Tareq Islam

Barriers to and Determinants of Medication Adherence in Hypertension Management: Perspective of the Cohort Study of Medication Adherence Among Older Adults

Low adherence to antihypertensive medication remains a public health challenge. Understanding barriers to, and determinants of, adherence to antihypertensive medication may help identify interventions to increase adherence and improve outcomes. The Cohort Study of Medication Adherence in Older Adults is designed to assess risk factors for low antihypertensive medication adherence, explore differences across age, gender, and race subgroups, and determine the relationship of adherence with blood pressure control and cardiovascular outcomes over time. This article discusses the relevance of this study in addressing the issue of barriers to anithypertensive medication adherence.

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

BACKGROUND Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Students t test followed by multiple logistic regression. RESULTS One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy.

BACKGROUND Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.

Vancomycin-resistant enterococcal bacteraemia: is daptomycin as effective as linezolid?

BACKGROUND The treatment of vancomycin-resistant enterococcal (VRE) bacteraemia remains challenging. Daptomycin is a new antibiotic with bactericidal activity against VRE, but available clinical data are limited. METHODS A retrospective study was performed on 98 adult patients with VRE bacteraemia admitted to two hospitals between September 2003 and December 2007 to compare the efficacy of daptomycin with that of linezolid. Multivariable analyses were performed to compare the microbiological and clinical outcomes of both groups. RESULTS Out of 98 patients with VRE bacteraemia, 68 were treated with linezolid and 30 with daptomycin. Univariate analyses showed no significant differences between the groups regarding baseline demographic and clinical characteristics, severity of illness and co-morbidity. Daptomycin was associated with a trend towards a higher mortality rate (26.7% versus 20.6%), longer median duration of bacteraemia (3 days versus 2 days) and higher relapse rate (6.7% versus 2.9%), but these differences did not reach statistical significance (P > 0.2). Microbiological cure rates were 90% for the daptomycin group and 88.2% for the linezolid group (P = 0.92). CONCLUSIONS Despite a trend towards worse outcomes, daptomycin was as effective as linezolid in treating VRE bacteraemia. A randomized clinical trial is needed to confirm these results.

Adverse Effects of Complementary and Alternative Medicine on Antihypertensive Medication Adherence: Findings from the Cohort Study of Medication Adherence Among Older Adults

OBJECTIVES: To determine the association between complementary and alternative medicine (CAM) use and antihypertensive medication adherence in older black and white adults.

Age-related associations of hypertension and diabetes mellitus with chronic kidney disease

BackgroundStudies suggest end-stage renal disease incidence and all-cause mortality rates among patients with chronic kidney disease (CKD) differ by age. The association of diabetes mellitus and hypertension with CKD across the adult lifespan is not well established.MethodsData from NHANES 1999–2004 were used to determine the association of risk factors for stage 3 or 4 CKD (n = 12,518) and albuminuria (n = 12,778) by age grouping (20 to 49, 50 to 69, and ≥70 years). Stage 3 or 4 CKD was defined as an estimated glomerular filtration rate of 15 to 59 ml/min/1.73 m2 and albuminuria as an albumin to creatinine ratio ≥30 mg/g.ResultsFor adults 20 to 49, 50 to 69 and ≥70 years of age, the prevalence ratios (95% confidence interval) of stage 3 or 4 CKD associated with hypertension were 1.94 (0.86 – 4.35), 1.51 (1.09 – 2.07), 1.31 (1.15 – 1.49), respectively (p-trend = 0.038). The analogous prevalence ratios (95% confidence interval) were 3.01 (1.35 – 6.74), 1.61 (1.15 – 2.25), 1.40 (1.15 – 1.69), respectively, for diagnosed diabetes mellitus (p-trend = 0.067); and 2.67 (0.53 – 13.4), 1.35 (0.69 – 2.63), 1.08 (0.78 – 1.51), respectively, for undiagnosed diabetes mellitus (p-trend = 0.369). The prevalence ratios of albuminuria associated with hypertension and diagnosed and undiagnosed diabetes mellitus were lower at older age (each p < 0.05).ConclusionAmong US adults, diabetes mellitus and hypertension are associated with CKD and albuminuria regardless of age. However, the associations were stronger at younger ages.

Medication adherence in older clinic patients with hypertension after Hurricane Katrina: implications for clinical practice and disaster management.

Background:In post-disaster situations, additional barriers may reduce antihypertensive medication adherence. Methods:Between November 2005 and August 2006, 210 hypertensive patients receiving care at a multispecialty group practice in New Orleans completed a structured questionnaire. Antihypertensive medication adherence was measured with the Hill-Bone medication compliance subscale. In a subset of patients, data on difficulties patients encountered with blood pressure medications in the aftermath of Hurricane Katrina were collected. Results:Seventy-six percent of patients reported damage to their residence and 46% of patients had less-than-perfect medication adherence. After multivariate adjustment, less than perfect medication adherence postdisaster was more common among people aged <65 years (prevalence ratio = 1.37; 95% confidence interval: 1.03–1.82) and non-whites (1.32; 95% confidence interval: 1.02–1.71). Uncontrolled blood pressure (systolic/diastolic ≥140/≥90 mm Hg) was more common in those with less-than-perfect adherence than their counterparts with perfect adherence (51% versus 42%, respectively). In addition, 7% of patients reported not bringing their blood pressure medications when they evacuated, 28% ran out of blood pressure medications, 16% reported difficulties getting medications filled, and 28% reported a blood pressure medication change postdisaster. Conclusions:Opportunities exist to improve disaster planning and prescription refill processes and increase medication adherence and hypertension control postdisasters.

Impact of obesity in damage control laparotomy patients.

BACKGROUND Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients. METHODS All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death. RESULTS During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients. CONCLUSION Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.

Cohort study of medication adherence in older adults (CoSMO): extended effects of Hurricane Katrina on medication adherence among older adults.

Background:Previous research indicates that many patients with hypertension ran out of medications and had difficulties getting refills immediately after Hurricane Katrina. The extended effect of Hurricane Katrina on antihypertensive medication adherence is not well characterized. Methods:Data were analyzed for 2194 participants who completed the baseline survey for the Cohort Study of Medication Adherence among Older Adults between August 2006 and September 2007. Based on pre-Katrina zip codes, the study population was categorized into high- and low-affected areas. Low medication adherence was defined as a score less than 6 on the 8-item Morisky Medication Adherence Scale. Results:Prevalence of low adherence was similar among participants living in high and low affected areas. Low medication adherence was similar for participants with greater than or less than 25% of the residence damaged by Hurricane Katrina and for participants with and without symptoms of post-traumatic stress disorder. In high affected areas, nonsignificant associations were present for those who had moved since the storm and those with a friend or immediate family member who had died in the month after the storm. These factors were not associated with low medication adherence in low affected areas. In both high- and low-affected areas, lower scores on the hurricane coping self-efficacy scale were associated with low medication adherence (P < 0.05). Conclusions:The effect of Hurricane Katrina on patient adherence to antihypertensive medication was limited in the second year after the storm. Intrinsic patient factors, such as low coping self-efficacy, remain important factors associated with low adherence.

Red light cameras: do they change driver behavior and reduce accidents?

BACKGROUND : Installation of red light cameras (RLC) at intersections associated with a high number of traffic accidents are currently in use to reduce the number of traffic collisions. The primary objective of this study was to evaluate the sustained effect of RLC on driver behavior. The secondary objective was to evaluate the number of collisions before and after RLC implementation. METHODS : For the primary objective, an 8-month prospective observational study after installation of RLC in September 2007 was undertaken at the intersection with the highest incidence of traffic accidents in the State of Louisiana. For the secondary objective, collision occurrences were collected 10 months before and after RLC installation. The mean number of citations was calculated by month, and the statistical significance of trend was obtained from a linear regression model across the study period and by t test to compare before and after citations were issued. The number of traffic collisions was compared using chi. RESULTS : During the initial 30 days, 2,428 violations per week were recorded, whereas in the subsequent 30 days, there were 534 citations per week issued (p < 0.001). After eight months, the number of citations was reduced to an average of 356 citations per week (p < 0.01). Mean number of citations decreased significantly during implementation of RLC. Three drivers received more than one citation. Although there was a trend in reduction of collisions from 122 to 97 before and after RLC, this did not reach statistical significance; p = 0.18. CONCLUSION : A significant and sustained reduction in the number of citations occurred as driving behavior was modified. Despite reducing the number of cars entering this intersection during a red light, RLC do not seem to prevent traffic collisions at this monitored intersection. Alternative means of injury prevention must be investigated.