Systematic review of adherence to direct oral anticoagulants in patients with atrial fibrilation in clinical practice

Direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, have in the past decade replaced vitamin k antagonists (VKAs), such as warfarin, as standard treatment for thrombosis prophylaxis and stroke prevention in patients with atrial fibrillation (AF). Adherence to DOACs is crucial to optimise clinical outcomes in patients with AF. The aim of this review is to systematically evaluate published evidence describing adherence to DOACs in patients with AF in real world clinical practice. A systematic search combining terms for direct oral anticoagulants, atrial fibrilation and relevant adherence measurement tools was conducted in PubMed in March 2018 to identify related English language publications. All observational cohort studies that assessed adherence of DOACs in patients with AF by using healthcare institution databases, including pharmacy records, medical claims datasets, and other relevant data were reviewed for inclusion. Data describing study characteristics and adherence profile were extracted and summarised using qualitative methods. The PubMed search identified 278 citations. After screening the titles and abstracts, full articles were obtained for 36 articles and of these, 22 articles were included. These 22 studies involved around 300,000 AF patients, described the adherence of DOACs in clinical practice in the United States, Europe, and Turkey and were published between 2013 to 2018. Proportion of days covered (PDC) was the most commonly used tool for adherence measurement followed by medicine possession ratio (MPR). Adherence to DOACs was found to be good in most studies, defined as PDC ≥80% and MPR ≥80%. While these published evidence indicated that adherence to DOACs in real world clinical practice is generally good, clinical outcomes can be optimised by identifying AF patients with sub-optimal adherence and developing interventions to improve adherence in these patients within clinical practice

Antibiotic Resistance Trends of Gram-negative Bacteria Most Frequently Isolated from Inpatients in a Tertiary Care Hospital in Sana'a, Yemen

Objective: To determine the trends of antibiotic resistance of Gram-negative bacteria, most frequently isolated from inpatients at the University of Science and Technology Hospital (USTH) in Sana'a, Yemen. Methods: A retrospective, cross-sectional study on the antibiotic resistance of Gram-negative bacteria most frequently isolated from respiratory tract, pus, urine, blood and other types of specimens from inpatients admitted to the USTH. Data were retrieved from the hospital records of culture-positive inpatients in the period from January 2006 to December 2013, and annual trends of resistance were compared using chi-square test for trends at P values < 0.05. Results: Of 2005 Gram-negative bacterial isolates in the period from 2006 to 2013, the most frequently isolated species were Escherichia coli (41.6%), Acinetobacter species (26.7%), Klebsiella species (21.0%) and Pseudomonas aeruginosa (10.6%). Amikacin and carbapenems were the most active drugs against E. coli, with a decrease in the susceptibility of this species to the third- and fourth-generation cephalosporins and a variable resistance rate to quinolones that significantly increased in 2013. Acinetobacter species susceptibility to most antibiotics decreased significantly over the years of the study, where polymyxin B was the only one found to be effective against this species. On the other hand, the trend of Klebsiella species resistance to imipenem, piperacillin-tazobactam, cefepime, ceftazidime increased over the years of the study. Susceptibility of Klebsiella species to ciprofloxacin, levofloxacin and moxifloxacin showed fluctuations, while the susceptibility of aminoglycosides (amikacin and gentamicin) and ampicillin-sulbactam showed no difference. The resistance of P. aeruginosa to the majority of antibiotics was not dramatically changed over the years of the study period, but gentamicin resistance rate was considerably dropped from 77.8% in 2008 to 25.9% in 2013. Conclusions: Of the most frequently isolated Gram-negative bacteria in Sana'a, Acinetobacter species has the highest resistance rate to the most commonly used antibiotics, where only polymyxin B is effective against this species. P. aeruginosa shows an unchanging rate of resistance to antibiotics in the USTH despite being quite resistant to antibiotics on a global scale, which could be attributed to the smaller number of P. aeruginosa isolates tested over the study period. Further large-scale studies on the trends of antibiotic resistance rates in hospital-based settings and the best ways to counteract such resistance in Yemen are recommended. &nbsp

Assessing adherence to direct oral anticoagulants (DOACs) among patients with atrial fibrillation in tertiary-care referral centers in Malaysia

INTRODUCTION Direct oral anticoagulants (DOACs), such as dabigatran and rivaroxaban, are now available for stroke prevention in patients with atrial fibrillation (AF) and are often clinically preferred over vitamin K antagonists (VKAs), such as warfarin. Data describing adherence to DOACs in real-life clinical practice in Malaysia are scarce. OBJECTIVES This study aimed to assess adherence to DOACs in patients with AF at Hospital Kuala Lumpur (HKL) and Hospital Serdang (HSDG), tertiary-care referral centers. METHODOLOGY This was a retrospective cohort study that included all AF patients who were treated with DOACs (dabigatran or rivaroxaban) in HKL and HSDG. Data were obtained from medical records and pharmacy database. Adherence was assessed by using proportion of days covered (PDC) over a 1-year duration and was calculated as the number of days that the medication was on hand over the total number of days in the time period. Good adherence was defined as PDC ≥80% RESULTS There were 281 patients who met the inclusion criteria, male 54.1% (n=152), with 75.1% (n=211) patients on dabigatran and others on rivaroxaban. The ethnic distribution was Chinese 49.8% (n=140), Malay 41.6% (n=117), and Indian 8.5% (n=24). Only 66.9% of patients achieved good adherence with PDC ≥ 80%. Adherence by institution was good in HKL with 85.2% (n=69/81) but poor in HSDG with 59.5% (n=119/200) [p<0.05]. CONCLUSION Overall adherence to DOACs was poor but it varied between institutions, potentially due to institution-specific administrative and clinical practice differences. Clinical care can potentially be optimized by identifying factors affecting adherence and implementing adherence-improving interventions

Risk assessment of atherosclerotic cardiovascular diseases before statin therapy initiation: Knowledge, attitude, and practice of physicians in Yemen.

BackgroundRisk evaluation of atherosclerotic cardiovascular disease (ASCVD) remains the cornerstone of primary prevention. The cardiovascular risk assessment can guide the decision-making on various preventive measures such as initiating or deferring statin therapy. Thus, our study aimed to assess the physicians' knowledge, attitude, and practices regarding atherosclerotic cardiovascular diseases risk assessment. Also, we evaluated the physician-patient discussion and counseling practices before statin therapy initiation in concordance with recommendations from the latest clinical practice guideline.MethodsA cross-sectional study was conducted between November 2020 and January 2021. A self-administered questionnaire was distributed to 350 physicians (GPs, residents, specialists, and consultants). Two trained pharmacists distributed the questionnaires in 5 major tertiary governmental hospitals and more than ten private hospitals. Also, private clinics were targeted so that we get a representative sample of physicians at different workplaces.ResultsA total of 270 physicians filled the questionnaire out of 350 physicians approached, with 14 being excluded due to high missing data, giving a final response rate of 73%. Participants had suboptimal knowledge and practices with a high positive attitude toward atherosclerotic cardiovascular diseases risk assessment. The knowledge and practices were higher among consultants, participants from the cardiology department, those with experience years of more than nine years, and those who reported following a specific guideline for cholesterol management or using a risk calculator in their practice. Notably, the risk assessment and counseling practices were lower among physicians who reported seeing more patients per day.ConclusionPhysicians had overall low knowledge, suboptimal practices, and a high positive attitude toward cardiovascular risk assessment. Therefore, physicians' training and continuing medical education regarding cholesterol management and primary prevention clinical practice guidelines are recommended. Also, the importance of adherence to clinical practice guidelines and their impact on clinical outcomes should be emphasized