CHICAGO—The clinical onset of autism appears to be preceded by two phases of brain growth abnormality, according to a study published in the July 16 issue of The Journal of the American Medical Association (JAMA).

"Behavioral signs and symptoms during the second and third years of life, including delayed speech, unusual social and emotional reactions, and poor attention to and exploration of the environment, raise warnings that a child might have autism," the authors provide as background information in the article. "Autism is a neurobiological disorder, and neurobiological abnormalities must necessarily precede the first behavioral expressions of the disorder. However, such neurobiological early warning signs have not yet been discovered for autism."

Eric Courchesne, Ph.D., from the University of California, San Diego, La Jolla, Calif., and colleagues analyzed data, including head circumference (HC), body length and body weight measurements, from the medical records of 48 children with autism spectrum disorder (ASD) aged two to five years. The children had previously participated in magnetic resonance imaging (MRI) studies reporting age-related changes in the brain in autism.

Of the 48 participants with ASD, 15 (12 males and 3 females) had pediatric HC measurements at four age periods: birth, one to two months, three to five months, and six to 14 months, and were termed the longitudinal group. The remaining 33 children (29 males and 4 females) were termed the partial HC data group because they had HC measurements at birth and six to 14 months (n=7) and at birth only (n= 28). Two of the participants did not have a birth HC measurement, but did have an HC measurement at two weeks of age.

"This is the first study to our knowledge to find a potential early warning biological sign for autism and to link it to a later brain abnormality," the authors write. "Specifically, we found a rapid and excessive increase in HC measurements, and therefore, presumably, brain size, beginning several months after birth. This abnormally accelerated rate of increase in HC measurements in infants with ASD was evident in comparisons to two nationally recognized normative databases, one a national cross-sectional survey and the other a longitudinal study of growth patterns in healthy infants. In our study, head size increased from the 25th percentile based on the Centers for Disease Control and Prevention (CDC) averages of healthy infants to the 84th percentile in six to 14 months. This excessive increase occurred well before the typical onset of clinical behavioral symptoms," the authors report.

The researchers add that only six percent of the individual healthy infants in the longitudinal data showed accelerated HC growth trajectories from birth to six to 14 months; 59 percent of infants with autistic disorder showed these accelerated growth trajectories.

CHICAGO—Behavioral training for urinary stress incontinence (caused by stress such as coughing or sneezing) in a clinic-based program with or without pelvic floor electrical stimulation is more effective than self-help booklets, according to a study in the July 16 issue of The Journal of the American Medical Association (JAMA).

According to background information from the authors, pelvic floor electrical stimulation (PFES) has been used for the treatment of urinary incontinence since 1952 and is widely used. PFES activates certain nerves causing contraction of muscles in the pelvic floor. "This provides a form of passive exercise with the goal of improving the urethral closure mechanism. In addition, PFES can be useful in teaching pelvic floor muscle contraction to women who cannot identify or contract these muscles voluntarily because of extreme weakness."

Patricia S. Goode, M.D. from the Department of Veterans Affairs Medical Center, and the Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham, Ala., and colleagues analyzed data from 200 women, aged 40 to 78 years with stress or mixed incontinence, to determine if PFES enhances the outcome of behavioral training in the treatment of stress incontinence.

The participants were randomly assigned to behavioral training (biofeedback-assisted pelvic floor muscle training, home exercises, bladder control strategies, and self-monitoring with bladder diaries), or the same program with the addition of home PFES treatments, or a control group consisting of self-administered behavioral training with a self-help booklet. For all patients, treatment was implemented over an eight-week period.

"Before treatment, the weekly frequency of incontinence was similar across the three groups," the authors report. "Behavioral training resulted in a mean (average) 68.6 percent reduction in frequency of episodes; behavioral training plus PFES, a mean 71.9 percent reduction; and treatment with the self-help booklet, a mean 52.5 percent reduction. ... The results of this study show that PFES did not enhance the outcomes of biofeedback-assisted behavioral training for stress incontinence in women." The authors continue, "Although PFES did not improve results on the primary outcome measure (reduction of incontinent episodes), patient self-reports indicated that women in the PFES group perceived significantly better outcomes."

CHICAGO—Patients with SARS often experience critical illness primarily involving severe respiratory failure, according to an article in the July 16 issue of The Journal of the American Medical Association (JAMA).

Severe acute respiratory syndrome (SARS) is a newly recognized illness that has rapidly spread through Asia, North America and Europe. According to the article, as of June 9, 2003, 8,241 people in 30 countries have developed SARS leading to 784 deaths. SARS typically produces an acute respiratory illness with 23 percent to 32 percent of patients becoming critically ill.

Robert A. Fowler, M.D., M.S., and Stephen E. Lapinsky, M.B., B.Ch., of the University of Toronto, and colleagues characterized the course, characteristics and 28-day outcomes in critically ill patients with SARS, and evaluated the effect of SARS transmission from critically ill patients to health care workers.

The researchers studied 38 adult patients who were critically ill due to SARS who were admitted to 13 intensive care units in the Toronto area between the onset of the SARS outbreak, and April 15, 2003. The researchers collected clinical data on the patients for each of the first 7 days of their admission in the intensive care unit (ICU), and followed them up for a total of 28 days.

The researchers found that of 196 patients with SARS, 38 (19 percent) became critically ill, and 7 (18 percent) of the critically ill were health care workers. The average age of the patients was 57.4 years. The average time between the first symptoms of SARS and admission to an intensive care unit was 8 days. The researchers also found that 29 patients (76 percent) required mechanical ventilation. After 28 days, 13 of the 38 critically ill patients had died (34 percent). Thirteen (45 percent) of the 29 patients on ventilators died within 28 days. Six patients (16 percent) remained ventilated at 28 days, two of whom died by 8 weeks follow-up. The researchers report that patients who died were more often older and had preexisting diabetes mellitus.

The researchers also found that in 2 of the university intensive care units studied, 164 health care workers were quarantined and 16 (10 percent) developed SARS. These events had a significant impact on Toronto's critical care resources, according to the authors.

"In this study, we identified that a high proportion of patients with probable and suspected SARS became critically ill," write the authors. "We found that the median [average] time from symptom onset to death was 19 days, with many deaths occurring beyond the follow-up time of previously reported SARS epidemiological studies."

UNUSUALLY RAPID INCREASE IN HEAD CIRCUMFERENCE BETWEEN BIRTH AND 12 MONTHS OF AGE MAY BE INDICATOR OF AUTISM