Early stages of bipolar disorder: characterization and strategies for early intervention

Objective: To characterize the early stages of bipolar disorder (BD), defined as the clinical prodrome/subsyndromal stage and first-episode phase, and strategies for their respective treatment. Methods: A selective literature search of the PubMed, Embase, PsycINFO, and ISI databases from inception until March 2014 was performed. Included in this review were articles that a) characterized prodromal and first-episode stages of BD or b) detailed efficacy and safety/tolerability of interventions in patients considered prodromal for BD or those with only one episode of mania/hypomania. Results: As research has only recently focused on characterization of the early phase of BD, there is little evidence for the effectiveness of any treatment option in the early phase of BD. Case management; individual, group, and family therapy; supportive therapy; and group psychoeducation programs have been proposed. Most evidence-based treatment guidelines for BD do not address treatment specifically in the context of the early stages of illness. Evidence for pharmacotherapy is usually presented in relation to illness polarity (i.e., manic/mixed or depressed) or treatment phase. Conclusions: Although early recognition and treatment are critical to preventing unfavorable outcomes, there is currently little evidence for interventions in these stages of BD

The nerves to the plantaris muscle and a bipennate part of the soleus muscle

We performed nerve fiber analysis of the nerve to the plantaris muscle in ten cases. Macroscopically, the nerve to the plantaris muscle has a tendency to branch off from the tibial nerve itself independent of the nerves to the gastrocnemius and soleus muscles (the triceps surae muscle). After removing the epineurium of the tibial nerve, it was revealed that, in all ten cases, the nerve to the plantaris muscle formed a common funicular trunk with the nerve to a bipennate part of the soleus. This trunk is akin to the nerves to the deep muscles of the calf. In addition, in five of the ten cases, the nerve to the plantaris muscle had another component, which arose from the branch to the popliteus muscle. By removing the perineurium of the nerves concerned, it became clear that the elements of the nerve to the plantaris muscle, and of the nerve to the bipennate part of the soleus, had an intimate relation (inseparable). On the other hand, the elements of the nerve to the plantaris muscle and those to the popliteus were separable and they showed different routes proximally. Based on the present findings derived from nerve fiber analysis, we postulate that the plantaris muscle and bipennate part of the soleus muscle were probably derived from the deep muscle anlage of the calf in spite of their topographical closeness to the superficial muscles of the calf