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Medscape
3 days ago
- Health
- Medscape
PANS and PANDAS: Diagnosis and Treatment
While anxiety symptoms are common in prepubertal children, they occasionally present suddenly and with a high degree of severity. In these circumstances, parents may turn to you, the pediatrician, to address the possibility that these syndromes are autoimmune, under the diagnostic umbrellas of pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). While the clinical community continues to debate many aspects of these diagnoses, families may seek treatment based on their own online research. Your understanding of what is known about the prevalence and assessment of immune-related neuropsychiatric disorders will help you to provide these patients and their families with meaningful support and responsible guidance for the management of these syndromes. Prevalence and Controversy Susan D. Swick, MD In 1989, researchers studying Sydenham chorea noted a high prevalence of obsessive thoughts and compulsive behaviors in children with rheumatic fever without chorea. Susan Swedo, MD, and colleagues at the National Institutes of Health eventually characterized this syndrome as PANDAS, occurring in 50 children who developed acute-onset obsessive compulsive disorder (OCD), anxiety, or tics with a preceding or concurrent group A streptococcal (GAS) infection. In 2012, PANS or childhood acute-onset neuropsychiatric syndrome was proposed to broaden the criteria to include similar abrupt-onset psychiatric symptoms (OCD and restricted eating) with inciting events other than GAS infection, including mycoplasma, influenza, Lyme disease, or even psychosocial stressors. Reliable prevalence estimates remain elusive, largely because of small numbers, diagnostic uncertainty, and lack of consensus criteria to be applied across studies. In the original studies, the mean age of onset was 6.3 years for tics and 7.4 years for OCD symptoms. The ratio of males to females was 4.7 to 1 under the age of 8 years. In one prospective study, only 10 cases were identified among 30,000 participants with throat cultures that were positive for GAS. The broader category of PANS has proven even more difficult to quantify, given its heterogeneous triggers. The high rate of GAS exposure and anxiety disorders in prepubertal children make the establishment of a causal link very difficult. Michael S. Jellinek, MD This has led to significant controversy over the diagnosis and treatment of PANDAS and PANS. While there is research interest in the role of the immune system in some psychiatric illnesses, neither diagnosis is listed in the DSM-V or the ICD-10. Nonetheless, there are parents who will come to you with questions about PANS and some small number of children each year who will develop it. Helpfully, the American Academy of Pediatrics (AAP) published a clinical report on PANS (encompassing PANDAS) in March 2025 to provide guidance. Our aim is to review the current guidance and help you use your best clinical judgment to treat all children thoughtfully and responsibly. Clinical Presentation and Assessment The hallmark symptom of PANDAS and PANS is the sudden, dramatic onset of symptoms of OCD, severely restricted food intake, or tic disorder, often appearing literally overnight in a prepubertal child. There are typically multiple severe symptoms starting abruptly together, like an 'explosion.' PANS diagnosis requires concurrent abrupt onset of additional severe neuropsychiatric symptoms in at least two of the following areas: anxiety, emotional lability or depression, irritability or aggression, developmental regression, deterioration in school performance, sensory or motor abnormalities, or somatic signs (sleep disturbances, enuresis, or urinary frequency). When any syndrome is sudden and severe, it is normal for parents to be very concerned and distressed. Express understanding and validation as you begin your assessment, which should include: Clinical History: Timing of symptom onset (Was it abrupt and severe? Did it reach a crescendo in 24-48 hours?) Assessment for signs of Sydenham chorea, Tourette, encephalitis, and anorexia nervosa History of developmental or psychiatric disorders Any recent illnesses, particularly GAS pharyngitis (documented via throat culture) Physical and Neurological Exam: To rule out signs of infection, systemic illness, or neurologic disease Motor examination, with attention to choreiform movements Laboratory Workup: Throat culture or rapid strep with symptomatic pharyngitis (although a negative rapid test may be inaccurate) Routine screening for GAS, antistreptolysin O, and anti-DNase B titers are not recommended by the AAP When the neurological examination is suggestive, lumbar puncture or MRI may be warranted to assess CNS inflammation If there is no evidence of GAS infection, PANDAS is unlikely. In general, the onset of OCD (and other anxiety disorders) is usually gradual and persistent, although children may internalize and hide symptoms until they no longer can. Tic disorders usually begin with isolated, intermittent motor or vocal tics, not an 'explosion.' The presence of cognitive decline, psychosis, catatonia, new seizures, or movement disorders other than tics should lead to an expanded and thorough neurological workup, including for autoimmune encephalitis. The AAP specifies that further laboratory testing and imaging have no evidence to support their use in the workup for PANS. Management Strategies If your assessment suggests PANS, how do you begin treatment? Explain to the family that treatment will address any confirmed infection, psychiatric symptoms, and inflammation. While some children may improve with antibiotics alone (symptoms may resolve fully within several weeks), most children will require treatment of persistent psychiatric symptoms even when all signs of GAS infection have resolved. Treatment typically involves three concurrent pathways: 1. Medical Management of Infection and Inflammation: Start with treatment of the GAS infection, if there is one. Antibiotics: The AAP recommends a standard (10-day) course with appropriate antibiotics for a positive culture in a symptomatic child. The AAP does not recommend prophylactic or long-term use of antibiotics, or treatment of asymptomatic positive culture (colonization). Some children's neuropsychiatric symptoms respond to antibiotics; others do not. The AAP recommends a standard (10-day) course with appropriate antibiotics for a positive culture in a symptomatic child. The AAP does not recommend prophylactic or long-term use of antibiotics, or treatment of asymptomatic positive culture (colonization). Some children's neuropsychiatric symptoms respond to antibiotics; others do not. Anti-inflammatory Treatment: The AAP does not recommend NSAIDS or more aggressive anti-inflammatories, given the absence of evidence and considerable side effects. The AAP does not recommend NSAIDS or more aggressive anti-inflammatories, given the absence of evidence and considerable side effects. Immune Modulation: Invasive therapies like intravenous immunoglobulin or plasmapheresis have no evidence to support their use in PANS. Patients with severe, persistent neuropsychiatric symptoms should have an expanded neurological and rheumatologic assessment before any consideration of these treatments. 2. Psychiatric Symptom Management: An infection may have caused the psychiatric symptoms or simply exacerbated or unmasked an underlying illness that will require independent treatment. OCD: Cognitive behavioral therapy (CBT) — specifically, exposure and response prevention (ERP) — is the gold standard for managing OCD symptoms, regardless of etiology. Selective serotonin reuptake inhibitors (SSRIs) are similarly effective and the combination of the two has demonstrated superior efficacy to either treatment alone. Each treatment may take 12 weeks or more to be effective. ERP may be difficult to access. SSRIs should be started at low doses and titrated gradually as they may cause temporary activation if started at too high a dose. They are not contraindicated in OCD, anxiety disorders, or PANS, and parents should be offered education to prevent any concern about these effective treatments. Cognitive behavioral therapy (CBT) — specifically, exposure and response prevention (ERP) — is the gold standard for managing OCD symptoms, regardless of etiology. Selective serotonin reuptake inhibitors (SSRIs) are similarly effective and the combination of the two has demonstrated superior efficacy to either treatment alone. Each treatment may take 12 weeks or more to be effective. ERP may be difficult to access. SSRIs should be started at low doses and titrated gradually as they may cause temporary activation if started at too high a dose. They are not contraindicated in OCD, anxiety disorders, or PANS, and parents should be offered education to prevent any concern about these effective treatments. Tics: Tics are only treated when they interfere with a child's function or lead to significant embarrassment or bullying. A behavioral psychotherapy (comprehensive behavioral intervention for tics, CBIT) has demonstrated efficacy. Medications (alpha-2 agonists) have modest efficacy and can be used in more severe cases. Tics are only treated when they interfere with a child's function or lead to significant embarrassment or bullying. A behavioral psychotherapy (comprehensive behavioral intervention for tics, CBIT) has demonstrated efficacy. Medications (alpha-2 agonists) have modest efficacy and can be used in more severe cases. Food Restriction ( Avoidant/Restrictive Food Intake Disorder, ARFID): Almost all children with ARFID and PANS also have underlying OCD. Treatment starts with a medical assessment of nutritional and hydration status and weight restoration and correction of electrolyte abnormalities, if needed. Then CBT (ERP again) is the effective treatment for the avoidant behaviors around food. This is a specialized treatment that requires a clinician who has training in CBT and experience working with ARFID specifically. Avoidant/Restrictive Food Intake Disorder, Almost all children with ARFID and PANS also have underlying OCD. Treatment starts with a medical assessment of nutritional and hydration status and weight restoration and correction of electrolyte abnormalities, if needed. Then CBT (ERP again) is the effective treatment for the avoidant behaviors around food. This is a specialized treatment that requires a clinician who has training in CBT and experience working with ARFID specifically. Additional Symptoms: Sleep disturbances and separation anxiety both can be addressed with CBT, with an additional component of parental skill building to complement and support the child's work. 3. Family Support: The sudden, severe onset of disruptive behavioral symptoms is bound to be very distressing for your patient and particularly for their parents, whatever the cause. Families of children with severe, sudden psychiatric symptoms experience significant stress and distress. If they suspect it might be caused by a current or recent infection, it is important that their pediatrician is genuinely curious about their observations and concerns. Some families may think they have been treated dismissively when they are told that there is 'no evidence' to support their observations. Remember, they are the experts on their children. When they have experienced your genuine curiosity and respect, it will be easier for them to trust your judgment should you conclude that their child may need treatment beyond antibiotics. Support, reassurance, and education are vital. Build a team with a psychiatrist and psychotherapist and engage the school to provide accommodations during treatment (eg, reduced workload and support for attention deficits or anxiety). The Pediatrician is Critical Pediatricians are the first point of contact when children present with symptoms that suggest PANS. Your responsiveness, targeted workup, and collaborative management are critical. Your ability to provide the family with meaningful support will create a strong foundation of trust that will improve the course of their child's care. Given the complex and uncertain nature of these diagnoses, your partnership with the parents is the critical first step. Acknowledge that inflammation is emerging as an important factor in many medical and psychiatric conditions, but that it may not always guide treatment. It should not be a matter of medical illness or psychiatric illness. Help families to understand that even if a strep infection triggered the psychiatric symptoms, they will both need treatment. Treatment may be slow, but with your guidance and partnership the child will recover. A parent's trust in you is the essential foundation for this process. Conclusion PANS and PANDAS are emerging clinical entities residing at the intersection of psychiatry, pediatrics, and immunology. While more research is needed to understand their pathophysiology and optimal treatment strategies, the reality is that affected children may be presenting to your offices today — suffering and in need of thoughtful, coordinated care. Maintain a curious, compassionate posture, acknowledge uncertainty where it exists, and provide clarity about our ability to offer reasonable and effective treatments guided by evidence and good judgment even when there is uncertainty.
Argaam
09-07-2025
- Business
- Argaam
SABIC, GASCO mull TASI listing for GAS
Saudi Basic Industries Corp. (SABIC) and National Gas and Industrialization Co. (GASCO) started studying and evaluating certain strategic options concerning their investee company, National Industrial Gases Co. (GAS), include the possibility of an initial public offering (IPO) of GAS and listing of its shares in the main market. In two separate statements to Tadawul, both Saudi-listed firms said that the step comes to enhance added value for shareholders, stressing that the strategic options currently being evaluated are subject to the completion of studies related to financial, technical, and legal aspects. For More IPOs In the event of reaching a decision to proceed with the IPO, the process will be subject to obtaining the relevant approvals, including regulatory approvals, and prevailing market conditions, both firms added. Until then, any material developments will be announced by SABIC as required by the relevant law and regulations, the Saudi-listed firms indicated. According to data available on Argaam, GAS' capital stands at SAR 248 million. SABIC owns 74% of the company's shares, while GASCO holds 9%. GAS was established in Saudi Arabia in 1983. Its primary activity is the production of industrial gases, which it supplies to various industries. The company achieved a net profit of SAR 415.8 million in 2024.
Yahoo
30-06-2025
- Business
- Yahoo
Pleasing Signs As A Number Of Insiders Buy State Gas Stock
Usually, when one insider buys stock, it might not be a monumental event. But when multiple insiders are buying like they did in the case of State Gas Limited (ASX:GAS), that sends out a positive message to the company's shareholders. While we would never suggest that investors should base their decisions solely on what the directors of a company have been doing, logic dictates you should pay some attention to whether insiders are buying or selling shares. We've found 21 US stocks that are forecast to pay a dividend yield of over 6% next year. See the full list for free. The Independent Non-Executive Chairman Philip St Baker made the biggest insider purchase in the last 12 months. That single transaction was for AU$362k worth of shares at a price of AU$0.045 each. So it's clear an insider wanted to buy, even at a higher price than the current share price (being AU$0.02). Their view may have changed since then, but at least it shows they felt optimistic at the time. We always take careful note of the price insiders pay when purchasing shares. As a general rule, we feel more positive about a stock if insiders have bought shares at above current prices, because that suggests they viewed the stock as good value, even at a higher price. While State Gas insiders bought shares during the last year, they didn't sell. The chart below shows insider transactions (by companies and individuals) over the last year. If you want to know exactly who sold, for how much, and when, simply click on the graph below! Check out our latest analysis for State Gas There are always plenty of stocks that insiders are buying. If investing in lesser known companies is your style, you could take a look at this free list of companies. (Hint: insiders have been buying them). Another way to test the alignment between the leaders of a company and other shareholders is to look at how many shares they own. Usually, the higher the insider ownership, the more likely it is that insiders will be incentivised to build the company for the long term. State Gas insiders own about AU$2.1m worth of shares. That equates to 27% of the company. While this is a strong but not outstanding level of insider ownership, it's enough to indicate some alignment between management and smaller shareholders. It doesn't really mean much that no insider has traded State Gas shares in the last quarter. On a brighter note, the transactions over the last year are encouraging. Insiders do have a stake in State Gas and their transactions don't cause us concern. In addition to knowing about insider transactions going on, it's beneficial to identify the risks facing State Gas. At Simply Wall St, we've found that State Gas has 5 warning signs (4 are concerning!) that deserve your attention before going any further with your analysis. But note: State Gas may not be the best stock to buy. So take a peek at this free list of interesting companies with high ROE and low debt. For the purposes of this article, insiders are those individuals who report their transactions to the relevant regulatory body. We currently account for open market transactions and private dispositions of direct interests only, but not derivative transactions or indirect interests. — Investing narratives with Fair Values A case for TSXV:USA to reach USD $5.00 - $9.00 (CAD $7.30–$12.29) by 2029. By Agricola – Community Contributor Fair Value Estimated: CA$12.29 · 0.9% Overvalued DLocal's Future Growth Fueled by 35% Revenue and Profit Margin Boosts By WynnLevi – Community Contributor Fair Value Estimated: $195.39 · 0.9% Overvalued Historically Cheap, but the Margin of Safety Is Still Thin By Mandelman – Community Contributor Fair Value Estimated: SEK232.58 · 0.1% Overvalued View more featured narratives — Have feedback on this article? Concerned about the content? Get in touch with us directly. Alternatively, email editorial-team (at) article by Simply Wall St is general in nature. We provide commentary based on historical data and analyst forecasts only using an unbiased methodology and our articles are not intended to be financial advice. It does not constitute a recommendation to buy or sell any stock, and does not take account of your objectives, or your financial situation. We aim to bring you long-term focused analysis driven by fundamental data. Note that our analysis may not factor in the latest price-sensitive company announcements or qualitative material. Simply Wall St has no position in any stocks mentioned. Error in retrieving data Sign in to access your portfolio Error in retrieving data Error in retrieving data Error in retrieving data Error in retrieving data
Yahoo
29-06-2025
- Business
- Yahoo
Pleasing Signs As A Number Of Insiders Buy State Gas Stock
Usually, when one insider buys stock, it might not be a monumental event. But when multiple insiders are buying like they did in the case of State Gas Limited (ASX:GAS), that sends out a positive message to the company's shareholders. While we would never suggest that investors should base their decisions solely on what the directors of a company have been doing, logic dictates you should pay some attention to whether insiders are buying or selling shares. We've found 21 US stocks that are forecast to pay a dividend yield of over 6% next year. See the full list for free. The Independent Non-Executive Chairman Philip St Baker made the biggest insider purchase in the last 12 months. That single transaction was for AU$362k worth of shares at a price of AU$0.045 each. So it's clear an insider wanted to buy, even at a higher price than the current share price (being AU$0.02). Their view may have changed since then, but at least it shows they felt optimistic at the time. We always take careful note of the price insiders pay when purchasing shares. As a general rule, we feel more positive about a stock if insiders have bought shares at above current prices, because that suggests they viewed the stock as good value, even at a higher price. While State Gas insiders bought shares during the last year, they didn't sell. The chart below shows insider transactions (by companies and individuals) over the last year. If you want to know exactly who sold, for how much, and when, simply click on the graph below! Check out our latest analysis for State Gas There are always plenty of stocks that insiders are buying. If investing in lesser known companies is your style, you could take a look at this free list of companies. (Hint: insiders have been buying them). Another way to test the alignment between the leaders of a company and other shareholders is to look at how many shares they own. Usually, the higher the insider ownership, the more likely it is that insiders will be incentivised to build the company for the long term. State Gas insiders own about AU$2.1m worth of shares. That equates to 27% of the company. While this is a strong but not outstanding level of insider ownership, it's enough to indicate some alignment between management and smaller shareholders. It doesn't really mean much that no insider has traded State Gas shares in the last quarter. On a brighter note, the transactions over the last year are encouraging. Insiders do have a stake in State Gas and their transactions don't cause us concern. In addition to knowing about insider transactions going on, it's beneficial to identify the risks facing State Gas. At Simply Wall St, we've found that State Gas has 5 warning signs (4 are concerning!) that deserve your attention before going any further with your analysis. But note: State Gas may not be the best stock to buy. So take a peek at this free list of interesting companies with high ROE and low debt. For the purposes of this article, insiders are those individuals who report their transactions to the relevant regulatory body. We currently account for open market transactions and private dispositions of direct interests only, but not derivative transactions or indirect interests. — Investing narratives with Fair Values A case for TSXV:USA to reach USD $5.00 - $9.00 (CAD $7.30–$12.29) by 2029. By Agricola – Community Contributor Fair Value Estimated: CA$12.29 · 0.9% Overvalued DLocal's Future Growth Fueled by 35% Revenue and Profit Margin Boosts By WynnLevi – Community Contributor Fair Value Estimated: $195.39 · 0.9% Overvalued Historically Cheap, but the Margin of Safety Is Still Thin By Mandelman – Community Contributor Fair Value Estimated: SEK232.58 · 0.1% Overvalued View more featured narratives — Have feedback on this article? Concerned about the content? Get in touch with us directly. Alternatively, email editorial-team (at) article by Simply Wall St is general in nature. We provide commentary based on historical data and analyst forecasts only using an unbiased methodology and our articles are not intended to be financial advice. It does not constitute a recommendation to buy or sell any stock, and does not take account of your objectives, or your financial situation. We aim to bring you long-term focused analysis driven by fundamental data. Note that our analysis may not factor in the latest price-sensitive company announcements or qualitative material. Simply Wall St has no position in any stocks mentioned. Sign in to access your portfolio
Scottish Sun
23-06-2025
- Science
- Scottish Sun
Haunting 1,000-year-old mummy found ‘seated with bent arms' and brown hair still visible just INCHES below ground
The desert heat dehydrates the bodies, naturally mummifying the bodies and leaving them fairly well preserved DEAD STRANGE Haunting 1,000-year-old mummy found 'seated with bent arms' and brown hair still visible just INCHES below ground Click to share on X/Twitter (Opens in new window) Click to share on Facebook (Opens in new window) GAS workers have discovered a 1,000-year-old mummy just a metre below the surface of the Earth during a routine pipe installation in Peru. The remains, believed to be a boy aged between 10 and 15-years-old, have been uncovered in surprisingly good condition, with some of his brown hair still intact. Sign up for Scottish Sun newsletter Sign up 6 Archaeologist Jose Aliaga excavates an ancient mummy Credit: AP 6 The remains are from the pre-Inca Chancay culture Credit: AFP 6 The body was wrapped in a shroud, which contained calabash gourds Credit: AP The burial was formal, with the trunk of a native huarango tree found next to the bound remains serving "as a tomb marker in the past," according to archaeologist Jesus Bahamonde, a scientific coordinator of Calidda gas company. The ancient boy's remains were discovered "in a sitting position, with the arms and legs bent," according to Bahamonde. "The burial and the objects correspond to a style that developed between 1000 and 1200 [AD]," he added. The body was found just 1.2metres beneath the Earth in Lima, Peru's capital, while the wooden tomb marker was found just a depth of 50cm (20 inches). READ MORE ON ARCHAEOLOGY TAT'S AMAZING Mysterious mummy with face tattoos STILL visible after 800 years found They were wrapped in a shroud, which contained calabash gourds - a vegetable that was not only eaten but etched with intricate art in ancient Peru. Calabash gourds are used for medicinal purposes in Peru, and throughout Bolivia and Ecuador today. Though it's unclear what the significance of the vegetable was at the time. Ceramic objects, including plates, bottles and jugs decorated with geometric figures and figures of fishermen, were also found next to the mummy. The mummy, found last week, belonged to a society of fishermen of the Chancay culture, which flourished between 1,000 and 1,470 AD, according to Jesús Bahamonde, director of the archaeological monitoring plan of metropolitan Lima at Cálidda. Despite not being covered by much ground, the mummy had gone unnoticed for a millennia - even with all of the urban development in the area. Dozens of medieval skeletons in mysterious stone coffins unearthed by man renovating his cellar Lima, a city home to 10million people, housed human civilisations for thousands of years before the Spanish arrived in Peru in 1535. As a result, there are more than 500 archaeological sites sprawled across the coastal city, including dozens of ancient cemeteries. In Peru, utility companies must hire archaeologists when drilling because of the possibility of stumbling upon ancient treasures and heritage sites. "It is very common to find archaeological remains on the Peruvian coast, including Lima, mainly funerary elements: tombs, burials, and, among these, mummified individuals," Pieter Van Dalen, dean of the College of Archaeologists of Peru, told the Associated Press. The desert heat dehydrates the bodies, naturally mummifying the bodies and leaving them fairly well preserved, according to Van Dalen, who was not involved in the discovery. 6 The body was found just 1.2metres beneath the Earth in Lima, Peru's capital, while the wooden tomb marker was found just a depth of 50cm (20 inches) Credit: AFP 6 Ceramic objects, including plates, bottles and jugs decorated with geometric figures and figures of fishermen, were also found next to the mummy Credit: AFP
