Clinical Impression Of Improvement Research Articles

53. Sham repetitive transcranial magnetic stimulation with H-coil as symptomatic treatment in functional disorder

Functional disorders-FD account for major disability and impairment. As multidisciplinary approach appears to be the most effective treatment, placebo can effectively relieve symptoms in some cases. Our aim was to assess FD outcome after sham rTMS and to identify response predictors. Sixteen consecutive patients (13 females, age 29.9 ± 11.2 years, disease duration-DD 3.8 years, range 0–26) underwent multiple sessions (5.4 + 4.5) of sham rTMS with H-coil as symptomatic treatment for FD. Global Clinical Impression of Improvement (CGI-I) was collected from the treating physician and correlated with clinical-demographical data using Spearman test. A coexisting neurological disease was diagnosed in 4 patients, while 8 had a psychiatric disorder; 8 patients presented with either sensitive or motor deficits, 7 had hyperkinetic movement disorders and 3 a mixture of both. Twelve patients improved following treatment (CGI-I 2.9 + 1.0) with only 1 patient with psychogenic tremor showing a mild and transitory feeling of postural instability. A greater CGI-I was found for shorter disease duration (r − 0.871, p < 0.001). Sham rTMS with H-coil appears to be safe and can improve symptoms in FD.

Is there a correlation between physicians' clinical impressions and patients' perceptions of change? Use of the Perceived Change Scale with inpatients with mental disorders.

Assessment of the results of treatment for mental disorders becomes more complete when the patient's perspective is incorporated. Here, we aimed to evaluate the psychometric properties and application of the Perceived Change Scale - Patient version (PCS-P) in a sample of inpatients with mental disorders. One hundred and ninety-one psychiatric inpatients answered the PCS-P and the Patients' Satisfaction with Mental Health Services Scale (SATIS) and were evaluated in terms of clinical and sociodemographic data. An exploratory factor analysis (EFA) was performed and internal consistency was calculated. The clinical impressions of the patient, family, and physician were correlated with the patient's perception of change. The EFA indicated a psychometrically suitable four-factor solution. The PCS-P exhibited a coherent relationship with SATIS and had a Cronbach's alpha value of 0.856. No correlations were found between the physician's clinical global impression of improvement and the patient's perception of change, although a moderate positive correlation was found between the patients' clinical global impression of improvement and the change perceived by the patient. The PCS-P exhibited adequate psychometric proprieties in a sample of inpatients with mental disorders. The patient's perception of change is an important dimension for evaluation of outcomes in the treatment of mental disorders and differs from the physician's clinical impression of improvement. Evaluation of positive and negative perceptions of the various dimensions of the patient's life enables more precise consideration of the patient's priorities and interests.

A novel pediatric treatment intensity score: development and feasibility in heart failure patients with ventricular assist devices

The evolution of pharmacologic therapies and mechanical support including ventricular assist devices (VADs) has broadened the scope of care available to children with advanced heart failure. At the present time, there are only limited means of quantifying disease severity or the concomitant morbidity for this population. This study describes the development of a novel pediatric treatment intensity score (TIS), designed to quantify the burden of illness and clinical trajectory in children on VAD support. There were 5 clinical domains assessed: nutrition, respiratory support, activity level, cardiovascular medications, and care environment. A scale was developed through expert consensus. Higher scores indicate greater morbidity as reflected by intensity of medical management. To evaluate feasibility and face validity, the TIS was applied retrospectively to a subset of pediatric inpatients with VADs. The Bland-Altman method was used to assess limits of agreement. The study comprised 39 patients with 42 implantations. Bland-Altman interobserver and intraobserver comparisons showed good agreement (mean differences in scores of 0.02, limits of agreement ±0.12). Trends in TIS were concordant with the overall clinical impression of improvement. Scores remained ≥0.6 preceding VAD implantation and peaked at 0.71 3 days after VAD implantation. We describe a pediatric VAD scoring tool, to assess global patient morbidity and clinical recovery. We demonstrate feasibility of using this TIS in a test population of inpatients on VAD support.

Topical Tacrolimus 0.03% as Sole Therapy in Vernal Keratoconjunctivitis

This study sought to evaluate the efficacy of the isolated use of tacrolimus compared with the combined use of tacrolimus and olopatadine for the treatment of severe vernal keratoconjunctivitis (VKC). Twenty-one patients with severe VKC were randomized into two groups: one treated with 0.03% tacrolimus ointment combined with 1% olopatadine ophthalmic solution and the other with 0.03% tacrolimus ointment combined with placebo eye drops. The clinical signs and symptoms were graded from 0 to 3, and the efficacy of treatment was determined by the difference between the score at the beginning of treatment and after 30 days. The clinical impression of improvement as perceived by the evaluator and the self-assessment provided by the patient were scored at day 30 of treatment and compared between the groups. The scores for symptoms decreased between the assessments in both groups (-1.7±3.9 in the experimental group; -0.6±1.6 in the control group), with no significant difference between groups (P=0.205). The scores for clinical signs decreased between the assessments in the experimental group (-1.1±2.7) and increased in the control group (0.3±0.9) but with no significant differences (P=0.205). There was no significant difference between the groups regarding the self-assessment (P=0.659) and the clinical impression of the evaluator (P=0.387). The isolated use of tacrolimus and the combined use of tacrolimus and olopatadine seems to have the same efficacy, although controlled studies with larger samples are required to confirm this hypothesis.

Does catatonic schizophrenia improve faster with electroconvulsive therapy than other subtypes of schizophrenia?

Objective. Electroconvulsive therapy (ECT) is generally recommended for treating catatonic schizophrenia. Non-catatonic schizophrenia patients also receive ECT. We compared the speed of response to ECT among patients with catatonic and other subtypes of schizophrenia. Methods and materials. Consecutive schizophrenia patients referred for ECT within 3 months of starting antipsychotic treatment were studied (19 with catatonic and 34 with non-catatonic schizophrenia). Nurse's Observation Scale for Inpatient Evaluation (NOSIE-30) and Clinical Global Impression (CGI) were used to rate improvement. Referring psychiatrists stopped ECTs based on clinical impression of improvement. Total number of ECTs was taken as an indirect measure of speed of response. NOSIE-30 scores were compared using repeated measures analysis of variance. Results. Catatonic schizophrenia patients required significantly fewer ECTs to achieve clinically significant improvement. There was a significant group×occasion effect in NOSIE scores, suggesting faster response to ECT in the catatonia group (F=41.6; P<0.001). Survival analysis suggested that patients with catatonic schizophrenia required significantly fewer ECTs (one less session on an average) to achieve clinical improvement (Log-rank statistic =5.31; P=0.02). Conclusions. Catatonic schizophrenia responds faster to ECT than non-catatonic schizophrenia. However, the magnitude of the difference is modest.

Risperidone Use in Children with Down Syndrome, Severe Intellectual Disability, and Comorbid Autistic Spectrum Disorders: A Naturalistic Study

We report on an open-label, naturalistic study using risperidone to treat disruptive behaviors and self-injury in children with Down syndrome, severe intellectual disability, and comorbid autism spectrum disorders (DS+ASDs). We hypothesized that hyperactivity and disruptive behaviors would improve in response to risperidone treatment consistent with previous studies of children with ASD. Subjects were children (mean age, 7.8 +/- 2.6 years), consisting of 20 males and three females identified through our outpatient Down Syndrome Clinic between 2000 and 2004. Using the Aberrant Behavior Checklist as the primary outcome measure, all five subscales showed significant improvement following risperidone treatment. The mean duration of treatment was 95.8 +/- 16.8 days, and mean total daily dose was 0.66 +/- 0.28 mg/day. The Hyperactivity, Stereotypy, and Lethargy subscale scores showed the most significant reduction (p < .001), followed by Irritability (p < .02), and Inappropriate Speech (p < .04). Children with disruptive behavior and self-injury showed the greatest improvement. Sleep quality improved for 88% of subjects with preexisting sleep disturbance. Subjects for whom a follow-up weight was available showed a mean weight increase of 2.8 +/- 1.5 kg during the treatment period. These findings support our clinical impression of improvement on important target behaviors such as aggression, disruptiveness, self-injury, stereotypy, and social withdrawal. Low-dose risperidone appears to be well tolerated in children with DS+ASD, although concerns about weight gain and metabolic alterations may limit its usefulness over the long term in some children.

Treatment of eating disorders improves eating symptoms but not alexithymia and dissociation proneness

Background Eating disorders have been reported to increase in frequency, but it is yet unclear what psychological characteristics increase the proneness toward the development of eating disorders. Alexithymia (AL; a difficulty in awareness to one's emotions) and dissociation proneness are 2 such plausible features. Method In this study, we evaluated the efficacy of a combined intervention (group therapy, individual therapy, and pharmacologic therapy) in a group of soldiers with eating disorders (n = 30) in the Israel Defense Forces. Moreover, we examined whether AL and dissociation proneness were frequent in this group and whether clinical improvement was associated with an improvement in these factors as well. Results High scores on the AL and dissociation measures were noted. The intervention was associated with a 50% decrease in the Eating Attitudes Test and Eating Disorders Inventory scores, consistent with our clinical impression of improvement in the eating symptoms. However, the decrease observed on the Dissociative Experiences Scale and Toronto Alexithymia Scale scores was minimal. Conclusions The combined intervention was efficient in our sample of patients with eating disorder despite the small sample size. The aforementioned specific psychometric change may be indicative of the lack of importance of changes in AL or dissociation proneness in the short-term improvement in patients with eating disorder.

Assessing Progress in Analysis Interminable

A case study is provided of a schizoid patient in her mid-sixties who in a lengthy analysis had made significant clinical improvement. The treating analyst's impression of clinical improvement was independently verified through systematic analysis of transcripts of audiotapes of thirty-six sessions over a four-year period of treatment. The patient showed significant improvement on measures of character pathology, object relations, mentalization, and superego anxiety. The results suggest that some patients with entrenched character pathology who seem to be in analysis interminable may still make clinically significant improvement. It is suggested that the scientific status of psychoanalysis would be greatly enhanced if the anecdotal evidence generated in private practice were supported by independent verification. The current study illustrates one methodology, "case study plus," for providing independent verification while retaining the richness of the traditional case study.

Histiocytosis X: Treatment with topical nitrogen mustard

The case histories of two elderly patients with cutaneous histiocytosis X treated topically with nitrogen mustard are presented. The cutaneous lesions cleared within 2 to 3 weeks, and remission was maintained with daily topical administration of nitrogen mustard. The clinical impression of improvement was substantiated by light and electron microscopic studies prior to and after therapy.

BROMOCRIPTINE SUPPRESSION OF PLASMA GROWTH HORMONE IN ACROMEGALY

Twelve acromegalic patients were studied in one or more of three protocols to establish the response of plasma growth hormone (hGH) concentraions to (a) a single oral test dose of bromocriptine, (b) incremental dose therapy from 10 mg/day to 40 mg/day over 4 weeks, and (c) sustained therapy with 20 mg/day over a 3 month period. Ten of the patients studied had previously been treated by yttrium implantation, external pituitary irradiation or surgical hypophysectomy. A high incidence of side effects including postural hypotension, hallucinations and peripheral vasospasm was noted reducing the numbers of patients completing the three protocols. Suppression of hGH concentrations was disappointing; significant reductions in hGH concentraions occurred in five of eleven patients in response to a single test dose of bromocriptine, and in only one of seven patients treated with the drug over a sustained period. An impression of clinical improvement was gained in one patient, but there was no associated reduction in plasma hGH concentrations. It seems likely that acromegalic patients who have failed to respond to conventional treatment may be more resistant to bromocriptine therapy.

Wolff-Parkinson-White Syndrome

Evaluation of the patient with Wolff-Parkinson-White (WPW) syndrome with tachyarrhythmia is often difficult, since episodes of tachyarrhythmia most often subside spontaneously before medical observation is obtained. Twenty patients with WPW syndrome documented by standard electrocardiogram, who had histories suggesting tachyarrhythmia, were selected for study with the Holter ten-hour ECG monitoring system. This system allowed flexibility of activity during the monitoring period. Episodes of tachyarrhythmia were documented by these techniques in five of the 20 patients studied. Paroxysmal atrial tachycardia was documented in all five, and one patient had both atrial tachycardia and an unrecognized episode of atrial fibrillation. Two patients have been monitored while receiving propranolol hydrochloride therapy, confirming the clinical impression of improvement. Long-term monitoring has been found to be a valuable technique for the evaluation of the patient with WPW syndrome and possible tachyarrhythmias.