Download the Free Unbound MEDLINE PubMed App to your smartphone or tablet.
Available for iPhone, iPad, iPod touch, and Android.
- Use of Opioids and Other Analgesics by Older Adults in the United States, 1999-2010. [JOURNAL ARTICLE]
- Pain Med 2014 Oct 28.
There has been concern over rising use of prescription opioids in young and middle-aged adults. Much less is known about opioid prescribing in older adults, for whom clinical recommendations and the balance of risks and benefits differ from younger adults. We evaluated changes in use of opioids and other analgesics in a national sample of clinic visits made by older adults between 1999 and 2010.Observational study of adults aged 65 and older from the 1999-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, serial cross-sectional surveys of outpatient visits in the United States.Medication use was assessed at each study visit and included medications in use prior to the visit and medications newly prescribed at the visit. Results were adjusted for survey weights and design factors to provide nationally representative estimates.Mean age was 75 ± 7 years, and 45% of visits occurred in primary care settings. Between 1999-2000 and 2009-2010, the percent of clinic visits at which an opioid was used rose from 4.1% to 9.0% (P < 0.001). Although use of all major opioid classes increased, the largest contributor to increased use was hydrocodone-containing combination opioids, which rose from 1.1% to 3.5% of visits over the study period (P < 0.001). Growth in opioid use was observed across a wide range of patient and clinic characteristics, including in visits for musculoskeletal problems (10.7% of visits in 1999-2000 to 17.0% in 2009-2010, P < 0.001) and in visits for other reasons (2.8% to 7.3%, P < 0.001).Opioid use by older adults visiting clinics more than doubled between 1999 and 2010, and occurred across a wide range of patient characteristics and clinic settings.
- Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. [JOURNAL ARTICLE]
- Ann Rheum Dis 2014 Oct 28.
We aimed to quantify the risk of major adverse cardiovascular events (MACE) among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA) and psoriasis without known PsA compared with the general population after adjusting for traditional cardiovascular risk factors.A population-based longitudinal cohort study from 1994 to 2010 was performed in The Health Improvement Network (THIN), a primary care medical record database in the UK. Patients aged 18-89 years of age with PsA, RA or psoriasis were included. Up to 10 unexposed controls matched on practice and index date were selected for each patient with PsA. Outcomes included cardiovascular death, myocardial infarction, cerebrovascular accidents and the composite outcome (MACE). Cox proportional hazards models were used to calculate the HRs for each outcome adjusted for traditional risk factors. A priori, we hypothesised an interaction between disease status and disease-modifying antirheumatic drug (DMARD) use.Patients with PsA (N=8706), RA (N=41 752), psoriasis (N=138 424) and unexposed controls (N=81 573) were identified. After adjustment for traditional risk factors, the risk of MACE was higher in patients with PsA not prescribed a DMARD (HR 1.24, 95% CI 1.03 to 1.49), patients with RA (No DMARD: HR 1.39, 95% CI 1.28 to 1.50, DMARD: HR 1.58, 95% CI 1.46 to 1.70), patients with psoriasis not prescribed a DMARD (HR 1.08, 95% CI 1.02 to 1.15) and patients with severe psoriasis (DMARD users: HR 1.42, 95% CI 1.17 to 1.73).Cardiovascular risk should be addressed with all patients affected by psoriasis, PsA or RA.
- Characterization of the Medical Subject Headings thesaurus for pharmacy. [Journal Article]
- Am J Health Syst Pharm 2014 Nov 15; 71(22):1965-72.
The completeness and utility of pharmacy-oriented Medical Subject Headings (MeSH) relative to MeSH terminology pertaining to other healthcare professions (dentistry and nursing) are evaluated.The 2013 version of the MeSH thesaurus-the standard vocabulary used by the National Library of Medicine (NLM) to index articles in PubMed and MEDLINE-was searched for dentistry-, nursing-, and pharmacy-specific terms using a truncation strategy (search terms: nurs*, dent*, and pharm*); the hierarchical level of each term and the number of descendant terms (an indication of the granularity of the associated NLM-indexed content) were determined. PubMed searches were conducted to identify areas of the MeSH hierarchy containing dentistry- and nursing-specific terms but no equivalent pharmacy-specific term.The search of the MeSH thesaurus identified 145 terms representing dentistry-specific activities and 94 and 26 terms specific to nursing and pharmacy practice, respectively. Analysis of the three sets of MeSH terms indicated that dentistry-oriented MeSH terms were generally situated more prominently within the MeSH hierarchy than terms for nursing- and pharmacy-oriented research; the MeSH terminology oriented toward nursing or dentistry practice was relatively more granular, allowing for increased specificity and power of information retrieval during PubMed and MEDLINE searches. Seventeen proposed new MeSH terms describing key areas of pharmacy practice were identified; the inclusion of these terms in the MeSH hierarchy could substantially expand and improve the retrievability of NLM-indexed literature.Imbalances and gaps were found in MeSH coverage of pharmacy concepts and terminology relative to MeSH terminology specific to the nursing and dentistry professions.
- Analysis of case-cohort designs with binary outcomes: Improving efficiency using whole-cohort auxiliary information. [JOURNAL ARTICLE]
- Stat Methods Med Res 2014 Oct 26.
The case-cohort design has been widely adopted for reducing the cost of covariate measurements in large prospective cohort studies. Under the case-cohort design, complete covariate data are collected only on randomly sampled cases and a subcohort randomly selected from the whole cohort. For the analysis of case-cohort studies with binary outcomes, logistic regression analysis has been routinely used. However, in many applications, certain covariates are readily measured on all samples from the whole cohort, and the case-cohort design may be regarded as a two-phase sampling design. Using this auxiliary covariate information, estimators for the regression parameters can be substantially improved. In this article, we discuss the theoretical basis of the case-cohort design derived from the formulation of the two-phase design and the improved estimators using whole-cohort auxiliary variable information. In particular, we show that the sampling scheme of the case-cohort design is substantially equivalent to that of conventional two-phase case-control studies (also known as two-stage case-control studies for epidemiologists), i.e., the methodologies of two-phase case-control studies can be directly applied to case-cohort data. Under this framework, we review and apply the following improved estimators to the case-cohort design with binary outcomes: (i) weighted estimators, (ii) a semiparametric maximum likelihood estimator, and (iii) a multiple imputation estimator. In addition, based on the framework of the two-phase design, we can obtain risk ratio and risk difference estimators without the rare-disease assumption. We illustrate these methodologies via simulations and the National Wilms Tumor Study data.
- Initial Choice of Oral Glucose-Lowering Medication for Diabetes Mellitus: A Patient-Centered Comparative Effectiveness Study. [JOURNAL ARTICLE]
- JAMA Intern Med 2014 Oct 27.
Although many classes of oral glucose-lowering medications have been approved for use, little comparative effectiveness evidence exists to guide initial selection of therapy for diabetes mellitus.To determine the effect of initial oral glucose-lowering agent class on subsequent need for treatment intensification and 4 short-term adverse clinical events.This study was a retrospective cohort study of patients who were fully insured members of Aetna (a large national health insurer) who had been prescribed an oral glucose-lowering medication from July 1, 2009, through June 30, 2013. Individuals newly prescribed an oral glucose-lowering agent who filled a second prescription for a medication in the same class and with a dosage at or above the World Health Organization's defined daily dose within 90 days of the end-of-day's supply of the first prescription were studied. Individuals with interim prescriptions for other oral glucose-lowering medications were excluded.Initiation of treatment with metformin, a sulfonylurea, a thiazolidinedione, or a dipeptidyl peptidase 4 inhibitor.Time to addition of a second oral agent or insulin, each component separately, hypoglycemia, other diabetes-related emergency department visits, and cardiovascular events.A total of 15 516 patients met the inclusion criteria, of whom 8964 (57.8%) started therapy with metformin. In unadjusted analyses, use of medications other than metformin was significantly associated with an increased risk of adding a second oral agent only, insulin only, and a second agent or insulin (P < .001 for all). In propensity score and multivariable-adjusted Cox proportional hazards models, initiation of therapy with sulfonylureas (hazard ratio [HR], 1.68; 95% CI, 1.57-1.79), thiazolidinediones (HR, 1.61; 95% CI, 1.43-1.80), and dipeptidyl peptidase 4 inhibitors (HR, 1.62; 95% CI, 1.47-1.79) was associated with an increased hazard of intensification. Alternatives to metformin were not associated with a reduced risk of hypoglycemia, emergency department visits, or cardiovascular events.Despite guidelines, only 57.8% of individuals began diabetes treatment with metformin. Beginning treatment with metformin was associated with reduced subsequent treatment intensification, without differences in rates of hypoglycemia or other adverse clinical events. These findings have significant implications for quality of life and medication costs.
- Post-Market Drug Evaluation Research Training Capacity in Canada: An Environmental Scan of Canadian Educational Institutions. [JOURNAL ARTICLE]
- J Popul Ther Clin Pharmacol 2014; 21(3):e370-e378.
Background Ongoing efforts by Health Canada intended to modernize the legislation and regulation of pharmaceuticals will help improve the safety and effectiveness of drug products. It will be imperative to ensure that comprehensive and specialized training sites are available to train researchers to support the regulation of therapeutic products. ObjectivesThe objective of this educational institution inventory was to conduct an environmental scan of educational institutions in Canada able to train students in areas of post-market drug evaluation research. MethodsA systematic web-based environmental scan of Canadian institutions was conducted. The website of each university was examined for potential academic programs. Six core programmatic areas were determined a priori as necessary to train competent post-market drug evaluation researchers. These included biostatistics, epidemiology, pharmacoepidemiology, health economics or pharmacoeconomics, pharmacogenetics or pharmacogenomics and patient safety/pharmacovigilance. Results Twenty-three academic institutions were identified that had the potential to train students in post-market drug evaluation research. Overall, 23 institutions taught courses in epidemiology, 22 in biostatistics, 17 in health economics/pharmacoeconomics, 5 in pharmacoepidemiology, 5 in pharmacogenetics/pharmacogenomics, and 3 in patient safety/pharmacovigilance. Of the 23 institutions, only the University of Ottawa offered six core courses. Two institutions offered five, seven offered four and the remaining 14 offered three or fewer. It is clear that some institutions may offer programs not entirely reflected in the nomenclature used for this review. Conclusions As Heath Canada moves towards a more progressive licensing framework, augmented training to increase research capacity and expertise in drug safety and effectiveness is timely and necessary.
- Adolescents' inhaled corticosteroid adherence: the importance of treatment perceptions and medication knowledge. [JOURNAL ARTICLE]
- J Asthma 2014 Oct 23.:1-22.
Abstract Studies measuring inhaled corticosteroid (ICS) adherence frequently report adherence rates below 50%. Although asthma is common in adolescents, few studies have explored determinants of ICS adherence in adolescents. The objective of this study was to examine adherence and related factors in adolescent inhaled corticosteroid (ICS) users. Adolescent ICS users, aged 12 - 18 years, were randomly recruited from a sample of 94 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research to complete an online questionnaire. The survey contained questions on asthma control, self-reported adherence, medication beliefs and medication knowledge. Data were collected between April and August 2013. Complete questionnaire data were received from 182 adolescents of which 40% reported to be adherent. Approximately 40% of the participants perceived strong needs, whilst only 10% was highly concerned about adverse effects regarding their ICS use. Good adherence was significantly associated with asthma control (OR: 2.1, 95% CI: 1.1 - 4.1). Necessity beliefs and sufficient medication knowledge were associated with better adherence (p < 0.05). Our results suggest that by improving knowledge about asthma treatments and stimulating positive perceptions towards medicines, especially regarding the necessity of medication use, better adherence rates might be achieved.
- Drug utilization in patients with OA: a population-based study. [JOURNAL ARTICLE]
- Rheumatology (Oxford) 2014 Oct 21.
Patients with OA use different drugs in their search for relief. We aimed to study the prevalence of use and combinations of different medications for OA in a population-based cohort of OA patients in Catalonia, Spain, while characterizing users of each of the drugs available, with a particular focus on cardiovascular risk factors.Data were obtained from the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària (SIDIAP) database, which includes electronic medical records and pharmacy invoice data for >5 million people from Catalonia. Study participants were those with a clinical diagnosis of OA in 2006-10. Drugs studied included oral and topical NSAIDs, analgesics (paracetamol, metamizole), opioids (tramadol, fentanyl), cyclooxygenase 2 (COX-2) inhibitors and symptomatic slow-acting drugs in OA. Drug utilization was described using medication possession ratios (MPRs), equivalent to the proportion of days covered with the drug of interest. The annual incidence of new users in the first year after OA diagnosis from 2006 to 2010 was estimated for all studied drugs among newly diagnosed OA patients using Poisson regression.We identified 238 536 study participants. The most common regimen of treatment consisted of at least three drugs (53.9% of patients). The drugs most frequently used regularly (MPR ≥50%) were chondroitin (21.2%), glucosamine (15.8%) and oral NSAIDs (14.4%). The incidence of the use of opioids, COX-2 inhibitors and chondroitin increased over the 5 year period, whereas all others decreased.Drug combinations are common in the treatment of OA patients, who are thus exposed to potential drug interactions, with unknown impacts on their health. The increasing use of opioids and COX-2 inhibitors is noteworthy because of the potential impact on safety and costs.
- Ensuring patient privacy in data sharing for postapproval research. [Journal Article]
- N Engl J Med 2014 Oct 23; 371(17):1644-9.
- Package leaflets of the most consumed medicines in Portugal: safety and regulatory compliance issues. A descriptive study. [JOURNAL ARTICLE]
- Sao Paulo Med J 2014 Oct 17.:0.
Package leaflets are necessary for safe use of medicines. The aims of the present study were: 1) to assess the compliance between the content of the package leaflets and the specifications of the pharmaceutical regulations; and 2) to identify potential safety issues for patients.Qualitative descriptive study, involving all the package leaflets of branded medicines from the three most consumed therapeutic groups in Portugal, analyzed in the Department of Pharmacoepidemiology, School of Pharmacy, University of Lisbon.A checklist validated through an expert consensus process was used to gather the data. The content of each package leaflet in the sample was classified as compliant or non-compliant with compulsory regulatory issues (i.e. stated dosage and descriptions of adverse reactions) and optional regulatory issues (i.e. adverse reaction frequency, symptoms and procedures in cases of overdose).A total of 651 package leaflets were identified. Overall, the package leaflets were found to be compliant with the compulsory regulatory issues. However, the optional regulatory issues were only addressed in around half of the sample of package leaflets, which made it possible to identify some situations of potentially compromised drug safety.Ideally, the methodologies for package leaflet approval should be reviewed and optimized as a way of ensuring the inclusion of the minimum essential information for safe use of medicines.