[Endocarditis and ischemic stroke of rare cause]. / Endokarditis und ischämischer Apoplex mit seltener Ursache.

A 60-year-old male patient presented with ischemic-embolic stroke. Transesophageal echocardiography revealed the cause to be aortic valve endocarditis with highly eccentric aortic valve regurgitation. The blood cultures taken several times remained sterile. The indication for surgical aortic valve replacement was made. Conventional microbiological work-up of the heart valve did not reveal any pathogens. The additional molecular genetic testing using eubacterial PCR ("polymerase chain reaction" [PCR]) finally demonstrated the presence of Tropheryma whipplei. A number of therapeutic options were available. The authors decided on intravenous antibiotic therapy with ceftriaxone for 14 days and follow-up therapy with oral trimethoprim/sulfamethoxazole for 1 year. The case illustrates the importance of additional molecular diagnostics beyond the conventional methods in blood culture-negative endocarditis to identify the pathogen and initiate appropriate therapy.

Cognitive-behavioral treatment of older veterans with substance abuse problems.

The authors describe the initial cohort of participants in the GET SMART program, an age-specific, outpatient program for older veterans with substance abuse problems. Chief among the program's services is a relapse-prevention intervention consisting of 16 weekly group sessions using cognitive-behavioral (CB) and self-management approaches. Group sessions begin with analysis of substance use behavior to determine high-risk situations for alcohol or drug use, followed by a series of modules to teach coping skills for coping with social pressure, being at home and alone, feelings of depression and loneliness, anxiety and tension, anger and frustration, cues for substance use, urges (self-statements), and slips or relapses. Of the first 110 admissions, more than one-third were homeless, which is indicative of the severity of psychosocial distress of the patients, and more than one-third used illicit drugs. A total of 49 patients completed CB treatment groups and 61 dropped out of treatment. At 6-month follow-up, program completers demonstrated much higher rates of abstinence compared to noncompleters. The results suggest that CB approaches work well with older veterans with significant medical, social, and drug use problems.

Treatment approaches for older problem drinkers.

Recent research suggests that older adults with alcohol problems often drink in response to loneliness, depression, and poor social support networks. Although a variety of approaches such as psychodynamic, Twelve Step, social support, behavioral, and cognitive-behavioral, have been suggested, only those studies involving behavioral and cognitive-behavioral interventions have provided empirical support for treatment effectiveness. Some research also suggests that age-specific group treatment produces better outcomes than when older adults are placed in treatment with younger alcoholics.

Antecedents of drinking for early- and late-onset elderly alcohol abusers.

The present study compared antecedents to recent drinking for two groups of elderly alcohol abusers admitted for treatment. Twenty-three early-onset alcohol abusers were matched with 23 late-onset alcohol abusers according to age and sex. Depression, loneliness and lack of social support were the most frequently reported antecedents to preadmission drinking behavior for both groups. However, early-onset subjects were more likely to have changed residence, were intoxicated more often and experienced more severe levels of depression and anxiety. Late-onset subjects had greater life satisfaction and motivation for treatment, but were rated by collaterals as having more severe alcohol problems. Early-onset subjects were more likely to drop out of treatment. Treatment implications for age-related commonalities are discussed.

Dual diagnosis among older adults: a new array of policy and planning problems.

Case finding and successfully engaging and treating older adults with substance abuse disorders continue to be enigmatic processes. Because of the adverse consequences on health of substance abuse among the elderly, substance abuse has serious implications not only for the well-being of the elderly but also for the future costs and resources of the mental health and health care systems for older adults. However, older adults with concurrent mental and substance abuse disorders are appearing in the public gerontological mental health system. This system is both unprepared and ill-equipped to manage and treat these often difficult clients. Further complicating the situation is the seeming lack of knowledge about "dual diagnosis" among the elderly. Policy and planning issues necessary to address this newly discovered array of problems are discussed.

The mentally ill substance abuser: challenges for the administrator.

Despite a high incidence of dual diagnosis among substance abusers and among the mentally ill, few programs provide the comprehensive services needed to address both problems simultaneously. Dual diagnosis presents a series of challenges for administrators: Which problem should be addressed first? Should admission criteria be altered to exclude such clients? Can more comprehensive services be offered within existing funding? Differences between the two domains of treatment exacerbate their inability to work together. Substance abuse programs often employ "recovering" individuals as treatment staff and offer relatively brief inpatient programs, often using confrontational approaches. Self-help groups are frequent adjuncts to treatment but disdain the use of prescribed medications. In contrast, programs for the chronic mentally ill usually do not employ former clients, have longer lengths of stay, include use of medications to alter behavior, and are more supportive and educational. Overcoming barriers to treatment must involve change in policies related to funding, staff training, admission criteria and differences in philosophy of treatment.

Antecedents of relapse and recent substance use.

The present study investigated determinants of relapse and antecedents of recent use for 30 substance abusers re-entering inpatient treatment. A structured interview assessment revealed that the patients relapsed within two months following previous treatment, yet waited 2.7 years before re-entering treatment. Alcohol was often the initial and subsequently the most frequently used substance. Determinants of relapse were a variety of interpersonal and intrapersonal events. However, antecedents to recent use were almost exclusively negative emotional states such as depression and loneliness. Implications for treatment are presented.

Tonic and phasic stimulus control of blood pressure responses using opposing unconditional stimuli.

The transswitching paradigm was used in the present study to investigate the effects of tonic (long duration) environmental stimuli paired with opposing unconditional stimuli on human blood pressure. Sixty volunteers participated for two sessions, one week apart. Subjects were presented with a pseudorandom sequence of four trials of red lights (five minutes each) and four trials of blue lights (five minutes each) within each session. All subjects received the cold pressor test during the red lights. During the blue lights, half the subjects received warm water and the other half received a neutral temperature water. Subjects received the presentations of the water in one of three methods: as determined by the experimenter, preceded by a warning signal, or self-administered. The results indicated that conditional and unconditional responses during the red lights were progressive increases in blood pressure. During the blue lights associated with warm water, conditional and unconditional responses were often progressive decreases in blood pressure. The method of administration of the water affected the magnitude of the unconditional responses. Evidence for phasic stimulus control was not as unequivocal as tonic stimulus control. The present results indicated that it is possible to modify blood pressure in two directions (increases and decreases) when two high contrast, opposing unconditional stimuli are presented.

A comparison of two behavioral treatments in decreasing the orofacial movement of tardive dyskinesia.

In a study with an elderly female subject, two behavioral treatments were evaluated in terms of their effectiveness in decreasing orofacial movement associated with tardive dyskinesia. Video feedback and discreet-discrete prompting, a self-control procedure using a portable audio signal generator, were compared by means of an alternating treatments experimental design. Video and instructional controls were included in the study. Results indicated that both procedures were effective in decreasing orofacial movement. In addition, during the concluding phase of the study, a prompting card was carried by the subject at all times as a reminder to control mouth movements on an ongoing basis. This concluding phase resulted in generalization of treatment effects to the nontreatment environment. Follow-up sessions indicated maintenance of treatment effects.