Current Prescriptions News Results

Patient-based continuum of care in nephrology: why read Thomas Addis' "Glomerular Nephritis" in 2010?

J Nephrol. 2010 Mar 1; 23(2): 164-167
Piccoli GB

The name of Thomas Addis (1881-1949) is linked to several aspects of nephrological practice: from the "Addis count" of urinary elements, to the history of diet in chronic kidney diseases. He was accustomed to working with limited funds, and developed his theories with relatively simple means, combined with the careful, long-term observation of single cases. His political ideas were progressive; his outlook on life was optimistic. This is deeply reflected in his Glomerular Nephritis: Diagnosis and Treatment, a book worth reading in the era of chronic kidney disease (CKD), as it contains sharp analyses of the organizational aspects, and accurate comments on the role of the physician - all subjects of interest for the present times and challenges. One of Addis' ingenious ideas was to follow his patients throughout their lifelong disease, thus anticipating the theories of continuum of care and of therapeutic alliance between patients and physicians. He used to tailor his prescriptions and frequency of controls to each patient and phase of the disease, thus anticipating the tailored therapies and the patient empowerment presently considered as fundamental in chronic diseases. Furthermore, he suggested that physicians should work outside the hospital in small coordinated teams, in which volunteers, dietitians and laboratory technicians would play a crucial role. Patient-centered care and the importance of nonmedical team members are clear from the first lines of his book. As far as we know, he was the first physician to stress the role of volunteers in CKD, anticipating by decades nonprofit organizations such as the National Kidney Foundation.

Generic substitution: micro evidence from register data in Norway.

Eur J Health Econ. 2010 Mar 6;
Dalen DM, Furu K, Locatelli M, Strøm S

The importance of prices, doctor and patient characteristics, and market institutions for the likelihood of choosing generic drugs instead of the more expensive original brand-name version are examined. Using an extensive dataset extracted from The Norwegian Prescription Database containing all prescriptions dispensed to individuals in February 2004 and 2006 on 23 different drugs (chemical substances) in Norway, we find strong evidence for the importance of both doctor and patient characteristics for the choice probabilities. The price difference between brand and generic versions and insurance coverage both affect generic substitution. Moreover, controlling for the retail chain affiliation of the dispensing pharmacy, we find that pharmacies play an important role in promoting generic substitution. In markets with more recent entry of generic drugs, brand-name loyalty proves to be much stronger, giving less explanatory power to our demand model.

Patients' Question-Asking Behavior During Primary Care Visits: A Report From the AAFP National Research Network.

Ann Fam Med. 2010 Mar-Apr; 8(2): 151-9
Galliher JM, Post DM, Weiss BD, Dickinson LM, Manning BK, Staton EW, Brown JB, Hickner JM, Bonham AJ, Ryan BL, Pace WD

PURPOSE: The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. METHODS: This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations. RESULTS: The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P=.04). CONCLUSIONS: In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Point-of-Care C-Reactive Protein Testing and Antibiotic Prescribing for Respiratory Tract Infections: A Randomized Controlled Trial.

Ann Fam Med. 2010 Mar-Apr; 8(2): 124-33
Cals JW, Schot MJ, de Jong SA, Dinant GJ, Hopstaken RM

PURPOSE: Antibiotics are only beneficial for subgroups of patients with acute lower respiratory tract infections (LRTI) and rhinosinusitis in family practice, yet overprescribing for these conditions is common. C-reactive protein (CRP) point-of-care testing and delayed prescribing are useful strategies to reduce antibiotic prescribing, but both have limitations. We evaluated the effect of CRP assistance in antibiotic prescribing strategies-including delayed prescribing-in the management of LRTI and rhinosinusitis. METHODS: We conducted a randomized controlled trial in which 258 patients were enrolled (107 LRTI and 151 rhinosinusitis) by 32 family physicians. Patients were individually randomized to CRP assistance or routine care (control). Primary outcome was antibiotic use after the index consultation. Secondary outcomes included antibiotic use during the 28-day follow-up, patient satisfaction, and clinical recovery. RESULTS: Patients in the CRP-assisted group used fewer antibiotics (43.4%) than control patients (56.6%) after the index consultation (relative risk [RR] = 0.77; 95% confidence interval [CI], 0.56-0.98). This difference remained significant during follow-up (52.7% vs 65.1%; RR = 0.81; 95% CI, 0.62-0.99). Delayed prescriptions in the CRP-assisted group were filled only in a minority of cases (23% vs 72% in control group, P <.001). Recovery was similar across groups. Satisfaction with care was higher in patients managed with CRP assistance (P = .03). CONCLUSIONS: CRP point-of-care testing to assist in prescribing decisions, including delayed prescribing, for LRTI and rhinosinusitis may be a useful strategy to decrease antibiotic use and increase patient satisfaction without compromising patient recovery.

Inappropriate utilization of intravenous proton pump inhibitors in hospital practice--a prospective study of the extent of the problem and predictive factors.

QJM. 2010 Mar 7;
Craig DG, Thimappa R, Anand V, Sebastian S

BACKGROUND: Intravenous (IV) proton pump inhibitors (PPI) reduce rebleeding from high-risk peptic ulcers following endoscopic therapy. The majority of IV PPI prescriptions in US hospital practice are inappropriate, leading to unnecessary drug costs, drug shortages and potential adverse events. To date, little is known about UK hospital IV PPI prescribing practice. AIMS: To examine IV PPI use in a large university teaching hospital to determine factors predicting inappropriate prescribing practices. METHODS: Prospective study of 276 recently hospitalized patients initiated on IV PPI over a 6-month period. IV PPI use was deemed appropriate for the following indications: endoscopic evidence of recent upper gastrointestinal (UGI) haemorrhage, patient nil by mouth with a valid indication for oral PPI therapy and stress ulcer prophylaxis in a critical care setting. RESULTS: The majority (208/276, 75.4%) of IV PPI prescriptions were deemed inappropriate in terms of either indication for use, dose or duration of therapy. The majority (168/276, 60.9%) of prescriptions were initiated on non-medical wards. Inappropriate prescribing was more common amongst female patients, surgical admissions, non-UGI haemorrhage cases and when initiated by junior hospital doctors. Surgical admission [odds ratio (OR) 2.88, 95% confidence interval (CI) 1.12-7.42] and female gender [OR 3.92 (95% CI 1.84-8.34)] were independently predictive of inappropriate use. CONCLUSION: This study suggests that the majority of IV PPI prescriptions in hospital are inappropriate, particularly when initiated for non-UGI bleeding indications. Improving prescribing awareness through education of junior medical staff on non-medical wards could reduce inappropriate IV PPI use.

Evidence of disparity in the application of quality improvement efforts for the treatment of acute myocardial infarction: The American College of Cardiology's Guidelines Applied in Practice Initiative in Michigan.

Am Heart J. 2010 Mar; 159(3): 377-384
Olomu AB, Grzybowski M, Ramanath VS, Rogers AM, Vautaw BM, Chen B, Roychoudhury C, Jackson EA, Eagle KA,

BACKGROUND: Racial disparities exist in the management of patients with cardiovascular disease in the United States. The aim of the study was to evaluate if a structured initiative for improving care of patients with acute myocardial infarction (Guidelines Applied in Practice [GAP]) led to comparable care of white and nonwhite patients admitted to GAP hospitals in Michigan. METHODS: Medicare patients comprised 2 cohorts: (1) those admitted before GAP implementation (n = 1,368) and (2) those admitted after GAP implementation (n = 1,489). The main outcome measure was adherence to guideline-based medications/recommendations and use of the GAP discharge tool. chi(2) and Fisher exact tests were used to determine differences between white patients (n = 2,367) and nonwhite patients (n = 490). RESULTS: In-hospital GAP tool and aspirin use significantly improved for white and nonwhite patients. beta-Blocker use in hospital improved significantly for nonwhite patients only (66% vs 83.3%; P = .04). At discharge, nonwhite patients were 28% and 64% less likely than white patients to have had the GAP discharge tool used (P = .004) and receive smoking cessation counseling (P < .001), respectively. Among white patients, GAP improved discharge prescription rates for aspirin by 10.8% (P < .001) and beta-blockers by 7.0% (P = .047). Nonwhite patients' aspirin prescriptions increased by 1.0% and beta-blocker prescriptions decreased by 6.0% (both P values nonsignificant). CONCLUSIONS: The GAP program led to significant increases in rates of evidence-based care in both white and nonwhite Medicare patients. However, nonwhite patients received less quality improvement discharge tool and smoking cessation counseling. Policies designed to reduce racial disparities in health care must address disparity in the delivery of quality improvement programs.

Secondary prevention of osteoporosis in australia: analysis of government-dispensed prescription data.

Drugs Aging. 2010 Mar 1; 27(3): 255-64
Hollingworth SA, Gunanti I, Nissen LM, Duncan EL

Osteoporosis is a common cause of disability and death in elderly men and women. Until 2007, Australian Government-subsidized use of oral bisphosphonates, raloxifene and calcitriol (1alpha,25-dihydroxycholecalciferol) was limited to secondary prevention (requiring x-ray evidence of previous low-trauma fracture). The cost to the Pharmaceutical Benefits Scheme was substantial (164 million Australian dollars in 2005/6). To examine the dispensed prescriptions for oral bisphosphonates, raloxifene, calcitriol and two calcium products for the secondary prevention of osteoporosis (after previous low-trauma fracture) in the Australian population. We analysed government data on prescriptions for oral bisphosphonates, raloxifene, calcitriol and two calcium products from 1995 to 2006, and by sex and age from 2002 to 2006. Prescription counts were converted to defined daily doses (DDD)/1000 population/day. This standardized drug utilization method used census population data, and adjusts for the effects of aging in the Australian population. Total bisphosphonate use increased 460% from 2.19 to 12.26 DDD/1000 population/day between June 2000 and June 2006. The proportion of total bisphosphonate use in June 2006 was 75.1% alendronate, 24.6% risedronate and 0.3% etidronate. Raloxifene use in June 2006 was 1.32 DDD/1000 population/day. The weekly forms of alendronate and risedronate, introduced in 2001 and 2003, respectively, were quickly adopted. Bisphosphonate use peaked at age 80-89 years in females and 85-94 years in males, with 3-fold higher use in females than in males. Pharmaceutical intervention for osteoporosis in Australia is increasing with most use in the elderly, the population at greatest risk of fracture. However, fracture prevalence in this population is considerably higher than prescribing of effective anti-osteoporosis medications, representing a missed opportunity for the quality use of medicines.

Off-label prescription of antineoplastic drugs: an Italian prospective, observational, multicenter survey.

Tumori. 2009 Nov-Dec; 95(6): 647-51
Roila F, Ballatori E, Labianca R, De Braud F, Borgonovo K, Martelli O, Gallo C, Tinazzi A, Perrone F,

AIMS AND BACKGROUND: An appropriate use of drugs should follow the registered indications. Different reasons can induce oncologists to prescribe drugs off-label. The aim of this study was to describe incidence and characteristics of these prescriptions in Italy. METHODS: Patients submitted to chemotherapy in 15 Italian oncology centers were evaluated for two randomized non-consecutive days of two weeks in May 2006. RESULTS: The study enrolled 644 patients receiving 1,053 drugs. Overall, 199 of 1053 (18.9%) prescriptions were off-label. In 92 of 199 cases (46.2%), the drugs were used for a neoplasm for which they were not approved, but there was scientific evidence (one or more randomized clinical trials or more phase II studies published in a major oncology journal) justifying the prescription. In 27 cases (13.6%), the drugs were prescribed for a rare neoplasm (cisplatin and gemcitabine in mesothelioma). In 20/21 cases (10.1%/10.5%), drugs were used in association/alone in contrast with the approved use (capecitabine in association in colorectal cancer). In 28/11 cases (14.0%/5.6%), the drugs were used in lines of chemotherapy subsequent/previous to that approved. CONCLUSIONS: Off-label use of antineoplastic drugs, in this observational survey, represents less than 20% of the prescriptions, and most of them are based on scientific evidence of efficacy.

[In Process Citation]

Can J Public Health. 2009 Nov-Dec; 100(6): 426-31
Lang PO, Hasso Y, Belmin J, Payot I, Baeyens JP, Vogt-Ferrier N, Gallagher P, O'Mahony D, Michel JP

OBJECTIVE: STOPP-START is a screening tool for detecting inappropriate prescriptions in older people. Recently validated in its English-language version, it is a reliable and easy-to-use tool, allowing assessment of prescription drugs often described as inappropriate (STOPP) or unnecessarily underused (START) in this population. An adaptation of the tool into French language is presented here. METHOD: A translation-back translation method, with validation of the obtained version by French-speaking experts from Belgium, Canada, France and Switzerland, has been used. An inter-rater reliability analysis completed the validation process. Fifty data sets of patients hospitalized in an academic geriatrics department (mean age +/- standard deviation: 77.6 +/- 7.9 years; 70% were women) were analyzed independently by one geriatrician and one general practitioner. RESULTS: The adaptation in French considers the 87 STOPP-START criteria of the original version. They are all organized according to physiological systems. The 50 data sets involved 418 prescribed medications (median 8; inter-quartile range 5-12). The proportions of positive and negative inter-observer agreements were 99% and 95% respectively for STOPP, and 99% and 88% for START; Cohen's kappa-coefficients were 0.95 for STOPP and 0.92 for START. These results indicated an excellent inter-rater agreement. CONCLUSION: Therefore, this French language version of STOPP-START is as reliable as the original English language version of the tool. For STOPP-START to have tangible clinical benefit to patients, a randomized controlled trial must be undertaken to demonstrate efficacy in the prevention of adverse clinical events connected with inappropriate prescriptions.

Use and reimbursement costs of smoking cessation medication under the Quebec public drug insurance plan.

Can J Public Health. 2009 Nov-Dec; 100(6): 417-20
Tremblay M, Payette Y, Montreuil A

OBJECTIVES: Since October 2000, the nicotine patch, nicotine gum and bupropion have been reimbursed under Quebec's public drug insurance plan. The objective of this study is to describe use of these medications between October 2000 and December 2004 by smokers covered by the public plan, as well as the costs of reimbursing these medications. METHODS: Data from the Régie de l'assurance maladie du Québec were used to analyze prescriptions for smoking cessation medication issued to persons insured under the public drug insurance plan. RESULTS: Between October 1, 2000, and December 31, 2004, more than 300,000 Quebeckers covered by the public drug insurance plan were reimbursed for smoking cessation medications. This corresponds to a yearly average of 14% of all smokers insured under the public plan. The proportion of employment assistance recipients who used these medications was higher than the proportion of seniors or "other" insurance plan participants. Nicotine patches were the treatment of choice for most users. A total of $55 million was reimbursed by the public drug insurance plan for the nicotine patch, nicotine gum and bupropion over this four-year period. CONCLUSION: The reimbursement provisions put in place in Quebec in 2000 were successful in reaching financially disadvantaged smokers, at a cost that was comparable with other effective smoking cessation services.

Agreement between self-reported and pharmacy data on medication use in the Northern Finland 1966 Birth Cohort.

Int J Methods Psychiatr Res. 2010 Mar 7;
Haapea M, Miettunen J, Lindeman S, Joukamaa M, Koponen H

Objective: To compare self-reported (SR) medication use and pharmacy data for major psychoactive medications and three classes of medications used for different indications, and to determine the socio-economic factors associated with the congruence.Methods: Postal questionnaire data collected in 1997 were compared with the register of the Social Insurance Institution of Finland on the reimbursed prescriptions purchased during 1997. Altogether 7625 subjects were included in this study. Drugs were categorized according to the Anatomical Therapeutic Chemical (ATC) system.Results: Kappa values were 0.77, 0.68, 0.84, 0.92 and 0.55 for antipsychotics, antidepressants, antiepileptics, antidiabetics and beta-blocking agents, respectively. Prevalence-adjusted and bias-adjusted kappa values were almost perfect (0.98-1.00). Reliability of antipsychotics use was better for married subjects than for those who were not married; and of antidepressants use for highly educated and married subjects than for those who were less educated and were not married. Altogether 414 (5.4%) responders and 285 (7.1%) non-responders had used at least one of the selected medications.Conclusion: Agreement between the SR and pharmacy data was moderate for psychoactive medication use. Even though data collected by postal questionnaire may underestimate the prevalence of medication use due to non-participation it can be assumed accurate enough for study purposes. Copyright (c) 2010 John Wiley & Sons, Ltd.

Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma.

J Am Board Fam Med. 2010 Mar-Apr; 23(2): 159-65
Bender BG, Apter A, Bogen DK, Dickinson P, Fisher L, Wamboldt FS, Westfall JM

Objective: This study was conducted to test the effectiveness of a theory-based interactive voice response (IVR) intervention to improve adherence to controller medications among adults with asthma. METHODS: Fifty participants aged 18 to 65 years who had a physician diagnosis of asthma and a prescription for a daily inhaled corticosteroid, attended a baseline visit and a final visit 10 weeks later. Participants randomized to the intervention group received 2 automated IVR telephone calls separated by one month, with one additional call if they reported recent symptoms of poorly controlled disease or failure to fill a prescription. Calls were completed in less than 5 minutes and included content designed to inquire about asthma symptoms, deliver core educational messages, encourage refilling of inhaled corticosteroid prescriptions, and increase communication with providers. Adherence was tracked during 10 weeks, with objective measures that included either electronic monitors or calculation of canister weight. Participants completed the Asthma Quality of Life Questionnaire, the Asthma Control Test, and the Beliefs in Medications Questionnaire (BMQ) during both visits. RESULTS: Adherence was 32% higher among patients in the IVR group than those in the control group (P = .003). A more favorable shift in perception of inhaled corticosteroids was seen on BMQ scores of patients in the IVR group (P = .003), which in turn correlated with degree of adherence change (r = 0.342; P = .0152). No differences emerged for the Asthma Quality of Life Questionnaire or Asthma Control Test. CONCLUSIONS: The IVR intervention resulted in a significant increase in adherence to inhaled corticosteroid treatment and improved BMQ scores during the study interval. The association of increased adherence with increased BMQ scores suggests that the intervention succeeded in helping participants adopt a more favorable perception of their controller medication, leading in turn to improved adherence.

Guideline-concordant antibiotic use and survival among patients with community-acquired pneumonia admitted to the intensive care unit.

Clin Ther. 2010 Feb; 32(2): 293-299
Frei CR, Attridge RT, Mortensen EM, Restrepo MI, Yu Y, Oramasionwu CU, Ruiz JL, Burgess DS

Objective: This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting. Methods: We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guidelineconcordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates. Results: The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis. Conclusion: Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.

[Psychiatrist views on stigmatization toward people with mental illness and recommendations.]

Turk Psikiyatri Derg. 2010; 21(1): 14-24
Kuş Saillard E

OBJECTIVE: The aim of this study is to understand and discover the processes of stigmatization toward people with mental illnesses through the experience of psychiatrists. This paper focuses on the views of psychiatrists concerning the role of psychiatric diagnosis and the attitudes of general medical professionals toward people with mental illnesses, together with the recommendations of psychiatrists for dealing with the stigmatization process. METHOD: The purposive sampling technique was used in this study. Nine psychiatrists and eight assistant psychiatrists from various health institutions in Ankara were interviewed between 2006 and 2007. The interviews were tape recorded and transcribed verbatim. The process of analysis evolved from concrete to more abstract categories. RESULTS: Psychiatrists proposed different views concerning the role played by psychiatric diagnosis in stigmatization. While some do not want to write their diagnoses on prescriptions, others argue that merely changing the name of the diagnosis cannot be regarded as a solution. Most of the psychiatrists interviewed stated that stigmatizing attitudes exist among physicians. The hesitancy among physicians and ignorance displayed by emergency services were the proof given of institutionalized stigma. CONCLUSION: It seems that psychiatrists need more time to come to an agreement concerning the role played by psychiatric diagnosis in stigmatization. Psychiatrists who participated in our research highlighted their informative and resistive role in anti-stigma strategies and proposed educational strategies for different groups in collaboration with various institutions. Concerning stigmatization in non-psychiatric health services, they proposed reorganization in medical education along with seminars for physicians and an increase of consultation-liaison.

Use of non-specific intravenous human immunoglobulins in Spanish hospitals; need for a hospital protocol.

Eur J Clin Pharmacol. 2010 Mar 5;
Ruiz-Antorán B, Agustí Escasany A, Vallano Ferraz A, Danés Carreras I, Riba N, Mateu Escudero S, Costa J, Sánchez Santiago MB, Laredo L, Durán Quintana JA, Castillo JR, Abad-Santos F, Payares Herrera C, Sádaba Díaz de Rada B, Gómez Ontañón E

Intravenous immunoglobulin (IVIG) use in non-approved indications, the increase in consumption and its high cost recommend rationalisation in its utilisation. AIMS: To assess the use of IVIG in Spanish hospitals. METHODS: An observational, prospective and multicentre drug utilisation study was conducted in 13 tertiary Spanish hospitals. Data were collected for 3 months in patients receiving any IVIG. Patient demographics, indication for IVIG use, dosage regimen and cost of treatment were collected. RESULTS: Five hundred and fifty-four patients (mean age of 52 years) were included in the study. A total of 1,287 prescriptions were administered, and the average number of prescriptions per patient was 2.3. The mean daily dose was 24 g (range 0.6-90 g). Overall, IVIG was prescribed for authorised indications in 335 patients (60%) with 953 prescriptions (74%), for non-authorised indications with scientific evidentiary support in 86 patients (16%) with 137 prescriptions (11%), and non-authorised and non-accepted indications in 133 patients (24%) with 197 prescriptions (15%). The most frequent authorised indications were primary and secondary immunodeficiencies, and the most frequent non-authorised and non-accepted indications were multiple sclerosis and bullous dermatosis. The mean cost of IVIG per patient for authorised indications was 2,636.2 , non-authorised indications with scientific support 5,262.1 and non-accepted indications 3,555.8 . CONCLUSIONS: IVIG is prescribed for a significant number of non-authorised and non-accepted indications with a notable cost. There is an important variability in IVIG prescriptions between hospitals, indicating room for improvement in IVIG use and the need for a consensus of protocol use.

Impact of metformin-induced gastrointestinal symptoms on quality of life and adherence in patients with type 2 diabetes.

Postgrad Med. 2010 Mar; 122(2): 112-20
Florez H, Luo J, Castillo-Florez S, Mitsi G, Hanna J, Tamariz L, Palacio A, Nagendran S, Hagan M

Aims: Gastrointestinal (GI) symptoms are common in patients with type 2 diabetes mellitus (T2DM). This study assesses the impact of 1) metformin on GI symptoms and health-related quality of life (HRQoL) and 2) metformin-associated GI symptoms on medication adherence in patients with type 2 diabetes newly beginning therapy. Methods: Patients with T2DM aged >/= 18 years starting metformin from January to June 2007 who filled their prescriptions for >/= 3 months were identified from a health benefits company database. Via telephone, GI symptom impact was evaluated in a 360-patient sample using the validated Bowel Symptom Questionnaire and Medical Outcomes Study 36-Item Short-Form Health (SF-36) survey. Adherence was assessed using the medication possession ratio (MPR). Logistic regression adjusting for demographic and clinical covariates was used to assess the relationship between GI symptoms and MPR < 80%. Results: The most and least common GI symptoms reported were diarrhea (62.1%) and retching (21.1%), respectively. Most GI symptoms were associated with lower physical and mental HRQoL (P < 0.05). Most changes in specific HRQoL reached the minimum important difference of 3 points. Bloating, nausea, and abdominal pain were significantly associated with MPR < 80%. Adjustment for demographic, clinical, and HRQoL factors made these relationships less evident. Conclusions: Metformin-associated GI symptoms in patients with T2DM lead to lower physical and mental HRQoL, which may result in patient nonadherence or physician reluctance to optimally titrate the metformin dose.

Shortage of child and adolescent psychiatrists in Texas.

Tex Med. 2010; 106(3): e1
Becker EA, King B, Shafer A, Thomas CR

This study was conducted to determine how the current shortage of Texas child and adolescent psychiatrists (CAPs) impacts the delivery of mental health care services to indigent Texas youth. The shortage of CAPs in Texas results in an unequal distribution of psychiatric care for those receiving Medicaid prescriptions or services through local mental health authorities, especially in rural areas. Suggestions to correct this shortage are made.

Trends in the epidemiology of asthma in England: a national study of 333,294 patients.

J R Soc Med. 2010 Mar; 103(3): 98-106
Simpson CR, Sheikh A

Background Observations in the UK at the end of the last century found increasing trends of asthma prevalence over time. However, it has been reported that the number of new cases of asthma presenting to general practice has declined, especially among younger children. Aim To study national trends in the epidemiology of asthma. Methods A cross-sectional observation analysis was performed using the QRESEARCH database, which is one of the world's largest national aggregated health databases containing records from 422 English practices yielding 30 million patient-years of observation. Data was extracted on 333,294 individuals with a recorded diagnosis of asthma and calculated annual age-sex standardized incidence, lifetime period prevalence and asthma-related prescribing rates for each year from 2001-2005. Results The incidence rate of asthma decreased in all patients (2001: 6.9 (95% confidence intervals [CI] 6.8-7.0); 2005: 5.2 (95% CI 5.1-5.3) per 1000 patient-years, p<0.001), but most particularly in children under 5 years of age (-38.4%) where a decrease in the lifetime prevalence of asthma (-34.3%) was also found. However, the lifetime prevalence rate of asthma for adults increased (15-44 years: 23.3%; 45-64 years: 27.7%; >65 years: 21.5%) with an estimated 5,658,900 (95% CI 5,639,700-5,678,200) or approximately one person in nine having being diagnosed with asthma in England. The number of asthma-related prescriptions also increased over the study period (17.1%), such that in 2005 an estimated 32,577,300 (95%CI 32,531,600-32,623,000) prescriptions were issued. Conclusions This large national study reveals that the rate of new diagnoses of asthma appears to have passed its peak; however, the number of adults with a lifetime asthma diagnosis continues to rise. Whether these trends are genuine or are a result of the introduction of incentives and guidelines to improve identification and recording of asthma or changing diagnostic trends is a question with important public health implications and one, therefore, that warrants detailed further enquiry.

[Medication dependency and physician's role.]

Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2010 Mar 4;
Holzbach R, Martens M, Kalke J, Raschke P

The administration of benzodiazepines in suicidal, anxious, or agitated patients with depression is common international practice. Nevertheless, the prescription of BZDs is recommended to be limited to a period of a few weeks. There are several epidemiological studies about the situation in Germany, but many questions are still unanswered. The BfArM sought a new method to track prescription of medications with the risk to induce dependency. The present article describes the methodology and the early results of the pilot study. As a new approach, data from a processing center for pharmacies were used; patient-years, a risk scale with six steps, and diazepam-equivalence dose instead of defined daily dose were used for the analysis. About 35% of prescriptions were long-term treatment. Even if several physicians prescribe the medication, the main physician prescribing the medication can identify the risk level of the patient in 80-90% of cases.

Ischemic Colitis and Complications of Constipation Associated With the Use of Alosetron Under a Risk Management Plan: Clinical Characteristics, Outcomes, and Incidences.

Am J Gastroenterol. 2010 Mar 2;
Chang L, Tong K, Ameen V

OBJECTIVES:Alosetron is a potent, selective 5-HT(3) receptor antagonist prescribed for women with severe diarrhea-predominant irritable bowel syndrome (IBS-D) under a risk management plan (RMP). The RMP was implemented following cases of ischemic colitis (IC) and complications of constipation (CoC) associated with the use of alosetron. The objectives of this study were to characterize IC and CoC clinical features, outcomes, and incidence rates in the new restricted patient population to evaluate the effectiveness of the RMP in the prevention of serious outcomes.METHODS:Safety data from adverse event reporting from November 2002 through June 2008 were reviewed for probable and possible IC and CoC using the US Food and Drug Administration/sponsor--defined criteria and definitions. Evidence for IC included medical documentation, colonoscopy, and sigmoidoscopy+/-biopsy. Evidence for CoC included medical history and confirmation from health-care professionals.RESULTS:Within the inclusion dates, 29,072 patients received 203,939 alosetron prescriptions. Although the absolute numbers of IC and CoC cases have declined, the incidence rates for IC and CoC (0.95 and 0.36 cases per 1,000 patient-years, respectively) were similar to rates during the postmarketing cycle before alosetron withdrawal. In patients with severe IBS-D receiving alosetron (n=998) or placebo (n=411) in clinical trials since reintroduction, incidence rates for IC were 4 and 2 cases per 1,000 patients, respectively. Rates for CoC were 2 and 0 cases per 1,000 patients in the alosetron and placebo groups, respectively. No mesenteric ischemia, surgeries, transfusions, or deaths occurred in patients with IC and no cases of CoC were associated with toxic megacolon, perforation, surgeries, transfusions, or deaths. IC and CoC cases were typically of short duration and all improved on prompt withdrawal of alosetron.CONCLUSIONS:Serious outcomes associated with IC and CoC appear to be mitigated since introduction of alosetron under the RMP.Am J Gastroenterol advance online publication, 2 March 2010; doi:10.1038/ajg.2010.25.