The 8-item Morisky medication adherence scale: validation of a Portuguese version in HIV patients

Background

Antiretroviral therapy (ART) has the most effective treatment for people with HIV, but its effectiveness depends on the individual medication adherence. Morisky Medication Adherence Scale (MMAS-8) is one of the most widely used scales to assess patient adherence. Thus, we aimed to validate a Portuguese version of MMAS-8 and determine its psychometric properties in HIV positive patients.

Methods

A cross-sectional survey was conducted in Centro Hospitalar Universitário São João (Porto, northern Portugal) at the infectious diseases department. After authorization to use the scale - granted by the author - and, a standard forward-backwards procedure to translate MMAS-8 to Portuguese, the questionnaire was applied to 233 patients with HIV doing ART. Reliability was assessed using Cronbach's alpha and test-retest reliability. Three levels of adherence were considered: 0 to < 6 (low), 6 to < 8 (medium), 8 (high).

Results

In the studied sample, the mean age was 45.03 years (SD = 11.63), 80.3% men, 19.3% women and 1 transgender, and 53.8% had ≤9 years of education. The mean number of prescribed ART per patient was 1.76. The mean score for the medication adherence scale was 7.29 (SD = 6.74). For the reliability analysis, 12 patients were excluded due to missing data (n = 221). Regarding the level of adherence, 22.5% were low adhering, 71.6% medium and 5.9% high. Corrected item-total correlations showed that 1 item does not correlate very well with the overall scale and was dropped. Scale reliability analysis for the remaining 7 items revealed an overall Cronbach's alpha of 0.661. Women had a protective effect on adherence (OR = 0.31;95%CI:0.15-0.66). Number of years doing ART, age of participants, and type of residence didn't show to be correlated with adherence.

Conclusions

MMAS-8 is a reliable and valid measure to detect patients at risk of non-adherence. A satisfactory Cronbach's alfa (0.661) was obtained. In general, adherence to medication was medium or high.

Key messages

This scale can be applied nationwide in other different hospitals, as it could serve as a tool for measuring adherence to ART that can allow for better health care to the ones that are low adhering. A Portuguese version of the MMAS-8 was created for measuring adherence to ART that maintained a similar structure to the original MMAS-8 and good psychometric properties.

The EBMT activity survey on hematopoietic-cell transplantation and cellular therapy 2018: CAR-T's come into focus

Hematopoietic-cell transplantation (HCT) is widely used for acquired and congenital disorders of the hematopoietic system. Number of transplants performed in Europe and associated countries continues to rise with 47,468 HCT in 42,901 patients [19,630 allogeneic (41%) and 27,838 autologous (59%)] reported by 701 centers in 50 countries in 2018. Main indications were myeloid malignancies 10,679 (25%; 97% allogeneic), lymphoid malignancies 27,318 (64%; 20% allogeneic), solid tumors 1625 (4%; 2.9% allogeneic), and nonmalignant disorders 3063 (7%; 81% allogeneic). This year's analysis focuses on cellular therapies with the marked growth in CAR T-cell therapies from 151 in 2017 to 301 patients reported in 2018. Other cellular therapy numbers show less significant changes. Important trends in HCT include a 49% increase in allogeneic HCT for chronic phase CML (although transplant numbers remain low) and a 24% increase in aplastic anemia. In autologous HCT, there is an ongoing increase in autoimmune diseases (by 19%), predominantly due to activity in multiple sclerosis. This annual report reflects current activity and highlights important trends, useful for health care planning.

Investigation and Management of Bone Mineral Density Following Hematopoietic Cell Transplantation: A Survey of Current Practice by the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation

Reduced bone mineral density (BMD) is a well-recognized complication of hematopoietic cell transplantation (HCT), with significant drops in BMD occurring within the first 12 months after HCT. Guidance on identifying and managing this complication is available in several published guidelines. In this study, we investigated current practices in the investigation and management of low BMD in centers registered with the European Society for Blood and Marrow Transplantation (EBMT). A questionnaire about bone health was sent to all registered centers, and responses were received from 99 centers in 25 countries (52%) currently registered with the EBMT. Our data highlight considerable heterogeneity in practices across European centers in relation to investigations, management, and use of guidelines. Our data demonstrate the need for better dissemination and implementation of existing guidelines and also for the development of multidisciplinary guidelines with input from all relevant stakeholders.

To be or not to be hospitalised with tuberculosis in Portugal

SETTING: In Portugal, as in other countries, tuberculosis (TB) is considered a disease that should be managed on an ambulatory basis. However, hospitalisation remains important to manage some at-risk groups and complications.OBJECTIVE: To identify the possible risk factors associated with hospitalisations in TB patients in Portugal.DESIGN: Data extraction through two national databases (one for registration of TB cases and the other with hospitalisation information in public health facilities) between 2007 and 2013. Univariate and multivariate analysis of demographic and clinical variables was performed.RESULTS: We identified 4421 hospitalisations. Chronic diseases, cancer, substance abuse, a higher social/economic risk, extra-pulmonary TB, lung cavitary disease and previous uncompleted treatment were more frequent among hospitalised patients. Human immunodeficiency virus coinfection, cancer, alcohol abuse, extra-pulmonary TB and uncompleted previous TB treatment were the most important predictors of hospitalisation with TB. The hospitalisation rate among TB patients in Portugal was lower when compared with other countries with lower and higher incidences.CONCLUSION: Immune dysfunctions and progression of chronic diseases are associated with more severe forms of TB and frequent adverse effects which can be sufficiently severe to necessitate hospital admission. Despite having an intermediate TB incidence, the hospitalisation rate in Portugal is not higher than that of other countries.

Ex vivo interaction between blood components and hormone-dependent breast cancer cells induces alterations associated with epithelial-mesenchymal transition and thrombosis

The prevalence of breast cancer is steadily increasing with metastasis and thromboembolic complications identified as the most common causes of death. The acquisition of an aggressive phenotype by hormone-dependent breast cancers is mediated by Transforming Growth Factor Beta 1 (TGF-β₁) expression and is associated with epithelial-mesenchymal transition (EMT) and, potentially, increased propensity for thrombosis. We investigated this phenomenon by assessing the effect of platelet-rich plasma (PRP) and whole blood (WB) on parameters of EMT and hypercoagulation in vitro. MCF-7 breast cancer cells were cultured under standard conditions, followed by co-culture with PRP or WB. Cells were processed for real-time PCR (TGF-β₁ and vimentin), electron microscopy or immunocytochemistry (TGF-β₁). Micrographs were qualitatively assessed, and real-time PCR data analyzed with PAST Statistical Software. The addition of blood components heightened TGF-β₁ immunolocalization and significantly increased corresponding gene expression. Both PRP and WB significantly increased vimentin expression and induced a shape change from a typical epithelial phenotype to a spindle-shape morphology, indicative of EMT. Fibrin fiber, network and plaque formation indicated a hypercoagulatory environment. The results thus show that in preparation for hematogenous metastasis, hormone-dependent breast cancer cells assume an aggressive phenotype associated with EMT, simultaneously increasing the propensity for the formation of thrombo-emboli.

Application of multivariate analysis on naphthalene adsorption in aqueous solutions

Naphthalene (NAP) is found as a pollutant in water, soil, and air, and adsorption is the most prominent removal process of this compound, among the methods studied. A study concerning the types of adsorbents and the parameters with the greatest influence on the adsorption process is interesting to direct future works on new adsorbents. The use of multivariate data analysis tools becomes an appealing way to compile data obtained from bibliographic reviews and to establish a behavior in NAP adsorption. This work aims to evaluate the parameters with greater influence on NAP adsorption process regarding adsorption capacity (qe_exp) with the principal component analysis (PCA), and to group common NAP adsorbents by chemical characteristics through hierarchical cluster analysis (HCA). The variables qe_exp, S, [NAP]₀, T, CT, and [Ads] were used to perform PCA with correlation matrix. For the HCA, the variables S, [NAP]₀, T, CT, and [Ads] with average linkage method (UPGMA) and Euclidean distance were used. Through PCA, it is possible to infer that S and [NAP]₀ are the factors with greater influence in qe_exp of NAP, while T, CT, and [Ads] have little correlation. PCA also shows that activated charcoal is the adsorbent with higher qe_exp. HCA grouped the adsorbents into four groups by their chemical classes, except group A. Both PCA and HCA methods show themselves as potential tools to evaluate a data set of NAP adsorption processes.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term CAPD in South Africa

Background

Occurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).

Methods

This was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.

Results

Atherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.

Conclusion

Atherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.

Pre-transplantation Risks and Transplant-Techniques in Haematopoietic Stem Cell Transplantation for Acute Leukaemia

BACKGROUND

The role of conditioning intensity and stem cell source on modifying pre-transplantation risk in allogeneic haematopoietic stem cell transplantation (HSCT) is a matter of debate, but crucial when benchmarking centres.

METHODS

This Retrospective, multicenter exploratory-validation analysis of 9103 patients, (55.5% male, median age 50 years; 1-75 years range) with an allogeneic HSCT between 2010 and 2016 from a matched sibling (N = 8641; 95%) or matched unrelated donor (N = 462; 5%) for acute myeloid (N = 6432; 71%) or acute lymphoblastic (N = 2671; 29%) leukaemia in first complete remission, and reported by 240 centres in 30 countries to the benchmark database of the European Society for Blood and Marrow Transplantation (EBMT) searched for factors associated with use of transplant techniques (standard N = 6375;70% or reduced intensity conditioning N = 2728;30%, respectively bone marrow N = 1945;21% or peripheral blood N = 7158;79% as stem cell source), and their impact on outcome.

FINDINGS

Treatment groups differed significantly from baseline population (p < 0.001), and within groups regarding patient-, disease-, donor-, and centre-related pre-transplantation risk factors (p < 0.001); choice of technique did depend on pre-transplantation risk factors and centre (p < 0.001). Probability of overall survival at 5 years decreased systematically and significantly with increasing pre-transplantation risk score (score 2 vs 0/1 HR: 1·2, 95% c.i. [1·1-1·.3], p = 0.002; score 3 vs 0/1 HR: 1·5, 95% c.i. [1·3-1·7], p < 0.001; score 4/5/6 vs 0/1 HR: 1·9, 95% c.i. [1·6-2·2], p < 0.001) with no significant differences between treatment groups (likelihood ratio test on interaction: p = 0.40). Overall survival was significantly associated with selection steps and completeness of information (p < 0.001).

INTERPRETATION

Patients' pre-transplantation risk factors determine survival, independent of transplant techniques. Transplant techniques should be regarded as centre policy, not stratification factor in benchmarking. Selection criteria and completeness of data bias outcome. Outcomes may be improved more effectively through better identifying pre-transplantation factors as opposed to refinement of transplant techniques.

FUNDING

The study was funded by EBMT.

Multidrug-resistant tuberculosis in Lisbon: unfavourable treatment and associated factors, 2000-2014

SETTING: The incidence of tuberculosis (TB) has been decreasing in Portugal. Lisbon concentrates the largest number of cases of multidrug-resistant (MDR) TB in the country. This study aims at identifying clinical and demographic factors associated with unfavourable treatment results of patients with MDR-TB in the city.METHOD: The data on 265 MDR-TB cases, notified from 2000 to 2014 in the District of Lisbon, were collected from the Tuberculosis Surveillance System. Unfavourable cases were classified as failure, loss to follow-up (LTFU) and death. Bivariate and multivariate logistic regressions were undertaken to estimate the factors associated with unfavourable outcomes, LTFU and death.RESULTS: The proportion of unfavourable outcomes was 30.5%. These were associated mostly with being male, foreign-born and resistant to kanamycin. Death was associated with being human immunodeficiency virus-positive and resistant to kanamycin. Being foreign-born had a 4.46-fold higher odds of a LTFU outcome than did being Portuguese-born. The foreign-born patients were mostly African immigrants.CONCLUSION: The main finding in this study is that foreign-born patients are associated with a higher probability of unfavourable outcomes than Portuguese-born patients. Therefore, foreign-born patients need more careful monitoring in the control of MDR-TB.

HIV screening of tuberculosis patients in Portugal: what are we missing?

BACKGROUND

Knowledge of human immunodeficiency virus (HIV) status is essential to effectively manage both tuberculosis (TB) and HIV infection. This is why the World Health Organization (WHO) recommends routine HIV testing in all TB patients.

OBJECTIVE

To determine the number of TB patients with unknown HIV status in Portugal and to identify the factors associated with unknown HIV status.

METHODS

A retrospective study of all TB notifications from 2008 to 2014 in Portugal was conducted. A multiple logistic regression model was used to evaluate the association of sociodemographic and clinical factors with unknown HIV status.

RESULTS

We examined the records of 18 445 patients with TB notification, 2402 of whom (13%) had unknown HIV status. Unknown HIV status was positively associated with age 65 years (adjusted odds ratio [aOR] 1.208, 95%CI 1.037-1.408) and extra-pulmonary TB (aOR 1.381, 95%CI 1.252-1.523), but negatively associated with unemployment (aOR 0.755, 95%CI 0.637-0.895), alcohol dependence (aOR 0.809, 95%CI 0.682-0.959) and drug dependence (aOR 0.566, 95%CI 0.449-0.713).

CONCLUSION

Risk perception is the most important barrier to complete knowledge of HIV status in TB patients in Portugal. Given the importance of HIV screening in TB patients, every effort should be made to ensure that all TB patients undergo HIV screening.

La Jument lighthouse: a real-scale laboratory for the study of giant waves and their loading on marine structures

This paper presents results from an experiment designed to improve the understanding of the relationship between extreme breaking waves and their mechanical loading on heritage offshore lighthouses. The experiment, conducted at La Jument, an iconic French offshore lighthouse, featured several records of wave, current and structure accelerations acquired during severe storm conditions, with individual waves as high as 24 m. Data analysis focuses on a storm event marked by a strong peak in the horizontal accelerations measured inside La Jument. Thanks to stereo-video wave measurements synchronized to the acceleration record we were able to identify and describe the breaking wave responsible for this intense loading. Our observations suggest that this giant wave (19 m high) had a crest elevation high enough to directly hit the lighthouse tower, above the substructure. This paper reveals the potential for conducting ambitious field experiments from offshore lighthouses in order to collect valuable storm waves and wave loading observations. This offers a possible second service life for these heritage structures as in situ laboratories dedicated to the study of the coastal hydrodynamics and its interaction with marine structures. This article is part of the theme issue 'Environmental loading of heritage structures'.

Death after hematopoietic stem cell transplantation: changes over calendar year time, infections and associated factors

Information on incidence, and factors associated with mortality is a prerequisite to improve outcome after hematopoietic stem cell transplantation (HSCT). Therefore, 55'668 deaths in 114'491 patients with HSCT (83.7% allogeneic) for leukemia were investigated in a landmark analysis for causes of death at day 30 (very early), day 100 (early), at 1 year (intermediate) and at 5 years (late). Mortality from all causes decreased from cohort 1 (1980-2001) to cohort 2 (2002-2015) in all post-transplant phases after autologous HSCT. After allogeneic HSCT, mortality from infections, GVHD, and toxicity decreased up to 1 year, increased at 5 years; deaths from relapse increased in all post-transplant phases. Infections of unknown origin were the main cause of infectious deaths. Lethal bacterial and fungal infections decreased from cohort 1 to cohort 2, not unknown or mixed infections. Infectious deaths were associated with patient-, disease-, donor type, stem cell source, center, and country- related factors. Their impact varied over the post-transplant phases. Transplant centres have successfully managed to reduce death after HSCT in the early and intermediate post-transplant phases, and have identified risk factors. Late post-transplant care could be improved by focus on groups at risk and better identification of infections of "unknown origin".

Management of patients with multidrug-resistant tuberculosis

The emergence of multidrug-resistant tuberculosis (MDR-TB; defined as resistance to at least rifampicin and isoniazid) represents a growing threat to public health and economic growth. Never before in the history of mankind have more patients been affected by MDR-TB than is the case today. The World Health Organization reports that MDR-TB outcomes are poor despite staggeringly high management costs. Moreover, treatment is prolonged, adverse events are common, and the majority of affected patients do not receive adequate treatment. As MDR-TB strains are often resistant to one or more second-line anti-TB drugs, in-depth genotypic and phenotypic drug susceptibility testing is needed to construct personalised treatment regimens to improve treatment outcomes. For the first time in decades, the availability of novel drugs such as bedaquiline allow us to design potent and well-tolerated personalised MDR-TB treatment regimens based solely on oral drugs. In this article, we present management guidance to optimise the diagnosis, algorithm-based treatment, drug dosing and therapeutic drug monitoring, and the management of adverse events and comorbidities, associated with MDR-TB. We also discuss the role of surgery, physiotherapy, rehabilitation, palliative care and smoking cessation in patients with MDR-TB. We hope that incorporating these recommendations into patient care will be helpful in optimising treatment outcomes, and lead to more MDR-TB patients achieving a relapse-free cure.

Thrombopoietin Receptor Agonists for Severe Thrombocytopenia after Allogeneic Stem Cell Transplantation: Experience of the Spanish Group of Hematopoietic Stem Cell Transplant

Persistent thrombocytopenia is a common complication after allogeneic hematopoietic stem cell transplantation (allo-SCT). Romiplostim and eltrombopag are the currently available thrombopoietin receptor agonists (TPO-RAs), and some studies with very small numbers of cases have reported their potential efficacy in the allo-SCT setting. The present retrospective study evaluated the safety and efficacy of TPO-RAs in 86 patients with persistent thrombocytopenia after allo-HSCT. Sixteen patients (19%) had isolated thrombocytopenia (PT), and 71 (82%) had secondary failure of platelet recovery (SFPR). TPO-RA therapy was started at a median of 127 days (range, 27 to 1177 days) after allo-SCT. The median initial and maximum administered doses were 50 mg/day (range, 25 to 150 mg/day) and 75 mg/day (range, 25 to 150 mg/day), respectively, for eltrombopag and 1 µg/kg (range, 1 to 7 µg/kg) and 5 µg/kg (range, 1 to 10 µg/kg), respectively, for romiplostin. The median platelet count before initiation of TPO-RA therapy was 14,000/µL (range, 1000 to 57,000/µL). Platelet recovery to ≥50,000/µL without transfusion support was achieved in 72% of patients at a median time of 66 days (range, 2 to 247 days). Eighty-one percent of the patients had a decreased number of megakaryocytes before treatment, showing a slower response to therapy (P = .011). The median duration of treatment was 62 days (range, 7 to 700 days). Grade 3-4 adverse events (hepatic and asthenia) were observed in only 2% of the patients. At last follow-up, 81% of patients had discontinued TPO-RAs and maintained response, and 71% were alive. To our knowledge, this is the largest series analyzing the use of TPO-RAs after allo-SCT reported to date. Our results support the efficacy and safety in this new setting. Further prospective trials are needed to increase the level of evidence and to identify predictors of response.

Gonadal Function after Busulfan Compared with Treosulfan in Children and Adolescents Undergoing Allogeneic Hematopoietic Stem Cell Transplant

Gonadal impairment is an important late effect with a significant impact on quality of life of transplanted patients. The aim of this study was to compare gonadal function after busulfan (Bu) or treosulfan (Treo) conditioning regimens in pre- and postpubertal children. This retrospective, multicenter study included children transplanted in pediatric European Society for Blood and Marrow Transplantation (EBMT) centers between 1992 and 2012 who did not receive gonadotoxic chemoradiotherapy before the transplant. We evaluated 137 patients transplanted in 25 pediatric EBMT centers. Median age at transplant was 11.04 years (range, 5 to 18); 89 patients were boys and 48 girls. Eighty-nine patients were prepubertal at transplant and 48 postpubertal. One hundred eighteen children received Bu and 19 Treo. A higher proportion of girls treated with Treo in the prepubertal stage reached spontaneous puberty compared with those treated with Bu (P = .02). Spontaneous menarche was more frequent after Treo than after Bu (P < .001). Postpubertal boys and girls treated with Treo had significantly lower luteinizing hormone levels (P = .03 and P = .04, respectively) compared with the Bu group. Frequency of gonadal damage associated with Treo was significantly lower than that observed after Bu. These results need to be confirmed in a larger population.

Why does it take so long? The reasons behind tuberculosis treatment delay in Portugal

INTRODUCTION

Delayed diagnosis and treatment of tuberculosis contributes to the spread of the disease. In this study, we aimed to determine the patient and healthcare system delay among tuberculosis patients in Portugal and identify associated factors at individual and contextual level.

METHODS

We analysed all TB cases notified in Portugal between 2010 and 2014 using data from the national surveillance system. Patient and healthcare system delay were computed, log-transformed, and used as outcomes. Adjusted generalized linear models were fitted to identify sociodemographic, contextual and clinical determinants.

RESULTS

The study included 6838 patients. The median of patient and healthcare system were 33 and 17 days, respectively. Adjusted regression models revealed that higher patient delay occurred in foreign patients (exponentiated beta: 1.177, 95%CI 1.091-1.270) and those addicted to alcohol (1.169, 1.072-1.276) and drugs (1.153, 1.027-1.295). Higher healthcare system delay was observed among patients with extra-pulmonary TB (2.067, 1.885-2.268) and pulmonary comorbidities - lung cancer (2.391, 1.656-3.452), sarcoidosis (3.316, 1.370-8.022) and COPD (1.295, 1.059-1.584) - and in patients residing further from a healthcare service (1.040, 1.018-1.062).

CONCLUSION

We found that various individual and contextual factors affect the time delay in tuberculosis treatment. Our findings indicate that some strategies, such as facilitating the access to healthcare services among foreign patients and patients with addictions and increasing the awareness towards TB among healthcare professionals, may result in better TB control.