Adherence to disease-modifying therapy in multiple sclerosis: Part II.

Multiple sclerosis (MS) is a chronic, debilitating disease for which there is no cure; however, the recent introduction of injectable immunomodulating agents has reduced the rate of relapsing episodes and possibly slowed the progression of the disease. These disease-modifying agents are recommended by the National MS Society, but their true potential cannot be realized if patients do not accept them and healthcare professionals do not promote them. Since MS has an unpredictable course, and treatments can produce side effects, adherence to the recommended therapy is a complex and challenging issue. Improved understanding of the obstacles to adherence and the identification of possible solutions should be of value to nurses, who have numerous opportunities to encourage patients to initiate and continue therapy. Part I of this article, published in the September/October 2001 issue of Rehabilitation Nursing, described the particular problems of treatment adherence in MS. Part II proposes that the transtheoretical model of behavior change can be a useful tool in achieving both patient acceptance and treatment goals. This model is founded upon the concept that readiness for change is crucial, and that attempts at intervention should be sensitive to the patients' changing conditions and states of mind.     

Adherence trajectories in oral therapy for chronic myeloid leukemia: Overview of a research protocol

Over a quarter of chemotherapy regimens now include oral agents. Individuals living with cancer are now responsible for administering this lifesaving therapy at home by taking every dose as prescribed. One type of oral chemotherapy, tyrosine kinase inhibitors (TKIs), is the current recommended treatment for chronic myeloid leukemia. This targeted therapy has markedly improved survival but comes with significant side effects and financial costs. In the study described in this protocol, the investigators seek to understand the dynamic nature of TKI adherence experienced by individuals diagnosed with CML. Using a mixed-method approach in this prospective observational study, funded by the National Cancer Institute, we seek to describe subjects' adherence trajectories over 1 year. We aim to characterize adherence trajectories in individuals taking TKIs using model-based cluster analysis. Next, we will determine how side effects and financial toxicity influence adherence trajectories. Then we will examine the influence of TKI adherence trajectories on disease outcomes. Additionally, we will explore the experience of patients taking TKIs by interviewing a subset of participants in different adherence trajectories. The projected sample includes 120 individuals taking TKIs who we will assess monthly for 12 months, measuring adherence with an objective measure (Medication Event Monitoring System). Identifying differential trajectories of adherence for TKIs is important for detecting subgroups at the highest risk of nonadherence and will support designing targeted interventions. Results from this study can potentially translate to other oral agents to improve care across different types of cancer.     

Interventions to enhance adherence of patients with HIV on ART: a literature review

The introduction of potent antiretroviral therapy led to a reduction of mortality and morbidity associated with HIV in industrial countries. HIV infection has changed from a lethal disease to a chronic illness that can be treated effectively. It can be assumed, that people who receive correct treatment now have a normal life expectancy. However, one of the most crucial predictors to ensure the effectiveness of ART is a nearly perfect adherence to the medication regime. This literature review summarizes the evidence resulting from randomised controlled trials which were conducted to enhance medication adherence to antiretroviral therapy. It shows that effective programs need to combine several methods. Generalized short-term interventions are easier to be tested by randomized controlled trials. However, for nursing guidelines we suggest long-term programs which are tailored to the patient's needs.     

Facilitating treatment adherence with lifestyle changes in diabetes

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.     

Do patients show the same level of adherence with all dry powder inhalers?

Poor adherence with inhaled therapy presents a considerable problem. In the UK, non-adherence is estimated to occur in 10-46% of those prescribed inhaled corticosteroids and may contribute to an estimated 18-48% of asthma deaths. Before dry powder inhalers can be considered interchangeable, it is important to check that adherence is unaffected by any switching of the device dispensed to patients. Numerous studies have shown that adherence with inhaled medication is a multifactorial issue. A number of evidence-based guidelines have concluded that there is no difference in the delivery of treatments from different inhaler devices. However, many studies comparing different devices are designed to show equivalence. It is therefore difficult to determine whether the studies on which the guidelines are based were conducted with treatments already being used at the top of a dose-response curve. Furthermore, studies use selected patient populations who consent to take part and consequently receive regular contact with healthcare professionals, with emphasis on using the correct inhaler technique and on compliance. These studies do not therefore necessarily reflect real life. It is possible that patient preferences or perceptions of differences in efficacy are behind complaints when devices are switched. Patients vary in their preference for different dry powder inhalers, as shown in numerous studies of patient attitudes. There is evidence to indicate that patient claims of differences between inhalers that contain the same molecule from different manufacturers may have an objective basis. Healthcare professionals increasingly recognise the impact of patient attitudes on adherence. Accepting that patients make choices about their therapy is an integral part of achieving the partnership in management recommended by guidelines. The most effective treatment will not achieve disease control if it is not used or if it is used incorrectly. It may be short-sighted to change a device that a patient has chosen to one that is just given without consent, as this may result in poor adherence to therapy with consequent loss of control.     

Ethical issues in the care of cancer patients.

Nearly all the topics considered by medical ethics generally present themselves to those caring for cancer patients. Although most attention may be given to questions of resource allocation and limiting treatment, other issues are of equal importance. Providing respect and compassion for patients may be even more important. The day-to-day treatment of the patient that recognizes the practical autonomy of the patient and legitimizes the patient's involvement in deciding about his or her own care may do more to preserve the integrity of the patient as a person than anything else that happens to someone who accepts the cancer diagnosis. The physician who can accept the patient's judgment and participation and who can help the patient find positive meaning in what can be a personally and socially devastating disease experience has enacted a highly laudatory ethical standard of patient care.     

人类免疫缺陷病毒感染者抗病毒治疗服药依从性监测与管理

高效抗反转录病毒治疗大大降低了人类免疫缺陷病毒(human immunodeficiency virus, HIV)感染者的病死率, 使HIV感染者可获得长期存活。服药依从性是实现病毒抑制、延缓疾病进展的关键因素之一。目前依从性的测量方法可分为间接和直接测量两种。影响依从性的因素大致可分为个体水平因素、药物治疗方案因素、人际关系问题和结构性问题4大类。可提高依从性的方法有:短消息提醒、指导治疗及制定计划、实时依从性监测和应用长效抗病毒药物制剂等。虽然已有较多相关依从性的研究, 获得可推广的行之有效的依从性监测及提高手段仍存在较大挑战。     

Managing the care of patients with dementia. How to maximize level of functioning and minimize behavior problems

Effective treatment of patients with dementia involves supporting and educating the primary caregiver, uncovering and correcting the underlying cause of any decompensation that may occur, and deciding when drug therapy is appropriate. Caregivers must be taught how to cope with the patient's denial and how to modify the patient's environment so that it is safe and easy to understand. Pharmacologic therapy for depression accompanying dementia can improve a patient's quality of life and independence considerably; drugs may also be of help in dealing with patients who resist care. Psychotic symptoms usually do not require pharmacologic treatment, and hypnotics should, if possible, be avoided as a solution to sleep problems.     

Training program for patients with multiple sclerosis at the start of immunomodulatory therapy

Multiple sclerosis (MS) is a central nervous system disease of unknown cause that affects approximately 22,500 people in Spain (mostly young adults). This disease normally takes the form of acute episodes (attacks) that require continuous follow-up. Currently, curative therapy is lacking but symptomatic treatment is available. In the initial phase of the disease, immunomodulatory agents such as interferon-beta and glatiramer acetate modify disease progression. However, this therapy may be abandoned due to the difficulty of using these drugs and their adverse effects. In our hospital, the provision of information, training and patient monitoring by nurses has helped to improve adaptation to the disease, treatment adherence, and quality of life in patients with MS.     

音乐疗法对慢性精神分裂症患者社会功能的影响

目的:探讨慢性精神分裂症患者辅以音乐治疗对其社会功能的改善。方法:选取62例符合CCMD-2-R关于精神分裂症诊断标准的患者,按入院顺序随机分为实验组(抗精神病药物辅以音乐治疗)和对照组(单用抗精神病药物治疗及传统护理),实验组32例,对照组30例。采用住院病人护士观察量表,在实验前后分别进行观察评分,并进行相关因素的比较。结果:两组在治疗后,NOSIE评分减分值有显著差异,实验组明显优于对照组(P<0.01)。音乐治疗的干预对慢性精神分裂症患者的社会功能产生了其它护理方法不可替代的积极作用。结论:在传统护理方法的基础上,辅以音乐治疗的方法更能有效地改善慢性精神分裂症患者的社会功能,明显提高慢性精神分裂症患者的生存质量。     

Opioids: How to Improve Compliance and Adherence

Abstract: Chronic pain has been recognized as a major worldwide health care problem. Today, medical experts and health agencies agree that chronic pain should be treated with the same priority as the disease that caused it, and patients should receive adequate pain relief. To achieve good analgesia, patient adherence to a prescribed pain treatment is of high importance. Patients with chronic pain often do not use their medication as prescribed, but change the frequency of intake. This can result in poor treatment outcomes and may necessitate additional emergency treatment, which increases the overall costs. Factors that influence adherence include knowledge of the disease, realistic treatment expectations, perceived benefit from treatment, side effects, depression, dosing frequency, and attitudes of relatives/significant others toward opioids. Addressing all these factors should ensure a good treatment outcome. Good adherence to pain therapy is associated with improved efficacy in pain relief and quality of life. Opioids have become an integral part of the treatment of moderate to severe chronic noncancer pain. They may cause unpleasant side effects such as nausea, vomiting, and constipation. Patients should be informed adequately about side effects, which should be treated pro‐actively to foster adherence to treatment. Signs of tolerance, hyperalgesia, and drug abuse should be monitored as these may occur in some patients. An individualized treatment algorithm with a clear treatment goal and regular treatment reassessment is key for successful treatment. Long‐acting opioids offer sustained pain relief over 24 hours with manageable side effects—they simplify treatment thereby supporting treatment adherence.     

Simplified approach to somatization disorder. When less may prove to be more

Somatization disorders--manifestations of mental pain--take many forms and can be difficult to diagnose and treat. By definition, most patients with this condition do not want to be cured. Antidepressant or antianxiety medication and referral to a support group or psychiatrist can help patients who are willing to participate in their treatment. Other patients may receive the most benefit from primary care physicians who accept the limitations of treatment, listen to their patient's concerns, and provide reassurance.     

Neutralizing Antibodies Are Associated with a Reduction of Interferon-β Efficacy during the Treatment of Japanese Multiple Sclerosis Patients

Multiple sclerosis (MS) is a chronic immune-mediated inflammatory demyelinating disease of the central nervous system. Interferon-β (IFN-β) has been used as the first line therapy for MS treatment in Japan, but patients treated with IFN-β may develop antibodies, known as neutralizing antibodies (NAbs), which abrogate its therapeutic effects. Intramuscular IFN-β 1a and subcutaneous IFN-β 1b are currently available in Japan, but large-scale studies evaluating the prevalence and clinical implications of NAbs against these IFN-β preparations in MS patients have only been performed in Caucasian populations. NAbs positivity has been reported to be associated with HLA-DRB1 alleles, suggesting that the positivity might differ among populations with distinct genetic backgrounds. Clinical information and sera were collected from 229 consecutive MS patients treated with IFN-β in 4 centers in Japan. Sera were tested for NAbs using a luciferase reporter gene assay. In total, 5.2% of IFN-β-1a-treated patients (4/77) and 30.3% of IFN-β-1b-treated patients (46/152) were positive for Nabs. The frequency of NAbs was highest in patients treated for 13 to 24 months. Clinical relapse and contrast-enhancing lesions in the magnetic resonance imaging increased together with NAbs titers in this group. In conclusion, the prevalence of NAbs in Japanese MS patients is similar to that in Caucasian populations and is associated with an increase in disease activity. Therefore, routine NAbs testing is recommended also in Asian populations to ensure the early identification of patients who would benefit from a change in therapy.     

Predictors of adherence to Copaxone therapy in individuals with relapsing-remitting multiple sclerosis.

The purpose of this study was to evaluate psychological, biophysical, and sociodemographic variables as predictors of adherence to glatiramer acetate (Copaxone) therapy in individuals with relapsing-remitting multiple sclerosis (MS). Because Copaxone is a daily subcutaneous injection, individuals with MS are challenged by the daily routine of preparation and administration of this medication. Despite the challenges, some individuals with MS adhere to treatment with injectable medications with little or no difficulty, while others struggle to adhere to, and soon abandon, the daily task. It is important to identify predictors of adherence to Copaxone therapy so those at risk can be identified early and provided with individualized support at the onset of therapy. Potential participants were identified from the Consortium of Multiple Sclerosis Centers North American Research Committee on Multiple Sclerosis Patient Registry database (n = 600) and from the Shared Solutions MS patient support database (n = 600). Individuals who had taken or stopped taking Copaxone were specifically selected. Those taking multiple immunomodulating drugs or not able to complete the data collection instruments were excluded. Booklets containing four instruments (MS Self-Efficacy Control and Function Subscales, Rosenberg Self-Esteem Scale, Herth Hope Index [HHI], and Performance Scale) and sociodemographic data sheets were mailed to 1,200 individuals. Of the 594 who completed and returned booklets, 341 individuals had relapsing-remitting MS and met the inclusion criteria. There were 225 individuals in the adherent group and 116 in the nonadherent group. Logistic regression analysis revealed four significant predictors of adherence: self-efficacy (control), hope, perception that the doctor was the most supportive of the individual taking Copaxone, and no previous use of other immunomodulators. The higher the score on the MS Self-Efficacy Control Subscale and HHI, the more likely the individual will adhere to Copaxone therapy. The MS Self-Efficacy Control Subscale and HHI show promise of being useful predictors of adherence. Further testing is recommended. Physician support should be conveyed to all individuals starting and maintaining Copaxone therapy for MS. Greater support needs to be provided to those who have previously taken immunomodulating drugs.     

Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure

BACKGROUND: The stages-of-change (SOC) model has been used to explain and predict how behavior change occurs, but it is new as an approach to understanding why patients fail to take their medications as prescribed. OBJECTIVE: This study validated a 2-item measure of SOC for adherence with medication regimens in 2 groups of patients prescribed pharmacologic therapy for chronic conditions. METHODS: Two cross-sectional studies of attitudes toward medication adherence included the same measure of SOC for medication adherence. One was a sample of 161 HIV-positive patients in the United States, and the other was an international sample of 731 patients with hypertension. The validity of the measure of SOC for medication adherence was examined in both convenience samples using previously validated self-reported measures of adherence (the Medication Adherence Scale and a measure of adherence from the Medical Outcomes Study), and in the HIV sample using electronic monitoring of adherence behavior in 85 patients. RESULTS: Construct validity was demonstrated in both samples by associations between SOC and the previously validated measures of adherence (P < 0.001), and predictive validity was supported by significant associations between SOC for medication adherence and electronically monitored medication-taking behavior during the next 30 days (P < 0.03). CONCLUSIONS: Behavior-change theory suggests that stage-tailored communication strategies are more effective than uniform health-promotion messages. Our results provide a foundation for the development of interventions for medication adherence that are tailored to patients' readiness for change. Our validated 2-item measure of SOC for medication adherence can be used to match communication strategies to individual motivation and readiness for adherence with chronic disease medication regimens.     

急诊患者放弃有创抢救的原因分析及处理对策

目的 分析急诊患者放弃有创抢救的原因并提出对策.方法 选择2014年1月至2014年12月收入北京协和医院急诊抢救室的2 673例患者,分为抢救组和放弃抢救组,对两组患者的基本情况、基础疾病、医疗费用支付方式、签署意见书的人员构成、患者的治疗情况以及预后进行分析.结果 两组患者男女性别构成差异无统计学意义(x2 =1.86,P=0.173);放弃抢救组患者年龄明显高于抢救组患者(69.5±12.5 vs.58.6±19.2岁,F=28.92,P=0.000);放弃抢救组中北京以外的患者比例更高(51.90％ vs.44.01％,x2=10.59,P=0.001);放弃抢救组中患慢性心衰、慢性呼吸衰竭、慢性肝性脑病、慢性肾衰竭、恶性肿瘤等慢性疾病的比例更高(8.17％vs.3.03％,8.17％ vs.2.61％,3.80％ vs.1.16％,5.32％ vs.1.44％,11.98％ vs.2.28％,均P=0.000);放弃抢救组中自费患者比例更高(52.09％ vs.41.08％,x2=20.87,P=0.000);在签署意见书的人员构成方面,由患者本人签署的放弃抢救的比例明显高于同意抢救(3.04％ vs.0.42％,x2=64.40,P=0.000),而患者的子女、配偶、父母、兄弟姐妹以及其他人员签署的同意抢救和放弃抢救的比例差异无统计学意义;Logistic回归分析结果显示患者高龄、非北京患者、患慢性基础病、自费、由患者本人签署意见书是放弃有创抢救的重要影响因素;放弃抢救组患者的病死率明显高于抢救组(19.39％ vs.7.68％,x2=64.40,P=0.000).结论 放弃有创抢救治疗的患者多为高龄或属于慢性疾病终末期,急诊医务人员应继续关注这些患者,采用无创的手段进行治疗或减轻患者的痛苦.     

Depression.

Depression often presents with physical symptoms, primarily fatigue, pain, or sleep disturbance. Depressed mood may or may not be present. Supportive counseling and pharmacotherapy are more effective than either modality alone. The newer drugs are better tolerated than earlier agents, and they achieve much greater patient adherence. Depression is considered a chronic disease. The likelihood of recurrence increases with the number of episodes, often calling for prolonged maintenance of medication. Most patients with mild to moderate depression can be effectively managed by their primary care physician, with referral required only for those who are unresponsive to therapy or who are suicidal.     

Interferon-beta treatment for multiple sclerosis and predictors of response

Interferon-beta (IFNbeta) is the most widely prescribed disease-modifying therapy for multiple sclerosis (MS) today. Large-scale clinical trials have established the clinical efficacy of IFNbeta in reducing relapses and slowing disease progression in relapsing-remitting MS. IFNbeta therapy was shown to be comparably beneficial for opticospinal MS (OSMS) and conventional MS in Japanese. IFNbeta is effective in reducing relapses in secondary progressive MS and may have a modest effect in slowing disability progression. Clinically isolated syndrome (CIS) refers to an initial demyelinating event that is suggestive of MS. Treatment for CIS with IFNbeta is effective in delaying conversion to clinically definite multiple sclerosis. Since neutralizing antibodies (NAbs) can reduce the clinical efficacy of IFNbeta in patients with MS, clinicians should consider the possible development of NAbs in patients demonstrating disease progression while receiving IFNbeta treatment. In some patients with neuromyelitis optica (NMO)/OSMS patients with anti-aquaporin-4 (APQ4) antibody or longitudinally extensive spinal cord lesions (LESCLs) extending over three vertebral segments as well as in patients with collagen disease, IFNbeta has been found to be ineffective or detrimental. In NMO/OSMS patients with LESCLs or patients with collagen disease, measurement of anti-APQ4 antibody is recommended. In these patients with anti-APQ4 antibody, careful consideration is necessary before initiating IFNbeta treatment.