Adherence therapy improves medication adherence and quality of life in people with Parkinson's disease: a randomised controlled trial.

BACKGROUND: Many factors are associated with medication non-adherence in Parkinson's disease (PD), including complex treatment regimens, mood disorders and impaired cognition. However, interventions to improve adherence which acknowledge such factors are lacking. A phase II randomised controlled trial was conducted investigating whether Adherence Therapy (AT) improves medication adherence and quality of life (QoL) compared with routine care (RC) in PD. METHODS: Eligible PD patients and their spouse/carers were randomised to intervention (RC plus AT) or control (RC alone). Primary outcomes were change in adherence (Morisky Medication Adherence Scale) and QoL (Parkinson's Disease Questionnaire-39) from baseline to week-12 follow up. Secondary outcomes were MDS-UPDRS (part I, II, IV), Beliefs about Medication Questionnaire (BMQ), EuroQol (EQ-5D) and the Caregiving Distress Scale. Blinded data were analysed using logistic and linear regression models based on the intention-to-treat principle. RESULTS: Seventy-six patients and 46 spouse/carers completed the study (intervention: n = 38 patients, n = 24 spouse/carers). At week-12 AT significantly improved adherence compared with RC (OR 8.2; 95% CI: 2.8, 24.3). Numbers needed to treat (NNT) were 2.2 (CI: 1.6, 3.9). Compared with RC, AT significantly improved PDQ-39 (-9.0 CI: -12.2, -5.8), BMQ general harm (-1.0 CI: -1.9, -0.2) and MDS-UPDRS part II (-4.8 CI: -8.1, -1.4). No significant interaction was observed between the presence of a spouse/carer and the effect of AT. CONCLUSION: Adherence Therapy improved self-reported adherence and QoL in a PD sample. The small NNT suggests AT may be cost-effective. A larger pragmatic trial to test the efficacy and cost-effectiveness of AT by multiple therapists is required.

Post-stroke seizure and post-stroke epilepsy.

Post-stroke seizure and post-stroke epilepsy are common causes of hospital admissions, either as a presenting feature or as a complication after a stroke. They require appropriate management and support in long term. With an increasingly ageing population, and age itself being an independent risk factor for stroke, the incidence and prevalence of post-stroke seizure and post-stroke epilepsy is likely to increase. This article examines aetiology, clinical presentation, and presents a management outline of these conditions with particular focus on adults. The aim of this review article is to provide the clinicians with background information and recommendations.

Intimal sarcoma of the right brachiocephalic vein presenting as the superior vena caval syndrome.

A case of an 84 year old man presenting with obstruction of the superior vena cava caused by an intimal sarcoma of the right brachiocephalic vein is reported. The tumour morphology was similar to intimal sarcomas arising in major arteries, a more common primary site, and showed malignant fibrous histiocytoma-like features. Immunohistochemistry was suggestive of myofibroblastic differentiation.

High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience.

There is a high mortality rate in patients admitted to hospitals acutely from care homes. In a retrospective case analysis study of 3772 older people admitted to the Department of Medicine for the Elderly between January and June 2005, 340 (9.0%) were from care homes, and 93 (27.3%) of the residents died during the index admission. Nearly 40% of these deaths occurred within 24h of admission indicating a high level of less appropriate admissions. Investigating eight nursing homes which admitted the highest number of patients from one primary care trust revealed that the most cited reasons for admission were the lack of advance care plans, access to General Practitioners (GPs) out of hours, as well as general access to palliative care and specialist nurses, and poor communication between patient, relatives, GPs, hospitals and care home staff. Our findings provide some useful insight into the factors that need to be addressed to avoid unnecessary or inappropriate admissions from care homes for better end of life care in aging societies.

Giant cell arteritis presenting as renal vasculitis.

Giant cell arteritis commonly presents with headache, polymyalgia, and visual signs and symptoms. Other neurological, respiratory or vascular symptoms occur in 10-30% of patients. It is extremely rare for giant cell arteritis to present initially with haematuria. Here we describe a case which presented with fever and haematuria, which emphasise the need to be vigilant about the diagnosis of giant cell arteritis as an underlying cause.

Urinary tract infection after cystometry.

Eighteen of 67 patients who underwent cystometry for assessment of incontinence had a urinary tract infection 72 hours later. Though four of the 18 had an infection prior to cystometry, the true postcystometry infection was still high at 21%. Clinical details and urodynamic studies on these patients showed no correlation with sex, mobility, mental score, random blood sugar, renal function, initial residual volume of urine, previous pelvic operations or the type of bladder abnormality diagnosed on cystometry. The elderly and males with a high residual volume seemed more susceptible to infection. Thus cystometry carries a definite risk of infection even under optimal conditions and should not be undertaken lightly or without arrangements to follow up patients.

The problem of bacteriuria with indwelling urethral catheterization.

Bacteriuria following long-term catheterization is more likely to occur in elderly females over the age of 50 years, in patients with some abnormality of the bladder and when traumatic catheterization has taken place. Breaks in the closed system of drainage are the most important factors leading to bladder infections which, once there, are difficult to eradicate. Antiseptics are important at the time of catheterization but have little place afterwards except to reduce cross-infection and growth in the catheter bag. Systemic antimicrobials are only of use over a short period of catheterization and should be reserved in long-term catheterized patients for those with systemic manifestations of infection.

Cervico-mediastinal lymphangioma.

Two cases of cervico-mediastinal lymphangioma ppesenting in adults are reported. In one the lesion originated in the mediastinum and only when advanced showed extension into the neck. The other was associated with a cervical cystic hygroma. Both wwer relieved by one-stage excision. Although they are benign, the tendency of these lesions is to become progressively larger, and to infiltrate between the vital structures in the neck and mediastinum. These features, and the importance of early surgery, are illustrated by the patients we now report.

A comparative study of the pharmacokinetics and pharmacodynamics of atenolol, hydrochlorothiazide and amiloride in normal young and elderly subjects and elderly hypertensive patients.

Six normal young and six normal elderly volunteers and six elderly hypertensive patients took part in an acute and chronic dose study of a combination capsule containing atenolol (50 mg), hydrochlorothiazide (25 mg) and amiloride (2.5 mg) designed for the treatment of hypertension. No difference in any of the drug pharmacokinetic parameters could be detected between the hypertensives and the normal elderly subjects. The bio-availability and the 24-h blood concentrations of all three drugs, half-life of atenolol and amiloride and the peak concentration of hydrochlorothiazide was significantly greater in the elderly. The 24-h blood concentrations of atenolol and hydrochlorothiazide did not alter with chronic dosing, but amiloride concentrations were significantly higher at this time in all groups. A significant fall in the blood pressure was observed in the hypertensive group. Heart rate fell more in the normal and hypertensive elderly subjects than in the young. The combination has shown to be an effective and well tolerated antihypertensive in the elderly patient with a 24-h duration of action.