Current issues in bipolar disorder: a critical review.

Although awareness on bipolar disorder has increased during the last decade, this condition remains characterized by a disabling burden, in terms of morbidity and functional impairment. This paper aims to review some critical issues in the current knowledge on Bipolar disorder. Although large European epidemiological studies are lacking, Bipolar disorder is characterized by a set of severe features, including an early age of onset, a chronic outcome and an important suicidal risk. A majority of bipolar patients also experience a comorbid Axis I condition, including substance abuse, anxiety disorder and attention-deficit hyperactivity disorder. This situation presents a therapeutic challenge, since antidepressants or methylphenidate may be associated with the risk of inducing mania. Recently, a large number of studies have provided evidence for the efficacy of new compounds in the treatment of both mania and bipolar depression, but also in long-term relapse prevention. Recent research has also allowed for the redefinition of the concept of mood stabilizer and for improving existing guidelines on the clinical management of Bipolar disorder.     

Early stage I adenocarcinoma of the uterine cervix: treatment results in patients with tumors less than or equal to 4 cm in diameter

Between 1965 and 1985, 160 patients had initial treatment at the M. D. Anderson Cancer Center for Stage I adenocarcinoma of the uterine cervix less than or equal to 4 cm in diameter. Of these patients, 84 were treated with radiation therapy (RT) alone, 20 were treated with external and intracavitary radiation followed by total hysterectomy (R + S), and 56 were treated with radical hysterectomy (RH). Survival rate was strongly correlated with tumor volume (P = 0.0008), lymphangiogram findings (P = 0.01), and tumor grade (P = 0.0018). Patients with a normal-appearing cervix or a small visible or palpable tumor that did not expand the cervix more than 3 cm had survival and pelvic-control rates of more than 90% after treatment with RH or RT. However, after 5 years, 45% of patients treated with RH for tumors 3-4 cm in diameter had disease recurrence in the pelvis, compared with 11% of patients treated with either RT or R + S (P = 0.025). For patients treated with RH, recurrence was also strongly correlated with findings of lymph/vascular space invasion (P = 0.0004) and poorly differentiated tumor (P = 0.018). Major complication rates were comparable for the three treatment groups. The high rate of pelvic recurrence following treatment with radical hysterectomy alone for patients with tumors greater than 3 cm in diameter, particularly in the presence of lymph/vascular space invasion, poorly differentiated features, and/or positive nodes, should be considered in planning the primary management of patients with Stage I adenocarcinoma of the cervix.     

Are tailored health education materials always more effective than non-tailored materials?

While promising, the evidence in support of tailored health communication has not been overwhelming. One explanation is that tailored materials may be far superior to non-tailored materials in some cases, but only slightly better, no different or less effective in others. In this study, 198 overweight adults were randomly assigned to receive either tailored or non-tailored weight loss materials. Participants' cognitive, affective and behavioral responses to the materials were measured at an immediate and 1 month follow-up. Analyses compared those who received tailored materials to those who received non-tailored materials that were--by chance alone--either a good fit, moderate fit or poor fit, based on the match between behavioral characteristics of the participant and content of the non-tailored materials. Findings showed that good-fitting non-tailored materials performed as well or better than tailored materials for several cognitive, affective and behavioral outcomes. However, moderate- and poor-fitting non-tailored materials were consistently inferior to both approaches. The art and science of creating tailored health communication programs is still evolving. Data from this study suggest present approaches to tailoring are more effective than non-tailored materials in most, but not all cases. Specific recommendations are made describing ways to refine tailoring methods to maximize the effectiveness of this approach.     

Contrast-medium enhanced reflux ultrasound in children. A comparison with radiologic imaging up to now

Voiding cystourethrography (VCUG) has long been the method of choice for the diagnosis of vesicoureteral reflux (VUR). Especially in the course of conservative treatment, the radiation dose involved might become quite high over the years. Since the development of such ultrasound echo-enhancing agents as Levovist (Schering, Germany), we now have the ability to assess the diagnostic efficacy of this agent in the evaluation of VUR with a view to replacing VCUG with the radiation-free ultrasound methodology. A total of 104 children with a mean age of 5.4 years were examined using echo-enhancing ultrasound after informed consent had been obtained from their parents. For control purposes, all children were examined by standard VCUG as well. The diagnosis of VUR was judged to be positive when microbubbles appeared in the ureter or renal pelvis. Correlations were sought between the sonographic findings and those obtained by standard VCUG. In 76 (37%) of the 208 ureter-kidney units investigated, VUR was detected by both technologies. VUR was diagnosed by ultrasonography only in 5 units and by VCUG only only in 3 units. All reflux grades (I-V) were identified. The specificity and sensitivity of the contrast reflux ultrasound were significantly high. The long contrast time of up to 30 min combined with the high contrast effect resulted in convincing images with high levels of diagnostic confidence. Our results clearly demonstrate that the safety and accuracy of the diagnosis of VUR by means of contrast-enhanced ultrasound is statistically comparable to those of standard radiologic VCUG. Therefore, this methodology is an exceptional approach to reducing the number of children being exposed to ionising radiation especially during conservative follow-up of children with reflux.     

Voiding cystourethrography using the suprapubic versus transurethral route in infants and children: results of a prospective pain scale oriented study

PURPOSE: We determined the advantages and disadvantages of different types of contrast medium injection into the bladder for imaging children during evaluation for urinary tract infection in regard to child behavior and distress during urethral catheterization or suprapubic puncture. MATERIALS AND METHODS: From December 2000 to September 2001 we prospectively compared transurethral catheter and suprapubic voiding cystourethrography in children with a history of urinary tract infection. A total of 65 children with a mean age of 33.8 months were entered into the study, of whom 32 underwent transurethral catheterization and 33 underwent suprapubic puncture with topical anesthesia. Each child was evaluated, particularly in regard to discomfort and pain using an objective pain score that measures stress and pain during a medical procedure. RESULTS: Objective pain score recording showed a mean pain score plus or minus SD of 4.25 +/- 1.3 in the transurethral catheterization and 3.03 +/- 1.21 in the suprapubic puncture groups. Correlation studies of age in the 2 groups also showed a significant impact of age on the objective pain score. In the transurethral group the score increased with age (p <0.001), whereas in the suprapubic group it decreased with age (p <0.001). CONCLUSIONS: The current study shows that the suprapubic puncture technique with topical anesthesia was well tolerated and associated with a low pain score independent of patient age. Transurethral catheterization was also tolerated but it was associated with a low pain score only in the younger age group. Thus, we recommend that voiding cystourethrography in children older than 24 months should be done via the suprapubic route.     

Interleukin-1 receptor antagonist genotype is associated with coronary atherosclerosis in patients with type 2 diabetes

Recently, inflammation has received considerable attention in the pathogenesis of both type 2 diabetes and atherosclerosis. The interleukin-1 receptor antagonist (IL-1ra) is a major modulator of the interleukin-1 pro-inflammatory pathway. We studied the relationship between a variable number tandem repeat (VNTR) polymorphism in intron 2 of the IL-1ra gene (IL1RN) and coronary artery disease (CAD) in patients with and without type 2 diabetes, following 787 consecutive patients admitted for suspected CAD. According to the current criteria of the American Diabetes Association, 250 patients had type 2 diabetes. In this group of patients, allele 2 carriers (n = 108) had an increased prevalence of CAD compared with noncarriers (85.2 vs. 73.2%), a difference that remained significant in a multivariate logistic regression model (odds ratio 2.2, 95% CI 1.1-4.3, P = 0.02). No association of CAD with allele 2 carrier status was present among nondiabetic patients (n = 537). Enzyme-linked immunosorbent assays showed decreased baseline plasma levels of IL-1ra in patients with type 2 diabetes, which may in part explain the role of the IL1RN VNTR in these patients.     

Diffusion and perfusion MRI for the localisation of epileptogenic foci in drug-resistant epilepsy

Drug-resistant epilepsy is an important clinical challenge, both diagnostically and therapeutically. More and more surgical options are being considered, but precise presurgical assessment is necessary. We prospectively studied eight patients with drug-resistant epilepsy, who underwent clinical examination, single photon emission computed tomography (SPECT) and interictal MRI, including diffusion- and perfusion-weighted echoplanar sequences. Lesions suspected on SPECT of being epileptogenic showed mild hypoperfusion, while the diffusion-weighted MRI (DWI) revealed increased apparent diffusion coefficients relative to the other side. However, these abnormalities were not visible on the corresponding maps. We showed that DWI and perfusion-weighted MRI could be used confirm the characteristics and site of an epileptogenic area in patients with drug-resistant epilepsy.     

Apparent diffusion coefficient mapping of infarcted tissue and the ischaemic penumbra in acute stroke

MRI assessment of diffusion changes in acute cerebral ischaemia necessitates analysis of the apparent diffusion coefficient (ADC). We used the concept of relative weighted mean ADC (rwmADC) to obtain an accurate estimate of the extent of infarcted tissue. We studied ten patient with of acute ischaemic stroke, using diffusion- and perfusion- weighted MRI. The rwmADC was used to calculate a corrected ADC-lesion volume (DLVR), which was compared with the diffusion-lesion volume (DLV), initial perfusion lesion volumes and the follow-up infarct volume on T2-weighted images. We looked at correlations between the MRI and clinical findings. DLVR was closest to the final infarct size and had the best clinicoradiological correlation (r=0.77). Weighting the mean ADC within the ischaemic and normal parenchyma can give a more correct estimate of the volume of infarcted brain parenchyma, thus improving the definition of the penumbra.     

Fibrinogen predicts restenosis after endovascular treatment of the iliac arteries

OBJECTIVE: Fibrinogen is an acute phase protein as well as a component of the coagulation cascade. Vascular inflammation and disturbed coagulation are suggested to cause restenosis after percutaneous transluminal angioplasty (PTA). We investigated the prognostic impact of fibrinogen on restenosis after endovascular treatment of iliac artery occlusive disease. METHODS: In a prospective cohort study 137 consecutive patients after iliac artery PTA (n = 74) and PTA plus selective stent implantation (n = 63) were included, 109 patients after lower limb angiography served as a control group. Patients were followed for 6 months with oscillography, ankle brachial index and duplex sonography for occurrence of restenosis. Fibrinogen and serum amyloid A (SAA), as a control parameter of inflammation, were obtained at baseline, 8, 24 and 48 h postintervention. RESULTS: PTA (adjusted OR 3.1, p = 0.05) and stenting (adjusted OR 13.3, p = 0.001) were independently associated with a higher postintervention increase of fibrinogen compared to angiography. Restenosis was found in 29 patients (21%). Patients with pre-intervention fibrinogen values in the third quartile (411-463 mg/dl) had a 6.2-fold increased adjusted risk for restenosis (p = 0.03), patients in the fourth quartile (> 463 mg/dl) had a 8.9-fold increased adjusted risk (p = 0.007). Pre-intervention SAA values were also significantly associated with restenosis (p < 0.0001). Postintervention fibrinogen and SAA levels showed no association with outcome. CONCLUSION: Balloon angioplasty and stenting of the iliac arteries cause an elevation of postintervention fibrinogen levels independently of angiographic factors. A higher pre-procedure fibrinogen level, presumably a marker of inflammatory activity, indicates a higher risk for restenosis.