Improved persistence and adherence to diuretic fixed-dose combination therapy compared to diuretic monotherapy

<p>Abstract</p> <p>Background</p> <p>Diuretics are recommended as initial treatment for hypertension. Several studies have suggested suboptimal persistence and adherence to thiazide diuretic monotherapy; this study compared patient persistence and adherence with hydrochlorothiazide (HCTZ) monotherapy to fixed-dose combinations containing HCTZ.</p> <p>Methods</p> <p>Patients with at least one prescription claim during 2001 to 2003 for either HCTZ or one of the following fixed-dose combinations: angiotensin-receptor blockers/HCTZ (ARB/HCTZ), angiotensin-converting enzyme inhibitor/HCTZ (ACEI/HCTZ), or beta blockers/HCTZ (BB/HCTZ) were identified. Patients were required to be continuously benefit-eligible six months pre- and one year post-index date, and to have no prescription claims for any antihypertensive therapy six months prior to the index date. Patients were followed for one year to assess persistence, medication possession ratio (MPR), adherence (MPR >80%), and proportion of days covered (PDC) with initial antihypertensive therapy. Logistic regression was used to calculate adjusted odds ratios for persistence, adherence and PDC, adjusted for age, gender, business segment, RxRisk disease categories, average co-pay and concurrent cardiovascular-related medication utilization.</p> <p>Results</p> <p>The study cohort consisted of 48,212 patients; 72.5% used HCTZ, 13.2% ACEI/HCTZ, 9.3% ARB/HCTZ, and 5.0% BB/HCTZ. Mean age was 53.7 years and 66.5% were female. A significantly lower proportion of patients using HCTZ (29.9%) remained persistent with therapy at 12 months compared with ARB/HCTZ (52.6%; OR = 0.37, CI = 0.36, 0.38), ACEI/HCTZ (51.4%; OR = 0.38, CI = 0.37, 0.39), and BB/HCTZ (51.9%; OR = 0.38, 0.37, 0.40). Similarly, PDC was lower for HCTZ patients (32.5%) as compared to ARB/HCTZ (53.7%; OR = 0.39, CI = 0.37, 0.40), ACEI/HCTZ (50.9%; OR = 0.42, CI = 0.40, 0.43), and BB/HCTZ (51.3%; OR = 0.44, CI 0.42, 0.45). MPR was also significantly lower for HCTZ patients as compared to those using fixed-dose combination therapies.</p> <p>Conclusion</p> <p>Initiating HCTZ fixed-dose combination therapy with an ACEI, ARB, or BB was associated with greater persistence and adherence as compared to HCTZ monotherapy. Further research is needed to determine the relationship between improved persistence and adherence with blood pressure control.</p

My Brain Hurts: A Focus on Somatosensory Complaints in Traumatic Brain Injury Patients Assessed by Neurobehavioral Symptom Inventory

PURPOSE: Somatosensory symptoms are common complaints from patients following a Traumatic Brain Injury (TBI), but are not specific to TBI diagnosis. This study investigated the prevalence of somatosensory symptoms in TBI patients, evaluated if symptoms severity was associated with TBI severity, and assessed the relationship of somatosensory complaints to psychological complaints commonly associated with depression and Post Traumatic Stress Disorder (PTSD). METHODS: Somatic symptoms following traumatic brain injury (TBI) were assessed using 7 of the 22 items from the Neurobehavioral Symptom Inventory (NSI) which included headache, nausea, vision problems/blurriness, body numbness/tingling, taste/smell changes, light sensitivity, and noise sensitivity. RESULTS: Prior to treatment, 90.8% of patients endorsed clinically-elevated pre-treatment somatosensory symptoms. The presence of clinically-elevated somatosensory symptoms decreased after treatment to 77.6%. This demonstrated a high prevalence at admission of somatosensory complaints in patients with TBI which remained high even after completion of TBI treatment. Patients with a history of LOC greater than 30 minutes were three times less likely to endorse clinically-elevated somatosensory complaints when assessed prior to starting treatment as compared to those with no history of TBI. A similar association was found when evaluated clinically-elevated somatosensory complaints assessed after treatment. This study also demonstrated patients with clinically-elevated somatosensory symptoms at admission were more likely to have and clinically-elevated depressive symptoms post-treatment. Similar significance was found assessing clinically-elevated somatosensory symptoms as admission and PTSD symptoms. CONCLUSION: Somatosensory symptoms are highly prevalent in TBI patients, but do not appear to correlate to TBI severity. Additionally, there is a strong association between somatosensory symptoms and psychological symptoms. The presence of both somatosensory and psychological symptoms before starting TBI treatment may be considered a strong indicator that somatosensory complaints will persist following completion of a TBI treatment program. Patients that endorse a high degree of psychological symptoms may benefit from targeted behavioral health therapies instead of traditional TBI treatment strategies. Special focus on somatosensory symptoms assessed by NSI may help guide clinical decision-making when treating TBI patients

Is the aquatic macrophyte Crassula helmsii a genuine copper hyperaccumulator?

Aims: The Australian native hemi-aquatic herb C. helmsii (Crassulaceae) is a copper (Cu) accumulator, tolerant to a wide range of climatic conditions and able to concentrate >9000 μg Cu g−1 in its living tissues. These characteristics suggest practical potential for decontamination of Cu-polluted mine waste waters using a phyto-extraction approach. The aim of this study was to investigate Cu uptake in C. helmsii at different Cu2+ concentrations in solution and to test for the effect of pH on the concentration of free Cu2+ and Cu accumulation in this species. Methods: Different solutions were tested in acid (pH 4.0) and mildly acidic (pH 5.8) conditions at five different Cu2+ concentrations (ranging from 0 to 5 mg Cu L−1). The concentration of free Cu2+ was evaluated using Geochem-EZ software. The distribution of Cu in C. helmsii tissues was examined with micro-X-ray Fluorescence (μXRF) elemental mapping and with Scanning Electron Microscopy with Energy Dispersive X-ray Spectroscopy (SEM-EDS). Results: The highest shoot Cu concentration in C. helmsii was 5870 μg Cu g−1 in the 5 mg Cu L−1 treatment. Copper bioaccumulation was positively correlated with the Cu2+ treatment in the different solutions. The μXRF and SEM-EDS analysis revealed that roots accumulated higher Cu concentrations than the shoots. The concentration of free Cu2+ was shown to be dependent upon the type of Fe-chelator (DTPA, EDDHA, HBED) used in the solution due to the displacement of Fe3+ and complexation of Cu2+. Conclusions: Crassula helmsii is highly tolerant to Cu2+ in solution at acidic and mildly acidic pH, and able to accumulate high Cu concentrations in its tissue. This confirms its potential for applications in Cu phyto-extraction of acidic mine effluent waters high in Cu2+

Root responses to localised soil arsenic enrichment in the fern Pityrogramma calomelanos var. austroamericana grown in rhizoboxes

The terrestrial fern Pityrogramma calomelanos, a cosmopolitan tropical species, is one of the strongest known arsenic (As) hyperaccumulator plants. This study aimed to determine whether P. calomelanos preferentially forages for arsenite (As3+) or arsenate (As5+) in As-contaminated soils, and whether a positive root response to As enhances accumulation in P. calomelanos. Therefore, an experiment using rhizoboxes divided in two halves were constructed with a control soil (C) and As3+ or As5+ dosed soil at either 50 and 100 μg g−1 As. Micro-X-ray Fluorescence elemental mapping (μXRF) was employed to analyze the distribution of As in roots and fronds, and Scanning Electron Microscopy with Energy Dispersive Spectroscopy (SEM-EDS) was used to determine As distribution in the reproductive tissues of P. calomelanos. The results showed that Pityrogramma roots do not specifically forage for As-contaminated soil; the area based on pixel counts was similar across all the treatments with no statistical differences. However, frond biomass was slightly higher in the treatments C ǀ As3+ and C ǀ As5+, and the highest accumulation of As in fronds was in the As5+ ǀ As3+ (100 μg g−1) treatment, with 3418 and 2370 μg g−1 in old and young fronds respectively. Arsenic cycling across the roots was observed by the μXRF mapping; in C ǀ As5+ (100) the As was higher and evenly distributed in both sections, whilst in C ǀ As3+ (50), the As was higher in the As3+ side. The μXRF mapping showed a broader As distribution in older fronds, where As was highest in the rachis and extended into the pinnule through the midrib. Pityrogramma calomelanos does not specifically root forage for As-enriched zones in the soil and grows healthily without signs of toxicity at lower (50 μg g−1) and higher (100 μg g−1) concentrations of As3+ and As5+ in the soil

Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members

Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings