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Grant JM, Lam J, Goyal SV, Lother S, Kassim SS, Lee SB, Chan J, Girouard G, Barrett L, Takaya S, Piszczek J, Vinh DC, Findlater AR, Saxinger L. AMMI Canada Practice Point: Updated recommendations for treatment of adults with symptomatic COVID-19 in 2023-2024. J Assoc Med Microbiol Infect Dis Can 2024; 8:245-252. [PMID: 38250615 PMCID: PMC10797770 DOI: 10.3138/jammi-2023-12-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Jennifer M Grant
- Divisions of Medical Microbiology and Infectious Diseases, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Lam
- Division of Infectious Diseases, Department of Medicine, University of California, Los Angeles, California, USA
| | - Sohal V Goyal
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvain Lother
- Sections of Infectious Diseases and Critical Care, University of Manitoba, Manitoba, Canada
| | - Sameer S Kassim
- Department of Family Medicine, University of Manitoba, Manitoba, Canada
| | - Stephen B Lee
- Division of Infectious Diseases, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Justin Chan
- Division of Infectious Diseases and Immunology, Department of Medicine, NYU Grossman School of Medicine, New York, USA
| | - Gabriel Girouard
- Centre hospitalier universitaire Dr-Georges-L.-Dumont Vitalité Health Network, Moncton, New Brunswick, Canada
| | - Lisa Barrett
- Infectious Diseases NSHA, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Satchan Takaya
- Division of Infectious Diseases, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jolanta Piszczek
- Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Donald C Vinh
- Division of Infectious Diseases, Department of Medicine; Division of Medical Microbiology, Department of Laboratory Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Aidan R Findlater
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lynora Saxinger
- Division of Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
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Dormuth CR, Kim JD, Fisher A, Piszczek J, Kuo IF. Nirmatrelvir-Ritonavir and COVID-19 Mortality and Hospitalization Among Patients With Vulnerability to COVID-19 Complications. JAMA Netw Open 2023; 6:e2336678. [PMID: 37782496 PMCID: PMC10546233 DOI: 10.1001/jamanetworkopen.2023.36678] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/25/2023] [Indexed: 10/03/2023] Open
Abstract
Importance Postmarket analysis of individuals who receive nirmatrelvir and ritonavir (Paxlovid [Pfizer]) is essential because they differ substantially from individuals included in published clinical trials. Objective To examine the association of nirmatrelvir and ritonavir with prevention of death or admission to hospital in individuals with different risks of complications from COVID-19 infection. Design, Setting, and Participants This is a cohort study of adult patients in British Columbia, Canada, between February 1, 2022, and February 3, 2023. Patients were eligible if they belonged to 1 of 4 higher-risk groups of individuals who received priority for COVID-19 vaccination. Two groups included clinically extremely vulnerable (CEV) people who were severely (CEV1) or moderately immunocompromised (CEV2). CEV3 individuals were not immunocompromised but had medical conditions associated with a high risk for complications from COVID-19. A fourth expanded eligibility (EXEL) group was added to allow wider access to nirmatrelvir and ritonavir for certain other higher-risk individuals who were not in a CEV group, such as those older than 70 years who were unvaccinated. Exposures Patients with COVID-19 who received nirmatrelvir and ritonavir were matched to patients in the same vulnerability group; who were of the same sex, age, and propensity score for nirmatrelvir and ritonavir treatment; and who were also infected within 1 month of the individual treated with nirmatrelvir and ritonavir. Main Outcomes and Measures The primary outcome was death from any cause or emergency hospitalization with COVID-19 within 28 days. Results There were 6866 individuals included in the study, of whom 3888 (56.6%) were female and whose median (IQR) age was 70 (57-80) years. Compared with unexposed controls, treatment with nirmatrelvir and ritonavir was associated with statistically significant relative reductions in the primary outcome in the CEV1 group (560 patients; risk difference [RD], -2.5%, 95% CI, -4.8% to -0.2%) and the CEV2 group (2628 patients; RD, -1.7%; 95% CI, -2.9% to -0.5%). In the CEV3 group, the RD was -1.3%, but the findings were not statistically significant (2100 patients; 95% CI, -2.8% to 0.1%). In the EXEL group, treatment was associated with higher risk of the outcome (RD, 1.0%), but the findings were not statistically significant (1578 patients; 95% CI, -0.9% to 2.9%). Conclusions and Relevance In this cohort study of 6866 individuals in British Columbia, nirmatrelvir and ritonavir treatment was associated with reduced risk of COVID-19 hospitalization or death in CEV individuals, with the greatest benefit observed in severely immunocompromised individuals. No reduction in the primary outcome was observed in lower-risk individuals, including those aged 70 years or older without serious comorbidities.
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Affiliation(s)
- Colin R. Dormuth
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason D. Kim
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anat Fisher
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Therapeutics Initiative, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jolanta Piszczek
- Department of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- BC COVID Therapeutics Committee, Vancouver, British Columbia, Canada
| | - I Fan Kuo
- Pharmaceutical Laboratory and Blood Services Division, British Columbia Ministry of Health, Vancouver, British Columbia, Canada
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Bahremand T, Yao JA, Mill C, Piszczek J, Grant JM, Smolina K. COVID-19 hospitalisations in immunocompromised individuals in the Omicron era: a population-based observational study using surveillance data in British Columbia, Canada. Lancet Reg Health Am 2023; 20:100461. [PMID: 36890850 PMCID: PMC9987330 DOI: 10.1016/j.lana.2023.100461] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 11/09/2022] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
Background People with immune dysfunction are at higher risk of severe outcomes from COVID-19 infection, but relatively little epidemiologic information is available for mostly vaccinated population in the Omicron era. This population-based study compared relative risk of breakthrough COVID-19 hospitalisation among vaccinated people identified as clinically extremely vulnerable (CEV) vs non-CEV individuals before treatment became more widely available. Methods COVID-19 cases and hospitalisations reported to the British Columbia Centre for Disease Control (BCCDC) between January 7, 2022 and March 14, 2022 were linked with data on their vaccination and CEV status. Case hospitalisation rates were estimated across CEV status, age groups and vaccination status. For vaccinated individuals, risk ratios for breakthrough hospitalisations were calculated for CEV and non-CEV populations matched on sex, age group, region, and vaccination characteristics. Findings Among CEV individuals, a total of 5591 COVID-19 reported cases were included, among which 1153 were hospitalized. A third vaccine dose with mRNA vaccine offered additional protection against severe illness in both CEV and non-CEV individuals. However, 2- and 3-dose vaccinated CEV population still had a significantly higher relative risk of breakthrough COVID-19 hospitalisation compared with non-CEV individuals. Interpretation Vaccinated CEV population remains a higher risk group in the context of circulating Omicron variant and may benefit from additional booster doses and pharmacotherapy. Funding BC Centre for Disease Control and Provincial Health Services Authority.
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Affiliation(s)
- Taraneh Bahremand
- British Columbia Centre for Disease Control (BCCDC), Vancouver, Canada
| | - Jiayun Angela Yao
- British Columbia Centre for Disease Control (BCCDC), Vancouver, Canada
| | - Christopher Mill
- British Columbia Centre for Disease Control (BCCDC), Vancouver, Canada
| | - Jolanta Piszczek
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Jennifer M Grant
- Division of Infectious Diseases and Medical Microbiology, Vancouver Coastal Health, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Kate Smolina
- British Columbia Centre for Disease Control (BCCDC), Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Stukas S, Goshua G, Kinkade A, Grey R, Mah G, Biggs CM, Jamal S, Thiara S, Lau TT, Piszczek J, Partovi N, Sweet DD, Lee AY, Wellington CL, Sekhon MS, Chen LY. Reduced fixed dose tocilizumab 400 mg IV compared to weight-based dosing in critically ill patients with COVID-19: A before-after cohort study. The Lancet Regional Health - Americas 2022; 11:100228. [PMID: 35345649 PMCID: PMC8941850 DOI: 10.1016/j.lana.2022.100228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Interleukin-6 inhibitors reduce mortality in severe COVID-19. British Columbia began using tocilizumab 8 mg/kg (maximum 800 mg) in January 2021 in critically ill patients with COVID-19, but due to drug shortages, decreased dosing to 400 mg IV fixed dose in April 2021. The aims of this study were twofold: to compare physiological responses and clinical outcomes of these two strategies, and examine the cost-effectiveness of treating all patients with 400 mg versus half the patients with 8 mg/kg and the other half without tocilizumab. Methods This was a single-centre, before-after cohort study of critically ill COVID-19 patients treated with tocilizumab, and a control cohort treated with dexamethasone only. Physiological responses and clinical outcomes were compared between patients receiving both doses of tocilizumab and those receiving dexamethasone only. We built a decision tree model to examine cost-effectiveness. Findings 152 patients were included; 40 received tocilizumab 8 mg/kg, 59 received 400 mg and 53 received dexamethasone only. Median CRP fell from 103 mg/L to 5.2 mg/L, 96 mg/L to 6.8 mg/L and from 81.3 mg/L to 48 mg/L in the 8 mg/kg, 400 mg tocilizumab, and dexamethasone only groups, respectively. 28-day mortality was 5% (n=2) vs 8% (n=5) vs 13% (n=7), with no significant difference in all pair-wise comparison. At an assumed willingness-to-pay threshold of $50,000 Canadian per life-year, utilizing 400 mg for all patients rather than 8 mg/kg for half the patients is cost-effective in 51.6% of 10,000 Monte Carlo simulations. Interpretation Both doses of tocilizumab demonstrated comparable reduction of inflammation with similar 28-day mortality. Without consideration of equity, the net monetary benefits of providing 400 mg tocilizumab to all patients are comparable to 8 mg/kg to half the patients. In the context of ongoing drug shortages, fixed-dose 400 mg tocilizumab may be a practical, feasible and economical option. Funding This work was supported by a gift donation from Hsu & Taylor Family to the VGH Foundation, and the Yale Bernard G. Forget Scholarship.
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Simeonova M, Piszczek J, Hoi S, Harder C, Pelligra G. 20 Evaluation of Compliance with the 2017 Canadian Pediatric Society (CPS) Position Statement for the Management of Newborns at Risk for Early-Onset Sepsis (EOS): A Retrospective Cohort Study. Paediatr Child Health 2020. [DOI: 10.1093/pch/pxaa068.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Due to the high mortality and non-specific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Pediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management.
Objectives
To examine the compliance with the CPS position statement at a tertiary perinatal site.
Design/Methods
A retrospective chart review was conducted between Jan 1 – Jun 30, 2018. Newborns were categorized into 5 groups, depending on the number of EOS risk factors. Management strategies were assessed against the CPS recommendations to establish the rate of non-compliance. The reason for non-compliance, readmission rate and rate of culture-positive EOS were also examined. Results were expressed using descriptive statistics. A Chi-squared test was conducted to assess the association between the readmission rate and initial management.
Results
The total non-compliance rate was 47%. This was mostly due to inappropriate investigations in lower EOS risk groups [3 (71%) and 4 (94%)] and withholding antibiotics in groups with more risk factors [1 (43%) and 2 (67%)]. The rate of readmission for a septic work-up was low (<2%), and no newborns had culture-positive EOS. There was no significant association between the readmission rate and initial management (p=0.13).
Conclusion
Although the rate of non-compliance to the 2017 CPS recommendations was high, no neonates had culture-positive EOS, suggesting that our management strategies may be too aggressive. An initial observational period for newborns at lower EOS risk (groups 3 and 4) may warrant consideration for future quality improvement initiatives.
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Simeonova M, Piszczek J, Hoi S, Harder C, Pelligra G. Evaluation of compliance with the 2017 Canadian Paediatric Society Position Statement for the management of newborns at risk for early-onset sepsis: A retrospective cohort study. Paediatr Child Health 2020; 26:e152-e157. [PMID: 33936345 DOI: 10.1093/pch/pxaa042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/26/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction Due to the nonspecific clinical presentation, clinicians often empirically treat newborns at risk of early-onset sepsis (EOS). Recently, the Canadian Paediatric Society (CPS) published updated recommendations that promote a more judicious approach to EOS management. Objective To examine the compliance with the CPS statement at a tertiary perinatal site and characterize the types of deviations. Methods A retrospective chart review was conducted for all term and late pre-term newborns at risk for sepsis, between January 1 and June 30, 2018. The prevalence of newborns with EOS risk factors was measured during the first month. Management strategies for eligible newborns during the 6-month period were compared to the CPS recommendations to establish the rate of noncompliance. The type of noncompliance, readmission rate, and rate of culture-positive EOS were examined. Results In the first month, 29% (66 of 228) of newborns had EOS risk factors. Among the 100 newborns born in the 6-month period for whom the CPS recommendations apply, 47 (47%) received noncompliant management. Of those, 51% (N=24) had inappropriately initiated investigations, 17% (N=8) had inappropriate antibiotics, and 32% (N=15) had both. The rate of readmission for a septic workup was 1.6% (N= 2). None had culture-positive sepsis while admitted. Conclusion A large proportion of term and late preterm newborns (29%) had EOS risk factors, but none had culture-confirmed EOS. The rate of noncompliance with the CPS recommendations was high (47%), mainly due to overzealous management. Future initiatives should aim at increasing compliance, particularly in newborns at lower EOS risk.
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Affiliation(s)
- Marina Simeonova
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Jolanta Piszczek
- Department of Pharmacy, Royal Jubilee Hospital, Victoria, British Columbia
| | - Sannifer Hoi
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Curtis Harder
- Department of Pharmacy, Victoria General Hospital, Victoria, British Columbia.,Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Gustavo Pelligra
- Department of Maternity Care and Pediatrics, Victoria General Hospital, Victoria, British Columbia.,Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia
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Piszczek J, Partlow E, Daniels SA, Semproni M, Ghesquiere W. 458. Diagnostic Accuracy and Management of Suspected Moderate to Severe Cellulitis Referred to an Infectious Diseases Outpatient Parenteral Antibiotic Clinic: A Prospective Cross-Sectional Study. Open Forum Infect Dis 2019. [PMCID: PMC6809660 DOI: 10.1093/ofid/ofz360.531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Moderate to severe cellulitis is a common reason for presentation to the emergency department and administration of intravenous antibiotics. Misdiagnosis of cellulitis occurs frequently as the disease can masquerade as a wide variety of noninfectious and infectious problems. There are currently no studies evaluating the impact of infectious diseases physicians on the diagnostic accuracy and management of cellulitis referred to an outpatient parenteral antibiotic clinic from the emergency department. The objective of this study was to quantify the prevalence of misdiagnosed moderate to severe cellulitis through an evaluation by an infectious diseases specialist, characterize the alternative diagnoses, and assess variables associated with misdiagnosis.
Methods
A prospective cross-sectional study of adults referred from emergency departments with presumed moderate to severe cellulitis to an outpatient parenteral antibiotic clinic staffed by infectious diseases specialists.
Results
301 consecutive patients with presumed cellulitis were evaluated over a 6-month period. A concurring diagnosis of cellulitis was found in 170 patients (56.5%), for a misdiagnosis rate of 43.5% (131/301). Table 1 summarizes the alternative diagnoses. Infectious conditions other than cellulitis were the most common (63/301; 20.9%), with abscess being present in 23 (7.6%) of patients. Fifty-two of 301 (17.3%) of the diagnoses were noninfectious and 16/301 (5.3%) patients had a dual diagnosis where minor cellulitis was present, but secondary to another, predomintating condition. The presence of stasis dermatitis (OR 6.62, P = 0.013) and a history of physical trauma (OR 1.76, P = 0.046) were associated with a misdiagnosis. 31.9% (107/335) of antibiotic regimens prescribed by emergency physicians were inappropriate or sub-optimal compared with 7.9% (22/280) of those ordered by infectious disease doctors.
Conclusion
Moderate to severe cellulitis was incorrectly diagnosed in nearly half of the patients referred for intravenous antibiotics and resulted in a high rate of unstewardly antimicrobial use. Infectious diseases physicians at an outpatient antibiotic clinic improved the diagnostic accuracy and management of this complicated condition.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
| | - Eric Partlow
- University of British Columbia, Victoria, BC, Canada
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Piszczek J, Partlow E. Stepped-wedge trial design to evaluate Ebola treatments. Lancet Infect Dis 2015; 15:762-3. [PMID: 26122441 DOI: 10.1016/s1473-3099(15)00078-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 05/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Jolanta Piszczek
- Department of Pharmacy, Island Health, 1952 Bay Street, Victoria, BC, V8R 1J8, Canada.
| | - Eric Partlow
- Department of Infectious Diseases, Island Health, Victoria, BC, Canada
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Affiliation(s)
| | - Renée St Jean
- Department of Pharmacy (Piszczek), Island Health, Victoria, BC
| | - Yasmin Khaliq
- Department of Pharmacy (Piszczek), Island Health, Victoria, BC
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10
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Piszczek J, Hutchinson J, Partlow E. Failure of combination therapy with daptomycin and synergistic ceftriaxone for enterococcal endocarditis-authors' response. J Antimicrob Chemother 2015; 70:1273-4. [PMID: 25558072 DOI: 10.1093/jac/dku514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Jolanta Piszczek
- Department of Pharmacy, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
| | - James Hutchinson
- Department of Laboratory Medicine, Medical Microbiology Division, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada Department of Pathology and Laboratory Medicine, University of British Columbia, G227-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
| | - Eric Partlow
- Department of Infectious Diseases, Island Health, 1952 Bay Street, Victoria, BC V8R 1J8, Canada
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Piszczek J, Hutchinson J, Partlow E. Failure of combination therapy with daptomycin and synergistic ceftriaxone for enterococcal endocarditis. J Antimicrob Chemother 2014; 70:623-4. [PMID: 25246438 DOI: 10.1093/jac/dku381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Jolanta Piszczek
- Department of Pharmacy, Island Health, 1952 Bay St, Victoria, BC V8R 1J8, Canada
| | - James Hutchinson
- Department of Laboratory Medicine, Medical Microbiology Division, Island Health, 1952 Bay St, Victoria, BC V8R 1J8, Canada Department of Pathology and Laboratory Medicine, University of British Columbia, G227-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada
| | - Eric Partlow
- Department of Infectious Diseases, Island Health, 1952 Bay St, Victoria, BC V8R 1J8, Canada
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Piszczek J, Mamdani M, Antoniou T, Juurlink DN, Gomes T. The impact of drug reimbursement policy on rates of testosterone replacement therapy among older men. PLoS One 2014; 9:e98003. [PMID: 25029014 PMCID: PMC4100730 DOI: 10.1371/journal.pone.0098003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 04/26/2014] [Indexed: 11/25/2022] Open
Abstract
Background Despite a lack of data describing the long-term efficacy and safety of testosterone replacement therapy (TRT), prescribing of testosterone to older men has increased with the availability of topical formulations. The magnitude of this increase and the impact of formulary restrictions on testosterone prescribing are poorly characterized. Methods We conducted a time series analysis using the linked health administrative records of men aged 66 years or older in Ontario, Canada between January 1, 1997 and March 31, 2012. We used interventional autoregressive integrated moving average models to examine the impact of a restrictive drug reimbursement policy on testosterone prescribing and examined the demographic profile of men initiating testosterone in the final 2 years of the study period. Results A total of 28,477 men were dispensed testosterone over the study period. Overall testosterone prescribing declined 27.9% in the 6 months following the implementation of the restriction policy (9.5 to 6.9 men per 1000 eligible; p<0.01). However, the overall decrease was temporary and testosterone use exceeded pre-policy levels by the end of the study period (11.0 men per 1000 eligible), largely driven by prescriptions for topical testosterone (4.8 men per 1000 eligible). Only 6.3% of men who initiated testosterone had a documented diagnosis of hypogonadism, the main criteria for TRT reimbursement according to the new policy. Conclusion Government-imposed restrictions did not influence long-term prescribing of testosterone to older men. By 2012, approximately 1 in every 90 men aged 66 or older was being treated with TRT, most with topical formulations.
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Affiliation(s)
- Jolanta Piszczek
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Center, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Tony Antoniou
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - David N. Juurlink
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Applied Health Research Center, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
- * E-mail:
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Piszczek J, Dalton B, Peters T, Ruether D, Urbanski S. Extensive necrotizing fasciitis associated with sunitinib therapy. Clin Genitourin Cancer 2014; 12:e47-9. [PMID: 24445249 DOI: 10.1016/j.clgc.2013.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 10/20/2013] [Accepted: 11/08/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Jolanta Piszczek
- University of Toronto, Leslie Dan Faculty of Pharmacy, Toronto, Canada; Vancouver Island Health Authority, Victoria, Canada.
| | - Bruce Dalton
- Pharmacy Services, Alberta Health Services, Foothills Medical Centre, Calgary, Canada
| | - Tess Peters
- Department of Dermatology, University of Calgary, Calgary, Canada
| | - Dean Ruether
- Department of Oncology, University of Calgary, Calgary, Canada
| | - Stefan Urbanski
- Department of Pathology, University of Calgary, Calgary, Canada
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Pukacki F, Oszkinis G, Piszczek J, Lyczkowski T, Podstawski W, Majewski W, Zapalski S. [Preoperative autotransfusion and hemodilution and its value in reconstructive vascular surgery]. Wiad Lek 1996; 49:26-35. [PMID: 9173652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Autotransfusion and haemodilution are the most safe and well known methods of blood protection in patients planned for vascular operations. During reconstructive vascular surgery autotransfusion with hypovolemic or normovolemic haemodilution were used. In the I group of patients hypovolemic haemodilution was done. In the II group of patients vascular bed was filed up with Ringer solution or with 6% solution of hydroxyethyl starch. The type of haemodilution and its influence on haemodynamics were estimated. Investigations were done by echocardiograph: ATL ULTRAMARK 8. It was concluded that the most effective are autotransfusion and normovolemic haemodilution with filing up vascular bed with Ringer solution.
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Affiliation(s)
- F Pukacki
- Kliniki Chirurgii Ogólnej i Naczyń, Akademii Medycznej w Poznaniu
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Szenowski H, Piszczek J, Morawiec H, Ilewicz L. [Structure-phase studies of amalgams]. Czas Stomatol 1977; 30:1025-31. [PMID: 271536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Morawiec H, Szenowski H, Piszczek J, Ilewicz L. [Structural phase analysis of plastic materials for permanent fillings]. Czas Stomatol 1977; 30:473-9. [PMID: 267535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Ilewicz L, Szenowski H, Morawiec H, Piszczek J. [Structural-phasic analysis of plastic materials for permanent filling. Base cements]. Czas Stomatol 1977; 30:377-83. [PMID: 266441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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