Complete Adherence Research Articles

What is the effect of regular group exercise on maternal psychological outcomes and common pregnancy complaints? An assessor blinded RCT

Objectiveto examine the effects of supervised group exercise on maternal psychological outcomes and commonly reported pregnancy complaints. Designan observer-blinded randomized controlled trial. SettingNorwegian School of Sport Sciences, Oslo, Norway. Participants105 sedentary, nulliparous pregnant women, mean age 30.7(±4.0) years, pre-pregnancy BMI 23.8 (±4.3), were assigned to either exercise (n=52) or control group (n= 53) at mean gestation week 17.7 (±4.2). Interventionthe exercise intervention followed ACOG guidelines and included a 60 minutes general fitness class, with 40 minutes of endurance training/aerobic and 20 minutes of strength training and stretching/relaxation, performed at least twice per week for a minimum of 12 weeks. Measurementsoutcome measures were assessed through standardized interviews pre- and post-intervention (gestation week 36.6, ±0.9), and included psychological variables related to quality of life, well-being, body image and pregnancy depression, as well as assessment of 13 commonly reported pregnancy complaints. Findingspost-intervention, using intention to treat (ITT) analysis, women randomized to exercise rated their health significantly better compared to women in the control group (p=0.02) and reported less fatigue related to everyday activities (p=0.04). Women with complete exercise adherence (≥24 sessions) had significantly better scores on measurements of feelings related to sadness, hopelessness and anxiety (p<0.01), compared to the control group. Contradictory, the control group reported higher life enjoyment (p<0.01). There were no significant group differences in body-image or pregnancy depression. With respect to analysing pregnancy complaints according to ITT, no differences between the groups were found. A comparison of the women who attended ≥19 (80%, n=21) or ≥24 (100%, n=14) exercise sessions with the control-participants, showed that fewer women in the exercise group reported nausea/vomiting and numbness/poor circulation in legs. Key conclusion and implication for practiseparticipation in regular group exercise during pregnancy contributed to improvements in some variables related to maternal well-being and quality of life. Women with high exercise adherence had significantly better results on several health variables reaping the highest benefits. A qualitative study exploring the barriers of women in achieving recommended amount of activity may be necessary to understand this population and developing better clinical practice educational tools.

WHO guidelines for a healthy diet and mortality from cardiovascular disease in European and American elderly: the CHANCES project

Background: Cardiovascular disease (CVD) represents a leading cause of mortality worldwide, especially in the elderly. Lowering the number of CVD deaths requires preventive strategies targeted on the elderly.Objective: The objective was to generate evidence on the association between WHO dietary recommendations and mortality from CVD, coronary artery disease (CAD), and stroke in the elderly aged ≥60 y.Design: We analyzed data from 10 prospective cohort studies from Europe and the United States comprising a total sample of 281,874 men and women free from chronic diseases at baseline. Components of the Healthy Diet Indicator (HDI) included saturated fatty acids, polyunsaturated fatty acids, mono- and disaccharides, protein, cholesterol, dietary fiber, and fruit and vegetables. Cohort-specific HRs adjusted for sex, education, smoking, physical activity, and energy and alcohol intakes were pooled by using a random-effects model.Results: During 3,322,768 person-years of follow-up, 12,492 people died of CVD. An increase of 10 HDI points (complete adherence to an additional WHO guideline) was, on average, not associated with CVD mortality (HR: 0.94; 95% CI: 0.86, 1.03), CAD mortality (HR: 0.99; 95% CI: 0.85, 1.14), or stroke mortality (HR: 0.95; 95% CI: 0.88, 1.03). However, after stratification of the data by geographic region, adherence to the HDI was associated with reduced CVD mortality in the southern European cohorts (HR: 0.87; 95% CI: 0.79, 0.96; I2 = 0%) and in the US cohort (HR: 0.85; 95% CI: 0.83, 0.87; I2 = not applicable).Conclusion: Overall, greater adherence to the WHO dietary guidelines was not significantly associated with CVD mortality, but the results varied across regions. Clear inverse associations were observed in elderly populations in southern Europe and the United States.

Use and overuse of proton pump inhibitors

In 2009, an editorial by Putman focused on the dramatic increase in the use of proton pump inhibitors (PPIs) in infants [1]. Considering the increasing evidence that PPIs offer little benefit for most of the symptoms for which they are prescribed, Putman strongly highlighted the need for a serious effort to curtail their empiric use. The editorial was linked to a study by Orenstein et al, which detected no difference in efficacy between lansoprazole and placebo for symptoms attributed to gastroesophageal reflux disease (GERD) in infants [2]. A very recent review on the effects of PPIs on irritability and crying in infants confirmed the conclusion that these drugs do not offer relief from these symptoms for which they are commonly prescribed [3]. After all, it has recently been pointed out that volume rather than acid is often the key promoter of reflux-associated symptoms in infants. Distension-induced increase in gastric wall tension has been associated with high rates of transient lower esophageal sphincter relaxations and is considered one of the main mechanisms contributing to postprandial GER [4]. Despite all these evidences on PPIs uneffectiveness for many of the symptoms for which they are commonly prescribed, the rate of their prescriptions have exponentially increased over the last years. The latest combined NASPGHAN/ESPGHAN guidelines already in 2009 highlighted the need to distinguish physiologic GER events from GERD, limiting for the latter the use of PPIs [5]. However, a 2012 European survey carried out by our study group showed that only 1.8% of pediatricians reported a complete adherence to the guideline recommendations in their clinical practice. The most relevant violation of the guideline recommendations concerned the prescription of unnecessary acid suppressive medications [6] (Figure ​(Figure1).1). In order to inquire into the reasons why pediatricians did not follow the guideline recommendations, we performed another trial with the same pediatricians undergoing specific training on the guidelines being supervised in their clinical practice. As a result, trained pediatricians showed a significantly higher compliance with the international guidelines and infants with unexplained crying and distressed behaviour or with uncomplicated recurrent regurgitation and vomiting who were unproperly prescribed PPIs decreased dramatically [7]. Besides these data on PPI overuse, recent studies highlighted the occurrence of several adverse effects related to their assumption, such as a higher risk of bronchoalveolar lavage culture positivity and gastric bacterial overgrowth, food allergy, Clostridium difficile infection, gastric polyps and nodules [8-12]. Figure 1 Rates of pediatricians over-prescribing PPIs in the different European countries

HIV prevalence, sexual behaviours and engagement in HIV medical care among an online sample of sexually active MSM in Venezuela.

In Venezuela, members of a social and sexual partner networking site for men who have sex with men (MSM) completed an online survey regarding sexual behaviours and HIV medical care. Among the 2851 respondents, self-reported HIV prevalence was 6.6%. Of participants living with HIV, 73.2% reported taking antiretroviral medication and 56.6% reported complete adherence within the past month. Participants living with HIV were more likely to be older (aOR = 1.04 per one-year increase in age, 95% CI: 1.02, 1.06) and diagnosed with a sexually transmitted infection in the previous year (aOR 3.26, 95% CI: 2.11, 5.04). These data provide further understanding of the HIV epidemic among MSM in Venezuela, and potential targets for HIV prevention interventions.

Psychiatric aspects of organ transplantation and donation.

Psychiatrists and other mental health professionals typically assist with evaluating and treating psychiatric and behavioral issues in transplant candidates, recipients, and living organ donors. In this review recent findings on specific psychiatric issues in adult solid organ transplant candidates and recipients, as well as living donors are discussed as well as their relevance to clinical practice. Patients with complex mental health and addiction histories can have outcomes similar to patients without these disorders but may require specialized pretransplant preparation or posttransplant interventions to optimize their outcomes. Specific attention to the preparation and wellbeing of living donors is needed. As transplant programmes increasingly consider patients with complex mental health histories, psychiatrists, and mental health professionals evaluating and treating these patients need to consider plans for early identification and treatment. Psychiatric care provided across the preoperative to postoperative periods will best address the longitudinal care needs of patients with mental health disorders. Abstinence from substances and complete adherence to medical directives provides the best chance for optimal outcomes. Treatment of depression may improve transplant outcomes. Research is needed to identify effective interventions and the best strategies to engage patients to improve adherence. http://links.lww.com/YCO/A30.

Blood pressure reductions following catheter-based renal denervation are not related to improvements in adherence to antihypertensive drugs measured by urine/plasma toxicological analysis.

Renal denervation can reduce blood pressure in patients with uncontrolled hypertension. The adherence to prescribed antihypertensive medication following renal denervation is unknown. This study investigated adherence to prescribed antihypertensive treatment by liquid chromatography-high resolution tandem mass spectrometry in plasma and urine at baseline and 6months after renal denervation in 100 patients with resistant hypertension, defined as baseline office systolic blood pressure ≥140mmHg despite treatment with ≥3 antihypertensive agents. At baseline, complete adherence to all prescribed antihypertensive agents was observed in 52 patients, 46 patients were partially adherent, and two patients were completely non-adherent. Baseline office blood pressure was 167/88±19/16mmHg with a corresponding 24-h blood pressure of 154/86±15/13mmHg. Renal denervation significantly reduced office and ambulatory blood pressure at 6-month follow-up by 15/5mmHg (p<0.001/p<0.001) and 8/4mmHg (p<0.001/p=0.001), respectively. Mean adherence to prescribed treatment was significantly reduced from 85.0% at baseline to 80.7%, 6months after renal denervation (p=0.005). The blood pressure decrease was not explained by improvements in adherence following the procedure. Patients not responding to treatment significantly reduced their drug intake following the procedure. Adherence was highest for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and beta blockers (>90%) and lowest for vasodilators (21%). In conclusion, renal denervation can reduce office and ambulatory blood pressure in patients with resistant hypertension despite a significant reduction in adherence to antihypertensive treatment after 6months.

Confocal fluorescence microscopy: An ultra-sensitive tool used to evaluate intracellular antiretroviral nano-drug delivery in HeLa cells.

In the last decade, confocal fluorescence microscopy has emerged as an ultra-sensitive tool for real-time study of nanoparticles (NPs) fate at the cellular-level. According to WHO 2007 report, Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is still one of the world's major health threats by claiming approximately 7,000 new infections daily worldwide. Although combination antiretroviral drugs (cARV) therapy has improved the life-expectancy of HIV-infected patients, routine use of high doses of cARV has serious health consequences and requires complete adherence to the regimen for success. Thus, our research goal is to fabricate long-acting novel cARV loaded poly(lactide-co-glycolic acid) (PLGA) nanoparticles (cARV-NPs) as drug delivery system. However, important aspects of cARV-NPs that require special emphasis are their cellular-uptake, potency, and sustained drug release efficiency over-time. In this article, ultra-sensitive confocal microscopy is been used to evaluate the uptake and sustained drug release kinetics of cARV-NPs in HeLa cells. To evaluate with the above goal, instead of cARV-drug, Rhodamine6G dye (fluorescent dye) loaded NPs (Rho6G NPs) have been formulated. To correlate the Rhodamin6G release kinetics with the ARV release from NPs, a parallel HPLC study was also performed. The results obtained indicate that Rho6G NPs were efficiently taken up at low concentration (<500 ng/ml) and that release was sustained for a minimum of 4 days of treatment. Therefore, high drug assimilation and sustained release properties of PLGA-NPs make them an attractive vehicle for cARV nano-drug delivery with the potential to reduce drug dosage as well as the number of drug administrations per month.

Infant Safe Sleep Interventions, 1990-2015: A Review.

Sleep-related infant deaths remain a major public health issue. Multiple interventions have been implemented in efforts to increase adherence to safe sleep recommendations. We conducted a systematic review of the international research literature to synthesize research on interventions to reduce the risk of sleep-related deaths and their effectiveness in changing infant sleep practices. We searched PubMed, CINAHL, PsycINFO, and Google Scholar for peer-reviewed articles published between 1990 and 2015 which described an intervention and reported results. Twenty-nine articles were included for review. Studies focused on infant caregivers, health care professionals, peers, and child care professionals. Targeted behaviors included sleep position, location, removing items from the crib, breastfeeding, smoke exposure, clothing, pacifier use, and knowledge of Sudden Infant Death Syndrome. Most articles described multi-faceted interventions, including: one-on-one or group education, printed materials, visual displays, videos, and providing resources such as cribs, pacifiers, wearable blankets, and infant t-shirts. Two described public education campaigns, one used an educative questionnaire, and one encouraged maternal note taking. Health professional interventions included implementing safe sleep policies, in-service training, printed provider materials, eliciting agreement on a Declaration of Safe Sleep Practice, and sharing adherence data. Data collection methods included self-report via surveys and observational crib audits. Over half of the studies utilized comparison groups which helped determine effectiveness. Most articles reported some degree of success in changing some of the targeted behaviors; no studies reported complete adherence to recommendations. Future studies should incorporate rigorous evaluation plans, utilize comparison groups, and collect demographic and collect follow-up data.

The effect of EUSOMA certification on quality of breast cancer care

Aim of the studyThe European Society of Breast Cancer Specialists (EUSOMA) has fostered a voluntary certification process for breast units to establish minimum standards and ensure specialist multidisciplinary care. In the present study we assess the impact of EUSOMA certification for all breast units for which sufficient information was available before and after certification. Materials and methodsFor 22 EUSOMA certified breast units data of 30,444 patients could be extracted from the EUSOMA database on the evolution of QI's before and after certification. ResultsOn the average of all units, the minimum standard of care was achieved for 12/13 QI's before and after EUSOMA certification (not met for DCIS receiving just one operation). There was a significant improvement of 5 QI's after certification. The proportion of patients with invasive cancer undergoing an axillary clearance containing >9 lymph nodes (91.5% vs 89.4%, p 0.003) and patients with invasive cancer having just 1 operation (83.1% vs 80.4%, p < 0.001) dropped, but remained above the minimum standard. The targeted standard of breast care was reached for the same 4/13 QI's before and after EUSOMA certification. ConclusionAlthough the absolute effect of EUSOMA certification was modest it further increases standards of care and should be regarded as part of a process aiming for excellence. Dedicated units already provide a high level of care before certification, but continuous monitoring and audit remains of paramount importance as complete adherence to guidelines is difficult to achieve.

Efficacy of human amniotic membrane and collagen in maxillofacial soft tissue defects – A comparative clinical study

ObjectiveManagement of traumatic facial soft tissue injury poses a major challenge for surgeons due to aesthetic concerns. Human amniotic membrane (AM) and collagen membrane (CM), biologic materials, have attained importance in various clinical fields, especially in wound healing. Though both materials have their own unique properties, there is a need to compare and evaluate the efficacy of AM and CM as a wound dressing material for post-traumatic soft tissue injuries of the maxillofacial region. MethodsA study was conducted in Department of Oral And Maxillofacial Surgery, at our institution which encompassed all the patients (total of 20 patients) with facial soft tissue injuries (abrasions), due to road traffic accidents from January 2014 to March 2014. They were randomly divided into two groups, with 10 patients treated with AM and 10 patients treated with CM. The groups were compared according to the wound compliance, time taken for granulation tissue formation and scarring. ResultsIt was observed that the pain score was much higher in Collagen group than in Amnion group and complete adherence of the membrane to the wound was detected in both the groups. A statistically significant result in favour of AM was found with regard to average time taken for granulation tissue formation (P=0.036) and the resultant scarring. Incidence of wound infection was reported in two cases in Collagen group. ConclusionWhen compared to Collagen, AM had good adhesive, antibacterial, anti-immunogenic and anti-scarring property. Its low cost of procurement and storage makes it an ideal wound dressing material.

Systematic Information to Health-Care Professionals about Vaccination Guidelines Improves Adherence in Patients With Inflammatory Bowel Disease in Anti-TNFα Therapy.

Implementation of guidelines for prevention of infectious diseases during anti-TNFα therapy in patients with inflammatory bowel disease (IBD) is important but difficult. We investigated whether systematic information to health-care professionals about these guidelines improves patients' adherence. The study comprised three parts: (1) cross-sectional evaluation of baseline vaccination status in all IBD patients in anti-TNFα therapy (reference group; n=130); (2) prospective interventional study, where health-care professionals received systematic oral and written information about vaccination guidelines at baseline and at 2-month intervals for 6 months, followed by reassessment of vaccination status (intervention group; n=99); (3) cross-sectional evaluation of representative gastroenterologists' knowledge of guidelines (n=53). Outcomes were assessed by validated questionnaires. Patients' adherence to vaccination guidelines increased significantly after a period of systematic information to health-care professionals. Hence, complete adherence increased from 5 to 26%, partial adherence from 38 to 56%, and complete non-adherence decreased from 57 to 18% (P<0.0001). Adherence to all individual vaccinations except human papilloma virus increased significantly (P≤0.0021). Improvement was independent of disease type and anti-TNFα agent. At baseline, only 8% of physicians could identify all elements in the reference guideline. Additional barriers reported by physicians were forgetfulness (32%) and insufficient consultation time (26%). Patient-perceived barriers were costs of vaccinations (35%) and forgetfulness (25%). Gastroenterologists' limited knowledge of vaccination guidelines during anti-TNFα therapy can be overcome by systematic education of health-care professionals. This inexpensive and easily accessible intervention immediately results in markedly improved patient adherence. Remaining obstacles for adherence comprise high vaccination costs and forgetfulness.

Affective tone in medical encounters and its relationship with treatment adherence in a multiethnic cohort of patients with rheumatoid arthritis.

Tone of voice in communication between patients and rheumatologists may offer insight into problems of treatment adherence in patients with rheumatoid arthritis. The aim of this study was to evaluate physician-patient affective vocal tone within the medical encounter and its relationship to treatment adherence in ethnically diverse patients with rheumatoid arthritis. The consultations of 174 patients with rheumatoid arthritis were audio recorded at a baseline visit. Of these, 135 completed follow-up adherence measures at 3 months. The positive and negative affective tones of patients, physicians, and interpreters (and distressed tones of patients and interpreters) were assessed using the Roter Interaction Analysis System affective communication scale. Treatment adherence was evaluated at baseline and at 3 months using the Compliance Questionnaire Rheumatology. A total of 117 baseline consultations were in English (n = 42, 36, and 39 white, African American, and Hispanic patients, respectively), 24 in Spanish, and 33 with an interpreter (total = 174). Patients reporting poorer adherence were rated as having more distressed affect and less positive affect than patients reporting greater adherence. Physicians expressed more positive affect to more educated patients. Physicians and patients reciprocated one another's positive and negative affect. Controlling for baseline adherence, physician negative affect predicted greater adherence at 3 months for Hispanic patients, regardless of language choice, compared with white patients. Patients' affective tones offer clues to problems patients may have with treatment adherence and well-being. More research is needed regarding why physicians' expression of negative affect may facilitate adherence for some groups of patients.

PTU-323 Cost effective resourcing of a colitis chromoendoscopy service from implementing new bsg barrett’s surveillance guidelines

Introduction Pan-colonic chromendoscopy (CE) is the gold standard for colitis surveillance. High quality procedures can reduce histology costs but require greater expertise but also additional time, estimated at 1 endoscopy slot per procedure. These, together with a competing rise in endoscopy demand have hindered the extra resource allocation for its widespread implementation. New BSG Barrett’s oesophagus (BO) surveillance guidelines have changed from previously biennial to lengthened surveillance intervals depending on an individual’s maximal BO length. The aim of this study was to model the reduction in endoscopic demand in our surveillance cohort after adoption of the new 2014 BSG guidelines and to determine whether sufficient capacity can be created to fully resource a dedicated CE service. Method A retrospective analysis of all BO patients at York Hospital in 5 years between 2009 and 2013 was performed. The endoscopy and histology costs based on complete adherence to old BO guidelines were calculated on an annualised basis. Patients were split into 3 groups: those who did not have IM and could be discharged; those with short ( Results Between 2009 and 2013, 453 BO surveillance patients, according to old BSG guidelines would require a mean of 227 OGDs per annum (p.a.). Based on current NHS tariffs and combined with associated histology costs, this would equate to £123,443 p.a. Seven (4.4%) patients had no evidence of IM and according to new BSG guidelines could potentially be discharged; 112 (24.7%) had short BO and 321 (70.9%) had long BO. Maximising their surveillance intervals would result in 128 surveillance OGDs and £69,940 in combined costs, thus freeing up a mean of 98 endoscopy slots p.a. with an overall annual cost saving of £53,503. Over the same period a mean of 92 surveillance colonoscopies were carried out for colitis with estimated histology costs of £18,400 p.a. Adopting Chromoendoscopy with targeted biopsies would reduce histology costs to £6,900, saving £11,500 per year. Conclusion The provision of extra endoscopy capacity for CE can almost entirely be met by adoption of the new BSG BO surveillance guidelines. Furthermore, the combined approach yields an overall net histology cost saving of around £14,000 p.a. These cost analyses should support individual NHS Trust’s business cases for the widespread implementation of CE. Disclosure of interest None Declared.

Endocrine therapy adherence: a cross-sectional study of factors affecting adherence and discontinuation of therapy.

Adjuvant endocrine therapy for at least 5years improves oncological outcomes in oestrogen receptor-positive breast cancer. Adherence rates to prescribed endocrine therapy are low and the search for modifiable causes of this continues. The aim of this study was to assess adherence rates in an Irish cohort of breast cancer patients prescribed adjuvant endocrine therapy and to assess modifiable factors associated with suboptimal adherence. A cross-sectional anonymous survey was performed on 261 patients currently prescribed endocrine therapy. Data were collected regarding demographics, treatment, social and emotional factors and medication side effects. Each patient completed a medication adherence score and provided information about discontinuation of therapy and reasons for same. Only 67.8% of patients assessed demonstrated complete medication adherence on the medication adherence scale. Twenty-nine patients (10.9%) permanently stopped taking their prescribed endocrine therapy. Suboptimal adherence was more likely in younger patients (p<0.001), those in employment (p=0.005), those who experienced side effects (p=0.006), those who perceived themselves to have low levels of emotional support (p<0.001) and those who use the internet to read about their illness (p=0.003). Endocrine therapy adherence is suboptimal in almost one-third of patients in our cohort. Appropriate assessment and management of side effects and negative emotions, combined with direction of patients to accurate internet sources of information, could help improve endocrine therapy adherence in women with early-stage breast cancer.

A Health Economic Evaluation of Stroke Prevention in Atrial Fibrillation: Guideline Adherence Versus the Observed Treatment Strategy Prior to 2012 in Denmark.

In 2012 the European Society of Cardiology (ESC) published new guidelines on pharmacological stroke prophylaxis in non-valvular atrial fibrillation (AF). The health economics of adhering to these guidelines in clinical practice remains to be elucidated. This paper offers a health economic evaluation of two stroke-prophylactic treatment strategies: complete national adherence to the ESC guidelines on stroke prophylaxis in AF versus stroke-prophylactic treatment prior to 2012 in Denmark. A cost-utility analysis was performed to compare two treatment strategies. The first strategy reflected national guideline adherence with the use of non-vitamin K antagonist oral anticoagulants (i.e. dabigatran etexilate), warfarin, and no treatment. The second strategy reflected observed stroke prophylaxis prior to 2012 with the utilization of warfarin, acetylsalicylic acid, and no treatment. A Danish health sector perspective was adopted. A Markov model was designed and populated with information on input parameters from the literature and local cost data reflecting 2014 values. A modeled patient cohort was constructed with a risk profile intended to reflect that of the Danish patient population with AF. The applied outcome was quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio amounted to <euro>3557 per QALY for the guideline-adherent treatment strategy (GTS) compared with the pre-2012 treatment strategy. This ratio is below a threshold of <euro>25,000 (£20,000) per QALY. Sensitivity analyses revealed that the result was largely robust to changes in input parameters. All analyses found the GTS to be cost effective. Guideline adherence is a cost-effective treatment strategy compared with the strategy employed prior to 2012 for pharmacological stroke prophylaxis in AF.

Novel Approaches for Visualizing and Analyzing Dose-Timing Data from Electronic Drug Monitors, or "How the 'Broken Window' Theory Pertains to ART Adherence".

Adherence to antiretroviral medications is usually expressed in terms of the proportion of doses taken. However, the timing of doses taken may also be an important dimension to overall adherence. Little is known about whether patients who mistime doses are also more likely to skip doses. Using data from the completed Adherence for Life randomized controlled trial, we created visual and statistical models to capture and analyze dose timing data collected longitudinally with electronic drug monitors (EDM). From scatter plots depicting dose time versus calendar date, we identified dominant patterns of dose taking and calculated key features [slope of line over calendar date; residual mean standard error (RMSE)]. Each was assessed for its ability to categorize subjects with 'sub-optimal' (<95% of doses taken) using area under the receiver operating characteristic (AROC) curve analysis. Sixty eight subjects contributed EDM data, with ~300 to 400 observations/subject. While regression line slopes did not predict 'sub-optimal' adherence (AROC 0.51, 95% CI 0.26-0.75), the variability in dose timing (RMSE) was strongly predictive (AROC 0.79, 95% CI 0.62-0.97). Compared with the lowest quartile of RMSE (minimal dose time variability), each successive quartile roughly doubled the odds of 'sub-optimal' adherence (OR 2.1, 95% CI 1.3-3.4). Patterns of dose timing and mistiming are strongly related to overall adherence behavior. Notably, individuals who skip doses are more likely to mistime doses, with the degree of risk positively correlated with the extent of dose timing variability.

Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

BackgroundAn increase in multidrug-resistant tuberculosis (MDR-TB) cases is evident worldwide. Its management implies a complex treatment, high costs, more toxic anti-tuberculosis drug use, longer treatment time and increased treatment failure and mortality. The aims of this study were to compare mortality between MDR and drug-susceptible cases of tuberculosis, and to determine risk factors associated with mortality among MDR-TB cases.Methods and ResultsA retrospective cohort study was performed using data from clinical records of the National Strategy for Prevention and Control of Tuberculosis in Lima, Peru. In the first objective, MDR-TB, compared to drug-susceptible cases, was the main exposure variable and time to death, censored at 180 days, the outcome of interest. For the second objective, different variables obtained from clinical records were assessed as potential risk factors for death among MDR-TB cases. Cox regression analysis was used to determine hazard ratios (HR) and 95% confidence intervals (95%CI). A total of 1,232 patients were analyzed: mean age 30.9 ±14.0 years, 60.0% were males. 61 patients (5.0%) died during treatment, whereas the MDR-TB prevalence was 19.2%. MDR-TB increased the risk of death during treatment (HR = 7.5; IC95%: 4.1–13.4) when compared to presumed drug-susceptible cases after controlling for potential confounders. Education level (p = 0.01), previous TB episodes (p<0.001), diabetes history (p<0.001) and HIV infection (p = 0.04) were factors associated with mortality among MDR-TB cases.ConclusionsMDR-TB is associated with an increased risk of death during treatment. Lower education, greater number of previous TB episodes, diabetes history, and HIV infection were independently associated with mortality among MDR-TB cases. New strategies for appropriate MDR-TB detection and management should be implemented, including drug sensitivity tests, diabetes and HIV screening, as well as guarantee for a complete adherence to therapy.

Adherence to guidelines for the prescription of secondary prevention medication at hospital discharge after acute coronary syndrome: a multicentre study.

BackgroundThe prescription of guideline-recommended medication for secondary prevention after acute coronary syndrome has been suboptimal in the past. In the present study, guideline adherence and associated patient, care and hospital characteristics at hospital discharge after acute coronary syndrome were studied.MethodsCharts of patients with acute coronary syndrome discharged from 13 Dutch hospitals in 2012 were reviewed. Guideline adherence was defined as the prescription of acetylsalicylic acid, P2Y12 receptor inhibitor, statin, beta-blocker and angiotensin-converting enzyme (ACE) inhibitor at discharge, or a documented contraindication. Associated characteristics were identified by means of generalized linear mixed models for binary outcomes.ResultsIn total, 2471 patients were included. Complete guideline adherence was achieved in 69.1 % of the patients, ranging from 42.1 to 87.0 % between hospitals. The ACE inhibitor was most often missing (21.2 %). Patients with non-ST-segment elevation myocardial infarction or unstable angina, patients with a history of coronary artery bypass grafting or elderly women were less likely to be discharged with the guideline-recommended medication.ConclusionsGuideline adherence for secondary prevention medication following acute coronary syndrome was substantial; however, variation between hospitals and patient groups was found. Efforts to increase guideline adherence can focus on underperforming hospitals and undertreated patient groups.

Guidance on guideline adherence.

Recurrent ischaemic events are common in patients discharged after an acute coronary syndrome (ACS). In a large observational study in 16,321 patients, 20 % were rehospitalised and 18 % of the men and 23 % of the women older than 40 years died in the first year following discharge [1]. Adequate secondary prevention after ACS may save at least as many lives as treatment provided during the acute phase [2, 3]. Equally important as preventive medication, improvements in lifestyle-related risk factors will result in significant risk reductions. In the OASIS-5 trial, patients with non-ST-segment elevation (STE) ACS were encouraged to adhere to a healthy diet, regular physical activity and smoking cessation. Patients who adhered to both diet and exercise had a relative risk reduction (RRR) of 54 % for myocardial infarction (MI), stroke or death (odds ratio (OR) 0.46; 95 % confidence interval (CI) 0.38–0.57; p = 0.0001), and for those who gave up smoking a RRR of 43 % for MI (OR 0.57; 95 % CI 0.36–0.89;p<0.0145) [4]. Written guidelines in medicine have been in use for thousands of years. However, their nature and status have changed substantially in recent years. Most importantly, they are now based primarily on evidence, as opposed to authority or tradition, and they now have a major legal and financial impact. In spite of substantial experience with guidelines in medicine, important issues remain, ranging from how to select members of the writing group to challenges with implementation in clinical practice. The paper in this issue by Tra et al. [5] addresses implementation. The design of this study has been published separately [6]. The authors report a large retrospective observation on adherence to European Society of Cardiology (ESC) guidelines on preventive medication after ACSs [7]. In the 13 (out of 91) medical centres in the Netherlands that were randomly selected for the analysis, overall adherence to guideline-recommended preventive medication was acceptable, with complete adherence to the five recommended classes of drugs in almost 70 % of the 2471 patients in the analysis. This proportion may in fact be underestimated, for several reasons. First, at discharge not all long-term medication may have been initiated. In particular, blood pressure lowering medication should be titrated to blood pressure and to patient tolerance. Gradual increases in drug therapy would be prudent, particularly in the 50 % of the patients in the study who were not classified as hypertensive. Second, no information on left ventricular function is presented. Patients with preserved ejection fraction and no other indication for renin-angiotensin-aldosterone system (RAAS) blocking agents (such as diabetes) may be managed without RAAS blockers, as per ESC guidelines. Third, angiotensin receptor-blocking agents may have been used in patients who do not tolerate ACE inhibitors. This was not recorded in the study, as the authors report, but should be considered as adherence to the guidelines. Several limitations need to be considered. The proportion of patients who reached the target levels for blood pressure, low-density lipoprotein cholesterol, glucose or HbA1c was not reported. Mere initiation of medication is not sufficient for achieving the full potential of prevention. Second, lifestyle risk factors are not addressed in the analysis. Clearly, smoking, physical activity and weight management should be addressed, even during the hospital phase. With no information in these aspects, even complete adherence to medication should not be seen as evidence of good overall adherence to the guideline. Third, oral anticoagulants are not considered in the analysis, although they would clearly impact on preventive drug selection. Fourth, the prescription of drugs that are in fact not indicated or contraindicated (e.g. beta blockers in patients with severe asthma) should have been part of the analysis since this may be classified as non-adherence. Although the findings in the study may therefore not be quantitatively accurate, they do provide a useful estimate. They may be used to rank medical centres according to adherence and to selectively address those where improvements would be most desirable. This may be accomplished by feedback and benchmarking. Advice could be tailored, depending on specific issues per centre. The involvement of nurses and nurse-led clinics may be considered. Important improvements in guideline adherence have been documented in randomised trials [8]. Preventive medicine requires discipline from healthcare providers, and this may not be a field where physicians outperform others.

Factors Affecting Adherence to Pediatrics Antiretroviral Therapy in Mekelle Hospital, Tigray Ethiopia

The most important factor in the success of HIV treatment is adherence to antiretroviral therapy (ART).The challenge to adherence to ART is particularly serious in Sub-Saharan Africa as the high rates of HIV/AIDS lead to greater numbers of affected individuals. Although long-term good ART adherence has been observed in certain settings of public sectors the magnitude of this challenge in Sub-Saharan Africa remains large and there is evidence for high rates of patient’s poor adherence. Study aimed to assess the factors affecting adherence to pediatrics antiretroviral therapy (ART) among children in Mekelle hospital, Tigray, Ethiopia. A Hospital based cross-sectional study was conducted on 226 children on antiretroviral therapy from May 01 to 30/2014 at Mekelle hospital. Data was collected from care givers of children under 15 years old who are on ART. Of the 226 children under 15 years, 90.3 % reported complete adherence to antiretroviral therapy medications at the regular schedule over the past 7 days. Factors associated with adherence were having male care giver (AOR=2.10[1.01, 7.22]), age of the child (AOR=1.43[1.16, 3.98]) below 5 years and use of first line ART drugs (AOR=2.86[1.54, 3.67]). Over all the adherence of children on ART to their medication in this study is relatively higher as compared to others. However, complete adherence is expected in order to make the drugs effective. Different strategies have to be designed to improve the adherence level.