Related Articles

BACKGROUND:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used agents that can cause serious gastrointestinal (GI) side effects. For patients at increased risk of NSAID-related GI complications, prophylaxis with either a nonselective NSAID plus gastroprotective agent (GPA) or, alternatively, therapy with a cyclooxygenase-2 selective inhibitor with or without a GPA such as a proton pump inhibitor (PPI), is recommended.

AIM:

To describe the rate, timing and duration of GI prophylaxis in Nova Scotia seniors receiving nonselective NSAIDs.

METHODS:

The Nova Scotia Seniors’ Pharmacare Program beneficiaries for the years 1998 to 2002 were studied. A cohort of incident NSAID and GPA users was selected from all nonselective NSAID users (no prescribed NSAID dispensed 12 months before the index month and no GPA dispensed two months before the index prescription). Monthly coprescribing rates were calculated by dividing the number of patients in the cohort using GPAs by the number of NSAID users. GI prophylactic coprescribing was defined as the coprescribing rate present at the first month (index month) of prescribing an NSAID.

RESULTS:

The cohort consisted of 12,906 patients. Seventy-five per cent of the nonselective NSAID prescriptions dispensed were for up to two months duration, with only 2.3% longer than one year. GI prophylaxis was given to only 3.8% of patients starting NSAIDs who were not on a GPA in the two months before starting NSAIDs. Of this 3.8%, 92.7% of the patients received H2-receptor antagonists (H2RAs), and 7% received PPIs. The rate of H2RA coprescribing increased with the number of consecutive months on an NSAID from 3.5% in the first month to 24.1% at 48 months. For PPIs, the coprescribing rate increased from 0.3% to 1.9% of all NSAID users in the cohort. The rate of gastroprophylaxis coprescribing for patients receiving NSAIDs did not rise with increasing age.

CONCLUSION:

In Nova Scotian seniors using nonselective NSAIDs, the rate of GI prophylaxis was low. Most patients received H2RAs as GPAs despite evidence that they offer insufficient protection.

OBJECTIVE: To assess the degree to which Nova Scotia cancer patients who may need palliative care are being referred to the comprehensive Halifax-based Palliative Care Program (PCP). METHODS: The authors conducted a retrospective, population-based study using administrative health data for all adults in Nova Scotia who died of cancer from 1988 to 1994. Proportions and odds ratios (ORs) were used to determine where there were differences in age, sex, place of residence, cancer cause of death, year of death and use of palliative radiotherapy between those who were referred to the PCP at the Halifax Infirmary and those who were not, and between those who were referred late (within 14 days of death) and those who were referred earlier. RESULTS: Of the 14,494 adults who died of cancer during the study period, 2057 (14.2%) were registered in the PCP. Within Halifax County, 1582 (36.4%) of the 4340 patients with terminal cancer were seen in the PCP. Predictors of PCP registration were residence in Halifax County (OR 19.2, 95% confidence interval [CI] 15.4-23.9), younger age compared with those 85 years of age or older (for those 20-54 years of age, OR 4.9, 95% CI 3.2-7.6; 55-64 years, OR 3.4, 95% CI 2.2-5.1; 65-74 years, OR 3.1, 95% CI 2.1-4.5; 75-84 years, OR 2.1, 95% CI 1.4-3.1), and having received palliative radiation (OR 1.8, 95% CI 1.5-2.2). PCP referral was associated directly with head and neck cancer (OR 5.4, 95% CI 3.0-9.7) and inversely with hematopoietic (OR 0.2, 95% CI 0.4-0.9), lymph node (OR 0.3, 95% CI 0.1-0.4) and lung (OR 0.6, 95% CI 0.4-0.9) cancer. Predictors of late referral (being referred to the PCP within 14 days of death) were age 65-84 years (OR 1.4, 95% CI 1.1-1.8) and 85 years and over (OR 1.8, 95% CI 1.1-3.0), no palliative radiation (OR 2.0, 95% CI 1.4-3.1) and cancer cause of death. People dying within 6 months of diagnosis were somewhat less likely to have been referred to the PCP (OR 0.8, 95% CI 0.6-0.9), but those who were referred were more likely to have been referred late (OR 2.6, 95% CI 2.0-3.5). INTERPRETATION: Referral to the PCP and earlier rather than late referral were more likely for younger people with terminal cancer, those who received palliative radiation and those living closer to the PCP. Referral rates also varied by cancer cause of death and the time between diagnosis and death.

OBJECTIVES

To examine the relation between hostility and incident ischemic heart disease (IHD) and to determine whether observed hostility is superior to patient-reported hostility for the prediction of IHD in a large, prospective observational study.

BACKGROUND

Some studies have found that hostile patients have an increased risk of incident IHD. However, no studies have compared methods of hostility assessment, nor considered important psychosocial and cardiovascular risk factors as confounders. Further, it is unknown whether all expressions of hostility carry equal risk, or whether certain manifestations are more cardiotoxic.

METHODS

We assessed the independent relationship between baseline observed hostility and 10-year incident IHD in 1,749 adults of the population-based Canadian Nova Scotia Health Survey.

RESULTS

There were 149 (8.5%) incident IHD events (140 non-fatal, 9 fatal) during the 15,295 person-years of observation (9.74 events/1000 person-years). Participants with any observed hostility had a greater risk of incident IHD than those without (p=0.02); no such relation was found for patient-reported hostility. After adjusting for cardiovascular (age, sex, Framingham Risk Score) and psychosocial (depression, positive affect, patient-reported hostility, and anger) risk factors, those with any observed hostility had a significantly greater risk of incident IHD (HR 2.06, 95% CI 1.04–4.08, P=0.04).

CONCLUSIONS

The presence of any observed hostility at baseline was associated with a two-fold increased risk of incident IHD over 10 years of follow-up. Compared to patient-reported measures, observed hostility is a superior predictor of IHD.

Background:

Opioid analgesics and benzodiazepines are often misused in clinical practice. We determined whether implementation of a centralized prescription network offering real-time access to patient-level data on filled prescriptions (PharmaNet) reduced the number of potentially inappropriate prescriptions for opioids and benzodiazepines.

Methods:

We conducted a time series analysis using prescription records between Jan. 1, 1993, and Dec. 31, 1997, for residents of the province of British Columbia who were receiving social assistance or were 65 years or older. We calculated monthly percentages of filled prescriptions for an opioid or a benzodiazepine that were deemed inappropriate (those issued by a different physician and dispensed at a different pharmacy within 7 days after a filled prescription of at least 30 tablets of the same drug).

Results:

Within 6 months after implementation of PharmaNet in July 1995, we observed a relative reduction in inappropriate filled prescriptions for opioids of 32.8% (95% confidence interval [CI] 31.0%–34.7%) among patients receiving social assistance; inappropriate filled prescriptions for benzodiazepines decreased by 48.6% (95% CI 43.2%–53.1%). Similar and statistically significant reductions were observed among residents 65 years or older.

Interpretation:

The implementation of a centralized prescription network was associated with a dramatic reduction in inappropriate filled prescriptions for opioids and benzodiazepines.

Background

With the goal of preventing open neural tube defects (NTDs), recommendations for folic acid supplementation before conception were introduced in Canada in 1994, and by November 1998 Canadian grain products were being fortified with folic acid. We wished to determine whether the annual incidence of open NTDs in Nova Scotia, including those in stillbirths and terminated pregnancies, changed after the introduction of either folic acid supplementation or fortification.

Methods

For the 10-year period from Jan. 1, 1991, to Dec. 31, 2000, we retrospectively extracted the total number of births in Nova Scotia and the number of live births and stillbirths with open NTDs from the Nova Scotia Atlee Perinatal Database as well as the number of terminated pregnancies affected by NTDs from the Fetal Anomaly Database. We determined the total annual incidence of all open NTDs, and of the subgroups spina bifida and anencephaly, per 1000 births in the province during the periods before (1991–1994) and after (1995–1998) folic acid supplementation initiatives were begun but before folic acid fortification of grain products was implemented, and during the periods before (1991–1997) and after (1998–2000) fortification.

Results

In the period after supplementation initiatives were begun but before fortification was implemented, the incidence of open NTDs did not change significantly: the mean annual rate was 2.55 per 1000 births during 1991–1994 and 2.61 per 1000 births during 1995–1997 (relative risk [RR] 1.02, 95% confidence interval [CI] 0.77–1.35). After the fortification was implemented the incidence of open NTDs decreased by more than 50%: the mean annual rate was 2.58 per 1000 births during 1991–1997 and 1.17 per 1000 births during 1998–2000 (relative risk 0.46, 95% CI 0.32–0.66).

Interpretation

The recommendations for folic acid supplementation alone did not appear to succeed in reducing the incidence of open NTDs in Nova Scotia, whereas the fortification of grain products with folic acid did result in a significant reduction in the incidence.

Background

Keeping current with drug therapy information is challenging for health care practitioners. Technologies are often implemented to facilitate access to current and credible drug information sources. In the Canadian province of Nova Scotia, legislation was passed in 2002 to allow nurse practitioners (NPs) to practice collaboratively with physician partners. The purpose of this study was to determine the current utilization patterns of information technologies by these groups of practitioners.

Methods

Nurse practitioners and their collaborating physician partners in Nova Scotia were sent a survey in February 2005 to determine the frequency of use, usefulness, accessibility, credibility, and current/timeliness of personal digital assistant (PDA), computer, and print drug information resources. Two surveys were developed (one for PDA users and one for computer users) and revised based on a literature search, stakeholder consultation, and pilot-testing results. A second distribution to nonresponders occurred two weeks following the first. Data were entered and analysed with SPSS.

Results

Twenty-seven (14 NPs and 13 physicians) of 36 (75%) recipients responded. 22% (6) returned personal digital assistant (PDA) surveys. Respondents reported print, health professionals, and online/electronic resources as the most to least preferred means to access drug information, respectively. 37% and 35% of respondents reported using "both print and electronic but print more than electronic" and "print only", respectively, to search monograph-related drug information queries whereas 4% reported using "PDA only". Analysis of respondent ratings for all resources in the categories print, health professionals and other, and online/electronic resources, indicated that the Compendium of Pharmaceuticals and Specialties and pharmacists ranked highly for frequency of use, usefulness, accessibility, credibility, and current/timeliness by both groups of practitioners. Respondents' preferences and resource ratings were consistent with self-reported methods for conducting drug information queries. Few differences existed between NP and physician rankings of resources.

Conclusion

The use of computers and PDAs remains limited, which is also consistent with preferred and frequent use of print resources. Education for these practitioners regarding available electronic drug information resources may facilitate future computer and PDA use. Further research is needed to determine methods to increase computer and PDA use and whether these technologies affect prescribing and patient outcomes.

Background

People of African descent living in Britain and the United States have higher rates of morbidity from chronic disease than among the general population. We investigated whether the same applied to people of African descent living in a Canadian province.

Methods

We used administrative data to calculate 10-year cumulative incidence rate ratios for the period 1996–2005 for treated circulatory disease, diabetes mellitus and psychiatric disorders in Preston (population 2425), a community of predominantly African Nova Scotians. We used data for the province of Nova Scotia as a whole as the population reference standard. We also calculated 10-year incidence rate ratios for visits to family physicians and specialists and for admissions to hospital. We compared these findings with those in 7 predominantly white communities in Nova Scotia with otherwise similar socio-economic characteristics.

Results

In the province as a whole, we identified 787 787 incident cases for the 3 disease groups over the 10-year period. Incidence rate ratios for the community of interest relative to the provincial population were significantly elevated for the 3 diseases: circulatory disease (1.19, 95% CI 1.08–1.29), diabetes (1.43, 95% CI 1.21–1.64) and psychiatric disorders (1.13, 95% CI 1.06–1.20). Incidence rate ratios in the community of interest were also higher than those in the comparison communities. Visits to family physicians and specialists for circulatory disease and diabetes were similarly elevated, but the pattern was less clear for visits for psychiatric disorders and hospital admissions.

Interpretation

African Nova Scotians had higher morbidity levels associated with treated disease, which could not be explained by socio-economic characteristics, recent immigration or language. Apart from psychiatric disorders, use of specialist services was consistent with morbidity. Further study is needed to investigate the relative contribution of genetic, biological, behavioural, psychosocial and environmental factors.

Acetaminophen (paracetamol) plays a vital role in American health care, with in excess of 25 billion doses being used annually as a nonprescription medication. Over 200 million acetaminophen-containing prescriptions, usually in combination with an opioid, are dispensed annually. While acetaminophen is recognized as a safe and effective analgesic and antipyretic, it is also associated with significant morbidity and mortality (hepatotoxicity) if doses in excess of the therapeutic amount are ingested inappropriately. The maximum daily therapeutic dose of 3900–4000 mg was established in separate actions in 1977 and 1988, respectively, via the Food and Drug Administration (FDA) monograph process for nonprescription medications. The FDA has conducted multiple advisory committee meetings to evaluate acetaminophen and its safety profile, and has suggested (but not mandated) a reduction in the maximum daily dosage from 3900–4000 mg to 3000–3250 mg. In 2011, McNeil, the producer of the Tylenol® brand of acetaminophen, voluntarily reduced the maximum daily dose of its 500 mg tablet product to 3000 mg/day, and it has pledged to change the labeling of its 325 mg/tablet product to reflect a maximum of 3250 mg/day. Generic manufacturers have not changed their dosing regimens and they have remained consistent with the established monograph dose. Therefore, confusion will be inevitable as both consumers and health care professionals try to determine the proper therapeutic dose of acetaminophen. Which is the correct dose of acetaminophen: 3000 mg if 500 mg tablets are used, 3250 mg with 325 mg tablets, or 3900 mg when 650 mg arthritis-strength products are used?

Background

The objective of this study was to determine the rate of blood pressure control according to 4 sets of Canadian guidelines published over a decade in patients with diabetes mellitus attending Diabetes Centres in the province of Nova Scotia.

Methods

One hundred randomly selected charts from each of 13 Diabetes Centres audited between 1997 and 2001 were extracted from the Diabetes Care Program of Nova Scotia Registry. Multivariate logistic regression analyses examined the relationship between individual characteristics and self-reported antihypertensive use. Included were 1132 adults, mean age 63 years (48% male), with 9 years mean time since diagnosis of diabetes.

Results

According to the 1992 guidelines, 63% of the patients and according to the 2003 guidelines, 84% of patients were above target blood pressure or receiving antihypertensive medications. Forty-seven percent of patients are considered to be hypertensive and not on treatment according to 2003 guidelines. The results of the multivariate analyses showed that the only factors independently associated with anti-hypertensive use was oral anti-hyperglycemic use.

Conclusion

Hypertension is an additional risk factor in those with diabetes mellitus for macrovascular and microvascular complications. The health and budgetary impacts of addressing the treatment gap need to be further explored.

BACKGROUND

The optimal treatment of cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains controversial and continues to be associated with a high mortality rate. The present study evaluated the outcomes of all patients having AMI complicated by CS in a single Canadian province.

METHODS

All consecutive patients diagnosed with AMI and CS from October 1997 to December 2002 in Nova Scotia were included in the present study. The Improving Cardiac Outcomes in Nova Scotia (ICONS) registry was used as the principal source of data. The outcome of interest was in-hospital mortality.

RESULTS

During the study period, a total of 11,300 patients with AMI were identified, with 707 complicated by CS, for an incidence of AMI+CS of 6.3%. The overall mortality rate for patients with AMI+CS was 60.1%. Multivariate regression analysis identified age older than 65 years (OR 2.0; 95% CI 1.4 to 2.9) and renal insufficiency (OR 2.1; 95% CI 1.4 to 3.2) as independent predictors of mortality, while access to invasive cardiac care (defined as admission or transfer to the only cardiac catheterization-capable centre in Halifax, Nova Scotia) was found to be an independent predictor of survival (OR 0.4; 95% CI 0.3 to 0.5). Access to invasive cardiac care was limited to 414 (59%) patients, 250 (35%) of whom actually underwent cardiac catheterization.

CONCLUSIONS

Admissions to a tertiary care centre that can provide invasive care was independently associated with improved survival, and older age and renal insufficiency were associated with death among patients with AMI and CS.

BACKGROUND:

Heart failure (HF) clinics are known to improve outcomes of patients with HF. Studies have been limited to single, usually tertiary centres whose experience may not apply to the general HF population.

OBJECTIVES:

To determine the effectiveness of HF clinics in reducing death or all-cause rehospitalization in a real-world population.

METHODS:

A retrospective analysis of the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) disease registry was performed. All 8731 patients with a diagnosis of HF (844 managed in HF clinics) who were discharged from the hospital between October 15, 1997, and July 1, 2000, were identified. Patients enrolled in any one of four HF clinics (two community-based and two academic-based) were compared with those who were not. The primary outcome was the one-year combined hospitalization and mortality.

RESULTS:

Patients followed in HF clinics were younger (68 versus 75 years), more likely to be men (63% versus 48%), and had a lower ejection fraction (35% versus 44%), lower systolic blood pressure (137 mmHg verus 146 mmHg) and lower serum creatinine (121 μmol/L versus 130 μmol/L). There was no difference in the prevalence of hypertension (56%), diabetes (35%) or stroke/transient ischemic attack (16%). The one-year mortality rate was 23%, while 31% of patients were rehospitalized; the combined end point was 51%. Enrollment in an HF clinic was independently associated with reduced risk of total mortality (hazard ratio [HR] 0.69 [95% CI 0.51 to 0.90], P=0.008; number needed to treat for one year to prevent the occurrence of one event [NNT]=16), all-cause hospital readmission (HR 0.27 [95% CI 0.21 to 0.36], P<0.0001; NNT=4), and combined mortality or hospital readmission (HR 0.73 [95% CI 0.60 to 0.89], P<0.0015; NNT=5).

DISCUSSION:

HF clinics are associated with reductions in rehospitalization and mortality in an unselected HF population, independent of whether they are academic- or community-based. Such clinics should be made widely available to the HF population.

Material from a three-year Maternal Mortality Study in the Province of Nova Scotia is presented. Thirty-eight maternal deaths were studied; the chief cause was hemorrhage—either antepartum or postpartum—in 52% of all cases. Seventy-six per cent of the cases were due to practically preventable factors. Inadequate prenatal care in which the family was at fault had existed in 35% of the cases studied. Physician error in judgment and/or technique was present in 65%. Efforts to correct this situation have been described briefly. The need for public education, increased numbers of consultants, continued physician education, critical hospital analysis and improved hospital facilities is stressed.

Doctors in Nova Scotia, as in most provinces in Canada, are facing the unique problems related to the injured athlete. With the development of Sport Nova Scotia, combined with the efforts of the Canadian Academy of Sports Medicine, sports medicine is rapidly moving to a more scientific platform. The Nova Scotia Sports Medicine Clinic, we hope, will provide the area for a multidisciplined approach to problems of the athlete and will function as an educational resource for doctors and paramedical personnel throughout the province.

OBJECTIVE: To determine the prevalence of smoking during pregnancy in Nova Scotia and to identify women at high risk of smoking during pregnancy. DESIGN: Population-based descriptive study. SETTING: All hospitals providing obstetric services in Nova Scotia. PATIENTS: All 60 754 women residing in Nova Scotia who had a baby in hospital between 1988 and 1992; smoking data were available for 57,750 (95.1%) of them. OUTCOME MEASURES: Proportion of women who smoked during pregnancy and the maternal smoking rates by age, marital status, parity, attendance at prenatal classes and residence. RESULTS: Overall, 32.4% of the women smoked at some point during their pregnancy. The rate was highest among the women less than 20 years of age (47.0%) and decreased with each increasing 5-year age interval. Overall, the unmarried women were 2.1 times as likely to smoke as the married women. The smoking rates were highest among the women who were para 3 or greater regardless of age (women less than 20 were excluded here, since very few had such a parity). Of the nulliparous women, those who attended prenatal classes were less likely to smoke during pregnancy than those who did not attend. There was no relation between urban or rural residence and smoking rates. The smoking rates decreased little between 1988 and 1992 and in fact increased among the women 35 and over and among those who were para 3 or greater. CONCLUSIONS: The smoking rates among pregnant women in Nova Scotia changed little between 1988 and 1992. Therefore, it seems that current strategies for smoking cessation have not been successful. Since prenatal classes are more likely to attract nonsmokers than smokers, other avenues for education and cessation are necessary.

Twenty-four Ixodes dammini ticks (23 adults and one nymph) have been recovered in Nova Scotia since 1984. There has not been a systematic search for larvae and none has been identified. The recovery of the nymph from a road-killed yellow throat bird, Geothypis trichas, in late May 1990 supports the contention that migrating birds are bringing deer ticks into the province every spring. In March and April 1991, four adult deer ticks were identified, suggesting that these ticks had overwintered. These deer tick specimens indicate that it is possible that I dammini is becoming established in Nova Scotia, if it is not already established. There has been no evidence for the existence of Borrelia burgdorferi in the province. The spirochete was not cultured from 650 Dermacentor variabilis ticks, nor were antibodies detected in a small sample of feral rodents using an indirect fluorescent antibody test. A survey of 137 dog sera samples, analyzed by enzyme-linked immunosorbent assay, also proved negative. There has been no confirmed indigenous case of Lyme disease in Nova Scotia to date.

Background

Breast reconstruction after mastectomy is associated with social, psychological and physical benefits. Barriers to breast reconstruction in the United States include age, stage of disease, socioeconomic status and geographic location; however, little is known about the effects of these factors in the Canadian context of a universal health care system. We sought to determine the rate of breast reconstruction in Nova Scotia, identify characteristics influencing access to the procedure and describe the rates of different reconstructive options.

Methods

We conducted a retrospective cohort study involving all women in Nova Scotia who received diagnoses of breast cancer and had mastectomies between 1991 and 2001. We linked data from 2 administrative databases and performed analyses for each year in the study period. We followed the women until the end of the study period (2001). We used logistic regression to evaluate potential barriers to reconstruction.

Results

A total of 3717 women had mastectomies during the 10-year study period; of these women, 142 (3.8%) had breast reconstruction. The reconstruction rate increased to more than 5% in 3 of the last 4 years. Factors affecting the rate of breast reconstruction included patient age, stage of disease and year of mastectomy. Household income did not significantly affect the likelihood of women seeking breast reconstruction.

Conclusion

The rate of breast reconstruction in Nova Scotia (3.8%) is considerably lower than rates reported in the United States (8%–45%). The fact that household income did not influence the breast reconstruction rate may reflect the universal nature of Canada's public health care system.

OBJECTIVE:

Respiratory syncytial virus (RSV) is the most common cause of severe lower respiratory tract infection in young children and is increasingly recognized as a cause of influenza-like illness in those older than 65 years of age. A surveillance system to provide timely local information about RSV activity in Nova Scotia (NS) is described.

METHODS:

A case report form was developed for weekly reporting of all laboratory isolates of RSV at diagnostic laboratories around the province. Laboratories were asked to send the forms by fax each Friday to the Nova Scotia Department of Health Promotion and Protection. Data were entered in Excel (Microsoft, USA) and aggregate results summarized by age, sex, health district and date of laboratory confirmation for 2005 to 2008.

RESULTS:

During three winter seasons (2005–2006, 2006–2007 and 2007–2008), there were 207, 350 and 186 isolates of RSV reported in NS, respectively. The average incidences of RSV in NS varied greatly by age, with the highest rates in infants younger than 24 months of age, and approaching 4000 cases per 100,000 population in infants up to five months of age. The duration of the RSV outbreak was approximately five to six months each year, but the month of onset varied.

CONCLUSIONS:

A RSV surveillance system was successfully established in NS that provides weekly data to the public health system, clinicians and infection control practitioners. The time of onset and severity of the RSV season varied over time. These data can be used to plan anti-RSV passive prophylaxis programs and infection control education, and distinguish RSV outbreaks from other viruses in acute care and long-term care settings.

Objectives

This paper describes characteristics of opioid use episodes for non-cancer pain and defines thresholds for the transition into Defacto Long-term Opioid Therapy.

Methods

CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of two health plans serving over one-percent of the U.S. population. Opioid use episodes beginning in 1997–2005 were classified as Acute, Episodic, Long-term/Lower Dose, or Long-term/Higher Dose.

Results

Defacto Long-term Opioid Therapy was defined by opioid use episodes lasting longer than 90 days with at least 10 prescriptions and/or at least 120 days supply dispensed. Long-term/Higher Dose episodes (<1.5% of all episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 milligrams. They accounted for more than half the total morphine equivalents dispensed from 1997–2006. Short-acting, less potent opioids (e.g. hydrocodone with acetaminophen) were by far the most commonly prescribed medications for acute, episodic and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6–12%).

Discussion

Defacto Long-term Opioid Therapy was characterized by considerable diversity in medications, dosage, and frequency of use. Long-term opioid therapy may evolve from acute or episodic use in the absence of an agreed upon treatment plan. Defined thresholds for Defacto Long-term Opioid Therapy provide a possible check point for physicians and health plans to ensure that patients receiving opioid medications long-term are managed according to a treatment plan that is documented and monitored.

Paracetamol is the commonest agent employed in self poisoning, however it is not clear whether adolescents possess insight into the serious complications associated with its misuse. Using a one page questionnaire, the availability, usage, and knowledge of toxicity of paracetamol among 1147 American and British adolescents was assessed. Although 90% of all students recognised that paracetamol could kill, the great majority of students overestimated the lethal dose. In addition, while knowledge regarding side effects of paracetamol was poor the drug was widely available to, and used by, the study population. It is proposed that gross overestimation of the number of tablets required to kill, poor understanding of paracetamol side effects, and wide availability of the drug contribute to its frequent use in adolescent suicidal behaviour. The inclusion of some over-the-counter medications in school drug education programs in addition to tighter control of the availability of paracetamol may help reduce the problem of adolescent self poisoning.

Healthy public policy plays a central role in creating environments that are supportive of health. Breastfeeding, widely supported as the optimal mode for infant feeding, is a critical factor in promoting infant health. In 2005, the Canadian province of Nova Scotia introduced a provincial breastfeeding policy. This paper describes the process and outcomes of an evaluation into the implementation of the policy. This evaluation comprised focus groups held with members of provincial and district level breastfeeding committees who were tasked with promoting, protecting and supporting breastfeeding in their districts. Five key themes were identified, which were an unsupportive culture of breastfeeding; the need for strong leadership; the challenges in engaging physicians in dialogue around breastfeeding; lack of understanding around the International Code of Marketing of Breast-milk Substitutes; and breastfeeding as a way to address childhood obesity. Recommendations for other jurisdictions include the need for a policy, the value of leadership, the need to integrate policy with other initiatives across sectors and the importance of coordination and support at multiple levels. Finally, promotion of breastfeeding offers a population-based strategy for addressing the childhood obesity epidemic and should form a core component of any broader strategies or policies for childhood obesity prevention.

The Medical Society of Nova Scotia and the provincial government hope to solve the physician shortage in rural parts of the province with a recruiting effort that includes monetary incentives to fill some positions. A new locum service is designed to improve physician retention by making it easier to take vacations and pursue education programs.

Images

A novel formulary has been developed in Nova Scotia with the objective of providing quality treatment with needed medications at affordable cost. Creation of the formulary has involved collaboration among health care professionals, seniors, the Department of Health and pharmaceutical companies. This is the first Canadian formulary to use the Anatomic, Therapeutic, Chemical system. Drug listing is comprehensive rather than exclusive. Colour-coded recommendations on use assist physicians with drug choice. Relative costs are indicated within each therapeutic grouping. Listings indicate drugs approved for reimbursement, interchangeable medications, maximum allowable cost, drug identification number and manufacturer code. Treatment summaries provide brief overviews of therapeutic advice. Updates on new products and new or modified treatment summaries are provided every 6 months. The formulary will be the focus of coordinated educational activities on treatment for seniors and health care professionals.

We examined the association between blood pressure (BP) reactivity to an anger provocation interview and 10-year incident CVD events in 1,470 adults from the population-based 1995 Nova Scotia Health Survey (NSHS95). In an unadjusted model, those in the highest decile of systolic BP reactivity were more than twice as likely to have an incident CVD event compared to those in the decile with no reactivity (HR = 2.33, 95% CI = 1.15 – 4.69, P = 0.02). However, after adjusting for age and sex, and then also for Framingham risk score, body mass index, and education, this relationship was attenuated and not statistically significant. Diastolic BP reactivity was not associated with CVD incidence in any model. Individual differences in BP reactivity to a laboratory-induced, structured anger provocation interview may not play a major role in clinical CVD endpoints.

Aseptic meningitis (AM) is a disease that causes grave clinical signs such as intensive neck pain, fever, and lethargy. The severity of this disease is reflected in the fact that affected animals require long-term, and in chronic cases, lifelong therapy with corticosteroids. A number of dogs must be euthanized because of therapeutic failure. In recent years, the Norwegian population of Nova Scotia duck tolling retrievers has experienced an increase in individuals with AM. The aim of the present study was to investigate the prevalence of AM and to pursue the suspicion of hereditary factors influencing an accumulation of AM cases in the breed. Using the Norwegian Kennel Club registery, a random sample (362 dogs) stratified by year of birth was drawn from the total population born from 1994 to 2003 (1525 individuals). The owners were contacted and questioned about clinical signs of AM in their dogs. Subsequently, the practising veterinarians and the breeders of positive responders were contacted in order to confirm a clinical diagnosis of AM and to identify possible affected family members. Pedigrees of AM positive individuals and affected relatives were investigated. The study estimated a prevalence of AM of 2.5%. For all affected dogs, it was possible to trace the pedigree of both parents of affected dogs back to a specific founder dog. The genealogical investigation strongly indicates that genetic factors are involved in the etiology of the disease.

Background

The healthcare expenditure on self-monitoring of blood glucose (SMBG) test strips under the Nova Scotia Seniors' Pharmacare Program (NSSPP) has increased significantly in recent years. The objective of this study was to identify the frequency and cost of claims for blood glucose monitoring test strips by NSSPP beneficiaries in the fiscal year 2005/06 and to explore the variation in the use of test strips by type of treatment, age and sex.

Methods

Retrospective analysis was conducted using pharmacy administrative claims data for NSSPP beneficiaries. Study subjects were aged ≥ 65 years on October 1, 2004, received SMBG test strips in the 110 days prior to April 1, 2005, and were alive throughout the twelve month study period. Subjects were categorized into four groups: insulin only, oral antihyperglycemic agents (OAA) only, both OAA and insulin; and no reimbursed diabetes medications. Statistical analysis was performed to identify differences in expenditure by medication group and in frequency of SMBG test strips claimed by medication group, age, and sex.

Results

Of 13,564 included beneficiaries, 13.2% were categorized as insulin only, 53.5% OAA only, 7.2% both OAA and insulin, and 26.0% no reimbursed diabetes medications. Over half (58.7%) were femle. The insulin only category had the highest mean (± SD) number of SMBG test strips claimed per day (2.0 ± 1.5) with a mean annual total cost of $615 ± $441/beneficiary. Beneficiaries aged 80 years and above claimed fewer test strips than beneficiaries below 80 years.

Conclusion

This population based study shows that in Nova Scotia the SMBG test strips claimed by the majority of seniors were within Canadian guidelines. However, a small proportion of beneficiaries claimed for SMBG test strips infrequently or too frequently, which suggests areas for improvement. The provincial drug plan covers the majority of the costs of test strip utilization, suggesting that the majority of test strips claimed did not exceed the maximum allowable cost (MAC) established in the program's MAC policy. Drug insurance programs need to work with healthcare providers to determine if patients are using test strips optimally; and to determine their impact on patient outcomes. In addition, they need to determine the cost-effectiveness of their SMBG test strip reimbursement policies.