Cannabis use during alcohol treatment is associated with alcohol-related problems one-year post-treatment.

BACKGROUND: Prior research shows that cannabis use during treatment for Alcohol Use Disorders (AUD) is related to fewer abstinent days from alcohol, although only among those who use cannabis 1-2x/month. Here we extend prior research by assessing the relationship between the frequency of cannabis use during AUD treatment and post-treatment alcohol-related consequences. METHODS: Data come from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study, a large US randomized control trial of treatments for AUD. The current analyses include 206 cannabis users and 999 cannabis abstainers and compare longitudinal drinking data between those who used cannabis versus those who abstained during COMBINE treatment. The primary exposure was quartiles of cannabis use (Q1: less than 1x/month during treatment, Q2: 1-2x/month, Q3: 4-8x/month, Q4: 12x/month or more), with cannabis abstainers as the reference group. Outcomes were alcohol-related problems at the end of treatment and one-year post-treatment as measured by the Drinker Inventory Consequences. RESULTS: Compared to cannabis abstinence, the most frequent use during treatment was related to 1.44 times as many physical consequences one-year post-treatment. Cannabis use was not related to physical consequences immediately after treatment, or to intrapersonal, interpersonal, social responsibility or impulse control problems at either post-treatment time point. CONCLUSIONS: In a sample of individuals in treatment for AUD, using cannabis 12x/month or more during treatment is associated with increased rates of physical consequences attributed to alcohol use. Individuals in treatment for AUD who also use cannabis might benefit from reducing or stopping cannabis use to avoid alcohol-related physical problems.

Exploring the characteristics of patients with mesothelioma who chose active symptom control over chemotherapy as first-line treatment: a prospective, observational, single centre study.

BACKGROUND: Mesothelioma is an aggressive thoracic tumour with a poor prognosis. The only treatment that extends survival is chemotherapy. However, in the UK, up to 50% of patients who are suitable for chemotherapy choose not to receive it, opting for active symptom control instead. The aim of this prospective, single-centre observational study was to describe the characteristics of patients who chose active symptom control over chemotherapy and explore their reasons for doing so. METHODS: Two hundred consecutive patients with mesothelioma from one UK centre were included. Eligibility for chemotherapy and choice of first-line treatment were recorded prospectively. Patient characteristics and outcomes were compared using descriptive statistics, regression analysis and survival analysis. Reasons for choosing active symptom control over chemotherapy were extracted, retrospectively. RESULTS: People who chose active symptom control were older, more likely to be female and had worse performance statuses than patients who received front-line chemotherapy. Concern over side effects, the modest survival benefit and previous adverse experiences with chemotherapy were reported as reasons for the decision. Median survival was 13.9 months in the chemotherapy group compared with 6.7 months in the active symptom control group. CONCLUSIONS: This is the first study to describe the characteristics of patients with mesothelioma who chose active symptom control over chemotherapy, in the front-line setting. Important differences were seen between this group and patients who received chemotherapy, although confounding is likely to have affected some outcomes. Future research could use qualitative methods to explore patients' reasons for choosing active symptom control, and to further elucidate the decision-making process.

Factors associated with medication adherence among patients with diabetes in the Middle East and North Africa region: A systematic mixed studies review.

Multiple systematic reviews were conducted investigating factors associated with medication adherence worldwide. However, investigations from the Middle East and North Africa (MENA) region were largely underrepresented in those reviews. Therefore, the objective of this systematic review is to identify the factors influencing medication adherence among patients with diabetes in the MENA region. A systematic literature search was conducted through Cochrane Library, EBSCO, EMBASE, Google Scholar, ISI Web of Science, PubMed, ScienceDirect, SCOPUS, and ProQuest. Studies were included if they determined factors associated with medication adherence among patients with diabetes within the MENA region. Quality was assessed using Crow Critical Appraisal Tool. Thirty primary studies from 10 MENA countries were included. The factors associated with medication adherence were categorized into demographics-related; disease- and medication-related; perception, attitude and psychological feelings-related; and societal-related factors. Positively associated factors included knowledge about the disease and medications, regular follow-up visits, and patients' positive beliefs about effectiveness and motivations about medications, while negatively associated factors included forgetfulness, side effects, and polypharmacy. Factors associated with medication adherence among patients with diabetes in the MENA region are highly diverse. The identified factors can serve as potential targets for culturally-relevant interventions to improve medication adherence and overall health outcomes.

Percepção do estigma e repercussões sociais em indivíduos com hanseníase / Perception of stigma and social impacts on individuals with Hansen's disease / Percepción del estigma y efectos sociales en personas con enfermedad de Hansen

Os portadores de hanseníase vivenciam situações de preconceito que, com o estigma e a discriminação, culminam para o isolamento social e a restrição dos relacionamentos sociais. Este estudo teve o objetivo de avaliar a percepção do estigma nos indivíduos com hanseníase e suas repercussões sociais. Caracterizou-se por um estudo qualitativo mediante aplicação de entrevistas semiestruturadas em 20 usuários cadastrados para tratamento poliquimioterápico nas unidades de referência na Zona da Mata Mineira, no primeiro semestre de 2014. A análise foi realizada por meio da análise de conteúdo e foram definidas as seguintes categorias de análise: Desconhecimento sobre a doença; Diagnóstico e cura; Discriminação e medo; Encobrimento da doença; Apoio social; e Vínculo e participação social. O desconhecimento sobre a doença interfere no enfrentamento por parte dos indivíduos e, aliado ao receio da discriminação, foi suficiente para que eles ocultassem seu diagnóstico para os outros. Dessa forma, não foi possível perceber nenhuma alteração em seu vínculo social. Destacaram-se as diversas reações emocionais no momento do diagnóstico além da ênfase dada à cura pelos entrevistados. Neste trabalho, ficou evidente que o encobrimento da doença e o suporte social atuaram como fatores de proteção que impediram momentos de discriminação e restrição de participação social.

The individuals with Hansen's disease experience situations of prejudice that, together with stigma and discrimination, culminate in social isolation and restrictions in social relationships. This study aimed to evaluate the perception of stigma in individuals with Hansen's disease and its social repercussions. It was configured as a qualitative study, by means of semi-structured interviews with 20 users registered to chemotherapy treatment in reference units of Zona da Mata Mineira, in the first half of 2014. The analysis was performed through content analysis and the following categories were defined: Lack of knowledge about the disease; Diagnosis and cure; Discrimination and fear; Concealment of the disease; Social support; and Bond and social participation. Lack of knowledge about the disease interferes with the individual's ability to cope with it, and coupled with fear of discrimination, it was enough for them to conceal their diagnosis from others. Thus, it was not possible to notice any changes in their social bonds. The different emotional reactions at the moment of diagnosis stood out, in addition to the emphasis on healing given by respondents. In this study, it became clear that the concealment of the disease and the social support acted as protective factors that prevented moments of discrimination and restriction in social participation.

Las personas con enfermedad de Hansen viven situaciones de prejuicio que, junto con el estigma y la discriminación, culminó con el aislamiento social y la restricción de las relaciones sociales. Este estudio tuvo como objetivo evaluar la percepción de estigma en personas con enfermedad de Hansen y sus repercusiones sociales. Caracterizado por un estudio cualitativo mediante la aplicación de entrevistas semiestructuradas con 20 usuarios registrados a tratamiento de quimioterapia en las unidades de referencia en la Zona da Mata Mineira, en el primer semestre de 2014. Se realizó el análisis mediante el análisis de contenido y las siguientes categorías del análisis se definieron: La ignorancia sobre la enfermedad; El diagnóstico y la cura; La discriminación y el miedo; El ocultamiento de la enfermedad; El apoyo social; y Enlace y la participación social. La ignorancia sobre la enfermedad interfiere con afrontamiento de los individuos y, junto con el temor a la discriminación fuera suficiente para ellos para ocultar su diagnóstico a los demás. Por lo tanto, no fue posible notar cualquier cambio en su enlace social. Destacado las diferentes reacciones emocionales al momento del diagnóstico, además del énfasis en la curación por los encuestados. En este estudio, se hizo evidente que el ocultamiento de la enfermedad y el apoyo social actuó como factores de protección que impedían momentos de la discriminación y la restricción de la participación social.

[Complex drug regimen in multimorbid elderly patients after hospital discharge - a qualitative study]. / Komplexe Medikamentenregime bei multimorbiden älteren Menschen nach Spitalaufenthalt - eine qualitative Studie.

BACKGROUND: Older people often have multimorbidity requiring a complex regime of medications, which may change following hospital discharge, thus presenting new challenges. The experiences of older people, who manage their own medications, in particular following hospital discharge, have rarely been studied. AIM: This study investigates the experiences of older people with multimorbidity taking multiple medications after hospital discharge and how they cope with medication-taking. METHOD: A qualitative-descriptive approach with ten interviews was chosen. The data were coded openly into two groups according to Saldaña (2013). RESULTS: It is important for older people, in spite of their multimorbidity, to maintain their independence and maintain responsibility for taking their medications. Routines are developed from taking medications over many years and the new medications are easily integrated. Unclear information by the medical staff and the inability of the older people to obtain the medications after discharge may lead to mistakes or interruptions in the drug therapy at home. The key person for this group is the general practitioner, even concerning the drug therapy initiated in hospital. CONCLUSION: It is advisable to adapt discharge education to the needs of older people, especially with regard to their drug therapy, to its integration into their daily routine, and to any possible shortcomings in their medication management.

Patients' experience and perceptions of polypharmacy in chronic kidney disease and its impact on adherent behaviour.

AIMS: To explore attitudes towards medicines, polypharmacy and adherence in patients with chronic kidney disease (CKD). BACKGROUND: Polypharmacy is common in CKD and associated with medication non-adherence. METHODS: As part of a mixed methodology project, a purposive sample of ten participants were recruited and interviewed to explore attitudes to medicines and reasons for adherent and non-adherent behaviour. RESULTS: Several reasons for non-adherence were reported. Interviewees described a variety of attitudes towards medicines. Complex medicine regimes were a frequently cited contributing factor in poor adherence. Concerns about or experience of side effects had a negative impact on adherence. Prioritisation of medicines was evident and the importance of communication with health professionals was a consistent theme. CONCLUSIONS: Non-adherence with prescribed medicines in CKD is a complex phenomenon, which has implications for clinical outcomes and cost. Adherent behaviour may change over time. Further research in this field is needed. No single intervention is likely to enhance adherence for all and clinicians should consider a variety of options to improve adherence with prescribed medicines.

Treatment and outcomes of an Australian cohort of outpatients with bipolar I or schizoaffective disorder over twenty-four months: implications for clinical practice.

BACKGROUND: The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, prospective, non-interventional, observational study designed to explore the clinical and functional outcomes associated with 'real-world' treatment of participants with bipolar I or schizoaffective disorder. All participants received treatment as usual. There was no study medication. METHODS: Participants prescribed either conventional mood stabilizers (CMS; n = 155) alone, or olanzapine with, or without, CMS (olanzapine ± CMS; n = 84) were assessed every 3 months using several measures, including the Young Mania Rating Scale, 21-item Hamilton Depression Rating Scale, Clinical Global Impressions Scale - Bipolar Version, and the EuroQol Instrument. This paper reports 24-month longitudinal clinical, pharmacological, functional, and socioeconomic data. RESULTS: On average, participants were 42 (range 18 to 79) years of age, 58%; were female, and 73%; had a diagnosis of bipolar I. Polypharmacy was the usual approach to pharmacological treatment; participants took a median of 5 different psychotropic medications over the course of the study, and spent a median proportion of time of 100%; of the study on mood stabilizers, 90%; on antipsychotics, 9%; on antidepressants, and 5%; on benzodiazepines/hypnotics. By 24 months, the majority of participants had achieved both symptomatic and syndromal remission of both mania and depression. Symptomatic relapse rates were similar for both the CMS alone (65%;) and the olanzapine ± CMS (61%;) cohorts. CONCLUSIONS: Participants with bipolar I or schizoaffective disorder in this study were receiving complex medication treatments that were often discordant with recommendations made in contemporary major treatment guidelines. The majority of study participants demonstrated some clinical and functional improvements, but not all achieved remission of symptoms or syndrome.

Correlation between different levels of placebo response rate and clinical trial outcome in major depressive disorder: a meta-analysis.

OBJECTIVE: To investigate the relationship between specific levels of placebo response rates and the drug response rate and the relative risk of response to drug versus placebo in clinical trials of antidepressant monotherapy and adjunctive polypharmacy for MDD. DATA SOURCES: MEDLINE/PubMed databases were searched for studies published in the English language between January 1980 and March 2011 by using the search terms depression, placebo, augmentation, adjunct, adjunctive, and each of the antidepressant agents identified. The search was supplemented by manual bibliographic review and examination of relevant review articles. STUDY SELECTION: The analysis included randomized, double-blind, placebo-controlled trials of antidepressants used as monotherapy for MDD, 4 weeks or longer, and of augmentation/combination treatments for antidepressant partial responders/nonresponders with MDD, 1 week or longer. 169 antidepressant monotherapy studies and 35 adjunctive polypharmacy studies were found eligible for inclusion in our analysis. DATA EXTRACTION: Data extracted included number of patients enrolled, patient characteristics, drug dosages and scheme (fixed vs flexible dosing), duration of the trial, and response rates. RESULTS: In antidepressant monotherapy studies, a higher placebo response rate correlated with a lower risk ratio of responding to antidepressant versus placebo (P < .001) and correlated with higher antidepressant response rates (P < .001); the number needed to treat (NNT) for response was approximately 4, 6, and 9 in trials with placebo response rates < 30%, ≥ 30% and < 40%, and ≥ 40%, respectively. In adjunctive trials, a higher placebo response rate correlated with a lower risk ratio of responding to the adjunctive drug versus placebo (P < .001) and correlated with a trend toward statistical significance with higher response rates to the adjunctive drug (P = .050); the NNT was approximately 6, 7, 11, and 17 in trials with placebo response rates < 20%, ≥ 20% and < 30%, ≥ 30% and < 40%, and ≥ 40%, respectively. CONCLUSIONS: These results suggest that the relative efficacy of the active drug compared to placebo in clinical trials for MDD is highly heterogeneous across studies with different placebo response rates, with a worse performance in showing a superiority of the drug versus placebo for studies with placebo response rates ≥ 30% and ≥ 40%, respectively, for monotherapy and adjunctive trials. It is important to maintain placebo response rates below this critical threshold, since this is one of the most challenging obstacles for new treatment development in MDD.

Antioxidants as antidepressants: fact or fiction?

Depression is a medical condition with a complex biological pattern of aetiology, involving genetic and epigenetic factors, along with different environmental stressors. Recent evidence suggests that oxidative stress processes might play a relevant role in the pathogenic mechanism(s) underlying many major psychiatric disorders, including depression. Reactive oxygen and nitrogen species have been shown to modulate levels and activity of noradrenaline (norepinephrine), serotonin, dopamine and glutamate, the principal neurotransmitters involved in the neurobiology of depression. Major depression has been associated with lowered concentrations of several endogenous antioxidant compounds, such as vitamin E, zinc and coenzyme Q10, or enzymes, such as glutathione peroxidase, and with an impairment of the total antioxidant status. These observations introduce new potential targets for the development of therapeutic interventions based on antioxidant compounds. The present review focuses on the possible role of oxidative stress processes in the pathogenesis of depression. The therapeutic potential of antioxidant compounds as a co-adjuvant treatment to conventional antidepressants is discussed. For instance, N-acetyl-cysteine has been shown to have a significant benefit on depressive symptoms in a randomized placebo-controlled trial. Additionally, curcumin, the yellow pigment of curry, has been shown to strongly interfere with neuronal redox homeostasis in the CNS and to possess antidepressant activity in various animal models of depression, also thanks to its ability to inhibit monoamine oxidases. There is an urgent need to develop better tolerated and more effective treatments for depressive disorders and several antioxidant treatments appear promising and deserve further study.

Bioavailability of S-adenosyl methionine and impact on response in a randomized, double-blind, placebo-controlled trial in major depressive disorder.

OBJECTIVE: To characterize the impact of S-adenosyl methionine (SAMe) on homocysteine and potential risk of adverse cardiovascular effects by examining plasma levels of SAMe, S-adenosyl homocysteine (SAH), total homocysteine (tHCY), methionine (MET), and 5-methyltetrahydrofolate (5-MTHF) in 35 of 73 patients from a 6-week randomized double-blind, placebo-controlled trial of SAMe augmentation in serotonin reuptake inhibitor partial responders with DSM-IV major depressive disorder (MDD), published in 2010. METHOD: Subjects were randomized from June 4, 2004, until August 8, 2008, to adjunctive placebo or SAMe 800-1600 mg/d for 6 weeks. Primary outcome measures included changes in one-carbon cycle intermediates within each treatment arm (by paired t test) and between treatment arms (by independent samples t test). Univariate analysis of variance and Fisher Protected Least Significant Difference were carried out to compare posttreatment levels of each one-carbon cycle intermediate. Secondary outcome measures included associations between clinical improvement and change in plasma intermediate levels, examined by linear regression (for change in Hamilton Depression Rating Scale scores) and logistic regression (for response or remission). RESULTS: We found significant differences in pretreatment plasma levels of tHCY (P = .03) between the SAMe and placebo arms. Following 6 weeks of treatment, plasma SAMe (P = .002) and SAH (P < .0001) levels increased significantly in the SAMe arm; no intermediates in the placebo group changed significantly. Posttreatment plasma SAMe (P = .0035), SAH (P < .0001), and tHCY (P = .0016) levels differed significantly between the SAMe and placebo groups. No significant associations were found between plasma intermediate levels and clinical improvement, response, or remission. CONCLUSIONS: Despite concerns about the impact that SAMe therapy may have on homocysteine levels and risk of adverse cardiovascular effects, the lack of significant increase in tHCY levels after treatment suggests that no toxic effects from SAMe should be expected. Our findings, however, have some significant limitations and should be interpreted with caution. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00093847.

Knowledge, stigma, and behavioral outcomes among antiretroviral therapy patients exposed to Nalamdana's radio and theater program in Tamil Nadu, India.

Arts-based programs have improved HIV-related knowledge, attitudes, and behavior in general and at-risk populations. With HIV transformed into a chronic condition, this study compares patients at consecutive stages of receiving antiretroviral treatment, coinciding with exposure to a radio-and-theater-based educational program (unexposed [N = 120], just exposed [N = 77], Exposed a month ago [N = 60]). Exposure was associated with significantly higher HIV-related knowledge (15-20%, all p < .01), lower levels of stigma (2-7% lower, all p < .10), and over four times the adjusted odds of asking doctors questions about HIV (p = .07). Higher dose of exposure was associated with lower felt stigma (28% reduction per message recalled), greater odds of consistent condom use (adjusted odds ratio [AOR]: 1.12, p = .01), doctor-patient communication (AOR: 1.20, p = .003), peer advice-giving (AOR: 1.18, p = .03) and HIV-related advocacy (AOR: 2.35, p = .07). Similar partnerships between arts-based nongovernmental organizations and government hospitals may improve patient outcomes in HIV treatment settings.

Fixed-dose combination therapies in the management of hyperglycaemia in Type 2 diabetes: an opportunity to improve adherence and patient care.

The medication-taking behaviour of patients may be key to avoiding the serious long-term micro- and macrovascular complications of Type 2 diabetes. However, the polypharmacy often required to achieve good metabolic control can be a significant barrier to adequate adherence. Reducing treatment complexity can be achieved through the use of single-tablet fixed-dose combinations of two oral hypoglycaemic agents. Studies to date suggest that this approach can significantly improve adherence over separate tablet dual therapy and has the potential to improve metabolic and clinical outcomes. A range of fixed-dose combination oral hypoglycaemic agents in several different dosage strengths are available and the strategies for optimal implementation of these options continue to evolve. This article describes the extent and consequences of poor adherence to oral hypoglycaemic agents in Type 2 diabetes and discusses the potential contribution of fixed-dose combinations to the provision of improved care.