Integration of Anal Dysplasia Screening into the Primary Care of Persons Living with HIV.

Anal dysplasia can lead to anal cancer, which affects persons living with HIV (PLWH) more than people in the general population. Screening for anal dysplasia is recommended to detect anal cancer at an early stage. The aim of our process improvement project was to improve compliance and consistency in implementing anal dysplasia screening for PLWH receiving care at a Ryan White facility covering 18 counties in western North Carolina. There were 291 PLWH screened for anal dysplasia during the 9-month data-gathering period. The compliance rate significantly increased from a preintervention rate of 31.3% to 57.5% (p < .001). There were 109 (37.5%) abnormal screening results. PLWH who had abnormal screening results were more likely to be White. Gender and age were not significantly associated with abnormal screening results. Anal dysplasia screening is a simple procedure to detect precursors to cancer that can be integrated into the primary care of PLWH.

Patient-perceived problems, compliance, and the outcome of hypertension treatment.

OBJECTIVE: To study the associations between the outcome of antihypertensive therapy with both patient-perceived problems and patient initiated modification of dosage instructions. DESIGN AND METHODS: In this cross-sectional survey, all chronic hypertensives aged less than 75 years (n = 971) visiting nine Finnish pharmacies between May and September of 1996 were asked to participate. Of the 866 agreeing to participate, 482 returned the questionnaire (56%). After excluding persons with missing data, the final study population consisted of 428 hypertensive patients. Information on problems with treatment, the modification of dosage instructions, and blood pressure levels was based on patient self-reports. RESULTS: Two-thirds (68%) of the study population reported suffering from one or more problems. The most common problems were symptoms of high blood pressure and adverse drug effects. Thirty-one percent of the male respondents and 21% of the female respondents reported having modified their dosage instructions. Only 36% of the patients had reached the goal blood pressure (< 160/90 mmHg). Patients having problems with hypertension treatment were significantly more likely to have modified their dosage instructions than those without problems (3+ problems, adjusted OR = 4.8). Not reaching goal blood pressure levels was significantly associated with both high number of patient-perceived problems (3+ problems, adjusted OR = 2.1) and modification of dosage instructions (adjusted OR = 1.9). CONCLUSION: The poor outcome in antihypertensive therapy is associated with both patient-perceived problems and patient initiated modification of dosage instructions.

Drug treatment for hypertension in Finnish primary health care.

OBJECTIVE: To analyse the prescribing patterns of antihypertensive drugs in Finnish primary health care and to describe the profiles of monotherapy and combination therapy in relation to the duration of high blood pressure. METHODS: Thirty out of 250 primary health care centres were randomly selected for the study. All doctors (n=337) from the participating health centres recorded all hypertensive patients (n=4405) during a 2-week period in May 1995. Adequate information was obtained concerning 4294 hypertensives, of whom 65% were women with a mean age for the total study population of 64 years. 85% of the patients (n=3638) had antihypertensive medication which was classified into five main categories: diuretics, beta blocking agents, calcium channel blockers, ACE inhibitors and hypotensives. RESULTS: Of the patients using antihypertensive medication, 48% were undergoing monotherapy and 52% combination therapy. Beta blocking agents were the most frequently prescribed drugs for hypertension, being used by half of the patients. ACE inhibitors and diuretics were prescribed in a different manner for male and female hypertensives, with men receiving more ACE inhibitors and women more diuretics. The number of antihypertensive drugs increased with the duration of hypertension, though 38% of the patients having hypertension for over 10 years were still undergoing monotherapy. Among patients undergoing combination therapy, 75% received two different agents, most often a diuretic with a beta blocking agent. CONCLUSIONS: With increasing duration of hypertension, the number of antihypertensive drugs also increased. Beta blocking agents were the drug of choice for all patients. For women, combination therapy more frequently included diuretics, whereas ACE inhibitors were favoured for men.

Who is using antihypertensive drugs? A prescription analysis from Finland.

OBJECTIVE: To analyse the prescribing of antihypertensives in Finland in 1993. DESIGN: A descriptive three-month follow-up study of reimbursed prescriptions for chronic hypertension dispensed in Finnish pharmacies. SETTING: The nationwide prescription data base of the Social Insurance Institution covering 80% of Finnish pharmacies. Material--The study material consisted of 479 744 antihypertensive prescriptions from ATC-groups hypotensives (C02), diuretics (C03), beta blocking agents (C07), and potassium (A12B) for 279 435 hypertensive patients. RESULTS: Of all the prescriptions (excluding potassium supplements), 30% were for beta blocking agents, 24% for diuretics, 22% for calcium channel blocking agents, 20% for ACE inhibitors or ACE inhibitor + diuretic combinations, and 4% for other hypotensives. Two thirds of the men received a drug from a hypotensive group, nearly half were prescribed a beta blocking agent, and 27% a diuretic. Among women the distribution of the different drug groups was more even: more than half the women (55%) were prescribed hypotensives while beta blocking agents and diuretics were prescribed for 43% and 44%, respectively. Due to the different treatment profile between men and women the expenses of treatment also differed. The cost of prescriptions for female patients was, on average, 17% less than that for male patients. CONCLUSION: The choice of antihypertensive drugs depends on the age and sex of a patient. Prescribing antihypertensive drugs does not fully meet national recommendations. New drugs are gaining ground in the treatment of hypertension. An increase in the cost of treatment will result from this development.

Self-initiated modification of hypertension treatment in response to perceived problems.

OBJECTIVE: To assess the prevalence of patient-initiated modification of drug instructions and the association between different classes of problems and the modification of hypertension therapy. DESIGN AND METHODS: In this cross-sectional study, all patients (n = 1215) who had been examined at a hypertension clinic during a 1-year period were surveyed. The response rate to the questionnaire was 85%. Of the 1035 respondents, 623 currently taking antihypertensive medication (self-report) were included in the study. RESULTS: Of the patients taking antihypertensive drugs, 36% admitted that they had tried to manage their condition with a lower dosage and/or fewer drugs than prescribed. The percentage of patients who modified their drug regimen decreased with increasing age. One or more problems with the treatment of hypertension were reported by 79% of the respondents. The odds ratio (95% confidence interval) for modification among patients who reported 1 or more problems compared with those not reporting any problem was 3.5 (2.12 to 5.67). The prevalence of modification increased with the number of problems; this was seen in all age groups and among men and women. CONCLUSIONS: Perceived problems in drug taking in the treatment of hypertension have an important impact on the prevalence of modifying drug instructions.

The effect of phase separation on biphasic waveform defibrillation.

It has been hypothesized that the defibrillation efficacy of a biphasic shock is caused by the large change in voltage between the two phases. This study examined the effects of separating the two phases in time thus splitting in half the rapid voltage change at phase reversal. The study was performed in three parts each using six dogs. Part I determined defibrillation thresholds (DFTs) for two exponentially truncated biphasic waveforms (3.5/2 msec and 6/6 msec) with interphase time delays of 0, 1, 2, 3, 4, 6, 8, and 10 msec. In Part II, probability of success curves were generated using an up down method with 15 shocks for each delay for the 3.5/2 msec biphasic waveform with interphase delays of 0, 2, 3, 4, and 5 msec. In Part III, DFTs were determined using a 3.5/2 msec and 6/6 msec biphasic as well as a third waveform that consisted of two sequential 6-msec pulses of the same polarity with interphase delays of 0, 5, 10, 15, 20, 25, 50, and 100 msec. In all three parts the defibrillating cathode was a 6.17 cm2 transvenous spring electrode positioned in the RV apex and the anode was a 113 cm2 cutaneous left chest wall electrode patch. With all waveforms, the trailing edge voltage of the first phase was equal to the negative of the leading edge voltage of the second phase. There was no statistical difference in DFTs or in 50% successful defibrillation points for phase separations from 0 to 6 msec and 0 to 5 msec for Parts I and II, respectively. In Part I there was a significant increase in DFTs for phase separations of 8 and 10 msec compared to a phase separation of 0 msec. In Part III there was no significant difference for separations of 0 and 5 msec; however, there was a significant increase in DFT requirements for separations from 5 to 50 msec, which then decreased with a separation of 100 msec for all three waveforms tested. In conclusion, defibrillation efficacy was unchanged with phase separations up to 6 msec. With phase separation, the rapid voltage change during phase reversal is split in half and, thus, cannot explain the improved efficacy of biphasic waveforms.

Adverse drug effects and the need for drug information.

The information needs of a group of patients taking antihypertensive medication were assessed with special emphasis on the influence of perceived symptoms of high blood pressure and adverse drug effects. All patients of a hypertension clinic currently on antihypertensive medication were included in the study. The response rate to the questionnaire was 85%. Of the 623 patients included, only 31% expressed satisfaction with the amount of information received on adverse effects of their antihypertensive drugs. Patients younger than 50 years explicitly expressed a need for information more often than those older than 64. There were no differences in the expressed information needs between men and women. The reported experience of symptoms related to high blood pressure and adverse drug effects was more common among younger patients than among the elderly. Of those who experienced both adverse drug effects and symptoms, 57% expressed a need for more information, whereas only 30% of those who had no such experiences expressed a need for more information on adverse drug effects. It was concluded that there is a substantial need for more information on adverse drug effects, especially among those who have experienced adverse drug effects or some symptoms of hypertension.