Methotrexate polyglutamates as a potential marker of adherence to long-term therapy in children with juvenile idiopathic arthritis and juvenile dermatomyositis:an observational, cross-sectional study

Introduction: Methotrexate (MTX) is a cornerstone of treatment in a wide variety of inflammatory conditions, including juvenile idiopathic arthritis (JIA) and juvenile dermatomyositis (JDM). However, owing to its narrow therapeutic index and the considerable interpatient variability in clinical response, monitoring of adherence to MTX is important. The present study demonstrates the feasibility of using methotrexate polyglutamates (MTXPGs) as a biomarker to measure adherence to MTX treatment in children with JIA and JDM. Methods: Data were collected prospectively from a cohort of 48 children (median age 11.5 years) who received oral or subcutaneous (SC) MTX therapy for JIA or JDM. Dried blood spot samples were obtained from children by finger pick at the clinic or via self- or parent-led sampling at home, and they were analysed to determine the variability in MTXPG concentrations and assess adherence to MTX therapy. Results: Wide fluctuations in MTXPG total concentrations (>2.0-fold variations) were found in 17 patients receiving stable weekly doses of MTX, which is indicative of nonadherence or partial adherence to MTX therapy. Age (P = 0.026) and route of administration (P = 0.005) were the most important predictors of nonadherence to MTX treatment. In addition, the study showed that MTX dose and route of administration were significantly associated with variations in the distribution of MTXPG subtypes. Higher doses and SC administration of MTX produced higher levels of total MTXPGs and selective accumulation of longer-chain MTXPGs (P < 0.001 and P < 0.0001, respectively). Conclusions: Nonadherence to MTX therapy is a significant problem in children with JIA and JDM. The present study suggests that patients with inadequate adherence and/or intolerance to oral MTX may benefit from SC administration of the drug. The clinical utility of MTXPG levels to monitor and optimise adherence to MTX in children has been demonstrated. Trial registration: ISRCTN Registry identifier: ISRCTN93945409. Registered 2 December 2011.

Patient experiences of serious adverse drug reactions and their attitudes to medicines:a qualitative study of survivors of Stevens-Johnson syndrome and toxic epidermal necrolysis in the UK

Background: Adverse drug reactions (ADRs) cause significant morbidity and mortality and account for around 6.5% of hospital admissions. Patient experiences of serious ADRs and their long-term impact on patients' lives, including their influence on current attitudes towards medicines, have not been previously explored. Objective: The aim of the study was to explore the experiences, beliefs, and attitudes of survivors of serious ADRs, using drug-induced Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) as a paradigm. Methods: A retrospective, qualitative study was undertaken using detailed semi-structured interviews. Fourteen adult survivors of SJS and TEN, admitted to two teaching hospitals in the UK, one the location of a tertiary burns centre, were interviewed. Interview transcripts were independently analysed by three different researchers and themes emerging from the text identified. Results: All 14 patients were aware that their condition was drug induced, and all but one knew the specific drug(s) implicated. Several expressed surprise at the perceived lack of awareness of the ADR amongst healthcare professionals, and described how the ADR was mistaken for another condition. Survivors believed that causes of the ADR included (i) being given too high a dose of the drug; (ii) medical staff ignoring existing allergies; and (iii) failure to monitor blood tests. Only two believed that the reaction was unavoidable. Those who believed that the condition could have been avoided had less trust in healthcare professionals. The ADR had a persisting impact on their current lives physically and psychologically. Many now avoided medicines altogether and were fearful of becoming ill enough to need them. © 2011 Adis Data Information BV. All rights reserved. Conclusions: Life-threatening ADRs continued to affect patients’ lives long after the event. Patients’ beliefs regarding the cause of the ADR differed, and may have influenced their trust in healthcare professionals and medicines. We propose that clear communication during the acute phase of a serious ADR may therefore be important.

Exploring the stages of change and perceived barriers to treatment models within the context of parental adherence to an early intervention program

Parent-mediated early intervention programs depend on the willingness and ability of parents to complete prescribed activities with their children. In other contexts, internal factors, such as stages of change, and external factors, such as barriers to treatment, have been shown to correlate with adherence to service. This researcher modified the Stages of Change Questionnaire as well as the Barriers to Treatment Participation Scale (BTPS) to use with this population. Despite initial interest, twenty-three parent participants were referred to the researcher over the course of three years, with only five parents taking part in the study. A population base ten times that of the current sample would be required recruit enough participants (fifty-one) to provide sufficient power. This feasibility study discusses the results of the five parent participants. Findings suggest that the modified Stages of Change Questionnaire may not be sensitive enough for use with the current sample, while the modified BTPS may yield useful information for service providers.

The role of time and risk preferences in adherence to physician advice on health behaviour change

Acknowledgements The Interdisciplinary Chronic Disease Collaboration (ICDC) is funded through the Alberta Heritage Foundation for Medical Research (AHFMR) Inter-disciplinary Team Grants Program. AHFMR is now Alberta Innovates – Health Solutions (AI-HS). The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates funds HERU. The views expressed in this paper are those of the authors only and not those of the funding bodies.

Adherence to latent tuberculosis treatment among immigrants in low endemic settings : a scoping review

Contexte : En dépit du fait que la tuberculose est un problème de santé publique important dans les pays en voie de développement, les pays occidentaux doivent faire face à des taux d'infection important chez certaines populations immigrantes. Le risque de développer la TB active est 10% plus élevé chez les personnes atteintes de TB latente si elles ne reçoivent pas de traitement adéquat. La détection et le traitement opportun de la TB latente sont non seulement nécessaires pour préserver la santé de l'individu atteint mais aussi pour réduire le fardeau socio- économique et sanitaire du pays hôte. Les taux d'observance des traitements préventifs de TB latente sont faibles et une solution efficace à ce problème est requise pour contrôler la prévalence de l'infection. L'objectif de ce mémoire est d'identifier les facteurs qui contribuent à l'observance thérapeutique des traitements de TB latente auprès de nouveaux arrivants dans les pays occidentaux où les taux endémiques sont faibles. Méthodologie : Une revue systématique a été effectuée à partir de bases de données et répertoires scientifiques reconnus tels Medline, Medline in Process, Embase, Global Health, Cumulative Index to Nursing, le CINAHL et la librairie Cochrane pour en citer quelques un. Les études recensées ont été publiées après 1997 en français, en anglais, conduites auprès de populations immigrantes de l'occident (Canada, Etats-Unis, Europe, Royaume-Uni, Australie et la Nouvelle Zélande) dont le statut socio-économique est homogène. Résultats : Au total, neuf (9) études réalisées aux Etats-Unis sur des immigrants originaires de différents pays où la TB est endémique ont été analysées: deux (2) études qualitatives ethnographiques, six (6) quantitatives observationnelles et une (1) quantitative interventionnelle. Les facteurs sociodémographiques, les caractéristiques individuelles, familiales, ainsi que des déterminants liés à l'accès et à la prestation des services et soins de santé, ont été analysés pour identifier des facteurs d'observance thérapeutique. L'âge, le nombre d'années passées dans le pays hôte, le sexe, le statut civil, l'emploi, le pays d'origine, le soutien familiale et les effets secondaires et indésirables du traitement de la TB ne sont pas des facteurs ii déterminants de l'adhésion au traitement préventif. Toutefois, l’accès à l'information et de l'éducation adaptées aux langues et cultures des populations immigrantes, sur la TB et des objectifs de traitement explicites, l'offre de plan de traitement plus court et mieux tolérés, un environnement stable, un encadrement et l'adhésion au suivi médical par des prestataires motivés ont émergés comme des déterminants d'observance thérapeutique. Conclusion et recommandation : Le manque d'observance thérapeutique du traitement de la TB latente (LTBI) par des populations immigrantes, qui sont déjà aux prises avec des difficultés d'intégration, de communication et économique, est un facteur de risque pour les pays occidentaux où les taux endémiques de TB sont faibles. Les résultats de notre étude suggèrent que des interventions adaptées, un suivi individuel, un encadrement clinique et des plans de traitement plus courts, peuvent grandement améliorer les taux d'observance et d'adhésion aux traitements préventifs, devenant ainsi un investissement pertinent pour les pays hôtes.

Adherence to latent tuberculosis treatment among immigrants in low endemic settings : a scoping review

Contexte : En dépit du fait que la tuberculose est un problème de santé publique important dans les pays en voie de développement, les pays occidentaux doivent faire face à des taux d'infection important chez certaines populations immigrantes. Le risque de développer la TB active est 10% plus élevé chez les personnes atteintes de TB latente si elles ne reçoivent pas de traitement adéquat. La détection et le traitement opportun de la TB latente sont non seulement nécessaires pour préserver la santé de l'individu atteint mais aussi pour réduire le fardeau socio- économique et sanitaire du pays hôte. Les taux d'observance des traitements préventifs de TB latente sont faibles et une solution efficace à ce problème est requise pour contrôler la prévalence de l'infection. L'objectif de ce mémoire est d'identifier les facteurs qui contribuent à l'observance thérapeutique des traitements de TB latente auprès de nouveaux arrivants dans les pays occidentaux où les taux endémiques sont faibles. Méthodologie : Une revue systématique a été effectuée à partir de bases de données et répertoires scientifiques reconnus tels Medline, Medline in Process, Embase, Global Health, Cumulative Index to Nursing, le CINAHL et la librairie Cochrane pour en citer quelques un. Les études recensées ont été publiées après 1997 en français, en anglais, conduites auprès de populations immigrantes de l'occident (Canada, Etats-Unis, Europe, Royaume-Uni, Australie et la Nouvelle Zélande) dont le statut socio-économique est homogène. Résultats : Au total, neuf (9) études réalisées aux Etats-Unis sur des immigrants originaires de différents pays où la TB est endémique ont été analysées: deux (2) études qualitatives ethnographiques, six (6) quantitatives observationnelles et une (1) quantitative interventionnelle. Les facteurs sociodémographiques, les caractéristiques individuelles, familiales, ainsi que des déterminants liés à l'accès et à la prestation des services et soins de santé, ont été analysés pour identifier des facteurs d'observance thérapeutique. L'âge, le nombre d'années passées dans le pays hôte, le sexe, le statut civil, l'emploi, le pays d'origine, le soutien familiale et les effets secondaires et indésirables du traitement de la TB ne sont pas des facteurs ii déterminants de l'adhésion au traitement préventif. Toutefois, l’accès à l'information et de l'éducation adaptées aux langues et cultures des populations immigrantes, sur la TB et des objectifs de traitement explicites, l'offre de plan de traitement plus court et mieux tolérés, un environnement stable, un encadrement et l'adhésion au suivi médical par des prestataires motivés ont émergés comme des déterminants d'observance thérapeutique. Conclusion et recommandation : Le manque d'observance thérapeutique du traitement de la TB latente (LTBI) par des populations immigrantes, qui sont déjà aux prises avec des difficultés d'intégration, de communication et économique, est un facteur de risque pour les pays occidentaux où les taux endémiques de TB sont faibles. Les résultats de notre étude suggèrent que des interventions adaptées, un suivi individuel, un encadrement clinique et des plans de traitement plus courts, peuvent grandement améliorer les taux d'observance et d'adhésion aux traitements préventifs, devenant ainsi un investissement pertinent pour les pays hôtes.

Associations of the FTO rs9939609 and the MC4R rs17782313 polymorphisms with type 2 diabetes are modulated by diet, being higher when adherence to the Mediterranean diet pattern is low

[EN]Although the Fat Mass and Obesity (FTO) and Melanocortin-4 Receptor (MC4R) genes have been consistently associated with obesity risk, the association between the obesity-risk alleles with type 2 diabetes is still controversial. In some recent meta-analyses in which significant results have been reported, the associations disappeared after adjustment for body mass index (BMI). However gene-diet interactions with dietary patterns have not been investigated. Our main aim was to analyze whether these associations are modulated by the level of adherence to the Mediterranean Diet (MedDiet).

Knowledge of the patients regarding leprosy and adherence to treatment

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is known for its great disfiguring capacity and is considered an extremely serious disease to public health worldwide. The state of Ceará ranks 13th in number of cases of leprosy in Brazil, and fourth in Northeastern region, with an average of 2,149 new cases diagnosed every year. This study aimed to evaluate the knowledge of leprosy patients regarding treatment, and to assess the level of treatment adherence and its possible barriers. The study was conducted in the reference center for dermatology, from September 2010 to October 2010, in Fortaleza, Ceará. The study data were collected by means of a structured interview, along with the Morisky-Green test, in order to assess treatment adherence and barriers to adherence. A total of 70 patients were interviewed, out of whom 66 were new cases. The majority of patients were between 42 and 50 years old, and 37 (52.9%) were male. Most patients were clinically classified as presentingmultibacillary leprosy (80%), and 78.6% of them were from Fortaleza, Brazil. The Morisky-Green test indicated that 62.9% of patients presented a low level of adherence (p < 0.005), despite claiming to aware of the disease risks. However, it was observed that 57.1% of the patients had no difficulty adhering to treatment, while 38.6% reported little difficulty. This study shows that despite the patients claiming to be familiar with leprosy and its treatment, the Morisky-Green test clearly demonstrated that they actually were not aware of the principles of therapy, which is evidenced by the low degree of treatment adherence

Adherence to antiretroviral therapy and its determinants among persons living with HIV/AIDS in Bayelsa state, Nigeria

Background: A high level of adherence is required to achieve the desired outcomes of antiretroviral therapy. There is paucity of information about adherence to combined antiretroviral therapy in Bayelsa State of southern Nigeria. Objectives: The objectives of the study were to determine the level of adherence to combined antiretroviral therapy among the patients, evaluate the improvement in their immune status and identify reasons for sub-optimal adherence to therapy. Methods: The cross-sectional study involved administration of an adapted and pretested questionnaire to 601 consented patients attending the two tertiary health institutions in Bayesla State, Nigeria: The Federal Medical Centre, Yenagoa and the Niger-Delta University Teaching Hospital Okolobiri. The tool was divided into various sections such as socio-demographic data, HIV knowledge and adherence to combined antiretroviral therapy. Information on the patient's CD4+ T cells count was retrieved from their medical records. Adherence was assessed by asking patients to recall their intake of prescribed doses in the last fourteen days and subjects who had 95-100% of the prescribed antiretroviral drugs were considered adherent. Results: Three hundred and forty eight (57.9%) of the subjects were females and 253 (42.1%) were males. The majority of them, 557 (92.7%) have good knowledge of HIV and combined anti-retroviral therapy with a score of 70.0% and above. A larger proportion of the respondents, 441 (73.4%), had > 95% adherence. Some of the most important reasons giving for missing doses include, “simply forgot” 147 (24.5%), and “wanted to avoid the side-effects of drugs” 33(5.5%). There were remarkable improvements in the immune status of the subjects with an increment in the proportion of the subjects with CD4+ T cells count of greater than 350 cells/mm3 from 33 (5.5%) at therapy initiation to 338 (56.3%) at study period (p<0.0001). Conclusion: The adherence level of 73.4% was low which calls for intervention and improvement. The combined antiretroviral therapy has significantly improved the immune status of the majority of patients which must be sustained. “Simply forgot” was the most important reason for missing doses.

Barriers to and facilitators of older adult’s adherence to health recommendations: Towards an EngAging two-way health communication

Non-adherence to health recommendations (e.g. medical prescriptions) presents potential costs for healthcare, which could be prevented or mitigated. This is often attributed to a person’s rational choice, to not adhere. However, this may also be determined by individual and contextual factors implied in the recommendations communication process. In accordance, this chapter focuses specifically on barriers to and facilitators of adherence to recommendations and engagement with the healthcare process, particularly concerning the communication between health professionals and patients. For this, the authors present examples of engagement increment through different degrees of participation, from a one-way/directive towards a two-way/engaging communication process. This focuses specifically on a vulnerable population group with increasing healthcare needs: older adults. Future possibilities for two-way engaging communications are discussed, aimed at promoting increased adherence to health recommendations and people’s self-regulation of their own health.

Knowledge of the patients regarding leprosy and adherence to treatment

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is known for its great disfiguring capacity and is considered an extremely serious disease to public health worldwide. The state of Ceará ranks 13th in number of cases of leprosy in Brazil, and fourth in Northeastern region, with an average of 2,149 new cases diagnosed every year. This study aimed to evaluate the knowledge of leprosy patients regarding treatment, and to assess the level of treatment adherence and its possible barriers. The study was conducted in the reference center for dermatology, from September 2010 to October 2010, in Fortaleza, Ceará. The study data were collected by means of a structured interview, along with the Morisky-Green test, in order to assess treatment adherence and barriers to adherence. A total of 70 patients were interviewed, out of whom 66 were new cases. The majority of patients were between 42 and 50 years old, and 37 (52.9%) were male. Most patients were clinically classified as presentingmultibacillary leprosy (80%), and 78.6% of them were from Fortaleza, Brazil. The Morisky-Green test indicated that 62.9% of patients presented a low level of adherence (p < 0.005), despite claiming to aware of the disease risks. However, it was observed that 57.1% of the patients had no difficulty adhering to treatment, while 38.6% reported little difficulty. This study shows that despite the patients claiming to be familiar with leprosy and its treatment, the Morisky-Green test clearly demonstrated that they actually were not aware of the principles of therapy, which is evidenced by the low degree of treatment adherence

Evaluation of factors affecting adherence to asthma controller therapy in chest clinics in a sub-Saharan African setting: a cross-sectional study

Background: Adherence to controller therapy in asthma is a major concern during the management of the disease. Objective: To determine the adherence rate and identify the predictors of low adherence to asthma controller therapy. Methods: A cross-sectional study including asthma patients was conducted from November 1, 2012 to May 31, 2013 in 4 chest clinics in Cameroon. The adherence to asthma treatment was rated using Morisky Medication Adherence Scale. A multivariate logistic regression analysis was performed for the identification of factors associated with adherence to asthma treatment. Results: Among the 201 asthma patients included, 133 (66.2%) were female. The mean age of participants was 41.2 years. Sixty-one (30.3%) of the patients did not visit the chest physician during the last year prior to the study. Asthma was well controlled in 118 patients (58.7%). The prevalence of low adherence rate to asthma controller therapy was 44.8% and the absence of any chest specialist visit within the last 12 months was the only factor associated with the low adherence rate to asthma treatment (OR 5.57 ; 95% CI 2.84–10.93). Conclusion: The adherence rate to asthma controller therapy in Cameroon is low and it could be improved if scheduled visits are respected by patients.

Sociodemographic factors influencing adherence to antenatal iron supplementation recommendations among pregnant women in Malawi: Analysis of data from the 2010 Malawi Demographic and Health Survey

Background and Aim: Maternal morbidity and mortality statistics remain unacceptably high in Malawi. Prominent among the risk factors in the country is anaemia in pregnancy, which generally results from nutritional inadequacy (particularly iron deficiency) and malaria, among other factors. This warrants concerted efforts to increase iron intake among reproductive-age women. This study, among women in Malawi, examined factors determining intake of supplemental iron for at least 90 days during pregnancy. Methods: A weighted sample of 10,750 women (46.7%), from the 23,020 respondents of the 2010 Malawi Demographic and Health Survey (MDHS), were utilized for the study. Univariate, bivariate, and regression techniques were employed. While univariate analysis revealed the percent distributions of all variables, bivariate analysis was used to examine the relationships between individual independent variables and adherence to iron supplementation. Chi-square tests of independence were conducted for categorical variables, with the significance level set at P < 0.05. Two binary logistic regression models were used to evaluate the net effect of independent variables on iron supplementation adherence. Results: Thirty-seven percent of the women adhered to the iron supplementation recommendations during pregnancy. Multivariate analysis indicated that younger age, urban residence, higher education, higher wealth status, and attending antenatal care during the first trimester were significantly associated with increased odds of taking iron supplementation for 90 days or more during pregnancy (P < 0.01). Conclusions: The results indicate low adherence to the World Health Organization’s iron supplementation recommendations among pregnant women in Malawi, and this contributes to negative health outcomes for both mothers and children. Focusing on education interventions that target populations with low rates of iron supplement intake, including campaigns to increase the number of women who attend antenatal care clinics in the first trimester, are recommended to increase adherence to iron supplementation recommendations.

Study on adherence to treatment with imatinib in chronic myeloid leukaemia and its association with therapeutic response

Objective: To assess the level of adherence to treatment with imatinib in patients with chronic myeloid leukaemia and its association with therapeutic response. Materials and methods: Study conducted on October, 2013 - March, 2014, including patients diagnosed with Chronic Myeloid Leukaemia on treatment with imatinib in the hospital. Therapeutic adherence was assessed through the standard Morisky-Green Questionnaire and the medication dispensing record. Those patients who did not complete 6 months of treatment and/or did not complete the questionnaire were excluded. Therapeutic response was assessed following clinical guidelines. The descriptive analysis of variables and correlation was conducted through Pearsons's Chi-Square Test. Results: The study included 31 patients. When assessing the level of association between response variables and therapeutic adherence: 1. The highest molecular response was reached by 68.4% of those patients with high adherence, and by 75% of those patients with intermediate adherence. 2. Complete molecular response was achieved by 57.9% of patients with high adherence, and by 58.3% of patients with intermediate adherence. No statistically significant differences were found in response variables between patients with high and intermediate therapeutic adherence. No association was observed between level of adherence and therapeutic response. Conclusions: We cannot confirm that a different level of therapeutic adherence might have an impact on response to imatinib, though this should be taken into account in cases of therapeutic failure or sub-optimal response.

Transcultural adaptation and validation of the Celiac Dietary Adherence Test: a simple questionnaire to measure adherence to a gluten-free diet

Background and aims: A gluten-free diet is to date the only treatment available to celiac disease sufferers. However, systematic reviews indicate that, depending on the method of evaluation used, only 42% to 91% of patients adhere to the diet strictly. Transculturally adapted tools that evaluate adherence beyond simple self-informed questions or invasive analyses are, therefore, of importance. The aim is to obtain a Spanish transcultural adaption and validation of Leffler's Celiac Dietary Adherence Test. Methods: A two-stage observational transversal study: translation and back translation by four qualified translators followed by a validation stage in which the questionnaire was administered to 306 celiac disease patients aged between 12 and 72 years and resident in Aragon. Factorial structure, criteria validity and internal consistency were evaluated. Results: The Spanish version maintained the 7 items in a 3-factor structure. Feasibility was very high in all the questions answered and the floor and ceiling effects were very low (4.3% and 1%, respectively). The Spearman correlation with the self-efficacy and life quality scales and the self-informed question were statistically significant (p < 0.01). According to the questionnaire criteria, adherence was 72.3%. Conclusion: The Spanish version of the Celiac Dietary Adherence Test shows appropriate psychometric properties and is, therefore, suitable for studying adherence to a gluten-free diet in clinical and research environments.