By P. Lisk. Ohio Valley College. 2018.

The director of health shall establish procedures for gathering evidence under this section cheap 100caps gasex with visa. Each reported victim shall be informed of available venereal disease cheap 100caps gasex with amex, pregnancy buy discount gasex 100caps on-line, medical, and psychiatric services. Notwithstanding any other provision of law, a minor may consent to examination under this section. The consent is not subject to disaffirmance because of minority, and consent of the parent, parents, or guardian of the minor is not required for an examination under this section. However, the hospital shall give written notice to the parent, parents, or guardian of a minor that an examination under this section has taken place. The parent, parents, or guardian of a minor giving consent under this section are not liable for payment for any services provided under this section without their consent. The consent of the parent, parents, or guardian of a minor is not required for such diagnosis or treatment. The parent, parents, or guardian of a minor giving consent under this section are not liable for payment for any diagnostic or treatment services provided under this section without their consent. A health care facility or health care provider that does not provide anonymous testing shall refer an individual requesting an anonymous test to a site where it is available. Should the health services include counseling concerning abortion, all alternatives will be fully presented to the minor. Services in this act shall not include research or experimentation with minors except where used in an attempt to preserve the life of that minor, or research as approved by an appropriate review board involved in the management of reportable diseases. Notwithstanding any other provision of law, the following minors may consent to have services provided by health professionals in the following cases: 1. Any minor who is separated from his parents or legal guardian for whatever reason and is not supported by his parents or guardian; 3. Any minor who is or has been pregnant, afflicted with any reportable communicable disease, drug and substance abuse or abusive use of alcohol; provided, however, that such self-consent only applies to the prevention, diagnosis and treatment of those conditions specified in this section. Any health professional who accepts the responsibility of providing such health services also assumes the obligation to provide counseling for the minor by a health professional. If the minor is found not to be pregnant nor suffering from a communicable disease nor drug or substance abuse nor abusive use of alcohol, the health professional shall not reveal any information whatsoever to the spouse, parent or legal guardian, without the consent of the minor; 4. Any spouse of a minor when the minor is unable to give consent by reason of physical or mental incapacity; 6. Any minor who by reason of physical or mental capacity cannot give consent and has no known relatives or legal guardian, if two physicians agree on the health service to be given; or 7. Any minor in need of emergency services for conditions which will endanger his health or life if delay would result by obtaining consent from his spouse, parent or legal guardian; provided, however, that the prescribing of any medicine or device for the prevention of pregnancy shall not be considered such an emergency service. Consent of the minor shall not be subject to later disaffirmance or revocation because of his minority. The health professional shall be required to make a reasonable attempt to inform the spouse, parent or legal guardian of the minor of any treatment needed or provided under paragraph 7 of subsection A of this section. In all other instances the health professional 95 may, but shall not be required to inform the spouse, parent or legal guardian of the minor of any treatment needed or provided. The judgment of the health professional as to notification shall be final, and his disclosure shall not constitute libel, slander, the breach of the right of privacy, the breach of the rule of privileged communication or result in any other breach that would incur liability. Information about the minor obtained through care by a health professional under the provisions of this act shall not be disseminated to any health professional, school, law enforcement agency or official, court authority, government agency or official employer, without the consent of the minor, except through specific legal requirements or if the giving of the information is necessary to the health of the minor and public. The health professional shall not incur criminal liability for action under the provisions of this act except for negligence or intentional harm. Minors consenting to health services shall thereby assume financial responsibility for the cost of said services except those who are proven unable to pay and who receive the services in public institutions. In cases where emergency care is needed and the minor is unable to give self-consent; a parent, spouse or legal guardian may authorize consent. A determination regarding the ability of the minor to perform independently such basic tasks shall be based upon the age of the minor and the reasonable and appropriate expectation of the abilities of a minor of such age to perform such tasks. The term “minor in need of treatment” shall not mean a minor afflicted with epilepsy, a developmental disability, organic brain syndrome, physical handicaps, brief periods of intoxication caused by such substances as alcohol or drugs or who is truant or sexually active unless the minor also meets the criteria for a minor in need of treatment pursuant to subparagraph a or b of this paragraph; 3. The plan shall be developed with maximum involvement of the family of the minor, consistent with the desire of the minor for confidentiality and with the treatment needs of the minor, and shall clearly include the following: 97 a. The short- and long-term goals shall be based upon a clinical evaluation and shall include specific behavioral and emotional goals against which the success of treatment can be measured, b. For the purposes of this paragraph, “licensed” means that the person holds a current, valid license issued in accordance with the laws of this state; 9. A parent of a minor or a minor sixteen (16) years of age or older may consent to the voluntary admission of the minor for inpatient mental health or substance abuse treatment. Upon the application of a minor sixteen (16) years of age or older or a parent of a minor, a mental health or substance abuse facility may admit the minor for inpatient evaluation or treatment if the person in charge of the facility, or a designee, determines the minor to be clinically eligible for such admission, and: 1.

We conclude that gaps in the existing treatment literature do not allow this question to be answered at this time and further conclude that treatment research in specific phobia will advance considerably by the addition of studies that test multiple treatments with participants presenting with different phobia subtypes trusted 100caps gasex. Hopefully purchase 100caps gasex free shipping, data from studies like these will provide the basis for developing empirically informed treatment matching strategies for the future purchase 100 caps gasex with visa. Effectiveness of psychological and pharmacological treatments for obsessive–compulsive disorder: A quantitative review. Psychosocial treatments for panic disorders, phobias, and generalized anxiety disorder. Effects of eye movement desensitization versus no treatment on repeated measures of fear of spiders. Emotional processing and fear measurement synchrony as indicators of treatment outcome in fear of flying. Treatment of claustrophobia and snake/spider phobias: Fear of arousal and fear of context. One-session cognitive treatment of dental phobia: Preparing dental phobics for treatment by restructuring negative cognitions. Computer-aided vicarious exposure versus live graded exposure for spider phobia in children. Virtual reality treatment versus exposure in vivo: A comparative evaluation in acrophobia. Controlled comparison of computer-aided vicarious exposure versus live exposure in the treatment of spider phobia. Cognitive-behavioral and pharmacological treatment for social phobia: A meta-analysis. Controlled comparison of single-session treatments for spider phobia: Live graded exposure alone versus computer-aided vicarious exposure. Emotional processing in the treatment of simple phobia: A comparison of imaginal and in vivo exposure. One-session therapist directed exposure versus two forms of manual directed self-exposure in the treatment of spider phobia. Effects of distraction and guided threat reappraisal on fear reduction during exposure treatments for specific fears. Comparison of behavioral and cognitive-behavioral one-session exposure treatments for small animal phobias. Drugs and psychological treatments for agoraphobia/panic and obsessive–compulsive disorders: A review. A comparison of in vivo and vicarious exposure in the treatment of childhood water phobia. Treating spider phobics with eye movement desensitization and reprocessing: A controlled study. Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemiological Catchment Area Program. Change mechanisms in cognitive therapy of a simple phobia: Logical analysis and empirical hypothesis testing. One vs five sessions of exposure and five session of cognitive therapy in treatment of claustrophobia. Applied tension, exposure in vivo, and tension only in the treatment of blood phobia. Individual response patterns and the effects of different behavioral methods in treatment of claustrophobia. One-session therapist directed exposure versus self-exposure in the treatment of spider phobia. Applied tension, applied relaxation, and the combination in the treatment of blood phobia. A comparison of negative practice and systematic desensitization in treatment of acrophobia. Emotional processing during eye-movement desensitization and reprocessing therapy of Vietnam veterans with chronic post-traumatic stress disorder. Disentangling the effects of safety behavior utilization and availability during exposure-based treatment: A placebo-controlled study. Active-imaginal exposure: Examination of a new behavioral treatment for cynophobia (dog phobia). Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. Effects of varied-stimulus exposure training on fear reduction and return of fear. Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures.

The patient may develop somatic symptoms such as hypertension purchase gasex 100caps online, sweating generic gasex 100 caps, shaking purchase 100caps gasex free shipping, tachycardia, headache, etc. Re-experiencing is highly distressing and causes disorders that may worsen over time; people isolate themselves, behave differently, stop fulfilling their family/social obligations, and experience diffuse pain and mental exhaustion. It is important to reassure the patient that his symptoms are a comprehensible response to a very abnormal event. Avoid over active explorations of the patient’s emotions: leave it to the patient to decide how far he wants to go. Associated symptoms (anxiety or insomnia), if persistent, can be relieved by symptomatic a 11 treatment (diazepam) for no more than two weeks. The classic diagnostic criteria for a major depressive episode are: – Pervasive sadness and/or a lack of interest or pleasure in activities normally found pleasurable And – At least four of the following signs: • Significant loss of appetite or weight • Insomnia, especially early waking (or, more rarely, hypersomnia) • Psychomotor agitation or retardation • Significant fatigue, making it difficult to carry out daily tasks • Diminished ability to make decisions or concentrate • Feeling of guilt or worthlessness, loss of self-confidence or self-esteem • Feeling of despair • Thoughts of death, suicidal ideation or attempt The features of depression can vary, however, from one culture to anothera. For example, the depressed patient may express multiple somatic complaints rather than psychological distress. Depression may also manifest itself as an acute psychotic disorder in a given cultural context. Management When faced with symptoms of depression, consider an underlying organic cause (e. These symptoms should not be neglected, especially as they have a negative impact on adherence to treatment. Symptoms of depression are usual right after a major loss (bereavement, exile, etc. Pharmacological treatment is justified if there is a risk of suicide or in the event of severe or long-lasting problems with significant impact on daily life, or if psychological follow-up alone is not enough. Before prescribing, make sure that a 6-month treatment and follow-up (psychological support, adherence and response) is possible. Be careful with tricyclic antidepressants, as the therapeutic dose is close to the lethal dose. In situations where antidepressants are required, use paroxetine rather than fluoxetine if the woman plans to breastfeed. In the event of pregnancy in a woman under antidepressants, re- evaluate the need to continue the treatment. Monitor newborns for signs of toxicity or withdrawal symptoms during the first few days of life. Antidepressant therapy Fluoxetine Paroxetine Amitriptyline (mg/day) (mg/day) (mg/day) Week/month W1 W2 W3 M1 W1 W2 W3 M1 W1 W2 W3 M1 Adults 20 20 20 40 20 20 20 40 25 50 75 100 > 60 years idem idem 25 25 50 75 Increase at M1 (end of the first month) only if still necessary. Can be used; Breastfeeding Avoid Can be used monitor the infant (risk of drowsiness). During this period, anxiety may be exacerbated and the risk of suicide increased, especially with fluoxetine and clomipramine. During this period, do not give 11 more tablets than the quantity required for each week. On the contrary – depressed people are often anxious and ambivalent about suicide and feel relieved when able to talk about it. Inform the patient about problems associated with abrupt treatment discontinuation (very common with paroxetine). If the patient is under fluoxetine, stop fluoxetine (withdrawal symptoms are unlikely) and wait at least 10 to 14 days before starting the tricyclic antidepressant. The patient is convinced of things that are not real, based on intuition, interpretation or hallucinations – especially auditory ones. Delusions are often accompanied by behaviour disorders, for example agitation, prostration, mutism, opposition, and fleeing. Treatment efficacy and the prognosis depend in large part on the quality of the relationship established with the patient and his family. Keeping the patient at home with outpatient follow-up is preferred if the patient is not a danger to himself or others, and if the family is capable of managing the disorder. For example, psychotic disordersa may be attributed to charms or to ancestor intervention. Patient are usually already under “traditional” treatments, this should not be seen as an obstacle to conventional medical treatment. Acute psychotic episode An acute psychotic episode can be a one-time occurrence, usually of sudden onset, or can occur repeatedly or may be the early phase of chronic psychosis. Before prescribing antipsychotic medication, consider the possibility of an underlying organic cause (see Mental confusion) or use of toxic substances. Antipsychotic therapy is the same as that for chronic psychoses (risperidone or haloperidol, see following page) and should last at least 3 months. After 3 months, if the patient is stable, stop the treatment gradually over 4 weeks, monitoring for potential relapse. For severe anxiety or agitation, an short-course anxiolytic or sedative treatment (see page 321) may be added to the antipsychotic treatment, at the beginning of treatment. In schizophrenia, delusions are accompanied by dissociation; the patient seems odd, his speech 11 and thoughts are incoherent, his behaviour unpredictable and his emotional expression discordant. It offers real benefits, even if chronic symptoms persist (tendency toward social isolation, possible relapses and periods of increased behavioural problems, etc.

Inpatient malaria deaths per 1 buy gasex 100caps amex,000 persons Rationale Mortality is a major component of the burden caused by malaria buy 100 caps gasex, and the overall goal of the Roll Back Malaria Partnership is to reduce malaria deaths to near zero by 2015 purchase 100 caps gasex overnight delivery. With intervention coverage data and repeated estimation, understanding of the epidemiology of malaria can be improved and progress of control efforts can be tracked more effectively if estimates of parasitemia prevalence are available. Under 5 Malaria Case Fatality Rate Definition of the indicator: Under 5 malaria case fatality rate is defined as the proportion of children under five years of age who die of malaria out of the total number of children under-five (5) years admitted with malaria. In other words it expresses the proportion of children under five years with malaria who die from it (ratio of deaths to cases). Data Sources: The data is obtained from the hospital In-patient Morbidity and Mortality Returns. Use: This indicator is used to assess the performance of the malarial control programme and quality of inpatient care of the health services. Malaria-specific deaths per 1,000 persons Rationale Mortality is a major component of the burden caused by malaria, and the overall goal of the Roll Back Malaria Partnership is a 50 percent reduction in malaria-associated mortality among children under-five (5) years old by 2010. Pharmacovigilance Data sources: Complete or sample vital registration systems, verbal autopsy (surveys). Reporting Timelines Reporting of serious adverse events (death, life threatening, prolonged hospitalisation) should be reported immediately and not later than 7 calendar days. For non-serious adverse effects, reports could be submitted within a period of 28 days. It is then spread on a glass slide ("blood smear"), dipped in a reagent that stains the malaria parasites (Giemsa stain), and examined under a microscope at a 1000-fold magni- fication. Malaria parasites are recognisable by their physical features and by the appearance of the red blood cells that they have infected. These characteristics often allow the laboratory technicians to identify the type (species) of parasite causing the infection, a finding that will guide the treatment. The laboratory technicians or Biomedical Scientist can also assess the percentage of red blood cells that are infected, a measure of severity of the infection. Microscopy can only be performed by specially trained laboratory technicians and other specially trained health care workers. For microscopy guidelines and Standard Operating Procedures, refer to the Guidelines for Laboratory Diagnosis of Malaria (Ghana Health Service: 2014). There is currently no international consensus on any particular brand and type, although the field is advan- cing rapidly. For a full set of technical guidelines, refer to the Guidelines for Laboratory Diagnosis of Malaria (Ghana Health Service: 2014). Principle and Purpose The test utilises a device coated with monoclonal antibodies against malaria parasite antigens. Blood flows along the device and if malaria parasite antigens are present in the sample, the antigen antibody complex binds with a conjugate forming a coloured line (usually red). The purpose of the test is to determine if a person has been recently exposed to malaria infection. Some tests are able to distinguish Plasmodium falciparum from other malaria species. Reagents and Materials Tests contain the following components in the kit: Ÿ Instruction sheet. Method: a· Ensure the kits have not expired by checking the date at the back of the package and read manufacturer’s insert. Therefore, test results must be read only within the time specified by the manufacturer. C T Negative Results: One line ‘C’ appears in the result window Positive Results: P. Test is positive even if the test line is faint Invalid Results: No ‘C’ line appears in the results window. This means that, in patients with suspected malaria, a confirmed diagnosis is recommended, wherever possible, before giving anti-malaria treatment. On the basis of clinical judgement, these patients may be treated for malaria in addition to any other cause of fever. Treatment failure may be due to drug resistance, poor adherence to treatment, poor quality of drugs, unusual pharmacokinetic properties in that individual, or misdiagnosis. The development of malarial symptoms and signs 28 days or more after the initiation of malaria therapy is considered as indicative of a new infection, and requires appropriate investigation. In all patients with suspected severe/complicated malaria with or without fever or history of fever, the use of a confirmatory blood slide is recommended, so that parasitaemia can be quantified. Note that, high parasitaemia is not always present in severe disease and initial blood slide examination may be negative.

However gasex 100caps free shipping, developing and implementing new legal regulatory models for currently illegal drugs is essentially working from a blank slate order gasex 100 caps fast delivery. This presents clear opportunities to learn from past policy successes and failures buy cheap gasex 100caps, but also risks unintended or unanticipated negative consequences. For certain elements of the reform agenda—for example incorporation of human rights principles and law into international drug control—a rapid change is warranted. For other elements of the reform process, such as the development of legal supply models and availability controls, the responsible approach is to phase in change over a period of months or years. This change should take place along various policy increments, 67 1 2 3 Introduction Five models for regulating drug supply The practical detail of regulation so that policy and regulatory models can be developed whilst outcomes on key indicators are carefully monitored and evaluated. This approach should be, by default, based on a precautionary prin- ciple, particularly where evidence from existing policy is thin, or specifc high-risks are identifed. New models will thus initially err towards stricter, more intrusive regulation, with lower restriction levels only subsequently coming into play. A precautionary and incremental approach allows for key concerns, such as availability to youth, increase in high risk behaviours or other specifc public health concerns, to be closely monitored. If problems do arise, policy can take a step back, be refned and adjusted, and alternative or additional regulatory tools can be deployed. Additionally, such an approach has democratic benefts, in that it allows for greater civil society involvement in policy development. It also goes some way to removing the fear that all drugs would somehow just become available ‘overnight’. By demonstrating that policy is being developed in a responsible and cautious fashion, based on evidence of effectiveness and sensitive to legitimate fears and concerns, it offers the opportunity to win a greater level of public and political support for a programme of reform. Such a cautious, measured approach will also help placate critics, who fear that moves towards regulation are a ‘gamble’, un-evidenced or in some way ‘reckless’. A useful precedent for this is provided by some of the more contentious harm reduction policy developments of the past two decades, such as needle exchanges, supervised injecting venues, or opiate prescribing. Due to the highly charged political environment around drugs issues, such interventions have been subject to unprecedented regulation and scrutiny. Particular attention has been given to their effectiveness in reducing health harms, and to high profle concerns that they can somehow encourage use. Responses to such scrutiny have demonstrated 68 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices how effective policy interventions can be developed, public concerns can be dealt with sensitively, sensationalist media coverage responded to intelligently, and political opposition ameliorated. The increments along which phased change can be implemented are essentially in line with the range of regulatory tools described in chapters two and three. There is the potential to move from greater to lesser levels of regulation, controlling the levels of availability either through deployment of the different regulatory controls over suppliers, purchasers and products, or through their deployment at varying inten- sities. Where possible the longer term aim would be to encourage and move from legal/administrative controls towards social controls. Different countries will necessarily take different approaches, and see their policy and legal infrastructure develop along different routes. There will, for example, be very different challenges faced by primarily producer, transit or consumer countries, states with different levels of economic resources, political stability and public health and enforce- ment infrastructure, and states that are geographically isolated, compared to those with large borders with highly populated regions. Cannabis is likely to be the frst drug to have regulatory models more seriously explored. At the other end of the spectrum, around problematic dependent use of opiates and stimulants, we are likely to see medicalised maintenance 29 R. Newcombe, ‘Attitudes to drug policy and drug laws; a review of the international evidence’, Transform Drug Policy Foundation, 2004. These models will be based on already established, functional and effective interventions in numerous countries. These two emerging trends are already defning an ongoing pragmatic reform process —addressing the areas of most pressing practical necessity where prohibition’s effects are the most egregious, in population terms (cannabis) and overall harm creation (chaotic use/dependence). Within broad groupings of similar types of drugs—stimulants, depres- sants or hallucinogens (see: chapter 5)—we might reasonably expect regulated legal availability pilots to begin by focussing on the drugs least likely to be associated with personal or social harms and costs (see: 4. Similarly, less potent preparations of drugs, for use through lower risk methods of administration, could be made available in the frst instance. First, such rankings should inform policy makers, so that they can develop effective, targeted and proportionate policy responses to a range of different drug harms, which can thereby be managed and minimised. This is an essential element of developing effective regula- tory frameworks and inevitably requires a degree of population based generalisation. The second is to facilitate the education of individuals about drug risks and harms, so enabling them to make informed and responsible decisions about their health and wellbeing. Getting to grips with these questions requires that two important 70 4 5 6 Making a regulated system happen Regulated drug markets in practice Appendices distinctions are made. First of all, primary health harms to individual users should be distinguished from the secondary social harms to third parties that follow from that use.

Myxoma is instead a rare tumour of the primitive connective tissue and is located most commonly in the heart generic 100 caps gasex mastercard. One of the first persons attributed to having described a benign mucocele of the appendix was the Bohemian nobleman and pathologist Karl von Rokitansky in 1842 generic gasex 100 caps visa. His original article could not be traced buy gasex 100 caps online, but Weaver described Rokitansky´s contribution to oncology in 1937 [4]. A gynaecologist named Werth introduced the term pseudomyxoma peritonei and reported the syndrome to be related to an ovarian neoplasm in 1884 [5]. In 1901, Frankel reported the association between pseudomyxoma and appendiceal cysts [6]. The current opinion is, that the appendix can be identified as the origin in the majority of cases [10, 11]. It is characterized by the accumulation of mucinous ascites within the peritoneal cavity. An epithelial neoplasm arises within the appendiceal lumen and consequently the lumen per se becomes occluded. This occlusion finally causes a rupture in the wall of the appendix and therefore mucus containing epithelial cells is spilled within the abdominal cavity [12]. The natural progression of the disease is usually moderately slow, although rapid advancement is also seen on occasions. The typical course of disease comprises tumour spread on the peritoneal surfaces, but invasion of the organs is also seen, especially in cases with a high-grade histology. Nevertheless, those that can be seen are found in the livers or lungs of patients with high-grade histology. Eventually the progressive amount of mucus causes dyspnea, gastrointestinal obstruction, malnutrition, hydronephrosis, and other organ malfunctioning. Another Dutch study, in which data were retrieved from the Eindhoven Cancer Registry noted an increase in age-standardized incidence of appendiceal mucinous adenocarcinoma that varied between 0. The study period was 1980 to 2010 and the data cover a large part of the southern Netherlands, which comprises about 2. The following section will examine more closely the schemes considered to be the most relevant for the debate on classification. Cytological atypia and architectural complexity are sufficient to establish a diagnosis of mucinous carcinoma. Despite the peritoneal lesions, the primary lesion in the appendix lacks evidence of invasive features. Pai and Longacre proposed their differential diagnosis spectrum of appendiceal mucinous neoplasms in 2005 [16]. They considered mucinous adenoma lesions, which involve appendiceal mucosal surface and are composed of mucin-rich epithelium. There is no invasion by the epithelium into the muscular wall nor is there a presence of epithelium on the serosa. According to Pai and Longacre’s definition, mucinous adenoma is restricted to those cases without epithelium involvement in extra- appendiceal mucin. Consequently, if the appendix is surgically excised, no further treatment is required. Therefore, the 14 differential diagnostics between these two groups is challenging. It is impossible to definitely exclude the possibility of extra-appendiceal spread of epithelial cells, even if no macroscopic tumour can be seen on the peritoneal surfaces. They also restricted the use of this category to those cases with extremely well-differentiated mucinous neoplasms but which also had an uncertain stage of invasion. In contrast, mucinous carcinoma exhibits architectural complexity and high- grade cytological atypia with high mitotic activity. There is always uncertainty as to whether the epithelial cells have sprayed on peritoneal surfaces, thus the division of histological comparably homogeneous group of lesions by invasiveness might be somewhat irrelevant. On the other hand, a clear dividing line can be drawn between the mucinous carcinoma and the other groups. The lesion can be classified according to the definition as low-grade or high-grade pseudomyxoma. The alternative terms low-grade and high-grade mucinous adenocarcinoma can be used as well. There are histopathological, immunochemical, and molecular genetic studies that suggest the appendix as an origin in those cases with synchronous tumour of appendix and ovary [10, 22, 24]. Thus, the pattern of immunoreactivity was distinct from primary ovarian tumour and similar to appendiceal adenoma [22]. The classic sign is increased abdominal girdle, which is caused by the accumulation of gelatinous ascites. This is characteristic of the progressive state of disease in which the most of the abdomen is filled with ascites and tumour [23].

A well chosen drug treatment consists of as few drugs as possible (preferably only one) generic 100caps gasex with visa, with rapid action trusted 100 caps gasex, with as few side effects as possible order gasex 100caps otc, in an appropriate dosage form, with a simple dosage schedule (one or two times daily), and for the shortest possible duration. Patients need information, instructions and warnings to provide them with the knowledge to accept and follow the treatment and to acquire the necessary skills to take the drugs appropriately. In some studies less than 60% of patients had understood how to take the drugs they had received. Information should be given in clear, common language and it is helpful to ask patients to repeat in their own words some of the core information, to be sure that it has been understood. A functional name, such as a ‘heart pill’ is often easier to remember and clearer in terms of indication. Box 9: Aids to improving patient adherence to treatment Patient leaflets Patient leaflets reinforce the information given by the prescriber and pharmacist. If they are not available, make pictorials or short descriptions for your own P-drugs, and photocopy them. Day calendar A day calendar indicates which drug should be taken at different times of the day. It can use words or pictorials: a low sun on the left for morning, a high sun for midday, a sinking sun for the end of the day and a moon for the night. Drug passport A small book or leaflet with an overview of the different drugs that the patient is using, including recommended dosages. Dosage box 73 Guide to Good Prescribing The dosage box is becoming popular in industrialized countries. It is especially helpful when many different drugs are used at different times during the day. The box has compartments for the different times per day (usually four), spread over seven days. The important thing is to give your patients the information and tools they need to use drugs appropriately. The six points listed below summarize the minimum information that should be given to the patient. Effects of the drug Why the drug is needed Which symptoms will disappear, and which will not When the effect is expected to start What will happen if the drug is taken incorrectly or not at all 2. Side effects Which side effects may occur How to recognize them How long they will continue How serious they are What action to take 3. Instructions How the drug should be taken When it should be taken How long the treatment should continue How the drug should be stored What to do with left-over drugs 4. Warnings When the drug should not be taken What is the maximum dose Why the full treatment course should be taken 5. Future consultations When to come back (or not) In what circumstances to come earlier What information the doctor will need at the next appointment 6. Ask the patient whether everything is understood Ask the patient to repeat the most important information Ask whether the patient has any more questions 74 Chapter 10 Step 5: Give information, instructions and warnings This may seem a long list to go through with each patient. You may think that there is not enough time; that the patient can read the package insert with the medicine; that the pharmacist or dispenser should give this information; or that too much information on side effects could even decrease adherence to treatment. Yet it is the prime responsibility of the doctor to ensure that the treatment is understood by the patient, and this responsibility cannot be shifted to the pharmacist or a package insert. Maybe not all side effects have to be mentioned, but you should at least warn your patients of the most dangerous or inconvenient side effects. Having too many patients is never accepted by a court of law as a valid excuse for not informing and instructing a patient correctly. Exercise: Patients 34-38 Review the following prescriptions and list the most important instructions and warnings that should be given to the patient. Patient 34 (depression) It will take approximately two to three weeks before the patient starts to feel better, but side effects, such as dry mouth, blurred vision, difficulty in urinating and sedation, may occur quickly. Because of this many patients think that the treatment is worse than the disease and stop taking the drug. If they are not told that this may happen and that these effects disappear after some time, adherence to treatment will be poor. For this reason a slowly rising dosage schedule is usually chosen, with the tablets taken before bedtime. You can also ask 75 Guide to Good Prescribing the pharmacist to explain it again (write this on the prescription). Instructions are to follow the dosage schedule, to take the drug at bedtime and not to stop the treatment. Warnings are that the drug may slow reactions, especially in combination with alcohol.