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This self-directed learning module highlights the general concepts and advances in therapeutic heat and cold, electrotherapy, and therapeutic exercise. This article is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. Special advances include lasers in medicine and the description of the appropriate type of exercise for weight control.
The present paper describes the therapeutic use of IPPB/I in postoperative pulmonary complications with ventilation disturbances of the lung. The beneficial effects of IPPB/I are shown in chest X-rays. The suppositions for performing IPPB/I, concerning equipment, staff and organization, are explained.
In a prospective, open clinical study, the relationship between serum levels of amitriptyline (At) and nortriptyline (Nt) and the therapeutic effect after 6 weeks of treatment was investigated. Serum levels were measured by gas-liquid chromatography and the therapeutic effect was assessed by the Hamilton Depression Rating Scale (HAMD) and the Clinical Global Impression Scale (CGI). A number of 25 non-delusional, moderate to severely depressed inpatients were included. A therapeutic window relationship was detected by means of regression analysis (quadratic model). Low and high serum levels were associated with low therapeutic effect. In an intermediate range, the probability of good therapeutic effect was increased. This relationship reached significance for the serum levels of At (p < 0.05) and a trend for the sum of serum levels of At and Nt (p < 0.1). As expressed by the regression coefficient r2, about 25% to 35% of the variability of therapeutic effect was explained by serum levels. Dichotomized data sets according to limits of final values of HAMD and CGI as well as limits of a therapeutic window of 70 ng/ml and 200 ng/ml (sum of At and Nt) revealed significant differences by means of Fisher's exact test (p < 0.05). Furthermore, increased ratios of serum level of Nt per serum level of At were found to be associated with decreased therapeutic effect. Thus, the present data support the existence of a therapeutic window of serum levels of At in depression. Also taking into account other reports, this therapeutic window can be defined as being between about 70 and 220 ng/ml. The assay of serum levels of At can be used to lower the risk of unsatisfactory therapeutic outcome.
Therapeutic interchange is a process of substituting a prescribed medication with one that offers therapeutic and cost benefits. The practice not only provides short-term savings but also is associated with decreases in lengths of stay in hospitals and total hospital drug expenses. There may be medicolegal implications when FDA-approved indications differ for interchanged drugs. The potential for liability is decreased when a standard of care is met, but since standards can change, guidelines should be reviewed regularly. High-tech, high-cost drugs are sometimes appropriate for therapeutic interchange. Pharmacy and therapeutics committees should assure best value by considering indirect expenses, quality, and therapeutic outcome, as well as product cost. Therapeutic interchange programs enable pharmacy managers to neutralize or at least slow the rate of drug cost increases, ensuring appropriate utilization of resources and more favorable patient outcomes.
Ancillary professions have been called upon to account for therapeutic benefits from their services or be eliminated from the health care system. A singular focus on therapy, however, would negate the unique contribution of therapeutic recreation within, while simultaneously restricting services to health care settings. It is proposed that panic over therapeutic recreation services meeting health care goals has hindered evaluation and solidification of the leisure-based philosophy presented in the NTRS Philosophical Position Statement (NTRS, 1982). It is argued that emphasizing the leisure orientation of the philosophical position statement can secure therapeutic recreation's position within, yet, not deny services to those outside of the health care system. An overview is presented on the adequacy of the position statement philosophy for therapeutic recreation. A potential danger of attempting to explain therapeutic recreation in terms of non-leisure based philosophies is also discussed.
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This article describes a research method that measures a therapist's effectiveness by assigning a composite value to each therapeutic verbal statement during a session. The intrasubject averaging of these values is called the mean therapeutic index (sigma). In this study, whether the mean therapeutic index could be used to predict treatment outcome was investigated. A successful case and an unsuccessful case were selected for 15 therapists, and an early session for each case was coded using the mean therapeutic index. The results show that the magnitude of the effect of the mean therapeutic index, as indicated by the correlation coefficient r, was .92 (r2 = 0.85). Thus, the mean therapeutic index accounted for 85% of the variance in the classification of treatment outcome as successful or unsuccessful. The findings point to the method's potential use for clinical practice and supervision of psychotherapy.
This paper maps the differential distribution of therapeutic work within the programmes of two therapeutic communities found in psychiatric hospitals. It is shown that in one of the two communities, therapeutic work was largely restricted to the small groups and to those large groups attended by the psychiatrists. The other community displayed a distribution of therapeutic work which was spread across the whole formal weekly programme and into informal interaction outside the programme. These contrasting distributions are traced to differing patterns of internal communication which affected the ability of nurses and patients to work collaboratively with the psychiatrists.
Research and education programs in therapeutics that combine the data, organizational capabilities, and expertise of several managed care organizations working in concert can serve an important role when a single organization is not large enough to address a question of interest, when diversity in populations or delivery systems is required, and when it is necessary to establish consistency of results in different settings. Nine members of the HMO Research Network, a consortium of health maintenance organizations (HMOs) that perform public domain research, have formed a Center for Education and Research on Therapeutics (CERT), sponsored by the Agency for Healthcare Research and Quality, to conduct multicenter research in therapeutics. The CERT uses a distributed organizational model with shared leadership, in which data reside at the originating organization until they are needed to support a specific study. Extraction of data from the host computer systems, and some manipulation of data, is typically accomplished through computer programs that are developed centrally, then modified for use at each site. For complex studies, pooled analysis files are created by a coordinating center, and then analysed by investigators throughout the HMOs. It is also possible to contact HMO members when necessary. This multicenter environment has several benefits, addressing: (1) a wide array of questions about the safety and effectiveness of therapeutics, (2) the impact of efforts to change clinicians' and patients' behavior, and (3) pharmacoeconomic and pharmacogenetic questions.
Oncolytic viruses are attractive therapeutics for cancer because they selectively amplify, through replication and spread, the input dose of virus in the target tumor. To date, clinical trials have demonstrated marked safety but have not realized their theoretical efficacy potential. In this review, we consider the potential of armed therapeutic viruses, whose lytic potential is enhanced by genetically engineered therapeutic transgene expression from the virus, as potential vehicles to increase the potency of these agents. Several classes of therapeutic genes are outlined, and potential synergies and hurdles to their delivery from replicating viruses are discussed.
Advances in biochemistry, protein chemistry and molecular biology over the last twenty-five years have spurred the increased use and development of proteins as injectable therapeutic agents. Introduction of proteins into the circulation exposes them to numerous different cells, enzymes and routes of extravasation that contribute to their clearance and their catabolism. Overly rapid clearance, particularly of small proteins, can limit therapeutic efficacy. Many strategies have been devised to retard the clearance of therapeutic or potentially therapeutic proteins, but relatively few proteins with clearance-retarding modifications are in clinical use. Proteins have been chemically modified towards this end by covalent attachment of polyethylene glycol or dextran chains or by protein-protein cross-linking. Genetic modification has also been employed to fuse proteins of interest to long-lived plasma proteins like albumin or immunoglobulins, or portions of these proteins. While all modifications may reduce the biological activity of the protein of interest or elicit antibody formation in recipient animals or patients, there now exists sufficient experience in this area that an optimal clearance-extending strategy can often be designed and successfully executed. With the explosive growth of genomic and proteomic information, an exponentially increasing number of engineered proteins are likely to be developed, with a probable need for clearance-related modification.
One thousand five hundred serum drug levels lying outside the defined therapeutic range have been followed up by the clinical pharmacology service at the Royal Adelaide Hospital over a thirteen month period. It was found that digoxin, phenytoin and theophylline were the most frequently monitored drugs. Blood levels outside the therapeutic range tended to be on the high side with digoxin, but were usually sub-therapeutic for the other two. Drug related toxicity was observed in 11.2 percent of those with a high serum level. Several potential drug interacting situations were also noted during the study. The value of therapeutic drug monitoring, to maximise efficacy of therapy and minimise side effects, is stressed. However, correct blood sampling, based on a knowledge of the clinical pharmacology and pharmacokinetics of the drug, must be performed in order to obtain optimal benefit from this exercise.
5-[4-(2-Carboxyethylcarbamoyl)phenylazo]salicylic acid disodium salt dihydrate (CAS 80573-04-2, BX661A) is being developed as a therapeutic drug for ulcerative colitis. To determine the active therapeutic moiety of BX661A, the therapeutic effects with single and combined administration of 5-aminosalicylic acid (5-ASA), 4-aminobenzoyl-beta-alanine (4-ABA) and 4-amino-N-2-pyridinyl-benzenesulfonamide (CAS 144-83-2, sulfapyridine, SP) on ulcerative colitis induced by dextran sulfate sodium (DSS) in rats were investigated, and the following results were obtained. 1. BX661A at doses of 30, 100 and 300 mg/kg (p.o.) dose-dependently decreased the erosion area (mm2) in the large intestine with % inhibition values of 28.7, 49.1 and 61.6%, and the shortening of the large intestine with % inhibition values of 17.1, 25.7 and 48.6%, respectively. Salazosulfapyridine (SASP) at doses of 30 and 100 mg/kg (p.o.) decreased the erosion area (mm2) in the large intestine with % inhibition values of 30.7 and 45.3%, respectively, but did not improve the shortening of the large intestine. However, at a dose of 300 mg/kg (p.o.) SASP, the % inhibition value of the erosion area in the large intestine was reduced. 2. A single intrarectal administration of 5-ASA (105 mg/kg, i.r.) significantly decreased the erosion area (mm2) in the large intestine, but a single administration of 4-ABA or SP did not show any significant effect on the erosion area. Combined administration with 5-ASA (105 mg/kg, i.r.) and 4-ABA (142.8 mg/kg, i.r.) significantly decreased the erosion area (mm2) in the large intestine with a % inhibition value of 63.8%. On the other hand, the efficacy of 5-ASA disappeared with combined administration with SP (% inhibition value of 7.3%). These results suggest that 5-ASA is the active moiety for the therapeutic effects of BX661A and indicate that the efficacy of 5-ASA disappears with the combined use of SP, but not of 4-ABA. Therefore, it seems that BX661A is clinically safe and more effective than SASP in the treatment of patients with ulcerative colitis.
This article argues that in the current setting of nursing practice, therapeutic touch should be treated as a religious practice. The article examines the religious sources of the ideas and documents the connection with the teachings of particular religious groups. Recognizing therapeutic touch as a religious issue requires new kinds of approaches in the practice and teaching of therapeutic touch in nursing.
Research in nurses' communications has concentrated on nurse to patient interactions. Those few studies which focus on nurse to nurse communications seem to be generated by a pragmatic and normative concern with effective information sharing. In this paper, which describes one aspect of a larger case study of a hospital-based therapeutic community, the description and analysis of nurses' reports flows not from a normative model of professional practice, but rather an exploration of how professional practice is articulated as discourse in nurses' written accounts. Foucault's ideas about therapeutic discourse inform the theoretical framework of the research. Ethnomethodological concerns with the importance of documentary analysis provide the methodological rationale for examining nurses' 24-hour report documents, as official discourse, reflecting therapeutic practice in this setting. A content analysis of nurses' reports, collected over a period of 4 months, demonstrated the importance of domesticity and ordinary everyday activities in nurses' accounts of hospital life. Disruption to the 'life as usual' domesticity in the community seemed to be associated with admission to and discharge from the hospital when interpersonal and interactional changes between patients occur. It is suggested that nurses in general hospital wards and more orthodox psychiatric settings might usefully consider the impact of admissions and discharges on the group of patients they manage, and make this a discursive focus of their work.
The prognoses of 110 patients with advanced hepatocellular carcinoma (HCC) in stages III and IV were studied retrospectively. These patients were treated mainly by transarterial chemoembolization (TAE) or chemoinfusion using Lipiodol. Some of the patients underwent percutaneous ethanol injection therapy (PEIT) or tumor resection following TAE. Hepatic function, tumor stage, vascular involvement, type of tumor invasion, number of tumors and number of treatments affected the prognosis of the patients. The prognosis was better in the Child A group than in Child B and C. In the Child C group, the prognosis was markedly poor, and was least affected by any treatment. The prognoses in the patients with multiple nodular lesions, massive or diffuse lesions, were much poorer than those with a few nodular lesions. Tumor thrombosis in the central portal vein and distant metastasis greatly exacerbated the therapeutic results. Repeat therapy yielded a favorable therapeutic result when hepatic function was tolerable. Surgical intervention and PEIT were an effective therapy in a few patients. In advanced HCC, liver function and tumor extension should be fully evaluated, and it is important to determine the most effective therapeutic modalities to improve the survival of patients.
BACKGROUND: Mild to moderate induced hypothermia has been used in the treatment of head injury for over 50 years, although few randomised controlled trials have been performed. Recent encouraging results from small, single-centre trials and consistent findings of a cerebral protection effect of cooling in laboratory models of global ischaemia has led to a renewed interest in the area. OBJECTIVES: To determine whether the use of mild therapeutic hypothermia in the treatment of moderate and severe head injury improves short-term control of intracranial pressure (ICP) and long-term functional outcome. SEARCH STRATEGY: Electronic searches of the Injuries Group trial registry and EMBASE for any relevant randomised trials, supplemented by hand searching of conference proceedings and reference lists of relevant articles. SELECTION CRITERIA: All randomised controlled trials of mild hypothermia versus control (open or normothermia) in the treatment of patients with any closed head injury requiring hospitalisation. Mild hypothermia was defined as local or systemic cooling to a target temperature of at most 34-35 degrees Celsius for a period of at least 12 hours. Outcome was all-cause mortality and death or severe disability at the end of the scheduled follow-up period. All trials were assessed by two reviewers, and included or excluded on a consensus basis. DATA COLLECTION AND ANALYSIS: Eleven potential trials of therapeutic hypothermia for head injury were found, of which two are ongoing and one is awaiting assessment. The eight remaining trials were included in the systematic review. Data on death, GOS score at final follow-up, complications and ICP were sought and extracted, either from published material or by contact with the investigators. Mantel-Haenzel odds ratios and 95% confidence intervals were calculated for death and death and severe disability for each trial on an intention-to-treat basis. No quantitative synthesis of data on either complications or ICP was attempted. Trials of immediate and deferred hypothermia were analysed separately. MAIN RESULTS: Active immediate hypothermic treatment was associated with a 33% non-significant (p=0.16) reduction in the odds of death at the end of treatment or final follow-up, (OR 0.67, 95% confidence interval 0.38 to 1.17), and a 61% reduction (p=0.004) in the odds of being dead or severely disabled, (OR 0.39, 95% confidence interval 0.20 to 0.74). Similar effect sizes were found for delayed hypothermia. These results are, however, based on a few small trials each of less than 100 patients. A multi-centre trials of hypothermia versus control in 392 patients will be reporting results in 1999, providing substantially more evidence than is currently available. REVIEWER'S CONCLUSIONS: Although this review would suggest a strong positive effect of therapeutic hypothermia, the results are based on several small trials carried out in single, specialist centres. The results of a large multi-centre trial are expected in 1999 and will more than treble the available evidence. Until these results have been released, it would be inappropriate to make any short-term recommendations for clinical practice or research.