The prognostic significance of "switching" in patients with bipolar disorder: a 10-year prospective follow-up study

OBJECTIVE: This study explored whether "switching" (i.e., the direct transition from one mood polarity to the other) has significant prognostic implications in patients with bipolar disorder. METHOD: Bipolar disorder patients (N=97) whose first prospectively observed episode included at least one mood polarity switch and 97 bipolar disorder patients whose index episode was monophasic were compared with respect to several demographic and historical variables, symptomatic features of the index episode, time to recovery from the index episode, time spent in an affective episode during a prospective observation period, and psychopathological and psychosocial outcome at a 10-year follow-up interview. RESULTS: Patients whose index episode included at least two mood polarity switches spent significantly more time in an affective episode during the observation period and had a significantly worse psychopathological and psychosocial outcome 10 years after recruitment than those whose index episode included only one mood polarity switch or was monophasic. Patients whose polyphasic index episode started with depression spent a significantly higher proportion of time in an affective episode and had a significantly worse 10-year outcome than those whose polyphasic index episode started with mania or hypomania. Retention of the switching pattern throughout the observation period was seen in 42.4% of patients whose index episode started with mania and in 65.2% of those whose index episode started with depression. CONCLUSIONS: An index episode including at least two mood polarity switches, especially if starting with depression, is associated with a poor long-term outcome in patients with bipolar disorder. This pattern represents a significant target for new pharmacological and psychosocial treatment strategies.     

Historical,psychopathological, neurological,and neuropsychological aspects of deficit schizophrenia: a multicenter study

OBJECTIVE: This multicenter study aimed to verify whether the historical and psychopathological characteristics of a large group of patients with deficit schizophrenia were consistent with those reported in previous studies. The authors also tested the hypothesis that neurological and neuropsychological indices sensitive to frontoparietal dysfunction, but not those sensitive to temporal lobe dysfunction, are more impaired in patients with deficit schizophrenia than in those with non-deficit schizophrenia. METHOD: For each patient with deficit schizophrenia enrolled in the study, a matched subject with non-deficit schizophrenia was recruited. Historical, psychopathological, neurological, and neuropsychological evaluations were carried out for all patients. RESULTS: Patients with deficit schizophrenia, compared with patients with non-deficit schizophrenia, had a similar severity of positive symptoms and disorganization and less hostility. They had poorer premorbid adjustment during childhood and early adolescence and exhibited more impairment in general cognitive abilities. The deficit state was associated with impairment in sequencing of complex motor acts, which suggests frontoparietal dysfunction. CONCLUSIONS: Previous reports of differences in historical, psychopathological, and neuropsychological characteristics between patients with deficit schizophrenia and those with non-deficit schizophrenia were mostly supported by the present findings. Neurological findings suggest that frontoparietal functioning is more impaired in patients with deficit schizophrenia. Deficit schizophrenia might represent a neurodevelopmental subtype of schizophrenia in which significant behavioral and cognitive impairment since childhood compromises the development of basic capacities relevant to subsequent cognitive and social functioning.     

Qualitative MRI findings in patients with schizophrenia: a controlled study

A variety of brain structural abnormalities, which can be identified only by qualitative methods, have been shown to correlate with clinical presentation and course of schizophrenia. In the present study, MRI scans of 122 patients with DSM-IV schizophrenia and 81 non-psychiatric controls were evaluated. Among males, the frequency of CNS developmental abnormalities (CDAs) was higher in patients than in controls. Lateral ventricular enlargement (LVE) was more frequent in patients than in controls; when subjects were grouped in three age classes, LVE was more frequent in patients than in controls in the youngest and the oldest age group. Patients with LVE or third VE were older than those without these abnormalities. Schizophrenic patients with LVE or cortical atrophy (CA) had a longer duration of illness than those without these abnormalities. Both patients with LVE and those with third VE had a poorer outcome than those without these abnormalities. CDA findings add to the evidence of a higher frequency of neurodevelopmental abnormalities in male schizophrenic patients. Results concerning LVE suggest that both developmental and degenerative processes underlie this abnormality. The association of LVE and third VE with a poor outcome indicates that qualitative MRI evaluation might be of clinical relevance.     

Circulating leptin in patients with anorexia nervosa, bulimia nervosa or binge-eating disorder: relationship to body weight, eating patterns, psychopathology and endocrine changes

A decreased production of leptin has been reported in women with anorexia nervosa (AN) and has been attributed merely to the patients' reduced body fat mass. The extent to which eating patterns, purging behaviors, psychopathology and endocrine changes may contribute to the genesis of leptin alterations has not been deeply investigated. Therefore, we measured plasma levels of leptin, glucose and other hormones in three groups of eating disorder patients with different body weight (BW), eating patterns and purging behaviors. Sixty-seven women, 21 with AN, 32 with bulimia nervosa (BN), 14 with binge-eating disorder (BED) and 25 healthy females volunteered for the study. We found that circulating leptin was significantly reduced in AN and BN patients, but significantly enhanced in women with BED. In anorexics, plasma glucose was decreased, whereas plasma cortisol was enhanced; blood concentrations of 17beta-estradiol and prolactin (PRL) were reduced in both AN, BN and BED patients. In all subject groups, a strong positive correlation emerged between plasma levels of leptin and the subjects' BW or body mass index, but not between leptin and psychopathological measures, plasma glucose, cortisol, PRL and 17beta-estradiol. Since leptin was reduced in both underweight anorexics and normal weight bulimics, but increased in overweight BED women, who compulsively binge without engaging in compensatory behaviors, we suggest that factors other than BW may play a role in the determination of leptin changes in eating disorders.     

Full-syndrome,partial-syndrome and subclinical eating disorders: an epidemiological study of female students in Southern Italy

We screened a sample of 919 female students, aged 13–19 years, by means of the EDI 2 and GHQ-28 questionnaires. Those students identified as being at risk for an eating disorder (281 subjects) underwent a psychiatric interview. We found 2 cases of full-syndrome anorexia nervosa (0.2%), 21 cases of full-syndrome bulimia nervosa (2.3%) and 2 cases of full-syndrome binge-eating disorder (0.2%). Moreover, 35 girls (3.8%) met the criteria for partial-syndrome and 98 girls (10.7%) fulfilled the criteria for subclinical eating disorders. Subjects with partial-syndrome and subclinical eating disorders had higher scores than those with no diagnosis, but lower scores than students with full-syndrome eating disorders, on both the EDI 2 and GHQ-28 questionnaires. A follow-up of subjects with partial-syndrome and subclinical eating disorders is now in progress.     

The liver scan in patients with cancer: Histologic correlation

Liver scans, biopsies, and function studies were reviewed in 63 cancer patients and correlated with autopsy material to determine the value of the liver scan in such patients. The scan is abnormal in 96% of patients with autopsy-confirmed hepatic disease, but the scan pattern is of little assistance in differentiating tumor from nontumor pathology. Liver function studies are equally nonspecific and even less sensitive than the scan. Percutaneous biopsy, while diagnostic when positive, is insensitive, showing false-negative results in up to 40% of cases. The liver scan, as the most sensitive indicator of liver disease, may be most valuable when normal, reflecting a better prognosis and aiding in the determination of treatment. When the liver scan is abnormal, more specific tests must be employed. A method of approach is suggested.     

The relationship between a pentagastrin-stimulated gastric luminal acid production test (Gastrotest) and enteral feeding-related gastrointestinal complications in critically ill patients

Gastrointestinal feeding-related complications (GICs) are common in critically ill patients. Unfortunately, patients at risk for GICs cannot be easily identified. Therefore, we performed a prospective study of 20 critically ill patients to determine the association between a pentagastrin-stimulated gastric acid production test and GICs. Before feeding, the change in the pH of gastric juice was measured in response to a subcutaneous injection of pentagastrin (Gastrotest). We recorded GICs and the feeding volume ratio during each patient's intensive care unit (ICU) stay. Nineteen patients' data were analyzed and 9 patients (47%) developed > or =1 GIC, including large gastric residuals, 26%; abdominal distension, 26%; and vomiting, 21%. Patients with GICs had a longer length of ICU stay (mean 21.3, range 5-45 versus 10.1, range 3-32; P < 0.05). The 9 patients (47%) who were Gastrotest responders before starting enteral feeding exhibited a significantly larger volume ratio (P = 0.01) and fewer GICs (1 [11%] versus 8 [80%]; P < 0.05). Abdominal distension was seen in only nonresponders. The positive and negative predictive values for this test's ability to predict GICs were 80% and 88.9%, respectively. Responding to a pentagastrin-stimulated gastric luminal acid production test is associated with the administration of larger volumes of enteral feed and fewer GICs.     

Conversion of manual to total computerized medical records

The use of computerized medical records for complex medical patients will depend upon the transfer of previous medical data from the manual record into the automated version. The complexity of these patients precludes the complete transfer of medical data into the automated record because of time requirements. This paper describes a method of transfer of medical data from the manual record to the computerized record that is efficient, accurate, and useful.