Acetazolamide in the treatment of acute mania. A case report

Respiratory syncytial virus and parainfluenza virus infection carry a poor prognosis in severe combined immunodeficiency (SCID), particularly if the viral load is high. Patients with high viral load develop severe pneumonitis at engraftment which may possibly be modulated by immunotherapy, including high dose nebulised corticosteroids. Further work is required to develop effective treatment for this severe condition.     

New perspectives in the treatment of acute mania: a single case report

1. There is increasing evidence that standard treatment of mania with lithium or neuroleptics fails in many subtypes of mania, e.g. dysphoric mania or rapid cycling, and new strategies are needed. 2. This single case report reports on possibilities and pitfalls in alternative attempts to tackle a severe manic syndrome successfully. 3. In this patient, lamotrigine and valproate, the latter only in an i.v. formulation, led to a relief from mania. 4. It is concluded that the success of this treatment may be due to a common underlying mechanism of action of these drugs, most likely on the level of ion channel regulation, and that further experience with alternative formulations of standard treatments such as valproate i.v. should be collected.     

Association of recurrent suicidal ideation with nonremission from acute mixed mania

OBJECTIVE: The authors' goal was to examine suicidality in relation to acute symptom remission in inpatients with mixed and pure bipolar disorder. METHOD: Using chart review of 184 adult inpatients with bipolar I disorder, the authors assessed patients' past and current suicidality, other psychopathology, treatment, and remission. RESULTS: Past, current, and recurrent suicidality were significantly more common among patients with mixed mania than among those with pure mania. The probability of remission declined by 49% for every suicide attempt made before the index manic episode. Mixed mania, multiple previous hospitalizations, and previous suicide attempts were significantly associated with current suicidality. CONCLUSIONS: Suicidality is linked with mixed manic states and may be a clinical marker for recurrent dysphoric mania. Multiple suicide attempts are associated with nonremission from mixed manic episodes.     

Childhood mania: insights into diagnostic and treatment issues

Our study's objective was to clarify the nosologic status of children who satisfy diagnostic criteria for bipolar disorder. Using blind raters and structured psychiatric interviews as well as data from other instruments, we undertook studies from various vantage points, examining children with bipolar disorder to confirm the existence of the diagnosis in children and to clarify its clinical course and characteristics. We found that (1) bipolar disorder in children referred to our clinical center is not as rare as previously thought; (2) bipolar disorder in children commonly presents with attention-deficit hyperactivity disorder, which makes diagnosis difficult; and (3) bipolar disorder in children presents with a clinical picture considered atypical by adult standards, with irritability, chronicity, and symptoms of mania mixed with those of depression. Our data suggest that childhood bipolar disorder is more common than previously thought, but it may be difficult to diagnose because of comorbidity with attention-deficit hyperactivity disorder and a developmentally different presentation from adults.     

Comparison of therapeutic modalities for mania

The results of sequential therapeutic trials in hospitalized manic patients conducted over a 16-year period are summarized, followed by an analysis of pooled data to assess relative efficacy. No clinically important baseline differences were found in the patients admitted to these studies despite the long time span. They were not overly "difficult to treat" or treatment resistant, and most were discharged to the community. Nearly all outcome measures showed statistically significant differences between groups after 8 weeks of treatment. The best responses occurred in the patients who received a mean series of nine electroconvulsive therapy (ECT) treatments with sparing use of neuroleptics followed by lithium maintenance. The next best outcome was observed with lithium combined with low doses of standard neuroleptics or risperidone. The combination of carbamazepine and lithium had significantly fewer neurological side effects than moderate doses of haloperidol with lithium, with equivalent therapeutic results. Monotherapy with either lithium or carbamazepine was less effective than the combination treatments. Minor differences in study design may contribute to the variance in outcome.     

Decision analysis for treatment of early stage prostate cancer

OBJECTIVE: The purpose of this study is to compare reports of alcohol use, drug use and sexual behavior from 30-day Summary measures with an expanded version of a Timeline Follow-back (Timeline) interview technique among gay/bisexual men entering outpatient substance abuse treatment at a gay-identified agency. METHOD: Respondents (N = 418) first completed self-administered questionnaires covering the 30-day period prior to their last use of alcohol or drugs. Summary measures included alcohol use, number of days of use for five categories of drugs and number of episodes of anal intercourse (with and without condoms) by partner type (primary or secondary). Participants then completed the Timeline interview procedure to recall their daily drinking, drug use and sexual behavior during the same 30-day period. RESULTS: The findings indicate that the Timeline method yielded significantly lower estimates of mean number of drinks consumed when heavier than usual drinking days is included in the Summary measure (124.0 vs 147.0 drinks), mean number of days drugs were used (9.3 vs 10.7) and mean number of episodes of anal intercourse with a primary partner (1.2 vs 2.2). Differences generally remained significant when assessed by length of time between the study interview and last use of alcohol or drugs, with the exception of number of anal sex episodes with primary partners. CONCLUSIONS: These findings indicate that Timeline estimates are lower than estimates using a more standard method (Summary measures). Discrepancies between these findings and those reported by other researchers indicate a need for further exploration of the effects of the mode of administration on various populations.     

Drug-induced mania in the elderly

Mania is a rare complication of prescribed drug use in elderly persons. The drugs most likely to produce mania include corticosteroids and dopamine agonists. It is uncertain if antidepressants cause mania or only increase the propensity for latent bipolar mania to be expressed. Drug-induced mania may promote poor judgment, risk-taking behaviours and medical noncompliance. The majority of episodes of drug-induced mania are short-lived and respond to discontinuation of the drug. Antipsychotic agents may hasten resolution of this psychiatric syndrome. Lithium may prevent corticosteroid-induced mania, but the role of lithium in the treatment of other drug-induced manic episodes has not been studied adequately.     

A home-based program for the treatment of acute psychosis

There is evidence that home treatment is an effective alternative to hospital admission for patients with acute psychiatric illnesses. This report describes processes necessary to establish and disseminate home treatment programs as well as the impact and comparative cost of a home treatment program developed in Metropolitan Toronto. Organizational analysis revealed a number of essential structures and interactions necessary to facilitate smooth functioning for home treatment programs involving several agencies. Attitudes towards home treatment were positive, symptoms were reduced, family burden decreased, satisfaction was high and home treatment was preferred to hospital admission. Economic data indicate that home treatment is less costly than hospitalization.     

Decision making analysis in the treatment of prostate cancer

The decision analysis technique has been used to estimate the benefits of treatment strategies for a variety of diseases. This analysis demonstrated that a selective treatment with a reasonable specificity and sensitivity for detecting clinically significant cancer is more beneficial to the patients with T1c cancer under 70 years of age than radical prostatectomy or watchful waiting assigned to all patients. Moreover, it was clearly indicated that quality-of-life (QOL) is the most important factor for deciding the optimal treatments of prostate cancer.     

Thrombolytic treatment for acute occlusion of the basilar artery

Sixteen patients with acute occlusion of the basilar artery were treated with systemic fibrinolysis. Recanalisation was achieved in 10 patients; five patients survived and 11 patients died. Survival was associated with vascular recanalisation in every case. Most of the survivors were younger than 50. An age above 50 and a comatose state on admission seem to indicate a poor clinical outcome. The problem of multimorbidity in the older age group also affects outcome adversely. Haemorrhagic complications were found in two cases (12.5%), with clinical deterioration in one.     

Decision analysis to optimize the outcomes for Class II Division 1 orthodontic treatment

Selection of the treatment method of choice in orthodontics is usually a question of the clinician's personal preference and is generally based on subjective criteria. Orthodontic treatment of malocclusions is unlike treatment of a disease and hence terms such as success and failure are relative and undefined. Ideally, both patients and providers should be able to arrive at treatment decisions that have the greatest potential for optimum outcomes at minimal cost and risks. This article applies the method of decision analysis to demonstrate how policy choices between "one-stage" or "two-stage" treatment of Class II Division 1 malocclusions for children between 11 and 14 years old can be based on objective criteria. A decision tree was designed to yield the value of payoffs, or outcomes, at each of the possible terminal nodes, and the probability of each payoff. Both positive (ie, improvement in malocclusion) and negative (ie, extraction of teeth and long treatment duration) attributes of outcomes were considered, and numerical values, or "utilities," were assigned to each outcome. For this model, one-stage nonextraction treatment yields the highest probability of maximum benefit. Further applications of decision analysis to resolve clinical uncertainties in orthodontics are discussed.     

Limitation of activity in an acute model of arthritis: effect of drug treatment

OBJECTIVE AND DESIGN: The limitation of activity and its modification by therapy in an experimental arthritis was studied. SUBJECTS: Female hamsters in groups of six per treatment were used. TREATMENT: An acute arthritis was induced by intraarticular injection of 0.1 microgram lipopolysaccharide (LPS) in hamsters with free access to running wheels. Tenidap at 100 mg%, and piroxicam and indomethacin at 30 mg% were administered in the hamster's normal diet. METHODS: Activity was monitored and analysed by computer. Plasma blood levels of drugs were determined by high pressure liquid chromatographic (HPLC) analysis. RESULTS: Hamsters normally run 10-15 km/day. That distance was reduced to less than 2 km/day after arthritis induction. Speed of movement, essentially the equivalent of walking time, was reduced 40% by the arthritis. However, the time spent in movement (activity time) was more severely affected by arthritic disease. Therapy gave a modest 1.3-fold increase in speed of movement, but a highly significant 2-fold increase in activity time. CONCLUSIONS: The effects of arthritis on activity in this animal model suggest that time spent in movement (activity time) should be considered as an outcome measure in clinical studies. These observations may also help explain why the modest disease improvements obtained with cyclooxygenase inhibition are valued. From a patient perspective, a doubling of activity time is a highly significant improvement in quality-of-life.     

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy

OBJECTIVE: To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. BACKGROUND: Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). METHODS: We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. RESULTS AND CONCLUSIONS: The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.     

Rating scales for mania: is self-rating reliable?

This commentary addresses the issue of whether self-rating mania scales are reliable. After a brief introduction, several newly developed self-rating mania scales are described and critically reviewed. Among the issues discussed are: the practical utility of self-assessment in patients with mania; the influence of severity of illness on ability to self-report; and, the extent to which the presence of psychosis or the absence of insight significantly interferes with a patients' ability to reliably complete self-rating measures. Data from recent studies suggests that self-rating mania scales are both reliable and valid for patients with manic symptoms, including those with psychotic features and those having little or no insight into their illness. The merits of including self-rating measures in the assessment of mania are discussed in terms of their value for both clinical and research purposes.     

Surgical treatment for acute aortic arch dissection

The authors describe 2 patients with Takayasu's arteritis in whom lupus anticoagulant was positive and the titer of anticardiolipin antibody was elevated. One patient developed diffusely stenotic and occlusive changes in the multiple larger arteries. Histology of the small-sized arteries in another patient showed occlusive vasculitis without thrombosis, in addition to the findings in large-sized arteries compatible with Takayasu's disease. These findings are uncommon in Takayasu's arteritis. These findings suggest that antiphospholipid antibodies may have contributed to the pathogenesis of the extensive vasculopathy and may have triggered vasculitis in these patients.