Initial Phase Of Therapy Research Articles

Metacognition, attachment and psychotherapy in first-episode psychosis: a case study.

Aim of the studyPsychotherapy in first-episode psychosis is essential for the recovery of affected users. Those with primary psychotic disorders experience impaired abilities to form complex ideas about themselves and others, called metacognitive deficits. They also present important attachment disturbances.Subject or material and methodsThis paper aims to review the concepts of metacognition and attachment in psychosis, present an interpersonal metacognitive model incorporating elements of attachment theory and analyze a clinical case to show the integration of different strategies in the initial phase of therapy. The Metacognitive Assessment Scale-Abbreviated (MAS-A) was used to assess changes in the user’s metacognitive ability.ResultsThe therapist adopted the role of secure base and safe-haven to develop an adequate therapeutic relationship, operating through metacommunication and self-participation. Normalization interventions were applied and the user’s agenda was consistently prioritized. The user developed greater metacognitive abilities in the MAS-A along with better functioning, maintained few symptoms and was able to move into a new phase of therapy.DiscussionThe review and clinical case presented highlight the importance of an interpersonal metacognitive model that considers the users’ attachment pattern and a solid therapeutic relationship. Hierarchical metacognitive interventions are presented that allowed the user to address more complex psychological conflicts in therapy.ConclusionsPsychotherapeutic models that integrate the concepts of metacognition and attachment theory are promising to improve self-reflective abilities in users with a first-episode psychosis. The clinical case presented would be a contribution to design future studies about these processes.

Effect of Regulated Add-on Sodium Chloride Intake on Stabilization of Serum Lithium Concentration in Bipolar Disorder: A Randomized Controlled Trial

IntroductionThe therapeutic use of lithium in bipolar disorder is often restricted due to its narrow therapeutic window and adverse drug reactions. Lithium-induced early renal dysfunction is clinically important as it may lead to sodium depletion due to natriuresis leading to lithium retention and lithium toxicity. This is most often seen in the initial phases of therapy, and psychiatrists struggle titrating the dose of lithium and stabilizing the serum lithium level.ObjectivesThe present study was conducted to evaluate the effect of add-on sodium chloride on serum lithium levels in bipolar disorder.MethodsThe present randomized controlled trial (NCT04222816) was conducted in 60 patients with type I bipolar disorder who were randomized into the control group who received lithium carbonate with the advice not to take additional salt (at the table) and the test group who received sachets of sodium chloride (1 g/d) as an add-on to lithium carbonate and were advised to restrict their additional salt intake (at the table) to 1 g/d. After baseline assessments, all patients were followed up at 4 weeks, 8 weeks, and 12 weeks when serum lithium, sodium and potassium were estimated. Serum creatinine and aldosterone were repeated at 12 weeks.ResultsIn the test group, the fluctuation rate in serum lithium (26.7%) was significantly (p=0.01) lower than in the control group (63.3%). There was a significant difference in serum lithium in the control group at different time points; however, the changes were not significant in the test group. There was a significant difference in serum lithium between the groups at 8 and 12 weeks of follow-up. There were no significant differences in the change in serum sodium, potassium, creatinine, aldosterone, creatinine clearance, and blood pressure within the group and between the groups. A significant positive correlation was found between serum lithium and aldosterone at baseline.ConclusionsIntake of add-on sodium chloride (1 gm/day) may reduce the fluctuations in serum lithium during the maintenance phase of lithium therapy in type I bipolar disorder.Disclosure of InterestNone Declared

Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study.

ObjectiveTo explore how therapists and clients act dyadically to establish a therapeutic relationship during the first five sessions of psychotherapy. The study aimed to identify both relational facilitative and hindering processes occurring in routine care.MethodsUsing the method ‘interpersonal process recall’ (IPR), we videotaped the third and fifth session of 12 psychotherapy dyads, and conducted video-assisted interviews with each therapist and client separately. In total, the data material consist of 47 IPR interviews. Data were analyzed using a thematic approach.ResultsThe analysis process revealed two main groups. The first group consisted of dyads with a positive relational outcome, and the second group consisted of dyads with a troubled or frail relational outcome. During the initial phase of therapy, clients described feeling overwhelmed by fear and shame. Positive relational development occurred when these emotions were successfully accommodated and replaced with a growing sense of safety with the therapist. However, the relationship became troubled when the client experienced an increase in shame and/or fear during the first sessions. When forming a therapeutic relationship, it is vital that the client experience the therapist as genuine and skilled, and that the therapist is able to engage and connect deeply with the client on a person-to-person level. The article further provides a discussion on how these dyadic experiences align with the working alliance and real relationship, and how the two consolidate during the first sessions of psychotherapy.ConclusionThe current study explored the complex relational processes underlying the formation of the therapeutic relationship. Core aspects of the real relationship are prerequisites to forming a collaborative working alliance in which both therapist and client are actively engaged. Facilitating a positive relationship is crucial in the early phase of psychotherapy, and therapists can actively identify and repair ruptures at this time.

Prognostic significance of CD163- and CD68-expressing macrophages in nodular sclerosis Hodgkin lymphoma

The objective of the study was to determine the clinical and morphological criteria and prognostic significance of CD163- and CD68-expressing macrophages in formalin-fixed paraffin-embedded (FFPE) lymph node samples of nodular sclerosis Hodgkin lymphoma.Materials and methods. We have studied clinical and laboratory characteristics and treatment results of 52 patients with newly diagnosed nodular sclerosis Hodgkin lymphoma. The treatment efficacy was assessed after 2–4 courses of chemotherapy by positron emission tomography combined with computed tomography scan (PET-CT) according to the Deauville scale.Results. In FFPE lymph node samples, differences in the localization and relative number of CD163-positive macrophages in patients of both study groups were determined. Morphometric counting of CD68-positive cells did not reveal statistically significant intergroup differences. The threshold of CD163-positive cells has been established. The relationship between the CD68 expression level and the response to frontline therapy was not revealed. The ratio of tumorassociated macrophages in each patient was assessed by the CD163/CD68 index. The threshold of the index was determined, which allows predicting the course of nodular sclerosis Hodgkin lymphoma.Conclusion. The following parameters could be used as additional morphological criteria for predicting the response to frontline therapy in patients with nodular sclerosis Hodgkin lymphoma: tissue distribution pattern and quantitative calculation of macrophage-histiocytic microenvironment subpopulation composition. The results could be used to risk group stratification of patients with nodular sclerosis Hodgkin lymphoma in order to predict the response to initial phase of therapy, as well as to determine personalized treatment approaches.

A Case Study of Sandplay Therapy for a Boy with Tic

Objectives: This study examined sandplay therapy in an elementary school boy with tic problems. The goal of the therapy was to reduce his tic problems by offering a free and protected space of sandplay therapy.Methods: The sandboxes were analyzed focusing on analytical psychology and theories of sandplay therapy using Turner (2005)’s content themes, which were the most comprehensive themes.Results: Seventy-seven therapy sessions were performed. The client showed a race car that was stuck in the sand and then rescued by forklifts in the initial phase of therapy (1-2, a race car stuck in the sand). In the intermediate phase of the therapy (3-70, struggle), he showed regression, meeting the opposites, victory of small animals, construction, and death. In the final phase of therapy (71-77, race, death II, adaptation to reality), he showed race, death, and adaptation to reality.Conclusion: The client who was entering adolescence saw life as a race. However, the race car that was moving toward masculinity was stuck in the sand. Therefore, the car was sent for repairs. In the middle of the therapy, the boy showed various fights, accidents, and construction. Lastly, there were deaths of an alligator and a bear. By showing a football match, the long journey of developing ego ended. During the therapy, archetypal patterns, such as regression to the primitive psyche, the journey of masculinity as a boy, and confrontation between good and bad, appeared. Sandplay therapy, in a free and protected space, relieved the client’s tic problems with improvement of his daily life. Thus, this study demonstrates the effectiveness of sandplay therapy.

Dengue-like fever and risk of hepatic injury following paracetamol overuse

Background: Dengue is one of the most feared seasonal diseases in India. The most significant symptoms associated with it are severe myalgia, headache, and fever. Since the disease carries a significant risk of bleeding, the drug of choice to combat these in-tolerable symptoms is paracetamol only, which frequently has to be used at supra therapeutic doses. Aims and Objectives: This study aims to evaluate the risk of hepatic injury following paracetamol over use in case of dengue-like fever. Materials and Methods: In this retrospective observational study, patient who required at least 4 g/day of paracetamol and whose medical records of 1 year were available following this disease were included in this study. Results: We would procure complete record of 33 patients who had received maximum or supratherapeutic dose of paracetamol. Mean alanine transferase was 50 after 12 h of therapy which rose to more than 1500 on day 3, started declining on day 7, and subsided by day 21. However, this did not correspond to ultrasonography finding where residual hepatic pathology was detected in 18% of cases. Conclusion: We suggest addition of hepatic protective agents such as methionine/N-acetylcysteine/others to be included during the initial phase of therapy with paracetamol in these cases. Supratherapeutic dose of paracetamol in variably produces hepatic injury, most of them benign but in significant number of cases, it leaves behind residual scarring.

Opening Up: Clients' Inner Struggles in the Initial Phase of Therapy.

ObjectiveTo explore how clients in clinical settings experience the process of opening up and sharing their inner experiences in the initial phase of therapy.MethodsTwo psychotherapy sessions of clients (N = 11) were videotaped and followed by interviews. Interpersonal process recall was used to obtain in-depth descriptions of clients’ immediate experiences in session. A follow-up interview was conducted 3 months later. The interviews were analyzed using thematic analysis.ResultsThe data revealed how and why clients distanced themselves from inner experiences in the initial phase of therapy. The overarching theme was “Holding back and struggling to open up,” which included four subthemes: (a) fearing the intensity and consequences of negative emotions; (b) experiences of being incapable and bodily stuck; (c) being insecure about one’s worthiness and right to share inner experiences with the therapist; and (d) struggling with feeling disloyal to loved ones.ConclusionThe participants held back because they feared different consequences of opening up. A range of concerns led participants to distance themselves from their inner experiences and/or to refrain from openly talking about them to the therapist. Concerns related to appropriate interpersonal conduct as client were especially important. This knowledge is highly relevant to clinicians when building safety for psychotherapeutic work.

Invasive Fungal Infections in Pediatric Patients with High-Risk Acute Lymphoblastic Leukemia during Initial Phases of Therapy: A Retrospective Evaluation

BACKGROUND Patients with newly diagnosed acute lymphoblastic leukemia (ALL) are at increased risk of infection. While previously published guidelines recommend primary antifungal prophylaxis in patients with T-cell ALL, we sought to determine the pattern of invasive fungal disease (IFI) at our center so as to assess risk factors for IFI, beyond the diagnosis of T-ALL, with the administration of dexamethasone and an anthracycline during induction. The current practice at Children's Health Children's Medical Center Dallas is to provide primary antifungal prophylaxis with micafungin during induction therapy for hospitalized patients with T-cell ALL and those with Down Syndrome. Additionally, we recently decided to provide primary antifungal prophylaxis to patients with HR B-ALL with hyperglycemia who remain hospitalized during induction. The primary objective of this study was to capture the institution-specific five-year incidence of IFI prior to the start of delayed intensification (DI) phase chemotherapy among pediatric patients with ALL. Secondary objectives were to identify potential IFI risk factors specifically amongst pediatric patients with HR ALL. METHODS This retrospective chart review included patients younger than 21 years with newly diagnosed ALL between July 1, 2014 and June 30, 2019. Patients with secondary leukemia, infantile leukemia, or those receiving treatment for a fungal infection at presentation were excluded. The primary outcome was the development of probable or proven IFI, as defined by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group criteria, prior to the start of the DI phase of therapy. Statistical methods included Chi-square test, t-test, and Wilcoxon Rank Sum test, as appropriate to the variable's level of measurement and distribution. Time series analyses were used to assess overall and seasonal trends of IFI incidence over the study period. RESULTS Of 220 included patients, there were 13 cases of IFI diagnosed during the induction and consolidation phases of therapy during the five-year period. IFI occurred in 15.3% of the HR group (11/72), 5.9% of the T-cell ALL group (1/17), and 0.8% of the standard risk (SR) group (1/131). Among individuals with HR ALL, the majority of cases occurred in the absence of primary antifungal prophylaxis (90.9%). The most common sites of IFI included the lungs (n=6) and sinuses (n=4). Implicated fungal pathogens included Aspergillus, Candida, Curvularia, Exserohilum, and Bipolaris. Univariate analysis of the potential IFI risk factors in HR ALL patients did not identify any significant differences between those patients that did or did not develop IFI, with respect to pre-existing comorbidities, body mass index, laboratory results at diagnosis, or hospital exposures during induction including length of stay, intensive care admissions, and receipt of systemic antibiotics (Table). Race and ethnicity was significantly different likely due to the skewed distribution of IFI among patients who identified as Asian (p = 0.03; 8/8 identified as Asian and did not develop IFI). With respect to seasonality of ALL diagnosis, the percent of patients in each group (winter, spring, summer, and fall) that developed IFI were 7.4%, 18.2%, 20%, and 31.2%, respectively. However, time series analysis did not show an association between seasonality of diagnosis and development of IFI (p=0.89). During the induction phase of therapy, hyperglycemia, defined as blood glucose 140-200 mg/dL for ≥ 2 days or >200 mg/dL for 1 day, was present in 100% of the HR patients that developed IFI and 74% of the HR patients that did not develop IFI (p=0.12). CONCLUSION In this pediatric population, patients with HR B-ALL developed more fungal infections during the early phases of therapy then those with SR disease (15.6% versus 0.8%). In analysis of potential risk factors, there were no significant differences between HR ALL groups that did or did not develop IFI. Larger-scale studies are needed in order to identify potential risk factors that will guide decisions on the routine use of primary antifungal prophylaxis in patients with HR ALL during induction therapy. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Micafungin use for primary antifungal prophylaxis during induction phase of therapy.

A Case Study of Sandplay Therapy for a Middle-aged Woman Who Goes the Way of Individuation Through Conflicts with an Adolescent Son

This study explored a sandplay therapy case of a woman maturing through conflicts with an adolescent son. The goal of the therapy was to relieve her from conflicts with going through individuation process under a free and protected space in sandplay therapy. Forty-six therapy sessions were held. The client exhibited that she needed a conversation with her feminity and maternity in the initial phase of therapy (1-5, regression). In the intermediate phase of therapy (6-43, struggle), she displayed the scenes of meeting of opposites, shadow, death, nurturing and integration of opposites. In the final phase of therapy (44-46, transformation), she showed the acception of her life with leaving her situations to God. Through sandplay therapy in the free and protected space, this study showed the effectiveness of sandplay therapy since the client achieved individuation by showing the acceptance of her life and could control her enraged feelings.

CHANGING EMBODIED RELATIONAL PATTERNS IN METACOGNITIVE INTERPERSONAL THERAPY

Individuals with personality disorders tend to attribute meaning according to stereotyped relationship patterns which prevent them from achieving social adaptation and fulfilment. These mental patterns are more than mere cognitive representations of the self and others. They are embodied and laden with affect, behavioral dispositions, and somatic experiences. The main purpose of this work is to present how metacognitive interpersonal therapy provides a platform for changing embodied patterns, via imagery and sensorimotor work. As discussed, these techniques facilitate the revision of the embodied component of maladaptive patterns and promote the emergence of new and healthier patterns. These new patterns comprise more adaptive aspects and correspondingly impede the enactment of previous maladaptive coping strategies that were driven by pathological schemas. We note how experiential work is best performed in a context of constant regulation of the therapeutic relationship, in order to detect any possible relational impasses and ruptures, reflecting on them until they are repaired. We also show the use of techniques in the initial phase of therapy to allow a more dynamic and rich case formulation. Finally, we discuss the implications of how experiential work might be a crucial component in psychotherapy for persons experiencing severe interpersonal problems such as personality disorders

Management of adverse effects of opioid therapy

More than 6 million people in Germany suffer from chronic pain which greatly impairs their wellbeing. Often the only therapeutic option is to use class 2 or 3 analgesic opioids in the WHO classification, as class 1 analgesics may be toxic or of limited efficacy. However, the high incidence of opioid side effects leads to high discontinuation rates. Thus, the success of opioid treatment is also highly dependent on the management of the safety and tolerability of the treatment. Most opioid side effects, such as nausea and sedation, predominantly occur in the initial phase of therapy. In contrast, opioid-induced constipation can last throughout opioid therapy. First-line treatment with laxatives does not solve the problem in all patients. Possible second-line therapies include opioid receptor antagonists, such as Naloxone, oral-administered Naloxegol, or subcutaneously given Methylnaltrexone. The discussion also covers the management of other common side effects of opioids, such as nausea, vomiting, sedation, pruritus, micturition disorder, and further symptoms.

Long-Term (15 to 20 Years) Outcomes of Papillae Preservation Flap Surgery in Esthetic Areas.

Several techniques have been proposed to maintain full papillary form and preserve soft tissue during periodontal surgical access. However, very little evidence of long-term results is available. The aim of the present paper is to report the 15- to 20-year follow-up outcomes of a case series study of papillae preservation flap surgery in esthetic areas. Twenty-two patients (10 women, 12 men; mean age: 41.3 years) with moderate to advanced generalized periodontitis were included in this study carried out in a private office from 1994 to 1996. In each patient, nonsurgical therapy with scaling and root planing was performed. Following this initial phase of therapy and the periodontal re-evalutaion, a papillae preservation flap surgery was performed in the anterior maxillary area in each subject. Full-mouth Plaque Index (FMPI), Gingival Index (GI), full-mouth Bleeding Score (FMBS), probing depth (PD), bleeding on probing (BOP), clinical attachment level (CAL), gingival recession (GR), and papilla height (PH) were assessed at the baseline and at each year of the follow-up. GI and BOP decreased with a statistical difference after surgery (P < .05) and remained low over the entire observation period. At the end of the follow-up period, PD and CAL decreased significantly (P < .05) compared to baseline (PD from 7.18 ± 0.91 mm to 2.98 ± 0.49 mm; CAL from 8.06 ± 1.2 mm to 4.01 ± 0.28 mm). Gingival recession and papilla height did not change significantly after surgery compared to baseline (GR from 0.88 ± 0.42 mm to 0.92 ± 0.36 mm; PH from 5.6 ± 1.1 mm to 4.2 ± 0.8 mm) and remained stable over the 15 to 20 years of the study (GR = 1.12 ± 0.36 mm; PH = 4.9 ± 0.9 mm) (P > .05). Results of the present long-term study show that the papillae preservation flap procedure may be applied successfully to the treatment of periodontal pockets in the maxillary anterior region.

Treatment trends in periodontics.

This volume of Periodontology 2000, entitled "Treatment Trends in Periodontics", evaluates the importance of nonsurgical periodontal therapy and defines its role as the key etiologic treatment of the disease. The need for scaling and root planing is mandatory step during the initial phase of therapy, as is self-care by the patient. Only after reevaluation of the outcome achieved by nonsurgical procedures should surgery be considered, and the concept of "critical probing depth" is emphasized. The chapters in this volume discuss different aspects of periodontal surgery, including regeneration and plastic periodontal procedures, and, looking toward the future, cell therapy in periodontics is explored. The impact of periodontal therapy on systemic diseases is reviewed, and the role of occlusion in periodontal disease is revisited and discussed. Topics on implants include their placement in fresh extraction sockets, socket healing with or without implant placement, and research on osseointegration. The important topic of maintenance care of teeth and implants for long-term therapeutic success is thoroughly evaluated, as is the efficacy of dentifrices in oral hygiene. The editors convey a nutshell review of the concepts of what periodontal treatment should entail, based on scientific evidence generated during half-a-century of work in periodontics.

A Retrospective Study on Prephase Therapy Prior to Definitive Multiagent Chemotherapy in Aggressive Lymphomas

Background: Diffuse large B-cell lymphoma (DLBCL) and Burkitt lymphoma (BL) are aggressive lymphomas that evolve rapidly and are fatal if untreated. Most treatment-related toxicities occur during the initial phase of therapy, particularly in the elderly and in patients with a high disease burden. Prephase therapy is used as a preventive strategy prior to definitive multiagent chemotherapy to ameliorate the development of toxicity, such as febrile neutropenia, tumor lysis syndrome, deterioration in performance status, and death. While this approach is often implemented, there are few data supporting when to initiate a prephase regimen, or whether this approach will be effective. We present data from our experience at the University of North Carolina Cancer Hospital.Methods: We conducted a retrospective analysis of patients (pts) diagnosed with DLBCL and BL between January 2016 and December 2017. Pts were divided into ‘prephase’ (PP) and ‘non-prephase’ (NPP) groups. The PP group received either prednisone (P) alone at 60 mg/kg oral daily from day -6 to day -1, or in combination with vincristine (V) 1 mg intravenously on day -6 (VP regimen), cyclophosphamide 200 mg/m2 on day -6 (CP regimen), or all three drugs (CVP regimen). Multiagent chemotherapy was given at day 0. Both groups were evaluated until day 30. ECOG performance status (PS), grade 3-4 cytopenias, absolute neutrophil count (ANC) and platelet nadirs, time to ANC and platelet recovery, episodes of febrile neutropenia, hospitalization and emergency (ER) visits, and next cycle dose reduction or delay, were compared in both groups.Results: Ninety-two pts (DLBCL n=82, and BL n=10) were identified. Clinical characteristics are shown in Table 1. Twenty-two pts received PP therapy (vs. NPP n=70). Median age at diagnosis was 59 years and 61 years for PP and NPP group, respectively. Female predominance was observed in both groups (PP 59% and NPP 54%). Poor baseline ECOG PS was significantly different between the PP and NPP group (median score 2 vs. 0, p<0.001). Stage III-IV and bulky disease were more common in the PP group, although this was not statistically significant. Oral prednisone was the most common prephase therapy used (P n=17, VP n=1, CP n=1, CVP n=3). All regimens were well tolerated. Definitive chemotherapy regimens and outcomes are summarized in Table 2. The PP group had a significant improvement in PS from a median PS of 2 at baseline to a median PS of 1 (p<0.001) by day 14. The NPP group did not have a significant change in PS. In a subgroup analysis, both pts older than 60 years with any PS (n=10, p=0.027), and pts 60 years or younger with a PS of 2 or more (n=6, p=0.023) had a significant improvement in PS after prephase therapy. PP pts had a shorter time for ANC and platelet count recovery than NPP pts (ANC 4 vs. 8 days, p=0.013; platelet 4 vs. 9 days, p=0.023). The platelet nadir was significantly lower in the PP (80 x 109 plt/L) compared to the NPP group (150 x 109 plt/L) (p=0.025). There was no significant difference in the episodes of febrile neutropenia.Conclusions: Prephase therapy significantly improved PS by day 14 of definitive multiagent chemotherapy at first cycle. The overall improvement in PS was primarily caused by improvements in 2 groups: pts older than 60 years, and pts 60 years or younger with poor PS (ECOG PS 2 or more). This is consistent with who we would expect to benefit the most from prephase therapy. Patients who received prephase therapy had a significant reduction in the length of their ANC nadir, although, interestingly, the rate of febrile neutropenia was low in both arms. The length of the platelet nadir was also significantly reduced in the PP group. Conversely, the depth of platelet nadir was significantly lower in the PP group, which may be a reflection of more aggressive disease in this group. The prephase group trended towards a reduction in the number of hospital admissions, ER visits, and next cycle dose reduction or delays, but these did not reach statistical significance. Based on these results, we will implement a provider reminder to consider prephase therapy when using multiagent chemotherapy in pts with aggressive lymphomas older than 60 years, or pts <60 with PS of 2 or greater. [Display omitted] DisclosuresGrover:Seattle Genetics: Consultancy. Dittus:Seattle Genetics: Consultancy.

A Case Study of Sandplay Therapy for a Woman with a Negative Mother Complex Who Wants to be Free From Family Life

This study explored the sandplay therapy case of a woman with a negative mother complex who wants to be free from family life. The goal of the therapy was to make her free from family life by expressing repressed emotions for getting out of a negative mother complex under a free and protected space in sandplay therapy. Twenty-three therapy sessions were held. The client exhibited a singing woman in a gorgeous dress and things she wanted to do in the initial phase of therapy (1-4, forgotten myself). In the intermediate phase of therapy (5-15, differentiation and integration), she displayed the scenes of differentiation and integration by emotionally getting rid of a begging boy and making mandalas. In the final phase of therapy (16-23, recovered myself), she showed scenes of rebirth, upgrading and singing songs again in front of family members and many people. Through sandplay therapy in the free and protected space, this study showed the effectiveness of sandplay therapy since the client achieved individuation by showing rebirth, having a new personality. Keywords: sandplay therapy, negative mother complex, individuation, rebirth

Predicting dropout in adolescents receiving therapy for depression

Objective: Therapy dropout is a common occurrence, especially in adolescence. This study investigated whether dropout could be predicted from a range of child, family, and treatment factors in a sample of adolescents receiving therapy for depression. Method: This study draws on data from 406 participants of the IMPACT study, a randomized controlled trial, investigating three types of therapy in the treatment of adolescent depression. Logistic regression was used to estimate the effects of predictors on the odds of dropout. Results: Few pre-treatment predictors of dropout were found, with the only significant predictors being older age, antisocial behaviour, and lower scores of verbal intelligence. Missed sessions and poorer therapeutic alliance early in treatment also predicted dropout. Most child and family factors investigated were not significantly associated with dropout. Conclusions: There may be little about depressed adolescents’ presentation prior to therapy starting that indicates their risk of dropout. However, within-treatment factors indicated that warning signs of dropout may be identifiable during the initial phase of therapy. Identifying and targeting early treatment indicators of dropout may provide possibilities for improving engagement.Clinical and methodological significance of this article: In the literature, a great deal of attention has been paid to child and family factors that predict therapy dropout, yet in this study, few pre-treatment characteristics were predictive of dropout. However, findings revealed possible warning signs of dropout in the early part of treatment, as poor therapeutic alliance and missed sessions were both found to be predictive of dropout. These findings call for therapists to be aware of such warning signs and clinical guidelines for managing cases at risk of dropout are warranted.

A Case Study of Sandplay Therapy with a Middle-Aged Woman Having Difficulty in Relationships

This study explored the sandplay therapy case of a middle-aged woman having difficulty with interpersonal relationships and wanting to increase her self-identity. The goal of the therapy was to change her relationships with others by self-examination and becoming conscious of her negative animus and femininity in a free and protected space provided by sandplay therapy. Forty-five therapy sessions were held. The client exhibited her lonesomeness and fantasies by making sandtrays of a house she would like to live in, a park she would like to relax at and dreams she would like to fulfill in the initial phase of therapy (1~8, Who am I?). In the intermediate phase of therapy (9~33, Meeting myself), she displayed scenes of her negative self and breaking away from her negative self by making sandtrays of shadows, deaths, creations, a soaring scene and a disappearing alligator. In the final phase of therapy (34~45, Discovery of the real Self), she showed scenes of her meeting a positive self by making sandtrays of hope, coexistence, start, harmony and community. This study showed the effectiveness of sandplay therapy since the client’ relationships with others were improved through her self-awareness by sandplay therapy in the free and protected space. Keywords: sandplay therapy, middle-aged woman, difficulty in relationships, individuation

Management of adverse effects of opioid therapy

More than 6 million people in Germany suffer from chronic pain which greatly impairs their wellbeing. Often the only therapeutic option is to use class 2 or 3 analgesic opioids in the WHO classification, as class 1 analgesics may be toxic or of limited efficacy. However, the high incidence of opioid side effects leads to high discontinuation rates. Thus, the success of opioid treatment is also highly dependent on the management of the safety and tolerability of the treatment. Most opioid side effects, such as nausea and sedation, predominantly occur in the initial phase of therapy. In contrast, opioid-induced constipation can last throughout opioid therapy. First-line treatment with laxatives does not solve the problem in all patients. Possible second-line therapies include opioid receptor antagonists, such as Naloxone, oral-administered Naloxegol, or subcutaneously given Methylnaltrexone. The discussion also covers the management of other common side effects of opioids, such as nausea, vomiting, sedation, pruritus, micturition disorder, and further symptoms.

International Normalized Ratio Relevance to the Observed Coagulation Abnormalities in Warfarin Treated and Those with Disseminated Intravascular Coagulation

Introduction: Disseminated intravascular coagulation (DIC) occurs as a complication of many underlying diseases. DIC is characterized by an ongoing systemic activation of the coagulation and fibrinolytic systems, which can exhaust coagulation factors, ultimately leading to bleeding. The International Society of Thrombosis and Hemostasis (ISTH) criteria for DIC consists of a scoring system that includes decreased platelet count, increased D-dimer/Fibrin degradation products, prolonged PT/INR, and decreased fibrinogen. Patients receiving warfarin for anticoagulation also have a prolonged PT/INR. Although the target INR for patients on warfarin is between 2.0 and 3.0, patients may have an INR of less than 2.0 during the initial phase of therapy. The purpose of this study was to compare the coagulopathy observed in patients with DIC and in patients in the initial phase of warfarin therapy.Methods: Citrated de-identified plasma samples were collected at baseline from patients diagnosed with sepsis-associated DIC (n= 100) and from patients in the initial phase of warfarin therapy (n=100) that were collected under an IRB approved protocol. These plasma samples were evaluated for PT/INR (Recombiplastin, Instrumentation Laboratory, Bedford, MA), APTT (Platelin, Stago, Parsippany, NJ) , fibrinogen (Recombiplastin, Bedford, MA) and functional (Aniara, West Chester, OH) and antigenic levels (Hyphen Biomed, Paris, France) of Factors VII, IX and X.Results: The PT/INR values were statistically significantly higher in warfarinized patients compared to DIC patients (p<0.001). The APTT showed no correlation with the INR in warfarinized patients but increased with an increase in the INR in the DIC group (p<0.001). Similarly, the fibrinogen levels showed no correlation with INR in warfarinized patients; however, in DIC patients, the fibrinogen levels decreased with an increase in the INR. In the factor assays, both the functional and antigenic levels of factors IX and X were decreased in the anticoagulated patients as INR increased, but showed no variation with INR in the DIC patient group. Factor VII levels were decreased with an increased INR in the anticoagulated patients but not the DIC patients. Results for each factor by INR category are shown in Table 1 (warfarinized patients) and Table 2 (DIC patients).Conclusions: An increase in INR correlated with an increase in APTT and a decrease in fibrinogen in DIC patients but not in patients receiving anticoagulation. Interestingly, in DIC patients, there was no definite tendency in either the functional Factor VII, IX and X or antigen Factor IX or X levels. This contrasts with patients receiving warfarin anticoagulation, where the Factor VII, IX, and X levels all decrease with an increasing INR. In warfarinized patients, changes in coagulation factor levels, but not in global coagulation parameters such as APTT and fibrinogen are demonstrated. However, in DIC greater changes in global coagulation parameters but less consistent changes in factor levels are observed. These results suggest that the coagulopathy observed in a patient with INR ≥ 1.4 is fundamentally different in a patient receiving warfarin for anticoagulation than in a patient with DIC. [Display omitted] [Display omitted] DisclosuresTsuruta:Asahi Kasei Pharma America: Employment.

Temporomandibular Disorders in Patients Undergoing Mandibular Advancement Device Therapy for Obstructive Sleep Apnea: A Systematic Review

Background: Mandibular advancement device (MAD) therapy is a popular and effective treatment for snoring and obstructive sleep apnea (OSA). However, there have been several reports in the literature of patients developing temporomandibular disorders (TMDs).&#x0D; Objective: The objective of this review is to evaluate the prevalence of TMD, both in the initial phase of therapy and at follow up appointments, amongst patients wearing a MAD for OSA.&#x0D; Methods: The authors conducted a systematic review of published articles in which the presence of TMDs in patients undergoing MAD therapy for OSA was investigated. Eligible studies met the following criteria: a diagnosis of TMD following mandibular advancement using a custom-made and titratable MAD using either the Diagnostic Criteria for TMD (DC/TMD), Helkimo Anamnestic Dysfunction Index or reproducible clinical signs/symptoms.&#x0D; Results: The average prevalence of TMD during the initial phase of MAD therapy was found to be 25%. The prevalence of TMD reduced in the follow up periods. The adherence to MAD, especially long term, appears to be variable and from our results, it appears an average of 20% of patients discontinue MAD therapy over six to one hundred and twenty months, and this number has been reported to be as high as 62.5%.&#x0D; Conclusions: There was some difficulty in comparing the studies due to the differences in follow up time, methodology, sample size and diagnostic criteria. Longer clinical follow-up studies, with an objective method of monitoring patient adherence and with a larger sample size are needed to evaluate the long-term effects of MADs