: __________
Medication status: ( ) pre-treatment? ( ) on Rx? ( ) OFF of Rx?
PATIENT STATUS: CHILD
Check off the symptoms which are unusually troublesome for your child (or YOU, if you
are an adult patient) which are clearly different from what other children or adults
typically experience. PLEASE USE THE BACK SIDE OF THIS FORM TO AMPLIFY ON ANY OF
THE "CHECKED" SYMPTOMS WHICH YOU FEEL I SHOULD KNOW MORE ABOUT.
ATTENTION PROBLEMS
displays failure to give close attention to
details; makes careless mistakes
has difficulty with sustained attention
doesn't listen even when spoken to directly
has REAL trouble following through on
instructions; fails to finish tasks
difficulty organizing tasks/activities
avoids, dislikes, or reluctant to engage in
tasks requiring sustained mental effort
(homework, work projects, etc.)
loses things necessary for tasks/activities
easily distracted by extraneous stimuli
(sounds or sights in the environment)
often forgetful in daily activities
For physician use only RECENT CLINICAL HISTORY:
HYPERACTIVITY, "WIGGLESOMENESS"
PROBLEMS
fidgets with hands or feet, squirms in seat
leaves seat in classroom in which remaining in
seat was expected, or can't stay put at work
runs about; climbs excessively in inappropriate
situations
difficulty playing or engaging in leisure activities
quietly
often was "on the go" as if "driven by a motor"
talks excessively - a "chatterbox"
PROBLEMS BEING IMPULSIVE
blurts out answers before questions are
completed
difficulty waiting your turn
interrupts or intrudes on others (butts into
conversations)
PARENTS: Please feel in your child's
CURRENT DRUG THERAPY... PLEASE LIST!
medication
TAKEN
____________
____________
____________
____________
____________
____________
____________
size of dose WHEN
_________
_________
_________
_________
_________
_________
_________
____________
____________
____________
____________
____________
____________
____________
physician use...
ADHD Diagnostic Symptom Checklist, adapted from DSM-IV, by:
Louis B. Cady, M.D. - 611 Harriet Street - Suite 304 - Doctors Plaza
Evansville, IN 47710 www.drcady.com
– Symptoms present
before age 7 (now 12 in
DSM-5) years
– Impairment from
symptoms present in 2
or
more settings
– Significant social,
academic, or
occupational
impairment
– Exclude other mental
disorders
22.
23. DSM-5 update
• 6 symptoms before
age 7
• 6 symptoms for adults
• 6 symptoms before
age 12
• 5 (FIVE) symptoms
for adults
24. ―The Total Picture‖ diagnostic
pearls [from Steven Grcevich, MD]
• Read comments on report cards!
• Ask siblings: “What’s (s)he like to live with?”
• Ask patient: “When was the last time you got
invited to someone else’s house to play?”
• Ask parents: “Is (s)he involved with any
activities in the community?”
33. Driving behavior and results in 27
clinically referred German adults
• N=27, with initial screen
– 19 studied – initial testing then either:
• 10- kept medication free
• 9 – tx’ed for 6 weeks with MPH
Sobanski E, et al. Driving-related risks and impact of metylphendiate
treatment on driving in adtuls with attenion-deficit/hyperactivity disorder
(ADHD). J Neural Trasm. 2008; 115(2):347-56.
34. Driving behavior and results in 27
clinically referred German adults
• Background findings:
– All ADHD subjects: drove significantly more kilometers
per year
– More often registered by traffic authorities
– Fined more frequently
– Involved in more MVA’s
– Self described driving style as “more insecure and
hectic” than controls.
• A high risk group was delineated with:
– 3-6 MVA’s per ADHD subject
Sobanski E, et al. Driving-related risks and impact of metylphendiate
treatment on driving in adtuls with attenion-deficit/hyperactivity disorder
(ADHD). J Neural Trasm. 2008; 115(2):347-56.
35. Do you want to
treat them?
STUDY CONCLUSIONS:
MPH tx improved
information processing
and sustained visual
attention compared to
baseline and untreated
control groups.
Sobanski E, et al. Driving-related risks and
impact of metylphendiate treatment on driving
in adtuls with attenion-deficit/hyperactivity
disorder (ADHD). J Neural Trasm. 2008;
115(2):347-56.
41. Psychiatric disorders (lifetime) in adults
with ADHD [multiple sources, % is estimated;
N.B. – this is WITHOUT TREATMENT GROWING UP]
• Substance use disorders (all) 50%
• Anxiety disorders 40%
• Major depression 35%
• Learning disabilities 20%
• Bipolar disorder 10%
• Antisocial disorder 10%
42. Adult ADHD’ers:
• Lower self esteem as
adults
• Lower educational
achievements
• Greater use of ancillary
educational resources
• Greater tobacco and
recreational drug use
• A lifelong pattern of
“consistent
inconsistency.”
Source: David Goodman, MD –
Johns Hopkins Adult ADHD
treatment center
43. 105 Adult ADHD Drivers vs. 64
Controls (CC)
• ADHD’ers self reported:
– More citations (esp. for SPEEDING),
crashes & license suspensions
than CC
• ADHD’ers:
Barkley RA, et al.
J Int.
Neuropsychol
Soc. 2002 (5):655762.
– less attentive, made more errors on
visual reaction task
– Lower scores on driving rules test.
• Driving difficulties: not related to
“ODD”, depression, anxiety, or
frequency of substance use.
46. Response to Psychostimulants
Meta-analysis of Within-Subject Comparative Trials
Evaluating Response to Stimulant Medications
50
41%
40
Best
Response
(Percent)
Betting
odds:
Amph –
69%
MPH 57%
28%
30
16%
20
10
0
AMP
.
MPH
Equal response to
either stimulant
Arnold et al. J Attention Dis. 2000;3:200.
47. Benefit-Risk Ratio and Efficacy
of Psychostimulants
• Very favorable benefit-risk ratio
– rapid, dramatic results
– low risk of long-term side effects
• Approximately 70% of patients with ADHD will
show a positive response on the first trial of
any one stimulant medication
• If two different stimulant medications are tried,
the response rate increases to ~90%
Greenhill. Child Adolesc Psychiatr Clin North Am. 1995;4:123; Spencer et al. JAACAP. 1996;35:409;
Goldman et al. JAMA. 1998;279:1100.
48. Amphetamines, methylphenidate, and
antidepressants - important differences:
Amphetamine - increases release and decreases uptake at
the DOPAMINE uptake transporter (Seiden, et al., 1993)
–effects release of DA from vesicles.
–also allows dopamine to be released from newly
synthesized pools inside the cell.
–also activates 5-HT receptors (Sloviter, et al., 1978)
–L-amphetamine = 50/50 NERI/DRI (Stahl, 2013)
Methylphenidate - effects release of DA from vesicles only
– inhibits dopamine reuptake, as well.
Antidepressants: inhibit reuptake of NE and DA; do not
cause release. [Atomoxetine = “NRI”]
49. Atomoxetine
• Superior to placebo (but slightly
less effective than MPH)
in large, double-blind, placebocontrolled trial-Heiligenstein, 2000
• Spencer et al. (JCAP 2001)-open study,
30 patients, 75% improved >25%.
HCl
O
N
H
CH3
CH3
SE’s: rhinitis, headache, anorexia, dizziness,
nervousness, somnolence
• Michaelson (Pediatrics, 2001) ATX>PLB, best response
at 1.2 mg/kg/day
• Kratchovil (JAACAP, 2002) ATX=generic MPH, open-label
study, inadequately powered
Heiligenstein et al. Presented at AACAP, October 24-29, 2000
Spencer et al. J. Child Adolesc Psychopharmacol 2001: 11(3) 229-238
50. ―Strattera* [coupled with
fluoxetine or paroxetine] has
been great for our
admissions.‖
-Dr. William Beute, MD
Pine Rest Campus Clinic
Grand Rapids, MI
* Brand name used in this
slide because this is a
direct quote
April 21, 2004
[quoted with permission]
51. “2P, or not
2P…
…that is
interaction.”
NB: Cytochrome p450
2D6:
- This is where
atomoxetine is
metabolized
- It is inhibited by
52. ―Alpha 2a agents‖
• Concept of SUSTAINED RELEASE AGENTS –
generic instant release agents not the same
• Extended release guanfacine – “1,2,3 or 4 mg at
bedtime”
• Extended release clonidine – “0.1 – 0.2mg (ER)
twice daily (a.m. and pm)”
• Both are approved for monotherapy or for add-on
therapy.
• Stimulants seem more potent; alpha-2 Rx seems
to be better for oppositional/defiant symptoms,
either by themselves or in combination therapy.
53. STIMULANTS: Time Course
Considerations
2 Classes: MPH or Amph
Amphetamines
MPH
~4 hrs
MPH
dexMPH
8 hrs
12 hrs
MPH LA
MPH ―CD‖
OROS-MPH D-amp
Dex-MPH SR
4-5 hrs
MPH Patch (12+)
SR Liquid
MPH-12 hrs
7-8 hrs 8-10-12
Dex spans
AMP
salts XR
Mixed
Lisamph salts
dexamph
Cady diagram, 2014 – includes current stimulants
54. KEY TAKE HOME POINT! The drug level must
Plasma Concentration Profiles Associated
ASCEND during the day in order to keep the
withtherapeutic effect STEADY.
Different MPH Delivery Patterns
Concentration (ng/mL)
MPH TWICE DAILY
MPH Oros
6
Flat – MPH sips
5
4
3
2
1
0
0
5
10
15
Time (h)
Simulated plasma methylphenidate concentrations for 20-mg total daily dose delivered by twicedaily (BID), flat, and ascending dosing regimens.
from Swanson J, et al. Clin Pharmacol Ther. 1999;66:295-305.
56. The Arnold studies
Randomized, double-blind, placebo controlled
31 children with “MBD” (1976)
Rx: 5 mg of d-AMP; 7 mg l-AMP [difference
d.t. MW's]
CONCLUSIONS (replicated previous 1972 study
of n=11):
–Both agents found effective
–Typically one agent was more effective than the
other for individual children
[Arnold LE, Huestis RD, Smeltzer DJ, et al. Levoamphetamine vs dextroamphetamine in minimal
brain dysfunction. Arch Gen Psychiatry 33:292-301, 1976
Arnold LE, et al. Levoamphetamine and dextroamphetamine: Differential effects on aggression and
hyperkinesis in children and dogs. Am J Psychiatry 130:165-170, 1973]
57. Typically one agent was more effective
than the other for individual children
• d-AMP "appeared non-significantly more
effective"
• slightly better for "over-anxious" children
• l-isomer - 2/3 of children improved
• seemed to be of more benefit to
"unsocialized-aggressive" kids
• 28% of responders preferred the l-AMP form
• “decreased tendency to blunt affect and
produce the „amphetamine look‟ [sic]”
58. Substance Use Disorders:
Drugs of Abuse vs Meds for ADHD
Drugs of Abuse
Medications for ADHD
Used to feel good
Feel nothing or feel bad in
overdose
Users crave the drug
Patients commonly forget to take
medication
Large and ready market exists
Readily available but long-term
use is rare
A “struggle” to get kids to stop
taking them
A “struggle” to get kids to take
them
Courtesy of William Dodson, MD – Denver, Colorado
60. OROS MPH – the first player
GI liquid
absorbed
into
osmotic
matrix
pump
MPH
pushed
out the
laser
drilled
hole at
end of
tablet
61. Peaks & troughs…
OROS MPH &
OROS MPH – 18 mg
Illustration from Alza promotional literature
62. Mixed amphetamine salts “XR” system
Immediate-Release Bead
Delayed-Release Bead
Bead Core
Bead Core
Drug Layer
Drug Layer
Overcoating
Release-Delaying
Polymer
Overcoating
50%
50%
Overcoating
Capsule
Available in 5, 10, 15, 20, 25, and 30 mg dosing forms
63. Chemical Structure of Lis-dexamfetamine
O
O
CH 3
H2
N
H2
N
N
H
Rate-limited
OH
+
Hydrolysis
CH3
H2
N
Site of cleavage
NH 2
Lisdexamfetamine
(Prodrug)
NH 2
l-lysine
d-amphetamine
(active)
Lis-dexamfetamine is a prodrug that is therapeutically
inactive until it is converted to active d-amphetamine in the
body
65. Basic MPH 101
• How much to Rx?!
• Old dosing charts show 0.3 – 0.7
mg/kg/dose
– But only “1.5 mg/kg/day”….
• But THREE doses of 0.3 – 0.7 mg/kg/dose
= 0.9 – 2.1mg/kg/day
• THEREFORE, theoretical maximum
should be ―2.1 mg/kg/day‖ (the
―Biederman max‖)
• But what is that really, in “Hoosier-speak”?
66. Cady/Desiderato Factor-Label, DownHome, Good-Ole Boy MPH
Calculation:
1 Kg
2.1mg MPH
=
X
Kg
ONE milligram
2.2 lbs
Lys-dexamph, amphetamine salts,
dex amph, dex-MPH = ½ the
typical amount of
methylphenidate
pound of kid
1mg / lb of kid / day
spread out over 12 hours, OR
About ½ that for
amphetamines or dex-MPH
67. So how much to dose?
• No correlation between plasma level and
therapeutic response:
– Big levels in small kids
– Small levels in big kids
• All medication titrations should be made by
informed, observant clinicians with good
solid follow-up and examinations
• Titrations should be based on
DYSFUNCTION
68. M.D. does not stand for ―minor deity‖
• Start lower than you think you probably should.
• Push it carefully until you get results
– a “just right” therapeutic effect
– absent side effects
• Use the “Biederman max” as a rough rule of
thumb to calculate the “ceiling,” NOT TO START!
• If you have to “break through the ceiling” – think
carefully, document your rationale, monitor
carefully for side effects, HTN, cardiac issues
• Explain both the “Goldilocks” and the “Cinderella”
aspects to patients/parents
69. How to screw it up: a case study
• 1/28/14 – 7 year old child presents for tx
• Oct 2013 – dx’ed with ADHD
• RX:
– Started on 30 mg lys-dexamph from start
• Zombied out for two days
– Dosage reduced to 15 mg. Worked well for 3 weeks.
“I like the way my brain is working.”
– Began hearing voices in his head at night.
• Medication stopped
• Voices persisted over the next 2 weeks, then d/c
71. Case of the ―disorganized daughter‖
• 7/18/12 – 29 yo MWF presents with classic
hypomania, sleep deprivation and psychosis.
– Known history of opioid abuse and
dependence.
• Per mother: “severe insomnia, mood swings,
periodic fits of rage followed by sadness/crying;
difficulty concentrating; flight of ideas, trouble
managing daily activities; little impulse control”
• Noted to have elevated symptoms of ADHD on
initial rating scales
72. TREATMENT COURSE
• By 8/28/2012, stabilized on:
– Paloperidone 6 mg daily + Benztropine 1 mg
three times daily
– Lamotrigine started with plan to cross titrate.
– Started on PNV with Fe and DHA due to low
iron.
• Further history: used opioids to sleep.
• Essentially psychiatrically stable. Euthymic.
• Viewed as stable enough to take Quotient
test.
76. STATS:
• ATTENTIVE
• Impulsive
• Distracted
• Disengaged
7.5% (!!!) of the time
47.5% of the time
32.5% of the time
12.5% of the time
77. Patient’s response to the Quotient
results:
• “Wow, that’s really bad isn’t it?!”
• Asked if she had had severe problems with
attention in school.
• “Well, there’s actually
something I’ve never told
you…”
78. More history, more treatment
• “I actually used cocaine [therapeutically] before
school( in high school) to concentrate.”
– Set the curve in all of her finals in her junior year.
– Stopped it in her senior year
– Used opioid (Lortabs) throughout college to study and
focus. (“It made me awake and helped me do stuff.”).
• Now concerned about her ability to focus.
• Brother, in law school, recently dx’ed with ADD.
On mixed amphetamine salts. Doing much better.
79. Current status: disorganized daughter
• RX:
– Lurasidone – 80 mg HS (bipolar)
– Lamotrigine – 50 mg per day (bipolar - &
couldn’t go up)
– Vilazodone – 30 mg in the a.m.(for OCD
symptoms)
– Lisdexamphetamine – 50 mg capsule in a.m. for
ADHD
• Supplements:
– L-tyrosine, PNV with Fe and DHA
• Status – perfect function and focus.
80. Key take-aways from this case
• Don’t let a substance abuse disorder give you
a constricted field of logic.
• Affective disorders and ADHD can coexist.
• Frequently ADHD’ers have used illegal drugs
or tried their kid’s stimulant.
• Avoid Puritanical blame/self-righteousness:
– Many ADHD’ers (and affective disorder patients)
fall into alcohol, marijuana, and other drugs in an
attempt to self-treat
• Treat the primary problem first.
83. Therapy Axioms: who needs it, when
to do it
• The later a child (or adult) is diagnosed, the
more complications (s)he has had, and the
more conflict – the higher the likelihood of
need for psychotherapy
• The converse applies.
• The higher the level of family dysfunction,
the more the need for:
– “parent training”
– Behavioral therapies, etc.
84. Inventor of NASDAQ screen
– Strong family hx of ADHD
– Dx’ed at 48 yoa
– Interviewed in Time
Square – “Don’t you feel
proud?”
–―Not really – all my
life, people were
telling me I would
never amount to
anything.‖
Quote & identity used by specific
permission of David Goodman,
MD & his patient
85.
86. Note: unstandardized co-efficients
• Prospective 33 year follow up of 135 white boys
with ADHD (w/p CD) in childhood & 136 matched
comparators w/o ADHD
• ―Development of CD/APD accounted for the
relationship between ADHD & risk-taking.‖
from: Olazagasti MAR, et al J Am Child Adolesc Psychiatry 2014, Feb 1.
published online 2013 January 5 doi:10.1016/j.aaac.2012.11.012
87. Integrated: how to avoid over-reliance
on meds
• Smart prescribing!
• School:
– Excellent working relationships with school
– Good teaching
• HOME:
–
–
–
–
–
Diminish “electronic screens” effect
Good home discipline
Good sleep/wake schedules
Good diet
Adequate exercise
• Parent training: parenting, stress tips
88. “There are things
known and there
are things
unknown, and in
between are the
doors.”
- Jim Morrison
90. Contact information:
Louis B. Cady, M.D.
www.cadywellness.com
www.tmsrelief.com
Office: 812-429-0772
E-mail: lcady@cadywellness.com
4727 Rosebud Lane – Suite F
Interstate Office Park
Newburgh, IN 47630 (USA)
91. Q & A – and answers
• Previous epidemiological data suggested prevalence of ADHD in 3 –
7% of school-aged children. According to more recent CDC data
(2009) the prevalence is probably around 9% for this group.
– TRUE
• Actually, the reported dx of ADHD by current providers is much higher
in the TriState (Indiana, Illinois, & Kentucky), ranging from
approximately 7 – 15%. (per CDC Vital & Health Statistics, 1997-2006)
-
TRUE
• SPECT imaging, as well as PET and functional MRI, may be a useful
way to look at the living brain and observe functioning.
– TRUE
92. Q & A – and answers
• Here is a comparison and contrast of DSM-IV (in use until
January 1, 2014, and DSM-5 (FIVE) in current use.) Either
ALL of the following statements are true, or ALL of them
are false.
- There are nine symptoms in each domain – nine for
inattentiveness and nine for hyperactivity and impulsivity
– In DSM-IV, the previous diagnosis criteria specified that any symptoms
used for diagnosis much be present before the age of 7 (SEVEN)
– In DSM-V, the current diagnostic criteria specify that the child (or adult)
must have the requisite number of symptoms before the age of 12
(TWELVE).
– The difference between the “cutoff” for diagnosis for ADULTS between
DSM-IV and DSM-5 (FIVE) is that in DSM-IV, for the full diagnosis, you
had to have at least 6 symptoms in either domain, and now in DSM-5
(FIVE) you just have to have FIVE symptoms as an adult to qualify.
ALL of these statements TRUE
93. Q & A – and answers
•
According to common dosing guidelines and the presented “Cady/Desiderato Good Old
Boy Down-Home Guide to Dosing Stimulants,” the theoretical MAXIMUM of
methylphenidate products should be 1 mg of methylphenidate per pound of kid per day,
and amphetamines should be half that: e.g., ½ mg per lb of kid per day.
–
•
TRUE
30 mg of Lisdexamfetamine (brand name = Vyvanse ®)* = 30 mg of amphetamine
equivalents for dosing calculations. [*note – brand name is cited here for this
medication because this medication is not in generic circulation at this time, and most
practitioners will not recognize the generic name.]
–
FALSE (oops – this was not covered this a.m.)
•
•
Explanation: 30 mg of Vyvanse = 10 mg amphetamine; 50 mg Vyvanse = 20 mg amphetamine; 70 mg of Vyvanse = 30
mg of amphetamine. This is a common dosing error by well meaning pediatricians – confusing Vvanse and
amphetamine doses. Sorry for not presenting this.
According to presented data and recommendation, the two longest acting and smoothest
agents in class are lisdexamfetamine and liquid 12 hour sustained release
methylphenidate.
–
TRUE
It was a great pleasure to present to you this morning! Hope the “Q
& A” was helpful. I will be back on April 2nd to present another CME
lecture on the use of TMS (transcranial magnetic stimulation) and
depression.
Editor's Notes
ADHD is recognized as a combination of 3 behavior types: inattention, impulsivity, and hyperactivity
DSM-IV characterizes 3 subtypes of ADHD based on the preponderance of these behaviors [Biederman, 1998 p4]
Inattentive
Hyperactive-impulsive
Combined inattentive and hyperactive-impulsive
In many patients, hyperactive and impulsive symptomology tend to decrease with age; however, inattention is persistent throughout the lifespan [Biederman1998 p5, 7-8]
Hyperactive-impulsive subtype occurs with the lowest frequency and in the youngest patients
The inattentive subtype is most commonly recognized in older adults, but can occur at all ages
The combined subtype occurs most frequently [Biederman, 1998 p4-5]
237 boys 6 to 17 years old were followed prospectively for 4 years and into mid-adolescence
Information on smoking history was determined using the Diagnostic Interview for Children and Adolescents/Parents’ version at the 4-year follow-up assessment only [Milberger 1997 p39]
Information on frequency of cigarette smoking, age at onset/offset of smoking, and associated impairments were determined by trained interviewers blind to the subjects’ clinical status [Milberger 1997 p39]
ADHD is a significant predictor of early smoking in adolescence
At the end of 4 years 19% of ADHD boys were smoking compared with 10% of controls (P=0.003)
Onset of substance abuse in subjects with ADHD averaged 3 years earlier than controls (late adolescence/early adulthood)
ADHD was a significant risk factor independent of comorbid diagnoses
The incidence of drug abuse was compared in 56 medicated ADHD patients, 19 non-medicated ADHD patients, and 137 non-ADHD control subjects [Biederman 1999 pe21]
Non-medicated ADHD patients were at a significantly higher risk for substance abuse than controls or medicated ADHD patients [Biederman 1999 pe22-23]
There was no significant difference between medicated ADHD patients and controls (chi-squared=3.7, P=0.15) [Biederman 1999 pe22-23]
Medication is associated with an 85% reduction in the risk of substance abuse in ADHD patients [Biederman 1999 pe22-23]
Poor compliance is often a more significant problem than addiction [Garland, 1998 p 387-388]
Studies comparing methylphenidate, dextroamphetamine, and pemoline have demonstrated equivalent efficacy.
However, there is much individual variability in response to any one particular psychostimulant. That is, a particular patient may not respond to methylphenidate, but may respond well to an amphetamine medication. This slide shows results of a meta-analysis of six controlled within-subject comparisons of methylphenidate and amphetamine. Of the 174 subjects, 28% responded best to amphetamine, 16% responded better to methylphenidate, while the remaining 41% responded equally well to either stimulant.
The response rate for any one particular stimulant medication is approximately 70%. No predictors of response have been identified; that is, there is no way to know whether a patient will respond to one stimulant vs another. Because patients may have a preferential response to one stimulant medication, different stimulants should be tried before considering a patient to be a stimulant nonresponder.
Stimulant medications have a very favorable benefit-risk ratio, with rapid, dramatic results and a low risk of long-term side effects. The Council on Scientific Affairs of the American Medical Association reviewed hundreds of trials involving thousands of patients, and concluded that “the risk-benefit ratio of stimulant treatment in ADHD must be evaluated and monitored on an on-going basis in each case, but in general is highly favorable” (Goldman et al. JAMA 1998;279:1100).
Studies consistently show that approximately 70% of pediatric patients will show a positive response to the first trial of any one stimulant medication (Spencer et al. JAACAP 1996;35:409).
Up to 78% of adult patients respond to a single stimulant (Spencer et al. Arch Gen Psych 1995;52:434).
The response rate for stimulant medications increases to approximately 90% when two different stimulant medications are tried (Goldman et al. JAMA 1998;279:1100).
Atomoxetine represents the first of a new generation of compounds treating ADHD through blockade of norepinephrine reuptake, as opposed to dopamine. Several other companies have similar products under development. Atomoxetine was FDA-approved on November 26, 2002.
Most patients are treated with an antidepressant that works on a single neurotransmitter system, either serotonin or norepinephrine. This includes 11 prominent agents that are widely prescribed.
Plasma MPH Concentrations
To assess whether different delivery patterns affected efficacy, the efficacy of BID dosing was compared with flat and ascending release profiles
BID dosing: 2 large bolus doses
Flat release: a large bolus followed by small constant doses
Ascending release: a large bolus followed by small increasing doses
As expected, BID dosing of MPH resulted in dual peaks, ascending release gave a slow steady increase in plasma levels, and flat release provided continuous plasma concentrations of MPH
N=38 with clinical diagnosis of ADHD and receiving current treatment with MPH doses of 5 to 15 mg/d
Age range: 7 to 12 years of age (mean: 9.2 years)
An extended-release formulation of Adderall® (Adderall XR™) is now available for the treatment of ADHD. This capsule formulation contains equal proportions of immediate release and extended release beads and the active ingredients are identical to Adderall® (equal mg portions of d-amphetamine sulfate, amphetamine sulfate, d-amphetamine saccharate, and amphetamine aspartate monohydrate). The IR beads are designed to release medication upon ingestion, and the extended-release beads are designed to release the drug approximately 4 hours post-dose. Thus, a single 20-mg ADDERALL XR™ dose is designed to release medication similar to a 10 mg IR Adderall tablet dosed BID given approximately 4 hours apart.
The contents of the capsule may be sprinkled onto food for patients who have difficulty swallowing pills.
Key Point: Vyvanse is a new chemical entity, a prodrug for the treatment of ADHD. After
ingestion, Vyvanse is converted (via enzymatic reaction [rate-limited hydrolysis]) to
l-lysine, a naturally occurring essential amino acid, and to active d-amphetamine. (Please read 2nd communication objective discussing enzyme responsible for metabolism)
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Communication Objectives:
[Reminder] Vyvanse is a new chemical entity with a different chemical structure than that of Adderall XR or Dexedrine Spansules.
Vyvanse is a prodrug, in which d-amphetamine is covalently bonded to l-lysine. It is therapeutically inactive until it is converted (via enzymatic reaction [rate-limited hydrolysis]) to active d-amphetamine in the body. The specific enzyme(s) responsible for this enzymatic reaction (rate-limited) has not been fully identified. The bond linking d-amphetamine to l-lysine is an amide bond, more specifically a peptide bond. Enzymes responsible for the breakdown of peptide bonds are peptidases. OVERALL, PEPTIDE BONDS ARE BROKEN BY PEPTIDASE ENZYMES.
____________________________________________________________________
Question:
How does Vyvanse become active where it is metabolized?
Answer:
Activation: Vyvanse is a prodrug that is therapeutically inactive until it is converted to active d-amphetamine in the body. Cleavage occurs at the amino-terminal group of d-amphetamine. An enzymatic reaction occurs converting (metabolizing) inactive lisdexamfetamine to its active form, d-amphetamine. This enzymatic reaction occurs via rate-limited hydrolysis.
Metabolism:
Vyvanse is rapidly absorbed from the gastrointestinal tract and converted to d-amphetamine, which is responsible for the drug’s activity. Vyvanse is converted to d-amphetamine and l-lysine, which is believed to occur by gastrointestinal and/or hepatic metabolism.
Release of the active ingredient in Vyvanse does not rely on gastrointestinal factors such as GI transit time or gastric pH.