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Objective: To describe demographic and clinical characteristics, healthcare resource use, costs, and treatment patterns in three migraine cohorts., Methods: This retrospective observational study using administrative data examined patients with episodic migraine (EM), chronic migraine (CM) (without medication overuse headache [MOH]), and medication overuse headache in Alberta, Canada. Migraine patients were identified between 2012 and 2018 based on ≥ 1 diagnostic codes or triptan prescription. Patients with CM were defined using parameter estimates of a logistic regression model, and MOH was defined as patients with an average of ≥ 15 supply days covered of acute medications. EM was defined as patients without CM or MOH. Study outcomes were summarized using descriptive statistics., Results: Patients with EM (n = 144,574), CM (n = 27,283), and MOH (n = 11,485) were included. Higher rates of healthcare use and costs were observed for CM (mean [SD] all-cause cost: ($12,693 [40,664]) and MOH ($16,611.5 [$38,748]) versus episodic migraine ($4,251 [$40,637]). Across all cohorts, opioids were the most dispensed acute medication (range across cohorts: 31.7%-89.8%), while antidepressants and anticonvulsants were the most dispensed preventive medication. Preventative medication classes were used by a minority of patients in each cohort, except anticonvulsants, where 50% of medication overuse patients had a dispensation., Conclusions: Patients with CM and MOH have a greater burden of illness compared to patients with EM. The overutilization of acute medication, particularly opioids, and the underutilization of preventive medications highlight an unmet need to more effectively manage migraine.

Background: Migraine poses a significant burden worldwide; however, there is limited evidence as to the burden in Canada. This study examined the treatment patterns, healthcare resource use (HRU), and costs among newly diagnosed or recurrent patients with migraine in Alberta, Canada, from the time of diagnosis or recurrence., Methods: This retrospective observational study utilized administrative health data from Alberta, Canada. Patients were included in the Total Migraine Cohort if they had: (1) ≥1 International Classification of Diseases diagnostic code for migraine; or (2) ≥1 prescription dispense(s) for triptans from April 1, 2012, to March 31, 2018, with no previous diagnosis or dispensation code from April 1, 2010, to April 1, 2012., Results: The mean age of the cohort (n = 199,931) was 40.0 years and 72.3% were women. The most common comorbidity was depression (19.7%). In each medication class examined, less than one-third of the cohort was prescribed triptans and fewer than one-fifth was prescribed a preventive. Among patients with ≥1 dispense, the mean rate of opioid prescriptions was 4.61 per patient-year, compared to 2.28 triptan prescriptions per patient-year. Migraine-related HRU accounted for 3%-10% of all use., Conclusion: Comorbidities and high all-cause HRU were observed among newly diagnosed or recurrent patients with migraine. There is an underutilization of acute and preventive medications in the management of migraine. The high rate of opioid use reinforces the suboptimal management of migraine in Alberta. Migraine management may improve by educating healthcare professionals to optimize treatment strategies.

Given the expanding knowledge base in cancer genomics, risk-based screening is among the promising avenues to improve breast cancer (BC) prevention and early detection at the population level. Semi-structured interviews were conducted to explore the perceptions of healthcare professionals (HPs) regarding the implementation of such an approach and identify tools that can support HPs. After undertaking an in-depth thematic content analysis of the responses, 11 themes were identified. These were embedded into a logical model to distinguish the potential eligible participants (who?), the main clinical activities (how?) and associated tools (what?), the key factors of acceptability (which?), and the expected effects of the strategy (why?). Overall, it was found that the respondents positively welcomed the implementation of this strategy and agreed on some of the benefits that could accrue to women from tailored risk-based screening. Some important elements, however, deserve clarification. The results also highlight three main conditions that should be met to foster the acceptability of BC risk stratification: respecting the principle of equity, paying special attention to knowledge management, and rethinking human resources to capitalize on the strengths of the current workforce. Because the functioning of BC risk-based screening is not yet well defined, important planning work is required before advancing this organizational innovation, and outstanding issues must be resolved to get HPs on board.

Background: Anxiety symptoms are common in patients with major depressive disorder (MDD) and usually confer worse treatment outcomes. The long-term, open-label AtWoRC study in working patients with MDD treated with vortioxetine demonstrated a significant correlation between severity of anxiety symptoms and impaired work productivity. This analysis was undertaken to further explore clinical characteristics and treatment outcomes in patients with different levels of severity of anxiety symptoms at baseline., Methods: Post hoc analysis in 199 working patients with MDD treated with vortioxetine (10-20 mg/day), stratified by Generalized Anxiety Disorder 7-item (GAD-7) score at baseline [mild/moderate anxiety (GAD-7 ⩽14), n  = 83; severe anxiety (GAD-7 ⩾15), n  = 116]. Associations were examined between GAD-7 and other outcome assessment scores at baseline. Observed mean changes from baseline to week 52 were compared between groups., Results: Patients with severe anxiety had significantly worse depressive and cognitive symptoms, functioning, and work productivity at baseline than those with mild/moderate anxiety, but similar cognitive performance. Statistically significant improvements from baseline were seen for all outcomes after 52 weeks of vortioxetine treatment, with no significant differences observed between the two groups after adjustment for baseline anxiety scores., Conclusion: Treatment with vortioxetine was associated with long-term improvement in clinical symptoms and measures of work productivity in patients with MDD in a real-world setting, irrespective of severity of anxiety symptoms at the start of treatment., Competing Interests: Conflict of interest statement: P.C. has received research grants and honoraria for serving on advisory boards and for speaking engagements from Allergan, Lundbeck, Otsuka, Shire, Purdue, and Janssen. H.G. was an employee of Lundbeck Singapore Pte Ltd, Singapore at the time of this analysis. J.B. and G.C. are employees of Lundbeck Canada Inc. A.E. is an employee of H. Lundbeck A/S., (© The Author(s), 2021.)

Objective: The AtWoRC study is an interventional, open-label Canadian study that demonstrated significant improvements in cognitive function and workplace productivity in patients with major depressive disorder (MDD) treated with vortioxetine for a current major depressive episode. The objective of the present analysis was to assess the Canadian economic impact of improved workplace productivity based on the AtWoRC study results., Methods: The economic impact of improved productivity in patients with MDD treated with vortioxetine was assessed over a 52-week period considering productivity loss due to absenteeism and presenteeism using the standard human capital approach and an employer's perspective. Absenteeism was measured with the Work Productivity and Activity Impairment questionnaire; and presenteeism with the Work Limitation Questionnaire. Productivity gains following treatment initiation with vortioxetine were estimated using the difference from baseline., Results: In the AtWoRC study, patients at baseline reportedly missed, in the past 7 days, an average of 8.1 h due to absenteeism and 3.0 h due to presenteeism. Following 52 weeks of treatment with vortioxetine, patients reportedly missed an average of 4.9 h due to absenteeism and 2.0 h due to presenteeism. This improved workplace productivity translated into savings of C$110.64 for 1 week of work following 52 weeks of treatment. The cumulative 52-week economic impact showed potential savings of C$4,550 when factoring in the cost of therapy., Conclusion: This study suggested that workplace productivity gain due to an improvement in symptoms of MDD following treatment with vortioxetine will lead to substantial cost savings for the Canadian economy.

Objective: To assess changes in workplace productivity and functioning in an open-label study in working patients receiving vortioxetine (10 to 20 mg/d) for major depressive disorder (MDD)., Methods: Associations between items in the Work Limitations Questionnaire (WLQ), the Sheehan Disability Scale (SDS), and the Work Productivity and Activity Impairment (WPAI) questionnaire were assessed at 12 and 52 weeks by Pearson correlation coefficients., Results: Significant improvements were observed across all domains of workplace productivity and functioning after 12 and 52 weeks' vortioxetine treatment. Strong correlations were seen between improvements in WLQ mental domains and WPAI presenteeism and SDS work/school items. Presenteeism showed stronger correlations with other workplace productivity measures than absenteeism., Conclusions: Presenteeism and absenteeism impact productivity in working patients with MDD. Vortioxetine confers long-term benefits across all workplace functioning domains.

Objective: AtWoRC (Assessment in Work productivity and the Relationship with Cognitive symptoms) was an interventional, open-label, Canadian study (NCT02332954) designed to assess the association between cognitive symptoms and workplace productivity in working patients with major depressive disorder (MDD) receiving vortioxetine., Methods: Eligible patients with MDD received vortioxetine (10-20 mg/day) and were assessed over 52 weeks at visits emulating a real-life setting (n = 199). Partial correlation between changes in patient-reported cognitive symptoms (20-item Perceived Deficits Questionnaire-Depression; PDQ-D-20) and workplace productivity (Work Limitations Questionnaire; WLQ) was assessed at 12 and 52 weeks. Additional assessments included depression severity, cognitive performance, and patient-reported functioning. Structural equations model (SEM) analyses assessed causal relationships between changes in measures of cognition and functioning over time, adjusted for improvements in depressive symptoms., Results: Statistically significant improvements in all outcomes from baseline to week 52 were seen in the overall population and both subgroups (first treatment and switch). Response and remission rates were 77% and 56%, respectively. Improvements in PDQ-D-20 and WLQ productivity loss scores at weeks 12 and 52 were significantly correlated. SEM analyses found patient-rated cognitive symptoms (PDQ-D-20) at weeks 12 and 26 were significantly predictive (p < 0.05) of patient-reported functioning (Sheehan Disability Scale) at the subsequent visit. Depression severity and objectively measured cognitive performance did not significantly predict functional outcomes at any timepoint., Conclusion: These results demonstrate the long-term benefits of vortioxetine treatment in working patients with MDD and emphasize the strong association between cognitive symptoms and functioning in a real-world setting.

Objective: The Assessment in Work Productivity and the Relationship with Cognitive Symptoms (AtWoRC) study aimed to assess the association between cognitive symptoms and work productivity in gainfully employed patients receiving vortioxetine for a major depressive episode (MDE)., Methods: Patients diagnosed with major depressive disorder (MDD) and treated with vortioxetine independently of study enrollment were assessed over 52 weeks at visits that emulated a real-life setting. Patients were classified as those receiving vortioxetine as the first treatment for their current MDE (first treatment) or having shown inadequate response to a previous antidepressant (switch). The primary endpoint was the correlation between changes in patient-reported cognitive symptoms (20-item Perceived Deficits Questionnaire [PDQ-D-20]) and changes in work productivity loss (Work Limitations Questionnaire [WLQ]) at week 12. Additional assessments included changes in symptom and disease severity, cognitive performance, functioning, work loss, and safety., Results: In the week 12 primary analysis, 196 eligible patients at 26 Canadian sites were enrolled, received at least one treatment dose, and attended at least one postbaseline study visit. This analysis demonstrated a significant, strong correlation between PDQ-D-20 and WLQ productivity loss scores (r=0.634; p&lt;0.001), and this correlation was significant in both first treatment and switch patients (p&lt;0.001). A weaker correlation between Digit Symbol Substitution Test and WLQ scores was found (r=-0.244; p=0.003)., Conclusion: At 12 weeks, improvements in cognitive dysfunction were significantly associated with improvements in workplace productivity in patients with MDD, suggesting a role for vortioxetine in functional recovery in MDD.

Background: With previously established efficacy of aripiprazole once-monthly injectable formulation (AOM) in pre-registration randomized controlled trials, the current study was designed to evaluate its effectiveness in patients treated for schizophrenia in regular clinical settings in Canada., Methods: Following their clinicians' decision to prescribe AOM, 193 patients with a diagnosis of schizophrenia, were recruited from 17 Canadian community or hospital-based settings. The primary outcome of global functioning was assessed with the Global Assessment of Functioning Scale (GAF) at 3-month intervals for 1 year. Secondary outcomes (social and occupational functioning and illness severity) and adverse drug reactions (ADR) were also assessed., Results: A majority of the 169 evaluable patients were within the first 5 years of diagnosis (early phase). A linear mixed model analysis showed a significant main effect of time (Type III test p < 0.001) after adjusting for baseline GAF score, with a change in mean GAF scores from 49 at baseline to 61 at 12 months. No differences between early vs late phase were observed. Results on secondary outcome measures of function (Social and Occupational Functioning Scale) and illness severity (Clinical Global Impression-Severity Scale and Brief Psychiatric Rating Scale) were similar. Serious ADRs were observed in 29 (14.6%) patients and akathisia in 18 (9.1%) patients. At month-12, significant (≥7%) weight gain was observed in 25.7% (n = 27/105) of patients., Conclusions: Treatment with AOM is effective in improving symptoms and functioning in schizophrenia patients treated in regular clinical settings. Akathisia was infrequent while one quarter of patients gained clinically significant weight., Trial Registration: Unique identifier: NCT02131415 . First posted: 06 May 2014.

Objectives: To identify common and specific individual factors that favour or impede women's interest in and willingness-to-pay (WTP) for breast cancer susceptibility testing (BCST) and to identify the most impactful factors on both outcome measures., Design and Methods: This study used a self-administered cross-sectional Web-based questionnaire that included hypothetical scenarios about the availability of a new genetic test for breast cancer., Participants: French-speaking women of the general population of Québec (Canada), aged between 35 and 69 years, were identified from a Web-based panel (2410 met the selection criteria, 1160 were reached and 1031 completed the survey)., Measures: The outcomes are the level of interest in and the range of WTP for BCST. Three categories of individual factors identified in the literature were used as potential explanatory factors, that is, demographic, clinical and psychosocial., Results: Descriptive statistics indicated that the vast majority of sampled women are interested in BCST (90%). Among those, more than half of them are willing-to-pay for such a test (57%). The regression models pointed out several factors associated with both outcomes (eg, age, income, family history, locus of control-powerful others) and marginal effects were used to highlight the most impactful factors for each outcome., Conclusion: The results of this study provide a proxy of the readiness of women of the general population to use and to pay for BCST. They also offer insights for developing inclusive and specific strategies to foster informed decision-making and guide the services offered by health organisations corresponding to women's preferences and needs., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Genetic stratification approaches in personalized medicine may considerably improve our ability to predict breast cancer risk for women at higher risk of developing breast cancer. Notwithstanding these advantages, concerns have been raised about the use of the genetic information derived in these processes, outside of the research and medical health care settings, by third parties such as insurers. Indeed, insurance applicants are asked to consent to insurers accessing their medical information (implicitly including genetic) to verify or determine their insurability level, or eligibility to certain insurance products. This use of genetic information may result in the differential treatment of individuals based on their genetic information, which could lead to higher premium, exclusionary clauses or even the denial of coverage. This phenomenon has been commonly referred to as "Genetic Discrimination" (GD). In the Canadian context, where federal Bill S-201, An Act to prohibit and prevent genetic discrimination , has recently been enacted but may be subject to constitutional challenges, information about potential risks to insurability may raise issues in the clinical context. We conducted a survey with women in Quebec who have never been diagnosed with breast cancer to document their perspectives. We complemented the research with data from 14 semi-structured interviews with decision-makers in Quebec to discuss institutional issues raised by the use of genetic information by insurers. Our results provide findings on five main issues: (1) the reluctance to undergo genetic screening test due to insurability concerns, (2) insurers' interest in genetic information, (3) the duty to disclose genetic information to insurers, (4) the disclosure of potential impacts on insurability before genetic testing, and (5) the status of genetic information compared to other health data. Overall, both groups of participants (the women surveyed and the decision-makers interviewed) acknowledged having concerns about GD and reported a need for better communication tools discussing insurability risk. Our conclusions regarding concerns about GD and the need for better communication tools in the clinical setting may be transferable to the broader Canadian context.

The aim of this paper is twofold: to analyze the genetic counseling process for breast cancer with a theoretical knowledge transfer lens and to compare generalists, medical specialists, and genetic counselors with regards to their genetic counseling practices. This paper presents the genetic counseling process occurring within a chain of value-adding activities of four main stages describing health professionals' clinical practices: (1) evaluation, (2) investigation, (3) information, and (4) decision. It also presents the results of a cross-sectional study based on a Canadian medical doctors and genetic counselors survey (n = 176) realized between July 2012 and March 2013. The statistical exercise included descriptive statistics, one-way ANOVA and post-hoc tests. The results indicate that even though all types of health professionals are involved in the entire process of genetic counseling for breast cancer, genetic counselors are more involved in the evaluation of breast cancer risk, while medical doctors are more active in the decision toward breast cancer risk management strategies. The results secondly demonstrate the relevance and the key role of genetic counselors in the care provided to women at-risk of familial breast cancer. This paper presents an integrative framework to understand the current process of genetic counseling for breast cancer in Canada, and to shed light on how and where health professionals contribute to the process. It also offers a starting point for assessing clinical practices in genetic counseling in order to establish more clearly where and to what extent efforts should be undertaken to implement future genetic services.

Objectives: This paper aims to identify relevant potential predictors of medical genetic counseling for breast cancer (MGC-BC) in primary care and to develop a comprehensive questionnaire to study MGC-BC., Methods: A scoping review was conducted to identify the predictors of MGC-BC among primary care physicians. Relevant articles were identified in selected databases (PubMed, Embase, CINAHL, ISI Web of Science, PsycINFO, and Cochrane CENTRAL) and 4 selected relevant electronic journals., Results: An inductive analysis of the 193 quantitatively tested variables, conducted by 3 researchers, showed that 6 conceptual categories of determinants, namely (1) demographic, (2) organizational, (3) experiential, (4) professional, (5) psychological, and (6) cognitive, influence MGC-BC practices., Conclusion: There is a scarcity of literature addressing the medical behavior determinants of MGC-BC. Future research is needed to identify effective strategies put into action to support the integration of MGC-BC in primary care medical practices and routines. However, our results shed light on 2 levels of actions that could improve genetic counseling services in primary care: (1) medical training and educational efforts emphasizing family history collection (individual level), and (2) clarification of roles and responsibilities in ordering and referral practices in genetic counseling and genetic testing for better healthcare management (organizational level)., (© 2014 S. Karger AG, Basel.)

We study a layer of grains atop a plate which oscillates sinusoidally in the direction of gravity, using three-dimensional, time-dependent numerical solutions of continuum equations to Navier-Stokes order as well as hard-sphere molecular dynamics simulations. For high accelerational amplitudes of the plate, the layer exhibits a steady-state "density inversion" in which a high-density portion of the layer is supported by a lower-density portion. At low accelerational amplitudes, the layer exhibits oscillatory time dependence that is strongly correlated to the motion of the plate. We show that continuum simulations yield results consistent with molecular dynamics results in both regimes.

In supersymmetric quantum mechanics, shape invariance is a sufficient condition for solvability. We show that all conventional additive shape-invariant superpotentials that are independent of ℏ can be generated from two partial differential equations. One of these is equivalent to the one-dimensional Euler equation expressing momentum conservation for inviscid fluid flow, and it is closed by the other. We solve these equations, generate the set of all conventional shape-invariant superpotentials, and show that there are no others in this category. We then develop an algorithm for generating all additive shape-invariant superpotentials including those that depend on ℏ explicitly.

Objective: This study examined the explicit targeted outcome (a criterion standard) and visual feedback on the immediate change in and the short-term retention of performance by novice operators for a high-velocity, low-amplitude procedure under realistic conditions., Methods: This study used a single-blind randomized experimental design. Forty healthy male (n = 26) and female (n = 14) chiropractic student volunteers with no formal training in spinal manipulative therapy participated. Biomechanical parameters of an L4 mammillary push spinal manipulation procedure performed by novice operators were quantified. Participants were randomly assigned to 2 groups and paired. One group received visual feedback from load-time histories of their performance compared with a criterion standard before a repeat performance. Participants then performed a 10-minute distractive exercise consisting of National Board of Chiropractic Examiners review questions. The second group received no feedback. An independent rating of performance was conducted for each participant by his/her partner. Results were analyzed separately for biomechanical parameters for partner ratings using the Student t test with levels of significance (P < .01) adjusted for repeated testing., Results: Expressed in percent change for each individual, visual feedback was associated with change in the biomechanical performance of group 2, a minimum of 14% and a maximum of 32%. Statistical analysis rating of the performance favored the feedback group on 4 of the parameters (fast, P < .0008; force, P < .0056; precision, P < .0034; and composite, P < .0016)., Conclusion: Quantitative feedback, based on a tangible conceptualization of the target performance, resulted in immediate and significant improvement in all measured parameters. Newly developed skills were retained at least over short intervals even after distractive tasks. Learning what to do with feedback on one's own performance may be more important than the classic teaching of how to do it.

Background Context: Spinal manipulation has undergone a resurgence of interest. Developing evidence suggests a relationship between safety, skill and clinical outcome. Training programs are variable and range from extensive formalized curricula to weekend seminars and individual demonstrations. Systematic study of a relationship between prerequisites and skill development has not been conducted., Purpose: This project evaluated programmatic differences in prerequisites of students during their training for spinal manipulation with respect to quantitative biomechanical evidence of procedural control and skill of performance of a novel task., Study Design/setting: The research used an experimental design comparing two cohorts involved in separate training programs at different institutions that had distinguishing characteristics in methods of prerequisites to manipulation training., Methods: A common manipulation procedure (L4 mamillary push [L4MP]) was chosen as a standard test maneuver. Performance of the procedure on initial effort by two cohorts of students (n=38 vs n=39) entering into training for lumbar spine procedures was measured. Comparisons were made based on quantitative biomechanical parameters to assess control and skill. Results were compared with a cohort of experts as a reference standard., Results: Significant differences were observed between the performance measures of the two cohorts. The more skilled performance group was more similar to the expert reference standard than was the lesser skilled group., Conclusions: The duration, extent and content of prerequisites for learning the dynamic and complex manual skills for spinal manipulation can significantly influence the level of skill attainment even early in the course of training.

Objective: To report a rare cause of lumbar radiculopathy., Clinical Features: A 72-yr-old man suffered from pain that radiated down the posterior thigh and calf for 3 wk. The right foot and first toe extensors were weak and sensation was decreased over the dorsum of the foot. Straight leg raising was positive at 50 degrees on the right. Computed tomography with contrast revealed a large cyst with focal vacuum change with displacement of the dural sac at the L4-5 level., Intervention and Outcome: An L4-5 laminectomy and facetectomy was performed with relief of the patient's complaint. The patient resumed full activity at 3 months., Conclusion: An unusual cause of an L5 radiculopathy is discussed. Of the reported cases, surgical intervention has been the treatment of choice. Conservative treatment, including injections with corticosteroids and chiropractic management, have been reported to be successful. Further investigations using controls are needed to determine if conservative care is more cost-effective than surgical intervention.