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Acute mania has always been one of the most intense acute psychiatric syndromes. While many controlled clinical trials of acute mania treatments have been completed in the last several decades, leading to numerous Food and Drug Administration-approved treatments, most of the questions that arise clinically remain unstudied. Many of the acute mania trials studied monotherapy or a combination of two medications for a syndrome often treated with polypharmacy. Most of the subjects in acute mania trials were only moderately ill, and even efficacious treatments had only modest effects. Mania associated with substances, a common clinical condition, was essentially excluded from most trials. Mixed episode has been studied largely as an afterthought. Traditionally, a treatment became known as a mood stabilizer if it was shown to have efficacy in mania. Evolving research in acute bipolar depression and bipolar maintenance has raised many new questions regarding the effects of mania treatments during other phases of illness. Treatment of bipolar disorder has now become highly complex, and most bipolar patients are treated with more than four medications. A lack of clear acceptance or consensus on the definitions of many crucial terms related to bipolar disorder often leads to further clinical confusion. Examples of these include mood stabilizers, hypomania (versus normal), mixed episode (versus mixed states), and antidepressant-induced mania.In this supplement, three experts present case discussions and attempt to tackle some of these commonly faced clinical problems. In each case, the experts draw from their own clinical experience to try to bridge the gap between evidence-based medicine and clinical practice. Michael H. Allen, MD, presents a case of first-episode mania without psychotic features. Many issues are discussed, including recognition of psychosis, a rationale for selecting medications from the numerous approved treatments, and subsequent implications during maintenance. In the next case, James C.-Y. Chou, MD, discusses mixed episode with psychotic features, one of the most severe among bipolar states. The topics of antipsychotics as mood stabilizers, predictors of treatment resistance, and a rationale for polypharmacy are discussed. Finally, Alan C. Swann, MD, presents three complex cases: pharmacologic mania, mania with comorbid attention-deficit/hyperactivity disorder, and antidepressant-induced destabilization during maintenance treatment. He addresses the challenging questions of when to use or avoid antidepressants in bipolar disorder, who is at risk for destabilization, and the destabilizing effects of antidepressant withdrawal. [ABSTRACT FROM AUTHOR]

It is well understood that nursing staff and physicians face potentially dangerous situations in giving care to patients. Studies have shown that patient assaults cause short- and long-term consequences for the staff, including anxiety disorders and burn-out This topic has been well discussed in the literature but focuses on inpatient settings. The authors of this article ferret out some of the differences between inpatient versus outpatient--including the differences in staffing and physical setting. Thought is given to situations that are uniquely different with the hope that clinicians might not take security for granted and possibly implement effective measures that help prevent an event from occurring. As this is not always possible, creating a protocol for likely emergent situations can be helpful 'in the moment' when thoughts are not always clear. After an incident has occurred, debriefing is critical to help prevent a related anxiety disorder and possibly reduce burn out Administrative review can be useful to help reduce further incidents. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess the value of a proposed classification of monochorionic placenta in reference to twin-twin transfusion syndrome.Study Design: The placentas from laser-treated patients with twin-twin transfusion syndrome and from uncomplicated monochorionic pregnancies that were delivered between January 1997 and December 2000 were included in the study. Placentas were classified as type A (no anastomoses), type B (only deep anastomoses), type C (only superficial anastomoses), and type D (deep and superficial anastomoses). The number and type of anastomoses were documented in each placental type. The severity of twin-twin transfusion syndrome was assessed in stages, as previously described. The relationship between placental types and the development and severity of twin-twin transfusion syndrome was determined.Results: One hundred thirty-one placentas were examined. Twin-twin transfusion syndrome developed in 0% (0/4 placentas) of type A, in 100% (85/85 placentas) of type B, in 5.6% (1/18 placentas) of type C, and in 79.17% (19/24 placentas) of type D placentas. An average of 4.17 (range, 1-11) vascular anastomoses was found. The mean number of superficial anastomoses was not different between patients with twin-twin transfusion syndrome and patients with no twin-twin transfusion syndrome (1.6 vs 1.71, respectively; P =.69, Student t test). The presence or absence of superficial anastomoses was not associated with differences in the severity of twin-twin transfusion syndrome.Conclusion: This classification represents a practical approach to the surgical pathologic assessment of vascular anastomoses in monochorionic placentas, with a strong clinical correlation. It also allows for the clarification of the relationship between superficial anastomoses and twin-twin transfusion syndrome. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Current treatment of patients with selective intrauterine growth retardation in monochorionic twins includes expectant management, termination of pregnancy, or umbilical-cord occlusion. The purpose of this study was to assess the outcome of monochorionic twins with selective intrauterine growth retardation who were treated with selective laser photocoagulation of the communicating vessels. STUDY DESIGN: Monochorionic twin pregnancies with selective intrauterine growth retardation at less than 26 weeks were eligible for the study. Selective intrauterine growth retardation was defined as <10th percentile for gestational age. Absent or reverse end-diastolic velocity in the umbilical artery of the twin with selective intrauterine growth retardation was required for eligibility after January 2000. RESULTS: Thirty patients met the criteria for the study: 17 patients were treated expectantly (group I); 2 patients underwent umbilical-cord ligation of the twin with selective intrauterine growth retardation, and 11 patients underwent selective laser photocoagulation of the communicating vessels (group II). Survival rates for at least 1 fetus were no different between groups I and II (14/17 [82.3%] vs 8/11 [72.3%]; P = .4). However, concomitant demise of the co-twin occurred in 4 of 7 patients, and iatrogenic premature delivery for deterioration of the twin with selective intrauterine growth retardation was necessary in 2 patients in group I, which resulted in significant neonatal morbidity. Of the live-born babies, neurologic handicap was present in 3 of 22 babies (13.6%) versus 0 of 12 in groups I and II, respectively (P < .0001). CONCLUSION: Selective intrauterine growth retardation in monochorionic twins can be effectively treated with selective laser photocoagulation of the communicating vessels. By unlinking the circulations between the fetuses, the pregnancy is rendered 'functionally' dichorionic, which improves pregnancy treatment and results in decreased neonatal morbidity. This approach constitutes a new valuable alternative in the treatment of monochorionic twin pregnancies with selective intrauterine growth retardation. A randomized clinical trial of expectant treatment versus selective laser photocoagulation of the communicating vessels for monochorionic selective intrauterine growth retardation can be considered. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Vesicoamniotic shunting may be difficult or impossible in selected cases of fetal lower obstructive uropathy. The purpose of this article is to describe the performance of fetal hydrolaparoscopy and endoscopic fetal cystotomy in two fetuses with complicated lower obstructive uropathy. STUDY DESIGN: Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a patient with a markedly thickened bladder that could not be entered percutaneously. A peritoneoamniotic (bridge) shunt was also placed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a second patient with a collapsed bladder from a previous vesicocentesis, because vesicoinfusion resulted in further ascites. Fetal cystoscopy was performed after endoscopic fetal cystotomy, and posterior urethral valves were ablated with neodymium:yttrium-aluminum-garnet laser energy. A vesicoamniotic shunt was left in place. RESULTS: Adequate bladder drainage was obtained in both cases. The first baby required bilateral nephrotomy and a permanent cystotomy at birth and is scheduled for a bladder expansion procedure at the age of year. The second patient had premature rupture of membranes and fetal death from treatment of this complication 5 days after the original procedure. CONCLUSION: Fetal hydrolaparoscopy-endoscopic fetal cystotomy can be performed in complicated cases of lower obstructive uropathy. The procedure involves the creation of a defect in the bladder dome under direct endoscopic visualization within a spontaneous or intentional hydroperitoneum. Peritoneoamniotic shunting, vesicoamniotic shunting, or ablation of posterior urethral valves may then be performed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy should be reserved only for complicated cases of lower obstructive uropathy in which conventional vesicoamniotic shunting is not safely possible. Further experience with fetal hydrolaparoscopy-endoscopic fetal cystotomy is necessary to establish its risks and benefits. [ABSTRACT FROM AUTHOR]

Selective laser photocoagulation of communicating vessels (SLPCV) is an application of minimally invasive endoscopic fetal surgery (ie, surgical fetoscopy) performed for severe cases of twin-to-twin transfusion syndrome (MS), a complication of monochorionic twin pregnancies. Advances in ultrasound and endoscopy have aided the identification and treatment of this potentially lethal or fatal condition. Surgical fetoscopy, an innovation in the field of surgery and maternal-fetal medicine, benefits patients by reducing the morbidity and mortality associated with MS, with minimal risks to the mother. [ABSTRACT FROM AUTHOR]