Creating virtual 3-dimensional models for teaching pre-clinical tooth preparation: Students' usages and perceptions.

PURPOSE: This research aimed to evaluate the students' usage and perceptions of using smartphones in their general dental education and learning tooth preparation with the individually designed virtual 3D instructional models in the pre-clinical removable partial denture course. MATERIALS AND METHODS: Second-year dental students were asked to voluntarily participate in a survey to investigate their demographic information, general usages of smartphones, perception of smartphones usage in dental education (construct 1) and perception of individually designed virtual 3D instructional models (construct 2). Students' responses of general usages of the smartphones were compared with their demographic and educational backgrounds using nonparametric Kruskal-Wallis test (for age) and Fisher's exact test (for sex, race and educational background). The sums of scores of the construct 1 and construct 2 were tested for associations with student's demographic and educational backgrounds using the Pearson product-moment correlation (for age), t test (for sex and educational background) or one-way ANOVA F test (for race) (α = .05). RESULTS: A 75% response rate (N = 90) was achieved in this study, and all 90 participants owned smartphones. Students' responses to general usages of the smartphones were not significantly influenced by their demographic background. For the construct 1, more than 73% of participants responded either agree or strongly agree to the usage of smartphones in general dental education and pre-clinical setting; however, only 49% of participants responded the same way in the clinical setting. For the construct 2, 48 of 90 participants viewed the 3D models, and more than 73% of these 48 participants responded either agree or strongly agree to the usage of the 3D models in the pre-clinical course. Student's demographic background did not have significant influence on the sums of scores of the construct 1 and construct 2. CONCLUSIONS: Within the limitations of this study, high usages and ownerships of smartphones were found amongst the students surveyed. The individually designed virtual 3D instructional models as supplemental teaching materials in the pre-clinical course were perceived positively by the students.

Effect of smile index and incisal edge position on perception of attractiveness in different age groups.

Changes in occlusal vertical dimension (OVD) and age have been found to affect Smile Index (SI, width/height of smile). Limited information is available regarding the aesthetic effects of these changes. The objective of this study was to evaluate the attractiveness of digitally manipulated smile images with differences in SI and incisal edge position (IEP) judged by respondents in different age groups. A total of 12 smile images were generated with varying SI (3·5, 5·3, 7·2, 9·0) and IEP (High, Medium, Low). Fifty respondents each in four age groups (15-24, 25-39, 40-54, 55+) evaluated the attractiveness of the 12 images using a 0-10 visual analog scale (VAS, 10 being most attractive). A repeated-measures three-factorial mixed model assessed differences. SI, IEP and age of respondents were found to significantly influence attractiveness score (P < 0·01 for all). With all age groups combined, SI = 7·2/IEP = Medium was most attractive (VAS = 7·22), followed by SI = 9·0/IEP = Medium, and SI = 5·3/IEP = Medium (VAS = 6·53 and 6·48, respectively). SI = 3·5/IEP = High and SI = 3·5/IEP = Low were least attractive (VAS = 1·99 and VAS = 2·58, respectively). Age group significantly influenced aesthetic perception, with younger respondents more critical in differences in SI and IEP. SI and IEP significantly influenced attractiveness of the smile in all respondent age groups. Low SI (i.e. 3·5) combined with high or low IEP was unattractive. Medium SI to high SI (i.e. 5·3-9·0) combined with medium IEP were considered attractive.

Partial Purification and Characterization of an Inducible Indole-3-Acetyl-L-Aspartic Acid Hydrolase from Enterobacter agglomerans.

Indole-3-acetyl-amino acid conjugate hydrolases are believed to be important in the regulation of indole-3-acetic acid (IAA) metabolism in plants and therefore have potential uses for the alteration of plant IAA metabolism. To isolate bacterial strains exhibiting significant indole-3-acetyl-aspartate (IAA-Asp) hydrolase activity, a sewage sludge inoculation was cultured under conditions in which IAA-Asp served as the sole source of carbon and nitrogen. One isolate, Enterobacter agglomerans, showed hydrolase activity inducible by IAA-L-Asp or N-acetyl-L-Asp but not by IAA, (NH4)2SO4, urea, or indoleacetamide. Among a total of 17 IAA conjugates tested as potential substrates, the enzyme had an exclusively high substrate specificity for IAA-L-Asp. Substrate concentration curves and Lineweaver-Burk plots of the kinetic data showed a Michaelis constant value for IAA-L-Asp of 13.5 mM. The optimal pH for this enzyme was between 8.0 and 8.5. In extraction buffer containing 0.8 mM Mg2+ the hydrolase activity was inhibited to 80% by 1 mM dithiothreitol and to 60% by 1 mm CuSO4; the activity was increased by 40% with 1 mM MnSO4. However, in extraction buffer with no trace elements, the hydrolase activity was inhibited to 50% by either 1 mM dithiothreitol or 1% Triton X-100 (Sigma). These results suggest that disulfide bonding might be essential for enzyme activity. Purification of the hydrolase by hydroxyapatite and TSK-phenyl (HP-Genenchem, South San Francisco, CA) preparative high-performance liquid chromatography yielded a major 45-kD polypeptide as shown by sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

Haloperidol blood levels and clinical effects.

This study explored the relationships between plasma levels and the clinical effects of haloperidol in 176 acutely exacerbated schizophrenic or schizoaffective patients. After a single-blind placebo period of 1 week (period 1), they entered the double-blind period 2 randomly assigned to one of three plasma levels of haloperidol: low (2 to 13 ng/mL), medium (13.1 to 24 ng/mL), or high (24.1 to 35 ng/mL). Patients whose conditions did not improve in period 2 continued on one of the three haloperidol levels (period 3). Periods 2 and 3 lasted 6 weeks each. Only minor differences in clinical responses were noted among the three levels of haloperidol. These results imply that low or moderate doses of neuroleptics are appropriate for many acutely psychotic patients.

A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Divalproex Maintenance Study Group.

BACKGROUND: Long-term outcomes are often poor in patients with bipolar disorder despite treatment; more effective treatments are needed to reduce recurrences and morbidity. This study compared the efficacy of divalproex, lithium, and placebo as prophylactic therapy. METHODS: A randomized, double-blind, parallel-group multicenter study of treatment outcomes was conducted over a 52-week maintenance period. Patients who met the recovery criteria within 3 months of the onset of an index manic episode (n = 372) were randomized to maintenance treatment with divalproex, lithium, or placebo in a 2:1:1 ratio. Psychotropic medications were discontinued before randomization, except for open-label divalproex or lithium, which were gradually tapered over the first 2 weeks of maintenance treatment. The primary outcome measure was time to recurrence of any mood episode. Secondary measures were time to a manic episode, time to a depressive episode, average change from baseline in Schedule for Affective Disorders and Schizophrenia-Change Version subscale scores for depression and mania, and Global Assessment of Function scores. RESULTS: The divalproex group did not differ significantly from the placebo group in time to any mood episode. Divalproex was superior to placebo in terms of lower rates of discontinuation for either a recurrent mood episode or depressive episode. Divalproex was superior to lithium in longer duration of successful prophylaxis in the study and less deterioration in depressive symptoms and Global Assessment Scale scores. CONCLUSIONS: The treatments did not differ significantly on time to recurrence of any mood episode during maintenance therapy. Patients treated with divalproex had better outcomes than those treated with placebo or lithium on several secondary outcome measures.

Dementia in an American-Chinese nursing home population.

Of 58 demented residents in an American-Chinese nursing home, 44 (75.9%) had multi-infarct dementia, seven (12.1%) had possible Alzheimer's disease, four (6.9%) had other dementias, and three 5.2% had unknown disorders. Alzheimer's disease was relatively less prevalent than in U.S. nursing homes overall.

Glutamate and other CSF amino acids in Alzheimer's disease.

The authors compared CSF amino acid levels of 10 patients with mild to moderate dementia and probable Alzheimer's disease who had never received antidepressant or neuroleptic medication with those of 10 normal subjects of similar age. The Alzheimer's patients had significantly higher levels of CSF glutamate. This finding was not related to age, sex, or severity of dementia. Elevated CSF glutamate may reflect greater glutamatergic activity early in the course of Alzheimer's disease. The authors speculate that the excitotoxic effects of glutamate may contribute to progressive neuronal loss in Alzheimer's disease.

Differential involvement of hippocampal G-protein subtypes in the memory process of rats.

Inactivation of Gi and G(o) proteins in the dentate gyrus of the hippocampus by pertussis toxin did not affect memory retention of a one-way passive avoidance learning task in rats. Interference of normal Gs activity in the dentate gyrus by cholera toxin impaired retention performance dose-dependently. Cholera toxin also antagonized the memory-enhancing effect of corticotropin-releasing factor in the hippocampus. However, although Gi and G(o) proteins are probably not involved in the memory consolidation process per se, in animals showing a full retention score there was a significant and long-lasting increase of G(o) concentration in the dentate gyrus. Results of ADP-ribosylation experiments have shown that there was a dose-dependent decrease of ADP-ribosylation in vitro as the concentration of in vivo pertussis toxin and cholera toxin increased. These results together suggest that Gs protein is probably involved in the initiation of the memory consolidation process, while enhanced G(o) expression is the ultimate result upon memory formation. These results provide the first in vivo evidence relating the functions of hippocampal G proteins to the memory process of mammals.

Risperidone in acutely exacerbated schizophrenia: dosing strategies and plasma levels.

BACKGROUND: The optimal risperidone dosing strategy for acute schizophrenia requires elucidation. Furthermore, plasma levels of risperidone and its active metabolite (9-hydroxyrisperidone) at a given dose vary greatly among different individuals. For patients who metabolize risperidone slowly, a medium dose results in excessively high plasma levels, which might be related to adverse events and perhaps poor response. We thus investigated whether dose reduction to diminish adverse reactions associated with ordinary risperidone doses could still yield efficacy for acutely exacerbated schizophrenia. METHOD: Thirty-one newly hospitalized Chinese patients with acute exacerbation of schizophrenia (DSM-IV) entered this prospective, 6-week open trial. Risperidone doses were titrated to 6 mg/day (if tolerable) over 3 days, but were lowered thereafter if side effects appeared. Efficacy and side effect assessments were conducted on days 0, 4, 14, 28, and 42. Endpoint steady-state plasma levels of risperidone and 9-hydroxyrisperidone were analyzed by high performance liquid chromatography with ultraviolet detection. RESULTS: Thirty patients completed the trial. Of them, 17 tolerated the 6-mg target dose well, while the other 13 received lower final doses (mean +/- SD = 3.6 +/- 0.9 mg, p = .0001) for curtailing treatment-emergent side effects. At endpoint, 92.3% of the 13 low-dose individuals responded to treatment (20% or more reduction in the total Positive and Negative Syndrome Scale score), compared with 52.9% of the 17 high-dose subjects (p < .05). No significant between-group differences were revealed in other minor efficacy measures. Of note, endpoint plasma levels of the active moiety (risperidone plus 9-hydroxyrisperidone) were similar between the low- and high-dose groups (40.4 +/- 31.1 ng/mL vs. 49.7 +/- 13.4 ng/mL, NS). CONCLUSION: The results of this preliminary trial suggest that up to 6 mg of risperidone is efficacious in treating patients with acute exacerbation of schizophrenia. Nearly 60% of the patients could tolerate a 6-mg dose. For the other 40%, reducing dosages to 3.6 +/- 0.9 mg for relieving side effects still yielded efficacy. The 2 dose groups were comparable in the endpoint steady-state plasma drug concentrations.

Course of violence in patients with schizophrenia: relationship to clinical symptoms.

To understand the heterogeneity of violent behaviors in patients with schizophrenia, one must consider underlying clinical symptoms of the illness and their change over time. The purpose of this study was to examine persistence and resolution of violence in relation to psychotic symptoms, ward behaviors, and neurological impairment. Psychiatric symptoms and ward behaviors were assessed in violent inpatients with schizophrenia or schizoaffective disorder and in nonviolent controls on entry into the study. Patients were followed for 4 weeks; those who showed resolution of assaults over this time were classified as transiently violent, and those who remained assaultive were categorized as persistently violent. At the end of the 4 weeks, psychiatric symptoms, ward behaviors, and neurological impairment were assessed. Overall, the two violent groups presented with more severe psychiatric symptoms and were judged to be more irritable than the nonviolent control subjects, but the transiently violent patients showed improvement in symptoms over time. At the end of 4 weeks, the persistently violent patients had evidence of more severe neurological impairment, hostility, suspiciousness, and irritability than the other two groups. Canonical discriminant analyses identified two significant dimensions differentiated the groups. The first, characterized by positive psychotic symptoms, differentiated the violent patients from the control subjects; the second, characterized by neurological impairment and high endpoint score for negative symptoms, differentiated the transiently from the persistently violent patients. Identification of certain symptoms associated with different forms of violence has important implications for the prediction and differential treatment of violent behavior in patients with schizophrenia.

Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation.

Cocaine intoxication and acute abstinence alter brain dopaminergic functioning, resulting in behavioral changes closely mimicking the positive and negative symptoms of schizophrenia. In emergency room settings, recent cocaine abuse can be mistaken for schizophrenia and may cause inappropriate diagnosis and in some instances medical mismanagement. Schizophrenia patients presenting with recent cocaine abuse may also present with significant diagnostic and treatment dilemmas. This study attempts to distinguish between cocaine and schizophrenic psychosis by examining patients who present with both recent cocaine abuse and acute schizophrenia (CA+SZ), cocaine intoxication without schizophrenic illness (CA), and acute schizophrenia with no comorbid substance abuse (SZ) within the first 24 hours after arrival at the Bellevue psychiatric emergency service. Clinical assessment included the Brief Psychiatric Rating Scale, the Schedule for the Assessment of Positive Symptoms, and the Schedule for the Assessment of Negative Symptoms. Both cocaine abusing groups were required to have positive urine toxicology screens for inclusion in the study. Multivariate analysis of variance showed the CA+SZ patients present with a clinical profile that overlaps with CA patients on mood and negative symptom dimensions and overlaps with SZ patients on most positive symptoms. CA+SZ patients differed from both groups, however, by presenting with significantly more hallucinatory experiences than cocaine abusing or schizophrenia patient counterparts. Despite considerable overlap, each group of patients presented with a discernible cross-sectional symptom pattern.

Pulsatile ocular blood flow in asymmetric exudative age related macular degeneration.

BACKGROUND/AIMS: Decreased perfusion or increased vascular resistance of the choroidal vessels had been proposed as the vascular pathogenesis for age related macular degeneration (AMD). This study planned to answer the question whether pulsatile ocular blood flow (POBF) was different in patients with asymmetric exudative AMD between eyes with drusen, choroidal neovascularisation (CNV), or disciform scar. METHODS: 37 patients with asymmetric exudative AMD were enrolled in this observational case series study. POBF were measured in both eyes of each subject. Eyes with high myopia, anisometropia, recent laser treatment, and glaucoma were excluded. RESULTS: After adjusting for ocular perfusion pressure, intraocular pressure, and pulse rate, multivariate regression analysis with generalised estimating equation showed POBF was significantly higher in eyes with CNV (1217 (SD 476) microl/min) than the contralateral eyes with drusen (1028 (385) microl/min) (p = 0.024). Eyes with disciform scar had lower POBF than the contralateral eyes with drusen (999 (262) microl/min and 1278 (341) microl/min, respectively, p<0.001). There was no significant correlation between the POBF and the lesion size of the CNV. CONCLUSION: The POBF in eyes with drusen was lower than their fellow eyes with CNV, but higher than their fellow eyes with disciform scar. This finding suggests that haemodynamic differences between fellow eyes in individuals are relevant to the development of CNV and the formation of disciform scar. Further studies on the follow up patients might shed light on the pathogenesis of exudative AMD.

Effect of latanoprost 0.005% and brimonidine tartrate 0.2% on pulsatile ocular blood flow in normal tension glaucoma.

AIM: To determine the effect of brimonidine tartrate 0.2% and latanoprost 0.005% on pulsatile ocular blood flow (POBF) in patients with normal tension glaucoma (NTG). METHOD: NTG patients with progressive optic neuropathy, new disc haemorrhage, or field defects that threatened fixation were enrolled into a randomised, investigator masked, crossover study. Group I patients received 4 weeks each of latanoprost, lubricant, and brimonidine, while group II patients received 4 weeks each of brimonidine, lubricant, and latanoprost. Diurnal POBF was measured at baseline and after each 4 week treatment. RESULTS: 25 patients completed the study and had reliable POBF measurement at each visit. There was no significant diurnal change in baseline POBF (p = 0.768). Latanoprost increased POBF by 213 (SD 257) micro l/min (22.8%, p <0.001) while brimonidine increased it by 97 (183) micro l/min (10.4%, p = 0.014). POBF increased at 8 am (p = 0.004), 12 noon (p = 0.002), and 4 pm (p <0.001) with latanoprost, while it increased only at 8 am (p = 0.016) with brimonidine. After adjusting for the factor of IOP, neither latanoprost nor brimonidine increased POBF significantly. CONCLUSIONS: Latanoprost increases the mean POBF that is related to its IOP lowering effect. The increase in POBF noted after brimonidine is within the range of long term variation and may not be attributable to the drug effect.

Pretreatment plasma HVA and haloperidol response in acute mania.

INTRODUCTION: Pretreatment plasma homovanillic acid (HVA) levels have been reported to be a correlate of clinical response to typical antipsychotics for schizophrenic, bipolar manic, and mixed groups of psychotic patients. Biological markers of clinical response to antipsychotics could be useful for optimizing drug treatment. METHOD: Thirty-one consenting acute inpatient subjects between ages 19 and 66 years with a DSM-III-R clinical diagnosis of bipolar disorder, manic with psychotic features were entered into this double-blind study and were randomly assigned to receive either haloperidol 25 mg/day or haloperidol 5 mg for the 3-week study. Subjects also received one of the following concomitant medications: standard lithium, lorazepam 4 mg/day, or placebo. RESULTS: The primary multiple regression analysis, including all subjects on both haloperidol doses, yielded a significant main effect for pretreatment plasma HVA (n=31, F=5.7, P=0.025), indicating that higher pretreatment plasma HVA was predictive of better clinical response. In addition, the interaction between haloperidol dose and pretreatment plasma HVA was also significantly associated with clinical response (F=12.59, P=0.0015). When the two haloperidol doses were analyzed separately, we found that pretreatment plasma HVA was only correlated with clinical response in the low haloperidol 5 mg/day group (n=18, F=11.73, P=0.0038) and was unrelated to clinical response to the high haloperidol 25 mg/day group. LIMITATIONS: The sample size was small. Results may have been confounded by prior antipsychotic treatment and concomitant use of lithium or lorazepam. DISCUSSION: These results suggest that pretreatment plasma HVA could be useful for dosing antipsychotics. Patients with high plasma HVA levels would be good candidates for low-dose treatment because they are more likely to improve on such a dose, while patients with low plasma HVA levels might warrant more rapid dosage escalation.

Heparin-surface-modified intraocular lens implantation in patients with glaucoma, diabetes, or uveitis.

We investigated the clinical outcome in two groups of patients who had an extracapsular cataract extraction and implantation of a heparin-surface-modified intraocular lens (HSM IOL) (Group 1) or a conventional poly(methyl methacrylate) (PMMA) lens (Group 2). Nineteen patients in Group 1 had bilateral cataract extraction with implantation of an HSM IOL in one eye and a conventional lens in the fellow eye. All patients had glaucoma, diabetes, or uveitis. Over the long term, there was no statistically significant difference between groups in visual acuity, corneal edema, anterior chamber reaction, and amount of posterior synechia formation and IOL deposits. Yet short-term clinical evaluation revealed significantly less reaction in eyes with the HSM IOL than in those with the PMMA lens. In patients with both lens types implanted, early postoperative anterior chamber reaction was less and IOL deposits fewer in the eye with the HSM IOL.

Learning and memory impairment in cocaine-dependent and comorbid schizophrenic patients.

Impairments in verbal learning and memory functioning have been found to be cardinal features among individuals with schizophrenia as well as among non-schizophrenic cocaine abusers. Cognitive deficits in these areas, moreover, have been associated with poor treatment response and short-term outcome. Little is known, however, about the acute effects of cocaine abuse on schizophrenic patients' learning and memory functioning. Consequently, a potentially reversible and treatable source of cognitive impairment has been virtually ignored. The present study examined the extent of verbal learning and memory impairment in a group of cocaine-dependent schizophrenic patients (n=42) and a group of non-schizophrenic cocaine-dependent patients (n=21) within 72 h of the last cocaine use using the California Verbal Learning Test (CVLT). Schizophrenic patients (n=34) without any substance-use disorders were also tested in an identical time frame and served as a comparison group. Results revealed that all groups demonstrated significant learning and memory impairment relative to CVLT published age and gender corrected norms. Both cocaine-dependent and non-substance abusing schizophrenic groups presented a very similar pattern of impaired learning and recall performance across all CVLT task domains. Comorbid patients, in contrast, presented with marked deficits in their ability to learn and recall verbal information relative to either schizophrenic or cocaine-only groups. Moreover, the cocaine-abusing schizophrenic patients showed significant forgetfulness of the information that they did acquire during delayed recall conditions. The performance deficits exhibited by cocaine-abusing schizophrenic patients differed not only in relative severity of impairment, but also qualitatively in their increased rates of forgetfulness of acquired information. These results are interpreted in terms of the neurobiological substrates of learning and memory and the neurobiological impact of cocaine on schizophrenic patients' cognition during the early phase of inpatient hospitalization. These results suggest that comorbid patients should be targeted for specialized remediation efforts at the beginning phases of inpatient treatment.

Change in plasma prolactin and clinical response to haloperidol in schizophrenia and schizoaffective disorder.

There has been a long-standing interest in plasma prolactin as a potential in vivo indicator of blockade of tuberoinfundibular D2 dopamine receptors. Potential relationships between prolactin response and neuroleptic treatment have been obscured by the use of high doses which have caused prolactin to plateau. With lower doses of neuroleptic now commonly in use, prolactin may be more valuable as a correlate of clinical response. In this study, 23 acutely exacerbated schizophrenic and schizoaffective patients were washed out for at least 6 days and were then treated with haloperidol to achieve fixed low to moderate plasma levels under double-blind conditions. Clinical response, plasma prolactin, and haloperidol plasma levels were measured weekly for 3 weeks. Clinical symptoms at endpoint were related to both prolactin change and final prolactin level during haloperidol treatment. Specifically, fewer symptoms at endpoint were associated with a greater increase in prolactin over time and a higher prolactin level at endpoint. Thus, prolactin increase caused by low to moderate doses of haloperidol may be a correlate of endpoint symptomatology. As lower doses of typical neuroleptics are now in use, prolactin response as a predictor of clinical response may have more clinical utility. Further study of prolactin and clinical response to typical neuroleptics should focus on low neuroleptic doses.

Characteristics of silicon nitride after O2 plasma surface treatment for pH-ISFET applications.

Silicon nitride (Si3N4) sensing gate pH-ion-selective field effect transistors (ISFETs) were treated by 2.54-GHz microwave O2 plasma, the results show the ISFET sensitivity has an advantage up to 24% increment after the plasma treatment. Electron spectroscopy for chemical analysis (ESCA) is used to make sure that the plasma treatment is not just a native oxide cleaning procedure. The samples, which were immobilized with glutaraldehyde used as a bifunctional reagent and 3-aminopropyItriethoxysilane used as an adhesion promoter were studied. The binding force between the glucose oxidase and glutaraldehyde immobilized samples, and the element concentrations of nitrogen in 3-aminopropyltriethoxysilane immobilized samples are higher which were treated by plasma.

Clinical research on antipsychotics in bipolar disorder.

Antipsychotics are commonly used in bipolar disorder, both for acute mania and in maintenance treatment. The authors review available clinical research concerning the use of both conventional and atypical antipsychotics in bipolar disorder and present recommendations for a number of key clinical situations based on this review. They also consider a number of important related questions, including whether there is evidence for an increased risk of tardive dyskinesia (TD) in patients with bipolar disorder, the potential role for antipsychotics in the treatment of bipolar depression, the role of antipsychotics in maintenance treatment of bipolar disorder, the potential for antipsychotics to induce depression in bipolar illness, and whether antipsychotics can be considered mood stabilizers with a place as monotherapy for bipolar mania. They conclude that standard treatment for acute mania should begin with a mood stabilizer, with benzodiazepines used as an adjunct for mild agitation or insomnia and antipsychotics used as an adjunct for highly agitated, psychotic, or severely manic patients. They also conclude that atypical antipsychotics are preferable to conventional antispychotics because of their more favorable side effect profile and reduced risk of tardive dyskinesia. They review the evidence for using atypical antipsychotics as first-line monotherapy for mania and conclude that more evidence concerning the risk of TD and their efficacy as maintenance treatment in bipolar disorder is needed before a conclusion can be made. Should the eventual risk of TD associated with atypical antipsychotics be found to be minimal and their efficacy in maintenance treatment found to be high, they could eventually be considered first line monotherapy for bipolar disorder. They conclude that treatment with an antipsychotic during bipolar depression should be limited to those patients who have psychosis and that atypical antipsychotics are preferred over conventional antipsychotics in this situation, not only because of their reduced risk of side effects but also because theoretically they may have antidepressant efficacy due to their effects on the serotonin system. The clinical research findings summarized in the article are, for the most part, supported by a recently published guideline based on a consensus of clinical experts.