Suicidal risk and management in borderline personality disorder.

This paper reviews recent advances in our understanding of suicidality in borderline personality disorder (BPD), with a focus on suicide risk assessment, guidelines for treatment, and medicolegal concerns. Relevant material on distinctions between suicide completers and suicide attempters, contributions of published American Psychiatric Association Guidelines, the controversial role of hospitalization, and management strategies regarding litigation is addressed. Despite accumulating data on suicidality in BPD, the current state of knowledge offers only partial clues to help identify the BPD patients most at risk of death by suicide, and offers a limited armamentarium of treatment targeted to suicide prevention, creating discomfort in clinicians and fears regarding litigation in the event of a successful suicide. Promising new interventions include less resource-intensive psychotherapies as well as brief crisis intervention.

Variability of histopathological changes in childhood celiac disease.

OBJECTIVES: Adult studies of celiac disease (CD) have shown that duodenal mucosal histopathological changes may be patchy, and the diagnostic utility of duodenal bulb biopsies is believed to be limited. Few related pediatric data exist. METHODS: We assessed the prevalence of variable biopsy findings and duodenal bulb involvement in children with CD, as well as its association with clinical parameters. A total of 198 consecutive cases of CD diagnosed at the Children's Hospital during 2001-2005 were analyzed. All biopsies were scored by a pathologist blinded to the clinical data using the Marsh criteria. Mucosal changes were classified as focal if changes consistent with CD and normal mucosa were found within a single biopsy fragment. Patchiness was defined as variation of at least one Marsh grade between separate fragments in a biopsy set. RESULTS: The median age was 9.3 years; 62% were female. An average of 3.6 biopsy samples was obtained per case. In 101 cases, biopsy samples were obtained from the duodenal bulb and the second portion of the duodenum. Focality was present in biopsy samples collected from 36 (18%) cases. Patchiness was found in 105 (53%) cases, and at least 1 normal biopsy fragment was present in 71 (36%) cases. In 10 cases, only the bulb biopsies were diagnostic of CD. There was no association with the clinical features examined. CONCLUSIONS: Duodenal involvement in pediatric CD is frequently patchy and may show variable severity even within a single biopsy fragment. Variability cannot be predicted by clinical characteristics. Multiple endoscopic biopsies, including the duodenal bulb, should be obtained in suspected pediatric CD cases to maximize diagnostic yield.