Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood,grandiose behaviors,decreased need for sleep,racing thoughts and hypersexuality

OBJECTIVE: Children are developmentally incapable of many manifestations of bipolar symptoms described in adults (e.g., children do not "max" out credit cards or have four marriages). To address this issue, our group investigated prepubertal and early adolescent age equivalents of adult mania behaviors. METHODS: Details of the methods appear in the companion article in this issue (Geller et al. 2002a). Subjects had a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) that was validated by reliable assessment (Geller et al. 2001b), 6-month stability (Geller et al. 2000c), and 1- and 2-year longitudinal diagnostic outcome (Geller et al. 2001a, 2002b). RESULTS: Examples of elation, grandiosity, decreased need for sleep, racing thoughts, and hypersexuality in PEA-BP subjects were compared to examples in prepubertal normal controls and to examples in late teenage/adult-onset mania. Because it is not intuitive that children can be pathologically happy or expansive, sections on guidelines for differentiating normal versus impairing elation and grandiosity are provided. CONCLUSION: Due to the high comorbidity of PEA-BP and attention deficit hyperactivity disorder (ADHD), recognition of mania symptoms that do not overlap with those for ADHD may aid in avoiding both under- and overdiagnosis of child bipolar disorder. A discussion of how "nonoverlapping with ADHD" Diagnostic and Statistical Manual of Mental Disorders (4th ed.) mania symptoms can be useful in the differential diagnosis of irritability is also provided.     

Mechanical circulatory support: new advances, new pumps, new ideas

Mechanical circulatory support (MCS) is a viable therapy for severe end-stage heart disease. Most obstacles to long-term MCS therapy have been overcome, and a number of clinical trials, including the recent REMATCH trial, have shown a clear benefit in terms of survival and improved quality of life. MCS should therefore no longer be considered as simply a temporary bridge to other therapies, but also a destination therapy whose potential should continue to expand through the development and use of newer, more innovative devices such as continuous flow pumps, next-generation centrifugal pumps, and total artificial hearts. The homebound heart failure patient and the patient facing imminent death from massive myocardial infarction receive little statistical benefit from current therapies, and the new and evolving MCS technologies offer the potential for effective therapy to these desperately ill patients.     

Maggot debridement therapy for chronic wounds

This article presents a general overview of maggot debridement therapy, as used in the management of chronic infected wounds. Much has been written about this treatment method, both historically and in the past decade. Current clinical practice is discussed and clinical and laboratory research are reviewed, with attention to the inherent challenges of such research. The nature of microbial and fungal bio-film formation in chronic wounds is considered, although little is yet known of the extent and characterization of this phenomenon. The prospects for the future are addressed. These include the need for globally acceptable criteria for clinical outcomes and guidelines for "best practice," together with the pressing need for appropriately structured randomized controlled studies.     

Abnormal neurologic maturation in adolescents with early-onset schizophrenia

OBJECTIVE: This study evaluated neurologic functioning in adolescents with schizophrenia with onset of psychosis before age 13. METHOD: The authors administered a structured neurologic examination to 21 adolescents with early-onset schizophrenia and 27 healthy age- and sex-matched comparison subjects. RESULTS: The adolescents with schizophrenia had a high frequency of neurologic abnormalities. Neurologic signs decreased with age in the healthy comparison subjects but not in the subjects with schizophrenia. CONCLUSIONS: The adolescents with schizophrenia had a high burden of neurologic impairment and a pattern of abnormalities similar to that of adults with schizophrenia. The persistence of neurologic signs in the adolescents with schizophrenia, which faded with age in the healthy comparison adolescents, supports earlier evidence of a delay in or failure of normal brain development during adolescence.     

A longitudinal and retrospective study of PTSD among older prisoners of war

OBJECTIVE: The authors examined the longitudinal changes in posttraumatic stress disorder (PTSD) symptom levels and prevalence rates over a 4-year time period among American former prisoners of war (POWs) from World War II and the Korean War. Retrospective symptom reports by World War II POWs dating back to shortly after repatriation were examined for 1) additional evidence of changing PTSD symptom levels and 2) evidence of PTSD cases with a long-delayed onset. METHOD: PTSD prevalence rates and symptom levels were measured by the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. For the longitudinal portion of the study, participants were 177 community-dwelling World War II and Korean POWs. For the retrospective portion, participants were 244 community-dwelling World War II POWs. RESULTS: PTSD prevalence rates and symptom levels increased significantly over the 4-year measurement interval. Retrospective symptom reports indicated that symptoms were highest shortly after the war, declined for several decades, and increased within the past two decades. Long-delayed onset of PTSD symptoms was rare. Demographic and psychosocial variables were used to characterize participants whose symptoms increased over 4 years and differentiate participants who reported a long-delayed symptom onset. CONCLUSIONS: Both longitudinal and retrospective data support a PTSD symptom pattern of immediate onset and gradual decline, followed by increasing PTSD symptom levels among older survivors of remote trauma.     

Fungal infections of the spine. Report of eleven patients with long-term follow-up

BACKGROUND: Fungal infections of the spine are noncaseating, acid-fast-negative infections that occur primarily as opportunistic infections in immunocompromised patients. We analyzed eleven patients with spinal osteomyelitis caused by a fungus, and we developed suggestions for treatment. METHODS: All patients with a fungal infection of the spine treated by the authors over a sixteen-year period at three teaching institutions were evaluated. There was a total of eleven patients. Medical records and roentgenograms were available for every patient. Long-term follow-up of the nine surviving patients was performed by direct examination by the authors or by the patient's primary physician. RESULTS: For ten of the eleven patients, the average delay in the diagnosis was ninety-nine days. Nine patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local extension (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spine infection developed in eight patients. Ten patients were treated with surgical debridement. All eleven patients were treated with systemic antifungal medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal hemorrhage at five months. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients. CONCLUSIONS: Treatment of fungal spondylitis is often delayed because of difficulty with the diagnosis. Delay in the diagnosis led to poorer results in terms of neurologic recovery in our study. Performing fungal cultures whenever a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible complications of the disease.