老年冠心病患者氯吡格雷联用钙拮抗剂的疗效观察:一项基于倾向评分的回顾性队列研究

目的比较老年冠心病患者单用氯吡格雷与氯吡格雷联用钙拮抗剂(CCB)的疗效。方法选自2000年1月~2011年2月有完整住院资料及门诊随访记录,服用氯吡格雷的老年冠心病患者1021名,其中单用氯吡格雷402例,氯吡格雷联用CCB 619例,其中二氢吡啶类钙拮抗剂547例,非二氢吡啶类钙拮抗剂72例;P糖蛋白(Pgp)抑制剂的钙拮抗剂患者357例,非Pgp抑制剂的CCB患者262例。研究主要终点为随访期内全因死亡,次要终点为心绞痛再入院,心梗再入院,血管再通术(PCI或CABG),脑卒中,TIA。结果氯吡格雷组和联用CCB组发病密度(全因死亡)分别是50.55/1000、42.02/1000,粗RR 0.83(95%CI:0.55~1.26),调整RR 0.47(95%CI:0.14~1.6),两组全因死亡率无显著差异(P>0.05);终点事件发生率比较也无显著差异(P>0.05)。对所有混杂因素进行倾向评分加权后,非二氢吡啶类CCB比二氢吡啶类CCB增加缺血性心脑血管事件风险,SMRW调整OR=1.97(95%:1.2~3.23),P=0.007;氯吡格雷联用CCB组与单用氯吡格雷组加权前后全因死亡率及终点事件比较,差异无统计学意义。不同代谢途径CCB加权前后全因死亡率比较无显著差异(P>0.05)。结论老年冠心病患者联用氯吡格雷及CCB治疗不增加全因死亡及缺血性心脑血管事件的发生,不同代谢途径CCB之间死亡率无明显差异,非二氢吡啶类CCB与氯吡格雷联用时比二氢吡啶类CCB致缺血性心脑血管终点事件的风险更高。     

南充市新发无强制适应证高血压患者药物治疗特点的调查分析

目的了解新发高血压患者降压方案的变化趋势。方法随机抽取2002～2008年南充市市级及各县公务员健康体检档案资料中诊断为高血压的1258名患者资料,对其初诊及高血压用药方案记录进行分析。结果降压治疗方案因年份、处方医疗单位级别、性别的差异存在着一定的差别。无论是单用或是联合应用,血管紧张素转化酶抑制剂（ACEI）和钙通道拮抗剂（CCBs）是处方比例较大的降压药物。血管紧张素受体阻断剂（ARBs）对高血压治疗的使用率有上升趋势。通过多因素分析控制其他的影响后发现,ACEI和CCBs应用存在着医疗单位级别和年份差异。结论通过对高血压人群的调查发现,当前南充市高血压降压治疗方案与高血压指南推荐方案存在着一定的差距,这可能是今后高血压慢性病治疗与管理的改进方向。     

社区高血压人群抗高血压药物应用分析

目的调查社区高血压人群抗高血压药物的应用情况,以指导规范用药。方法采用问卷调查方法,于2009年3月—8月对我院所管辖的社区452例高血压患者进行相关病史资料搜集及问卷调查,对用药名称、类型,联合用药等进行分析。结果在452例高血压患者中,343例患者服用降血压药物(75.88%),其中151例单用非复方制剂(44.02%),89例采用2种药物联用(25.95%),11例采用3种药物联用(3.21%),采用复方制剂92例(26.82%)。服用钙离子拮抗制剂(CCB)184例(53.64%),血管紧张素转换酶抑制剂(ACEI)61例(17.78%),血管紧张素Ⅱ受体拮抗剂(ARB)66例(19.24%),β受体阻滞剂51例(14.86%)利尿剂11例(3.2%),氨氯地平及复方降压片处于排序前两位。结论规范社区高血压患者降压药物的合理应用,可以干预各种危险因素,提高降压效果,减少并发症的发生。     

基于专家咨询法的慢性肾脏病中西医服药依从性的影响因素研究

目的　基于专家咨询法探讨慢性肾脏病（CKD）患者中西医服药依从性的影响因素。方法　于2017年4—9月共选取23名中西医肾病领域专家,以知信行理论为基础形成调查问卷,包括知识部分、信念部分和行为部分,进行3轮调查问卷,记录每个条目的专家认可率。结果　经过3轮问卷调查,共形成44个条目。知识部分包括药物治疗作用、药物不良作用、药物名称及用法等18个条目,专家认可率均>90%;信念部分包括服药能让人相处融洽、服药能让人思维清晰、服药能让人更有活力等19个条目,其中服药能让人更有活力、服药能让人减少住院、服药能让人更轻松等12个条目的专家认可率均>90%;行为部分包括忘记服药、不注意服药、症状改善自行停药等7个条目,其中忘记服药、不注意服药、症状改善自行停药等5个条目的专家认可率均>90%。结论 　CKD患者服药依从性影响因素包括患者对日常服用药物了解的程度、对中药煎煮的了解及中药味道的接受程度、服药后自我感觉、治疗效果和预后、日常生活对服药的影响等。针对服药依从性影响因素进行临床宣教,建立正性信念,避免负性信念,可能会有效改善CKD患者服药依从性,提高临床疗效。     

Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized controlled trial

Context  Poor medication adherence diminishes the health benefits of pharmacotherapies. Elderly patients with coronary risk factors frequently require treatment with multiple medications, placing them at increased risk for nonadherence. Objective  To test the efficacy of a comprehensive pharmacy care program to improve medication adherence and its associated effects on blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C). Design, Setting, and Patients  A multiphase, prospective study with an observational phase and a randomized controlled trial conducted at the Walter Reed Army Medical Center of 200 community-based patients aged 65 years or older taking at least 4 chronic medications. The study was conducted from June 2004 to August 2006. Intervention  After a 2-month run-in phase (measurement of baseline adherence, BP, and LDL-C), patients entered a 6-month intervention phase (standardized medication education, regular follow-up by pharmacists, and medications dispensed in time-specific packs). Following the intervention phase, patients were randomized to continued pharmacy care vs usual care for an additional 6 months. Main Outcome Measures  Primary end point of the observation phase was change in the proportion of pills taken vs baseline; secondary end points were the associated changes in BP and LDL-C. Primary end point of the randomization phase was the between-group comparison of medication persistence. Results  A total of 200 elderly patients (77.1% men; mean [SD] age, 78 [8.3] years), taking a mean (SD) of 9 (3) chronic medications were enrolled. Coronary risk factors included drug-treated hypertension in 184 patients (91.5%) and drug-treated hyperlipidemia in 162 (80.6%). Mean (SD) baseline medication adherence was 61.2% (13.5%). After 6 months of intervention, medication adherence increased to 96.9% (5.2%; P<.001) and was associated with significant improvements in systolic BP (133.2 [14.9] to 129.9 [16.0] mm Hg; P = .02) and LDL-C (91.7 [26.1] to 86.8 [23.4] mg/dL; P = .001). Six months after randomization, the persistence of medication adherence decreased to 69.1% (16.4%) among those patients assigned to usual care, whereas it was sustained at 95.5% (7.7%) in pharmacy care (P<.001). This was associated with significant reductions in systolic BP in the pharmacy care group (–6.9 mm Hg; 95% CI, –10.7 to –3.1 mm Hg) vs the usual care group (–1.0 mm Hg; 95% CI, –5.9 to 3.9 mm Hg; P = .04), but no significant between-group differences in LDL-C levels or reductions. Conclusions  A pharmacy care program led to increases in medication adherence, medication persistence, and clinically meaningful reductions in BP, whereas discontinuation of the program was associated with decreased medication adherence and persistence. Trial Registration  clinicaltrials.gov Identifier: NCT00393419      

Improving the validity of determining medication adherence from electronic health record medications orders

We developed an accurate and valid medication order algorithm to identify from electronic health records the definitive medication order intended for dispensing and applied this process to identify a cohort of patients and to stratify them into one of three medication adherence groups: early non-persistence, primary non-adherence, or ongoing adherence. We identified medication order data from electronic health record tables, obtained the orders, and linked the orders to dispensings. These steps were then used to identify patients newly prescribed antihypertensive, antidiabetic, or antihyperlipidemic medications and to determine the adherence group of each patient. Record review validated each process step, thus increasing the accuracy of group assignment as well as the criteria used to select patients. This work is an important first step to accurately identify study-specific patient adherence cohorts and allow more comprehensive estimates of population medication adherence.     

狼疮肾炎合并高血压的治疗

目的观察并比较ACEI联合利尿剂与ACEI联合CCB治疗狼疮肾炎合并高血压的疗效。方法 78例狼疮肾炎合并高血压病患者,随机分为两组,各39例。一组给予ACEI联合利尿剂治疗,一组给予ACEI联合CCB治疗。记录治疗前后血压、尿素氮、血肌酐的变化并进行统计学分析。结果治疗前两组患者临床各项指标比较差异无统计学意义(P>0.05)。治疗12周后,两组血压均明显下降,差异有统计学意义(P<0.05),两组之间降压疗效比较无统计学意义(P>0.05)。两组尿素氮、血肌酐较治疗前均明显下降,差异有统计学意义(P<0.05)。治疗后两组尿素氮、血肌酐的变化比较无统计学意义(P>0.05)。结论 ACEI联合利尿剂与ACEI联合CCB治疗狼疮肾炎合并高血压均有较好疗效。     

不同降压药物对原发性高血压患者臂踝脉搏波动传导速度的影响

目的:评价不同降压药物对原发性高血压患者臂踝脉搏波动传导速度的影响。方法:将我院收治的原发性高血压患者120例随机分为3组,每组40例,分别给予培哚普利(ACEI组)、替米沙坦(ARB组)和氨氯地平(CCB组)治疗,在治疗后第1、3个月分别测定患者心率(HR)、收缩压(SBP)、舒张压(DBP)、脉压(PP)及臂踝脉搏波动传导速度(baPWV)。结果:治疗前3组患者SBP、DBP、PP、HR、baPWV无统计学差异(P>0.05);降压治疗后1个月3组患者SBP、DBP、PP、baPWV均较治疗前明显降低(P<0.01),治疗后3个月3组患者SBP、DBP、PP、baPWV均较治疗后1个月明显降低(P<0.01),3组患者治疗前后HR无显著变化(P>0.05)。治疗后3组baPWV变化(△baPWV)比较,ARB组>CCB组>ACEI组,3组数据间比较有统计学差异(P<0.05)。结论:培哚普利、氨氯地平、替米沙坦均可以改善高血压患者动脉弹性功能,其中替米沙坦改善动脉弹性功能最为明显。     

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008

Introduction

Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures.

Aim

To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region.

Methodology

We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James’s Hospital, Dublin.

Results

The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers.

Conclusion

The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.     

老年冠心病患者二级预防用药随访研究

目的探讨老年冠心病患者二级预防用药情况及健康教育对老年冠心病患者用药依从性的影响。方法对北京某医院干部门诊和病房确诊为冠心病的患者,随访了解患者的用药状况（1年）,然后分批给冠心病患者做＂关于冠心病规范治疗,三高达标＂等健康教育讲座,并现场答题,发放《就诊信息提示手册》,随访1年,定期收回手册统计用药情况,参考Mofisky-Green（MG）测评表进行服药依从性评判。结果未做健康教育随访1年,冠心病患者二级预防用药依从性佳的百分率为23.9%,多因素Logistic回归分析显示影响用药依从性因素有冠心病合并症情况及患者是否掌握冠心病知识：合并症少、冠心病知识丰富,则服药依从性好。健康教育后随访1年,药物治疗依从性佳的百分率为51.2%,二者之间差异有统计学差异。结论老年冠心病患者服药依从性差,影响用药依从性因素有冠心病合并症情况及患者是否掌握冠心病知识;健康教育可以明显提高老年患者服药依从性,从而提高冠心病控制率。     

基于大五人格理论应用潜在剖面分析探究2型糖尿病患者的用药依从性

目的: 探究2型糖尿病 (type 2 diabetes mellitus, T2DM)患者的人格画像,探讨其与用药依从性的关系及用药依从性的影响因素。方法: 选取北京市通州区、顺义区中4个社区卫生服务中心所属的22个社区卫生服务站的T2DM患者作为研究对象,采用自行设计的问卷收集人口学信息,采用大五人格量表简式版收集人格信息,运用潜在剖面分析探究人格画像。采用用药依从性量表评估用药依从性,运用方差分析探究不同人格画像的用药依从性是否有差异,应用有序多分类Logistic回归探究用药依从性的影响因素。结果: 751例T2DM患者被纳入研究,潜在剖面分析结果显示,本研究中的T2DM患者可分为4类人格画像,包括内敛稳定型(42.7%)、消极型(12.7%)、焦虑型(15.3%)和活泼负责型(29.3%),其中75例患者表示自己不用药也不打胰岛素,5例患者数据缺失,最终671例患者被纳入用药依从性的相关分析。方差分析结果显示,人格画像为焦虑型的患者其用药依从性得分(5.55±1.65)与消极型患者得分(5.94±1.53)差异无统计学意义(P=0.089),但显著低于内敛稳定型(6.17±1.46,P=0.001)和活泼负责型(6.09±1.65,P=0.004)。将人格画像为焦虑型和消极型的患者合并为焦虑消极型纳入有序多分类Logistic回归,结果显示,相比焦虑消极型患者,人格画像为活泼负责型、内敛稳定型是用药依从性好的保护因素(OR=1.567,95%CI:1.096~2.237;OR=1.774,95%CI:1.214~2.591),且受教育程度也影响患者的用药依从性。结论: 基于大五人格理论,T2DM患者可分为4类人格画像,将焦虑型和消极型合并后的焦虑消极型是患者用药依从性差的独立危险因素;此外,受教育程度也是用药依从性的影响因素。     

围生期心肌病36例临床分析

目的探讨药物治疗围生期心肌病（peripartumcardiomyopathy,PPCM）的方法。方法收集新疆和田市人民医院内科2007年2月-2012年2月36例住院PPCM患者的临床资料,进行回顾性分析。结果36例患者经过强心、利尿和血管扩张剂治疗,适时加用β受体阻滞剂,产后予以ACEI或ARB,全部患者均获治愈,无1例死亡,治疗6个月后X线检查心脏基本恢复正常。结论PPCM的治疗仍以利尿剂、硝酸酯和洋地黄为主,但β受体阻滞剂、ACEI的使用也很重要,远期疗效显著;应用抗凝药物预防血栓治疗值得关注。     

武汉市高血压患者遵医态度对遵医行为的影响

目的:探讨高血压患者遵医态度对遵医行为的影响,提出改善患者遵医行为的干预措施。方法:采用分层随机抽样的方法,选取在武汉市部分社区卫生服务中心就诊的450名高血压患者进行问卷调查,应用SARS分析被调查高血压患者的遵医态度对遵医行为的影响。结果:调查的438例高血压患者遵医态度为正向的有379人,其中79.95%的人能做到不自行停药、86.54%的人不自行换药、87.45%的人经常测血压;遵医态度为负向的有59人,并有61.02%的人不自行停药、67.80%的人不自行换药、85.43%的人经常测血压,均有统计学差异。结论:健康教育是改善高血压患者遵医行为的有效措施。     

Calcium-channel blockers and cognitive function in elderly people: results from the Canadian Study of Health and Aging

BACKGROUND: Concern has been raised about the potential for adverse cognitive effects associated with the use of calcium-channel blockers (CCBs) in older people. This study was undertaken to examine prospectively the association between the use of these and other antihypertensive drugs and cognitive function. METHODS: The authors examined data from the Canadian Study of Health and Aging (CSHA), a population-based, prospective 5-year investigation of the epidemiology of dementia and other health problems in Canadians 65 years of age and older. The risk of cognitive decline, as indicated by a decline in performance on the Modified Mini-Mental State (3MS) examination over the 5-year period, was assessed in relation to the use of antihypertensive and diuretic drugs by 205 subjects with a history of hypertension and no evidence of dementia at baseline. RESULTS: The proportion of subjects whose cognitive performance declined over the study period was significantly higher in the group using CCBs than in the group using other antihypertensive agents (75% v. 59%). The adjusted odds ratio (OR) for a significant decline in cognitive performance (defined as a decrease in 3MS score of 10 points or more) was 2.28 (95% confidence interval [CI] 1.12-4.66) for subjects using CCBs. The adjusted ORs (and 95% CIs) for cognitive decline in subjects using selected antihypertensive agents or diuretics relative to those exposed to beta-blockers were as follows: angiotensin-converting-enzyme inhibitor, OR 1.36 (95% CI 0.41-4.55); diuretic or other antihypertensive drug, OR 1.45 (95% CI 0.51-4.14); dihydropyridine CCB (nifedipine), OR 1.94 (95% CI 0.52-7.27) and non-dihydropyridine CCB (diltiazem or verapamil), OR 3.72 (95% CI 1.22-11.36). INTERPRETATION: Older people taking CCBs were significantly more likely than those using other agents to experience cognitive decline. These findings are consistent with the results of previous cross-sectional research and emphasize the need for further trials to examine the associations between CCB use, blood pressure and cognitive impairment in elderly patients.