The effectiveness of a pharmacy-based eHealth intervention promoting correct use of medication in patients with asthma and COPD: Results from a non-randomized pre-post study (Preprint)

BACKGROUND Asthma and chronic obstructive pulmonary disease (COPD) affect millions of people worldwide. Whilst medication can control and improve disease symptoms, incorrect use of medication is a common problem. eHealth intervention ‘SARA’ aims to improve participants’ correct use of inhalation medication by providing information, as well as as-needed tailored follow-up support by a pharmacist. OBJECTIVE The primary aim of this study was to investigate the effect of SARA on exacerbation rates in participants with asthma and COPD. Secondary aims were to investigate its effects in terms of adherence to maintenance medication and antimycotic treatment. METHODS In this non-randomized pre-post study, medication dispensing data of 382 Dutch community pharmacies were included. Exacerbation rates were assessed with dispensed oral corticosteroids short courses. Medication adherence was assessed by calculating the proportion of days covered (PDC) from dispensed inhalation maintenance medication, wherefore a distinction was made between new and chronic users. Antimycotic treatment was investigated from dispensed oral antimycotics in participants who were also dispensed inhaled corticosteroids (ICS). Outcomes were assessed one year before and one year after implementation of SARA and compared between SARA participants and control participants. More specifically, for exacerbation rates and medication adherence, a difference score was calculated (year after SARA minus year before SARA), and subsequently compared between the study groups with independent samples t-tests. For antimycotics, the relative number of participants who were dispensed antimycotics was calculated and subsequently analyzed with a mixed-effects logistic regression RESULTS The study population comprised 9,452 participants, of whom 2,400 were SARA participants. The mean age of the population was about 61, and approximately two-third was female. The results showed an increase in mean exacerbation rates over time for both study groups; 0.05 increase in SARA and 0.15 in controls. However this increase in exacerbations was significantly lower in the SARA condition (t9450= 3.10, 95% CI= 0.04 – 0.16, P= .002, Cohen d = 0.06). Chronic users of inhalation medication showed an increase in medication adherence over time in both study groups (6.73 in SARA and 4.48 control participants respectively); yet, this increase was significantly higher for SARA participants (t5886= -2.74, 95% CI= -3.86 – -0.84, P=.01, Cohen d = -0.07). In new users of inhalation medication, results showed no significant difference in medication adherence between SARA and controls in the year after implementation of SARA (t1434= -1.85, 95% CI= -5.60 – 0.16, P=.06, Cohen d = -0.10). In ICS-users, no significant differences between the study groups were found over time in terms of the proportion of participants who were dispensed antimycotics (t5654= 0.29, 95% CI= -0.40 - 0.54, P=.76, Cohen d = 0.00). CONCLUSIONS This study provides preliminary evidence that eHealth intervention SARA might have the potential to decrease exacerbation rates and improve medication adherence.

Intracraniaal infectieus aneurysma: belang van vroegtijdige diagnose

Intracranial aneurysm: importance of early detection A 45-year old woman presented at the emergency department with a decreased level of consciousness. She was under treatment for acute myeloid leukemia. An MRI scan of the brain showed diffuse vasoconstriction of the intracranial vasculature, suggestive for vasculitis. Aspergillus fumigatus was discovered in the cerebrospinal fluid (CSF), for which antimycotic treatment was initiated. Because of further neurological decline (acute decreased consciousness, unilateral gaze impairment and irregular obstructive respiration pattern) a CT scan was performed which showed diffuse subarachnoid and intraventricular hemorrhaging. CT-angiography showed an aneurysm at the left posterior inferior cerebellar artery. Because of the severe clinical condition of the patient, there was no indication for invasive therapy.

Candida albicans Osteochondromyelitis after Gastroesophageal Surgery: Two Case Reports

Candida osteochondromyelitis is a rare complication after thoracoabdominal surgery. We herein report two such cases after uncomplicated thoracoabdominal surgery, who presented with chronic postsurgical site infection and fistula. CT scans showed fistulas reaching the costochondral areas of the fifth rib. Inflammatory parameters were not elevated. Both patients were treated successfully after the initiation of systemic antimycotic treatment and surgical debridement. We conclude that C. albicans infections should always be considered in cases of chronic postoperative surgical site infections after thoracoabdominal surgery. Additional risk factors do not need to be present. Appropriate therapy consists of the application of systemic antimycotics and surgical debridement.

Case report: Candida krusei spondylitis in an immunocompromised patient

Background Invasive infections with Candida krusei are uncommon and rarely complicated by spondylitis. Previous described cases were solely treated with antimycotic therapy, despite guidelines recommending surgical interventions. Case presentation We describe a case of C. krusei spondylitis in a patient treated with chemotherapy for acute myeloid leukemia. After induction chemotherapy, the patient developed a candidemia, which was treated with micafungin. One month after the candidemia, the patient was admitted with severe lumbar pain. Spondylitis of the L4 and L5 vertebra was diagnosed on MR-imaging, with signs suggesting an atypical infection. The patient was treated with anidulafungin combined with voriconazole. Despite maximal conservative management symptoms gradually worsened eventually requiring surgical intervention. Conclusions In contrast to previous case reports, antimycotic treatment alone could be insufficient in treating C. krusei spondylitis.