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NON-COMPLIANCE OR MIS-PRESCRIBING ?
937 to a number of antibiotics including All their strains were inhibited by 0-25 (1.g.
it is not possible to calculate the extent to which patient conformed to his treatment regimens over the
tract infections
reasons
ampicillin.
this
per ml. of ampicillin or less. The organism reported here seems to be of doubtful clinical significance in this patient. However, it is of interest if it represents a recent development of such strains in the community, perhaps secondary to the widespread use of ampicillin. It may also need to be considered in the treatment of chronic bronchitic patients who often suffer infections due to H. influenzae and for whom the treatment of choice at the moment is ampicillin or
amoxycillin.
King’s College Hospital Medical School, Denmark Hill,
ELIZABETH PRICE PAUL A. BOSWELL.
London SE5 8RX.
years.
Though the sum total of unconsumed tablets in this is astounding, it is perhaps not surprising that the patient failed to conform to his treatment regimen. Analysis of the prescriptions issued reveals that over a period of 17 months he was expected to take 27 tablets daily; four preparations were involved, each with different instructions. For a shorter period his consumption should have been 32 tablets daily. With such requirements perhaps only those with obsessional traits would comply. It seems unwise, particularly for the elderly, to prescribe in such a manner that compliance with the doctor’s instructions is unlikely. With resuscitation this patient recovered and he was discharged home after three weeks. Medication was prescribed again as before. case
Department of Pharmacology, St. Thomas’s Hospital Medical School.
NON-COMPLIANCE OR MIS-PRESCRIBING ? studies have revealed that patients do not always take medicines as prescribed by the doctor.1 Such non-compliance, which has been the subject of reviews, 2,3 is probably commoner than many of us believe, at least judging from the number of unwanted tablets and capsules which have been recovered from patients’ homes.4 Failure to take drugs is particularly associated with advanced age, with prolonged and complex prescribing, and with drugs which produce unpleasant side-effects. It is both a cause of treatment failure and a source of wasted effort, time, and
SIR,-Many
money.
We report here a case of non-compliance which struck us forcibly and from which an old lesson can be relearned. A 71-year-old bachelor was admitted to the intensive-care ward at this hospital on Nov. 4, 1973. He had been found unconscious in bed at home with three open empty bottles labelled nitrazepam by his bedside. He had been extensively investigated in the past 9 years for hypertension, polycythaemia thought to be of renal origin, cardiac failure, and atrial fibrillation with multiple pulmonary He had been treated with digoxin, diuretics, and emboli. potassium supplements and, since 1966, with methyldopa as an outpatient, but he required admission on 6 occasions during this period for recurrent cardiac failure and, in 1970, for hypokalsmia. Two notes in his outpatient records, made in 1970 and 8 months before the present admission, indicated that he did not take his tablets reliably at home. Prescriptions for methyldopa in increasing dosage during this time suggest that either his hypertension was becoming worse or that he was not taking the
prescribed
Pharmacy, St. Thomas’s Hospital, London SE1.
K. C. STEAD.
VITAMIN A AND SEASONAL VARIATION
SIR,-Sinha and Bang reported seasonal variation in the symptoms children.1
of vitamin-A
in
deficiency
West
Bengali
We have studied seasonal variations in the serumvitamin-A levels of women resident in London. These findings were incidental to a recently completed comprehensive survey on the role of vitamin A in human reproduction 2-5 and teratology.6 Seasonal variation in serumvitamin-A was analysed because vitamin-A deficiency7 or 8 is teratogenic in animals and there is some indicaexcess tion that human congenital malformations show a seasonal variation.9 Analyses of variance were carried out on the serumvitamin-A and carotenoid levels of five groups of women to see whether there were any seasonal differences. Group SEASONAL VARIATIONS IN MEAN VITAMIN-A AND CAROTENOID LEVELS
treatment.
On this occasion because of his apparent suicide attempt the ambulance staff who brought the patient to hospital collected a large number of tablet bottles from his home and returned these to the hospital pharmacy. In all, 46 bottles containing 10,685 tablets were handed in. The numbers of particular tablets, in descending order, were as follows:
Methyldopa (250 mg.) Slow-K Frusemide (40
......
..........
mg.) Digoxin (0-25 mg.) Amiloride (5 mg.) Paracetamol (0-5 g.) Spironolactone (25 mg.) Effervescent K Inositol
......
......
......
......
......
......
nicotinate (500 mg.) Dihydrocodeine (30 mg.) ’
Moduretic
....
....
........
Tetracycline (250 mg.)
......
Unidentified Total........
........
5954 3123 567 347 298 95 67 62 59 41 40 31 1
10,685
The estimated present cost of these tablets, as dispensed from the hospital pharmacy, is E125. For a number of 1. 2. 3. 4.
S. E. SMITH.
Porter, A. M. W. Br. med. J. 1969, i, 218. Steward, R. B., Cluff, L. E. Clin. Pharmac. Ther. 1972, 13, 463. Blackwell, B. ibid. p. 841. Nicholson, W. A. Br. med. J. 1967, iii, 730.
v
i
Vit. A=Vitamin A
n
i
(Lg.1 100 ml.).
n
i
n
i
Car.=Carotenoids (!j.g./100 ml.).
100
randomly selected, healthy, non-pregnant Group 11 was 400 women at randomly selected stages of pregnancy (the stage of pregnancy did not have a significant influence); group ill was 48 women in the first
I
was
women.
trimester of pregnancy; group iv was 2 non-pregnant women who provided serial trimonthly blood-samples throughout one year; and group v was 74 women on the sixth day post partum after giving birth to a baby with Sinha, D. P., Bang, F. B. Lancet, 1973, ii, 228. Gal, I., Parkinson, C. E., Craft, I. Br. med. J. 1971, ii, 436. Gal, I., Parkinson, C. E. Int. J. Vit. Nutr. Res. 1972, 42, 4, 565. Gal, I., Parkinson, C. E. Contraception, 1973, 8, 1, 13. Gal, I., Parkinson, C. E. Am. J. clin. Nutr. (in the press). Gal, I., Sharman, I. M., Pryse-Davis, J. in Advances in Teratology (edited by D. H. M. Woollam); vol. 5, chap. 6. London, 1972. 7. Hale, F. J. Hered. 1933, 24, 105. 8. Cohlan, S. Q. Science, 1953, 117, 535. 9. McKeown, T., Record, R. G. Lancet, 1951, i, 192.
1. 2. 3. 4. 5. 6.
it is not possible to calculate the extent to which patient conformed to his treatment regimens over the
tract infections
reasons
ampicillin.
this
per ml. of ampicillin or less. The organism reported here seems to be of doubtful clinical significance in this patient. However, it is of interest if it represents a recent development of such strains in the community, perhaps secondary to the widespread use of ampicillin. It may also need to be considered in the treatment of chronic bronchitic patients who often suffer infections due to H. influenzae and for whom the treatment of choice at the moment is ampicillin or
amoxycillin.
King’s College Hospital Medical School, Denmark Hill,
ELIZABETH PRICE PAUL A. BOSWELL.
London SE5 8RX.
years.
Though the sum total of unconsumed tablets in this is astounding, it is perhaps not surprising that the patient failed to conform to his treatment regimen. Analysis of the prescriptions issued reveals that over a period of 17 months he was expected to take 27 tablets daily; four preparations were involved, each with different instructions. For a shorter period his consumption should have been 32 tablets daily. With such requirements perhaps only those with obsessional traits would comply. It seems unwise, particularly for the elderly, to prescribe in such a manner that compliance with the doctor’s instructions is unlikely. With resuscitation this patient recovered and he was discharged home after three weeks. Medication was prescribed again as before. case
Department of Pharmacology, St. Thomas’s Hospital Medical School.
NON-COMPLIANCE OR MIS-PRESCRIBING ? studies have revealed that patients do not always take medicines as prescribed by the doctor.1 Such non-compliance, which has been the subject of reviews, 2,3 is probably commoner than many of us believe, at least judging from the number of unwanted tablets and capsules which have been recovered from patients’ homes.4 Failure to take drugs is particularly associated with advanced age, with prolonged and complex prescribing, and with drugs which produce unpleasant side-effects. It is both a cause of treatment failure and a source of wasted effort, time, and
SIR,-Many
money.
We report here a case of non-compliance which struck us forcibly and from which an old lesson can be relearned. A 71-year-old bachelor was admitted to the intensive-care ward at this hospital on Nov. 4, 1973. He had been found unconscious in bed at home with three open empty bottles labelled nitrazepam by his bedside. He had been extensively investigated in the past 9 years for hypertension, polycythaemia thought to be of renal origin, cardiac failure, and atrial fibrillation with multiple pulmonary He had been treated with digoxin, diuretics, and emboli. potassium supplements and, since 1966, with methyldopa as an outpatient, but he required admission on 6 occasions during this period for recurrent cardiac failure and, in 1970, for hypokalsmia. Two notes in his outpatient records, made in 1970 and 8 months before the present admission, indicated that he did not take his tablets reliably at home. Prescriptions for methyldopa in increasing dosage during this time suggest that either his hypertension was becoming worse or that he was not taking the
prescribed
Pharmacy, St. Thomas’s Hospital, London SE1.
K. C. STEAD.
VITAMIN A AND SEASONAL VARIATION
SIR,-Sinha and Bang reported seasonal variation in the symptoms children.1
of vitamin-A
in
deficiency
West
Bengali
We have studied seasonal variations in the serumvitamin-A levels of women resident in London. These findings were incidental to a recently completed comprehensive survey on the role of vitamin A in human reproduction 2-5 and teratology.6 Seasonal variation in serumvitamin-A was analysed because vitamin-A deficiency7 or 8 is teratogenic in animals and there is some indicaexcess tion that human congenital malformations show a seasonal variation.9 Analyses of variance were carried out on the serumvitamin-A and carotenoid levels of five groups of women to see whether there were any seasonal differences. Group SEASONAL VARIATIONS IN MEAN VITAMIN-A AND CAROTENOID LEVELS
treatment.
On this occasion because of his apparent suicide attempt the ambulance staff who brought the patient to hospital collected a large number of tablet bottles from his home and returned these to the hospital pharmacy. In all, 46 bottles containing 10,685 tablets were handed in. The numbers of particular tablets, in descending order, were as follows:
Methyldopa (250 mg.) Slow-K Frusemide (40
......
..........
mg.) Digoxin (0-25 mg.) Amiloride (5 mg.) Paracetamol (0-5 g.) Spironolactone (25 mg.) Effervescent K Inositol
......
......
......
......
......
......
nicotinate (500 mg.) Dihydrocodeine (30 mg.) ’
Moduretic
....
....
........
Tetracycline (250 mg.)
......
Unidentified Total........
........
5954 3123 567 347 298 95 67 62 59 41 40 31 1
10,685
The estimated present cost of these tablets, as dispensed from the hospital pharmacy, is E125. For a number of 1. 2. 3. 4.
S. E. SMITH.
Porter, A. M. W. Br. med. J. 1969, i, 218. Steward, R. B., Cluff, L. E. Clin. Pharmac. Ther. 1972, 13, 463. Blackwell, B. ibid. p. 841. Nicholson, W. A. Br. med. J. 1967, iii, 730.
v
i
Vit. A=Vitamin A
n
i
(Lg.1 100 ml.).
n
i
n
i
Car.=Carotenoids (!j.g./100 ml.).
100
randomly selected, healthy, non-pregnant Group 11 was 400 women at randomly selected stages of pregnancy (the stage of pregnancy did not have a significant influence); group ill was 48 women in the first
I
was
women.
trimester of pregnancy; group iv was 2 non-pregnant women who provided serial trimonthly blood-samples throughout one year; and group v was 74 women on the sixth day post partum after giving birth to a baby with Sinha, D. P., Bang, F. B. Lancet, 1973, ii, 228. Gal, I., Parkinson, C. E., Craft, I. Br. med. J. 1971, ii, 436. Gal, I., Parkinson, C. E. Int. J. Vit. Nutr. Res. 1972, 42, 4, 565. Gal, I., Parkinson, C. E. Contraception, 1973, 8, 1, 13. Gal, I., Parkinson, C. E. Am. J. clin. Nutr. (in the press). Gal, I., Sharman, I. M., Pryse-Davis, J. in Advances in Teratology (edited by D. H. M. Woollam); vol. 5, chap. 6. London, 1972. 7. Hale, F. J. Hered. 1933, 24, 105. 8. Cohlan, S. Q. Science, 1953, 117, 535. 9. McKeown, T., Record, R. G. Lancet, 1951, i, 192.
1. 2. 3. 4. 5. 6.