Comparative gastrointestinal safety of weekly oral bisphosphonates

SUMMARY

Weekly bisphosphonates are the primary agents used to treat osteoporosis. Although these agents are generally well tolerated, serious gastrointestinal adverse events, including hospitalization for gastrointestinal bleed, may arise. We compared the gastrointestinal safety between weekly alendronate and weekly risedronate and found no important difference between new users of these agents.

INTRODUCTION

Weekly bisphosphonates are the primary agents prescribed for osteoporosis. We examined the comparative gastrointestinal safety between weekly bisphosphonates.

METHODS

We studied new users of weekly alendronate and weekly risedronate from June 2002 to August 2005 among enrollees in a state-wide pharmaceutical benefit program for seniors. Our primary outcome was hospitalization for upper gastrointestinal bleed. Secondary outcomes included outpatient diagnoses for upper gastrointestinal disease, symptoms, endoscopic procedures, use of gastroprotective agents, and switching between therapies. We used Cox proportional hazard models to compare outcomes between agents within 120 days of treatment initiation, adjusting for propensity score quintiles. We also examined composite safety outcomes and stratified results by age and prior gastrointestinal history.

RESULTS

A total of 10,420 new users were studied, mean age = 79 years (SD, 6.9), and 95% women. We observed 31 hospitalizations for upper gastrointestinal bleed (0.91 per 100 person-years) within 120 days of treatment initiation. Adjusting for covariates, there was no difference in hospitalization for upper gastrointestinal bleed among those treated with risedronate compared with alendronate (HR, 1.12; 95%CI, 0.55 to 2.28). Risedronate switching rates were lower; otherwise, no differences were observed for secondary or composite outcomes.

CONCLUSIONS

We found no important difference in gastrointestinal safety between weekly oral bisphosphonates.

Dealing with dental insurance

Dental insurance companies can have many different policies, with varying requirements depending on the company. This requires a tremendous amount of time on the part of dentists and their office teams to communicate with insurance companies, file all the proper data, acquire predetermination information when required and address a myriad of other factors. By managing this process carefully, practices can save time and labor expenses, especially if patients are well-educated regarding what their dental insurance covers and what it does not.

Improving women's health through modernization of our bioinformatics infrastructure

Our nationwide bioinformatics infrastructure used to detect important sex differences associated with medical product use is antiquated. The Food and Drug Administration (FDA) has embarked on an ambitious bioinformatics modernization effort that will improve our ability to assess the safety and effectiveness of new medical products. This, in turn, will improve our ability to detect important sex differences.

Uric acid lowering therapy: prescribing patterns in a large cohort of older adults

BACKGROUND

Uric acid lowering therapy (UALT) is considered a chronic treatment for gout. Relatively little is known about adherence to UALT.

METHODS

We assessed adherence with UALT over a 1-year study period among 9823 older adults enrolled in a pharmacy benefit program. Two adherence measures were calculated, the percentage of days covered (PDC) and the time until an extended break (at least 60 days) in treatment. A PDC <80% was considered poor adherence and its predictors were examined in multivariable logistic models.

RESULTS

The mean (SD) PDC was 54% (36%) with 64% of patients considered poorly compliant over the study period. A total of 56% had experienced an extended break in UALT. Predictors of poor adherence included younger age (odds ratio (OR) 1.50, 95% CI 1.33-1.69 for ages 65-74 compared with 85 and above) and African-American race (OR 1.86, 95% CI 1.52-2.27 compared with Caucasian race). Most patients (93%) received their initial UALT prescription from a non-specialist and this also predicted poor adherence (OR 1.15, 95% CI 0.96-1.38 compared with rheumatologists or nephrologists).

CONCLUSION

Adherence with UALT is poor. While uric acid levels were not measured in this study, poor adherence with UALT is likely to reduce attainment of goal uric acid levels.

Interpersonal communication

Interpersonal relationships are a critical factor in any service business. The stronger the relationship between the patient and the dental team, the better the patient will feel about the practice. He or she will assess dental recommendations much more carefully, and it certainly is possible that even referrals may increase. People love to talk with others about the positive experiences in their lives. Three simple questions can make a tremendous difference in how patients perceive a practice, whether they will trust the dentist and team, and what level of treatment they ultimately will accept. Dentists who want to provide the highest quality of care to as many patients as possible will have a greater chance of achieving this goal if interpersonal relationships in the practice are strong.

Drug-induced home cage conspecifics' behavior can potentiate behavioral sensitization in mice

The effect of home cage conspecifics' behavior on locomotor sensitization to amphetamine (AMP) or ethanol (ETOH) were investigated. Female mice were repeatedly treated with saline or AMP (2.0 mg/kg for 13 days--Experiment 1) or saline or ETOH (1.8 g/kg for 21 days--Experiment 2) in home cages where all the animals had the same treatment (homogeneous home cages--HOM-HC) or in home cages where half of the animals were drug-treated and half of them were saline-treated (heterogeneous home cages--HET-HC). Behavioral sensitization was evaluated by the quantification of open-field locomotor activity after AMP or ETOH challenge injection, respectively. In both experiments, behavioral sensitization was potentiated in HOM-HC maintained animals. These results suggest that the behavioral sensitization phenomenon can be modified by home cage conspecifics' behavior.

Conflict resolution

The sooner conflict is identified and confronted, the more quickly it can be resolved (and the sooner, the better). When this is accomplished calmly and objectively, many areas of conflict will be eliminated. Addressing conflict as it arises also sends a clear message to the team that the practice seeks resolution, not punishment or negative consequences. In addition, the dentist and the office manager need to lead by example by avoiding gossip and encouraging open communication. The goal is to go from a parent-child relationship with the dental team to an adult-adult relationship using this series of managerial conflict resolution steps.

Dealing with dental insurance

Dental insurance companies can have many different policies, with varying requirements depending on the company. This requires a tremendous amount of time on the part of dentists and their office teams to communicate with insurance companies, file all the proper data, acquire predetermination information when required and address a myriad of other factors. By managing this process carefully, practices can save time and labor expenses, especially if patients are well-educated regarding what their dental insurance covers and what it does not.

First Report of Meloidogyne partityla on Pecan in Florida

Pecan (Carya illinoensis (Wagenh.) K. Koch) is an important tree in the southern United States for commercial nut production and residential use. Meloidogyne partityla (pecan root-knot nematode) is only known to parasitize trees in the Juglandaceae including pecan, walnut, and hickory. In the United States, it has been reported on pecan in Texas, New Mexico, and Georgia and internationally in South Africa. Portions of a large pecan nursery in Madison County, Florida were infested with an unknown species of root-knot nematode. The pecan trees at this nursery are grafted onto rootstock and grown in the field until the trees are large enough to sell as bare-root transplant stock in several states including and adjoining Florida. Trees infected by the root-knot nematodes were stunted, had extensive galling and rotting of the root system, and pulled from the ground relatively easily compared with noninfected trees. Attempts to rear these nematodes on tomato in the greenhouse were unsuccessful. Young egg-laying females were isolated directly from pecan roots for speciation. Enzymes extracted from females were resolved with polyacrylamide gel electrophoresis [4% stacking (pH 6.8) and 8% separating gel (pH 8.8) with Tris-glycine buffer]. The esterase (Est) and malate dehydrogenase (Mdh) phenotypes of the unknown Meloidogyne sp. were consistent with those reported for M. partityla. In addition, specimens of M. partityla maintained by the USDA Southeastern Fruit and Tree Nut Research Laboratory in Byron, GA were obtained and their Est and Mdh phenotypes compared with the unknown Meloidogyne sp. under identical electrophoretic and enzyme staining protocols. The Est and Mdh phenotypes of the two isolates were identical. Therefore, we conclude that the root-knot nematodes infesting the pecan nursery in Florida are M. partityla. To our knowledge, this is the first report of this nematode in Florida and also the first report of this nematode from infected nursery stock. It is unknown how long the field has been infested but clearly, there is potential for spread of M. partityla to locations around Florida and bordering states. This nematode may be widespread throughout pecan-growing regions of the United States. References: (1) K. P. N. Kleynhans. Phytophylactica 18:103, 1986. (2) A. P. Nyczepir et al. Plant Dis. 86:441, 2002. (3) J. L. Starr et al. J. Nematol. 28:565, 1996. (4) S. H. Thomas et al. Plant Dis. 85:1030, 2001.

Consistency

Consistency is a reflection of having the right model, the right systems and the right implementation. As Vince Lombardi, the legendary coach of the Green Bay Packers, once said, "You don't do things right once in a while. You do them right all the time." To provide the ultimate level of patient care, reduce stress for the dentist and staff members and ensure high practice profitability, consistency is key.

Productive use of office time

Anything that takes the dentist away from patients must be addressed and, when appropriate, delegated to others. A practitioner's time is too precious to be doing tasks others can effectively and efficiently perform. Look first to staff members and then to advisers and outsource providers when deciding how to delegate various tasks. Once a practice begins to take administrative responsibilities away from the practitioner, chairside time will increase, patient care and customer service will be enhanced, and the practice will have greater growth potential.

Performance reviews

Performance reviews should be a consistent part of the management process. They should take place at approximately the same time every year and focus on improvement in a positive way. The performance review can be an energizing process, rather than a demoralizing one, and it truly can be an agent for positive development of team members.

Dental practice and dental insurance

The time has come for dentists to recognize that the dental insurers, as an outside factor, must be considered when designing a practice business model. The same efficiencies that would be well-placed in any business now need to be considered carefully in a dental practice to keep income from being reduced. Fortunately, there is a great deal of opportunity to increase practice efficiency and maintain or exceed the current level of financial performance.

Leadership and team building

Leadership is not something that can be done once. It's not a procedure that is performed and then you are all set. It is a way of thinking and acting--an hourly, daily and annual activity based on desire, skills, training and specific behaviors. Dentists who are willing to spend a small amount of time focused on leadership inevitably will build better teams with lower turnover and higher efficiency.

Measuring patient satisfaction

Many businesses use customer satisfaction surveys successfully. You may notice that you find one in almost every restaurant or hotel room. I do not think it is a coincidence that the hotel industry provides some of the finest customer service available. When it comes to providing excellent customer service, dental practices can learn from businesses that regularly assess customer satisfaction.

The challenge of esthetic dentistry and elective services

Many dentists would like to increase the number of esthetic and elective procedures they perform. What may be holding them back is the ability to communicate with, educate and motivate patients in the area of esthetic and elective dentistry. While implants, esthetic dentistry or elective dentistry is not for every patient, each of these areas has improved the quality of many people's lives, allowing the dental profession to continue to serve the public in the broadest possible way.

Practice progress

This column is not based on wishful thinking about how things should be, but rather is a candid look at the reality of everyday practice. Prioritization is critical. Each dentist should select three to five major initiatives that he or she would like to achieve and prioritize these accordingly. The best approach for most practices is to deal with each of these only one or two at a time. Consider scoring each priority on a scale of one to 10 (one being the lowest, 10 the highest), gauging its overall importance, its potential effect on the practice and whether it helps achieve preset practice goals.

Leverage in dentistry

Leverage is a powerful tool that can make a tremendous difference in the satisfaction and lifetime production of most dentists. Dentists typically do not use leverage properly, and as a result, the entire burden of the practice constantly falls on their shoulders. It is difficult for dentists to practice dentistry and handle administrative issues at the same time. Doing so leads to decreased production and increased stress. As an interesting exercise, try the following: take a stopwatch and time how long you are involved in direct patient care during the course of a day. Performing this exercise will be a true revelation in understanding the importance of leverage.

Is the dentist an entrepreneur?

Although dentists may have an entrepreneurial spirit, they are not true entrepreneurs. Simply by selecting dentistry as a profession, dentists have engaged in a business that has a high level of success and limited growth potential. By limited growth potential, I do not mean to imply that practices cannot be successful and create excellent lifestyles for dentists. As stated above, they will be limited in growth by the physical capacity of the dentist, the team and the facilities. There is a great deal of security in dental practice if basic management principles are followed and business systems are put in place. In my next column, I will continue to explore the similarities and differences between entrepreneurs and dentists, and how a dentist can take a practice through the multiple stages necessary to achieve the highest levels of dental practice success.

Evaluating your office staff

The most important assets in a dental practice are the people. We no longer live in an era in which an employee stays in the same job for decades. Change is inevitable and often comes at inopportune times. Evaluation gives the dentist the opportunity to identify key team members who will join the core team and train new staff members. Conversely, executive evaluation also demonstrates that there may not be a proper fit for a team member, if he or she cannot demonstrate the ability to grow and change with a practice despite support, training and career path development. As author Alvin Toffler noted, "The illiterate of the 21st century will not be those who cannot read or write, but those who cannot learn, unlearn and relearn."

Maximizing the physical use of the office

When referring to the physical plant in a dental practice, I am referring mainly to the use of dental chairs, because this is where dental practice production occurs. By maximizing the use of chairs or adding the necessary number of chairs to a practice, any office can grow and experience a proper patient flow. Since most offices have significantly high rates of no-shows, last-minute cancellations and overdue patients, the potential for growth is enormous. By using the schedule and chairs properly, the office has the opportunity to maximize production, create convenient appointments for patients and significantly increase practice profitability.

How home care is essential to ensuring successful orthodontic treatment outcomes

Patients can significantly affect the outcome of their orthodontic treatment. A practice committed to developing the right systems, scripts, and educational materials will experience a more satisfied patient, increased efficiencies, and higher profits. Educating and motivating patients to maintain their oral health and providing recommendations or dispensing of home care tools such as a power toothbrush increases patient compliance, positively impacts treatment outcomes, enhances customer service, and generates a new revenue stream for the practice. In a tight economy and a highly competitive orthodontic market, a power toothbrush can positively impact your marketing and case close rate. Treatment and fees being relatively equal, patients will tend to accept treatment from a practice that can demonstrate concern for the patients' overall oral health and greater value-added components to the orthodontic case. Power toothbrushes as part of a comprehensive orthodontic treatment provide a great differentiating marketing strategy.

Inventory control

By establishing clear inventory ordering targets and following the guidelines outlined in this column, the staff member handling the process will understand the high and low levels of inventory control and be able to maintain an accurate system. Inventory control represents approximately 6 to 8 percent of practice purchasing. The main goal of the advice in this column is not to reduce the cost, unless there is waste involved, but rather to establish a process that allows the practice to purchase supplies on a regular basis, avoid mistakes and maintain a steady expense level.