Medication Adherence, Burden and Health-Related Quality of Life in Adults with Predialysis Chronic Kidney Disease: A Prospective Cohort Study

This study examines the associations between medication adherence and burden, and health-related quality of life (HRQOL) in predialysis chronic kidney disease (CKD). A prospective study targeting adults with advanced CKD (estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 ) and not receiving renal replacement therapy was conducted in Tasmania, Australia. The actual medication burden was assessed using the 65-item Medication Regimen Complexity Index, whereas perceived burden was self-reported using a brief validated questionnaire. Medication adherence was assessed using a four-item Morisky-Green-Levine Scale (MGLS) and the Tool for Adherence Behaviour Screening (TABS). The Kidney Disease and Quality of Life Short-Form was used to assess HRQOL. Of 464 eligible adults, 101 participated in the baseline interview and 63 completed a follow-up interview at around 14 months. Participants were predominantly men (67%), with a mean age of 72 (SD 11) years and eGFR of 21 (SD 6) mL/min/1.73 m2 . Overall, 43% and 60% of participants reported medication nonadherence based on MGLS and TABS, respectively. Higher perceived medication burden and desire for decision-making were associated with nonadherent behaviour. Poorer HRQOL was associated with higher regimen complexity, whereas nonadherence was associated with a decline in physical HRQOL over time. Medication nonadherence, driven by perceived medication burden, was prevalent in this cohort, and was associated with a decline in physical HRQOL over time

Is distortion of the bioprosthesis ring a risk factor for early calcification ?

<p>Abstract</p> <p>Background</p> <p>As the population ages, bioprosthesis are increasingly being used in cardiac valve replacement. Pericardial bioprosthesis combine an excellent hemodynamic performance with low thrombogenicity, but valve failure associated with calcification remains a concern with these valves. We describe distortion of the bioprosthesis ring as a risk factor for early calcification.</p> <p>Methods</p> <p>A total of 510 patients over the age of 70 years underwent isolated aortic valve replacement with the Mitroflow (A12) pericardial bioprosthesis. Thirty two patients (6,2%) have undergone a second aortic valve replacement due to structural valve dysfunction resulting from valve calcification. In all patients a chest radiography and coronary angiography was performed before reoperation. A 64 Multidetector Computed Tomography (MDCT) with retrospective ECG gating study was performed in four patients to evaluate the aortic bioprosthesis.</p> <p>Results</p> <p>Chest radiography showed in all patients an irregular bioprosthesis ring. At preoperative coronary angiography a distorted bioprosthesis ring was detected in all patients. Macroscopic findings of the explanted bioprostheses included extensive calcification in all specimens.</p> <p>Conclusion</p> <p>There was a possible relationship between early bioprosthetic calcification and radiologic distortion of the bioprosthesis ring.</p

Medication prescribing quality in Australian primary care patients with chronic kidney disease

Background: Australian patients with chronic kidney disease (CKD) are routinely managed in general practices with multiple medications. However, no nationally representative study has evaluated the quality of prescribing in these patients. The objective of this study was to examine the quality of prescribing in patients with CKD using nationally representative primary care data obtained from the NPS MedicineWise's dataset, MedicineInsight. Methods: A cross-sectional analysis of general practice data for patients aged 18 years or older with CKD was performed from 1 February 2016 to 1 June 2016. The study examined the proportion of patients with CKD who met a set of 16 published indicators in two categories: (1) potentially appropriate prescribing of antihypertensives, renin-angiotensin system (RAS) inhibitors, phosphate binders, and statins; and (2) potentially inappropriate prescribing of nephrotoxic medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), at least two RAS inhibitors, triple therapy (an NSAID, a RAS inhibitor and a diuretic), high-dose digoxin, and metformin. The proportion of patients meeting each quality indicator was stratified using clinical and demographic characteristics. Results: A total of 44,259 patients (24,165 (54.6%) female; 25,562 (57.8%) estimated glomerular filtration (eGFR) 45-59 mL/1.73 m2) with CKD stages 3-5 were included. Nearly one-third of patients had diabetes and were more likely to have their blood pressure and albumin-to-creatinine ratio monitored than those without diabetes. Potentially appropriate prescribing of antihypertensives was achieved in 79.9% of hypertensive patients with CKD stages 4-5. The prescribing indicators for RAS inhibitors in patients with microalbuminuria and diabetes and in patients with macroalbuminuria were achieved in 69.9% and 62.3% of patients, respectively. Only 40.8% of patients with CKD and aged between 50 and 65 years were prescribed statin therapy. The prescribing of a RAS inhibitor plus a diuretic was less commonly achieved, with the indicator met in 20.6% for patients with microalbuminuria and diabetes and 20.4% for patients with macroalbuminuria. Potentially inappropriate prescribing of NSAIDs, metformin, and at least two RAS inhibitors were apparent in 14.3%, 14.1%, and 7.6%, respectively. Potentially inappropriate prescribing tended to be more likely in patients aged ≥65 years, living in regional or remote areas, or with socio-economic indexes for areas (SEIFA) score ≤ 3. Conclusions: We identified areas for possible improvement in the prescribing of RAS inhibitors and statins, as well as deprescribing of NSAIDs and metformin in Australian general practice patients with CKD

Hand-carried ultrasound performed at bedside in cardiology inpatient setting – a comparative study with comprehensive echocardiography

BACKGROUND: Hand-carried ultrasound (HCU) devices have been demonstrated to improve the diagnosis of cardiac diseases over physical examination, and have the potential to broaden the versatility in ultrasound application. The role of these devices in the assessment of hospitalized patients is not completely established. In this study we sought to perform a direct comparison between bedside evaluation using HCU and comprehensive echocardiography (CE), in cardiology inpatient setting. METHODS: We studied 44 consecutive patients (mean age 54 ± 18 years, 25 men) who underwent bedside echocardiography using HCU and CE. HCU was performed by a cardiologist with level-2 training in the performance and interpretation of echocardiography, using two-dimensional imaging, color Doppler, and simple calliper measurements. CE was performed by an experienced echocardiographer (level-3 training) and considered as the gold standard. RESULTS: There were no significant differences in cardiac chamber dimensions and left ventricular ejection fraction determined by the two techniques. The agreement between HCU and CE for the detection of segmental wall motion abnormalities was 83% (Kappa = 0.58). There was good agreement for detecting significant mitral valve regurgitation (Kappa = 0.85), aortic regurgitation (kappa = 0.89), and tricuspid regurgitation (Kappa = 0.74). A complete evaluation of patients with stenotic and prosthetic dysfunctional valves, as well as pulmonary hypertension, was not possible using HCU due to its technical limitations in determining hemodynamic parameters. CONCLUSION: Bedside evaluation using HCU is helpful for assessing cardiac chamber dimensions, left ventricular global and segmental function, and significant valvular regurgitation. However, it has limitations regarding hemodynamic assessment, an important issue in the cardiology inpatient setting

Effect of pharmacist‐led medication review on medication appropriateness in older adults with chronic kidney disease

This study evaluated the effect of pharmacist‐led review on medication appropriateness in 204 older patients with chronic kidney disease (CKD) admitted to an Australian hospital. Medication appropriateness was evaluated using the Medication Appropriateness Index (MAI) prior to medication review, after review (assuming all recommendations were accepted by physicians) and after outcome (acceptance/non‐acceptance) of recommendations. Overall, 95 patients (46%) received a medication review by pharmacists. The median (interquartile range) MAI score decreased significantly from a baseline of 7 (3–12) to 5 (2–10) after medication review (p < 0.001) and to 6 (2–10) after the outcome of recommendations (p < 0.01). The MAI score also decreased in patients with no medication review by a pharmacist from 6 (3–11) at admission to 5 (2–9) at discharge (p < 0.001). MAI scores declined markedly in people with all pharmacist‐conducted medication review recommendations accepted (from 7 to 3; p < 0.05). Reassuringly, hospitalisation alone improved medication appropriateness. However, pharmacist‐led medication review can further optimise medication appropriateness in older CKD patients, particularly when the recommendations are implemented

Strain-induced Evolution of Electronic Band Structures in a Twisted Graphene Bilayer

Here we study the evolution of local electronic properties of a twisted graphene bilayer induced by a strain and a high curvature. The strain and curvature strongly affect the local band structures of the twisted graphene bilayer; the energy difference of the two low-energy van Hove singularities decreases with increasing the lattice deformations and the states condensed into well-defined pseudo-Landau levels, which mimic the quantization of massive Dirac fermions in a magnetic field of about 100 T, along a graphene wrinkle. The joint effect of strain and out-of-plane distortion in the graphene wrinkle also results in a valley polarization with a significant gap, i.e., the eight-fold degenerate Landau level at the charge neutrality point is splitted into two four-fold degenerate quartets polarized on each layer. These results suggest that strained graphene bilayer could be an ideal platform to realize the high-temperature zero-field quantum valley Hall effect.Comment: 4 figure

Managing lifestyle change to reduce coronary risk: a synthesis of qualitative research on peoples’ experiences

Background Coronary heart disease is an incurable condition. The only approach known to slow its progression is healthy lifestyle change and concordance with cardio-protective medicines. Few people fully succeed in these daily activities so potential health improvements are not fully realised. Little is known about peoples’ experiences of managing lifestyle change. The aim of this study was to synthesise qualitative research to explain how participants make lifestyle change after a cardiac event and explore this within the wider illness experience. Methods A qualitative synthesis was conducted drawing upon the principles of meta-ethnography. Qualitative studies were identified through a systematic search of 7 databases using explicit criteria. Key concepts were identified and translated across studies. Findings were discussed and diagrammed during a series of audiotaped meetings. Results The final synthesis is grounded in findings from 27 studies, with over 500 participants (56% male) across 8 countries. All participants experienced a change in their self-identity from what was ‘familiar’ to ‘unfamiliar’. The transition process involved ‘finding new limits and a life worth living’ , ‘finding support for self’ and ‘finding a new normal’. Analyses of these concepts led to the generation of a third order construct, namely an ongoing process of ‘reassessing past, present and future lives’ as participants considered their changed identity. Participants experienced a strong urge to get back to ‘normal’. Support from family and friends could enable or constrain life change and lifestyle changes. Lifestyle change was but one small part of a wider ‘life’ change that occurred. Conclusions The final synthesis presents an interpretation, not evident in the primary studies, of a person-centred model to explain how lifestyle change is situated within ‘wider’ life changes. The magnitude of individual responses to a changed health status varied. Participants experienced distress as their notion of self identity shifted and emotions that reflected the various stages of the grief process were evident in participants’ accounts. The process of self-managing lifestyle took place through experiential learning; the level of engagement with lifestyle change reflected an individual’s unique view of the balance needed to manage ‘realistic change’ whilst leading to a life that was perceived as ‘worth living’. Findings highlight the importance of providing person centred care that aligns with both psychological and physical dimensions of recovery which are inextricably linked