Efficacy of electroconvulsive therapy in treatment-resistant bipolar disorder: a case series

The response to electroconvulsive therapy for six bipolar patients after pharmacotherapy failure is discussed. METHODS: Inclusion criteria were as follows: (1) bipolar mood disorder, manic, depressive or mixed episode (DSM-IV); (2) failure of pharmacotherapy, that is, for mania, manic episode unresponsive to at least 2 adequate antimanic trials for 6 weeks; and for bipolar depression, bipolar depressive episode unresponsive to at least 2 adequate antidepressant trials for 8 weeks. The patients underwent 12 bilateral sessions of ECT 3 times per week. Clinical response was considered a reduction of 50% or greater in the Young Mania Rating Scale (YMRS) and in the Hamilton Rating Scale for Depression-21 items (HAMD-21). Final YMRS <6 and HAMD-21 <8 defined remission. RESULTS: Six of the 9 referred patients consented to be submitted to ECT. Four were male, with ages ranging from 29 to 61 years, and their age at onset ranged from 19 to 49 years. Four showed psychotic features. All responded to ECT.     

Late-onset, "Gastaut type", childhood occipital epilepsy: an unusual evolution.

We report on two girls and one boy with clinical and electroencephalographic features of late-onset childhood epilepsy with occipital paroxysms of the "Gastaut type", showing an unusual evolution. Neurological examination and brain imaging were normal in all three. At the age of 7.5 years, eight years and ten years respectively, the three children presented with episodes of visual symptoms when awake, and in one of them, the seizures were occasionally followed by oculocephalic deviation. The interictal EEG showed bilateral occipital spike-wave activated by eye closing. In two patients, the occipital seizures had been immediately followed by typical absences, since onset; in the other patient, five months after onset. The ictal EEG showed irregular bilateral occipital spike-wave discharges during the visual symptoms, followed by generalized spike-wave activity during the typical absences. The typical absences were activated by hyperventilation; the EEG did not show continuous spikes and waves during slow sleep. These three patients, with typical electroclinical features of "Gastaut type", childhood occipital epilepsy, demonstrated an evolution which, to our knowledge, has not been previously described. We investigated whether this unusual, age-dependent evolution was due to secondary bilateral synchrony or if these electroclinical features represent two types of idiopathic epileptic syndromes in the same patients.     

Diffusion-perfusion MR evaluation and spectroscopy before and after surgical therapy for intracerebral hemorrhage

Introduction: Advanced magnetic resonance imaging (MRI) techniques provide metabolic/hemodynamic information that is useful in the diagnosis of ischemic stroke. To date, however, their application in intracerebral hemorrhage (ICH) has been limited. We postulate that these MRI techniques may help define mechanisms of secondary damage and assess effects of therapeutic interventions in perihematoma tissue after ICH. Methods: A 44-year-old woman presented with severe headache resulting from a right temporal ICH. After developing neurological deterioration 5 days after the bleed, the patient underwent evacuation of the hematoma. Specimen pathology suggested the presence of a small vascular malformation. Diffusion- and perfusion-weighted imaging as well as proton magnetic resonance spectroscopic imaging (¹H-MRSI) investigations to assess perihematoma brain tissue metabolic and circulatory profiles were performed before and after hematoma evacuation. Results: Pre-operative results showed mild oligemia posterior to the hematoma, increased average diffusion coefficient (DAV), and normal perihematoma N-acetyl-aspartate (NAA) concentration on ¹H-MRSI. This profile was interpreted as inconsistent with ischemia (as defined by reduced DAV and NAA) but compatible with perihematoma inflammation (as defined by elevated DAV and lactate signal). Postsurgical MRI investigations showed near normalization of the perfusion deficit. Conclusion: We postulate that mass effect produced by the hematoma, and perhaps inflammation, can induce perilesional reduced cerebral perfusion in a reversible manner.     

The developing intestinal ecosystem: implications for the neonate

Interactions of resident intestinal microbes with the luminal contents and the mucosal surface play important roles in normal intestinal development, nutrition, and innate and adaptive immunity. The neonate, especially the premature, who possesses a highly immunoreactive intestinal submucosa underlying a single layer of epithelial cells that are continuously exposed to the luminal environment, is highly susceptible to perturbations of the luminal environment. Understanding the interactions of the intestinal ecosystem with the host and luminal nutritional environment, especially in regard to human milk and pre- and probiotics, has major implications for the pathogenesis of diseases that affect not only the intestine but distal organs such as the lung and brain.     

Reduced-antigen-content-diphtheria-tetanus-acellular-pertussis and inactivated polio vaccine as a booster for adolescents 10 to 14 years of age

High rates of pertussis disease in adolescents suggest that additional boosting against pertussis would be beneficial. A combined acellular-pertussis-containing booster vaccine (dTpa-IPV; Boostrix Polio, n =440) was compared to separately administered dTpa (Boostrix) and inactivated polio virus (IPV; Imovax Polio^®, n =219), and to DTPa-IPV (Infanrix IPV, n =111) vaccine in a partially blind, randomised controlled trial in 10–14 year olds. One month after vaccination, seroprotection/seropositivity rates for all antigens were similar for all groups. Although pertussis and diphtheria antibody geometric mean antibody concentrations were higher after DTPa-IPV, all subjects had protective antibodies against diphtheria, tetanus and polio, and at least 97% had a vaccine response to pertussis antigens. Reactogenicity of dTpa-IPV was comparable to dTpa + IPV, but dTpa-IPV was generally better tolerated than DTPa-IPV. Conclusion:The combined reduced-antigen-content-diphtheria-tetanus-acellular-pertussis and IPV vaccine is immunogenic and well tolerated when administered to adolescents and could be used to improve the control of pertussis disease in this age group.     

Small bowel obstruction caused by a congenital jejuno-jejuno band in a child

A case of small bowel obstruction in a 4-year-old boy with pica is described. The child habitually chewed on his plastic toy action figures. Abdominal radiography and endoscopy confirmed the presence of chewed pieces of plastic within the digestive tract. At surgery, the cause of the obstruction was found to be an internal hernia involving a congenital fibrous band connecting 2 segments of the jejunum and unrelated to pica. Intestinal obstruction caused by foreign bodies is extremely rare, and obstruction caused by congenital bands is even more uncommon. This particular variant of a congenital band has not been previously described. Physicians should be aware that congenital bands can cause small bowel obstruction in children and that surgical treatment is required.     

Heterotopic Neurons in the Umbilical Cord

Several types of tissues have been reported to present ectopically in the umbilical cord (UC). Most of these are found in the UC proximal to the fetus. Featuring tissues are developmentally related to the area, thus representing vestigial remnants. In this report we describe the recognition of neurons and nerves within the UC in a stillborn with several malformations, an observation that we did not find in the literature.     

Luteinized cystic ovarian hyperplasia associated with placentomegaly due to chorangiomatosis

Luteinized cystic ovarian hyperplasia (LCOH) is a rare benign condition characterized by bilateral ovarian enlargement during pregnancy secondary to high maternal human chorionic gonadotropin serum levels referred to occur under several conditions. We report the case of a 29-year-old obese woman with LCOH incidentally discovered during cesarean section of a single pregnancy at 35 weeks of gestation for fetal intrauterine demise. The fetus showed external ambiguous genitalia, imperforate anus, bilateral dysplastic kidneys, and hydrometrocolpos secondary to atresia of the vagina. The placental weight was 1,450 g (normal for gestational age: 415 g). The placenta showed diffuse chorangiomatosis (CM) characterized by multifocal stem villi enlargement containing increased number of small vessels with alpha-smooth muscle actin positive cells in the walls in a dense reticulin fibers-rich stroma. The combination of LCOH and placentomegaly due to CM appears to be unique.     

Empty sella syndrome, panhypopituitarism, and diabetes insipidus

We present an 18-month-old girl with short stature, obesity, panhypopituitarism, diabetes insipidus, and visual defects. Postmortem examination revealed brain atrophy due to a diffuse encephalopathy, numerous calcified neurons in cerebral cortex, deep telencephalic and diencephalic nuclei, diffuse neuronal necrosis in hypothalamic nuclei, moderate atrophy of optic nerves, very thin hypophyseal stalk, and empty sella with the hypophysis compressed to the dorsal aspect of the concavity. Our hypothesis is that the presence of an empty sella in a child with hypophyseal-hypothalamic abnormalities should alert physicians to the existence of hypothalamic lesions secondary to a perinatal insult. We discuss the possible pathogenesis of these findings as well as lines of evidence available in the literature.