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By Z. Rhobar. The National Graduate School.

During oxidation reactions chlorine dioxide readily accepts an electron to form chlorite: - - ClO2 + e → ClO2 In drinking water cheap sildigra 25mg fast delivery erectile dysfunction incidence age, chlorite formation is usually the dominating reaction end product cheap 25 mg sildigra with mastercard erectile dysfunction patanjali medicine, with typically up to 70% - - of the chlorine dioxide being reduced to chlorite 50 mg sildigra with mastercard impotence lipitor. The reaction rate is slow compared with the chlorine processes, and production rates for acid:chlorite are limited e. In the chlorine solution:chlorite solution process, yield of up to 98% has been reported in laboratory reactors, but commercial reactors usually have a lower yield and the reaction is relatively slow. In the chlorine gas:solid chlorite process, dilute, humidified Cl2 reacts with specially processed solid sodium chlorate. This process is only dependent on the feed rate of Cl2 and the product is free of chlorate and chlorite as these remain in the solid phase. Other types of ClO2 generators are available such as ClO2 generation by transformation of sodium chlorate with hydrogen peroxide and sulphuric acid or electrochemical production from sodium chlorite solution (Gates, 1998) and are used in the pulp and paper industry for pulp bleaching. The chlorate based processes will also generate ClO2 through reaction with acid and have previously not been thought capable of producing ClO2 of the purity needed for water treatment. The main advantage of using chlorate rather than chlorite is that chlorate is considerably cheaper. The disadvantage with the electrochemical process is high concentrations of chlorate in the product. Its oxidizing ability is lower than ozone but much stronger than chlorine and chloramines. The pathogen inactivation efficiency of chlorine dioxide is as great as or greater than that of chlorine but is less than ozone. Cryptosporidium require an order of magnitude higher Ct values compared to Giardia and viruses. Different viruses also have different sensitivity to ClO2 (Thurston-Enriquez et al. Cl2 Ct values for pH 7 Chlorine dioxide is generally at least as effective as chlorine for inactivation of bacteria of sanitary significance, and Ct values less than those for viruses shown in Table 4. Salmonella, Shigella) has been demonstrated in the laboratory with chlorine dioxide concentrations of 0. This is produced from reduction of chlorine dioxide by reaction with organics (or iron and manganese) in the water. Unreacted chlorite can also be Water Treatment Manual: Disinfection present for systems using chlorite solution. Chlorite is not present in the product if gaseous Cl2 and solid chlorite is used when generating ClO2. As up to 70% of the added ClO2 can be reduced to chlorite, this limits the amount of ClO2 that can be added and thereby the amount of disinfection that can be achieved. High pH values (pH>9) also lead to enhanced chlorite production and works with softening or corrosion control with increased pH may experience more problems with chlorite. The rate of reduction will vary depending on parameters such as temperature and disinfectant demand and no general advice can be given. There is also a photolytic mechanism for breakdown of chlorine dioxide to chlorate. The effects of pH indicated above should not normally be a problem in water treatment. Chlorate is not present in the product if gaseous Cl2 and solid chlorite is used when generating ClO2. It should be noted that dialysis patients are potentially sensitive to the toxic effects of chlorate or chlorite. This only applies where chlorine dioxide is used, and there is otherwise no standard for chlorate or chlorite in the drinking water regulations. Typical dosages of chlorine dioxide used as a disinfectant in drinking water treatment range from 0. During the acid:chlorite reaction, side reactions can result in the production of chlorine. In the chlorine solution:chlorite solution process, if chlorine is used in excess of the stoichiometric requirements, chlorine can also be present in the product. The chlorine associated with the chlorine dioxide can then cause chlorinated organic by-products to form, but to a much smaller extent than if Cl2 was used on its own. The amount of chlorine associated with the chlorine dioxide needs to be minimised by control of the reactions. Halogenated by-products could also form if ClO2 is used as a primary disinfectant followed by Cl2 as a secondary disinfectant, as the organic precursors may still be present for reaction with the chlorine. Organic by-products therefore seems to be a minor problem when using ClO2 but potential problems should be considered if ClO2 is followed by chlorination, or in areas with high bromide concentrations. The majority of chlorate and chlorite formation will usually be at the treatment works. However, it can continue in distribution from residual chlorine dioxide reacting with organics in the water. Ferrous iron (Fe ) is efficient in chlorite removal, chloride being the likely end product. Using ClO2 as pre-oxidant before ferrous iron coagulation could therefore be a potential option. Generally, the best option to minimise the formation of chlorite is to reduce the oxidant demand before the addition of ClO2. Keeping the pH in the range of 6-9 during the contact time will also ensure disinfection efficiency and minimise chlorite formation. If a chlorine dioxide concentration after contact of 1 mg/l could be achieved, contact time of 4 - 9 hours (at perfect flow conditions) would therefore be needed. To achieve these Ct values, the water treated would need to have a low demand for chlorine dioxide (i. This will limit the potential of chlorine dioxide for Cryptosporidium control, although it would be appropriate for other disinfection applications.

Use of an electronic clinical reminder for brief alcohol counseling is associated with resolution of unhealthy alcohol use at follow-up screening order 50 mg sildigra otc erectile dysfunction treatment youtube. A multisite initiative to increase the use of alcohol screening and brief intervention through resident training and clinic systems changes order sildigra 100mg with amex erectile dysfunction filthy frank lyrics. Implementing alcohol screening and intervention in a family medicine residency clinic generic 100 mg sildigra with amex erectile dysfunction in cyclists. Local implementation of alcohol screening and brief intervention at fve Veterans Health Administration primary care clinics: Perspectives of clinical and administrative staff. Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis. Report to Congress on the nation’s substance abuse and mental health workforce issues. Stafng patterns of primary care practices in the comprehensive primary care initiative. Outlining the scope of behavioral health practice in integrated primary care: Dispelling the myth of the one- trick mental health pony. Perceptions of mental health and substance use disorder services integration among the workforce in primary care settings. Strategic plan for interdisciplinary faculty development: Arming the nation’s health professional workforce for a new approach to substance use disorders. An action plan for behavioral health workforce development: A framework for discussion. Comparative analysis of state requirements for the training of substance abuse and mental health counselors. Workforce issues related to: Bi-directional physical and behavioral healthcare integration specifically substance use disorders and primary care. Workforce issues related to: Physical and behavioral healthcare integration: Specifically substance use disorders and primary care. A national review of state alcohol and drug treatment programs and certification standards for substance abuse counselors and prevention professionals. Prescription drug monitoring programs: An assessment of the evidence for best practices. Evaluation of the Medicaid health home option for beneficiaries with chronic conditions: Final annual report - base year. Cost, utilization, and quality of care: An evaluation of Illinois’ Medicaid primary care case management program. Joint principles: Integrating behavioral health care into the patient-centered medical home. Accountable health communities — Addressing social needs through Medicare and Medicaid. On the road to better value: State roles in promoting accountable care organizations. Community‐clinical linkages to improve hypertension identification, management, and control. Institute of Medicine, Roundtable on Population Health Improvement, & Board on Population Health and Public Health Practice. Integrating buprenorphine maintenance therapy into federally qualifed health centers: Real-world substance abuse treatment outcomes. Health coaching via an internet portal for primary care patients with chronic conditions: A randomized controlled trial. Eligible professional meaningful use table of contents core and menu set objectives. Meaningful adoption: What we know or think we know about the fnancing, effectiveness, quality, and safety of electronic medical records. Challenges and opportunities for integrating preventive substance-use-care services in primary care through the Affordable Care Act. Personal health record reach in the Veterans Health Administration: A cross- sectional analysis. Electronic patient portals: evidence on health outcomes, satisfaction, efciency, and attitudes: A systematic review. Integrating information on substance use disorders into electronic health record systems. Development of a prescription opioid registry in an integrated health system: Characteristics of prescription opioid use. Alcohol and drug use and aberrant drug-related behavior among patients on chronic opioid therapy. Opioid overdose prevention programs providing naloxone to laypersons— United States, 2014. Integrated treatment continuum for substance use dependence “Hub/Spoke” Initiative—Phase 1: Opiate dependence. Embedding prevention, treatment, and recovery services into the larger health care system will increase access to care, improve quality of services, and produce improved outcomes for countless Americans. A national opioid overdose epidemic has captured the attention of the public as well as federal, state, local, and tribal leaders across the country. Ongoing efforts to reform health care and criminal justice systems are creating new opportunities to increase access to prevention and treatment services. Health care reform and parity laws are providing signifcant opportunities and incentives to address substance misuse and related disorders more effectively in diverse health care settings. These changes represent new opportunities to create policies and practices that are more evidence-informed to address health and social problems related to substance misuse. The moral obligation to address substance misuse and substance use disorders effectively for all Americans also aligns with a strong economic imperative. Substance misuse and substance use disorders are estimated to cost society $442 billion each year in health care costs, lost productivity, and criminal justice costs.

In pregnant women buy 50 mg sildigra erectile dysfunction shakes menu, poorly controlled asthma increases the risk of pre-eclampsia 25 mg sildigra with mastercard best erectile dysfunction pills over the counter, eclampsia purchase sildigra 50mg visa erectile dysfunction yahoo answers, haemorrhage, in utero growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment remains inhaled salbutamol and beclometasone at the usual dosage for adults. If symptoms are not well controlled during a period of at least 3 months, check the inhalation technique and adherence before changing to a stronger treatment. If symptoms are well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma has become intermittent): try a step-wise reduction in medication, finally discontinuing treatment, if it seems possible. If the patient has redeveloped chronic asthma, restart long-term treatment, adjusting doses, as required. In immunocompetent patients, the pulmonary lesion heals in 90% of cases, but in 10%, patients develop active tuberculosis. Tuberculosis may also be extrapulmonary: tuberculous meningitis, disseminated tuberculosis, lymph node tuberculosis, spinal tuberculosis, etc. Clinical features Prolonged cough (> two weeks), sputum production, chest pain, weight loss, anorexia, fatigue, moderate fever, and night sweats. The most characteristic sign is haemoptysis (presence of blood in sputum), however it is not always present and haemoptysis is not always due to tuberculosis. If sputum is smear-negative, consider pulmonary distomatosis (Flukes, Chapter 6), melioidosis (Southeast Asia), profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for all patients consulting for respiratory symptoms for over two weeks who do not respond to non-specific antibacterial treatment. Treatment The treatment is a combination of several of the following antituberculous drugs [isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), streptomycin (S)]. The regimen is standardised and organized into 2 phases (initial phase and continuation phase). Only uninterrupted treatment for several months may lead to cure and prevent the development of resistance, which complicates later treatment. It is essential that the patient understands the importance of treatment adherence and that he has access to correct case management until treatment is completed. Diseases, such as malaria, acute otitis media, upper and lower respiratory tract infections, etc. Treatment General principles: – Prevent or treat dehydration: rehydration consists of prompt replacement of fluid and electrolyte losses as required, until the diarrhoea stops. However, for treating cholera, the administration of a single dose should not provoke any adverse effects. Bloody diarrhoea (dysentery) – Shigellosis is the most frequent cause of dysentery (amoebic dysentery is much less common). If there is no laboratory diagnosis to confirm the presence of amoebae, first line treatment is for shigellosis. Prevention – Breastfeeding reduces infant morbidity and mortality from diarrhoea and the severity of diarrhoea episodes. Shigella dysenteriae type 1 (Sd1) is the only strain that causes large scale epidemics. Clinical features Bloody diarrhoea with or without fever, abdominal pain and tenesmus, which is often intense. Patients with at least one of the following criteria have an increased risk of death: – Signs of serious illness: • fever > 38. After confirming the causal agent, antimicrobial susceptibility should be monitored monthly by culture and sensitivity tests. Organise home visits for daily monitoring (clinically and for compliance); hospitalise if the patient develops signs of serious illness. Shigellosis is an extremely contagious disease (the ingestion of 10 bacteria is infective). Note: over the past few years, Sd1 epidemics of smaller scale and with lower case fatality rates (less than 1%) have been observed. Transmission is faecal-oral, by ingestion of amoebic cysts from food or water contaminated with faeces. Usually, ingested cysts release non-pathogenic amoebae and 90% of carriers are asymptomatic. In 10% of infected patients, pathogenic amoebae penetrate the mucous of the colon: this is the intestinal amoebiasis (amoebic dysentery). The clinical picture is similar to that of shigellosis, which is the principal cause of dysentery. Occasionally, the pathogenic amoebae migrate via the blood stream and form peripheral abscesses. Clinical features – Amoebic dysentery • diarrhoea containing red blood and mucus • abdominal pain, tenesmus • no fever or moderate fever • possibly signs of dehydration – Amoebic liver abscess • painful hepatomegaly; mild jaundice may be present • anorexia, weight loss, nausea, vomiting • intermittent fever, sweating, chills; change in overall condition Laboratory – Amoebic dysentery: identification of mobile trophozoites (E. Treatment – First instance, encourage the patient to avoid alcohol and tobacco use. Gastric and duodenal ulcers in adults Clinical features Burning epigastric pain or epigastric cramps between meals, that wake the patient at night. They are most characteristic when they occur as episodes of a few days and when accompanied by nausea and even vomiting. Gastrointestinal bleeding Passing of black stool (maelena) and/or vomiting blood (haematemesis). Gastric lavage with cold water is not essential, but may help evaluate persistence of bleeding. If a diagnosis of ulcer is probable, and the patient has frequent attacks requiring repeated treatment with antiulcer drugs or, in cases of complicated ulcers (perforation or gastrointestinal bleeding) treatment to eradicate H. Dyspepsia is most commonly functional, linked with stress and not linked to the quantity of gastric acid (antiacids and antiulcer drugs are ineffective). Treatment If the symptoms persist, short term symptomatic treatment may be considered.

The following chart shows the number of patients with breast and lung cancer who gained access to treatment as a result of the government’s action buy discount sildigra 50 mg on line how to cure erectile dysfunction at young age. If you add another five countries – Indonesia sildigra 120 mg on-line erectile dysfunction yoga exercises, Pakistan 120mg sildigra visa erectile dysfunction qof, Tanzania, Ethiopia, and Kenya – the total grows to 80 percent of the extreme poor. That will increase to 19 million by 2025, 22 million by 2030, and 24 million by 2025. More than 60 percent of the world’s cancer cases occur in Africa, Asia, and Central and South America. Breast cancer is on the rise globally and has become a leading cause of cancer death in low- and middle- income countries. Planning for screening and treatment of cancer in low- and middle-income countries is lagging behind. Any strategic approach towards increasing access to cancer treatment needs to take into account the cost as well as the complexity of treatment, and include measures to ensure access to low-cost cancer drugs of assured quality. While problems with access to cancer treatments are most serious in low- and middle-income countries, they are by no means confined to those countries. Equitable pricing, and access strategies for low- and middle- 41 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. For example, the industry’s concern about flow back of lower priced medicines to high-income markets or the use of reference pricing by high- income governments may be legitimate. But it will be easier to gain political support for solutions if the prices charged for new cancer medicines were more affordable in high-income countries. The industry will maintain that research and development of new medicines is dependent on high prices, and that any restrictions will hurt new drug development. This is the current model for innovation: companies invest part of their earnings into R&D for new products. Since this innovation model leads to access problems, it seems necessary to look at alternatives to high prices as the main means to fund R&D. One such alternative model is changing the relationship between the cost of R&D and the price of the product, which has become known as ‘delinkage’. In 2008, Bolivia and Barbados developed a proposal for a prize fund for cancer drugs for developing countries. They proposed that developing country governments introduce a system for rewarding the development of new medicines and vaccines against cancer that would permit free entry by generic suppliers for vaccines and medicines, avoiding monopoly control. In return for ending the monopoly, the governments should agree to provide a domestic system of rewards for developers of new products that is funded through a fixed proportion of the budget for cancer (other bases for financing 130 were suggested). Box 9 – R&D demonstration projects Demonstration Projects are aimed at developing health technologies (medicines, diagnostics, medical devices, vaccines, etc. The projects must demonstrate effectiveness of alternative, innovative and sustainable financing and coordination approaches to address identified R&D gaps. The selection of projects will be based primarily upon the following considerations: 42 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. To break the cycle of ever-higher drug prices needed to sustain the costs of R&D, new models for the financing of R&D need to be explored. Such models should have, as a guiding principle, that they equitably serve both health driven R&D and access to the innovations that are a result of such R&D. But opposition from powerful industries and their home governments, strongly attached to monopoly ownership, is likely to be fierce. To counter such opposition it will be important that low- and middle-income countries make proposals based on burden sharing of the cost of R&D. Only 5 percent of the global resources for cancer are spent in the developing world, yet these countries account for almost 80 percent of disability adjusted years of life lost 131 to cancer globally. Increasing access to effective cancer treatments in low- and middle-income countries requires the development and implementation of comprehensive cancer prevention, detection, treatment and care policies that include palliative care and pain control. Non-price barriers to access to opioids, for example, continue to be a problem in many developing countries thrown up by international agreements targeting illicit trade in narcotic 132 drugs. There is an urgent need for advocacy for cancer care at the national and international level. In particular the development of strong civil society in countries like India, Thailand, South- Africa, and other middle-income countries will be necessary. There are, however, important international 43 Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication. Some examples are:  The Global Task Force on Expanding Access to Cancer Care and Control, established in 2009, published in its report in 2011 a wealth of data and recommendations for action. These recommendations include bringing cost down of cancer medicines, emphasizing how to deal with high-priced patented cancer drugs. The goal of universal health coverage is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. These global developments are important to create the political momentum to strengthen healthcare for cancer patients at national level and take action globally to provide guidance for treatment and care, share knowledge about treatment cost and provide a legal framework to ensure treatment is available. Box 10 – Specific recommendations for India India should develop a national cancer policy for the prevention, diagnosis, and treatment of cancer. Such a policy should pay special attention to payment for care since most people in India today pay out-of-pocket. According to the Indian Commission on Macroeconomic and Health Financing, at least 70 percent of payments for healthcare come from household budgets. A comprehensive cancer prevention and care policy should include addressing pricing of cancer medicines.

Ceftriaxone defervescence cheap 100mg sildigra impotence at 70; reduction in direct or rebound abdominal has better coverage against N discount sildigra 120 mg fast delivery impotence sexual dysfunction. If retesting at 3 months is not for 1–2 doses buy sildigra 25 mg low price erectile dysfunction medication uk, followed by 250 mg orally daily for 12–14 days) possible, these women should be retested whenever they next or in combination with metronidazole (745), and in another present for medical care in the 12 months following treatment. However, the woman should treating male partners of women who have chlamydia or receive treatment according to these recommendations and gonococcal infections (see Partner Services) (93,94). If no clinical improvement should be instructed to abstain from sexual intercourse until occurs within 48–72 hours of initiating treatment, providers they and their sex partners have been adequately treated (i. A systematic review of until therapy is completed and symptoms have resolved, if evidence found that treatment outcomes did not generally originally present). The risk for penicillin cross-reactivity is highest Epididymitis with first-generation cephalosporins, but is negligible between Acute epididymitis is a clinical syndrome consisting of most second-generation (cefoxitin) and all third-generation pain, swelling, and inflammation of the epididymis that lasts (ceftriaxone) cephalosporins (428–431) (see Management of <6 weeks (755). Sometimes the testis is also involved— a Persons who Have a History of Penicillin Allergy). These women should symptoms associated with epididymitis, as this condition is a be hospitalized and treated with intravenous antibiotics. More comprehensive observational and accompanied by urethritis, which frequently is asymptomatic. Diagnostic Considerations All suspected cases of acute epididymitis should be tested Men who have acute epididymitis typically have unilateral for C. Although inflammation and swelling usually Urine cultures for chlamydia and gonococcal epididymitis are begins in the tail of the epididymis, it can spread to involve insensitive and are not recommended. The spermatic cord is might have a higher yield in men with sexually transmitted usually tender and swollen. Spermatic cord (testicular) torsion, enteric infections and in older men with acute epididymitis a surgical emergency, should be considered in all cases, but caused by genitourinary bacteriuria. In men with severe, unilateral pain with sudden onset, those whose test Treatment results do not support a diagnosis of urethritis or urinary-tract To prevent complications and transmission of sexually infection, or men in whom diagnosis of acute epididymitis is transmitted infections, presumptive therapy is indicated questionable, immediate referral to a urologist for evaluation at the time of the visit before all laboratory test results are of testicular torsion is important because testicular viability available. The Bilateral symptoms should raise suspicion of other causes goals of treatment of acute epididymitis are 1) microbiologic of testicular pain. Radionuclide scanning of the scrotum is cure of infection, 2) improvement of signs and symptoms, the most accurate method to diagnose epididymitis, but it 3) prevention of transmission of chlamydia and gonorrhea to is not routinely available. Ultrasound should be primarily others, and 4) a decrease in potential chlamydia/gonorrhea used for ruling out torsion of the spermatic cord in cases of epididymitis complications (e. However, because Although most men with acute epididymitis can be treated on partial spermatic cord torsion can mimic epididymitis an outpatient basis, referral to a specialist and hospitalization on scrotal ultrasound, when torsion is not ruled out by should be considered when severe pain or fever suggests other ultrasound, differentiation between spermatic cord torsion and diagnoses (e. Because high fever is uncommon and and swelling associated with epididymitis, it provides minimal indicates a complicated infection, hospitalization for further utility for men with a clinical presentation consistent with evaluation is recommended. Ultrasound should be reserved for men with scrotal pain who cannot receive an accurate diagnosis by history, physical examination, and objective laboratory findings or if torsion of the spermatic cord is suspected. Arrangements should be made to link Ofloxacin 300 mg orally twice a day for 10 days female partners to care. Partners should be instructed to abstain from sexual intercourse until they and their sex partners are adequately treated and symptoms Therapy including levofloxacin or ofloxacin should be have resolved. This includes men who have undergone prostate Special Considerations biopsy, vasectomy, and other urinary-tract instrumentation Allergy, Intolerance, and Adverse Reactions procedures. As an adjunct to therapy, bed rest, scrotal elevation, and nonsteroidal anti-inflammatory drugs are recommended The cross reactivity between penicillins and cephalosporins until fever and local inflammation have subsided. The risk for penicillin cross-reactivity is after completion of the antibiotic regimen. Men who have acute epididymitis confirmed or suspected to Alternative regimens have not been studied; therefore, be caused by N. The routine use States, the vaccines are not licensed or recommended for use of this procedure to detect mucosal changes attributed to in men or women aged >26 years (16). Precancerous lesions are detected through against most cases of cervical cancer; Gardasil also protects cervical cancer screening (see Cervical Cancer, Screening against most genital warts. Anogenital warts occur commonly at certain treatments needed to treat them, might lower a woman’s anatomic sites, including around the vaginal introitus, under ability to get pregnant or have an uncomplicated delivery. These tests are not also can occur in men and women who have not had a history of anal sexual contact. Follow-up visits after several Diagnosis of anogenital warts is usually made by visual weeks of therapy enable providers to answer any questions inspection. The diagnosis of anogenital warts can be confirmed about the use of the medication and address any side effects by biopsy, which is indicated if lesions are atypical (e. Biopsy might also be indicated in the following circumstances, particularly if the patient is Recommended Regimens for External Anogenital Warts (i. If left untreated, anogenital warts * Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the can resolve spontaneously, remain unchanged, or increase in anal canal by digital examination, standard anoscopy, or high-resolution size or number. With either formulation, the Treatment of anogenital warts should be guided by wart treatment area should be washed with soap and water 6–10 size, number, and anatomic site; patient preference; cost hours after the application. Local inflammatory reactions, of treatment; convenience; adverse effects; and provider including redness, irritation, induration, ulceration/erosions, experience. No definitive evidence suggests that any one and vesicles might occur with the use of imiquimod, and recommended treatment is superior to another, and no hypopigmentation has also been described (770). The use number of case reports demonstrate an association between of locally developed and monitored treatment algorithms treatment with imiquimod cream and worsened inflammatory has been associated with improved clinical outcomes and or autoimmune skin diseases (e.

Patient preference is an important factor to consider when developing an individual treatment plan cheap 50mg sildigra overnight delivery intracavernosal injections erectile dysfunction. The psychiatrist should explain and discuss the range of treatments available for the patient’s condition sildigra 50 mg low price best erectile dysfunction pills for diabetes, the modalities he or she recommends purchase 120mg sildigra visa erectile dysfunction from anxiety, and the rationale for having selected them. He or she should take time to elicit the patient’s views about this provisional treatment plan and modify it to the extent feasible to take into account the patient’s views and preferences. The hazard of nonadherence makes it worthwhile to spend whatever time may be required to gain the patient’s assent to a viable treatment plan and his or her agreement to collaborate with the clinician(s) before any therapy is instituted. Multiple- versus single-clinician treatment Treatment can be provided by more than one clinician, each performing separate treatment tasks, or by a single clinician performing multiple tasks; both are viable approaches to treating borderline personality disorder. When there are multiple clinicians on the treatment team, they Treatment of Patients With Borderline Personality Disorder 19 Copyright 2010, American Psychiatric Association. For example, it brings more types of expertise to the patient’s treatment, and multiple clinicians may better contain the patient’s self-destructive tendencies. For this type of treatment to be successful, good collaboration of the entire treatment team and clarity of roles are essential (7). Regardless of whether treatment involves multiple clinicians or a single therapist, its effectiveness should be monitored over time, and it should be changed if the patient is not improving. Nor are there any systematic investigations of the effects of combined medication and psychotherapy to either modality alone. Hence, in this section we will consider psychotherapy and pharmacotherapy separately, knowing that in clinical practice the two treatments are frequently combined. In- deed, many of the pharmacotherapy studies included patients with borderline personality dis- order who were also in psychotherapy, and many patients in psychotherapy studies were also taking medication. A good deal of clinical wisdom supports the notion that carefully focused pharmacotherapy may enhance the patient’s capacity to engage in psychotherapy. Psychotherapy Two psychotherapeutic approaches have been shown to have efficacy in randomized controlled trials: psychoanalytic/psychodynamic therapy and dialectical behavior therapy. We emphasize that these are psychotherapeutic approaches because the trials that have demonstrated efficacy (8–10) have involved sophisticated therapeutic programs rather than simply the provision of individual psychotherapy. Both approaches have three key features: 1) weekly meetings with an individual therapist, 2) one or more weekly group sessions, and 3) meetings between therapists for consultation/supervision. No results are available from direct comparisons of the two ap- proaches to suggest which patients may respond better to which modality. One characteristic of both dialectical behavior therapy and psycho- analytic/psychodynamic therapy involves the length of treatment. Although brief therapy has not been systematically tested for patients with borderline personality disorder, the studies of extended treatment suggest that substantial improvement may not occur until after approxi- mately 1 year of psychotherapeutic intervention has been provided and that many patients re- quire even longer treatment. In addition, clinical experience suggests that there are a number of “common features” that help guide the psychotherapist who is treating a patient with borderline personality disorder, regardless of the specific type of therapy used. The psychotherapist must emphasize the build- ing of a strong therapeutic alliance with the patient to withstand the frequent affective storms within the treatment (11, 12). This process of building a positive working relationship is greatly enhanced by careful attention to specific goals for the treatment that both patient and therapist view as reasonable and attainable. Clinicians may find it useful to keep in mind that often patients will attempt to redefine, cross, or even violate boundaries as a test to see whether the treatment situation is safe enough for them to reveal their feelings to the therapist. Regular meeting times with firm expectation of attendance and participation are important as well as an understanding of the relative contributions of pa- tient and therapist to the treatment process (12). As seen in Figure 1, some therapists create a hierarchy of priorities to be considered in the treatment. For example, practitioners of dia- lectical behavior therapy (5) might consider suicidal behaviors first, followed by behaviors that interfere with therapy and then behaviors that interfere with quality of life. Practitioners of psy- choanalytic or psychodynamic therapy (4, 13) might construct a similar hierarchy. Treatment Priorities of Two Psychotherapeutic Approaches for Patients With Borderline Personality Disorder. Treatment of Patients With Borderline Personality Disorder 21 Copyright 2010, American Psychiatric Association. Many patients with borderline personality disorder have experienced considerable child- hood neglect and abuse, so an empathic validation of the reality of that mistreatment and the suffering it has caused is a valuable intervention (12, 14–17). This process of empathizing with the patient’s experience is also valuable in building a stronger therapeutic alliance (11) and pav- ing the way for interpretive comments. While validating patients’ suffering, therapists must also help them take appropriate respon- sibility for their actions. Many patients with borderline personality disorder who have experi- enced trauma in the past blame themselves. Effective therapy helps patients realize that while they were not responsible for the neglect and abuse they experienced in childhood, they are cur- rently responsible for controlling and preventing self-destructive patterns in the present. Psy- chotherapy can become derailed if there is too much focus on past trauma instead of attention to current functioning and problems in relating to others. Most therapists believe that inter- ventions like interpretation, confrontation, and clarification should focus more on here-and- now situations than on the distant past (18). Interpretations of the here and now as it links to events in the past is a particularly useful form of interpretation for helping patients learn about the tendency toward repetition of maladaptive behavior patterns throughout their lives. More- over, therapists must have a clear expectation of change as they help patients understand the origins of their suffering. Because patients with borderline personality disorder possess a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy.

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