Difference in patterns of prescribing antidepressants known for their weight-modulating and cardiovascular side effects for patients with obesity compared to patients with normal weight

BACKGROUND

Patients with depression and comorbid obesity may be more prone to weight modulating and cardiovascular side effects of selected antidepressants (AD). It is important to ascertain whether these AD prescriptions differ by patient weight status.

METHODS

Canadian Primary Care Sentinel Surveillance Network (CPCSSN) electronic medical records were used. Participants were adults with depression prescribed an AD in 2000-2016, with weight categories established before the first prescription. Logistic regression and mixed effects models were applied to examine associations between obesity and AD prescribing, adjusted for sex, age, and comorbidities. Machine learning algorithm random forest (RF) was used to evaluate the importance of weight in predicting prescribing patterns.

RESULTS

Of 26,571 participants, 72.4% were women, mean age was 38.9 years (standard deviation (SD)=14.2) and mean BMI 27.0 kg/m² (SD = 6.5); 9.5% had ≥ 1 comorbidity. Patients with obesity, compared to normal weight patients, were more likely to receive bupropion (adjusted odds ratio (aOR) 1.24, 95%CI: 1.09,1.42), fluoxetine (aOR 1.14, 95%CI: 0.97,1.34), and amitriptyline (aOR 1.13, 95%CI: 0.93,1.36), and less likely to receive mirtazapine (aOR 0.55, 95%CI: 0.44,0.68) and escitalopram (aOR 0.88, 95%CI: 0.80, 0.97). RF analysis showed that weight was among the most important predictors of prescribing patterns, equivalent to age and more important than sex.

CONCLUSIONS

AD prescribing patterns for patients with obesity appear to be different for selected AD types, including AD known for their weight-modulating and cardiovascular side effects. Longitudinal studies are needed to examine whether these prescribing patterns are associated with significant health outcomes.

Identification of performance indicators across a network of clinical cancer programs

BACKGROUND

Cancer quality indicators have previously been described for a single tumour site or a single treatment modality, or according to distinct data sources. Our objective was to identify cancer quality indicators across all treatment modalities specific to breast, prostate, colorectal, and lung cancer.

METHODS

Candidate indicators for each tumour site were extracted from the relevant literature and rated in a modified Delphi approach by multidisciplinary groups of expert clinicians from 3 clinical cancer programs. All rating rounds were conducted by e-mail, except for one that was conducted as a face-to-face expert panel meeting, thus modifying the original Delphi technique. Four high-level indicators were chosen for immediate data collection. A list of confounding variables was also constructed in a separate literature review.

RESULTS

A total of 156 candidate indicators were identified for breast cancer, 68 for colorectal cancer, 40 for lung cancer, and 43 for prostate cancer. Iterative rounds of ratings led to a final list of 20 evidence- and consensus-based indicators each for colorectal and lung cancer, and 19 each for breast and prostate cancer. Approximately 30 clinicians participated in the selection of the breast, lung, and prostate indicators; approximately 50 clinicians participated in the selection of the colorectal indicators.

CONCLUSIONS

The modified Delphi approach that incorporates an in-person meeting of expert clinicians is an effective and efficient method for performance indicator selection and offers the added benefit of optimal clinician engagement. The finalized indicator lists for each tumour site, together with salient confounding variables, can be directly adopted (or adapted) for deployment within a performance improvement program.

LINA: a laboratory inventory system for oligonucleotides, microbial strains, and cell lines

In this article, we present the Laboratory Inventory Network Application (LINA), a software system that assists research laboratories in keeping track of their collections of biologically relevant materials. This open source application uses relational Microsoft Access database technology as a back end and a Microsoft .NET application as a front end. Preconstructed table templates are provided that contain standardized and customizable data fields. As new samples are added to the inventory, each is provided with a unique laboratory identifier, which is assigned automatically and sequentially, allowing rapid retrieval when a given reagent is required. The LINA contains a number of useful search tools including a general search, which allows database searches using up to four user-defined criteria. The LINA represents an easily implemented and useful organizational tool for biological laboratories with large numbers of strains, clones, or other reagents.

Evaluation of standardized tasks for primary care physicians using the MOXXI electronic prescribing and integrated drug management system

The Medical Office for the Twenty First Century (MOXXI) is a research project testing the potential benefits of an electronic prescription and drug management system for primary care physicians. This system includes a dynamic electronic pad for prescription entry with fields for treatment indications; a drug profiler with a graphic representation of the list of prescription medications purchased in the last year; a refill compliance calculator; dates of emergency room visits and hospital admissions; cost of drugs dispensed; and an alert system that detects interactions among drugs, treatment duplications, and contraindications with certain allergies or specific diseases. One concern expressed by physicians that could influence uptake and acceptability is the increased time that may be required to use the system. User abilities are a factor in this process, as well as user interface, user training and system speed.

Tuberous breast deformity: principles and practice

The tuberous breast deformity is one of the most challenging congenital breast anomalies. The nomenclature, classification, and treatment of this pathological condition have varied considerably. In this study, 16 patients with 23 tuberous breast deformities are evaluated. The breast deformities are classified according to the three-tier classification system used at the authors' institution. The treatment pattern is evaluated and a flexible algorithm is discussed for the treatment of the tuberous breast deformity.

Time-dependence of survival predictions based on markers of HIV disease. Swiss HIV Cohort Study

OBJECTIVE

To determine whether the ability of baseline clinical stage, viremia, and CD4 cell counts to predict mortality in HIV-1-infected patients changes with duration of follow-up.

METHODS

Three hundred ninety-four patients were followed for an average of 29 months by the Swiss HIV Cohort Study, a practice-based registry of HIV-1-infected patients in Switzerland. Predictor variables were the baseline clinical stage, CD4 cell count, circulating HIV-1 RNA level, and the RNA/CD4 ratio; the outcome was death. The changes in relative risks of death over time were examined using survival models that extend the Cox model to allow for nonproportionality of hazards.

RESULTS

During 949 person-years of follow-up, 169 patients died (mortality rate 17.8 per 100 person-years). Compared with clinical stage A, patients in stages B and C at baseline had much higher mortality rates in the subsequent year. The prognostic ability of stage C decayed over time (P = 0.03). By contrast, the relative risks associated with a 2-fold difference in CD4 counts remained remarkably stable, at approximately 0.6 (P = 0.81 for the time-dependence test). Relative hazards associated with a 10-fold difference in HIV RNA per milliliter and in HIV RNA per CD4 cell both tended to increase over time, but this trend failed to reach statistical significance (P = 0.21 and P = 0.08, respectively).

CONCLUSIONS

Time-dependence patterns of prognostic ability varied widely among predictors, displaying gradual decay (clinical stage), stability (CD4 cells), and a trend to progressive increase (viremia). These results may affect clinical monitoring of HIV-infected patients and the interpretation of cohort studies of HIV-infected patients.

Effect of inhaled fluticasone propionate on airway responsiveness in treatment-naive individuals--a lesser benefit in females

A randomized double-blind placebo-controlled parallel group study with inhaled fluticasone propionate over 6 weeks, designed to quantify the beneficial effect on airway responsiveness, and so assess whether short pulses of intermittent prophylactic treatment might serve as an alternative means of managing mild asthma, is reported. The 20-50-yr-old participants, who were recruited from an epidemiological study of the general population, had never knowingly received any regular treatment for asthma. Fluticasone propionate at the maximum recommended dose level (2,000 microg daily) and placebo were administered via metered-dose inhalers, and airway responsiveness was quantified conventionally by the provocative dose of methacholine causing a 20% fall in forced expiratory volume in one second (FEV1) (PD20) at 2-week intervals during the treatment phase and at various intervals subsequently. Compared with placebo fluticasone propionate was associated with a highly significant decrease in airway responsiveness (1.9 doublings of the geometric mean PD20), which was maximal at the end of the 6-week treatment period. No persisting benefit was detectable at the next measurement 2 weeks later, or thereafter. Multiple linear regression analysis showed that the magnitude of the fluticasone propionate effect was significantly greater in males than in females (3.2 versus 1.2 doublings respectively of the geometric mean PD20), but was uninfluenced by current smoking, age or FEV1. In conclusion, in the absence of any possibility of tachyphylaxis, inhaled fluticasone propionate at this dose causes a steadily increasing improvement in airway responsiveness over a 6-week period, which is modified by sex but lost almost immediately on treatment cessation. Short pulses of intermittent prophylactic treatment would not, therefore, be useful as a means of managing mild asthma.

Variation over time of the effects of prognostic factors in a population-based study of colon cancer: comparison of statistical models

The authors compare the performance of different regression models for censored survival data in modeling the impact of prognostic factors on all-cause mortality in colon cancer. The data were for 1,951 patients, who were diagnosed in 1977-1991, recorded by the Registry of Digestive Tumors of Côte d'Or, France, and followed for up to 15 years. Models include the Cox proportional hazards model and its three generalizations that allow for hazard ratio to change over time: 1) the piecewise model where hazard ratio is a step function; 2) the model with interaction between a predictor and a parametric function of time; and 3) the non-parametric regression spline model. Results illustrate the importance of accounting for non-proportionality of hazards, and some advantages of flexible non-parametric modeling of time-dependent effects. The authors provide empirical evidence for the dependence of the results of piecewise and parametric models on arbitrary a priori choices, regarding the number of time intervals and specific parametric function, which may lead to biased estimates and low statistical power. The authors demonstrate that a single, a priori selected spline model recovers a variety of patterns of changes in hazard ratio and fits better than other models, especially when the changes are non-monotonic, as in the case of cancer stages.

Measuring the quality of performance in the management of waiting lists: using cataract surgery as an example

BACKGROUND

Quality of care committees monitor waiting lists to ensure that patient care is not compromised. Frequently, waiting lists are determined by individual physicians, and no explicit criteria determine who is first in the queue. The quality of ophthalmologists' decisions for managing waiting lists of cataract patients, a high-volume elective patient group, was examined in a study of patients undergoing cataract surgery in 1997 in the Regina Health District, Saskatchewan, Canada.

METHOD

Ninety-eight patients scheduled for surgery were interviewed pre- and postoperatively regarding cataract symptomatology, visual and emotional functioning, coping strategies, and concerns with waiting periods. Ophthalmologists provided preoperative and postoperative information on visual functioning.

RESULTS

Even though no formal criteria guided decision making about how long patients should wait, wait periods conformed to general standards set by consensus of ophthalmologists unless patients decided to delay surgery. Patients voiced little concern about the waiting period, and difficulties with visual and emotional functioning were minimal. Surgery outcomes were not negatively affected by waiting periods, which were in part a function of physician case load but were also related to patient preference and the tendency to seek out reassurance. Visual acuity, cataract symptomatology, and visual functioning were not predictive of waiting time, suggesting that this information is not consistently being used to prioritize patients.

CONCLUSION

Waiting lists can be well managed by using individual physician decision making, although explicit formal decision-making rules would be helpful. A variety of methodologies and analyses can be used to evaluate the management of waiting lists and to assist in identifying criteria for assigning priority to patients.

Normal distributions of thermal and vibration sensory thresholds

The distributions of sensory thresholds were estimated in a healthy population while controlling for potential covariates. Using the method of levels and the two-alternative forced choice, thermal and vibration thresholds respectively were measured in the hand and foot of 148 subjects. Age was uniformly distributed between 20 and 86 years. Independent effects of age, gender, height, and skin temperature were estimated using multiple linear regression. Parametric and nonparametric methods were used to estimate the distributions of interest. Significant age-related increases were observed for all vibration thresholds (P < 0.0001), and for thermal thresholds in the foot (P < 0.0002). Percentiles were estimated for thermal thresholds in the hand and age-adjusted continuous distributions were calculated for all other thresholds. Height was positively associated with vibration thresholds in the foot (P < 0.003), and appropriate corrections were made. Our results provide reference values for thermal and vibration sensory thresholds in a healthy population, allowing for the accurate diagnosis of disordered sensory function.

Normal distributions of thermal and vibration sensory thresholds

The distributions of sensory thresholds were estimated in a healthy population while controlling for potential covariates. Using the method of levels and the two-alternative forced choice, thermal and vibration thresholds respectively were measured in the hand and foot of 148 subjects. Age was uniformly distributed between 20 and 86 years. Independent effects of age, gender, height, and skin temperature were estimated using multiple linear regression. Parametric and nonparametric methods were used to estimate the distributions of interest. Significant age-related increases were observed for all vibration thresholds (P < 0.0001), and for thermal thresholds in the foot (P < 0.0002). Percentiles were estimated for thermal thresholds in the hand and age-adjusted continuous distributions were calculated for all other thresholds. Height was positively associated with vibration thresholds in the foot (P < 0.003), and appropriate corrections were made. Our results provide reference values for thermal and vibration sensory thresholds in a healthy population, allowing for the accurate diagnosis of disordered sensory function.

The maximum medical aid price programme. A review of the concept and of its ability to reduce expenditure on medicines

Medicine prices in South Africa have increased significantly in recent years. Furthermore, a consideration of expenditure on medicines by medical schemes shows that this component of health care costs had grown to 26.1% in 1988, which is high by comparison with other Western economies. The use of generic medicines offers one possible solution to rising expenditure. For savings to be optimised, however, generics need to be used on a planned and structured basis. The maximum medical aid price (MMAP) system of the Pharmaceutical Society of South Africa provides such a programme. MMAP is a programme through which certain medical schemes elect to pay only a specified maximum price for off-patent products that have generic equivalents. Although MMAP does not require substitution by generic medicines, it does have the effect of encouraging their use. Two case studies measuring the savings that can be achieved through adoption of MMAP by medical schemes are reviewed. Although they differ in their respective methodologies, their results are consistent and show that savings of about 9.3% were possible in 1989. Medical schemes with higher proportions of older members tend to show greater savings. The studies also show that the potential for achieving savings through the use of MMAP increases with the passage of time.