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BACKGROUNDAlthough mania is characteristic of bipolar disorder, it can also occur following focal brain damage. Such cases may provide unique insight into brain regions responsible for mania symptoms and identify therapeutic targets.METHODSLesion locations associated with mania were identified using a systematic literature search (n = 41) and mapped onto a common brain atlas. The network of brain regions functionally connected to each lesion location was computed using normative human connectome data (resting-state functional MRI, n = 1000) and contrasted with those obtained from lesion locations not associated with mania (n = 79). Reproducibility was assessed using independent cohorts of mania lesions derived from clinical chart review (n = 15) and of control lesions (n = 490). Results were compared with brain stimulation sites previously reported to induce or relieve mania symptoms.RESULTSLesion locations associated with mania were heterogeneous and no single brain region was lesioned in all, or even most, cases. However, these lesion locations showed a unique pattern of functional connectivity to the right orbitofrontal cortex, right inferior temporal gyrus, and right frontal pole. This connectivity profile was reproducible across independent lesion cohorts and aligned with the effects of therapeutic brain stimulation on mania symptoms.CONCLUSIONBrain lesions associated with mania are characterized by a specific pattern of brain connectivity that lends insight into localization of mania symptoms and potential therapeutic targets.FUNDINGFundação para a Ciência e Tecnologia (FCT), Harvard Medical School DuPont-Warren Fellowship, Portuguese national funds from FCT and Fundo Europeu de Desenvolvimento Regional, Child Neurology Foundation Shields Research, Sidney R. Baer, Jr. Foundation, Nancy Lurie Marks Foundation, Mather's Foundation, and the NIH.

ObjectiveManic and depressive phases of bipolar disorder (BD) show opposite symptoms in psychomotor, thought, and affective dimensions. Neuronally, these may depend on distinct patterns of alterations in the functional architecture of brain intrinsic activity. Therefore, the study aimed to characterize the spatial and temporal changes of resting-state activity in mania and depression, by investigating the regional homogeneity (ReHo) and degree of centrality (DC), in different frequency bands. MethodsUsing resting-state functional magnetic resonance imaging (fMRI), voxel-wise ReHo and DC were calculated—in the standard frequency band (SFB: 0.01–0.10 Hz), as well as in Slow5 (0.01–0.027 Hz) and Slow4 (0.027–0.073 Hz)—and compared between manic (n = 36), depressed (n = 43), euthymic (n = 29) patients, and healthy controls (n = 112). Finally, clinical correlations were investigated. ResultsMania was mainly characterized by decreased ReHo and DC in Slow4 in the medial prefrontal cortex (as part of the default-mode network [DMN]), which in turn correlated with manic symptomatology. Conversely, depression was mainly characterized by decreased ReHo in SFB in the primary sensory-motor cortex (as part of the sensorimotor network [SMN]), which in turn correlated with depressive symptomatology. ConclusionsOur data show a functional reconfiguration of the spatiotemporal structure of intrinsic brain activity to occur in BD. Mania might be characterized by a predominance of sensorimotor over associative networks, possibly driven by a deficit of the DMN (reflecting in internal thought deficit). Conversely, depression might be characterized by a predominance of associative over sensorimotor networks, possibly driven by a deficit of the SMN (reflecting in psychomotor inhibition).

Mania is a serious neuropsychiatric condition associated with significant morbidity and mortality. Previous studies have suggested that environmental exposures can contribute to mania pathogenesis. We measured dietary exposures in a cohort of individuals with mania and other psychiatric disorders as well as in control individuals without a psychiatric disorder. We found that a history of eating nitrated dry cured meat but not other meat or fish products was strongly and independently associated with current mania (adjusted odds ratio 3.49, 95% confidence interval (CI) 2.24–5.45, p < 8.97 × 10−8). Lower odds of association were found between eating nitrated dry cured meat and other psychiatric disorders. We further found that the feeding of meat preparations with added nitrate to rats resulted in hyperactivity reminiscent of human mania, alterations in brain pathways that have been implicated in human bipolar disorder, and changes in intestinal microbiota. These findings may lead to new methods for preventing mania and for developing novel therapeutic interventions.

BackgroundObsessive–compulsive disorder (OCD) is a major cause of disability in western country and responsible for severe impairment of quality of life. About 10% of patients present with severe OCD symptoms and require innovative treatment such as deep brain stimulation (DBS). Among possible targets, the non-motor subthalamic nucleus (STN) is a key node of the basal ganglia circuitry, strongly connected to limbic cortical areas known to be involved in OCD.MethodWe analysed, in a prospective, observational, monocentric, open label cohort, the effect of chronic non-motor STN-DBS in 19 patients with treatment-resistant OCD consecutively operated in a single centre. Severity of OCD was evaluated using the Yale and Brown Obsessive–Compulsive Scale (YBOCS). YBOCS scores at 6, 12 and 24 months postoperatively were compared with baseline. Responders were defined by >35% improvement of YBOCS scores. Global Assessment Functioning (GAF) scale was used to evaluate the impact of improvement.ResultsAt a 24-month follow-up, the mean YBOCS score improved by 53.4% from 33.3±3.5 to 15.8±9.1 (95% CI 11.2–20.4; p<0.0001). Fourteen out of 19 patients were considered as responders, 5 out of 19 being improved over 75% and 10 out of 19 over 50%. GAF scale improved by 92% from 34.1±3.9 to 66.4±18.8 (95% CI 56.7–76.1; p=0.0003). The most frequent adverse events consisted of transient DBS-induced hypomania and anxiety.ConclusionChronic DBS of the non-motor STN is an effective and relatively safe procedure to treat severe OCD resistant to conventional management.

COVID-19 may affect central nervous system. The symptoms related to the CNS may occur through the direct neuroinvasion of the virus, inflammation, autoimmunity, psychosocial stressors and treatment side effects. COVID-19 can increase the severity of existing mental illnesses and also trigger the onset of a new mental illness. In this case report, we present a 52-year-old male patient with no previous psychiatric history as well as no family history of mental illness. The patient's manic symptoms began while he was hospitalized due to severe COVID-19 pneumonia. The patient, who self-discharged himself from the hospital was brought to the emergency department involuntarily by his relatives 14 days later and was admitted to the psychiatry service. In this case report, possible etiological factors were discussed and the treatment course during the hospitalization and one year follow-up were presented. Our aim is to contribute to the literature by discussing possible etiological factors and management of mania that started during the treatment of COVID-19. COVID-19 can affect the central nervous system and be associated with psychiatric symptoms. Keywords: COVID-19, Mania, Bipolar Disorder, Central Nervous System.

Sleep loss is a key trigger for a manic episode of bipolar disorder (BD), but the underlying microglial and molecular mechanisms remain unclear. Sleep loss induces microglial and inflammatory responses. Microglia, resident macrophages in the central nervous system, regulate synaptic pruning by engulfing dendritic spines. Here, we introduce a modified paradoxical sleep deprivation (SD) paradigm as a BD mouse model. After intermittent 16-h daily SD for 4 days, the mice showed mania-like behavior, reduced cytokine/chemokine production, mitochondrial damage, microglial loss, decreased synaptic engulfment by microglia, and synaptic gain. Single-nucleus RNA sequencing (snRNA-seq) revealed cell-type-specific inflammation- and synapse-related gene expression profiles in the prefrontal cortex (PFC) and hippocampus of SD-treated male mice. Interestingly, much more differentially expressed genes were observed in SD-treated female versus male mouse brain, especially in the PFC. Pharmacological depletion of microglia by colony stimulating factor-1 receptor (CSF1R) inhibitor PLX3397 blocked SD-induced inflammation-related and senescence-associated abnormalities in a sex-specific manner. Microglial elimination reversed SD-induced synapse gain and mania-like behavior in males but not in females. However, microglial inhibition by minocycline had no effect on SD-induced behaviors in a sex-independent manner. These findings demonstrate that microglia-mediated neuroinflammation and synaptic pruning contribute to SD-induced mania-like behavior in a mouse model of BD in a sex-specific manner.

Protein kinase C inhibitor tamoxifen reduces symptoms of acute mania in bipolar patients and mania-like behaviors in animals. Memory impairment and altered levels of glutamate and glutamate/glutamine ratio have been reported in mania. Tamoxifen suppresses glutamate release which plays an important role in memory. The present study evaluated whether tamoxifen’s activity participates in its antimanic efficacy in repeated sleep deprivation mania model. Mice were divided into control and 24-h sleep-deprived groups and were treated with vehicle or 1 mg/kg tamoxifen twice daily for 8 days. Sleep deprivation was repeated three times at intervals of 2 days. Square crossing and rearing were recorded as measures of locomotor activity. Memory and risk taking behavior were evaluated using novel object recognition and staircase tests, respectively. Glutamate and glutamine levels were measured in the frontal cortex and hippocampus. Behavioral tests were conducted 24 h after the second or immediately after the third sleep deprivations. Sleep deprivation increased locomotor activity and risk taking. Glutamate and glutamine levels and glutamate/glutamine ratio in the frontal cortex and hippocampus were unaffected. Locomotor hyperactivity was prevented by tamoxifen treatment. No change in the recognition index suggested lack of memory impairment in the model. These findings confirm the relevance of repeated sleep deprivation as a mania model and tamoxifen as an antimanic agent. However, future research is needed to further address lack of memory impairment in the model and lack of glutamatergic influence on the model and antimanic effect of tamoxifen.

The purpose of this case study is to review the clinical presentation and medical workup of a young adult male presenting with acute behavior changes in the setting of undiagnosed ornithine transcarbamylase deficiency (OTCD). This case study involves a 19-year-old male with a psychiatric history of depression and one previous suicide attempt, who presented to a large midwestern university hospital emergency department after being found by police naked in a neighbor's yard. He displayed manic signs and symptoms, including euphoria, lack of sleep for five days, and attempting to purchase a new car and three large screen TVs. Family reported the patient uncharacteristically announced three weeks earlier that he was vegetarian and stopped eating his frequent customary cheeseburgers. Due to increased anxiety and inability to sleep, the patient received lorazepam 2 mg in the emergency department. Upon transfer to the psychiatric unit, therapy was initiated with aripiprazole 5 mg daily and valproate 1000 mg nightly on Day 1 of treatment. The patient refused medications on hospital Day 2, then received this combination again on Day 3. The next morning, the patient complained of lethargy, headache, nausea, and vomiting. The patient's ammonia level was found to be 204 micromol/L with ALT and AST of 714 and 647 IU/L respectively. Tests for infectious hepatitis were negative. Medical consultation recommended discontinuation of current medications, vigorous hydration, and further work up. On further investigation, the patient was found to have low plasma citrulline level of 8 micromol/L, undetectable plasma arginine, and high urinary orotic acid. The laboratory data showed a biochemical phenotype consistent with a diagnosis of partial OTCD, an X-linked urea cycle disorder resulting in toxic hyperammonemia. The patient was treated with a low protein diet modification as well as a combination of sodium benzoate and sodium phenylbutyrate to reduce serum ammonia concentration. With treatment the patient's laboratory values normalized, and mental status improved. In conclusion, partial ornithine transcarbamylase deficiency may manifest with psychiatric symptoms in early adulthood. In young patients with elevated ammonia and mental status change, OTCD is an important diagnosis to consider, as it is the most common inherited cause of hyperammonemia.

ABSTRACT Mania is typically associated with psychiatric disorders but can also be secondary to other conditions, such as brain tumors. A notably rapid response to antimanic treatment suggests secondary mania. However, identifying such cases can be challenging. Mrs. M., a 52‐year‐old woman with a history of anxiety and dysthymia, presented with her first manic episode, marked by elevated mood, agitation, reduced sleep, racing thoughts, and grandiose delusions. Her manic symptoms emerged outside the usual age range for mania. She responded remarkably quickly to antimanic medication. Furthermore, her Young Mania Rating Scale (YMRS) score decreased from 36 to 6 within 3 days. This unusual response prompted further investigation, revealing a 46 mm enhancing mass in the medial frontal lobe, affecting the anterior cingulate cortex (ACC). This was confirmed as a meningioma upon surgical removal. The rapid treatment response, combined with the atypical age of onset, raised the suspicion of secondary mania. The discovery of a medial frontal meningioma and its subsequent surgical removal supported this diagnosis. Given the ACC's role in emotional regulation, its involvement likely contributed to the manic symptoms. A swift response to antimanic treatment can indicate secondary mania, such as that caused by a brain tumor. This case highlights the importance of considering secondary causes when mania presents atypically or responds unusually well to treatment. A 52‐year‐old woman with a history of anxiety and dysthymia experienced her first manic episode with rapid symptom resolution after antimanic treatment. Her atypical age of onset and unusually fast response prompted further investigation, revealing a medial frontal meningioma affecting the anterior cingulate cortex (ACC). This case underscores the need to consider secondary causes, such as brain tumors, when mania presents atypically or resolves rapidly.

The rate of syphilis in Canada has been increasing in the last decade. Outbreaks often disproportionately affect men who have sex with men, though outbreaks among heterosexual people have been documented in recent years in both urban and rural areas. Neurosyphilis presents more frequently in people with concurrent HIV infection, particularly those with CD4 T-cell counts < 350 cells/μL (0.35 x 109/L). According to retrospective studies, 40% of patients have ocular involvement, including uveitis, retinal pathology and vision loss. A third of patients have cognitive impairment and a third have neurologic manifestations, such as headache, aphasia, auditory hallucinations and stroke. Psychiatric symptoms vary widely, when they occur. Hypomania is uncommon, affecting fewer than 10% of people with neurosyphilis Neurological sequela are often permanent, but our patient made a full recovery after outpatient treatment with intravenous penicillin. Here, Jeon and Gough examine the case of 60-year-old man with neurosyphilis.