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PubMedDate not supplied

Relapse to substance abuse: empirical findings within a cognitive-social learning approach.

A cognitive-social learning model of relapse prevention, specifically Albert Bandura's theory of self-efficacy, is one of the most influential theoretical frameworks that has been applied to the problem of relapse in the substance abuse field. Theory and related empirical findings within this approach are reviewed, including the following: the assessment of a client's high-risk situations for relapse; the development of an individualized treatment plan; the distinction between treatment strategies aimed at "initiation" versus "maintenance" of behavior change; the importance of growth in client self-efficacy; the difference between the process of lapse versus relapse; the use of drugs in relapse prevention counseling; and the role of client-treatment matching. On the basis of the empirical evidence reviewed, it is concluded that a cognitive-social learning approach to relapse prevention is showing promise. Future directions for research are suggested.

Cognition↗

PubMedDate not supplied

Treating crack cocaine dependence: the critical role of relapse prevention.

In order to adequately address the treatment needs of crack cocaine dependent persons, a multidimensional approach to relapse prevention must be utilized. The value of a biopsychosocial model of crack addiction and the concept of phases of recovery in providing a rationale for the recommended approach to relapse prevention are emphasized. Research findings on the determinants of relapse for crack dependent patients and the psychosocial characteristics of the crack dependent individual justify the utility of certain relapse prevention strategies. Specifically, an approach to relapse is advocated that includes the provision of pharmacological adjuncts, psychoeducation on the multideterminants of relapse, and psychotherapy that attempts to remediate underlying psychological problems that are typically found in crack dependent patients.

Cocaine↗

PubMedDate not supplied

Culture and social class as intervening variables in relapse prevention with chemically dependent women.

Craving and relapse are complex, poorly understood phenomena. A distinctive and baffling characteristic of the disease of chemical dependency is the continuing impulse to use alcohol and/or other drugs, even after lengthy periods of sobriety. This article discusses relapse prevention, focusing on public-sector chemically dependent women. Relapse among these women must be seen in the total context of their lives. Poverty and social disorganization do not directly cause relapse, but problems related to daily life under such conditions represent significant risk factors. The Eagleville Hospital treatment model and relapse prevention programs are described, and it is noted that public-sector women typically present with problems related to being raised in addicted households, residing in drug-saturated inner-city environments, deficits in child-rearing skills, destructive (often abusive) relationships with men, social interactions involving other substance abusers, few (if any) work skills, minimal educational achievement, low self-esteem, and poor self-image. A case study illustrates the course of treatment and relapse prevention efforts with a typical public-sector chemically dependent woman.

Adult↗

PubMedDate not supplied

Treating crack cocaine dependence: the critical role of relapse prevention.

Animals↗

PubMed2005

Relapse and acquired rifampin resistance in HIV-infected patients with tuberculosis treated with rifampin- or rifabutin-based regimens in New York City, 1997-2000.

BACKGROUND: The relationship between rifamycin use and either relapse or treatment failure with acquired rifampin resistance (ARR) among human immunodeficiency virus (HIV)-infected patients with tuberculosis (TB) is not well understood. METHODS: We conducted a retrospective cohort study of HIV-infected and HIV-uninfected persons with rifampin-susceptible TB, (1) to compare relapse rates, ARR, and treatment failure, according to HIV serostatus; and (2) to examine whether and how use of rifamycin was associated with clinical outcomes of interest among HIV-infected patients with TB. RESULTS: HIV-infected patients were more likely to have ARR than were HIV-uninfected patients (0.9% vs. 0.1%; P = .007), and the association remained significant in multivariate analysis (adjusted odds ratio [OR], 5.5; 95% confidence interval [CI], 1.4-21.5). Among HIV-infected patients with TB, none of 57 patients treated with rifabutin-based regimens alone had ARR, and only 1 of 395 patients treated with rifabutin given in combination with a rifampin-based regimen had ARR, whereas 6 of 355 patients treated with a rifampin-based regimen alone had relapse and ARR. HIV-infected patients treated with rifampin-based regimens alone had a higher risk for relapse and development of rifampin resistance if intermittent dosing of rifampin was started during the intensive phase of treatment, compared with patients who did not receive intermittent dosing (hazard ratio [HR] for relapse, 6.7 [95% CI, 1.1-40.1]; HR for ARR, 6.4 [95% CI, 1.1-38.4]). This association remained when confined to patients with a CD4+ T lymphocyte count of < 100 lymphocytes/mm3. Intermittent dosing started only after the intensive phase of treatment did not increase the risks of relapse and ARR among HIV-infected patients with TB. CONCLUSION: The risk for ARR among HIV-infected persons with TB did not depend on the rifamycin used but, rather, on the rifampin dosing schedule in the intensive phase of treatment.

AIDS-Related Opportunistic Infections↗

PubMed2006

Symptomatic relapse of HIV-associated cryptococcal meningitis after initial fluconazole monotherapy: the role of fluconazole resistance and immune reconstitution.

BACKGROUND: Cryptococcal meningitis (CM) in South Africa is often treated with fluconazole as initial therapy. Surveillance data suggest that the prevalence of fluconazole-resistant CM is increasing, and expanding access to antiretroviral therapy is resulting in increasing recognition of immune reconstitution inflammatory syndrome. Therefore, we conducted a study to assess the contribution of these factors to CM relapse in this context. METHODS: Patients with symptomatic relapse of CM were prospectively identified at 2 hospitals in Cape Town, South Africa, during the period of 2003-2005. Patients met the following criteria: (1) a previous laboratory-confirmed episode of CM, with resolution of symptoms after treatment; (2) reported adherence to fluconazole treatment; (3) recurrence of typical CM symptoms; (4) cerebrospinal fluid antigen test and/or culture positive for Cryptococcus neoformans; and (5) no alternative diagnosis. Data on patients' human immunodeficiency virus (HIV) and CM infections and treatment were collected and analyzed. RESULTS: Thirty-two episodes of relapse occurred among 27 patients. Episodes were classified into 3 groups: culture-positive episodes in antiretroviral therapy-naive patients (6 episodes), culture-positive episodes in patients receiving antiretroviral therapy (15 episodes), and culture-negative episodes in patients receiving antiretroviral therapy (11 episodes). Seventy-six percent of culture-positive relapses were associated with isolates that had reduced susceptibility to fluconazole. Drug-resistant cases required prolonged intravenous therapy with amphotericin B, and despite this treatment, the mortality rate was high (54% at a median of 6 months of follow-up). Despite a long interval between initiation of antifungal therapy and initiation of antiretroviral therapy (median interval, 144 days), immune reconstitution inflammatory syndrome contributed to at least one-third of relapses. CONCLUSIONS: After initial treatment with fluconazole, relapses of symptomatic CM are often associated with fluconazole resistance and immune reconstitution inflammatory syndrome. These data add to concern about the efficacy of fluconazole, compared with amphotericin B, for initial treatment of HIV-associated CM.

AIDS-Related Opportunistic Infections↗

PubMed2002

Relapse of Graves' disease after successful outcome of antithyroid drug therapy: results of a prospective randomized study on the use of levothyroxine.

Antithyroid drugs are effective in restoring euthyroidism in Graves' disease, but many patients experience relapse after withdrawal. Prevention of recurrence would therefore be a desirable goal. In a prospective study, patients with successful outcome of 12 to 15 months antithyroid drug therapy were stratified for risk factors and randomly assigned to receive levothyroxine in a variable thyrotropin (TSH)-suppressive dose for 2 years or no treatment. The levothyroxine group was randomized to continue or discontinue levothyroxine after 1 year. End points included relapse of overt hyperthyroidism. Of 346 patients with Graves' disease enrolled 225 were euthyroid 4 weeks after antithyroid drug withdrawal and were randomly assigned to receive levothyroxine (114 patients) or no treatment (controls, 111 patients). Of those not randomized, 39 patients showed early relapse within 4 weeks, 61 endogenous TSH suppression, 7 TSH elevation, and 14 had to be excluded. Dropout rate during the study were 13.3%. Kaplan-Meier analyses showed relapse rates to be similar in the levothyroxine group (20% after 1 year, 32% after 2 years) and the randomized controls (18%, 24%), whereas relapses were significantly more frequent in the follow-up group of patients with endogenously suppressed TSH (33%, 49%). Levothyroxine therapy did not influence TSH-receptor antibody, nor did it reduce goiter size. The best prognostic marker available was basal TSH determined 4 weeks after withdrawal of antithyroid drugs (posttreatment TSH). The study demonstrates that levothyroxine does not prevent relapse of hyperthyroidism after successful restoration of euthyroid function by antithyroid drugs and characterizes posttreatment TSH as a main prognostic marker.

Adult↗

PubMed1992

Relapse of Graves' disease following development of a pheochromocytoma.

Catecholamines stimulate thyroid hormone synthesis as well as release of thyroid hormone and cause immunologic disturbances that possibly contribute to the manifestations of Graves' disease. This has led to repeated speculations about the possible role of catecholamines in the initiation and maintenance of hyperthyroidism. We describe a patient with Graves' disease who was treated with antithyroid drugs for 2 years. After withdrawal of antithyroid drugs, the patient was in remission for 5 years. After the antithyroid drug treatment and the long remission, the probability of relapse of Graves' disease was very low. Nonetheless, a relapse did occur. Two years after subtotal thyroid resection, further investigation because of persistent hypertension revealed a pheochromocytoma. Retrospective anamnestic data suggest that this pheochromocytoma had been present 2 years before the patient's relapse of Graves' disease. This sequence of diseases has not been described previously. The low probability for a Graves' disease relapse in this patient and the association of this patient's relapse with the manifestation of a pheochromocytoma suggest a possible etiologic role of excess catecholamine production in the relapse of Graves' disease.

Adrenal Gland Neoplasms↗

PubMed1998

The presence of CD34+ cell clusters predicts impending relapse in children with acute lymphoblastic leukemia receiving maintenance chemotherapy.

Early detection of relapse in children with acute lymphoblastic leukemia (ALL), as well as distinction of leukemic blasts from hematogones, can be difficult by morphologic examination alone. Using CD34 and terminal deoxynucleotidyl transferase (TdT) immunoperoxidase stains, we studied specimens from 25 children with ALL in morphologic remission to determine if we could identify children at risk of relapse. We studied morphologic remission bone marrow specimens from 9 patients who experienced relapse during the subsequent 6 months and 16 children who remained in complete remission, including 10 specimens with increased numbers of hematogones. Despite morphologic remission, clusters of more than 5 CD34+ and/or TdT-positive cells were identified before overt relapse in 6 of 9 cases of relapse, but were noted in only 1 of 10 specimens from children in continuous complete remission and none of 10 specimens with increased numbers of hematogones. Clusters of CD34+ or TdT-positive cells can identify individual patients at risk for imminent relapse. Hematogones may be differentiated from lymphoblasts by this method.

Adolescent↗

PubMed1994

Multiclonality and altered RFLP patterns for immunoglobulin heavy-chain and T-cell receptor genes in relapsing lymphomas.

BACKGROUND: Alteration of morphological appearance as well as of clinical behaviour is common in relapsing non-Hodgkin's lymphomas. The aim of this study was to investigate the stability of the genes encoding the immunoglobulin heavy-chain and the T-cell receptor during the course of the disease in relapsing non-Hodgkin's lymphomas. MATERIAL AND METHODS: Nineteen patients with relapsed or progressive non-Hodgkin's lymphomas were analysed with respect to alterations of the restriction fragment length polymorphism (RFLP) pattern for Ig heavy chain (IgH) using probes for the C mu and J regions and for T-cell receptor (T-beta, T-gamma chain) genes. DNA was extracted from tumour material taken at different occasions during the course of the disease. RESULTS: All 19 cases showed clonal rearrangements of the IgH locus, and 2 cases showed simultaneous rearrangement of the genes coding for the T-cell receptors. Three or more rearranged bands, indicating more than one malignant clone, were detected in 1 case at the time of the diagnosis and in 5/19 (26%) cases in DNA from samples taken at relapse, all 6 cases showing discordant or transformed morphology. Altogether, in 11 out of 19 cases (58%), changes of the IgH rearrangement pattern could be visualized by RFLP. In all these cases except one, the new RFLP pattern included at least one rearranged band from the pattern of the first taken sample. In one case a clonal T-gamma receptor gene rearrangement was detected in a diagnostic sample but not in a sample taken at relapse. In 4 out of 6 cases with transformed lymphomas, clonal changes were observed at time of transformation. Evolution of clones with different RFLP patterns in different compartments were observed in 1 out of 6 studied cases. CONCLUSIONS: The present study illustrates that non-Hodgkin's lymphomas are unstable in their IgH genome. The observations of clonal evolution, multiclonality, and different clones in different compartments offer an explanation to the troublesome situation when treating relapsed lymphomas.

Cloning, Molecular↗

PubMed2002

Ifosfamide, carboplatin and etoposide in children with poor-risk relapsed Wilms' tumor: a Children's Cancer Group report.

BACKGROUND: The outcome of children with relapsed Wilms' tumor is poor, especially with poor-risk factors such as unfavorable histology, early recurrence, previous three-drug therapy, relapse not confined to lungs and abdominal relapse following abdominal radiotherapy. We report the overall response rate, progression-free survival and overall survival of 11 children with relapsed and poor-risk Wilms' tumor following ifosfamide/carboplatin/etoposide (ICE) chemotherapy. PATIENTS AND METHODS: ICE therapy consisted of ifosfamide 1800 mg/m2/day (on day 0-4), carboplatin 400 mg/m2/day (on day 0-1) and etoposide 100 mg/m2/day (on day 0-4). The median age at diagnosis was 39 months (range from 13 months to 16 years) and the median time to relapse after initial diagnosis was 9 months (range 4-72 months). All but one patient had at least one poor prognostic feature, with eight patients showing three or four. RESULTS: After ICE chemotherapy the number of patients showing a complete response (CR) was three (27%) and a partial response (PR) was six (55%). The overall response rate (CR+PR) was 82%. Five of the six patients with a PR subsequently achieved a CR with further therapy. The 3-year event-free survival and overall survival were 63.6 +/- 14.5%. CONCLUSIONS: The response rate in children with relapsed and poor-risk Wilms' tumor is >80% with ICE re-induction chemotherapy followed by post-ICE therapy. The optimal approach for post-ICE consolidation therapy has yet to be determined.

Adolescent↗

PubMed2006

Relapse and mortality following cardioversion of new-onset vs. recurrent atrial fibrillation and atrial flutter in the elderly.

AIMS: Trials of rate control vs. rhythm control for atrial fibrillation or flutter included few patients with new-onset arrhythmia. Our objective was to assess the relapse rate and the effect of the relapse of new-onset atrial arrhythmias on mortality after direct-current cardioversion (DCCV). METHODS AND RESULTS: A cohort of 351 patients with atrial fibrillation (new onset in 179) and 126 patients with atrial flutter (new onset in 78) was followed-up after DCCV. Cox proportional hazard models were used. Median age was 74.6 years. Mean follow-up for relapse was 7.7 months; for death, 29.4 months. Patients with new-onset atrial flutter [adjusted hazard ratio (HR) = 1] were more likely to maintain sinus rhythm than the patients with recurrent atrial flutter (adjusted HR = 2.5, P < 0.01), new-onset atrial fibrillation (adjusted HR = 2.4, P < 0.01), or recurrent atrial fibrillation (adjusted HR = 2.7, P < 0.01). Patients with new-onset atrial fibrillation were as likely to have relapses as patients with recurrent atrial fibrillation or flutter. Relapse of atrial arrhythmia after DCCV was associated with increased mortality (adjusted HR= 3.1, P < 0.01). CONCLUSION: DCCV is more successful in maintaining sinus rhythm in patients with new-onset atrial flutter than in patients with new-onset atrial fibrillation. Relapse of atrial arrhythmia after cardioversion is associated with increased mortality.

Aged↗

PubMed1992

Postpartum relapse to smoking: a prospective study.

A substantial proportion of women who quit smoking during pregnancy will relapse in postpartum. In order to better understand the psychosocial factors which precipitate relapse to smoking we conducted a prospective study of postpartum smoking relapse among a cohort (N = 106) of women who quit smoking during pregnancy. Participants were surveyed by telephone after the 28th week of pregnancy, and at 6 weeks and 6 months postpartum. Point prevalence estimates of smoking relapse indicated that at 6 weeks and 6 months follow-up, 24% (n = 26) and 40% (n = 42), respectively, of the women had returned to regular smoking. Spouse's smoking status, social support, decreases in self-efficacy, and the types of coping strategies used to resist smoking in pregnancy and postpartum predicted relapse to smoking in postpartum. Longitudinal data indicated that relapse occurred relatively gradually suggesting that early postpartum is not too late to encourage new mothers to remain abstinent.

Adolescent↗

PubMed1988

Specific antibodies detected during relapse of human brucellosis.

We studied 10 patients who had a relapse of brucellosis for significant serological changes during relapse. By the Coombs test, the pre-relapse and post-relapse median (range) titers of antibody to Brucella were 1:1120 (1:40-1:10,240) and 1:10,240 (1:40-1:81,920), respectively (P = .0069); by enzyme-linked immunosorbent assay (ELISA) for IgG, these values were 1:2240 (1:60-1:10,240) and 1:10,240 (1:160-1:81,920; P = .0069); by ELISA for IgA, the median titer increased 3.36 times but did not reach statistical significance (P = .0929); by tube agglutination, dithiothreitol (DTT) agglutination, and ELISA for IgM, median titers did not change. Nine patients had a significant titer increase by Coombs test and IgG ELISA, three had a significant increase by tube and DTT agglutination, none had significant increases by IgM ELISA, and one had no significant increase after relapse. Our findings show that for most patients with a relapse of brucellosis, there is an increase in IgG titers, as detected by ELISA and Coombs test, but no change in IgM titers.

Adolescent↗

PubMed1996

Molecular analysis of strains of Plasmodium vivax from paired primary and relapse infections.

Relapse infections are an important obstacle to the successful treatment and control of Plasmodium vivax malaria, but the molecular basis of relapse remains poorly understood. To provide insight into the molecular mechanisms of relapse, paired primary and relapse isolates of P. vivax were subjected to single-strand conformational polymorphism (SSCP) and sequence analysis of the circumsporozoite and merozoite surface protein 1 genes. All unrelated isolates were unique by both SSCP and sequence analysis, but 5 of 6 relapse isolates were identical to or were clones of their matched primary isolates. These results indicate that most relapses are caused by the same parasite populations that circulate during the primary infection and do not arise from a genetically distinct subpopulation.

Adult↗

PubMed1992

Sequential estrogen receptor determinations from primary breast cancer and at relapse: prognostic and therapeutic relevance. The International Breast Cancer Study Group (formerly Ludwig Group).

We retrospectively evaluated 401 selected patients who had estrogen receptor (ER) assays both at primary surgery and at relapse in an accessible site to determine the clinical relevance of the subsequent ER determination. The median time between ER assessments was 27 months (range: 2-122 months). The median follow-up time from diagnosis was 6 years (range: 2-12 years). For patients with ER+ tumors at primary diagnosis, 29% (76/261) had ER- tumors at relapse, while for ER- primaries, the conversion rate was 33% (46/140). Conversions from ER+ to ER- occurred more often when the time interval between assays was less than one year (p = 0.004), while conversions from ER- to ER+ tended to occur late (beyond three years; p = 0.0003). Treatments received between assays (usually adjuvant therapy) had only a slight influence on ER status conversion. Post-relapse survival was poor for patients who had the biopsy accessible recurrence within one year; an expression of the aggressive nature of the disease. Among patients whose accessible relapse was beyond one year, those with ER- primaries who converted to ER+ had a longer survival than those whose recurrence was classified again as ER- (p = 0.006). This group of patients with ER- primaries who recurred beyond one year with an ER+ tumor in an accessible site represented 29% (40/140) of all patients with ER- primaries and had an estimated overall survival rate of more than 60% at 6 years from the accessible relapse. ER determination upon relapse within one year has very little clinical relevance.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1992

Differing prognostic significance of reinfection and relapse in CAPD peritonitis.

All episodes of recurrent infection in a CAPD unit over a 26-month period have been analysed to discover whether relapse and reinfection have different prognostic importance. Relapse and reinfection were distinguished by detailed microbiological investigation. Prognosis was expressed in terms of outcome of treatment and the fate of the Tenckhoff catheter. Twenty-nine patients suffered recurrent infections (i.e. more than one infection during a 12-month period). Nine (6 male, 3 female, age range 42-73 years) had relapses, and 20 (16 male, 4 female, age range 42-74 years) reinfections. The characteristics of the two groups of patients were indistinguishable. Relapse was of graver prognostic consequence: patients who relapsed were significantly less likely to respond to antibiotic treatment (78% versus 20%) and have to have their catheters removed (78% versus 10%) than those with reinfections. Thus it is important to differentiate relapse from reinfection in CAPD peritonitis. In addition to being helpful for the management of individual patients, this is essential if results of therapeutic trials are to be interpreted correctly.

Adult↗

PubMed1995

Cost of relapse in schizophrenia.

To estimate the national annual cost of rehospitalization for multiple-episode schizophrenia outpatients, and to determine the relative cost burden from loss of medication efficacy and from medication noncompliance, the yearly number of neuroleptic-responsive multiple-episode schizophrenia inpatients in the United States who are discharged back to outpatient treatment was estimated. The cohort at risk for future relapse and rehospitalization was determined. The research literature on the expected rates of relapse for schizophrenia patients on maintenance antipsychotic medication was reviewed; in particular, monthly relapse rates under the optimal medication conditions of compliant patients taking optimal doses of a depot neuroleptic (optimal neuroleptic dose) and under the less optimal conditions of patients stopping medication (medication noncompliant) was estimated. Using established noncompliance rates from the literature, it became possible to estimate a "real world" rehospitalization rate for this cohort, as well as the relative burden accruing from loss of medication efficacy and from medication noncompliance. Finally, cost estimates for index hospitalizations and rehospitalizations were derived from data on national expenditures for inpatient mental health care. The monthly relapse rates are estimated to be 3.5 percent per month for patients on maintenance neuroleptics and 11.0 percent per month for patients who have discontinued their medication. Postdischarge noncompliance rates in community settings are estimated to be 7.6 percent per month. These estimates were entered into a survival analysis model to determine the real world relapse rate of this cohort. An estimated 257,446 multiple-episode (> or = two hospitalizations) schizophrenia patients were discharged from short-stay (< or = 90 days) inpatient units in the United States during 1986. The estimated aggregate baseline inpatient cost for the index hospitalizations of this cohort was $2.3 billion (1993 dollars). Within 2 years after discharge, the aggregate cost of readmission approached $2 billion. Loss of neuroleptic efficacy accounted for roughly 60 percent of the rehospitalization costs and neuroleptic noncompliance for roughly 40 percent. The economic burden due to loss of efficacy is relatively higher during the first postdischarge year, whereas the burden from noncompliance is higher in the second year. Because loss of medication efficacy and medication noncompliance act synergistically on relapse, substantial inpatient cost savings can be realized by linking better pharmacologic treatments of schizophrenia with more effective strategies to manage medication noncompliance.

Ambulatory Care↗