Risk factors for ulceration over tophi in patients with gout

Ulceration over tophi in patients with gout usually causes a number of clinical problems. The aim of this study was to investigate the risk factors for ulceration of tophi in patients with gout. Patients with gout who had tophi with or without ulceration were prospectively recruited and underwent a comprehensive clinical assessment. Clinical factors independently associated with the presence of ulceration were analysed using logistic regression models. Of the 113 participants, 18 (13·7%) had clinically apparent ulceration over tophi. In univariate analysis, ulceration over tophi correlated with age, tophus duration, size, location and lack of protective sensation. In logistic regression analysis, age, tophus size and lack of protective sensation were associated with ulceration over tophi. These findings indicate that old age, large tophus size and lack of protective sensation were independent risk factors for ulceration over tophi.     

Treatment adherence in patients with gout

The treatment objectives in gout are to promptly terminate the acute flares and to prevent the long-term complications via chronic pharmacotherapy, usually with urate-lowering drugs, combined with diet and lifestyle changes. Published data indicate that adherence with pharmacotherapy is particularly poor in gout patients. In studies of pharmacy dispensing of gout medications, the percentage of patients with good adherence, defined as purchasing at least 80% of the prescribed amount of medication, ranged from 18 to 44%. In a comparative study showing a 36.8% adherence rate among gout patients, patients with hypertension or type 2 diabetes had considerably higher rates, of 72.3 and 65.4%, respectively. In addition, data are lacking on adherence to recommended dietary and lifestyle changes, whose importance has been emphasized in recent years. Poor adherence has well-documented adverse consequences on the treatment success rate and on disease progression. These data identify treatment adherence in gout as a key target of patient education.     

Implication of nurse intervention on engagement with urate-lowering drugs: A qualitative study of participants in a RCT of nurse led care

ObjectivesTo explore patient perception of the role of a nurse-led complex package of care in facilitating engagement with urate-lowering therapies (ULTs) in the management of gout.MethodsThirty people who had participated in a randomised controlled trial investigating the effect of a nurse-led complex package of care for gout, were purposively sampled and interviewed between 18–26 months after the end of the trial. Interviews were recorded, transcribed and analysed using a modified grounded-theory approach. Data were managed using Nvivo. STATA v15 was used to describe summary statistics.ResultsParticipants described their views and experiences of engaging with a nurse-led intervention designed to provide holistic assessment, individualised patient education, and involvement in shared decision-making for the long-term management of gout. The analysis revealed key themes in how nurse-led intervention facilitated engagement with ULT, namely by proving improved knowledge and understanding of gout and its treatment, involvement of patients in decision-making about treatment, and increased confidence about benefits from treatment. However, some treatment uncertainty and concern remained and one participant free of gout flares discontinued ULT, while another halved the dose after the end of the trial.ConclusionsThis study reports data on patient experience of engaging with ULT to manage gout after receiving nurse-led care. It demonstrates that shared decision-making and the joint efforts of fully informed practitioners and patients persuades patients to engage with ULTs, and that experiencing the benefits of curative treatment motivates them to maintain adherence.     

UltraSound evaluation in follow-up of urate-lowering therapy in gout phase 2 (USEFUL-2): Duration of flare prophylaxis

ObjectivesTo determine whether changes in ultrasonography (US) features of monosodium urate crystal deposition is associated with the number of gouty flares after stopping gout flare prophylaxis.MethodsWe performed a 1-year multicentre prospective study including patients with proven gout and US features of gout. The first phase of the study was a 6-month US follow-up after starting urate-lowering therapy (ULT) with gout flare prophylaxis. After 6 months of ULT, gout flare prophylaxis was stopped, followed by a clinical follow-up (M6 to 12) and ULT was maintained. Outcomes were the proportion of relapsing patients between M6 and M12 according to changes of US features of gout and determining a threshold decrease in tophus size according to the probability of relapse.ResultsWe included 79 gouty patients [mean (± SD) age 61.8 ± 14 years, 91% males, median disease duration 4 (IQR 1.5;10) years]. Among the 49 completers at M12, 23 (47%) experienced relapse. Decrease in tophus size ≥ 50% at M6 was more frequent without than with relapse (54% vs. 26%, P = 0.049). On ROC curve analysis, a threshold decrease of 50.8% in tophus size had the best sensitivity/specificity ratio to predict relapse [AUC 0.649 (95% confidence interval 0.488; 0.809)]. Probability of relapse was increased for patients with a decrease in tophus size < 50% between M0 and M6 [OR 3.35 (95% confidence interval 0.98; 11.44)].ConclusionA high reduction in US tophus size is associated with lower probability of relapse after stopping gout prophylaxis. US follow-up may be useful for managing ULT and gout flare prophylaxis.     

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey

Objective To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis.Design Cross-sectional survey.Setting National survey in the UK.Participants Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months.Main outcome measures Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy.Results Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14–3.02], concerns about medication (OR 1.49, 95% CI 1.01–2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44–0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38–2.43), side effects (HR 3.69, 95% CI 2.74–4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48–3.30). For both daily (HR 1.53, 95% CI 1.1–2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17–3.07), practical difficulties taking bisphosphonate medication—in particular, too frequent dosing—were associated with nonpersistence.Conclusions Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.     

Adherence to bisphosphonates and hormone replacement therapy in a tertiary care setting of patients in the CANDOO database

Therapies for osteoporosis must be taken for at least 1 year to be effective. The purpose of this study was to determine the difference in adherence to etidronate, alendronate and hormone replacement therapy in a group of patients seen at our tertiary care centres. The Canadian Database of Osteoporosis and Osteopenia (CANDOO), a prospective observational database designed to capture clinical data, was searched for patients who started therapy following entry into CANDOO. There were 1196 initiating etidronate, 477 alendronate and 294 hormone replacement therapy women and men aged (mean, SD) 65.8 (8.7) years in the study. A Cox proportional hazards regression model was used to assess differences between treatment groups in the time to discontinuation of therapy. Several potential covariates such as anthropometry, medications, illnesses, fractures and lifestyle factors were entered into the model. A forward selection technique was used to generate the final model. Hazard ratios and 95% confidence intervals (CI) were calculated. Adjusted results indicated that alendronate-treated patients were more likely to discontinue therapy as compared with etidronate-treated patients (1.404; 95% CI: 1.150, 1.714). After 1 year, 90.3% of patients were still taking etidronate compared with 77.6% for alendronate. No statistically significant differences were found between hormone replacement therapy and etidronate users (0.971; 95% CI: 0.862, 1.093) and hormone replacement therapy and alendronate users (0.824; 95% CI: 0.624, 1.088) after controlling for potential covariates. After 1 year, 80.1% of patients were still taking hormone replacement therapy, which decreased to 44.5% after 6 years. Increasing age and presence of incident non-vertebral fractures were found to be independent predictors of adherence. In conclusion, alendronate users were more likely to discontinue therapy than etidronate users over the follow-up period. Potential barriers to long-term patient adherence to osteoporosis therapies need to be evaluated.     

The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: A quantitative systematic review

BackgroundHormone Therapy (HT) is recommended for most women with HR-positive primary breast cancer. When taken as intended, HT reduces breast cancer recurrence by 40% and mortality by one-third. The recommended duration of treatment ranges from 5 to 10 years depending on risk of recurrence and the specific HT regimen. However, recent data indicates that rates of HT non-adherence are high and research suggests this may be due to the impact of HT side effects. The contribution of side effects to non-adherence and non-persistence behaviours has rarely been systematically explored, thereby hindering the implementation of targeted intervention strategies. Our aim is to identify, evaluate and summarise the relationship between HT side effects and patterns of adherence and persistence.MethodsElectronic searches were conducted from inception and were completed by September 2021, utilising Cochrane CENTRAL, Medline, Embase, Web of Science and PsycINFO databases. Searches included a combination of terms related to breast cancer, adherence, hormone therapy and side effects.ResultsSixty-two eligible papers were identified and study quality varied by study type. Most observational and cross-sectional studies were rated good quality, whereas most controlled intervention studies were rated fair quality. Three studies were rated poor quality. The most frequently measured side effects were pain, low mood, hot flashes, insomnia, anxiety, fatigue, weight gain, concentration/memory problems.ConclusionsThis review identified a lack of consistency in the measurement of adherence and the definition of persistence across studies. The instruments used to measure side effects also varied significantly. This variation and lack of consistency makes it difficult to evaluate and summarise the role of HT side effects in HT adherence and persistence behaviour.     

Factors associated with adherence to ursodeoxycholic acid or placebo in patients after bariatric surgery

BackgroundUrsodeoxycholic acid (UDCA) reduces symptomatic gallstone disease after Roux-en-Y gastric bypass (RYGB). The beneficial effect of UDCA is reduced by poor adherence.ObjectivesWe aimed to identify factors associated with poor adherence to UDCA or placebo after bariatric surgery.SettingOutpatient clinic and department for bariatric surgery in three hospitals in the Netherlands.MethodsPatients in the multicenter, double-blind, randomized, placebo-controlled UPGRADE trial were assessed for adherence to 900 mg UDCA or placebo for 6 months through a pill count, inquiries during follow-up, and a questionnaire. Poor adherence was defined as the usage of <300 of 364 pills within a maximum of 8 months postoperatively. Multivariable logistic regression analysis was used to identify factors contributing to poor adherence.ResultsIn total, 967 patients were included (mean age [standard deviation (SD)]: 45.1 [11.1] years; female: 772 [80%]; RYGB: 889 [92%]; sleeve gastrectomy: 78 [8%]), of whom 357 (37%) were poor adherers. Factors associated with poor adherence were age (OR .97; 95% confidence interval [CI] .96–.98, a decrease in age increases the odds for poor adherence), foreign origin (odds ratio [OR] 2.07; 95%CI 1.50–2.84), unemployment (OR 1.73; 95%CI 1.28–2.34), and sleeve gastrectomy (OR 1.79; 95%CI 1.06–3.01). Furthermore, a difference in adherence status was also noted for the centers of surgery.ConclusionsThe adherence rate to UDCA and placebo in the UPGRADE trial was suboptimal. Several factors were independently associated with poor adherence. Our findings can help to identify patients who may benefit from extra guidance to improve adherence.     

Frequency and factors associated with adherence to and completion of combination antiretroviral therapy for prevention of mother to child transmission in western Kenya

Introduction

The objective of this analysis was to identify points of disruption within the prevention of mother-to-child transmission (PMTCT) continuum from combination antiretroviral therapy (CART) initiation until delivery.

Methods

To address this objective, the electronic medical records of all antiretroviral-naïve adult pregnant women who were initiating CART for PMTCT between January 2006 and February 2009 within the Academic Model Providing Access To Healthcare (AMPATH), western Kenya, were reviewed. Outcomes of interest were clinician-initiated change or stop in regimen, disengagement from programme (any, early, late) and self-reported medication adherence. Disengagement was categorized as early disengagement (any interval of greater than 30 days between visits but returning to care prior to delivery) or late disengagement (no visit within 30 days prior to the date of delivery). The association between covariates and the outcomes of interest were assessed using bivariate (Kruskal-Wallis test for continuous variables and the Chi-square test for categorical variables) and multivariate logistic regression analysis.

Results

A total of 4284 antiretroviral-naïve pregnant women initiated CART between January 2006 and February 2009. The majority of women (89%) reported taking all of their medication at every visit. There were 18 (0.4%) deaths reported. Clinicians discontinued CART in 10 patients (0.7%) while 1367 (31.9%) women disengaged from care. Of those disengaging, 404 (29.6%) disengaged early and 963 (70.4%) late. In the multivariate model, the odds of disengagement decreased with increasing age (odds ratio [OR] 0.982; confidence interval [CI] 0.966–0.998) and increasing gestational age at CART initiation (OR 0.925; CI 0.909–0.941). Women receiving care at a district hospital (OR 0.794; CI 0.644–0.980) or tuberculosis medication (OR 0.457; CI 0.202–0.935) were less likely to disengage. The odds of disengagement were higher in married women (OR 1.277; CI 1.034–1.584). The odds of early disengagement decreased with increasing age at CART initiation (OR 0.902; CI 0.881–0.924). The odds of late disengagement decreased with increasing age at CART initiation (OR 0.936; CI 0.917–0.956). While they increased with higher CD4 counts at CART-initiation (OR 1.001; CI 1.000–1001) and in married women (OR 1.297; CI 1.000–1.695)

Conclusions

In a PMTCT programme embedded in an antiretroviral treatment programme with an active outreach department, the majority (67.4%) of women remained engaged and received uninterrupted prenatal CART.     

Assessment of the adherence to disease-modifying drugs in patients with chronic inflammatory rheumatic diseases: Results of a survey of 1594 patients

Objectivesa) to describe the self-reported adherence to disease modifying drugs (DMARDs) (methotrexate and biological DMARDs) among patients with chronic inflammatory rheumatic diseases (CIRDs); b) to assess factors associated with non-adherence.MethodsAn observational, cross-sectional, nationwide study was conducted through the use of an electronic survey, which was released via patient organizations in France to rheumatic patients. The main outcome was the rate of non-adherence to DMARDs, which was evaluated with the following question “Have you ever tried to stop or space out your treatment in contrast to what was planned with your doctor?” A positive answer was considered “low adherent”. Sociodemographic variables, type of CIRD and treatment information were also collected. Factors associated with low adherence to methotrexate and bDMARDs were explored by univariate and multivariate logistic regressions.ResultsAmong the 1594 participants who completed the survey, 795 (49.9%) were receiving methotrexate and 709 (44.5%) bDMARDs. A total of 159 (20.0%) were identified as low adherents to methotrexate, and being a woman was independently associated with low adherence (OR 1.90 [95% CI 1.07 – 3.36)] to this drug. Regarding bDMARDs, 177 (25.0%) were identified as low adherent, and the factors independently associated with low adherence were being employed (OR 1.47 [95% CI 1.04 – 2.09]) and no concomitant use of methotrexate (OR 0.51 [95% CI 0.36 – 0.73]).ConclusionsThis study suggests that more than 20% of CIRDs patients are low adherent to their DMARDs, and this is more frequent when bDMARDs are administered as a monotherapy.     

High self‐reported non‐adherence to antiretroviral therapy amongst adolescents living with HIV in Malawi: barriers and associated factors

Introduction : Globally adolescents and young adults account for more than 40% of new HIV infections, and HIV‐related deaths amongst adolescents increased by 50% from 2005 to 2012. Adherence to antiretroviral therapy (ART) is critical to control viral replication and preserve health; however, there is a paucity of research on adherence amongst the growing population of adolescents living with HIV/AIDS (ALHIV) in Southern Africa. We examined levels of self‐reported ART adherence, barriers to adherence, and factors associated with non‐adherence amongst ALHIV in Malawi. Methods : Cross‐sectional study of 519 ALHIV (12–18 years) attending two large HIV clinics in central and south‐eastern Malawi. Participants self‐reported missed doses (past week/month), barriers to adherence, and completed questionnaires on past traumatic events/stressors, disclosure, depression, substance use, treatment self‐efficacy, and social support. Biomedical data were retrieved from existing medical records. Multivariate logistic regression was performed to identify factors independently associated with self‐reported ART adherence (7 day recall). Results : The mean age of participants (SD) was 14.5 (2) years and 290 (56%) were female. Of the 519 participants, 153 (30%) reported having missed ART doses within the past week, and 234 (45%) in the past month. Commonly reported barriers to adherence included forgetting (39%), travel from home (14%), busy with other things (11%), feeling depressed/overwhelmed (6%), feeling stigmatized by people outside (5%) and within the home (3%). Factors found to be independently associated with missing a dose in the past week were drinking alcohol in the past month (OR 4.96, 95% CI [1.41–17.4]), missed clinic appointment in the past 6 months (OR 2.23, 95% CI [1.43–3.49]), witnessed or experienced violence in the home (OR 1.86, 95% CI [1.08–3.21]), and poor treatment self‐efficacy (OR 1.55 95% CI [1.02–2.34]). Sex and age were not associated with adherence. Conclusions : In our study, nearly half of all ALHIV reported non‐adherence to ART in the past month. Violence in the home or alcohol use in the past year as well as poor treatment self‐efficacy were associated with worse adherence. Sub‐optimal adherence is a major issue for ALHIV and compromise treatment outcomes. Programmes specifically tailored to address those challenges most pertinent to ALHIV may help improve adherence to ART.     

Effectiveness of interventions to improve therapy adherence in people with upper limb conditions: A systematic review

Study DesignSystematic review.IntroductionPatient adherence to orthosis wear and/or prescribed exercises improves functional outcome after acute injury and can prevent deformities, contractures, and reinjury of tissues. This is the first systematic review to review the evidence of the effectiveness of interventions to improve treatment adherence in children and adults with acute or chronic upper limb injuries or conditions.Purpose of the StudyThe purpose of this study is to establish the effectiveness of interventions to improve hand therapy adherence in people with upper limb conditions and to report on outcome measures used when reporting adherence.MethodsA literature search of MEDLINE (OVID), Embase (OVID), CENTRAL (OVID), CINAHL (EBSCO), and EmCare (OVID) (from inception to March 2017) was undertaken. Studies were selected if they met the following inclusion criteria: clinical trials; in adults or children with any injury or condition affecting the upper limb including acute trauma and injury; chronic and acquired musculoskeletal conditions; and neurological conditions. Two independent assessors rated the study quality and risk of bias using the Cochrane Collaboration tool for assessing the risk of bias.ResultsEight studies met the inclusion criteria. Study quality ranged from 3 to 6 out of 7 points on the Cochrane risk of bias tool. There were 4 categories of intervention for improving adherence: orthosis/cast material/design; orthosis wear schedule; patient education mode for home exercise programs; and behavioral approaches. Due to heterogeneity of condition acuity, interventions, and outcomes reported, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is weak evidence from a very small number of trials that orthosis/cast material has no influence on treatment adherence in acute or chronic conditions and mode of patient education (audio-visual vs written) has no effect in acute conditions. There is low-to-moderate quality of evidence in support of behavioral interventions for achieving treatment adherence in chronic rheumatoid arthritis.ConclusionBehavioral approaches that encourage self-efficacy are likely to be useful in achieving treatment adherence in populations with chronic upper limb conditions. There is insufficient evidence for other interventions aimed at improving adherence in acute upper limb injuries and conditions.     

Effectiveness of pelvic floor muscle exercise therapy supplemented with a health education program to promote long-term adherence among women with urinary incontinence

AIMS: A longitudinal randomized controlled trial (RCT) was conducted to evaluate the effectiveness of physiotherapeutic pelvic floor muscle exercise (PFME) therapy supplemented with a health education program to promote long-term adherence among women with stress, mixed, and urge urinary incontinence (UI). METHODS: Women (n = 129) were evaluated by their general practitioner (GP) and randomized in either the control group (PFME therapy alone) or one of the three experimental groups (PFME therapy with one of the three health education program versions). Therapy consisted of 9-18 individual 30 min sessions with a specialized physiotherapist, over 14-22 weeks. Outcome measures were weekly frequency of wet episodes and adherence behavior. Women were assessed up to 1 year after therapy. RESULTS: The health education program had no additional impact to individual contact during PFME therapy on treatment outcome, nor on adherence. However, the individual physiotherapeutic treatment protocol was very effective in reducing weekly frequency of wet episodes from 23 to 8 times a week immediately after therapy, and effects were maintained during the 1-year follow-up period. Adherence was very high; most women followed the behavioral advice on average 6 days/week at posttest and still 4-5 days 1 year after therapy. Results were not different between incontinence types. Women who had relatively frequent wet episodes before and 1 year after therapy had higher adherence levels compared to women who had fewer weekly losses. CONCLUSIONS: Results suggest that a standardized protocol checklist for physiotherapists covering all treatment aspects of PFME therapy, may optimize long-term treatment outcome and adherence behavior among patients, and outshines the addition of a health education program.     

Implications of worse renal dysfunction and medical comorbidities in patients with NASH undergoing liver transplant evaluation: impact on MELD and more

Increasing numbers of patients with non-alcoholic steatohepatitis (NASH) are referred for liver transplant (LT). Our objective was to characterize patients with NASH among referred LT candidates (from 1998 to 2008), and we compared demographics, etiology of liver disease, diabetes, hypertension, smoking, obesity, cardiac disease, cancer, laboratory data, model for end-stage liver disease (MELD), and outcomes between NASH and non-NASH patients. Patients with NASH (n = 71) were compared to other chronic liver disease (n = 472). Patients with NASH were older (58.7 vs. 52.5 yr, p < 0.0001), Asian (53.5% vs. 34.7%, p = 0.03) and women (50.7% vs. 32.1%, p = 0.003). Patients with NASH had more diabetes, hypertension, obesity, cardiac disease, and smoking history (p < 0.05). Patients with NASH were equally likely to have liver cancer, but more likely to have non-liver cancers (20.8% vs. 4.4%, p = 0.008). There was no difference in MELD, but patients with NASH had lower protime/international normalized ratio (1.14 vs. 1.27, p = 0.04) and higher creatinine (1.26 vs. 0.98 mg/dL, p = 0.0018). Patients with NASH were equally likely to undergo evaluation, listing, and transplantation compared to non-NASH patients. While all patients with chronic liver disease can have renal dysfunction because of hepatorenal syndrome, patients with NASH have more renal dysfunction, perhaps related to diabetes, hypertension, and cardiovascular disease. Transplant centers should consider this carefully in selection of candidates for LT.     

Apocrine ductal carcinoma in situ associated with testosterone therapy in a transgender individual

We report the first case of apocrine ductal carcinoma in situ (DCIS) in a female-to-male transgender individual on testosterone therapy (TT). The gender confirmation total mastectomy revealed 2 cm DCIS with apocrine cytology, high nuclear grade with associated calcification, and necrosis. Immunohistochemistry revealed the DCIS was negative for ER, positive for AR with HER2/neu overexpression (3+). This patient with negative screening mammography developed apocrine DCIS on TT, suggesting that gender-affirming hormone therapy may have advanced malignant transformation of atypical apocrine cells. This may have implications for increased surveillance within the transgender population.