What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic narrative review

Background: Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder with international prevalence estimates of 5 % in childhood, yet significant evidence exists that far fewer children receive ADHD services. In many countries, ADHD is assessed and diagnosed in specialist mental health or neuro-developmental paediatric clinics, to which referral by General (Family) Practitioners (GPs) is required. In such ‘gatekeeper’ settings, where GPs act as a filter to diagnosis and treatment, GPs may either not recognise potential ADHD cases, or may be reluctant to refer. This study systematically reviews the literature regarding GPs’ views of ADHD in such settings. Methods: A search of nine major databases was conducted, with wide search parameters; 3776 records were initially retrieved. Studies were included if they were from settings where GPs are typically gatekeepers to ADHD services; if they addressed GPs’ ADHD attitudes and knowledge; if methods were clearly described; and if results for GPs were reported separately from those of other health professionals. Results: Few studies specifically addressed GP attitudes to ADHD. Only 11 papers (10 studies), spanning 2000–2010, met inclusion criteria, predominantly from the UK, Europe and Australia. As studies varied methodologically, findings are reported as a thematic narrative, under the following themes: Recognition rate; ADHD controversy (medicalisation, stigma, labelling); Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes. Conclusions: Across times and settings, GPs practising in first-contact gatekeeper settings had mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributed to presentation. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for possible ADHD cases, there needs to be a focused and collaborative approach to training

The impact of induction and/or concurrent chemoradiotherapy on acute and late patient-reported symptoms in oropharyngeal cancer:Application of a mixed-model analysis of a prospective observational cohort registry

BACKGROUND The goal of this study was to comprehensively investigate the association of chemotherapy with trajectories of acute symptom development and late symptom recovery in patients with oropharyngeal cancer (OPC) by comparing symptom burden between induction chemotherapy followed by concurrent chemoradiotherapy (ICRT), concurrent chemo-radiotherapy (CRT), or radiotherapy (RT) alone.METHODS Among a registry of 717 patients with OPC, the 28-item patient-reported MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) symptoms were collected prospectively at baseline, weekly during RT, and 1.5, 3 to 6, 12, and 18 to 24 months after RT. The effect of the treatment regimen (ICRT, CRT, and RT alone) was examined with mixed-model analyses for the acute and late period. In the CRT cohort, the chemotherapy agent relationship with symptoms was investigated.RESULTS Chemoradiation (ICRT/CRT) compared with RT alone resulted in significantly higher acute symptom scores in the majority of MDASI-HN symptoms (ie, 21 out of 28). No late symptom differences between treatment with or without chemotherapy were observed that were not attributable to ICRT. Nausea was lower for CRT with carboplatin than for CRT with cisplatin; cetuximab was associated with particularly higher scores for acute and late skin, mucositis, and 6 other symptoms. The addition of ICRT compared with CRT or RT alone was associated with a significant increase in numbness and shortness of breath.CONCLUSION The addition of chemotherapy to definitive RT for OPC patients was associated with significantly worse acute symptom outcomes compared with RT alone, which seems to attenuate in the late posttreatment period. Moreover, induction chemotherapy was specifically associated with worse numbness and shortness of breath during and after treatment.LAY SUMMARYChemotherapy is frequently used in addition to radiotherapy cancer treatment, yet the (added) effect on treatment-induced over time is not comprehensively investigatedThis study shows that chemotherapy adds to the symptom severity reported by patients, especially during treatment</p

Limits on additional planetary companions to OGLE-2005-BLG-390L

We investigate constraints on additional planets orbiting the distant M-dwarf star OGLE-2005-BLG-390L, around which photometric microlensing data has revealed the existence of the sub-Neptune-mass planet OGLE-2005-BLG-390Lb. We specifically aim to study potential Jovian companions and compare our findings with predictions from core-accretion and disc-instability models of planet formation. We also obtain an estimate of the detection probability for sub-Neptune mass planets similar to OGLE-2005-BLG-390Lb using a simplified simulation of a microlensing experiment. We compute the efficiency of our photometric data for detecting additional planets around OGLE-2005-BLG-390L, as a function of the microlensing model parameters and convert it into a function of the orbital axis and planet mass by means of an adopted model of the Milky Way. We find that more than 50 % of potential planets with a mass in excess of 1 M_J between 1.1 and 2.3 AU around OGLE-2005-BLG-390L would have revealed their existence, whereas for gas giants above 3 M_J in orbits between 1.5 and 2.2 AU, the detection efficiency reaches 70 %; however, no such companion was observed. Our photometric microlensing data therefore do not contradict the existence of gas giant planets at any separation orbiting OGLE-2005-BLG-390L. Furthermore we find a detection probability for an OGLE-2005-BLG-390Lb-like planet of around 2-5 %. In agreement with current planet formation theories, this quantitatively supports the prediction that sub-Neptune mass planets are common around low-mass stars.Comment: 10 pages, 4 figures, accepted by A&

The effect of hypoxia and work intensity on insulin resistance in type 2 diabetes

Context:Hypoxia and muscle contraction stimulate glucose transport in vitro. We have previously demonstrated that exercise and hypoxia have an additive effect on insulin sensitivity in type 2 diabetics.Objectives:Our objective was to examine the effects of three different hypoxic/exercise (Hy Ex) trials on glucose metabolism and insulin resistance in the 48 h after acute hypoxia in type 2 diabetics.Design, Participants, and Interventions:Eight male type 2 diabetics completed 60 min of hypoxic [mean (sem) O(2) = ∼14.7 (0.2)%] exercise at 90% of lactate threshold [Hy Ex(60); 49 (1) W]. Patients completed an additional two hypoxic trials of equal work, lasting 40 min [Hy Ex(40); 70 (1) W] and 20 min [Hy Ex(20); 140 (12) W].Main Outcome Measures:Glucose rate of appearance and rate of disappearance were determined using the one-compartment minimal model. Homeostasis models of insulin resistance (HOMA(IR)), fasting insulin resistance index and β-cell function (HOMA(β-cell)) were calculated at 24 and 48 h after trials.Results:Peak glucose rate of appearance was highest during Hy Ex(20) [8.89 (0.56) mg/kg · min, P < 0.05]. HOMA(IR) and fasting insulin resistance index were improved in the 24 and 48 h after Hy Ex(60) and Hy Ex(40) (P < 0.05). HOMA(IR) decreased 24 h after Hy Ex(20) (P < 0.05) and returned to baseline values at 48 h.Conclusions:Moderate-intensity exercise in hypoxia (Hy Ex(60) and Hy Ex(40)) stimulates acute- and moderate-term improvements in insulin sensitivity that were less apparent in Hy Ex(20). Results suggest that exercise duration and not total work completed has a greater influence on acute and moderate-term glucose control in type 2 diabetics

MOA-2009-BLG-387Lb: A massive planet orbiting an M dwarf

We report the discovery of a planet with a high planet-to-star mass ratio in the microlensing event MOA-2009-BLG-387, which exhibited pronounced deviations over a 12-day interval, one of the longest for any planetary event. The host is an M dwarf, with a mass in the range 0.07 M_sun < M_host < 0.49M_sun at 90% confidence. The planet-star mass ratio q = 0.0132 +- 0.003 has been measured extremely well, so at the best-estimated host mass, the planet mass is m_p = 2.6 Jupiter masses for the median host mass, M = 0.19 M_sun. The host mass is determined from two "higher order" microlensing parameters. One of these, the angular Einstein radius \theta_E = 0.31 +- 0.03 mas, is very well measured, but the other (the microlens parallax \pi_E, which is due to the Earth's orbital motion) is highly degenate with the orbital motion of the planet. We statistically resolve the degeneracy between Earth and planet orbital effects by imposing priors from a Galactic model that specifies the positions and velocities of lenses and sources and a Kepler model of orbits. The 90% confidence intervals for the distance, semi-major axis, and period of the planet are 3.5 kpc < D_L < 7.9 kpc, 1.1 AU < a < 2.7AU, and 3.8 yr < P < 7.6 yr, respectively.Comment: 20 pages including 8 figures. A&A 529 102 (2011

Frequency of Solar-Like Systems and of Ice and Gas Giants Beyond the Snow Line from High-Magnification Microlensing Events in 2005-2008

We present the first measurement of planet frequency beyond the "snow line" for planet/star mass-ratios[-4.5<log q<-2]: d^2 N/dlog q/dlog s=(0.36+-0.15)/dex^2 at mean mass ratio q=5e-4, and consistent with being flat in log projected separation, s. Our result is based on a sample of 6 planets detected from intensive follow-up of high-mag (A>200) microlensing events during 2005-8. The sample host stars have typical mass M_host 0.5 Msun, and detection is sensitive to planets over a range of projected separations (R_E/s_max,R_E*s_max), where R_E 3.5 AU sqrt(M_host/Msun) is the Einstein radius and s_max (q/5e-5)^{2/3}, corresponding to deprojected separations ~3 times the "snow line". Though frenetic, the observations constitute a "controlled experiment", which permits measurement of absolute planet frequency. High-mag events are rare, but the high-mag channel is efficient: half of high-mag events were successfully monitored and half of these yielded planet detections. The planet frequency derived from microlensing is a factor 7 larger than from RV studies at factor ~25 smaller separations [2<P<2000 days]. However, this difference is basically consistent with the gradient derived from RV studies (when extrapolated well beyond the separations from which it is measured). This suggests a universal separation distribution across 2 dex in semi-major axis, 2 dex in mass ratio, and 0.3 dex in host mass. Finally, if all planetary systems were "analogs" of the Solar System, our sample would have yielded 18.2 planets (11.4 "Jupiters", 6.4 "Saturns", 0.3 "Uranuses", 0.2 "Neptunes") including 6.1 systems with 2 or more planet detections. This compares to 6 planets including one 2-planet system in the actual sample, implying a first estimate of 1/6 for the frequency of solar-like systems.Comment: 42 pages, 10 figure

MOA-2010-BLG-477Lb: constraining the mass of a microlensing planet from microlensing parallax, orbital motion and detection of blended light

Microlensing detections of cool planets are important for the construction of an unbiased sample to estimate the frequency of planets beyond the snow line, which is where giant planets are thought to form according to the core accretion theory of planet formation. In this paper, we report the discovery of a giant planet detected from the analysis of the light curve of a high-magnification microlensing event MOA-2010-BLG-477. The measured planet-star mass ratio is $q=(2.181\pm0.004)\times 10^{-3}$ and the projected separation is $s=1.1228\pm0.0006$ in units of the Einstein radius. The angular Einstein radius is unusually large $\theta_{\rm E}=1.38\pm 0.11$ mas. Combining this measurement with constraints on the "microlens parallax" and the lens flux, we can only limit the host mass to the range $0.13<M/M_\odot<1.0$. In this particular case, the strong degeneracy between microlensing parallax and planet orbital motion prevents us from measuring more accurate host and planet masses. However, we find that adding Bayesian priors from two effects (Galactic model and Keplerian orbit) each independently favors the upper end of this mass range, yielding star and planet masses of $M_*=0.67^{+0.33}_{-0.13}\ M_\odot$ and $m_p=1.5^{+0.8}_{-0.3}\ M_{\rm JUP}$ at a distance of $D=2.3\pm0.6$ kpc, and with a semi-major axis of $a=2^{+3}_{-1}$ AU. Finally, we show that the lens mass can be determined from future high-resolution near-IR adaptive optics observations independently from two effects, photometric and astrometric.Comment: 3 Tables, 12 Figures, accepted in Ap