A pilot study of barriers to medication adherence in schizophrenia

BACKGROUND: Interventions to improve adherence to antipsychotic medication are needed. The aims of the current study were to identify the most common barriers to medication adherence in a cohort of patients receiving outpatient and inpatient treatment for an acute exacerbation of schizophrenia, compare clinical and demographic characteristics of patients with lower versus higher numbers of barriers, and characterize patients most likely to be nonadherent to antipsychotic medication. METHOD: The present study analyzed data collected during the Schizophrenia Guidelines Project (SGP), a multisite study of strategies to implement practice guidelines that was funded by the U.S. Department of Veterans Affairs and conducted from March 1999 to October 2000. Nurse coordinators had conducted clinical assessments and performed an intervention designed to improve medication adherence by addressing barriers to adherence. Data on patient symptoms, functioning, and side effects had been obtained using the Positive and Negative Syndrome Scale (PANSS), the Schizophrenia Outcomes Module, the Medical Outcomes Study 36-item Short-Form Health Survey, and the Barnes Akathisia Scale (BAS). Administrative data were used to identify patients with an ICD-9 code for schizophrenia. A total of 153 patients who met this criterion and participated in the intervention arm of the SGP had complete data available for analysis in the current study. RESULTS: The most common patient-reported barriers were related to the stigma of taking medications, adverse drug reactions, forgetfulness, and lack of social support. Bivariate analysis showed that patients with high barriers were significantly more likely to be nonadherent (p < or =.02), to have problems with alcohol or drug use (p =.02), to have higher PANSS total scores (p =.03), and to have higher mean BAS scores (p =.02). Logistic regression showed that lower patient education level (odds ratio [OR] = 3.95, p =.02), substance abuse (OR = 3.24, p =.01), high PANSS total scores (OR = 1.02, p =.05), and high barriers (OR = 2.3, p =.05) were significantly associated with the probability of nonadherence. CONCLUSIONS: It may be possible to identify patients most likely to benefit from adherence intervention. The data presented here will help to inform future research of clinical interventions to improve medication adherence in schizophrenia and help to stimulate further work in this area.     

Quantitative coronary arteriography: design and validation

The authors assessed the performance of an automatic and rapid coronary quantification method by evaluating its accuracy in a stenosis phantom. Measurements were obtained with a lucite phantom with 2-, 3-, and 4-mm vessel diameters and concentric stenoses of 33%, 50%, 67%, and 75%. Direct digital angiographic images as well as 10 X 10 spot films and 35-mm cine angiography films were acquired with and without structural noise and mask subtraction. The films were digitized with magnification factors of one and two. An interactive analysis program was used to automatically determine the vessel edges with a Gaussian fit to the cross-sectional density profiles perpendicular to the center line of the vessel. Relative changes of the densitometric cross-sectional area along the vessel were used to assess the percentage of stenosis. Densitometric measurements were comparable in both digital and cine angiograms (r = .99 and r = .98, respectively); however, diameter measurements showed a higher variability and were dependent on the amount of magnification applied to the images.     

Evaluation of attempted prevention of unexpected infant death in very high-risk infants by planned health care

Three hundred and ninety-six babies born in Sheffield between 1982 and 1990 identified as being at "very high risk" of unexpected infant death by means of a scoring system, received an intensive programme of health care including a case discussion between a paediatrician, the GP and the health visitor held in the family doctor's surgery, weekly visits from the health visitor and informal hospital admission. Significantly fewer sudden unexpected infant deaths occurred in this group than were expected by logistic regression anlysis or occurred in the best available control group with comparable scores ( p = 0.024). Problems in evaluation include identification of an adequate control population, ethical difficulties in introducing a controlled study when the programme is already perceived as effective, and the calculation of "expected death rates". The results of this study indicate that very energetic programmes of intervention may prevent some deaths in vulnerable infants.     

Outcome of congenital lung abnormalities detected antenatally

To determine the outcome of congenital lung abnormalities, data were collected retrospectively between January 1991 and December 1996 on any foetus found to have a lung lesion on antenatal ultrasound. A total of 23 foetuses had lung lesions on antenatal ultrasound. In two foetuses the antenatal ultrasound showed bilateral enlarged "bright" echogenic lungs with evidence of hydrops. Both pregnancies were terminated and tracheal atresia was confirmed. In 15 foetuses the antenatal ultrasound appearance was of a unilateral "bright" echogenic lung. There was one case of bronchial atresia and two cases of congenital lobar emphysema, which all had surgery. In nine cases there was a reduction in the size of the lesion on serial antenatal ultrasounds and no lesion was detected after birth. In three cases a small lesion was present after birth on chest radiography. In six foetuses the antenatal ultrasound appearance was of unilateral cystic or mixed cystic and echogenic lung lesions. Two pregnancies were terminated; both had congenital cystic adenomatoid malformation. Four pregnancies were continued and three infants had surgery soon after birth and were confirmed to have had congenital cystic adenomatoid malformation. One infant has been managed conservatively. In conclusion, a definitive diagnosis cannot usually be made antenatally. A large lesion on initial scan does not necessarily predict a poor outcome. The natural history of small asymptomatic postnatal lesions is unknown and a long-term prospective study is needed to determine the outcome of these lesions.     

Variation of salivary immunoglobulins in exercising and sedentary populations

PURPOSE: This study examined the nature of the variability in salivary immunoglobulin and albumin concentrations within an individual, between individuals, and between populations with differing levels of habitual physical activity. METHODS: Fourteen elite swimmers, and 21 active and 18 sedentary individuals provided 12 saliva samples over a 30-d period. Group classifications were based on interviews, anthropometric measurements, and physical activity records. Symptoms of illness and physical activity data were recorded daily. Salivary IgA, IgG, and IgM were measured by ELISA, and albumin concentrations were measured by nephelometry. Variability was assessed using ANOVA procedures. RESULTS: Elite swimmers, compared with active and sedentary individuals, had higher concentrations of salivary IgA (geometric mean=65 vs 32 and 40 mg.L, P=0.002) and greater variability in salivary IgA concentrations as individuals (P=0.007) and as a group (P=0.03). Salivary IgG variability in swimmers was also twofold greater than the other two groups (P=0.008). Salivary IgM and albumin variability were not significantly different between groups, but individual variability differed for swimmers and active individuals. The intraclass correlations for salivary IgA and IgG (but not for IgM or albumin) were 50% lower for swimmers than the other two groups (ICC for IgA: 20% swimmers vs 54% active and 46% sedentary individuals; ICC for IgG: 36 vs 59 and 57%). CONCLUSION: The variability and fluctuation of salivary immunoglobulin concentrations were consistently greater in the elite swimmers, but multiple samples from individual swimmers were less correlated compared with participants with lower physical activity levels. These findings have implications for monitoring mucosal immune status within individuals and when comparing salivary immunoglobulin concentrations between groups with differing levels of physical fitness and activity.     

Characterising the individual performance responses to mild illness in international swimmers

Objectives: To determine individual differences in the impact of illness on the change in performance of swimmers in international competitions. Methods: Subjects were members of the Australian swimming team (33 male and 39 female, aged 15–27 years). Swimmers provided a weekly seven day recall of symptoms of illness during final six weeks of preparations for international competition over a three year period. Swimmers were categorised as either ill (one or more episodes of illness) or healthy. The measure of performances was the international point score. Mean changes in points score were calculated for healthy and ill swimmers between a national championship and an international competition (∼16 weeks later). Likelihoods of substantial effects of illness on an individual''s true change in performance (beneficial/trivial/harmful) were estimated from means and standard deviations, assuming a smallest substantial change of 6 points. Results: Illness was reported before international performances by 38% of female and 35% of male swimmers. For female swimmers the change in performance was –3.7 (21.5) points (mean (SD)) with illness and –2.6 (19.0) points when healthy; for male swimmers the changes were –1.4 (17.5) points with illness and 5.6 (13.2) points when healthy. The likelihoods that illness had a substantial beneficial/trivial/harmful effect on performance of an individual swimmer were 32%/31%/37% for female and 17%/31%/52% for male participants (90% confidence limits ∼±10% to 20%). Conclusions: Although mild illness had only a trivial mean effect on female swimmers and a small harmful mean effect on male swimmers, there were substantial chances of benefit and harm for individuals.     

Diagnosis and current treatment options of shoulder impingement

A comprehensive review of shoulder impingement reveals numerous causes, contributing factors, and therapeutic options for the resolution of symptoms and return to optimal shoulder function. The clinical diagnosis of shoulder impingement is rather straightforward, but the challenge arises in identifying causative factors and directing treatment options to alleviate symptoms and restore normal function. Shoulder impingement occurs when the space between the proximal humerus and the coracoacromial arch is narrowed such that the transversing tendons, primarily the supraspinatus and to a lesser degree, the infraspinatus, are injured. As the most diagnosed shoulder ailment an understanding of shoulder anatomy, supporting musculature and function, inciting factors, and individual demands are critical in directing the appropriate treatment plan. Medications, therapeutic exercise and surgical interventions all have their place in the treatment of shoulder impingement.