Adherence According to Mary Poppins: Strategies to Make the Medicine Go Down

PURPOSE. This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence. CONCLUSION. A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden. PRACTICE IMPLICATIONS. Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers.     

Simple and inexpensive point-of-care tests improve diagnosis of vaginal infections in resource constrained settings

Objective  Bacterial vaginosis (BV) and Trichomonas vaginalis infection (TV) have been associated with adverse birth outcomes and increased risk for HIV. We compare the performance of simple inexpensive point-of-care (POC) tests to laboratory diagnosis and syndromic management of BV and TV in poor settings.
Methods  Between November 2005 and March 2006, 898 sexually active women attending two reproductive health clinics in Mysore, India were recruited into a cohort study investigating the relationship between vaginal flora and HSV-2 infection. Participants were interviewed and screened for reproductive tract infections. Laboratory tests included serology for HSV-2; cultures for TV, Candida sp., and Neisseria gonorrhoeae ; Gram stains; and two POC tests: vaginal pH; and Whiff test.
Results  Of the 898 participants, 411 [45.7%, 95% confidence interval (95% CI): 42.4–49.0%] had any laboratory diagnosed vaginal infection. BV was detected in 165 women (19.1%, 95%CI: 16.5–21.9%) using Nugent score. TV was detected in 76 women (8.5%, 95%CI: 6.7–10.4%) using culture. Among the entire study population, POC correctly detected 82% of laboratory diagnosed BV cases, and 83% of laboratory diagnosed TV infections. Among women with complaints of vulval itching, burning, abnormal vaginal discharge, and/or sores (445/898), POC correctly detected 83% (60 of 72 cases) of laboratory diagnosed BV cases vs. 40% (29 of 72 cases) correctly managed using the syndromic approach ( P  <   0.001). Similarly, POC would have detected 82% (37 of 45 cases) of TV cases vs. 51% (23 of 45 cases) correctly managed using the syndromic approach ( P  =   0.001).
Conclusions  In the absence of laboratory diagnostics, POC is not only inexpensive and practical, but also significantly more sensitive than the syndromic management approach, resulting in less overtreatment.     

Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet.

OBJECTIVE: To evaluate the effect of a standardized worksheet on physicians' and nurses' perceptions of their understanding of goals of care and on patients' length of stay in an intensive care unit. METHODS: A worksheet was completed daily during multidisciplinary rounds and was posted at each bedside in the medical intensive care unit at Beth Israel Medical Center in New York. Information recorded included tests or procedures, medications, sedation, analgesia, catheters, consultations, nutrition, mobilization, family discussions, consents, and disposition. Attending physicians, residents, and nurses completed a questionnaire before implementation of the worksheet and 3 times afterwards. Responses were scored on a 5-point scale (1 = understand nothing, 5 = completely understand). Continuous variables were analyzed by using a t test; categorical variables, by using a chi(2) test. RESULTS: Before the worksheet was implemented, scores for understanding goals were 3.9 for nurses and 4.6 for physicians. Scores increased to 4.8 for nurses (P = .001) and 4.9 for physicians (P = .03) 6 weeks later, an improvement that remained at 9 months. Both groups showed significant improvement in communication scores that lasted for 9 months. Most responders wanted to continue using the worksheet. During the study, the mean stay in the unit was 4.3 days, down from 6.4 days for the analogous 9-month period in the preceding year (P= .02). CONCLUSION: Nurses' and physicians' perceptions of their understanding of the goals of care and of communication between them were improved and stays in the unit were shortened when the worksheet was used.     

Gender disparity in failure rate for arterial catheter attempts

We examined risk factors associated with failure of arterial catheterization in the medical intensive care unit of a large urban teaching hospital. We analyzed 92 consecutive arterial catheterizations by internal medicine house staff and critical care fellows. Of the 92 attempts, 26.1% were done on femoral arteries, and 73.9% were done on radial arteries. Failure, which occurred in 28% of attempts, was more common in female patients (P < .001). The failure rate was 50.0% for attempts on femoral arteries and 20.6% on radial arteries. Systolic blood pressure was significantly lower in patients where the attempt failed (P = .024). In univariate analyses, hemoglobin values were lower (P = .028) and number of percutaneous punctures were higher (P = .019) in patients where catheterization failed. After multivariate analysis, only gender and systolic blood pressure remained statistically significant. The strongest predictor of failure was female gender. A possible explanation not explored here could be smaller arterial size in female patients.     

Mechanistic relationships between polymer microstructure and drug release kinetics in bioerodible polyanhydrides.

This work investigates the relationship between polymer microstructure and drug release kinetics in the bioerodible polyanhydride system, poly[(1,6-bis-p-carboxyphenoxy hexane)-co-(sebacic anhydride)] (CPH-SA). Model drugs, p-nitroaniline (PNA) and disperse yellow 3 (DY), were selected based on compatibility with CPH and SA, respectively. The polymer microstructure and compatibility of the drug with the constituent monomers were determined to have significant influence over the release kinetics of the drugs studied. Polymer systems with homogeneous microstructure, poly(SA) and 50:50 CPH-SA, showed simultaneous polymer degradation and drug release, although the solubility of the drug in the polymer influenced the shape of the release profiles. For the heterogeneous copolymers, 20:80 and 80:20 CPH-SA, individual monomer release kinetics demonstrated the effects of drug partitioning within a phase-separated microstructure. The PNA molecules partition preferentially into the CPH microdomains in the 20:80 CPH-SA copolymer while the DY molecules partition preferentially into the SA microdomains in the 80:20 CPH-SA copolymer. These studies suggest that the drug release mechanism is driven by polymer microstructure, compatibility of the drug with the constituent polymer phases, and solubility of the drug within the polymer. A thorough understanding of drug-polymer interactions as well as the polymer microstructure will pave the way for more accurate predictions of drug release from bioerodible polyanhydrides.     

Multiple comparisons model-based clustering and ternary pattern tree numerical display of gene response to treatment: procedure and application to the preclinical evaluation of chemopreventive agents

Microarray technology has greatly aided the identification of genes that are expressed differentially. Statistical analysis of such data by multiple comparisons procedures has been slow to develop, in part, because methods to cluster the results of such comparisons in biologically meaningful ways have not been available. We isolated and analyzed, by Northern blot and GeneChip, replicate liver RNA samples (n = 4/group) from rats fed with control diet or diet containing one of three chemopreventive compounds, selected because their pharmacological activities, including RNA expression response, are relatively well understood. We report on a classification tree, based on the results of nonparametric multiple comparisons, which results in the bipolar hierarchical clustering of genes in relation to their response to treatment. In addition to identifying treatment-responsive genes, application of this procedure to our test study identified the known pharmacological relationships among the treatment groups without supervision. Also, small treatment-specific subsets of genes were identified that may be indicative of additional pharmacophores present in the test compounds.