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1.
Dermatol Surg ; 47(2): 189-193, 2021 02 01.
Article in English | MEDLINE | ID: mdl-32796326

ABSTRACT

BACKGROUND: As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients. OBJECTIVE: To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications. METHODS: A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics. RESULTS: This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19-6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08-5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05-4.90; p = .036). CONCLUSION: Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.


Subject(s)
Mohs Surgery/adverse effects , Postoperative Complications/epidemiology , Skin Neoplasms/surgery , Age Factors , Aged, 80 and over , Anticoagulants/administration & dosage , Anticoagulants/adverse effects , Extremities , Female , Humans , Incidence , Male , Neoplasm Staging , Postoperative Complications/etiology , Retrospective Studies , Risk Factors , Skin/pathology , Skin Neoplasms/diagnosis , Skin Neoplasms/pathology , Surgical Flaps/adverse effects , Surgical Flaps/transplantation
3.
Dermatol Surg ; 46(6): 773-779, 2020 06.
Article in English | MEDLINE | ID: mdl-31592927

ABSTRACT

BACKGROUND: Typical prophylactic coverage of suspected cutaneous surgical-site infections (SSIs) predominantly covers gram-positive bacteria. Data regarding the frequency of infection with unusual bacteria, not covered by prophylaxis, are not available. OBJECTIVE: A retrospective 10-year review of culture-positive infections at a single academic site was performed. MATERIALS AND METHODS: All positive bacterial culture results at the Washington University Center for Dermatologic and Cosmetic Surgery between October 31, 2007, and October 31, 2017, were collected and analyzed. RESULTS: Coagulase-negative staphylococcus accounted for 20.8% of positive culture results. Staphylococcus aureus caused 45.4% of infections. The remaining 33.8% were due to non-S. aureus bacteria, most frequently with Pseudomonas aeruginosa (10.8%). Numerous other gram-negative organisms and unusual gram-positive organisms were cultured. The lower extremity and ear were the only sites more likely to be infected with non-S. aureus bacteria. Smokers and immunosuppressed individuals were not more likely to have an SSI with non-S. aureus bacteria. CONCLUSION: A significant proportion of all SSIs with positive culture results was due to bacteria that are not sensitive to beta-lactam prophylaxis. Broader coverage for suspected SSI should be considered, particularly on the lower extremity and ear.


Subject(s)
Antibiotic Prophylaxis/standards , Dermatologic Surgical Procedures/adverse effects , Pseudomonas Infections/epidemiology , Staphylococcal Infections/epidemiology , Surgical Wound Infection/microbiology , Anti-Bacterial Agents/pharmacology , Anti-Bacterial Agents/therapeutic use , Antibiotic Prophylaxis/methods , Humans , Pseudomonas Infections/diagnosis , Pseudomonas Infections/microbiology , Pseudomonas Infections/prevention & control , Pseudomonas aeruginosa/drug effects , Pseudomonas aeruginosa/isolation & purification , Retrospective Studies , Staphylococcal Infections/diagnosis , Staphylococcal Infections/microbiology , Staphylococcal Infections/prevention & control , Staphylococcus aureus/drug effects , Staphylococcus aureus/isolation & purification , Surgical Wound Infection/diagnosis , Surgical Wound Infection/epidemiology , Surgical Wound Infection/prevention & control , beta-Lactam Resistance , beta-Lactams/pharmacology , beta-Lactams/therapeutic use
4.
Neurorehabil Neural Repair ; 28(8): 779-87, 2014 Oct.
Article in English | MEDLINE | ID: mdl-24526709

ABSTRACT

BACKGROUND: While prior preliminary studies have broadened our understanding of how repetitive transcranial magnetic stimulation (rTMS) improves language outcomes in stroke patients with nonfluent aphasia, the evidence base of the effectiveness of this method remains inadequate. OBJECTIVE: In this study, we aimed to strengthen the evidence that this approach improves language performance and to identify characteristics of patients predisposed to benefit most from this treatment. METHODS: Fifty-six stroke patients with nonfluent aphasia were randomly allocated to a real or a sham stimulation group: Group A (n = 33), who underwent 10 sessions of 1-Hz rTMS over the contralesional pars triangularis (PTr), and Group B (n = 23), who received sham 1-Hz stimulation. We performed the Picture Naming Test and the Concise Chinese Aphasia Test (CCAT) at the baseline, post-rTMS intervention, and at 3-month follow-up. RESULTS: Group A showed significantly greater improvement than Group B in CCAT scoring (P < .001), object-naming accuracy (P = .01), and naming reaction time (P = .004). The CCAT scoring and naming testing changes for Group A were persistent at 3 months following intervention (P = .008). Patients who had a lower contralesional rest motor threshold (rMT) were predisposed to a favorable therapeutic outcome (P = .006), independent of aphasia type, severity, and duration. CONCLUSIONS: The results of this study provide evidence that inhibitory rTMS, through downregulating the circuitry of the right pars triangularis (PTr), achieves a persistent and broadly modulating effect, irrespective of aphasia severity and subtype. Patients who show lower rMT in the right motor system would seem to benefit the most from inhibitory rTMS.


Subject(s)
Aphasia, Broca/rehabilitation , Broca Area/physiopathology , Neural Inhibition , Stroke/complications , Transcranial Direct Current Stimulation , Aged , Double-Blind Method , Female , Humans , Male , Middle Aged
5.
Biomaterials ; 35(1): 25-35, 2014 Jan.
Article in English | MEDLINE | ID: mdl-24099707

ABSTRACT

We sought to explore the biological mechanisms by which endosseous implant surface topography contributes to bone anchorage. To address this experimentally, we implanted five groups of custom-made commercially pure titanium implants of varying surface topographical complexity in rat femora for 9 days; subjected them to mechanical testing; and then examined the interfacial bone matrix by electron microscopy. The five implant surfaces were prepared by combinations of dual acid etching and grit blasting the titanium substrates and, in some cases, modifying the created surfaces with the deposition of nanocrystals of calcium phosphate, which resulted in 10 samples per group. In parallel, we cultured rat bone marrow cells on surrogate implants constructed from polymer resin coated with the same calcium phosphate nanocrystals, and monitored the deposition of bone sialoprotein by transmission electron immunohisto-micrography. We found that implant samples modified with sub-micron scale crystals were bone-bonding, as described by the interdigitation of a mineralized cement line matrix with the underlying implant surface. The in vitro assay showed that bone sialoprotein could be deposited in the interstices between, and undercuts below, the nanocrystals. In addition, when mineralized, the cement line matrix globules occupied micron-sized pits in the implant surfaces, and in part obliterated them, creating an additional form of anchorage. Our results also showed that collagen, elaborated by the osteogenic cells, wrapped around the coarse-micron features, and became mineralized in the normal course of bone formation. This provided a mechanism by which coarse-micron implant features contributed to a functional interface, which we have previously described, that is capable of resisting the mechanical loading that increases as peri-implant bone matures. Thus, our findings provide mechanistic explanations for the biologically-relevant criteria that can be employed to assess the importance of implant surface topography at different scale-ranges.


Subject(s)
Bone and Bones , Prostheses and Implants , Animals , Male , Microscopy, Electron, Scanning , Rats , Rats, Wistar
6.
Oncology ; 82(2): 98-107, 2012.
Article in English | MEDLINE | ID: mdl-22328009

ABSTRACT

BACKGROUND: This study investigated one-stop breast screening combining magnetic resonance imaging (MRI) and ultrasound (US) in asymptomatic Asian women. METHODS: 3,586 asymptomatic women (mean age, 45.3 years) were retrospectively analyzed by breast MRI followed by US. US-guided biopsy was performed when the MRI-detected lesion was confirmed by US. When the lesion was not detected on the initial US, a second-look US guided by MRI findings was performed. Then biopsy was done. MRI-positive and US-negative patients were followed up according to MRI lesion size, MRI lesion morphology, and mammographic diagnosis. RESULTS: In total, 115 subjects had suspicious malignant lesions and received US-guided biopsy, and 47 malignant lesions, including 35 invasive cancers and 12 carcinoma in situ (CIS) lesions, were diagnosed. More than half (22/35, 63%) of the women with invasive cancer were <50 years of age, and 27 (57.4%) of the 47 cancer cases had early breast cancers. Two invasive cancers (5.7%) and 7 CIS lesions (58.3%) were found at the second-look US. The overall cancer incidence was 1.31% (47/3,586) and increased to 2.2% (78/3,586) if precancerous lesions were included. Subjects aged 41-50 years had the highest incidence of cancer detection (1.97%). Five MRI and US-negative cases had cancers found 1 year after the screening. CONCLUSIONS: The results from the one-stop breast screening in this study showed that combining MRI and US is an efficient multimodality tool for screening asymptomatic Asian women in a metropolitan area of Taiwan who had concerns about the diagnosis and radiation of mammography.


Subject(s)
Breast Neoplasms/diagnosis , Magnetic Resonance Imaging/methods , Ultrasonography, Mammary/methods , Adolescent , Adult , Aged , Aged, 80 and over , Breast Neoplasms/epidemiology , Child , Female , Humans , Incidence , Middle Aged , Taiwan/epidemiology
7.
BMC Cancer ; 11: 242, 2011 Jun 13.
Article in English | MEDLINE | ID: mdl-21668954

ABSTRACT

BACKGROUND: Recent refinements of lung MRI techniques have reduced the examination time and improved diagnostic sensitivity and specificity. We conducted a study to assess the feasibility of MRI for the detection of primary lung cancer in asymptomatic individuals. METHODS: A retrospective chart review was performed on images of lung parenchyma, which were extracted from whole-body MRI examinations between October 2000 and December 2007. 11,766 consecutive healthy individuals (mean age, 50.4 years; 56.8% male) were scanned using one of two 1.5-T scanners (Sonata and Sonata Maestro, Siemens Medical Solutions, Erlangen, Germany). The standard protocol included a quick whole-lung survey with T2-weighted 2-dimensional half Fourier acquisition single shot turbo spin echo (HASTE) and 3-dimensional volumetric interpolated breath-hold examination (VIBE). Total examination time was less than 10 minutes, and scanning time was only 5 minutes. Prompt referrals and follow-ups were arranged in cases of suspicious lung nodules. RESULTS: A total of 559 individuals (4.8%) had suspicious lung nodules. A total of 49 primary lung cancers were diagnosed in 46 individuals: 41 prevalence cancers and 8 incidence cancers. The overall detection rate of primary lung cancers was 0.4%. For smokers aged 51 to 70 years, the detection rate was 1.4%. TNM stage I disease accounted for 37 (75.5%). The mean size of detected lung cancers was 1.98 cm (median, 1.5 cm; range, 0.5-8.2 cm). The most histological types were adenocarcinoma in 38 (77.6%). CONCLUSION: Rapid zero-dose MRI can be used for lung cancer detection in a healthy population.


Subject(s)
Carcinoma, Non-Small-Cell Lung/diagnosis , Early Detection of Cancer/methods , Lung Neoplasms/diagnosis , Magnetic Resonance Imaging/methods , Mass Screening/methods , Adolescent , Adult , Aged , Aged, 80 and over , Carcinoma, Non-Small-Cell Lung/epidemiology , Carcinoma, Non-Small-Cell Lung/pathology , Child , Contrast Media , Early Detection of Cancer/statistics & numerical data , Female , Humans , Image Processing, Computer-Assisted , Lung Neoplasms/epidemiology , Lung Neoplasms/pathology , Male , Mass Screening/statistics & numerical data , Middle Aged , Neoplasms, Multiple Primary/diagnosis , Neoplasms, Multiple Primary/epidemiology , Neoplasms, Multiple Primary/pathology , Retrospective Studies , Smoking/adverse effects , Smoking/epidemiology , Taiwan/epidemiology , Whole Body Imaging , Young Adult
8.
Otol Neurotol ; 32(3): 478-82, 2011 Apr.
Article in English | MEDLINE | ID: mdl-21317672

ABSTRACT

BACKGROUND: Our previous study had demonstrated that verterbral artery hypoplasia (VAH) contribute to ipsilateral vestibular dysfunction. The aim of this study was to test if VAH contributes to prognosis of vestibular neuronitis (VN) through presumed regional malperfusion. METHODS: We performed a prospective magnetic resonance angiographic registry in patients with acute vestibular neuritis in which were then assigned to VAH (n=29) and control group (n=40). Vestibular function was determined by caloric irrigation, with the use of the vestibular paresis formula (to measure the extent of unilateral caloric paresis) within 3 days after the onset of symptoms and 12 months afterward. RESULTS: The baseline vestibular paresis was higher (56.8 ± 15.9%) in the VAH VN subjects (n=29), than in VN subjects without VAH (n=40) (37.4 ± 17.7%) (p=0.01). Analysis of variance showed a less percentage of the VAH group return to normal at 4th and 12th week visit. CONCLUSION: Our results suggested that comorbid VAH may predispose to severe VN at acute stage.


Subject(s)
Vertebral Artery/abnormalities , Vestibular Neuronitis/diagnosis , Adult , Caloric Tests , Female , Humans , Magnetic Resonance Angiography , Male , Middle Aged , Radiography , Risk Factors , Vertebral Artery/diagnostic imaging , Vestibular Function Tests , Vestibular Neuronitis/diagnostic imaging
9.
Anesth Analg ; 109(6): 1930-4, 2009 Dec.
Article in English | MEDLINE | ID: mdl-19923523

ABSTRACT

Scoliosis can pose challenges to the initiation and function of neuraxial anesthetics. We reviewed the available literature exploring neuraxial techniques in parturients with uncorrected or corrected (i.e., surgically instrumented) scoliosis. The 22 articles reported 117 attempted neuraxial procedures (uncorrected n = 24 and corrected n = 93). Of these procedures, 79% of uncorrected patients and 69% of corrected patients were successfully managed with neuraxial anesthesia. Procedures were typically more challenging in corrected patients; 90% of all reported difficulties in this subgroup involved epidural anesthetics. Complications were reported in 3 of 103 patients. We provide suggestions for optimizing efficacy of neuraxial techniques in these patients.


Subject(s)
Analgesia, Obstetrical/methods , Anesthesia, Obstetrical/methods , Labor Pain/drug therapy , Scoliosis/complications , Analgesia, Epidural , Anesthesia, Epidural , Anesthesia, Spinal , Female , Humans , Labor Pain/complications , Orthopedic Procedures , Pain Measurement , Pregnancy , Radiography , Scoliosis/diagnostic imaging , Scoliosis/surgery
10.
Int J Pharm Compd ; 12(5): 426-30, 2008.
Article in English | MEDLINE | ID: mdl-23969867

ABSTRACT

Patients with allergies or intolerances and those requiring special diets are among the groups that require formulations with special excipients. When compounding preparations for this population, the suitability of dyes, flavorings, sweeteners, preservatives, gelatins, milk products, gluten, corn, soy, nuts, alcohol, chocolate, and other animal-derived ingredients must be considered. Unlike manufacturers of foods and nutritional supplements, pharmaceutical companies are not required to list certain ingredients of manufactured drugs, such as wheat. Therefore, a patient may unknowingly purchase a manufactured drug containing an excipient that he cannont tolerate. Once informed of a patient's allergy, intolerance, or special diet, the compounding pharmacist is able to prepare a prescription from which a particular excipient has been eliminated. In many cases, however, the particulars of a patient's specific allergy or intolerance are difficult to determine and predict, and thus creative thinking is required from the copounding pharmacist. Without question, the need for special excipients will continue.

11.
Echocardiography ; 24(2): 166-73, 2007 Feb.
Article in English | MEDLINE | ID: mdl-17313549

ABSTRACT

Due to reliance upon geometric assumptions and foreshortening issues, the traditionally utilized transthoracic two-dimensional echocardiography (2DTTE) has shown limitations in assessing left ventricular (LV) volume, mass, and function. Cardiac magnetic resonance imaging (MRI) has shown potential in accurately defining these LV characteristics. Recently, the emergence of live/real time three-dimensional (3D) TTE has demonstrated incremental value over 2DTTE and comparable value with MRI in assessing LV parameters. Here we report 58 consecutive patients with diverse cardiac disorders and clinical characteristics, referred for clinical MRI studies, who were evaluated by cardiac MRI and 3DTTE. Our results show good correlation between the two modalities.


Subject(s)
Echocardiography, Three-Dimensional , Heart Ventricles/anatomy & histology , Heart Ventricles/diagnostic imaging , Hypertrophy, Left Ventricular/diagnosis , Magnetic Resonance Imaging , Stroke Volume , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Organ Size
12.
Semin Oncol ; 33(3): 333-41, 2006 Jun.
Article in English | MEDLINE | ID: mdl-16769422

ABSTRACT

Seizures commonly occur in people with brain tumors. They may be the presenting symptom of a brain tumor, or develop some time after tumor diagnosis. The risk of seizures is greatest when the tumors have a central location, slow growth rate, and when multiple lesions are present. Interactions between anti-epileptic drugs (AEDs), chemotherapeutic agents, and corticosteroids increase the complexity and challenge in managing seizures, and drugs that do not interfere with the cytochrome P-450 enzyme complex and have low protein binding may be preferable. The comparative efficacy and side effects of the various AEDs are not established in brain tumors, so drug choice relies on both the theoretical advantages of pharmacokinetic properties and clinical judgment. Prophylactic anticonvulsant treatment is not advisable in brain tumor patients who have not experienced seizures.


Subject(s)
Brain Neoplasms/complications , Seizures/etiology , Anticonvulsants/therapeutic use , Antineoplastic Agents/therapeutic use , Brain Neoplasms/drug therapy , Brain Neoplasms/physiopathology , Drug Interactions , Glucocorticoids/therapeutic use , Humans , Risk Factors , Seizures/drug therapy
13.
Psychopathology ; 37(5): 222-6, 2004.
Article in English | MEDLINE | ID: mdl-15353888

ABSTRACT

OBJECTIVE: To assess depressive features of a proposed definition of bipolar spectrum disorder (BSD). METHODS: Thirty-six patients with bipolar disorder type I or II were compared to 37 patients with unipolar major depressive disorder through patient interview and chart review. RESULTS: Univariate analysis suggests that 7 of 12 (recurrent major depressive episodes, brief major depressive episodes, atypical depressive symptoms, early age of onset, family history of bipolar disorder, antidepressant tolerance, and antidepressant-induced mania) features of major depressive episodes were more likely to occur in bipolar versus unipolar patients. After adjustment in a multivariable regression model, however, the five most powerful predictors of bipolar disorder were brief major depressive episodes, early age of onset, antidepressant- induced mania, postpartum depression, and atypical depressive symptoms. CONCLUSIONS: This preliminary study supports the idea that bipolar disorder is characterized by some depressive features less likely to be found in unipolar depression. Further prospective study needs to be conducted comparing BSD with unipolar depression.


Subject(s)
Bipolar Disorder/psychology , Adult , Age of Onset , Antidepressive Agents/therapeutic use , Case-Control Studies , Depression , Depression, Postpartum/complications , Female , Humans , Male , Middle Aged , Pedigree , Recurrence , Risk Factors
14.
J Chin Med Assoc ; 67(1): 41-7, 2004 Jan.
Article in English | MEDLINE | ID: mdl-15077890

ABSTRACT

Pulmonary Langerhans cell granulomatosis is defined as an abnormal Langerhans cells infiltration in the lungs. Multifocal involvement is unusual, however. We report 3 cases of pulmonary Langerhans cell granulomatosis combined with either rib, thyroid or hypothalamus involvement.


Subject(s)
Histiocytosis, Langerhans-Cell/pathology , Adult , Child , Humans , Hypothalamus/pathology , Male , Ribs/pathology , Thyroid Gland/pathology
15.
Am J Psychiatry ; 161(1): 163-5, 2004 Jan.
Article in English | MEDLINE | ID: mdl-14702267

ABSTRACT

OBJECTIVE: Antidepressant responses were compared in DSM-IV bipolar and unipolar depression. METHOD: The authors analyzed clinical records for outcomes of antidepressant trials for 41 patients with bipolar depression and 37 with unipolar depression, similar in age and sex distribution. RESULTS: Short-term nonresponse was more frequent in bipolar (51.3%) than unipolar (31.6%) depression. Manic switching occurred only in bipolar depression but happened less in patients taking mood stabilizers (31.6% versus 84.2%). Cycle acceleration occurred only in bipolar depression (25.6%), with new rapid cycling in 32.1%. Late response loss (tolerance) was 3.4 times as frequent, and withdrawal relapse into depression was 4.7 times less frequent, in bipolar as in unipolar depression. Mood stabilizers did not prevent cycle acceleration, rapid cycling, or response loss. Modern antidepressants, in general, did not have lower rates of negative outcomes than tricyclic antidepressants. CONCLUSIONS: The findings suggest an unfavorable cost/benefit ratio for antidepressant treatment of bipolar depression.


Subject(s)
Antidepressive Agents, Tricyclic/adverse effects , Bipolar Disorder/drug therapy , Depressive Disorder/drug therapy , Selective Serotonin Reuptake Inhibitors/adverse effects , Antidepressive Agents, Tricyclic/therapeutic use , Bipolar Disorder/epidemiology , Depressive Disorder/epidemiology , Diagnostic and Statistical Manual of Mental Disorders , Female , Humans , Male , Middle Aged , Selective Serotonin Reuptake Inhibitors/therapeutic use , Sex Distribution
16.
Bipolar Disord ; 4(1): 70-4, 2002 Feb.
Article in English | MEDLINE | ID: mdl-12047498

ABSTRACT

OBJECTIVE: To determine if oxcarbazepine is effective as treatment for refractory bipolar illness in a naturalistic setting. METHODS: All charts of out-patients treated with oxcarbazepine (n=13) were reviewed and clinical response assessed retrospectively using the Clinical Global Impression of Improvement (CGI-I) rating scale. All patients had failed treatment with at least one previous mood stabilizer. RESULTS: Mild improvement was seen in 46% (n=6) and moderate improvement in 16% (n=2). Fifty-four percent (n=7) of the total sample discontinued treatment because of adverse effects. CONCLUSION: Oxcarbazepine may possess mild to moderate mood-stabilizing properties in this refractory, mostly depressed, bipolar sample. This naturalistic study is limited by its uncontrolled nature.


Subject(s)
Anticonvulsants/therapeutic use , Bipolar Disorder/drug therapy , Carbamazepine/analogs & derivatives , Carbamazepine/therapeutic use , Adult , Anticonvulsants/administration & dosage , Carbamazepine/administration & dosage , Female , Humans , Male , Middle Aged , Oxcarbazepine , Retrospective Studies , Treatment Outcome
17.
Headache ; 42(4): 301-2, 2002 Apr.
Article in English | MEDLINE | ID: mdl-12010390

ABSTRACT

We report the case of a man who suffered from Valsalva-induced cluster headaches. The headaches deviated from classic cluster in that they were solely induced by activity involving the Valsalva maneuver, such as coughing and sneezing, and never occurred spontaneously. The attacks were prevented by treatment with indomethacin. This may be the first reported case of cluster that only occurs after a defined trigger and never spontaneously. It also may be the first cluster headache subtype that is indomethacin responsive.


Subject(s)
Cluster Headache/etiology , Cough , Valsalva Maneuver , Aged , Aged, 80 and over , Anti-Inflammatory Agents, Non-Steroidal/therapeutic use , Cluster Headache/classification , Cluster Headache/drug therapy , Humans , Indomethacin/therapeutic use , Recurrence
18.
Can J Psychiatry ; 47(2): 125-34, 2002 Mar.
Article in English | MEDLINE | ID: mdl-11926074

ABSTRACT

The diagnosis and treatment of bipolar disorder (BD) has been inconsistent and frequently misunderstood in recent years. To identify the causes of this problem and suggest possible solutions, we undertook a critical review of studies concerning the nosology of BD and the effects of antidepressant agents. Both the underdiagnosis of BD and its frequent misdiagnosis as unipolar major depressive disorder (MDD) appear to be problems in patients with BD. Underdiagnosis results from clinicians' inadequate understanding of manic symptoms, from patients' impaired insight into mania, and especially from failure to involve family members or third parties in the diagnostic process. Some, but by no means all, of the underdiagnosis problem may also result from lack of agreement about the breadth of the bipolar spectrum, beyond classic type I manic-depressive illness (what Ketter has termed "Cade's Disease"). To alleviate confusion about the less classic varieties of bipolar illness, we propose a heuristic definition, "bipolar spectrum disorder." This diagnosis would give greater weight to family history and antidepressant-induced manic symptoms and would apply to non-type I or II bipolar illness, in which depressive symptom, course, and treatment response characteristics are more typical of bipolar than unipolar illness. The role of antidepressants is also controversial. Our review of the evidence leads us to conclude that there should be less emphasis on using antidepressants to treat persons with this illness.


Subject(s)
Antidepressive Agents/therapeutic use , Bipolar Disorder/diagnosis , Antidepressive Agents/adverse effects , Antimanic Agents/adverse effects , Antimanic Agents/therapeutic use , Bipolar Disorder/drug therapy , Bipolar Disorder/genetics , Bipolar Disorder/psychology , Depressive Disorder, Major/diagnosis , Depressive Disorder, Major/drug therapy , Depressive Disorder, Major/genetics , Depressive Disorder, Major/psychology , Diagnosis, Differential , Humans , Psychiatric Status Rating Scales , Treatment Outcome
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