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Kim L Lavoie,1–3 Gregory Moullec,1,2,4 Catherine Lemiere,2 Lucie Blais,2 Manon Labrecque,2 Marie-France Beauchesne,2 Veronique Pepin,2,4 André Cartier,2 Simon L Bacon1,2,41Montreal Behavioural Medicine Centre, 2Research Centre, Hôpital du Sacré-Cœur de Montréal – A University of Montreal Affiliated Hospital, Montréal, 3Department of Psychology, University of Quebec at Montreal (UQAM), Succursale Center-Ville, Montreal, 4Department of Exercise Science, Concordia University, Montreal, Quebec, CanadaPurpose: Daily adherence to inhaled corticosteroid (ICS) regimens is one of the most important factors linked to achieving optimal asthma control. Motivational interviewing (MI) is a client-centered communication style that focuses on enhancing intrinsic motivation to engage in appropriate self-management behaviors. MI has been shown to improve a variety of health behaviors including medication adherence in other disorders, but its efficacy for the improvement of ICS adherence in asthmatics has yet to be examined. This pilot “proof of concept” trial assessed the feasibility of MI to improve daily ICS adherence and asthma control levels in adult asthmatics.Methods: Fifty-four poorly controlled (Asthma Control Questionnaire [ACQ] score ≥1.5), highly nonadherent (filled

Extensive literature exists on potential risk factors for childhood asthma. To the authors' knowledge, no investigators have yet attempted to disentangle the effects of those determinants within a single study setting. The authors aimed to evaluate the independent effects of 47 potential determinants (from the prenatal, perinatal, and childhood periods) of asthma development in children within the first 10 years of life. From a Canadian birth cohort of 26,265 children (1990-2002), a 2-stage case-control study was conducted. In the first stage, 20 controls per case were selected from 3 administrative databases. In the second stage, selected mothers were mailed questionnaires for assessment of additional determinants. Increased risks of childhood asthma were found for > or =1 previous diagnosis of bronchopulmonary disease and atopic dermatitis in the child, oxygen administration after birth, prescription of antibiotics within the first 6 months of life, male gender, asthma during pregnancy, use of antibiotics during pregnancy, maternal receipt of social aid, paternal asthma, and asthma in siblings. Protective effects included use of intranasal corticosteroids during pregnancy, having a wood-burning fireplace, having pets in the home prior to the index date, breastfeeding, and day-care attendance. This study allowed the authors to identify, within a single setting, the most influential determinants of childhood asthma among 47 predictors assessed for the prenatal, perinatal, and childhood periods. [ABSTRACT FROM AUTHOR]

Background: The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in nephrology practice is increasingly becoming standard of care in patients with diabetes or those with proteinuria., Objectives: The primary outcome was to identify the proportion of pre-dialysis patients with chronic kidney disease (CKD) G3a, G3b, or G4 prescribed an SGLT2i and describe their characteristics., Methods: This was a retrospective, multicentric, cross-sectional study of patients with CKD followed at 4 pre-dialysis clinics in the province of Quebec, Canada. We collected data of multiple covariates associated with prescribing SGLT2i in patients over 18 years of age with CKD G3a, G3b, or G4. We then performed a multivariate logistic regression to assess their associations., Results: Of the 874 patients included, 22.7% were prescribed an SGLT2i. Factors most strongly associated included male sex (odds ratio [OR] = 4.88, 95% CI = 2.38-10.03), being prescribed metformin (OR = 4.30, 95% CI = 2.23-8.31), having type 2 diabetes (OR = 4.00, 95% CI = 1.86-8.62), or having an albumin-to-creatinine ratio greater than 300 mg/g (OR = 1.84, 95% CI = 1.08-3.14). The majority of patients (60.4%) had their SGLT2i initiated by the pre-dialysis clinic and the most frequent adverse event was an initial increase in serum creatinine 1 week after starting treatment (33.9%)., Conclusion and Relevance: An increasing number of patients with CKD are being prescribed SGLT2i. Nonetheless, significant disparities in sex, severity of disease, and comorbidities remain. We suggest that specific strategies be put in place to promote prescribing of SGLT2i in women and other at-risk populations, in particular among nephrology teams, to improve patient care., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sandrine Gaudreau, Aylon Wisbaum, Isabelle Cloutier, Pascale Robert, Regina Kolment, and Marie-France Beauchesne have no conflicts of interest to declare. Jodianne Couture has received funding from AstraZeneca, Amgen, and Otsuka Pharmaceuticals.

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients., Competing Interests: Financial/Nonfinancial Disclosures Members of the CTS COPD Guideline Panel declared potential conflicts of interest at the time of appointment, and these were updated throughout the process in accordance with the CTS Conflict of Interest Disclosure Policy. J. B. reports grants from McGill University, the McGill University Health Centre Foundation, the Canadian Institute Health Research, Grifols, Novartis, Sanofi, and the Respiratory Health Network of the Fonds de la recherche en santé du Québec; grants and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, and Trudell Canada Ltd; and personal fees from Pfizer Canada Ltd, and COVIS Pharma Canada Ltd, outside the submitted work. M. B. reports personal fees and grants outside the submitted work from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme, the Canadian Institute Health Research, CHEST, The Lung Association of Alberta, The University of Alberta Hospital Foundation, Alberta Innovates Health Solutions, Valeo, and Covis. P. H. reports grants from the Canadian Institute Health Research, the Lung Association of Nova Scotia, the Nova Scotia Health Authority Research Fund, Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, Cyclomedica, Grifols, Respivant, and Vertex; and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Janssen, Merck, Novartis, Sanofi-Aventis, and Trudell, outside the submitted work. S. D. A. receives grants from CIHR. He has received speaking honoraria or has participated on advisory boards for GSK, AZ, Chiesi, and Sanofi. M-F. B. reports grants and personal fees from the Cercle du doyen (Faculté de pharmacie, Université de Montréal) and Astra Zeneca Canada Ltd. A. D. reports receiving research, consulting and lecturing fees from GlaxoSmithkline, Sepracor, Schering Plough, Altana, Methapharma, AstraZeneca, ONO pharma, Merck Canada, Forest Laboratories, Novartis Canada/USA, Boehringer Ingelheim (Canada) Ltd, Pfizer Canada, SkyePharma, and KOS Pharmaceuticals and Almirall, Sanofigenzyme and TEVA Canada, Valeopharma Canada. F. M. reports grants from AstraZeneca and GlaxoSmithKline, Boehringer Ingelheim, GSK, Sanofi, and Novartis, and personal fees for serving on speaker bureaus and consultation panels from GlaxoSmithKline, Grifols, and Novartis. He is financially involved with Oxynov, a company which is developing an oxygen delivery system. S. M. reports grants outside the submitted work from Canadian Institute of Health Research and Canadian Lung Association in partnership with Boehringer Ingelheim Canada Ltd and Astra Zeneca Canada Ltd. E. P. reports personal fees from COVIS Pharma, Sanofi Genzyme, Boehringer Ingelheim Canada Ltd, Astra Zeneca Canada Ltd, GlaxoSmithKline Canada Ltd, and Novartis; and grants from the Canadian Institute Health Research, the Saskatchewan Research Foundation, the Respiratory Research Centre, and Astra Zeneca Canada Ltd, outside the submitted work. D. D. S. reports personal fees from GlaxoSmithKline Canada Ltd, Boehringer Ingelheim, and AstraZeneca outside of the submitted work. J. W. reports personal fees from GlaxoSmithKline Canada Ltd and Astra Zeneca Canada Ltd and a grant from Fisher & Paykel, outside the submitted work. B. L. W. reports personal fees from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme and Covis Pharma Canada, outside of the submitted work. D. D. M. reports consultancy work with Alberta Health Services, Health Canada, Lung Saskatchewan, Ontario Ministry of Health and Long-Term Care, Saskatchewan Health Authority, Saskatchewan Ministry of Health, Yukon Health and Social Services; reports grants (managed by University of Saskatchewan) from AstraZeneca, Boehringer Ingelheim, Canadian Institute of Health Research, GlaxoSmithKline, Grifols Therapeutics, Lung Saskatchewan, Novartis, Sanofi-Aventis, Saskatchewan Health Research Foundation, Syneos Health, Schering-Plough; employee/roles with University of Saskatchewan, Deputy Editor - CHEST Journal, Board Member - Saskatchewan Health Research Foundation; outside the submitted work. None declared (A. L., A. V. D., S. B. K., J. D. M.)., (Copyright © 2023 Canadian Thoracic Society and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: e-MEDRESP is a novel web-based tool that provides easily interpretable information on patient adherence to asthma/chronic obstructive pulmonary disease (COPD) medications, using pharmacy claims data. This study investigated the feasibility of implementing e-MEDRESP in primary care., Material and Methods: In this 16-month prospective cohort study, e-MEDRESP was integrated into electronic medical records. Nineteen family physicians and 346 of their patients were enrolled. Counters embedded in the tool tracked physician use during the follow-up. Patient/physician satisfaction with e-MEDRESP was evaluated though telephone interviews and online questionnaires. The capacity of e-MEDRESP to improve adherence was explored using a pre-post analysis., Results: Overall, 245 patients had at least one medical visit during follow-up. e-MEDRESP was consulted by 15 (79%) physicians for 85 (35%) patients during clinic visits. Seventy-three patients participated in telephone interviews; 84% reported discussing their medication use with their physician; 33% viewed their e-MEDRESP report and indicated that it was easy to interpret. The physicians reported that the tool facilitated their evaluation of their patients' medication adherence (mean ± standard deviation rating: 4.8 ± 0.7, on a 5-point Likert scale). Although the pre-post analysis did not reveal improved adherence in the overall cohort, adherence improved significantly in patients whose adherence level was <80% and who were prescribed inhaled corticosteroids (26.9% [95% CI 14.3-39.3%]) or long-acting muscarinic agents (26.4% [95% CI 12.4-40.2%])., Conclusions: e-MEDRESP was successfully integrated in clinical practice. It could serve as a useful tool to help physicians monitor their patients' medication adherence.

Background: Achieving asthma control is often difficult, despite the availability of effective medications. Because of their expertise, regular contact with patients, and accessibility, community pharmacists can play an important role in helping patients manage uncontrolled asthma., Objective: To develop a community pharmacy-based intervention for improving asthma control in patients with uncontrolled moderate to severe asthma., Methods: A qualitative study involving two focus groups with six and five community pharmacists, respectively, five individual interviews with community pharmacists, and three individual interviews with asthma patients was conducted using semi-structured interview guides. Focus groups aimed to develop the first prototype of the intervention and the topics included criteria to identify patients with uncontrolled asthma, content of the intervention to manage uncontrolled asthma, and potential logistical issues. Interviews were subsequently conducted with individual pharmacists and asthma patients to evaluate the prototype and finalize the intervention. The interviews and focus group transcripts were analyzed thematically, using an iterative process., Results: In focus groups and interviews, the pharmacists discussed how they screen patients with uncontrolled asthma using prescriptions refills, their needs for a convenient tool to assess asthma control, the necessity to identify causes of uncontrolled asthma to guide asthma management strategies, and the importance of patient follow-up. During interviews, patients shared their interest for the commitment of pharmacists to managing asthma. The final intervention consists of structured face-to-face counselling sessions at community pharmacies, with six steps: screening of patients with potential uncontrolled moderate to severe asthma, assessment of asthma control, identification of the causes of uncontrolled asthma, strategies for controlling asthma, an optional follow-up at the next prescription refill, and a follow-up 3 months after the initial intervention., Conclusions: The patients and community pharmacists reached consensus on the intervention's key elements and provided support for implementing the intervention in community pharmacies., Competing Interests: None., (© 2022 The Authors.)

Background: False penicillin allergies lead to increased antimicrobial resistance, adverse effects, and health care costs by promoting the use of broad-spectrum antibiotics. The Infectious Diseases Society of America recommends the implementation of allergy testing., Objectives: The primary objective of this research was to estimate the number of pharmacist full-time equivalents (FTEs) required for an intervention aimed at determining penicillin allergy in hospitalized patients. Acceptance of pharmacists' suggestions on antibiotic therapy are described., Methods: A quasi-experimental study was conducted in a 712-bed university hospital involving hospitalized patients with a suspected penicillin allergy and an infection treatable with penicillin. The time required for the intervention, which included a questionnaire, penicillin allergy testing (skin-prick test, intradermal injection, and oral provocation test), and recommendations on antibiotic therapy were measured to calculate the number of pharmacist FTEs., Results: A total of 55 patients were included. Scarification allergy testing was performed on 37, intradermal allergy test on 33, and oral provocation test on 26 patients. The intervention ruled out penicillin allergy in 26 patients, with no serious adverse effects. The intervention was associated with a median weekly pharmacist FTE of 0.15 (interquartile range = 0.12-0.25). The acceptance of pharmacists' suggestions was high and led to 9 patients being switched to an antibiotic with a narrower spectrum of activity., Conclusions and Relevance: This study describes penicillin allergy testing and the number of median weekly hospital pharmacist FTEs required, which was approximately 0.15. These data may aid in the implementation of this safe intervention that promotes narrower-spectrum antibiotherapy.

Background: In recent years, there has been growing interest in studying asthma treatment escalation patterns in the real-world setting, particularly with the advent of expensive biologic therapies. Healthcare administrative claims databases can be used to study treatment escalation patterns at a population-level; however, the reported definitions for claims-based asthma treatment escalation are highly variable in the literature., Objective: The aim of this study was to develop an operational definition of treatment escalation in adults with asthma that can be applied to healthcare administrative data., Methods: A mixed-methods research design incorporating the Delphi process was used to establish an expert consensus for this definition. A multi-disciplinary expert panel participated in three iterative rounds of online questionnaires covering treatment escalation criteria inspired by a systematic review, which was conducted as part of this study. The final definition was constructed using criteria for which a 75% level of agreement was achieved among the experts., Results: We developed a claims-based treatment escalation definition that was adapted from the Global Initiative for Asthma (GINA) strategy. The definition comprised seven treatment steps, as well as escalation options for treatments that are not typically included in clinical guidelines. The definition also incorporated methods to identify treatments in severe asthma, such as oral corticosteroid maintenance therapy and chronic azithromycin use., Conclusions: The operational definition of treatment escalation developed in this study bridges the gap between clinical guidelines and real-world clinical practice and lays the groundwork for future observational studies on treatment escalation patterns among patients with asthma., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Community pharmacists are best placed to improve medication adherence because they frequently interact with patients and have been trained to manage medication-related problems. Therefore, it is essential to equip pharmacists adequately to detect non-adherent patients quickly and intervene to improve medication adherence., Objective: To design e-AdPharm, a tool that addresses unmet needs and barriers of community pharmacists to provide medication adherence support to patients with chronic diseases., Methods: A qualitative study using 4 focus group discussions with community pharmacists was conducted with a semi-structured interview guide and discussions lasting for 1-2 h. The discussions covered the barriers and needs of pharmacists related to medication adherence support provided to patients, their expectations of an electronic tool based on prescription refills to help them provide this support, and the design of the tool. Focus group data were coded and analyzed using an iterative process, with thematic and descriptive analyses., Results: Twenty-six community pharmacists participated. Lack of time and motivation from pharmacists and patients were common barriers to the provision of medication adherence support. Accordingly, community pharmacists wished to measure medication adherence quickly, provide easily interpretable data to patients on their medication use, and raise the patient's awareness of non-adherence. The pharmacists expressed their need to have an electronic tool to share medication adherence information with the treating physician. Regarding the design of e-AdPharm, the pharmacists wanted a table displaying medication adherence with a color code representing adherence level. They also stressed the importance of a structured section enabling them to continuously document the interventions made and the need for patient follow-ups., Conclusions: e-AdPharm meet the needs and overcome the barriers of community pharmacists to provide medication adherence support to their patients. Future studies should examine the feasibility of implementing e-AdPharm in community pharmacies and test its efficacy for improving medication adherence., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the effect of digital-based reading versus paper-based reading on reading comprehension among students, trainees, and residents participating in health professional education., Introduction: Several reviews have examined the effects of reading media on reading comprehension; however, none have considered health professional education specifically. The growing use of electronic media in health professional education, as well as recent data on the consequences of digital-based reading on learning, justify the necessity to review the current literature to provide research and educational recommendations., Inclusion Criteria: Studies conducted with health professions students, trainees, and residents individually receiving educational material written in their first language in a paper-based or a digital-based format will be considered. Studies conducted among participants with cognitive impairment or reading difficulties will be excluded. Observational, experimental and quasi-experimental studies that assess reading comprehension measured by previously validated or researcher-generated tests will be considered., Methods: Relevant studies will be sought from CINAHL, Embase, ERIC, Google Scholar, MEDLINE, PsycINFO, and Web of Science (SCI and SSCI), without date or language restrictions. Two independent reviewers will perform title and abstract screening, full-text review, critical appraisal, and data extraction. Disagreements will be resolved through discussion or with a third independent reviewer. Synthesis will occur at four levels (i.e., study, participant, intervention, and outcome levels) in a table format. Data will be synthesized descriptively and with meta-analyses if appropriate., Systematic Review Registration Number: PROSPERO CRD42020154519., Competing Interests: The other authors declare no conflict of interest., (Copyright © 2020 JBI.)

Background: Medication adherence in asthma and COPD is notoriously low. To intervene effectively, family physicians need to assess adherence accurately, which is a challenging endeavor. In collaboration family physicians and individuals with asthma or COPD, we aimed to explore the barriers and facilitators of assessing medication adherence in clinical practice (exploratory phase), and to develop a novel web-based tool (e-MEDRESP) that will allow physicians to monitor adherence using pharmacy claims data (development phase)., Methods: We used qualitative research methods and a framework inspired by user-centered design principles. Five focus groups were held: 2 with subjects ( n = 15) and 3 with physicians ( n = 20), and 10 individual interviews were conducted with physicians. In the exploratory phase, data were analyzed using thematic networks. In the development phase, we identified components to be included in an e-MEDRESP prototype through an iterative approach. The web-based e-MEDRESP tool was constructed by applying algorithms to pharmacy claims data that reflected end-users' recommendations through an informatics approach designed for electronic medical records., Results: The main barriers to assessing medication adherence included a lack of objective information regarding medication use and short duration of medical visits. Physicians emphasized that identifying patients at risk for nonadherence requires a team effort from pharmacists, respiratory therapists, and nurses. Subjects also agreed that the use of easily interpretable pharmacy claims data could be an important facilitator and contributed to the development of the e-MEDRESP prototype, which contains graphical representations of the adherence to respiratory controller medications and dispensing of rescue medications., Conclusions: The e-MEDRESP tool has the potential to allow physicians to measure adherence objectively and to facilitate patient-physician communication concerning medication use. Future studies are needed to evaluate the feasibility of implementing e-MEDRESP in clinical practice. It would be relevant to develop strategies that could facilitate the sharing of information presented in e-MEDRESP among primary care health professionals., Competing Interests: This study was funded by the Canadian Foundation for Innovation, AstraZeneca, and Omnimed. Dr Blais has disclosed relationships with AstraZeneca, GlaxoSmithKline, and Genentech. Dr Beauchesne has disclosed relationships with AstraZeneca, Boehringer-Ingelheim, and Novartis. Dr Lemière has disclosed relationships with AstraZeneca, GlaxoSmithKline, Sanofi Genzyme, and TEVA Innovation. Ms Yousif received a doctoral training award from the Fonds de Recherche du Québec – Santé. The other authors have disclosed no conflicts of interest., (Copyright © 2020 by Daedalus Enterprises.)

Competing Interests: Competing interests: Marie-France Beauchesne has received grant support and speaker fees from Novartis in the last 3 years. Catherine Lemiere has received grant support from AstraZeneca and Teva Innovation, consultancy fees from AstraZeneca, GlaxoSmithKline, Metapharm, Novartis, Sanofi and Teva Innovation in the last 3 years. Catherine Lemiere currently sits on the executive board of the Canadian Thoracic Society.

Background: Community pharmacists have direct access to prescription refill information and regularly interact with their patients. Therefore, they are in a unique position to promote optimal medication use., Objectives: To describe how community pharmacists in Quebec, Canada, identify nonadherent patients, monitor medication use and promote optimal medication adherence., Methods: An invitation to complete a web-based survey was published online through different platforms, including a Facebook pharmacists' group, an electronic newsletter, a pharmacy network forum and e-mail. The survey included questions on participant characteristics, methods used by pharmacists to identify nonadherent patients and monitor medication use and interventions they used to promote medication adherence., Results: In total, 342 community pharmacists completed the survey. The participants were mainly women (71.6%), staff pharmacists (56.7%) and aged 30 to 39 years (34.2%). The most common method to identify nonadherent patients was to check gaps between prescription refills (98.8%). The most common intervention to promote adherence was patient counselling (82.5%). The most common barriers to identifying nonadherent patients were lack of time (73.1%) and lack of prescription information (65.8%), whereas the most common barriers to intervening were anticipation of a negative reaction from their patients (91.2%) and lack of time (64%)., Conclusion: Lack of time and lack of prescription information are frequent challenges encountered by community pharmacists regarding effective monitoring and management of patients with poor medication adherence. Pharmacists could benefit from electronic tools based on prescription refills that would provide quick and easily interpretable information on their patients' medication adherence. Can Pharm J (Ott) 2020;153:xx-xx., Competing Interests: Conflict of interest statement:The authors have no conflicts of interest to declare., (© The Author(s) 2020.)

Aim: To evaluate the current opinion, experience and educational preferences of pharmacists in Quebec concerning pharmacogenomics. Method: A web-based survey containing 25 questions was sent to all Quebec pharmacists. Results: Most pharmacists were willing to advise patients (81%) and physicians (84%) on treatment choices based on pharmacogenomic test results after proper training. Only 31% had been previously exposed to pharmacogenomic test results, and 91% were favorable to pharmacogenomics training, with e-learning through interactive video sessions (69%). The preferred training session length was between 1 and 3 h (59%). Hospital pharmacists were more often exposed to pharmacogenomic tests (p < 0.0001) and more frequently advised patients on treatment choices (p < 0.001) than community pharmacists. Conclusion: Pharmacists remain favorable toward pharmacogenomics, but its use in clinical practice stays limited. Identifying the educational preferences of pharmacists may help in the development of educational programs to help them integrate pharmacogenomics in their clinical practice.

Background: Respiratory distress protocols (RDPs) are protocolized prescriptions comprised of 3 medications (a benzodiazepine, an opioid, and an anticholinergic) administered simultaneously as an emergency treatment for respiratory distress in palliative care patients in the province of Quebec, Canada. However, data on appropriate use that justifies the combination of all 3 components is scarce and based on individual pharmacodynamic properties along with expert consensus., Objectives: Our study aimed to evaluate the conformity and the effectiveness of RDPs prescribed and administered to hospitalized adult patients., Methods: This was a prospective and descriptive study conducted in a single center. Prescription and administration conformity were assessed based on predefined appropriateness criteria., Results: A total of 467 adult patients were prescribed a RDP, 175 administrations were documented, and 78 patients received at least 1 RDP. Prescription conformity was assessed on 1473 separate occasions over the trial period. Overall prescription conformity was found to be 37% (95% confidence interval [CI]: 33.6-40.4), and administration conformity was 37.7% (95% CI: 26.2-50.7). Low administration conformity was primarily explained by incorrect indications for RDP use. Seemingly important determinants of higher conformity were prescriber's speciality in palliative care, use of preprinted orders, pharmacist involvement, and hospitalization in the palliative care unit., Conclusion: This study highlights important gaps in the use of RDPs in our institution. Health-care provider training appears necessary in order to ensure adequate conformity and allow for further evaluation of RDP effectiveness.

Background: Several epidemiological studies have suggested that the risk of depression is increased in patients with asthma, but the impact of asthma during pregnancy on postpartum depression remains unknown., Objective: To assess the association between maternal asthma and postpartum depression in a population-based cohort study retrieved from administrative databases., Methods: A cohort of 35,520 pregnancies in women with asthma during pregnancy and 197,057 pregnancies in women without asthma who delivered between 1998 and 2009 was extracted from the Quebec Asthma and Pregnancy Database. They were followed from the day of delivery up to 1 year postpartum. A generalized estimating equation model was used to estimate the adjusted odds ratios of postpartum depression with 95% CIs in women with asthma during pregnancy versus women without asthma., Results: Postpartum depression within 1 year after delivery occurred in 6.1% of women with asthma versus 2.9% of women without asthma. After adjusting for several potential confounders, including depression/postpartum depression up to 10 years before pregnancy, we found that women with asthma were 58% more likely to experience postpartum depression within 1 year after delivery than women without asthma during pregnancy (adjusted odds ratio, 1.58; 95% CI, 1.50-1.67)., Conclusions: Our findings suggest that women with asthma are more likely to suffer from postpartum depression. A close monitoring of signs of depression for pregnant women with asthma is indicated, allowing prompt and efficient interventions if needed., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Inhaler technique and patient preferences are often overlooked when selecting maintenance treatments for patients with chronic obstructive pulmonary disease (COPD), but are important issues in ensuring drug efficacy and patient adherence. Few data on these issues are available for new inhalation devices., Objectives: To evaluate the inhalation techniques for the HandiHaler ® , Breezhaler ® , Genuair ® , and Respimat ® inhalation devices, and patient preferences for the three latter inhalers that were recently developed., Methods: A prospective two-center cross-sectional study of COPD patients was conducted. The patients were required to be current HandiHaler users who had not previously used the new inhalers (Breezhaler, Genuair, Respimat). The patients were given the new devices and asked to identify the one they preferred before and after using the inhaler. Each patient tried the HandiHaler and two devices out of the three new inhalers: one preferred by the patient and one imposed by the investigator. Their inhalation technique was evaluated using an assessment checklist. A logistic regression model was used to determine which device was used with the fewest errors., Results: Of the 98 patients who completed the study, 57.1% (95% CI: 47.4-66.9) had an adequate HandiHaler technique. There was no difference between the proportions of patients with an adequate Breezhaler and Genuair inhalation technique (aOR 1.08, 95% CI: 0.51-2.30), but 62% fewer patients using Respimat had an adequate technique than those using Genuair (aOR for adequate technique 0.38, 95% CI: 0.18-0.82). There were no significant differences in the initial patient preferences for the three new inhalers, and no association between the patient's preference and an adequate inhaler technique., Conclusion: Inhalation techniques were suboptimal and varied between inhalers. The arrival of new inhalers is an opportunity to reassess patient techniques and preferences. Further studies should also explore the association between the inhaler preferences and treatment adherence of patients.

The objective of this study is to evaluate whether a chronic obstructive pulmonary disease (COPD) self-management education program with coaching of a case manager improves patient-related outcomes and leads to practice changes in primary care. COPD patients from six family medicine clinics (FMCs) participated in a 1-year educational program offered by trained case managers who focused on treatment adherence, inhaler techniques, smoking cessation, and the use of an action plan for exacerbations. Health-care utilization, health-related quality of life (HRQL), treatment adherence, inhaler technique, and COPD knowledge were assessed at each visit with validated questionnaires. We also evaluated whether the use of spirometry and the assessment of individual patient needs led to a more COPD-targeted treatment by primary care physicians, based on changes in prescriptions for COPD (medication, immunization, and written action plan). Fifty-four patients completed the follow-up visits and were included in the analysis. The number of unscheduled physician visits went from 40 the year before intervention to 17 after 1 year of educational intervention ( p = 0.033). Emergency room visits went from five to two and hospitalizations from two to three (NS). Significant improvements were observed in HRQL ( p = 0.0001), treatment adherence ( p = 0.025), adequate inhaler technique ( p < 0.0001), and COPD knowledge ( p < 0.001). Primary care physicians increased their prescriptions for long-acting bronchodilators with/without inhaled corticosteroid, flu immunizations, and COPD action plans in the event patient had an exacerbation. The COPD self-management educational intervention in FMCs reduced unscheduled visits to the clinic and improved patients' quality of life, self-management skills, and knowledge. The program had a positive impact on COPD-related practices by primary care physicians in the FMCs.

Background: Maternal asthma has been found to be associated with an increased risk of hypertensive disorders of pregnancy (HDP), that is, gestational hypertension, preeclampsia, and eclampsia. There is limited data, however, regarding the relationship between the use of long-acting beta-agonists (LABAs) during pregnancy and these outcomes., Objective: To investigate whether exposure to a LABA in addition to an inhaled corticosteroid increases the risk of HDP or preeclampsia/eclampsia, as compared with nonexposure to LABAs, in pregnant women with asthma., Methods: A cohort of 8,936 pregnancies in women with asthma who delivered between 1998 and 2010 was reconstructed using Quebec (Canada) health administrative databases. Cox proportional hazard regression models, adjusted for potential confounders, were used for statistical analyses. The primary exposure was LABA use (yes/no) measured on the first day of the 20th week of pregnancy. HDP were identified on the basis of recorded diagnoses and on prescriptions of antihypertensive drugs filled on or after the first day of week 20 of gestation., Results: There were 567 (6.3%) cases of HDP and 256 (2.9%) cases of preeclampsia/eclampsia in the cohort, and the rates of both disorders were similar in women exposed or not exposed to LABAs. LABA use was not associated with increased risks of HDP (adjusted hazard ratio, 0.96; 95% CI, 0.69-1.33) or preeclampsia/eclampsia (adjusted hazard ratio, 0.89; 95% CI, 0.53-1.50)., Conclusions: The results of this study provide evidence suggesting the safety of LABAs for the treatment of asthma in pregnancy, in terms of the risks of HDP and preeclampsia/eclampsia., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: No studies have examined adherence or persistence to long-acting anticholinergics (LAAC) treatment episodes in patients with chronic obstructive pulmonary disease (COPD)., Objective: To estimate 1-year adherence and 5-year persistence to LAAC during treatment episodes, and the likelihood of initiating a subsequent treatment episode., Methods: A retrospective cohort of LAAC-treated COPD patients was reconstructed from Quebec databases. A treatment episode was initiated at cohort entry, defined as the first LAAC prescription date on/after the first COPD diagnosis date recorded between October 1, 2003, and March 31, 2014. We identified a subsequent treatment episode up to 5 years after the end of the episode initiated at cohort entry. We measured adherence as the proportion of days covered over 1 year. Persistence was defined as prescription renewal within 90 days of the previous prescription and was plotted using Kaplan-Meier curves over 5 years. The 5-year hazard and cumulative incidence of initiating a subsequent episode were estimated with survival analyses. We compared adherence and persistence between the treatment episodes using t and log-rank tests., Results: The cohort included 113 435 COPD patients. Adherence and persistence to LAAC were significantly lower in the subsequent treatment episode (55% vs 63%; P < 0.0001). The likelihood of initiating a subsequent episode was greatest immediately after the cessation of the initial episode, with 59% of patients starting a subsequent episode within 1 year., Conclusion: Adherence and persistence to LAAC were lower in the subsequent treatment episode. Interventions should be offered quickly after LAAC cessation.

Several authors have studied predictors of outcomes following a hospitalization for chronic obstructive pulmonary disease (COPD); however, few have reported outcomes following a first hospitalization for COPD. The objective is to develop a predictive mortality risk model in patients surviving a first hospitalization for COPD. This is a retrospective cohort study using linked administrative and clinical data. The cohort included 1129 patients of 40-84 years, discharged alive from a hospitalization for COPD in a regional hospital (Sherbrooke, Canada) between 04/2006 and 03/2013 and to whom were prescribed at least two COPD drugs during their hospitalization. One-year mortality was analysed using logistic regression on a derivation sample and validated on a testing sample. In total, 141 (12.5%) patients died within one year from discharge of their first hospitalization for COPD. Predictors were: older age (OR (95% CI): 1.055 (1.026-1.085)), male sex (OR (95% CI): 1.474 (0.921-2.358)), having a severe COPD exacerbation (OR (95% CI): 2.548 (1.571-4.132)), higher hospital length of stay (OR (95% CI): 1.024 (0.996-1.053)), higher Charlson co-morbidity index (OR (95% CI): 1.262 (1.099-1.449)), being diagnosed of cancer (OR (95% CI): 2.928 (1.456-5.885)), the number of prior all-cause hospitalizations (OR (95% CI): 1.323 (1.097-1.595)), and a COPD duration exceeding 3 years (OR (95% CI): 1.710 (1.058-2.763)). A simple clinical prognosis tool is proposed and shows good discrimination in both the derivation and validation cohorts (c-statistic >0.78). One over eight patients discharged alive from a first COPD hospitalization will die the following year. It is thus important to identify higher-risk patients in order to plan and manage appropriate treatment.

Approximately 15-20% of patients with chronic obstructive pulmonary disease (COPD) also display characteristics of asthma. In May 2014, the asthma-COPD overlap syndrome (ACOS) was briefly addressed in the Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy documents. We evaluated how pulmonologists diagnose and treat ACOS and how they assess its control. Pulmonologists from two university healthcare centers, having ≥ 1 year experience, treating patients with asthma, COPD, or ACOS, were invited to participate in focus groups. Two focus groups (1 hour duration) were convened with seven and five participants, respectively. According to pulmonologists from both institutions, ACOS is a new name for an existing syndrome rather than a new disease. It is characterized by incomplete reversible airflow limitations and changes in forced expiratory volume in one second over time. The pulmonologists noted that its diagnosis must be based on clinical characteristics, pulmonary function test results, and clinical intuition. To diagnose ACOS, pulmonologists must rely on their clinical judgment. They also agreed that the treatment of patients with ACOS should target the features of both asthma and COPD. Pulmonologists from both institutions used asthma control criteria to assess ACOS control. A deeper understanding would enable clinicians to establish specific criteria for the diagnosis, treatment, and follow-up of subjects with ACOS.

Social sciences are important for training in pharmacy faculties. The course set up at the Faculty of Pharmacy of the University of Montreal in 2011 is a very innovative way to meet this challenge. The purpose of this report is to share this experience by providing a synthetic description. Many students were able to develop new skills and strengthen their skills, including leadership and critical thinking. The Faculty of Pharmacy was also able to achieve greater visibility in the Montreal community, that is to say from the associations, but also with what is out there called the "local health network" linking various health care professionals and institutions. Beyond the quantifiable results, this course is an evolving learning process in which the group interactions, individual and collective values and the task sharing allow students to build a working knowledge of social factors, which d.etermine health problems.

Purpose: Several factors have been associated with the prescription of direct oral anticoagulants (DOAC) over warfarin such as younger age, fewer concomitant medications, and lower CHADS2 or bleeding scores. The primary objective of this study was to identify predictors of DOAC choice compared with warfarin for patients who are starting a new oral anticoagulant (OAC) for atrial fibrillation (AF). The secondary objective was to describe the proportion of DOAC prescriptions in new users of OAC for AF., Methods: A retrospective cross-sectional study was conducted in a teaching hospital in Canada. Medical records of adult patients hospitalized in any medical units between October 1st, 2011 and October 1st, 2014, who were newly prescribed an OAC for non valvular AF were systematically reviewed. Baseline characteristics of warfarin and DOAC users were compared and a multivariate logistic regression analysis was completed to identify predictors of DOAC use. Variables included in the multiple regression analysis were: age, hypertension, diabetes, history of stroke or transient ischemic attack, coronary artery disease, peripheral arterial disease, CHADS2 score of 2 or more, creatinine clearance 30mL/min or more, polypharmacy, concomitant use of ASA or clopidogrel, and prescription by a neurologist., Results: Among OAC users (144 patients on DOAC and 295 patients on warfarin), older age (odds ratio [OR] 0.97; 95%CI 0.95-0.98), peripheral arterial disease (OR: O.41;95%CI: 0.21-0.82), polypharmacy (OR: 0.30;95%CI:0.10-0.89), and concomitant use of clopidogrel (OR: 0.19;95%CI:0.07-0.56) decreased the probability of DOAC use. Prescription by a neurologist (OR: 2.77;95%CI:1.34-5.76) and an estimated creatinine clearance of at least 30mL/min (OR: 3.53;95%CI:1.18-10.57) increased the likelihood of DOAC prescription., Conclusion: To the best of our knowledge, this is the first observational study finding that concomitant use of clopidogrel reduced the likelihood of DOAC utilization while prescription by a neurologist increased the probability of receiving a DOAC over warfarin in patients with AF.This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page.

Purpose: There are very few studies on primary adherence (i.e., first filling of a prescription) to inhaled corticosteroids (ICS) in asthma patients; two have involved children. Moreover, adherence can be overestimated when considering only secondary adherence (i.e., following the medication recommendations for a defined period) and ignoring primary adherence. We aimed thus to evaluate the real-world primary and secondary adherence to ICS and to develop an integrated primary and secondary adherence (IPSA) measure., Methods: From two clinical databases of pediatric and adult asthma patients, we included 198 children and 206 adults with one ICS prescription recorded in their medical chart between 2010 and 2012 and follow-up data for ≥12 months. Adherence was estimated from written prescriptions and prescription claims data. Primary adherence was defined as filling the ICS prescription at a pharmacy within 12 months. Secondary adherence was defined as the proportion of days covered (PDC) in subjects who filled their prescription at least once. The IPSA was based on the PDC with a correction factor for primary adherence., Results: Primary adherence to ICS at 12 months was 89.4 % in children and 69.4 % in adults. Secondary adherence at 12 months in children was 33.9 %, and the IPSA was 30.3 %. These values were 52.8 and 36.6 %, respectively, in adults., Conclusions: Primary adherence to ICS is low in adults and secondary adherence is poor in children and adults. Using the PDC as a unique measure of adherence led to significant overestimation in adults; IPSA leads to more valid estimates of adherence to ICS.

Atrial fibrillation (AF) is a common cardiovascular disease for which newer oral anticoagulants are available. The main objective of this study was to evaluate the appropriateness in prescriptions of direct oral anticoagulant (DOACs), more specifically apixaban, dabigatran and rivaroxaban. This was a singlecentre, retrospective study conducted in the province of Quebec, Canada. Adult subjects hospitalized between October 2011 and October 2014, with a diagnosis of AF, and a DOAC prescription were included. Data were retrieved from the electronic medical records and prescriptions were evaluated according to appropriateness criteria. A total of 500 subjects were included (235 subjects on dabigatran,222 on rivaroxaban and 43 on apixaban). Overall, 70.4% (95% confidence interval [Cl] 66.4-74.1) of DOAC prescriptions were considered appropriate. About 24% of subjects received an inappropriate dose of apixaban, dabigatran or rivaroxaban. A reduced dose was prescribed in 56.8% of subjects with no clearindication, and 43.2% received a dose that was not reduced while indicated. DOACs were frequentlyprescribed at a dose that was considered inappropriate. There is a need to strengthen dosing recommendations of DOACs in clinical practice.

Background: Few studies have identified patterns and predictors of use of direct oral anticoagulants for venous thromboembolism (VTE)., Objective: To describe the use of anticoagulants and assess predictors associated with the prescription of rivaroxaban over vitamin K antagonist (VKA) for the subsequent treatment of VTE., Methods: This cross-sectional study was built with all consecutive patients newly diagnosed with acute VTE admitted between February 18, 2013, and September 18, 2013, in an academic tertiary care center in Quebec, Canada. Patient characteristics and VTE treatments were described. Univariate analyses and a multiple forward stepwise logistic regression were performed to assess predictors of rivaroxaban use over VKA for the subsequent treatment of VTE., Results: The study included 256 patients, 36.7% with a diagnosis of deep vein thrombosis (DVT) and 63.3% with pulmonary embolism (PE). Mean age was 63.1 years, and 28.1% of patients had cancer-associated VTE. Overall, rivaroxaban was prescribed in 1.6% of patients for the initial treatment and in nearly 20% of patients for the subsequent treatment of VTE. Low-molecular-weight heparin and VKA were mostly prescribed. Independent predictors associated with the prescription of rivaroxaban over VKA were as follows: age < 65 years (OR: 2.86, 95% CI 1.29-6.37), a diagnosis of DVT versus PE (OR 2.54, 95% CI 1.20-5.40), and an emergency department visit rather than a hospitalization (OR 2.24, 95% CI 1.06-4.71)., Conclusion: Several months following its availability, rivaroxaban was rarely prescribed for acute VTE disease. It also appears to be prescribed in different patient populations than VKA., (© The Author(s) 2015.)

Background: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in Canada. Most patients with COPD receive long-term treatment with long-acting anticholinergics (LAAC) and/or long-acting β2-agonists (LABA). Adverse events (AEs) are also likely during long-term treatment with these medications., Objective: To evaluate the prevalence of AEs in COPD patients on LAAC and LABA in a real-world setting., Methods: We conducted a cross-sectional study of patients enrolled in the Registre de Données en Santé Pulmonaire (RESP) database, which records information on Canadian patients with asthma or COPD. COPD Patients completed a questionnaire about AEs that may be associated with LAAC and/or LABA. The prevalence of AEs and the corresponding 95% CI were calculated for three groups of patients (LAAC + LABA, LAAC alone, and LABA alone)., Results: Most patients with COPD (n = 154) were current or ex-smokers. Over 50% of patients were overweight or obese, and had an annual family income of less or equal to $42,000. Dry mouth (55.2%, 40%, and 43.5%) and dry throat (33.6%, 26.7%, and 34.8%) occurred most of the time or always in the LAAC + LABA, LAAC, and LABA groups, respectively. Headache was reported by 17.4% of patients in the LABA group, but less than 11.2% in the other groups., Conclusion: AEs reported in this study deserve clinical attention because they may negatively affect quality of life and treatment adherence of COPD patients., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Oxaliplatin plays a major role in the treatment of colorectal cancer (crc), but is associated with the development of neuropathies. The main objective of the present prospective study was to estimate the proportion of participants with grade 1, 2, 3, or 4 peripheral sensory neuropathies according to the U.S. National Cancer Institute's Common Terminology Criteria for Adverse Events (version 4) among crc patients treated with oxaliplatin (adjuvant or metastatic, folfox or xelox regimens) at the Centre hospitalier universitaire de Sherbrooke. Among the 57 patients so treated between May 2012 and April 2013, about 60% reported grade 2 neuropathy, at maximum, during treatment. About 25% of patients had to stop treatment because of neuropathies. In a subset of patients contacted approximately 22 months after treatment cessation, neuropathies persisted in 70%. Oxaliplatin-induced neuropathy affects a significant number of crc patients and can influence the course of treatment and outcomes.

Background: Our previous work on the association between maternal asthma and congenital malformations was based on cohorts formed by women with public drug insurance, i.e., over-represented by women with lower socioeconomic status, questioning the generalizability of our findings. This study aimed to evaluate whether or not drug insurance status, as a proxy of socioeconomic status, is an effect modifier for the association between maternal asthma and major congenital malformations., Methods: A cohort of 36,587 pregnancies from asthmatic women and 198,935 pregnancies from nonasthmatic women selected independently of their drug insurance status was reconstructed with Québec administrative databases (1998-2009). Asthmatic women were identified using a validated case definition of asthma. Cases of major congenital malformations were identified using diagnostic codes recorded in the hospitalization database. Drug insurance status at the beginning of pregnancy was classified into three groups: publicly insured with social welfare, publicly insured without social welfare, and privately insured. Adjusted odds ratios were estimated with generalized estimation equations, including an interaction term between maternal asthma and drug insurance status., Results: The prevalence of congenital malformations was 6.8% among asthmatic women and 5.8% among nonasthmatics. The impact of asthma on the prevalence of congenital malformations was significantly greater in women publicly insured with social welfare (odds ratio = 1.42; 95% confidence interval, 1.25-1.61) than in the other two groups ([odds ratio = 1.10; 1.00-1.21] in the publicly insured without social welfare and [odds ratio = 1.13; 1.07-1.20] in the privately insured group)., Conclusion: The increased risk of major congenital malformation associated with asthma was significantly higher among pregnant women publicly insured with social welfare than among those privately insured. As a result of this effect modification by drug insurance status, findings from Québec observational studies using databases mainly formed of patients publicly insured with social welfare may not be generalized to the entire population., (© 2015 Wiley Periodicals, Inc.)

Background: Although it is a key-recommendation of all recent asthma guidelines, self-management education is still insufficiently offered in primary care settings., Aims of the Study: To demonstrate the benefits of an educational program offered at the site of primary care (Family Medicine Clinics- FMC) by trained asthma educators on patient outcomes and healthcare use., Methods: This was a one-year pre-post intervention study. Patients with a diagnosis of mild to moderate asthma were enrolled from six FMC. After an initial encounter by the educator, an assessment of educational needs and a spirometry were done, followed by 3 follow-up visits at 4-6 weeks, 4-6 months and one year. Expiratory flows, asthma control criteria, knowledge about asthma, adherence to medication and healthcare and medication use were assessed at each visit., Results: Data from 124 asthma patients (41M/83F), aged 55 ± 18 years, were analyzed. After initiating the intervention, there was a progressive increase in asthma knowledge and an improvement in medication adherence. The number of unscheduled visits for respiratory problems went from 137 to 33 (P < 0.0001), the number of antibiotic treatments from 112 to 33 (P = 0.0002) and the number of oral corticosteroids treatments from 26 to 8 (NS). Marked improvements were observed in regard to inhaler technique and provision of a written action plan., Conclusion: This study shows that an educational intervention applied at the site of primary care can result in significant improvements in patient asthma outcomes and reduce unscheduled visits and inappropriate use of medications such as antibiotics., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: We previously reported an increased prevalence of any congenital malformation among women experiencing moderate-to-severe asthma exacerbations during the first trimester of pregnancy, based on a study in which 90.1% of the cohort of women were social welfare recipients. This study re-examined the association between asthma exacerbations and congenital malformations in a new large representative cohort of asthmatic pregnant women., Methods: A cohort of 36 587 pregnancies in asthmatic women was reconstructed from Québec Province administrative databases (1998-2009). Occurrences of asthma exacerbations during the first trimester of pregnancy were assessed and categorised into severe, moderate and no such exacerbations. For comparison, we also considered moderate and severe asthma exacerbations combined. Congenital malformations were identified using diagnoses recorded in the hospitalisation database. Generalised estimation equations were used to estimate adjusted ORs of congenital malformations., Results: The prevalence of any congenital malformation was 19.1%, 11.7% and 12.0% among women with severe, moderate and no such exacerbations during the first trimester, respectively. The adjusted OR for all malformations was 1.64 (95% CI 1.02 to 2.64) when women with severe exacerbations were compared with those in the reference group, while no association was seen for moderate exacerbations. Also, no association was observed between cases of moderate and severe asthma exacerbations combined and any congenital malformation., Conclusions: Only severe asthma exacerbations were found to significantly increase the risk of congenital malformations in this representative study. Previous studies possibly overestimated the risk because they were based mainly on women at a lower socioeconomic status., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Current recommendations for managing persistent asthma during pregnancy when low-dose inhaled corticosteroids (ICSs) are insufficient include adding a long-acting β₂-agonist (LABA) or increasing the ICS dose. However, there are no data to help clinicians evaluate the safest regimen during pregnancy., Objective: We sought to compare the risk of major congenital malformations in asthmatic women exposed to a LABA plus ICS combination and those exposed to ICS monotherapy at higher doses during the first trimester., Methods: A cohort of asthmatic pregnant women exposed to ICSs during the first trimester who delivered between January 1990 and March 2009 was established. The primary outcome was major malformation recorded at birth or during the first year of life. Two subcohorts were established as follows: (1) users of a LABA plus low-dose ICS combination or users of a medium-dose ICS and (2) users of a LABA plus medium-dose ICS combination or users of a high-dose ICS. Generalized estimating equations were used to compare the risk of major malformations between the groups., Results: In one subcohort there were 643 women who used a LABA plus low-dose ICS and 305 who used a medium-dose ICS; the other subcohort included 198 users of a LABA plus medium-dose ICS and 156 users of a high-dose ICS. The prevalence of major malformations was 6.9% and 7.2%, respectively. The adjusted odds ratio for major malformations was 1.1 (95% CI, 0.6-1.9) when a LABA plus low-dose ICS was used compared with a medium-dose ICS and 1.2 (95% CI, 0.5-2.7) when a LABA plus medium-dose ICS was used compared with a high-dose ICS., Conclusion: The risk of major malformations was similar with a LABA plus ICS combination and ICS monotherapy at higher doses, suggesting that both therapeutic options can be considered during pregnancy., (Copyright © 2014 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Novel oral anticoagulants are available for the management of atrial fibrillation and are considered more convenient to use than warfarin., Objective: The main objective of this study was to describe patterns of oral anticoagulant use in the 6 months period following the availability of dabigatran at our hospital., Methods: A cross-sectional study was conducted in a single University hospital in the province of Québec, Canada. Medical records of subjects on oral anticoagulants for atrial fibrillation that were hospitalized between October 1st, 2011 and March 31th, 2012 were reviewed. Type of use (prevalent, incident and switch) and patient's characteristics of warfarin and dabigatran users were compared using Chi-squared and T-tests., Results: In the 6-month period following dabigatran availability in the hospital, 59 patients (13%) were on dabigatran and 388 (87%) on warfarin. Mean CHADS2 score, mean age and mean number of chronic medications were lower in the dabigatran group. The percentage of patients with coronary artery disease was lower and renal function was higher in the dabigatran group., Conclusion: Dabigatran use remained low in the first 6 months period following the approval of dabigatran at our hospital, which could be explained by limited data on the efficacy and safety of this agent in subjects with multiple comorbidities.

Objectives and Hypotheses: Adherence to inhaled corticosteroids (ICS) is a major issue in asthma. This study aimed to estimate the accuracy of the days' supply and number of refills allowed, variables recorded in Québec claims databases and used to estimate adherence, and to develop correction factors, if required. We hypothesised that the accuracy of the days' supply for ICS would be low whereas the accuracy of the number of refills allowed would be high., Setting: 40 community pharmacies in Québec (Canada) and a medication registry., Participants: We collected data for 1108 ICS original prescriptions stored in the 40 pharmacies (sample 1), and we obtained a second sample of 2676 ICS prescriptions selected from reMed, a medication registry (sample 2)., Primary and Secondary Outcomes: We estimated the concordance of the days' supply and number of refills between Québec claims databases and the original prescription from sample 1. We developed a correction factor for the days' supply in sample 1 and validated it in sample 2. Analyses were stratified by age: 0-11 and 12-64 years., Results: In sample 1, the concordance for the days' supply was 39.6% (95% CI 37.6% to 41.6%) in those aged 0-11 years and 56% (54.9% to 57.2%) in those aged 12-64 years. The concordance increased to 59.4% (58.2% to 60.5%) in those aged 0-11 years and 74.2% (73.5% to 74.9%) in those aged 12-64 years after applying the correction factors in sample 2. The concordance for the refills allowed was 92.1% (91% to 93.1%) in those aged 0-11 years and 93.1% (92.5% to 93.7%) in those aged 12-64 years in sample 1., Conclusions: The accuracy of the days' supply was moderate among those aged 0-11 years and substantial among those aged 12-64 years after applying the correction factors. The accuracy of the number of refills was almost perfect in both groups., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Asthma exacerbations are common during pregnancy with a prevalence as high as 51.9% among women with severe asthma., Objective: To compare the treatment of asthma exacerbations in an acute-care setting during and outside of pregnancy., Methods: We formed a cohort of women who sought medical care for an asthma exacerbation at a teaching hospital during or in the year preceding pregnancy, between 1998 and 2008. An exacerbation was composed of one or more medical encounters in an acute-care setting (hospital-based outpatient clinic, emergency department, or during hospitalization). Data were retrieved from medical charts and health administrative databases. We compared the use of systemic corticosteroids (SCSs) during and outside of pregnancy with a Cox proportional hazards model., Results: The cohort was formed of 39 women who had 40 exacerbations during and 39 exacerbations outside of pregnancy. Use of SCSs to treat exacerbations was less frequent (adjusted hazard ratio: 0.51; 95% CI: 0.31-0.84) during pregnancy. Moreover, upon the first medical encounter related to the exacerbation, SCSs, when administered, were given less frequently to women when pregnant than when non-pregnant (83% vs. 100%). The SCS prescription was filled at the community pharmacy 65% and 67% of the time when it was prescribed at discharge to women when pregnant than when non-pregnant, respectively., Conclusion: We observed a reduced and delayed use of SCSs for the treatment of asthma exacerbations in women when pregnant than when non-pregnant, with similar numbers of women in both conditions filling their SCSs prescription in pharmacies., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Recent asthma guidelines endorse the safety of long-acting β2-agonists (LABAs) and of mild and moderate doses of inhaled corticosteroids (ICSs) when required to control asthma during pregnancy, yet do not state a preferred medication within each class., Objective: To estimate the relative perinatal safety with the use of salmeterol and formoterol (LABAs) and that of fluticasone and budesonide (ICSs) during pregnancy., Methods: A subcohort of pregnancies from asthmatic women was selected from health care administrative databases of Quebec, Canada. Low birth weight (LBW) was defined as weight less than 2,500 g, preterm birth (PB) as delivery before 37 weeks of gestation, and small for gestational age (SGA) as a birth weight below the 10th percentile. The effect of treatment with salmeterol vs formoterol and fluticasone vs budesonide on the outcomes was determined with generalized estimating equation models., Results: The LABA and ICS subcohorts were composed of 547 (385 salmeterol and 162 formoterol users) and 3,798 (3,190 fluticasone and 608 budesonide users) pregnancies, respectively. No statistically significant differences were observed for LBW (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.44-1.88), PB (OR, 1.11; 95% CI, 0.56-2.23), and SGA (OR, 1.16; 95% CI, 0.67-2.02) newborns between women exposed to salmeterol vs formoterol or between women exposed to fluticasone vs budesonide (LBW: OR, 1.08; 95% CI, 0.76-1.52; PB: OR, 1.07; 95% CI, 0.78-1.49; and SGA, OR: 1.10; 95% CI, 0.85-1.44)., Conclusion: This study does not provide evidence of greater perinatal safety for one LABA or one ICS over the other., (Copyright © 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the quality of glycemic control in patients in intensive care units (ICUs) treated with an intravenous (IV) insulin infusion at a teaching hospital., Method: This retrospective study included patients admitted to the ICU and treated with an IV insulin infusion for at least 12 h between August 1 and November 30, 2011. Medical charts were reviewed. The primary quality indicator for glycemic control was the mean percent of blood glucose values per patient in the 6.1 to 8 mmol/L target range., Results: A total of 351 patients were included; 61.5% of subjects had no known diabetes. Admissions were mainly for surgery (61.3%). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 16.8±7.3. The mean percent of blood glucose values per patient in the 6.1 to 8 mmol/L range was 35% for all subjects and 26.2% for patients with diabetes. If a target of 6.1 to 10 mmol/L was considered, those values became 63% and 54.6%. At least 1 episode of hyperglycemia (>10 mmol/L), hypoglycemia (<4 mmol/L) or severe hypoglycemia (<2.2 mmol/L) was documented in 68%, 9% and 1% of subjects, respectively. Glycemic variability (SD) was 1.9 mmol/L, and the median hyperglycemic index was 0.77 (interquartile [IQ]: 0.24 to 1.63)., Conclusion: The quality of glycemic control in patients in the ICU at our hospital needs to be improved. A new computerized IV insulin protocol is currently being tested., (Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Objective: Insulin is regularly used in hospitalized patients for glycemic control but is associated with significant risks. The goals of this study were to describe the strengths and weaknesses of a university health centre in the safe use of insulin, to collect improvement proposals from health professionals involved in the management of insulin therapy and to assess inpatient glycemic control., Methods: This is a qualitative study. Physicians, nurses and pharmacists practising at the Centre Hospitalier Universitaire de Sherbrooke (CHUS) for at least 2 years were invited to join focus groups on safe insulin treatment. Themes up for discussion were roles of professionals in insulin therapy, problems encountered, solutions put forward and strengths of the hospital. The Quality Hyperglycemia Score (QHS) was assessed using an existing cohort of inpatients who were prescribed insulin., Results: A total of 5 focus groups were held in February and March of 2012, involving 31 healthcare professional participants. Several groups pointed out the same problems, namely, lack of access to useful information for optimal management of insulin therapy and lack of communication among personnel on different work shifts. Results of the QHS suggest room for improvement in blood glucose control at our institution., Conclusion: These focus groups allowed better identification of the management problems related to the use of insulin in our health institution and possible interventions to solve them. The QHS will be reassessed to measure quality of inpatient glycemic control over time., (Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Medication adherence reduces disease morbidity. Data regarding changes in a patient's adherence before and after hospitalization and how this hospitalization influences a pharmacist's interventions are scarce., Objective: To assess changes in adherence to cardiovascular and respiratory medications in the year preceding and following a hospitalization; explore patients' perceptions about medication adherence and the pharmacist's role; and describe pharmacists' interventions regarding medication adherence., Methods: This cohort study included patients hospitalized for acute coronary syndrome, acute worsening of heart failure, or acute COPD exacerbations. Adherence to cardiovascular and respiratory medications was measured by calculating the proportion of days covered (PDC) from prescription refills. Patient interviews were completed to explore their perceptions about medication adherence and the role of the pharmacist. Community pharmacists were invited to complete an online survey and to participate in focus groups to discuss interventions to improve medication adherence., Results: Medication adherence was assessed for 61 patients; the mean PDC was 69.8% 12 months before hospitalization and 72.4% 12 months following hospitalization. Patients reported that they felt the need to take their medications to prevent worsening of their disease. They were satisfied with current pharmaceutical services. A total of 136 questionnaires completed by pharmacists were analyzed and 9 participants attended the focus groups. Most pharmacists reported monitoring prescription renewals to assess adherence, with no significant influence from the hospitalization itself. The patient's interest was reported to be an important facilitator, whereas a lack of time and face-to-face interaction with patients who had their medication delivered to their home was reported a main barrier to interventions. This study was limited by a small sample size., Conclusions: Patient medication adherence did not significantly change following hospitalization. Hospitalization does not appear to significantly influence patient and pharmacist behavior towards medication adherence.

Background: Only one study has investigated the combined effect of maternal asthma and obesity on perinatal outcomes; however, it did not consider small-for-gestational age and large-for-gestational age infants., Objectives: To examine the impact of obesity on perinatal outcomes among asthmatic women., Methods: A cohort of 1386 pregnancies from asthmatic women was reconstructed using three of Quebec's administrative databases and a questionnaire. Women were categorized using their prepregnancy body mass index. Underweight, overweight and obese women were compared with normal weight women. The primary outcome was the birth of a small-for-gestational-age infant, defined as a birth weight below the 10th percentile for gestational age and sex. Secondary outcomes were large-for-gestational-age infants (birth weight >90th percentile for gestational age) and preterm birth (<37 weeks' gestation). Logistic regression models were used to obtain the ORs of having small-for-gestational-age infants, large-for-gestational-age infants and preterm birth as a function of body mass index., Results: The proportions of underweight, normal weight, overweight and obese women were 10.8%, 53.3%, 19.7% and 16.2%, respectively. Obese asthmatic women were not found to be significantly more at risk for giving birth to small-for-gestational-age infants (OR 0.6 [95% CI 0.4 to 1.1]), large-for-gestational-age infants (OR 1.2 [95% CI 0.7 to 2.2]) or having a preterm delivery (OR 0.7 [95% CI 0.4 to 1.3]) than normal-weight asthmatic women., Conclusions: No significant negative interaction between maternal asthma and obesity on adverse perinatal outcomes was observed.

Background: Asthma during pregnancy usually requires treatment with controller medications about which more safety information is needed. The objectives are to assess the impact of the use of long-acting β2-agonists (LABAs) and the dose of inhaled corticosteroids (ICSs) during pregnancy on the prevalence of low birth weight (LBW), preterm birth (PB) and small for gestational age (SGA)., Methods: A cohort of women with asthma giving birth from 1998 to 2008 was constructed from Québec (Canada) administrative databases. LBW was defined as weight <2500 g, PB as delivery before 37 weeks' gestation and SGA as a birth weight below the 10th percentile. The impact of the use of LABAs and the dose of ICSs during pregnancy on the outcomes was determined with generalised-estimating-equation models., Results: The cohort included 7376 pregnancies: 8.8% exposed to LABAs and 56.9% exposed to ICSs. All LABA users also received ICSs. The prevalence of LBW, PB and SGA was 7.7%, 9.5% and 13.5%, respectively. LABA use was not found to be associated with increased prevalence of LBW (OR 0.81; 95% CI 0.58 to 1.12), PB (OR 0.84; 95% CI 0.61 to 1.15) or SGA (OR 0.92; 95% CI 0.70 to 1.20). Mean ICSs doses >125 μg/day (fluticasone-equivalent) were associated with a non-significant trend of increased LBW, PB and SGA., Conclusions: Despite the possibility of residual confounding due to uncontrolled or more severe asthma or smoking status, the use of LABA and low to moderate doses of ICSs were not associated with increased prevalence of perinatal outcomes. Additional research on higher ICSs doses is required to better evaluate their safety during pregnancy.

Objective: To compare adherence to, and persistence with, antidepressants (AD) in Quebec patients who are covered by private and public drug insurance., Method: A matched cohort study was conducted using prescription claims databases: reMed, a medication data registry for Quebec residents covered by private drug insurance, and Régie de l'assurance maladie du Québec database for Quebec residents with public drug insurance. Patients were aged 18 to 64 years and filled at least 1 prescription for an AD in monotherapy between December 2007 and September 2009 (194 privately and 2055 publicly insured patients). Adherence over 1 year was estimated using the proportion of prescribed days covered (PPDC). The difference in mean PPDC between patients with private and public drug insurance was estimated with linear regression. Persistence was compared between the groups with a Cox regression model., Results: The PPDC was 86.4% (95% CI 83.3% to 89.5%) in privately insured and 82.2% (95% CI 78.5% to 85.9%) in publicly insured patients and the adjusted mean difference was 5.1% (95% CI 1.6% to 8.6%). Persistence was 51.0% in the private group and 19.7% in the public group at 1 year (P < 0.001); the adjusted hazard ratio was 0.49 (95% CI 0.30 to 0.79)., Conclusion: Better adherence and persistence were observed in privately insured patients. Adherence difference may be due to lower copayment among privately insured patients.