Therapeutic compliance: a prospective analysis of various factors involved in the adherence rate in type 2 diabetes

It's established that adherence rates to treatment are bad in chronic illnesses. The number of medicines prescribed and the rates of daily dosages have been shown to be of major influence for therapeutic compliance in AIDS or hypertension. Nevertheless, data on adherence to prescribed medications amongst diabetics are scarce. The aim of our study was to evaluate parameters influencing therapeutic compliance in type 2 diabetes. Adherence to treatment was evaluated by a questionnaire filled out during patient's hospitalisation in the diabetology department of a French general hospital of 450 beds. Factors influencing compliance were quantified taking into account demographic characteristics of our population, the treatments used, biological and medical data. 94 patients hospitalised for uncontrolled diabetes, aged 41-89 years, were studied. Non-adherence rate was high, 33 of them showed poor adherence to their drug treatment. Non-compliers were younger than compliant patients (56.512.1 vs. 65.512.5 years old; P<0.0001) and with a lower social position. Clinically, they were characterised by a shorter duration of diabetes and a lower number of clinical complications as macroangiopathy (6.9 vs. 33.3%; P=0.006). The number of daily doses or medicines didn't affect adherence rate. Improved control in therapeutic compliance may lead to better diabetic patients education. The implication is that instead of increasing the dose, changing the medication, or adding a second drug when glucose and HbA_1clevels are high, clinicians should consider counselling patients on how to improve therapeutic compliance.     

Survival after avalanche-induced cardiac arrest

Aim

Criteria to prolong resuscitation after cardiac arrest (CA) induced by complete avalanche burial are critical since profound hypothermia could be involved. We sought parameters associated with survival in a cohort of victims of complete avalanche burial.

Methods

Retrospective observational study of patients suffering CA on-scene after avalanche burial in the Northern French Alps between 1994 and 2013. Criteria associated with survival at discharge from the intensive care unit (ICU) were collected on scene and upon admission to Level-1 trauma center. Neurological outcome was assessed at 3 months using cerebral performance category score.

Results

Forty-eight patients were studied. They were buried for a median time of 43 min (25–76 min; 25–75th percentiles) and had a pre-hospital body core temperature of 28.0 °C (26.0–30.7). Eighteen patients (37.5%) had pre-hospital return of spontaneous circulation and 30 had refractory CA. Rewarming of 21 patients (43.7%) was performed using extracorporeal life support. Eight patients (16.7%) survived and were discharged from the ICU, three (6.3%) had favorable neurological outcome at 3 months. Pre-hospital parameters associated with survival were the presence of an air pocket and rescue collapse. On admission, survivors had lower serum potassium concentrations than non-survivors: 3.2 mmol/L (2.7–4.0) versus 5.6 mmol/L (4.2–8.0), respectively (P < 0.01). They also had normal values for prothrombin and activated partial thromboplastin compared to non-survivors.

Conclusions

Our findings indicate that survival after avalanche burial and on-scene CA is rarely associated with favorable neurological outcome. Among criteria associated with survival, normal blood coagulation on admission warrants further investigation.     

The effect of partial patients’ adherence to antihypertensive drugs: scope for pharmacists’ role in hypertension care

In many individuals, blood pressure varies between clinic visits conducted days, weeks, or months apart. This visit-to-visit variability (VVV) of blood pressure has been recently related with an increased risk of coronary heart disease, stroke, and mortality, independently of mean blood pressure. As for other chronical diseases, patients’ adherence to hypertensive therapies remains low and partial adherence to antihypertensive treatment may constitute a source of VVV, as suggested by recent studies. This data should lead to a new clinical approach for hypertension care, based on patients’ real adherence to treatment. Therapeutic strategies should include patients’ adherence. In this context, the role of community pharmacists for patients’ follow-up of hypertension should be reinforced, as they represent efficient and easily accessible health professionals.

     

Evaluation of a hypertension-based patient education program in a stroke center

Background The benefits of educational programs are recognized in chronic diseases. An education program was designed in our hospital, for hypertensive patients after an acute episode of stroke to prevent stroke recurrence. Objective Evaluate the effects of such program on patient knowledge and blood pressure management. Setting The 12-bed stroke center of the Groupe Hospitalier Paris Saint-Joseph, France. Method An individual educational session was provided to all the patients by the pharmacist a few days after admission. The effectiveness of the session was evaluated using a questionnaire completed by each patient before and after education. The patients had to identify the correct responses and to judge their answer’s self-confidence. The answers were ranked based on their accuracy and the surety of the respondent. Reported medication adherence and self-measurement of blood pressure were analyzed as part of the survey. Patient satisfaction with the intervention was also measured by means of a separate questionnaire. Main outcome measure Evolution of response correctness and self-confidence as well as medication adherence and blood pressure self-measurement practice. Results 64 patients were enrolled. Correct response rate increased from 77.9 to 94.1% and the absolutely sure response rate raised from 52.9 to 80.8%. Patient self-confidence was improved mainly for correct responses. Patients reported a better medication adherence and a more frequent practice of blood pressure self-measurement. They were highly satisfied. A negative correlation was found between knowledge evolution and baseline knowledge. Conclusion Education can improve stroke patient knowledge, which may enhance medication adherence and blood pressure control. Such programs should be developed even early after a stroke.     

Balanced versus chloride-rich solutions for fluid resuscitation in brain-injured patients: a randomised double-blind pilot study

Introduction

We sought to investigate whether the use of balanced solutions reduces the incidence of hyperchloraemic acidosis without increasing the risk for intracranial hypertension in patients with severe brain injury.

Methods

We conducted a single-centre, two-arm, randomised, double-blind, pilot controlled trial in Nantes, France. Patients with severe traumatic brain injury (Glasgow Coma Scale score ≤8) or subarachnoid haemorrhage (World Federation of Neurosurgical Society grade III or higher) who were mechanically ventilated were randomised within the first 12 hours after brain injury to receive either isotonic balanced solutions (crystalloid and hydroxyethyl starch; balanced group) or isotonic sodium chloride solutions (crystalloid and hydroxyethyl starch; saline group) for 48 hours. The primary endpoint was the occurrence of hyperchloraemic metabolic acidosis within 48 hours.

Results

Forty-two patients were included, of whom one patient in each group was excluded (one consent withdrawn and one use of forbidden therapy). Nineteen patients (95%) in the saline group and thirteen (65%) in the balanced group presented with hyperchloraemic acidosis within the first 48 hours (hazard ratio = 0.28, 95% confidence interval [CI] = 0.11 to 0.70; P = 0.006). In the saline group, pH (P = .004) and strong ion deficit (P = 0.047) were lower and chloraemia was higher (P = 0.002) than in the balanced group. Intracranial pressure was not different between the study groups (mean difference 4 mmHg [-1;8]; P = 0.088). Seven patients (35%) in the saline group and eight (40%) in the balanced group developed intracranial hypertension (P = 0.744). Three patients (14%) in the saline group and five (25%) in the balanced group died (P = 0.387).

Conclusions

This study provides evidence that balanced solutions reduce the incidence of hyperchloraemic acidosis in brain-injured patients compared to saline solutions. Even if the study was not powered sufficiently for this endpoint, intracranial pressure did not appear different between groups.

Trial registration

EudraCT 2008-004153-15 and {"type":"clinical-trial","attrs":{"text":"NCT00847977","term_id":"NCT00847977"}}NCT00847977The work in this trial was performed at Nantes University Hospital in Nantes, France.     

A case-control study indicates that coagulation imbalance is associated with arteriosclerosis and markers of endothelial dysfunction in kidney failure

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Characteristics and outcomes of SARS-COV 2 critically ill patients after emergence of the variant of concern 20H/501Y.V2: A comparative cohort study

There are currently no data regarding characteristics of critically ill patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variant of concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean). Consecutive patients with Covid-19 and over 18 years admitted in the unique intensive care unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a LR comparing wave 1 and wave 2 as outcomes. To complete analysis, we built a Random Forest model (RF), that is, a machine learning classification tool- using the same variable set as that of the LR. We included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% confidence interval (CI) 1.89–14.48, p = .001) and a lower simplified acute physiology score (SAPS II) (aOR 0.95, 95% CI 0.91–0.99, p = .007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98–12.51, p = .055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98–0.99, p = .03). Patients in wave 2 had also an increased risk of ventilator-associated pneumonia (VAP) (aOR 4.64, 95% CI 1.54–13.93, p = .006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model. Our data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.     

Complete Atrioventricular Block in an Elderly Patient Treated with Low-Dose Lacosamide

Lacosamide, one of the last antiepileptic drugs marketed, can cause extension of PR interval. Precautions are recommended when used in elderly and with other drugs extending PR interval. Cases of severe third-degree atrioventricular block have been reported only in post-marketing case reports when used at high-doses and remain rare. We report the case of an 88-year-old woman treated with bisoprolol, who experienced a complete atrioventricular block after initiation of lacosamide for epilepsy associated with neurodegenerative disease. This dramatic event required a pacemaker implementation. Not being dose-dependent (initiation dosage used), it seemed partially explained by drug–drug interaction with bisoprolol.