[Mixed Episodes in Bipolar Disorders--Changes in DSM-5 and Treatment Recommendations]. / Die gemischte Episode bei bipolarer affektiver Störung--Änderungen im DSM-5 und aktuelle Behandlungsempfehlungen.

Mixed episodes in the course of affective disorders are challenging for any psychiatrist, because they are often characterized by a complicated and difficult treatment course (e. g. higher suicide rates) and a worse treatment outcome. In DSM-5, one of the main changes is that the diagnosis of a mixed episode was disestablished and replaced with affective episodes with so called "mixed features". This alteration markedly reduces the diagnostic threshold. The available literature on pharmacological treatment of mixed episodes is not sufficient; however, treatment with atypical antipsychotics, especially olanzapine and aripiprazole and the mood stabilizers valproate and carmabazepine has proved to be beneficial.

Getting in early: primary skin cancer prevention at 55 German kindergartens.

BACKGROUND: Skin neoplasms are the most frequent types of neoplasms in white populations, and their incidence is increasing. Epidemiological studies have shown that the major environmental aetiological factor for their development is sunlight exposure. Sun protection programmes are urgently needed to raise awareness of the health hazards of ultraviolet radiation. In 2010 the 'SunPass' project was implemented at 55 kindergartens in Germany. This is the first nationwide environmental education programme for sun safety designed to teach children in kindergartens and their caregivers how to protect themselves from overexposure to the sun. OBJECTIVES: An interventional lecture, site inspections and a certification were part of the programme. Effects of these interventions were studied. METHODS: The gain in knowledge and changed sun-behavioural attributes were quantified by questionnaires administered before and after the 'SunPass' interventions. RESULTS: The total number of children was 5424. Sun-protection behaviour after the intervention improved significantly (P < 0·001). Among parents, 22·2% reported one to five sunburns of their child since birth. There was a significant increase in hat use by children in kindergartens (P = 0·029), as well as some significantly improved shade practices. There was a significantly increased demand for protective clothing for children (P < 0·001). The change in sunscreen use in kindergartens was not significant. CONCLUSIONS: Although some aims of the 'SunPass' project were not fulfilled, such as the precise knowledge of skin types and a change of sunscreen use, the study had some positive outcomes in increasing the awareness of skin cancer and its prevention possibilities. The findings of the present study suggest that relatively brief interventions in kindergartens lead to improved sun protection of children. The whole investigation reaching over 5400 children and their parents underlines the importance of learning appropriate sun-protective behaviour in early childhood in order to decrease the risk for skin cancer.

Effect of disinfectants on microbial ecology in model distribution systems.

This research was conducted to assess the impact of various disinfectants on bacterial water quality within model distribution systems (i.e. annular reactors). After colonization with non-disinfected water, annular reactors were treated with relatively low doses of chlorine (0.4 mg/l), chlorine dioxide (0.15 mg/l), or chloramines (0.9 mg/l). Under the tested conditions, bacterial inactivation varied as a function of disinfectant type (ranking by efficiency per mg of oxidant: ClO2 > Cl2 > ClNH2) and sample type (bulk water vs. biofilm). Depending on the disinfectant, the log inactivation of suspended and attached bacteria were 0.7-1.2 and 0.5-1.0, respectively. The characterization of microbial communities in drinking water can be performed using biochemical and/or molecular methods. In this study, biochemical tests were used, showing that pseudomonad and pseudomonad-like bacteria, as in other studies, were the most predominant micro-organisms (e.g. Pseudomonas fluorescens, Brevundimonas vescularis). The ratio Gram-positive to Gram-negative organisms was 1 to 3. No drastic differences were observed between the non-treated and disinfected pipes. Based on the bacteriological data presented in these experiments, chlorine dioxide represents an alternative to chlorine for certain distribution systems.

Pharmacokinetics of gemcitabine and 2',2'-difluorodeoxyuridine in a patient with ascites.

Gemcitabine (dFdC) is a prodrug that undergoes metabolism by cytidine deaminase to form an inactive metabolite, 2',2'-difluorodeoxyuridine (dFdU). The pharmacokinetics of dFdC and dFdU have been studied; however, their disposition has never been evaluated in a patient with ascites. A patient with pancreatic cancer and malignant ascites was treated with dFdC 1,500 mg/m2 over 150 minutes weekly for 3 weeks, repeated every 4 weeks. Serial plasma and ascites samples were obtained on weeks 1 and 2 of cycle 2. High-pressure liquid chromatography was used to quantify dFdC and dFdU in plasma and ascites. The systemic dispositions of dFdC and dFdU were similar to those reported in patients without ascites. The concentration of dFdC in ascites approached 1 mg/ml. Ascitic fluid did not serve as a depot for dFdC, and the agent's concentration in ascites approached that at which its phosphorylation is saturated.

Cochlear generation of intermodulation distortion revealed by DPOAE frequency functions in normal and impaired ears.

Distortion product otoacoustic emission (DPOAE) frequency functions were measured in normal-hearing and hearing-impaired ears. A fixed-f2/swept-f1 paradigm was used with f2 fixed at half-octave intervals from 1 to 8 kHz. L1 was always 10 dB greater than L2, and L2 was varied from 65 to 10 dB SPL in 5-dB steps. The responses were quantified by the frequency and amplitude of the peak response. Peak responses were closer to f2 in higher frequency regions and for lower intensity stimulation. Results from hearing-impaired subjects suggest that audiometric thresholds at the distortion product frequency, fdp, in addition to hearing status at f2, can affect DPOAE results. Results are discussed in terms of several manifestations of a second resonance model, as well as a dual source model for the generation of DPOAEs as measured in the ear canal of humans. It appears that a dual source model accounts for the data better than second filter models.

Responding to tricyclic antidepressant overdose.

Tricyclic antidepressant overdose produces rapid multisystem complications for the patient. Treatment of the patient requires careful assessment and aggressive nursing interventions in order to produce a positive outcome.

Toward optimizing the clinical utility of distortion product otoacoustic emission measurements.

This study examined the effect of primary stimulus level on the ability of distortion product otoacoustic emission (DPOAE) measurements to separate normal-hearing from hearing-impaired ears. Complete I/O functions were obtained for nine f2 frequencies on 210 people approximately evenly divided between normal hearing and hearing impaired. Clinical decision theory was used to assess both DPOAE amplitudes and DPOAE threshold as diagnostic indicators of hearing status. Moderate level primary stimuli elicited responses that separated normal from impaired better than either lower level or higher level stimuli. The two populations were differentiated for all frequencies above 500 Hz by DPOAE amplitude, given primary levels, L1 and L2, of 65 and 55 dB SPL. DPOAE threshold performed equally well, but threshold ambiguity in noise and longer testing times make it a less suitable DPOAE measure to use diagnostically.

The use of cumulative distributions to determine critical values and levels of confidence for clinical distortion product otoacoustic emission measurements.

Distortion product otoacoustic emission (DPOAE) input/output functions were measured at nine f2 frequencies ranging from 500 to 8000 Hz in 210 normal-hearing and hearing-impaired subjects. In a companion paper [Stover et al., J. Acoust. Soc. Am. 100, 956-967 (1996)], L1-L2 was held constant at 10 dB, and L2 was varied from 65 to 10 dB SPL in 5-dB steps. Based upon analyses using clinical decision theory, it was demonstrated that DPOAE amplitudes for 65/55 dB SPL primaries (L1/L2) and DPOAE thresholds resulted in the greatest separation between normal and impaired ears. In this paper, the data for these two conditions were recast as cumulative distributions, which not only describe the extent of overlap between normal and impaired distributions, but also provide the measured value (i.e., the specific DPOAE amplitude or threshold) for any combination of hit and false alarm rates. From these distributions, confidence limits were constructed for both DPOAE amplitude and threshold to determine the degree of certainty with which any measured response could be assigned to either the normal or impaired population. For these analyses, DPOAE measurements were divided into three categories (a) response properties that would be unlikely to come from normal ears, (b) response properties that would be unlikely to come from impaired ears, and (c) response properties for which hearing status was uncertain. Based upon DPOAE amplitude measurements, the region of uncertainty, defined between the 95 percentile for impaired ears and the 5 percentile for normal ears, was relatively narrow for f2 frequencies ranging from 707 to 4000 Hz. For DPOAE thresholds, this region was relatively narrow for F2 frequencies ranging from 1414 to 4000 Hz.

Critical thinking as an educational outcome: an evaluation of current tools of measurement.

Critical thinking, an outcome criterion of the National League for Nursing and the Council of Baccalaureate and Higher Degree Programs, is an abstract skill difficult to measure. The authors provide a comprehensive review of four instruments designed to measure critical thinking and summarize research in which the tools were used. Analysis of this information will empower nursing faculty members to select a critical-thinking instrument that is individualized to the needs of their respective nursing programs.

Latency and multiple sources of distortion product otoacoustic emissions.

A novel analysis approach has been developed to examine the latency of distortion product otoacoustic emissions (DPOAEs). DPOAEs were measured in ten normal-hearing adults in a paradigm in which f2 was held constant and f1 was varied. This paradigm was used with a wide range of primary levels. Latency was estimated in two ways. In the first, a phase-slope delay measurement was used which showed a significant response latency increase as stimulus intensity was decreased. In the second approach, an inverse-FFT procedure was used to provide a temporal analysis of the data. Results of this analysis reveal a complex latency structure with multiple peaks in the envelope of the time waveform. The latencies of individual peaks remain constant across level, however, short latency peaks have the greatest amplitudes at higher levels, and longer latency peaks are largest at low levels. These results would be consistent with the idea that there are multiple intracochlear sources for distortion product generation; however, a simple model, in which generation is assigned to the f2 and the 2f1-f2 place, does not adequately explain the number of envelope peaks that were present in many ears.

The effects of aging on otoacoustic emissions.

Otoacoustic emissions were measured in 42 normal hearing subjects ranging from 20 to 80 years old. For each subject spontaneous, click-evoked, tone-burst-evoked, stimulus frequency and distortion product emissions were measured across a wide intensity range for frequencies between 1 and 3 kHz. Although there are significant differences between age groups, the results indicate no age effect independent of hearing sensitivity on any type or parameter of otoacoustic emissions (OAE). The effect of increasing age is confounded with the effect of decreasing sensitivity such that post hoc analyses are inadequate to separate the effects of sensitivity and age on otoacoustic emissions. Even within the range of audiometrically normal hearing, OAE characteristics vary with threshold for all age groups. The conclusion is that hearing sensitivity must be included as a controlled variable in order to accurately assess intrinsic aging effects.

Tinnitus and otoacoustic emissions: is there a link?

Attempts to identify the mechanisms underlying tinnitus and to develop effective treatments have been frustrating, in part because there are no objective measures of tinnitus. Following Kemp's initial reports of evoked and spontaneous otoacoustic emissions (OAEs), many people hoped that OAEs were an objective correlate of tinnitus. The results of several studies suggest that in about 6 to 12% of normal-hearing persons with tinnitus and spontaneous otoacoustic emissions (SOAEs), the SOAEs are at least partly responsible for the tinnitus. In addition, recent work indicates that some subjects with tinnitus display oscillating or ringing evoked otoacoustic emissions (EOAEs). In these cases, it is hypothesized that the oscillating EOAEs and tinnitus are related to a common underlying pathology rather than the emissions being the source of the tinnitus.

New dip-and-read test for determining leukocytes in urine.

A new reagent strip for the determination of leukocytes in urine (LEUKOSTIX; Ames) is described. The test is based on the esterase activity in leukocytes as a marker. Upon contact between the reagent matrix and a urine containing leukocytes, an amino acid ester is hydrolyzed by the esterase to its corresponding alcohol. The free alcohol then couples with a diazonium salt to produce a purple azo dye. The relative concentration of leukocytes in the urine is obtained by visually comparing the strip reaction with a color chart. Performance of the strip was evaluated in a clinical study involving eight different sites and 867 urine specimens. The comparison method was sediment microscopy; specimens containing five cells or more per high-power field were considered to be positive. Sensitivity was 76.3%, specificity 80.8%. Performance was comparable with that of the CHEMSTRIP LN (Boehringer-Mannheim Diagnostics, Inc.) leukocyte test, which we evaluated concurrently.

A control system for monitoring the performance of leukocyte strip tests.

The control system described here is used to monitor the performance of urinary reagent-strip tests for leukocytes. The presence of leukocyte esterase in the urine is used as a marker for leukocytes in urine. The control system is based on sonicated leukocytes, isolated from whole blood. The esterase activity of this sonicate is determined by spectrophotometry with the N-tosyl-L-alanine ester of 5-phenyl-3-hydroxypyrrole as substrate. The assay result is used to determine the amount of sonicate needed to prepare buffered esterase-containing solutions. Such control solutions mimic leukocytic urines and are stable for 6 h at room temperature. The variability of the control system was tested by preparing it five times in a day on five separate days. The overall CV for Leukostix Reagent Strips (Ames Division, Miles Laboratories, Inc.) when tested with these solutions and analyzed with a reflectance spectrophotometer was 8%; for visual readings it was 10%. The overall CV for Chemstrip LN Reagent Strips (Biodynamics, Indianapolis, IN) was 10%.