Self-Reported Overall Adherence and Correct Inhalation Technique Discordance in Chronic Obstructive Pulmonary Disease Population.

Background: Adherence to inhaled medication constitutes a major problem in patients with chronic obstructive pulmonary disease (COPD) globally. However, large studies evaluating adherence in its entirety and capturing a large variety of potentially associated factors are still lacking. Objective: To study both elementary types of adherence to chronic inhaled COPD medication in "real-life" COPD patients and to assess relationships with a wide-ranging spectrum of clinical parameters. Methods: Data from the Czech Multicentre Research Database (CMRD) of COPD, an observational prospective study, were used. Overall adherence (OA) was evaluated with Morisky Medication Adherence Scale (©MMAS-4) and adherence to an application technique (A-ApplT) with the Five Steps Assessment. Mann-Whitney U test, Spearman's correlation, and logistic regression were used to explore relationships between variables. Results: Data of 546 participants (69.6% of all patients from the CMRD) were analyzed. Two-thirds self-reported optimal OA, but only less than one-third demonstrated A-ApplT without any error. OA did not correlate with A-ApplT. Next, better OA was associated with higher education, a higher number of inhalers, a lower rate of exacerbations, poorer lung function, higher degree of upper respiratory tract symptoms (SNOT-22), absence of depressive symptoms, ex-smoking status, regular mouthwash after inhaled corticosteroids (ICS), and flu vaccination. By contrast, better A-ApplT was associated with a lower number of inhalers, better lung function, and regular mouthwash after ICS. Independent predictors of nonoptimal OA included lower degree of education, absence of flu vaccination, anemia, depression, and peptic ulcer history, whereas independent predictors of lower A-ApplT were lower education, absence of regular mouthwash after ICS, and higher COPD Assessment Test score. Conclusions: Parameters associated with OA and A-ApplT differ, and those associated with both adherence domains are sometimes associated inversely. Based on this finding, we understand these as two separate constructs with an overlap.

Breathing Out Completely Before Inhalation: The Most Problematic Step in Application Technique in Patients With Non-Mild Chronic Obstructive Pulmonary Disease.

Background: Patient adherence to an inhaled medication application technique (A-ApplT) represents a major health-care issue in patients with chronic obstructive pulmonary disease (COPD). However, there is a lack of studies evaluating this issue thoroughly. The aim of our study was to introduce a universal easy-to-use method of assessing the A-ApplT to chronic medication in moderate to very severe COPD individuals. Methods: The Czech Multicenter Research Database of COPD (COPD CMRD), a large observational prospective study, was used as a source of clinical data. A-ApplT was evaluated using our Five Steps Assessment. This measure is based on dichotomous evaluation of each of five predefined consecutive application technique steps and can be used in all settings for all currently available inhalation systems in COPD subjects. Results: A total of 546 participants (75.0% men; mean age 66.7 years; mean forced expiratory volume in 1s 44.7%) were available for analysis. This represents 69.6% of all patients recruited in the COPD CMRD. Less than one third of patients presented their application technique without any erroneous steps. The most problematic steps were breathing out completely in one breath immediately before inhalation (step No. 3), and the actual inhalation maneuver (step No. 4). The total number of errors was similar for dry powder inhalers and pressurized metered-dose inhalers. Conclusion: Our novel instrument, Five Steps Assessment, is comfortable for use in routine clinical practice to explore A-ApplT. The A-ApplT in real-life patients with non-mild COPD was inadequate and patients should be repeatedly trained by properly (re-)educated medical staff.

Patterns of Non-adherence to Supplementation with Calcium and Vitamin D in Persistent Postmenopausal Women Are Similar at Start and 1 Year Later: A Qualitative Longitudinal Study.

Background: Osteoporosis is a chronic disease and adherence can fluctuate over time. Therefore, longer observation is necessary to investigate the stability of patients' adherence. The study aim was to compare the overall adherence (OA) to supplementation with the fixed combination of calcium and vitamin D (Ca/D) in postmenopausal women at baseline and after 1 year, and to evaluate the fluctuation of the OA in individual months. Furthermore, we studied whether adherence is influenced by signing of informed consent and routine medical check-up. Methods: This was a longitudinal, observational study. The data were obtained from the Osteocenter of University Hospital in Hradec Kralove, Czech Republic. Adherence was measured using electronic bottles type Medication Events Monitoring System (MEMS). The study was carried out in two 3-month periods; the baseline in 2013 (signing of informed consent while medical check-up) and the follow-up (medical check-up) in 2014. The adherence and adherence-related outcomes were studied in patients who had initiated osteoporosis treatment and were persistent. Results: 21 (49%) out of 43 patients who avoided drug dispenser and were persistent both at baseline and at follow-up, completed the study and were included. Median age was 76. Evaluating the whole 3-month periods, the OA did not differ significantly at baseline and at follow-up, the OA was 71 and 68%, respectively. However, the adherence in month 1 at baseline was significantly higher than the adherence in month 2 at baseline (p < 0.001) and also than the adherence in month 1 at follow-up (p = 0.010). Analysing the study period without month 1, a stable adherence was observed in 48% of patients. About 33% of doses were omitted at baseline and 34% at follow-up. As many as 71% of the patients took drug holidays at baseline, and 76% at follow-up. Conclusion: The OA was insufficient, around 70% both at baseline and at follow-up. One half of the patients showed a stable adherence. The patterns of non-adherence were very similar at follow-up. Signing of the informed consent seems to act as bias more than regular medical check-up.

Fat- and fiber-related diet behavior among type 2 diabetes patients from distinct regions.

PURPOSE: Diet and eating habits are of key importance in patients with type 2 diabetes mellitus (T2DM). The purpose of this comparative study was to analyze fat- and fiber-related behavior (FFB) in patients with T2DM from distinct cultural areas. PATIENTS AND METHODS: Observational study was carried out in the Czech Republic (CR) (n=200), the US (n=207), and Yemen (n=200). Patients completed the Fat- and Fiber-related Diet Behavior Questionnaire (FFBQ). RESULTS: Differences in all aspects of FFB among countries were found (P<0.05). The best fat-related behavior reported was from patients from the CR. Patients from the US showed the worst fat-related behavior in total. On the other hand, patients from the US reported the best fiber-related behavior. Patients from Yemen reached the worst scores in all fat-related domains. Patients from all studied countries reported the best results in the "modify meat" and "avoid fat as flavoring" and the worst in the "substitute high fiber" subscales. CONCLUSION: Professionals involved in the diet education of T2DM patients should be aware of the specificity of diet in their country when advising patients keeping general recommendations. We suggest them to be as specific as possible and concentrate on fiber-related behavior.

Drug holidays: the most frequent type of noncompliance with calcium plus vitamin D supplementation in persistent patients with osteoporosis.

PURPOSE: All current recommendations include calcium and vitamin D (Ca-D) as an integrated part of osteoporosis treatment. The purpose of this pilot study was to analyze compliance with a fixed combination of Ca-D in women persistent with the treatment. PATIENTS AND METHODS: An observational study was carried out in three osteocenters in the Czech Republic. Women with osteoporosis ≥55 years of age concurrently treated with oral ibandronate were eligible. Compliance was evaluated in a period of 3 months by Medication Event Monitoring System (MEMS), tablet count, and self-report. Nonpersistence was defined as a MEMS-based gap in the use of Ca-D to be 30 days or more. RESULTS: A total of 73 patients were monitored, of which 49 patients were analyzed (target population). Based on MEMS, mean overall compliance was 71%; good compliance (≥80%) was observed in 59% of the patients. As many as 71% of the patients took drug holidays (≥3 consecutive days without intake); overall compliance of these patients was 59% and was slightly lower on Fridays and weekends. Patients without drug holidays were fully compliant (did not omit individual doses). Compliance differed according to daily time at which the patients mostly used the Ca-D. Afternoon/evening takers showed a mean overall compliance of 82% while morning/night takers only 51% (P=0.049). Based on MEMS, tablet count, and self-report, compliance ≥75% was observed in 59%, 100%, and 87% of the patients, respectively. Outcomes obtained by the three methods were not associated with each other. Undesirable concurrent ingestion of Ca-D and ibandronate was present only twice. CONCLUSION: Despite almost perfect self-reported and tablet count-based compliance, MEMS-based compliance was relatively poor. Consecutive supplementation-free days were common; more than two-thirds of the patients took at least one drug holiday. This pilot study showed drug holiday to be the most important type of noncompliance with Ca-D in those who are persistent with the treatment.

Consumption of osteoanabolic drugs and strontium ranelate in the treatment of osteoporosis in the Czech Republic in 2005-2011.

Anti-osteoporosis drugs with osteoanabolic (teriparatide, intact parathormone) and dual (strontium ranelate) mechanism of action are currently available for the treatment of postmenopausal, glucocorticoid induced or male osteoporosis in the Czech Republic (CZ). These expensive drugs are subjects of special prescribing limitations (2nd line treatments). The objective was to analyze trends in consumption of osteoanabolic and dual drugs in the treatment of osteoporosis since their introduction onto the market in CZ (2005-2011). The prescription-based database of the General Health insurance Company of the Czech Republic that covers approximately 60% of the Czech population was used as the data source. An insured person with a recorded prescription for teriparatide (TRPD), intact parathormone (iPTH) or strontium ranelate (SR) in the period of interest was defined as a patient; 271 (224), 77 (75) and 5930 (5545) patients (women) treated with TRPD, iPTH and SR in 2011, respectively, were identified. The median age of patients on TRPD and SR ranged from 71 to 74 years in 2006-2011. The number of patients treated with TRPD between 2009 and 2011 has been stable, while in iPTH the number increased 2.8 times in the same time period. The number of patients treated with SR has been steadily rising since its introduction in 2005. SR was prescribed most often by physicians specialized in internal medicine (42%) and rheumatology (25%). Male patients accounted for 6% of the SR consumers in 2011. The consumption of dual and osteoanabolic drugs has been rapidly increasing. Consumption rates in men (both absolute and relative) have been increasing but still remain relatively low.

Prescription of evidence-based medicine drugs by general practitioners to patients after myocardial infarction: outcomes from the Czech Republic.

Ischemic heart disease is the most frequent cause of both serious morbidity and mortality of adult population in developed countries. The main aim of the study was to carry out the analysis of general practitioners (GP) prescription of evidence-based therapy in patients after myocardial infarction (MI). Data were retrospectively collected in 2011, by a single application with the help of software that GPs use in their surgeries. All patients of a particular GP who had MI in their history and who were at the time of data collection treated only by GPs (not by the specialists of internal medicine or cardiology) were always included. Four hundred ninety one patients were included in the study. The average age was 70.7 (+/- 11.6) and 69.2% of the involved patients were men. Seventy nine percent of patients used beta-blockers, 80% antiplatelet drugs, 77% statins and 79% used angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs). Forty four percent of patients used drugs from all four groups. The significant prescription decrease was proved in all four groups in dependence on patients' age (p < 0.05). Although the evidence-based medicine usage in patients after MI in the Czech Republic is comparable to other countries, it is not optimal. More intensive involvement of pharmacists in the care of patients after MI would further improve the situation.

An analysis of fat-related and fiber-related behavior in men and women with type 2 diabetes mellitus: key findings for clinical practice.

BACKGROUND: Despite the efforts of health care providers, adherence of patients with type 2 diabetes to the recommended diet is poor. The aim of this study was to describe the eating habits with emphasis on fat and fiber-related behavior (FFB) as well as the relationship between FFB behavior and parameters of diabetes control in men and women with type 2 diabetes mellitus. METHODS: The subjects in this observational cross-sectional study were 200 patients (54.5% male, mean age 66.2 ± 10.1 years, mean Diabetes Control and Complications Trial [DDCT] glycosylated hemoglobin [HbA1c] 7.6% ± 1.7%) recruited from diabetes outpatient clinics in the Czech Republic. The subjects filled out the Fat- and Fiber-related Diet Behavior Questionnaire. The most recent patient data on diabetes control and drug therapy were derived from patient medical records. RESULTS: Patients tend to modify the dishes they are used to, rather than remove them completely from their diet and replace them by other types of foods. It is easier to perform healthier fat-related behaviors than fiber-related ones. Women scored significantly better than men on the fat-related diet habits summary scale (P = 0.002), as well as on "modify meat" (P = 0.001) and "substitute specially manufactured low-fat foods" (P = 0.045) subscales. A better score on the fat-related diet habits summary scale was significantly associated with higher HbA1c (ρ = -0.248; P = 0.027) and higher waist circumference (ρ = -0.254; P = 0.024) in women. CONCLUSION: Type 2 diabetes patients are likely to vary in their FFB behavior, and their dietary habits depend on gender. Health care professionals should pay attention to these facts when providing specific education. Emphasis should be placed on how to increase the fiber intake in diabetic patients.

Adherence in adults with type 1 diabetes mellitus correlates with treatment satisfaction but not with adverse events.

PURPOSE: Diabetes self-care and self-monitoring adherence has a positive effect on the metabolic control of the disease. The aim of this study was to analyze the adherence to self-care recommendations and to identify its correlates in adults with type 1 diabetes mellitus. PATIENTS AND METHODS: One hundred and eleven patients with type 1 diabetes were enrolled in an observational cross-sectional study conducted at the Diabetes Center of the University Hospital in Hradec Králové, Czech Republic. Diabetes self-care adherence was measured by the Self Care Inventory-Revised, and treatment satisfaction by the Diabetes Treatment Satisfaction Questionnaire-status version. Additional data were collected from self-administered questionnaires and medical records. The Mann-Whitney test, Spearman correlations, and multiple linear regressions were used in the statistical analysis. RESULTS: The mean age of patients was 42.4 years; 59.5% of them were females and 53.2% of all patients used an insulin pump. The mean glycosylated hemoglobin (HbA1c) was 66.2 ± 15.3 mmol/mol and the mean insulin dosage was 0.6 ± 0.3 IU insulin/kg/day. The number of hypoglycemic episodes (including severe) that patients had in the last month before taking the survey was 3.6 ± 3.2. Self-care adherence was associated with treatment satisfaction (0.495; P = 0.004) along with frequency of self-monitoring of before meal blood glucose (0.267; P = 0.003). It was not associated with the incidence of hypoglycemic events or any other insulin therapy-related problems or with socio-demographic or clinical characteristics. CONCLUSION: Treatment satisfaction is one of the key factors that need to be targeted to maximize benefits to patients. Self-care adherence in adults with type 1 diabetes did not correlate with socio-demographic and clinical characteristics, nor with adverse events.

Binding of quinidine radically increases the stability and decreases the flexibility of the cytochrome P450 2D6 active site.

Human cytochrome P450 2D6 (CYP2D6) is an enzyme of the CYP superfamily responsible for biotransformation of about 20% of drugs of known metabolism containing a basic nitrogen and a planar aromatic ring. Here, we present a combined experimental and computational study on the compressibility and flexibility of unliganded and quinidine-bound CYP2D6. Experimentally, high-pressure induced Soret band shifts of the enzyme were measured by UV/VIS spectroscopy, while 100 ns all atomic molecular dynamics (MD) simulations in explicit water were used in the computational analysis. We identified sharp differences between ligand-free and quinidine-bound CYP2D6 forms in compressibility, flexibility parameters and active site solvation. While the unliganded CYP2D6 is compressible, quinidine binding significantly rigidifies the CYP2D6 active site. In addition, MD simulations show that quinidine binding results in pronounced reductions in active site flexibility and solvation.

Dynamics and hydration of the active sites of mammalian cytochromes P450 probed by molecular dynamics simulations.

The flexibility, active site volume, solvation, and access path dynamics of six metabolically active mammalian cytochromes P450 (human 2A6, 2C9, 2D6, 2E1, 3A4 and rabbit 2B4) are extensively studied using molecular dynamics (MD) simulations. On average, the enzymes' overall structures equilibrate on a 50+ ns timescale. The very open CYP2B4 structure closes slowly over the course of the simulation. The volumes of the active sites fluctuate by more than 50% during the MD runs; these fluctuations are mainly due to movements of the main chains, with only a handful of amino acid residues in CYP2B4, CYP2D6, CYP2A6 and CYP2C9 showing significant independent side chain movement. The volume of the active site of CYP2E1 fluctuates heavily, ranging from 220 to 1310 A(3), due to the opening and closing of gates to two adjacent cavities. CYP2E1 has the least hydrated active site of the studied CYPs; this is consistent with its preference for non-polar substrates. The CYP2A6 and CYP2E1 active sites are deeply buried, with access paths that are narrower than the radius of a water molecule. However, waters are still able to access these active sites due to local adaptations of the channel to accommodate their passage. This finding may imply that the access paths of the CYPs never fully open prior to contact with the substrate; instead, the substrate may induce adaptive conformational changes during its passage to the active site. This may also explain why some substrate recognition sites are localized along individual enzymes' access paths.

Membrane position of ibuprofen agrees with suggested access path entrance to cytochrome P450 2C9 active site.

Cytochrome P450 2C9 (CYP2C9) is a membrane-anchored human microsomal protein involved in the drug metabolism in liver. CYP2C9 consists of an N-terminal transmembrane anchor and a catalytic cytoplasmic domain. While the structure of the catalytic domain is well-known from X-ray experiments, the complete structure and its incorporation into the membrane remains unsolved. We constructed an atomistic model of complete CYP2C9 in a dioleoylphosphatidylcholine membrane and evolved it by molecular dynamics simulations in explicit water on a 100+ ns time-scale. The model agrees well with known experimental data about membrane positioning of cytochromes P450. The entry to the substrate access channel is proposed to be facing the membrane interior while the exit of the product egress channel is situated above the interface pointing toward the water phase. The positions of openings of the substrate access and product egress channels correspond to free energy minima of CYP2C9 substrate ibuprofen and its metabolite in the membrane, respectively.

Flexibility of human cytochrome P450 enzymes: molecular dynamics and spectroscopy reveal important function-related variations.

To gain more complete insight into flexibility and malleability of five forms of human liver cytochrome P450 enzymes, which play major roles in drug metabolism (CYPs 1A2, 2A6, 2C9, 2D6 and 3A4), we employed UV/VIS and resonance Raman spectroscopy in combination with all-atomic molecular dynamics simulations under normal and high pressure conditions (300 MPa). In general, the high pressure reduces the flexibility of CYPs, which become more dense and compact as their radii of gyration and temperature B-factors diminish. The flexibility of CYPs spans the regions, which are localized in solvent exposed loops. A considerable degree of flexibility is also observed at amino-acids making the pw2 and solvent channels, which are suggested to serve for substrate access and/or product release. The number of water molecules as well as the number of protein backbone atoms of the active site in close proximity of heme cofactor generally increases under high pressure. This finding provides new insights regarding the interpretation of pressure-related Soret band red shifts. Presented results also point towards considerable differences between the CYP forms studied: CYP2A6 and CYP1A2 have the least malleable active sites while those of CYP2D6, CYP2C9 and CYP3A4 have considerably greater degrees of flexibility or malleability. In addition, the number of water molecules in the active site cavity of CYP3A4 anomalously decreases under high pressure due to opening of the active site. These results correlate with the known substrate promiscuity of the respective CYP forms, with CYP3A4 displaying the highest substrate promiscuity, corresponding to the most open and malleable active site, whereas CYP1A2 and CYP2A6 show a high substrate-specificity and have a small and rigid active sites.

A cancer-derived mutation in the PSTAIRE helix of cyclin-dependent kinase 2 alters the stability of cyclin binding.

Cyclin-dependent kinase 2 (cdk2) is a central regulator of the mammalian cell cycle. Here we describe the properties of a mutant form of cdk2 identified during large-scale sequencing of protein kinases from cancerous tissue. The mutation substituted a leucine for a proline in the PSTAIRE helix, the central motif in the interaction of the cdk with its regulatory cyclin subunit. We demonstrate that whilst the mutant cdk2 is considerably impaired in stable cyclin association, it is still able to generate an active kinase that can functionally complement defective cdks in vivo. Molecular dynamic simulations and biophysical measurements indicate that the observed biochemical properties likely stem from increased flexibility within the cyclin-binding helix.