Kenny V. Bahn, MD

• Clinical Instructor
• Department of Emergency Medicine
• University of California, San Francisco-Fresno
• Fresno, California

Alternative: Pad around prominent areas without trimming to protect and prevent irritation medicine cups purchase kytril now. Primitive: Sand callus or corn gently with abrasive stone Patient Education General: Daily foot inspections in the field if possible medicine for bronchitis purchase kytril 2 mg amex. Follow-up Actions Evacuation/Consultation Criteria: Evacuation not normally necessary medicine over the counter discount kytril online. Refer to podiatrist for orthotics or surgery to correct deformities medicinebg cheap generic kytril canada, or for other advanced foot care medicine you take at first sign of cold kytril 1mg mastercard. The most common stress fracture in the foot medicine park cabins order kytril 2 mg without a prescription, known in the military as a march fracture, is the second metatarsal. Stress fractures are often seen in intense training programs around week four, when bone absorption exceeds bone-building activity. Improper preparation as well as errors in training (warm-up, stretching, program progression) are causative factors. Subjective: Symptoms Pain in a specific area that persists during and after exercise; history of increased activity in a new program; or a specific event, such as a long run, which significantly exceeds previous training. Using Advanced Tools: X-rays (if available) Initially normal but repeat study at 3-4 weeks after onset will often show slight callus formation. Alternate exercise: Swimming or biking in place of running to maintain cardiovascular fitness. Short term immobilization if necessary, especially with non-compliant individuals. A metatarsal pad or doughnut cutout will decrease weight on the metatarsal when correctly placed. Primitive: For metatarsal stress fractures, duct tape two tongue blades transversely across boot just behind the metatarsal heads, or use other substitute material to fill arch area to get some weight off the involved metatarsal head. Follow-up Actions Return evaluation: At 2 week intervals until released to full duty. Consider immobilization Evacuation/Consultation Criteria: Evacuation not necessary unless mission requires heavy weight-bearing or long hikes. Training programs subject individuals to high intensity activities, including high-mileage running and land navigation. Hyperhidrosis (excessive sweating) of the feet may increase friction over pressure areas in the shoe. A high arch or cavus foot may be more susceptible to shoe rub and blister formation on the top of the foot as well as over the metatarsal head area. Subjective: Symptoms Sore feet, blister, history of high-level training or running Objective: Signs Obvious blisters over involved areas. Differential Diagnosis genetic blister disease, epidermolysis bullosa (inherited disease in which bullae form from slight trauma), insect bite, or burn. Do not inject blister with benzoin (no longer the preferred method for blister treatment). If infected, the blistered skin covering should be removed using a scalpel or scissors. Cleanse the area and apply a thin layer of Neosporin or Bacitracin followed by a thin non-adherent dressing. Then apply moleskin over the dressing and adjacent skin to hold everything in place. Avoid bulky coverings if an operator is in the field (in boots) and must continue with the mission. Alternative: Option 1: If the blister is already open as a result of repetitive irritation, the underlying skin is usually clean and red. Option 2: Apply tincture of benzoin topically to toughen the skin and hold moleskin in place. Apply an antibiotic ointment, a layer of DuoDerm over top and a doughnut pad to prevent rubbing. Blister roof may reattach to underlying skin, allowing rapid healing and return to duty Primitive: Pop the blister if large and painful. If infection or deeper ulceration develops, rest feet and eliminate pressure to allow healing. If orthotics or other shoe devices are used, remember to try shoes on with the orthotics in them before purchasing. The longest toe should be one thumb width from the end of the shoe Try a short test run and then check your feet. For hyperhidrosis, apply products such as alum or Drysol (drying prevents skin softening) to the soles of the feet three times a week as needed. An optional method: spray clean, dry feet with Aerozoin (40% tincture of benzoin, 60% alcohol), let dry, then apply thin layer of hydropel. Follow-up Actions Return evaluation: Only if needed Evacuation/Consultation Criteria: Evacuation is not usually necessary. Refer to dermatology or podiatry (structural foot abnormality) for evaluation of underlying foot or skin problems. A tooth has two major parts: the crown, normally visible in the mouth, and the root or roots embedded in the socket and partially covered by soft tissue (Figure 5-1). The crown has five surfaces: the occlusal (biting) surface, the lingual or tongue side surface, the facial (buccal) or cheek side surface, and the two surfaces that come in contact with adjacent teeth (mesial the contacting surface nearest the midline and distal the farthest from the midline) (Figure 5-2). Objective: Signs Finding the offending tooth may be difficult, but it will usually be grossly decayed, with the carious enamel and dentin area discolored. If a mix of zinc oxide and eugenol is applied directly to vital pulp, it will kill the pulp. Subjective: Symptoms History of trauma or biting hard object; feels jagged tooth edge; finds tooth fragment; sensitivity to heat/cold. Plan: Simple fractures of the crown involving little or no dentin, smooth the rough edges of the tooth with an emery board or small flat file. Extensive fractures of the crown involving considerable dentin but not the pulp: 1. An aluminum crown, trimmed and contoured to avoid lacerating the gingiva, can be filled with this paste and placed over the tooth. Incorporate cotton fibers into a mix of zinc oxide and eugenol (the fibers give additional strength) and place this over the involved tooth, using the adjacent teeth and the spaces between them for retention. If a glass ionomer cement was not used, cover the calcium hydroxide or zinc-eugenol base and adjacent enamel with several coats of cavity varnish (Copalite). If a glass ionomer cement is available, it can be substituted for the (Dycal) calcium hydroxide. The efficiency of this treatment regimen depends on the size of the pulp exposure. If all you have available is zinc oxide and eugenol you must also consider extraction. Objective: Signs Severe tooth pain on percussion* (very significant); swollen, tender gingival tissues around the tooth; fever; bright red elevation of the soft tissues in the area (parulis) due to untreated periapical abscess burrowing through alveolar bone. Assessment: Pain on percussion of posterior maxillary teeth may indicate sinusitis. Subjective: Symptoms Various presentations, depending on direction of spread of the abscess, which is usually toward the lateral aspect of the jaw, but may drain into the palate, mouth (rare), tongue or facial skin. Tongue infection can spread through the facial spaces of the neck, and grave, possibly fatal complications. Assessment: Rapid progression of an oncologic process must be included in the differential diagnosis. Otherwise the infection will recur, especially during periods of lowered resistance. Subjective: Symptoms History of trauma or severe dental caries; may present with tooth in hand. If tooth has been saved, transport avulsed tooth in any clean liquid medium (saline, milk, and saliva). If blood clot prevents tooth placement, rinse socket with saline to remove blood clot. When the replacement time exceeds one hour, the long-term retention rate drops and root resorption usually occurs. It most often is due to irritation from a foreign body, subgingival calculus (tartar, hard calcium deposits on the teeth) or local trauma, and subsequent bacterial invasion of the periodontal tissues. Subjective: Symptoms Deep, throbbing, well-localized pain of the soft tissues surrounding the tooth; tooth feels elevated in its socket. Objective: Signs Redness, tenderness and swelling of the surrounding gingiva; sensitivity to percussion; mobile tooth; cervical lymphadenopathy; fever; purulent exudate. Assessment: Differential Diagnosis chronic apical abscess, necrotic pulp Plan: 1. Spread the tissues gently and irrigate with warm water to remove remaining pus or debris from the abscess area. Administer antibiotic regimen if systemic conditions are present (elevated temperature, general malaise). Necrotic gingival lesions result from ordinarily harmless surface parasites exposed to an altered environment. Virulent fusospirochetal organisms have been implicated, but the precise cause has not been proven. General health, diet, fatigue, stress, and lack of oral hygiene are the most important precipitating factors. Untreated lesions are destructive with progressive involvement of the gingival tissues and underlying structures. Subjective: Symptoms Constant gnawing pain, marked gingival sensitivity and hemorrhage, fetid odor, foul metallic taste, general malaise and anorexia. Objective: Signs Necrosis, ulcers with pseudomembrane cover, cervical lymphadenitis, fever. First day: Wearing surgical or exam gloves if possible, swab the teeth and gingiva thoroughly with a 1:1 aqueous solution of 3% hydrogen peroxide on a cotton-tipped applicator twice. Instruct the patient to rinse 5-15 5-16 his mouth at hourly intervals with this same 1:1 solution. Caution him not to use this treatment for more than 2 days (due to possibility of precipitating a fungal infection). Maintain the hourly hydrogen peroxide mouthwash regimen and have patient brush with a soft toothbrush soaked in hot water every hour. Although clinical symptoms are minimal, tissue destruction continues until further corrective measures are completed. Definitive care consists of cleaning and scaling of the teeth, instruction in oral hygiene and, in some cases, re contouring the tissues involved in the infection. As in other oral disorders, the use of silver nitrate or other caustics is definitely contraindicated. Any case of gingivitis that does not respond well within 24 to 48 hours should be referred for evaluation for underlying blood dyscrasias or vitamin deficiencies. Subjective: Symptoms Intense pain, itching, burning; in children: greater pain, larger affected area, anorexia, dehydration. Objective: Signs Small, localized ulcerations (few blisters in mouth) with a bright red, flat or slightly raised border; later, ulcer covered by white plaque; generalized infections produce large area of fiery red, swollen, and extremely pain ful mucosa; children have more extensive and serious oral involvement resulting in anorexia and dehydration. They are not contagious or caused by an infectious agent, and will heal in 1-2 weeks without sequelae. Plan: Apply topical steroids (Kenalog in Orabase gel, Lidex gel, Decadron rinses) to reduce pain and duration of lesions. Subjective: Symptoms Marked pain radiating to the ear, throat and the floor of the mouth; fever; general malaise; muscle spasm in jaw. Objective: Signs Red, swollen, tender, suppurative gums localized over tooth; fever; cervical lymphadenopathy; trismus of the masticator muscles. Assessment: Differential Diagnosis periapical abscess, trauma from opposing tooth. Dip the cotton in 3% peroxide and carefully clean the debris from beneath the tissue flap; pus may be released. Initiate antibiotic therapy if there is involvement of the cervical nodes, fever, and/or trismus of the masticator muscle. Subjective: Symptoms Constant moderate to severe pain, may involve entire side of mandible; occurs 3 to 5 days after extraction 5-17 5-18 of lower molar; bad taste in mouth Objective: Signs No fever, purulent exudates or other signs of systemic infection; visible open wound without clot Assessment: Differential Diagnosis abscess, trauma, osteomyelitis (systemic signs) Plan: Antibiotics are rarely indicated. The mandibular condyle translocates anteriorly in front of the articular eminence and becomes locked in that position. Muscle spasm may then prevent the patient from closing the jaw into normal occlusion. Dislocation may be unilateral or bilateral and may occur spontaneously after opening the mouth widely while yawning, eating, or during a dental procedure. Subluxation is a displacement of the condyle that is self-reducing and requires no medical management. If the patient is sitting in a chair, their head should be at the level of your waist.

Thus medicine 319 pill buy 2mg kytril overnight delivery, at 10 having anterior lumbar interbody fusion was the one years medications high blood pressure buy kytril 1mg fast delivery, the survivorship analysis predicted that 36 2 medications that help control bleeding buy 2 mg kytril amex. Degeneration was isolated to the segment vivor analyzes [10 symptoms 0f ms generic 2 mg kytril mastercard, 19] are very informative in terms of adjacent in 23 medications reactions purchase cheap kytril line. Breaking down the defning the risk and likely time frames for the devel data symptoms ptsd kytril 2mg low cost, overall 56. The survivor analysis [10, 19], in particular, was a relation between fusion and development of helps defne the parameters against which nonfusion adjacent level pathology. Percent 0 development of Adjacent level disease per year and Cervical Lumbar predicted survivorship at 10 years Per year 10 years 162 D. Hybrid/Novel Approaches Because of the consideration for stabilization, kine matic and biomechanical studies have been performed Wardlaw [29] has used Dynesis instrumentation in a which also give data on the adjacent levels [23]. At the fusion implants have suggested that the mechanical pressures level, a slightly long plastic spacer is compressed, in the disk at the index operated segment are reduced leading to a more rigid construct to help enhance (20% reduction in neutral, 41% in extension) [24]. Nonrigid stabilization of the adjacent level that the pressures at adjacent levels were not signif holds some theoretical hope of reducing transfer of cantly affected. Other cadaver studies have looked at mechanical stress and decreasing adjacent level degen the biomechanics of the facets. Patients involved in the preliminary technical that the facet pressure can be reduced 39% at the oper report have not been followed for a suffcient time to ated level, again without a signifcant pressure change confrm or deny the theoretical usage. Limited in vivo studies of the addition of a metal plate to an anterior cervical kinematics after implantation of an X-Stop device have fusion increases the rigidity of the fused segment and shown a similar lack of effect on adjacent levels [26]. In an effort properties suggest that an indication for interspinous to avoid this long-term stress shift, there have been devices would be correction of sagittal plane instabil limited applications of biodegradable plate technology ity and avoidance of adjacent level pathology [27]. Preliminary reports only have been published the literature lacks any long-term studies that with insuffcient data to form a conclusion concerning would more defnitively answer whether interspinous the effects of biodegradable implants. Using a positional magnetic authors have addressed the infuence of disk arthro resonance imaging methodology, Beastall [28] observed plasty on adjacent levels. Although a few cases of screw loosening were regarding shifting mechanical stresses to adjacent lev observed, no signifcant adjacent level disease was seen els. Chang [32] performed disk pressure studies of in the follow-up period which averaged almost 4 years. However, References other studies have shown higher rates of adjacent level degeneration. Okuda S, Iwasaki M, Miyauchi A, Aono H, Morita M, [36] reviewed 42 semiconstrained prostheses and found Yamamoto T (2004) Risk factors for adjacent segment a 23. Hilibrand A, Robbins M (2004) Adjacent segment degenera tion and adjacent segment disease: the consequences of spi nal fusion Katsuura A, Huduka S, Saruhashi Y et al (2001) Kyphotic In consideration of nonfusion stabilization proce malalignment after anterior cervical fusion is one of the fac dures as a whole, kinematic studies give us hope that a tors promoting the degenerative process in adjacent interver similar connection to adjacent level pathology might tebral levels. Kulkarni V, Rajshekhar V, Raghuram L (2004) Accelerated spondylotic changes adjacent to the fused segment following weight of clinical evidence currently available to fac central cervical corpectomy: magnetic resonance imaging tually resolve the question is limited. Teramoto T, Ohmori K, Takatsu T et al (1994) Long term of avoiding adjacent level pathology by the use of results of the anterior cervical spondylodesis. Goffn J, Geusens E, Vantomme N et al (2004) Long term technology, hybrid surgeries, biodegradable instru follow up after interbody fusion of the cervical spine. Neurosurg Focus 16(3):E7 tive randomized multi-center study for the treatment of lum 31. Pain is experienced between fxator was tightened, sacrum rotated anteriorly (nuta the posterior iliac crest and the gluteal fold, particularly tion) to a more stable position. The pain may radiate in the proved the hypothesis proposed by Vleeming and posterior thigh and can also occur in conjunction with/ Snijders [26, 27]. The endurance capac this study is a preliminary report based on patient ity for standing, walking and sitting is diminished. Only a few factors are proven to have an impact on the development of the Among the patients referred to the hospitals in Malmo (3) condition. In symptoms were intolerable pain in the sacroiliac area these latter cases, there is no disease or trauma to initiate and reduced ability to sit, stand and walk. All patients the condition, as there is in, for example, ankylosing underwent a 3 weeks test period with the external fx spondylitis or after trauma. The pain uate patients for surgery was previously used by Slatis duration before surgery was between 2 and 12 years. All patients had undergone a longstanding individually tailored physiotherapy before surgery. Sturesson two men and fve women, had no positive effect with Department of Orthopaedics, Angelholm Hospital, 262 81, Angelholm, Sweden the external fxator test, and thus, not fulflled the cri e-mail: bengt. Sturesson Methods two patients had a too short follow-up (6 months) and three patients from Hong Kong (2) and Canada (1) were impossible to reach for a telephone follow-up. The frame was ated on the opposite side, and after 10 years on sick tightened until the pain in the posterior part of the pel leave she has now returned to work 1 year after the vis was relieved and the ability to walk was restored. The patients were then sent home and told to do nor No patient deteriorated after surgery. Forty patients were sick-listed fusion surgery was depended on the effect of the fx before surgery and 22 patients are now in full-time ator. Of the 52 patients tested with the external fxator, work and three in part-time work. One is retired because 45 patients, 36 women and 9 men, were accepted for a of age and 16 are still on sick leave or disabled. The fusion was performed with the technique described by Smith-Peterson and Rogers [19] with the difference that the patient was allowed to ambulate. Twenty-fve patients were operated bilater Discussion ally and had the external fxator during the healing process. About 1% [2] have persisting pain unilateral screw fxation to the S1 vertebral body. Two 2 years after delivery, but the pain is intolerable only in patients were operated unilaterally on both sides with very few. The fusion was considered physiotherapy treatment consists of stabilizing exer successful if the patient was pain free or if the function cises where the transverse and oblique abdominal as to sit, stand and walk was restored. If the son why not all patients can stabilize the pelvis can patient showed no relief in symptoms, a computed have different explanations. One possible explanation tomography was performed to evaluate the healing is that there is a neuromuscular malfunction in the more accurately. Another possible explanation is that low virulent anaerobic bacteria can infect the joint. Results Among patients with a trauma, the cartilage is most likely injured with a secondary arthritis as a cause of the patients were followed up with a telephone inter pain. Histology [5] reveals that the degenerative pro view 6 months to 18 years after surgery. There are, how patients judged the operation as a success and the life ever, no evidence that degenerative fndings can be and pain situation was considerably changed. On the other hand, it is well-known patients considered improved result and improved that knee arthritis is not necessary painful, even if radi function after surgery. One is that the external fxator is ineffective in posterior midline fascial splitting approach and pedicle reducing the pain, which for example would be the screw instrumentation: a new technique. Another explanation can be that these Possible use of arthrodesis for intractable sacroiliitis in spon patients had a low lumbar cause of pain. In: probably the case when two patients assessed by a Movement, stability and low back pain. Neither of (1999) the active straight leg raising test and mobility of the them had improvement after surgery. In: Vleeming A et al (eds) has many similarities with patients with nerve entrap Movement, stability and low back pain. Slatis P, Eskola A (1989) External fxation of the pelvic gir on fles and telephone interviews. However, taking into dle as a test for assessing instability of the sacro-iliac joint. Stuge B, Hilde G, Vollestad N (2003) Physical therapy for (1990) Relation between form and function in the sac pregnancy-related low back and pelvic pain: a systematic roiliac joint. Sturesson B, Uden A, Onsten I (1999) Can an external frame Sacroiliac joint arthrodesis for chronic lower back pain. Lieberman With the increasing rate of spine surgery being greater risk of bleeding during the surgery. Osteoporotic performed worldwide, the complexity of these surgeries patients have greater bleeding channels from their is also increasing. Anterior spine exposures are also affected procedures most at risk for signifcant blood loss and by osteoporotic bone, particularly since the vertebral covers various options, surgical and anesthetic, which bodies themselves are generally more severely affected can be implemented to decrease that blood loss. Of course, the anterior the consequences of high blood loss cases are vasculature has great potential for extensive bleeding; numerous. The increased stress to the cardiac system experience with anterior exposures by the spine sur and the major perfusion needs, including cerebral, car geon or vascular surgeon is critical for minimizing this diac, and renal, are well-known. Revision surgery is usually associated with higher can range from mild itching or fevers to major reac blood loss, with the potential for critical blood loss tions. Exposure to allogenic blood transfusion can also being greatest for revision anterior spinal surgery if the increase the risk of bacterial infections, ranging from major vessels are injured. In addition, multiple osteotomies, pedicle sub which may contain even small amounts of plasma [3]. Large volume blood loss during It is worth noting that pediatric spine cases differ posterior procedures is also associated with the devel from adult spine cases. Pediatric Certainly, any spine surgeon is well aware of the patients have more fexible curves, which may allow potential for bleeding during posterior spinal surgery, shorter fusions. Adults have stiffer curves which may where the muscles stripped from the spine have numer require inclusion of longer segments, including compen ous potential bleeding points, and any intracanal work satory curves. These stiffer curves may require anterior has the potential to cause epidural bleeding. For the release and fusion and/or multiple osteotomies to enable former, patients with neuromuscular conditions have curve correction; Adult bones may be more osteoporotic and have increased bleeding from their surfaces. Lieberman pediatric patients, except those with neurofbromatosis, Controlled hypotension has been used successfully connective tissue conditions, and neuromuscular condi to decrease blood loss during spine surgery [9]. The fusion rate is lower been demonstrated that decreasing the venous pressure in adults, thus it is more common to require revision sur will result in a decrease of the intraosseous pressure, gery which has greater potential for blood loss. A vari While not actually reducing surgical bleeding, ety of agents have been used to induce hypotension, blood conservation methods, such as cell salvage and including anesthetics or vasoactive agents. Its use is lim autologous blood combined with intraoperative use of ited if the patient has vascular disease, cardiac disease, cell saver may not both be necessary unless signifcant or poorly managed hypertension. Where appropriate, nitroglycerin is more effective local methods, which can be utilized by the surgeon, than halothane for inducing controlled hypotension. It and systemic methods, such as hemodilution, con is worth noting that Tsuji and colleagues (2001) studied trolled hypotension, proper use of blood products, and patients undergoing cervical laminaplasty for myelopa antifbrinolytics. Local agents such as gelfoam, surgi or two of blood with subsequent maintenance of intra cal, and oxycel, essentially different formulations of vascular volume with colloid and crystalloid. While cellulose or gelatin, can be used to improve local hemo not reducing blood loss, the intraoperative bleeding stasis when applied to bleeding surfaces such as muscle will be of more dilute blood, decreasing the need for or bone, which is not easily cauterized. Some concern substances are mixed with thrombin, a component of the was raised that hemodilution might lead to early coag clotting cascade, for additional effcacy.

Within the framework of the therapeutic relationship treatment ingrown hair cheap kytril 2mg overnight delivery, adaptive changes in these behavioural patterns would be attempted medications canada quality kytril 1mg. Obviously treatment zygomycetes kytril 1mg without prescription, in this psychological treatment medicine abbreviations purchase kytril 2mg fast delivery, the interpersonal aspect of the behaviour is pri oritised symptoms torn rotator cuff order 2mg kytril visa, but it is not family therapy treatment receding gums kytril 1 mg for sale. It is an approach that takes ideas and techniques from other schools and organises them in an original way. Thus, concepts and techniques of cognitive behavioural therapy, experiential therapy, and supportive therapy are characteristically used. Over time, since interpersonal therapy arrived on the scene as a form of treatment for de pressive disorders, it has adapted to the peculiarities of other psychopathologies such as bulimia nervosa, somatisation, substance abuse, or post-traumatic stress disorder. Therapy lasts approximately 12 to 16 weeks in one-hour sessions on a weekly basis, which are structured by an initial evaluation phase (normally the frst interviews are the evaluation phase). The evaluation phase is followed by the therapeutic intervention phase, which focuses on the indicated interpersonal areas throughout the following sessions. It is characterised by using an especially applied format and mode and not by belonging to a specifc school. Alternative projections of mortality and disability by cause 1990 2020: Global Burden of Disease Study. Prevalencia de trastornos psicologicos en ninos y adolescentes, su relacion con la edad y el genero. 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Alprazolam versus amitriptyline in the treatment of depressed out-patients: a randomized double-blind trial symptoms 5 days before missed period best order kytril. Treatment of depressive outpatients with lorazepam natural pet medicine discount kytril 2 mg without prescription, alprazolam medications qhs buy cheap kytril 2mg, amytriptyline and placebo treatment zone tonbridge buy kytril 2mg fast delivery. Acute and prophylactic therapies of patients with affective disorders using valpromide (dipropylacetamide) medicine 1920s 2mg kytril with amex. A controlled study of the efficacy and safety of mianserin and maprotiline in outpatients with major depression symptoms 38 weeks pregnant proven 2 mg kytril. Are antidepressants not or less effective in the acute treatment of bipolar I compared to unipolar depres sion Induction of mania with selective serotonin re-uptake inhibitors and tricyclic antidepressants. Drug therapy in the prevention of recurrences in unipolar and bipolar affective disorders. Prophylactic lithium carbonate with and without imipramine for bipolar 1 patients. Bipolar mood disorder: practical strategies for acute and maintenance phase treatment. Antidepressant treatment of bipolar depression 403 Tondo L, Laddomada P, Serra G, Minnai G, Kukopulos A. Empfehlungen fur die Behandlung bipolarer affektiver Storungen [Recommendations for the treatment of bipolar affective disorder]. For Falret, signs and symptoms were not sufficient to characterize a mental disorder. In his opinion the folie circulaire (see also Chapter 1, by Marneros and Angst) the prognosis of the illness was considered very grave: "sounds desperate. Unlike Falret, however, Kraepelin assumed that manic-depressive insanity (see also Chapter 1, by Marneros and Angst) had a good prognosis and did not develop into severe residual states, although he described "asthenic states" ("Schwachezustande") after recovery from the episodes (Kraepelin 1913, p. As early as the 5th edition of his Lehrbuch (1896), Kraepelin stressed "the decisive shift from the symptomatic approach to the clinical approach of mad ness. In this "clinical approach" the previously defined clinical syndromes ("Zustandsbilder") became obsolete and useless. Therefore, Kraepelin denied most of the clinical interest of symptomatology (all symptoms could be A. Marneros seen in every psychiatric condition) and chose as his major criterion the longitudinal approach (course of the illness and prognosis). What defines an illness and lends it unity (evolution and consequences of the process, "Vorgang") is a fundamental concept in German conceptualization of psychopathology (Geraud 1995), following the paradigm of Karl Kahlbaum (1863). Disturbance of psychic functioning, behaviour, thinking, willing and psychomotor activity prevailed in his definition of manic-depressive illness. In the chapter "Das manisch-depressive Irresein" ("Manic-depressive illness") of the 1913 edition of his Lehrbuch, Emil Kraepelin reunited "several pathological conditions with certain common traits (gemeinsame Grundzuge)". Chapter 9 addresses the problem of course and evolution (Verlauf), on the basis of 899 cases classified by mood "colouring" (Farbung). Kraepelin distinguished three clinical categories: depression, mania, mixed states. As the number of episodes increased there was increasing of alternation of Farbung and mixing (Beimischung). Unlike Falret and Jules Baillarger, who described clinical subtypes, Kraepelin was convinced that attempts to classify such subtypes were doomed to fail. They could play a role in the very first episodes, but later "manic-depressive Prognosis of bipolar disorders 407 episodes can be surprisingly independent from external events" (Kraepelin 1913, p. It is not rare in the literature for the term "course" to be used synonymously with the term "outcome". This equivalence of the terms "course" and "outcome" is not legitimate, because outcome is only one of many elements of course (Marneros et al. Sometimes "course" and "outcome" are grouped together under the head ing "prognosis", but with a very global meaning. Marneros sis" means few recurrences, and sometimes full remission or recovery (Boland and Keller 1996, Goodwin and Jamison 1990, Marneros et al. The MacArthur Foundation Research Network on the Psychobiology of Depression recommended some descriptive terms for use in assessing the course and outcome of depression which will also serve for bipolar disorders (Franket al. Episode: episodes are defined as consisting of a number of symptoms and lasting longer than some days. Response and partial remission: A partial remission is a period during which an improvement of sufficient magnitude is observed that the individual is no longer fully symptomatic. Treatment is not a requirement of the definition, partial remission can be spontaneous. Full remission: a full remission is a period during which an improvement of sufficient magnitude is observed that the individual is asymptomatic. Recovery: this term is used to designate recovery from the episode, not from the illness per se. Relapse: relapse is a return of symptoms satisfying the full syndrome criteria for an episode that occurs during the period of remission, but before recovery. Recurrence: recurrence is the appearance of the disorder, and thus can occur only during a recovery. In spite of the obvious advantages of these recommendations, especially for statistical and pharmacological research, they do not cover all aspects of prognosis. In the following we present the most important elements of course and outcome of bipolar affective disorders. This chapter concerns only bipolar affective, not schizoaffective disorders, which are described in Chapter 5. Onset Age at onset the exact definition of age at onset is difficult, because the age when symptoms first appear is not always identical with the age at first medical Prognosis of bipolar disorders 409 consultation or with the age at first admission to hospital. Symptoms gen erally appear some time before medical consultation is first sought (Weissman 1988, Egeland et al. In spite of this discrepancy, bipolar affective patients usually become ill at a younger age than unipolar patients. Type of onset the type of onset of bipolar disorders depends on the initial episode, i. An acute onset of depressive symptomatology, in which the symptoms develop from a healthy state to a full-blown disorder within a few days, is rare. Usually the onset of depressive symptomatology is subacute, with signs and symptoms begin ning several weeks or months before the full manifestation of the illness. More than 20% of patients have a gradual onset with prodromal signs for anything between several months and some years before the full manifesta tion (Marneros et al. Usually the average duration of prodromal signs was 1 year, but for dysphoria, as well as for anhedonia, psychomotor distur bances, feelings of guilt and insufficiency, 5 years are described (Eaton et al. Manic symptomatology is usually acute in onset, over a number of days, although in some cases long-lasting prodromal signs have been observed (Kraepelin 1913, Carlson and Goodwin 1973, Jacobson 1965, Marneros et al. Research showed a partial relation of stressful life events and the manifestation of episodes (Goodwin and Jamison 1990, Marneros 1999). Some theories on the pathogenesis of affective disorders assign primary causal relevance to psychosocial environmental events (Paykel and Cooper 1992). It is, however, now generally accepted that psychosocial or physical events contribute more to the timing of an episode than to causing it. Causality is likely to be largely biological and, especially, genetic (Goodwin and Jamison 1990, 410 M. Precipitating events seemingly play an important role in the onset of the first episodes but not in the later ones (Angst 1987, 1988, Marneros et al. The frequency of precipitating factors reported in the literature varies considerably, from 25% to 75% (overview in Goodwin and Jamison 1990, Marneros 1999). Many serious studies find no differences in precipitating factors between unipolar and bipolar patients. We found in the Cologne study that approximately 53% of the unipolar and 47% of the bipolar patients have stressful life events at the onset of an episode (the difference is statistically insignificant) (Marneros et al. A review of all episodes of a long-term course (more than 25 years duration) indicates that only in approximately 13% of all episodes can stressful life events be found in a period of 6 months before onset of the episode (Marneros et al. It is interesting that the difference between manic and melancholic episodes regarding the frequency of life events in a longitu dinal perspective is not significant (Marneros et al. Not only depressive episodes but also manic episodes show a correlation between life events and first manifestation (Ambelas and George 1988). Episodes Number of episodes Unipolar and bipolar affective disorders are usually recurrent. Studies reporting low relapse rates have usually had methodological limitations such as short duration of the observation time, consideration only of severe episodes, and lack of knowledge of short intervals (Angst and Sellaro 2000, Marneros 1991a). The majority of unipolar and bipolar patients are polyphasic, which means they have more than three episodes within an illness duration of 20 years. Bipolar patients have significantly more episodes than unipolars (Angst 1966, 1992, Goodwin and Jamison 1990, Marneros et al. Frequency of episodes and length of cycles the frequency of episodes in unipolar and bipolar diseases can be estimated by evaluating the number and length of cycles (see Figure 1). A cycle is Prognosis of bipolar disorders 411 defined as the time from the onset of one episode to the onset of the next (Angst 1986a). A variation of cycle length usually reflects variations in the length of intervals between episodes, because the length of episodes com monly varies only insignificantly (Angst 1986a, Marneros et al. Since the length of cycles in bipolar diseases is significantly shorter than in unipolar ones, the frequency of remanifestations of episodes in bipolar diseases is higher than in unipolar. This means that in bipolar diseases the second episode occurs significantly sooner than in unipolar ones. Subsequent cycles are usually shorter, so that the remanifestation of episodes occurs more fre quently in later periods of the course (Angst et al. In a survival analysis of the Zurich follow-up data (Angst and Preisig 1995a), the differences between cycles 1 and 5 were significant: difficult to interpret. In conclusion, Angst and Preisig (1995a) found a shortening of cycle length at the beginning of the disorder only; later episodes were persistently recurrent but came at irregular intervals without any systematic deterioration or amelioration, thus confirming the results of Winokur et al. The same factors that influence the number of episodes can also influence cycle length (Marneros et al. The phenomenon of rapid cycling is more frequent in females and usually occurs later in the course of the illness (Calabrese et al. This could reflect the impact of certain treatments accelerating the natural course of illness, or may reflect underlying patho physiological mechanisms (Goodwin and Jamison 1990, Marneros 1999). Patients with rapid cycles are more likely to be unresponsive to prophylactic 412 M. Marneros lithium treatment than patients with no rapid cycling (Prien 1979, Koukopoulos et al. Length of episodes Angst and Sellaro (2000) reviewed the findings of studies on the natural length of episodes which were published prior to the introduction of effec tive treatments. The data of Mendel (1881), Panse (1924), Wertham (1929), Rennie (1942) and Kinkelin (1954) describe durations of episodes between 2 months and more than a year. It can be concluded that since the introduction of effective treatment the duration of depressive episodes in both unipolar and bipolar patients exceeds that of manic episodes (Keller 1988, Silverstone and Hunt 1992, Zarate and Tohen 1996). It seems that the duration of an episode is depen dent on various factors, of which the most important is the response to the pharmacological treatment. Some studies reported discrepant findings regarding the difference in length between initial episodes (longer) and subsequent episodes (shorter). The duration of an episode also seems to be exclusively dependent on the type of disorder, i. The duration of manic episodes is on average 2 months (Keller 1988, Silverstone and Hunt 1992, Zarate and Tohen 1996, Marneros et al. Stability of syndromes We define as stable syndromes in which the same type of episode occurs consistently during a long-term course (more than 25 years). The stability is dependent on the kind of initial episode as well as on the duration of the illness, as shown in Figure 3 (Marneros et al. Schizodepressive and depressive symptomatology is much more stable than that of manic symptomatology (see Figure 3). Outcome In evaluating the outcome of mental disorders we must consider the term "outcome" as problematic. Many studies have demonstrated that, as the Prognosis of bipolar disorders 413 ultimate stage of a mental disorder, "outcome" is seldom a final state without further psychological and interactional mobility. The term "out come" should therefore be used only as a compromise to describe the psychopathological and social status of a patient after a certain duration of illness. Outcome is not a monolithic phenomenon but has many psycho pathological, psychological, interactional and social aspects. All of these aspects can be affected by the illness in different ways and to different degrees. Marneros sidering these aspects and applying operational criteria for evaluating the various aspects of outcome (Marneros et al. Long-term investigations have shown that a significant proportion of patients with affective disorders have an unfavorable outcome (Angst 1987, Marneros and Deister 1990, Marneros and Tsuang 1990, 1991). However, studies investigating the outcome of affective disorders suffer from varying criteria and heterogeneous definitions of "unfavourable out come". Although the term "chronic depression" is frequently used to indi cate affective disorders with an unfavourable outcome, the criteria for it vary widely among studies (Angst 1987).

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