Fluid compliance among patients having haemodialysis: can an educational programme make a difference?

Title. Fluid compliance among patients having haemodialysis: can an educational programme make a difference? Aim. This paper is a report of a study to examine the effectiveness of a patient education programme on fluid compliance as assessed by interdialytic weight gain, mean predialysis blood pressure and rate of fluid adherence. Background. Patients with end stage renal disease who receive haemodialysis are often non‐compliant with their treatment regime, especially adherence to fluid restrictions. Method. An exploratory study was conducted in 2004–05 using a quasi‐experimental, single group design to examine the effectiveness of patient education on fluid compliance in a dialysis centre located in a major teaching hospital in Kuala Lumpur, Malaysia. Twenty‐six patients with an interdialytic weight gain of greater than 2·5 kg were identified as non‐compliant and recruited to the study. The intervention was carried out over a 2‐month period and included teaching and weekly reinforcement about diet, fluids and control of weight gain. Findings. Patients’ mean interdialytic weight gain decreased following the educational intervention from 2·64 kg to 2·21 kg (P < 0·05) and adherence to fluid restrictions increased from 47% to 71% following the intervention. Predialysis mean blood pressure did not improve following the intervention, although the maximum recording for predialysis systolic pressure dropped from 220 mmHg to 161 mmHg. Whilst no statistically significant associations were detected between interdialytic weight gain and age, educational level, marital status or employment status, women demonstrated a greater decrease in mean interdialytic weight gain than men. Conclusion. Nephrology nurses often have long‐term relationships with their patients and are ideally placed to provide ongoing education and encouragement, especially for those experiencing difficulties in adhering to fluid and dietary restrictions.     

The depression status of patients with end‐stage renal disease in different renal replacement therapies

Depression is a common emotional problem among end‐stage renal disease (ESRD) patients, but there is a paucity of research comparing the prevalence of depression between patients in different types of renal replacement therapies in Taiwan. The purpose of this study was to describe the prevalence of depression among ESRD patients in Taiwan who received different treatment regimens, and to determine the factors related to depression among these participants across various treatment regimens. A convenience sample of 342 participants was recruited from two medical centres. Participants were diagnosed with ESRD and received one of three renal replacement therapies, and screened for depression using the Taiwanese Depression Questionnaire (TDQ). The prevalence of depression (defined as TDQ score above 19) varied by treatment type: 36·3% (27/102) among peritoneal dialysis (PD) patients, 18·5% (17/92) among haemodialysis (HD) patients and 14·8% (21/142) among transplant patients. There were significant differences in the TDQ scores between the three treatment types (p < 0·001), indicating that participants' depression status varied by treatment type. Prevalence of depression among PD patients was higher than among HD and transplant patients. Logistic regression analysis revealed that treatment duration (p < 0·01) was a predictor of PD patients' depression, whereas self‐reported health status was a predictor of depression among both HD patients (p < 0·01) and transplant patients (p < 0·05). Screening for and treatment of depression should be important parts of the standard care of ESRD patients. Pre‐ and post‐therapy counselling by nurses and early recognition of emotional difficulties may also help these patients adapt to psychosocial stressors.     

Withdrawal of inhaled steroids in children with non‐cystic fibrosis bronchiectasis

Background: To study the effects of inhaled steroid withdrawal on bronchial hyperreactivity, sputum inflammatory markers and neutrophilic apoptosis in children with non‐cystic fibrosis (non‐CF) bronchiectasis. Objectives: To evaluate the role of inhaled steroids in the treatment of children with non‐CF bronchiectasis with specific emphasis on the bronchial hyperreactivity and neutrophilic apoptosis. Methods: Twenty‐seven children with steady‐state non‐CF bronchiectasis were evaluated primarily with metacholine challenge tests and apoptotic neutrophil ratios in induced sputum and secondarily with symptom scores, pulmonary function tests and tumour necrosis factor‐alpha (TNF‐α), interleukin‐8 (IL‐8) levels and neutrophil ratios in induced sputum before and after 12‐week withdrawal of inhaled steroids. Results: There were 16 girls and 11 boys. Median (interquartile range) age was 11·4 (9·5–13·6) years, follow‐up duration was 3·5 (2–6·5) years. Symptom scores (4 vs. 3; P = 0·27), oxygen saturation (95% vs. 97%; P = 0·06), pulmonary function tests (FEV1: 82% predicted vs. 83% predicted; P = 0·73), sputum neutrophil ratios (29·9% vs. 46·8%; P = 0·20), TNF‐α (58 pg/mL vs. 44·5 pg/mL; P = 0·55) and IL‐8 (2·7 ng/mL vs. 2·4 ng/mL; P = 0·82) levels in induced sputum were similar before and after 12‐week withdrawal of inhaled steroids. However, the number of patients with bronchial hyperreactivity increased (37% vs. 63% of patients; P = 0·016) and neutrophilic apoptosis in induced sputum decreased (42·8% vs. 20·2%; P = 0·03) after withdrawal. Conclusion: In this study, 12 week‐withdrawal of inhaled steroid treatment resulted in a significant increase in bronchial hyperreactivity and decrease in neutrophil apoptosis, but no change in sputum inflammatory markers in children with non‐CF bronchiectasis was observed.     

Estimating GFR in children with 99mTc‐DTPA renography: a comparison with single‐sample 51Cr‐EDTA clearance

Glomerular filtration rate (GFR) measurement by ⁵¹Cr‐ethylenediaminetetraacetic acid (EDTA) and blood sampling in children is usually cumbersome for the patient, parents and laboratory technicians. We have previously developed a method accurately estimating GFR in adults. The aim of the present study was to evaluate the accuracy of this non‐invasive method in children. We calculated GFR from ^99mTc‐diethylene triamine pentaacetic acid (DTPA) renography and compared with ⁵¹Cr‐EDTA plasma clearance of 29 children between the age of 1 month and 12 years (mean 4·7 years). The correlation between ^99mTc‐DTPA renography and ⁵¹Cr‐EDTA plasma clearance was for all children R = 0·96 (n = 29, P<0·0001), for children above 2 years of age R = 0·96 (n = 18, P<0·0001) and for children <2 years R = 0·84 (n = 11, P<0·001). We conclude that assessment of GFR from ^99mTc‐DTPA renography is reliable and comparable to GFR calculated from ⁵¹Cr‐EDTA plasma clearance. Because our method is non‐invasive and only takes 21 min, it may be preferable in many cases where an assessment of renal function is needed in children especially when renography is performed anyhow.     

Pharmacokinetics of single‐dose rosiglitazone in chronic ambulatory peritoneal dialysis patients

Background: End‐stage renal disease (ESRD) is associated with marked alterations in the pharmacokinetics of many drugs, not only from reduction in renal clearance but also from changes in metabolic activity, bioavailability, volume of distribution and plasma protein binding. Objective: To study the pharmacokinetics of a single 8‐mg oral dose of rosiglitazone in patients with ESRD and requiring long‐term chronic ambulatory peritoneal dialysis (CAPD). Method: The medication was administered just before the first exchange of peritoneal dialysis fluid on the day that blood and peritoneal dialysate collection was performed. Results: In our CAPD patients the mean (±SD) T_max and T_1/2 of rosiglitazone were 1·20 ± 0·26 and 21·38 ± 21·96 h respectively. These values were different to those reported for healthy volunteers reported in previous studies. The mean area under the concentration–time curve (AUC_(0–∞)) and an average maximum observed plasma concentration (C_max) of rosiglitazone in our CAPD patients were 4203·56 ± 2916·97 ng h/mL and 409·67 ± 148·89 ng/mL respectively. These appear no different from those reported in healthy volunteers . Conclusion: The apparently significant difference in T_1/2 of rosiglitazone in CAPD patients compared with healthy volunteers suggest that dose adjustment may be necessary in order to avoid toxicity.     

Low serum fetuin‐A concentration predicts poor outcome only in the presence of inflammation in prevalent haemodialysis patients

Background Fetuin‐A, a negative acute phase protein that inhibits vascular calcification, has a controversial association with mortality in chronic kidney disease (CKD) patients. Chronic inflammation, which is common in CKD, may promote vascular calcification. Materials and methods We investigated the impact of inflammation on the relationship between serum fetuin‐A and mortality (42 months) in 222 prevalent haemodialysis (HD) patients. Results Serum fetuin correlated negatively with comorbidity score (assessed by Davies score) and circulating inflammatory markers. Patients with low fetuin‐A levels (< median) had higher mortality (Hazard ratio ‘HR’ 2·2; CI 1·4–3·5, P < 0·001), but this association was lost after adjustment for age, gender, comorbidities score, dialysis vintage and inflammation (CRP > median). In inflamed patients with low fetuin a significantly independent association with mortality (HR 2·3; CI 1·2–4·5, P = 0·01) was observed compared to non‐inflamed patients with high fetuin‐A, after adjusting for the same variables. Non‐inflamed patients with low fetuin‐A and inflamed patients with high fetuin‐A did not have increased mortality compared to non‐inflamed patients with high fetuin‐A. Conclusions The results show that low levels of serum fetuin‐A are associated with increased mortality in HD patients only in the presence of inflammation. This suggests that coexistence of a low serum fetuin‐A level and low‐grade inflammation exerts an additive effect on the risk of death in HD patients.     

Technetium‐99m‐anti‐tumour necrosis factor alpha scintigraphy as promising predictor of response to corticotherapy in chronic active Graves' ophthalmopathy

It has been suggested that technetium‐99m (99mTc)‐anti‐tumour necrosis factor alpha (TNF‐α) scintigraphy (SCI) may be a useful diagnostic tool in Graves' ophthalmopathy (GO). This study evaluated whether orbit total radioactivity uptake on SCI could be used to predict corticosteroid therapy (CorT) responses in active‐GO patients. A longitudinal study of patients with active GO defined by Clinical Active Score (CAS) >3/7 was done. Clinical, laboratory and SCI evaluations were performed at baseline and 3 months after concluding intravenous CorT. SCI (planar and tomographic) was assessed after intravenous injection of 10 mCi of 99mTc‐anti‐TNF‐α. Orbits and cerebral hemispheres were defined as regions of interest (ROIs) to enable orbit/hemisphere ROI‐ratios of total radioactive uptake. ROI‐ratios were considered positive at >2·5. Average total radiation uptake (TRU) was also determined for each orbit (AVG_ROI). Clinical, laboratory and SCI data were compared between responders (CAS became inactive) and non‐responders to CorT (18 patients). At baseline, AVG_ROI were higher in active OG orbits (67·3 cps) than in inactive ones (33·6 cps; P<0·05). AVG_ROI (absolute values) reduced (?29·9 cps) in CorT responders and tended (P = 0·067) to differ from variations occurred in non‐responders (+6·9 cps in patients with maintained CAS positivity post‐treatment). Higher baseline ROI‐ratios (4·9 versus 3·3; P = 0·056) and its pronounced reductions following CorT (?37% versus +56% in non‐responders; P = 0·036) tended to be associated with good CorT responses in the subgroup of GO history ≥1 year. SCI showed a good association with active eye disease and may be an additional tool to identify CorT responders.     

Late potentials and QT dispersion after high‐dose chemotherapy in patients with non‐Hodgkin lymphoma

The most common cardiotoxic effects of high‐dose cyclophosphamide (CY) are electrocardiographic changes and transient arrhythmias. Therefore, we prospectively assessed serial electrocardiogram (ECG) and signal‐averaged electrocardiogram (SAECG) recordings in 30 adult patients with non‐Hodgkin lymphoma (NHL) receiving high‐dose CY as part of high‐dose chemotherapy (HDT) regimen. All patients were treated with anthracyclines earlier. Heart‐rate‐corrected QT interval and QT dispersion (QTc and QTc dispersion) were measured from ECG. QRS duration and late potentials (LPs) were analysed from SAECG. Both ECG and SAECG were recorded 1 day (d) prior to HDT (d?7) at baseline, and 1 day (d?2), 7 days (d+7), 12 days (+12) and 3 months (m+3) after HDT. Stem cells were infused on day 0 (d0). Cardiac systolic and diastolic function were assessed on (d?7), (d+12) and (m+3) by radionuclide ventriculography. At baseline, four patients presented with LPs. Cardiac systolic function decreased significantly (53 ± 2; 49 ± 2%, P = 0·009 versus baseline), whilst no patient developed acute heart failure. QRS duration prolonged and RMS₄₀ reduced significantly versus baseline (104 ± 3; 107 ± 3 ms, P = 0·003; 41 ± 4; 38 ± 3 μV, P = 0·03), and six patients (21%) presented with LPs after CY treatment. Both QTc interval and QTc dispersion increased versus baseline (402 ± 5; 423 ± 5 ms, P<0·001; 32 ± 2; 44 ± 3 ms, P = 0·012), and six patients (20%) developed abnormal QT dispersion. In conclusion, high‐dose CY causes subclinical and transient electrical instability reflected by occurrence of LPs as well as increased QTc interval and QT dispersion. Thus, longer follow‐up is required to confirm the meaning of these adverse effects on cardiac function and quality of life.     

Disease knowledge and treatment adherence among patients with thalassemia major and their mothers in Taiwan

Aims. The current study had three aims: (i) to examine disease knowledge in both thalassemia major patients and their mothers; (ii) to understand the relationships between disease knowledge and treatment adherence in thalassemia major patients; and (iii) to explore the importance of selected factors in predicting patients’ knowledge about thalassemia major. Background. Patients with thalassemia major must be treated with life‐long blood transfusions. Evidence suggests that patients with more knowledge/information about their illnesses adhere more readily to treatment schedules. However, there has been little evaluation of knowledge and treatment adherence in thalassemia major patients. Design and methods. A cross‐sectional correlational survey design and purposive sampling were used. Thirty‐two thalassemia major patients (mean age 17·5 years) and 32 mothers (mean age 40·5 years) were recruited. Results. On a scale ranging from 0–20, the average of the patients’ disease knowledge about thalassemia major was 15·19 and the average of their mothers’ disease knowledge was 16·44. The scores for the patients’ disease knowledge about thalassemia major were positively correlated with follow‐up visit adherence (r = 0·690, p < 0·001) and with desferrioxamine infusion adherence (r = 0·791, p < 0·001). 95.6% of variance in patients’ knowledge was explained by a model that included mothers’ knowledge (β = 0·901, p < 0·001), follow‐up visit adherence (β = 0·084, p = 0·140) and annual household income (β = 0·042, p < 0·387). Conclusions. The positive association between knowledge and treatment adherence and factors of patients’ knowledge indicate the need for systematic education for patients and caregivers to improve adherence to treatment. Relevance to clinical practice. Improvement of the quality of patient care, reinforcement of medical education and enhanced efforts by clinical staff to provide practical knowledge to patients with thalassemia major should significantly improve patient adherence to treatment.     

Doxycycline vs. levofloxacin in the treatment of community‐acquired pneumonia

Background: Community‐acquired pneumonia (CAP) affects 5–10 million adults annually in the United States with approximately 1·1 million hospitalizations. Current guidelines recommend fluoroquinolones as monotherapy for treatment of CAP in general medical wards and doxycycline monotherapy for outpatient therapy only. Fluoroquinolones are expensive and development of bacterial resistance to them has become a concern. Therefore, we studied whether doxycycline is as efficacious as levofloxacin in treatment of CAP in general medical wards. Methods: In this prospective double‐blinded trial, non‐pregnant adults with clinical and radiological evidence of pneumonia requiring hospitalization were enrolled. Patients who were septic, hypoxic requiring intubations, nursing home residents, diagnosed with severe hepatic or renal dysfunction, recently hospitalized or immunocompromised were excluded from the study. Subjects were randomly assigned to either i.v. levofloxacin 500 mg daily or doxycycline 100 mg twice daily. After discharge, patients were followed for 2 months. Results: There were 30 patients in the levofloxacin group and 35 patients in the doxycycline group. Groups were comparable in both clinical and laboratory profiles. Additionally, efficacy of treatment was not significantly different between the two groups (P = 0·844). Length of stay was 5·7 ± 2·05 days in the levofloxacin group and 4·0 ± 1·82 days in the doxycycline group (P < 0·0012). Failure rate was similar in both groups (P = 0·893). Total antibiotic cost was $122·07 ± 15·84 for levofloxacin and $64·98 ± 24·4 for doxycycline (P < 0·0001). Conclusions: Our study supports doxycycline as an effective and economical alternative therapy for levofloxacin in the empirical treatment of CAP in general medical wards.     

The effectiveness of silver‐releasing dressings in the management of non‐healing chronic wounds: a meta‐analysis

Aim. The purpose of this study was to examine the efficacy of silver‐releasing dressings in the management of non‐healing chronic wounds. Background. Non‐healing chronic wounds often have a negative physical impact on patients and place a financial burden on healthcare systems. Silver dressings are wound products designed to control infection and provide a wound environment conducive to healing. However, validation of the clinical efficacy of these dressings is lacking. Design. Systematic review and meta‐analysis. Methods. A systematic search of the major electronic databases PubMed, CINAHL, Cochrane, MEDLINE, British Nursing Index, EBSCO, OCLC and Proquest between 1950–June 2007 was conducted. Hand searches of selected periodicals, textbooks and checking reference lists and contacting experts was also performed. Results. Eight studies were selected from a potentially relevant 1957 references screened. Analysis incorporated data from 1399 participants in the eight randomised control trials. We found that silver dressings significantly improved wound healing (CI₉₅: 0·16–0·39, p < 0·001), reduced odour (CI₉₅: 0·24–0·52, p < 0·001) and pain‐related symptoms (CI₉₅: 0·18–0·47, p < 0·001), decreased wound exudates (CI₉₅: 0·17–0·44, p < 0·001) and had a prolonged dressing wear time (CI₉₅: 0·19–0·48, p = 0·028) when compared with alternative wound management approaches. An analysis of sensitivity in these studies by subgroup analysis generally supported these associations. Furthermore, studies indicated an improvement in quality of life (CI₉₅: 0·04–0·33, p = 0·013) using silver dressings in wound management with no associated severe adverse events. Conclusion. This meta‐analysis confirms the effectiveness of silver dressings in wound healing and improving patients’ quality of life. However, it also highlights the need for additional well‐designed randomised controlled trials to evaluate the effectiveness of silver‐related dressings further. Relevance to clinical practice. The results of this study provide objective data on the effectiveness of silver‐related dressing when applied to non‐healing chronic wounds.     

Comparison of SSRIs and SNRIs in major depressive disorder: a meta‐analysis of head‐to‐head randomized clinical trials

Context: Controversy exists whether serotonin–norepinephrine reuptake inhibitors (SNRIs) have improved efficacy compared with selective serotonin reuptake inhibitors (SSRIs). Objective: To compare clinical outcomes of adults treated with SSRIs or SNRIs for major depressive disorder (MDD) under ideal clinical condition, research design, and outcome measure. Data sources: Electronic databases searched were Medline, Embase and Cochrane Library from inception to July 2007. Study selection: Included studies were those head‐to‐head randomized trials comparing remission (HAMD‐17 ≤7–8, MADRS ≤10–12) after 8–12 weeks of therapeutic doses of SSRIs or SNRIs in patients diagnosed with MDD were targeted for analysis. Reviews, letters, commentaries, economic studies, etc. were excluded. Studies were reviewed by two independent researchers. Where disagreements occurred in study selection, a consensus approach was used. Data extraction and analysis: Targeted outcome data included number of patients achieving remission, withdrawing from therapy due to lack of efficacy (LoE) and/or adverse drug reactions (ADRs), and total patients in trial. A random effects model combined intent‐to‐treat (ITT) and per‐protocol (PP) odds ratio (OR), and remission and dropout rates. Chi‐square assessed heterogeneity. Quality assessment was done using Downs‐Black checklist. Results: Thirty‐three studies were identified; 18 were rejected (patients had co‐morbidities in 7, outcomes differed in 5, different follow‐up in 3, and three reviews). Fifteen head‐to‐head trials of 3094 patients, average age was 41·9 ± 11·9 years (for SNRIs) and 41·6 ± 12·1 years (for SSRIs), P = 0·941. All analyses displayed non‐heterogeneity (P > 0·05). The OR (under ITT) was 1·27 (1·06–1·52 95% CI) favoring SNRIs. Meta‐analytic remission rates were 48·5 ± 3·2% and 41·9 ± 4·2% for SNRIs and SSRIs, respectively. The meta‐analytic difference in remission rates between drugs was 5·7% (P = 0·007). Dropout rates due to ADRs were higher with SNRIs than SSRIs (3·2% difference, P < 0·001). Dropout rates due to LoE were non‐significant between studied groups (P > 0·05). Conclusions: Serotonin and norepinephrine reuptake inhibitors showed statistical but not clinical significance when compared with SSRIs in treating MDD.     

Population pharmacokinetics of high‐dose methotrexate in Japanese adult patients with malignancies: a concurrent analysis of the serum and urine concentration data

Objective: This study aimed to develop a population pharmacokinetic model for high‐dose methotrexate (MTX), specifically focusing on the drug urinary excretion process. Methods and results: Three hundred and forty‐eight serum samples and 416 urine samples from 51 Japanese adult patients with malignancies were concurrently fitted into a multi‐compartment model using the nonmem program. In the final model, creatinine clearance (CCR, mL/min) and the MTX dose (DOSE10G; 0 when <10 g, 1 when ≥10 g) were the most significant factors that affected the renal clearance (CL_r) and non‐renal clearance (CL_nr), respectively: CL_r(L/h) = 5·57 × (CCR/80·0)^0·112, V₁(L) = 26·9, Q(L/h) = 0·0778, V₂(L) = 2·27, CL_nr(L/h) = 0·567 × 3·39^DOSE10G, where V₁ and V₂ are the volumes of distribution of the central and peripheral compartments, respectively, and Q is the inter‐compartmental (central–peripheral) clearance. For another nine patients, the model enabled a satisfactory Bayesian estimation using two time‐point serum concentrations. Conclusion: The newly developed population pharmacokinetic model should improve the quality of serum concentration monitoring of high‐dose MTX to predict and control toxic events.     

Heart rate recovery after constant‐load exercise tests is decreased in proportion to the importance (severity and diffusion) of exercise‐induced lower‐limb ischaemia

Background: Conditions that may influence heart rate recovery at 1 min of recovery from exercise (HRR1: end‐exercise heart rate minus heart rate 1 min after exercise) are not fully understood. We hypothesized that the ‘importance’ (both local severity and regional diffusion) of peripheral skeletal muscle ischaemia is associated with low HRR1. Design and Methods: In 529 patients with suspected or confirmed peripheral vascular disease not receiving beta‐blockers (61·4 ± 11·3 years old), we retrospectively studied the relationship of HRR1 to exercise‐induced changes in transcutaneous oxygen DROP index (limb changes minus chest changes from rest). The sum of DROP indices observed on both calves and both buttocks (DROPtot) provides the unique opportunity to estimate both the severity and the diffusion of exercise‐induced ischaemia on the right and left side simultaneously. It was used during a constant‐load treadmill test (3·2 km h^?1; 10% grade) to classify patients in quartiles, the fourth quartile representing the more ‘important’ ischaemias. Results: There was an inverse relationship between quartiles of DROPtot and HRR1, even after adjustment for heart rate reserve (Delta HR: end‐exercise minus resting heart rate), age (≤ or >60 years), gender, body mass index, treadmill maximal walking distance and ankle brachial index: adjusted R = 0·629; P<0·0001. Conclusions: During constant‐load treadmill testing, DROPtot, an index of the ‘importance’ of exercise‐induced lower‐limb ischaemia, correlates with HRR1. Whether HRR1 is improved in proportion of DROPtot improvement in patients undergoing surgery or rehabilitation for peripheral artery disease is a fascinating issue for future studies.     

Impact of a self-administration of medications programme on elderly inpatients' competence to manage medications: a pilot study

What is known and objectives: Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non‐adherence at home after discharge. Self‐administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients’ competence to manage medications and their medication adherence behaviours. Methods: The SAMP comprised three stages: education, progressing to supervised self‐administration and finally to independent self‐administration. Decisions to progress patients to the next level, and whether they passed or failed the SAMP, were made by the ward pharmacist and nursing staff. The Drug Regimen Unassisted Grading Scale (DRUGS) was used to assess patients’ competence to manage medications at various time points. Tablet count and the Tool for Adherence Behaviour Screening (TABS) were used as adherence measures. Results and discussion: Participants (n = 24) with a mean age of 77·4 years, were mainly female and generally had a high level of functioning. They were prescribed a mean of 9·0 medications at the time of commencing the SAMP. Twenty‐two of the 24 participants successfully completed the SAMP. DRUGS scores at discharge improved significantly (P < 0·001) compared with that before commencement of medication self‐administration. Participants reported a significant decrease (P = 0·02) in non‐adherent behaviour and a trend towards improved adherent behaviour (P = 0·08) after participation in the SAMP. What is new and conclusion: An inpatient SAMP improved elderly patients’ ability to competently manage and adhere to their prescribed medications regimen. This finding needs to be confirmed in a larger controlled trial.     

Predictors of the intima‐media thickness of carotid artery in asymptomatic newly detected severe hypercholesterolemic patients

Background: Data about predictors of intima‐media thickness (IMT) of common carotid artery (CCA) in asymptomatic subjects with newly detected severe hypercholesterolemia is scarce. Aim: This research is aimed at studying the predictors of the IMT of CCA among basic atherogenic risk biomarkers – lipid [total cholesterol (TC), triglycerides, high‐density lipoprotein cholesterol, low‐density lipoprotein (LDL) cholesterol, Apolipoprotein‐B, Apolipoprotein‐Ai, Apolipoprotein‐B/A₁ index] and non‐lipid, [asymmetric dimethylarginine (ADMA), total homocysteine, cell adhesion molecules] in asymptomatic subjects with newly detected severe hypercholesterolemia. Methods: Two hundred and fifty asymptomatic patients with severe, newly hypercholesterolemia and 200 controls were evaluated. Hypercholesterolemia was defined as TC > 7·5 mm and LDL cholesterol > 4·9 mm . The ADMA and cell adhesion molecules were determined by ELISA and total homocysteine by high‐performance liquid chromatography. Results: There was significant difference between the two groups in respect to all lipid biomarkers (P<0·001). Hypercholesterolemic patients had significantly higher level of ADMA, sVCAM‐1, sICAM‐1, IMT (P<0·001), whereas no significant difference was found between two groups with respect to total homocysteine, P‐selectin and E‐selectin (P>0·05). A strong positive correlation between IMT mean and age (r_xy = 0·714; P<0·001), Apolipoprotein‐B (r_xy = 0·706; r_xy < 0·001), Apolipoprotein‐B/A₁ (r_xy = 0·324; P<0·001), ADMA (r_xy = 0·603; P<0·001) was found. The subsequent linear and multiple regression analysis selected age and Apolipoprotein‐B as most significant factors in relation to IMT mean. Apolipoprotein‐B is a better factor for assessment of risk, as LDL cholesterol underestimates the risk in asymptomatic subjects with newly detected severe hypercholesterolemia, until more rapid and feasible methods for measurement of small and dense LDL are available.