Practical management of pressure ulcers

The use of wound dressings that are based on the principles of moist wound healing has recently changed the management of pressure ulcers. These products may improve healing rates but also offer improved comfort to the patient, reduced dressing time and improved cosmesis. However, healing is unlikely to be achieved unless the factors that contribute to ulcer formation are addressed. Principles of management include the elimination or reduction of pressure and other contributing factors, treatment of infection, appropriate wound management, involvement and education of the patient and caregivers, and maintenance of healed tissue. It is estimated that 95 percent of all pressure ulcers are preventable. Prevention rather than mere treatment of established ulcers remains a top priority in the effort to reduce the incidence of this common, complex and difficult problem. Use of assessment tools that quantify the primary risk factors for the development of pressure ulcers is helpful in predicting and preventing compromise of tissue.     

Practical management of the poisoned patient

Clinical toxicology is undergoing a change in its previously perceived unscientific image. As in other medical disciplines, there is an effort to ensure that its treatments are evidence based. A successful outcome seems likely not only to rationalize the management of poisoned patients but to simplify it.     

Pharmacologic management of depression in the elderly

Depression, the most common geriatric psychiatric disorder, is a disabling mood disorder that impairs one's well-being and may even threaten a sufferer's life. Severely depressed elderly persons are more likely to kill themselves than individuals in any other age group. However, geriatric depression is, for the most part, a treatable and manageable illness. Antidepressant medication can be very effective in treating major depressive disorder (MDD). Because age-related physical changes in the elderly produce pharmacokinetics that are often different than that experienced by younger adults, different doses are often necessary. This article summarizes recommendations for selecting and initiating appropriate antidepressant therapy in elderly persons suffering from MDD. The benefits and drawbacks of tricyclic antidepressant agents, and other atypical antidepressant agents are discussed. Phases of treatment, drug selection, dosing, and educational tips for pharmacotherapy are presented.     

Management of treatment-resistant schizophrenia with olanzapine

BACKGROUND: The term oral allergy syndrome (OAS) describes an IgE-mediated reaction that takes place minutes after ingestion of some food to which the organism is previously sensitised. The clinical manifestations are typically localized to the mouth and throat. Oral allergy syndrome is commonly elicited by fresh fruits and vegetables, especially in subjects with hypersensitivity to pollens. METHODS: We report a patient with OAS following intake of chicken meat. We performed (1) skin prick test to chicken meat, egg, milk, and wheat and to common inhalants, (2) determination of serum specific IgE, (3) histamine release test, and (4) in vitro antigen-specific production of sulphidoleukotrienes and challenge test with chicken meat. RESULTS: Skin prick test was positive only for chicken meat. The patient had serum specific IgE, positive histamine release test, and specific production of sulphidoleukotrienes to chicken meat. We confirmed these findings by means of the challenge test.     

Psychotherapeutic techniques with treatment-resistant adolescents.

Psychotherapy with adolescent clients (ACs) is difficult for at least 2 reasons: ACs frequently do not trust adults and ACs are often poorly motivated for treatment. Consequently there may be significant problems eliciting the cooperation needed to implement successfully various psychotherapeutic treatment techniques (PTTs) with ACs in general, and treatment-resistant ACs in particular. Several PTTs designed to capture ACs' attention, further the psychotherapeutic alliance, and facilitate cooperation are presented. PTTs include siding with the AC, teaching strategic skills, exploring moral dilemmas, wagering on cognitions and behaviors, and alternative communication strategies. Case illustrations are provided to demonstrate the effectiveness of PTTs. It is recommended that psychotherapists consistently review the quality of their relationship with ACs to facilitate successful implementation of PTTs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Practical aspects in the diagnosis and management of aplastic anemia

Groups of F344 rats and B6C3F1 mice were exposed to furfuryl alcohol vapor for 6 hours per day, 5 days per week for 14 days (0, 16, 31, 63, 125, 250 ppm) or 13 weeks (0, 2, 4, 8, 16, 32 ppm). Reduced survival was observed in the 14-day study at 250 ppm. Final mean body weights of rats and mice exposed to 125 ppm and of female mice exposed to 63 ppm were lower than controls at the end of the 14-day study; there were no significant differences in mean body weight among chemical-exposed and control groups in the 13-week study. Exposure to furfuryl alcohol had no toxicologically significant effect on organ weights in either rats or mice, and did not cause any adverse changes in hematology or serum chemistry parameters evaluated in rates in the 13-week study. Microscopic lesions associated with exposure to furfuryl alcohol were present in the nose of both rats and mice at all exposure concentrations in both the 14-day and 13-week studies. Lesions observed in the 14-day study consisted of inflammation of the nasal turbinates accompanied by necrosis and squamous metaplasia of the respiratory epithelium and necrosis and degeneration of the olfactory epithelium. Similar lesions were observed in both rats and mice in the 13-week study. In addition, squamous metaplasia and goblet cell hyperplasia of the respiratory epithelium, squamous metaplasia of the transitional epithelium and degeneration, hyperplasia and some respiratory metaplasia of the olfactory epithelium were also observed in rats in the 13-week study, and hyaline droplets in the respiratory epithelium and chronic inflammation and respiratory metaplasia in the olfactory epithelium were observed in mice in the 13-week study. In general the nasal passages of mice appeared less sensitive than those of rats at the concentrations used in the 13-week study; a no-observable-effect level was not achieved in either the 14-day or the 13-week study.     

Practical guidelines for the management of closed spinal cord injuries

The principles underlying the necessity of operative management in handling closed spinal cord trauma, its indications and types of operative interventions are comprehensively discussed. Under separate headings are described the peculiarities of the approach to injuries involving cervical, thoracic and lumbal segments of the vertebral column, with a summarization of currently used methods and procedures, contributing to the more complete functional recovery of the spine, preservation and creation of optimal conditions for regaining the functions of the spinal cord affected which in turn, renders easier the performing of daily living activities, precludes the development of a variety of complications in the body as a whole, and first and foremost, allows for early initiation of rehabilitation measures.     

Occupational asthma. Practical points for diagnosis and management

Asthma is a common chronic illness characterized by episodes of reversible airflow obstruction. A cornerstone of asthma management is identifying and avoiding agents that cause bronchospasm. The workplace is an important potential source of respirable exposures that can cause or trigger asthma. Identification of an occupational factor in asthma is important: early diagnosis and removal of the worker from the exposure is associated with improved prognosis; the diagnosis of occupational asthma may lead to compensation for work-related impairment and disability; and the diagnosis of occupational asthma is a Sentinel Health Event with implications for public health and prevention. In this article, we review specific causes of occupational asthma and general settings in which an occupational factor should be suspected and explored as part of the management of the worker with asthma. We also review specific and simple elements of history and pulmonary function testing that can be easily assessed by most health care practitioners and may be sufficient to establish a diagnosis of occupational asthma. Finally, we review the medical-legal implications of occupational asthma.     

Physician management preferences and barriers to care for rural patients with depression

OBJECTIVE: To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. DESIGN: Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. SETTING: Primary care practices in nonmetropolitan counties. PARTICIPANTS: Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. MAIN OUTCOME MEASURES: Physician preferences for and barriers to the effective management of depression. RESULTS: An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. CONCLUSIONS: The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.     

Effects of switching inpatients with treatment-resistant schizophrenia from clozapine to risperidone

A prospective, open-label study in a 400-bed state psychiatric hospital evaluated change in therapeutic response among ten patients with treatment-resistant schizophrenia who were switched from clozapine to risperidone. Drug effects were examined before discontinuation of clozapine and at three, six, nine, and 12 weeks of risperidone treatment. No patients improved, and five discontinued treatment due to exacerbation of psychosis or adverse effects. Changes in scores on the Positive and Negative Syndrome Scale, the Brief Psychiatric Rating Scale, and the Barnes Akathisia Scale indicated clinically significant worsening of symptoms. The findings do not support replacing clozapine with risperidone for patients with treatment-resistant schizophrenia.     

Review of The behavioral management of anxiety, depression and pain.

Reviews the book, The Behavioral Management of Anxiety, Depression and Pain edited by Park O. Davidson (1976). Every year since 1969 the Banff Conference has assembled outstanding behavioral scientists who discuss and present their data about a topic of major current importance. In addition, the major presenters prepare a chapter for an annual publication hi which relevant literature is reviewed, concepts are developed and each contributor reports on his own current applied programme. The present book, which grew out of the 1975 conference, is about the behavioral assessment and treatment of anxiety, depression, and pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder.

The authors introduce a manual-based treatment, labeled dynamic deconstructive psychotherapy, developed for those patients with borderline personality disorder who are most difficult to engage in therapy, such as those having co-occurring substance use disorders. This treatment model is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions, including association, attribution, and alterity that form the basis for a coherent and differentiated self. Dynamic deconstructive psychotherapy aims to activate and remediate neurocognitive self-capacities by facilitating elaboration of affect-laden interpersonal experiences and integration of attributions, as well as providing novel experiences in the patient-therapist relationship that promote self-other differentiation. Treatment involves weekly individual sessions for a predetermined period of time and follows sequential stages. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does risperidone improve verbal working memory in treatment-resistant schizophrenia?

OBJECTIVE: Treatment efficacy in schizophrenia is typically defined in terms of symptom reduction. However, new antipsychotic medications could potentially have an impact on aspects of disability, such as neurocognitive deficits. The authors evaluated the effects of risperidone on verbal working memory, a memory component of theoretical interest because of its link to prefrontal activity and of practical interest because of its link to psychosocial rehabilitation. METHOD: Verbal working memory of 59 treatment-resistant schizophrenic patients was assessed as part of a randomized, double-blind comparison of treatment with risperidone and haloperidol. Verbal working memory was measured under both distracting and nondistracting conditions at baseline and after 4 weeks of both fixed- and flexible-dose pharmacotherapy. RESULTS: Risperidone treatment had a greater beneficial effect on verbal working memory than haloperidol treatment across testing conditions (with and without distraction) and study phases (fixed and flexible dose). The treatment effect remained significant after the effects of benztropine cotreatment, change in psychotic symptoms, and change in negative symptoms were controlled. Neither benztropine status nor symptom changes were significantly related to memory performance. CONCLUSIONS: Treatment with risperidone appears to exert a more favorable effect on verbal working memory than treatment with a conventional neuroleptic. The beneficial effect appears to be due, at least partially, to a direct effect of the drug, possibly through antagonism of the 5-HT2A receptor. Results from this study suggest that pharmacotherapeutic efficacy in schizophrenia treatment could be broadened to include impact on neurocognitive abilities.     

Mixed anaclitic-introjective psychopathology in treatment-resistant inpatients undergoing psychoanalytic psychotherapy.

Utilizing data from the Riggs-Yale Project, 45 male and 45 female 18-29-year-old treatment-resistant inpatients undergoing intensive psychoanalytically oriented treatment were studied. Twenty-seven mixed-type anaclitic-introjective inpatients were compared with 29 "pure" anaclitic and 34 "pure" introjective inpatients. At intake, mixed-type inpatients were more clinically impaired (i.e., were more symptomatic, cognitively impaired, and thought disordered) and more vulnerable (i.e., less accurate object representations and more frequently used maladaptive defense mechanisms) in comparison with clearly defined anaclitic and introjective patients. Mixed-type patients, however, improved significantly more in the course of psychoanalytically oriented treatment, in terms of clinical functioning (i.e., symptoms, cognitive functioning) and psychological vulnerability (i.e., utilization of more adaptive defense mechanisms). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management treatment of outpatient unipolar depression: A comparison of reinforcement and extinction.

This study examined the differential effects of reinforcement versus extinction in contingency management of outpatient unipolar depression for 6 depressed subjects and their significant others. We used an alternating-treatments design (with a multiple baseline across subjects) to provide subjects with 4 weeks of reinforcement for a targeted deficit and 4 weeks of extinction for a targeted excess. The results (a) confirmed the efficacy of contingency management, administered by significant others, for outpatient unipolar depression; (b) demonstrated the predicted behavior change and decreased depression for both reinforcement and extinction; and (c) showed that responses covaried in an individualistic manner across subjects and varied across reinforcement and extinction. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

EEG coherence following acute and chronic clozapine in treatment-resistant schizophrenics.

Electroencephalographic (EEG) coherence is an index of brain regional coupling that has been found to be abnormal in people with schizophrenia but has not been systematically examined in response to neuroleptics. EEG coherence in slow (delta and theta) frequencies was assessed in 17 treatment-resistant people with schizophrenia at baseline, 2 hr after their first oral dose (25 mg) and after 6 weeks of clozapine treatment. Compared with EEG norms, participants exhibited significant interhemispheric and intrahemispheric coherence abnormalities prior to treatment. Both acute and chronic treatments altered coherence but differed with respect to their relationship to symptom reduction and their ability to normalize or augment pretreatment abnormalities. Findings are discussed in relation to "disconnection" theories of schizophrenia. (PsycINFO Database Record (c) 2010 APA, all rights reserved)