Strategies to improve compliance with therapy.

The failure of patients to comply with their therapeutic regimen has an extensive impact on the costs and strategies of medical care. Compliance with long-term regimens can be improved by linking the timing of the medication to existing daily habits, reducing the number of times that a medication is to be taken each day, and identifying the side effects that a patient attributes to the treatment. In addition, providing written instructions, shortening the duration of therapy, and periodically evaluating compliance by determining drug serum levels can reduce non-compliant behavior. The establishment of a strong patient/physician relationship is central to long-term therapeutic success.

Suppression of ventricular arrhythmias with intravenous disopyramide and lidocaine: efficacy comparison in a randomized trial.

Twenty-six patients with clinically significant ventricular arrhythmias were randomly assigned to treatment with either intravenous disopyramide or lidocaine; crossover to the other agent was permitted in nine cases of primary drug failure. In addition, disopyramide was administered nonrandomly to seven patients with ventricular arrhythmias not controlled by lidocaine in standard doses. Arrhythmia control (greater than 50 percent reduction of premature ventricular complexes) was achieved in all 22 trials with disopyramide and in 9 of 13 trails with lidocaine in the random study, whereas clinical efficacy (arrhythmia control with absence of side effects) occurred respectively in 15 of 22, and 8 of 13 trials. In all 11 patients (7 nonrandom, 4 random) whose arrhythmia was not controlled with lidocaine the arrhythmia was controlled with disopyramide. Thus, the clinical efficacy of intravenous disopyramide ran parallel to that of lidocaine in patients with ventricular arrhythmias. Furthermore, intravenous disopyramide was an effective alternative agent for patients with arrhythmia not controlled by lidocaine.

A prospective study of mitral valvular prolapse in young men.

A cardiac history, a physical examination, an electrocardiogram, phonocardiograms in the supine and standing positions, and an M-mode echocardiogram were obtained in 100 randomly selected, presumably healthy, male medical students (mean age, 26 years). Four percent met standard echocardiographic criteria for mitral valvular prolapse. No midsystolic clicks or late systolic murmurs were appreciated in this group, and none complained of chest pain or palpitations. To elucidate further the clinical implication of the echocardiographic pattern of mitral valvular prolapse, 24-hour ambulatory ECGs, multistage exercise tests, and scintiscans of myocardial perfusion at rest and after exercise (using radioactive 13nitrogen-labelled ammonium) were obtained, with normal results. The absence of life-threatening arrhythmias and exercise-induced abnormalities in these four asymptomatic subjects without abnormal physical findings suggests that the echocardiographic pattern of mitral valvular prolapse in such individuals may represent a variant of normal which does not require extensive evaluation.

Tuberculosis screening. Evaluation of a food handlers' program.

An evaluation of a tuberculosis screening program for food handlers revealed an unexpectedly low cost ($45) per identifiable candidate for preventive treatment (324 of 6,090 individuals screened). Four new active cases of tuberculosis were identified, and a risk/benefit analysis projected a potential reduction of 19.4 new active cases over the subsequent ten-year period.

The effect of amyl nitrite on the mitral valve echocardiogram in presumably healthy young adults.

We analyzed the use of amyl nitrite as a provocative factor in the diagnosis of mitral valve prolapse in a population of healthy young adults. Sixty-five men and 11 women underwent continuous M-mode echocardiographic and phonocardiographic monitoring before, during and after the administration of inhaled amyl nitrite. All of the 76 subjects had normal baseline echocardiograms, and all had a satisfactory hemodynamic response to amyl nitrite. Mitral valve prolapse, defined by echocardiography and phonocardiography, was not provoked in any of the subjects. Therefore, we concluded that, although this technique may be difficult, significant false-positive results should not occur if adherence to strict diagnostic criteria takes place.

Short-term incarceration for the management of noncompliance with tuberculosis treatment.

STUDY OBJECTIVES: To review the use of incarceration for noncompliance with tuberculosis treatment. DESIGN: Retrospective review. SETTING: An urban tuberculosis control program. PATIENTS: Patients treated for active tuberculosis. MEASUREMENTS AND RESULTS: We reviewed the legal basis and practical application of quarantine for active tuberculosis, including the use of incarceration for noncompliance. The records of patients treated at the Denver Metro Tuberculosis Clinic during 1984 to 1994 were reviewed to identify patients who were incarcerated and to evaluate the effectiveness of this intervention. Of 424 cases of tuberculosis, 20 patients (4.7%) were incarcerated for noncompliance; an additional 21 patients (5.0%) were lost to follow-up prior to completing therapy. Incarcerated patients were predominantly men who were born in the United States and had a history of homelessness and alcohol abuse. The median duration of the initial incarceration was 20 days (range, 7 to 51 days). Of the 17 patients released prior to completing therapy, 13 (76%) were compliant with outpatient, directly observed therapy after one or two short-term incarcerations (<60 days); only three patients were incarcerated for the duration of treatment. Overall, 18 of 20 incarcerated patients (90%) were successfully treated. CONCLUSIONS: Approximately 5% of the patients treated through our program were incarcerated for noncompliance; an additional 5% were unavailable for follow-up and would have been candidates for incarceration if found. Homelessness and alcoholism were closely associated with the use of incarceration. Short-term incarceration followed by outpatient, directly observed therapy was relatively successful in the management of this difficult patient population.

Noncompliance with directly observed therapy for tuberculosis. Epidemiology and effect on the outcome of treatment.

STUDY OBJECTIVES: To describe the epidemiology and clinical consequences of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis. DESIGN: Retrospective review. SETTING: An urban tuberculosis control program that emphasizes DOT. PATIENTS: All patients treated with outpatient DOT from 1984 to 1994. MEASUREMENTS AND RESULTS: We defined noncompliance as follows: (1) missing > or = 2 consecutive weeks of DOT; (2) prolongation of treatment > 30 days due to sporadic missed doses; or (3) incarceration for presenting a threat to public health. Poor outcomes of therapy were defined as a microbiologic or clinical failure of initial therapy, relapse, or death due to tuberculosis. Fifty-two of 294 patients (18%) who received outpatient DOT fulfilled one or more criteria for noncompliance. Using multivariate logistic regression, risk factors for noncompliance were alcohol abuse (odds ratio, 3.0; 95% confidence interval, 1.2 to 7.5; p = 0.02) and homelessness (odds ratio, 3.2; 95% confidence interval, 1.5 to 7.2; p = 0.004). Noncompliant patients had poor outcomes from the initial course of therapy more often than compliant patients: 17 of 52 (32.7%) vs 8 of 242 (3.3%); relative risk was 9.9; 95% confidence interval was 4.5 to 21.7 (p < 0.001). CONCLUSIONS: In an urban tuberculosis control program, noncompliance with DOT was common and was closely associated with alcoholism and homelessness. Noncompliance was associated with a 10-fold increase in the occurrence of poor outcomes from treatment and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuberculosis.

Directly observed therapy. Who is responsible?

Care of the tuberculosis patients is ultimately the responsibility of the community's public health officer-an agent of the executive branch of government with the legal obligation to protect each citizen from life-threatening communicable diseases. Any physician electing to care for a tuberculosis patient becomes accountable for either directly administering each dose of medication to the patient, or assuring that treatment is provided through a competent and responsive health department.

Public health aspects of tuberculosis: supervision of therapy.

The public health objectives of tuberculosis control are to interrupt and to prevent transmission of tubercle bacilli and therapy ultimately eradicate tuberculosis. The methods used in tuberculosis control are "surveillance" and "containment." 56 Surveillance includes a variety of case-finding efforts, maintenance of tuberculosis registers, and the continued collection of epidemiologic data on frequency of disease and distribution through the community. Containment impose a responsibility on the professional to insure adequate and complete treatment for those individuals capable of spreading disease and preventive treatment for those individuals at high risk of developing contagious disease. Because modern treatment is curative and its administration so easily assured, there is no further need for prolonged follow-up of patients after chemotherapy has been completed.

Prediction of single versus multivessel disease following myocardial infarction using 201thallium scintigraphy and electrocardiographic stress testing.

We evaluated 50 patients who suffered a single myocardial infarction with graded electrocardiographic stress testing, 201thallium myocardial perfusion imaging and coronary angiography to assess the role of noninvasive indices as predictors of single versus multivessel coronary artery disease. Multivessel involvement was defined angiographically as the presence of two or more major coronary arteries with at least a 70% intraluminal diameter narrowing. Multivessel disease was defined scintigraphically as the presence of stress and/or redistribution perfusion defects in the distribution of more than one coronary artery. The results of stress electrocardiography were not useful in differentiating patients with single (9/16 positive) versus multivessel (22/34 positive) disease. The degree of exercise-induced ST-segment depression was also not helpful. Stress 201thallium imaging did offer limited additional information with correct predictions of multivessel disease in 21 of 26 patients. Predictions of single-vessel disease were accurate in 11 of 24 patients. Eleven of these 13 incorrect predictions of single-vessel disease were due to the relative insensitivity of the thallium stress image to perceive defect in the anterior wall when the left anterior descending artery had significant obstruction at catheterization. Further refinements of stress perfusion imaging are needed before this method can be used to reliably separate patients with single and multivessel disease after myocardial infarction.

Pericardial effusion and electrical alternans: echocardiographic assessment.

Clinical diagnosis of pericardial effusion is often difficult, and assessment of the effects of effusion on cardiac hemodynamics is often imprecise. Electrical alternans is a reasonably specific ECG indicator of the presence of a large effusion and imminent or actual cardiac tamponade. If echocardiography verifies the presennce of pericardial fluid and shows abnormal cardiac motion, a diagnosis of cardiac tamponade can be made without further, more invasive, studies.