Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

The case notes of 24 children diagnosed as elective mutes were compared with those of 24 matched controls with diagnosed emotional disorders. One-third of the elective mutes (but none of the controls) had experienced delayed development of speech or difficulties in articulation. All the elective mutes lived in two-parent families, but marital discord was noted in half the families in both groups. Compared with the controls, the mute children were more often described as 'anxious', 'depressed' and 'manipulative', and their mothers were characterised as 'over-protective', and tending to 'spoil' their children. Three unusual cases, of mutism at home, are described in detail. It is proposed that elective mutism is associated with particular personal and family characteristics and represents a condition different from any recognised emotional disorder.

That adults with mental handicap∗ are particularly vulnerable to sexual exploitation is not new, although relatively unacknowledged or investigated. Indeed successive acts under the mental health legislation have sought to protect them, particularly those with severe mental handicap. With the growing awareness and identification of sexual abuse of children, and the growing knowledge of the long-term psychological effects (Jehu, 1989), which may be even more severe for people who have disabilities (Kennedy, 1990; Sinason, 1989), it has been acknowledged that not only are the mentally handicapped particularly vulnerable to abuse (Benedict et al, 1990), but the problem may well be seriously underestimated by those working in management positions (Brown & Craft, 1989). While it is recognised that the mentally handicapped have rights and need to express their sexuality, they also have the right not to be exploited or abused. We therefore need to know more about the numbers, indicators and circumstances where this group may be sexually abused and to develop policies, systems and training to protect them (Brown & Craft, 1989). This pilot study was a step in this process.

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Although the percentage of mothers believing they can recognize pneumonia through rapid breathing and chest retraction seems to have increased in recent years, there is still a sizable percentage of mothers who remain uninformed about pneumonia and its possible fatal consequences. Efforts need to continue to educate Peruvian mothers about the causes, recognition of the signs, and treatment of pneumonia. The results suggest that the Government of Peru pneumonia campaign should use television much more, as well as the health centers, where most of the mothers receive medical attention and health information.