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Ventilation dramatically dilutes the concentration of infectious droplet nuclei (see Chapter 15 cholesterol not the cause of heart disease buy generic tricor 160mg line, the Prevention and Control of Tuberculosis Transmission in Health Care and Other Settings cholesterol wiki order generic tricor from india, for further information on clearance times) cholesterol in chicken eggs purchase tricor 160mg line. Proximity to the source case Proximity to the source case is also a determinant of transmission cholesterol vegan diet buy tricor 160mg with mastercard. Related to this is overcrowding: if, as a result of there being many people in a room, an individual is forced into close proximity with an infectious case his or her risk of infection is likely to increase. Duration of exposure Because of the dilution of infected air and the low concentration of infectious droplet nuclei, the duration of exposure required to ensure that transmission occurs is commonly prolonged (days, months or even years), and yet reports have confirmed that exposures as short as a few minutes may be sufficient to infect a close contact. The latter would appear to be supported by the high proportion of active cases that deny any history of exposure. At that point, when the patient is often at his or her most infectious, any further delay caused by the physician, nurse or system allows unnecessary transmission to others. Administrative and engineering controls that aim to reduce exposure in health care and other congregate settings complement—but cannot replace—prompt diagnosis and appropriate therapy. Bill Dock and the location of pulmonary tuberculosis: how bed rest might have helped consumption. Overview of the pathogenesis of tuberculosis from a cellular and molecular perspective. Reichman and Hershfields Tuberculosis, A rd Comprehensive International Approach, 3 Edition. An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. The natural history of childhood intrathoracic tuberculosis: a critical review of literature from the pre-chemotherapy era. Piecing the puzzle together: foreign born tuberculosis in an immigrant receiving country. Autolysis and secondary growth of Mycobacterium tuberculosis in submerged culture. Glyoxylate metabolism and adaptation of Mycobacterium tuberculosis to survival under anaerobic conditions. Incipient and subclinical tuberculosis: defining early disease in the context of immune response. Risk of progression to active tuberculosis following reinfection with Mycobacterium tuberculosis. The natural history of tuberculosis: the implications of age-dependent risks of disease and the role of reinfection. Epidemiological and clinical study of tuberculosis in the district of Kolin, Czechoslovakia. Pulmonary tuberculosis treated with directly observed therapy: serial changes in lung structure and function. Reciprocal seasonal variation in vitamin D status and tuberculosis notifications in Cape Town, South Africa. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Transmission, pathogenesis, pathology and clinical manifestations of tuberculosis. Exogenous reinfection as a cause of recurrent tuberculosis after curative treatment. Identifying predictors of interferon release assay results in pediatric latent tuberculosis: a protective role of bacillus Calmette-Guerin Issues in the management of contacts of patients with active pulmonary tuberculosis. The influence of the number of bacilli on the development of tuberculosis disease in children. Infection and disease among contacts of tuberculosis cases with drug-resistant and drug susceptible bacilli. Grading of positive sputum smear and the risk of Mycobacterium tuberculosis transmission. Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli. Transmission of tuberculosis from smear negative patients: a molecular epidemiology study. Predictive model to identify positive tuberculosis skin test results during contact investigations. The public health consequences of smear-positive pulmonary tuberculosis in patients with typical versus atypical chest radiographs. International Union against Tuberculosis and Lung Disease North American Regional Meeting. The use of environmental factors as adjuncts to traditional tuberculosis contact investigation. The infectiousness of laryngeal tuberculosis: appropriate public heath action based on false premises. Aerial dissemination of pulmonary tuberculosis: a two year study of contagion in a tuberculosis ward. Tuberculosis disseminators: a study of the variability of aerial infectivity of tuberculosis patients. Infectiousness of air from a tuberculosis ward— ultraviolet irradiation of infected air: comparative infectiousness of different patients. The early bacteriocidal activity of drugs in patients with pulmonary tuberculosis. Relative versus absolute noncontagiousness of respiratory tuberculosis on treatment. Factors influencing the transmission and infectivity of Mycobacterium tuberculosis: implications for clinical and public health management. Reduced transmissibility of East African Indian Strains of Mycobacterium tuberculosis. Some observations on the pathogenicity of isoniazid-resistant variants of tubercle bacilli. Childhood drug-resistant tuberculosis in the Western Cape Province of South Africa. A city wide outbreak of a multiple-drug-resistant strain of Mycobacterium tuberculosis in New York. Drug-resistant tuberculosis, clinical virulence, and the dominance of the Beijing strain family in Russia. Transmission of Mycobacterium tuberculosis Beijing strains, Alberta, Canada, 1991-2007. This cough is initially dry but after several weeks to months will become productive. Cough of 2 weeks duration is a more sensitive criterion, but cough of 3 weeks duration will be more specific. Fever and night sweats are common but may be absent in the very young and the elderly. Hemoptysis, anorexia, weight loss, chest pain and other symptoms are generally manifestations 1,2 of more advanced disease. This results in irregular, poorly defined, small nodular shadows, which represent acinar shadows. Inter-reader variability: 4 One of the greatest problems of chest x-ray reading is that the interpretation is highly variable. There is very poor agreement among readers regarding the presence of cavitation, hilar 4 lymphadenopathy and the likelihood of active disease. If processing within o 1 hour is not possible, samples should be refrigerated at 4 C (not frozen) and protected from light. Clinical specimens should be handled, processed and transported in an environment in which biosafety procedures are in place. Sputum At least three sputum specimens of 5-10 mL each should be collected and tested with microscopy as well as culture. Compared with the standard approach of examination of two smears with Ziehl-Neelsen microscopy over 2 days, examination of two smears taken on the same day had much the same sensitivity (64% [95% confidence interval 60% to 69%] for standard microscopy vs 63% [58% to 68%] for same-day microscopy) and specificity (98% [97% to 99%] vs 98% [97% to 99%]). Another recent systematic review of 23 studies reported that the overall success of sputum induction was high, ranging from 76. The sensitivity of microscopy compared with culture on induced sputum samples ranged from 0% to 100%.
In an aggravation claim cholesterol shrimp facts cheap tricor online amex, number of documents or greater number of concurrences; rather permanent disability caused by the compensable injury includes it means the more probative and more reliable medical opinion disability caused by: based upon factors including cholesterol medication bad breath buy 160mg tricor with mastercard, but not limited to cholesterol in eggs is good cheap 160 mg tricor with mastercard, one or more of (a) An accepted worsened condition; or the following:(a) the most accurate history cholesterol control foods eat purchase tricor 160 mg line, (b) A direct medical sequela of an accepted worsened (b) the most objective findings, condition. A worker is eligible for an award for (17) "Superimposed condition" means a condition that arises impairment if: after the compensable injury or disease that contributes to the (A) the worker suffers permanent loss of use or function of a workers overall disability or need for treatment but is not the body part or system; result of the original injury or disease. For example: the (B) the loss is established by a preponderance of medical compensable injury results in a low back strain. Two months evidence based upon objective findings of impairment; and after the injury, the worker becomes pregnant (non-work (C) the loss is due to the compensable injury. An award for impairment or system is due to the compensable injury must be established is modified by the factors of age, education, and adaptability if by the attending physician or medical arbiter. A (6) Objective findings made by a consulting physician or other worker is eligible for an award for work disability if: medical providers (e. For (d) the worker is unable to return to the job held at the time of example: the medical provider determines that giveaway injury because the worker has a permanent work restriction that weakness is due to pain attributable to the compensable injury. If there is no measurable impairment, no award of permanent (3) When a new or omitted medical condition has been disability is allowed for pain. To the extent that pain results in accepted since the last arrangement of compensation, the extent disability greater than that evidenced by the measurable of permanent disability must be redetermined. Reproducibility of abnormal motion accepted new or omitted medical condition creates restrictions is used to validate optimum effort. Have the worker actively move the joint as far as possible in (b) When performing a redetermination of the extent of each motion with the arm of the goniometer following the permanent disability under this section, the amount of motion. Injury prior to 1/1/2005) the examiner must take at least three consecutive (1) Scheduled disability with a date of injury prior to January measurements of mobility, which must fall within 10% or 5 1, 2005, is rated on the permanent loss of use or function of a degrees (whichever is greater) of each other to be considered body part caused by a compensable injury. The measurements must be repeated up to six times scheduled impairment benefit, use the following steps: to obtain consecutive measurements that meet these criteria. Inconsistent measurements may be considered invalid and that (a) Determine the percent of scheduled impairment using the portion of the examination disqualified. If examination, findings of impairment that are determined to be there are multiple extremities with impairment then each is ratable under these rules are rated unless the physician determined and awarded separately, including hearing and determines the findings are invalid. If the Example: Scheduled impairment benefit validity criteria are not met but the physician determines the 0. Prorating or interpolating (a) To calculate the unscheduled impairment benefit when the between the listed values is not allowed. Example: Unscheduled impairment benefit (worker returns/is (b) Not all medical conditions or diagnoses result in loss of released to regular work) use, function, or earning capacity. There is no additional value granted for the varying extent of waxing and waning of the = $7,065. X 320 Maximum degrees for unscheduled impairment (a) Determine the percent of impairment as a whole person = 57. This percentage is then used to determine the loss of (2) When rating disability the movement in a joint is measured strength for the injured deltoid. Impairment findings describing lost Range of motion examples: ranges of motion are converted to retained ranges of motion by Flexion (knee): 80° retained on injured side, the contralateral subtracting the measured loss from the normal of full ranges joint flexes to 140°. A proportion is established to determine the expected degrees (a) Range of motion values for each direction in a single joint of flexion since 140° has been established as normal for this are first added, then combined with other impairment findings. Example: Range of motion of elbow Arm Impairment One method of determining this proportion is: 80/140 = X/150. Other Impairment Values 86° of retained flexion of the knee is calculated under these Weakness 7% rules, after rounding, to 23% impairment. Prosthetic radial head replacement 10% Extension (knee): 35° retained on injured side, the Combine 14 and 10 = 23 contralateral joint extends to 15°. This value is then combined with other the values for ranges of motion established under these rules, impairment values. The injured knee is reported to have severe instability of the (a) Except for subsection (b) of this section, before combining, anterior cruciate ligament. The standards grant an impairment the sum of the impairment values is rounded to the nearest value of 15% for severe instability of the anterior cruciate whole number. The contralateral knee is reported to have mild instability of Example: the anterior cruciate ligament. The standards grant an Range of motion of the wrist Impairment impairment value of 5% for mild instability of the anterior Dorsiflexion 36 = 3. Example: Example: Impairment of the wrist/hand Impairment Range of motion of the wrist Impairment Loss of range of motion = 6% of the wrist/hand Dorsiflexion 60 = 0. If the given body part is an upper or lower extremity, (sum of impairment values) ear(s), or eye(s) then the impairment value is to be converted to a whole person value before combining with other impairment (5) If there are impairment findings in two or more body parts values, except when the date of injury for the claim is prior to in an extremity, the total impairment findings in the distal body part are converted to a value in the most proximal body part Jan. This Example: conversion is done prior to combining impairment values for Low back Impairment the most proximal body part. The grade of follows: strength is reported by the physician and assigned a percentage (a) the combined value is obtained by inserting the values for value from the table in subsection (a) of this section. The larger of the two impairment value of the involved nerve, which supplies numbers is A and the smaller is B. Upon combining the largest two percentages, the resulting percentage is combined with any lesser percentage(s) in descending order using the same formula until all percentages have been combined prior to performing further computations. After the calculations are completed, the decimal result is then converted back to a percentage equivalent. The social-vocational factor is determined according to 3-/5 60% the steps described in section (15) of this rule and is used in the 2+/5 70% calculation of permanent disability benefits. Evaluation of Permanent Impairment may be referenced to (4) A value of a workers formal education is given as follows: identify the specific muscle(s), peripheral nerve(s) or spinal (a) Workers who have earned or acquired a high school nerve root(s) involved. Example: Forearm Radial nerve (50%) supplies (innervates): Muscles (grade) (%) (nerve) Supinator 4/5 = 20% x. A worker is also sedentary 7 1 2+ years 4 years restricted if the worker can perform the full range of sedentary 8 1 4+ years 10 years activities, but with restrictions. A worker is also sedentary/light if the worker of time required by a typical worker to acquire the knowledge, can perform the full range of light activities, but with skills, and abilities needed to perform a specific job. If a occasionally lift 20 pounds and can frequently lift or carry preponderance of evidence establishes that the requirements of objects weighing up to 10 pounds. College training organized around a specific occasionally lift 100 pounds and the ability to frequently lift or vocational objective is considered specific vocational training. Residual functional capacity is (m) "Occasionally" means the activity or condition exists up evidenced by the attending physicians release unless a to 1/3 of the time. Apply the subsection in this section that most provided in order to allow an accurate determination of these accurately describes the workers base functional capacity. If the workers that the strength requirements are in between strength capacity to perform work is diminished by a superimposed or categories then use the higher strength category. If the job workers capacity to perform work would be if it had not been description determines that the strength requirements are in diminished by the superimposed, pre-existing, or denied between strength categories then use the higher strength condition. For the purposes of the determination of adaptability, complete the following steps. If the date of injury is before (b) Determine the appropriate value for the education factor Jan. Findings of M 6 5 4 3 2 1 1 1 1 impairment are objective medical findings that measure the extent to which a worker has suffered permanent loss of use or H 7 6 6 5 4 3 2 1 1 function of a body part or system. If the worker is medically stationary, findings of categories and who also have restrictions, the next lower impairment are determined by performing the following steps: classification is used. The disease or a direct medical sequela of an accepted occupational worker is eligible for an impairment disease. In medically stationary; the closing examination, the attending (B) For each body part or system identified in paragraph (A) physician describes range of motion findings of this subsection, estimate the extent to which the use or and states that 60% of the range of motion function of the body part or system is likely to be permanently loss is due to the accepted conditions and lost at the time the worker is likely to become medically 40% of the range of motion loss is due to the stationary; and pregnancy. Under these rules, the range of (C) Estimate the portion of the loss that is likely to be caused motion loss is valued at 10%. Surgery (lumbar diskectomy) = 9% (4) the following are considered when determining what Combine: 10% and 9% which equals 18% low back disability findings can be offset from a prior claim: impairment due to this compensable injury. The current accepted condition is (b) the conditions or findings of impairment from the prior the component of the otherwise denied combined condition that awards which were still present just prior to the current claim; remains related to the compensable injury. After considering and comparing the claims, (1) A prior award can be used to offset an award for a any award of compensation in the current claim for loss of use subsequent claim when all the following are true: or function or loss of earning capacity caused by the current (a) the prior claim is closed under Oregon Workers injury or disease (which did not exist at the time of the current Compensation Law; injury or disease and for which the worker was not previously (b) the prior claim has an award of permanent disability; compensated) is granted.
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If you have difficulty concentrating cholesterol raising foods order tricor 160 mg without prescription, try setting aside small blocks of time to do one thing and noth Finally cholesterol levels hdl ldl generic tricor 160 mg fast delivery, try to avoid high cholesterol in eggs myth generic tricor 160mg otc, manage or cope with stress cholesterol medication triplex order tricor 160 mg amex. Among women, they are the second leading hormone estrogen has been shown to improve memory. Because this stances build up in the blood vessels then break off and hormone increases the risk of breast cancer and cannot obstruct the flow of blood to the brain. You can reduce be given to men without feminizing side effects such your chances of having a stroke by following a low-fat, as breast enlargement, scientists are working on low-cholesterol diet, quitting smoking, keeping alcohol “designer” estrogens that target brain function without consumption minimal, and exercising regularly. Hot Fact: Exercise Helps the Brain the easiest way to protect your brain is to maintain Other animal studies have shown that exercise a program of regular, moderate exercise. A regular exercise routine provides and lifts depression, in addition to being good structure to the day and brings people out of isola for the heart, lungs and waistline. One research group has studied 1,200 people between with Huntingtons disease (which causes memory loss, the ages of seventy and eighty. Would knowing your people for ten years, the researchers found that the ones fate make you live your life differently, or would you just start who kept their excellent mental functioning had three traits carrying the burden of the disease that much earlier Nowadays, however, America glorifies youth, and all too often the elderly are seen 2. At present there is no definitive laboratory test for as comical, querulous and infirm. As the countrys popula Alzheimers disease and no cure, though some medications tion ages, what steps could we take as a society to give can help ameliorate the symptoms. Raise the retirement identified many of the genes that confer an increased risk for age, for example Have mediation sessions in nursing the disease, its possible that a genetic test will become homes, where minor grievances are aired before a panel of available. Brush your teeth with the opposite hand, take the side Try gardening, playing chess or even memoir writing. It may sound off-the-wall, Defer retirement, mentor others in your field, take up but creating new associations — even arbitrary ones — challenging causes, travel to exotic lands, step up your is tantamount to brain-building. Ask the bus driver his name, Memory is not just for sights and sounds, but for tex start a conversation, recall his name on the next occa ture, emotions and even smell. If he tells you his son is taking tuba lessons, make Asian market and get to know the spices and unfamiliar a note to ask him how the boy is progressing. Find hobbies, take classes or do work that uses also about creating new, more dynamic ones. Reading, from short stories to Tolstoy, is a For more information on improving your memory, visit: great brain-builder, as are classes in anything from. It occupies ticity underlies everything the brain the normal programs of neuronal a certain amount of space: 8 1/2 inch does. But this normal wear experience new connections and tear doesnt bring are formed. Change the expe about any basic modifica rience, and you change the tion to the size of the brain. Abnormalities will lar terms — that once it also occur if, because of pre reached a certain level of mature birth, the brain enters development it remained the world too soon and is pretty much the same overwhelmed with more except for some biologi stimuli than it is equipped to cal wear and tear (loss of handle. At the conclusion the brain remains a of infancy, a sculpting dynamic structure that process begins, becoming the alters from year-to-year, dominant force shaping the day-to-day, even moment brain. Thanks Next come the formation of the major contains many more neurons than it to what neuroscientists call plasticity, brain regions and a migration of neu requires, so excess neurons are pruned the brain possesses amazing capacities rons from their original sites of gener away according to the most funda for change. Indeed, most congenital (present that are used are strengthened and (continued) B Essay 1 The ing ones career results in the forma tips of the fingers undergoes measura neurons established during gestation tion of new networks composed of ble changes in blind readers of Braille and infancy are thinned out in millions of nerve cells. Thanks to this process limits his or her experiences, or fails new challenges and opportunities. Most interesting is the finding pally as a holding operation, an dren vastly increase their abilities to that important brain changes can attempt to retain past gains while pay attention and remember and occur in extremely short periods of yielding as little as possible to decline begin mastering the universe. We now know that such a brain that receives impulses from the view is unduly pessimistic. Thus the older person Essentially, stem cells are primitive the likely consequences of ones has a choice: Accept the stereo unspecialized cells that can “morph” into mature actions, planning, reasoning and types about aging and sit in a cells while continuing to multiply and provide a controlling ones emotions. Since their frontal lobes are not Stem cells in the skin and bone account for the fully developed, adolescents While the aging brain may be a healing that took place. Stem cells also give birth sometimes exhibit such frontal bit slower in learning, manipu to the cells in the liver, the lining of the intestines, lobe-based difficulties as impul lating and rapidly retrieving and all the cellular constituents of the blood. The siveness, foreshortened attention discovery of stem cells within the brain suggests new information (one of the spans, and failure to realize the they are capable of turning into adult neurons. Once the growth the brain, end up in specific locations and then adults), it remains highly plas and pruning process has been suc fully differentiate into neurons,” explains Fred tic and adaptable. For cessfully completed, adolescents Gage, Professor of Genetics at the Salk Institute. And thats younger colleagues when it continues but without the dra really a key feature in understanding the larger comes to integrating new matic level of pruning observed picture of what plasticity is all about. But one doesnt the adult, plasticity involves the place for the treatment of dementia: the induction have to be a college professor formation and maintenance of of nerve cell multiplication and the replacement to possess these talents. Both of these strate his essay “On Old Age,” gies could potentially treat presently incurable on ones interests and activities. Nurture and the Individual Child by Sandra Ackerman “She gets that easygoing temperament According to psychologist Eleanor “The concept of nature versus nurture from her father,” a mother may say, as Maccoby, we are neither and we are is so ingrained in our thinking,” says her two-year-old sits happily dumping both. Or, tions and their parents childrearing ology, psychology and pediatrics at applauding an eight-year-old after his regimes,” Dr. Maccoby says, express the University of Alabama, “its first school concert, the parents may ing the predominant view of develop almost impossible to get beyond. Perhaps because chil that determines how a child dren keep surprising us will think, feel and behave. From generation to genera tion, the more curious Although all siblings emerge among us have wondered from the same gene pool, each how we can each start out one receives a unique set of as a single fertilized cell genes: some from the mother and yet become a unique “I” with our closely interwoven. They function and others from the father, some dom own thoughts, feelings and behavior. Then, even in the most stable family, this new popularity arose from a single scientific paper pub each childs experience will be differ lished in 1993, in which a research team showed that listening to ent. The parents may be new at rais Mozarts music improved the performance at certain mental tasks of ing children or old hands at it; the sib elementary school students. Gradually, as the story was reported to lings are older, younger, all of one sex larger and less specialized audiences, this finding grew in perceived importance, until the so-called “Mozart effect” was said to increase or the other, or mixed; household cir babies overall ability to learn or even in some way to enhance their cumstances may be comfortable or brain for life. At the same time, though, further scientific studies did difficult; the family may exist in a not confirm these results, and soon the exaggerated claims for the long-established network of friends Mozart effect began to appear to be just that. All nal study: not only did the students improved performance on the test these factors together form the fail to carry over to other kinds of schoolwork, but it also proved to be childs microenvironment, rather short-lived. The furor over the Mozart effect has largely died and they produce major down, but the story of its popular rise and fall lingers as a warning and lasting effects. Genes can set up a tenden cy or predisposition toward certain likes or dislikes, talents, levels of energy, and even self image. But these ten dencies may fit well or How the child responds to such a label, and badly into the childs what she has made of her own inherited environment — above traits and experiences so far, will have an all his home environ impact on the way her family perceives and ment — in ways that fur treats her, which may in turn modify her ther shape the childs traits self-image and her dealings with parents and view of himself. In a and siblings, and so on, in a cycle lasting family fond of sports and well into adulthood. Paradoxical as it games, for example, a less seems, each child takes part in creating actively inclined child may the very environment that helps to shape be encouraged to join in, or her as a unique person. We able to watch the equivalent of an Scientists learned this from early know this because addictive drugs incredibly scintillating game of pin experiments with rats. When lab rats mimic the action of one or more of the ball, as the pleasure centers light up eat or become sexually aroused, brains neurotransmitters. And as a and play off one another in response dopamine levels increase in the areas result of this successful mimicry, the to the steak. But the same thing brain is fooled into responding as it happens when rats inject themselves would to the natural neurotransmitter. If you dont fancy steak, think about with addictive drugs like cocaine, for “The drugs do that,” says Steven whatever else “turns you on” — a example, by pressing a lever or turning Hyman, director of the National term, incidentally, that provides an a wheel. They will repeat these behav Institute of Mental Health, “by tap apt description of what is happening iors hundreds of times to experience ping into the brain-reward sys the pleasure set off by the tem and fooling that system. The brain-reward system is Liz, a patient at the Caron made up of areas of the brain foundation in Wernersville, collectively referred to as the Pennsylvania, which specializes pleasure centers.
In another report by Suppes and colleagues (1999) cholesterol lowering foods indian diet order 160 mg tricor with amex, there was a significant improvement in psychotic and affective symptoms 6 months after being randomized through either clozapine or usual treatment cholesterol content in eggs during the laying period order tricor us. In a retrospective review that included 52 patients with bipolar disorder remnant cholesterol definition purchase tricor discount, 81 with schizoaffective disorder cholesterol lowering foods and herbs order tricor 160 mg visa, and 14 with psychotic depression, the authors found that psychotic mania and schizoaffective bipolar patients had significantly better outcomes than patients with psychotic depression or schizoaffective-depressed type; suggesting that the index episode of mania or schizoaffective bipolar type predicted a better outcome. In addition, patients with a psychotic affective disorder had a better outcome in social 380 M. Tohen functioning compared to 40 patients with schizophrenia who were followed as a comparison group. A number of other case reports have also suggested that risperidone has mood-altering properties (Hillert et al. Similarly, Keck and colleagues (1995), in a retrospective chart review, found that patients with bipolar disorder or schizoaffective disorder depressed type had a good response when risperidone was added to mood stabilizers. The investigators studied 45 patients in a 4-week trial random ized to up to 6 mg of risperidone, up to 10 mg of haloperidol, and lithium 800–1200 mg daily, with blood levels 0. The authors concluded that monotherapy with risperi done was of comparable efficacy to that of lithium and haloperidol. This review included 150 patients with psychotic disorders, including 47 patients with bipolar disorder with psychotic features, 29 patients with schizophrenia, 23 patients with schizoaffective disorder bipo lar type, 17 patients with schizoaffective disorder depressive type, 22 patients with major depression with psychotic features, and 12 patients with psychosis not otherwise specified. Of interest in this review is that Antipsychotics in acute mania 381 patients more likely to respond to olanzapine had a bipolar disorder diagno sis, were younger, female, and had a shorter duration of illness. McElroy and colleagues (1998) also reported that olanzapine was effective in treat ment-resistant mania. To date, two double-blind, placebo-controlled studies with olanzapine have been conducted. In this study, of 3 weeks duration, efficacy was assessed by mean change from baseline to end point. Of note, when patients with and without psychotic features were compared, no statistical difference was found in the difference of olanzapine relative to placebo. In a subgroup of patients with a rapid-cycling course there was a statistically significant improvement in those receiving olanzapine with a mean change from baseline to endpoint of –13. In order to assess an antidepressant response in this population of bipolar manic or mixed patients, a subgroup of patients who scored 20 or more in the Hamilton Rating Scale were compared. This study suggests that olanzapine has a fast onset of action, and also that it may have mood-stabilizing properties in patients with acute mania. However, antidepressant properties still need to be confirmed in a population with bipolar depression. To summarize, antipsychotics in the treatment of mania have been utilized since they became available almost half a century ago. Although typical antipsychotics have proven to be a valuable treatment tool for acute mania, they have limitations regarding the adverse effect profile, and possible depressogenic effects. The role that these agents will have in the treatment of bipolar disorder, vis-a vis mood stabilizers, remains unclear. Although the evidence of the efficacy in the treatment of acute mania has been demonstrated, studies assessing 382 M. Tohen its efficacy in bipolar depression and relapse prevention need to be con ducted to determine their role in the therapeutic armamentarium in the treatment of bipolar disorder. A controlled Nordic multicentre study of zuclopenthixol acetate in oil solution, haloperidol and zuclopenthixol in the treatment of acute psychosis. Clozapine therapy in refractory affective disorders: polarity predicts response in long-term follow-up. Proceedings of the 32nd Annual Meeting of the American College of Neuropsychopharmacology; December 1993; Oahu, Hawaii, p. Incidence and correlates of tardive dyskin esia in first episode of schizophrenia. In: New Research Program and Abstracts of the 146th Annual Meeting of the American Psychiatric Association; 26 May 1993; San Francisco, Calif. Psychiatric Diagnosis in New York and London: a Comparative Study of Mental Hospital Admissions. A comparison of haloperidol, lithium carbonate and their combination in the treatment of mania. Predictors of occurrence, severity, and course of tardive dyskinesia in an outpatient population (Review; 37 refs). Treatment of manic episodes: zuclopenthixol and clonazepam versus lithium and clonazepam. Risperidone in the treatment of disorders with a combined psychotic and depressive syndrome: a functional approach. Risperidone in the treatment of affective illness and obsessive–compul sive disorder. Clinical predictors of acute risperidone response in schizophrenia, schizoaffective disorder, and psychotic mood disor ders. A retrospective study on the long-term efficacy of clozapine in 96 schizophrenic and schizoaffective patients during a 13-year period. Clozapine in the treatment of psychotic mood disorders, schizoaffective disorder, and schizophrenia. A randomized comparison of divalproex oral loading versus haloperidol in the initial treatment of acute psychotic mania. Identifying risk factors for tardive dyskinesia among long-term outpatients maintained with neuroleptic medications. Efficacy and adverse effects with clozapine in the treatment of schizophrenia and tardive dyskinesia: a retrospective study of 387 patients. Clinical management of clozapine patients in relation to efficacy and side-effects. Risperidone compared with both lithium and haloperidol in mania: a double-blind randomized controlled trial. Treatment outcome with clozapine in tardive dyskinesia, neuroleptic sensitivity, and treatment-resistant psychosis. Clozapine treatment of non-psychotic rapid cycling bipolar disorder: a report of three cases. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania. Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. Clinical predictors of acute response with olanzapine in psychotic mood disorders. This modern development is especially based on some risks induced by antidepressants in bipolar depression, such as switch into mania and rapid cycling. Some bipolar experts even question the generally held hypothesis that antidepres sants which have been proven to be effective in unipolar depression are also effective in bipolar depression. In the following, the possibilities, limitations and risks of antidepressants in the treatment of acute bipolar depression will be reviewed, focusing on bipolar I depression, since most of the findings in the literature refer to this group of bipolar depressions. At that time the efficacy of antidepressants in episodes of acute bipolar depression was not generally evaluated separately. Angst (eds), Bipolar Disorders: 100 years after manic-depressive insanity, 387–403. Grunze hypothesis that drugs which have been shown as effective in unipolar depression are also effective in bipolar depression is still commonly accepted. For a long time it did not seem relevant or necessary to prove the efficacy of antidepressants in separate samples of bipolar depression. However, the situation is currently changing and arguments have been made that this view possibly does not hold true (Hirschfeld et al. In addition, this led to the performance of a small number of controlled trials on antidepres sants in samples of acute bipolar depressive patients (Baumhackl et al. Apparently, the sceptical view that antidepressants might not be effective in acute bipolar depression, which seems to be very extreme, or the position that they might not be as effective as in unipolar depression, or that the induced risk of switch into mania and rapid cycling might override the benefits of a good antidepressive response, which were expressed in this very sceptical and maybe over-critical tendency especially in the most recent years, is not supported by empirical evidence. Zornberg and Pope (1993) reviewed seven controlled studies that exam ined the efficacy of tricyclic antidepressants in the treatment of bipolar depression.