美国药物治疗管理服务的应用现状及对我国的启示

为解决不合理用药问题,美国政府正尝试利用药师的专业技术优势加强对患者药物治疗的管理.在查阅分析国外文献的基础上介绍了美国药物治疗管理服务的形成背景、运作模式、核心要素和实施效果等应用现状,以期为我国临床药学服务的发展提供启示和政策建议.     

药物治疗的风险及其处理

造成药物治疗风险的因素包括药物因素、病情因素、患者因素、用药因素及管理因素等。通过对药物进行严格监管,对医药从业人员加强培训和教育,对民众开展科普教学和用药指导,可以降低药物治疗的风险。风险事件主要表现为用药差错、药物不良反应或药物治疗无效。在药物治疗中,首先必须时刻警惕和及时发现风险;其次需要全面评估风险,还要对疾病风险和药物治疗风险进行比较。应尽可能避免药物治疗的风险,对于必须承受的风险,需采取相应措施,减少风险事件发生的概率和严重程度。如果存在较大风险,务必同时设计处理风险事件的预案,并与患者及其家属保持良好的交流和沟通。     

正念疗法在高血压患者中应用的研究进展

近些年,中国高血压患者存在症状重、难控制的问题,国内对于高血压患者,强调药物治疗与非药物治疗并重的治疗方针。而正念疗法为非药物治疗方式的一种,以其容易理解、简单易行的优点,成为了治疗慢性疾病的热门研究方向。正念疗法在高血压患者情绪管理,疾病症状控制与压力缓解等方面发挥着重要的作用。因此,本文拟从正念的内涵、正念干预技术及应用于高血压患者的研究现状方面进行论述,以期为高血压患者中的血压情绪管理提供依据。     

哮喘控制与医疗改革

达到并维持哮喘控制和减少未来风险是哮喘的管理目标,绝大多数患者通过药物治疗可以实现这一目标。但目前哮喘控制率很低,除与GINA和我国哮喘诊治规范实施不足有关外,还与传统医疗结构、医疗体制和医疗观念有关,加速医疗改革,人人享有基本医疗卫生服务是提高哮喘控制率的重要环节。     

慢性乙型肝炎抗病毒治疗的策略

抗病毒治疗是慢性乙型肝炎治疗的关键,有效的抗乙型肝炎病毒药物主要有干扰素和核苷（酸）类似物。单药抗病毒治疗可获得较好的疗效,便于监测、管理;联合抗病毒治疗增加抗病毒疗效尚难肯定,更无法避免耐药发生,并可导致多药耐药、增加药物副作用和治疗费用。因此,优选单药进行抗病毒治疗才是目前理想的方案。     

哮喘控制与医疗改革

达到并维持哮喘控制和减少未来风险是哮喘的管理目标,绝大多数患者通过药物治疗可以实现这一目标.但目前哮喘控制率很低,除与GINA和我国哮喘诊治规范实施不足有关外,还与传统医疗结构、医疗体制和医疗观念有关,加速医疗改革,人人享有基本医疗卫生服务是提高哮喘控制率的重要环节.     

外科手术患者围手术期药物治疗决策

外科手术患者的医疗质量不但与手术本身有关,也与药物治疗息息相关。外科手术患者常常合并疾病复杂,用药种类多,药物治疗的矛盾、风险和困难,一点不比内科病房少。而且外科疾病、术前术后处理和手术本身也会对药代动力学产生影响,无疑使外科医生在药物治疗决策时更加艰难和必须更加慎重。因此外科手术医生不但要精于手术,也要善于药物治疗。作为临床药师,我们也意识到外科将成为开展临床药学工作的重要岗位和阵地。临床药师可以全程化监护患者的用药和开展药学服务;可以发挥自身学术优势,提高药物治疗的有效性、安全性和经济性。     

高血压病人管理的几点思考

我国高血压发病率不断增高,对其管理及高血压病的知晓率、治疗率和控制率未见明显提高。根据相关文献资料,结合临床工作,强调加强以高血压病人的管理,尤其是非药物管理,如建立健康生活方式:调整心态、保证睡眠、增加运动、戒烟少酒、控制体重。进而,指出在参考国外治疗指南的基础上,探索适合我国的治疗方法,如应对不同类型的高血压病人,进行个体化的药物治疗。最后,强调对年轻人、老年人,不同类型冠心病及心功能不全的高血压病人的综合管理。     

关于过度医疗服务的思考

过度医疗服务是指医疗行业提供了超出个体和社会医疗保健实际需求的医疗服务。有关资料表明 ,近几年 ,医疗费用的增长速度大大超过同期国家财政收入的增长速度 ,这其中一个重要和普遍的原因是过度医疗服务 ,它给个人和社会带来沉重的经济和精神负担。1　过度医疗服务的行业表现为 :放宽住院及治疗标准 ;过度检查检验 ;过度治疗 ,如选择高档药物 ,扩大手术范围等 ;医用材料过度浪费 ;过度医疗保健等。2　分析过度医疗服务的原因有以下 :(1 )经济利益诱惑 :在市场经济下 ,各医院为了提高经济效益千方百计争夺病源 ,提高门诊量和住院率 ,甚至给…     

妊娠期糖尿病治疗中的共识和争议

妊娠期糖尿病(GDM)是一种常见的妊娠期疾病,全球范围内GDM的发病率日益增加。血糖升高可导致围产期母婴不良结局和子代成年后代谢紊乱,GDM的治疗和管理需要得到高度重视。目前GDM的治疗中仍存在许多争议,不同国家针对GDM的药物治疗策略不尽相同,在GDM人群中多个国家进行了不同药物的临床研究。本文基于近年来多种指南及循证医学依据,结合GDM治疗获益、营养和运动干预、药物治疗、监测等进行全面探讨。     

Group therapy as an adjunct to medication in the management of bipolar affective disorder

This paper asserts that, contrary to the beliefs of many clinicians, patients with bipolar affective disorder often experience a deteriorating course characterized by pervasive social dysfunction. It reviews the literature, identifying a rationale for group psychotherapy as an adjunct to medication in the management of these chronic patients. It outlines a theoretical approach to bipolar group therapy, and presents a retrospective study comparing the course of 43 lithium-treated bipolar patients before and after entering bipolar groups. During the year in group therapy, bipolar patients displayed significant improvements in symptom relief as well as social functioning. It is proposed that group process enhances treatment with medication, providing benefits not evident with medication alone.     

Psychological therapy for adults with Attention Deficit Hyperactivity Disorder

In the liteature, the clinical management of adults with Attention Deficit Hyperactivity Disorder has focused almost exclusively on stimulant medication. Yet psychological therapy may be a useful adjunct to stimulant medication. Pharmacotherapy is generally reported to be efficacious and, as such, treated individuals are likely to be more receptive to psychological intervention. The aim of this paper is to consider how an individual may best be supported by psychological therapy. It is recommended that a structured pragmatic, psychoeducative approach is the most appropriate. The development of specific self-management skills is discussed within a cognitive behavioural framework. Family, marital and group therapies are also discussed.     

Generalized anxiety disorder: acute and chronic treatment

Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.     

Apathy is Associated with Critical Psychological Determinants of Medication Adherence in HIV Disease

Apathy is common in HIV, separable from depression, and has been associated with non-adherence to antiretroviral therapy (ART). We examined the associations between apathy and critical psychological determinants of ART adherence, as per the information-motivation-behavioral model, in 85 persons living with HIV. Apathy was measured using a composite of the apathy subscale of the Frontal Systems Behavioral Scale and the vigor-activation scale of the Profile of Mood States. Independent of major depressive disorder, apathy was related at small-to-medium effect sizes with motivation to adhere and self-efficacy for health-related decision-making and medication management, but not with HIV knowledge or medication management skills. These findings suggest that apathy plays a unique role in several critical health adherence determinants and support the importance of assessment and management of apathy to maximize health outcomes among individuals with HIV disease.

     

The Process of Group Treatment with the Chronically Mentally Ill

Group treatment has been used with inpatient psychiatric clients for numerous years. Only since the advent of deinstitutionalization have outpatient services begun to utilize this format. Over the ears, mental health professionals have realized that traditional talk therapy approaches do not adequately address the multiple, pressing needs resented by the person with chronic mental illness. A multi-modalry approach that utilizes case management, medication, family support, and group therapy has evolved. Specifically, activity focused group therapy has been recognized as an integral treatment modality. The author presents a model of group treatment and process which underscores the value of Occupational Therapy's contribution to the treatment of the chronically mentally ill.     

Behavioral assessment of methylphenidate in a child with frontal lobe damage

The assessment and management of inattentive, hyperactive, and impulsive behavior in a 6-year-old girl who experienced frontal lobe damage are described. A multimodel approach combining medical, educational, and behavioral techniques to assess hyperactive behavior, optimal medication level, and medication and psychotherapeutic effectiveness is described. The results of the study suggest that in similar cases, children and adolescents manifesting these behaviors should be given a trial of stimulant medication in a controlled environment to assess if such therapy is indicated. Additional support is given for the increasing need for detanté and cooperation with health-care professionals.     

Ex-hospital clients evaluate their aftercare experiences

Seventy-two previously hospitalized clients of an inner-city community clinic, assigned to three treatment groups - medication-only, medication plus individual therapy, and medication plus therapy plus group experiences - evaluated their respective aftercare programs by responding to five questions. As compared with the others, medication-only clients were less inclined to see either the clinic or the medication as preventing rehospitalization, were alone in reporting that the clinic was responsible for preventing rehospitalization to the extent that the medication was effective, and responded to the question of rehospitalization by emphasizing worsening symptoms. Others emphasized therapy failure. Clients agreed with the professionals - aftercare should not be medication alone.     

A selected review of the literature and an empirical analysis of drug treatment compliance by schizophrenic patients

One of the significant issues in the treatment of schizophrenic patients is their nonadherence to medication. While maintenance without medication may be possible for a minority of this group (Gardos and Cole, 1976; Cheung, 1981), most authorities believe that drug therapy should be continued indefinitely, particularly in view of the substantial risk of relapse when medication is discontinued (Prien and Klett, 1972). Davis (1975) reported that the evidence for the efficacy of neuroleptics in preventing relapse was substantial.     

Treatment-resistant depression in late life

Treatment resistance is reported in up to 40% of older patients with major depression. Before labeling an episode of depression as treatment resistant, it is important to ensure that the diagnosis is correct and that the patient has received and adhered to an adequate dose of treatment for an appropriate length of time. It is also important to assess the patient for comorbid physical and psychiatric conditions that can contribute to treatment resistance. In patients who do not experience remission of symptoms with an adequate trial of medication, the following options can be considered: augmenting the antidepressant with a drug that is not primarily an antidepressant, adding a second antidepressant to the first, switching to a different antidepressant medication, or switching to electroconvulsive therapy. This paper reviews the concept of treatment-resistant depression and discusses its assessment and management in the elderly. The author concludes that when a systematic stepped-care approach to treatment is followed, most older patients with major depression will experience remission of symptoms.