Promoting quality use of medicines in South-East Asia: reports from country situational analyses

BACKGROUND

Irrational use of medicines is widespread in the South-East Asia Region (SEAR), where policy implementation to encourage quality use of medicines (QUM) is often low. The aim was to determine whether public-sector QUM is better in SEAR countries implementing essential medicines (EM) policies than in those not implementing them.

METHODS

Data on six QUM indicators and 25 EM policies were extracted from situational analysis reports of 20 country (2-week) visits made during 2010-2015. The average difference (as percent) for the QUM indicators between countries implementing versus not implementing specific policies was calculated. Policies associated with better (> 1%) QUM were included in regression of a composite QUM score versus total number of policies implemented.

RESULTS

Twenty-two policies were associated with better (> 1%) QUM. Twelve policies were associated with 3.6-9.5% significantly better use (p < 0.05), namely: standard treatment guidelines; formulary; a government unit to promote QUM; continuing health worker education on prescribing by government; limiting over-the-counter (OTC) availability of systemic antibiotics; disallowing public-sector prescriber revenue from medicines sales; not charging fees at the point of care; monitoring advertisements of OTC medicines; public education on QUM; and a good drug supply system. There was significant correlation between the number of policies implemented out of 22 and the composite QUM score (r = 0.71, r² = 0.50, p < 0.05).

CONCLUSIONS

Country situational analyses allowed rapid data collection that showed EM policies are associated with better QUM. SEAR countries should implement all such policies.

Isolated hypoglossal nerve palsy as a presenting symptom of metastatic peripheral T-cell lymphoma - not otherwise specified (PTCL-NOS): a unique case & a review of the literature

Extensive and significant technological advancements have enhanced the sensitivity and accuracy of the pathologic classification, diagnosis, and therapeutics of lymphoma. These advances have prompted a more comprehensive understanding of neoplastic behavior and have led to improvements in both treatment and prognosis. This paper presents a comprehensive review of lymphoma and features a case report of a unique presentation of peripheral T-cell lymphoma - not otherwise specified that presented with isolated hypoglossal nerve dysfunction.

Unlocking First Nations health information through data linkage

Introduction

The importance of Indigenous data sovereignty and Indigenous-led research processes is increasingly being recognized in Canada and internationally. For First Nations in Ontario, Canada, access to routinely-collected demographic and health systems data is critical to planning and measuring health status and outcomes in their populations. Linkage of this data with the Indian Register (IR), under First Nations data governance, has unlocked data for use by First Nations organizations and communities.

Objectives

To describe the linkage of the IR database to the Ontario Registered Persons Database (RPDB) within the context of Indigenous data sovereignty principles.

Methods

Deterministic and probabilistic record linkage methods were used to link the IR to the RPDB. There is no established population of First Nations people living in Ontario with which we could establish a linkage rate. Accordingly, several approaches were taken to determine a denominator that would represent the total population of First Nations we would hope to link to the RPDB.

Results

Overall, 201,678 individuals in the national IR database matched to Ontario health records by way of the RPDB, of which 98,562 were female and 103,116 were male. Of those First Nations individuals linked to the RPDB, 90.2% (n=181,915) lived in Ontario when they first registered with IR, or were affiliated with an Ontario First Nation Community. The proportion of registered First Nations people linking to the RPDB improved across time, from 62.8% in the 1960s to 94.5% in 2012.

Conclusion

This linkage of the IR and RPDB has resulted in the creation of the largest First Nations health research study cohort in Canada. The linked data are being used by First Nations communities to answer questions that ultimately promote wellbeing, effective policy, and healing.

Minimisation of Signal Intensity Differences in Distortion Correction Approaches of Brain Magnetic Resonance Diffusion Tensor Imaging

OBJECTIVES

To evaluate the effects of signal intensity differences between the b0 image and diffusion tensor imaging (DTI) in the image registration process.

METHODS

To correct signal intensity differences between the b0 image and DTI data, a simple image intensity compensation (SIMIC) method, which is a b0 image re-calculation process from DTI data, was applied before the image registration. The re-calculated b0 image (b0_ext) from each diffusion direction was registered to the b0 image acquired through the MR scanning (b0_nd) with two types of cost functions and their transformation matrices were acquired. These transformation matrices were then used to register the DTI data. For quantifications, the dice similarity coefficient (DSC) values, diffusion scalar matrix, and quantified fibre numbers and lengths were calculated.

RESULTS

The combined SIMIC method with two cost functions showed the highest DSC value (0.802 ± 0.007). Regarding diffusion scalar values and numbers and lengths of fibres from the corpus callosum, superior longitudinal fasciculus, and cortico-spinal tract, only using normalised cross correlation (NCC) showed a specific tendency toward lower values in the brain regions.

CONCLUSION

Image-based distortion correction with SIMIC for DTI data would help in image analysis by accounting for signal intensity differences as one additional option for DTI analysis.

KEY POINTS

• We evaluated the effects of signal intensity differences at DTI registration. • The non-diffusion-weighted image re-calculation process from DTI data was applied. • SIMIC can minimise the signal intensity differences at DTI registration.

Multi-Level Cultural Intervention for the Prevention of Suicide and Alcohol Use Risk with Alaska Native Youth: a Nonrandomized Comparison of Treatment Intensity

Suicide and alcohol use disorders are primary determinants of health disparity among Alaska Native people in contrast to the US general population. Qungasvik, a Yup'ik word for toolbox, is a strengths-based, multi-level, community/cultural intervention for rural Yup'ik youth ages 12-18. The intervention uses "culture as intervention" to promote reasons for life and sobriety in young people using local expertise, high levels of community direction, and community based staff. The intervention is grounded in local practices and adaptive to local cultural differences distinctive to rural Yup'ik communities. The current study compares the effectiveness of high-intensity intervention in one community (treatment), operationalized as a high number of intervention activities, or modules, implemented and attended by youth, contrasted to a lower intensity intervention in a second community (comparison) that implemented fewer modules. A Yup'ik Indigenous theory of change developed through previous qualitative and quantitative work guides intervention. In the model, direct intervention effects on proximal or intermediate variables constituting protective factors at the individual, family, community, and peer influences levels lead to later change on the ultimate prevention outcome variables of Reasons for Life protective from suicide risk and Reflective Processes about alcohol use consequences protective from alcohol risk. Mixed effects regression models contrasted treatment and comparison arms, and identified significant intervention effects on Reasons for Life (d = 0.27, p < .05) but not Reflective Processes.

On three-dimensional Gerstner-like equatorial water waves

This paper reviews some recent mathematical research activity in the field of nonlinear geophysical water waves. In particular, we survey a number of exact Gerstner-like solutions which have been derived to model various geophysical oceanic waves, and wave-current interactions, in the equatorial region. These solutions are nonlinear, three-dimensional and explicit in terms of Lagrangian variables.This article is part of the theme issue 'Nonlinear water waves'.

Prediction of the free-surface elevation for rotational water waves using the recovery of pressure at the bed

This paper considers the pressure-streamfunction relationship for a train of regular water waves propagating on a steady current, which may possess an arbitrary distribution of vorticity, in two dimensions. The application of such work is to both near shore and offshore environments, and in particular, for linear waves we provide a description of the role which the pressure function on the seabed plays in determining the free-surface profile elevation. Our approach is shown to provide a good approximation for a range of current conditions.This article is part of the theme issue 'Nonlinear water waves'.

Trends and uptake of new formulations of controlled-release oxycodone in Canada

Purpose

This study investigated the impact of changing availability of tamper‐deterrent and non‐tamper‐deterrent oxycodone on prescribing patterns of controlled‐release oxycodone across Canada.

Methods

We conducted a population‐based, serial cross‐sectional study of controlled‐release oxycodone dispensing from community pharmacies across Canada between October 2007 and April 2016. We calculated rates of dispensing (tablets per 100 population) and reported the relative market share of generic non‐tamper‐deterrent controlled‐release oxycodone. All analyses were reported nationally and stratified by province.

Results

After the introduction of a tamper‐deterrent formulation, the national rate of controlled‐release oxycodone dispensing fell by 44.6% (from 26.4 to 14.6 tablets per 100 population from February 2012 to April 2016). Between December 2012 and July 2013, there was moderate uptake of generic non‐tamper‐deterrent controlled‐release oxycodone (968 452 tablets; 16.0% in July 2013), which appeared to have little impact on the overall rate of controlled‐release oxycodone dispensing in Canada. However, the uptake of generic non‐tamper‐deterrent oxycodone varied considerably by province. By April 2016, 55.0% of all controlled‐release oxycodone tablets dispensed in Quebec were for the generic formulation. Elsewhere in Canada, this prevalence was less than 30%, ranging between 1.6% (Prince Edward Island) and 26.9% (British Columbia) at the end of our study period.

Conclusions

The changing availability of tamper‐deterrent and non‐tamper‐deterrent formulations of controlled‐release oxycodone in Canada has had variable influence on the rate of use of these products across Canada. Future research should explore whether the availability of generic controlled‐release oxycodone has led to measurable changes in the safety of oxycodone use in Canada.

Fathers' Criminal Behavior and Involvement With Children: The Moderating Role of Family Relationships

OBJECTIVE

Research indicates that fathers' criminal behavior can be problematic for children through multiple pathways, yet few studies have examined the effect of fathers' kinship networks in this process. This study examines the association between fathers' criminal behavior and involvement with their children and the extent to which a father's relationships with individuals in his extended family network moderate this association.

METHOD

Hierarchical linear modeling was used to predict fathers' involvement using data from a longitudinal intergenerational study of 335 children and 149 low-income, minority fathers. Measures included 8 father-involvement outcomes, a measure of fathers' criminal behavior, and 2 moderator variables.

RESULTS

High-quality relationships between fathers and their male relatives moderated the negative effect of criminal behavior on measures of fathers' involvement. Criminal behavior was only associated with decreasing levels of father involvement when fathers had low-quality relationships with male relatives.

CONCLUSIONS

Strong and affirmative relationships-with male relatives specifically-may attenuate the adverse effects of antisocial and criminal behavior on fathers' involvement in at-risk families. Implications for tailoring practice to improve relationships between fathers and male relatives and to enhance fathers' prosocial involvement are noted.

Regional Inequalities in All-Cause and Premature Mortality in Ontario

Although all-cause mortality rates have fallen in many countries in the last 40 years, the well-off and city dwellers have experienced the greatest gains. In this paper, we report on socio-economic and regional variations in premature mortality in Ontario. Premature mortality rates were highest in areas with the greatest degrees of social deprivation. While premature mortality continued to fall in the least deprived group, they flattened in the other groups and rose between 2000-2007 and 2008-2015 in the most deprived group. There were substantial variations in premature mortality rates across the Local Health Integration Networks, with the greatest disadvantage being seen in the southeast, northwest and northeast regions of Ontario. These data present a major challenge to policy makers. Health, social and economic policies need to be directed toward narrowing the gaps we have identified here. We have excellent metrics with which to measure their success.

High frequency of identical clonal immunoglobulin DNA in pre-treatment tumor and plasma from untreated patients with HIV-associated lymphoma: prospective multicenter trial of the AIDS malignancies consortium (AMC 064)

Patients with HIV are at increased risk for developing B-cell lymphomas likely due in part to chronic antigen stimulation leading to clonal immunoglobulin (Ig) gene rearrangements. Next-generation sequencing (NGS)-based identification of circulating Ig clonotypes has not been well-characterized in HIV-related lymphomas. The AIDS Malignancies Consortium (AMC) enrolled 51 untreated patients with HIV-related B-cell lymphomas and analyzed paired tumor/plasma specimens for Ig clonotypes using an NGS approach (AMC064, NCT00981097). Lymphoma-specific clonotypes (>5% frequency) were identified in 83% (33/40) of tumor specimens. Results from paired tumor/plasma specimens showed identical circulating clonotypes in the plasma from 97% (32/33) of patients. High International Prognostic Index (IPI) scores of 3-4 among patients with B-cell lymphoma correlated with higher lymphoma molecules/million diploid genomes in the plasma compared with lower IPI scores of 0-2, median 77335 vs. 6876, p = .005. Further studies are merited to determine whether plasma clonal Ig DNA is prognostic in HIV-related lymphomas.

Changes in the dispensing of opioid medications in Canada following the introduction of a tamper-deterrent formulation of long-acting oxycodone: a time series analysis

BACKGROUND

In February 2012, a reformulated tamper-deterrent form of long-acting oxycodone, OxyNeo, was introduced in Canada. We investigated the impact of the introduction of OxyNeo on patterns of opioid prescribing.

METHODS

We conducted population-based, cross-sectional analyses of opioid dispensing in Canada between 2008 and 2016. We estimated monthly community pharmacy dispensing of oral formulations of codeine, morphine, hydromorphone and oxycodone, and a transdermal formulation of fentanyl, and converted quantities to milligrams of morphine equivalents (MMEs) per 1000 population. We used time series analysis to evaluate the effect of the introduction of OxyNeo on these trends.

RESULTS

National dispensing of long-acting opioids fell by 14.9% between February 2012 and April 2016, from 36 098 MMEs to 30 716 MMEs per 1000 population (p < 0.01). This effect varied across Canada and was largest in Ontario (reduction of 22.8%) (p = 0.01) and British Columbia (reduction of 30.0%) (p = 0.01). The national rate of oxycodone dispensing fell by 46.4% after the introduction of OxyNeo (p < 0.001); this was partially offset by an increase of 47.8% in hydromorphone dispensing (p < 0.001). Although dispensing of immediate-release opioids was a substantial contributor to overall population opioid exposure across Canada, it was unaffected by the introduction of OxyNeo (p > 0.05 in all provinces).

INTERPRETATION

The findings suggest that the introduction of a tamper-deterrent formulation of long-acting oxycodone in Canada, against a background of changing public drug benefits, was associated with sustained changes in selection of long-acting opioids but only small changes in the quantity of long-acting opioids dispensed. This illustrates the limited effect a tamper-deterrent formulation and associated coverage policy can have when other, non-tamper-deterrent alternatives are readily available.

Impact of restricting diagnostic imaging reimbursement for uncomplicated low back pain in Ontario: a population-based interrupted time series analysis

BACKGROUND

In 2012, the Ontario government withdrew public insurance coverage of imaging tests for uncomplicated low back pain. We studied the impact of this restriction on test ordering by physicians.

METHODS

We compared the numbers of lumbar spine radiography, computed tomography (CT) and single-segment magnetic resonance imaging (MRI) studies ordered by physicians in the 3 years before and after the policy change. We linked claims data from the Ontario Health Insurance Program with physician details to calculate rates per test-ordering physician. We compared changes in rates of monthly test ordering by family physicians and specialists before and after the policy change using segmented regression analysis of interrupted time series data.

RESULTS

The number of lumbar spine radiography and spine CT studies ordered by family physicians decreased by 98 597 (28.7%) and 17 499 (28.7%), respectively, in the year after the policy change; there was little change in ordering by specialists. The number of lumbar spine radiography studies ordered per family physician by month decreased by 0.81 tests (p < 0.001) after the intervention, followed by a smaller rebound increase that remained below baseline. Monthly ordering of spine CT per family physician declined by 0.1 tests (p < 0.001), and that of limited spine MRI rose before the intervention, decreased by 0.18 tests (p < 0.001) after the intervention, then started to rise again. Monthly ordering of limited spine MRI by specialists, which had been stable before the policy change, decreased by 0.1 tests per specialist (p < 0.001) afterward, then rose to preintervention levels.

INTERPRETATION

The restriction in coverage of imaging tests caused a larger decrease in test ordering by family physicians than by specialists and a larger, more sustained reduction in the use of lumbar spine radiography and spine CT than of spine MRI.

A population-based study of homicide deaths in Ontario, Canada using linked death records

Background

Homicide – a lethal expression of violence – has garnered little attention from public health researchers and health policy makers, despite the fact that homicides are a cause of preventable and premature death. Identifying populations at risk and the upstream determinants of homicide are important for addressing inequalities that hinder population health. This population-based study investigates the public health significance of homicides in Ontario, Canada, over the period of 1999–2012. We quantified the relative burden of homicides by comparing the socioeconomic gradient in homicides with the leading causes of death, cardiovascular disease (CVD) and neoplasm, and estimated the potential years of life lost (PYLL) due to homicide.

Methods

We linked vital statistics from the Office of the Registrar General Deaths register (ORG-D) with Census and administrative data for all Ontario residents. We extracted all homicide, neoplasm, and cardiovascular deaths from 1999 to 2012, using International Classification of Diseases codes. For socioeconomic status (SES), we used two dimensions of the Ontario Marginalization Index (ON-Marg): material deprivation and residential instability. Trends were summarized across deprivation indices using age-specific rates, rate ratios, and PYLL.

Results

Young males, 15–29 years old, were the main victims of homicide with a rate of 3.85 [IC 95%: 3.56; 4.13] per 100,000 population and experienced an upward trend over the study period. The socioeconomic neighbourhood gradient was substantial and higher than the gradient for both cardiovascular and neoplasms. Finally, the PYLL due to homicide were 63,512 and 24,066 years for males and females, respectively.

Conclusions

Homicides are an important cause of death among young males, and populations living in disadvantaged neighbourhoods. Our findings raise concerns about the burden of homicides in the Canadian population and the importance of addressing social determinants to address these premature deaths.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-017-0632-9) contains supplementary material, which is available to authorized users.

Combining freeform optics and curved detectors for wide field imaging: a polynomial approach over squared aperture

In the recent years a significant progress was achieved in the field of design and fabrication of optical systems based on freeform optical surfaces. They provide a possibility to build fast, wide-angle and high-resolution systems, which are very compact and free of obscuration. However, the field of freeform surfaces design techniques still remains underexplored. In the present paper we use the mathematical apparatus of orthogonal polynomials defined over a square aperture, which was developed before for the tasks of wavefront reconstruction, to describe shape of a mirror surface. Two cases, namely Legendre polynomials and generalization of the Zernike polynomials on a square, are considered. The potential advantages of these polynomials sets are demonstrated on example of a three-mirror unobscured telescope with F/# = 2.5 and FoV = 7.2x7.2°. In addition, we discuss possibility of use of curved detectors in such a design.