Compliance with inhaled asthma medication in preschool children

BACKGROUND: Previous studies have shown poor compliance with regular drug therapy in children and adults with asthma. In preschool children the parents supervise and are responsible for drug administration, but little is known of compliance in this group. In addition, there are few data on the patterns of drug use of inhaled prophylactic asthma therapy or of the relation between compliance and symptom control. A study was undertaken to address these issues with the hypothesis that parental supervision would result in good compliance. METHODS: The subjects were 29 asthmatic children aged 15 months to five years already established on inhaled prophylactic medication delivered through a large volume spacer. The prescribed drug regimens varied between subjects. This was an observational study using an electronic inhaler timer device to record the date and time of each actuation of the aerosol canister. Diary cards were used for parallel recording of symptoms and parentally reported compliance with a drug regimen. RESULTS: Variable and generally poor compliance was demonstrated with a median of 50% of study days with full compliance (subject range 0-94%) and an overall median of 77% of prescribed doses of therapy taken during the study period. No relation was found between frequency of prescribed regimen and good compliance. Day care was associated with poorer compliance. No relation between good compliance and low symptom scores was found. CONCLUSION: Compliance with inhaled prophylactic therapy is poor in preschool children with asthma whose medication is administered under parental supervision.     

Adverse drugs reactions associated with glaucoma medications

We undertook a non-concurrent prospective study of 191 Puerto Rican patients from August 1993 to April 1994. All patients had open angle glaucoma (OAG) (age ranged from 50 to 80 yrs; mean = 65 yrs). Patient's symptomatology associated to side effects of their glaucoma medicadons was reviewed. Incidence percent of ocular and/or systemic side effects per medication were: levobunolol 45.0%; betaxolol 42.0%; timolol 27.3%; pilocarpine 100%; dipivefrin 14.0%; and acetazolamide 250 mg 64.1%. Incidence percent of ocular and/or systemic side effects of topical beta-blockers used with concomittant medications were determined. Ocular side effects were more frequent in patients using levobunolol 44.2% than in those patients using betaxolol 42.0%, 8.5% of patients using levobunolol did report systemic side effects. No systemic side effects were reported by patients using betaxolol. Ocular side effects in patients using pilocarpine were frequent (100%); whereas the frequency of systemic side effects was low (6.1%). Systemic side effects were common in patients using carbonic anhydrase inhibitors. These results suggest that non-selective and cardio-selective topical Beta-blockers, differ in their ocular or systemic side effects.     

Body adaptation to the action of ecological factors at the cellular and subcellular levels

While poor drug compliance is a significant impediment to the effective treatment of hypertension, knowledge of what patients wish to know about their medications in order to improve compliance is very limited. To develop a preliminary understanding of patients' medication requirements and expectations, a simple 30-item questionnaire was developed and administered to 66 patients who were either taking antihypertensive drugs, or about to commence antihypertensive drug treatment. Ninety percent of patients wanted to know about all possible side effects of medications as well as the most likely side effects. Ninety-six percent wanted to know if their drug treatment would keep them well. In addition, most patients wanted to avoid multiple medications, were concerned about the prospect of life-long treatment, and were worried about potential drug interactions. Effects of the drugs on their lifestyles as well as any lifestyle changes required to augment drug therapy were other issues of concern. The elderly were less interested in many of these issues. A strong desire for further knowledge about their disease was noted in most subjects (82%). If compliance with medication therapy is to be improved, a better understanding of patients' concerns and fears about medications is required, particularly in a relatively asymptomatic disease like hypertension.     

Extracapsular cataract extraction with posterior chamber lens implantation in primary angle-closure glaucoma

PURPOSE: To evaluate long-term intraocular pressure (IOP) control after extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (IOL) implantation in patients with primary angle-closure glaucoma. SETTING: Ophthalmology Department, Groote Schuur Hospital, Cape Town, South Africa. METHODS: This retrospective study comprised 17 patients (19 eyes) with primary angle-closure glaucoma who had ECCE and posterior chamber IOL implantation. Four presented initially with acute glaucoma, 5 with subacute angle-closure glaucoma, and 8 (10 eyes) with chronic angle-closure glaucoma. In all, less than half the circumference of the angle was permanently closed. The drainage angle was evaluated preoperatively and postoperatively to monitor changes in the amount of angle closure. Intraocular pressure was measured in the early and late postoperative periods. RESULTS: On the first postoperative day, mean IOP was 17.2 mm Hg, although 5 patients (26%) had an IOP rise above 21 mm Hg despite the use of perioperative topical pilocarpine gel. After a mean follow-up of 19 months, IOP remained below 22 mm Hg without medication in 13 eyes (68%) and with topical medication in 5 eyes (26%). Mean number of glaucoma medications was reduced from 1.5/eye preoperatively to 0.5/eye postoperatively. CONCLUSION: Cataract extraction with IOL implantation resulted in good long-term IOP control in patients with primary angle-closure glaucoma, suggesting that combined cataract and trabeculectomy surgery may not be necessary to achieve long-term IOP control in these patients.     

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.     

Efficacy of silicone punctal plugs as adjuncts to topical pharmacotherapy of glaucoma--a pilot study. Punctal Plugs in Glaucoma Study Group

BACKGROUND: The concept of enhancing the ocular hypotensive effects of topical antiglaucoma medications by impeding lacrimal drainage of medication has been insufficiently studied. This investigation sought to evaluate the effect of bilateral inferior punctal occlusion using silicone punctal plugs on the ocular hypotensive effect of topically applied timolol. METHODS: A randomized, double-masked, cross-over clinical trial was conducted, comparing the ocular hypotensive effect of timolol maleate 0.25 percent, both with and without occlusion of the inferior punctum with the Freeman silicone punctal plug. Following a 2-week washout of topical medication, 17 subjects with early primary open-angle glaucoma or ocular hypertension received one drop of timolol 0.25 percent in each eye with or without punctal plugs in place. Blood pressure, resting pulse rate, and intraocular pressure were measured both before timolol instillation and at intervals of 1, 2, 4, 8, and 12 hours following drop instillation. Following a 2-week washout period, the subjects were evaluated with the alternative treatment. RESULTS: There was no statistically significant difference (p = 0.648) in IOP levels between treatment groups. CONCLUSIONS: This pilot suggests that need for a longer-term study with larger numbers of subjects to evaluate the potential role of silicone punctal plugs to enhance the ocular bioavailability of topically applied antiglaucoma medications.     

Intraocular pressure regulation after combined glaucoma and cataract operation

BACKGROUND: The success rate of combined glaucoma and small incision cataract surgery is not yet established. PATIENTS AND METHODS: Therefore, 56 eyes of 52 patients (mean age 79.0 years) having trabeculectomy combined with phacoemul-sification and implantation of a silicone posterior chamber lens were retrospectively investigated. RESULTS: The mean follow-up was 21.6 weeks. Due to the combined surgery the mean intraocular pressure decreased significantly (p < 0.001) from 21.8 to 14.8 mmHg. Seventy-five percent of the patients did not need any antiglaucomatous medication, while 25% still had to use a local medication, but less frequently. The overall visual acuity increased significantly (p < 0.001) from a preoperative value of 0.24 to 0.52 postoperatively. CONCLUSIONS: The results of combined glaucoma and cataract surgery seem as good as those reported for two separate glaucoma and cataract procedures.     

Naltrexone and alcohol dependence. Role of subject compliance

BACKGROUND: Two previous double-blind, placebo-controlled studies demonstrated that naltrexone (50 mg/d) reduces alcohol drinking in alcohol-dependent subjects. In both studies, treatment compliance was excellent. However, a robust treatment effect size for naltrexone relative to placebo has been shown for compliant subjects but not for subjects who missed research visits. The goal of this study was to determine the effectiveness of naltrexone in subjects who received psychosocial treatment in a more naturalistic setting with respect to the role of treatment attendance and medication compliance. METHODS: Ninety-seven alcohol-dependent subjects were randomly assigned to receive either naltrexone (n = 48) or matching placebo (n = 49) for 12 weeks. All subjects received individual counseling (twice per week for the first month followed by once per week). RESULTS: Overall, naltrexone showed only modest effects in reducing alcohol drinking for the 12 weeks of treatment. However, naltrexone treatment efficacy improved across a variety of outcome measures for subjects who completed treatment and were highly compliant with taking medication. CONCLUSIONS: Naltrexone is clinically effective relative to placebo in individuals who comply with the treatment protocol and take medication. The modest treatment effects in the entire sample suggest that the clinical efficacy of naltrexone could be improved by enhancing treatment compliance.     

Beer drinkers have fewer myocardial infarcts. Moderate beer drinking lowers infarct incidence and total mortality]

Hypotensive efficacy and tolerance of a new antiglaucoma drug lathanoprost, a 0.005% xalathane solution, prostaglandin F2 alpha analog, is studied. A single instillation of xalathane decreased ophthalmic tone in normal subjects and glaucoma patients with increased intraocular pressure. Combination of the drug with other hypotensive agents (pilocarpine + timolol) amplified their hypotensive effects. Long (3 months) follow-up showed that xalathane efficacy is comparable to that of pilocarpine and timolol combination but it is tolerated much better.     

Effect of pilocarpine on anterior chamber angles

Pilocarpine is widely used in the treatment of glaucoma, especially for the acute form of angle-closure glaucoma. Previous studies have shown that pilocarpine decreases central anterior chamber depth. In the present study, a quantitative measurement method, applying Scheimpflug photography, was used to report whether pilocarpine also affected the anterior chamber angles. Twenty-nine normal Chinese subjects, 17 female and 12 male with an age range from 11 to 63 years old, were enrolled. One eye of each subject was treated with one drop of 2% pilocarpine. Photographs of each of four quadrants were taken prior to, and after, pilocarpine treatment in both eyes, using a rotating slit-lamp video camera based on the Scheimpflug principle. The slit beams were set at 0 degrees and 90 degrees. The eyes which did not receive pilocarpine treatment served as control. The angles of the four quadrants were calculated for both eyes both prior to, and after, pilocarpine treatment, and results were compared by Student's paired t-test. The comparison of angles between the eyes prior to, and after, pilocarpine treatment indicated that there is a significant narrowing of angles in all quadrants. The complex factors involved in the change of anterior chamber angle are reviewed in the light of muscarinic action of pilocarpine.     

Glaucoma and the dry eye syndrome

During the past decade 2,436 patients with primary glaucoma were treated in the Budapest Eye Clinic. Symptoms and/or signs of dry eye syndrome were seen in 108 of them, i.e., 4.43%. In 42 cases these symptoms developed during conservative glaucoma treatment. Strikingly, there were more men among these patients than in the control group of sicca patients without glaucoma and there were less patients with generalized diseases related to keratoconjunctivitis sicca in the group of glaucoma patients with dry eyes. The Schirmer test was positive in a smaller percentage and corneal staining with bengal rose was more frequent in the group of sicca patients with glaucoma than in the group of sicca patients without glaucoma. Most of the glaucoma patients with dry eyes received pilocarpine dropps. The most noteworthy electron-microscopic feature of the bulbar conjunctiva was the reduction in frequency, height and width of the microplicae on the surface of the epithelial cells. The intercellular spaces were enlarged among the superficial cells and vacuoles appeared in their cytoplasm.     

Design of low cost glaucoma screening

In 1991 the Netherlands Glaucoma Patient Association organized a glaucoma screening survey. This survey was designed to evaluate the effectiveness of a low cost screening setting. During a screening period of 8 days, 1259 subjects over the age of 49 years were examined by a team of non-ophthalmologically trained students. The following screening methods were used: visual field analysis (Henson CFS3000 perimeter), retinal nerve fiber layer photography (Canon non-mydriatic camera), intraocular pressure measurement (Pulsair non-contact tonometer) and determination of the peripheral anterior chamber depth (slitlamp biomicroscope, the van Herick method). In a later stage, subjects with glaucomatous abnormalities in the visual field and/or the photograph were re-examined by a glaucoma specialist using applanation tonometry, gonioscopy, ophthalmoscopy and Humphrey 30-2 visual field analysis. The time taken to conduct the individual screening tests in a subject varied from 1 to 5 min: perimetry took 5 min, photography 2 min, tonometry 3 min and angle-width determination 1 min. Fifty-six (4.4%) subjects showed glaucomatous defects in perimetry and/or photography. Thirty-seven could be re-examined and glaucoma was diagnosed in 16 subjects. Visual field defects and glaucomatous abnormalities in the photograph were confirmed by Humphrey perimetry in 72.7% and 35.7% respectively. Sixty-seven (5.3%) subjects had an intraocular pressure above 21 mm Hg, while no cases of angle closure glaucoma were found in this population. The costs of this screening setting were estimated at F1. 48,60 per screen. A future low cost screening survey might be limited to non-contact tonometry and visual field analysis with the Henson CFS3000 perimeter or a similar device, using suprathreshold testing with a limited number of points. Screening might be performed by non-medically trained employees. The costs of such a screening program may be estimated at F1. 16,- per screen and F1. 1.989,- per glaucoma case using a mobile screening unit (addendum).     

Informed consent: assessment of comprehension

OBJECTIVE: The authors designed and evaluated a structured and rigorous informed consent procedure involving subjects with schizophrenia. METHOD: Informed consent forms were read and explained to 49 schizophrenic patients participating in ongoing clinical treatment research trials. The subjects answered a questionnaire relating to each research protocol. Protocol procedures were reiterated until the patients answered 100% of the questions correctly. Subjects were asked the same questions 7 days later to ascertain how much of the information they had retained. RESULTS: The patients' median score on the first trial of the informed consent questionnaire was 80% correct. To achieve 100% correct responses, 53% of the patients required a second trial of the questionnaire, and 37% of them required three or more trials. Scores improved between the first trial and the trial on day 7. Ninety-six percent of the subjects felt adequately informed, 66% reported participating in the research protocol for personal reasons, and 34% reported participating at the suggestion of others. CONCLUSIONS: These findings demonstrate that when adequate informed consent procedures are established, schizophrenic research subjects are able to understand and retain critical components of informed consent information.     

Isolation of soil actinomycetes on selective media with novobiocin

The diurnal intraocular pressure was measured in 14 eyes of patients with glaucoma while they were using no medication and compared to the diurnal pressures while they were using pilocarpine drops. During the 48 hour control period, the pressures measured every 3 hours by the non-contact tonometer had a mean value of 26 mm. Hg and a mean maximum diurnal variation of 18.5 mm. Hg. During the pilocarpine treatment period, the mean pressure and maximum diurnal variation dropped to 17 and 8.5 mm. Hg, respectively. The greatest pressure-lowering effect occurred between 9 A.M. and 6 P.M.     

Fathers and breast feeding: a pilot observational study

A small pilot survey (n = 113) by questionnaire of the fathers of a sample of children under one year of age was undertaken in order to investigate the involvement of fathers with infant feeding and their attitudes to the method of feeding adopted. The response rate was 72% overall and 79% when the partners of 'single parent' mothers were excluded. Nearly 30% of respondents had not discussed the method of feeding with anyone, but over 60% had discussed it with their partner. 64% of fathers sometimes helped with feeding their child and 17% said that they always helped. The majority of fathers did not mind their partner breast feeding in front of friends or relatives but 42% did not like them feeding in front of strangers and over half did not like them breast feeding in a public place. From this study, based on relatively small numbers, we conclude that fathers may feel left out of infant feeding. They should be given more opportunity to become involved from an early stage and take part in the decision about the method of infant feeding to be adopted.     

Lack of effect of coumarin in women with lymphedema after treatment for breast cancer

BACKGROUND: Lymphedema of the arms can be a serious consequence of local and regional therapy in women with breast cancer. Coumarin has been reported to be effective for the treatment of women with lymphedema; we undertook a study in which we attempted to replicate those findings. METHODS: We studied 140 women with chronic lymphedema of the ipsilateral arm after treatment for breast cancer. The women received 200 mg of oral coumarin or placebo twice daily for six months and then the other treatment for the following six months. The end points of the study consisted of the volume of the arm (calculated from measurements of hand and arm circumference) and the answers on a questionnaire completed by the patient about symptoms potentially related to lymphedema. RESULTS: The volumes of the arms at 6 and 12 months, were virtually identical, regardless of whether coumarin or placebo was given first. After six months, the average volume of the affected arm increased by 21 ml during placebo treatment and 58 ml during coumarin treatment (P=0.80). In addition, answers to patient-completed questionnaires were similar in the two treatment groups. After six months only 15 percent of the women in the coumarin group and 10 percent of those in the placebo group reported that the study medication had helped a moderate or large amount (P=0.19). Coumarin was well tolerated, except that it resulted in serologic evidence of liver toxicity in 6 percent of the women. CONCLUSIONS: Coumarin is not effective therapy for women who have lymphedema of the arm after treatment for breast cancer.     

Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up

PURPOSE: To evaluate the results of topical plus subconjunctival anesthesia for phacotrabeculectomy surgery and postoperative glaucoma control over 1 year. SETTING: Pacific Eye Center, Brisbane, Australia. METHODS: In this retrospective study of consecutive patients with glaucoma and cataract, topical plus subconjunctival anesthesia was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy). Patients with proliferative diabetic retinopathy or neovascular glaucoma were excluded. RESULTS: Thirty-eight eyes had phacotrabeculectomy using topical plus subconjunctival anesthesia over 2 years. Patients reported no discomfort intraoperatively or postoperatively, and none required intravenous sedation. Eighty-one percent of patients achieved a best corrected visual acuity of 20/40 or better 6 months after surgery. Mean drop in intraocular pressure (IOP) was 5.91 mm Hg at 3 months and 5.86 mm Hg at 12 months, at which time IOP was controlled without additional medication in 72% of patients. There were no serious complications postoperatively. CONCLUSION: In this series, no patient reported intraoperative or postoperative discomfort and surgical results were excellent in terms of visual outcome and IOP control.     

Efficacy of a portable acustimulation device in controlling seasickness

BACKGROUND: Nausea and vomiting caused by motion sickness are serious and sometimes debilitating symptoms for commercial and recreational seafarers. HYPOTHESIS: In order to treat these symptoms, a portable device, the Relief Band, was designed to deliver acustimulation to the Neiguan (P6) acupuncture point. METHOD: Nine volunteers used the device on a placebo point or the P6 active point on the open seas outside the San Francisco Bay. Motion sickness symptoms were graded from 1 ("feel fine") to 5 ("intermittent vomiting, with or without nausea"). RESULTS: Five subjects with motion sickness initially positioned the device at the placebo site and reported minimal symptom improvement (3.6 +/- 0.6 to 3.4 +/- 1.1) (mean, +/- SD), whereas the other four subjects initially used the device in the P6 position and reported decreased symptoms (4.3 +/- 1.0 to 1.0 +/- 0.2). The position of the Relief Band was then switched; in the four subjects who switched to the placebo position, symptoms worsened (1.0 +/- 0.2 to 4.0 +/- 1.4); whereas, in the five subjects where the device was switched to the P6 position, symptoms improved in each subject (3.4 +/- 1.1 to 1.0 +/- 0.7) (p < 0.01). CONCLUSIONS: Motion sickness symptoms were suppressed by portable acustimulation in field studies of seasickness. The Relief Band may be an alternative to drug treatments of the nausea and vomiting of seasickness.     

The role of enactment in prospective remembering

This study investigated, in a laboratory setting, whether prospective memory (remembering to perform intended actions in the future) would be improved by self-enactment of the to-be-remembered tasks. The subjects, 45 university students, were asked to remember later to perform five tasks that they initially enacted themselves, watched the experimenter perform, or had described to them. These tasks were to be performed, ostensibly in preparation for the next subject, at the end of 30 min of filler activity, which was presented as the experimental task. Surprisingly, self-enactment produced the poorest prospective remembering. Speculative explanations are offered in terms of both metacognitive expectations about memory and output-monitoring deficiencies.