Adherence to Prophylaxis in Adolescents and Young Adults with Severe Haemophilia: A Quantitative Study with Patients.

INTRODUCTION: haemophilia is an inherited bleeding disorder caused by a deficiency in one of the blood coagulation factors. For people affected by severe haemophilia, the deficiency can cause spontaneous internal bleeding. Most young people with severe haemophilia in the UK follow a preventative treatment regimen (prophylaxis) consisting of several intravenous injections of factor concentrate each week. There is good evidence that prophylaxis reduces bleeds whilst also improving quality of life. However, levels of adherence among young people with haemophilia reported in the existing literature vary widely and are predominately based on estimations made by healthcare professionals and parents. Additionally, drivers of (non)adherence among young people specifically have not been evidenced. AIM: to assess self-reported adherence among young people with haemophilia, provide evidence of psychosocial predictors of adherence, and to establish the associations between non-adherence and number of bleeds and hospital visits. METHODS: 91 participants were recruited during outpatient appointments in 13 haemophilia centres across England and Wales, and invited to complete a questionnaire assessing self-reported adherence (VERITAS-Pro), Haemophilia-related pain and impact of pain, Illness Perceptions, Beliefs about Medications, Self-efficacy, Outcome expectations, Positive and Negative Affect, and Social support. Number of hospital visits and bleeds during the previous six months were collected from medical files. RESULTS: Of 78 participants with complete data, just 18% had scores indicating non-adherence. Psychosocial predictors differed between intentional (skipping) and un-intentional (forgetting) non-adherence. Overall, however, better adherence was reported where participants perceived the need for prophylaxis was greater than their concern over taking it as well as having a positive expectancy of its effectiveness, good social support and a stronger emotional reaction to having haemophilia. CONCLUSION: The findings indicate that adherence is generally good, and that assessing illness and treatment beliefs, social support and outcome expectations may play a valuable role in identifying which individuals are at risk of non-adherence. Interventions aimed at improving adherence should particularly consider improving social support, reducing patients' concerns about prophylaxis, increasing their belief in the necessity of prophylaxis, and increasing positive outcome expectations.

Changing patterns of under- and over-nutrition in South African children-future risks of non-communicable diseases.

Under- and over-nutrition in children in KwaZulu-Natal, South Africa was investigated comparing data collected from primary school children in a rural district (643 children aged 8-11 years in 1994) with secondary data from the National Schools Study (16,179 children, 4-11 years in 1994), the Vitamin A Consultative Group Study (408 children, 2-5 years in 1994) and the Income Dynamics Study (1,593 children, 2-11 years in 1998). Stunting and wasting (WHO/NCHS guidelines) and overweight and obesity (International Obesity Task Force guidelines) were retrospectively analysed from these studies and compared in the children aged 4-5 and 8-11 years. There was moderate stunting in 10-25%, wasting in 1-6%, 5-24% were overweight and 1-10% obese. Girls in the National Schools Study (p<0.005) and in the primary datasets (p=0.02) had a significantly higher prevalence of overweight than boys; girls (1.4%) were also more obese than boys (0.9%) in the Schools Study (p=0.002), and the boys significantly more stunted (p<0.005) and wasted (p<0.005). An increasing prevalence of overweight and obesity was seen in both the 4-5- and 8-11-year age-groups. The finding that moderate stunting co-exists with overweight and obesity suggests that patterns of under- and over-nutrition in South African children are changing and might indicate the early stages of a complex nutritional transition. Action is required to prevent the future risk of non-communicable diseases.

Dinoprostone versus misoprostol: a randomized study of nulliparous women undergoing induction of labor.

BACKGROUND: The objectives of the study were to compare the efficacy and safety of intravaginal misoprostol and intravaginal dinoprostone for induction of labor and to quantify the clinical response to suspicious cardiotocographic (CTG) readings. METHODS: One hundred and ninety-one patients were randomized to receive either 50 micro g misoprostol initially then a further identical dose 6 h later or 2 mg dinoprostone initially followed by 1 mg 6 h later, over a period of 24 h. If not in labor after 24 h, then both arms of the study would thereafter receive dinoprostone alone as per hospital protocol. RESULTS: The induction to delivery interval (1047 vs. 1355 min, p = 0.01), delivery within 12 h (35.4% vs. 18.9%, p = 0.02) and delivery within 24 h (83.3% vs. 63.3%, p = 0.01) were all shorter in the misoprostol arm. There were no differences in rates of oxytocin augmentation (p = 0.47), tachysystole (p = 0.32) and hyperstimulation syndrome (p = 0.82). There was an increase in the median number of times a doctor was called to advise on a suspicious CTG in the misoprostol group (1 vs. 2 occasions, p = 0.052), but there was no difference in neonatal outcome. CONCLUSIONS: Intravaginal misoprostol led to a shorter, more efficient labor, and although there was more anxiety related to the CTG, there was no increase in neonatal adverse effects.

Randomized trial in multiparous patients: investigating a single vs. two-dose regimen of intravaginal misoprostol for induction of labor.

BACKGROUND: Multiparous patients have a higher risk of hyperstimulation and uterine rupture than nulliparous patients. The minimum possible dose of uterotonic drug should be used in induction of labor for multiparous patients to avoid excessive uterine activity, which could increase both maternal and fetal risks. METHODS: One hundred and four women were randomized to either a single dose of 50 micro g of intravaginal misoprostol in 24 h, or two consecutive doses of intravaginal 50 micro g misoprostol 6 h apart. RESULTS: The mean induction to delivery interval (789 min [95% CI: 637-941] vs. 576 min [95% CI: 484-667], p = 0.018) and delivery rate within 12 h (63% vs. 83%, p = 0.035) were higher in the two-dose group. The oxytocin augmentation rate (14% vs. 2%, p = 0.03) was higher in the single-dose group. There was a higher rate of clinician input related to suspicious cardiotocographic readings in the single-dose arm (p = 0.04). There was no statistical difference (p > 0.05) between the one- and two-dose regimens with respect to the rates of tachysystole (21% vs. 15%), hyperstimulation (3.9% vs. 0%), and meconium staining at delivery (9.8% vs. 13.2%). CONCLUSIONS: The two-dose regimen was most efficient, but both regimens were well tolerated by the fetuses.