Psychological disorder in asthma is associated with poor control and poor adherence to inhaled steroids.

Previous studies have linked psychological morbidity to poor control of asthma, but have not objectively measured adherence to treatment, and have linked poor adherence to depression, but have not measured asthma severity. This study assessed asthma and psychological morbidity and objectively measured adherence to medication and showed that psychological morbidity in those with asthma is significantly increased when control of asthma is poor, especially when control is poor and adherence to inhaled steroid regimen is low.

Compliance in asthma.

Low rates of compliance with medication pose a major challenge to the effective management of most chronic diseases, including asthma. The high medical and social costs of non-compliance, and the apparent lack of effective methods for dealing with it, has stimulated renewed interest in this complex issue. Two broad categories of non-compliance have been identified, namely unintentional (or 'accidental') and intentional (or 'deliberate'). Unintentional non-compliance may result from poor doctor-patient communication or a lack of ability to follow advice. Intentional non-compliance occurs when the patient knows what is required but decides not to follow this to some degree. Healthcare professionals need to be aware of the various issues affecting compliance in all patients. The reasons for non-compliance are many and varied, and include factors such as complexity of the treatment regimen, administration route, patient beliefs about therapy and other psychological factors. Improvement in patient compliance with therapy will require better doctor-patient communication, improved patient education, the tailoring of therapy to the individual and possible novel strategies such as offering feedback to the patients on their level of compliance.

Evaluation of an electronic hand-held spirometer in patients with asthma.

In this pilot study we assessed patient compliance and acceptability of data recorded in the home environment by asthmatics using a Vitalograph 2110 spirometer which measures peak expiratory flow rate (PEFR) and forced expiratory volume in 1 s (FEV1). This meter automatically time and date stamps all measurements and can also assess the technical acceptability of results. Data are uploaded to a personal computer for review and analysis. We recruited 30 patients (10 male and 20 female, age range 21-72 years) from the chest clinic at Guy's Hospital (n = 20) and from a GP clinic (n = 10). Patients were asked to record spirometry data using the meter at set times (8.00 a.m. and 8.00 p.m.) for 2 weeks. The spirometer incorporated an alarm to remind patients to take measurements. All patients completed the study. Mean (SD) compliance with spirometer use was 100.8% (49.9%). Nineteen patients had a compliance rate of between 80% and 120% of expected use. Timing of recordings was compared with the scheduled times of 8.00 a.m. and 8.00 p.m. Values recorded with +/- 2 h were judged as acceptable. For morning recordings 67.4% of all values and for evening recordings 71.7% of all values met this criterion. Technical acceptability of spirometry data was also assessed by using quality assurance criteria recorded by the spirometer. Valid tests were performed for 75.2% of all recordings. Twenty-two patients performed valid tests for 80-100% of the time. We suggest that the use of an electronic meter in the home environment is practical and is likely to generate more accurate and reliable data.

Single centre open study to compare patient recording of PRN salbutamol use on a daily diary card with actual use as recorded by the MDI compliance monitor.

The aim of this study was to assess the patients' use of inhaled short acting bronchodilators as rescue therapy during a 4-week study period. In this study an electronic metered-dose inhaler compliance monitor (MDI-CM) was used to measure the time and date of actuations of the device and this information was then compared with the patients' self reporting diary card (DC). Salbutamol canisters were used in the compliance monitor. The study was approved by the local ethics committee, and written informed consent was obtained from all patients. Patients aged 18 years and over who were either receiving, or in the investigators opinion required, inhaled salbutamol on a PRN basis were enrolled for a 4-week monitoring phase during which all rescue salbutamol used was obtained from the MDI-CM. Patients were recording their use of salbutamol in the DC each morning and evening. There was a 2-week follow-up period following completion of the monitoring phase or withdrawal from the study. Forty-four patients were enrolled and 35 patients completed the study. The mean age (range) was 43 (20-76) years and mean FEV1 2.32 (0.7-4.0) 1, with male:female ratio of 19:25. Comparison of MDI-CM and DC recordings showed patients fell into three categories: (1) patients who used rescue salbutamol appropriately and whose MDI-CM and DC recordings matched closely; (2) patients who used rescue salbutamol for acute relief but whose MDI-CM and DC recordings did not correlate and (3) patients whose use of rescue salbutamol was inappropriate or erratic according to the MDI-CM but whose DC indicated good compliance. This category of patients include those who 'dumped' all their salbutamol before attending clinic appointments. There was no significant difference in the demographic details or the severity of disease in the three groups. Recorded use of 'rescue' bronchodilator is frequently used as an indicator of efficacy for new anti-asthma therapies. This study comparing electronic data monitoring and remembered rescue salbutamol highlights the potential errors that can occur without accurate recording systems.

Home nebulized therapy for patients with COPD: patient compliance with treatment and its relation to quality of life.

STUDY OBJECTIVES: To assess compliance with home nebulized therapy in patients with COPD. DESIGN: Patients' home nebulizers were replaced with nebulizers that recorded the date and time of each treatment over a period of 4 weeks. Poor compliance was defined as taking <70% of the prescribed dose (or <60% for those prescribed treatments five or more times daily). SETTING: Patients were seen at the hospital COPD outpatient clinic. The compliance data obtained were recorded while they were at home. PATIENTS: Ninety-three patients aged 44 to 76 years (mean, 64.9 years) were recruited from the hospital nebulizer database. MEASUREMENTS: Patients completed a self-reported quality of life scale, the St. George's Respiratory Questionnaire (SGRQ), both before (SGRQ1) and after (SGRQ2) the 4-week study period to look at whether quality of life was either predictive of or subsequent to level of compliance. RESULTS: Data were obtained from 82 patients. Mean compliance was 57% (range, 0 to 124%). Thirty-six (44%) patients were compliant and 46 (56%) were poorly compliant. There was no difference between the two groups in age or sex distribution. Compliance was negatively correlated with the total score on the SGRQ2 (p=0.03). CONCLUSION: The study shows that levels of compliance with nebulized therapy are low in a large proportion of patients with COPD and that patients with low levels of compliance report greater impairment in their quality of life.

Corticosteroids restore the balance between locally produced Th1 and Th2 cytokines and immunoglobulin isotypes to normal in sarcoid lung.

In this study, we have investigated the balance between Th1- and Th2-like activity in the lungs in sarcoidosis and have determined the effect of corticosteroid treatment on this. Twenty-one patients with acute untreated sarcoidosis were investigated by bronchoalveolar lavage (BAL) and compared with 11 normal volunteers. Sixteen of the sarcoid patients required corticosteroid therapy and seven of these were reinvestigated after 2-3 months' treatment. In order to assess Th1- and Th2-like activity in the lungs, IgG subclasses and IgE were measured in BAL fluid and serum, and IL-2, IL-4 and interferon-gamma (IFN-gamma) in BAL. In patients with untreated sarcoidosis, albumin-corrected BAL/serum ratios for IgG4 and IgE were significantly reduced (IgG4, 1.04 +/- 0.18 (mean +/- s.e.m.); IgE 9.58 +/- 3.11) compared with those in normal controls (IgG4 5.3 +/- 0.72, P < 0.001; IgE 67.7 +/- 28.9, P < 0.01). Estimates of actual levels of immunoglobulins produced in the lungs were also made and showed extremely high levels of total IgG in sarcoid patients (39.56 +/- 8.2 mg/l) compared with controls (1.17 +/- 0.5 mg/l, P < 0.001). Although there was no difference between the groups in amount of IgG4 locally produced, the proportion of total IgG which was IgG4 was greatly reduced in those with sarcoidosis (1.6 +/- 0.4% compared with 38.5 +/- 3.2%; P < 0.001). Lavage levels of IL-4 were also reduced in sarcoid patients (IL-4 2.103 +/- 0.21 pg/ml) compared with those in normals (IL-4 6.8 +/- 1.05; P < 0.001). Levels of IL-2 were lower (7.63 +/- 0.51 pg/ml compared with 9.4 +/- 0.95 pg/ml), but this difference was not significant. IFN-gamma, however, could not be detected above 0.4 pg/ml in any of the normal lavage fluid, but was detectable in 12/21 patients with sarcoidosis (chi2 = 7.74; P < 0.001). These changes reverted towards normal on treatment with oral corticosteroids. The mean albumin-corrected BAL/serum ratio for IgG4 before treatment was 0.88 +/- 0.33 compared with 5.5 +/- 2.1 (P < 0.05) on treatment, and for IgE before treatment 9.52 +/- 2.15 compared with 50.8 +/- 17.9 (P < 0.05) on treatment. Total IgG produced in the lung fell from 26.16 +/- 7.9 to 6.12 +/- 2.4 mg/l (P < 0.001) on treatment, and the proportion of IgG4 locally produced rose from 2.3 + 0.8% to 23.9 +/- 6.1% (P < 0.01). The mean level of IL-4 in lavage before treatment was 2.53 +/- 0.34 pg/ml compared with 4.7 +/- 0.34 (P < 0.001) on treatment. Levels of IL-2 also rose significantly on treatment from 8.74 +/- 0.95 pg/ml before to 14.44 +/- 1.38 pg/ml (P < 0.001) on treatment. Levels of IFN-gamma fell from 1.65 +/- 0.43 pg/ml before treatment to undetectable levels in all patients (P < 0.001) on treatment. These results demonstrate an imbalance between Th1- and Th2-like activity in the lungs in sarcoidosis, with suppression of Th2 and increase in Th1. Corticosteroid therapy restores the normal balance between Th1 and Th2 cytokines and immunoglobulins in the lungs, suggesting an effect on local immune regulation.

Psychological factors associated with use of home nebulized therapy for COPD.

This study examined the relationship between adherence to domiciliary nebulized therapy and psychological factors; patient attitudes, anxiety, depression, and quality of life. Ninety three patients aged 45-77 yrs with chronic obstructive pulmonary disease (COPD) and using domiciliary nebulizers were recruited from a hospital database. They completed the St George's respiratory questionnaire (SGRQ)-1 and the hospital anxiety and depression scale (HADS) and attended a semistructured interview. Their usual nebulizers were replaced by Dataloggers, which record the date, time and duration of each treatment, to use for 4 weeks. The SGRQ was then repeated (SGRQ-2). Eighty two patients completed the study. Fifty six percent were poorly adherent; taking less than 70% of the dose prescribed (or less than 60% on regimens of > or = 5 times daily). The total scores on the SGRQ-2 were negatively correlated with percentage adherence. Multiple regression analysis showed that the SGRQ-2 total score was associated with percentage adherence, depression score, feeling supported by clinic staff, and patients feeling that they tried to ignore their chest disease. Patients who report poor quality of life are more likely to be depressed, feel unsupported by clinic staff and be poorly adherent to treatment. Increased levels of clinic support, with the addition of psychological treatments, may be of benefit to some patients with chronic obstructive pulmonary disease.

Compliance and outcomes in patients with asthma.

The severity of asthma varies within and between individuals, and the disease has a variable impact on quality of life. Disease severity can be modified but not cured by long term anti-inflammatory therapy. Compliance with, or adherence to, such therapeutic regimens is difficult, and it is affected by a number of factors. Patterns of compliance are variable; some patients take only half the prescribed drug all the time, while others take all their prescribed medication for a while and then "take a break'. Understandably, there is no single factor that would account for such a variety of human behaviour, but generally the frequency and ease of drug administration, as well as adverse effects (real or imagined), can affect compliance. Poor communication regarding the precise regimen will also impair compliance. Psychosocial factors such as depression, poor interpersonal skills and coping strategies, and rejection of the diagnosis will lead to lower levels of compliance. Interventional programmes using a combination of education, skills training and methods to modify behaviour are needed to improve the quality of life in asthmatics. The role of the newer generations of once-/twice-daily oral anti-inflammatory preparations in improving compliance requires further investigation.

The psychological factors associated with poor compliance with treatment in asthma.

Poor patient compliance with inhaled medication is known to cause morbidity and mortality in asthma. The reasons for nonadherence are not fully understood. We wondered whether psychological factors, such as patient attitudes to asthma and its treatment, anxiety, depression, and interpersonal problems, may be related to asthma self-care and compliance. In a prospective study, 102 patients with asthma, aged 18-70 yrs, requiring treatment with regular inhaled corticosteroids and beta-agonists were recruited from a hospital out-patient clinic and four general practices in South East London. They underwent psychological assessment using the Hospital Anxiety and Depression Scale (HADS), the Inventory of Interpersonal Problems (IIP), and a semi-structured interview focusing on patient attitudes, self-care, compliance, social support and treatment beliefs. Patients were given terbutaline and budesonide turbohalers to use twice daily over 12 weeks. Turbohaler Inhalation Computers (TICs) recorded each inhalation, providing a measurement of compliance. Seventy two patients completed the study. Thirty seven took less than 70% of the prescribed dose over the study period or omitted doses for 1 week and were defined as noncompliant. The noncompliant group had a higher mean (SD) score for depression (4.7 (3.3)) than the compliant group (3.2 (2.5)). The sample had a high mean (SD) score for anxiety (8.3 (4.4)), but there was no significant difference between the compliant and noncompliant groups. Patients' self-report and clinicians' impressions of compliance were not good predictors of actual compliance. Using discriminant analysis, a model was obtained from the questionnaires and interview items, which correctly classified 74% of the patients as compliant or non-compliant.(ABSTRACT TRUNCATED AT 250 WORDS)

Swallowing in motor neurone disease.

Ninety-two patients with motor neurone disease have been assessed clinically and radiologically for evidence of swallowing problems. At the time of examination, moderate or severe swallowing difficulty was present in 89% of those whose disease had presented as bulbar palsy, in 45% of those in whom the disease began many months before as progressive muscular atrophy and in 29% of those with amyotrophic lateral sclerosis. Patients with more severe swallowing symptoms appeared more likely to have abnormal findings on videofluoroscopy overall. However, not all patients with an abnormal radiological picture had swallowing difficulties. It is suggested that radiological signs should only be used within the context of clinical symptoms and signs in the selection of patients for palliative surgery. Thirteen patients with pseudobulbar symptoms and signs had a cricopharyngeal myotomy performed: two suffered major post-operative complications. However, the satisfaction rate was 89% and we recommend cricopharyngeal myotomy for such patients. Pharyngostomy was performed for seven patients unable to initiate swallowing, six had post-operative complications.

Patient compliance with inhaled medication: does combining beta-agonists with corticosteroids improve compliance?

Patient compliance with an inhaled corticosteroid may be greater if it is combined with a beta-agonist. This study compared compliance with an inhaled corticosteroid (budesonide), and a short-acting inhaled beta-agonist (terbutaline sulphate), and a Turbuhaler inhaler containing a combination of the two drugs. In an open, multicentre, parallel group study 102 asthmatic patients were randomly divided into two groups, either receiving the two drugs in separate Turbuhalers or combined into one Turbuhaler. A twice daily regimen was prescribed and a preweighed metered-dose inhaler (MDI) of salbutamol was provided for rescue use. Compliance was measured using the Turbuhaler Inhalation Computer (TIC), which recorded the time and date of each inhalation over a 12 week period. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) measurements were carried out at week 0, 6 and 12. Results from 72 patients were analysed. The average compliance was 60-70%. Treatment was taken as prescribed on 30-40% of the study days, and over-usage occurred on less than 10% of days. Only 15% of patients took the drugs as prescribed for more than 80% of the days. Compliance was no greater in patients using the combined inhalers. Other ways of improving patient self-management need further investigation.