Items in AFP with MESH term: Patient Compliance
Management of Asthma in Children - Article
ABSTRACT: The prevalence of asthma in children has increased 160 percent since 1980, and the disease currently affects nearly 5 million children in the United States. The National Asthma Education and Prevention Program provides guidelines for improved asthma care. The goals of this program are to limit the frequency, severity and costliness of asthma exacerbations through extensive education of physicians, children and caregivers. The four components of asthma management include regular assessment and monitoring, control of factors that contribute to or aggravate symptoms, pharmacologic therapy and education of children and their caregivers. The guidelines recommend a stepwise approach to pharmacologic treatment, starting with aggressive therapy to achieve control and followed by a "step down" to the minimal therapy that will maintain control. Quick relief of symptoms can be achieved preferentially by the use of short-acting beta2 agonists. Medications for long-term control should be considered for use in children with persistent symptoms. Inhaled corticosteroids are the most potent long-term anti-inflammatory medications. Other options include long-acting beta2 agonists, cromolyn sodium and nedocromil, antileukotriene agents and theophylline. All have advantages and disadvantages in individual situations.
ABSTRACT: Older Americans comprise 13 percent of the population, but they consume an average of 30 percent of all prescription drugs. Every day, physicians are faced with issues surrounding appropriate prescribing to older patients. Polypharmacy, use of supplements, adherence issues, and the potential for adverse drug events all pose challenges to effective prescribing. Knowledge of the interplay between aging physiology, chronic diseases, and drugs will help the physician avoid potential adverse drug events as well as drug-drug and drug-disease interactions. Evidence is now available showing that older patients may be underprescribed useful drugs, including aspirin for secondary prevention in high-risk patients, beta blockers following myocardial infarction, and warfarin for nonvalvular atrial fibrillation. There is also evidence that many older adults receive medications that could potentially cause more harm than good. Finding the right balance between too few and too many drugs will help ensure increased longevity, improved overall health, and enhanced functioning and quality of life for the aging population.
ABSTRACT: Antiretroviral regimens are complicated and difficult for patients to follow, and they can have serious side effects, such as osteonecrosis and bone demineralization. Protease inhibitor therapy has been associated with hyperlipidemia, hyperglycemia, gastrointestinal symptoms, and body-fat distribution abnormalities. Nonnucleoside reverse transcriptase inhibitors can cause rashes and hepatotoxicity, and nucleoside reverse transcriptase inhibitors can cause lactic acidosis, hypersensitivity reactions, neuropathies, pancreatitis, anemia, and neutropenia. Malabsorption can occur if antiretroviral agents are taken improperly with regard to meals or if they are taken with certain other drugs or herbal remedies. Some commonly prescribed drugs can cause dangerous drug toxicities if they are taken by patients who are also taking certain antiretroviral medications. Suboptimal exposure to antiretrovirals because of noncompliance or malabsorption can result in viral resistance and loss of future treatment options.
Diaphragm Fitting - Article
ABSTRACT: When used with a spermicide, the diaphragm can be a more effective barrier contraceptive than the male condom. The diaphragm allows female-controlled contraception. It also provides moderate protection against sexually transmitted diseases and is less expensive than some contraceptive methods (e.g., oral contraceptive pills). However, diaphragm use is associated with more frequent urinary tract infections. Contraindications to use of a diaphragm include known hypersensitivity to latex (unless the wide seal rim diaphragm is used) or a history of toxic shock syndrome. A diaphragm is fitted properly if the posterior rim rests comfortably in the posterior fornix, the anterior rim rests snugly behind the pubic bone, and the cervix can be felt through the dome of the device. The diaphragm should not be left in the vagina for longer than 24 hours. When the diaphragm is the chosen method of contraception, patient education is key to compliance and effectiveness. An extended visit with the physician or a nurse may be required for a woman to learn proper insertion, removal, and care of the diaphragm.
ABSTRACT: Healthy eating and increased physical activity can prevent or delay diabetes and its complications. Techniques that facilitate adherence to these lifestyle changes can be adapted to primary care. Often, the patient's readiness to work toward change must be developed gradually. To prepare patients who are reluctant to change, it is effective to assess and address their conviction and confidence. Patients facing the long-term task of making lifestyle changes benefit from assistance in setting highly specific behavior-outcome goals and short-term behavior targets. Individualization is achieved by tailoring these goals and targets to the patient's preferences and progress, building the patient's confidence in small steps, and implementing more intensive interventions according to a stepped-care model. At each office visit, physician follow-up of the patient's self-monitored goals and targets enhances motivation and allows further customization of the plan. A coaching approach can be used to encourage positive choices, develop self-sufficiency, and assist the patient in identifying and overcoming barriers. More intensive intervention using a team approach maximizes adherence.
ABSTRACT: Medications for treating alcohol dependence primarily have been adjunctive interventions, and only three medications--disulfiram, naltrexone, and acamprosate--are approved for this indication by the U.S. Food and Drug Administration. Disulfiram, an aversive agent that has been used for more than 40 years, has significant adverse effects and compliance difficulties with no clear evidence that it increases abstinence rates, decreases relapse rates, or reduces cravings. In contrast, naltrexone, an anticraving agent, reduces relapse rates and cravings and increases abstinence rates. Acamprosate also reduces relapse rates and increases abstinence rates. Serotonergic and anticonvulsant agents promise to play more of a role in the treatment of alcohol dependence. Although not approved by the U.S. Food and Drug Administration for this indication, the anticonvulsant topiramate and several serotonergic agents (e.g., fluoxetine, ondansetron) have been shown in recent studies to increase abstinence rates and decrease drinking.
ABSTRACT: The problem of getting children to follow a treatment regimen is widespread and is frustrating for physicians. The extent to which any patient adheres to a medical regimen is an essential determinant of clinical success. Strategies to improve adherence in children include using simplified drug regimens (e.g., once-daily dosing), pleasant-tasting medicines, liquid or other nonpill formulations, regular phone contact between parents and physicians, reminders, information counseling, self-management plans, and other forms of individualized supervision or attention. Physicians also can encourage adherence by providing a dearly written explanation or patient information sheets that list generic and brand names, dosage, schedule, duration, and common side effects and practical ways of coping with them. Physicians, children, and parents should develop a mutually agreed-upon treatment plan. Having the child participate in devising the plan improves adherence.
Update on the Treatment of Tuberculosis - Article
ABSTRACT: Approximately one third of the world's population, including more than 11 million persons in the United States, is latently infected with Mycobacterium tuberculosis. Although most cases of tuberculosis in the United States occur in foreign-born persons from endemic countries, the prevalence is generally greater in economically disadvantaged populations and in persons with immunosuppressive conditions. Delays in detection and treatment allow for greater transmission of the infection. Compared with the traditional tuberculin skin test and acid-fast bacilli smear, newer interferon-gamma release assays and nucleic acid amplification assays lead to more rapid and specific detection of M. tuberculosis infection and active disease, respectively. Nine months of isoniazid therapy is the treatment of choice for most patients with latent tuberculosis infection. When active tuberculosis is identified, combination therapy with isoniazid, rifampin, pyrazinamide, and ethambutol should be promptly initiated for a two-month "intensive phase," and in most cases, followed by isoniazid and a rifamycin product for a four- to seven-month "continuation phase." Directly observed therapy should be used. Although currently limited in the United States, multidrug-resistant and extensively drug-resistant strains of tuberculosis are increasingly recognized in many countries, reaffirming the need for prompt diagnosis and adequate treatment strategies. Similarly, care of persons coinfected with human immunodeficiency virus and tuberculosis poses additional challenges, including drug interactions and immune reconstitution inflammatory syndrome.
A Systematic Approach to Managing Warfarin Doses - Improving Patient Care