ME/CFS is real: confirmation if it is needed...

"Scientists discover robust evidence that chronic fatigue syndrome is a biological illness" went the title of the press release for the study by Mady Hornig and colleagues [1] (open-access) detailing an immune 'signature' and also possible staging of the illness.

I couldn't help but wince at some of the media headlines reporting on this study as 'proof' that chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME) is a real illness. As I've indicated before on this blog (see here) anyone who has trawled through the collected peer-reviewed research in this area would be hard pressed to arrive at any other conclusion than that CFS/ME is very real and severely impacts on a person's quality of life. I say that accepting that the various definitions and descriptions of the conditions (note the plural) have not always been kind to CFS/ME research and to a large extent, perhaps held back science from making the breakthroughs we've potentially seen with the Hornig results. Hopefully SEID [systemic exertion intolerance disease] might help this process along a little...

Back to the paper:

• The authorship of the latest research paper includes the great and the good of CFS/ME (and autism) research. Mady Hornig and Ian 'virus hunter' Lipkin have talked quite a bit in recent times about their research commitment to CFS/ME following the whole XMRV de-discovery issue a few years back (see here). José Montoya has similarly impressed with the idea that certain anti-virals *might* be indicated for some cases of CFS/ME (see here).
• Cytokines - those chemical messengers of the immune system - were the target molecules predominating in the Hornig paper taking into account "diagnosis and other clinical variables". Said immune molecules (over 50 of them) were analysed in nearly 300 participants diagnosed with CFS/ME compared against nearly 350 asymptomatic controls. Authors drew on participants derived from two large US studies of CFS/ME, and those all-important case definitions relied on meeting either or both of the "1994 CDC Fukuda criteria... and the 2003 Canadian consensus criteria for ME/CFS." Participants were also categorised according to how long they had reported experiencing symptoms.
• Results: "No substantive differences were found between cases and controls when short- and long-duration cases were combined and compared with healthy control subjects." You could see how that sentence could be taken by certain people/groups. But... "Analyses that considered duration of illness revealed that early ME/CFS cases had a prominent activation of both pro- and anti-inflammatory cytokines as well as a dissociation of characteristic intercytokine regulatory networks." Those describing a shorter duration of illness, as a group, presented with elevated levels of several proinflammatory cytokines than controls or longer illness duration participants. As per the press release: "The association was unusually strong with a cytokine called interferon gamma that has been linked to the fatigue that follows many viral infections, including Epstein-Barr virus (the cause of infectious mononucleosis)." When they say 'unusually strong association', they talk about an odds ratio (OR) of 104.77 (95% CI, 6.975 to 1574.021; P = 0.001) (noting the very wide confidence intervals too).
• Various other analyses were also applied to the data. "The CART (Classification and Regression Tree) decision tree machine learning method was applied to plasma cytokine and clinical covariate data to find predictors that distinguished ME/CFS cases of short illness duration (≤3 years) from those with a long illness duration (>3 years)." In that respect, the age of participants seemed to play something of a role in the results obtained. But, the authors also acknowledge that this data was "not then validated on an independent test set."
• Discussions surround the possible reasons for the results obtained, particularly how symptom duration seemed to play an important role in the authors' findings. I do like the idea that "an “exhaustion” of the cytokine-producing cells" might account for why there seems to be a 'burst' of immune system involvement in the early stages of the disease followed by a kind of cytokine burn-out. "The study supports the idea that ME/CFS may reflect an infectious "hit-and-run" event" is one way of looking at it.

What's more to say about this work? Well, we might be seeing 'immune markers' mentioned a little more in CFS/ME research circles in the near future on top of what has been previously reported (see here). Whether specific cytokine profiles might be considered 'diagnostic' for CFS/ME needs quite a bit more replication before anyone gets too ahead of themselves. That being said, as and when such a profile is detected, one might reasonably assume that there could be ways and means to intervene. Another quote: "There are already human monoclonal antibodies on the market that can dampen levels of a cytokine called interleukin-17A that is among those the study shows were elevated in early-stage patients." I say this without making any judgement calls nor providing anything that looks, sounds or smells like clinical/medical advice. I might also advance the idea that other factors might also link into something like IL-17A (see here).

I'm also minded to say that the excitement over immune issues being associated with CFS/ME shouldn't also push other areas back into the shadows as per the very interesting findings being reported on things like mitochondrial function (see here), the gut microbiota (see here) and potential intervention options (see here) to name but a few.

Still, only a few months into 2015 and CFS/ME (or SEID if you wish) is really making some research headlines...

[Update: 2 March 2015: The full IoM report is available here].

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[1] Hornig M. et al. Distinct plasma immune signatures in ME/CFS are present early in the course of illness. Science Advances. 2015; 1: 1: e1400121.

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Mady Hornig, José G. Montoya, Nancy G. Klimas, Susan Levine, Donna Felsenstein, Lucinda Bateman, Daniel L. Peterson, C. Gunnar Gottschalk, Andrew F. Schultz, Xiaoyu Che, Meredith L. Eddy, Anthony L. Komaroff, & W. Ian Lipkin (2015). Distinct plasma immune signatures in ME/CFS are present early in the course of illness Science Advances, 1 (1) : http://dx.doi.org/10.1126/sciadv.1400121

Hyperprolactinemia and risperidone use in autism

The findings reported by Yaowaluck Hongkaew and colleagues [1] (open-access) on prolactin levels being "positively and significantly associated with risperidone dose" in cases of children and adolescents diagnosed with an autism spectrum disorder (ASD) is the point of discussion today.

Prolactin by the way, is the hormone most commonly associated with stimulating breast development and milk production in women. To quote from the US National Institute of Health (NIH) entry on prolactin: "There is no known normal function for prolactin in men." Risperidone is a neuroleptic (antipsychotic) which has quite a few clinical indications including for the management of irritability in (some) autism [2]. Indeed, risperidone is one of the few (only?) drugs to be specifically approved for pediatric autism and dealing with irritability.

It's been known for a while that risperidone use is associated with elevations in prolactin levels [3]. More recently, the research base has expanded to suggest that various factors might impact on the elevations in prolactin correlated with risperidone use [4] including "sex, pubertal stage, psychiatric disease, and associated autoimmune disorders."

So, then to the Hongkaew study which is open-access but...

• Data on 147 children and young adults diagnosed with an autism spectrum disorder (ASD) were included for study. "All participants receiving a risperidone-based regimen for at least 4 weeks were enrolled in this study." Researchers also made sure that (a) medication was taken before the donation of a blood sample, and (b) participants were not taking other medications "that could potentially affect risperidone metabolism and prolactin elevation." This did not however exclude all other medicines.
• Said blood draws was analysed for serum prolactin concentration using a chemiluminescence immunoassay system.
• Results: "mean risperidone dose of the subjects was 1 mg/day or 0.03 mg/kg/day" and "mean duration of therapy was 46.06 months". Sixty-six participants (44%) presented with hyperprolactinemia - elevated levels of serum prolactin - most of whom were male. 
• Dosage of risperidone also seemed to have an effect on prolactin results: "The median prolactin level at the high dose was significantly higher than at the recommended dose and low dose" based on categorisations of dose higher or lower than the FDA recommended amount taking into account body weight.
• Duration of treatment, age, weight and other variables did not show any statistical correlation with prolactin levels.
• The authors conclude: "This information will be helpful to clinicians by providing significantly important clinical information to properly inform therapeutic practice and prevent sexual dysfunction consequently in autistic children treated with risperidone."

I don't mean to come down too hard on risperidone with this post but this is not the first time that prolactin levels have been reported as elevated when it comes to autism [5] following the use of this pharmaceutic. Aside from the aesthetic changes potentially associated with higher prolactin levels and in particular, their potential effects on males (the subject of litigation), there is some suggestion in the literature that elevations in prolactin over the longer term might elevate risk of certain other issues [6] albeit correlation not necessarily being the same as causation and reiterating the duration of treatment measured by Hongkaew et al. As an aside, I'm going to be coming to the paper by Stubbs and colleagues [7] in the near future in light of other work on the potential effects of elevated prolactin.

Insofar as the use of risperidone for managing irritability in cases of autism, I've talked before about it's usefulness in this area and how certain adjuvant therapies might also help (see here). Accepting that irritability under the heading of 'challenging behaviours' is a mighty complicated issue (see here) and potentially tied into many different factors, there remains a place for risperidone under certain circumstances (assuming good medicines management accompanies such use). 

Still, the collected literature on prolactin and risperidone use with autism in mind adds a cautionary note to this medicine and other relations allied to other important side-effects such as weight gain. Use and monitor with care is perhaps the important message from the Hongkaew and other data...

Music: the quite controversial Disarm from the Smashing Pumpkins.

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[1] Hongkaew Y. et al. Hyperprolactinemia in Thai children and adolescents with autism spectrum disorder treated with risperidone. Neuropsychiatr Dis Treat. 2015 Jan 22;11:191-6.

[2] Dinnissen M. et al. Clinical and pharmacokinetic evaluation of risperidone for the management of autism spectrum disorder. Expert Opin Drug Metab Toxicol. 2015 Jan;11(1):111-24.

[3] Aboraya A. et al. Hyperprolactinemia associated with risperidone: a case report and review of literature. Psychiatry (Edgmont). 2004 Nov;1(3):29-31.

[4] Margari L. et al. Prolactin variations during risperidone therapy in a sample of drug-naive children and adolescents. Int Clin Psychopharmacol. 2015 Mar;30(2):103-8.

[5] Anderson GM. et al. Effects of short- and long-term risperidone treatment on prolactin levels in children with autism. Biol Psychiatry. 2007 Feb 15;61(4):545-50.

[6] Tworoger SS. et al. A 20-year prospective study of plasma prolactin as a risk marker of breast cancer development. Cancer Res. 2013 Aug 1;73(15):4810-9.

[7] Stubbs B. et al. Schizophrenia and the risk of fractures: a systematic review and comparative meta-analysis. Gen Hosp Psychiatry. 2015 Jan 15. pii: S0163-8343(15)00005-5.

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Hongkaew Y, Ngamsamut N, Puangpetch A, Vanwong N, Srisawasdi P, Chamnanphon M, Chamkrachchangpada B, Tan-Kam T, Limsila P, & Sukasem C (2015). Hyperprolactinemia in Thai children and adolescents with autism spectrum disorder treated with risperidone. Neuropsychiatric disease and treatment, 11, 191-6 PMID: 25653528

Carnitine and autism continued

The paper from everyone's favourite Saudi - Egyptian autism research tag-team that is Gehan Mostafa and Laila AL-Ayadhi [1] (open-access) on plasma polyunsaturated fatty acids and serum carnitine levels in a cohort of children diagnosed with autism / autism spectrum disorder (ASD) is served up for your reading delight today.

Regular readers of this blog might have heard me talk before about the pretty interesting research findings to come from this research partnership (see here and see here for example) covering all-manner of different sectors of the autism research environment.

This times around the name of the game was: "to investigate plasma levels of PUFAs [polyunsaturated fatty acids] and serum carnitine in relation to GI [gastrointestinal] manifestations in autistic children." The idea being that: "Carnitine and PUFAs are antiinflammatory molecules and their deficiency may result in GI inflammation and gut injury" following other work with autism in mind (see here).

A few pointers about the study might be in order:

• "This cross-sectional study was conducted on 100 children with autism." Participants ranged in age between 3-10 years and importantly were not taking additional fatty acids or anticonvulsants. A control group of 100 age- and sex-matched children asymptomatic for autism were also studied: "not related to the children with autism, and demonstrated no clinical findings suggestive of immunological, GI or neuropsychiatric disorders."
• Autism severity was assessed using the CARS and GI issues were examined "by an experienced pediatric gastroenterologist according to the Questionnaire on Pediatric Gastrointestinal Symptoms - Rome III Version used by previous studies that assessed gastrointestinal dysfunction in autism." Fasting blood samples were also provided and serum carnitine and plasma PUFAs examined.
• Results: both biological measures were lower as a group for the children with autism compared to controls. Indeed: "Low serum carnitine and plasma DHA [Docosahexaenoic acid], AA [Arachidonic acid], linolenic and linoleic acids, below the 5th percentile of the control values, were found in 66%, 62%, 60%, 43% and 38%, respectively of autistic children."
• Bearing in mind that PUFAs can exist in more than one form as per the old omega-3 / omega-6 issue (see here), authors also reported a group difference in the ratio of ω6/ω3 PUFAs: "ω6/w3 ratio (AA/DHA) was significantly higher in autistic patients" compared with controls. This is something also reported by the authors in other publications [2].
• GI symptoms were reported to be present in about half of the autism group. An important sentence is included about GI issues: "They were recurrent, severe and the patients were attending the clinic because of these agonizing symptoms." Further: "Autistic patients with GI manifestations had significantly lower serum carnitine and plasma DHA than patients without such manifestations."

I know I tend to say this about nearly every study I blog about but this is interesting work. Carnitine and autism is an area which I've got quite a bit of time for on this blog and the growing consistency in results suggesting lower levels of this stuff in quite a few cases of autism (see here). Some of the genetics of carnitine metabolism might also be 'linked' to at least some autism too (see here) with a particular focus on the idea of inborn errors of metabolism. Certainly, autism research should know a thing or two about them (see here).

The relationship between fatty acids and autism reflects a slightly less clear picture in terms of results. In a post going back to 2011, I talked about some of the peer-reviewed research on the use of supplementary fatty acids for autism (see here) and how certain comorbidity present in quite a bit of autism (see here) might be the bigger target. More recent research has kinda corroborated that idea (see here).

"How GI factors are related to autism is not yet clear" is another important quote from the authors. Yes, we are now in an era where there is general acceptance that certain functional GI issues are over-represented among those with autism (see here) but the hows and whys are still the source of significant speculation. I'd be minded to suggest that it's likely to be complicated and probably without a universal factor for everyone with autism and GI issues. There are some areas emerging that may yield further information such as examination (not hype) of those trillions of wee beasties which call our gut home (see here) and a 'possible' relationship with more pathological bowel states (see here). The Mostafa/AL-Ayadhi findings suggest another possible correlate.

I leave you with a quote from the authors: "these data should be treated with caution until further investigations are performed, with a larger subject population, to determine whether the occurrence of GI manifestations is a mere association or a consequence to reduced plasma PUFAs and serum carnitine levels in autistic patients." I couldn't agree more.

Music then. The Strokes with New York City Cops.

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[1] Mostafa GA. & AL-Ayadhi LY. Reduced levels of plasma polyunsaturated fatty acids and serum carnitine in autistic children: relation to gastrointestinal manifestations. Behavioral and Brain Functions 2015, 11:4.

[2] Mostafa GA. et al. A possible association between elevated serum levels of brain-specific auto-antibodies and reduced plasma levels of docosahexaenoic acid in autistic children. J Neuroimmunology. 2015. Jan 27.

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Mostafa, G., & AL-Ayadhi, L. (2015). Reduced levels of plasma polyunsaturated fatty acids and serum carnitine in autistic children: relation to gastrointestinal manifestations Behavioral and Brain Functions, 11 (1) DOI: 10.1186/s12993-014-0048-2

Analysing the salivary proteome in autism

The paper from Armand Ngounou Wetie and colleagues [1] (open-access here) reporting pilot results from a mass spectrometry based proteomic analysis of saliva in cases of autism or autism spectrum disorder (ASD) compared with asymptomatic controls is served up for your reading delight today. There has already been some media attention about this paper (see here).

It's an interesting paper for quite a few reasons; not least the continuing voyage of the analytical technique known as mass spectrometry into autism research (see here) and further beyond [2]. Mass spec by the way, represents a rather advanced way of looking at biological samples for potential biomarkers or compounds of interest to specific states or conditions (among other things). Ngounou Weite et al have some research form in this area as per a previous paper titled: 'Mass spectrometry as a tool for studying autism spectrum disorder' [3] which I would encourage you to peruse for some background reading.

Their latest study delves into an interesting analytical medium, saliva, something we all generally have and importantly, something pretty non-invasive when it comes to collecting a sample [4]. "Using nano liquid chromatography-tandem mass spectrometry, we found statistically significant differences in several salivary proteins" the authors report, comparing saliva samples from those with autism vs. asymptomatic controls. The sorts of differences detected between the groups - quite small groups (N=6 per) - tended to fall into the domain of 'immune function' as per issues with neutrophil elastase and various antigen binding sites of immunoglobulin. Indeed, the authors conclude: "Our results indicate that this is an effective method for identification of salivary protein biomarkers, support the concept that immune system and gastrointestinal disturbances may be present in individuals with ASDs." I would agree with those sentiments.

Aside from the small participant groups and the fact that all participants were male and many carried some comorbidity (ADHD, epilepsy) alongside their autism label, 4 of the participants with autism were taking some kind of pharmaceutic/nutraceutical compared with none of the controls. As per other biomarker studies of autism, one always needs to be a little mindful of any effects from these factors particularly when looking at functional biofluids. In terms of the mass spec method, it all looks pretty comprehensive including the use of Q-ToF as the detector of choice and pooled group samples run in triplicate to ensure some kind of reproducibility in results. The authors did subject saliva samples to some preparation before analysis as per their focus on peptide content and a "full MS scan [that] covered the m/z range from 400 to 1,350". What this might mean is that some very low molecular weight compounds and indeed, potentially important larger compounds might have escaped their attention. But certainly I'm not going to quibble about this for now.

Of course this is not the first time that saliva has been used as an analytical medium in autism research (see here) outside of just looking at parameters such as cortisol (see here). And I assume it won't be the last either...

Music to close: Jane's Addiction and Stop.

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[1] Ngounou Wetie AG. et al. A Pilot Proteomic Analysis of Salivary Biomarkers in Autism Spectrum Disorder. Autism Res. 2015 Jan 27. doi: 10.1002/aur.1450.

[2] Dumas M-E. & Davidovic L. Metabolic Profiling and Phenotyping of Central Nervous System Diseases: Metabolites Bring Insights into Brain Dysfunctions. Journal of Neuroimmune Pharmacology. 2015. Jan 24.

[3] Wood AG. et al. Mass spectrometry as a tool for studying autism spectrum disorder. Journal of Molecular Psychiatry 2013; 1: 6.

[4] Wormwood KL. et al. Salivary proteomics and biomarkers in neurology and psychiatry. Proteomics Clin Appl. 2015 Jan 29.

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Ngounou Wetie AG, Wormwood KL, Russell S, Ryan JP, Darie CC, & Woods AG (2015). A Pilot Proteomic Analysis of Salivary Biomarkers in Autism Spectrum Disorder. Autism research : official journal of the International Society for Autism Research PMID: 25626423

Maternal recall vs. medical records: implications for autism research

I don't want to dwell too much on the findings reported by Paula Krakowiak and colleagues [1] talking about the accuracy of "maternally-reported diabetes and hypertensive disorders, and reliability of BMI [body mass index] measurements during periconception and pregnancy compared with medical records when mothers are interviewed 2-5 years after delivery" but they are potentially important.

With authors such as Krakowiak and Irva Hertz-Picciotto on the paper in question, those who follow the autism research scene might have already made the connection back to the CHARGE (CHildhood Autism Risks from Genetics and the Environment) study (beincharge!) as the source of the current data. Indeed from CHARGE, findings such as a link between maternal obesity and offspring autism risk (see here) and maternal diabetes and autism (see here) have been previously discussed on this blog. For the most part, examination of such factors linked to subsequent offspring autism diagnosis has been through self-report and post-event questioning which potentially opens up such studies to various forms of bias.

The results from Krakowiak et al seemed to suggest when questioned about such issues: "self-reported diabetes and hypertensive disorders during periconception and pregnancy show high validity among mothers." Further: "Recall of pre-pregnancy BMI is reliable compared with self-reported values in medical records." In other words, still with some caution, families involved in initiatives such as CHARGE can and do quite accurately communicate their medical history. Of course this is not the first time that science has shown parentally-derived medical information to be pretty accurate when it comes to autism as per the Gorrindo findings [2]: "sensitive to the existence, although not necessarily the nature of" gastrointestinal issues related to autism (see here). That being said, developmental history recall is still subject to some forms of bias (see here).

There's little more for me to say about this topic aside from highlighting how: "Multiparity was associated with higher discrepancies in BMI and misreporting of hypertensive disorders" suggestive that 'the state of having borne a number of children' might interfere with recall in these areas. Still, when it comes to asking parents about their health and wellbeing before, during and after the birth of their children with autism research in mind and without over-generalising, one might be a little less critical of the value of the information received.

Music to close: The Flaming Lips and Race For The Prize. Scientists... don't race for the prize!

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[1] Krakowiak P. et al. Maternal Recall Versus Medical Records of Metabolic Conditions from the Prenatal Period: A Validation Study. Matern Child Health J. 2015 Feb 6.

[2] Gorrindo P. et al. Gastrointestinal dysfunction in autism: parental report, clinical evaluation, and associated factors. Autism Res. 2012 Apr;5(2):101-8.

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Krakowiak P, Walker CK, Tancredi DJ, & Hertz-Picciotto I (2015). Maternal Recall Versus Medical Records of Metabolic Conditions from the Prenatal Period: A Validation Study. Maternal and child health journal PMID: 25656730

Late, delayed and mis-diagnosis of autism

It's inevitable that with all the mountains of autism research published on a daily basis, certain themes will occur at certain times. My post today is reflective of one of those themes and how, on occasion, the autism diagnostic process does not run as smoothly as we would all like to think.

I start this post with a link to an article discussing some forthcoming research to be published titled: 'The autistic pupils ‘traumatised’ by delayed diagnosis'. Describing the results of a survey of parents included as part of a scheme of work (see here) where experiences of the diagnostic process were gauged, researchers reported that over half of parents were "unhappy with the diagnostic process" for their children. The observation that children were waiting an average of 3.5 years from initial contact with healthcare professionals to final receipt of a diagnosis is a pretty eye-watering statistic too, albeit a step up from previous research in this area [1].

Next up is the paper from Davidovitch and colleagues [2] reporting that: "Subsequent late diagnosis of ASD [autism spectrum disorder] after an initial ASD-negative comprehensive assessment is a common clinical experience." Based on an: "Extensive chart review of patients' electronic medical records" from "a representative population-based registry of patients seen during 2004 to 2011" researchers reported that over 200 children were diagnosed with an ASD after their 6th birthday "although their initial comprehensive developmental evaluations before the age of 6 were negative for ASD." The authors discuss possible reasons for the reversal of diagnosis including "evolving diagnosis as well as missed and overdiagnosed cases of ASD."

Finally, is the paper from Aggarwal & Angus [3] with the conclusion: "ASDs can go undetected during childhood and these clients can sometimes present during adolescence to mental health services for a psychiatric comorbidity." This followed their experiences of a diagnosis of autism being potentially missed or masked during childhood, only to be picked up during adolescence when a referral was made "for a psychiatric comorbidity."

Taken as a collection, these articles/features reiterate that the diagnosis and diagnostic process of autism is often a very complicated thing even before one starts to talk about politics, the availability of resources to undertake such a task and on occasion, actually getting someone to take notice of the need for a referral (see here). I've talked before on this blog about the various factors than can influence the age of autism diagnosis (see here) stressing for example, the fluidity in behavioural expression particularly during the early years (see here) and even into adulthood (see here). Outside of the idea that there may be a number of diverse developmental trajectories when it comes to autism (see here) impacting on presentation, including the idea of regression potentially being present for some (see here), even the most seasoned autism professionals are not error-free when it comes to something like autism screening and diagnosis (see here).

Insofar as the Aggarwal/Angus results, and the idea that the label of autism may only come to diagnostic attention when other psychiatric comorbidity lead, this is something discussed previously on this blog (see here and see here). The overlap between the autism and for example, the schizophrenia spectrums (see here) is an area crying out for further research attention and how intersecting with the idea of ESSENCE in autism (lots of different labels/symptoms potentially following a diagnosis of autism), symptom masking can be a real issues (see here). That also goes for the potential appearance of autism in other conditions such as Down's syndrome for example (see here).

With the growing tide of research suggesting that early (sometimes very early) intervention may be able to make a real impact on the course of autism for some (see here and see here), late, delayed or even mis-diagnosis should be viewed not only as a source of significant stress for those on the autism spectrum and their loved ones, but also as an area of vital importance to autism research on the ways and means of minimising such issues.

[Update: 25 March 2015: The paper from Crane and colleagues [4] has been published. The full-text is available here.]

Music then. I've probably linked to this before but here is Blondie and One Way Or Another.

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[1] Howlin P. & Asgharian A. The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families. Dev Med Child Neurol. 1999 Dec;41(12):834-9.

[2] Davidovitch M. et al. Late Diagnosis of Autism Spectrum Disorder After Initial Negative Assessment by a Multidisciplinary Team. J Dev Behav Pediatr. 2015 Feb 2.

[3] Aggarwal S. & Angus B. Misdiagnosis versus missed diagnosis: diagnosing autism spectrum disorder in adolescents. Australas Psychiatry. 2015 Feb 4. pii: 1039856214568214.

[4] Crane L. et al. Experiences of autism diagnosis: A survey of over 1000 parents in the United Kingdom. Autism. 2015. March 25.

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Davidovitch M, Levit-Binnun N, Golan D, & Manning-Courtney P (2015). Late Diagnosis of Autism Spectrum Disorder After Initial Negative Assessment by a Multidisciplinary Team. Journal of developmental and behavioral pediatrics : JDBP PMID: 25651066



Aggarwal S, & Angus B (2015). Misdiagnosis versus missed diagnosis: diagnosing autism spectrum disorder in adolescents. Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists PMID: 25653302

Coeliac disease: genes, autoimmunity, gut bacteria and bafflement?

Some things in life really do baffle me. When it comes to this blog, nothing seems to baffle me more than some of the talk about the triad that is autoimmunity, coeliac disease and gluten (see here for an example).

My bafflement continued upon reading the papers by Emilsson and colleagues [1] and by Olivares and colleagues [2]. Respectively suggesting that: "spouses of individuals with celiac disease are at increased risk of non-celiac autoimmune disease" and "a specific disease-biased host genotype may also select for the first gut colonisers and could contribute to determining disease risk" I admit that I had to do a double-take on both these papers.

Accepting that this post is published at the weekend and readers don't necessarily want to listen to me droning on and on, a few quick pointers about each study...

• Emilsson et al including the name of Jonas Ludvigsson (he of the not-quote-coeliac-disease-but-something-in-cases-of-autism (see here)) looked to assess "the risk of non-celiac autoimmune disease [in] first-degree relatives and spouses of people with celiac disease."
• They did this by "searching computerized duodenal and jejunal biopsies, collected from 1969 through 2008, at 28 pathology departments in Sweden" to identify those with coeliac disease (CD) and further through "Swedish healthcare registries" identify first-degree relatives and spouses of those with CD. Hazard ratios (HRs) were calculated "for non-celiac autoimmune disease (Crohn's disease, type 1 diabetes mellitus, hypothyroidism, hyperthyroidism, psoriasis, rheumatoid arthritis, sarcoidosis, systemic lupus erythematosus, or ulcerative colitis) in relatives/spouses compared with controls."
• Results: over a median follow-up period of about 10 years, some 4% of first-degree relatives of those with CD were diagnosed with an autoimmune condition not CD. This compared with 3% of controls. When it came to calculating those HRs, this translated as a slightly increased likelihood of relatives being diagnosed with an autoimmune condition. Results also suggested something of a similar statistic for spouses (I assume an unrelated individual as a partner).
• Conclusion: "First-degree relatives and spouses of individuals with celiac disease are at increased risk of non-celiac autoimmune disease." 

Then to the Olivares paper:

• Drawing on an increasing interest in how those trillions of wee beasties which inhabit our inner depths (the gut microbiota) might do so much more than help us digest our food, researchers set out to look at "whether the human leukocyte antigen (HLA)-DQ2 genotype is an independent factor influencing the early gut microbiota composition of healthy infants at family risk of CD." HLA genotype by the way is all about the genetics of identification and communication and how the body distinguishes between 'self' and 'foreign' from an immune perspective (see here). HLA-DQ2 is a bit of a biggie when it comes to risk of CD.
• The gut bacterial composition of infants (exclusively breastfed) either at high or low risk of developing CD by virtue of their genotype (HLA-DQ2 carriers vs. non-HLA-DQ2/8 carriers) were analysed.
• "Infants with a high genetic risk had significantly higher proportions of Firmicutes and Proteobacteria and lower proportions of Actinobacteria compared with low-risk infants" among other things. 
• Conclusion: "The genotype of infants at family risk of developing CD, carrying the HLA-DQ2 haplotypes, influences the early gut microbiota composition."

There are some pretty obvious issues potentially associated with these papers. Olivares and colleagues in particular, relied on a very small sample size and as far as I can see, were talking about high risk over and above actual diagnosis of CD yet. It will be interesting to see how this pans out. I might also add that whilst gut bacterial composition is a rising star in CD research circles, it would be a brave person/research team who suggested that we have a gut bacterial 'phenotype' of CD (see here). We don't (yet).

The Emilsson findings are just down-right confusing. How can a diagnosis of CD - an autoimmune condition - translate into an increased risk of an autoimmune condition outside of CD for an unrelated spouse? It could be a chance finding; some else to add to the strange collection of results which seem to be emerging [3]. It could be that spouses were by chance also more likely to harbour some of the genetics of autoimmune related conditions as per the cross-over between genotype for CD and something like type 1 diabetes [4]. Now, there's a psychology / sociology experiment waiting to happen. Or it could be due to other factors [5]?

I wonder however whether there may be other explanations for this finding. Short of suggesting that autoimmune conditions might be 'transmissible' I hark back to the peculiar findings reported by Kalliokoski and colleagues [6] and the idea of passive transference of CD "by serum or immunoglobulins" in mice. Granted this was work done with mice and said mice were athymic. But it does present a tantalising suggestion that we might not know as much about autoimmunity as we perhaps thought and even less when it comes to other factors potentially indicated by the results from Moon and colleagues [7] also described in accompanying media (see here) (I'm gonna be blogging about the Moon findings soon too). Think back also to my previous musings on how alcohol and head injury might also tie into sensitisation to gluten and CD respectively.

I continue to be baffled...

And while I remain baffled here is Teenage Fanclub with Star Sign.

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[1] Emilsson L. et al. Autoimmune Disease in First-degree Relatives and Spouses of Individuals with Celiac Disease. Clin Gastroenterol Hepatol. 2015 Jan 30. pii: S1542-3565(15)00112-3.

[2] Olivares M. et al. The HLA-DQ2 genotype selects for early intestinal microbiota composition in infants at high risk of developing coeliac disease. Gut 2015; 64: 406-417.

[3] Namatovu F. et al. Neighborhood conditions and celiac disease risk among children in Sweden. Scand J Public Health. 2014 Nov;42(7):572-80.

[4] Bao F. et al. One third of HLA DQ2 homozygous patients with type 1 diabetes express celiac disease-associated transglutaminase autoantibodies. J Autoimmun. 1999 Aug;13(1):143-8.

[5] Skaaby T. et al. Prospective population-based study of the association between vitamin D status and incidence of autoimmune disease. Endocrine. 2015 Feb 11.

[6] Kalliokoski S. et al. Injection of celiac disease patient sera or immunoglobulins to mice reproduces a condition mimicking early developing celiac disease. J Mol Med (Berl). 2015 Jan;93(1):51-62.

[7] Moon C. et al. Vertically transmitted faecal IgA levels determine extra-chromosomal phenotypic variation. Nature. 2015. Feb 16.

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Emilsson L, Wijmenga C, Murray JA, & Ludvigsson JF (2015). Autoimmune Disease in First-degree Relatives and Spouses of Individuals with Celiac Disease. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association PMID: 25645875




Olivares M, Neef A, Castillejo G, Palma GD, Varea V, Capilla A, Palau F, Nova E, Marcos A, Polanco I, Ribes-Koninckx C, Ortigosa L, Izquierdo L, & Sanz Y (2014). The HLA-DQ2 genotype selects for early intestinal microbiota composition in infants at high risk of developing coeliac disease. Gut PMID: 24939571

Behavioural sleep intervention for ADHD?

I was really quite interested to read about the study from Harriet Hiscock and colleagues [1] (open-access) suggesting that: "A brief behavioural sleep intervention modestly improves the severity of ADHD [attention deficit hyperactivity disorder] symptoms in a community sample of children with ADHD." I had heard that these results would be forthcoming based on the publication of the study trial protocol [2] a few years back, alongside the trial entry listed in the ISRCTN registry (see here). There is also the promise of more to come from this group [3].

The Hiscock paper is open-access but a few pointers might be useful:

• Based on the idea that sleep issues have been reported in quite a large proportion of those diagnosed with ADHD [4], authors set about testing the idea that consultations with specialists on managing sleep issues might impact on said problems and "might have lasting benefits not only on sleep but on the ADHD itself."
• Participants were randomly assigned to sleep intervention or usual clinical care for such matters. As with these kinds of trials and the various issues of attrition (drop-outs) and loss at follow-up, although 122 children were initially allocated to each group, a mix of sample sizes were available at the 3 month and 6 month follow-up periods. Statistical analysis of the results was made on the basis of intention to treat.
• Various outcomes were measured during the study. The ADHD rating scale IV was the primary outcome for ADHD symptoms (something I have a little experience of in my own research). Various sleep related issues were also monitored including actigraphy to measure movement "and used to differentiate between sleep and wake times."
• Results: "The families reported greater improvements in their children’s ADHD symptoms, sleep, behaviour, health related quality of life, and daily functioning, and teachers reported improved behaviour" as a function of the sleep intervention. The effects for parents were also noticeable insofar as "intervention parents reported fewer days late for work as a result of their child’s behaviour than control parents."
• The more objective actigraphy results also suggested: "an improved sleep duration of around 70 minutes a week in the intervention group" bearing in mind researchers reporting a few 'practical issues' with this method.
• Accepting a few limitations associated with their study methods, authors highlight the positive effects of the intervention and how: "These benefits occur over and above the effects of stimulant medications." Further: "Effects are comparable to those seen with intensive behavioural interventions targeting ADHD symptoms, more wide reaching than those reported in studies of melatonin, and importantly seem to be sustained over six months." Not bad at all.

Of course further research is implied from such results to "determine whether these benefits can be replicated when the sleep intervention is implemented by community based clinicians in a rigorous effectiveness trial." Translational medicine I think its called. But there is little doubt that there is much more to see when it comes to the presentation of ADHD and the very valuable resource called sleep.

Just before I leave you, the paper from Papadopoulos and colleagues [5] potentially also indicates how the Hiscock results might translate into improvements for those with autism also diagnosed with ADHD (see here). Based on an analysis of a "subsample of children with ADHD-ASD [autism spectrum disorder]... participating in the Sleeping Sound With ADHD study" (the Hiscock study) authors reported that those in receipt of the behavioural sleep intervention "had large improvements in sleep problems and moderate improvements in child behavioral functioning 3 and 6 months post-randomization."

Further food for thought perhaps, added to what is already known about sleep and [some] autism (see here). Oh, and remember, screen time whilst useful, might also impact on sleep time as we are perhaps already seeing...

So: Primal Scream - Kill All Hippies ('though not literally I might add).

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[1] Hiscock H. et al. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ. 2015 Jan 20;350:h68.

[2] Sciberras E. et al. Study protocol: the sleeping sound with attention-deficit/hyperactivity disorder project. BMC Pediatr. 2010 Dec 30;10:101.

[3] Lycett K. et al. Behavioural sleep problems in children with attention-deficit/hyperactivity disorder (ADHD): protocol for a prospective cohort study. BMJ Open. 2014 Feb 12;4(2):e004070.

[4] Silvestri R. et al. Sleep disorders in children with Attention-Deficit/Hyperactivity Disorder (ADHD) recorded overnight by video-polysomnography. Sleep Med. 2009 Dec;10(10):1132-8. 

[5] Papadopoulos N. et al. The Efficacy of a Brief Behavioral Sleep Intervention in School-Aged Children With ADHD and Comorbid Autism Spectrum Disorder. J Atten Disord. 2015 Feb 2. pii: 1087054714568565.

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Hiscock H, Sciberras E, Mensah F, Gerner B, Efron D, Khano S, & Oberklaid F (2015). Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. BMJ (Clinical research ed.), 350 PMID: 25646809

Metal sensitisation and chronic fatigue syndrome?

I have to admit that I pondered longer than usual over whether I should talk about the paper by Vera Stejskal [1] (open-access here) and the idea that: "Patients with CFS [chronic fatigue syndrome] and fibromyalgia are frequently sensitized to metals found in the environment or used in dentistry and surgery."

It was't that I doubted that metals - certain types present in the wrong place or wrong concentration - can affect physical and psychological health and wellbeing as per the example of lead (see here). I was even happy to accept some mention of ASIA (‘autoimmune (auto-inflammatory) syndrome induced by adjuvants’) in the Stejskal paper given my previous exploration of this potentially tricky concept with chronic fatigue syndrome in mind (see here) and some more recent data [2]. The editor-in-chief of the publishing journal, I should add, knows a little more about this than I.

It's just that when I read the paper in its entirety and then googled the analytical weapon of choice - MELISA (Memory Lymphocyte ImmunoStimulation Assay) or rather the lymphocyte transformation test (LTT) - I couldn't help but be a little unsettled at some of the results displayed. When I also found that Dr Stejskal "is the inventor of the MELISA test and holder of trademarks" (see here) without however seemingly any mention of this as a potential conflict of interest on her paper, my brow furrowed a little more.

Putting those issues to one side and hopefully avoiding any terse replies from proponents of MELISA, I am actually quite interested in the findings reported as they were in a peer-reviewed journal. A paper by Kern and colleagues [3] potentially intersecting with the Stejskal results bolstered my decision to blog about this issue and the potential to offer something important for at least some people falling onto the ME/CFS spectrum, subject to further inquiry. Oh, and by the way, when I say ME/CFS I mean SEID...

The Stejskal paper is open-access but that's never stopped me before...

• Based on a very, very small participant number - three subjects with CFS and two with fibromyalgia - where metal exposure was "as a trigger for their ill health", MELISA testing was undertaken to measure "delayed-type hypersensitivity to metals (metal allergy)".
• The assay involves culturing lymphocytes (white blood cells) with selected metals at various concentrations and then measuring lymphocyte proliferation and using something called the Stimulation Index (SI) to describe "reactivity to metals". Just in case you might be querying the method, it has been validated by others as per the paper from Valentine-Thon and colleagues [4].
• Results are presented in a case-by-case format. Control participant data (n=9) based on MELISA testing is also provided: "In the majority of controls, MELISA was negative, indicating non-responsiveness to metals at the lymphocyte level." The same could not however be said for the symptomatic participants who presented with a range of results suggestive of issues with metal allergy. Interestingly, data is presented at both initial testing and "follow-up" after removal of various metal sources and is also complemented in some cases by more traditional patch testing results.
• The author concludes: "In this study, reduction of inflammation-causing metals resulted in an alleviation of symptoms and long-term health improvement. The decrease of metal-specific lymphocyte responses in vitro after removal of sensitizing metals supports the clinical relevance of these findings."

As per other discussions on this blog, CFS/ME is a condition which has seen it's fair share of discussion and debate down the years (see here). A few weeks back, part of those discussions 'kicked off' again focused on the paper by Chalder and colleagues [5] and headlines about 'fear of exercise'. I might also draw your attention to a pretty good critique on that Chalder paper too (see here) alongside what the Cochrane Library recently said about exercise 'therapy' and CFS [6]. In this context, the Stejskal paper talking about metals potentially perpetuating symptoms and even the notion that something else - "As a child she had received at least eight thimerosal and aluminium-containing vaccines" - *might* be implicated in cases, is never going to be particularly well-received in some quarters.

I'm not falling hook, line and sinker for the Stejskal results by the way, based as they were, on case reports and with very little discussion of objective measures of symptom profiles for example, outside of sentences like: "Rapid health improvement followed and she became symptom free." I am however interested in research which talks about clinical improvement in cases of ME/CFS recognising how destructive an illness this can be and the stigma which still pervades some discussions of the condition. The Stejskal paper perhaps offers a template for the consideration of further, more controlled study is this area, expanding on our current understanding of metal allergy [7] outside of just a generalised reaction to jewellery and possibly contributing further to some of the biology potentially involved in at least some CFS/ME [8].

Music then... One by Johnny Cash. Oh and happy birthday Questioning Answers (4 today and therefore ready for reception!)

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[1] Stejskal V. Metals as a common trigger of inflammation resulting in non-specific symptoms: diagnosis and treatment. Isr Med Assoc J. 2014 Dec;16(12):753-8.

[2] Somers EC. et al. Mercury Exposure and Antinuclear Antibodies among Females of Reproductive Age in the United States: NHANES. Environ Health Perspect. 2015. Feb 10.

[3] Kern JK. et al. Evidence supporting a link between dental amalgams and chronic illness, fatigue, depression, anxiety, and suicide. Neuro Endocrinol Lett. 2014 Dec 24;35(7):537-552.

[4] Valentine-Thon E. et al. LTT-MELISA is clinically relevant for detecting and monitoring metal sensitivity. Neuro Endocrinol Lett. 2006 Dec;27 Suppl 1:17-24.

[5] Chalder T. et al. Rehabilitative therapies for chronic fatigue syndrome: a secondary mediation analysis of the PACE trial. The Lancet Psychiatry. 2015. Jan 13.

[6] Larun L. et al. Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2015 Feb 10;2:CD003200.

[7] Thyssen JP. & Menné T. Metal allergy--a review on exposures, penetration, genetics, prevalence, and clinical implications. Chem Res Toxicol. 2010 Feb 15;23(2):309-18.

[8] Morris G. & Maes M. Oxidative and Nitrosative Stress and Immune-Inflammatory Pathways in Patients with Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS). Curr Neuropharmacol. 2014 Mar;12(2):168-85.

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Stejskal V (2014). Metals as a common trigger of inflammation resulting in non-specific symptoms: diagnosis and treatment. The Israel Medical Association journal : IMAJ, 16 (12), 753-8 PMID: 25630203

Autism and the inter-pregnancy interval (again)

The paper from Maureen Durkin and colleagues [1] adds to something of a growing research evidence base suggesting that the temporal spacing between pregnancies / births - the inter-pregnancy interval (IPI) - may have something of an effect on the risk of receipt of a diagnosis of autism or autism spectrum disorder (ASD).

We've been here before. In fact, a couple of times I've talked about the IPI in relation to autism risk (see here and see here) not including other, similar research findings in this area [2]. If I were to generalise from the collected data so far, it might be to say something like a short IPI (below 12 months) and a longer IPI (above about 5 years) seems to carry some elevated risk of offspring receipt of a diagnosis of autism or autism spectrum disorder (ASD). But remember risk is risk...

Durkin et al looking through the records of almost 32,000 second-born children, reported that: "In adjusted analyses, both short (<12) and long (>84 month) IPIs were associated with a two-fold risk of ASD relative to IPIs of 24-47 months."

I don't want to dwell too long on this topic outside of reiterating a suggestion made in the paper from Nina Gunnes and colleagues [3]: "A possible explanation is depletion of micronutrients in mothers with closely spaced pregnancies." That being said, there may be other factors influencing risk such as a heightened risk for preterm birth also being associated with a small IPI. The elevated risk associated with a longer IPI is slightly more difficult to explain away, assuming that is, that one doesn't include the variable of 'older mother' into proceedings (see here) and possibly some contribution from the young upstart discipline that is epigenetics (see here). More research is indicated although I might also throw into the research mix the idea that a longer IPI might also raise the risk of something like preeclampsia [4] and how this might also impact on offspring autism risk (see here).

Patio Song to close (and some excellent interpretive dancing).

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[1] Durkin MS. et al. Inter-Pregnancy Intervals and the Risk of Autism Spectrum Disorder: Results of a Population-Based Study. J Autism Dev Disord. 2015 Feb 1.

[2] Cheslack-Postava K. et al. Increased risk of autism spectrum disorders at short and long interpregnancy intervals in Finland. J Am Acad Child Adolesc Psychiatry. 2014 Oct;53(10):1074-81.e4.

[3] Gunnes N. et al. Interpregnancy interval and risk of autistic disorder. Epidemiology. 2013 Nov;24(6):906-12.

[4] Shachar BZ. & Lyell DJ. Interpregnancy interval and obstetrical complications. Obstet Gynecol Surv. 2012 Sep;67(9):584-96.

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Durkin MS, DuBois LA, & Maenner MJ (2015). Inter-Pregnancy Intervals and the Risk of Autism Spectrum Disorder: Results of a Population-Based Study. Journal of autism and developmental disorders PMID: 25636677

Congenital rubella, autism and remote stroke

Case reports. I know they rank pretty low in the order of what counts as objective scientific evidence [1] despite their often interesting findings. That being said, when it comes to a diagnosis like autism, with all its associated heterogeneity and elevated risk of various comorbidity probably better encapsulated in a more 'plural autisms' understanding, case reports can offer something of an important view into the many and varied ways in which someone might arrive on the autism spectrum and their subsequent individual experiences. A focus on the N=1 if you like...

The case report from Jill and George Hutton [2] (open-access) describing how the "diagnosis of congenital rubella was recognized more than ten years after the birth" of their male infant subject and how "congenital rubella is linked to both autism and ischemic brain injury" provides some rather interesting details for science and practice. The paper is open-access but a few pointers might be useful:

• The paper describes a boy delivered at 38 weeks to a "USA born physician at 30 years of age mostly working at a busy, urban, county hospital with a large immigrant population". Mum had been vaccinated against rubella at least once some decades earlier (possibly with a booster 7-8 years before giving birth). "She was non-immune to rubella at her first prenatal visit at 10 weeks gestation" but at delivery showed immunity to rubella suggesting intervening exposure. The authors reported the detail about 'large immigrant population' because of the issue of risk of transmission from those "emigrating from countries with absent or suboptimal national vaccination programs" [3].
• Her son "met all motor milestones, but was delayed in speech and exhibited social anxiety" during early infancy. He had a single seizure at 18 months (febrile seizure). He was eventually diagnosed with autism between 5-7 years old.
• An MRI was fortuitously offered at 10 years old with findings "most consistent with a remote stroke". The authors conclude that: "As causes of stroke were eliminated, the diagnosis of congenital rubella as a unifying diagnosis of autism and stroke became more probable."

I was drawn to talk about this paper for various reasons.

First is the continuing association between viral/bacterial exposures during pregnancy and offspring behavioural outcomes (see here). As per the research of people such as Stella Chess, mentioned in the Hutton article, discussing autism presenting in cases of congenital rubella [4] and reporting that "a high rate of autism and a high rate of recovery were observed" there is potentially so much more to see in this area of autism research. In-utero rubella exposure, by the way, is not the only infective agent linked to the presentation of autism for some (see here).

Second were some of the details reported by the Huttons on their young participant and in particular, the idea that congenital rubella may 'unify' the findings of stroke + autism. Pediatric stroke has been looked at with infectious disease in mind before [5]. The research literature in the area of stroke and autism is however not exactly straight-forward. It would be easy to say that stroke had a deleterious effect on the brain which then 'lead' to autism as per other research in this area [6], but this perhaps rather simplifies an all-too-likely more complex relationship. Certainly, I would like to see a little more investigation done on this topic and in particular the delayed manifestations of congenital rubella [7] as and when appropriate to a diagnosis of autism or autism spectrum disorder [8]. If and when this connection is further established, one could also reasonably ask about intervention strategies and whether autistic symptoms could be ameliorated in any way in this group? Remember those words from Chess: "a high rate of recovery was observed"...

Finally, the question is raised about the role of vaccination in preventing congenital rubella and possible knock-on effects for offspring development including autism-related outcomes. In a previous post on the talking point that is vaccination and autism (see here) I discussed some data which suggested that rubella vaccination may very well have "prevented hundreds, and perhaps thousands, of ASD [autism spectrum disorder] cases from 2001 through 2010 in the US." [9] The Hutton paper kinda overlaps with such discussions alongside detailing the issue of waning immunity [10]. I might add that analysis of the biology of individual responses (or not) to rubella vaccination [11] and even transmission from previous vaccinees [12] in light of other data is perhaps also implied in any future work in this area.

What the Hutton paper serves to reiterate is that there may be many potential paths towards a diagnosis of autism or ASD. Receipt of said diagnosis should also perhaps be a starting point for further inquiry rather than an endpoint...

Music: Blur - Out Of Time.

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[1] Nissen T. & Wynn R. The clinical case report: a review of its merits and limitations. BMC Res Notes. 2014 Apr 23;7:264.

[2] Hutton J. & Hutton GJ. Congenital Rubella with Autism and Evidence of a Remote Stroke. J Vaccines Vaccin 2014, 5:6

[3] Fang J. et al. Case report: congenital rubella syndrome: a rare but persistent concern in the United States. J Perinatol. 2013 Nov;33(11):899-902.

[4] Chess S. Follow-up report on autism in congenital rubella. J Autism Child Schizophr. 1977 Mar;7(1):69-81.

[5] Salih MA. et al. Infectious and inflammatory disorders of the circulatory system as risk factors for stroke in Saudi children. Saudi Med J. 2006 Mar;27 Suppl 1:S41-52.

[6] Weir K. & Salisbury DM. Acute onset of autistic features following brain damage in a ten-year-old. J Autism Dev Disord. 1980 Jun;10(2):185-91.

[7] Sever JL. et al. Delayed Manifestations of Congenital Rubella. Clin Infect Dis. 1985; 7 (Supplement 1): S164-S169.

[8] Hwang SJ. & Chen YS. Congenital rubella syndrome with autistic disorder. J Chin Med Assoc. 2010 Feb;73(2):104-7.

[9] Berger BE. et al. Congenital rubella syndrome and autism spectrum disorder prevented by rubella vaccination--United States, 2001-2010. BMC Public Health. 2011 May 19;11:340.

[10] Just M. et al. Duration of immunity after rubella vaccination: a long-term study in Switzerland. Rev Infect Dis. 1985 Mar-Apr;7 Suppl 1:S91-4.

[11] Kennedy RB. et al. Genetic polymorphisms associated with rubella virus-specific cellular immunity following MMR vaccination. Hum Genet. 2014 Nov;133(11):1407-17.

[12] Wilkins J. et al. Transmission of rubella vaccine virus from vaccinees to contacts. Calif Med. 1971 Nov;115(5):16-22.

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George J Hutton, J. (2014). Congenital Rubella with Autism and Evidence of a Remote Stroke Journal of Vaccines & Vaccination, 05 (06) DOI: 10.4172/2157-7560.1000258