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Chapter 3 examines how medical formulae for ‘preparations of the bark’ traversed Atlantic societies over the late 1700s, and early 1800s – through practitioners’ and sufferers’ exposure to the written word, medical practice, or word of mouth. The chapter argues that methods for arranging and administering the bark had by that time coalesced into identifiable formulae – ‘bittersweet’ ‘febrifugal lemonades’, and ‘aromatic’ ‘compound wines of the bark’, most notably – that would have been familiar, and ‘agreeable’ to men and women the Atlantic World over: home-made in a Lima household, available from an Italian apothecary and popular at the Moroccan court. The chapter contends that these formulae, though they commonly exhibited structural similarities in the composition, also accommodated a measure of variability. Indeed, medical practitioners tinkered with their particulars, subtly adapting them to the sufferers’ palate, creed or means, in ways that would frequently have accounted for these preparations’ prevalence and appeal.
Adult attention-deficit/hyperactivity disorder (aADHD) is still a largely unrecognized psychiatric condition despite its strong impact on individuals’ well-being. Here, we describe the healthcare situation of individuals with incident aADHD over 4 years before and 4 years after initial administrative diagnosis.
A retrospective, longitudinal cohort analysis was conducted using German claims data. The InGef database contained approximately 5 million member-records from over 60 nationwide statutory health insurances (SHI). Individuals were indexed upon initial diagnosis of aADHD.
Average age at diagnosis of aADHD was 35 years, and 60% of individuals were male. Comorbidities, resource use, and healthcare costs were substantial before initial diagnosis and decreased within the 4 years thereafter. Only 32% of individuals received initial ADHD medication and adherence was low. The majority received psychotherapy. Individuals with initial ADHD medication showed the highest share in comorbidities, physician visits, medication use for comorbidities, psychotherapy, and costs. Overall, healthcare costs were at over €4,000 per individual within the year of aADHD diagnosis.
We conclude that earlier recognition of aADHD could prevent the development and aggravation of comorbid mental illnesses. At the same time, comorbid conditions may have masked (“over-shadowed”) aADHD and delayed diagnosis. The burden of disease in aADHD is high, which was noticeable especially among individuals who received initial ADHD-medication, suggesting that psychopharmacological treatment was mainly considered for the most severely ill. We conclude that measures to facilitate access of aADHD patients to clinical experts are required to improve reality of care in the outpatient setting.
Approximately half of the individuals diagnosed with schizophrenia or bipolar disorder also suffer from SUD. Disorders of unipolar depression and anxiety are associated with an incidence of SUD double or triple that seen in the general population. Self-medication of distressing states with addictive drugs results in SUD for some individuals. Conversely, heavy drug use can cause or worsen non-drug psychiatric disorders. The co-occurrence of both disorders could also result from a third factor such as genetic predisposition. The term “addictive personality” has little scientific credibility, but certain personality disorders (antisocial, bipolar) and factors (impulsivity, negativity) are also SUD risk factors. However, many with SUD do not display these troublesome extremes of emotion and behavior. A major risk factor for SUD is regular use of an addictive drug before age 15 – an early indicator of addictive vulnerability associated with a four-fold increase in the probability of eventual SUD. Other adolescent risk factors include deviant and drug-using friends, expectations of positive drug effects, and impaired self-regulation of behavior, emotions, and cognition.
Human-induced climate change is increasing the likelihood and severity of wildfires across the globe. This has negative consequences for the health of affected communities through the loss of health systems’ infrastructure and disrupted health services. Community pharmacies are a central hub between patients and the health care system and can provide continuity of care during wildfires. However, there is little in peer-reviewed literature about the impacts of wildfires on community pharmacy operations.
The aim of this study was therefore to explore the impacts of the 2018/2019 summer bushfires in Tasmania, Australia on community pharmacy operations in affected areas.
Semi-structured telephone interviews were conducted with four community pharmacists who were working in the affected region during the bushfires. Interviews were audio recorded and transcribed verbatim. Qualitative data were analyzed using two methods– manual coding utilizing NVivo software and Leximancer analysis. Inter-rater reliability was ensured by two researchers analyzing the data independently. Differences in coding were discussed and agreement reached through negotiation amongst the research team.
From the manual coding analysis, five key themes emerged – communication and collaboration; support; patient health challenges; pharmacist experiences in delivering health care; and future planning. These aligned with the five themes that emerged from the Leximancer analysis – community; local; town; patients; and work. Participants described working during the wildfires as difficult, with multiple challenges reported including communication difficulties, operational barriers such as power cuts, legislative barriers, logistical issues with obtaining and storing medication supplies, and lack of preparation, support, and funding. They highlighted a lack of operational and financial support from the government and received most assistance from local council bodies and local branches of professional pharmacy organizations.
During disasters, community pharmacies help reduce the burden on public hospitals by maintaining medication supplies and treating patients with minor ailments. However, increased support and inclusion in disaster management planning is needed to continue this role.
Predictors of compliance with aspirin in children following cardiac catheterisation have not been identified. The aim of this study is to identify the caregivers’ knowledge, compliance with aspirin medication, and predictors of compliance with aspirin in children with Congenital Heart Disease (CHD) post-percutaneous transcatheter occlusion.
A cross-sectional explorative design was adopted using a self-administered questionnaire and conducted between May 2017 and May 2018. Recruited were 220 caregivers of children with CHD post-percutaneous transcatheter occlusion. Questionnaires included child and caregivers’ characteristics, a self-designed and tested knowledge about aspirin scale (scoring scale 0–2), and the 8-item Morisky Medication Adherence Scale (scoring scale 0–8). Data were analysed using multivariate binary logistic regression analysis to identify predictors of compliance with aspirin.
Of the 220 eligible children and caregivers, 210 (95.5%) responded and 209 surveys were included in the analysis. The mean score of knowledge was 7.25 (standard deviation 2.27). The mean score of compliance was 5.65 (standard deviation 1.36). Child’s age, length of aspirin use, health insurance policies, relationship to child, monthly income, and knowledge about aspirin of caregivers were independent predictors of compliance with aspirin (p < 0.05).
Caregivers of children with CHD had an adequate level of knowledge about aspirin. Compliance to aspirin medication reported by caregivers was low. Predictors of medium to high compliance with aspirin were related to the child’s age and socio-economic reasons. Further studies are needed to identify effective strategies to improve knowledge, compliance with medication, and long-term outcomes of children with CHD.
Romantic love is a universal feeling that most individuals hope to experience in their lifetime. At its best, it is fulfilling, joyous, committed, and stable. However, there is a chance that love can become dysregulated, associated with a preoccupation with love objects, stalking, and/or depression. Feelings of love mimic individual’s neurobiological responses to drugs of abuse and can become an obsession that resembles behaviors of a substance-dependent addict. In this chapter, we discuss the evolution of romantic love and love addiction etiology. We speculate on four personality dimensions that may distinguish certain love-related behaviors and addiction. Finally, we draw from substance and behavioral addiction literature to suggest various prevention and treatment strategies for those who are susceptible to or currently afflicted by love addiction.
Vascular disorders of the gastrointestinal tract range from non-symptomatic lesions to acute life-threatening disorders. Generally, they can be classified as ischemic or bleeding, although this is often a superficial distinction with much overlap. Primary vascular disorders of the gastrointestinal tract are assessed by pathologists at the time of biopsy or surgical resection, as well as at autopsy. Diagnoses requires a multidisciplinary approach, but pathology often plays a particularly important role in suggesting or confirming a diagnosis. Careful attention to pathologic specimens is important, as the distinguishing features of each entity may be subtle and difficult to appreciate. Likewise, patient management may differ significantly among conditions with overlapping diagnostic features. This chapter will provide a concise review of the diagnostic elements to consider in vascular disorders of the gastrointestinal tract, and will discuss practical aspects that should help the pathologist to arrive at the best diagnosis for each case.
A common clinical indication for duodenal biopsy is the exclusion of coeliac disease / gluten sensitive enteropathy. However, a variety of inflammatory and infectious disorders may affect the duodenum, some of which are associated with subtle endoscopic findings. The indications for duodenal biopsy are often the same as the broader indications for upper gastrointestinal endoscopy and include chronic dyspepsia, unexplained anaemia, abdominal pain, bloating, nausea, and diarrhoea
Endoscopic findings associated with inflammatory duodenal biopsies range from normal-appearing duodenal mucosa to mild hyperaemia and congestion of the duodenal bulb to erosions, severe congestion, mucosal haemorrhage, mucosal contact bleeding, and luminal narrowing.
No relationship has been reported between nonopiate neonatal abstinence syndrome (NAS) and anthropometric indices, including head circumference (HC). The purpose of this study was to determine the relationship between maternal nonopioid drug use and HC at birth in neonates with NAS.
This retrospective observational study included neonates born between January 1, 2010 and March 31, 2019, whose mothers had been taking antipsychotic, antidepressant, sedative, or anticonvulsant medications. The outcome measures were HCs of NAS infants and controls.
Of 159 infants, 33 (21%) were diagnosed with NAS. There was no maternal opioid use among mothers during pregnancy. The HCs in the NAS group were significantly smaller than those in the control group. The median z-scores for HC at birth were −0.20 and 0.29 in the NAS group and the control group, respectively (P = .011). The median HCs at birth were 33.0 and 33.5 cm in the NAS group and the control group, respectively. Multivariate analysis revealed that maternal antipsychotic drug use and selective serotonin reuptake inhibitors were independently associated with NAS (P < .001 and P = .004, respectively). Notably, benzodiazepine use and smoking were not independent risk factors.
The results suggest an association between maternal antipsychotic drug use and NAS, which was further associated with decreased HC. Careful monitoring of maternal drug use should be considered to improve fetal outcomes.
To investigate whether district nurses (DNs) can identify factors related to the quality and safety of medication use among older patients via a clinical decision support system (CDSS) for medication and an instrument for assessing the safety of drug use [the Safe Medication Assessment tool (SMA)]. A secondary aim was to describe patients’ experiences of the assessment.
DNs in Stockholm County have the opportunity to establish special units at primary health care centers (PHCCs) for patients aged 75 years and older. The units conduct drug utilization reviews and create care plans for older adults.
Nine DNs at 7 PHCCs in Stockholm County used the tools with 45 patients aged 75 years and older who used one or more drugs. Outcome measures were the number of drugs, potential drug-related problems, nursing interventions, and patient satisfaction. Prevalences of drug-related problems and nursing interventions were calculated. Eleven patients answered a telephone questionnaire on their experiences of the assessment.
DNs identified factors indicative of drug-related problems, including polypharmacy (9.8 drugs per person), potential drug–drug interactions (prevalence 40%), potential adverse drug reactions (2.7 per person), and prescribers from more than two medical units (60%). DNs used several nursing interventions to improve the safety of medication use (e.g., patient education, initiating a pharmaceutical review). The patients thought it was meaningful to receive information about their drug use and important to identify potential drug-related problems. With the support of the CDSS and the SMA tool, the DNs could identify several factors related to inappropriate or unsafe medication and initiated a number of interventions to improve medication use. The patients were positive toward the assessments. Using these tools, the DNs may help promote safe medication use in older patients.
People with dementia can face barriers when trying to access care after a diagnosis, particularly in young-onset dementia (YOD). Little is known about the effects of ethnicity on the use of anti-dementia medication and variations between age groups. The aim of this study was to analyze national data on variations in the uptake of anti-dementia medication between people with YOD and late-onset dementia (LOD).
Cross-sectional longitudinal cohort study.
Data from the U.S. National Alzheimer’s Coordinating Centre were obtained from September 2005 to March 2019.
First visits of people with a diagnosis of Alzheimer’s disease (AD) dementia, Lewy body dementia (LBD), and Parkinson’s disease dementia (PDD) were included.
Logistic regression was used to analyze the effects of education and ethnicity on use of cholinesterase inhibitors and memantine, accounting for YOD/LOD, gender, living situation, severity stage, and comorbidities.
In total, 15,742 people with AD dementia and LBD/PDD were included, with 11,019 PwD having completed a first follow-up visit. Significantly more people with YOD used memantine than those with LOD, while fewer used cholinesterase inhibitors. PwD from minority ethnic backgrounds used memantine and cholinesterase inhibitors less often than those from a White ethnic background. Logistic regression analysis showed that ethnicity was a significant determinant of both memantine and cholinesterase inhibitors usage, while education was only a significant determinant for memantine usage.
Findings highlight the impact of social factors on current usage of anti-dementia medication and the need for more resources to enable equitable use of anti-dementia medication.
While polypharmacy is common in long-term residential psychiatric patients, prescription combinations may, from an evidence-based perspective, be irrational. Potentially, many psychiatric patients are treated on the basis of a poor diagnosis. We therefore evaluated the DITSMI model (i.e., Diagnose, Indicate, and Treat Severe Mental Illness), an intervention that involves diagnosis (or re-diagnosis) and appropriate treatment for severely mentally ill long-term residential psychiatric patients. Our main objective was to determine whether DITSMI affected changes over time regarding diagnoses, pharmacological treatment, psychosocial functioning, and bed utilization.
DITSMI was implemented in a consecutive patient sample of 94 long-term residential psychiatric patients during a longitudinal cohort study without a control group. The cohort was followed for three calendar years. Data were extracted from electronic medical charts. As well as diagnoses, medication use and current mental status, we assessed psychosocial functioning using the Health of the Nations Outcome Scale (HoNOS). Bed utilization was assessed according to length of stay (LOS). Change was analyzed by comparing proportions of these data and testing them with chi-square calculations. We compared the numbers of diagnoses and medication changes, the proportions of HoNOS scores below cut-off, and the proportions of LOS before and after provision of the protocol.
Implementation of the DITSMI model was followed by different diagnoses in 49% of patients, different medication in 67%, some improvement in psychosocial functioning, and a 40% decrease in bed utilization.
Our results suggest that DITSMI can be recommended as an appropriate care for all long-term residential psychiatric patients.
Drawing on data from the Clinical Practice Research Datalink, Price et al reported UK regional variations in primary care prescribing and referral rates to adult mental health services for young people with attention-deficit hyperactivity disorder (ADHD) in transition from child and adolescent mental health services. Overall, considering that around 65% of young adults with childhood ADHD present with impairing ADHD symptoms and up to 90% of individuals with ADHD may benefit from ADHD medications, the study by Price et al shows that the rate of appropriate treatment for youngsters in the transition period varies from low to very low across the UK. As such, there is a continuous need for education and training for patients, their families, mental health professionals and commissioners, to eradicate the misconception that, in the majority of the cases, ADHD remits during adolescence and to support the devolvement of appropriate services for the evidence-based management of adult ADHD across the UK.
A total of 28 long-term mentally ill patients, the majority schizophrenic, treated with cognitive therapy in the context of milieu-therapy and group therapy, were investigated at admission and discharge with regard to changes in symptomatology, quality of life, global functioning, need for medication, and perceived target complaints. The results showed a significant relief in perceived burden of illness and an improvement in quality of life. A better pre-admission functioning with regard to social functioning, occupational function, and symptoms predicted a more favourable outcome.
In neuroleptic long-term medication, only part of the patients accept regular intake of neuroleptic drugs. The question is whether an interval medication regimen as opposed to continuous medication can help to reduce drop outs in patients with critical attitudes towards long-term medication. In a 2-year prospective study, 122 patients were randomised to an interval and 164 to a continuous neuroleptic medication regimen. The drop out rates were 62.5% in the interval and 53.7% in the continuous medication group. Drop outs generally show more negative attitudes towards treatment. Patients with negative attitudes do not do better under interval medication. Moreover, this regimen even requires more cooperation and trust in terms of the necessity of medication on the part of the patient compared to the continuous medication regimen. Interval medication therefore is a strategy which can only be successful in highly cooperative, but not in treatment-reluctant patients.
Medication compliance is associated with the treatment outcomes. The reported consequences of non-compliance are chronification, poor psychosocial outcomes and increased suicide rates. We measured the drug compliance using medication event monitoring system (MEMS) and several compliance measures in the outpatients with depressive disorders. In addition, we tried to find out the relationship of antidepressant compliance with other clinical correlates including insight in depressive disorders.
This study was performed in Korea university medical center, Guro hospital. Outpatients diagnosed as having depressive disorders were enrolled. Monitoring was performed in 76 depressive patients who were taking the mono-antidepressant therapy during the at least 4-week evaluation period. 17 item Hamilton Rating Scale for Depression (HRSD), Multidimensional Scale of Perceived Social Support (MSPSS) and the mood disorders insight scale (MDIS) were investigated. Compliance was measured using MEMS, clinician rating scale of antidepressant compliance, pill count, and patient's self-report.
A total of 76 outpatients were enrolled in this study. As the severity of depression increases, patients tended to perceive poor social support from others in the correlation analysis. Level of depression by HRSD was significantly correlated with MDIS scores. Compliance rates for MEMS, pill count, clinician rating scale of compliance and self-report were 51.9%, 71.4%, 79.2% and 75.3% respectively. We did not find any statistical significance between compliance variables and other clinical scale scores (MDIS, HRSD, and MSPSS).
More severely depressed patients have higher scores of insight in case of depression. However, increased perception of insight in depressive patients was not directly related with the increase in treatment compliance. Further investigation is needed to understand other factors affecting the drug compliance especially in depressive patients.
For young people experiencing a first-episode of schizophrenia, the first and most important matter to be attended to, once the diagnosis of schizophrenia has been made and patients have entered the care system, is to establish a treatment alliance. The next step is to conceive an individually tailored treatment programme (non-pharmacological as well as pharmacological). The use of antipsychotic drugs needs to be carefully discussed with both patients and families, as medication tends to have a poor public perception. Maintaining treatment is vitally important in terms of relapse prevention, but people who suffer a first-episode tend to terminate treatment early. Patients often discontinue their medication because of side-effects, although a number of other factors can also exert a negative influence on the continuous intake of medication. Among others, these include insufficient information provided to patients and significant others as well as lack of insight and problems in the doctor-patient-relationship. The published data indicate that the outcome of treatment is better for younger patients in a first-episode of schizophrenia than it is for patients who are more chronically ill. However, young patients are much more sensitive to compliance problems than older patients. The main challenge in this phase of the illness is therefore to convince patients that maintenance treatment is necessary in order to assure the best possible outcome.
The adverse effects of insomnia on health and quality of life are matters receiving increasing attention. Yet, surveys have consistently shown that most people suffering from insomnia do not seek medical help, perhaps, in part, because of a concern of becoming dependent on hypnotic medication. The treatment of chronic insomnia poses a particular dilemma in that continuous hypnotic treatment is restricted in many countries to a maximum of 4 weeks, and behavioural treatment is not readily available. Non-nightly hypnotic treatment of chronic insomnia offers a promising alternative option for the many patients whose symptoms do not necessitate nightly drug intake, allaying fears of psychological dependence on medication and respecting regulatory constraints on hypnotic use while providing patients with adequate symptom relief. The practical feasibility and efficacy of this approach has been demonstrated with zolpidem using various treatment regimens and study designs. So far, six clinical trials have been completed on over 4000 patients. Published results show effective treatment of insomnia without any evidence of either adverse event associated with a discontinuous regimen or increased hypnotic use over the treatment period.
The electronic Schizophrenia Treatment Adherence Registry (e-STAR) is a prospective, observational study of patients with schizophrenia designed to evaluate long-term treatment outcomes in routine clinical practice.
Parameters were assessed at baseline and at 3 month intervals for 2 years in patients initiated on risperidone long-acting injection (RLAI) (n = 1345) or a new oral antipsychotic (AP) (n = 277; 35.7% and 36.5% on risperidone and olanzapine, respectively) in Spain. Hospitalization prior to therapy was assessed by a retrospective chart review.
At 24 months, treatment retention (81.8% for RLAI versus 63.4% for oral APs, p < 0.0001) and reduction in Clinical Global Impression Severity scores (−1.14 for RLAI versus −0.94 for APs, p = 0.0165) were significantly higher with RLAI. Compared to the pre-switch period, RLAI patients had greater reductions in the number (reduction of 0.37 stays per patient versus 0.2, p < 0.05) and days (18.74 versus 13.02, p < 0.01) of hospitalizations at 24 months than oral AP patients.
This 2 year, prospective, observational study showed that, compared to oral antipsychotics, RLAI was associated with better treatment retention, greater improvement in clinical symptoms and functioning, and greater reduction in hospital stays and days in hospital in patients with schizophrenia. Improved treatment adherence, increased efficacy and reduced hospitalization with RLAI offer the opportunity of substantial therapeutic improvement in schizophrenia.