Modifiable risk factors for adherence to adjuvant endocrine therapy among breast cancer patients

Objective

Breast cancer incidence and mortality are declining due to improvements in early detection and treatment. One advance in treatment is the development of adjuvant endocrine therapy (AET) for women with hormone receptor positive breast cancer. Despite strong evidence linking AET to better health outcomes, AET adherence continues to be suboptimal. This study tests the hypothesis that patient beliefs about medication mediate the relationship between frequency of physician communication and AET adherence.

Methods

This cross-sectional study utilizes data from patient self-report and medical chart abstraction (N = 200). Survey measures included frequency of physician communication, patient beliefs about medicine, AET adherence, and demographic characteristics.

Results

Necessity beliefs mediated the relationship between frequency of physician communication and medication adherence (necessity beliefs β = .18, p < .05; physician communication β = .13, p > .05). There was no evidence of medication concerns mediating the relationship between frequency of physician communication and medication adherence.

Conclusion

More frequent physician communication that shapes what patients believe about AET importance may be associated with greater AET adherence; however, frequent physician communication that shapes patient concerns about side effects may not be associated with greater AET adherence.

Practice implications

Research is needed to enhance understanding of the type of physician communication that is most consistently associated with patient beliefs about medication and AET adherence.     

Haemolysis due to formaldehyde-induced anti-N-like antibodies in haemodialysis patients

Summary During reuse of formaldehyde sterilized Kiil-dialysers, red cell survival, measured by means of⁵¹Cr t/2, was significantly reduced (p<0.001) in 16 patients with anti-N-like positive sera, when compared with 19 antibody negative control patients (Mean±SD: 16.5±2.7 versus 22.4±3.1 days.) In antibody negative patients (n=10) replacement of form-aldehyde sterilized dialysers by ethylene-oxide sterilized disposable dialysers resulted in a significant increase (p<0.002) of⁵¹Cr t/2 (Mean±SD, days: Kiil-dialyser 16.3±1.9; disposable dialyser 20.3±3.5). This improvement took place, although antibody titres persisted during the⁵¹Cr-measurements and declined thereafter only slowly. In antibody negative patients (n=6) red cell survival did not increase, when formaldehyde as a sterilant was avoided. In antibody positive patients mean haematocrit rose significantly (p<0.05), whereas in none of the antibody negative patients a definite change of haematocrit occurred. The data demonstrate, that formaldehyde sterilisation of dialysers may cause antibody-mediated haemolysis contributing to the extent of renal anaemia. This immunohaemolysis may be corrected, in spite of continuing antibody persistance, when formaldehyde exposure is totally avoided, or possibly when minimized.     

Prevalence of HBV and HCV dual infection in patients on haemodialysis

Hepatitis viral infections are important causes of morbidity and mortality in haemodialysis patients. One hundred and thirty four patients attending haemodialysis unit were screened for the presence of HBV and HCV infections. Eight (5.9%) patients were HCV positive while two (1.4%) patients had HBV infection. A dual infection with both the viruses was observed in five patients (3.7%).     

The association of emotional well-being and marital status with treatment adherence among patients with hypertension

We were interested in examining the relationship between psychosocial factors and hypertension-related behaviors. We hypothesized that lower emotional well-being and unmarried status would be related to higher BP, poorer medication adherence, greater difficulty adhering to diet and exercise, and current smoking. In a cross-sectional design, 636 hypertensive patients completed the Mental Component Summary (MCS) Scale of the SF-12 and rated their difficulty with adherence to diet, exercise, and medication-taking. In logistic regression analyses, lower MCS scores were associated with difficulty adhering to diet (OR = 0.97, p < .05) and exercise (OR = 0.97, p < .01), and current smoking status (OR = 0.98, p < .05). Being married was associated with higher probability of medication adherence (OR = 1.66, p < .01) and a lower probability of being a current smoker (OR = 0.34, p < .0001). Neither MCS scores nor being married were related to BP levels in adjusted analyses. Results emphasize the importance of assessing psychosocial factors to optimize hypertension treatment.     

Factors influencing bacterial adherence to biomaterials.

The adherence of bacteria to implanted medical devices is believed to be important in the development of implant associated infections. Measures which reduce bacterial adherence should reduce the incidence of these infections. However, in order to assess the importance of adherence, the effectiveness of methods to reduce adherence, and compare data from different laboratories, the conditions of the in vitro studies on adherence need to be specified. There are currently no correct and incorrect methods, however, methods used need to be carefully described. The studies reported here indicate that the definition of adherence needs to be established, with the use of polystyrene as the reference material recommended. Since the adherent organisms lose adherence traits with culture, cultures must be selected for adherence regularly. It is important to control the number of organisms/ml but the volume used is not important. The medium used to grow the organisms and the use of stationary, rocking or flow conditions will alter adherence and need to be specified and be consistent within a set of experiments. Culture conditions, methods of rinsing the material, methods of elution and counting, or direct counting of organisms on the material need to be specified. Finally, as much information as possible on the bulk and surface properties of the material should be provided. The handling of the material for the experiments should be careful and defined. Fingerprints, contact with protein, wet surfaces vs dry surfaces, etc., will all affect the subsequent adherence. The materials should not be re-used since the removal of the adherent proteins or the biofilm is very difficult. Progress can be made in this important area if the details of procedures are specified.     

Decreased antigen-specific T-cell proliferation by moDC among hepatitis B vaccine non-responders on haemodialysis

Patients with end-stage kidney disease, whether or not on renal replacement therapy, have an impaired immune system. This is clinically manifested by a large percentage of patients unresponsive to the standard vaccination procedure for hepatitis B virus (HBV). In this study, the immune response to HBV vaccination is related to the in vitro function of monocyte-derived dendritic cells (moDC). We demonstrate that mature moDC from nonresponders to HBV vaccination have a less mature phenotype, compared to responders and healthy volunteers, although this did not affect their allostimulatory capacity. However, proliferation of autologous T cells in the presence of tetanus toxoid and candida antigen was decreased in non-responders. Also, HLA-matched CD4+ hsp65-specific human T-cell clones showed markedly decreased proliferation in the group of non-responders. Our results indicate that impairment of moDC to stimulate antigen-specific T cells provides an explanation for the clinical immunodeficiency of patients with end-stage kidney disease.     

Determinants of adherence to medical regimens by hypertensive patients

This study employed multivariate analyses and structural modeling procedures to examine a model for the determinants of adherence to medical regimens. Fifty adult hypertensive patients at a health maintenance organization completed questionnaires and participated in home interviews over a 10-week period. Knowledge of medical regimens, information communication between the patient and the medical professionals, satisfaction with health-care providers, health locus of control, social support, and treatment disruption to life-style were assessed. Adherence was assessed through self-report and behavioral (i.e., pill-count ratio, percentage of kept medical appointments) indices. Finally, repeated blood-pressure measurements were obtained. Structural modeling procedures revealed that greater expectancy for internal control over health and hypertension, greater knowledge of the treatment regimen, and stronger social support were significant determinants of adherence; in turn, higher levels of adherence facilitated blood-pressure reduction.This article is based on the author's doctoral dissertation completed at the University of Connecticut and was supported in part by that institutions's Research Foundation.Portions of this work were presented at the annual meeting of the American Psychological Association, Los Angeles, 1983.     

Multiorgan aluminium deposits in a chronic haemodialysis patient

Summary The study reports an aluminium-intoxicated haemodialysis patient who had encephalopathy, osteomalacia and congestive cardiomyopathy prior to his death. Detailed light and electron microscope examination revealed the presence of aluminium deposits within lysosomes of cells from many organs, including the kidney, liver, brain and heart. The heavy aluminium deposits in myocardial lysosomes favor a possible role of the trace element in the patient's congestive cardiomyopathy.     

Validating a path model of adherence to prenatal care recommendations among pregnant women

ObjectiveTo date, no study has reported a diagrammatic path model that involves patient-provider communication on pregnant women’s adherence to prenatal care recommendations. To bridge this gap, this study aimed to validate a path model to display the direct and indirect influences on adherence to prenatal care recommendations.MethodsA cross-sectional study founded on an evidence-based proposed theoretical framework was conducted among pregnant women (18–45 years) in their second or third trimester (n = 401) in the Midwestern United States. The proposed theoretical framework examined multiple levels of influences. Previously validated instruments were pilot tested and modified. Path analysis was conducted to validate the best-fit path model.ResultsThe path model showed shared decision-making and motivation significantly predicted adherence to prenatal care recommendations and accounted for 10% (R²) of the variance. Cultural competency, interaction, perceived discrimination, and satisfaction accounted for 30% (R²) of the variance of shared decision-making. Patient’s trust, distrust, and self-efficacy accounted for 5% (R²) of motivation’s variance.ConclusionOur work identified the best-fit path model for adherence to prenatal care recommendations.Practice implicationsIncorporating findings from this study could assist prenatal care providers in understanding many complex variables affecting prenatal care, ultimately reducing infant mortality.     

Measuring clinical pathway adherence

As clinical pathway adoption continues worldwide, it is necessary to establish adherence measurement methods in order to understand the difficulties and results of implementation. Adherence measurement literature mostly provides binary measurements of adherence to guidelines regarding individual medical activities over patient groups. The resulting measurements are of limited value in view of the pathways actually followed by individual patients. We develop and test dynamic programming formulations for adherence measurement in clinical pathways – based on partially ordered data in medical records and pathway definitions. With these new methods at hand, we analyze clinical pathway adherence at the Cardiovascular Center of Maastricht University Medical Center.     

The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma

Objective

To develop and assess the feasibility of a motivational interviewing (MI) based asthma self-management program for inner-city, African-American, adolescents with asthma.

Methods

37 African-American adolescents (age 10-15 years) recently seen in an inner-city emergency department for asthma and prescribed an asthma controller medication participated in the newly developed program consisting of 5 home visits. Adolescents and their caregivers completed phone-based surveys before and after the intervention.

Results

95% of the adolescents completed all 5 sessions; 89% of caregivers and 76% of adolescents believed other families would benefit from the intervention. Caregivers were more likely to report 100% adherence post-intervention compared to pre-intervention and reported a trend for adolescents taking greater responsibility for their asthma. There were no pre-post-differences in adolescent-reported medication adherence, but adolescents did reported increased motivation and readiness to adhere to treatment. Caregivers and adolescents each reported statistically significant increases in their asthma quality of life.

Conclusions

The findings from this pilot study suggest that MI is a feasible and promising approach for increasing medication adherence among inner-city adolescents with asthma and is worthy of further evaluation in a randomized trial.

Practice Implications

Incorporating MI into disease management programs may enhance their effectiveness.     

Factors influencing mother-child reports of depressive symptoms and agreement among clinically referred depressed youngsters in Hungary

BACKGROUND: Psychiatric assessments of children typically involve two informants, the child and the parent. Understanding discordance in their reports has been of interest to clinicians and researchers. We examine differences between mothers' and children's report of children's depressive symptom severity, and factors that may influence their reports and level of agreement. We hypothesized that agreement between mother and child would improve if (1) the mother is depressed, due to improved recall of mood congruent symptoms, (2) the child is older, due to better social-cognitive and communication skills, and (3) the child is a female. METHODS: Subjects were 354 children (158 girls; mean age 11.69 years, SD: 2.05 years) with Major Depressive Disorder. Depressive symptoms were evaluated by a semi-structured interview separately with the mother and the child. Agreement on symptom severity was based on concordance of the presence and extent of symptoms. RESULTS: Maternal reports were significantly higher than their son's but not daughters'. Girls, particularly with increasing age, reported higher levels of symptoms; however mothers' reports were not affected by child sex or age. Maternal depression predicted more severe symptom reports for both children and mothers. Agreement between the mother and the child increased as children got older. LIMITATIONS: The same clinician interviewed the mother and the child, which might inflate rates of agreement. However, this method mirrors clinical evaluation. CONCLUSION: During a clinical interview one must consider the age and sex of the child and the depressive state of the mother in assimilating information about the child.     

Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma

BACKGROUND: Regular use of inhaled corticosteroids (ICSs) can improve asthma symptoms and prevent exacerbations. However, overall adherence is poor among patients with asthma. Objective To estimate the proportion of poor asthma-related outcomes attributable to ICS nonadherence. METHODS: We retrospectively identified 405 adults age 18 to 50 years who had asthma and were members of a large health maintenance organization in southeast Michigan between January 1, 1999, and December 31, 2001. Adherence indices were calculated by using medical records and pharmacy claims. The main outcomes were the number of asthma-related outpatient visits, emergency department visits, and hospitalizations, as well as the frequency of oral steroid use. RESULTS: Overall adherence to ICS was approximately 50%. Adherence to ICS was significantly and negatively correlated with the number of emergency department visits (correlation coefficient [ R ] = -0.159), the number of fills of an oral steroid ( R = -0.179), and the total days' supply of oral steroid ( R = -0.154). After adjusting for potential confounders, including the prescribed amount of ICS, each 25% increase in the proportion of time without ICS medication resulted in a doubling of the rate of asthma-related hospitalization (relative rate, 2.01; 95% CI, 1.06-3.79). During the study period, there were 80 asthma-related hospitalizations; an estimated 32 hospitalizations would have occurred were there no gaps in medication use (60% reduction). CONCLUSIONS: Adherence to ICS is poor among adult patients with asthma and is correlated with several poor asthma-related outcomes. Less than perfect adherence to ICS appears to account for the majority of asthma-related hospitalizations.     

Equipment using an impedance technique for automatic recording of fluid-volume changes during haemodialysis

An instrument for continuous monitoring of fluid-volume changes has been developed. A tetrapolar whole-body impedance technique is employed with a constant current of 100 μA at 1·5 kHz and 150 kHz. A microprocessor automatically calculates changes in fluid volume from changes in whole-body impedance. Body-surface area is used as a normalising factor together with an empirically determined constant to obtain readings expressed in litres. Estimates of fluid-volume changes obtained by the method were compared with concomitant changes in the body weight of ten patients undergoing haemodialysis, and a correlation coefficient of 0·89 was found.     

青少年正常甲状腺体积及其影响因素分析

本文应用7.5MHz Ultrasound 9 HDI探头的彩超测定了深圳市64名15～18岁中小学生甲状腺大小,计算出甲状腺体积,并对比分析体积与性别、年龄、身高、体重等的关系。结果是:甲状腺体积与年龄呈高度正相关;与身高、体重也呈中高度正相关,相关系数分别为0.684和0.570;在同一年龄组内,男性甲状腺体积大于女性。     

Computerised analysis of auscultatory sounds associated with vascular patency of haemodialysis access

Vascular access for renal dialysis is a lifeline for about 120 000 individuals in the United States. Stethoscope auscultation of vascular sounds has some utility in the assessment of access patency, yet can be highly skill-dependent. The objective of the study was to identify acoustic parameters that are related to changes in vascular access patency. The underlying hypothesis is that stenoses of haemodialysis access vessels or grafts cause vascular sound changes that are detectable using computerised data acquisition and analysis. Eleven patients participated in the study. Their vascular sounds were recorded before and after angiography, which was accompanied by angioplasty in most patients. The sounds were acquired using two electronic stethoscopes and then digitised and analysed on a personal computer. Vessel stenosis changes were found to be associated with changes in acoustic amplitude and/or spectral energy distribution. Certain acoustic parameters correlated well (correlation coefficient=0.98, p<0.0001) with the change in the degree of stenosis, suggesting that stenosis severity may be predictable from these parameters. Parameters also appeared to be sensitive to modest diameter changes (>20%), (p<0.005, Wilcoxon rank sum test). These results suggest that computerised analysis of vascular sounds may be useful in vessel patency surveillance. Further testing using longitudinal studies may be warranted.