Treatment case example

Many of the most useful syntheses of 1,4-oxazepines are of this type. Either the N—C or the O—C bond may be formed first depending on the nature of the substituents on N and O and in most cases the intermediate of type C—C—N—C—C—C—O or N—C—C—C—O—C—C can be isolated. In this treatment the examples are presented in that order. 

Case Example Because of a patient s partial response to 5 months of clozapine therapy at 600 mg/day, risperidone was added for augmentation (started with 0.5 mg b.i.d. and increased to 1 mg b.i.d. after 1 week). Before this addition, the clozapine plasma level was 344 ng/mL, but after 2 weeks of risperidone augmentation, the level was elevated to 598 ng/mL with no adverse effects and substantial clinical benefit. In another report, there was an increase in the steady-state plasma levels of clozapine (675 mg/day) and its active metabolite norclozapine after the addition of risperidone 2 mg/day in a patient treated for 2 years. Before the addition of risperidone, her clozapine and norclozapine levels were 829 and 1,384 ng/mL, respectively. Two days after risperidone was added, these levels rose to 980 and 1,800 ng/mL. Clozapine dosage was reduced to 500 mg/day, and after 5 days of combined treatment with 4 mg/day of risperidone, the clozapine and norclozapine levels were 110 and 760 ng/mL, respectively. Aside from some mild oculogyric crises, she had no symptoms of clozapine toxicity or clinical changes during the period of cross-tapering. In another case, risperidone was added to clozapine because the patient had relapsed after discontinuation of fluphenazine and had not responded to clozapine. The addition of risperidone resulted in an acute remission of psychosis ( 100). 

Case Example A 29-year-old woman presented for consultation on referral from a psychiatrist who had seen her in psychodynamically oriented psychotherapy for approximately 10 years. The primary difficulty was intermittent interpersonal strife with fellow workers and supervisors. Thus, although quite competent, she had switched positions frequently because of these difficulties. Her history indicated that she had never experienced a full depressive, hypomanic, or manic episode, but that these problems seemed to coincide with intermittent periods of irritability. As a result, she was placed on a trial of lithium, with therapeutic blood levels. Within several weeks of treatment initiation, her difficulties with fellow coworkers and supervisors ceased, and during 1 year of follow-up, she did not have a recurrence of these problems. 

Case Example A 28-year-old woman had been stable on lithium treatment for several years. When she became pregnant, her lithium was discontinued, and within a few weeks she was hospitalized for a severe exacerbation of mania unresponsive to CPZ in doses up to 1,200 mg/day. After a course of ECT she became euthymic and was adequately maintained on lower doses of CPZ (i.e., 50 to 100 mg/day) for the remainder of her pregnancy. The delivery and the immediate postpartum period went well, but lithium was not resumed because she opted to nurse her infant. Several weeks later, she was rehospitalized for an episode of depression, which also responded to a course of ECT. She then agreed to discontinue nursing her child and resume lithium. The patient was doing well at follow-up 1 year later. 

An immediately life-threatening disease means a stage of a disease in which there is a reasonable likelihood that death will occur within a matter of months, or in which premature death is likely without early treatment. For example, advanced cases of AIDS, herpes simplex encephalitis, and subarachnoid hemorrhage are all considered immediately life-threatening diseases. Treatment INDs are made available to patients before general marketing begins, typically... 

When a therapist is evaluating a patient who demonstrates intermittent loss of impulse control, it is important to look for the sequence of events that kindled the condition. Sometimes, one discovers an obsessional antecedent to the loss of control, and this may respond very well to antiobsessional medication. The woman in the example that follows could have had an intermittent explosive disorder, a personality disorder, or other diagnoses but given her poverty and lack of health care insurance or access, she would probably have received no treatment. Had she been wealthy, she might have received psychotherapy, which may have helped, given time. However, medication management did result in prompt remission of her symptoms, and it may have saved her life and that of her son. In some cases, medication consultation for a patient with one of the impulse control disorders can be a life-saving collaboration between therapist and physician (see case example below). 

Case Example Because public health officials suspect a stealth bioterror attack, they request that hospitals secretly test all of their new patients for the suspected contagious disease. The patient is to be notified only if he or she tests positively for the disease, and he/she will be offered standard medical treatment. Reports are to go directly to public health officials. Can a nurse legally or ethically participate in such a program ... 

The use of catalysts, furthermore, is required in the processes of wastewater purification by reducing treatments. Catalysts also find also application as complementary technologies to other wastewater treatment methods, such as in the control of odour, VOC, N2O and NOx emissions from wet oxidation treatments (for example, in the wet oxidation of industrial sludges), and of odours and VOC emitted from biological processes (aerobic and anaerobic). Although usually commercial catalysts are used in these cases, there are often unpredicted effects in treating complex mixtures and thus more specific catalysts would be preferable. The same is valid for catalysts used to convert stripped VOC from contaminated groundwater. 

---