scholarly journals Interventions to improve uptake of urate-lowering therapy in patients with gout: a systematic review

BJGP Open ◽  
2020 ◽  
Vol 4 (3) ◽  
pp. bjgpopen20X101051 ◽  
Author(s):  
Iqbal Gill ◽  
Nicola Dalbeth ◽  
Malakai 'Ofanoa ◽  
Felicity Goodyear-Smith
Keyword(s):  
Systematic Review ◽  
Patient Education ◽  
Illness Perceptions ◽  
Patient Adherence ◽  
Serum Urate ◽  
Primary Care Settings ◽  
Lowering Therapy ◽  
Included Patient ◽  
Medication Dosage

BackgroundGout treatment is suboptimal despite available therapy, with low levels of initiation and persistence of urate-lowering therapy (ULT) in many patients.AimTo identify all interventions that have attempted to improve the uptake of ULT and analyse the clinical outcomes.Design & settingA systematic review of international articles published in English.MethodA systematic search was conducted through MEDLINE, Embase, CINAHL Plus, and Scopus databases to identify all studies on relevant interventions for gout. Interventions were included if they aimed to address patient adherence with serum urate (SU) level as an outcome. This included patient education, practitioner monitoring, medication titration, SU monitoring, and ongoing patient engagement and follow-up. Follow-up studies to original interventions and those with only an abstract available were included.ResultsTwenty articles met the inclusion criteria, describing outcomes of 18 interventions conducted in primary care settings: six nurse-led, five pharmacist-led, and seven multidisciplinary, multifaceted interventions. Improvement in SU levels was observed in all interventions. Nurse-led interventions were effective at empowering patients as they addressed illness perceptions and provided education, advice, and telephone follow-up. Pharmacist-led interventions primarily aimed to monitor patients, alter medication dosage, and provide automated telephone follow-up. Various multifaceted programmes involving a range of providers resulted in increased sustained use of urate-lowering medication.ConclusionA nurse-led approach focusing on patient understanding about gout is the most effective in achieving improved patient adherence, and lowered SU levels among patients. An intervention should include patient education and follow-up components.

Systematic Review and Meta-analyses of Effects of Phosphate-lowering Agents in Non-dialysis Chronic Kidney Disease

2021 ◽  
pp. ASN.2021040554
Author(s):  
Nicole Lioufas ◽  
Elaine Pascoe ◽  
Carmel Hawley ◽  
Grahame Elder ◽  
Sunil Badve ◽  
...  
Keyword(s):  
Systematic Review ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Outcomes ◽  
Serum Phosphate ◽  
Risk Of Bias ◽  
Lowering Therapy ◽  
Mean Differences ◽  
Meta Analyses

Background: Benefits of phosphate-lowering interventions on clinical outcomes in patients with chronic kidney disease (CKD) are unclear; systematic reviews have predominantly involved dialysis patients. This study aimed to summarize evidence from randomized controlled trials (RCTs) concerning benefits and risks of non-calcium-based phosphate-lowering treatment in non-dialysis CKD. Methods: We conducted a systematic review and meta-analyses of RCTs involving noncalcium-based phosphate-lowering therapy compared to placebo, calcium-based binders, or no study medication, in adults with CKD not on dialysis or post-transplant. RCTs had ≥3 months follow up and outcomes included biomarkers of mineral metabolism, cardiovascular parameters, and adverse events. Outcomes were meta-analyzed using the Sidik-Jonkman method for random effects. Unstandardized mean differences were used as effect sizes for continuous outcomes, with common measurement units and Hedge's g standardized mean differences (SMD) otherwise. Odds ratios were used for binary outcomes. Cochrane risk of bias and GRADE assessment determined the certainty of evidence. Results: Twenty trials involving 2,498 participants (median sample size 120, median follow up 9 months) were eligible for inclusion. Overall, risk of bias was low. Compared with placebo, non calcium-based phosphate binders reduced serum phosphate (12 trials, weighted mean difference -0.37, 95% CI -0.58,-0.15 mg/dL, low certainty evidence) and urinary phosphate excretion (8 trials, SMD -0.61, 95% CI -0.90,-0.31, low certainty evidence), but resulted in increased constipation (9 trials, log odds ratio [OR] 0.93, 95% CI 0.02, 1.83, low certainty evidence) and greater vascular calcification score (3 trials, SMD 0.47, 95% CI 0.17, 0.77, very low certainty evidence). Data for effects of phosphate-lowering therapy on cardiovascular events (log OR 0.51 [95% CI -0.51, 1.17]) and death were scant. Conclusions: Non-calcium-based phosphate-lowering therapy reduced serum phosphate and urinary phosphate excretion, but there was an unclear effect on clinical outcomes and intermediate cardiovascular end-points. Adequately powered RCTs are required to evaluate benefits and risks of phosphate-lowering therapy on patient-centered outcomes.

scholarly journals Adherence of older emergency department patients to community-based specialized geriatric services

CJEM ◽  
2019 ◽  
Vol 21 (5) ◽  
pp. 659-666
Author(s):  
Zachary MacDonald ◽  
Ian G. Stiell ◽  
Ioanna Genovezos ◽  
Debra Eagles
Keyword(s):  
Emergency Department ◽  
Patient Adherence ◽  
Cognitively Impaired ◽  
Study Participation ◽  
Convenience Sample ◽  
Home Based ◽  
Included Patient ◽  
Emergency Department Patients ◽  
Future Work

ABSTRACTObjectivesOur objective was to determine emergency department (ED) patient adherence to outpatient specialized geriatric services (SGS) following ED evaluation by the geriatric emergency management (GEM) nurse, and identify barriers and facilitators to attendance.MethodsWe conducted a prospective cohort study at two academic EDs between July and December 2016, enrolling a convenience sample of patients ≥ 65 years, seen by a GEM nurse, referred to outpatient SGS, and consented to study participation. We completed a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used.ResultsWe enrolled 103/285 eligible patients (86 eligible but not enrolled, 86 declined specialized geriatric referrals, and 10 declined study participation). Patients were mean age of 83.1 years, 59.2% female, and 73.2% cognitively impaired. Reasons for referral included mobility (86.4%), cognition (56.3%), pain (38.8%), mood (35.0%), medications (33.0%), and nutrition (31.1%). Referrals were to Geriatric Day Hospital (GDH) programs (50.5%), geriatric outreach (26.2%), falls clinic (12.6%), and geriatric psychiatry (8.7%). Adherence with follow-up was 59.2%. Barriers to attendance included patient did not feel SGS were needed (52.1%), inability to recall GEM consultation (53.4%), and dependence on family for transportation (72.6%). Home-based assessments had the highest adherence (81.5%).ConclusionAdherence of older ED patients referred by the GEM team to SGS is suboptimal, and a large proportion of patients decline these referrals in the ED. Future work should examine the efficacy of home-based assessments in a larger confirmatory setting and focus on interventions to increase referral acceptance and address barriers to attendance.

scholarly journals Adherence to urate-lowering therapy while following the national guidelines for the management of patients with gout (preliminary evidence)

2020 ◽  
Vol 14 (4) ◽  
pp. 70-75
Author(s):  
M. N. Chikina ◽  
E. V. Ilyinykh ◽  
M. S. Eliseev
Keyword(s):  
Patient Adherence ◽  
Preliminary Evidence ◽  
Dose Titration ◽  
National Guidelines ◽  
Tophaceous Gout ◽  
Antiinflammatory Therapy ◽  
Lowering Therapy ◽  
Anti Inflammatory ◽  
Therapeutic Doses

Low compliance in patients with gout is one of the reasons for inadequate disease control.Objective: to study treatment adherence in compliance with the national guidelines for the management of gout patients, which provide for the continuous use of urate-lowering drugs, a gradual increase in their dose until the target serum uric acid (UA) level is reached, prophylactic antiinflammatory therapy, and regular patient monitoring.Patients and methods. This was a prospective single-center study. By now, 60 of the 80 enrolled gout patients had completed the study. The follow-up period was at least 24 weeks, during which allopurinol or febuxostat was used at the final dose. During initiation of urate-lowering therapy, allopurinol 100 mg/day was prescribed, followed by dose titration to reach the target UA level (<360 μmol/L) for all patients or <300 μmol/L for those with severe tophaceous gout. Patients with ineffective allopurinol and/or in the presence of its associated adverse reactions were prescribed febuxostat (Azurix®) 80 mg/day; the dose was increased up to 120 mg/day as needed. To prevent acute arthritis attacks, all the patients received a nonsteroidal anti-inflammatory drug (NSAID) at minimal therapeutic doses or colchicine 0.5 mg/day, and in the presence of contraindications to their use, they took glucocorticoid (GC) 7.5 mg/day calculated with reference to prednisolone. The four-item Morisky–Green questionnaire was used to assess patient adherence to therapy.Results and discussion. At 24 weeks after the start of their follow-up, 53 (88%) of the 60 patients received urate-lowering therapy; 38 (72%) of these 53 patients achieved the target UA level. The dose of allopurinol was titrated in 19 patients; and 10 (53%) of them achieved the target serum UA levels. Due to its inefficacy, allopurinol was replaced by febuxostat in 24 patients. In this group, the target UA level was recorded in 16 (67%) patients. Seventeen patients were immediately prescribed febuxostat that could achieve the target UA level in 12 (71%) of them. All the patients enrolled in the study received prophylactic anti-inflammatory therapy: NSAIDs were used in 9 (15%) patients, colchicine and GC were given to 46 (77%) and 5 (8%), respectively. Twenty-six (49%) patients who had completed the investigation were ascertained to have a high adherence therapy. Moderate and low adherence was observed in 9 (17%) and 18 (34%) patients, respectively. High therapy adherence was noted in more than half of cases in the febuxostat group and in 40% in the allopurinol one.Conclusion. High compliance in gout patients can be achieved through the observance of the national guidelines for the treatment of this disease.

Abstract 1544: Early Statin Therapy Reduces Risk Of ICD Shocks In Patients With An Implantable Cardioverter-defibrillator Undergoing Ablation For Ventricular Tachycardia

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
T. J Bunch ◽  
Paul A Friedman ◽  
Bernard J Gersh ◽  
Samuel J Asirvatham ◽  
Peter A Brady ◽  
...  
Keyword(s):  
Statin Therapy ◽  
Ventricular Arrhythmias ◽  
Beta Blockers ◽  
Lipid Lowering ◽  
Lipid Lowering Therapy ◽  
Lowering Therapy ◽  
Included Patient ◽  
Nonischemic Dilated Cardiomyopathy ◽  
Artery Disease

Background : Lipid lowering therapy reduces mortality in patients with both ischemic and nonischemic cardiomyopathies and recently has been shown to decrease ICD shocks. Radiofrequency ablation (RFA) of recurrent VT in patients with an ICD also reduces shocks following intervention. It is unclear if statin therapy after VT RFA will further impact ICD shock rates. Methods : All patients from 1993–2005 who underwent a RFA procedure for recurrent VT at the Mayo Clinic with an ICD were included. Patient records were extracted for medical and procedural details and all ICD interrogations were reviewed for VT recurrence and therapies. Results: 63 patients (age 62±15 years) were followed over 3.9±3.6 years. Comorbid diseases included: coronary artery disease 37(58%, 34 prior myocardial infarction), ARVD/C 6(10%), nonischemic dilated cardiomyopathy 7(11%), moderate-severe valve disease 14(22%), hypertension 34(54%), and hyperlipidemia 35(56%). Ejection fraction was <0.35 in 34(56%). VT was induced in all patients (LV 55 (LVOT 1), RV 8 (RVOT 3) with multiple inducible VTs in 21(33%). VT was noninducible after RFA in 39(62%) patients. Dismissal medications included: statins 19(30%), beta blockers 40(66%), ACE/ARB 37(61%), diuretics 34(55%), and digoxin 23(37%). 5-year overall survival was 63%(95% CI 55–71). Age, diabetes, and renal insufficiency were associated with increased post ablation mortality, with no medication improving survival. 5-year survival free of ICD shocks was 31%(95% CI 24–38). Only statin therapy at discharge was associated with a decreased risk of ICD shocks [5(26%) versus 26(59%), p=0.020]. 7 additional patients received statins during follow-up, but not at discharge, of these 5(71%) had shocks. Conclusion : Statin use at discharge in patients with an ICD undergoing RFA for refractory VT significantly reduced recurrent ventricular arrhythmias and ICD shocks. Although the mechanism underlying the effects of statins on arrhythmic recurrence early after RFA requires further study, these data support aggressive therapy of the underlying substrate responsible for the VT.

Post-Hospitalization Follow-up of two Noncommunicable Diseases using eHealth Solutions: A Restricted, Systematic Review (Preprint)

2021 ◽  
Author(s):  
Anne Marie Lunde Husebø ◽  
Marianne Storm ◽  
Kristin Hjorthaug Urstad ◽  
Jon Arne Søreide ◽  
Bjørg Karlsen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Assessment Tool ◽  
Patient Adherence ◽  
Interactive Voice Response ◽  
Self Care ◽  
Significant Risk ◽  
Noncommunicable Diseases ◽  
Cochrane Library ◽  
Literature Searches

BACKGROUND Heart failure (HF) and colorectal cancer (CRC) are non-communicable diseases (NCD) with high incidence rates, substantial treatment burden, and significant risk of readmission within 30 days following hospitalization. During the transition between hospital and home, electronic health (eHealth) can be one way to improve follow-up on HF and CRC patients’ care needs to support self-care, increase quality of life (QoL), and reduce readmission rates. OBJECTIVE The objectives of this review are to summarize research on the content and delivery modes of HF and CRC post-hospitalization eHealth interventions, explore patient adherence to the interventions, and examine the effects on patient outcomes of self-care, QoL, and readmissions. METHODS A restricted, systematic review study design was employed. Literature searches and reviews followed the PRISMA-S checklist. Literature searches were performed in CINAHL, Medline, EMBASE, and Cochrane Library for studies published between 2015 and 2020. The review process involved three groups of researchers working in pairs. The Mixed Method Assessment Tool was used to assess included studies’ methodological quality. A thematic analysis method was employed to analyze data extracted from the studies. RESULTS Twenty-two studies were examined in this review, including 18 interventions provided to HF populations and four delivered to CRC patients. The studies were published between 2015 and 2019, 11 of them in the USA. The majority were randomized, controlled trials (N=19), and 14 of the studies recruited patients upon hospital discharge to eHealth interventions lasting for 14 days to 12 months. The studies involved structured telephone calls, video chat, interactive voice response, a web-based mobile platform, and telemonitoring, and included elements of patient education, counseling, social and emotional support, and self-monitoring of symptoms and vitals. Half of the studies provided information on patient adherence, which was reported as ranging from satisfactory to high. When used to follow up on HF patients post-hospitalization, eHealth can positively affect QoL, while its impact is less evident for self-care and readmissions. Among CRC patients, QoL was improved by eHealth follow-up, but the small number of eligible studies complicated the ability to draw conclusions. CONCLUSIONS This review suggests that NCD patients with HF and CRC should receive prompt follow-up after hospitalization, and eHealth holds the potential to improve these patients’ QoL. Patient adherence in eHealth follow-up trials shows promise for successful future interventions and adherence research. Further research is warranted to examine the effects of eHealth on self-care and readmissions, especially within relatively understudied NCD populations.

Effective Approaches to Patient Education for the Busy Pediatrician

PEDIATRICS ◽  
1984 ◽  
Vol 74 (5) ◽  
pp. 920-923
Author(s):  
Edward E. Bartlett
Keyword(s):  
Patient Education ◽  
Behavior Change ◽  
Patient Care ◽  
Interpersonal Skills ◽  
Patient Adherence ◽  
Direct Patient Care ◽  
Traditional Approaches ◽  
Physician Recommendations ◽  
Selection Of

Pediatricians spend 35% to 41% of their direct patient care time on patient education and counselling. However, studies indicate that teaching alone generally is ineffective. It is logical that the patient or parent must have an understanding of the basics of the regimen in order to follow the pediatrician's advice. However, teaching, even when supplemented by pamphlets or audiovisual programs, generally is not sufficient to bring about behavior change. A "stepped approac" to patient education is recommended. This approach consists of three steps: (1) using interpersonal skills to establish rapport and provide reassurance; (2) teaching about the illness, regimen, and other health matters; and (3) identifying and overcoming obstacles to behavior change. Step 3 is not necessary if steps l and 2 have been successful in achieving patient adherence to physician recommendations. By questioning the patient or parent at the follow-up visit, the pediatrician can identify the obstacles that are interfering with acceptance of his or her advice—this process is the "behavioral diagnosis." Once the cause of the problem has been determined, selection of the appropriate solution is usually straight-forward. This three-step approach to patient education can be more effective and less time-consuming than traditional approaches.

Therapy of post-stroke depression – a systematic review

2013 ◽  
Vol 10 (02) ◽  
pp. 108-129 ◽  
Author(s):  
W. Gaebel ◽  
W. Wannagat ◽  
J. Zielasek
Keyword(s):  
Systematic Review ◽  
Large Scale ◽  
Repetitive Transcranial Magnetic Stimulation ◽  
Placebo Control ◽  
Post Stroke ◽  
Pharmacological Studies ◽  
Post Stroke Depression ◽  
Control Procedures ◽  
Antidepressant Pharmacotherapy

SummaryWe performed a systematic review of randomized placebo-controlled pharmacological and non-pharmacological trials for the therapy and prevention of post-stroke depression that have been published between 1980 and 2011. We initially identified 2 260 records of which 28 studies were finally included into this review. A meta-analytic approach was hampered by considerable differences regarding the kinds of therapeutic regimens and the study durations. Modest effects favoring treatment of post-stroke depression could be found for pharmacological treatment as well as repetitive transcranial magnetic stimulation. For the prevention of post-stroke depression, antidepressant pharmacotherapy showed promising results. However, large-scale studies with better standardized study populations, optimized placebo control procedures in non-pharmacological studies, and replication in larger follow-up studies are still necessary to find the optimal therapeutic regimens to prevent and treat post-stroke depression.

Mechanical thrombectomy in pediatric stroke: systematic review, individual patient data meta-analysis, and case series

2019 ◽  
Vol 24 (5) ◽  
pp. 558-571 ◽  
Author(s):  
Kartik Bhatia ◽  
Hans Kortman ◽  
Christopher Blair ◽  
Geoffrey Parker ◽  
David Brunacci ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Case Reports ◽  
Meta Analysis ◽  
Case Series ◽  
Neurological Outcomes

OBJECTIVEThe role of mechanical thrombectomy in pediatric acute ischemic stroke is uncertain, despite extensive evidence of benefit in adults. The existing literature consists of several recent small single-arm cohort studies, as well as multiple prior small case series and case reports. Published reports of pediatric cases have increased markedly since 2015, after the publication of the positive trials in adults. The recent AHA/ASA Scientific Statement on this issue was informed predominantly by pre-2015 case reports and identified several knowledge gaps, including how young a child may undergo thrombectomy. A repeat systematic review and meta-analysis is warranted to help guide therapeutic decisions and address gaps in knowledge.METHODSUsing PRISMA-IPD guidelines, the authors performed a systematic review of the literature from 1999 to April 2019 and individual patient data meta-analysis, with 2 independent reviewers. An additional series of 3 cases in adolescent males from one of the authors’ centers was also included. The primary outcomes were the rate of good long-term (mRS score 0–2 at final follow-up) and short-term (reduction in NIHSS score by ≥ 8 points or NIHSS score 0–1 at up to 24 hours post-thrombectomy) neurological outcomes following mechanical thrombectomy for acute ischemic stroke in patients < 18 years of age. The secondary outcome was the rate of successful angiographic recanalization (mTICI score 2b/3).RESULTSThe authors’ review yielded 113 cases of mechanical thrombectomy in 110 pediatric patients. Although complete follow-up data are not available for all patients, 87 of 96 (90.6%) had good long-term neurological outcomes (mRS score 0–2), 55 of 79 (69.6%) had good short-term neurological outcomes, and 86 of 98 (87.8%) had successful angiographic recanalization (mTICI score 2b/3). Death occurred in 2 patients and symptomatic intracranial hemorrhage in 1 patient. Sixteen published thrombectomy cases were identified in children < 5 years of age.CONCLUSIONSMechanical thrombectomy may be considered for acute ischemic stroke due to large vessel occlusion (ICA terminus, M1, basilar artery) in patients aged 1–18 years (Level C evidence; Class IIb recommendation). The existing evidence base is likely affected by selection and publication bias. A prospective multinational registry is recommended as the next investigative step.

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