Sticky issue of adherence

The phenomenon of adherence, also known as compliance, is the vital link that allows effective medications to have the desired clinical effect when self-administered. It is often assumed that the population is generally adherent, but more than 50% of people with chronic illness do not take their medication as prescribed. We highlight how the terminology and language of non-adherence act to conceptualize adherence as a patient problem in a manner that is inadvertently judgmental, narrowly focused and clinically unhelpful. In contrast, knowledge of the dynamic nature of adherence promotes the conceptualization of adherence as the common problem that it is, where the responsibility for improving it lies primarily with the health professional. The example of asthma is used to highlight how individually focused clinical strategies can fit within a population perspective that, in its entirety, can be conceptualized as a framework of adherence-promoting strategies.     

Health-service use by children with asthma over a 6-month period

OBJECTIVES: The present study aims to describe the use of health services by children with asthma, and examine disease-specific, parental and sociodemographic variables associated with different levels of health-service utilization. METHODS: Parents of 135 children attending an emergency room (ER) completed questionnaires measuring the children's asthma symptoms, and sociodemographic and psychological variables. Parents were contacted monthly for 6 months to document the number of planned and unplanned visits to hospital and community health-care services for asthma. RESULTS: At least one further unplanned visit to the ER was made by 37% of children, while 62% made at least one unplanned visit to a general practitioner (GP). Fifty-five per cent made planned review visits to a GP, 30% to paediatricians and 5% to hospital clinics. After controlling for the level of asthma symptoms, parental anxiety and parental perceptions of children's vulnerability were associated with unplanned GP visits (P = 0.05 and P = 0.01, respectively); a planned review visit and the child being admitted to hospital for the index attack were associated with unplanned ER visits (P = 0.05 and P = 0.004, respectively). CONCLUSIONS: Children with asthma more frequently attend GP services than hospital services for both planned and unplanned asthma management. Different variables predict the unplanned use of GP and ER services. Understanding these differences is imperative if children and families are to make the most effective use of health services.     

General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family's perspective

Background: Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and nurses as being well tolerated by children and their families. Aim: To compare the efficacy of inhalational general anaesthesia and midazolam sedation for these procedures. Methods: A total of 96 children with neoplastic disorders, who received either inhalational general anaesthesia with sevoflurane, nitrous oxide, and oxygen (GA) or sedation with oral or nasal midazolam (SED) as part of their routine preparation for procedures were studied. The experiences of these childen were examined during their current procedure and during their first ever procedure. Main outcome measures were the degree of physical restraint used on the child, and the levels of distress and pain experienced by the child during the current procedure and during the first procedure. The family‘s preference for future procedures was also determined. Results: During 102 procedures under GA, restraint was needed on four occasions (4%) when the anaesthetic mask was first applied, minimal pain was reported, and children were reported as distressed about 25% of the time. During 80 SED procedures, restraint was required in 94%, firm restraint was required in 66%, the child could not be restrained in 14%, median pain score was 6 (scale 0 (no pain) to 6 (maximum pain)), and 90% of the parents reported distress in their child. Ninety per cent of families wanted GA for future procedures. Many families reported dissatisfaction with the sedation regime and raised concerns about the restraint used on their child. Conclusions: This general anaesthetic regime minimised the need for restraint and was associated with low levels of pain and distress. The sedation regime, by contrast, was much less effective. There was a significant disparity between the perceptions of health professionals and those of families with respect to how children coped with painful procedures.     

Relation between measurements of cough severity

Background: In asthma, measurements of airway inflammation correlate poorly with clinical markers and airway hyperresponsiveness. While the relation between determinants of asthma severity is known, that for cough is unknown. We hypothesised that cough sensitivity changes relate to changes in cough scores and objectively measured cough frequency. Aims: To examine the relation between commonly used outcome measurements of cough severity in children. Methods: The concentration of capsaicin causing two and five or more coughs (C2 and C5 respectively), cough frequency objectively measured using an ambulatory cough meter, and parent and child recorded subjective cough scores were determined in 40 children with recurrent cough on two occasions. Results: On occasion one, log cough frequency significantly correlated with parent and child recorded log cough score (r_s = 0.32, p = 0.05; and r_s = 0.32, p = 0.046 respectively) and significantly negatively correlated with log C2 (r_s= -0.5, p = 0.005). Subjective cough scores did not relate to either C2 or C5. On occasion two, the relation between cough frequency and C2 and C5 measures was lost, but C2 had a weak but significant relation to parent recorded cough score (r_s = -0.38, p = 0.047). When the changes in the log values were determined, C5 but not C2 significantly related to cough frequency. Conclusion: In children, measures of cough sensitivity have a weak relation with cough frequency. Subjective cough scores have a stronger and consistent relation with cough frequency. These cough severity indices measure different aspects of cough. The choice of indices depends on the reason for performing the measurement.     

Oxidative stress in the male germ line and its role in the aetiology of male infertility and genetic disease

The human male is characterized by extremely poor semen quality as reflected in the number, morphology and motility of the spermatozoa and a high incidence of nuclear and mitochondrial DNA damage. As a consequence of these factors, defective sperm function is thought to be a major contributor to the aetiology of human infertility, as well as childhood diseases including dominant genetic mutations such as achondroplasia and cancer. Factors associated with the origin of poor semen quality include: (i) a lack of selection pressure for high fecundity genes in developed countries, (ii) an evolutionary lineage associated with the deterioration of several male fertility genes in humans and their close ancestors, (iii) genetic factors including, but not limited to, Y-chromosome deletions (iv) paternal age and (v) environmental factors. A model is proposed whereby factors such as ageing or environmental toxicants initiate DNA strand breakage in the spermatozoa of affected males, eventually leading to a mutation in the embryo. This hypothesis stresses the importance of discovering the identity of those environmental factors that are capable of damaging DNA integrity in the male germ line. Such information could make an important contribution to understanding of the origins of both male infertility and a variety of pathological conditions that affect humans, including cancer and dominant genetic disease.     

The outcome of adolescent eating disorders: findings from the Victorian Adolescent Health Cohort Study

The study aimed to ascertain the outcome of adolescent onset eating disorders in a representative cohort of females. The design was a seven wave cohort study conducted over 6 years. 982 female participants from a total sample of 2032 secondary school students initially aged 14-15 years at 44 schools in the state of Victoria Australia. Branched questionnaires (BET) were used for assessing symptoms of eating disorder. A partial syndrome was defined where a subject met two DSM-IV criteria for either anorexia or bulimia nervosa. The revised Clinical Interview Schedule (CIS-R) was used for assessing depression and anxiety, and self-report frequency of use and retrospective diaries for substance use. The mean point prevalence of eating disorders in females between 15-18 years at the partial syndrome level was 2.4 % (1.8-31). At follow-up at the age of 20 years the point prevalence was 3 % (1.9-4.1). In all 8.8 % reported an eating disorder across the six year study period. Eleven percent of those with eating disorder in the teens had persisting disorder at follow-up. In contrast, close to 50 % had high levels of depression and anxiety, a finding that was particularly marked for those with the partial syndrome of bulimia nervosa during the teens. The bulimia group tended to report a higher level of heavy alcohol use at follow-up. Eating disorders at the partial syndrome level are common in young women but most teenage syndromes are brief and self-limiting. The findings are consistent with the partial syndrome of bulimia nervosa being viewed as a variant of affective disorder with different associated behaviours at particular developmental points.