Association of symptoms of attention deficit-hyperactivity disorder and impulsive-aggression with severity of suicidal behavior in adult attempters.

Literature emphasizes the relationship between attention deficit-hyperactivity disorder (ADHD) and suicidal behavior (SB). However, the link between ADHD and the severity of SB is yet to be determined. We investigated the association between a probable diagnosis of ADHD and the severity of SB in 539 hospitalized suicide attempters, and determined the role of comorbid psychiatric diagnoses. The severity of SB was defined as the number of suicide attempts, age at first suicide attempt, seriousness and violence of suicide attempts. A diagnosis of probable adult ADHD (probable ADHD) was defined as the presence of both current ADHD symptoms and ADHD symptoms in childhood. We evaluated the combined effect of high impulsive-aggression levels and probable ADHD. Probable ADHD was not associated with early or frequent suicide attempts after adjustment for psychiatric disorders and treatment intake. High levels of impulsive-aggression increased the risk of an early suicide attempt, particularly in patients with ADHD symptoms, and independently of other clinical factors. The association between serious suicide attempts and probable ADHD remained significant after adjustment. Although ADHD is involved in suicidal vulnerability, psychiatric comorbidities and impulsive-aggression appear to largely explain the severity of SB in adult attempters with ADHD symptoms.

Affect intensity measure in bipolar disorders: a multidimensional approach.

BACKGROUND: Emotional dysregulation, characterized by high levels of both arousal and intensity of emotional responses, is a core feature of bipolar disorders (BDs). In non-clinical populations, the 40-item Affect Intensity Measure (AIM) can be used to assess the different dimensions of emotional reactivity. METHODS: We analyzed the factor structure of the AIM in a sample of 310 euthymic patients with BD using Principal Component Analysis and examined associations between AIM sub-scale scores and demographic and illness characteristics. RESULTS: The French translation of the AIM demonstrated good reliability. A four-factor solution similar to that reported in non-clinical samples (Positive Affectivity, Unpeacefulness [lack of Serenity], Negative Reactivity, Negative Intensity), explained 47% of the total variance. Age and gender were associated with Unpeacefulness and Negative reactivity respectively. 'Unpeacefulness' was also positively associated with psychotic symptoms at onset (p=0.0006), but negatively associated with co-morbid substance misuse (p=0.008). Negative Intensity was positively associated with social phobia (p=0.0005). LIMITATIONS: We cannot definitively exclude a lack of statistical power to classify all AIM items. Euthymia was carefully defined, but a degree of 'contamination' of the self-reported levels of emotion reactivity may occur because of subsyndromal BD symptoms. It was not feasible to control for the possible impact of on-going treatments. CONCLUSIONS: The AIM scale appears to be a useful measure of emotional reactivity and intensity in a clinical sample of patients with BD, suggesting it can be used in addition to other markers of BD characteristics and sub-types.

Duration of untreated bipolar disorder: missed opportunities on the long road to optimal treatment.

OBJECTIVE: Duration of untreated illness represents a potentially modifiable component of any diagnosis-treatment pathway. In bipolar disorder (BD), this concept has rarely been systematically defined or not been applied to large clinically representative samples. METHOD: In a well-characterized sample of 501 patients with BD, we estimated the duration of untreated bipolar disorder (DUB: the interval between the first major mood episode and first treatment with a mood stabilizer). Associations between DUB and clinical onset and the temporal sequence of key clinical milestones were examined. RESULTS: The mean DUB was 9.6 years (SD 9.7; median 6). The median DUB for those with a hypomanic onset (14.5 years) exceeded that for depressive (13 years) and manic onset (8 years). Early onset BD cases have the longest DUB (P < 0.0001). An extended DUB was associated with more mood episodes (P < 0.0001), more suicidal behaviour (P = 0.0003) and a trend towards greater lifetime mood instability (e.g. rapid cycling, possible antidepressant-induced mania). CONCLUSION: Duration of untreated bipolar disorder (DUB) will only be significantly reduced by more aggressive case finding strategies. Reliable diagnosis (especially for BD-II) and/or instigation of recommended treatments is currently delayed by insufficient awareness of the early, polymorphous presentations of BD, lack of systematic screening and/or failure to follow established guidelines.

Clinical features associated with trait-impulsiveness in euthymic bipolar disorder patients.

BACKGROUND: A strong association has been reported between trait-impulsiveness and bipolar disorder (BD). Much attention has been focused on this association, but subgroup analysis has generated conflicting results, raising questions about the role of trait-impulsiveness in suicidal behavior and substance misuse in bipolar patients. METHOD: We compared Barratt Impulsiveness Scale-10 scores between 385 euthymic bipolar patients and 185 healthy controls. We then investigated possible association between impulsiveness scores and the following clinical characteristics: suicide attempt (SA), lifetime alcohol/cannabis misuse, rapid cycling and mixed episodes. RESULTS: Bipolar patients and healthy controls had significantly different BIS-10 total score and subscores (motor, attentional and nonplanning impulsiveness) (all p values <0.0001). No association was observed between BIS-10 total score, personal history of SA, number of SA, age at first SA and history of violent SA. Higher BIS-10 total scores were associated with alcohol misuse (p=0.005), cannabis misuse (p<0.0001), with an additive effect for these two substances (p=0.005). Higher BIS-10 total scores were also associated with rapid cycling (p=0.006) and history of mixed episodes (p=0.002), with an additive effect of these two variables (p=0.0006). LIMITATIONS: We used only one clinical measurement of impulsiveness and did not carry out cognitive assessment. CONCLUSION: This study demonstrates that trait-impulsiveness may be considered as a dimensional feature associated with BD and with a more severe clinical expression of the disease, characterized by a history of substance misuse, rapid cycling and mixed episodes. We found no association between impulsiveness and SA characteristics in bipolar patients, confirming some previous negative results.

Interleukin-8 expression by head and neck squamous cell carcinoma.

OBJECTIVE: To test the hypothesis that interleukin-8 (IL-8) is produced by human head and neck squamous cell carcinomas (HNSCCAs) and may therefore be a possible mediator for lymphocyte recruitment and neovascularization by these tumors. METHODS: Nine fresh samples of HNSCCA were analyzed for expression of IL-8 antigen using radioimmunoassay and immunohistochemical staining techniques. Also, four short-term primary cultures of HNSCCA and two continuous HNSCCA cell lines were then analyzed for production of IL-8 expression under both baseline conditions and following stimulation with other cytokines. RESULTS: The IL-8 antigen was detected in all fresh tumor homogenates by radioimmunoassay (5.58 to 331.69 ng of IL-8 per gram of tissue), and immunohistochemical results localized staining predominantly within the tumor cells. Primary cultures of HNSCCA and continuous HNSCCA cell lines produced only low levels of IL-8 (0.04 to 4.49 ng of IL-8 per 10(6) cells) under baseline (unstimulated) conditions. Stimulation of both primary cultures and cell lines with interleukin-1 and tumor necrosis factor induced significant increases in IL-8 antigen, while other cytokines failed to induce a significant increase. CONCLUSIONS: This study demonstrates that IL-8 antigen is expressed by HNSCCA in vivo, and that cultured HNSCCA in vitro can be stimulated to express IL-8 antigen by both interleukin-1 and tumor necrosis factor. Local production of IL-8 by HNSCCA cells, and its regulation by other cytokines, may be important in both the lymphocyte recruitment and tumor neovascularization seen in HNSCCA, and may thus ultimately affect the natural history of the disease.

Criteria for progressive modification of neurobehavioral batteries.

Six specific issues affecting the progressive modification of neurobehavioral test batteries used in field studies of populations exposed to neurotoxicants are discussed and test review recommendations are provided addressing each issue. The issues include: (a) general test review standards, (b) comprehensive assessment, (c) tailored batteries, (d) incorporation of new tests and techniques, (e) personnel and mechanisms for review, and (f) development of a battery assessing peripheral nervous system function.

Trust is the prescription for hospital/physician relations under health care reform.

Hospitals are reacting to health care reform by forming collaborative physician/hospital organizations and other ventures. The success of these new partnerships depends on what shape the reformed system takes and establishing trust between all players.

The selective use of modified human umbilical vein as an arterial substitute in the lower extremity.

Experience with 100 MHUV grafts implanted as femoropopliteal or femorocrural bypass was reviewed to evaluate the results of this conduit obtained in a selected group of patients. Indications for use of MHUV were limited to patients in whom the autologous greater saphenous vein was either absent or unsuitable or when its use would untowardly prolong the duration of the operation in patients with a poor general condition. General medical factors contributed to the choice for MHUV grafts in 25 per cent of the patients, while lack of an adequate saphenous vein necessitated its use in 70 per cent. In 5 per cent, the patient was considered a candidate for future (re)operative coronary arterial reconstruction. Cumulative graft patency rate in femoropopliteal bypass was 75 per cent in 48 months. No significant differences could be demonstrated between categories with good, fair and poor runoff or grafts with above-knee and below-knee anastomosis. In femorocrural grafts, a two year patency rate of 56 per cent was obtained. Cumulative patency rates between anterior tibial, posterior tibial and peroneal bypass did not reveal statistical differences. Late graft failure in initially jeopardized limbs without secondary reconstruction was not associated with amputation in 47 per cent of the instances. This finding reflects the fact that collateral perfusion may increase with time. On the other hand, four patients lost a leg in spite of a functioning bypass because of distally located arterial disease not amenable for reconstruction.

Gas gangrene: a postoperative complication.

Gas gangrene, also known as clostridial myonecrosis, is a severe and acute infection usually caused by Clostridium septicum, which may contaminate a wound. On rare occasions it is a complication of elective bone surgery, although it is usually found in elderly persons after hip surgery. The onset is usually sudden and it may occur from 6 hr. to 3 days after tissue injury. Diagnosis may be difficult because of the similarity of symptoms to those of anaerobic cellulitis. Treatment consists of surgical debridement, antibiotic therapy, hyperbaric oxygen, and supportive measures. The authors review the literature, discuss the clinical aspects, and present a case history.