Impact of Adherence, Patient Perception, and Knowledge to Statin Therapy - A Cross-Sectional Study.

BACKGROUND AND OBJECTIVE: Cardiovascular diseases and its risk factors, such as diabetes and hyperlipidemia, are common in Indian population. Statin utilization is high across the country and it is important to assess the adherence because it plays an important role in treatment outcome. Statin adherence is not studied well in India. This study aims at measuring the adherence, perception, and knowledge of individuals on statin therapy. STUDY DESIGN: Cross-sectional observational study on 130 consented individuals visiting a tertiary care teaching hospital. Study was conducted for a duration of 9 months. METHODS AND MATERIALS: After obtaining approval from the institutional ethics committee the study subjects were assessed for knowledge, perception, and adherence to statin therapy using a systematically developed interview questionnaire. RESULTS: Good adherence was seen in 42.30% patients. Higher proportions of females were reported to have good adherence. Good adherence was observed in patients with a history of coronary heart disease and atorvastatin as monotherapy (P = 0.0029) and fixed dose combination (P = 0.0012), whereas lipid reduction was found directly related to type of adherence. Lack of knowledge, cost, re-fill issues, and adverse effects were some of the barriers identified. INTERPRETATION AND CONCLUSION: Knowledge and patient perception plays a very important role in determining the adherence to statin therapy. A history of coronary heart disease, choice of statin, and cost of therapy are the contributing factors to adherence. Patient counselling and improving the cost-effectiveness of statin therapy can be considered as interventional strategies to overcome adherence issues.

Harmonizing scientific rigor with political urgency: policy learnings for identifying accelerators for scale-up from the safe childbirth checklist programme in Rajasthan, India.

BACKGROUND: Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up. METHODS: The narrative review - done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words 'pilot', 'health innovations', 'scale-up', 'replication', 'expansion', 'increased coverage', 'conceptual models for scale-up', 'frame-works for scale-up', 'evidence for scale-up' in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up. RESULTS: The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems. CONCLUSION: These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere.

Autoimmune Polyglandular Syndrome Type 2 with Alopecia Universalis and Hypoparathyroidism.

A 46 years old female, presented with severe fatigue, nypotension ana hyperpigmentation. Her basal serum cortisol level at 8 a.m. was < 1.0 µg/dl which suggested a diagnosis of Addison's disease. An association with latent autoimmune diabetes of adult and autoimmune hypothyroidism led to a diagnosis of Polyglandular Autoimmune Syndrome type II (PAS II). She also had alopecia universalis and hypoparathyroidism which are very rare in PAS type II syndrome. On treatment with hydrocortisone and fludrocortisone there was drastic improvement in the clinical features.

Evan's syndrome revisited.

A female aged 43 years presented with acute per vaginal bleeding since six days, severe thrombocytopenia and anaemia, she responded partially to platelets and blood transfusion initially. Four days later she started bleeding from nose, intravenous access sites, developed right sided hemiparesis and subsequently died. Her investigations were suggestive of Idiopathic Thrombocytopenia Purpura (ITP) and Autoimmune Haemolytic Anaemia (AIHA). So a diagnosis of Evan's syndrome was made.

Levetiracetam.

Levetiracetam (LEV) is a novel antiepileptic drug (AED) which was discovered in early 1980s and soon, in 1999 FDA approved LEV for the management of partial onset seizure. In India, LEV tablet was approved in April 2005. It acts by binding to the synaptic vesicle protein SV2A, which is present on synaptic vesicles and some neuroendocrine cells. Pharmacokinetics of LEV such as, less protein binding and lack of hepatic metabolism makes LEV less susceptible to drug interactions with other anticonvulsants. Evidence also suggests that LEV is much better than other AEDs in the way of broad therapeutic window, convenient dosing and less adverse effect. Besides the pharmacological effects, pharmacoeconomically also, LEV is a beneficial drug. All these valuable pharmacological and pharmacoeconomic aspect makes LEV an important option in management of various types of epilepsy.