Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit

On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.     

Hierarchy of simulation models in predicting structure and energetics of the Src SH2 domain binding to tyrosyl phosphopeptides.

Structure and energetics of the Src Src Homology 2 (SH2) domain binding with the recognition phosphopeptide pYEEI and its mutants are studied by a hierarchical computational approach. The proposed structure prediction strategy includes equilibrium sampling of the peptide conformational space by simulated tempering dynamics with the simplified, knowledge-based energy function, followed by structural clustering of the resulting conformations and binding free energy evaluation of a single representative from each cluster, a cluster center. This protocol is robust in rapid screening of low-energy conformations and recovers the crystal structure of the pYEEI peptide. Thermodynamics of the peptide-SH2 domain binding is analyzed by computing the average energy contributions over conformations from the clusters, structurally similar to the predicted peptide bound structure. Using this approach, the binding thermodynamics for a panel of studied peptides is predicted in a better agreement with the experiment than previously suggested models. However, the overall correlation between computed and experimental binding affinity remains rather modest. The results of this study show that small differences in binding free energies between the Ala and Gly mutants of the pYEEI peptide are considerably more difficult to predict than the structure of the bound peptides, indicating that accurate computational prediction of binding affinities still remains a major methodological and technical challenge.     

Pre- and postoperative antihypertensive treatment with calcium antagonist in pheochromocytoma

Medical preparation for pheochromocytoma surgery requires adrenergic blockade and restoration of euvolemia. Usually, this preoperative preparation consisted essentially of sequential and progressive adrenergic antagonism, alpha then beta blockade. This therapy is not easy to introduce and exposes to blood pressure collapses after tumor removal. By contrast, calcium channel blocking drugs like dihydropyridines offer efficacy and safety. Moreover, new intravenous (IV) agents (nicardipine, diltiazem) provide useful therapeutic tools to control, rapidly and with a dose-dependent effect, any undesired hemodynamic event during surgery. As a demonstration of this new therapeutic strategy for management of pheochromocytoma resection, we report here the cases of two patients who were exclusively treated with dihydropyridines. A 61 year-old woman and a 41 year-old man were scheduled for pheochromocytoma resection (left and right adrenal tumors, respectively). Both patients received dihydropyridines for preoperative preparation (nicardipine and nifedipine, respectively, 60 mg/day). This treatment allowed a good control of arterial blood pressure (BP) (from 210/110 to 170/90 and 180/100 to 140/80 mmHg, respectively) and was maintained up to the morning of the operative day. After patient installation on the operating-table, IV nicardipine infusion was started (2 mg/hour). Anesthesia consisted of high doses of fentanyl, flunitrazepam and vecuronium. Hemodynamic measurements (radial artery and Swan ganz catheters) allowed adjustment of nicardipine infusion rate to maintain peripheral arterial resistances under 1,000 dynes.s.cm-5, and adequate volume loading. A hypertensive crisis (270/130 mmHg) occurred at the time of the intubation in the first case but responded to higher infusion rate of nicardipine (5 mg/10 min).(ABSTRACT TRUNCATED AT 250 WORDS)     

Tailoring the psychotherapy to the borderline patient

Views still differ as to the optimal psychodynamic treatment of borderline patients. Recommendations range from psychoanalysis and exploratory psychotherapy to an explicitly supportive treatment aimed at strengthening adaptive defenses. The authors contend that no single approach is appropriate for all patients in this wide-ranging diagnostic category, which spans a continuum from close-to-neurotic to close-to-psychotic levels of functioning. Careful differentiations based on developmental considerations, ego structures, and relationship patterns provide the basis for the optimal treatment approach.     

Clinical and virological factors associated with hepatitis B virus reactivation in HBsAg‐negative and anti‐HBc antibodies‐positive patients undergoing chemotherapy and/or autologous stem cell transplantation for cancer

Summary. We studied clinical outcome and clinico‐virological factors associated with hepatitis B virus reactivation (HBV‐R) following cancer treatment in hepatitis B virus surface antigen (HBsAg)‐negative/anti‐hepatitis B core antibodies (anti‐HBcAb)‐positive patients. Between 11/2003 and 12/2005, HBV‐R occurred in 7/84 HBsAg‐negative/anti‐HBcAb‐positive patients treated for haematological or solid cancer. Virological factors including HBV genotype, core promoter, precore, and HBsAg genotypic and amino acid (aa) patterns were studied. Patients presenting with reactivation were men, had an hepatitis B virus surface antibody (HBsAb) titre <100 IU/L and underwent >1 line of chemotherapy (CT) significantly more frequently than controls. All were treated for haematological cancer, 3/7 received haematopoietic stem cell transplantation (HSCT), and 4/7 received rituximab. Using multivariate analysis, receiving >1 line of CT was an independent risk factor for HBV‐R. Fatal outcome occurred in 3/7 patients (despite lamivudine therapy in two), whereas 2/4 survivors had an HBsAg seroconversion. HBV‐R involved non‐A HBV genotypes and core promoter and/or precore HBV mutants in all cases. Mutations known to impair HBsAg antigenicity were detected in HBV DNA from all seven patients. HBV DNA could be retrospectively detected in two patients prior cancer treatment and despite HBsAg negativity. HBV‐R is a concern in HBsAg‐negative/anti‐HBcAb‐positive patients undergoing cancer therapy, especially in males presenting with haematological cancer, a low anti‐HBsAb titre and more than one chemotherapeutic agent. HBV DNA testing is mandatory to improve diagnosis and management of HBV‐R in these patients. The role of specific therapies such as rituximab or HSCT as well as of HBV aa variability deserves further studies.