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PubMed2005

The therapeutic alliance in the treatment of personality disorders.

Because personality disorders are associated with significant impairment in interpersonal relationships, special issues and problems arise in the formation of a therapeutic alliance in the treatment of patients with these disorders. In particular, patients with narcissistic, borderline, and paranoid personality traits are likely to have troubled interpersonal attitudes and behaviors that will complicate the patient's engagement with the therapist. While a strong positive therapeutic alliance is predictive of more successful treatment outcomes, strains and ruptures in the alliance may lead to premature termination of treatment. Therefore, clinicians need to consider the patient's characteristic way of relating in order to select appropriate interventions to effectively retain and involve the patient in treatment. Research has shown not only the importance of building an alliance but also that this alliance is vital in the earliest phase of treatment. The author first reviews several definitions of the therapeutic alliance with reference to how they apply to the treatment of patients with personality disorders. Issues relevant to forming a therapeutic alliance with patients with personality disorders are then discussed in terms of the three DSM-IV-TR personality disorder clusters. However, the author notes that these categories do not adequately capture the complexity of character pathology and that clinicians also need to consider which aspects of a patient's personality pathology are dominant at the moment in considering salient elements of the therapeutic alliance. In dealing with Cluster A personality disorders (schizotypal, schizoid, and paranoid personality disorders), what is most relevant for alliance building is the profound impairment in interpersonal relationships. The Cluster B "dramatic" personality disorders (antisocial, borderline, histrionic, and narcissistic) are all associated with pushing the limits. Consequently, clinicians need to exercise great care to avoid crossing inappropriate lines in a quest to build an alliance with patients with one of these disorders. Patients with Cluster C "anxious/fearful" personality disorders (avoidant, dependent, and obsessive-compulsive personality disorders) are emotionally inhibited and averse to interpersonal conflict. These patients frequently feel guilty and internalize blame for situations even when there is none, a tendency that may facilitate alliance building because the patients are willing to take some responsibility for their dilemma and may engage somewhat more readily with the therapist to sort it out, compared with patients with more severe Cluster A or B diagnoses. The author then reviews considerations relevant to treatment alliance that arise in the different treatment approaches that may be used with patients with personality disorders, including psychodynamic psychotherapy/psychoanalysis, cognitive-behavioral therapies, and psychopharmacology. The author also discusses issues, especially splitting, that arise in the alliance when patients with personality disorders are treated in inpatient psychiatric hospital settings.

Adult↗
PubMedDate not supplied

Glomerular therapeutics: looking back, looking forward.

Fifty years ago, the prospects for treatment of glomerulonephritis were dim. Beginning around 1950 the field of "glomerular therapeutics" was begun by the introduction of new agents (adrenocorticotrophic hormone, cortisone, nitrogen mustard) as possible disease-modifying therapies for the various forms of glomerular disease. For the next several decades these and other agents (azathioprine, cyclophosphamide, chlorambucil, prednisone) were used therapeutically in a largely uncontrolled and anecdotal fashion. The application of randomized, controlled trials led to the adoption of some forms of therapy as both effective and reasonably safe, and the rejection of others as either ineffective or hazardous. New regimens involving different routes of administration or dosing schedules were adopted. After about another two decades, new and increasingly selective agents began to be introduced into the therapeutic armamentarium (cyclosporine, mycophenolate mofetil). Diseases previously associated with a very poor outcome were transformed into manageable disorders. The consequences of glomerular disease (e.g., nephrotic syndrome, chronic renal failure) were now subject to control and alleviation in many circumstances. The next transformation of "glomerular therapeutics" is now under way. The revolution in molecular genetics and pharmacogenomics will allow new agents to be developed that target specific aspects of the pathogenic mechanisms underlying glomerular disease. This transformation will not be an easy one, because development, testing, approval, and application of these new concepts in therapeutics (e.g., somatic gene therapy) will be time consuming and expensive. Eventually, the understanding of the genetic basis of susceptibility to glomerular disease and its progression will allow a preventative and curative, rather than palliative, strategy to emerge.

Disease Progression↗
PubMed2003

Retrospective case series of therapeutic applications of lotrafilcon a silicone hydrogel soft contact lenses.

PURPOSE: To report a series of consecutive cases for which a lotrafilcon A silicone hydrogel soft contact lens was used in therapeutic applications. METHODS: Three practitioners in Spain, Denmark, and Germany supplied 41 consecutive case reports of 39 patients for whom a lotrafilcon A silicone hydrogel soft contact lens was used in therapeutic applications. Applications included erosion or recurrent erosion, bullous keratopathy, corneal edema, corneal dystrophy, neurotrophic corneal ulcer, entropion, and use after corneal surgeries. Practitioners reported their judgments of pain relief, change in corneal signs by slitlamp evaluation, additional complications, and success of therapeutic lens treatment. Twenty cases of completed treatment and 21 cases of ongoing treatment were reported. RESULTS: Complete pain relief was reported for 78% of all cases, with 94% of all cases reporting pain relief of 50% or higher. Corneal signs were restored to normal for 74% of all cases, with 100% of all cases showing at least partial improvement. No additional complications were reported in 83% of all cases. Therapeutic contact lens application was judged fully successful for 71% of all cases, with 93% of all cases showing at least partial improvement. CONCLUSION: The high-oxygen permeable (Dk) lotrafilcon A lens met or exceeded the outcomes reported from historic reports of therapeutic applications of low-Dk soft contact lenses. Although the case reporting conditions vary among the historic studies and from the current study, this study indicates that success may be improved with the lotrafilcon A high-Dk lens.

Adult↗
PubMed2006

The effects of therapeutic taping on gross motor function in children with cerebral palsy.

PURPOSE: Therapeutic taping to address dysfunctional sitting control in children with cerebral palsy (CP) was investigated in this study. METHODS: Eighteen children with quadriplegic CP, Gross Motor Function Classification System for Cerebral Palsy levels IV (n = 9) and V (n = 9) participated in the 12-week program. Subjects were assigned randomly to one of two groups: therapeutic taping + physical therapy or physical therapy only. Therapeutic taping was applied for periods of up to 72 hours over the paraspinal region. The effects were assessed with the Gross Motor Function Measure (GMFM-88) at baseline, six weeks, and 12 weeks. A factorial analysis of variance was used to examine group differences over time. RESULTS: No significant differences were found for the GMFM-88 scores between groups over time. CONCLUSION: Therapeutic taping does not evoke a positive functional change in the seated postural control of children with quadriplegic cerebral palsy. Subjective observation, however, suggested that one child with athetosis benefited from therapeutic taping over the paraspinal region.

Back↗
PubMed2003

The therapeutic use of gene therapy in inflammatory demyelinating diseases of the central nervous system.

PURPOSE OF REVIEW: Gene therapy protocols aimed to deliver therapeutic molecules into the central nervous system may represent an alternative therapeutic strategy in patients affected by inflammatory demyelinating diseases of the central nervous system where systemic therapies have shown limited therapeutic efficacy possibly owing to the blood-brain barrier, a major obstacle for the entry of therapeutic molecules into the central nervous system. RECENT FINDINGS: Among inflammatory demyelinating diseases of the central nervous system, gene therapy approaches have been so far developed almost exclusively for multiple sclerosis. However, the chronic/relapsing nature of the disease, the restriction to the central nervous system of the pathological process as well as the necessity to inhibit the ongoing inflammatory process but also to foster endogenous remyelinating pathways, have posed several questions which still need to be properly addressed for the development of a successful gene therapy strategy in multiple sclerosis patients. SUMMARY: The gene therapy approaches for multiple sclerosis have been so far developed and tested only in rodents and monkeys with experimental autoimmune encephalomyelitis, the animal model of multiple sclerosis. The results of these studies clearly indicate that the delivery of therapeutic genes within the central nervous system is superior to the peripheral delivery. In particular, the intracerebral delivery of genes coding for anti-inflammatory and/or neurotrophic molecules, using gene vectors derived from non-replicative viruses, showed to inhibit not only the detrimental function of blood-borne mononuclear effector cells but also to foster proliferation and differentiation of surviving oligodendrocytes within demyelinated areas. Here, we summarize the most recent findings of this novel area of research.

Animals↗
PubMed1999

Effect of therapeutic hypothermia on the incidence and treatment of intracranial hypertension.

Therapeutic hypothermia initiated immediately after a severe head trauma holds promise for improving outcomes. However, the effect of hypothermia on intracranial pressure (ICP) is not yet known. This study was a secondary analysis, conducted within a National Institutes of Health clinical trial on the efficacy of therapeutic hypothermia, to determine the effects of therapeutic hypothermia on ICP and of interventions (i.e., cerebrospinal fluid drainage and mannitol administration) on intracranial hypertension. There were no significant differences in the overall incidence or treatment of intracranial hypertension between patients who were treated with therapeutic hypothermia and normal controls. Therapeutic hypothermia maintained the ICP at lower levels during the cooling phase, but once patients were rewarmed, the ICP elevated to the levels of normothermic patients.

Adolescent↗
PubMed1983

A study of the relationship between photosensitizing and therapeutic activity of 4,5',8-trimethylpsoralen, and its major metabolite 4,8-dimethyl, 5'-carboxypsoralen.

The molecular basis for the clinically observed differences in the skin photosensitizing activity and therapeutic effectiveness of the topically applied and orally administered drug trimethylpsoralen (TMP) was investigated. TMP, when tested topically, is a very potent photosensitizing and therapeutically effective furocoumarin in the treatment of psoriasis. When administered orally, however, it is significantly less photosensitizing and therapeutically a less effective drug than the commonly used furocoumarin 8-methoxypsoralen. This decreased reactivity of oral TMP is attributable to its poor solubility and rapid in vivo metabolic transformation to several inactive (nonphotosensitizing) metabolites, one of which is referred to as 4,8-dimethyl,5'-carboxypsoralen (DMeCP). The supporting evidence has been obtained by: (a) isolation of the urinary metabolite DMeCP and subsequent comparison of its properties with the synthetically prepared DMeCP and its methyl ester; (b) examining the dark and photochemical interactions of TMP, DMeCP, and DMeCP methyl ester with DNA and determining their ability to form interstrand cross-links with DNA; and (c) studying the inhibition of DNA and RNA synthesis in Ehrlich ascites tumor cells and the killing of bacteria and T2 bacteriophages. The structure-activity relationship of TMP and DMeCP also has been examined in normal human subjects and in patients with psoriasis. The order of topical therapeutic effectiveness in terms of ability to clear psoriasis plaques appeared to be: TMP greater than 8-MOP greater than DMeCP methyl ester greater than DMeCP. The data also suggest the methyl ester of DMeCP to be an interesting nonphotosensitizing furocoumarin that photoconjugates to DNA better than 8-MOP and is therapeutically effective in psoriasis.

Animals↗
PubMed2005

The effect of a therapeutic trial of high-dose rabeprazole on symptom response of patients with non-cardiac chest pain: a randomized, double-blind, placebo-controlled, crossover trial.

BACKGROUND: Therapeutic trials with high-dose lansoprazole and omeprazole have been shown to be sensitive clinical tools for diagnosing patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. AIM: To determine the clinical value of a therapeutic trial of high-dose rabeprazole over 7 days in detecting patients with gastro-oesophageal reflux disease-related non-cardiac chest pain. METHODS: Double-blind, randomized, placebo-controlled, crossover study. Patients referred by a cardiologist after a comprehensive cardiac work-up were enrolled into the study. Oesophageal mucosal disease was determined by upper endoscopy and 24-h oesophageal pH monitoring assessed acid exposure. Patients were then randomized to either placebo or rabeprazole 20 mg am and 20 mg pm for 7 days. After a washout period of 1 week, patients crossed over to the other arm of the study for an additional 7 days. Patients completed a daily diary assessing severity and frequency of chest pain throughout the baseline, treatment and wash-out periods. The rabeprazole therapeutic trial was considered as a diagnostic tool, if chest pain scores improved > or =50% from baseline. RESULTS: Of the 35 patients enrolled, 16 (46%) were diagnosed as gastro-oesophageal reflux disease-positive and 19 (54%) as gastro-oesophageal reflux disease-negative. Of the gastro-oesophageal reflux disease-positive patients, 12 of 16 (75%) had a significant symptom improvement on rabeprazole when compared with 3 of 16 (19%) on placebo (P = 0.029). Of the gastro-oesophageal reflux disease-negative group, only two of 19 (11%) improved significantly on the medication and four of 19 (21%) on placebo (P = 0.6599). The calculated sensitivity and specificity of the rabeprazole therapeutic trial was 75% and 90%, respectively. CONCLUSIONS: A rabeprazole therapeutic trial is highly sensitive and specific for diagnosing gastro-oesophageal reflux disease-related non-cardiac chest pain patients.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed2006

Rapidly progressing high o,p'DDD doses shorten the time required to reach the therapeutic threshold with an acceptable tolerance: preliminary results.

INTRODUCTION: It has been reported that the therapeutic threshold of mitotane, plasma level above 14 microg/ml, is achieved within 3-5 months after o,p'DDD treatment initiation in patients with adrenocortical carcinoma (ACC). OBJECTIVE AND DESIGN: We evaluated pharmacokinetic and tolerance of a high-dose schedule of pure o,p'DDD treatment given in 500-mg tablets of mitotane (Lysodren, Bristol-Myers Squibb, HRA Pharma, Paris, France) in four patients with ACC and two patients with Cushing's syndrome-related endocrine tumours. It was administered at a starting dosage of 3 g/day, which was rapidly increased to 6-9 g/day within 2 weeks according to digestive tolerance and then adjusted according to tolerance and plasma o,p'DDD monitoring. Patients were followed up until they reached the therapeutic threshold of mitotane, and toxicity was recorded. A relationship between o,p'DDD dose and plasma level was sought. RESULTS: The highest starting dosage given ranged between 6 and 9 g a day, during the first two weeks. The daily maintenance dose ranged 4.5-9 g during the next 2 weeks and 3-9 g by the second month of treatment. The therapeutic threshold was reached in all four patients who received o,p'DDD treatment for at least 1 month. Among these four patients, the toxic threshold (plasma mitotane level > 20 microg/ml) was even reached at 6 weeks of therapy in three patients. Grade 1, 2 or 3 toxicity was observed in 3, 2 and 1 patients, respectively. Toxicity resolved after reduction or discontinuation of o,p'DDD therapy. A significant linear correlation was found between plasma mitotane dose and plasma level. CONCLUSIONS: These results suggest that a high-dose o,p'DDD therapeutic schedule is feasible with an acceptable toxicity and may shorten the time required to reach the therapeutic schedule from 3-5 months to 4 weeks. These patients require a close follow-up, combining clinical and plasma o,p'DDD level monitoring every second week. A confirmatory study is ongoing.

Adrenocortical Carcinoma↗
PubMed1996

Conflict, enactment, empowerment: conditions of independent therapeutic nursing intervention.

The purpose of this qualitative study was to describe the use of independent therapeutic nursing interventions by registered nurses in a variety of health care delivery agencies. The process used to integrate nursing interventions into the daily routines of agencies that did not formally require their use, the conditions in which they were implemented, and the consequences of their use, were examined. Data collection methods include observations and interviews of 36 participant nurses, employed in five health care agencies, for 1 year. The organizational culture of each environment was observed and its impact on the enactment of independent therapeutic nursing interventions was evaluated. Data analysis, done by using the constant comparative method, generated a proposal of a substantive theory that integrates conditions and consequences of therapeutic nursing intervention. Intra-role conflict, the product of incompatible expectations of the professional conception of nursing and task oriented/medically controlled work environments, served as the motivating force behind strategies of enactment utilized to overcome barriers to implement therapeutic nursing interventions. As a consequence of using therapeutic nursing interventions, participants perceived empowerment in relation to clients, peers and other health care professionals.

Choice Behavior↗
PubMed2005

Releasing the therapeutic potential of the psychiatric nurse: a human relations perspective of the nurse-patient relationship.

In psychiatry mental health nurses form the largest professional discipline providing care on an everyday basis for sustained periods. Mental health nurses therefore are in a pivotal position to establish valued therapeutic alliances. In practice, however, a disproportionate amount of nursing time is taken up by administration, time spent talking to patients is minimal and when interactions do occur they remain notionally therapeutic and often are not theoretically informed. This noted paucity of therapeutic contact is antithetical to the aspirations of service users who increasingly are asking for a more skilled approach to the talking-listening that occurs in the therapeutic encounter. It is hypothesized by the present authors that an object-relations perspective of the nurse-patient relationship could release the largely untapped therapeutic potential of the psychiatric nurse by (1) bridging the gap between theory and practice and (2) providing a professional identity from within which nurses can begin to 'get to know' and understand the predicament of the patient with severe mental illness.

Humans↗
PubMedDate not supplied

Illumination of therapeutics by toxicology: a personal view.

1. My specialties are therapeutics and toxicology. When we think in classical terms about drugs, therapeutics refers to curative healing, toxicology to the capacity to produce harm. However, they are not opposite disciplines, but rather reflect a continuum along the dose-response curve of a drug or toxin. Since antiquity, the study of toxicology has underpinned and illuminated therapeutics. Even the most potent toxins, such as botulinum and ricin, are used for therapeutic purposes. 2. In the case of one of my favourite research topics, the herbicide paraquat, I illustrate how investigating methods to treat patients poisoned by it has led to important advances in knowledge in medicine and therapeutics. Studying paraquat has launched my own research group on a path towards elucidating the mechanisms of the chronic neurological side effects of the antipsychotic drug, haloperidol, which is used widely to treat schizophrenia. In tracing these tortuous paths, the roles that serendipity and creativity play in research and their implications for education and funding policies are high-lighted.

Dose-Response Relationship, Drug↗
PubMedDate not supplied

A survey of ocular therapeutic pharmaceutical agents in optometric practice.

BACKGROUND: In all Australian states optometrists are permitted to use diagnostic topical ocular drugs in the practice of their profession. In addition, legislation has just been passed in Victoria allowing optometrists to prescribe topical S4 medications for ocular conditions. Changing optometric legislation to incorporate S4 ophthalmic agents is a topical issue within optometry. METHODS: By postal survey, we asked Queensland optometrists to gauge their level of education, current mode of practice and whether they were in favour of gaining access to prescription-only therapeutic medications. Their opinions on the education requirements, perceived potential public benefits and the possible barriers to optometrists gaining prescribing rights to therapeutic agents were also investigated. RESULTS: A 45 per cent response rate to the survey (231 responses out of 517) was obtained. The majority of respondents (88 per cent) wanted to be able to prescribe therapeutic agents. Over 50 per cent considered themselves competent and believed they were capable of treating dry eye, blepharitis, allergic conjunctivitis, corneal abrasions and contact lens induced papillary conjunctivitis. Over 90 per cent would be confident recommending topical lubricants and antihistamines, while 65 per cent felt they were adequately prepared to prescribe topical antibiotics. Education level, in particular the completion of a therapeutic drugs course, was the main factor that determined whether the respondents practised or were willing to practise at a higher level. CONCLUSION: The majority of Queensland optometrists are well aware of the issues surrounding the use of pharmaceutical agents. Many optometrists feel they are well prepared for prescribing ocular therapeutic agents.

Journal Article↗
PubMed1993

Assessing therapeutic problem solving skills: empirical analysis of a measuring operation.

Employment of caregivers as trainers is an imperative in the training and treatment of mentally retarded persons. Besides being taught specific behavior modification skills, these paraprofessional trainers have to obtain a set of general skills in order to adjust their specific skills to new clients, situations, and behaviors across time. Empirical research on the characteristics of therapeutic problem-solving skills are scarce. This may be due to a reluctance of behavior researchers against including cognitive factors in the analysis of behaviour influence. However, the development of basic knowledge on the existence of therapeutic problem-solving and skills should be one of the primary research goals. This article describes the development and application of four scales assumed to be representative of an important set of general skills--therapeutic problem-solving skills. By means of these four scales 21 caregivers were evaluated before and after extensive training. A multifaceted measuring operation is employed with the main objective of empirically testing the dimensionality of problem-solving skills. Rater consistency and individual differences in change from pre- to post-training level are also uncovered. It is concluded that the four scales of therapeutic skills, largely reflect the same underlying concept of a rather general therapeutic problem-solving skill. Discussion of the findings also pointed to future research.

Behavior Therapy↗
PubMed2006

Bleomycin tattooing as a promising therapeutic modality in large keloids and hypertrophic scars.

BACKGROUND: Cryotherapy combined with intralesional triamcinolon injection is the most common traditional therapy for hypertrophic scars and keloids. The literature contains few articles on the use of bleomycin tattoo for treatment of these conditions. OBJECTIVE: This study compares the efficacy of bleomycin tattoo with that of cryotherapy combined with intralesional triamcinolon injection for the treatment of keloids and hypertrophic scars. MATERIALS AND METHODS: Forty-five patients with hypertrophic scars or keloids were randomly divided into two groups. Group A was treated with bleomycin tattoo, and group B, with cryotherapy combined with intralesional triamcinolon injection. There were four therapeutic sessions at 1-month intervals. All patients were followed for 3 months after the end of treatment. RESULTS: Therapeutic response in lesions less than 100 mm2 was higher than 88% in both groups, but in larger lesions, the therapeutic response to bleomycin was significantly better than cryotherapy combined with intralesional triamcinolon injection (p = .03). In group A, no relationship was observed between therapeutic response and lesion size (p = .58); however, in group B smaller lesions (< 100 mm2) displayed better therapeutic response (p = .007). CONCLUSIONS: Bleomycin tattoo may be more effective than cryotherapy combined with intralesional triamcinolon injection in treatment of larger keloids and hypertrophic scars (size > 100 mm2).

Adolescent↗
PubMed2003

Moclobemide: therapeutic use and clinical studies.

Moclobemide is a reversible inhibitor of monoamine-oxidase-A (RIMA) and has been extensively evaluated in the treatment of a wide spectrum of depressive disorders and less extensively studied in anxiety disorders. Nearly all meta-analyses and most comparative studies indicated that in the acute management of depression this drug is more efficacious than placebo and as efficacious as tricyclic (or some heterocyclic) antidepressants or selective serotonin reuptake inhibitors (SSRIs). There is a growing evidence that moclobemide is not inferior to other antidepressants in the treatment of subtypes of depression, such as dysthymia, endogenous (unipolar and bipolar), reactive, atypical, agitated, and retarded depression as with other antidepressants limited evidence suggests that moclobemide has consistent long-term efficacy. However, more controlled studies addressing this issue are needed. For patients with bipolar depression the risk of developing mania seems to be not higher with moclobemide than with other antidepressants. The effective therapeutic dose range for moclobemide in most acute phase trials was 300 to 600 mg, divided in 2 to 3 doses. While one controlled trial and one long-term open-label study found moclobemide to be efficacious in social phobia, three controlled trials subsequently revealed either no effect or less robust effects with the tendency of higher doses (600 - 900 mg/d) to be more efficacious. Two comparative trials demonstrated moclobemide to be as efficacious as fluoxetine or clomipramine in patients suffering from panic disorder. Placebo-controlled trials in this indication are, however, still lacking. A relationship between the plasma concentration of moclobemide and its therapeutic efficacy is not apparent but a positive correlation with adverse events has been found. Dizziness, nausea and insomnia occurred more frequently on moclobemide than on placebo. Due to negligible anticholinergic and antihistaminic actions, moclobemide has been better tolerated than tri- or heterocyclic antidepressants. Gastrointestinal side effects and, especially, sexual dysfunction were much less frequent with moclobemide than with SSRIs. Unlike irreversible MAO-inhibitors, moclobemide has a negligible propensity to induce hypertensive crisis after ingestion of tyramine-rich food ("cheese-reaction"). Therefore, dietary restrictions are not as strict. However, with moclobemide doses above 900 mg/d the risk of interaction with ingested tyramine might become clinically relevant. After multiple dosing the oral bioavailability of moclobemide reaches almost 100%. At therapeutic doses, moclobemide lacks significant negative effects on psychomotor performance, cognitive function or cardiovascular system. Due to the relative freedom from these side effects, moclobemide is particularly attractive in the treatment of elderly patients. Moclobemide is a substrate of CYP2C19. Although it acts as an inhibitor of CYP1A2, CYP2C19, and CYP2D6, relatively few clinically important drug interactions involving moclobemide have been reported. It is relatively safe even in overdose. The drug has a short plasma elimination half-life that allows switching to an alternative agent within 24 h. Since it is well tolerated, therapeutic doses can often be reached rapidly upon onset of treatment. Steady-state plasma levels are reached approximately at one week following dose adjustment. Patients with renal dysfunction require no dose reduction in contrast to patients with severe hepatic impairment. Cases of refractory depression might improve with a combination of moclobemide with other antidepressants, such as clomipramine or a SSRI. Since this combination has rarely been associated with a potentially lethal serotonin syndrome, it requires lower entry doses, a slower dose titration and a more careful monitoring of patients. Combination therapy with moclobemide and other serotonergic agents, or opioids, should be undertaken with caution, although no serious adverse events have been published with therapeutic doses of moclobemide to date. On the basis of animal data the combined use of moclobemide with pethidine or dextropropoxyphene should be avoided. There is no evidence that moclobemide would increase body weight or produce seizures. Some preclinical data suggest that moclobemide may have anticonvulsant property.

Adult↗
PubMed2004

The therapeutic alliance in couples therapy: clinical considerations.

This article presents clinical considerations about the therapeutic alliance in couples therapy, stimulated by pertinent new research findings reported in this issue. A loyalty dimension of the couple's relationship is described, as well as its influence on the therapeutic alliance in couples therapy. The therapist's establishment of a "meta-alliance" with the couple around their loyalty conflicts, avoidance of splits and disruptions, and prioritization of marital distress (versus individual symptoms) as the primary focus of treatment all serve to solidify the therapeutic alliance. In addition, identifying the partners' early family-of-origin distress can help predict and respond to strains in the therapeutic alliance that may occur later in therapy. Finally, the therapist helping the couple to balance their relational power differences in therapy and to address their concerns about the impact of the therapist's gender also strengthens their therapeutic alliance. A clinical case and vignettes are included to illustrate these issues.

Adult↗
PubMed2006

Therapeutic drug monitoring and human immunodeficiency virus (HIV) antiretroviral therapy.

Treatment with antiretroviral drugs such as the HIV protease inhibitors and non-nucleoside reverse transcriptase inhibitors have contributed to the improvement of life of many HIV-infected patients in recent years, but antiretroviral therapy is not without problems. In some patients, treatment is not effective and suppression of viral replication is not achieved. Other patients experience toxicity and have to stop treatment or change to a less effective treatment. Several studies have demonstrated a relationship between plasma concentrations of the protease inhibitors and non-nucleoside reverse transcriptase inhibitors and viral suppression and toxicity. Therapeutic drug monitoring uses drug concentrations to individualize and optimise therapy by dosage adjustments and many clinicians have advocated for the use of therapeutic drug monitoring in HIV antiretroviral therapy. Evidence from a number of randomized clinical trials supports the use of therapeutic drug monitoring, but the studies have limitations and might not apply to all the antiretroviral drugs. However, the consensus is that certain patients are very likely to benefit from therapeutic drug monitoring. Additionally, the combination of therapeutic drug monitoring and genotypic or phenotypic resistance testing might further improve antiretroviral therapy.

Anti-HIV Agents↗