Medication Noncompliance Research Articles

High-Frequency Prefrontal Repetitive Transcranial Magnetic Stimulation for the Negative Symptoms of Schizophrenia

The negative symptoms of schizophrenia are difficult to treat and are predictors of poor outcome. New somatic treatments are needed to reverse these symptoms and improve function. One promising approach is repetitive transcranial magnetic stimulation (rTMS), although results to date have been mixed. This pilot study assessed higher doses of rTMS and assessed particular demographic factors that may influence treatment response. Five patients with schizophrenia or schizoaffective disorder enrolled to receive 20 sessions of rTMS administered with a Magstim Super Rapid device (The Magstim Company Ltd, Wales, UK). Treatment was administered at 20 Hz for 2 seconds, intertrain interval of 28 seconds, and at 100% motor threshold to the left dorsolateral prefrontal cortex in an open-label pilot study. Positive and Negative Syndrome Scale symptom assessments occurred at 2-week intervals during treatment and twice at 4-week intervals after termination. Treatments were well tolerated with no adverse events. One patient withdrew from the study in the setting of medication noncompliance. Of the patients who completed treatment, 2 had reductions in positive symptoms by 9% and 26%, maintained at 1 month. A third patient had a 14% reduction in negative symptoms at week 4, and a fourth patient had a 55% reduction at week 4. Negative symptom improvement was not related to depressive or extrapyramidal symptoms, which were unchanged with treatment. This pilot study of rTMS treatment for the negative symptoms of schizophrenia is promising with respect to safety and feasibility. The promising preliminary evidence for improvements in this open-label setting should be followed up with a randomized clinical trial to establish efficacy. Further work may explore the potential utility of rTMS for the otherwise largely untreatable negative symptoms, which account for so much of the morbidity of schizophrenia.

Platypnea-Orthodeoxia Syndrome Associated with Bioprosthetic Tricuspid Valve Stenosis and Reverse Lutembacher Syndrome

A 43-year-old woman presented with shortness of breath. She developed dyspnea on exertion 6 months prior to presentation, with resting shortness of breath for 2 months. Dyspnea was worse in the upright position. She recently noted that her lips were turning blue in color. Her past medical history was significant for intravenous drug abuse, hepatitis C, and tricuspid valve (TV) endocarditis 3 years prior. She underwent TV replacement with a bioprosthetic valve that was complicated by chest wall necrotizing fasciitis and septic embolism with brain abscess requiring craniotomy. She reported tobacco use, medication noncompliance, and continued intravenous drug abuse. Medications included albuterol/ipratropium, pantoprazole, and furosemide. She had been started on continuous home oxygen. She presented to another institution and was found to have a patent foramen ovale (PFO). Coronary angiography showed no significant coronary artery disease, and chest computed tomography angiography demonstrated normal lung parenchyma and no pulmonary embolus. She was referred to our institution for percutaneous PFO closure. Admission vital signs and basic labs are shown in Table 1. Pulse oximetry on 5L continuous oxygen by nasal cannula was 75% to 78%. When upright, her oxygen saturation decreased to 65% and she became more tachypneic, findings consistent with the platypnea-orthodeoxia syndrome. Physical examination showed perioral cyanosis, no jugular venous distention, …

Indications for Inferior Vena Cava (IVC) Filter Placement - Assessing Compliance with Accepted Standards Set by Two Professional Societies

AbstractAbstract 2553 Background:Inferior Vena Cava (IVC) filter placement has increased significantly over the past few decades, due to expanding indications for filter placement. Indications for filter placement vary widely depending on which professional society recommendations are followed. Our objectives were to record the number of IVC filters placed in our medium sized metropolitan teaching hospital, assess the effect of medical specialty on placement and evaluate compliance with accepted standards as set by the American College of Chest Physicians (ACCP) and the Society of Interventional Radiology (SIR). Methods:Single-center, retrospective medical record review of all patients who received an IVC filter over 26 months (01/30/2008 - 4/5/2010). Inclusion criteria included patients from both sexes, all ages, filter placement within the aforementioned dates and inpatient procedures performed by interventional radiology. A total of 443 IVC filters were placed in our institution over the time period studied. 48.1% (213) of these filters were placed by interventional radiology. Of these, 187 were reviewed with 26 excluded do to incomplete patient records available at the time of review (July 2010). Medical records were reviewed for patient demographics, clinical course, and compliance with accepted guidelines set by the ACCP and SIR. Results:The average age was 75.3 years and 43.9% of the patients were males. 76.2% of patients were on the medical service (internal medicine and its subspecialties) whereas 22.8% were on non medical services. 87.2 % of filters were recommended by medicine and its subspecialties and 12.8% by non medical specialties. 43.3% of filters placed met guidelines established by the ACCP (Table 1). 79.1% of filters placed met SIR guidelines (Table 2). No documentation was available to assess compliance for 20.9% of filters. 46% of filters placed by internal medicine and its subspecialties met ACCP criteria whereas only 25% of filters recommended by non medicine specialties were compliant with criteria (p value=0.039, 95% CI). Physicians within internal medicine and its subspecialties were compliant with SIR guidelines for 84% of the filters placed, whereas only 46% of non medicine physicians met these indications (p=0.001, 95% CI). 35.8% of filters placed met SIR criteria but did not meet ACCP guidelines. Conclusions:Indications for IVC filter placement varied significantly in this study, less than half of filters placed met ACCP guidelines, yet over three-fourths met criteria set by the SIR, especially when comparing medicine and non medicine specialties. In analyzing the filters which meet indications set by SIR but not ACCP it becomes apparent that most of these are placed for patients classified as “fall risks”, failures of anticoagulation, limited cardiopulmonary reserve and medication noncompliance. Further research needs to be guided towards evaluating if these indications truly merit the placement of an IVC filter. This study strongly suggests a need for harmonization of current guidelines espoused by professional societies. A limitation of our study was that 230 filters placed by vascular surgery and interventional cardiology were not reviewed. Disclosures:No relevant conflicts of interest to declare.

The independent influence of apathy and depression on cognitive functioning in Parkinson's disease.

The purpose of the present study was to examine the independent influence of symptoms of depression and apathy, two of the most common neuropsychiatric symptoms in Parkinson's disease (PD), on executive functioning and memory in PD patients using measures designed to discriminate between these symptoms. Participants included 68 nondemented, idiopathic PD patients, ages 56-82 years. The Apathy Evaluation Scale-Self-Rating and select items of the Beck Depression Inventory II were used to assess symptoms of apathy and depression, respectively. Cognitive function was assessed using the Wisconsin Card Sorting Test and Hopkins Verbal Learning Test-Revised. Correlations and hierarchical regressions were conducted to investigate the relationships between apathy, depression, and cognitive function. Hierarchical regression analyses were conducted to evaluate the degree of influence of depression and apathy on cognitive function. Results revealed that symptoms of apathy, but not depression, were significantly and negatively associated with executive functioning. Immediate memory was significantly and negatively associated with both apathy and depression. However, apathy accounted for additional variance in memory performance after controlling for depression at a level approaching significance. Apathy is not only associated with cognitive impairment, but also with impaired daily functioning, caregiver burden and distress, medication noncompliance, and increased mortality. Differentiating apathy and depression, understanding their unique effects, and appropriately identifying apathy symptoms in patients have robust implications for the development of neuropsychological models of these effects in PD as well as practical implications in guiding improvements to patient care and enhancing quality of life in patients and caregivers.

Magnetic Resonance Imaging and Spectroscopy in Metronidazole Induced Encephalopathy: A Case Report

Purpose: A 59-year-old African-American female with a history of hepatitis C cirrhosis with a MELD (Model for End Stage Liver Disease) score of 26, ascites, and grade 3 esophageal varices presented with altered mental status of two days duration. She was found to be nonverbal and unable to follow commands. She was then admitted directly to the Medical Intensive Care Unit. A head CT scan showed mild cerebellar atrophy. A subsequent MRI showed new FLAIR signal hyperintensity bilaterally in the dentate nucleus and splenium of the corpus callosum, and restricted diffusion in the splenium (Figure 1). Proton MR spectroscopy showed increased choline (Cho) signals, lactate plus lipid (Lac+Lipid), and decreased N-acetyl aspartate (NAA), suggesting axonal loss/dysfunction as well as inflammatory demyelination. Creatine (Cr), glutamine plus glutamate (Glx) and myo-inositol (mI) signals are similar between case and control subjects. Five months previously, she had been admitted for hepatic encephalopathy due to medication noncompliance with lactulose. Flagyl 250 mg by mouth every 8 hours was started at that time. The above neuroimaging and spectroscopy findings were thus concordant with metronidazole induced encephalopathy (MIE), rather than hepatic encephalopathy, which typically shows a different pattern of markedly increased glutamine, decreased Cho and myo-inositol. MIE is a rare toxic encephalopathy with an unknown mechanism of action. The antibiotic is often used to treat patients with hepatic encephalopathy and therefore the diagnosis can be difficult to establish. This case highlights a unique, rare disease and demonstrates how MRI and MR spectroscopy can identify the characteristic topographic distribution and appearance of lesions that can distinguish MIE from conventional HE. MRI and MR Spectroscopy maybe essential to help elucidate a further understanding of the pathophysiology of metronidazole neurotoxicity.Figure: FLAIR and diffusion-weighted MRI (DWI) and ADC maps. FLAIR hyperintensity in seen bilaterally in the cerebellar dentate nuclei (black arrow) and medial lemnisci (white arrow), and in the splenium of the corpus callosum (solid white arrow), which also shows hyperintensity on DWI.

Improving medication compliance in patients with depression: Use of orodispersible tablets

The treatment of major depressive disorder requires prolonged pharmacotherapy with antidepressants in order to resolve the current episode and reduce the risk for recurrence of depressive symptoms. Such prolonged therapy requires considerable commitment on the part of patients to take their medication as prescribed. Medication compliance is often poor among psychiatric patients, including those with major depressive disorder; this can result in poor long-term outcomes and, ultimately, treatment failure. The onus lies with the prescribing physician to support patients in complying with their medication regimen. Establishing and maintaining a supportive therapeutic relationship is an essential foundation for ensuring patient compliance. Difficulty in swallowing conventional tablets and capsules has emerged as an additional factor in medication noncompliance and has led to the development of alternative drug delivery strategies such as orodispersible tablets (ODTs). ODTs are associated with improved medication compliance compared with traditional tablet formulations. An ODT formulation of the antidepressant mirtazapine has been available since 2001 and an ODT formulation of escitalopram is currently in development. Such formulations offer convenient alternatives to traditional tablets and may support patient compliance with extended therapy. This review discusses practical methods of improving compliance in patients with depression with a particular focus on ODTs.

Rapid Reduction of Severely Elevated Serum Triglycerides with Insulin Infusion, Gemfibrozil and Niacin

The conventional methods of treatment of severe hypertriglyceridemia are dietary restriction and lipid lowering medications, mainly fibric acid derivatives. In the medical literature, use of insulin infusion to treat hypertriglyceridemia has not been highlighted sufficiently. We report a 53-year-old male who presented with a four-day history of epigastric pain. The patient's clinical history was significant for hypertriglyceridemia, type-2 diabetes mellitus with medication noncompliance, obesity, status post-gastric bypass surgery, and alcohol abuse with prior admissions for detoxification. Physical examination revealed mild epigastric tenderness. Laboratory studies revealed severely elevated serum triglyceride (TG) level (8116 mg/dL). Computed tomography (CT) scan of the abdomen exhibited no evidence of pancreatitis. Regular insulin infusion was started at 3 U/h and gradually increased to 7-10 U/h. Dextrose infusion was titrated to avoid hypoglycemia and maintain blood glucose levels below 150 mg/dL. Gemfibrozil and niacin were also started. After 24 hours, his TG levels were decreased to 2501 mg/dL. Insulin infusion was continued for about 48 hours. A low carbohydrate diet excluding simple carbohydrates was given. The patient's serum TG levels normalized over a period of one month. Thus insulin infusion can be considered a safe modality of treatment for rapid reduction of serum TG in addition to fibrates and niacin.

Neuropsychiatric symptomatology predicts seizure recurrence in newly treated patients

To test the hypothesis that neuropsychiatric symptomatology is predictive of the success of seizure control in patients newly treated with antiepileptic drugs (AEDs), and that this predictive value adds to that provided by other clinical, imaging, and genomic factors in a multivariate model. One hundred seventy newly treated patients with epilepsy completed the A-B Neuropsychological Assessment Scale (ABNAS) before commencing AED therapy and were prospectively followed up for 12 months. Patients were classified as nonresponsive if they had at least 1 seizure not explained by medication noncompliance or other significant provoking factors. Of the 138 patients in whom a drug response phenotype at 12 months was able to be determined, nonresponsive patients (n = 45) had a higher pretreatment ABNAS score than patients whose seizures were controlled (n = 93) (p = 0.007). A lesion on MRI was also associated with a higher risk of seizure recurrence (p = 0.003). On multivariate logistic regression, the ABNAS score, the MRI results, and a genomic classifier were all independently predictive of treatment outcome. For AED pharmacoresponse, this multivariate model had diagnostic values of 91% sensitivity, 64% specificity, 84% positive predictive, and 78% negative predictive values. The predictive value of the ABNAS score was validated in a second prospective cohort of 74 newly treated patients with epilepsy (p = 0.005). The ABNAS provides prognostic information regarding successful seizure control in patients newly treated with AEDs. Furthermore, these results demonstrate the multifactorial nature of the determinants of AED response, with neuropsychological, structural, and genomic factors all contributing to the complex response phenotype.

Priapism During Treatment With Olanzapine, Quetiapine, and Risperidone in a Patient With Schizophrenia

Priapism During Treatment With Olanzapine, Quetiapine, and Risperidone in a Patient With Schizophrenia

Determining Psychosocial Research Priorities for Adolescents With Implantable Cardioverter Defibrillators Using Delphi Methodology

Adolescents with implantable cardioverter defibrillators (ICDs) have unique psychosocial needs that are not currently addressed in the literature. To prioritize these issues into a concise cardiovascular nursing research agenda, the objective of this study was to identify current psychosocial issues in this population by obtaining expert consensus from experienced pediatric dysrhythmia clinicians. A 3-round electronic Delphi study was conducted. A multidisciplinary purposive sample was drawn from 2 international organizations of pediatric and young adult cardiovascular caregivers who specialize in rhythm disturbances in this patient population. Round 1 included an open-ended question in which respondents were asked to provide as many psychosocial issues as desired, but at least 5. Round 2 included the 10 most frequent issues, which participants were asked to rank (1 = most important, 10 = least important). Round 3 included the collective ranking of the respondents using mean values; respondents were asked to indicate agreement/disagreement with the final ranking. If they disagreed, they were asked to re-rank the items. The top 10 psychosocial issues identified by the panel included, in order of importance: fear of being shocked, sports participation/activity restrictions, feeling different from peers/peer acceptance, depression, adjustment problems, fear of death, medication noncompliance, acting out, body change/weight gain, and issues related to planning for adulthood. There was 90% agreement among the expert panel members. Ascertaining the opinions and consensus of pediatric cardiovascular dysrhythmia experts has led to the development of a concise research agenda for the psychosocial issues faced by children and adolescents with ICDs. The identification of these issues will allow nurse researchers to incorporate these findings into future studies in which interventions aimed at promoting positive adjustment to the ICD in the child and adolescent age group can be tested.

Role of tacrolimus prolonged release in the prevention of allograft rejection

Role of tacrolimus prolonged release in the prevention of allograft rejection Peter Abrams, Abhinav Humar, Henkie P TanDepartment of Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pennsylvania, USAAbstract: Successful management of the solid-organ transplant recipient begins with prevention of rejection and achieving a balance between insufficient and excessive immunosuppression. Standard tacrolimus therapy for prevention of solid-organ transplant rejection consists of 2 divided doses per day. In an effort to simplify tacrolimus dosing to once daily, a new formulation (tacrolimus prolonged release [PR]) was chosen for its combination of a similar extent of bioavailability and a substantially reduced rate of clearance. Several clinical conversion studies have now been completed using PR to clarify its pharmacokinetics, efficacy at prevention of allograft rejection, and safety profiles in solid-organ transplant patients. A cohort of 67 stable kidney transplant recipients was converted from standard tacrolimus to PR in an open-label, multicenter study in the United States and Canada. A second open-label, multicenter study was performed in liver transplant recipients with stable graft function on standard tacrolimus therapy converted to PR. A third conversion study was performed as an open-label study at 5 centers in the United States in stable pediatric liver transplant recipients. As medication noncompliance can significantly contribute to the incidence of graft rejection and graft loss in transplant recipients, a potentially significant advance in the transplant community’s ongoing mission to optimize prevention of rejection occurred with the development of a once-daily tacrolimus PR. The results of these preliminary studies suggest that select solid-organ transplant recipients converted to PR can be safely maintained using the same monitoring and patient care techniques historically used for standard tacrolimus therapy.Keywords: immunosuppression, tacrolimus allograft, organ transplant, rejection

Development of clinical utility of zoledronic acid and patient considerations in the treatment of osteoporosis.

Osteoporosis is a major health concern, which results in the increased risk of fractures. There is a high risk for the first or consecutive fractures leading to considerable morbidity and debilitating consequences if osteoporosis is untreated. Currently, bisphosphonates are the mainstay of treatment for osteoporosis though long-term persistence and adherence to bisphosphonates, especially those taken orally, remain low. This medication noncompliance has serious consequences on osteoporotic patients as it is associated with a significantly higher fracture risk. Intravenous (IV) zoledronic acid (ZOL), developed to increase compliance by overcoming the frequent and burdensome dosing requirements of oral bisphosphonates, is the first and the only once-yearly bisphosphonate globally approved for use in the treatment of up to 6 indications of osteoporosis. Several clinical studies have documented that a single infusion of IV ZOL resulted in decreased bone turnover and improved bone density for at least 12 months post infusion. This article traces the development of ZOL's clinical utility and evaluates its patient preference by collating data from all major clinical trials, studying the efficacy and safety of ZOL in the treatment of osteoporosis and other benign bone disorders.

Clinical investigation of medication adherence of glaucoma patients

To investigate the medication adherence and modulation factors of medication adherence in long-term treated glaucoma patients. It was a cross-sectional study. One hundred glaucoma patients who have been followed-up for more than 6 month in the Second Hospital affiliated to Medical College of Zhejiang University were investigated with questionnaires and interview. The data was analyzed by binary logistic regression and χ(2) test. In the 100 glaucoma patients being investigated, the medication compliance of patients is 61(61.0%), the medication non-compliance of patients is 39 (39.0%). Age, gender, habitat, glaucoma types, surgical history, ingesting patient before writing out a prescription and informing them the methods for application of eyedrops were not significantly co-related with medication adherence (χ(2) = 0.718, 0.537, 0.338, 3.797, 0.338, 0.297, 0.157; P > 0.05). Intraocular pressure before treatment, types of eyedrops, instillation of eye-drops to the eyelids, request for help during application of eyedrops, rechecking regularly and confidence in glaucoma treatment were found significantly related to medication adherence (P = 0.013, 0.005, 0.005, 0.012, 0.011, 0.004). However, drug side effect, forgetting application of eyedrops and inconvenience to see a doctor was considered the most important factors by patients in the interview. Glaucoma physicians should discuss with patients about the methods for the application of glaucoma medication. This can improve the medication adherence of glaucoma patients and promote the therapeutic effect.

Persistent Reflux Symptoms in the Proton Pump Inhibitor Era: The Changing Face of Gastroesophageal Reflux Disease

Given the widespread use of potent acid suppressive therapies and primary caregivers’ increasing comfort with prescribing these medications at high doses, the patient population presenting to gastroenterologists for symptoms of gastroesophageal reflux disease (GERD) has changed. Whereas previous consultation often revolved around the control of erosive disease and other mucosal manifestations of GERD, and terminated with the prescription of proton pump inhibitor (PPI) therapy, gastroenterologists often now only enter the scene after failure of PPI therapy, for symptoms either resistant or only partially responsive to these medications. Because of the high proportion of subjects with esophagitis who are healed with PPI, 1,2 upper endoscopy of such individuals is low yield, 3 with only a small minority demonstrating erosive disease. The care of such patients is challenging. High-quality evidence supporting useful diagnostic testing or alternative effective therapies is largely lacking. However, the number of subjects with GERD symptoms incompletely or nonresponsive to PPI therapies is high, and their utilization of healthcare resources is substantial. The purpose of this mini-review is to examine the definition and epidemiology of esophageal GERD symptoms incompletely responsive to PPI therapy, the potential pathophysiologic mechanisms behind these symptoms, the differential diagnosis and evaluation of such patients, and current and developing therapeutic options.

Laparoscopic donor nephrectomy – safety in a small‐volume transplant center

Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center. A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures. There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance. For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Observance médicamenteuse chez un échantillon d’hypertendus dans la région de Sfax (Tunisie)

The aim of the study Medication noncompliance is one of the daily problems of the physician. Improving the medication adherence allows better management of hypertension. The aim of this work was to determine the level of compliance for patients with hypertension and to identify factors that determine compliance. Methods A cross-sectional study was carried out among a sample of hypertensive patients attending general and specialist practitioners in public or private clinics of Sfax. Two hundred and seventy-three participants had accepted to be interviewed. Patients were identified as noncompliants using a questionnaire developed by the Comité de lutte contre l’hypertension artérielle (CFLHTA). Results Non-compliance rate was 63.4%. The low level of education was associated with a lower adherence. The monotherapy, the once-daily regimen with fewer number of tablets were associated with a better adherence ( p < 10 −6). The welcome and the availability of drugs in the public clinic affect positively the adherence of patients ( p < 0.0002). A patient very satisfied with his consultation and the explanation given by the doctor about his illness and its treatment had a better adherence ( p < 0.00003). Conclusion Our study had demonstrated a low compliance with antihypertensive drug therapy. Tunisian health care system should elaborate a management plan which takes into account our particular predictors of compliance to improve adherence to antihypertensive medication.

Amelioration of metabolic acidosis in patients with low GFR reduced kidney endothelin production and kidney injury, and better preserved GFR

Metabolic acidosis often accompanies low glomerular filtration rate and induces secretion of endothelin, which in turn might mediate kidney injury. Here we tested whether treatment of metabolic acidosis in patients with low glomerular filtration rate reduced the progression of kidney disease. Fifty-nine patients with hypertensive nephropathy and metabolic acidosis had their blood pressure reduced with regimens that included angiotensin-converting enzyme inhibition. Thirty patients were then prescribed sodium citrate, and the remaining 29, unable or unwilling to take sodium citrate, served as controls. All were followed for 24 months with maintenance of their blood pressure reduction. Urine endothelin-1 excretion, a surrogate of kidney endothelin production, and N-acetyl-beta-D-glucosaminidase, a marker of kidney tubulointerstitial injury, were each significantly lower, while the rate of estimated glomerular filtration rate decline was significantly slower. The estimated glomerular filtration rate was statistically higher after 24 months of sodium citrate treatment compared to the control group. Hence it appears that sodium citrate is an effective kidney-protective adjunct to blood pressure reduction and angiotensin-converting enzyme inhibition.

Using Self-Regulation Theory to Examine Patient Goals, Barriers, and Facilitators for Taking Medication

: Self-regulation theory predicts that patient behavior is determined by the patient's assessment of his/her condition (illness presentation) and related health goals. Patients will adapt their behavior to achieve those goals. However, there are multiple levels of goals. In such cases, those lower-level goals (health goals) that are strongly correlated with higher-level goals (i.e. quality of life [QOL]) are more likely to drive patient behavior. Medication non-compliance is a health behavior that challenges healthcare practitioners. Thus, the primary aim of this paper is to explore the relationship between the lower-level goals for taking medication with higher-level goals. This paper also identifies patient-perceived barriers and facilitators toward achieving goals as they may relate to patients' illness representation. : To identify lower- and higher-level goals associated with medication use for chronic conditions. To determine if there is a relationship between higher-level (global) goals and lower-level (health-related) goals. To identify patient-perceived facilitators and barriers to achieving those goals. : This was a prospective, observational study using a mailed survey. The setting was a US Midwestern state-wide survey. Participants were patients living in the community with hypertension, heart disease, diabetes mellitus, or arthritis, and taking prescription medication for any one of those conditions. The main outcome measures were lower- and higher-level goals related to medication use. The survey asked the participants if they had achieved their goals and to identify factors that may pose as barriers or facilitators to achieving them. Pearson correlation was used to test the relationship between the lower- and higher-level goals at p < 0.05. : Responses from 292 qualifying patients were obtained. A significant relationship between lower- and higher-level goals existed (p = 0.03). Preventing future health problems was the most important lower-level goal for almost half of the respondents. Approximately 43% of the respondents said 'improving or maintaining quality of life' was their most important higher-level goal. Elderly respondents (65 years or older) said that being able to carry out daily activities on their own was their most important higher-level goal. To achieve this goal, they identified 'preventing future health problems' as the associated lower-level goal. One-third of the respondents stated that they had not yet achieved their medication-related goals. Patients identified good communication with their physicians (35%), the effectiveness of the drug product (32%), and their ability to monitor their condition (20%) as important factors toward helping them achieve their goals. Medication costs (30%), drug adverse effects (25%), and the lack of drug effectiveness (22%) were factors that patients identified as barriers to achieving their goals. : There is a significant and positive relationship between the lower- and higher-level goals. Healthcare providers can work with their patients to achieve their goals. Both good communication with the prescriber and the effectiveness of the drug product were identified as the most important facilitator by one-third of the respondents. Future research should study if relating the impact of good symptom control or the reduction of future health risks to QOL or longevity, as deemed relevant by the patient, influences medication adherence behavior.

Effect of Hurricane Katrina on the Incidence of Acute Coronary Syndrome at a Primary Angioplasty Center in New Orleans

In August 2005, New Orleans was hit by Hurricane Katrina, the costliest natural disaster in US history. Previous studies have shown an increase in acute myocardial infarction (AMI) in the immediate hours to weeks after natural disasters. The goals of our study were to detect any long-term increase in the incidence of AMI after Katrina and to investigate any pertinent contributing factors. This was a single-center retrospective cohort observational study. Patients admitted with AMI to Tulane Health Sciences Center hospital in the 2 years before Katrina and in the 2 years after the hospital reopened (5 months after Katrina) were identified from hospital records. The 2 groups (pre- and post-Katrina) were compared for prespecified demographic and clinical data. In the post-Katrina group, there were 246 admissions for AMI, out of a total census of 11,282 patients (2.18%), as compared with 150 AMI admissions out of a total of 21,229 patients (0.71%) in the pre-Katrina group (P < 0.0001). The post-Katrina group had a significantly higher prevalence of unemployment (P = 0.0003), lack of medical insurance (P < 0.0001), medication noncompliance (P = 0.0001), smoking (P = 0.001), substance abuse (P = 0.03), first-time hospitalization (P < 0.001), local residents rather than visitors affected (P < 0.0001), and people living in temporary housing (P = 0.003). The role of chronic stress in the pathogenesis of AMI is poorly understood, especially in the aftermath of natural disasters. Our data suggest that Katrina was associated with prolonged loss of employment and insurance, decreased access to preventive health services, and an increased incidence of AMI. In addition, it appears that chronic stress after a natural disaster can be associated with tobacco abuse and medication and therapeutic noncompliance. We found a 3-fold increased incidence of AMI more than 2 years after Hurricane Katrina. Even allowing for the loss of some local hospitals after the disaster, this represents a significant change in overall health of the study population and supports the need for further study into the health effects of chronic stress.

Effects of Omega-3 Fatty Acid Supplementation on Lipid Levels in Endstage Renal Disease Patients

Our purpose was to determine if over-the-counter fish oil improves the cardiovascular-disease risk profile of endstage renal disease patients. This study used a double-blind, permuted-block, randomized, placebo-controlled design. The experimental intervention consisted of fish-oil concentrate supplementation, whereas corn-oil capsules were used as a control. Compliance follow-ups were performed 3 times per week. Patients of Central Texas Nephrology Associates clinics were eligible for this study. Exclusion criteria comprised a life-expectancy of less than 6 months, pregnancy, a history of hemodialysis or medication noncompliance, or age below 18 years. The final sample size was 87 patients. The attrition rate was 9%. Participants in the experimental group consumed six 1-g soft-gel capsules of fish-oil concentrate each day for 6 months. The control group consumed corn-oil capsules, following the same protocol. Venous blood samples were acquired before and after the intervention. We assessed a number of serum lipid indicators. There were significant supplement/time interactions in low-density lipoprotein cholesterol (LDL) levels (P = .0001) and LDL particle number (P = .0001). Repeated-measures analysis of variance revealed significant time trends in high-density lipoprotein cholesterol (P = .012) and LDL (P = .001). High-density lipoprotein cholesterol levels significantly decreased in the control group, and increased in the fish-oil group, at 6 months, and LDL levels increased significantly in both groups. The analysis indicates mixed results with respect to cardiovascular disease risk. Further research is needed to assess the benefits of an over-the-counter fish-oil supplement in the renal population.