A systematic review of factors associated with non-adherence to treatment for immune-mediated inflammatory diseases.

Background: Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence. Objective: To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology. Design: Systematic review Data sources: Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from 1 January 1980 to 14 February 2014. Study selection: Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence. Data extraction: Data were extracted by the first reviewer using a standardised 23-item form and verified by a second/ third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist. Results: 73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional-patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment. Conclusions: While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Isolated cardiac sarcoidosis presenting as transient ischemic attack

Key clinical message Isolated cardiac sarcoidosis may rarely present with TIA or stroke as an initial clinical manifestation. This case highlights the necessity of a broad differential and a high degree of suspicion for cardiac sarcoidosis in a patient with new neurologic symptoms and evidence of cardiac disease. Abstract Cardiac sarcoidosis is a rare disease with a variety of clinical manifestations including heart failure and sudden death. Stroke as the earliest sign of disease has been described in rare cases. We present a case of a 54‐year‐old female with recurrent transient ischemic attacks (TIAs) of unknown etiology, initially in the absence of left ventricular dysfunction. Cardiomyopathy was later identified on echocardiography after a second TIA. Cardiac MRI was remarkable for focal left ventricular wall thinning with akinesis and dyskinesis of multiple wall segments, a right ventricular aneurysm, and diffuse myocardial late gadolinium enhancement. PET/CT showed multifocal areas of myocardial FDG uptake. At follow‐up, echocardiography showed a left ventricular apical thrombus, in a previously identified thinned, akinetic region, suggesting cardioembolic origin for previous TIAs. She was started on anticoagulation therapy, prednisone, methotrexate, and adalimumab, with resolution of the thrombus and improvement in cardiac function. In conclusion, this case highlights the need to consider CS as a potential cause of cerebrovascular ischemic events in patients with few stroke risk factors but findings indicative of cardiac disease. It is essential to further explore the mechanisms behind these events and develop treatments that target their causes in this patient population