Adherence to Glaucoma Medications Over 12 Months in Two US Community Pharmacy Chains

This study determined the degree of adherence to medications for glaucoma among patients refilling prescriptions in community pharmacies. Methods: Data abstracted from the dispensing records for 3615 adult patients (18 years or older, predominantly over 45) receiving glaucoma medications from two retail pharmacy chains (64 stores in total) were analyzed. From a 24-month historic data capture period, the 12-month levels of adherence were determined using standard metrics, the proportion of days covered (PDC) and the medication possession ratio (MPR). The overall 12-month mean PDC was only 57%, and the mean MPR was 71%. Using a criterion by which 80% coverage was considered satisfactory adherence, only 30% had satisfactory overall 12-month PDC coverage, and only 37% had satisfactory overall 12-month MPR coverage. Refill adherence increased with age and was highest in the 65-and-older age group (p < 0.001). Differential adherence was found across medication classes, with the highest satisfactory coverage seen for those taking alpha2-adrenergic agonists (PDC = 36.0%; MPR = 47.6%) down to those taking direct cholinergic agonists (PDC = 25.0%; MPR = 31.2%) and combination products (PDC = 22.7%; MPR = 31.0%). Adherence to glaucoma medications in the community setting, as measured by pharmacy refill data, is very poor and represents a critical target for intervention. Community pharmacists are well positioned to monitor and reinforce adherence in this population.

Adherence to controller asthma medications: 6-month prevalence across a US community pharmacy chain

WHAT IS KNOWN AND OBJECTIVE

Non-adherence to controller asthma medications is an important public health problem. It is estimated to occur in 30-70% of individuals and is a significant risk factor for asthma morbidity and mortality. The aim of this study was to determine the level of adherence, as indicated by refill rates, to controller asthma medications in a community pharmacy setting.

METHODS

Secondary analyses of a community pharmacy dispensing database in 15 locations throughout Utah.

RESULTS AND DISCUSSION

The dispensing records of 2193 patients who received controller medications for asthma in a 12-month period, and had a minimum of 6-month potential coverage (180 days) from the date of their first receipt of a controller medication in that period, were examined. Using standard metrics to gauge adherence, the proportion of days covered (PDC) and the medication possession ratio (MPR), the average coverage for controller asthma medications across a 6-month period (180 days) was poor, averaging less than 50% of days' availability. Standard cut-offs (≥80% medication availability) indicated that only 14-16% of patients had 'satisfactory' adherence over their 6-month follow-on period. Females and older patients had significantly greater satisfactory adherence. Medication adherence was significantly greater with inhaled corticosteroid (ICS)-long-acting β₂ -agonist (LABA) combinations than with ICS alone.

WHAT IS NEW AND CONCLUSION

This study confirms the considerable scope of the asthma therapy non-adherence problem. Therefore, it is imperative to conduct survey-based research linked directly to pharmacy-based dispensing data to derive patient behavioural, attitudinal and environmental factors that may contribute to the issue, and then pilot and evaluate interventions for change.

Parental perspectives regarding primary-care weight-management strategies for school-age children

To identify parental perspectives regarding weight-management strategies for school-age children, focus groups were conducted of parents of overweight and obese (body mass index ≥ 85th percentile) 6-12-year-old children recruited from primary-care clinics. Questions focused on the role of the primary-care provider, effective components of weight-management strategies and feasibility of specific dietary strategies. Focus groups were recorded, transcribed and analysed using margin coding and grounded theory. Six focus groups were held. The mean age (in years) for parents was 32, and for children, eight; 44% of participants were Latino, 33%, African-American and 23%, white. Parents' recommendations on the primary-care provider's role in weight management included monitoring weight, providing guidance regarding health risks and lifestyle changes, consistent follow-up and using discretion during weight discussions. Weight-management components identified as key included emphasising healthy lifestyles and enjoyment, small changes to routines and parental role modelling. Parents prefer guidance regarding healthy dietary practices rather than specific weight-loss diets, but identified principles that could enhance the acceptability of these diets. For dietary guidance to be feasible, parents recommended easy-to-follow instructions and emphasising servings over counting calories. Effective weight-management strategies identified by parents include primary-care provider engagement in weight management, simple instructions regarding healthy lifestyle changes, parental involvement and deemphasising specific weight-loss diets. These findings may prove useful in developing primary-care weight-management strategies for children that maximise parental acceptance.

Identifying subtypes of patients with neovascular age-related macular degeneration by genotypic and cardiovascular risk characteristics

BACKGROUND

One of the challenges in the interpretation of studies showing associations between environmental and genotypic data with disease outcomes such as neovascular age-related macular degeneration (AMD) is understanding the phenotypic heterogeneity within a patient population with regard to any risk factor associated with the condition. This is critical when considering the potential therapeutic response of patients to any drug developed to treat the condition. In the present study, we identify patient subtypes or clusters which could represent several different targets for treatment development, based on genetic pathways in AMD and cardiovascular pathology.

METHODS

We identified a sample of patients with neovascular AMD, that in previous studies had been shown to be at elevated risk for the disease through environmental factors such as cigarette smoking and genetic variants including the complement factor H gene (CFH) on chromosome 1q25 and variants in the ARMS2/HtrA serine peptidase 1 (HTRA1) gene(s) on chromosome 10q26. We conducted a multivariate segmentation analysis of 253 of these patients utilizing available epidemiologic and genetic data.

RESULTS

In a multivariate model, cigarette smoking failed to differentiate subtypes of patients. However, four meaningfully distinct clusters of patients were identified that were most strongly differentiated by their cardiovascular health status (histories of hypercholesterolemia and hypertension), and the alleles of ARMS2/HTRA1 rs1049331.

CONCLUSIONS

These results have significant personalized medicine implications for drug developers attempting to determine the effective size of the treatable neovascular AMD population. Patient subtypes or clusters may represent different targets for therapeutic development based on genetic pathways in AMD and cardiovascular pathology, and treatments developed that may elevate CV risk, may be ill advised for certain of the clusters identified.

[Merkel cell carcinoma of the skin in a patient with myasthenia gravis]

Merkel cell carcinoma is a rare, aggressive neuroendocrine tumor of the skin commonly seen in the elderly on the head, neck and extremities, with a predisposition for local regional and distant spreading. A case of Merkel cell carcinoma occurred in a woman treated with immunosuppressive therapy for myasthenia gravis, is described and the possibility of a link between the immunosuppressive and/or oncogenic therapy and this tumor is suggested.

The relationship between depressive symptoms and male erectile dysfunction: cross-sectional results from the Massachusetts Male Aging Study

OBJECTIVE

Studies have shown that there is an association between depression and male erectile dysfunction (MED). However. these earlier studies suffer considerable methodological flaws including: a) lack of a multidisciplinary approach; b) poor sampling techniques; and finally, c) poor and variable measures of MED and depression. Our objectives are: a) to determine whether MED is associated with depressive symptoms and b) to determine whether this association is independent of aging and para-aging factors.

METHOD

Data were obtained from the Massachusetts Male Aging Study (MMAS). The MMAS was a cross-sectional, population-based multidisciplinary survey of health in normally aging men (aged 40-70 years) conducted from 1986 to 1989. In the analytic model, depressive symptoms, as measured by a score of 16 or greater on the Center for Epidemiological Studies-Depression (CES-D) scale, was used as a predictor of MED, which was assessed with a self-administered questionnaire.

RESULTS

MED was associated with depressive symptoms after controlling for potential confounders (odds ratio (OR) 1.82, 95% confidence interval (Ct) 1.21-2.73).

CONCLUSIONS

We conclude that the relationship between depressive symptoms and MED in middle-aged men is robust and independent of important aging and para-aging confounders, such as demographic, anthropometric and lifestyle factors, health status, medication use, and hormones.

The influences of patient characteristics and physician experience on case recall

The study focused on the influences of both patient characteristics and physician experience on the recall of two breast cancer cases. Two general research questions were addressed: 1) whether patient characteristics such as age, race, and assertiveness affect a physician's initial problem representation, and 2) whether the recall advantage for physicians of intermediate levels of experience extends to physicians who have been out of medical school for at least six years, 128 physicians with a minimum of six years' experience were presented with two videotapes of a doctor-patient encounter. In the first videotape (the pre-workup scenario), the patient had just discovered a lump; in the second (the post-workup scenario), she had recently had a biopsy. Following the presentation of each videotape, the physicians were instructed to record a synopsis of the case prior to making diagnoses, ordering tests, and providing treatment recommendations. The synopses were coded to capture information from the cases that the physicians were able to recall and inferences that they generated based on this information. Two critical findings were obtained. First, none of the patient characteristics investigated consistently produced differences in recall or inference generation across the two scenarios. Second, physician recall was a monotonically decreasing function of years of experience. The latter result is interpreted using a theoretical framework from Schmidt and Boshuizen.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

The recall of physical activity: using a cognitive model of the question-answering process

Issues related to the validity and reliability of self-reports of physical activity are an important consideration in assessing the relation between physical activity and various health outcomes that are of interest to epidemiologists. This paper examines the case for incorporating survey methods procedures into the development, refinement, and administration of instruments designed to obtain self-report information on physical activity. In doing so, we present a method of question analysis that enables researchers to identify potential cognitive difficulties with a question and then identify possible methods for improving data quality that have successfully improved the validity of survey instruments in other areas. In doing this, we review portions of the literature in cognitive psychology devoted to autobiographical memory and discuss methods that have emerged from this research that enhance the overall validity and reliability of the data obtained in a variety of health-related areas. We also illustrate ways in which these methods can be incorporated into existing physical activity surveys.

Evaluation of use of tiletamine/zolazepam for anesthesia of bullfrogs and leopard frogs

Use of tiletamine hydrochloride and zolazepam hydrochloride (1:1 fixed ratio combination) as an anesthetic agent in 2 anuran species was studied. A dosage of 5 mg/kg of body weight, administered IM, resulted in variable weak tranquilization. Intramuscular administration at dosages of 10 and 20 mg/kg induced variable states of tranquilization or anesthesia in leopard frogs (Rana pipiens) and bullfrogs (R catesbeiana). The dosages of 50 mg/kg induced anesthesia with greater consistency than lower dosages in bullfrogs, but resulted in mortalities. The same dosage was uniformly fatal in leopard frogs. Neither gross nor histologic lesions were identified in the frogs that died. Depth and duration of anesthesia was dosage related. At the 20 and 50 mg/kg dosages, leopard frogs attained a greater depth of anesthesia and remained anesthetized for a significantly greater duration than did bullfrogs; however, at the 5 and 10 mg/kg dosages, bullfrogs developed greater tranquilization for longer periods than did leopard frogs. Results of this study revealed profound intraspecies variation in depth and duration of effect of tiletamine/zolazepam; therefore, the drug does not appear to be a suitable injectable anesthetic in anurans.

LHRH-induced gonadotropin release before and after short-term therapy with cabergoline in hyperprolactinaemic patients

Cabergoline is a new ergot derivative with long-lasting PRL lowering effect. Basal and LHRH stimulated (50 micrograms i.v.) gonadotropin secretion was evaluated before and during cabergoline treatment (0.5-2 mg/week) in 28 women with pathological hyperprolactinaemia. After 4 weeks, PRL and E2 were significantly (p less than 0.01) reduced and increased, respectively. Basal LH and FSH levels did not change. Both LH (p less than 0.05) and FSH (p less than 0.02) responsiveness to LHRH was decreased from the former to the latter test. The study underlines drug-induced variations in gonadotropin responsiveness to LHRH which are probably due to variations in the steroid milieu.

Prolactin secretion in idiopathic hypogonadotropic hypogonadism during pulsatile luteinizing hormone-releasing hormone long-term administration

Recent data seem to suggest that LHRH may be involved in the modulation of PRL secretion. We studied the PRL pattern in 9 males (age range 18-38 yr) with idiopathic hypogonadotropic hypogonadism (IHH) before and during long-term pulsatile LHRH therapy (120-160 ng/kg bw every 120 min sc) in order to evaluate variations in the spontaneous PRL secretion or LHRH-induced presence of PRL pulse. LH, FSH and PRL secretion was evaluated every 15 min for 3 h on day 0, day 30 and days 90-150. Before and during LHRH therapy PRL 24-h integrated concentration (IC) and gonadotropin or PRL response to LHRH test (50 micrograms iv/bolus) were evaluated. On day 0 spontaneous PRL pulses were found in 2 IHH patients. On day 30 PRL pulses were found in 4 cases. On days 30-90 PRL pulses were sporadically concomitant with LHRH-induced LH pulses. Mean PRL levels and 24-h IC of PRL were found to be significantly (p less than 0.05) increased during pulsatile LHRH administration. A significant positive (p less than 0.01) correlation was observed between testosterone and PRL levels during LHRH therapy. When compared to a significant LH response to LHRH iv bolus, no modification of PRL secretion was found. The present study did not show any relationship between LHRH administration and PRL secretion. It might be hypothesized that LHRH does not play a determinant role in PRL secretion and does not seem to modulate PRL secretory pattern in IHH males.

Effect of subacute cabergoline treatment on prolactin, thyroid stimulating hormone and growth hormone response to simultaneous administration of thyrotrophin-releasing hormone and growth hormone-releasing hormone in hyperprolactinaemic women

It is known that dopaminergic neurotransmission is involved in the control of PRL, TSH and GH secretion. Cabergoline (CAB) is a new ergolinic derivative with a long-acting dopaminergic activity. We evaluated 11 women with pathological hyperprolactinaemia before and during sub-acute CAB treatment (0.8-1.2 mg/p.o.; 8 weeks). Simultaneous administration of TRH (200 micrograms i.v.) and GHRH 1-44 (50 micrograms i.v.) were carried out before and after 4, 8 and 10 week intervals from the beginning of CAB treatment. Basal PRL levels (2453.5 +/- S.E. 444.5 mU/l) were significantly reduced during CAB administration (week 4: 164.5 +/- 66.5 mU/l; week 8: 168.0 +/- 66.5 mU/l; P less than 0.01) and no variations were observed 2 weeks after drug discontinuation (week 10: 210.0 +/- 98.0 mU/l). PRL percentage change after TRH was increased by CAB (P less than 0.05). No variation in basal and TRH-stimulated TSH levels was found during CAB administration. A slight increase in GH basal levels (3.0 +/- 0.6 mU/l) was found after weeks 4 (6.4 +/- 2.0 mU/l) and 10 (5.8 +/- 1.6 mU/l) (P less than 0.05). GH response to GHRH was significantly enhanced (ANOVA: P less than 0.01) during sub-acute CAB treatment. A positive correlation was found between GH secretory area and weeks of CAB therapy (P less than 0.01). Our data show that CAB is very effective in lowering PRL secretion in hyperprolactinaemia, and is able to modify PRL and GH responses after TRH and GHRH. The increasing trend in GH basal and GHRH-stimulated GH levels seems to indicate that CAB can override the central dopaminergic tone which is operative in hyperprolactinaemia.