RESUMEN
OBJECTIVES: The purpose of this study was to assess surgical availability and readiness in 8 African countries using the WHO's Service Availability and Readiness Assessment (SARA) tool. SETTING: We analysed data for surgical services, including basic and comprehensive surgery, comprehensive obstetric care, blood transfusion, and infection prevention, obtained from the WHO's SARA surveys in Sierra Leone, Uganda, Mauritania, Benin, Zambia, Burkina Faso, Democratic Republic of Congo and Togo. PRIMARY AND SECONDARY OUTCOME MEASURES: Among the facilities that were expected to offer surgical services (N=3492), there were wide disparities between the countries in the number of facilities per 100â 000 population that reported offering basic surgery (1.0-12.1), comprehensive surgery (0.1-0.8), comprehensive obstetric care (0.1-0.8) and blood transfusion (0.1-0.8). Only 0.1-0.3 facilities per 100â 000 population had all three bellwether procedures available, namely laparotomy, open fracture management and caesarean section. In all the countries, the facilities that reported offering surgical services generally had a shortage of the necessary items for offering the services and this varied greatly between the countries, with the facilities having on average 27-53% of the items necessary for offering basic surgery, 56-83% for comprehensive surgery, 49-72% for comprehensive obstetric care and 54-80% for blood transfusion. Furthermore, few facilities had all the necessary items present. However, facilities that reported offering surgical services had on average most of the necessary items for the prevention of infection. CONCLUSIONS: There are important gaps in the surgical services in the 8 African countries surveyed. Efforts are therefore urgently needed to address deficiencies in the availability and readiness to deliver surgical services in these nations, and this will require commitment from multiple stakeholders. SARA may be used to monitor availability and readiness at regular intervals, which will enable stakeholders to evaluate progress and identify gaps and areas for improvement.
Asunto(s)
Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Servicio de Cirugía en Hospital/estadística & datos numéricos , Benin , Burkina Faso , República Democrática del Congo , Países en Desarrollo , Humanos , Mauritania , Estudios Retrospectivos , Sierra Leona , Togo , Uganda , ZambiaRESUMEN
BACKGROUND: Cerebral palsy (CP) has largely been an unaddressed problem in low and middle income countries (LMIC's). The purpose of this retrospective study is to provide a facility-based snapshot of CP in Nepal. METHODS: A retrospective chart review of 1001 patients diagnosed as having cerebral palsy, presenting to our institution from December 2008 to December 2011, was carried out. RESULTS: Majority of cases were found to be a result of birth complications and post-natal infections. Most children with CP were born at home, presented after walking age and came from socioeconomically unstable or borderline households. Less than 20% were attending school. Spastic diplegia was the most common presentation. Children with post-natal spasticity secondary to infection seemed to retain greater ambulatory potential. CONCLUSIONS: In contrast to CP in developed countries, the etiology in LMIC's is largely related to birth-related complications and post-natal infections. There is an urgent need to address preventable causes of cerebral palsy in Nepal.
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Parálisis Cerebral/epidemiología , Hospitales Pediátricos/estadística & datos numéricos , Adolescente , Distribución por Edad , Parálisis Cerebral/etiología , Parálisis Cerebral/fisiopatología , Niño , Preescolar , Enfermedades Transmisibles/complicaciones , Femenino , Humanos , Lactante , Recién Nacido , Enfermedades del Recién Nacido/epidemiología , Masculino , Espasticidad Muscular , Nepal/epidemiología , Embarazo , Complicaciones del Embarazo , Características de la Residencia , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores SocioeconómicosRESUMEN
Methylglyoxal (MGO) is a major glycating agent that reacts with basic residues of proteins and promotes the formation of advanced glycation end products (AGEs) which are believed to play key roles in a number of pathologies, such as diabetes, Alzheimer's disease, and inflammation. Here, we examined the effects of MGO on immortalized mouse hippocampal HT22 nerve cells. The endpoints analyzed were MGO and thiol status, the glyoxalase system, comprising glyoxalase 1 and 2 (GLO1/2), and the cytosolic and mitochondrial Trx/TrxR systems, as well as nuclear Nrf2 and its target genes. We found that nuclear Nrf2 is induced by MGO treatment in HT22 cells, as corroborated by induction of the Nrf2-controlled target genes and proteins glutamate cysteine ligase and heme oxygenase 1. Nrf2 knockdown prevented MGO-dependent induction of glutamate cysteine ligase and heme oxygenase 1. The cystine/glutamate antiporter, system xc(-), which is also controlled by Nrf2, was also induced. The increased cystine import (system xc(-)) activity and GCL expression promoted GSH synthesis, leading to increased levels of GSH. The data indicate that MGO can act as both a foe and a friend of the glyoxalase and the Trx/TrxR systems. At low concentrations of MGO (0.3mM), GLO2 is strongly induced, but at high MGO (0.75 mM) concentrations, GLO1 is inhibited and GLO2 is downregulated. The cytosolic Trx/TrxR system is impaired by MGO, where Trx is downregulated yet TrxR is induced, but strong MGO-dependent glycation may explain the loss in TrxR activity. We propose that Nrf2 can be the unifying element to explain the observed upregulation of GSH, GCL, HO1, TrxR1, Trx2, TrxR2, and system xc(-) system activity.
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Oxidorreductasas de Alcohol/metabolismo , Regulación de la Expresión Génica/efectos de los fármacos , Hipocampo/metabolismo , Neuronas/metabolismo , Piruvaldehído/farmacología , Tiorredoxina Reductasa 1/metabolismo , Tiorredoxinas/metabolismo , Oxidorreductasas de Alcohol/genética , Animales , Apoptosis , Western Blotting , Proliferación Celular , Células Cultivadas , Glutatión/metabolismo , Hemo-Oxigenasa 1/genética , Hemo-Oxigenasa 1/metabolismo , Hipocampo/citología , Hipocampo/efectos de los fármacos , Inmunoprecipitación , Proteínas de la Membrana/genética , Proteínas de la Membrana/metabolismo , Ratones , Factor 2 Relacionado con NF-E2/genética , Factor 2 Relacionado con NF-E2/metabolismo , Neuronas/citología , Neuronas/efectos de los fármacos , Proteínas Nucleares/genética , Proteínas Nucleares/metabolismo , ARN Mensajero/genética , Reacción en Cadena en Tiempo Real de la Polimerasa , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Tiorredoxina Reductasa 1/genética , Tiorredoxinas/genéticaRESUMEN
BACKGROUND: The sequelae of acute musculoskeletal conditions, especially injuries and infections, are responsible for significant disability in low- and middle-income countries. This study characterizes the availability of selected musculoskeletal surgical services at different tiers of the health system in a convenience sample of 883 health facilities from 24 low- and lower-middle-income countries. METHODS: Selected data points from the World Health Organization's (WHO) tool of situational analysis of surgical availability were extracted from the WHO's database in December, 2013. These included infrastructure, physical resources and supplies, interventions, and human resources. For a descriptive analysis, facilities were divided into two groups based on number of beds (<100, 100-300, and >300) and level of facility (primary referral, secondary/tertiary, and Private/NGO/Mission). Statistical comparison was made between public and Private/NGO/Mission facilities based on number of beds (≤100, 100-300, and >300) using a Chi-Square analysis, with statistical significance at p < 0.05. FINDINGS: Significant deficiencies were noted in infrastructure, physical resources and supplies, and human resources for the provision of essential orthopedic surgical services at all tiers of the health system. Availability was significantly lower in public versus Private/NGO/Mission facilities for nearly all categories in facilities with ≤100 beds, and in a subset of measures in facilities with between 100 and 300 beds. INTERPRETATION: Deficiencies in the availability of orthopedic surgical services were observed at all levels of health facility and were most pronounced at facilities with ≤100 beds in the public sector. Strengthening the delivery of essential surgical services, including orthopedics, at the primary referral level must be prioritized if we are to reduce the burden of death and disability from a variety of emergent health conditions. FUNDING: There were no sources of funding.
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Países en Desarrollo/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales , Equipo Ortopédico/provisión & distribución , Procedimientos Ortopédicos , Ortopedia , Recursos en Salud/provisión & distribución , Capacidad de Camas en Hospitales , Humanos , Recursos HumanosRESUMEN
Our goal was to evaluate the use of Ponseti's method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel-toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.
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Pie Equinovaro/terapia , Manipulación Ortopédica/métodos , Moldes Quirúrgicos , Niño , Preescolar , Pie Equinovaro/fisiopatología , Pie Equinovaro/cirugía , Femenino , Estudios de Seguimiento , Marcha , Humanos , Masculino , Osteotomía/métodos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tenotomía/métodos , Resultado del Tratamiento , Soporte de PesoRESUMEN
We performed a clinical and radiographic review of 15 patients (19 limbs) with longitudinal deficiency of the tibia treated between 1981 and 2001. Ten limbs with Kalamchi type I deficiencies were managed by through-knee amputation. Five type II deficiencies were treated by foot ablation and tibiofibular synostosis, either at the same time or staged, but prosthetic problems may arise from varus alignment and prominence of the proximal fibula. Patients with type III deficiencies (four cases) were treated by foot ablation. Prosthetic problems relating to proximal or distal tibiofibular instability may necessitate additional surgical intervention.
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Tibia/anomalías , Anomalías Múltiples , Amputación Quirúrgica , Preescolar , Desarticulación , Femenino , Humanos , Lactante , Masculino , Radiografía , Tibia/diagnóstico por imagen , Tibia/cirugíaRESUMEN
[reaction: see text] Assembly of the carbocyclic core of CP-263,114 has been accomplished efficiently and in high yield. Key steps include a phenolic oxidation/intramolecular Diels-Alder sequence, tandem radical cyclization, and the late-stage fragmentation of a densely functionalized isotwistane skeleton.
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Inhibidores Enzimáticos/síntesis química , Anhídridos Maleicos/síntesis química , Ciclización , Indicadores y Reactivos , Modelos Moleculares , Oxidación-ReducciónRESUMEN
A review of clinical records and radiographs revealed that five of 10 patients with conjoined twinning (three of six ischiopagus and two of two pyopagus twins) had congenital vertebral anomalies including hemivertebrae (3), multiple thoracic anomalies (1), right hemisacral agenesis (1), and three lumbar vertebra (1). No mirror image anomalies were identified, and different regions of the spine were involved in the two cases in which both twins had anomalies. Coexisting visceral and musculoskeletal anomalies included dextrocardia (3), atrial septal defect (1), congenital vertical talus (2), Sprengel's deformity (1), and multiple unilateral foot anomalies (1). Hip subluxation or dislocation was seen in five of eight ischiopagus or pyopagus twins after separation and required femoral and pelvic osteotomies. Lumbar scoliosis not associated with congenital vertebral anomalies was seen in two ischiopagus twins. These observations suggest an association between ischiopagus and pyopagus conjoined twins and congenital vertebral anomalies, and their coexistence is explained best by a nonspecific teratogenic insult during early embryogenesis.
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Isquion/anomalías , Isquion/cirugía , Columna Vertebral/anomalías , Columna Vertebral/cirugía , Gemelos Siameses/cirugía , Humanos , Recién Nacido , Isquion/diagnóstico por imagen , Radiografía , Columna Vertebral/diagnóstico por imagenRESUMEN
STUDY DESIGN: This in vitro biomechanical study examines segmental anterior vertebral screw strain and solid rod construct stiffness with and without the addition of multilevel, threaded cortical bone dowels in a bovine model. OBJECTIVE: To determine whether strain at the bone-screw interface is higher at the end levels during physiologic range loading, and whether solid interspace support decreases segmental strain on the implant. SUMMARY OF BACKGROUND DATA: Anterior instrumentation provides greater correction and preserves distal motion segments. However, nonunion and implant failure are observed more frequently than with posterior segmental instrumentation, and when observed, loss of fixation occurs at the end levels. METHODS: Eight calf spines underwent mechanical testing in the following sequence: 1) intact condition, 2) anterior release with anterior solid rod and bicortical rib grafts, and 3) anterior release with anterior solid rod and threaded cortical bone dowels (L2-L5). Instrumented vertebral screws were used to assess strain within the vertebral body by the near cortex, whereas an anterior extensometer spanning the instrumented segments was used to measure segmental displacements to calculate construct stiffness. The protocol included axial compression (-400 N), right lateral bending (4 Nm (Newton-meter), away from the implant), and left lateral bending (4 Nm, toward the implant). Statistical analysis included a one-way analysis of variance and a Student-Newman-Keuls post hoc test. A pilot study was performed using four additional specimens loaded for 4000 cycles to investigate macroscopic loosening after fatigue loading. RESULTS: In lateral bending toward the implant, the strain was higher at both end levels, with no differences between the rib and dowel reconstructions. The stiffness values were greater than the intact values for both groups. In lateral bending away from the implant, the strain also was higher at both end screws, and the dowel group had less strain at these levels than the rib group. Both groups were stiffer than the intact condition, and the dowel group was stiffer than the rib group. Axial compressive strain also was higher at the end levels, but this difference did not reach statistical significance. The rib group did not reach intact stiffness values, whereas the dowel group was stiffer than the intact condition. The fatigue study showed gross loosening at one or both end levels in all cases. CONCLUSIONS: Higher strain was observed at the bone-screw interface in both end screws of an anterior solid rod construct during lateral bending, which correlates with the clinically observed failure location. This suggests that physiologic range loading may predispose to failure at the end levels. Disc space augmentation with solid implants increased construct stiffness in all three load paths and decreased strain at the end levels in lateral bending away from the implant. Future implant modifications should achieve better fixation at the end screws, and the current model provides a means to compare different strategies to decrease strain at these levels.
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Tornillos Óseos , Vértebras Lumbares/fisiología , Vértebras Lumbares/cirugía , Fusión Vertebral/métodos , Animales , Bovinos , Fuerza Compresiva/fisiología , Análisis de Falla de Equipo , Técnicas In Vitro , Articulaciones/fisiología , Escoliosis/fisiopatología , Escoliosis/cirugía , Fusión Vertebral/instrumentaciónRESUMEN
Successful discontinuation of therapeutic drugs requires patients to negotiate two potentially difficult phases. First, they must complete the drug discontinuation procedure itself, which may entail coping with rebound and withdrawal symptoms as well as anxiety due to stopping a treatment on which they depend psychologically. Second, they must maintain drug abstinence over time, despite possible exacerbations or recurrences of the disorder that the drug was treating. For optimal success, interventions aimed at assisting patients to discontinue drug use must address both of those tasks. Patients' ability to discontinue benzodiazepines seems to be strongly influenced by cognitive appraisals of the threat represented by symptoms and of their own competence to cope with it without medication. For problems of that kind, cognitive and behavioral techniques such as those developed for the treatment of panic disorder may be especially well-suited. Currently, the most successful approaches to benzodiazepine discontinuation include the following components: (1) assisting with initial drug discontinuation, educating patients about benzodiazepine dependence and withdrawal, and about the kinds of symptoms that can emerge as the drug dose is decreased, combined with a flexible drug taper conducted in supportive collaboration with the patient; and (2) dealing with exacerbations of the illness, and providing disorder-specific cognitive-behavioral treatment as an alternative to the resumption of pharmacotherapy. It seems to be crucial that the drug taper be completed before psychological treatment concludes.
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Ansiolíticos/administración & dosificación , Benzodiazepinas/administración & dosificación , Trastorno de Pánico/tratamiento farmacológico , Síndrome de Abstinencia a Sustancias/psicología , Ansiolíticos/efectos adversos , Benzodiazepinas/efectos adversos , Humanos , Trastorno de Pánico/psicologíaRESUMEN
STUDY DESIGN: This static, nondestructive, in vitro biomechanical study examines anterior solid rod construct stiffness following the addition of multilevel, threaded cortical bone dowels in a bovine model. A comparison is made with a clinically relevant posterior construct with and without an anterior release. OBJECTIVES: To determine if the addition of solid, multilevel disc space implants will increase construct rigidity, while maintaining or enhancing anterior column length. SUMMARY OF BACKGROUND DATA: Anterior instrumentation for thoracolumbar and lumbar scoliosis has achieved greater correction and preserved distal motion segments; however, kyphosis over the instrumented segments and nonunion have been observed more frequently than with posterior segmental spinal instrumentation. METHOD: Fifteen calf spines underwent mechanical testing. Group A (n = 7) included anterior constructs: 1) intact, 2) anterior release/rod/rib graft (L2-L5), and 3) anterior release/rod/dowels (L2-L5). Group B (n = 8) included posterior constructs: 1) intact, 2) posterior rod without anterior release (T13-L5), 3) posterior rod (T13-L5)/anterior release/rib graft (L2-L5). The protocol included axial compression (-600 N), axial rotation (+7 Nm), flexion/extension (+7.5 Nm), and lateral bending (+7.5 Nm). An anterior extensometer measured segmental displacements to calculate construct stiffness. Lateral radiographs evaluated alignment for the anterior constructs. Statistical analysis involved a one way analysis of variance (ANOVA) and a Student-Newman-Keuls post hoc test. RESULTS: All reconstructions restored stiffness to intact values with the exception of the dowels alone in axial rotation. The rod/dowel construct was stiffer than all other groups in axial compression, flexion/extension, and lateral bending, with the exception of the posterior rod without discectomy, which was superior in flexion and statistically similar in extension, lateral bending, and axial rotation. The anterior construct with rib graft was equivalent to the posterior construct with rib graft in all modes of testing. The dowels created greater lordosis than the bicortical rib grafts. CONCLUSIONS: Disc space augmentation increased stiffness except in axial rotation, in which values were restored to the intact level. Stiffness was superior to a clinically relevant posterior instrumentation comparison group following anterior release, and was equivalent to a posterior construct without anterior release except in anterior flexion. In addition, the implants enhanced lordosis. Increased rigidity should improve rates of arthrodesis, while maintenance of sagittal alignment may prevent pathologic compensatory curves in adjacent spinal segments. Further research is required to determine the optimal method of achieving structural interspace support.
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Clavos Ortopédicos , Trasplante Óseo , Animales , Bovinos , Ensayo de Materiales , Costillas/trasplante , Escoliosis/cirugía , Estrés MecánicoRESUMEN
Aggressive fibromatosis is a rare fibroproliferative disorder with a variable biologic potential that is locally morbid but does not metastasize. Eighteen patients with extraabdominal fibromatosis were treated with a multidisciplinary approach over a 27-year period. Our observations, coupled with a review of the literature, suggest that conservative surgery with the goal of a wide margin coupled with adjuvant therapies may result in adequate control of disease from infancy to adolescence. Amputation should be reserved for cases in which the disease or its treatment have resulted in a nonfunctional or chronically painful extremity. Radiation should be used as a last resort in the skeletally immature because of the risk of growth disturbance, contracture, and secondary malignancy. Chemotherapy may have a role in children with inoperable disease, in those who have gross residual tumor after an intralesional procedure, for disease progression or recurrence, and neoadjuvant therapy should be investigated as a means to achieve a wide margin in some cases.
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Neoplasias Óseas/diagnóstico , Neoplasias Óseas/terapia , Fibromatosis Agresiva/diagnóstico , Fibromatosis Agresiva/terapia , Neoplasias de los Músculos/diagnóstico , Neoplasias de los Músculos/terapia , Adolescente , Neoplasias Óseas/mortalidad , Niño , Preescolar , Terapia Combinada , Progresión de la Enfermedad , Estudios de Evaluación como Asunto , Femenino , Fibromatosis Agresiva/mortalidad , Estudios de Seguimiento , Humanos , Lactante , Imagen por Resonancia Magnética , Masculino , Monitoreo Fisiológico , Neoplasias de los Músculos/mortalidad , Tasa de SupervivenciaAsunto(s)
Osteosarcoma/cirugía , Sacro/cirugía , Neoplasias de la Columna Vertebral/cirugía , Sobrevivientes , Adolescente , Quimioterapia Adyuvante , Supervivencia sin Enfermedad , Humanos , Imagen por Resonancia Magnética , Masculino , Aparatos Ortopédicos , Osteosarcoma/diagnóstico , Osteosarcoma/tratamiento farmacológico , Sacro/diagnóstico por imagen , Sacro/patología , Neoplasias de la Columna Vertebral/diagnóstico , Neoplasias de la Columna Vertebral/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Neoplasias Femorales/diagnóstico , Osteosarcoma Yuxtacortical/diagnóstico , Dolor/etiología , Muslo , Adolescente , Diagnóstico Diferencial , Diagnóstico por Imagen , Femenino , Neoplasias Femorales/patología , Neoplasias Femorales/cirugía , Fémur/patología , Fémur/cirugía , Humanos , Articulación de la Rodilla/patología , Articulación de la Rodilla/cirugía , Osteosarcoma Yuxtacortical/patología , Osteosarcoma Yuxtacortical/cirugíaRESUMEN
Pyomyositis initially was observed more commonly in the developing world but now is reported with increasing frequency in the United States. The presentation is nonspecific and the differential diagnoses are many. We found the clinical history, laboratory findings, and response to treatment similar to those observed in different areas of the world. Magnetic resonance imaging (MRI) with gadolinium injection, in addition to helping to make the diagnosis, may help differentiate between early and late stages that help guide treatment. Coexisting bone changes (58%) may represent either the sensitivity of MRI to reactive inflammatory changes or the presence of a coexisting osteomyelitis. All patients responded to antibiotics and drainage if abscesses were present. Although the optimal duration of antibiotic therapy remains unclear, a shorter course should be considered in patients with a good clinical response, even when MRI shows nonspecific bony abnormalities. Percutaneous drainage was successful in five cases and may represent an alternative to the traditional surgical approach.
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Infecciones Bacterianas , Miositis , Adolescente , Adulto , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/terapia , Niño , Preescolar , Femenino , Humanos , Lactante , Imagen por Resonancia Magnética , Masculino , Miositis/diagnóstico , Miositis/microbiología , Miositis/terapia , Estudios RetrospectivosRESUMEN
The present research evaluated patients from 2 previous studies (1 conducted in Peoria, the other at Dartmouth) during a 2- to 5-year posttreatment period. Results showed that 75% of the Peoria sample and 76% of the Dartmouth sample were able to discontinue alprazolam therapy, remain abstinent of any type of treatment for panic disorder, and maintain their acute-treatment clinical gains over this follow-up period. The degree to which patients' anxiety sensitivity declined during treatment predicted relapse versus survival during the 1st 6 months of follow-up, when most relapses occurred. Implications of these findings for benzodiazepine discontinuation, combined pharmacotherapy and psychotherapy, and relapse prevention in panic disorder are discussed.
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Alprazolam/uso terapéutico , Benzodiazepinas/uso terapéutico , Terapia Cognitivo-Conductual , Trastorno de Pánico/terapia , Alprazolam/administración & dosificación , Benzodiazepinas/administración & dosificación , Terapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Prevención Secundaria , Síndrome de Abstinencia a Sustancias/prevención & control , Análisis de SupervivenciaRESUMEN
Panic Control Treatment (PCT) is a widely used, empirically validated cognitive-behavioral treatment for panic disorder. Initially developed for the treatment of panic disorder with limited agoraphobic avoidance, PCT more recently has been finding broader applications. It has been used as an aid to pharmacotherapy discontinuation in panic disorder; in the treatment of panic attacks associated with other disorders such as schizophrenia; and, in combination with a situational exposure component, in the treatment of patients with moderate to severe agoraphobia. The authors critically review the evidence for the clinical efficacy of PCT and recent work directed at further enhancing the long-term efficacy and cost-effectiveness of treatment.
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Trastorno de Pánico/terapia , Benzodiazepinas/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Humanos , Trastorno de Pánico/diagnóstico , Trastorno de Pánico/psicología , Escalas de Valoración Psiquiátrica , Esquizofrenia/complicacionesAsunto(s)
Neoplasias Óseas/diagnóstico , Condroma/diagnóstico , Esternón , Biopsia , Neoplasias Óseas/cirugía , Niño , Condroma/cirugía , Diagnóstico Diferencial , Humanos , Masculino , Examen Físico , Esternón/diagnóstico por imagen , Esternón/patología , Esternón/cirugía , Tomografía Computarizada por Rayos XRESUMEN
Alprazolam was the first pharmacological agent to be approved for the treatment of panic disorder. In seeking that approval, the Upjohn Company conducted the earliest large, multicenter drug trials in panic disorder, involving nearly 1,700 patients in 14 countries. The administrative and quality assurance procedures developed for those studies have become a model for subsequent research. Despite this history, the efficacy of alprazolam for panic disorder has been contested. This article summarizes the published multicenter data from the perspective of the assessment criteria recommended by Shear and Maser (1994) and presents comparative findings from the Philadelphia maintenance study and the London/Toronto study of alprazolam and exposure therapy. Data on relapse following treatment discontinuation are also reviewed.
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Alprazolam/uso terapéutico , Ansiolíticos/uso terapéutico , Trastorno de Pánico/tratamiento farmacológico , Alprazolam/efectos adversos , Ansiolíticos/efectos adversos , Ensayos Clínicos como Asunto , Humanos , Trastorno de Pánico/psicologíaRESUMEN
OBJECTIVE: Concurrent use of benzodiazepines and psychotherapy for panic disorder is a prevalent but highly controversial practice. Although there are many rationales for that approach, critics contend that benzodiazepines foster drug abuse and dependence and undermine psychosocial treatments in various ways. The authors examine that controversy in the light of recent empirical findings and offer some tentative conclusions and recommendations. METHOD: Data from studies combining benzodiazepines and the leading psychosocial treatment for panic disorder, exposure-based cognitive behavior therapy, are reviewed, and their application to clinical practice is discussed. RESULTS: The strongest support for combined treatment is for the addition of cognitive behavior therapy to pharmacotherapy for patients with agoraphobia and for those whose benzodiazepine treatment is being discontinued. The greatest problem with combined treatment is relapse after drug discontinuance. CONCLUSIONS: Combined treatment may be advantageous for some patients, but it must be carefully designed to avoid potential problems. Suggestions for that are given.