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COVID-19 associated public health measures and school closures exacerbated symptoms in some children and youth with attention-deficit hyperactivity disorder (ADHD). Less well understood is how the pandemic influenced patterns of prescription stimulant use. We conducted a population-based study of stimulant dispensing to children and youth ≤ 24 years old between January 1, 2013, and June 30, 2022. We used structural break analyses to identify the pandemic month(s) when changes in the dispensing of stimulants occurred. We used interrupted time series models to quantify changes in dispensing following the structural break and compare observed and expected stimulant use. Our main outcome was the change in the monthly rate of stimulant use per 100,000 children and youth. Following an initial immediate decline of 60.1 individuals per 100,000 (95% confidence interval [CI] − 99.0 to − 21.2), the monthly rate of stimulant dispensing increased by 11.8 individuals per 100,000 (95% CI 10.0–13.6), with the greatest increases in trend observed among females, individuals in the highest income neighbourhoods, and those aged 20 to 24. Observed rates were between 3.9% (95% CI 1.7–6.2%) and 36.9% (95% CI 34.3–39.5%) higher than predicted among females from June 2020 onward and between 7.1% (95% CI 4.2–10.0%) and 50.7% (95% CI 47.0–54.4%) higher than expected among individuals aged 20–24 from May 2020 onward. Additional research is needed to ascertain the appropriateness of stimulant use and to develop strategies supporting children and youth with ADHD during future periods of long-term stressors. [ABSTRACT FROM AUTHOR]

Aim/Hypothesis: To describe the influence of diabetes on temporal changes in rates of lower extremity revascularisation and amputation for peripheral artery disease (PAD) in Ontario, Canada. Methods: In this population‐based repeated cross‐sectional study, we calculated annual rates of lower extremity revascularisation (open or endovascular) and amputation (toe, foot or leg) related to PAD among Ontario residents aged ≥40 years between 2002 and 2019. Annual rate ratios (relative to 2002) adjusted for changes in diabetes prevalence alone, as well as fully adjusted for changes in demographics, diabetes and other comorbidities, were estimated using generalized estimating equation models to model population‐level effects while accounting for correlation within units of observation. Results: Compared with 2002, the Ontario population in 2019 exhibited a significantly higher prevalence of diabetes (18% vs. 10%). Between 2002 and 2019, the crude rate of revascularisation increased from 75.1 to 90.7/100,000 person‐years (unadjusted RR = 1.10, 95% CI = 1.07–1.13). However, after adjustment, there was no longer an increase in the rate of revascularisation (diabetes‐adjusted RR = 0.98, 95% CI = 0.96–1.01, fully‐adjusted RR = 0.94, 95% CI = 0.91–0.96). The crude rate of amputation decreased from 2002 to 2019 from 49.5 to 45.4/100,000 person‐years (unadjusted RR = 0.78, 95% CI = 0.75–0.81), but was more pronounced after adjustment (diabetes‐adjusted RR = 0.62, 95% CI = 0.60–0.64; fully‐adjusted RR = 0.58, 95% CI = 0.56–0.60). Conclusions/Interpretation: Diabetes prevalence rates strongly influenced rates of revascularisation and amputation related to PAD. A decrease in amputations related to PAD over time was attenuated by rising diabetes prevalence rates. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The American Academy of Pediatrics recommends developmental surveillance and screening in early childhood in primary care. The 18-month visit may be an ideal time for identification of children with delays in language and communication, or symptoms of autism spectrum disorder (ASD). Little is known about the predictive validity of developmental screening tools administered at 18 months. Our objective was to examine the predictive validity of the Infant Toddler Checklist (ITC) at the 18-month health supervision visit, using school readiness at kindergarten age as the criterion measure. METHODS: We designed a prospective cohort study, recruiting in primary care in Toronto, Canada. Parents completed the ITC at the 18-month visit. Teachers completed the Early Development Instrument (EDI) when the children were in Kindergarten, age 4-6 years. We calculated screening test properties with 95% confidence intervals (CIs). We used multivariable logistic and linear regression analyses adjusted for important covariates. RESULTS: Of 293 children (mean age 18 months), 30 (10.2%) had a positive ITC including: concern for speech delay (n = 11, 3.8%), concern for other communication delay (n = 13, 4.4%), and concern for both (n = 6, 2.0%). At followup (mean age 5 years), 54 (18.4%) had overall EDI vulnerability, 19 (6.5%) had vulnerability on the 2 EDI communication domains. The ITC sensitivity ranged from 11% to 32%, speci- ficity from 91% to 96%, false positive rates from 4% to 9%, PPV from 16% to 35%, NPV from 83% to 95%. A positive ITC screen and ITC concern for speech delay were associated with lower scores in EDI communication skills and general knowledge (β = -1.08; 95% CI: -2.10, -0.17; β = -2.35; 95% CI: -3.63, -1.32) and EDI language and cognitive development (β = -0.62; 95% CI: -1.25, -0.18; β = -1.22; 95% CI: -2.11, -0.58). CONCLUSIONS: The ITC demonstrated high specificity suggesting that most children with a negative ITC screen will demonstrate school readiness at 4-6 years, and low false positive rates, minimizing over-diagnosis. The ITC had low sensitivity highlighting the importance of ongoing developmental surveillance and screening. [ABSTRACT FROM AUTHOR]

Purpose: Data extraction from radiology free-text reports is time consuming when performed manually. Recently, more automated extraction methods using natural language processing (NLP) are proposed. A previously developed rule-based NLP algorithm showed promise in its ability to extract stroke-related data from radiology reports. We aimed to externally validate the accuracy of CHARTextract, a rule-based NLP algorithm, to extract stroke-related data from free-text radiology reports. Methods: Free-text reports of CT angiography (CTA) and perfusion (CTP) studies of consecutive patients with acute ischemic stroke admitted to a regional stroke center for endovascular thrombectomy were analyzed from January 2015 to 2021. Stroke-related variables were manually extracted as reference standard from clinical reports, including proximal and distal anterior circulation occlusion, posterior circulation occlusion, presence of ischemia or hemorrhage, Alberta stroke program early CT score (ASPECTS), and collateral status. These variables were simultaneously extracted using a rule-based NLP algorithm. The NLP algorithm's accuracy, specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were assessed. Results: The NLP algorithm's accuracy was > 90% for identifying distal anterior occlusion, posterior circulation occlusion, hemorrhage, and ASPECTS. Accuracy was 85%, 74%, and 79% for proximal anterior circulation occlusion, presence of ischemia, and collateral status respectively. The algorithm confirmed the absence of variables from radiology reports with an 87–100% accuracy. Conclusions: Rule-based NLP has a moderate to good performance for stroke-related data extraction from free-text imaging reports. The algorithm's accuracy was affected by inconsistent report styles and lexicon among reporting radiologists. [ABSTRACT FROM AUTHOR]

Aims: To characterize comparative risks and benefits of methadone versus buprenorphine/naloxone in a contemporary cohort where the unregulated drug supply is dominated by fentanyl. Design, Setting and Participants: Population‐based propensity‐score matched cohort study conducted in Ontario, Canada among people aged 18+ initiating opioid agonist therapy (OAT) for an opioid use disorder between October 2016 and December 2018 (n = 18 880). Intervention: Initiation of methadone versus buprenorphine/naloxone. Measurements The primary outcome was opioid overdose (fatal and non‐fatal) while on treatment, with secondary outcomes including opioid overdose (first 30 days of treatment), treatment discontinuation, health‐care interactions related to treatment of opioid use disorder, receiving a weekly supply of take‐home doses and opioid overdose within 30 days of treatment discontinuation. Outcomes were assessed over 1 year. Findings Overall, 7517 people initiating buprenorphine were matched to an equal number of methadone‐treated individuals. Risk of opioid overdose while on treatment [hazard ratio (HR) = 0.50; 95% confidence interval (CI) = 0.37–0.68] or within the first 30 days of treatment (HR = 0.51, 95% CI = 0.31–0.85) was lower among buprenorphine recipients compared to methadone recipients. In secondary analyses, people initiating buprenorphine had a higher risk of treatment discontinuation within the first year (median time to discontinuation 104 versus 265 days, HR = 1.43, 95% CI = 1.37–1.49), had lower rates of health‐care interactions for OUD (186.4 versus 254.3 per person‐year; rate ratio = 0.73; 95% CI = 0.72–0.75), and a higher rate of receiving weekly take‐home doses (HR = 2.33; 95% CI = 2.20–2.46). Overdose rates in the period following OAT discontinuation were higher than those observed while on treatment, but did not differ significantly by OAT type. Conclusions: Although treatment retention is higher among methadone recipients, overdose risk is also elevated compared to buprenorphine recipients. These findings demonstrate the benefits of any OAT on avoidance of overdose, particularly following treatment discontinuation and with the increasingly unpredictable drug supply in North America. [ABSTRACT FROM AUTHOR]

Background Case reports have described instances of peripheral and central nervous system toxicity during treatment with metronidazole; however, no large-scale studies have examined this association. Methods We conducted a population-based nested case-control study of adults aged 66 years or older living in Ontario, Canada, between 1 April 2003 and 31 March 2017. Cases were individuals who attended hospital for any of cerebellar dysfunction, encephalopathy, or peripheral neuropathy within 100 days of a prescription for either metronidazole or clindamycin. We matched each case patient with up to 10 event-free control subjects who also received metronidazole or clindamycin. We used conditional logistic regression to test the association between metronidazole exposure and neurologic events, with clindamycin as the reference exposure. Results We identified 1212 cases with recent use of either metronidazole or clindamycin and 12 098 controls. Neurologic adverse events were associated with an increased odds of metronidazole exposure compared to clindamycin (odds ratio [OR], 1.72 [95% confidence interval {CI}, 1.53–1.94]), which persisted after accounting for patient demographics, comorbidities, and other medication exposures (adjusted odds ratio [aOR], 1.43 [95% CI, 1.26–1.63]). We found a consistent association limited to either central (aOR, 1.46 [95% CI, 1.27–1.68]) or peripheral (aOR, 1.34 [95% CI, 1.02–1.76]) nervous system events. Among metronidazole recipients, the overall incidence of neurologic events at 100 days was approximately 0.25%. Conclusions Metronidazole is associated with an increased risk of adverse peripheral and central nervous system events relative to clindamycin. Clinicians and patients should be aware of these rare but potentially serious adverse events. [ABSTRACT FROM AUTHOR]

Background and aims: In June 2016, the Ontario, Canada government implemented the Ontario Naloxone Program for Pharmacies (ONPP), authorizing pharmacists to provide injectable naloxone kits at no charge to all Ontario residents. In March 2018, the program was amended to include intranasal naloxone and remove the requirement to present a government health card to the dispensing pharmacist. We examined whether these changes increased naloxone dispensing through the ONPP. Design Population‐based time–series analysis using interventional autoregressive integrated moving average models. Setting: Ontario, Canada. Participants: All Ontario residents between 1 July 2016 and 31 March 2020. Measurements Monthly rates of pharmacy naloxone dispensing. Findings Overall, 199 484 individuals were dispensed a naloxone kit during the study period. In the main analysis, the rate of pharmacy naloxone dispensing increased by 65.1% following program changes (55.6–91.8 kits per 100 000 population between February 2018 and May 2018; P = 0.01). In subgroup analyses, naloxone dispensing increased among individuals receiving opioid agonist therapy (OAT) (3374.9–7264.2 kits per 100 000 OAT recipients; P = 0.04) among individuals receiving other prescription opioids (192.8–381.8 kits per 100 000 population prescribed opioids; P < 0.01), among individuals with past opioid exposure (134.7–205.6 kits per 100 000 population with past opioid exposure; P < 0.01) and in urban centers (56.2–91.4 kits per 100 000 population; P < 0.01). We did not observe a clear impact on pharmacy‐dispensed naloxone to individuals with no or unknown opioid exposure (34.4–39.3 kits per 100 000 population with no/unknown opioid exposure; P = 0.42) and in rural regions (50.4–97.2 kits per 100 000 population; P = 0.09). Conclusions: Changes to the Ontario Naloxone Program for Pharmacies to add intranasal naloxone and remove the requirement to present a government health card appeared to increase pharmacy‐based naloxone dispensing uptake in Ontario, Canada, particularly among individuals at high risk of inadvertent opioid overdose. [ABSTRACT FROM AUTHOR]

Background Variations in inpatient medical care are typically attributed to system, hospital or patient factors. Little is known about variations at the physician level within hospitals. We described the physician-level variation in clinical outcomes and resource use in general internal medicine (GIM). Methods This was an observational study of all emergency admissions to GIM at seven hospitals in Ontario, Canada, over a 5-year period between 2010 and 2015. Physician-level variations in inpatient mortality, hospital length of stay, 30-day readmission and use of 'advanced imaging' (CT, MRI or ultrasound scans) were measured. Physicians were categorised into quartiles within each hospital for each outcome and then quartiles were pooled across all hospitals (eg, physicians in the highest quartile at each hospital were grouped together). We report absolute differences between physicians in the highest and lowest quartiles after matching admissions based on propensity scores to account for patient-level variation. Results The sample included 103 085 admissions to 135 attending physicians. After propensity score matching, the difference between physicians in the highest and lowest quartiles for in-hospital mortality was 2.4% (95% CI 0.6% to 4.3%, p<0.01); for readmission was 3.3% (95% CI 0.7% to 5.9%, p<0.01); for advanced imaging was 0.32 tests per admission (95% CI 0.12 to 0.52, p<0.01); and for hospital length of stay was 1.2 additional days per admission (95% CI 0.5 to 1.9, p<0.01). Physician-level differences in length of stay and imaging use were consistent across numerous sensitivity analyses and stable over time. Differences in mortality and readmission were consistent across most sensitivity analyses but were not stable over time and estimates were limited by sample size. Conclusions Patient outcomes and resource use in inpatient medical care varied substantially across physicians in this study. Physician-level variations in length of stay and imaging use were unlikely to be explained by patient factors whereas differences in mortality and readmission should be interpreted with caution and could be explained by unmeasured confounders. Physician-level variations may represent practice differences that highlight quality improvement opportunities. [ABSTRACT FROM AUTHOR]

Background In September 2009, a live attenuated herpes zoster vaccine (ZVL) became available in Canada. Beginning in September 2016, ZVL was made available to all Ontario residents aged 65–70 through a publicly funded immunization program. We assessed the impact of ZVL availability and its subsequent public funding on herpes zoster burden in this population. Methods A population-based study of Ontario residents aged 65–70 between January 2005 and September 2018. We used interventional autoregressive integrated moving average models to examine the impact of ZVL market availability and the publicly funded ZVL program on monthly incidence rate of medically attended herpes zoster, defined as an outpatient visit for herpes zoster with a prescription for a herpes zoster antiviral dispensed ≤5 days before or after the visit, or a herpes zoster–related emergency department (ED) visit or hospitalization. In secondary analyses, we examined impacts on any herpes zoster–related ED visits and hospitalizations. Results We found no association between ZVL market availability and monthly incidence of herpes zoster (P  = .32) or monthly rates of ED visits and hospitalizations (P  = .88). Conversely, the introduction of publicly funded ZVL reduced the monthly rate of medically attended herpes zoster by 19.1% (from 4.8 to 3.8 per 10 000 population; P  < .01) and herpes zoster–related ED visits and hospitalizations by 38.2% (from 1.7 to 1.0 per 10 000 population; P  < .05). Conclusions The introduction of a publicly funded immunization program for herpes zoster was associated with reduced disease burden and related acute healthcare service use. [ABSTRACT FROM AUTHOR]

Aim: To estimate the cost‐minimizing size and skill mix of a nursing resource team (NRT). Background: Nurse absences can be filled by an NRT at lower hourly cost than staffing agencies or nurses working overtime, but an NRT must be appropriately sized to minimize total cost. Methods: Using all registered nurse (RN) absences at an academic teaching hospital from 1 October 2014 to 31 March 2018, we developed a generalized additive model (GAM) to forecast the weekly frequency of each of ten types of absence over 52 weeks. We used the forecasts in an optimization model to determine the cost‐minimizing NRT composition. Results: The median weekly frequencies for the ten absence types ranged between 12 and 65.5. The root mean squared errors of the GAMs ranged between 4.55 and 9.07 on test data. The NRT dimensioned by the optimization model yields an estimated annual cost reduction of $277,683 (Canadian dollars) (7%). Conclusions: The frequency of RN absences in a hospital can be forecasted with high accuracy, and the use of forecasting and optimization to dimension an NRT can substantially reduce the cost of filling RN absences. Implications for Nursing Management: This methodology can be adapted by any hospital to optimize nurse staffing. [ABSTRACT FROM AUTHOR]

Background: Strengthening self-efficacy in job-seeking among individuals with dental problems has been identified as an important factor in facilitating job procurement and maintenance. There is no knowledge about whether receiving dental treatment improves someone’s self-efficacy in seeking a job. This work explores this relationship. Methods: An exploratory pilot study of a convenience sample of 30 social assistance recipients of Ontario, Canada, was conducted using a pre- and post-dental treatment survey, which included both quantitative and qualitative components. The survey included two validated instruments Oral Health Impact Profile (OHIP-14) and Job-Seeking Self-efficacy scale (JSS). Changes in scores of both scales following dental treatment were calculated. Pearson correlation was performed between OHIP-14 and JSS scores. Qualitative data were transcribed and interrelated ideas were grouped together to generate themes. Results: Mean scores for OHIP-14 (23.4 to 6.7, p < 0.001, effect size: 1.75) and median scores for JSS (4.9 to 5.5, p = 0.002, effect size: 0.40) changed significantly after receiving dental treatment. A significant negative correlation (−0.56, p = 0.001) was observed between OHIP-14 and JSS scores indicating that job-seeking self-efficacy improves with improvement in oral health related quality of life (OHRQoL). Qualitative analysis reveals participants' physical and psychosocial impacts of dental problems; barriers experienced in accessing dental care and seeking a job; and changes perceived after receiving dental care. Conclusion: Results of our survey indicate that social assistance recipients experience negative impacts of dental problems and perceive improvements in OHRQoL and job-seeking self-efficacy after receiving dental treatment. [ABSTRACT FROM AUTHOR]

Background In Ontario, approximately $3.8 billion is spent annually on publicly funded drug programs. The annual growth in Ontario Public Drug Program ( OPDP) expenditure has been limited to 1.2% over the course of 3 years. Concurrently, the Ontario Drug Policy Research Network ( ODPRN) was appointed to conduct drug class review research relating to formulary modernization within the OPDP. Drug class reviews by ODPRN incorporate a novel methodological technique called reimbursement-based economics, which focuses on reimbursement strategies and may be particularly relevant for policy-makers. Objectives To describe the reimbursement-based economics approach. Methods Reimbursement-based economics aims to identify the optimal reimbursement strategy for drug classes by incorporating a review of economic literature, comprehensive budget impact analyses, and consideration of cost-effectiveness. This 3-step approach is novel in its focus on the economic impact of alternate reimbursement strategies rather than individual therapies. Results The methods involved within the reimbursement-based approach are detailed. To facilitate the description, summary methods and findings from a recent application to formulary modernization with respect to the drug class tryptamine-based selective serotonin receptor agonists (triptans) used to treat migraine headaches are presented. Conclusions The application of reimbursement-based economics in drug policy reforms allows policy-makers to consider the cost-effectiveness and budget impact of different reimbursement strategies allowing consideration of the trade-off between potential cost savings vs increased access to cost-effective treatments. [ABSTRACT FROM AUTHOR]

Background: Immigrants may be at a higher risk of adverse drug reactions, in that poor language proficiency reduces individuals understanding of drug label instructions. Additionally, there are reports of severe or fatal toxicity due to CYP2D6 ultrarapid hepatic metabolism of codeine to morphine among some ethnic groups, especially those from Eastern Africa. Methods: Between 2002 and 2012 we conducted a population-based cohort study among residents of Ontario, Canada. We used administrative health databases that linked immigrants and Canadian-born individuals to both prescription medication use and emergency department visits and hospital admissions. The primary composite outcome was the risk of drug overdose or all-cause mortality within 30 days of codeine prescription, comparing patients from various world regions to Canadian-born individuals. A secondary analysis stratified by codeine dose and ability to speak English and/or French. Results: There were 553 504 individuals exclusively prescribed codeine. Relative to an incidence rate of 57.1/ 100 000 person-days among Canadian-born codeine recipients, those who migrated from various world regions were at a lower risk of drug overdose or death. For example, Eastern Africans had an adjusted HR of 0.60 (95% CI 0.31 to 1.17) on controlling for potential confounders such as age, sex, income and physician visits. Patients unable to speak English or French who were prescribed codeine were at a lower risk of the composite outcome relative to those proficient in either language (adjusted HR 0.63, 95% CI 0.54 to 0.74). Interpretation: Overdose and death following the institution of codeine therapy are not more commonly observed among immigrants from world regions with a high prevalence of ultrarapid CYP2D6 status relative to those born in Canada. Lower proficiency in English or French also did not appear to heighten the risk. [ABSTRACT FROM AUTHOR]

Background and Aims The burden of premature mortality due to opioid-related death has not been fully characterized. We calculated temporal trends in the proportion of deaths attributable to opioids and estimated years of potential life lost (YLL) due to opioid-related mortality in Ontario, Canada. Design Cross-sectional study. Setting Ontario, Canada. Participants Individuals who died of opioid-related causes between January 1991 and December 2010. Measurements We used the Registered Persons Database and data abstracted from the Office of the Chief Coroner to measure annual rates of opioid-related mortality. The proportion of all deaths related to opioids was determined by age group in each of 1992, 2001 and 2010. The YLL due to opioid-related mortality were estimated, applying the life expectancy estimates for the Ontario population. Findings We reviewed 5935 opioid-related deaths in Ontario between 1991 and 2010. The overall rate of opioid-related mortality increased by 242% between 1991 (12.2 per 1 000 000 Ontarians) and 2010 (41.6 per 1 000 000 Ontarians; P < 0.0001). Similarly, the annual YLL due to premature opioid-related death increased threefold, from 7006 years (1.3 years per 1000 population) in 1992 to 21 927 years (3.3 years per 1000 population) in 2010. The proportion of deaths attributable to opioids increased significantly over time within each age group (P < 0.05). By 2010, nearly one of every eight deaths (12.1%) among individuals aged 25–34 years was opioid-related. Conclusions Rates of opioid-related deaths are increasing rapidly in Ontario, Canada, and are concentrated among the young, leading to a substantial burden of disease. [ABSTRACT FROM AUTHOR]

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Background Primary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care. Methods Pragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted. Results 789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met. Conclusions A Prevention Practitioner, can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims To determine the extent to which other opioids are prescribed to patients receiving methadone in Ontario, Canada. Design Retrospective cohort study. Setting Ontario, Canada from 1 April 2003 to 31 March 2010. Participants We studied patients aged 15-64 years with publically funded drug coverage who received at least 30 days of continuous methadone maintenance therapy (MMT). Measurements The proportion of patients who received more than 7 days of a non-methadone opioid during MMT. A secondary analysis examined the extent to which non-methadone opioids were prescribed by physicians or dispensed by pharmacies not involved in a patient's MMT. Findings Among 18 759 patients treated with methadone, 3456 (18.4%) received at least one prescription for non-methadone opioids of more than 7 days' duration. In this group, the median number of non-methadone opioid prescriptions dispensed per year was 11.9 (interquartile range 4.1-25.0). The most frequently prescribed opioids were codeine and oxycodone. Of the 73 520 non-methadone opioid prescriptions of more than 7 days' duration, nearly half (45.8%) originated from non-MMT prescribers and pharmacies. Conclusions Many patients receiving methadone maintenance therapy in Ontario receive overlapping prescriptions for other opioids, often for extended periods. The associated prescribing patterns suggest that many such prescriptions may be duplicitous. The prescribing and dispensing of non-methadone opioids to patients receiving methadone maintenance therapy is likely to be observed in jurisdictions outside Ontario, Canada. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to investigate whether the use of cholinesterase inhibitors (ChEIs) was associated with a risk of upper gastrointestinal bleeding in elderly adults with dementia. Researchers evaluated 203,279 dementia patients. They found that there was no significant association between ChEIs and bleeding in elderly adults.

Purpose: To compare persistence of oxybutynin or tolterodine therapy among older patients newly prescribed one of these drugs. Methods: We conducted a retrospective cohort study of Ontarians aged 66 years and older who were newly prescribed either drug between January 1, 2000 and December 31, 2007. Persistence with treatment was defined on the basis of refills for the drug within a grace period equal to 50% of the prescription duration. Results: We identified 31,996 patients newly treated with oxybutynin and 24,855 newly treated with tolterodine. After 2 years of follow-up, persistence on oxybutynin (9.4%) was significantly lower than that on tolterodine (13.6%, p < 0.0001). The median time to discontinuation of oxybutynin and tolterodine was 68 and 128 days, respectively. Conclusions: Our findings suggest that the tolerability of these drugs differs substantially. [ABSTRACT FROM AUTHOR]

The article discusses a study on co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system. Topics covered include the use of co-trimoxazole for urinary tract infections, the increased risk of sudden death within seven days, and how ciprofloxacin was tied to increased sudden death risk.

The article discusses a study which determines the association between increased risk of diabetes and patients treated with 3-hydroxy-3-methyl-glutaryl (HMG)-CoA reductase inhibitors. It states that patients aged 66 and older without diabetes who started statin treatment were included. Results showed an increased risk of diabetes with atorvastatin and rosuvastatin.

BACKGROUND AND OBJECTIVE: Over the past 20 years, the prescribing of opioids has increased dramatically in North America, with parallel increases in opioid addiction, overdose, and associated deaths. We examined whether young children of women prescribed opioids were at increased risk of opioid overdose. METHODS: We conducted a population-based, nested case control study in Ontario, Canada, between 2002 and 2015. We identified children aged ≤10 years, whose mothers received publicly funded prescriptions for an opioid or a nonsteroidal antiinflammatory drug (comparator analgesic) in the preceding year. Cases were children who presented to hospital for or died of opioid overdose. Each case was matched with 4 controls with no opioid overdose. The primary outcome was the risk of opioid overdose. RESULTS: We identified 103 children who presented to the hospital with opioid overdose and matched them with 412 controls. Half of the children with opioid overdose were <2 years old. Compared with controls, children with an opioid overdose were far more likely to have a mother who received a prescription opioid (unadjusted odds ratio, 2.41; 95% confidence interval, 1.68-3.45) and who was prescribed antidepressants. The most commonly implicated overdose opioids were codeine (53.4%), oxycodone (32.0%), and methadone (15.5%). CONCLUSIONS: Young children of mothers prescribed opioids are at a markedly increased risk of overdose. Physicians, pharmacists, and parents should take measures to mitigate the risk of opioid-related harm to children, such as prescribing smaller quantities, emphasizing the importance of secure medication storage, and the prompt disposal of unused opioids. [ABSTRACT FROM AUTHOR]

Although randomized studies have shown optimal medical therapy (OMT) to be as efficacious as revascularization in stable coronary heart disease (CHD), the application of OMT in routine practice is suboptimal. We sought to understand the predictors of receiving OMT in stable CHD and its impact on clinical outcomes. All patients with stable CHD based on coronary angiography from October 2008 to September 2011 were identified in Ontario, Canada. OMT was defined as concurrent use of β blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statin. Aspirin use was not part of the OMT definition because of database limitations. Multivariable hierarchical logistic models identified predictors of OMT in the 12 months after angiography. Cox proportional hazard models with time-varying covariates for OMT and revascularization status examined differences in death and nonfatal myocardial infarction (MI). In these models, patients transitioned among 4 mutually exclusive treatment groups: no OMT and no revascularization, no OMT and revascularization, OMT and no revascularization, OMT and revascularization. Our cohort had 20,663 patients. Over a mean period of 2.5 years, 8.7% had died. Only 61% received OMT within 12 months. The strongest predictor of receiving OMT at 12 months was OMT before the angiogram (odds ratio 14.40, 95% confidence interval [CI] 13.17 to 15.75, p <0.001). Relative to no OMT and nonrevascularized patients, patients on OMT and revascularized had the greatest reduction in mortality (hazard ratio 0.52, 95% CI 0.45 to 0.60, p <0.001) and nonfatal MI (hazard ratio 0.74, 95% CI 0.64 to 0.84, p <0.001). In conclusion, our study highlights the low rate of OMT in stable CHD. Patients who received both OMT and revascularization achieved the greatest reduction in mortality and nonfatal MI. [ABSTRACT FROM AUTHOR]

Purpose: Previous studies have shown hematologists and medical oncologists may not accept the financial limits set by governing agencies on patient access to oral chemotherapy. The purpose of this study was to capture the methods physicians used to overcome barriers to accessing chemotherapeutic regimens for their patients. Methods: A total of 640 medical oncologists and hematologists across Canada were surveyed using a 13-item Web-based survey tool. The survey was delivered by e-mail with three follow-up reminders. After a response period of 3 months, results were collated and analyzed with descriptive statistics. Results: Of the 640 invitations, 568 were successfully delivered, and 183 responses were received (response rate, 32.0%). Among respondents, 101 treated solid malignancies (55.2%), 49 treated nonsolid malignancies (26.8%), and 33 treated both (18.0%). To overcome funding barriers, participating oncologists enrolled patients onto clinical trials (90.5%), used compassionate access programs (96.1%), and made special requests to government (91.8%). Other methods included writing false claims on forms to fit funding criteria for drugs (31.1%) and using leftover drug supplies (31.0%). Physicians felt their inability to obtain unfunded medications had a negative impact on their patients' clinical outcomes (56.0%) and psychosocial quality of life (73.0%). Only 28.5% of physicians contacted their governing body with concerns about oral chemotherapy funding. Conclusion: Canadian physicians use numerous methods to obtain unfunded oral chemotherapies, including falsifying claims on access forms and submitting special requests to government agencies. Further study is warranted to explore the disconnection between policymakers and physicians with regard to funding of oral chemotherapies. [ABSTRACT FROM AUTHOR]