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Peritoneal surface malignancies are a group of aggressive cancers involving the peritoneum. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy can improve outcomes and survival in select patients. Despite significant advancements in care, racial disparities in peritoneal malignancy outcomes persist and may have even worsened over time. Poor adherence to guideline-recommended therapy introduces wide variability in patient care and often results in fewer options and suboptimal treatment of vulnerable populations. This review explores biological, sociodemographic, and environmental factors that contribute to disparities in peritoneal malignancy outcomes.

The effect of direct oral anticoagulants (DOACs) on evolution of a post-thrombotic syndrome (PTS) is unknown.This retrospective study included patients (n = 98) with a PTS occurring after a proximal deep-vein thrombosis (DVT). The PTS progression was assessed by the Villalta scale change over time from when patients were started on DOACs for the prevention of DVT recurrence according to current guidelines. The PTS evolution was compared between patients with good (n = 63) vs. poor (n = 35) DOACs adherence, defined by using a medication possession ratio cut point of 0.80. The mean follow-up was 41.7 ± 17.7 and 27.5 ± 10.5 months in patients with good or poor adherence, respectively. The primary endpoint of PTS improvement (defined when the Villalta score became5 and/or decreased by ≥30% from baseline) was higher in patients with good vs. poor adherence (66.7% vs. 20%, p 0.001). None of the patients in the good adherence group experienced at any time of follow-up the co-primary endpoint of PTS worsening (defined as the Villalta score increase ≥30%), which instead occurred in 12 (34.3%) of those with poor adherence (p 0.001). All study-defined primary endpoints occurred within 2 years. The mean values of the Villalta partial scores related to the subjective symptoms (patient-rated) and to the potentially reversible physician-rated signs were significantly improved in the good adherence group, while they were unchanged among patients with poor adherence.In this study a good vs. poor DOACs adherence was associated with a more favorable progression of PTS over a long-term follow-up. Larger studies are needed to explore the clinical efficacy of DOACs on PTS manifestations.

Introduction Poor adherence to the 2011 American Society for Radiation Oncology (ASTRO) evidence-based guideline on whole-breast irradiation (WBI) has been reported. We utilized theMednet to assess the views of the updated 2018 guideline among radiation oncologists (ROs). Methods We identified 11 questions asked by community ROs on theMednet, a web-based platform, between October 27, 2014 and May 2, 2017 that were updated in the 2018 guideline. New answers provided by senior authors of the 2018 guideline, cited guidelines, and polls to survey ROs were disseminated in 3 theMednet's newsletters between March 16, 2018 and May 1, 2018. Any question with less than 60% consensus was resubmitted on October 9, 2019 and assessed on February 13, 2020. Results A total of 792 ROs responded to the initial surveys. In each survey, the answer choice(s) that received the majority of the votes aligned with the 2018 guideline. The strongest consensus was for the use of hypofractionated (HF)-WBI regardless of histology (97%), followed by HF-WBI boost dose (92%), molecular subtype (90%), grade (88%), and concurrent use of trastuzumab (87%). The least consensus was for age at which HF-WBI should be offered with 53% of respondents, specifically 73% of academic ROs versus 47% of community ROs (P = .001), agreeing with the guideline. The re-submitted survey 19 months later showed 77% of 287 new respondents now agreed with the guideline regarding age. Conclusion The majority of ROs concur with the 2018 WBI guideline in theMednet surveys, with better agreement among academic ROs than community ROs for certain components of the guideline. Further research into the different practice patterns may optimize patient care.

Poor adherence is a global health issue, affecting all chronic conditions and all age groups. Medications will only work if they are taken, and ongoing adherence to medication and treatment is difficult in chronic illness. Average adherence rates are approximately 50% in paediatric patients with asthma, and this can lead to poor disease control and an increase in morbidity. Thus, it is prudent to consider and discuss non-adherence, whether it be intentional or unintentional, to avoid unnecessary escalation of treatment. In this review, we discuss the fundamentals of adherence and the importance of goal setting. We discuss the challenges in varying age-groups, and methods that can be incorporated in various settings to optimize adherence. We explore how the advent of e-health (the combination of healthcare and technology) has impacted upon our ability to monitor adherence.

The 1500mg/day dietary sodium-restriction commonly recommended for patients with heart failure has recently been questioned. Poor adherence to sodium restricted diets makes assessing the efficacy of sodium restriction challenging. Therefore, successful behavioral interventions are needed. We reviewed sodium restriction trials and descriptive studies of sodium restriction to: 1) determine if sodium restriction was achieved in interventions among heart failure patients; and 2) characterize predictors of successful dietary sodium restriction. Among 638 identified studies, 10 intervention trials and 25 descriptive studies met inclusion criteria. We used content analysis to extract information about sodium restriction and behavioral determinants of sodium restriction. Dietary sodium was reduced in seven trials; none achieved 1500 mg/day (range=1938–4564mg/day). The interventions implemented in the interventional trials emphasized knowledge, skills, and self-regulation strategies, but few addressed the determinants correlated with successful sodium restriction in the descriptive studies (e.g., social/cultural norms, social support, taste preferences, food access, self-efficacy). Findings suggest incorporating determinants predictive of successful dietary sodium restriction may improve the success of interventional trials. Without effective interventions to deploy in trials, the safety and efficacy of sodium restriction remains unknown.

Colorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.RCT.Adults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.A mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.Colorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.Colorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.A mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.

Background Delusional disorder is an uncommon psychotic disorder. The first-line treatments for this chronic and resistant condition are antipsychotic medications, usually associated with several side effects that can exacerbate poor adherence. Conversely, aripiprazole is a well-tolerated antipsychotic drug that is effective in the treatment of other psychotic disorders. Here, we aimed to systematically review and summarize the currently available literature to evaluate the effectiveness and tolerability of aripiprazole in delusional disorders. Methods A comprehensive literature search from inception until February 2020 was performed in PubMed, Cochrane Database of Systematic Reviews, and Scopus databases using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results We identified 21 single cases of delusional disorders, mostly somatic type, treated with aripiprazole. All studies reported patient clinical improvements after the beginning of the treatment with aripiprazole. The average dose of aripiprazole was 11.1 mg/day, and the average time to achieve a clinical response was 5.7 weeks. Few adverse effects were reported, including asthenia, extrapyramidal symptoms, hyperprolactinemia, and insomnia. Conclusions Our findings suggest that aripiprazole may be an effective treatment for delusional disorders with good tolerability. Further studies comparing aripiprazole with other antipsychotics in the treatment of delusional disorders are needed.

About one-third of women of reproductive age are obese, predisposing both mother and baby to unfavourable pregnancy outcomes and initiating an intergenerational cycle of chronic metabolic disorders. Here we summarise recent research on the influence of maternal metabolic health on offspring susceptibility to future cardiometabolic diseases. Current primary lifestyle approaches (i.e., diet and exercise interventions) to halt the succession of inherited and epigenetic metabolic abnormalities have met with limited success due to late implementation, poor adherence, and/or generic guidelines. In our opinion, such interventions must commence prior to conception to improve both maternal and child health outcomes, with new approaches urgently needed to increase adherence to primary lifestyle changes among reproductive-age women.

Polypharmacy is a common observation among older adults secondary to their complex medical needs requiring management with 1 or more medications. The use of numerous medications may result in medication-related problems such as inappropriate indications, therapeutic duplication, adverse effects, drug interactions, unnecessary medications, poor adherence, and a strain on health care resources. Nurse practitioners will be required to review and streamline the appropriate and safe use of medications in patients to minimize some of the highlighted concerns. This article uses a case-based approach to showcase various issues that a nurse practitioner may encounter as it relates to polypharmacy and pharmacotherapeutic considerations. Tools are also explored to assess polypharmacy in the field.

Introduction Operation notes are fundamental for clinical, academic and medico-legal purposes. Good Surgical Practice (2014) provides guidelines to assist note completion but the literature suggests poor adherence to these. The aim of this study was to evaluate and improve operation note quality at a UK burns centre through implementation of a burns surgery-specific checklist. Methods A 22-component burns surgery-specific checklist, modified from Good Surgical Practice (2014), was designed and implemented. The quality of 80 operation notes (40 pre and 40 post-implementation) was assessed against this checklist. Fisher’s exact and Mann-Whitney U statistical tests were used to evaluate pre and post-intervention note quality. Results Before checklist implementation, only 6/22 components (27.3%) were recorded on every note. 4/22 components (18.2%) were not recorded on any, including microbiology specimen and clinical photography, which are particularly important in burns. After implementation, 16/22 (72.7%) were recorded on every note, with a statistically significant improvement in all other components (p ≤ 0.01), except venous thromboembolism prophylaxis (p = 0.10). The median percentage score of components recorded improved from 78.2 to 100% (p Conclusion To our knowledge, this is the first study in available literature to show that a burns surgery-specific checklist can significantly improve burns operation note quality. This presents a simple and cheap method to improve note quality and may enhance post-operative intra/inter-team communication and patient care. At our unit, we have now developed an electronic checklist format with mandatory field completion to facilitate total compliance.

Objective To establish current practice of the management of learning and clustering effects, by treating center and surgeon, in the design and analysis of randomized surgical trials. Study design and setting The need for more surgical randomized trials is well recognized, and in recent years conduct has grown. Rigorous design, conduct, and analyses of such studies is important. Two methodological challenges are clustering effects, by center or surgeon, and surgical learning on trial outcomes. Sixteen leading journals were searched for randomized trials published within a two-year period. Data were extracted on considerations for learning and clustering effects. Results A total of 247 eligible studies were identified. Trials accounted for learning with 2% using an expertise-based design and 39% accounting for expertise by predefining surgeon credentials. One study analyzed learning. Clustering, by site and surgeon, was commonly managed by stratifying randomization, although one-third of center and 40% of surgeon stratified trials did not also adjust analysis. Conclusion Considerations for surgical learning and clustering effects are often unclear. Methods are varied and demonstrate poor adherence to established reporting guidelines. It is recommended that researchers consider these issues on a trial-by-trial basis, and report methods or justify where not needed to inform interpretation of results.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasou ...

Background: Rheumatic heart disease is a major cause of premature cardiovascular related death in the developing countries. It is preventable disease by secondary prophylaxis injection if good adherence is maintained. But, information regarding adherence rate and its associated factors is limited and inconsistent in Ethiopia. Objective: The study was aimed to assess the adherence rate of rheumatic heart disease patients to secondary prophylaxis and its associated factors in multiple hospitals Jimma zone, Southwest Ethiopia. Methods: A cross sectional study was conducted from August –November, 2019 among selected rheumatic heart disease patients on follow-up at four hospitals in Jimma zone. Data was collected by face-to-face interview and record review using semi-structured questionnaire. Adherence status of rheumatic heart disease patients to secondary prophylaxis in the last consecutive 12 months was assessed based on the annual frequency of received prophylaxis (monthly injection of Benzathine Penicillin). Good adherence was considered if the patient was covered >80% of annual dose. The collected data was entered into Epidata 3.1 and analysed using SPSS 23. Results: A total of 253 rheumatic heart disease patients taking prophylaxis were finally included in the analysis. About 178 (70.4%) of them were females with male to female ratio of 1:2.4. The mean age was 24 ± 11 years that ranged from 6 to 65 years. The adherence rate of the rheumatic heart disease patients was 63.2% while the remaining 36.8% were considered as poor adherent for missing more than three times of the annual dose. New York Heart Association functional class I and II; rural residency, distance >30 km from health facility and duration of prophylaxis (>5 years)) were associated with poor adherence (AOR(95%CI) and P-value of 12.6(2.5-63), 0.016; 6.8(1.9-24.4), 0.003;5.5(1.2-26.7), 0.046; and 1.2(1.1-3.2), 0.021 respectively. The main reasons to miss prophylaxis more than three times were long distance from the treatment setting (56.9%) followed by lack of money (38%). Conclusion: Patients with class I and II heart failure and those living in rural areas especially at distance of >30 kms from the hospitals were identified to be poor adherent to secondary prophylaxis. Funding Statement: Jimma University provided fund for data collectors. Declaration of Interests: The authors declared that there is not conflict of interests. Ethics Approval Statement: Institutional ethics approval was obtained from the research and the ethics committee of institute of health of Jimma University. Before data collection, informed consent and assent (for those unable to give consent) was obtained.

Background and purpose Pharmacist-delivered medication therapy management (MTM) services are an important part of practice, and students should be trained in MTM provision. Current MTM utilization falls short of the potential benefits that pharmacists could provide, and there are barriers to successful MTM completion. New MTM models need to be explored to demonstrate the pharmacist's role on the medical team and to provide models for cost saving to insurers. Educational activity and setting This manuscript describes a novel grant-funded MTM model supported by fourth year pharmacy students in partnership with several medical clinics. Qualifying patients receive MTM services in the provider office. Students are responsible for maintaining day-to-day operations of the MTM program. Findings Twe pharmacy students completed their MTM training through this model between April 2016 and September 2017. 123 patients received MTM services, with the average time spent with patients estimated at 41 min. A total of 238 patient encounters were provided. Poor adherence, inappropriate drug dose/dosage form or frequency, and patient side effects were the most common problems addressed. Students reported high satisfaction with this model. Discussion Providing MTM services, directly in the medical clinic, represents an innovative model of care where students have multiple interprofessional interactions. The extended period of time spent with patients is not supported by reimbursement rates, suggesting an expansion may be appropriate. Further cost analyses and health outcomes need to be collected to justify this increased expense. Summary This MTM model represents an important alternative to current practice and promotes interprofessional collaboration.

Purpose To report the clinical features, management, and outcomes of patients with ocular surface damage secondary to Roman candle explosion accidents. Methods Retrospective, noncomparative, interventional case series of 11 patients with Roman candle explosion-related ocular surface injuries referred to the Cincinnati Eye Institute between 2007 and 2016. Results Eleven patients (10 male, 1 female, mean age 22.4 years) sustained unilateral ocular surface injuries with presenting visual acuity ranging from count fingers to light perception. All patients had severe limbal stem cell deficiency with total ocular surface failure. Eight eyes received a conjunctival-limbal autograft (CLAU) with a keratolimbal allograft (KLAL), 1 eye received a living related-conjunctival limbal allograft (lr-CLAL) with a KLAL, and 2 eyes received a CLAU with lr-CLAL. Nine eyes underwent subsequent penetrating keratoplasty, and 7 eyes had reconstructive eyelid surgery. Nine eyes demonstrated improved visual acuity at last follow-up; seven eyes demonstrated a stable ocular surface at last follow-up. Nonadherence was noted in 7 patients, either with poor adherence with post-operative treatment or poor follow-up; this portended a worse visual result. Conclusions Roman candle-related accidents can lead to severe ocular surface injury. Despite total ocular surface failure, these eyes can achieve good postoperative visual results following limbal stem cell transplantation and subsequent keratoplasty with appropriate compliance.

Introduction Schizophrenia increases the risk of offending. Recidivism rates are significant. Literature doesn't provide recidivism risk factors specific to patients with schizophrenia independently of the offenses' types. Objective Identifying recidivism risk factors in schizophrenia patients independently of the offenses' types. Methods We conducted a case-control study. All included patients were admitted, at least once, to the forensic psychiatry unit in Razi Hospital between January 1st, 1985 and December 31st, 2014 after a decision of irresponsibility by reason of insanity. All those who reoffended during this period were considered as cases. Univariate and multivariate analyses were performed to identify recidivism risk factors. Results We included 25 cases and 38 controls. Eight recidivism risk factors were identified. Living in poor urban neighborhoods (P = 0.023; OR = 4.86), having been unemployed (P = 0.042; OR = 2.18) and not having lived with the family (P = 0.039; OR = 1.36) after discharge were considered as risk factors. The same applied to alcohol (P = 0.026; OR = 4.89) and cannabis use disorders (P = 0.018; OR = 6.01). A hospitalization shorter than 6 months multiplied the risk by 1.79 (P = 0.046). A combination of conventional antipsychotics (P = 0.023; OR = 4.81) and a poor adherence to treatment (P = 0.001; OR = 10.42) were considered as recidivism risk factors too. Conclusions All eight recidivism risk factors are dynamic. This makes recidivism prevention conceivable. Measures involving the patient, the health care system, patients' families, society and the government should be undertaken.

Minority individuals in the United States (US) have an increased prevalence of obstructive sleep apnea syndrome (OSA) compared to their white/Caucasian counterparts. In general, adherence to positive airway pressure (PAP) therapy is poor and some studies suggest that PAP use among minority individuals is inferior to that of whites. However, there has not been a review of the evidence that addresses racial-ethnic disparities for PAP adherence in the treatment of OSA, and no review has systematically examined the contributing factors to poor adherence among minority individuals compared to whites. We searched the literature for studies published between January 1990 to July 2016 that included objective PAP use comparisons between adult US minority individuals and whites. Twenty-two studies met the inclusion criteria. All studies compared the PAP adherence of blacks to whites. Seven studies compared the PAP adherence of additional minority groups to that of whites. Sixteen of the 22 studies (73%) showed worse PAP adherence in blacks compared to whites. Four studies found equivalent PAP use in US Hispanics compared to whites. Little is known about the PAP adherence of other US minority groups. We present a framework and research agenda for understanding PAP use barriers among US minority individuals.

We prospectively examined rates of outpatient oral medication adherence in children after hematopoietic stem cell transplant (post-HSCT). For 6 months after first discharge post-HSCT, 50 patients (aged 0 to 16 years) and their primary caregivers agreed to store 1 oral medication in an electronic pill bottle that date and time stamps each bottle opening. Demographics, disease, donor type, and prescribed post-HSCT medication regimen were collected via chart review. For each patient percent adherence was calculated by dividing the number of doses taken as indicated by the electronic pill bottle by the number of doses prescribed for the same time period. Average percent adherence ranged from 63% at 1 month after discharge to 57% at 6 months after discharge. For patients who received an allogeneic transplant, lower adherence was associated (P .005) with higher infection rates, after controlling for age and time since transplant. No such relationship was observed for patients who received an autologous transplant. This study demonstrates that poor oral medication adherence is prevalent, persistent, and, for patients receiving an allogeneic transplant, associated with increased incidence of infections during the outpatient treatment period. This study highlights the need for further research examining factors that hinder medication adherence as well as monitoring, promoting, and intervening to maximize medication adherence throughout the HSCT course.

Medication adherence is a complex, multi-determined behavior that is often influenced by system- (e.g., cost), drug- (e.g., regimen complexity), and patient-related (e.g., depression) factors. System-level approaches (e.g., making medications more affordable) are critically important but do not address patient-level factors that can undermine adherence. In this paper, we identify patient-level determinants of non-adherence and discuss whether mindfulness-training approaches that target these determinants can help to improve adherence to medical treatment. We highlight two chronic medical conditions (viz., heart failure and HIV) where poor adherence is a significant concern, and examine the evidence regarding the use of mindfulness interventions to improve medication adherence in these two conditions. We also discuss the theoretical underpinnings of mindfulness training with respect to medication adherence, and conclude by suggesting directions for future research.

A 21 year-old man, HIV infected, and with poor adherence to antiretroviral treatment, consulted us due to a papular rash on trunk and extremities, showing simultaneously hypochromic stains on his back. He was afebrile and hemodynamically stable. In the mycological study of the clinical samples taken from different lesions, yeasts compatible with Malassezia were observed. Oral itraconazole was prescribed, with an excellent clinical response. Finding the same etiolologic agent in 2different clinical pictures on a single patient is extremely rare.

The purpose of gout treatment is to alleviate symptoms of flares, prevent flares from recurring by lowering serum urate, and minimize structural joint damage and functional impairment. In recent years, several new medications to treat gout have been developed, and novel agents continue to be investigated, in addition to several long-established treatments. Although a number of effective therapies are available, optimal management and outcomes are frequently not achieved due to physician under prescribing of urate-lowering therapy (ULT) and poor adherence with therapy when it is prescribed. This article reviews recent developments in the management of gout with reference to recently published clinical guidelines, outlines some important questions regarding the safety and efficacy of particular agents, and remaining gaps in our knowledge about the most effective strategies for using currently available treatments.

Introduction Anemia during pregnancy increases the risk of premature delivery as well as maternal and child mortality. More than 40% and almost one-third of pregnant women are anemic worldwide and in Ethiopia respectively. Iron supplementation is important to prevent anemia during pregnancy in developing countries including Ethiopia. Despite this fact, it is at a substandard level in Ethiopia. Therefore, this study was conducted to identify the determinant factors of poor adherence to iron supplementation among pregnant women in Ethiopia. Methods A cross-sectional study was conducted based on the EDHS data for 2016 from two city administrations and nine regions of Ethiopia. A total of 3, 266 women were included. Bivariable and multivariable logistic regression analysis was employed. P-value < 0.05 and odds ratios were used to determine the significance and strength of association. Results Those pregnant women who had no mobile telephone [AOR; 0.79, 95% CI (0.65–0.95)], a history of cigarette smoking & alcohol use [AOR; 0.20, 95% CI (0.09–0.45)] and [AOR; 0.77, 95% CI (0.64–0.93)], and less than four antenatal care visits [AOR; 0.56, 95% CI (0.46, 0.68)] had higher odds of poor adherence. Conclusion Not having a mobile telephone, a history of smoking and alcohol use, and less than four antenatal care visits were determinant factors of poor adherence to iron supplementation. It is important to empower women, strengthen communication for behavioral change, and give attention to counseling pregnant women., Poor adherence, Iron supplementation, Pregnant women, Ethiopia.

Adolescent and young adult (AYA) patients with acute lymphoblastic leukaemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents aged 15-20 years old, the use of full paediatric protocols is supported by many comparative studies of paediatric and adult cooperative groups. In young adults, growing evidence suggests that paediatric-inspired approaches may also improve outcomes and lead to long-term survival rates of almost 70%. In the last decade, better knowledge of ALL oncogenic landscape, age distribution, and minimal residual disease prognostic impact have improved risk stratification. New targets have emerged mostly in the heterogeneous subgroup of Philadelphia-like ALL and will require both in-depth molecular investigations and specific evaluations in rare subgroups of ALL. The remaining gap with the excellent results reported in children has many other contributing factors that should not be underestimated including late or difficult access to care, or poor adherence to treatment.

This study examined the feasibility and impact of a multicomponent adherence intervention among youth with Inflammatory Bowel Disease (IBD) who presented to clinic with poor adherence.Medical providers referred twelve adolescents for the intervention, who participated in 4 weekly visits with a caregiver aimed at improving adherence.Intervention session attendance was 100% and the intervention was rated as feasible and acceptable. Mean adherence increased 12% from baseline to post-intervention (p0.01), and 6% from baseline to 1-month follow-up (p0.025). A generalized linear model revealed significantly greater adherence from baseline to post-intervention (p0.001), and from baseline to 1-month follow-up (p0.01). Logistic Regression revealed a nearly 2:1 odds ratio during post-intervention when compared to the Baseline period (p0.001).Findings suggest that the delivery of a multicompoment adherence intervention to poorly adherent youth with IBD can result in significant improvements in their adherence to oral medication.An intervention individually tailored to each family's unique adherence barriers is a feasible and promising treatment approach for improving medication adherence among nonadherent youth seen in clinical care.

Introduction While the benefits of pulmonary rehabilitation programs (PR) in COPD have been demonstrated, poor adherence, related with worse clinical outcomes, is common. Objective The purpose of this study was to examine causes for drop-out during a 12-week multidisciplinary pulmonary rehabilitation program and to investigate the characteristics of patients with poor adherence, with special emphasis on functional and clinical characteristics. Method A prospective study was performed between February and November 2015 in 83 COPD patients enrolled in an outpatient program of 36 strength+resistance training sessions. Ambulances were provided to facilitate access to the clinic. Patients were divided into: adherent (A) (attended at least 70% of the program) or non-adherent (NA) (at least one session). Results A total of 83 patients were evaluated and 26 excluded; 15.7% refused to participate. The drop-out rate was 38.5%. The main causes were low motivation and transport problems. Lower forced vital capacity (NA, 58.9% vs A, 67.8%; P=.03), worse results on submaximal exercise test (NA, 6.2 min vs A, 9.2 min; P=.02), in total distance walked (NA, 42.6 vs A, 56.5; P=.03) and VO2 in ml/min/kg (NA, 11.4 vs A, 13.6; P=.03) and in ml/min (NA, 839 vs A, 1020; P=.04) were found in the non-adherent group. This group also showed higher use of oral steroids (NA, 23.8% vs A, 2.9%; P=.01). Conclusions More than 1/3 of patients leave programs. The main causes are related to motivation and transport. The patients who dropout are those with worse functional tests, more exacerbations, steroids and smoking habit.

Allopurinol is the most commonly used medication to treat hyperuricaemia as a cause of gout. One of the challenging aspects of initiating allopurinol therapy is that treatment can precipitate flares, and can therefore do the opposite of what it is intended for—a situation that patients can understandably find confusing. To reduce the likelihood of flares, allopurinol needs to be started at a low dose and uptitrated; anti-inflammatory prophylaxis, such as colchicine, needs to be co-prescribed; and a treatment plan for managing flares should be given to the patient. The result is that allopurinol initiation becomes a complicated three-pronged strategy, with the consequent poor continuation rates we see in practice. In addition, there are widespread negative sociocultural beliefs about gout and patients with gout. Patients with gout can experience social stigma that deters both initiation and continuation of treatment. Other important barriers include the reluctance of physicians to initiate treatment for gout and poor adherence by physicians to recommended treatment pathways; health system issues, such as limitations on how quickly patients can be reviewed; and health-care funding models.

ResumenLa enfermedad celíaca (EC) es un trastorno sistémico inmune mediado por la ingesta de gluten en individuos genéticamente susceptibles. Se caracteriza por manifestaciones clínicas variables, auto anticuerpos anti-endomisio, anti-transglutaminasa (tTG) y/o anti-péptidos de gliadina deamidados (PGD) en sangre, más daño variable de la mucosa intestinal. En Chile el 0,76% de los mayores de 15 años tiene IgA-tTG positiva y la prevalencia de EC se estima en ∼0,6%. En familiares de primer grado de celíacos se ha identificado ∼17% de casos tTG positivos. Hasta hoy el único tratamiento es la dieta libre de gluten (DLG), que para ser efectiva debe ser estricta, permanente y durante toda la vida. La DLG no contiene cero gluten, sino que lo disminuye hasta un «punto de corte», que en Chile es 3ppm (o mg/kg de producto). La mortalidad de la EC es mayor que la de la población general, y la falta de adherencia al tratamiento se asocia a complicaciones (procesos autoinmunes y cáncer principalmente). La DLG es difícil de mantener estrictamente, y las transgresiones son por lejos la principal causa de falta de respuesta al tratamiento. El seguimiento también es difícil, porque no existen marcadores objetivables que midan la adherencia. En la práctica clínica se utiliza la medición de auto anticuerpos anti-endomisio, tTG y/o PGD; más recientemente se están evaluando las entrevistas por una nutricionista especializada, cuestionarios validados y la medición de péptidos 33-mer en heces como alternativas o complementos de la evaluación de adherencia. En este artículo se revisan las herramientas de seguimiento actualmente utilizadas, poniendo énfasis en aquellas disponibles en Chile.AbstractCoeliac disease (CD) is a systemic autoimmune disorder triggered by gluten consumption in genetically susceptible individuals. It exhibits several clinical features, such as blood auto-antibodies (anti-endomysial antibodies EMA, anti-transglutaminase antibodies tTG, anti-deamidated gliadin peptides PGD), plus variable degrees of damage in the small intestinal mucosa. In Chile, tTG is positive in 0.76% in individuals >15 years, with the prevalence of CD being estimated at 0.6%. Approximately17% of first-degree relatives of coeliac patients have been reported tTG positive. To date, the gluten free diet (GFD) is the only known treatment for CD. To be effective, this must be lifelong, permanent, and strict. Gluten content in the GFD is not zero, but is limited to a cut-off of 3ppm (ormg/kg of product) in Chile. Mortality higher than that of the general population has been reported among coeliac patients, and poor adherence to GFD is associated with complications (mainly autoimmune processes and cancer). GFD is difficult to maintain strictly and poor adherence is by far the main cause of lack of response to treatment. Follow-up of adherence is also difficult because there are no objective measurements to assess it. In clinical practice determination of serum EMA, tTG and PGD is routinely used for these purposes, although more recently, the interview by an expert dietitian, validated questionnaires and measurement of faecal 33-mer peptide are being assessed as alternatives or complements to measure adherence to GFD. A review is presented with the current concepts on the available tools to follow up patients on GFD, emphasising those available in Chilel.

The effectiveness of amblyopia therapy can be limited by poor adherence. Dichoptic therapies are a new approach, but recent trials have demonstrated difficulty maintaining high adherence over extended periods of at-home treatment. We evaluated the efficacy and adherence of Luminopia One-a dichoptic treatment that applies therapeutic modifications to streaming content chosen by the patient.This single-arm, multicenter prospective pilot study enrolled children aged 4-12 with anisometropic, strabismic, or mixed amblyopia at 10 pediatric ophthalmic and optometric practices across the United States. The therapeutic was prescribed for 1 hour/day, 6 days/week for 12 weeks of at-home use. The primary endpoint was best-corrected visual acuity (BCVA) at the 12-week follow-up visit.In total, 90 participants (mean age, 6.7 ± 2.0 years) were enrolled, and 73/90 participants (81%) had prior treatment beyond refractive correction. For those who completed the 12-week visit, mean amblyopic eye BCVA improved from 0.50 logMAR to 0.35 logMAR (1.5 logMAR lines; 95% CI, 1.2-1.8 lines; P 0.0001). Mean stereoacuity improved by 0.28 log arcsec (95% CI, 0.14-0.42 log arcsec; P 0.0001). Median adherence was 86% (interquartile range, 70%-97%).In our study cohort, adherence over the 12-week study period was high, and participants demonstrated clinically and statistically significant improvements in visual acuity and stereoacuity.

New diagnostic and treatment tools are the "stars" of scientific meetings but other aspects may have an even greater impact on patients' lives. Several new studies presented at DDW (Digestive Disease Week) 2016 demonstrated that: a) treatment adherence continues to be suboptimal even in the most advanced health systems; b) lack of adherence correlates with low treatment effectiveness, with higher levels of intestinal damage and higher costs; and c) the factor most consistently associated with poor adherence is age (the younger the patient, the poorer the adherence). In any new programme aiming to enhance the quality of inflammatory bowel disease management, a key element should be the inclusion of new patient information and communication systems to increase treatment adherence. The new tools available in the telemedicine era provide an opportunity to improve the care of inflammatory bowel disease, but their success is limited by multiple problems. Overcoming these barriers should be our key goal in the next few years.

In children with growth disorders, mean final height is associated to poor adherence to Growth Hormone therapy. The primary goal of this study is to identify patients who do not adhere to GH therapy and determine the influence of adherence in response to the treatment. The role of serum IGF-I and influence of socio-economic factors on the therapeutic adherence will also be evaluated.158 children under treatment with rhGH were included in the study. Age, gender, etiology, Tanner stage, duration of treatment, growth rate, IGF-I serum values, daily dose, and annual rhGH dose data were collected. Adherence to therapy was defined as moderate-to-poor when the patient had taken less than 92% of the prescribed medication. A subgroup of 106 patients completed a questionnaire to assess social and environmental effects.Moderate-to-poor adherence to rhGH treatment was determined in 33.5% of study patients. A decrease in adherence was associated to treatment duration (p=0.001). A significant correlation was determined between adherence and height velocity (p=0.002) and IGF-I (p0.0001) levels. Adherence rates were associated to the mother's educational level (p=0.007).Poor adherence to GH therapy was observed in one-third of study patients, resulting in suboptimal growth. IGF-I levels can be helpful to identify patients with poor adherence to GH medication. Physicians should pay special attention to certain characteristics of the patient and their environment, and encourage desirable therapeutic compliance.

Aim We evaluated the prevalence of barriers to self-care and associations between these barriers and adherence to self-care behaviours among people with type 2 diabetes. Methods Cross-sectional study among people with type 2 diabetes recruited from the diabetes clinics of three hospitals. A survey assessed barriers to self-care conceptualised into the constructs of the theory of planned behaviour (TPB) (i.e. attitudes, subjective norms, perceived behavioural control). The Summary of Diabetes Self-care Activities scale was used to assess adherence to self-care. Results The study included 252 (90% response rate) participants. Prevalent barriers included: lack of knowledge on how to use a glucometer (59.8%, n = 150); difficulty in changing dietary habits (58.7%, n = 148); and lack of money to purchase a glucometer (55.2%, n = 139). Attitudinal barriers were commonly reported for diet, exercise and foot care; perceived behavioural control barriers were frequently reported for self-monitoring of blood glucose (SMBG); and subjective norm barriers for medication taking. The only significant association was between adherence to foot care and subjective norms barriers. Conclusions The commonly-reported types of barriers varied according to the type of self-care behaviour but no specific type of barrier was associated with poor adherence to diabetes self-care behaviours.

Purpose The purpose of the study was to evaluate adherence to prescribed antiepileptic drugs (AEDs) and influencing factors in children with epilepsy from western China. Methods In this cross-sectional study, children with epilepsy were recruited from Western China Second Hospital. Questionnaires were used to collect baseline patient data and medication adherence, which was assessed using the Morisky scale. An ordinal logistic regression model was used to examine the factors affecting medication adherence. Results In total, 399 children were included. The age of participants ranged from 0.3 to 17.8 years, with a male-to-female ratio of 1.36:1. Overall, 57.1% (228/399) had generalized seizures. Further, 21.3% (85/399) patients showed good adherence, 51.4% (205/399) moderate adherence, and 27.3% (109/399) poor adherence. Ordered multiclassification logistic regression analysis showed that the age of patient, type of epilepsy, total household income, and source of drug information were associated with adherence. Conclusions Medication adherence is not high in children with epilepsy from western China. Medication adherence is affected by many factors, and we suggest that efforts are focused on tailored approaches to epilepsy education and behavioral interventions for better adherence.

Sore throat remains a common disease of childhood, and a major cost and cause for antibiotic prescriptions. The management of sore throat remains controversial in affluent countries with various guidelines available and overall poor adherence to those guidelines. Group A streptococcus is the commonest bacterial cause with important sequelae including acute rheumatic fever (ARF). The driver for diagnosis and treatment is still questionable. In most affluent populations it is difficult to justify antibiotic treatment on the basis of preventing ARF, whereas this remains the major driver for sore throat management in populations at higher risk of ARF. Reduction in severity and duration of symptoms may be a reasonable basis to consider antibiotic treatment, and thus accurate diagnosis of GAS pharyngitis, particularly in those with more severe symptoms. The potential role of rapid tests in diagnosis appears to be increasing.

Condoms remain the most effective barrier against the sexual transmission of the human immunodeficiency virus (HIV). Male condoms have proven to be 80% to 90% effective, and female condoms have similar results. Poor adherence and improper use limit their effectiveness. In addition to condoms, microbicides are a promising barrier against HIV transmission. More than 50 candidate topical microbicide compounds have undergone preclinical or clinical testing in the last 10 years, but there are currently no US Food and Drug Administration (FDA)-approved compounds. Rectal microbicides are also being developed, as anal receptive sex is an effective mode of HIV transmission.

Guidelines encourage the utilization of best practice based on the latest evidence or expert consensus opinion. If used correctly they can drive changes to service provision that are important for patients and offer a confident, defensible foundation for the clinical health-care professional. Producing good, evidence-based clinical guidelines is an expensive process even when accounting for the fact that the clinical health-care professionals on the development groups do much of the work in their spare time. If a guideline is not subsequently used widely and correctly, the value of the whole exercise has to be questioned. If the uptake of recommendations is slow, they may be out of date by the time they are being used and even inhibit the adoption of more contemporary guidelines; it appears that this may apply to guidelines on the management of pulmonary nodules. A previous evaluation of the use of current pulmonary nodule guidelines found that 44.7% received care inconsistent with recommendations, and the strongest independent predictor of this was inappropriate advice given by the radiologist.1 Other studies have consistently shown poor adherence to pulmonary nodule guidelines.2-4

Colonoscopies play a vital role in population screening programs, either for initial examinations or as a test carried out after a positive result from a fecal occult blood test or sigmoidoscopy. Colonoscopies, and ancillary techniques such as polipectomies, must comply with basic quality criteria that must be reflected in the quality standards of screening programs. A quality colonoscopy is absolutely vital to avoid the occurrence of interval cancers. It is extremely important to detect any proximal lesions during a colonoscopy, especially those which are serrated, because they are difficult to identify and due to the increased risk of colorectal cancer. Regarding follow-up programs for resected colorectal polyps, current evidence of the relationship between the risk of neoplasia and certain variables (age, sex, smoker, BMI, diabetes, etc.) must allow for individualized risk and algorithms for screening and follow-up frequency to be developed for these patients. However, initial endoscopic exploration in a screening colonoscopy is essential to establishing the optimum interval and ensuring follow-up. Despite poor adherence to follow-up programs, mostly due to their overuse, follow-up colonoscopies 3 years after resection of all polypoid lesions detect clinically significant lesions as effectively as colonoscopies at one year.

Adherence to surgical safety checklists remains challenging. Our institution demonstrated acceptable rates of checklist utilization but poor adherence to all checkpoints. We hypothesized that stepwise, multifaceted interventions would improve checklist adherence.From 2011 to 2013, adherence to the 14-point, pre-incision checklist was assessed directly by trained observers during three, 1-year periods (baseline, observation #1, and observation #2) during which interventions were implemented. Interventions included safety workshops, customization of a stakeholder-derived checklist, and implementation of a report card system. Chi-square and Kruskal-Wallis tests were utilized.Checklist performance was assessed for 873 cases (baseline, n = 144; observation #1, n = 373; observation #2, n = 356). Total checkpoint adherence increased (from 30% to 78% to 96%; P.001), as did cases with correct completion of all checkpoints (from 0% to 19% to 61%; P.001). The median (interquartile range) number of checkpoints completed per case improved from 4 (3-5) to 11 (10-12) to 14 (13-14; P.001).A strategic, multifaceted approach to perioperative safety significantly improved checklist adherence over 2 years. Checklist content and process need to reflect local interests and operative flow to achieve high adherence rates. Successful checklist implementation requires efforts to change the safety culture, stakeholder buy-in, and sustained efforts over time.

Antiretroviral drugs are used for the treatment and prevention of HIV infection. Non-adherence to antiretroviral drug regimens can compromise their clinical efficacy and lead to emergence of drug-resistant HIV. Clinical trials evaluating antiretroviral regimens for HIV treatment and prevention can also be compromised by poor adherence and non-disclosed off-study antiretroviral drug use. This report describes the development and validation of a high throughput, qualitative method for the identification of antiretroviral drugs using high-resolution mass spectrometry (HRMS) for the retrospective assessment of off-study antiretroviral drug use and the determination of potential antiretroviral therapy (ART) non-compliance.Serum standards were prepared that contained 15 antiretroviral drugs: 9 protease inhibitors (PIs), 4 nucleotide/nucleoside reverse transcriptase inhibitors (NRTIs), and 2 non-nucleoside/nucleotide reverse transcriptase inhibitors (NNRTIs). Analytical separation was achieved on a Hypersil Gold PFP (100×3mm) column and the eluent was analyzed using the Thermo Exactive Orbitrap mass spectrometer (Exactive-MS) operated in full scan mode. Limit of identification, signal intensity precision, retention time analysis, selectivity, and carryover studies were conducted. Concordance with liquid chromatographic-tandem mass spectrometric (LC-MS/MS) methods was evaluated using remnant plasma samples from a clinical trial.The limit of identification ranged from 5 to 10ng/ml for 14 drugs (9 PIs, 1 NNRTI, 4 NRTIs) and was 150ng/ml for 1 NNRTI. Precision studies with high and low control mixtures revealed signal intensity coefficients of variation of 3.0-27.5%. The Exactive-MS method was selective for the compounds of interest. Overall, concordance ranged from 89.1% to 100% for the screening of antiretroviral drugs in clinical plasma specimens as compared to LC-MS/MS methods.Using the Exactive-MS, we developed and validated a highly selective, robust method for the multiplexed detection of 15 antiretroviral drugs.

Objective To explore possible links between adherence to the Mediterranean Diet (MeD), excess body weight, energy balance behaviors, and academic performance in Greek primary schoolchildren. Design Cross-sectional study. Setting Primary schools in Athens, Greece. Participants A total of 528 students (256 boys and 272 girls), 10–12 years of age, were recruited from 21 primary schools in the area of Athens, Greece. Main Outcome Measures Students completed a specifically designed energy balance behaviors questionnaire together with the KIDMED index, which evaluates the degree of adherence to the MeD. The teacher assessed academic performance through a specifically designed, 5-scale questionnaire. Standard anthropometric measurements were also taken. Analysis Block stepwise regression analysis was conducted. Results Adherence to the MeD (β = .140; P = .001), obesity (β = −.095; P = .001), physical activity levels (β = .206; P = .001), hours of sleep (β = .100; P = .003), television viewing (β = −.068; P = .05), and global self-esteem levels (β = .122; P = .001) are significant factors in predicting academic performance in primary schoolchildren. Conclusions and Implications Poor adherence to the MeD, obesity, and low physical activity levels seem to negatively affect academic performance in children. Understanding these interrelationships could facilitate the formation of policies focused on improving children's academic achievement.

Introduction This study evaluated and compared the completeness of reporting of abstracts of orthodontics systematic reviews before and after the publication of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Abstracts Checklist (PRISMA-A). Methods Abstracts of systematic reviews and meta-analyses in orthodontics published in PubMed, Latin American and Caribbean Health Sciences Literature, and the Cochrane Database of Systematic Reviews databases before March 23, 2018, that met the predefined inclusion and exclusion criteria, were evaluated using the 12 items of PRISMA-A, scoring each item from 0 to 2. Abstracts were classified into 2 groups: before and after publication of the PRISMA-A checklist. Three calibrated evaluators (intraclass correlation coefficient and kappa > 0.8) assessed the scores for compliance with the checklist. The number of authors, country of affiliation of the first author, performance of meta-analysis, and topic of the article were recorded. A regression analysis was performed to assess the associations between abstract characteristics and the PRISMA-A scores. Results Of 1034 abstracts evaluated, 389 were included in the analysis. The mean PRISMA-A score was 53.39 (95% CI, 51.83-54.96). The overall score for studies published after the publication of the checklist was significantly higher than for studies published before (P ≤ 0.0001). The components returning significantly higher scores after publication of PRISMA-A were title (P = 0.024), information from databases (P = 0.026), risk of bias (P ≤ 0.0001), included studies (P ≤ 0.0001), synthesis of results (P ≤ 0.0001), interpretation of results (P = 0.035), financing and conflict of interest (P ≤ 0.0001), and registration (P ≤ 0.0001). These results showed the positive effect of PRISMA-A had on the quality of reporting of orthodontics systematic reviews. Nevertheless, the poor adherence revealed that there is still need for improvement in the quality of abstract reporting. Conclusions The quality of reporting of abstracts of orthodontic systematic reviews and meta-analyses increased after the introduction of PRISMA-A.

Background Bronchiolitis is the number one cause of hospitalization in children under 2 years of age. AAP guidelines emphasize that only supportive care is needed for bronchiolitis. Data obtained from our institution showed poor adherence to AAP guidelines. This project was undertaken with the goal of improving compliance with these guidelines. Aim Statement Our aim was to reduce length of stay (LOS) for admitted low risk patients with bronchiolitis, age 1-24 months, from 67 hours to Interventions A care path and respiratory score were adapted for our institution. Every patient admitted for bronchiolitis was assessed and given a score using respiratory rate, auscultation, and use of accessory muscles. All patients was ordered nasal suction, saline and reassessed. Persistently high scores resulted in escalation of care. The respiratory score and order set were built into the EMR. The care path was made hospital policy. Physicians, respiratory and nursing received education. Measures Data from patients age 1-24 months hospitalized with bronchiolitis from Nov - Dec 2017 were obtained. Excluded were those born Results Charts of patients with bronchiolitis from Jan to Dec 2018 were reviewed. Data were collected regarding LOS, PICU use, and use of chest x ray, albuterol, steroids, epinephrine and antibiotics. We saw an increase in cases in Sept-Dec 2018 with no increase in PICU use. Nov and Dec 2018 average LOS was Conclusions and Next Steps Conclusions and Next Steps With additional education and reinforcement, we hope to make the trend toward improved care for bronchiolitis the standard in our institution. Early observations after implementation of the care path indicate a reduced length of stay, but further data points are needed to know if this change will be sustained.

Introduction The treatment of heart failure is one of the main pillars of the management of patients with chronic heart failure and adherence to treatment is a real problem in managing these patients. Several personal, social and environmental factors can participate in this component, which is why it is worthwhile to look into the question. Aim The aim of our work was to study the adherence of patients to different treatments for heart failure and to study the main influencing factors. Methods We carried out a cross-sectional study related to a survey at the heart failure unit in the cardiology department of the IBN ROCHD CHU Casablanca, conducted on 180 patients regularly followed in the service over a period of 6 months from January to June 2018, the data were collected by a survey: CARDIA, and analyzed by SPSS software. Results The mean age of our patients was 60.6 years, with male predominance (62 vs 38%), the main cause of heart failure was ischemic and the ejection fraction was between 35 and 40% in 40%. Adherence to treatment was optimal in 59% of patients. Patient's knowledge of the importance of each drug was only present in 40%. In non-adherent patients, the main etiology was low socio-economic status (22%) followed by age and non-support (15%). Conclusion Poor adherence to treatment is a real public health problem in Morocco hence the interest to create support units and explanation to patients with heart failure.

Adherence is a common, important and under-recognised problem in paediatric practice, especially around chronic disease management. Poor adherence, usually either for some of the time or for some elements of treatment, is a complex phenomenon with sociological, psychological and medical roots, which requires a patient and skillful approach. This paper presents the scope and degree of the problem, before explaining some of the ways in which patients arrive at a position of poor adherence, before presenting a practical approach to tackling poor adherence in paediatric clinics, incorporating ideas from motivational interviewing.

Summary Children exposed to multidrug-resistant (MDR) Mycobacterium tuberculosis are at risk of developing MDR tuberculosis. Where treatment is available, it is lengthy, expensive, and associated with poor adherence and notable morbidity and mortality. Preventive treatment effectively lowers the risk of disease progression for contacts of individuals with drug-susceptible tuberculosis, but this strategy is poorly studied for contacts of people with MDR tuberculosis. In this Review we discuss the management of child contacts of source cases with MDR tuberculosis. We pay particular attention to assessment, existing international guidelines, possible preventive treatments, rationales for different management strategies, and the interaction with and implications of HIV infection.