Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas.

OBJECTIVES: To assess the impact of student telephone motivational interviewing intervention on angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) adherence trajectories and identify predictors of each trajectory. METHODS: The intervention group included continuously enrolled Medicare Advantage Plan patients non-adherent to ACEI/ARBs vs the control group (1:2 ratio). The intervention was tailored by pre-intervention trajectories and included an initial and five follow-up calls. Adherence was measured 6 months after initial calls using the proportion of days covered (PDC). Monthly PDCs were integrated into a group-based trajectory model and categorized patients into 4-groups. A multinomial logistic regression model was used to evaluate trajectory predictors. RESULTS: The study comprised 240 intervention patients and 480 controls with four trajectories: adherent trajectory 44.2%, gradual improvement in adherence 13.4%, slow decline in adherence 24.1%, and discontinuation 18.3%. Patients with the intervention were less likely to experience a slow decline in adherence than controls (OR: 0.627 [0.401-0.981]). Patients with specialty prescribers' visits, ≥ 1 previous hospitalization, rapid decline in adherence as pre-intervention trajectory, and higher CMS risk score were associated with discontinuation trajectory. CONCLUSION: Intervention patients vs controls had a lower likelihood of following a slow decline in adherence pattern. PRACTICE IMPLICATIONS: This study underscores the importance of individualized interventions and the association between past adherence patterns and post-intervention trajectories.

Differences in Perceived Threat and Efficacy in Managing Opioid Use Disorder versus Alcohol Use Disorder.

Background: Efforts to increase the availability of Medication Assisted Treatment for alcohol use disorder (AUD) and opioid use disorder (OUD) may be futile if patients lack motivation for recovery and are unwilling to seek treatment. Objectives: In this cross-sectional, online survey, we used the Extended Parallel Process Model (EPPM) to assess how participants at risk of AUD or OUD react to their perceived threat and assess their response to pharmacotherapy as a potential treatment. EPPM constructs were assessed using the Risk Based Diagnosis Scale. Descriptive statistics measure the proportion of treated vs untreated participants. Untreated participants were sorted into one of three groups categorizing perceived threat - low threat appraisal, and danger or fear control. Results: Of 411 total responses, most (n = 293[71.29%]) sorted into the AUD cohort and 118(28.71%) into the OUD cohort. Overall, 104(25.30%) had received treatment and 307(74.70%) didn't. Within the OUD cohort, there were 67 untreated participants - 16(23.88%) exhibited low threat appraisal, 13(19.40%) were likely to undergo fear control, and 38(56.72%) were likely to undergo danger control. Within the AUD cohort, there were 240 untreated participants - 75(31.25%) exhibited low threat appraisal, 100(41.67%) were likely to experience fear control, and 65(27.08%) were likely to experience danger control. Participants in the OUD cohort were more likely to undergo danger control than those in the AUD cohort (χ2 = 19.26, p < 0.05). Conclusions: This study identified perceived threat and efficacy when an individual was at risk of a SUD, but more insight into potential early interventions is needed - particularly in those individuals with polysubstance use disorder.

Acceptance of COVID-19 vaccination in a sample of Middle Eastern and North African (MENA) Houston residents.

BACKGROUND: COVID-19 vaccination has averted a significant number of deaths in the United States, but vaccination hesitancy continues to be a problem. Therefore, examining vaccination acceptance and/or hesitancy in local communities is critical. METHODS: A quantitative survey and a multivariable logistic regression model was utilized to determine predictors of COVID-19 vaccination in Middle Eastern and North African (MENA) origin Houston residents. The outcome of interest was COVID-19 vaccination status (vaccinated versus not vaccinated). Covariates included: demographics, health, and COVID-19 factors. Statistical analyses included SAS version 9.4 at a priori significance level of 0.05. RESULTS: The overall vaccine acceptance rate was significantly high in this population subset (N = 366), with 77.60% vaccinated, and 22.40% not vaccinated. MENA individuals with some college degrees were less likely to report vaccination than those with a graduate degree [Odds Ratio (OR): 0.18; 95% Confidence Interval (CI): 0.04, 0.77]. Homeowners were more likely to get vaccinated than renters (OR: 2.58; 95%CI: 1.17, 5.68). Individuals practicing Islamic faith were more likely to get vaccinated than other religious affiliations (OR: 3.26; 95%CI: 1.15, 9.19). Individuals with hypertension were less likely to get vaccinated than those without it (OR: 0.34; 95%CI: 0.13, 0.92), and those with anxiety were more likely to get vaccinated than those without anxiety (OR: 4.23; 95%CI: 1.68, 10.64). CONCLUSIONS: Health status, education level, financial stability, and religious affiliation are some of the determining factors that potentially influence vaccination acceptance/hesitancy among the MENA community.

Demographics of Skin Cancer Knowledge Among Middle and High Schoolers in Texas.

INTRODUCTION: Adolescents, an age group that can reduce sun exposure early, may benefit from school-based skin cancer education programs. Literature regarding the demographics of melanoma knowledge is sparse. OBJECTIVES: This study sought to evaluate melanoma knowledge among students in Texas viewing John Wayne Cancer Foundation Block the Blaze (JWCFBTB) presentations and identify group differences with regard to sociodemographic factors. METHODS: Before JWCFBTB presentations delivered in Houston and Dallas by health professions students, a pre-presentation melanoma knowledge quiz was distributed. This survey was adapted from a 2000 study evaluating melanoma knowledge in middle and high schoolers in Houston and Dallas. Respondents were also asked to provide their gender, age, grade, race, parent education level, and whether they are first-generation American. ANOVA and Tukey tests were used to evaluate demographic group differences in scores. Logistic regression models determined predictors of answering selected true/false questions correctly. RESULTS: One-way ANOVA tests showed statistically significant group differences in pre-test scores for all demographic factors evaluated. Females, Whites/Caucasians, students whose parents hold graduate degrees, and older students had higher scores. Black students and non-first-generation Americans were more likely to answer selected commonly missed questions correctly. CONCLUSIONS: Results from 2000 and 2020-2021 indicate older students from higher grade levels know more about melanoma, suggesting adolescents may benefit from earlier skin cancer education. Racial minorities and individuals of low socioeconomic status, who suffer from disparities in melanoma treatment and mortality, showed poorer melanoma knowledge. Targeting skin cancer education to disadvantaged schools may help remedy such gaps.

A Motivational Interviewing Intervention to Improve Adherence to ACEIs/ARBs among Nonadherent Older Adults with Comorbid Hypertension and Diabetes.

BACKGROUND: Hypertension and diabetes mellitus are independent risk factors for cardiovascular diseases. Due to the cardioprotective nature of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), they are recommended for patients with comorbid hypertension and diabetes. However, poor adherence to ACEIs/ARBs among older adults is a major public health concern. This study aimed to assess the effectiveness of a telephonic motivational interviewing (MI) intervention conducted by pharmacy students among a nonadherent older population (≥ 65 years old) with diabetes and hypertension. METHODS: Patients continuously enrolled in a Medicare Advantage Plan who received an ACEI/ARB prescription between July 2017 and December 2017 were identified. Group-based trajectory modeling (GBTM) was used to identify distinct patterns of ACEI/ARB adherence during the 1-year baseline period: adherent, gaps in adherence, gradual decline, and rapid decline in adherence. Patients from the three nonadherent trajectories were randomized into MI intervention or control group. The intervention consisted of an initial call and five follow-up calls administered by MI-trained pharmacy students and tailored to the baseline ACEI/ARB adherence trajectories. The primary outcome was adherence to ACEI/ARB during the 6- and 12-month periods post-MI implementation. The secondary outcome was discontinuation, defined as no refills for ACEI/ARB during the 6- and 12-month periods post-MI implementation. Multivariable regression analyses examined the impact of MI intervention on ACEI/ARB adherence and discontinuation while adjusting for baseline covariates. RESULTS: A total of 240 patients in the intervention group and 480 patients as randomly selected controls were included in this study. At 6 months, patients receiving the MI intervention had significantly better adherence (ß = 0.06; p = 0.03) compared with the controls. Linear and logistic regression models also showed patients in the intervention group were more likely to be adherent than controls within 12 months of intervention implementation (ß = 0.06; p = 0.02 and OR: 1.46; 95% CI 1.05-2.04, respectively). MI intervention did not have any significant impact on the ACEI/ARB discontinuation. CONCLUSION: Patients who received the MI intervention were more likely to be adherent at 6 and 12 months following the intervention initiation, despite gaps in the follow-up calls due to COVID-19. Pharmacist-led MI intervention is an effective behavioral strategy to improve medication adherence among older adults and tailoring the intervention to past adherence patterns may enhance the intervention effectiveness. This study was registered with the United States National Institutes of Health (ClinicalTrials.gov identifier NCT03985098).

Cost-Effectiveness Analysis of Macitentan in Comparison With Bosentan in the Treatment of Pulmonary Arterial Hypertension in Iran.

OBJECTIVES: Pulmonary arterial hypertension (PAH) is a chronic and progressive disease that, if left untreated, shortens the life expectancy of patients. Endothelin receptor antagonists, such as macitentan and bosentan, play an essential role in improving the patient's symptoms, quality of life, and life expectancy. This study aimed to evaluate the cost-utility of macitentan compared with bosentan in treating PAH from the health system perspective in Iran. METHODS: For evaluating the cost-effectiveness of macitentan, a Markov model consisting of 5 states, functional class (FC) I, FC II, FC III, FC IV, and death, was designed using the TreeAge software. The lifetime time horizon and a 3-month cycle length were set. Patients entered the model from FC II or FC III states based on the initial probabilities. Costs were measured in US dollars (USD), and outcomes were measured in terms of quality quality-adjusted life-years (QALYs). Consequently, the incremental cost-effectiveness ratio (ICER) was calculated. In addition, sensitivity analysis was performed to determine the robustness of the model by examining the possible effects of uncertainties on the final result. RESULTS: The costs of treatment with macitentan and bosentan in PAH in Iran were calculated at 19 429 and 17 246 USD, and the outcomes were 4.02 and 3.04 QALYs, respectively. Therefore, ICER was calculated at 2233.46 USD/QALY. One-way sensitivity analysis demonstrates that the model is robust; nevertheless, it is most sensitive to the price of macitentan and bosentan. CONCLUSION: Treatment with macitentan was associated with both higher costs and QALYs than bosentan. Nevertheless, it is considered the cost-effective treatment strategy in Iran given that the calculated ICER falls below the willingness to pay threshold.

Patient-Reported Barriers to Adherence Among ACEI/ARB Users from a Motivational Interviewing Telephonic Intervention.

Purpose: Hypertension is a common comorbidity among type 2 diabetes mellitus (T2DM) patients, which increases the risk of cardiovascular diseases. Despite the proven benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this population, poor medication adherence is prevalent, resulting in higher complications and mortality rate. Motivational interviewing (MoI) has demonstrated effectiveness in improving medication adherence and identifying barriers. This study aimed to assess and identify patient-reported barriers to adherence to ACEI/ARB from an MoI telephonic intervention conducted by student pharmacist interns. Patients and Methods: This retrospective study was conducted within an MoI intervention customized by past ACEI/ARB adherence trajectories for nonadherent patients with T2DM and hypertension enrolled in a Medicare Advantage Plan. Adherence barriers were extracted from the interviewers' notes by two independent researchers. Descriptive analysis was performed to summarize the overall frequency of barriers as well as across trajectory groups, identified from the initial and follow-up calls. Results: In total, 247 patients received the initial MoI call from which 41% did not communicate any barrier for ACEI/ARB use despite having low adherence. About 59% of the patients reported at least one barrier during the initial call. The most common barriers included forgetfulness, discontinuation by physicians, side effects, multiple comorbidities, polypharmacy, lack of knowledge about disease/medication, and cost issues. The follow-up calls helped with uncovering at least one new barrier for 28 patients who previously communicated a different issue with their medication during the first call. Additionally, 18 patients with initial denial for having any barrier to adherence reported at least one barrier throughout the follow-up calls. Conclusion: This study summarized patient-reported barriers to ACEI/ARB adherence from an MoI telephonic intervention performed among nonadherent patients. Identifying specific barriers for patients may help to further design tailored interventions that address the barriers and improve adherence.

Group based trajectory modeling to assess adherence to oral anticoagulants among atrial fibrillation patients with comorbidities: a retrospective study.

BACKGROUND: Poor adherence to oral anticoagulants is a significant problem in atrial fibrillation (AF) patients with comorbidities as it increases the risk for cardiac and thromboembolic events. AIM: The primary objective was to evaluate adherence to direct oral anticoagulants (DOACs) or warfarin using group-based trajectory modeling (GBTM). The secondary objective was to identify the predictors of adherence to oral anticoagulants. Finally, to report the drug interactions with DOACs/warfarin. METHOD: This retrospective study was conducted among continuously enrolled Medicare Advantage Plan members from January 2016-December 2019. AF patients with comorbid hypertension, diabetes and hyperlipidemia using warfarin/DOACs were included. Monthly adherence to DOAC/warfarin was measured using proportion of days covered (PDC) and then modeled in a logistic GBTM to identify the distinct patterns of adherence. Logistic regression model was conducted to identify the predictors of adherence to oral anticoagulants adjusting for all baseline characteristics. Concomitant use of DOACs/warfarin with CYP3A4,P-gp inhibitors were measured. RESULTS: Among 317 patients, 137 (43.2%) and 79 (24.9%) were DOAC, and warfarin users, respectively. The adherence trajectory model for DOACs included gradual decline (40.4%), adherent (38.8%), and rapid decline (20.8%). The adherence trajectories for warfarin adherence included gradual decline (8.9%), adherent (59.4%), and gaps in adherence (21.7%). Predictors of adherence included type of oral anticoagulant, stroke risk score, low-income subsidy, and baseline PDC. CYP3A4,P-gp drugs were co-administered with DOACs /warfarin resulting in adverse events. CONCLUSION: Adherence to oral anticoagulants is suboptimal. Interventions tailored according to past adherence trajectories may be effective in improving patient's adherence.

Perception Regarding Knowledge of COVID-19 Prevention in a Sample of a Middle Eastern and North African (MENA) Community in Houston, Texas, USA.

(1) Background: Knowledge of COVID-19 prevention among communities is the first step towards protective behaviors. The objective of this study was to assess COVID-19 prevention knowledge among a Middle Eastern and North African community in Houston, Texas. (2) Methods: A cross-sectional study was conducted using a validated quantitative survey; survey questions consisted of three parts: COVID-19 specific questions, general health questions, and sociodemographic questions. A multivariable logistic regression model was used to determine predictors of perception of knowledge on preventing COVID-19 spread. The outcome of interest comprised of "good/excellent" versus "average and below" knowledge. (3) Results: A total of 366 participants (66.39% males) completed the survey. A univariate analysis demonstrated significant differences in self-reported COVID-19 prevention knowledge among those with and without health insurance, different ages, level of knowledge, and perceived severity of COVID-19 infection. In the multivariate logistic regression, two predictors were identified: those in the 18-25-year-old group were more likely to have "excellent/good" knowledge on COVID-19 spread compared to the ≥40-year-old group (OR: 6.36; 95% CI: 1.38, 29.34). Those who somewhat agree with knowing how to protect themselves from COVID-19 were more likely to have "excellent/good" knowledge of preventing COVID-19 spread compared to those that neither agree nor disagree or disagree (OR: 7.74; 95% CI: 2.58, 23.26). (4) Conclusions: Younger adults reported higher knowledge of COVID-19 prevention.

Interventions to improve medication adherence in inflammatory bowel disease: A systematic review.

OBJECTIVE: To summarize existing literature examining interventions to enhance medication adherence and their effectiveness in enhancing care for inflammatory bowel disease (IBD) patients. METHODS: This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. PubMed and Embase were searched for studies from June 2014 to Dec 2020. Only the studies published in English were included. RESULTS: Our systematic literature search identified 488 published articles. Seventeen studies with a total of 7073 patients were included. Out of seventeen different interventions, five were classified as educational, eight as multicomponent, three as behavioral and one as cognitive behavioral. Adherence was measured using patient self-report, administrative/pharmacy claims data, and electronic monitoring devices/pill dispensing systems. Twelve out of seventeen interventions showed a statistically significant improvement in medication adherence including three educational, seven multicomponent, one behavioral and one cognitive behavioral intervention. CONCLUSIONS: Multicomponent interventions demonstrated the greatest success in IBD patients in promoting medication adherence. Future research should focus on a multidisciplinary approach to design multicomponent interventions to optimize treatment adherence and enhance long-term clinical outcomes. PRACTICE IMPLICATIONS: While stand-alone strategies have demonstrated effectiveness in improving adherence, better outcomes may be achieved by combining multiple strategies.

Using group-based trajectory modeling to characterize the association of past ACEIs/ARBs adherence with subsequent statin adherence patterns among new statin users.

BACKGROUND: Despite well-documented benefits, statin adherence remains suboptimal. Studies have suggested that previous adherence to other chronic medications is a strong predictor of future adherence to newly initiated statins. Group-based trajectory modeling (GBTM) has been applied as a method to longitudinally depict the dynamic nature of adherence. OBJECTIVES: This study aimed to examine the association between patients' adherence patterns to newly initiated statins and previous adherence trajectories of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) using GBTM. METHODS: This retrospective cohort study was conducted among continuously enrolled statin initiators using claims data. Patients were included if they had ACEI/ARB use within 1 year before statin initiation (preindex period). Monthly adherence to ACEIs/ARBs was calculated during the preindex period and monthly adherence to statins was assessed 1 year after statin initiation using proportion of days covered (PDC). The monthly PDCs were modeled as a longitudinal response in a logistic GBTM to provide distinct patterns of adherence for ACEIs/ARBs and statins, separately. A multinomial logistic regression was conducted to determine an association between ACEI/ARB adherence trajectories and future statin trajectories, controlling for patient characteristics. RESULTS: A total of 1078 patients were categorized into 4 distinct statin adherence trajectories: adherent (40.8%), gradual decline (37.4%), gaps in adherence (13.9%), and rapid decline (7.9%). Patients were further categorized into 4 groups on the basis of their distinct past ACEIs/ARBs trajectories: adherent (43%), gaps in adherence (29%), delayed nonadherence (15.2%), and gradual decline (12.8%). In the multinomial logistic regression, patients in the gaps in adherence or gradual decline groups were more likely to follow similar trajectories for future statin use than the adherent trajectory. CONCLUSION: Previous adherence trajectories of ACEIs/ARBs may predict future adherence patterns for newly initiated statins. Knowledge of past medication-taking behavior could provide valuable information for developing tailored interventions to improve adherence.

Efficacy and safety of Tocilizumab in severe and critical COVID-19: A Systematic Review and Meta-Analysis.

OBJECTIVES: Currently published papers and clinical guidelines regarding the effects of tocilizumab in severe and critical COVID-19 are contradictory. The aim of this meta-analysis was to combine the results of clinical studies of different designs to investigate the efficacy and safety of tocilizumab in severely-to-critically ill COVID-19 patients. METHODS: A systematic search was performed in PubMed, Embase, CENTRAL, ClinicalTrials.gov, Scopus, and preprint servers up to 26 December 2020. Since a substantial heterogeneity was expected, a random-effects model was applied to calculate the pooled effect size (ES) and 95% confidence interval (CI) for each study outcome. RESULTS: Forty-five comparative studies involving 13,189 patients and 28 single-arm studies involving 1,770 patients were analyzed. The risk of mortality (RR of 0.76 [95%CI 0.65 to 0.89], P < 0.01) and intubation (RR of 0.48 [95%CI 0.24 to 0.97], P = 0.04) were lower in tocilizumab patients compared with controls. We did not find any significant difference in secondary infections, length of hospital stay, hospital discharge before day 14, and ICU admission between groups. CONCLUSION: Tocilizumab can improve clinical outcomes and reduce mortality rates in severe to critical COVID-19 patients. Large-scale randomized controlled trials are still required to improve the statistical power of meta-analysis.

Impact of a motivational interviewing intervention targeting statins on adherence to concurrent hypertension or diabetes medications.

OBJECTIVE: This study explored if a motivational interviewing intervention customized for statins impacted adherence to concomitantly used antidiabetic/antihypertensive medications. METHODS: The intervention was conducted among patients with a history of suboptimal adherence to statins and included 152 patients in intervention and 304 controls. This retrospective study design identified patients with claims for statins and either antidiabetic/antihypertensive medications. The outcome variable was adherence, measured as proportion of days covered ≥ 0.80, to antidiabetic/antihypertensive medications. Multivariable linear and logistic regression evaluated the effect of intervention on adherence to antidiabetic/antihypertensive medications during the 6 months post-intervention. RESULTS: The antidiabetic group had 53 intervention patients and 102 controls. The antihypertensive group had 80 intervention patients and 159 controls. There was no significant improvement in adherence for antidiabetic/antihypertensive medications following the intervention. Adherence at baseline was a significant predictor of adherence post-intervention in the antidiabetic (OR = 6.5;P < 0.0001) and antihypertensive (OR = 4.1; P = 0.0001 & ß = 0.09; P = 0.008) users. Physician specialty (OR = 3.902; P = 0.01& ß = 0.09; P = 0.015) among antidiabetic users and age >70 years (OR = 2.148; P = 0.025) among antihypertensive users were predictors of adherence. CONCLUSION: The intervention targeting statin did not significantly improve antihypertensive/antidiabetic adherence. PRACTICE IMPLICATIONS: Targeted interventions tailored to patient past adherence and specific medications should be explored.

Identifying adherent patients to newly initiated statins using previous adherence to chronic medications.

BACKGROUND: Statins are one of the most frequently prescribed medications in the United States. Despite well-documented benefits in managing hyperlipidemia and reducing cardiovascular risks, statin adherence remains suboptimal. Several effective interventions have been implemented to improve adherence to statins. However, identifying patients who are at risk for developing poor medication adherence at the time of treatment initiation could assist in planning early targeted interventions. Studies have suggested that previous adherence to chronic medications is a strong predictor of future adherence to newly initiated medications. OBJECTIVE: To investigate patients' adherence to newly initiated statins by measuring previous adherence to angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and oral antidiabetic drugs (OADs). METHODS: A retrospective cohort study was conducted using administrative claims data from January 2016 to May 2018. New statin initiators were identified and included in the study if they were continuously enrolled in the health plan and had at least 1 prescription for ACEIs, ARBs, or OADs 1 year before statin initiation (pre-index period). Baseline adherence to ACEIs/ARBs, OADs, or both was calculated during a 1-year pre-index period using proportion of days covered (PDC) and defined as PDC ≥ 0.80. Adherence to statins was assessed 1 year after statin initiation and was the primary outcome, with a PDC ≥ 0.80 considered as adherent. Patient demographics were measured during the pre-index period. Multivariable logistic regression was conducted for each cohort separately to determine an association between baseline adherence and future statin adherence controlling for various demographic and clinical characteristics. RESULTS: 1,223 ACEI/ARB users, 714 OAD users, and 452 concomitant ACEI/ARB and OAD users were identified. In the regression model, adherence to baseline medications was significantly associated with 1-year adherence to statins (ACEI/ARB users: OR = 1.75, 95% CI = 1.37-2.25; OAD users: OR = 2.02, 95% CI = 1.46-2.79; concomitant ACEI/ARB and OAD users: OR = 1.73, 95% CI = 1.16-2.58). CONCLUSIONS: Past adherence to baseline medications may predict future adherence to newly initiated statins. Identifying patients likely to become nonadherent during treatment initiation could enable health care providers in recognizing individuals at risk of nonadherence and intervene earlier to enhance future adherence. DISCLOSURES: No funding was received for this study. Abughosh reports grants from Regeneron-Sanofi, BMS-Pfizer, and Valeant, unrelated to this work. Majd, Mohan, and Paranjpe have nothing to disclose.

Group-Based Trajectory Modeling to Identify Patterns of Adherence and Its Predictors Among Older Adults on Angiotensin-Converting Enzyme Inhibitors (ACEIs)/Angiotensin Receptor Blockers (ARBs).

PURPOSE: Commonly prescribed medications among patients with comorbid diabetes mellitus and hypertension include ARBs and ACEIs. However, these medications are associated with suboptimal adherence leading to inadequately controlled blood pressure. Unlike traditional single estimates of proportion of days covered (PDC), group-based trajectory modeling (GBTM) can graphically display the dynamic nature of adherence. The objective of this study was to evaluate adherence using GBTMs among patients prescribed ACEI/ARBs and identify predictors associated with each adherence trajectory. PATIENTS AND METHODS: Patients with an ACEI/ARBs prescription were identified between July 2017 and December 2017 using a Medicare Advantage dataset. PDC was used to measure monthly patient adherence during the one-year follow-up period. The monthly PDC was added to a logistic group-based trajectory model to provide distinct patterns of adherence. Further, a multinomial logistic regression was conducted to determine predictors of each identified adherence trajectory. Predictors included various socio-demographic and clinical patient characteristics. RESULTS: A total of 22,774 patients were included in the analysis and categorized into 4 distinct adherence trajectories: rapid decline (12.6%); adherent (58.5%); gaps in adherence (12.2%), and gradual decline (16.6%). Significant predictors associated with all lower adherence trajectories included 90 days refill, >2 number of other medications, ≥1 hospitalizations, and prevalent users. Significant predictors associated with the rapid decline trajectory included male sex, comorbidities, and increased CMS risk score. Further, significant predictors associated with the gaps in adherence trajectory included increasing age, and comorbidities. Lastly, significant predictors associated with the gradual decline trajectory included increasing age, no health plan subsidy, comorbidities, and increasing CMS risk score. CONCLUSION: Identifying various patient characteristics associated with non-adherent trajectories can guide the development of tailored interventions to enhance adherence to ACEI/ARBs.

Country Pharmaceutical Situation on Access, Quality, and Rational Use of Medicines: An Evidence from a middle-income country.

Evaluation of pharmaceutical systems performance is an essential prerequisite for promoting evidence-based policy-making and improvement in health system performance. This study attempts to evaluate the performance of Iran pharmaceutical system based on the world health organization (WHO)'s indicators, including access, quality, and rational use of medicines. In this cross-sectional descriptive study, inspired by the instructions proposed by WHO, public and private pharmaceutical service-providers were evaluated in three dimensions and 16 indicators. Accordingly, eleven separate checklists were developed and, in terms of translation, face and content validity were certified by pharmaceutical sector's experts. Sampling was randomly carried out in five cities. Depending on the type of indicators, retrospective or prospective approaches was determined for data collection. The data were collected from April to November 2018 and analyzed by SPSS 24. The availability of targeted key medicines in various cities as well as in public and private pharmacies was 97.5% with no significant difference. Although the medicines cost was higher in private sectors than in public ones, they were affordable in both sectors. In quality indicators, public sectors enjoyed a higher level than the private sectors did. The average number of medicines per prescription in public pharmacies was 3.2 and it was 3.4 in private ones. On average, in public sectors 33% and 32% of outpatients received antibiotics and injectable medicines, respectively. Finally, 77% of medicines were prescribed by using their generic names and 25% of prescriptions were in accordance with key medicines list. This study reveals that the availability and affordability of targeted key medicines in Iran are in good condition; however, in terms of rational use of medicines, Iran fails to meet the standard levels.

Effects of Extremely Low-Frequency Electromagnetic Fields on Neurogenesis and Cognitive Behavior in an Experimental Model of Hippocampal Injury.

Exposure to extremely low-frequency electromagnetic fields may induce constant modulation in neuronal plasticity. In recent years, tremendous efforts have been made to design a suitable strategy for enhancing adult neurogenesis, which seems to be deterred due to brain senescence and several neurodegenerative diseases. In this study, we evaluated the effects of ELF-EMF on neurogenesis and memory, following treatment with trimethyltin chloride (TMT) as a neurotoxicant. The mice in all groups (n = 56) were injected with BrdU during the experiment for seven consecutive days to label newborn cells. Spatial memory was assessed by the Morris water maze (MWM) test. By the end of the experiment, neurogenesis and neuronal differentiation were assessed in the hippocampus, using immunohistochemistry and Western blot analysis. Based on the findings, exposure to ELF-EMF enhanced spatial learning and memory in the MWM test. ELF-EMF exposure significantly enhanced the number of BrdU+ and NeuN+ cells in the dentate gyrus of adult mice (P < 0.001 and P < 0.05, resp.). Western blot analysis revealed significant upregulation of NeuroD2 in ELF-EMF-exposed mice compared to the TMT-treated group (P < 0.05). These findings suggest that ELF-EMF might have clinical implications for the improvement of neurodegenerative processes and could help develop a novel therapeutic approach in regenerative medicine.

Selective separation and determination of isoproterenol on thin layers of bismuth silicate ion-exchanger.

A simple and sensitive method for the separation and determination of isoproterenol from other doping drugs has been developed on thin layers of bismuth silicate, a synthetic inorganic ion exchanger as adsorbent in thin layer chromatography (TLC). A mixture of methanol and 0.1 mol/L formic acid (3:7, v/v) was employed as the mobile phase. The development time was 32 min. The quantitative measurement were performed with a Camag TLC Scanner-3 at wavelength (λ) of 410 nm. The isoproterenol recovery in this procedure was 98.9%. The linear correlation coefficient was greater than 0. 987 1 and the relative standard deviation (RSD) was less than 0.94. The limit of detection (LOD) and limit of quantification ( LOQ) were 7.7 x 10(-7) mol/L and 3.85 x 10(-6) mol/L, respectively. This method has been applied in the determination of isoproterenol in dosage forms and in biological fluids.

Serum Ferritin Levels Correlation With Heart and Liver MRI and LIC in Patients With Transfusion-Dependent Thalassemia.

BACKGROUND: Iron-loaded cardiac complication is the essential cause of mortality in patients with thalassemia. Early detection and treatment of cardiac over-load can reduce mortality. OBJECTIVES: The current study aimed to evaluate the relationship between serum ferritin levels and T2* magnetic resonance imaging (MRI) of heart and liver and liver iron concentration (LIC) to diagnose iron over load in countries with limited access. PATIENTS AND METHODS: In the current cross-sectional study, 85 Iranian patients with thalassemia with the mean age of 22.7 ± 7 years were randomly selected. All patients were on regular blood transfusion. Echocardiography of heart and liver T2* MRI, determination of serum ferritin levels, and LIC were performed in all subjects at the same time. The correlation of serum ferritin levels with T2*MRI of heart and liver, and LIC was assessed. P value < 0.05 was considered statistically significant. RESULTS: Abnormal myocardial iron load (T2* MRI < 20 ms) was detected in 58% of the patients and among whom, 36% had severe myocardial iron load (T2* MRI < 10 ms). Median and interquartile range of serum ferritin levels were 1434 and 2702 respectively in patients with thalassemia. Serum ferritin levels showed a statistically significant positive correlation with LIC (rs = 0.718, P < 0.001) and significant negative correlation with T2* Heart (rs = -0.329, P = 0.002), and T2* Liver (rs = -0.698, P < 0.001). However, Ejection fraction was not significantly correlated with serum ferritin levels in the patients (P = 0.399). CONCLUSIONS: Serum ferritin levels can be used to diagnose iron over-load in patients with thalassemiaas an alternative method in areas where T2* MRI is not available.

The Frequency of Adrenal Insufficiency in Adolescents and Young Adults with Thalassemia Major versus Thalassemia Intermedia in Iran.

BACKGROUND: Endocrine dysfunction is not uncommon complication in patients with transfusion-dependent thalassemia and is thought to occur as a consequence of excessive iron overload. The primary objective of this study is to determine the frequency of adrenal insufficiency in patients with thalassemia major and thalassemia intermediate. METHODS: This cross-sectional study was done at the Shiraz University of Medical Sciences, Shiraz, Southern Iran, in 2013. One hundred and ninety patients were divided into two groups; thalassemia major(TM) and thalassemia intermediate (TI) groups. We measured 8 AM serum cortisol, ACTH and ferritin concentrations in all patients. RESULTS: The mean age of the TM and TI group were 22.5±5.7 and 23.8±6 years, respectively. 90 patients (47.4%) were splenectomized, 34 (36.2%) with TM and 56 (58.2%) with TI (p :<0.001). The median and interquartile range of serum ferritin levels were 2184±3700 ng/ml and 437±443ng/ml in TM and TI respectively (p< 0.001). Three patients with TM (1.6%) had low basal cortisol and ACTH levels. However, their cortisol response to ACTH stimulation was normal. CONCLUSIONS: Low basal concentrations of cortisol and ACTH occurred in 1.6% of our adolescents young adult patients with TM suggesting a central defect in cortisol secretion at the basal state. However, cortisol response to standard - dose ACTH was normal in all patients with TM and TI.