Late acute rejection and subclinical noncompliance with cyclosporine therapy in heart transplant recipients

BACKGROUND: Although noncompliance with immunosuppressive medication is recognized as a critical behavioral risk factor for late acute rejection episodes and graft loss after transplantation, little is known about the degree of subclinical cyclosporine noncompliance, its associated risk for acute late rejection episodes (>1 year after transplantation), and its determinants in heart transplant recipients. METHODS: The convenience sample of this longitudinal study included 101 European heart transplant recipients (87 men and 14 women), with a median age of 56 (Q1 = 50, Q3 = 61) and a median posttransplantation status of 3 (range 1 to 6) years. Subclinical cyclosporine noncompliance was measured during a 3-month period with electronic event monitoring. Selected sociodemographic, behavioral, cognitive, emotional, health, and treatment-related determinants of medication noncompliance were measured by using instruments with established psychometric properties or by patient interviews. With the use of iterative partitioning methods of cluster analysis, including nonstandardized electronic event monitoring compliance parameters, patients were categorized by degree of subclinical cyclosporine noncompliance into a 3-cluster solution. RESULTS: Overall compliance was high, with a median medication taking compliance of 99.4%. The 3 derived clusters, that is, excellent compliers (84%), minor subclinical noncompliers (7%), and moderate subclinical noncompliers (9%), differed significantly by degree of subclinical noncompliance (p < .0001) and showed a 1.19%, 14.28%, and 22.22% incidence of late acute rejections (p = .01), respectively. The 3 groups also differed in terms of former medication noncompliance (p = .02), appointment noncompliance (p = .03), and perceived self-efficacy with medication taking (p = .04). CONCLUSIONS: Although in absolute numbers cyclosporine compliance in this sample was high, minor deviations from dosing schedule were associated with an increased risk for acute late rejection episodes. This suggests a pivotal role of patient compliance in successful long-term outcome after transplantation.     

An experimental test of adolescents' compliance with dental appointments

This study assessed factors associated with adolescents' compliance with dental appointments. Patients (n = 162) attending an adolescent clinic were administered a pretest questionnaire assessing health locus of control, self-esteem, and beliefs and attitudes about dental health from the Health Belief Model. Adolescents needing dental care were randomly assigned to groups for whom their dental appointment was made by a health professional or one in which the patient made his or her own appointment and to groups receiving an appointment reminder card versus not receiving a reminder card. Dental records were then reviewed to examine previous experiences with dental treatment. Neither the method used for making the appointment nor the use of reminder cards had a significant effect on compliance with the dental appointments. Also, compliance was not associated with health locus of control, self-esteem, or variables from the Health Belief Model. Older patients were more noncompliant than younger patients (tau = 0.14). Noncompliance was negatively correlated with the number of previous dental visits and previous dental procedures, oral hygiene instruction, and x-rays. Number of previous x-rays and previous broken appointments explained 5.1% of the variation in noncompliance. The Health Belief Model was not successful in predicting compliance behavior in this sample of adolescents.     

Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients

OBJECTIVE: The purpose of this study was to explore the value of patient self-report assessment in heart transplant candidacy evaluation, utilizing the Millon Behavioral Health Inventory (MBHI). Patient's MBHI measures were related to important pretransplant patient characteristics and posttransplant measures of health behavior, medical morbidity, and mortality. METHOD: Ninety heart patients with end-stage cardiac disease completed the MBHI during pretransplant candidacy evaluations, and also were interviewed concerning their coping effectiveness, support resources, and compliance history. Postransplant follow-up of 61 living and 29 deceased patients included measures of survival time, postsurgical medical care, rejection and infection episodes, and nurse ratings of medication compliance and problematic interpersonal health behaviors. RESULTS: The MBHI coping scales were found to significantly discriminate good and poor pretransplant compliance, and interview judgments of good and poor coping and support resources, with modest accuracy. The MBHI also was superior to these interview judgments in predicting posttransplant survival time and medical care used. Certain scales were also positively associated with physical parameters of pretransplant and posttransplant status. CONCLUSIONS: Patient self-report with the MBHI can contribute to identification of patients at risk for a problematic outcome with transplant, by providing information pertinent to clinical decision making and outcome management analysis with this special population of cardiac patients.     

Impact of attrition on studies of noncompliance.

Describes 2 studies that investigated past compliant behavior of volunteers and nonvolunteers in noncompliance research. In Study 1, past attendance compliance was examined for 87 Ss divided into 5 groups; Ss responded to 2 requests to participate. Participants were found to have been compliant and nonparticipants to have been noncompliant. Study 2, with 67 Ss, extended the research on the participants to determine that early dropouts were more noncompliant than those who remained to the end of the study. Taken together, the findings indicate that sampling bias exists in studies of noncompliance in volunteer samples. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist behavior as a determinant for client noncompliance: A paradox for the behavior modifier.

Examined the immediate impact of therapist behavior on client noncompliance in 2 studies involving 12 3.8–13.1 yr old socially aggressive children and their families. One family participated in both studies. Observation systems describing client and therapist behavior were used to code videotaped therapy sessions. In Study 1, the therapist behaviors teach and confront were associated with significant increases in the likelihood of client noncompliant reactions. Therapist behaviors facilitate and support were followed by reliable decreases in client noncompliance. In Study 2, the therapist behaviors teach and confront were manipulated in a series of single-S ABAB reversal designs. Results demonstrate that changes in therapist behaviors produced increases in client noncompliance. (9 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

From careless consumptives to recalcitrant patients: the historical construction of noncompliance

Thousands of articles on "noncompliance" have appeared since 1975. Yet the term has been criticized as paternalistic--as wrongly implying that patients should necessarily follow doctors' orders. This paper, which reviews how noncompliance has been constructed historically, argues that the problem with noncompliance is more than just one of terminology. Changing social and cultural factors during the 20th century have influenced the way in which uncooperative patients have been described. For example, resentment of poor immigrants in the early 1900s led doctors to describe tuberculosis patients who did not follow advice as "ignorant" and "vicious." Following World War II, patients who balked at taking new curative antibiotics for tuberculosis were called "recalcitrant." The term "noncompliance," popularized by Sackett and Haynes in the 1970s, reflected their early role in the field of research now termed "evidence-based medicine." While Sackett and Haynes had hoped that the new term would eschew earlier value judgments, noncompliance, through its association with the positivistic ethos of evidence-based medicine, has been conceptualized as a "tragic" problem potentially solvable by clinical research. Hence, noncompliant patients are still seen as deviant. With the growth of managed care in the United States, there is increasing pressure to get patients to follow medical recommendations. History suggests that labels such as "noncompliant" are invariably judgmental. Rather than seeing the provider's role as trying to get noncompliant patients to comply, we should emphasize the importance of negotiation and accommodation within the provider-patient relationship.     

Diamide acts intracellularly to enhance transmitter release: the differential permeation of diamide, DIP, DIP+1 and DIP+2 across the nerve terminal membrane

Eighty-nine patients with newly diagnosed asymptomatic elevations of intraocular pressure were followed up over a 12- to 20-month interval. During this period 33 (37%) of the patients were lost to ophthalmic follow-up evaluation. The majority of these patients dropped out within one month following the initial diagnosis. While institution of medical therapy for the elevated ocular pressure improved patient compliance when compared to the nontreated group, the rates of noncompliance in both groups were unacceptably high in view of the disease risk. Management of the noncompliant patient requires good physician-patient communication, emphasis on patient education activities, and the use of selective reminder and recall systems within the ophthalmologist's office.     

CD4 lymphocytopenia as a risk factor for skin cancers in renal transplant recipients

BACKGROUND: Renal transplant recipients are at increased risk of developing skin cancer. It remains difficult to establish the actual influence of overimmunosuppression in the development of skin cancers. We investigated whether lymphocyte subset count may predict the risk of developing skin cancer in long-term renal transplant recipients. METHODS: One hundred fifty long-term renal transplant recipients were followed for a mean period of 26 months. Each patient was examined at least annually by a dermatologist. Lymphocyte subsets were measured annually. RESULTS: Fifteen patients exhibited skin cancers. Patients with and without skin cancer did not differ in age, gender, transplant duration, hemodialysis duration before transplantation, immunosuppressive regimen, and serum creatinine concentration. CD4 cell counts were significantly lower in patients with skin cancers (330+/-179/mm3 vs. 503+/-338/mm3; P<0.01), whereas total lymphocyte and CD8 and CD19 cell counts were similar between the two groups. CONCLUSIONS: CD4 cell depletion is associated with skin cancer in long-term renal transplant recipients.     

Noncompliance to hemodialysis dietary regimens: Literature review and treatment recommendations.

Reviews dietary noncompliance in patients with chronic renal failure treated with hemodialysis and evaluates the current status of assessment and intervention. Pharmacological and behavioral interventions used to treat noncompliance and implications for the development of treatment design strategies for increasing compliance are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pneumocystis carinii pneumonia in HIV-negative immunocompromised adults

OBJECTIVES: To identify patient populations at risk of Pneumocystis carinii pneumonia (PCP) and assess the potential role of chemoprophylaxis. METHODS: Review of cases of PCP among patients admitted to a tertiary referral hospital in Sydney between January 1990 and April 1993. Cases were identified by indirect immunofluorescent antibody microscopy performed on respiratory tract specimens. RESULTS: Ninety-two episodes of PCP were diagnosed in 64 HIV-positive patients and 28 others. All HIV-negative patients had received corticosteroids combined with other immunosuppressive agents before the onset of PCP symptoms, which occurred within six months of immunosuppression. The group included nine of 150 kidney transplant recipients (6%) six of 138 liver transplant recipients (4.3%) and three of 25 patients with Wegener's granulomatosis (12%). Mortality associated with PCP in HIV-negative patients was significantly higher than in those who were HIV-positive (32% v. 8%, P < 0.005). CONCLUSION: Solid organ transplant recipients and individuals receiving treatment for Wegener's granulomatosis have a significant risk of developing PCP. Given the high mortality associated with this disease in HIV-negative patients, primary PCP chemoprophylaxis should be considered during the first six months of immunosuppression.     

Effects of medication, behavioral, and combined treatments on parents' and children's attributions for the behavior of children with attention-deficit hyperactivity disorder.

Seventy-four mothers and 41 fathers and their 6 to 13 year old sons with attention-deficit hyperactivity disorder (ADHD) watched videos of child ADHD symptoms, compliance, and noncompliance. Participants were told either that the child was receiving medication, behavioral treatment, a combination of the two, or was not receiving treatment and were asked to rate the cause of the behavior. Parents attributed less control but greater stability to positive child behaviors when the child was receiving medication. However, for negative behaviors, medication increased attributions of control but diminished stability. With behavior management, compliance was seen as more external and stable and noncompliance as more controllable but less stable. For all treatments, boys reported increased control over ADHD symptoms and noncompliance. The implications of these treatment-related attributions for parenting and children's self-perceptions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parital cutaneous necrosis of the abdominal wall after cesarean section

OBJECTIVE: The assess the incidence of tardive dyskinesia (TD) in a sample of adolescents treated with neuroleptic medication and to identify the presence of any risk factors for TD within the affected group. METHOD: A retrospective chart review was conducted for 40 cases. The Abnormal Involuntary Movement Scale (AIMS) was used to measure side effects from medication at 6-month intervals over 2 years. Drug exposure was converted to chlorpromazine (CPZ) equivalent and the presence of risk factory for TD, such as a diagnosis of affective disorder, medication noncompliance, early age of illness onset, and concomitant antiparkinsonian medication, was also noted. RESULTS: Of the 40 cases reviewed, 2 patients (5%) met diagnostic criteria for TD, and another 5 patients (12.5%) showed symptoms of TD. CONCLUSIONS: TD is a serious risk at any age. Medication noncompliance, early age of illness onset, and concomitant use of antiparkinsonian medication may increase susceptibility to TD and should be carefully monitored.     

Renal transplantation in adults with thrombotic thrombocytopenic purpura/haemolytic-uraemic syndrome

BACKGROUND: Thrombotic thrombocytopenic purpura/haemolytic-uraemic syndrome (TTP/HUS) is a rare cause of renal failure in adults. There is little data concerning the outcome of adult patients who receive a renal transplant for TTP/HUS: METHODS: We have carried out a survey of 22 transplant centres in the USA to determine the outcome of patients who developed ESRD from TTP/HUS and latter received a renal transplant. RESULTS: Twelve of the 22 centres responded to our inquiry. Seven centres had not transplanted any patients with TTP/HUS, and five centres had transplanted a total of 24 grafts in 17 patients with TTP/HUS: Thirty-three per cent of patients demonstrated definite clinical and pathological evidence of recurrence of TTP/HUS: An additional 16% of patients demonstrated pathological evidence of possible recurrence of TTP/HUS in the absence of clinical manifestations. The overall 1-year graft survival rate was 42% and the 2-year graft survival rate was 35%. In our experience recurrence TTP/HUS was associated with universal graft failure. Although cyclosporin A does occasionally cause a thrombotic angiopathy in patients with no history of TTP/HUS, we found no evidence that it should be avoided in patients with a previous history of ESRD from TTP/HUS who subsequently receive a renal transplant. CONCLUSIONS: TTP/HUS frequently recurres in adults who receive a renal transplant, with a 2-year graft survival rate of 35%.     

Factors affecting patient compliance among women with abnormal Pap smears

The relationship among health beliefs, health locus of control and diagnosis with Human papillomavirus and compliance with medical recommendations for an abnormal Pap test was explored through use of a survey in a sample 272 women. A total of 29 women (11%) indicated they failed to comply with the medical recommendation. Logistic regression analysis was used to assess relative risk for noncompliance. Two items from the health belief scale were statistically significant. Women who agree with the statement, "The uncertainty about my Pap test makes me nervous," were four times as likely to comply with the medical recommendations as compared to women who disagreed with the statement. Women who agreed with the statement, "I have not been able to cope with my abnormal pap test," were three times as likely to not comply with the recommendations as compared to women who disagreed. There were no statistically significant relationships between compliance and locus of control, Human Papillomavirus diagnosis, or demographic variables.     

Should we pay the patient? Review of financial incentives to enhance patient compliance

OBJECTIVE: To determine whether financial incentives increase patients' compliance with healthcare treatments. DATA SOURCES: Systematic literature review of computer databases--Medline, Embase, PsychLit, EconLit, and the Cochrane Database of Clinical Trials. In addition, the reference list of each retrieved article was reviewed and relevant citations retrieved. STUDY SELECTION: Only randomised trials with quantitative data concerning the effect, of financial incentives (cash, vouchers, lottery tickets, or gifts) on compliance with medication, medical advice, or medical appointments were included in the review. Eleven papers were identified as meeting the selection criteria. DATA EXTRACTION: Data on study populations, interventions, and outcomes were extracted and analysed using odds ratios and the number of patients needed to be treated to improve compliance by one patient. RESULTS: 10 of the 11 studies showed improvements in patient compliance with the use of financial incentives. CONCLUSIONS: Financial incentives can improve patient compliance.     

Risk factors for noncompliance with glaucoma follow-up visits in a residents' eye clinic

OBJECTIVE: This study aimed to identify factors associated with compliance with glaucoma follow-up visits. DESIGN: Computer records of a university residents' eye clinic were reviewed to identify a random sample of all persons who had an examination with International Classification of Disease (ICD) 9 coding (ICD9) for glaucoma suspect or glaucoma during a 2-year period (1991-1993) to undergo telephone interview. PARTICIPANTS: Those who were seen at least every 6 months regardless of earlier return instructions were defined as compliant with follow-up (controls, n = 362). Those who had any lapse between visits of longer than 6 months were defined as noncompliant (cases, n = 362). RESULTS: Interviews were completed for 196 cases and 242 controls. Noncompliant persons were significantly more likely to be suspects for glaucoma rather than to have definite glaucoma and to be dissatisfied with waiting time in the clinic (29.1% vs. 17.8%, P < 0.005) and to state that they did not take their glaucoma medications as prescribed (25.4% vs. 13.4%, P < 0.004). They also were less likely to have been prescribed eyedrop medication. A high percentage of both patients and controls knew that glaucoma can lead to blindness (85.2% and 88.4%, respectively). The most common reasons patients gave for not keeping follow-up visits were the perception that their eye problem was "not serious enough," the cost of examinations, and that the doctor did not tell them to come back. CONCLUSION: Compliance with follow-up visits for glaucoma is associated with markers for early disease. Attempts to improve compliance might focus on improved communication of the seriousness of the disease and improvements in clinic waiting time.     

The impact of side effects on hypertension management: a Japanese survey

The purpose of this study was to assess medication compliance and to document side effects among a large number of Japanese patients receiving antihypertensive treatment. A total of 6289 patients being treated for hypertension returned completed questionnaires about their current blood pressure, therapy, side effects, and compliance with physicians' instructions. In addition, 4417 physicians returned completed questionnaires about their prescribing practices, side effects experienced by patients, and patient compliance. The antihypertensive agents they most often prescribed were calcium channel blockers, followed by angiotensin-converting enzyme inhibitors, beta-blockers, and diuretics. The proportion of patients who had well-controlled blood pressure, defined as systolic blood pressure < 160 mm Hg and diastolic blood pressure < 95 mm Hg, was similar regardless of the class of antihypertensive agent prescribed. Forty-nine percent of the patients with well-controlled blood pressure reported having at least one side effect while taking their current antihypertensive therapy, whereas a significantly greater percentage of patients (61%) with poorly controlled blood pressure reported side effects. Patients whose blood pressure was poorly controlled tended to have a higher incidence of most side effects than did those with well-controlled blood pressure. Also, the rate of intentional noncompliance was significantly higher in the group with poorly controlled blood pressure. In addition, the rate of noncompliance increased with the number of side effects reported. Although the causal relationship between side effects and non-compliance cannot be determined from this study, further investigation is warranted to better understand the impact these factors may have on overall cardiovascular morbidity and mortality.     

A Markov mixed effect regression model for drug compliance

Patient compliance (adherence) with prescribed medication is often erratic, while clinical outcomes are causally linked to actual, rather than nominal medication dosage. We propose here a hierarchical Markov model for patient compliance. At the first stage, conditional upon individual random effects and a set of individual-specific nominal daily dose times, we assume that (i) the subject-specific probability of taking zero, one, or more than one dose associated with a given nominal dose time depends on the value of certain covariates, and on the number of doses associated with the immediate previous time, but is independent of any other previous or future dosing events (the Markov hypothesis); and (ii) the set of 'errors' between actual dose times associated with each nominal time is multivariate normally distributed, conditional on covariates and the number of such actual dose times, as in (i). At the second stage, a multivariate normal distribution is assumed for the individual random effects. We fit this model by maximum likelihood to data collected over three months using an electronic system for recording actual dose times in HIV-positive patients assigned to a regimen of zidovudine thrice daily. Beyond its value for describing and quantifying compliance behaviour, as illustrated here, the model may prove useful for explanatory analyses of clinical trials.