Effective patient-provider communication is essential to ensure the best possible treatment outcomes for patients with HIV and other chronic diseases. Patients with HIV who report better relationships with their providers are more likely to begin antiretroviral therapy and to remain adherent to long-term care. Many studies have shown that healthcare providers interact differently with their minority patients, who in turn report lower levels of satisfaction with the healthcare that they receive. In their conversations with minority patients, providers are more likely to restrict themselves to biomedical issues, to engage less on interpersonal or psychosocial topics, and to exert greater verbal dominance. Communication problems are especially challenging for patients with language barriers, who are less likely to access a variety of healthcare services. Reliance on family members or other ad hoc translators often results in incomplete transmission of health information between patient and provider. Regardless of the patient's language or culture, it is essential to understand the patient's perspectives toward HIV infection and treatment in order to identify and overcome barriers to treatment. Providers often fail to engage the emotional concerns of their patients, either because they do not recognize statements about emotional well being, because they do not feel competent to engage patients on these topics, or for other reasons. Several practical steps can help providers to improve their use of empathy in patient-provider communication.
For patients with cystic fibrosis, adherence with lifelong treatment may be challenging, particularly as individuals enter into emerging adulthood (age 19‐25 years). This article explores the various factors that are known to impact adherence, with a focus on the contribution of emerging adulthood on the major nonadherence typologies (erratic adherence, unwitting nonadherence, and intelligent nonadherence). Social support is considered critical to adherence, with practical support (eg, instrumental support, assistance, reminders, and organization), emotional support (eg, nurturance and empathy), and having a cohesive family all highly associated with treatment compliance. Patients who fall into one of the nonadherence typologies have a general higher risk of nonadherence as they enter adulthood because a major aspect of social support (parental involvement) begins to diminish. For example, patients with erratic adherence (understand and agree with therapy but have difficulty consistently maintaining regimens) may find it particularly difficult to adhere to regimens during emerging adulthood, in the face of variable college and sleeping schedules, work schedules, travel, alcohol consumption, and impromptu social opportunities. Also discussed in this article are reliable ways of measuring adherence (medication refill history and patient reports of nonadherence) and empirically supported adherence promotion techniques. (Adv Stud Med. 2009;9(1):14-19)
Many patients with fibromyalgia syndrome (FMS) receive inadequate or ineffective treatment, often because of multifactorial barriers that stand in the way of appropriate care. These barriers include the high prevalence of medical and psychiatric comorbidities in patients with FMS, the challenges inherent in diagnosing FMS, and the perception among many that FMS is not a “real” disease. Another major obstacle is that there is often little or no coverage for patients with FMS who do have health insurance, and restricted access to healthcare for those who do not. This article reviews these and other patient-, physician-, and process-related barriers and explains how they interfere with treatment. The article also suggests several common-sense strategies aimed at overcoming these obstacles and improving care for patients with FMS. (Adv Stud Med. 2009;9(4):115-121) M any patients with fibromyalgia syndrome (FMS) receive inadequate or ineffective treatment. In part, this is a direct reflection of the lack of consensus among clinicians with respect to diagnosis, causes, and effective treatments. In large measure, however, inappropriate care can be attributed to numerous multifactorial barriers that need to be overcome. These barriers fall into 4 broad but interrelated categories: patient-related factors; physician-related factors; work and social impairment; and factors involving “process,” such as delayed diagnosis and inadequate healthcare coverage. The categories overlap to some extent, just as FMS frequently overlaps with several other pain syndromes and psychiatric conditions. Factors in each of the categories are reviewed in detail in this article, as well as strategies to overcome these obstacles. PATIENT-RELATED FACTORS
Conventional magnetic resonance imaging (MRI) techniques are important tools in the diagnosis and management of patients with multiple sclerosis (MS), but they reveal only a small part of the overall disease process. Lesion burden on T2weighted MRI correlates to some extent with disability during the early stages of the disease, but is less sensitive to increasing disability among patients with more advanced disease. New approaches are required to assess neurodegenerative changes that occur at even the earliest stages of MS but become the predominant pathophysiology in the progressive stages of MS. Diffusion tensor imaging (DTI) is an MRI technique that allows quantification of tissue water molecules that are restricted in their direction of motion by central nervous system (CNS) whitematter tracts. DTI provides several measures that can be used to assess the integrity of axons and myelin, and these DTI indices correlate significantly with histologic measures of CNS injury. Magnetization transfer imaging provides a relatively specific measure of lipid-associated macromolecules, and is therefore sensitive to changes in myelin, perhaps before typical lesions appear on conventional MRI. Optical coherence tomography (OCT) uses infrared light to calculate the thickness of the retinal nerve fiber layer, which consists of axons that form the optic nerve. Several studies have demonstrated that OCT is able to visualize and quantify neurodegeneration in patients with MS. New imaging technologies may provide opportunities to examine neurodegeneration in patients with MS and to assess the neuroprotective effects of new MS therapies. (Adv Stud Med. 2009;9(2):48-52)
When using immunosuppressant agents in renal transplantation, achieving low rejection rates while minimizing long-term toxicities (eg, nephrotoxicity and cardiovascular disease) associated with these agents is a primary goal. Strategies that reduce exposure to calcineurin inhibitors (CNIs) have demonstrated reasonable safety and efficacy in some targeted patient populations, but registry data and multicenter studies show that CNI-free regimens involving sirolimus and mycophenolate mofetil (MMF) generally have higher rejection rates and inferior graft outcomes. Longer term studies are needed to evaluate a possible learning curve with sirolimus and to study possible long-term toxicities such as wound healing, anemia, and hyperlipidemia. Converting to sirolimus and MMF after initial CNI therapy has also been studied. For example, results from the ongoing Spare the Nephron Trial demonstrate low rejection rates in stable transplant patients, short-term improvement in kidney function, and good safety results. In the future, agents such as belatacept may provide a nonnephrotoxic alternative to CNIs. Minimizing corticosteroid exposure is another worthy goal, and studies using induction protocols (eg, with lymphocyte-depleting agents or interleukin-2 receptor antagonists) and/or newer immunosuppressive agents (eg, MMF, sirolimus, and tacrolimus) have demonstrated that steroids can be withdrawn early in many patients without increasing the risk of acute rejection or long-term allograft problems. (Adv Stud Med. 2007;7(9):275-280)
The diagnosis of chronic constipation and constipation-predominant irritable bowel syndrome (IBS-C) is challenging because of the considerable degree of symptom overlap, the difficulty in eliciting important information about bowel habits during the history, and the limitations of various diagnostic tests used to evaluate constipation. This article explores these challenges and reviews the elements of the diagnostic process, including the history, the physical examination, the diagnostic criteria for constipation, IBS-C, and dyssynergic defecation, and the motility studies used to differentiate slow-transit constipation from dyssynergic defecation. It also includes 2 case studies to illustrate the overall diagnostic process. The first case study is presented in segments that coincide with the main elements of the evaluation; the second case study is presented at the close as a diagnostic summary for clinicians. (Adv Stud Med. 2006;6(2A):S74-S83)
