Joyce S Nicholas

Medical University of South Carolina, Charleston, South Carolina, United States

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Publications (101)178.57 Total impact

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    ABSTRACT: Object In Tanzania, there are 4 neurosurgeons for a population of 46 million. To address this critical shortage of neurosurgical care, the authors worked with local Tanzanian health care workers, neurosurgeons, the Ministry of Health and Social Welfare, and the Office of the President of Tanzania to develop a train-forward method for sustainable, self-propagating basic and emergency neurosurgery in resource-poor settings. The goal of this study was to assess the safety and effectiveness of this method over a 6-year period. Methods The training method utilizes a hands-on bedside teaching technique and was introduced in 2006 at a remote rural hospital in northern Tanzania. Local health care workers were trained to perform basic and emergency neurosurgical procedures independently and then were taught to train others. Outcome information was retrospectively collected from hospital records for the period from 2005 (1 year before method implementation) through 2010. Analysis of de-identified data included descriptive statistics and multivariable assessment of independent predictors of complications following a patient's first neurosurgical procedure. Results By 2010, the initial Tanzanian trainee had trained a second Tanzanian health care worker, who in turn had trained a third. The number of neurosurgical procedures performed increased from 18 in 2005 to an average of 92 per year in the last 3 years of the study period. Additionally, the number of neurosurgical cases performed independently by Tanzanian health care providers increased significantly from 44% in 2005 to 86% in 2010 (p < 0.001), with the number of complex cases independently performed also increasing over the same time period from 34% to 83% (p < 0.001). Multivariable analysis of clinical patient outcome information to assess safety indicated that postoperative complications decreased significantly from 2005 through 2010, with patients who had been admitted as training progressed being 29% less likely to have postoperative complications (OR 0.71, 95% CI 0.52-0.96, p = 0.03). Conclusions The Madaktari Africa train-forward method is a reasonable and sustainable approach to improving specialized care in a resource-poor setting.
    Journal of neurosurgery. 09/2014;
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    ABSTRACT: Medication adherence in children is poor, particularly among those with chronic or mental health disorders. However, adherence has not been fully assessed in autism spectrum disorders (ASDs). The validated proportion of days covered method was used to quantify adherence to psychotropic medication in Medicaid-eligible children who met diagnostic criteria for ASD between 2000 and 2008 (N = 628). Among children prescribed attention deficit hyperactivity disorder (ADHD) medications, antidepressants, or antipsychotics, 44, 40 and 52 % were adherent respectively. Aggressive behaviors and abnormalities in eating, drinking, and/or sleeping, co-occurring ADHD, and the Medication Regimen Complexity Index were the most significant predictors of adherence rather than demographics or core deficits of ASD. Identifying barriers to adherence in ASD may ultimately lead to improved treatment outcomes.
    Journal of Autism and Developmental Disorders 06/2014; · 3.34 Impact Factor
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    ABSTRACT: Background: The prevalence of Autism Spectrum Disorder (ASD) is now 1 in 88, a 78% increase over the past six years. Efforts are being made to quantify this change. Previous studies have found a significant urban-rural difference in the prevalence of psychological and other mental disorders. Yet little data on geographic differences has been collected on ASD. A recent study in the UK found that the rate of ASD was higher in the rural population (Kiani), but a study from Taiwan showed that the incidence of ASD was higher in urban areas (Lai). Due to these conflicting reports and different locations, it is imperative that we determine the relationship between ASD and geographical classification so that we may better allocate resources for diagnosis and follow-up care. Objectives: Using the Bureau of the Census definition of a rural area (any incorporated place or census designated place with fewer than 2500 inhabitants that is located outside an urban area), we will determine the rate of change for children meeting criteria for ASD from the South Carolina Autism and Developmental Disabilities Monitoring Program (SC ADDM) in an urban versus rural setting. Methods: Data for this study came from SC ADDM (43% rural in 2000 and 37% rural in 2008). ADDM is a collaborative agreement between 14 sites and the Centers for Disease Control to conduct ASD surveillance in the United States. Data includes all 8-year-old children with an ASD who lived in one of 21 counties in the Coastal and Pee Dee regions of South Carolina in 2000 or 2008 and who were designated as having ASD based on record review. ASD status was determined through extensive screening and records abstraction at multiple educational and clinical sites, followed by expert clinician review and final case determination. This multi-site population-based approach has been used since 2000 and has collected data on 5 cohorts of data (children born in 1992, 1994, 1996, 1998, and 2000). Prevalence will be compared for rural and urban areas and assessed over time to determine whether an increase in rural prevalence is responsible for any of the increase in prevalence seen over the past 6 years. Chi-square tests for differences in two independent proportions will be used to determine significance of changes in the proportion of children with ASD in rural and urban areas. Results: In urban SC, prevalence increased 57% from 7 per 1,000 in 2000 to 11 per 1,000 in 2008 (x2=14.6, p=0.0001). In rural SC, prevalence increased 137% from 5.8 per 1,000 in 2000 to 13.7 per 1,000 (x2=32.5, p<0.0001). Conclusions: The current increases in ASD prevalence in South Carolina can partly be attributed to increases within rural areas. Awareness and outreach throughout the state are possible reasons. Expansion of the current analysis to more ADDM states will focus on quantification of the amount of prevalence increase due to rural prevalence increases.
    2014 International Meeting for Autism Research; 05/2014
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    ABSTRACT: Retrospective analysis of prospectively collected follow-up data for 2.9 years. To determine the natural history of subsequent morphometric fracture rates at adjacent levels (one level above or below a previous known baseline fracture) in a large patient database. The long-term risk and risk factors for adjacent-level vertebral fractures in patients with osteoporosis are unknown. The fracture intervention trial is a large randomized, placebo-controlled trial of alendronate treatment for osteoporosis. Data from both bisphosphonate-treated and bisphosphonate-naive patients (N = 1950, vertebral fracture arm) was analyzed to detect incident morphometric fracture rates. During a mean follow-up of 2.9 years, 3.4% of patients in the alendronate group and 7.4% in the placebo group experienced adjacent-level vertebral fractures. The annual rate of adjacent-level vertebral fractures was 1.2% in the alendronate group, and 2.5% in the placebo group (overall, 1.8% per year in both groups combined). As expected, the thoracolumbar region (defined as T11, T12, and L1) seemed to be the most prone to new adjacent-level fractures. Among females with baseline prevalent fractures at the thoracolumbar junction, who subsequently experienced at least one new fracture anywhere along the spine (N = 124), 40.3% had a new adjacent-level fracture in this region. Older age at randomization, lower bone mineral density, inactivity, and placebo therapy were significantly associated with the development of adjacent-level fractures in univariate analysis (P ≤ 0.05). Multivariate analysis indicated decreased odds of adjacent-level fractures with bisphosphonate therapy and higher bone mineral density, and increased odds with older age at randomization (P ≤ 0.05). New vertebral fractures adjacent to prevalent fractures occurred relatively infrequently in this treatment trial of alendronate in females with osteoporosis, and were more common with older age at randomization, lower bone mineral density and placebo treatment.Level of Evidence: 3.
    Spine 12/2013; 38(25):2201-2207. · 2.16 Impact Factor
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    ABSTRACT: There remains no FDA approved medication for the treatment of cocaine dependence. Preclinical studies and early pilot clinical investigations have suggested that N-acetylcysteine (NAC) may be useful in the treatment of the disorder. The present report assessed the efficacy of NAC in the treatment of cocaine dependence. Cocaine-dependent volunteers (n = 111) were randomized to receive daily doses of 1,200 mg of NAC, 2,400 mg of NAC, or placebo. Participants were followed for 8 weeks (up to three visits weekly). At each of these visits, urine samples were collected, along with self-reports of cocaine use. Urine samples were assessed for quantitative levels of benzoylecognine (ie, cocaine metabolite). Overall, the primary results for the clinical trial were negative. However, when considering only subjects who entered the trial having already achieved abstinence, results favored the 2,400 mg NAC group relative to placebo, with the 2,400 mg group having longer times to relapse and lower craving ratings. While the present trial failed to demonstrate that NAC reduces cocaine use in cocaine-dependent individuals actively using, there was some evidence it prevented return to cocaine use in individuals who had already achieved abstinence from cocaine. N-acetylcysteine may be useful as a relapse prevention agent in abstinent cocaine-dependent individuals. (Am J Addict 2013;22:443-452).
    American Journal on Addictions 09/2013; 22(5):443-52. · 1.74 Impact Factor
  • 2013 International Meeting for Autism Research; 05/2013
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    ABSTRACT: There is considerable interest in translating laboratory advances in neuronal regeneration following spinal cord injury (SCI). A multimodality approach has been advocated for successful functional neuronal regeneration. With this goal in mind several biomaterials have been employed as neuronal bridges either to support cellular transplants, to release neurotrophic factors, or to do both. A systematic review of this literature is lacking. Such a review may provide insight to strategies with a high potential for further investigation and potential clinical application. To systematically review the design strategies and outcomes after biomaterial-based multimodal interventions for neuronal regeneration in rodent SCI model. To analyse functional outcomes after implantation of biomaterial-based multimodal interventions and to identify predictors of functional outcomes. A broad PubMed, CINHAL, and a manual search of relevant literature databases yielded data from 24 publications; 14 of these articles included functional outcome information. Studies reporting behavioral data in rat model of SCI and employing biodegradable polymer-based multimodal intervention were included. For behavioral recovery, studies using severe injury models (transection or severe clip compression (>16.9 g) or contusion (50 g/cm)) were categorized separately from those investigating partial injury models (hemisection or moderate-to-severe clip compression or contusion). The cumulative mean improvements in Basso, Beattie, and Bresnahan scores after biomaterial-based interventions are 5.93 (95% CI = 2.41 - 9.45) and 4.44 (95% CI = 2.65 - 6.24) for transection and hemisection models, respectively. Factors associated with improved outcomes include the type of polymer used and a follow-up period greater than 6 weeks. The functional improvement after implantation of biopolymer-based multimodal implants is modest. The relationship with neuronal regeneration and functional outcome, the effects of inflammation at the site of injury, the prolonged survival of supporting cells, the differentiation of stem cells, the effective delivery of neurotrophic factors, and longer follow-up periods are all topics for future elucidation. Future investigations should strive to further define specific factors associated with improved functional outcomes in clinically relevant models.
    The journal of spinal cord medicine 05/2013; 36(3):174-190. · 1.54 Impact Factor
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    ABSTRACT: The DSM-IV-TR specifies 12 behavioral features that can occur in hundreds of possible combinations to meet diagnostic criteria for autism spectrum disorder (ASD). This paper describes the frequency and variability with which the 12 behavioral features are documented in a population-based cohort of 8-year-old children under surveillance for ASD, and examines whether documentation of certain features, alone or in combination with other features, is associated with earlier age of community identification of ASD. Statistical analysis of behavioral features documented for a population-based sample of 2,757 children, 8 years old, with ASD in 11 geographically-defined areas in the US participating in the Autism and Developmental Disabilities Monitoring Network in 2006. The median age at ASD identification was inversely associated with the number of documented behavioral features, decreasing from 8.2 years for children with only seven behavioral features to 3.8 years for children with all 12. Documented impairments in nonverbal communication, pretend play, inflexible routines, and repetitive motor behaviors were associated with earlier identification, whereas impairments in peer relations, conversational ability, and idiosyncratic speech were associated with later identification. The age dependence of some of the behavioral features leading to an autism diagnosis, as well as the inverse association between age at identification and number of behavioral features documented, have implications for efforts to improve early identification. Progress in achieving early identification and provision of services for children with autism may be limited for those with fewer ASD behavioral features, as well as features likely to be detected at later ages.
    Journal of the American Academy of Child and Adolescent Psychiatry 04/2013; 52(4):401-413.e8. · 6.97 Impact Factor
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    ABSTRACT: Commercial closed-suctions drainage systems are commonly used in the United States and many other countries for use in neurosurgical cases. However, in Tanzania and other developing nations with fewer resources, these are not available. This report explores another option for a closed-system drainage system utilizing inexpensive supplies found commonly in hospitals around the world. Sterile IV-tubing is cut, inserted into the wound, and brought out through an adjacent puncture incision. For suction, an empty plastic bottle can be attached to the tubing. The IV-tubing closed-suction drainage system was applied in both cranial and spinal neurosurgical procedures, including as subdural, subgaleal, epidural, and suprafacial drains. It maintained suction and was an adequate substitute when commercial drains are unavailable. This report illustrates how sterile IV-tubing can be adapted for use as a closed-drainage system. It utilizes inexpensive supplies commonly found in many hospitals throughout the world and can be applied to both cranial and spinal neurosurgical procedures.
    Surgical Neurology International 01/2013; 4:76. · 1.18 Impact Factor
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    ABSTRACT: Autism spectrum disorders (ASD) prevalence estimates derived from a single data source under-identify children and provide a biased profile of case characteristics. We analyzed characteristics of 1,919 children with ASD identified by the Autism and Developmental Disabilities Monitoring Network. Cases ascertained only at education sources were compared to those identified at health sources. 38 % were education-only. These were older at their earliest evaluation (54.5 vs. 42.0 months, p < 0.001) and earliest ASD diagnosis (62 vs. 53 months, p < 0.001). More lived in census blocks with lower adult education (p < 0.001). Lower educational attainment of adults in census blocks of residence of education-only cases suggests disparities in access to clinical services with the schools providing crucial services to many families.
    Journal of Autism and Developmental Disorders 12/2012; · 3.06 Impact Factor
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    ABSTRACT: BACKGROUND: The treatment of acute ischemic stroke is traditionally centered on time criteria, although recent evidence suggests that physiologic neuroimaging may be useful. In a multicenter study we evaluated the use of CT perfusion, regardless of time from symptom onset, in patients selected for intra-arterial treatment of ischemic stroke. METHODS: Three medical centers retrospectively assessed stroke patients with a National Institute of Health Stroke Scale of ≥8, regardless of time from symptom onset. CT perfusion maps were qualitatively assessed. Patients with defined salvageable penumbra underwent intra-arterial revascularization of their occlusion. Functional outcome using the modified Rankin Score (mRS) was recorded. RESULTS: Two hundred and forty-seven patients were selected to undergo intra-arterial treatment based on CT perfusion imaging. The median time from symptom onset to procedure was 6 h. Patients were divided into two groups for analysis: ≤8 h and >8 h from symptom onset to endovascular procedure. We found no difference in functional outcome between the two groups (42.8% and 41.9% achieved 90-day mRS ≤ 2, respectively (p=1.0), and 54.9% vs 55.4% (p=1.0) achieved 90-day mRS ≤ 3, respectively). Overall, 48 patients (19.4%) had hemorrhages, of which 20 (8.0%) were symptomatic, with no difference between the groups (p=1.0). CONCLUSIONS: In a multicenter study, we demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CT perfusion selection rather than time-guided selection. Our findings suggest that physiologic imaging-guided patient selection rather than time for endovascular reperfusion in ischemic stroke may be effective and safe.
    Journal of Neurointerventional Surgery 11/2012; · 2.50 Impact Factor
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    ABSTRACT: BACKGROUND: Patient selection for acute ischemic stroke has been largely driven by time-based criteria, although emerging data suggest that image-based criteria may be useful. The purpose of this study was to directly compare outcomes of patients treated within a traditional time window with those treated beyond this benchmark when CT perfusion (CTP) imaging was used as the primary selection tool. METHODS: A prospectively collected database of all patients with acute ischemic stroke who received intra-arterial therapy at the Medical University of South Carolina was retrospectively analyzed, regardless of time from symptom onset. At presentation, CTP maps were qualitatively assessed. Selected patients underwent intra-arterial therapy. Functional outcome according to the modified Rankin scale (mRS) score at about 90 days was documented. RESULTS: 140 patients were included in the study. The median time from symptom onset to groin access was 7.0 h. Overall, 28 patients (20%) had bleeding complications, but only 10 (7.1%) were symptomatic. The average National Institute of Health Stroke Scale (NIHSS) score for patients treated ≤7 h from symptom onset was 17.3 and 30.2% had a mRS score of 0-2 at 90 days. Patients treated >7 h from symptom onset had an average NIHSS score of 15.1 and 45.5% achieved a mRS score of 0-2 at 90 days (p=0.104). Patients in the two groups had similar rates of symptomatic intracerebral hemorrhage (8.5% and 5.8%, respectively; p=0.745). CONCLUSIONS: No difference was found in the rates of good functional outcome between patients treated ≤7 h and those treated >7 h from symptom onset. These data suggest that imaging-based patient selection is a safe and viable methodology.
    Journal of Neurointerventional Surgery 08/2012; · 2.50 Impact Factor
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    ABSTRACT: The Autism and Developmental Disabilities Monitoring Network (ADDM), sponsored by the Centers for Disease Control and Prevention, is the largest-scale project ever undertaken to identify the prevalence of Autism Spectrum Disorders (ASD) in the United States. The objective of the present study was to examine the accuracy of the ADDM methodology in terms of completeness of case ascertainment; that is, to assess the success of the ADDM Network in identifying and accurately classifying all existing cases of ASD among 8-year-old children in the target study areas. To accomplish this objective, the ADDM methodology was applied to a selected region of South Carolina for 8-year olds in 2000 (birth year 1992) and again seven years later for the same region and birth year. For this region and birth year, completeness of case ascertainment was high, with prevalence estimates of 7.6 per 1000 at both ages 8- and 15-years. For children common to both surveillance years, concordance in case status was also high (82%). Given that prevalence did not change within this region and birth year, continued research is needed to better understand the changes in prevalence estimates being found by the ADDM network across surveillance groups.
    Disability and Health Journal 07/2012; 5(3):185-9. · 1.50 Impact Factor
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    ABSTRACT: Background: Data from the Centers for Disease Control and Prevention indicates that approximately 1 in 110 8-year-old children are affected with an Autism Spectrum Disorder (ASD). Different studies have found a variety of perinatal and neonatal factors as risk factors for ASD, but the data is inconsistent and often lacks a comparison population. Objectives: The purpose of this study was to link data from the South Carolina Autism and Developmental Disabilities Monitoring Project (SC ADDM) with the Perinatal Information System (PINS) at the Medical University of South Carolina (MUSC) to allow exploration of perinatal and neonatal factors for a group of children with ASD and a control group without ASD. Methods: Information was collected on 8-year old children (born in 1992, 1994, 1996, 1998, and 2000) residing in a 23-county area of South Carolina between 2000 and 2008 as part of an ongoing, population-based multiple source surveillance of Autism Spectrum Disorders in South Carolina. At MUSC the Division of Pediatric Epidemiology oversees an integrated patient information system referred to as the Perinatal Information System (PINS). The data contained in this system encompass the events and clinical experiences of maternal and child outcomes from the onset of pregnancy until discharge from developmental pediatrics care and include almost 4,000 different perinatal and neonatal variables. This data has been collected and maintained since 1992. Data from the two databases will be linked. For children with an ASD that are linked to the PINS database, an additional 3 controls from PINS will be picked and matched on age, gender, and race. Differences in perinatal and neonatal risk factors will be compared between the groups and possible associations with ASD risk will be assessed. Results: To date, only 1 of the 5 study years has been linked. In 2000, there were 2,463 births documented in the PINS dataset. In 2008, there were 264 children with a confirmed surveillance case of ASD. Approximately 12% of the children with ASD (n=31) from SC ADDM were located in the PINS database. The group was 58% black, 42% white, 90% male and 10% female. There was no difference in insurance status (private, Medicaid, self-pay) between the two groups. Conclusions: The initial findings indicate the feasibility of performing this data linkage. Based on the current knowledge of prevalence, we would expect approximately 1% of the 2,463 births to be confirmed with ASD. In fact, the 31 children represent 1.26% of the cohort with ASD. Further there was a larger than expected percentage of African Americans found in this population. The outcome allows further exploration of this group that, to date, has little information available. It is planned to complete the linkage of the remaining 4 study years (includes 609 children with ASD from SC ADDM) with PINS and expect approximately 73 more matches, to total 104 children linked between the 2 databases. Variables to be explored include birth weight, past pregnancy outcome, parity, prenatal information, maternal pregnancy complications, maternal therapy, neonatal diagnosis, neonatal medications, and neonatal procedures.
    2012 International Meeting for Autism Research; 05/2012
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    ABSTRACT: Background: More than half of children with autism spectrum disorders (ASD) are prescribed psychotropic medication for treating problem behaviors. To date, only one study has assessed any treatment adherence in ASD (Moore 2011), even though adherence is an important predictor of treatment outcome. Adherence research in other chronic conditions suggests that medication adherence is poor among young children, particularly those with chronic or mental health conditions. Objectives: This study will describe multiple measures of medication adherence and identify predictors of poor adherence to medications among Medicaid-eligible children with ASD. Methods: Medicaid-eligible children who were identified with an ASD by the South Carolina Autism and Developmental Disabilities Monitoring Network (SCADDM) across 5 study years (2000, 2002, 2004, 2006, and 2008) were included. All confidentiality procedures were followed and appropriate regulatory approvals were granted. Data linkages were made using unique identifiers common to both datasets; protected health information was removed following this linkage, resulting in a completely de-identified database. Child characteristic variables included age, race, gender, intellectual disability, co-occurring conditions, ASD diagnostic history, and indicators of behavioral and emotional problems (e.g., the presence of associated features such as tantrums, self-injurious behavior, hyperactivity, etc and DSM-IV diagnostic criteria). Medicaid data included for each child the individual eligibility status, county of residence, amount paid per claim, dispense date, drug name and therapeutic class, dosage, quantity, days supply, and prescribing provider type. The primary outcome measure was adherence, measured by the validated (Karve 2008) Medication Possession Ratio (MPR) and defined as the number of days supply in the index period divided by the number of days in the study period. Additional outcome measures included the proportion of days covered (PDC), and the refill compliance rate (RCR). To quantify the complexity of medication regimens and the impact on adherence, a modified version of the Medication Regimen Complexity Index (MRCI) (George 2004) was used. This index includes the total number of medications, dosing schedule, dosing form (e.g., pill, liquid, etc), and special instructions (e.g., “take on an empty stomach”). Categorical and continuous variable differences were assessed using chi-square or t tests respectively. Results: Medication adherence is a complex phenomenon that appears to be best represented via multiple methodologies. Patient-related factors (e.g., knowledge of the condition as evidenced by a documented formal diagnosis), condition-related factors (e.g., associated features, co-occurring mental health disorders), and medication regimen-related factors (e.g., medication regimen complexity index) are among the most robust predictors of adherence. Conclusions: Results provide a more complete and precise estimate of medication adherence in ASD by combining population-based data and Medicaid. Appreciating factors associated with poor adherence could lead to targeted interventions aimed at improving medication-taking habits, and ultimately improving treatment outcomes.
    2012 International Meeting for Autism Research; 05/2012
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    ABSTRACT: Background: Omega-3 fatty acids are essential for brain development and function, and may play a role in gene expression. Omega-3 fatty acid supplementation has shown some promise in recent pilot studies in treating associated behavioral problems, particularly hyperactivity, in autism. Objectives: This double blind placebo controlled trial evaluated the safety and efficacy of omega-3 fatty acid supplementation on hyperactivity and other behaviors in children with autism. The study also investigated whether changes in plasma fatty acid concentration and cytokine markers were associated with behavioral changes in response to treatment. Methods: Children with ADOS-confirmed autism (n=58) were randomized to receive 12 weeks of omega-3 fatty acid supplementation (625 mg DHA and 875 mg EPA per day) or a soybean oil placebo matched for scent and appearance. Soybean oil provides Omega-6 fatty acids (linoleic acid), but not Omega-3 fatty acids. Plasma fatty acid concentrations and cytokine markers were measured at baseline and again at 12 weeks. Behavioral changes were monitored at three time points (baseline, 6 weeks, and 12 weeks) via the Aberrant Behavior Checklist and PDD-Behavior Inventory. Adverse events and treatment adherence were monitored bi-weekly. Results: The treatment was well-tolerated by both groups, with no serious adverse events in either group, and no differences between groups in terms of adverse events or side effects. In the unadjusted analysis, the active treatment group demonstrated a significant increase in DHA and EPA in plasma blood concentrations relative to the control group. Adjusting for baseline behavior scores, age, gender, race, and baseline severity of illness by ANCOVA analysis did not reveal significant differences in hyperactivity for the active treatment and control groups. In addition, ANCOVA analyses also did not reveal significant group differences for other associated behavioral problems in autism (e.g. irritability) or for core symptoms of autism. Conclusions: Omega-3 fatty acid supplementation appears to be safe and effective in increasing DHA and EPA in plasma blood concentration. This study did not demonstrate improvements in hyperactivity, or in other core or associated symptoms of autism.
    2012 International Meeting for Autism Research; 05/2012
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    ABSTRACT: Past research is inconsistent in the stability of autism spectrum disorder (ASD) diagnoses. The authors therefore sought to examine the proportion of children identified from a population-based surveillance system that had a change in classification from ASD to non-ASD and factors associated with such changes. Children with a documented age of first ASD diagnosis noted in surveillance records by a community professional (n = 1392) were identified from the Autism and Developmental Disabilities Monitoring Network. Children were considered to have a change in classification if an ASD was excluded after the age of first recorded ASD diagnosis. Child and surveillance factors were entered into a multivariable regression model to determine factors associated with diagnostic change. Only 4% of our sample had a change in classification from ASD to non-ASD noted in evaluation records. Factors associated with change in classification from ASD to non-ASD were timing of first ASD diagnosis at 30 months or younger, onset other than developmental regression, presence of specific developmental delays, and participation in a special needs classroom other than autism at 8 years of age. Our results found that children with ASDs are likely to retain an ASD diagnosis, which underscores the need for continued services. Children diagnosed at 30 months or younger are more likely to experience a change in classification from ASD to non-ASD than children diagnosed at 31 months or older, suggesting earlier identification of ASD symptoms may be associated with response to intervention efforts or increased likelihood for overdiagnosis.
    Journal of developmental and behavioral pediatrics: JDBP 05/2012; 33(5):387-95. · 2.27 Impact Factor
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    ABSTRACT: Pulsatile arterial compression (AC) of the ventrolateral medulla (VLM) is hypothesized to produce the hypertension in a subset of patients with essential hypertension. In animals, a network of subpial neuronal aggregates in the VLM has been shown to control cardiovascular functions. Although histochemically similar, neurons have been identified in the retro-olivary sulcus (ROS) of the human VLM, but their function is unclear. The authors recorded cardiovascular responses to electrical stimulation at various locations along the VLM surface, including the ROS, in patients who were undergoing posterior fossa surgery for trigeminal neuralgia. This vasomotor mapping of the medullary surface was performed using a bipolar electrode, with stimulation parameters ranging from 5- to 30-second trains (20-100 Hz), constant current (1.5-5 mA), and 0.1-msec pulse durations. Heart rate (HR) and blood pressure (BP) were recorded continuously from baseline (10 seconds before the stimulus) up to 1 minute poststimulus. In 6 patients, 17 stimulation responses in BP and HR were recorded. The frequency threshold for any cardiovascular response was 20 Hz; the stimulation intensity threshold ranged from 1.5 to 3 mA. In the first patient, all stimulation responses were significantly different from sham recordings (which consisted of electrodes placed without stimulations). Repeated stimulations in the lower ROS produced similar responses in 3 other patients. Two additional patients had similar responses to single stimulations in the lower ROS. Olive stimulation produced no response (control). Hypotensive and/or bradycardic responses were consistently followed by a reflex hypertensive response. Slight right/left differences were noted. No patient suffered short- or long-term effects from this stimulation. This stimulation technique for vasomotor mapping of the human VLM was safe and reproducible. Neuronal aggregates near the surface of the human ROS may be important in cardiovascular regulation. This method of vasomotor mapping with measures of responses in sympathetic tone (microneurography) should yield additional data for understanding the neuronal network that controls cardiovascular functions in the human VLM. Further studies in which a concentric bipolar electrode is used to generate this type of vasomotor map should also increase understanding of the pathophysiological mechanisms of neurogenically mediated hypertension, and assist in the design of studies to prove the hypothesis that it is caused by pulsatile AC of the VLM.
    Journal of Neurosurgery 04/2012; 117(1):150-5. · 3.15 Impact Factor
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    ABSTRACT: Reported associations between gestational tobacco exposure and autism spectrum disorders (ASDs) have been inconsistent. We estimated the association between maternal smoking during pregnancy and ASDs among children 8 years of age. This population-based case-cohort study included 633,989 children, identified using publicly available birth certificate data, born in 1992, 1994, 1996, and 1998 from parts of 11 U.S. states subsequently under ASD surveillance. Of these children, 3,315 were identified as having an ASD by the active, records-based surveillance of the Autism and Developmental Disabilities Monitoring Network. We estimated prevalence ratios (PRs) of maternal smoking from birth certificate report and ASDs using logistic regression, adjusting for maternal education, race/ethnicity, marital status, and maternal age; separately examining higher- and lower-functioning case subgroups; and correcting for assumed under-ascertainment of autism by level of maternal education. About 13% of the source population and 11% of children with an ASD had a report of maternal smoking in pregnancy: adjusted PR (95% confidence interval) of 0.90 (0.80, 1.01). The association for the case subgroup autistic disorder (1,310 cases) was similar: 0.88 (0.72, 1.08), whereas that for ASD not otherwise specified (ASD-NOS) (375 cases) was positive, albeit including the null: 1.26 (0.91, 1.75). Unadjusted associations corrected for assumed under-ascertainment were 1.06 (0.98, 1.14) for all ASDs, 1.12 (0.97, 1.30) for autistic disorder, and 1.63 (1.30, 2.04) for ASD-NOS. After accounting for the potential of under-ascertainment bias, we found a null association between maternal smoking in pregnancy and ASDs, generally. The possibility of an association with a higher-functioning ASD subgroup was suggested, and warrants further study.
    Environmental Health Perspectives 04/2012; 120(7):1042-8. · 7.26 Impact Factor
  • Journal of Neurosurgery 04/2012; · 3.15 Impact Factor

Publication Stats

743 Citations
178.57 Total Impact Points


  • 1998–2014
    • Medical University of South Carolina
      • • Division of Biostatistics and Epidemiology
      • • Department of Medicine
      Charleston, South Carolina, United States
  • 2013
    • University of Pittsburgh
      • Department of Neurological Surgery
      Pittsburgh, PA, United States
  • 2009
    • University of North Carolina at Chapel Hill
      • Department of Epidemiology
      Chapel Hill, NC, United States