Are two commonly used self-report questionnaires useful for identifying antihypertensive medication nonadherence?

Objective: Medication nonadherence is a major cause of uncontrolled hypertension, but clinicians are poor at judging adherence, and the gold standard for measuring adherence, electronic monitoring, is rarely available in clinical settings. Self-report questionnaires (SRQs), by contrast, are inexpensive, easy to administer, and hence, may be useful for ‘diagnosing’ nonadherence. In this study, we evaluated the validity of two commonly used medication adherence SRQs among patients with uncontrolled hypertension, using electronic pillbox measurement as the gold standard. Methods: A total of 149 patients with uncontrolled hypertension had adherence to their antihypertensive medication regimen monitored using a four-compartment electronic pillbox (MedSignals) between two primary care visits (median 50 days). Participants completed the 8-item Morisky Medication Adherence Scale (MMAS-8) and the Visual Analog Scale (VAS) at the second visit. Likelihood ratios were calculated using less than 80% correct dosing adherence by electronic measurement as the gold standard. Results: SRQ scores indicating low adherence (MMAS-8 <6 and VAS <80%, 23 and 9% of participants, respectively) had likelihood ratios of 2.00 [95% confidence interval (CI) 1.10–3.65] and 7.72 (95% CI 1.77–33.6), respectively, for detecting nonadherence compared to electronic measurement. SRQ scores indicating highest adherence (MMAS-8 = 8 and VAS = 100%, 43 and 61% of participants, respectively) had likelihood ratios of 0.55 (95% CI 0.35–0.85) and 0.76 (95% CI 0.57–1.01), respectively, for detecting nonadherence. Conclusion: The MMAS-8 and VAS are modestly useful in identifying antihypertensive medication nonadherence. Other tools, including electronic measurement, may be needed to guide titration of antihypertensive medications among patients with uncontrolled hypertension

Depression and Clinical Inertia in Patients With Uncontrolled Hypertension

Depression is a known risk factor for poor prognosis among patients with cardiovascular disease.1 Numerous biological and behavioral mechanisms have been proposed.2 However, few studies have investigated the association between depression and “clinical inertia,” or lack of treatment intensification in individuals not at evidence-based goals for care.3 To address this gap, we assessed whether a diagnosis of depression is associated with clinical inertia in patients with uncontrolled hypertension

Prevalence of PTSD in Survivors of Stroke and Transient Ischemic Attack: A Meta-Analytic Review

Background and Purpose Posttraumatic stress disorder (PTSD) is common in survivors of acute life-threatening illness, but little is known about the burden of PTSD in survivors of stroke and transient ischemic attack (TIA). This study estimated the prevalence of stroke or TIA-induced posttraumatic stress disorder (PTSD) using systematic review and meta-analysis. Methods Potentially relevant peer-reviewed journal articles were identified by searching the Ovid MEDLINE, PsycINFO, PILOTS Database, The Cochrane Library and Scopus from inception to January 2013; all searches were conducted on January 31, 2013. Observational cohort studies that assessed PTSD with specific reference to a stroke or TIA that occurred at least 1 month prior to the PTSD assessment were included. PTSD rates and characteristics of the study and sample were abstracted from all included studies. The coding of all articles included demographics, sample size, study country, and method and timing of PTSD assessment. Results Nine studies (N = 1,138) met our inclusion criteria. PTSD rates varied significantly across studies by timing of PTSD assessment (i.e., within 1 year of stroke/TIA versus greater than 1 year post-stroke/TIA; 55% of heterogeneity explained; Q1 = 10.30; P = .001). Using a random effects model, the estimated rate of PTSD following stroke or TIA was 23% (95% CI, 16%–33%) within 1 year of the stroke or TIA and 11% (95% CI, 8%–14%) after 1 year. Conclusions Although PTSD is commonly thought to be triggered by external events such as combat or sexual assault, these results suggest that 1 in 4 stroke or TIA survivors develop significant PTSD symptoms due to the stroke or TIA. Screening for PTSD in a large population-based prospective cohort study with cardiovascular outcome assessments is needed to yield definitive prevalence, and determine whether stroke or TIA-induced PTSD is a risk factor for subsequent cardiovascular events or mortality

Behavioral economics implementation: Regret lottery improves mHealth patient study adherence.

Background: Nonadherence to study protocols reduces the generalizability, validity, and statistical power of longitudinal studies. Purpose: To determine whether an automated electronically-delivered regret lottery would improve adherence to an intensive mHealth self-monitoring protocol as part of a longitudinal observational study. Methods: We enrolled 77 adults into a 52-week study requiring five daily ecologic momentary assessments (EMA) of stress and daily accelerometer use. We performed a pre/post single-arm study to evaluate the efficacy of a lottery intervention in improving adherence to this protocol. Midway through the study, participants were invited to enter a weekly regret lottery ($50 prize, expected value Results: 62 participants consented to lottery participation. In the 12 weeks prior to lottery initiation, weekly adherence was declining (slope -1.4%/week). The weekly per-participant probability of adherence was higher after lottery initiation when comparing the 4-week (32% pre-lottery vs 50% post-lottery, p \u3c 0.001), 8-week (37% vs 49%, p \u3c 0.001), and 12-week periods (39% vs 45%, p = 0.001) before and after lottery initiation. However, the rate of decline in adherence over time was unchanged. Conclusion: The implementation of an automated, electronically-delivered weekly regret lottery improved adherence with an intensive self-monitoring study protocol. Regret lotteries may represent a cost-effective tool to improve adherence and reduce bias caused by dropout or nonadherence

Skin Conductance Reactivity as a Predictor of Stroke-Induced Posttraumatic Stress Disorder Symptoms: A Dimensional Approach

BackgroundPosttraumatic stress disorder (PTSD) symptoms can develop following acute, life-threatening medical events. This study explores a potential biomarker of PTSD risk that is novel to a medical trauma population: a noninvasive, mobile skin conductance (SC) measurement.MethodsParticipants (N=64) were enrolled in-hospital following a stroke or transient ischemic attack (TIA). Mobile measurement of SC reactivity to recalling the stroke/TIA traumatic event was conducted at hospital bedside in the days following the stroke/TIA. PTSD symptoms that developed in response to the stroke/TIA were measured at 1-month follow-up. We tested the association between SC reactivity and total 1-month PTSD symptoms, as well as PTSD symptom dimensions of fear and dysphoria.ResultsIn unadjusted analyses, there were significant positive associations between in-hospital SC reactivity to recalling the stroke/TIA traumatic event and higher-order fear-related symptoms (r=.30, p=.016), as well as lower-order fear-related symptoms of anxious arousal (r=.27, p=.035) and avoidance (r=.25, p=.043) at 1 month. Associations between SC reactivity and the fear, anxious arousal, and avoidance symptom dimensions remained significant in multivariable regression models that adjusted for relevant covariates including age, gender, stroke severity, medical comorbidity, and psychosocial factors. Although there was a positive association observed between SC reactivity to recalling the stroke/TIA event and total PTSD symptom severity at 1-month follow-up, it did not reach the level of statistical significance (r=.23, p=.070). Further, no significant association was detected for dysphoria-related symptoms (r=.11, p=.393).ConclusionsThis is the first study to test the prospective association of SC reactivity with PTSD symptom development following a medical trauma. The findings indicate that mobile measures of SC reactivity may be useful for in-hospital identification of individuals at risk for fear-related PTSD symptom development following a medical event and highlight the potential mechanisms involved in the development of these symptoms following a medical event

Loss of bacterial diversity during antibiotic treatment of intubated patients colonized with Pseudomonas aeruginosa

Management of airway infections caused by Pseudomonas aeruginosa is a serious clinical challenge, but little is known about the microbial ecology of airway infections in intubated patients. We analyzed bacterial diversity in endotracheal aspirates obtained from intubated patients colonized by P. aeruginosa by using 16S rRNA clone libraries and microarrays (PhyloChip) to determine changes in bacterial community compositions during antibiotic treatment. Bacterial 16S rRNA genes were absent from aspirates obtained from patients briefly intubated for elective surgery but were detected by PCR in samples from all patients intubated for longer periods. Sequencing of 16S rRNA clone libraries demonstrated the presence of many orally, nasally, and gastrointestinally associated bacteria, including known pathogens, in the lungs of patients colonized with P. aeruginosa. PhyloChip analysis detected the same organisms and many additional bacterial groups present at low abundance that were not detected in clone libraries. For each patient, both culture-independent methods showed that bacterial diversity decreased following the administration of antibiotics, and communities became dominated by a pulmonary pathogen. P. aeruginosa became the dominant species in six of seven patients studied, despite treatment of five of these six with antibiotics to which it was sensitive in vitro. Our data demonstrate that the loss of bacterial diversity under antibiotic selection is highly associated with the development of pneumonia in ventilated patients colonized with P. aeruginosa. Interestingly, PhyloChip analysis demonstrated reciprocal changes in abundance between P. aeruginosa and the class Bacilli, suggesting that these groups may compete for a similar ecological niche and suggesting possible mechanisms through which the loss of microbial diversity may directly contribute to pathogen selection and persistence