To provide an overview of medication adherence, discuss the potential for smartphone medication adherence applications (adherence apps) to improve medication nonadherence, evaluate features of adherence apps across operating systems (OSs), and identify future opportunities and barriers facing adherence apps.
Medication nonadherence is a common, complex, and costly problem that contributes to poor treatment outcomes and consumes health care resources. Nonadherence is difficult to measure precisely, and interventions to mitigate it have been largely unsuccessful.
Using smartphone adherence apps represents a novel approach to improving adherence. This readily available technology offers many features that can be designed to help patients and health care providers improve medication-taking behavior.
Main outcome measures
Currently available apps were identified from the three main smartphone OSs (Apple, Android, and Blackberry). In addition, desirable features for adherence apps were identified and ranked by perceived importance to user desirability using a three-point rating system: 1, modest; 2, moderate; or 3, high. The 10 highest-rated apps were installed and subjected to user testing to assess app attributes using a standard medication regimen.
160 adherence apps were identified and ranked. These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.
Despite being untested, medication apps represent a possible strategy that pharmacists can recommend to nonadherent patients and incorporate into their practice.
Smartphones; nonadherence; applications
We evaluated the association of microvascular invasion (MVI) and capillary-lymphatic invasion (CLI) with patient outcome following nephrectomy for renal cell carcinoma (RCC).
Material and Methods
We identified 1,433 patients surgically treated for sporadic, unilateral RCC between 2001 and 2008. All specimens were reviewed by a single uropathologist for MVI and CLI. Associations with time to metastases and death from RCC were evaluated using Cox proportional hazards models, controlling for established clinicopathologic prognostic variables.
MVI and CLI were identified in 11% (119/1,103) and 2% (17/1,103) with clear cell, 2% (5/219) and <1% (1/219) with papillary, and 1% (1/86) and 0 with chromophobe RCC, respectively. Median follow-up for patients still alive was 6.4 years (range 0-11). In clear cell RCC, MVI was univariately associated with an increased risk of metastases (HR 3.5,p<0.001) and cancer-specific death (HR 3.0,p<0.001). However, on multivariate analyses, these associations were no longer statistically significant (HR 1.2,p=0.4 and HR 1.3,p=0.1, respectively). CLI remained significantly associated with an increased risk of metastases and death both univariately (HR 15.9,p<0.001 and HR 11.6,p<0.001, respectively) and on multivariate analyses (HR 3.2,p<0.001 and HR 3.1,p<0.001, respectively).
MVI is associated with an increased risk of metastases and cancer death for patients with clear cell RCC, although this does not remain significant after controlling for established prognostic variables. Meanwhile, CLI appears to be independently associated with metastases and cancer death even after controlling for known prognostic risk factors; however, given its rarity, this feature may prove to be of limited clinical significance.
Renal cell carcinoma; microvessels
The rotary motor F1-ATPase from the thermophilic Bacillus PS3 (TF1) is one of the best-studied of all molecular machines. F1-ATPase is the part of the enzyme F1FO-ATP synthase that is responsible for generating most of the ATP in living cells. Single-molecule experiments have provided a detailed understanding of how ATP hydrolysis and synthesis are coupled to internal rotation within the motor. In this work, we present evidence that mesophilic F1-ATPase from Escherichia coli (EF1) is governed by the same mechanism as TF1 under laboratory conditions. Using optical microscopy to measure rotation of a variety of marker particles attached to the γ-subunit of single surface-bound EF1 molecules, we characterized the ATP-binding, catalytic and inhibited states of EF1. We also show that the ATP-binding and catalytic states are separated by 35±3°. At room temperature, chemical processes occur faster in EF1 than in TF1, and we present a methodology to compensate for artefacts that occur when the enzymatic rates are comparable to the experimental temporal resolution. Furthermore, we show that the molecule-to-molecule variation observed at high ATP concentration in our single-molecule assays can be accounted for by variation in the orientation of the rotating markers.
F1-ATPase; single molecule; molecular motors
Stress Urinary Incontinence (SUI) affects women both acutely and chronically after vaginal delivery. Current SUI treatments assume the neuromuscular continence mechanism, comprised of the pudendal nerve (PN) and external urethral sphincter (EUS), is either intact or irreparable. This study investigated the ability of neurotrophin therapy to facilitate recovery of the neuromuscular continence mechanism.
Virgin, Sprague Dawley rats received simulated childbirth injury or sham injury and treatment with continuous infusion of brain derived neurotrophic factor (BDNF) or saline placebo to the site of PN injury. Continence was assessed by leak point pressure (LPP) and EUS electromyography (EMG) 14 and 21 days after injury. Structural recovery was assessed histologically. Molecular assessment of the muscular and neuroregenerative response was determined via measurement of EUS BDNF and PN βII-tubulin expression respectively, 4, 8, and 12 days after injury.
Following injury, LPP was significantly reduced with saline compared to either BDNF treatment or sham injury. Similarly, compared to sham injury, resting EUS EMG amplitude and firing rate, as well as amplitude during LPP were significantly reduced with saline but not BDNF treatment. Histology confirmed improved EUS recovery with BDNF treatment. EUS BDNF and PN βII-tubulin expression demonstrated that BDNF treatment improved the neurogenerative response and may facilitate sphincteric recovery.
Continuous targeted neurotrophin therapy accelerates continence recovery after simulated childbirth injury likely through stimulating neuroregeneration and facilitating EUS recovery and re-innervation. Neurotrophins or other therapies targeting neuromuscular regeneration may be useful for treating SUI related to failure of the neuromuscular continence mechanism.
Urinary Incontinence; Stress; Vaginal Delivery; Childbirth Injury; Pudendal Nerve; Neurotrophin
To evaluate the impact of histology on cancer-specific and overall survival for patients with metastatic renal cell carcinoma (mRCC) undergoing cytoreductive nephrectomy (CN).
Materials and Methods:
We retrospectively reviewed the data of 505 patients with mRCC who underwent CN at Mayo Clinic, Rochester, MN, USA, between 1970 and 2008. All specimen were re-reviewed by a single genitourinary pathologist. Survival was estimated using the Kaplan–Meier method and compared according to histology with the log-rank test. Cox proportional hazard regression models were used to evaluate the association of histology with outcome.
Forty (8%) patients with non-clear cell histology and 465 (92%) patients with clear cell histology were identified. The median follow-up was 7.8 years. Metastatic non-clear cell histology was associated with a significantly older median age at nephrectomy (66 vs. 60 years; P = 0.002), larger median tumor size (11.5 vs. 9.2 cm; P = 0.02), and higher rate of lymph node involvement (50% vs. 16%; P < 0.001). No significant difference in 3-year cancer-specific survival (25% vs. 22%; P = 0.50) was noted between patients with clear cell and non-clear cell histology. On multivariate analysis, non-clear cell histology was not significantly associated with patients’ risk of death from cancer (HR 0.96; 95% CI 0.61, 1.51; P = 0.85).
Non-clear cell histology was not independently associated with adverse survival for patients with mRCC undergoing CN. As such, we advocate that surgical resection should continue to be considered in the multimodal treatment approach to these patients, while additional efforts to risk stratify and optimize management in this setting remain necessary.
Histology; kidney cancer; metastasis; nephrectomy; renal cell carcinoma
Clinicians, providers and guideline panels use absolute effects to weigh the advantages and downsides of treatment alternatives. Relative measures have the potential to mislead readers. However, little is known about the reporting of absolute measures in systematic reviews. The objectives of our study are to determine the proportion of systematic reviews that report absolute measures of effect for the most important outcomes, and ascertain how they are analyzed, reported and interpreted.
We will conduct a methodological survey of systematic reviews published in 2010. We will conduct a 1:1 stratified random sampling of Cochrane vs. non-Cochrane systematic reviews. We will calculate the proportion of systematic reviews reporting at least one absolute estimate of effect for the most patient-important outcome for the comparison of interest. We will conduct multivariable logistic regression analyses with the reporting of an absolute estimate of effect as the dependent variable and pre-specified study characteristics as the independent variables. For systematic reviews reporting an absolute estimate of effect, we will document the methods used for the analysis, reporting and interpretation of the absolute estimate.
Our methodological survey will inform current practices regarding reporting of absolute estimates in systematic reviews. Our findings may influence recommendations on reporting, conduct and interpretation of absolute estimates. Our results are likely to be of interest to systematic review authors, funding agencies, clinicians, guideline developers and journal editors.
Systematic reviews; Meta-analysis; Statistical data; Evidence-based medicine; Numbers needed to treat; Data reporting; Absolute effect measures
The residence time of hyaluronan (HA) in the synovial fluid (SF) of knee joints was investigated using the rabbit anterior cruciate ligament transection (ACLT) model. The aims were to assess at 7 and 28 days after surgery for non-operated (NonOp), ACLT, and SHAM groups: 1) HA molecular mass (Mr) distribution in SF, 2) endogenous replenishment of HA after saline washout, 3) HA residence times in SF, and 4) synovium and subsynovium cellularity.
Adult NZW rabbits underwent ACLT or SHAM surgeries on one hind limb, while each contralateral limb was a NonOp control. At 7 or 28d after surgery, joints were aspirated for SF, lavaged with saline, injected with saline or polydisperse HA, and sampled over 8hrs. Fluid samples were analyzed for HA concentration and Mr distribution to calculate HA residence times.
HA Mr-distributions showed 1) loss of high-Mr HA at day 7, and a shift towards a lower-Mr HA distribution at day 28, 2) endogenous replenishment of high-Mr HA after washout, and 3) Mr-dependent HA loss, particularly at day 7 after ACLT. The residence time of HA decreased with Mr (~27hrs for 7000–2500kDa to ~7hrs for 250–50kDa) and at day 7 after ACLT (~70% decrease). The subsynovium of ACLT joints contained 4) increased cellularity and neovascularization at 7 and 28 days.
The residence time of HA in SF is transiently decreased after ACLT, suggesting a biophysical transport mechanism for the altered SF composition post-injury or during inflammation.
hyaluronan; synovial fluid; synovitis; ACLT; transport; lubricant
Studies have examined the association between acetaminophen (APAP) use and asthma; however, their interpretation is limited by a number of methodological issues.
We sought to investigate the association between recent and chronic prescription acquired acetaminophen use and asthma.
This was a retrospective case control study using a 10% random sample of the IMS LifeLink commercial claims data from 1997 to 2009. Cases had to have at least 1 incident claim of asthma. 3:1 controls matched on age, gender, and region were randomly chosen. APAP exposure, dose and duration were measured in the 7 and 30 days (recent) and in the 1-year (chronic) look-back period. Multivariable conditional logistic regression was used to estimate the risk of asthma associated with acetaminophen use adjusted for comorbidities, other drugs increasing asthma risk, and health system factors.
There were 28,892 cases and 86,676 controls with mean age 42.7 years and 37.7% were males. 22.6% cases and 18.2% controls had APAP exposure in the pre-index year with mean cumulative doses of 78.7 gm and 59.8 gm respectively. There was no significant association between recent prescription APAP exposure and asthma (7 days: OR = 1.02, p = 0.74; 30 days: OR = 0.97, p = 0.38). Cumulative prescription APAP dose in the year prior increased asthma risk compared to APAP nonusers (<=1 kg: OR = 1.09, p <0.001 and >1 kg: OR = 1.60, p=0.02). Duration of prescription APAP use >30 days was associated with elevated asthma risk (OR = 1.39, p <0.001).
Chronic prescription-acquired APAP use was associated with an increased risk of asthma while recent use was not. However, over the counter APAP use was not captured in this study and further epidemiologic research with complete APAP exposure ascertainment and research on pathophysiological mechanisms is needed to confirm these relationships.
Asthma; Acetaminophen; Pharmacoepidemiology; Acetaminophen toxicity
People with symptoms of depression show impairments in decision-making. One explanation is that they have difficulty maintaining rich representations of the task environment. We test this hypothesis in the context of exploratory choice. We analyze depressive and non-depressive participants' exploration strategies by comparing their choices to two computational models: 1) an “Ideal Actor” model that reflectively updates beliefs and plans ahead, employing a rich representation of the environment and 2) a “Naïve Reinforcement Learning” (RL) model that updates beliefs reflexively utilizing a minimal task representation. Relative to non-depressive participants, we find that depressive participants' choices are better described by the simple RL model. Further, depressive participants were more exploratory than non-depressives in their decision-making. Depressive symptoms appear to influence basic mechanisms supporting choice behavior by reducing use of rich task representations and hindering performance during exploratory decision-making.
While a network of cortical regions contribute to face processing, the lesions in acquired prosopagnosia are highly variable, and likely result in different combinations of spared and affected regions of this network. To assess the residual functional sensitivities of spared regions in prosopagnosia, we designed a rapid event-related functional magnetic resonance imaging (fMRI) experiment that included pairs of faces with same or different identities and same or different expressions. By measuring the release from adaptation to these facial changes we determined the residual sensitivity of face-selective regions-of-interest. We tested three patients with acquired prosopagnosia, and all three of these patients demonstrated residual sensitivity for facial identity changes in surviving fusiform and occipital face areas of either the right or left hemisphere, but not in the right posterior superior temporal sulcus. The patients also showed some residual capabilities for facial discrimination with normal performance on the Benton Facial Recognition Test, but impaired performance on more complex tasks of facial discrimination. We conclude that fMRI can demonstrate residual processing of facial identity in acquired prosopagnosia, that this adaptation can occur in the same structures that show similar processing in healthy subjects, and further, that this adaptation may be related to behavioral indices of face perception.
face perception; identity; expression; fMRI; adaptation; sensitivity; prosopagnosia
Obesity is commonplace, and surgical treatment usually includes Roux-en-Y gastric bypasses (RYGBs). RYGBs have the most documented side effects including vitamin deficiencies, rebound weight gain, and symptomatic hypoglycemia; fewer series exist describing hypoglycemia following other bariatric operations. We reviewed all patients undergoing laparoscopic adjustable gastric banding (LAGB) at our institution between 2008 and 2012. Three patients were identified to have symptomatic hypoglycemia following LAGB. Mean time from surgery was 33 months (range 14–45 months), and mean weight loss was 32.7 kg (range 15.9–43.1 kg). None of the patients had preexisting diabetes. Therefore, symptomatic hypoglycemia should be investigated irrespective of bariatric operation.
To estimate recent age- and sex-specific changes in long-term opioid prescription among patients with chronic pain in two large American Health Systems.
Analysis of administrative pharmacy data to calculate changes in prevalence of long-term opioid prescription (90 days or more during a calendar year) from 2000 to 2005, within groups based on sex and age (18–44, 45–64, and 65 years and older). Separate analyses were conducted for patients with and without a diagnosis of a mood disorder or anxiety disorder. Changes in mean dose between 2000 and 2005 were estimated, as were changes in the rate of prescription for different opioid types (short-acting, long-acting, and non-Schedule 2).
Enrollees in HealthCore (N = 2,716,163 in 2000) and Arkansas Medicaid (N = 115,914 in 2000).
Within each of the age and sex groups, less than 10% of patients with a chronic pain diagnosis in HealthCore, and less than 33% in Arkansas Medicaid, received long-term opioid prescriptions. All age, sex, and anxiety/depression groups showed similar and statistically significant increases in long-term opioid prescription between 2000 and 2005 (35–50% increase). Per-patient daily doses did not increase.
No one group showed especially large increases in long-term opioid prescriptions between 2000 and 2005. These results argue against a recent epidemic of opioid prescribing. These trends may result from increased attention to pain in clinical settings, policy or economic changes, or provider and patient openness to opioid therapy. The risks and benefits to patients of these changes are not yet established.
Opioids; Prescriptions; Chronic Pain; Disparities—Gender; Aged; Mood; Anxiety
Variations in serum markers of collagen production (CICP) and degradation (ICTP), insulin-like growth factor I (IGF-I) and anterior knee laxity (AKL) were measured in 20 women [10 with spontaneous cycles (eumenorrheic), 10 using oral contraceptives] over 5 consecutive days at menses (M1-M5, 1st pill week), the initial estrogen rise near ovulation (O1-O5, 2nd pill week), the initial progesterone rise of the early luteal phase (EL1-EL5, 3rd pill week) and post progesterone peak of the late luteal phase (LL1-LL5, 4th pill week). ICTP was higher in oral contraceptive women (5.3±1.7 vs. 3.7±1.3µg/L; P=.030), primarily during days near ovulation and the early luteal phase when concentrations decreased in eumenorrheic women (P=.04). IGF-I concentrations increased during menses then decreased and remained lower during the early and late luteal phase in oral contraceptive women, resulting in lower concentrations compared to eumenorrheic women at EL2 and LL1 (P=.03). CICP decreased in early and late luteal days (P<.01), and there was a trend toward lower concentrations in eumenorrheic vs. oral contraceptive women (85.7±35.7 vs. 123.2±49.8 ng/mL; P=.07). Lower CICP and greater IGF-I concentrations predicted greater AKL across the 20 cycle days in both groups (R2=.310 and .400). Sex hormone concentration changes across the menstrual cycle are of sufficient magnitude to influence collagen metabolism, and may indirectly influence knee structure and function.
collagen markers; growth factors; menstrual cycle; sex hormones; knee laxity; ACL
This study examined the effect of clopidogrel and proton pump inhibitors (PPIs) interaction on subsequent acute coronary syndrome (ACS)-related inpatient and emergency room (ER) visits.
Population based, retrospective cohort study.
IMS LifeLink Health Plan administrative claims database containing a large nationally dispersed group of commercially insured subjects between 2001 and 2008.
Subjects age ≥18 years with a diagnosis of ACS and at least one clopidogrel prescription within 90 days after the diagnosis were included. Exposed group was defined as having overlapping clopidogrel-PPI prescriptions. Subjects were followed from their first clopidogrel prescription until they experienced an adverse cardiovascular event (re-hospitalization or errors visit due to ACS), were disenrolled or reached the end of study period.
Measurements and Main Results
The clopidogrel plus PPIs group was matched 1:1 with the clopidogrel alone group using the propensity scoring method. Exposure to overlapping clopidogrel-PPI prescriptions was modeled as a time dependent covariate. Cox hazards regression was used to estimate the risk of an adverse cardiovascular event for those having overlapping clopidogrel-PPI prescriptions versus those having clopidogrel alone. Propensity score matching resulted in 2,674 patient pairs. The mean age was 61.30 years with a mean follow-up of 268 days and 70.04% were male. Clopidogrel use co-medicated with PPIs was associated with a significantly increased risk of cardiovascular adverse events (HR=1.438; 95% CI, 1.237-1.671), as compared to clopidogrel use not co-medicated with PPIs.
Concurrent use of clopidogrel plus PPIs was associated with a significant increase in risk of adverse cardiovascular events for ACS patients.
Clopidogrel; Proton; Pump; Inhibitors; Interaction; Cardiovascular; Adverse; Events; Outcomes; Acute; Coronary; Syndrome
Training in action video games can increase the speed of perceptual processing. However, it is unknown whether video-game training can lead to broad-based changes in higher-level competencies such as cognitive flexibility, a core and neurally distributed component of cognition. To determine whether video gaming can enhance cognitive flexibility and, if so, why these changes occur, the current study compares two versions of a real-time strategy (RTS) game. Using a meta-analytic Bayes factor approach, we found that the gaming condition that emphasized maintenance and rapid switching between multiple information and action sources led to a large increase in cognitive flexibility as measured by a wide array of non-video gaming tasks. Theoretically, the results suggest that the distributed brain networks supporting cognitive flexibility can be tuned by engrossing video game experience that stresses maintenance and rapid manipulation of multiple information sources. Practically, these results suggest avenues for increasing cognitive function.
There has been an increase in over dose deaths and emergency department visits (EDVs) involving use of prescription opioids, but the association between opioid prescribing and adverse outcomes is unclear.
Data were obtained from administrative claim records from Arkansas Medicaid and HealthCore commercially insured enrollees, 18 years and older, who used prescription opioids for at least 90 continuous days within a 6-month period between 2000 and 2005 and had no cancer diagnoses. Regression analysis was used to examine risk factors for EDVs and alcohol- or drug-related encounters (ADEs) in the 12 months following 90 days or more of prescribed opioids.
Headache, back pain, and preexisting substance use disorders were significantly associated with EDVs and ADEs. Mental health disorders were associated with EDVs in HealthCore enrollees and with ADEs in both samples. Opioid dose per day was not consistently associated with EDVs but doubled the risk of ADEs at morphine-equivalent doses over 120 mg/d. Use of short-acting Drug Enforcement Agency Schedule II opioids was associated with EDVs compared with use of non–Schedule II opioids alone (relative risk range, 1.09–1.74). Use of Schedule II long-acting opioids was strongly associated with ADEs (relative risk range, 1.64–4.00).
Use of Schedule II opioids, headache, back pain, and substance use disorders are associated with EDVs and ADEs among adults prescribed opioids for 90 days or more. It may be possible to increase the safety of chronic opioid therapy by minimizing the prescription of Schedule II opioids in these higher-risk recipients.
Category learning is a complex phenomenon that engages multiple cognitive processes, many of which occur simultaneously and unfold dynamically over time. For example, as people encounter objects in the world, they simultaneously engage processes to determine their fit with current knowledge structures, gather new information about the objects, and adjust their representations to support behavior in future encounters. Many techniques that are available to understand the neural basis of category learning assume that the multiple processes that subserve it can be neatly separated between different trials of an experiment. Model-based functional magnetic resonance imaging offers a promising tool to separate multiple, simultaneously occurring processes and bring the analysis of neuroimaging data more in line with category learning’s dynamic and multifaceted nature. We use model-based imaging to explore the neural basis of recognition and entropy signals in the medial temporal lobe and striatum that are engaged while participants learn to categorize novel stimuli. Consistent with theories suggesting a role for the anterior hippocampus and ventral striatum in motivated learning in response to uncertainty, we find that activation in both regions correlates with a model-based measure of entropy. Simultaneously, separate subregions of the hippocampus and striatum exhibit activation correlated with a model-based recognition strength measure. Our results suggest that model-based analyses are exceptionally useful for extracting information about cognitive processes from neuroimaging data. Models provide a basis for identifying the multiple neural processes that contribute to behavior, and neuroimaging data can provide a powerful test bed for constraining and testing model predictions.
category learning; model-based imaging; medial temporal lobe; entropy; recognition
Systematic reviews and meta-analyses of randomized trials that include patient-reported outcomes (PROs) often provide crucial information for patients and clinicians facing challenging health care decisions. Based on emerging methods, guidance on combining PROs in meta-analysis is likely to enhance their usefulness.
The objectives of this paper are: i) to describe PROs and why they are important for health care decision-making, ii) illustrate the key risk of bias issues that systematic reviewers should consider and, iii) address outcome characteristics of PROs and provide guidance for combining outcomes.
We suggest a step-by-step approach to addressing issues of PROs in meta-analyses. Systematic reviewers should begin by asking themselves if trials have addressed all the important effects of treatment on patients’ quality of life. If the trials have addressed PROs, have investigators chosen the appropriate instruments? In particular, does evidence suggest the PROs used are valid and responsive, and is the review free of outcome reporting bias? Systematic reviewers must then decide how to categorize PROs and when to pool results.
Patient-reported outcomes; Health-related quality of life; Meta-analysis; Systematic review; Health care decision-making
The objective was to study the effect of colpocleisis on pelvic support, symptoms, and quality of life and report-associated morbidity and postoperative satisfaction. Women undergoing colpocleisis for treatment of pelvic organ prolapse (POP) were recruited at six centers. Baseline measures included physical examination, responses to the Pelvic Floor Distress Inventory, and Pelvic Floor Impact Questionnaire. Three and 12 months after surgery we repeated baseline measures. Of 152 patients with mean age 79 (±6) years, 132 (87%) completed 1 year follow-up. Three and 12 months after surgery, 90/110 (82%) and 75/103 (73%) patients following up had POP stage ≤1. All pelvic symptom scores and related bother significantly improved at 3 and 12 months, and 125 (95%) patients said they were either ‘very satisfied’ or ‘satisfied’ with the outcome of their surgery. Colpocleisis was effective in resolving prolapse and pelvic symptoms and was associated with high patient satisfaction.
Pelvic organ prolapse; Urinary incontinence; Pelvic floor disorders; Colpocleisis; Quality of life; Surgical outcomes
To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications.
Data Sources/Study Setting
Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000–December 31, 2002.
We used a pre–post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures.
Data Collection/Extraction Methods
Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded.
Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures.
Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.
Medicaid; prescription drugs; chronic medications; days' supply
The purpose of this study was to examine the association between mental health disorders and subsequent risk for chronic opioid use among adolescents and young adults presenting with common chronic pain complaints (back pain, neck pain, headache and arthritis/joint pain).
Using claims data from January 1, 2001 to June 30, 2008, we conducted a longitudinal analysis of opioid use patterns among 13–24 year-olds presenting with a new episode of chronic pain. Chronic opioid use was defined as receiving >90 days of opioids within a 6-month period with no gap in use of >30 days in the 18 months following the fist qualifying pain diagnosis. Mental health disorders were identified from claims in the 6 months prior to the first qualifying pain diagnosis.
59,077 youth met criteria for a new episode of chronic pain. Among these youth, 321 (0.5%) met criteria for chronic opioid use and 16,172 (27.4%) had some opioid use. After controlling for demographic and clinical factors, youth with pre-existing mental health diagnoses had a 2.4-fold increased risk of subsequently receiving chronic opioids versus no opioids (OR: 2.36, 95% CI = 1.73–3.23) and a 1.8-fold increased likelihood of receiving chronic opioids versus some opioids (OR: 1.83, 95% CI= 1.34–2.50).
Mental health disorders are associated with increased risk for chronic opioid use among adolescents and emerging young adults. Further study is warranted to examine risks and benefits of chronic opioid use in this population.
The use of a multidisciplinary approach is becoming increasingly important when developing management strategies that mitigate the economic and biological costs associated with invasive pests. A framework of simulated dispersal is combined with life-history information and analyses of population genetic structure to investigate the invasion dynamics of a plant disease vector, the island sugarcane planthopper (Eumetopina flavipes), through an archipelago of significant Australian quarantine concern. Analysis of eight microsatellite loci from 648 individuals suggests that frequent, wind-assisted immigration from multiple sources in Papua New Guinea contributes significantly to repeated colonization of far northern islands. However, intermittent wind-assisted immigration better explains patterns of genetic diversity and structure in the southern islands and on the tip of mainland Australia. Significant population structuring associated with the presence of clusters of highly related individuals results from breeding in-situ following colonization, with little postestablishment movement. Results also suggest that less important secondary movements occur between islands; these appear to be human mediated and restricted by quarantine zones. Control of the planthopper may be very difficult on islands close to Papua New Guinea given the apparent propensity for multiple invasion, but may be achievable further south where local populations appear highly independent and isolated.
colonization; invasion pathway; isolation by distance; long-distance dispersal; microsatellites; pest management; planthopper
To determine the effect of contact with a podiatrist on the occurrence of Lower Extremity Amputation (LEA) in people with diabetes.
Design and data sources
We conducted a systematic review of available literature on the effect of contact with a podiatrist on the risk of LEA in people with diabetes. Eligible studies, published in English, were identified through searches of PubMed, CINAHL, EMBASE and Cochrane databases. The key terms, ‘podiatry’, ‘amputation’ and ‘diabetes’, were searched as Medical Subject Heading terms. Reference lists of selected papers were hand-searched for additional articles. No date restrictions were imposed.
Published randomised and analytical observational studies of the effect of contact with a podiatrist on the risk of LEA in people with diabetes were included. Cross-sectional studies, review articles, chart reviews and case series were excluded. Two reviewers independently assessed titles, abstracts and full articles to identify eligible studies and extracted data related to the study design, characteristics of participants, interventions, outcomes, control for confounding factors and risk estimates.
Meta-analysis was performed separately for randomised and non-randomised studies. Relative risks (RRs) with 95% CIs were estimated with fixed and random effects models as appropriate.
Six studies met the inclusion criteria and five provided data included in meta-analysis. The identified studies were heterogenous in design and included people with diabetes at both low and high risk of amputation. Contact with a podiatrist did not significantly affect the RR of LEA in a meta-analysis of available data from randomised controlled trials (RCTs); (1.41, 95% CI 0.20 to 9.78, 2 RCTs) or from cohort studies; (0.73, 95% CI 0.39 to 1.33, 3 Cohort studies with four substudies in one cohort).
There are very limited data available on the effect of contact with a podiatrist on the risk of LEA in people with diabetes.