Background Non-vitamin K antagonist oral anticoagulants (NOAC) have superior safety and comparable efficacy profile compared to vitamin-K antagonists (VKAs), with more convenient dosing schemes. However, issues with adherence to the NOACs remain unsolved. Aims We sought to investigate the adherence to oral anticoagulation (OAC) and baseline factors associated with poor adherence after ischaemic stroke in patients with atrial fibrillation (AF). Methods We recruited hospitalised patients (2013-2019) from two prospective stroke registries in Larissa and Helsinki University Hospitals and invited survived patients to participate in a telephone interview. We assessed adherence with the Adherence to Refills and Medications Scale (ARMS) and defined poor adherence as a score of over 17. In addition to demographics, individual comorbidities, and stroke features, we assessed the association of CHA(2)DS(2)-VASc and SAMe-TT2R2 scores with poor adherence. Results Among 396 patients (median age 75.0 years, interquartile range [IQR] 70-80; 57% men; median time from ischaemic stroke to interview 21 months [IQR 12-33]; median ARMS score 17 [IQR 17-19]), 56% of warfarin users and 44% of NOAC users reported poor adherence. In the multivariable regression model adjusted for site, sex, and age, poor adherence was independently associated with tertiary education, absence of heart failure, smoking history, use of VKA prior to index stroke, and prior ischaemic stroke. CHA(2)DS(2)-VASc and SAMe-TT2R2 scores were not associated with poor adherence. Conclusions Adherence was poor in half of AF patients who survived an ischaemic stroke. Independent patient-related factors, rather than composite scores, were associated with poor adherence in these patients. KEY MESSAGES Adherence was poor in half of the atrial fibrillation patients who survived an ischaemic stroke. Independent patient-related factors rather than composite scores were associated with poor adherence. The findings support the importance of recognising adherence support as a crucial part of holistic patient care recommended by recent AF guideline.

Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry-based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011-2018. The implementation analyses included 74 222 (mean age 72.7 +/- 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 +/- 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA(2)DS(2)-VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR >= 0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135-day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest adjusted odds ratios 1.18 (1.12-1.25) and 1.21(1.15-1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.

Chronic myeloid leukemia (CML) is a malignant hematologic disorder, which is fatal without a treatment. Oral tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of CML and transformed the disease to a chronic condition that can be treated at patient's home. The common problem in the treatment of CML is patient's poor adherence to TKIs. The regular, consistent use of TKIs is crucial to keep disease under control. For this reason and to obtain an optimal treatment outcome, adherence to TKIs is extremely important. The aim of the study was to assess reasons for poor adherence to TKI-medications in Finnish CMLpatients, including patient characteristics, treatment related factors, comorbidities and concomitant medications. In addition, patients' experiences, beliefs, knowledge and perception about CML and its treatment were explored and how these could contribute to nonadherent behaviour. This study is part of the larger study, assessing adherence to TKI treatment among Finnish CML population. The data was obtained by using patient questionnaires and semi-structured theme-interview during patient meetings in 2012. Study population consisted of Finnish adult CML patients who had been on TKI -medication (imatinib, nilotinib or dasatinib) for more than six months prior to the study baseline. Patients' adherence was measured using Morisky Medication Adherence 8-Item Scale (MMAS-8) and based on their score, patients were divided into three groups: high, medium and low adherence. Both quantitative and qualitative methods were used in data analysis. Study findings show that 21% (n=18) of the patients were low adherent and 23% (n=20) were high adherent to their treatment. Patient sociodemographic characteristics or experienced adverse drug reactions (ADRs) did not predict adherence, while more concomitant medications and comorbidities were associated with high adherence. However, ADRs had negative effect on the quality of life of several nonadherent patients. All nonadherent patients reported unintentional nonadherence and the most common reason was forgetting. Two-thirds of the patients (n=12) reported intentional nonadherence, which often was a result of experienced ADRs. The knowledge of CML and its treatment was poor among all patients while over half of the nonadherent patients (n=11) thought that they received enough information received. Overall, patients were very satisfied with care provided by the hospitals, physicians and other healthcare professionals. Managing TKI-treatment regimen is challenging for many patients and ADRs can have a negative impact on the quality of life. Healthcare professionals should regularly assess patient adherence and provide information and support for the patients to help them to succeed in medication management. Reasons for poor adherence are complex and have to be identified from each individual patient so that adherence can be improved.

This study aims to address how easily an individual with no prior inhaler experience can learn to use a dry powder inhaler (DPI) through video education. This is a comparative study of four DPIs (Diskus, Easyhaler, Ellipta and Turbuhaler). Different properties affecting ease of use, patient preference as well as educational videos as a method of providing inhaler instructions were investigated. The study used a triangular methodology. The sample consisted of 31 individuals (24-35 years). All participants were considered inhaler naïve. After watching the video education material for a particular inhaler the participants' demonstrated the use of it. Educational videos for all four inhalers were watched and use of all placebo inhalers was demonstrated in a random order. These demonstrations were videotaped. The demonstrations were thereafter checked against a predefined checklist and all mistakes were recorded. Only 33 % of inhaler demonstrations were completed without the participants making any mistakes that could compromise the efficacy of the inhaled medication in a real-life situation. The frequency of error varied greatly between different types of inhalers. Ellipta proved to be most often used correctly with 55 % demonstrating use without making any mistakes. This was closely followed by Diskus for which 48 % demonstrated correct use. The difference between the average error frequency for Ellipta and Diskus was statistically insignificant. With Easyhaler 19 % percent of participants were able to demonstrate correct use, the corresponding percentage for Turbuhaler was 16 %. When comparing participants' demonstrations for Easyhaler and Turbuhaler, the difference in average error frequency between the devices were not statistically significant. The average frequency of error was lower when using Ellipta in comparison to Easyhaler and Turbuhaler (statistically significant). The same indications were found when comparing average frequency of error for Diskus, to those for Easyhaler and Turbuhaler. Comparing the participants self-reported correct use against the actual numbers it is clear that participants often thought they were using the inhaler correctly when they in fact were not. When asked to rank the inhalers from most preferred to least preferred, Ellipta emerged as a favorite. Turbuhaler received the second highest scores, Diskus the third and Easyhaler was least preferred. However, only the difference between preference scores for Ellipta and Easyhaler was deemed statistically significant. The high frequency of error suggests that even though participants generally considered the inhalers intuitive and easy to use, they would have required more comprehensive inhaler education in order to achieve correct inhaler technique. Further, the results indicate that video demonstrations are not ideal for providing inhaler education for first time inhalers users. The most prominent problem with video education is that it provides no feedback to the user regarding their inhaler technique. This may present real problems as the results of this study show that participants tended to overestimate their own inhaler technique. Patient education plays a central role in asthma care and needs to be given proper attention even though the inhalers might be considered intuitive and easy to operate. Interesting areas for future research include investigating interactive learning videos as a way of improving video education on inhaler technique.

Sutterella species have been frequently associated with human diseases, such as autism, Down syndrome, and inflammatory bowel disease (IBD), but the impact of these bacteria on health still remains unclear. Especially the interactions of Sutterella spp. with the host are largely unknown, despite of the species being highly prevalent. In this study, we addressed the interaction of three known species of Sutterella with the intestinal epithelium and examined their adhesion properties, the effect on intestinal barrier function and the pro-inflammatory capacity in vitro. We also studied the relative abundance and prevalence of the genus Sutterella and Sutterella wadsworthensis in intestinal biopsies of healthy individuals and patients with celiac disease (CeD) or IBD. Our results show that Sutterella spp. are abundant in the duodenum of healthy adults with a decreasing gradient toward the colon. No difference was detected in the prevalence of Sutterella between the pediatric IBD or CeD patients and the healthy controls. Sutterella parvirubra adhered better than the two other Sutterella spp. to differentiated Caco-2 cells and was capable of decreasing the adherence of S. wadsworthensis, which preferably bound to mucus and human extracellular matrix proteins. Furthermore, only S. wadsworthensis induced an interleukin-8 production in enterocytes, which could be due to different lipopolysaccharide structures between the species. However, its pro-inflammatory activity was modest as compared to non-pathogenic Escherichia coli. Sutterella spp. had no effect on the enterocyte monolayer integrity in vitro. Our findings indicate that the members of genus Sutterella are widely prevalent commensals with mild pro-inflammatory capacity in the human gastrointestinal tract and do not contribute significantly to the disrupted epithelial homeostasis associated with microbiota dysbiosis and increase of Proteobacteria. The ability of Sutterella spp. to adhere to intestinal epithelial cells indicate that they may have an immunomodulatory role.

Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a >= 14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)-measured depressive symptoms and time spent in treatment. Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice.

Background: Mobile phone apps offer a promising medium to deliver psychological interventions. A mobile app based on Acceptance and Commitment Therapy (ACT) was developed and studied in a randomized controlled trial (RCT). Objective: To study usage metrics of a mobile ACT intervention and dose-response relationship between usage and improvement in psychological flexibility. Methods: An RCT was conducted to investigate the effectiveness of different lifestyle interventions for overweight people with psychological stress. This paper presents a secondary analysis of the group that received an 8-week mobile ACT intervention. Most of the analyzed 74 participants were female (n=64, 86%). Their median age was 49.6 (interquartile range, IQR 45.4-55.3) years and their mean level of psychological flexibility, measured with the Acceptance and Action Questionnaire II, was 20.4 (95% confidence interval 18.3-22.5). Several usage metrics describing the intensity of use, usage of content, and ways of use were calculated. Linear regression analyses were performed to study the dose-response relationship between usage and the change in psychological flexibility and to identify the usage metrics with strongest association with improvement. Binary logistic regression analyses were further used to assess the role of usage metrics between those who showed improvement in psychological flexibility and those who did not. In addition, associations between usage and baseline participant characteristics were studied. Results: The median number of usage sessions was 21 (IQR 11.8-35), the number of usage days was 15 (IQR 9.0-24), and the number of usage weeks was 7.0 (IQR 4.0-8.0). The participants used the mobile app for a median duration of 4.7 (IQR 3.2-7.2) hours and performed a median of 63 (IQR 46-98) exercises. There was a dose-response relationship between usage and the change in psychological flexibility. The strongest associations with psychological flexibility (results adjusted with gender, age, and baseline psychological variables) were found for lower usage of Self as context related exercises (B=0.22, P=.001) and higher intensity of use, described by the number of usage sessions (B=-0.10, P=.01), usage days (B=-0.17, P=.008), and usage weeks (B=-0.73, P=.02), the number of exercises performed (B=-0.02, P=.03), and the total duration of use (B=-0.30, P=.04). Also, higher usage of Acceptance related exercises (B=-0.18, P=.04) was associated with improvement. Active usage was associated with female gender, older age, and not owning a smart mobile phone before the study. Conclusions: The results indicated that active usage of a mobile ACT intervention was associated with improved psychological flexibility. Usage metrics describing intensity of use as well as two metrics related to the usage of content were found to be most strongly associated with improvement.