Costs of Medication Nonadherence in Patients with Diabetes Mellitus: A Systematic Review and Critical Analysis of the Literature

Objectives:  Information on the health care costs associated with nonadherence to treatments for diabetes is both limited and inconsistent. We reviewed and critically appraised the literature to identify the main methodological issues that might explain differences among reports in the relationship of nonadherence and costs in patients with diabetes.
Methods:  Two investigators reviewed Medline, EMBASE, Cochrane library and CINAHL and studies with information on costs by level of adherence in patients with diabetes published between January 1, 1997 and September 30th 2007 were included.
Results:  A total of 209 studies were identified and ten fulfilled the inclusion criteria. All included studies analyzed claims data and 70% were based on non-Medicaid and non-Medicare databases. Low medication possession ratios were associated with higher costs. Important differences were found in the ICD-9/ICD-9 CM codes used to identify patients and their diagnoses, data sources, analytic window period, definitions of adherence measures, skewness in cost data and associated statistical issues, adjustment of costs for inflation, adjustment for confounders, clinical outcomes and costs.
Conclusions:  Important variation among cost estimates was evident, even within studies of the same population. Readers should be cautious when comparing estimated coefficients from various studies because methodological issues might explain differences in the results of costs of nonadherence in diabetes. This is particularly important when estimates are used as inputs to pharmacoeconomic models.     

Chronic hepatitis C in the Latino population

Latinos with hepatitis C virus (HCV) infection have more rapid progression of fibrosis and decreased response to anti-HCV treatment. The high rates of metabolic syndrome, insulin resistance, and hepatic steatosis, as well as genetic differences, may explain the severity of chronic hepatitis C (CHC) in this population. In addition, Latinos encounter substantial barriers to medical care, including language, cultural differences, and socioeconomic factors such as lack of medical insurance. This article reviews evidence regarding the natural history of CHC in Latinos, efficacy of therapy, and possible strategies to improve outcomes.     

Danazol fails to increase factor VIII or IX levels in a double-blind crossover study of patients with haemophilia A and B

Twenty-one patients, 14 with haemophilia A and seven with haemophilia B, completed a double-blind crossover study to evaluate the effects of danazol on factor VIII and factor IX levels. Clotting and immunoradiometric assays were used to measure factor levels at baseline, 2 weeks and 8 weeks on both danazol and placebo. Fibrinogen, plasminogen and activated partial thromboplastin time were measured on all patients during placebo and danazol treatment. Although plasminogen levels rose significantly (P less than 0.01) and fibrinogen decreased (P less than 0.01), factor VIII and IX levels did not change. While on danazol, three patients had increased bleeding and shortened euglobulin lysis times compared to their baseline levels. We conclude that danazol does not raise factor VIII or IX levels and increases bleeding in some patients.     

Early neonatal sudden death or near death syndrome. An epidemiological study of 29 cases

Early neonatal sudden death syndrome (SIDS) is a rare but well known disease entity. Between January 1975 and December 1991, 29 full-term newborn infants delivered in our maternity unit and, considered healthy at birth, suffered early SIDS ( n = 15) or early apparent life threatening events (ALTE) ( n = 14). Data from the whole population of live full-term infants born in our hospital during the past five years have been used as a reference (n = 27 841). The general rate of early SIDS was 0.14 per 1000 (15/107 263). Combining early ALTE cases, the overall rate was 0.27 per 1000 (291107263). A postmortem examination was performed for all infants who died (20/29): no cause of death could be determined, and we did not observe a single case with evident sequelae. There were 9 deaths (31 %) within the first hour after delivery and 12 deaths occurred in the early morning hours (04:00–08:00; RR = 3.76; p = 0.0008). The lowest incidence was in the spring (RR = 0.21; p = 0.03). There was a tendency for an increased incidence during the weekend and the summer. No influence of sex, maternal age, gestational age, infant weight presentation, delivery, anesthesia or presence of meconium-stained fluid was found. In our opinion, SIDS can take place even during the first hour of life and it is not possible to predict when a baby might be affected. Pediatrically trained caregivers, close observation by the mother during the first few days and resuscitation facilities in maternity wards may be the most important preventive measures to reduce the risk of early SIDS and the consequences of ALTE in the early newborn period.     

TRAP induces more intense tyrosine phosphorylation than thrombin with differential ultrastructural features

We have analyzed modifications on platelet ultrastructural morphology, cytoskeletal assembly, and tyrosine phosphorylation developing in platelets activated by both thrombin and the thrombin receptor-activating peptide (TRAP). Washed platelets exposed to various concentrations of thrombin or TRAP, for different periods, were: fixed and examined by electron microscopy, or lysed and analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Under similar activating conditions, thrombin and TRAP induced different sequences of activation causing distinctive morphological and biochemical changes. Platelets exposed to thrombin showed centralized organelles encircled by constricted microtubule coils and granules secreting their contents through narrow channels of the open canalicular system. In contrast, activation by TRAP induced swelling of the open canalicular system with organelles remaining randomly dispersed and microtubules peripherally distributed. Compared to thrombin activation, TRAP induced higher rates of actin polymerization; increased association of actin-binding protein, myosin, and alpha-actinin; and higher association of tyrosine-phosphorylated proteins with the insoluble cytoskeletal fraction. Secretion of intragranule substances, measured as expression of P-selectin and lysosomal integral membrane protein at the surface level, were similar for both agonists at equivalent concentrations. Our biochemical observations indicate that TRAP causes more intense changes in signaling through tyrosine phosphorylation of proteins associated with the cytoskeletal fraction than thrombin. However, as derived from ultrastructural observations, TRAP seems to be less efficient in triggering cytoskeletal assembly and internal contraction in an organized manner in contrast with the natural protease.     

Fecal Markers of Intestinal Inflammation and Permeability Associated with the Subsequent Acquisition of Linear Growth Deficits in Infants

Enteric infections are associated with linear growth failure in children. To quantify the association between intestinal inflammation and linear growth failure three commercially available enzyme-linked immunosorbent assays (neopterin [NEO], alpha-anti-trypsin [AAT], and myeloperoxidase [MPO]) were performed in a structured sampling of asymptomatic stool from children under longitudinal surveillance for diarrheal illness in eight countries. Samples from 537 children contributed 1,169 AAT, 916 MPO, and 954 NEO test results that were significantly associated with linear growth. When combined to form a disease activity score, children with the highest score grew 1.08 cm less than children with the lowest score over the 6-month period following the tests after controlling for the incidence of diarrheal disease. This set of affordable non-invasive tests delineates those at risk of linear growth failure and may be used for the improved assessments of interventions to optimize growth during a critical period of early childhood.     

Efectividad a corto y largo plazo de un programa tutelado de formación en espirometrías para profesionales de atención primaria

Introduction

Despite the importance of spirometry, its use and quality are limited in the Primary Care setting. There are few accredited training programs that have demonstrated improvement in the quality of spirometric studies. In this paper, we analyze the short- and long-term effectiveness of a supervised training program for performing and interpreting spirometries.

Methodology

Ours is an intervention study with before and after measurements. The target population included teams of physicians and nursing staff at 26 health-care centers in the area of Vigo (Galicia, Spain). The structured training program involved 2 theoretical and practical training sessions (that were 2 months apart), an intermediate period of 30 supervised spirometries performed in the respective centers and weekly e-mail exercises. Effectiveness was evaluated using exercises at the beginning (test 1) and the end (test 2) of the 1 st day, 2 nd day (test 3) and one year later (test 4), as well as the analysis of spirometries done in month 1, month 2 and one year later. Participants also completed a survey about their satisfaction.

Results

74 participants initiated the program; 72 completed the program, but only 45 participated in the one-year evaluation. Mean test scores were: 4.1 ± 1.9 on test 1; 7.5 ± 1.6 on test 2; 8.9 ± 1.3 on test 3, and 8.8 ± 1.4 on test 4. During month 1, the percentage of correctly done/interpreted tests was 71%, in month two it was 91% and after one year it was 83% (P < .05).

Conclusions

A training program based on theoretical and practical workshops and a supervised follow-up of spirometries significantly improved the ability of Primary Care professionals to carry out and interpret spirometric testing, although the quality of the tests diminished over time.     

Sonographic Evaluation of the Distal Iliopsoas Tendon Using a New Approach

Sonography of the iliopsoas tendon plays an important role in the diagnosis and preoperative and postoperative management for the increasing number of patients under consideration for arthroscopically guided hip interventions such as iliopsoas tenotomy in a variety of conditions, including arthropathy, periarticular calcifications, and cam‐type deformities of the femoral head. The ability to visualize the iliopsoas tendon pre‐operatively can be helpful diagnostically in patients presenting with hip pain and can aid in planning surgery, while evaluating the tendon postoperatively is important in the assessment of causes of postoperative pain and other potential complications. We present a novel technique for visualizing the distal iliopsoas tendon complex in the longitudinal axis at its insertion on the lesser trochanter on sonography.