Bipolar disorder: Managing the peaks and valleys.

Bipolar disorder is a psychiatric illness that is relatively common among patients presenting for treatment in primary care clinics. Physicians in primary care often face difficult decisions about how and when to intervene when a patient is experiencing depressive, manic, or hypomanic episodes consistent with bipolar disorder. This article reviews the literature on how to assess and diagnose bipolar disorder in primary care, and how to choose from the array of treatment options that exist. The psychotherapy and pharmacotherapy evidence base provides guidance on how to help patients effectively manage this ailment. Collaboration among health and mental health practitioners is key in helping manage the "peaks and valleys" of bipolar disorder. Special considerations need to be made to routinely assess for impulsivity, suicidality, and patient progress throughout the course of treatment.

Physician-patient communication: breaking bad news.

Physicians often struggle with how to manage the task of breaking bad news with patients. Moreover, the arduous nature of the task can contribute to physician detachment from the patient or an avoidance of breaking the news in a timely manner. A plan of action can only improve physician confidence in breaking bad news, and also make the task more manageable. Over a decade ago, Rabow and McPhee offered a strategy; the ABCDE plan, which provided a patient centered framework from which to deliver troubling news to patients and families. At the heart of this plan was the creation of a safe environment, the demonstration of timely communication skills, and the display of empathy on the physician's part. Careful consideration of the doctor's own reactions to death and dying also played an important role. A close review of the five tenets of this plan indicates the relevance of Rabow and McPhee's strategy today. The patient base in our nation and state continues to be older, on average, and physicians are faced with numerous patients who have terminal illness. A constructive plan with specific ideas for breaking bad news can help physicians effectively navigate this difficult task.

Methadone as an analgesic: a review of the risks and benefits.

While methadone has been available for over 50 years, its use in opiate dependence has overshadowed its use as an analgesic. Within the last 10-15 years, though, methadone has been increasingly used to manage neuoropathic pain and cancer pain, but its use is causing an alarming number of deaths in the U.S. Last June, The Charleston Gazette ran a series titled "The Killer Cure" by Scott Finn and Tara Tuckwiller that found that the number of Americans whose deaths were caused by methadone rose from 790 in 1999 to 2,992 in 2003. The series also reported other statistics from the National Center for Health Statistics that revealed that West Virginia ranked first per capita in methadone overdose deaths, and that methadone was more likely involved in overdose deaths than any other prescription drug. Methadone has several unique properties that can be beneficial in the treatment of neuropathic pain and cancer pain unresponsive to other opioids, but some of these properties make it very dangerous and difficult to prescribe properly. As a result of these factors, methadone should not be the first-choice drug for pain and it should not be used in opioid-naive patients. The goal of this article is to provide a review of the properties and protocols for safe prescribing of methadone to help physicians recognize situations where this drug offers the greatest advantage as an analgesic.

Cardiac surgery in octogenarians: does age alone influence outcomes?

HYPOTHESIS: Outcome differences in octogenarians vs patients younger than 80 years undergoing coronary artery bypass grafting or valve surgery can be analyzed to isolate the effect of age alone on morbidity and mortality. DESIGN: Eight-year hospitalization cohort study. Physicians, nurses, and perfusionists prospectively collected data on 225 variables. SETTING: Community hospital. PATIENTS: A consecutive sample of 7726 patients undergoing coronary artery bypass grafting or valve surgery between October 1, 1993, and February 28, 2001. MAIN OUTCOME MEASURES: There were 9 main outcomes of interest: mortality, length of hospital stay, gastrointestinal tract complications, neurologic complications, pulmonary complications, renal complications, return to intensive care unit, intraoperative complications, and reoperation to treat bleeding. We controlled for 16 potential confounding variables to isolate outcome differences according to age. RESULTS: Of 7726 patients who fit the inclusion criteria, 522 were octogenarians. Compared with nonoctogenarians, octogenarians had a significantly higher New York Heart Association functional classification, higher incidence of hypertension, and underwent a greater number of coronary artery bypass grafting plus valve surgical procedures (P<.05). They also had significantly lower body surface area, fewer total number of grafts used, less history of tobacco use, and less abnormal left ventricular hypertrophy, and there were fewer nonwhite patients and fewer men. At multivariate analysis, octogenarians had a higher risk for death (relative risk [RR], 1.72; 95% confidence interval [CI], 1.52-1.83), longer hospital stay (RR, 1.03; 95% CI, 1.01-1.04), more neurologic complications (RR, 1.51; 95% CI, 1.26-1.67), and were more likely to undergo a reoperation to treat bleeding (RR, 1.49; 95% CI, 1.09-1.72). Univariate analyses revealed no difference between octogenarians and nonoctogenarians for diabetes mellitus, urgency of procedure, prior myocardial infarction, time since last myocardial infarction, cerebrovascular history, chronic obstructive pulmonary disease, or pump time. CONCLUSIONS: Age alone has been shown to influence outcomes after cardiac bypass or valve surgery. Octogenarians undergoing cardiac surgery have more comorbidities and higher mortality even after controlling for 16 potential confounding variables, compared with nonoctogenarians.

Chronic acalculous biliary disease: cholecystokinin cholescintigraphy is useful in formulating treatment strategy and predicting success after cholecystectomy.

Patients with symptoms consistent with biliary colic who do not demonstrate calculi on routine sonography present a diagnostic dilemma for clinicians. For those patients in whom other disease entities have been excluded and in whom the history and physical examination exemplify classic signs and symptoms of biliary disease we show in this study that cholecystokinin cholescintigraphy with calculation of gallbladder ejection fraction is a predictor of pathology as well as subsequent symptom relief after cholecystectomy. The spectrum of pathology that makes up chronic acalculous biliary disease lacks a distinct definition, yet this review shows that cholecystokinin cholescintigraphy offers the surgeon the means to better counsel his or her patient with regard to surgical indications, options, and benefits. We reviewed 26 patients who had no gallstones detectable, had gallbladder ejection fraction <35 per cent, and were status postlaparoscopic cholecystectomy for suspected chronic acalculous biliary disease. Our results show histopathologic evidence of chronic cholecystitis in 100 per cent, and 92 per cent of the patients had improvement of symptoms and satisfaction with the operation to the point that they would undergo the surgery again without reservation.