By Q. Ressel. Whitman College. 2018.
Only one study showed a difference in abnormal Technical Remarks proximal tubular handling of phosphate for tenofovir versus entecavir (48 generic 20mg levitra visa popular erectile dysfunction drugs. Counseling patients about medication adherence a difference in bone mineral density in 42 tenofovir- is important discount levitra 10mg amex erectile dysfunction surgical treatment options, especially in those with persistent and 44 entecavir-treated adults with an average treat- viremia on antiviral therapy. Antiviral Options for Management of Antiviral Resistance Add Strategy: Antiviral Resistance Switch Strategy 2 Drugs Without Cross-Resistance Ref(s) Lamivudine-resistance Tenofovir Continue lamivudine; add tenofovir 90 (or alternative emtricitabine-tenofovir) Telbivudine-resistance Tenofovir Continue telbivudine; add tenofovir — Adefovir-resistance Entecavir Continue adefovir; add entecavir 91 Entecavir-resistance Tenofovir Continue entecavir; add tenofovir 92,93 (or alternative emtricitabine-tenofovir) Multi-drug resistance Tenofovir Combined tenofovir and entecavir 92,94 2. This time point was defined by outcomes rants a switch to another antiviral monotherapy of virological response in clinical trials and reflects with high genetic barrier to resistance or the addi- an era of antiviral therapy with drugs of lower tion of a second antiviral with a complementary antiviral potency and higher rates of resistance. For those switching to another drug in lieu of continuing treated with tenofovir, viral suppression rates were 76% monotherapy. For persons on therapy who fail to Medical providers should ensure patient adherence to therapy. Con- additional high-potency antiviral therapy to an existing firmatory testing should be obtained before mak- monotherapy versus switching to another high-potency ing a therapy change. Resistance testing may assist antiviral monotherapy versus continuing monotherapy with decisions regarding subsequent therapy. In contrast, virological break- 98,99 confirmed virological breakthrough constitutes a through on antiviral treatment is typically associated 100 rationale for switching to another antiviral mono- with viral resistance and warrants a change of therapy. There is insufficient There was no evidence of harm owing to continued long-term comparative evidence to advocate one monotherapy among persons with persistent low-level approach over another. Based upon virological viremia, though the quality of evidence was low regard- principles, the risk of viral resistance is predicted ing the clinical outcomes of persons with persistent low- to be lower with combination antiviral therapy level viremia who continued entecavir or tenofovir compared to monotherapy. Current evidence does not provide an optimal entecavir, the rate of viral suppression at week 48 was length of treatment. In another randomized study of 102 persons with adefovir resistance treated with tenofovir alone or viral rebound that could lead to decompensation. Treatment with antivirals does not eliminate the for resistance with longer-term treatment courses. We speciﬁcally need criteria that should trigger Quality/Certainly of Evidence: Moderate a change in antiviral therapy, and studies evaluating the Strength of Recommendation: Strong cost-effectiveness of different strategies. Tenofovir and entecavir are preferred because of Background their potency and minimal risk of resistance. If treatment is not offered to persons with compen- cations is highest and the rationale for treatment can be sated cirrhosis and low levels of viremia, they must made. The only antivirals studied in pregnant women reduction in mortality with both drugs (6. Antiviral therapy was started at 28-32 weeks of 253 persons with decompensated cirrhosis, including 102 gestation in most of the studies. Antiviral therapy was discontinued at birth to 3 niﬁcantly lower in the treated group (22% vs. For pregnant women with immune-active hepati- tion in the Child-Pugh score and improved survival was tis B, treatment should be based on recommenda- 113 tions for nonpregnant women. In a study comparing compensated and virals are minimally excreted in breast milk and decompensated persons with cirrhosis treated with ente- are unlikely to cause significant toxicity. There are insufficient long-term safety data in sons with advanced decompensated cirrhosis may be at infants born to mothers who took antiviral agents 74 higher risk. C-section is not indicated owing to insufficient Future Research data to support benefit. As a result, drug labels recommend avoidance of breastfeeding when on these drugs. Several studies have investigated lamivudine occur at delivery, given that a combination of hepatitis 122-124 levels in breastfed infants. One study of 30 mother- B immunoglobulin and vaccination given within 12 infant pairs demonstrated that the lamivudine concentra- hours of birth has reduced the rate of perinatal transmis- tion in breastfed infants was only 3. Similar ﬁndings have ral drugs are pregnancy class C except for telbivudine been reported in studies looking at tenofovir and breast- (class B) and tenofovir (class B).
Prior experience with non-prescribed buprenorphine: Role in treatment entry and retention generic 10 mg levitra with amex erectile dysfunction doctor san jose. Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories buy 10 mg levitra amex erectile dysfunction va form. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. An introduction to extended-release injectable naltrexone for the treatment of people with opioid dependence. Clinical use of extended- release injectable naltrexone in the treatment of opioid use disorder: A brief guide. Substance Abuse and Mental Health Services Administration, & National Institute on Alcohol Abuse and Alcoholism. Pharmacological means of reducing human drug dependence: A selective and narrative review of the clinical literature. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. Meta- analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Testing the effectiveness of cognitive-behavioral treatment for substance abuse in a community setting: Within treatment and posttreatment fndings. Cognitive-behavioral therapy for comorbid bipolar and substance use disorders: A systematic review of controlled trials. A randomized factorial trial of disulfram and contingency management to enhance cognitive behavioral therapy for cocaine dependence. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Community reinforcement approach plus vouchers among cocaine-dependent outpatients: Twelve-month outcomes. Does treatment readiness enhance the response of African American substance users to motivational enhancement therapy? Motivational enhancement and other brief interventions for adolescent substance abuse: Foundations, applications and evaluations. Methamphetamine use and infectious disease-related behaviors in men who have sex with men: Implications for interventions. Using matrix with women clients: A supplement to the matrix intensive outpatient treatment for people with stimulant use disorders. Facilitating involvement in Alcoholics Anonymous during out‐patient treatment: A randomized clinical trial. Effectiveness of making Alcoholics Anonymous easier: A group format 12-step facilitation approach. A randomized controlled trial of intensive referral to 12- step self-help groups: One-year outcomes. Network support for drinking, Alcoholics Anonymous and long‐term matching effects. Toward enhancing 12-step facilitation among young people: A systematic qualitative investigation of young adults’ 12-step experiences. A systematic review of the research on mechanisms of behavior change in Alcoholics Anonymous. New addiction-recovery support institutions: Mobilizing support beyond professional addiction treatment and recovery mutual aid. Increasing diabetes self-management education in community settings: A systematic review. Family behavior therapy for substance abuse and other associated problems: A review of its intervention components and applicability. Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment.
From a self-psychological perspective order 10 mg levitra with mastercard erectile dysfunction treatment alprostadil, a major goal is to strengthen the self so that there is less fragmentation and a greater sense of cohesion or wholeness in the patient’s self-experience buy discount levitra 20 mg on line erectile dysfunction nursing interventions. On the supportive end of the continuum, the goals involve strengthening of de- fenses, the shoring up of self-esteem, the validation of feelings, the internalization of the thera- peutic relationship, and creation of a greater capacity to cope with disturbing feelings. Treatment of Patients With Borderline Personality Disorder 45 Copyright 2010, American Psychiatric Association. Of these interventions, only interpretation is unique to the psychodynamic approach. The more exploratory interventions (interpretation, confrontation, and clarification) may be fo- cused on either transference or extratransference issues. In its simplest form, interpretation involves making something con- scious that was previously unconscious. An interpretation is an explanatory statement that links a feeling, thought, behavior, or symptom to its unconscious meaning or origin. For example, a therapist might make the following observation to a patient with borderline personality dis- order: “I wonder if your tendency to undermine yourself when things are going better is a way to ensure that your treatment with me will continue. A confrontation may be geared to clarifying how the patient’s behavior affects others or reflects a denied or suppressed feeling. An example might be, “I think talking exclusively about your medication problems may be a way of avoiding any discussion with me about your painful feelings that make you feel suicidal. A therapist might say, “It sounds like what you’re saying is that in every relationship you have, no one seems to be adequately attuned to your needs. Encouragement to elaborate may be broadly defined as a request for information about a topic brought up by the patient. Simple comments like “Tell me more about that” and “What do you mean when you say you feel ‘empty’? This approach draws from self psychology, which emphasizes the value of empa- thy in strengthening the self. A typically validating comment is, “I can understand why you feel depressed about that,” or, “It hurts when you’re treated that way. Advice involves direct suggestions to the patient regarding how to behave, while praise reinforces certain patient behaviors by expressing overt approval of them. An example of advice would be, “I don’t think you should see that man again because you get beaten up every time you’re with him. Patients who lack good abstraction capacity and psy- chological mindedness may require a therapy that is primarily supportive, even though it is psychodynamically informed by a careful analysis of the patient’s ego capacities, defenses, and weak- nesses. Most psychotherapies involve both exploratory and supportive elements and include some, although not exclusive, focus on the transference. Hence, psychodynamic psychotherapy is often conceptualized as exploratory-supportive or expressive-supportive psychotherapy (16, 139, 141). One randomized controlled trial assessed the efficacy of psychoanalytically in- formed partial hospitalization treatment, of which dynamic therapy was the primary modality (9). In this study, 44 patients were randomly assigned to either the partial hospitalization pro- gram or general psychiatric care. Treatment in the partial hospitalization program consisted of weekly individual psychoanalytic psychotherapy, three-times-a-week group psychoanalytic psy- chotherapy, weekly expressive therapy informed by psychodrama, weekly community meet- ings, monthly meetings with a case administrator, and monthly medication review by a resident. The control group received general psychiatric care consisting of regular psychiatric review with a senior psychiatrist twice a month, inpatient admission as appropriate, outpatient and community follow-up, and no formal psychotherapy. Relative to the control group, the completers of the partial hospitalization program showed significant improvement: self-mutilation decreased, the proportion of patients who attempted suicide decreased from 95% before treatment to 5% after treatment, and patients improved in terms of state and trait anxiety, depression, global symptoms, social adjustment, and interpersonal problems. In the last 6 months of the study, the number of inpatient episodes and duration of inpatient length of stay dramatically in- creased for the control subjects, whereas these utilization variables remained stable for subjects in the partial hospitalization group. One can conclude from this study that patients with borderline personality disorder treated with this program for 18 months showed significant improvement in terms of both symptoms and functioning. Reduction of symptoms and suicidal acts occurred after the first 6 months of treatment, but the differences in frequency and duration of inpatient treatment emerged only during the last 6 months of treatment. Although the principal treatment received by subjects in the partial hospitalization group was psychoanalytic individual and group therapy, one cannot definitively attribute this group’s better outcome to the type of therapy received, since the overall community support and social network within which these therapies took place may have exerted significant effects. Pharmacotherapy received was similar in the two treatment groups, but subjects in the partial Treatment of Patients With Borderline Personality Disorder 47 Copyright 2010, American Psychiatric Association. In a subsequent report (10), patients who had received partial hospitalization treatment not only maintained their substantial gains at an 18-month follow-up evaluation but also showed statistically significant continued improvement on most measures, whereas the control group showed only limited change during the same period.
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