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Mark J Makowsky,1 Andrew J Cave,2 Scot H Simpson1 1Faculty of Pharmacy and Pharmaceutical Sciences, 2Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada Background and objectives: Pharmacists working in primary care clinics are well positioned to help optimize medication management of community-dwelling patients who are at high risk of experiencing medication-related problems. However, it is often difficult to identify these patients. Our objective was to test the feasibility of a self-administered patient survey, to facilitate identification of patients at high risk of medication-related problems in a family medicine clinic. Methods: We conducted a cross-sectional, paper-based survey at the University of Alberta Hospital Family Medicine Clinic in Edmonton, Alberta, which serves approximately 7,000 patients, with 25,000 consultations per year. Adult patients attending the clinic were invited to complete a ten-item questionnaire, adapted from previously validated surveys, while waiting to be seen by the physician. Outcomes of interest included: time to complete the questionnaire, staff feedback regarding impact on workflow, and the proportion of patients who reported three or more risk factors for medication-related problems. Results: The questionnaire took less than 5 minutes to complete, according to the patient's report on the last page of the questionnaire. The median age (and interquartile range) of respondents was 57 (45–69) years; 59% were women; 47% reported being in very good or excellent health; 43 respondents of 100 had three or more risk factors, and met the definition for being at high risk of a medication-related problem. Conclusions: Distribution of a self-administered questionnaire did not disrupt patients, or the clinic workflow, and identified an important proportion of patients at high risk of medication-related problems. Keywords: screening tool, pharmacists, primary care, medication related problems

Suliman A AlGhurair, Scot H Simpson, Lisa M GuirguisDepartment of Pharmacy Practice, University of Alberta, Edmonton, CanadaBackground: Optimal medication management requires an effective relationship between the patient and health care professional. As pharmacists move from the traditional dispensing role to become more actively involved in patient care, factors influencing their relationship with patients need to be identified. A better understanding of these factors will facilitate more effective relationships.Objective: To explore the effect of patient-perceived pharmacist expertise on relationship quality, self-efficacy, patient satisfaction, and relationship commitment.Methods: This was a cross-sectional study conducted in five community pharmacies within the province of Alberta, Canada. A total of 500 patients were asked to complete a set of validated, self-administered questionnaires that measured perceived pharmacist expertise, relationship quality, self-efficacy, patient satisfaction, and relationship commitment. Hierarchical multiple regression was used to examine the associations between variables.Results: A total of 112 surveys were returned. Internal consistency ranged from 0.86–0.92, suggesting good reliability, except for the relationship commitment scale. There was a significant, positive correlation between patient-perceived pharmacist expertise and quality of the relationship (0.78; P < 0.001). There were also significant, positive correlations between perceived expertise and patient satisfaction (0.52; P < 0.001) and relationship commitment (0.47; P < 0.001). These associations remained significant but the magnitude of correlation decreased when relationship quality was taken into account (0.55; P < 0.001 and 0.56; P < 0.001, respectively). On the other hand, there was no significant association between either patient-perceived pharmacist expertise or relationship quality and medication self-efficacy (0.06; P = 0.517 and 0.10; P = 0.292, respectively).Conclusion: Patient-perceived pharmacist expertise is an independent determinant of relationship quality, patient satisfaction, and relationship commitment. Relationship quality also appears to mediate the effect of perceived expertise on patient satisfaction and relationship commitment.Keywords: relationship quality, pharmacist expertise, self-efficacy, relationship commitment, satisfaction

Boiling water (BW) is a common global practice, especially in Asia, for ensuring safe drinking water, though it does not remove chemical contaminants. The World Health Organisation recommends BW as an emergency measure against microbial contamination. In Hong Kong, the Water Supplies Department ensures water quality through strict regulations and extensive monitoring. Comparisons with Norway and Canada reveal effective practices such as water safety planning and risk-based advisories. Norway mandates water safety planning and uses messaging notifications for water advisories, ensuring high compliance, while Canada issues site-specific BW advisories based on risk assessments. Hong Kong faces unique challenges, such as a warm climate and complex building infrastructure, which impact water quality. Many buildings lack proper maintenance, leading to potential health risks and necessitating regular maintenance. Health management, public health education and expert guidance are essential for promoting efficient practices and ensuring safe drinking water.

Objective: To evaluate the effect of adding pharmacists to primary care teams on the management of hypertension and other cardiovascular risk factors in patients with type 2 diabetes.Research Design and Methods: We conducted a randomized controlled trial with blinded ascertainment of outcomes within primary care clinics in Edmonton, Canada. Pharmacists performed medication assessments and limited history and physical examinations and provided guideline-concordant recommendations to optimize medication management. Follow-up contact was completed as necessary. Control patients received usual care. The primary outcome was a ≥10% decrease in systolic blood pressure at 1 year.Results: A total of 260 patients were enrolled, 57% were women, the mean age was 59 years, diabetes duration was 6 years, and blood pressure was 129/74 mmHg. Forty-eight of 131 (37%) intervention patients and 30 of 129 (23%) control patients achieved the primary outcome (odds ratio 1.9 [95% CI 1.1-3.3]; P = 0.02). Among 153 patients with inadequately controlled hypertension at baseline, intervention patients (n = 82) were significantly more likely than control patients (n = 71) to achieve the primary outcome (41 [50%] vs. 20 [28%]; 2.6 [1.3-5.0]; P = 0.007) and recommended blood pressure targets (44 [54%] vs. 21 [30%]; 2.8 [1.4-5.4]; P = 0.003). The 10-year risk of cardiovascular disease, based on changes to the UK Prospective Diabetes Study Risk Engine, were predicted to decrease by 3% for intervention patients and 1% for control patients (P = 0.005).Conclusions: Significantly more patients with type 2 diabetes achieved better blood pressure control when pharmacists were added to primary care teams, which suggests that pharmacists can make important contributions to the primary care of these patients. [ABSTRACT FROM AUTHOR]

INTRODUCTION: In ST elevation myocardial infarction (STEMI), prehospital management (PHM) may improve clinical outcomes through a reduction in reperfusion delay. The purpose of this study was to evaluate perceptions among healthcare stakeholder groups relating to the barriers and facilitators of implementing a PHM programme. METHODS: A 25-question cross-sectional survey, using a four-point Likert scale assessing barriers and facilitators of PHM, was distributed to paramedics, cardiologists, emergency physicians and emergency nurses within the Edmonton region, where prehospital STEMI treatment is established. The proportion of responses on each question was compared and differences between groups were determined using chi(2) and Fisher's exact tests. RESULTS: 57% (355/619) of subjects responded: 69% paramedics, 50% cardiologists, 54% emergency physicians and 45% emergency nurses. A majority believed PHM reduced treatment delays in both rural (96-100%) and urban (86-96%) areas, while decreasing patient mortality (paramedics 97%, cardiologists 74%, emergency physicians 85%, emergency nurses 88%). Regarding the capability of paramedics to deliver PHM, paramedics 25%, cardiologists 33%, emergency physicians 67%, and emergency nurses 47% stated that urban paramedics are better equipped and trained than rural paramedics. Although 81% of paramedics supported the possibility of PHM delivery without physician overview, 0% of cardiologists, 98% of emergency physicians and 95% emergency nurses agreed. A majority (71-88%) favoured mandatory signed informed consent. CONCLUSIONS: While stakeholders agreed on the benefits of PHM, perceptual differences existed on paramedics' ability to deliver PHM without physician overview. Addressing real and perceived barriers through communication and educational programmes may enhance PHM within this healthcare region and facilitate the implementation of PHM programmes. [ABSTRACT FROM AUTHOR]

Objective: We aimed to evaluate the changes in cardiovascular-related health care utilization (drug therapies, hospitalizations) and mortality for the diabetic population during a 9-year period in Saskatchewan, Canada.Research Design and Methods: We identified annual diabetes prevalence rates for people aged >or=30 years between 1993 and 2001 from the administrative databases of Saskatchewan Health. Annual rates of evidence-based drug therapies (antihypertensives, ACE inhibitors, beta-blockers, calcium channel blockers, 3-hydroxy-3-metaglutaryl coenzyme A reductase inhibitors [statins]), hospitalizations for cerebrovascular and cardiac events, and all-cause mortality were estimated. Rates were direct age and sex standardized using the 2001 Canadian population, and trends over time were assessed using Joinpoint regression.Results: From 1993 to 2001, diabetes prevalence increased 34% (4.7-6.5%, P < 0.001) with the highest rates in men and those aged >or=65 years. The rate of increase in diabetes prevalence appeared to slow in those aged <65 years (P < 0.01 for trend). Significant increased use of evidence-based drug therapies was observed (41% increase in antihypertensive agents, 97% increase in ACE inhibitors, 223% increase in statin therapies; all P < 0.05 for trend). During this period, both cerebrovascular and cardiac-related hospitalizations declined by 36% (9.5 vs. 6.1 per 1,000) and 19% (38.0 vs. 30.6 per 1,000) (P < 0.05 for trends), respectively, with similar reductions regardless of sex. No change in all-cause mortality was observed (17.7 vs. 17.8 deaths per 1,000; P > 0.05).Conclusions: During our period of study, there was an increase in the utilization of evidenced-based drug therapies in people with diabetes and reductions in cardiovascular-related hospitalizations. Despite this, we observed no change in all-cause mortality. [ABSTRACT FROM AUTHOR]

Abstract Background In a recent exploratory randomised trial we found that a novel, internet-based psychoeducation programme for bipolar disorder (Beating Bipolar) was relatively easy to deliver and had a modest effect on psychological quality of life. We sought to explore the experiences of participants with respect to feasibility, acceptability and impact of Beating Bipolar. Methods Participants were invited to take part in a semi-structured interview. Thematic analysis techniques were employed; to explore and describe participants’ experiences, the data were analysed for emerging themes which were identified and coded. Results The programme was feasible to deliver and acceptable to participants where they felt comfortable using a computer. It was found to impact upon insight into illness, health behaviour, personal routines and positive attitudes towards medication. Many participants regarded the programme as likely to be most beneficial for those recently diagnosed. Conclusions An online psychoeducation package for bipolar disorder, such as Beating Bipolar, is feasible and acceptable to patients, has a positive impact on self-management behaviours and may be particularly suited to early intervention. Alternative (non-internet) formats should also be made available to patients.

Abstract Background Smoking, excessive alcohol consumption, lack of exercise and an unhealthy diet are the key modifiable factors contributing to premature morbidity and mortality in the developed world. Brief interventions in health care consultations can be effective in changing single health behaviours. General Practice holds considerable potential for primary prevention through modifying patients' multiple risk behaviours, but feasible, acceptable and effective interventions are poorly developed, and uptake by practitioners is low. Through a process of theoretical development, modeling and exploratory trials, we have developed an intervention called Behaviour Change Counselling (BCC) derived from Motivational Interviewing (MI). This paper describes the protocol for an evaluation of a training intervention (the Talking Lifestyles Programme) which will enable practitioners to routinely use BCC during consultations for the above four risk behaviours. Methods/Design This cluster randomised controlled efficacy trial (RCT) will evaluate the outcomes and costs of this training intervention for General Practitioners (GPs) and nurses. Training methods will include: a practice-based seminar, online self-directed learning, and reflecting on video recorded and simulated consultations. The intervention will be evaluated in 29 practices in Wales, UK; two clinicians will take part (one GP and one nurse) from each practice. In intervention practices both clinicians will receive training. The aim is to recruit 2000 patients into the study with an expected 30% drop out. The primary outcome will be the proportion of patients making changes in one or more of the four behaviours at three months. Results will be compared for patients seeing clinicians trained in BCC with patients seeing non-BCC trained clinicians. Economic and process evaluations will also be conducted. Discussion Opportunistic engagement by health professionals potentially represents a cost effective medical intervention. This study integrates an existing, innovative intervention method with an innovative training model to enable clinicians to routinely use BCC, providing them with new tools to encourage and support people to make healthier choices. This trial will evaluate effectiveness in primary care and determine costs of the intervention. Trial Registration ISRCTN22495456

Abstract Background The Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial. Methods Semi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis. Results The majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data. Conclusion Participants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program. Trial registration Current Controlled Trials ISRCTN63355948

Abstract Background Bipolar disorders affect between 3–5% of the population and are associated with considerable lifelong impairment. Since much of the morbidity associated with bipolar disorder is caused by recurrent depressive symptoms, which are often only poorly responsive to antidepressants, there is a need to develop alternative, non-pharmacological interventions. Psychoeducational interventions have emerged as promising long-term therapeutic options for bipolar disorder. Methods/design The study is an exploratory, individually randomised controlled trial. The intervention known as 'Beating Bipolar' is a psychoeducational programme which is delivered via a novel web-based system. We will recruit 100 patients with a diagnosis of DSM-IV bipolar disorder (including type I and type II) currently in clinical remission. The primary outcome is quality of life. This will be compared for those patients who have participated in the psychoeducational programme with those who received treatment as usual. Quality of life will be assessed immediately following the intervention as well as 10 months after randomisation. Secondary outcomes include current depressive and manic symptoms, number of episodes of depression and mania/hypomania experienced during the follow-up period, global functioning, functional impairment and insight. An assessment of costs and a process evaluation will also be conducted which will explore the feasibility and acceptability of the intervention as well as potential barriers to effectiveness. Discussion Bipolar disorder is common, under-recognised and often poorly managed. It is a chronic, life-long, relapsing condition which has an enormous impact on the individual and the economy. This trial will be the first to explore the effectiveness of a novel web-based psychoeducational intervention for patients with bipolar disorder which has potential to be easily rolled out to patients. Trial registration Current Controlled Trials ISRCTN81375447

Abstract Background After some years of a downward trend, antibiotic prescribing rates in the community have tended to level out in many countries. There is also wide variation in antibiotic prescribing between general practices, and between countries. There are still considerable further gains that could be made in reducing inappropriate antibiotic prescribing, but complex interventions are required. Studies to date have generally evaluated the effect of interventions on antibiotic prescribing in a single consultation and pragmatic evaluations that assess maintenance of new skills are rare. This paper describes the protocol for a pragmatic, randomized evaluation of a complex intervention aimed at reducing antibiotic prescribing by primary care clinicians. Methods and design We developed a Social Learning Theory based, blended learning program (on-line learning, a practice based seminar, and context bound learning) called the STAR Educational Program. The 'why of change' is addressed by providing clinicians in general practice with information on antibiotic resistance in urine samples submitted by their practice and their antibiotic prescribing data, and facilitating a practice-based seminar on the implications of this data. The 'how of change' is addressed through context-bound communication skills training and information on antibiotic indication and choice. This intervention will be evaluated in a trial involving 60 general practices, with general practice as the unit of randomization (clinicians from each practice to either receive the STAR Educational Program or not) and analysis. The primary outcome will be the number of antibiotic items dispensed over one year. An economic and process evaluation will also be conducted. Discussion This trial will be the first to evaluate the effectiveness of this type of theory-based, blended learning intervention aimed at reducing antibiotic prescribing by primary care clinicians. Novel aspects include feedback of practice level data on antimicrobial resistance and prescribing, use of principles from motivational interviewing, training in enhanced communication skills that incorporates context-bound experience and reflection, and using antibiotic dispensing over one year (as opposed to antibiotic prescribing in a single consultation) as the main outcome. Trial registration Current Controlled Trials ISRCTN63355948.

Abstract Background Respiratory tract infections in children result in more primary care consultations than any other acute condition, and are the most common reason for prescribing antibiotics (which are largely unnecessary). About a fifth of children consult again for the same illness episode. Providing parents with written information on respiratory tract infections may result in a reduction in re-consultation rates and antibiotic prescribing for these illnesses. Asking clinicians to provide and discuss the information during the consultation may enhance effectiveness. This paper outlines the protocol for a study designed to evaluate the use of a booklet on respiratory tract infections in children within primary care consultations. Methods/Design This will be a cluster randomised controlled trial. General practices will be randomised to provide parents consulting because their child has an acute respiratory tract infection with either an interactive booklet, or usual care. The booklet provides information on the expected duration of their child's illness, the likely benefits of various treatment options, signs and symptoms that should prompt re-consultation, and symptomatic treatment advice. It has been designed for use within the consultation and aims to enhance communication through the use of specific prompts. Clinicians randomised to using the interactive booklet will receive online training in its use. Outcomes will be assessed via a telephone interview with the parent two weeks after first consulting. The primary outcome will be the proportion of children who re-consult for the same illness episode. Secondary outcomes include: antibiotic use, parental satisfaction and enablement, and illness costs. Consultation rates for respiratory tract infections for the subsequent year will be assessed by a review of practice notes. Discussion Previous studies in adults and children have shown that educational interventions can result in reductions in re-consultation rates and use of antibiotics for respiratory tract infections. This will be the first study to determine whether providing parents with a booklet on respiratory tract infections in children, and discussing it with them during the consultation, reduces re-consultations and antibiotic use for the same illness without reducing satisfaction with care. Trial registration Current Controlled Trials ISRCTN46104365

Aim: To examine the likelihood of mortality or rehospitalization following acute coronary syndrome with glyburide versus gliclazide use in adults with type 2 diabetes undergoing cardiac catheterization., Research Design and Methods: This retrospective cohort study used clinical data linked with administrative health data from Alberta, Canada between April 2008 and March 2021. Three methods were used to define exposure to glyburide and gliclazide in the year before catheterization. Multivariable logistic regression was used to compare the likelihood of a composite outcome of 1-year mortality or rehospitalization with use of glyburide versus use of gliclazide., Results: A total of 11 140 individuals with type 2 diabetes had a cardiac catheterization for acute coronary syndrome. Their mean age was 66 years and 31% were female. In the year before catheterization, 5% used glyburide and 19% used gliclazide. Any glyburide or gliclazide exposure in the year before catheterization was associated with a similar likelihood of all-cause mortality or rehospitalization (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 0.93-1.41; p = 0.20). However, current glyburide exposure (aOR 1.37, 95% CI 1.06-1.79; p = 0.018) and long exposure to glyburide (aOR 1.37, 95% CI 1.03-1.83; p = 0.030) were associated with a higher likelihood of the composite outcome compared to current and long exposure to gliclazide, respectively., Conclusions: Current and long exposure to glyburide was associated with a greater likelihood of mortality or rehospitalization following cardiac catheterization for acute coronary syndrome, when compared to similar gliclazide exposure definitions. This study adds further evidence of the need to avoid using glyburide if a sulphonylurea is required for type 2 diabetes management., (© 2024 The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Objectives: Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management., Methods: We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing., Results: Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence., Conclusions: Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Antihyperglycemic drug utilization studies are conducted frequently and describe the uptake of new drug therapies across may jurisdictions. An increasingly important, yet often absent, aspect of these studies is the impact of rurality on drug utilization., Objectives: The objective of this study was to explore the association between place of residence (rural, urban, metropolitan) and the use of dipeptidyl peptidase 4 inhibitors (DPP-4i) for first treatment intensification of type 2 diabetes., Methods: A retrospective cohort study was conducted from April 1, 2008 to March 31, 2019 of new metformin users. A multivariable logistic regression analysis was performed to determine the association between place of residence (using postal codes) and likelihood of DPP-4i dispensing., Results: After adjusting for confounders, analysis revealed that rural-dwellers are less likely to have a DPP-4i dispensed, compared with metropolitan-dwellers (aOR:0.64; 95%CI:0.61-0.67) and over-time, the uptake in rural areas was slower., Conclusions: This study demonstrates that rurality can have an impact on drug therapy decisions at first treatment intensification, with respect to the utilization of new therapies., Competing Interests: No potential conflicts of interest relevant to this article were reported. S.H.S. is supported as the Chair in Patient Health Management, jointly held by the Faculty of Pharmacy and Pharmaceutical Sciences and Faculty of Medicine and Dentistry, University of Alberta. This study is based in part on data provided by Alberta Health. The interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the Government of Alberta. Neither the Government of Alberta nor Alberta Health express any opinion in relation to this study., (© 2024 The Authors.)

Objective: To develop a machine-learning (ML) model using administrative data to estimate risk of adverse outcomes within 30-days of a benzodiazepine (BZRA) dispensation in older adults for use by health departments/regulators., Design, Setting and Participants: This study was conducted in Alberta, Canada during 2018-2019 in Albertans 65 years of age and older. Those with any history of malignancy or palliative care were excluded., Exposure: Each BZRA dispensation from a community pharmacy served as the unit of analysis., Main Outcomes and Measures: ML algorithms were developed on 2018 administrative data to predict risk of any-cause hospitalization, emergency department visit or death within 30-days of a BZRA dispensation. Validation on 2019 administrative data was done using XGBoost to evaluate discrimination, calibration and other relevant metrics on ranked predictions. Daily and quarterly predictions were simulated on 2019 data., Results: 65,063 study participants were included which represented 633,333 BZRA dispensation during 2018-2019. The validation set had 314,615 dispensations linked to 55,928 all-cause outcomes representing a pre-test probability of 17.8%. C-statistic for the XGBoost model was 0.75. Measuring risk at the end of 2019, the top 0.1 percentile of predicted risk had a LR + of 40.31 translating to a post-test probability of 90%. Daily and quarterly classification simulations resulted in uninformative predictions with positive likelihood ratios less than 10 in all risk prediction categories. Previous history of admissions was ranked highest in variable importance., Conclusion: Developing ML models using only administrative health data may not provide health regulators with sufficient informative predictions to use as decision aids for potential interventions, especially if considering daily or quarterly classifications of BZRA risks in older adults. ML models may be informative for this context if yearly classifications are preferred. Health regulators should have access to other types of data to improve ML prediction., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

We explore, experimentally and theoretically, the emergence of coherent coupled oscillations and synchronization between a pair of non-Hermitian, stochastic, opto-mechanical oscillators, levitated in vacuum. Each oscillator consists of a polystyrene microsphere trapped in a circularly polarized, counter-propagating Gaussian laser beam. Non-conservative, azimuthal forces, deriving from inhomogeneous optical spin, push the micro-particles out of thermodynamic equilibrium. For modest optical powers each particle shows a tendency towards orbital circulation. Initially, their stochastic motion is weakly correlated. As the power is increased, the tendency towards orbital circulation strengthens and the motion of the particles becomes highly correlated. Eventually, centripetal forces overcome optical gradient forces and the oscillators undergo a collective Hopf bifurcation. For laser powers exceeding this threshold, a pair of limit cycles appear, which synchronize due to weak optical and hydrodynamic interactions. In principle, arrays of such Non-Hermitian elements can be arranged, paving the way for opto-mechanical topological materials or, possibly, classical time crystals. In addition, the preparation of synchronized states in levitated optomechanics could lead to new and robust sensors or alternative routes to the entanglement of macroscopic objects., (© 2023. Springer Nature Limited.)

Objective: To construct a machine-learning (ML) model for health systems with organised falls prevention programmes to identify older adults at risk for fall-related admissions., Design: This prognostic study used population-level administrative health data to develop an ML prediction model., Setting: This study took place in Alberta, Canada during 2018-2019., Participants: Albertans aged 65 and older with at least one prior admission. Those with palliative conditions or emigrated out of Alberta were excluded., Exposure: Unit of analysis was the individual person., Main Outcomes/measures: We identified fall-related admissions. A CatBoost model was developed on 2018 data to predict risk of fall-related emergency department visits or hospitalisations. Temporal validation was done using 2019 data to evaluate model performance. We reported discrimination, calibration and other relevant metrics measured at the end of 2019 on both ranked predictions and predicted probability thresholds. A cost-savings simulation was performed using 2019 data., Results: Final number of study participants was 224 445. The validation set had 203 584 participants with 19 389 fall-related events (9.5% pretest probability) and an ML model c-statistic of 0.70. The highest ranked predictions had post-test probabilities ranging from 40% to 50%. Net benefit analysis presented mixed results with some net benefit using the ML model in the 6%-30% range. The top 50 percentile of predicted risks represented nearly $C60 million in health system costs related to falls. Intervening on the top 25 or 50 percentiles of predicted risk could realise substantial (up to $C16 million) savings., Conclusion: ML prediction models based on population-level administrative data can assist health systems with fall prevention programmes identify older adults at risk of fall-related admissions and reduce costs. ML predictions based on ranked predictions or probability thresholds could guide subsequent interventions to mitigate fall risks. Increased access to diverse forms of data could improve ML performance and further reduce costs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To examine the intersection between location of residence along the rural-urban continuum (metropolitan, urban, and rural) and sulfonylurea dispensation records for the management of type 2 diabetes., Research Design and Methods: This retrospective cohort study used administrative health records of adult new metformin users between April 2008 and March 2019 in Alberta, Canada. Multivariable logistic regression was performed to examine the association between sulfonylurea-based treatment intensification and location of residence., Results: Treatment was intensified in 66,084 (38%) of 171,759 new metformin users after a mean of 1.5 years. At treatment intensification, mean age was 55 years, 62% of users were male, and 27% were rural residents. The most common antihyperglycemic drug, given to 30,297 people (46%) for treatment intensification, was a sulfonylurea. At the beginning of our observation period, the proportion of people dispensed a sulfonylurea at first treatment intensification was highest in rural (57%), compared with urban (54%) and metropolitan (52%) areas (P = 0.009). Although proportions decreased over time across the province, rural residents continued to constitute the highest proportion of sulfonylurea users (45%), compared with urban (35%) and metropolitan (37%) residents (P < 0.001), and the trend away from sulfonylurea use was delayed by ∼4 years for rural residents. Adjusting for potential sources of confounding, rural residence was associated with a significantly higher likelihood of using a sulfonylurea compared with metropolitan residence (adjusted odds ratio 1.34; 95% CI 1.29-1.39)., Conclusions: Variation in sulfonylurea dispensation across the rural-urban continuum provides a basis for continued research in the differences in process of care by location., (© 2023 by the American Diabetes Association.)

Background: Pharmacists in Alberta have been authorized to administer vaccines and other medications by injection for more than 10 years; however, little is known about the provision of this service and their opinions regarding this service. Understanding pharmacists' experiences regarding injection services would inform development of strategies to improve provision of injection services., Objectives: To describe the actions related to administering an injection, including identification of commonly administered medications, and to identify perceived barriers and facilitators pharmacists face when providing injection services., Methods: An online survey was developed and loaded into REDCap, and e-mail invitations were sent to 5714 pharmacists registered with the Alberta College of Pharmacy in October 2020. Responses were analyzed using descriptive statistics. Pharmacists who administered at least one injection in the previous year were considered active providers, and their opinions regarding injection services were compared with nonactive providers., Results: A total of 397 pharmacists responded to our survey, mean age was 42 years, 66% were female, 82% were community pharmacists, and 90% were active providers. The most common injection, administered by 98% of active providers, was influenza vaccine, followed by vitamin B12 (95%), herpes zoster vaccine (88%), hepatitis vaccines (86%), and pneumococcal vaccines (82%). Nonactive providers were more likely than active providers to report that comfort with administering injections (P < 0.001) and managing adverse reactions (P = 0.013) were moderate or major barriers to providing injections. More than 60% of pharmacists indicated that access and automated reporting to the provincial immunization registry would be essential to increasing the frequency of providing injection services., Conclusion: We identified that Alberta pharmacists administer a wide variety of vaccines and other medications by injection. Respondents identified several barriers and facilitators to providing these services. Addressing these barriers may help improve provision of injection services by pharmacists., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Importance: Machine learning approaches can assist opioid stewardship by identifying high-risk opioid prescribing for potential interventions., Objective: To develop a machine learning model for deployment that can estimate the risk of adverse outcomes within 30 days of an opioid dispensation as a potential component of prescription drug monitoring programs using access to real-world data., Design, Setting, and Participants: This prognostic study used population-level administrative health data to construct a machine learning model. This study took place in Alberta, Canada (from January 1, 2018, to December 31, 2019), and included all patients 18 years and older who received at least 1 opioid dispensation from a community pharmacy within the province., Exposures: Each opioid dispensation served as the unit of analysis., Main Outcomes and Measures: Opioid-related adverse outcomes were identified from administrative data sets. An XGBoost model was developed on 2018 data to estimate the risk of hospitalization, an emergency department visit, or mortality within 30 days of an opioid dispensation; validation on 2019 data was done to evaluate model performance. Model discrimination, calibration, and other relevant metrics are reported using daily and weekly predictions on both ranked predictions and predicted probability thresholds using all data from 2019., Results: A total of 853 324 participants represented 6 181 025 opioid dispensations, with 145 016 outcome events reported (2.3%); 46.4% of the participants were men and 53.6% were women, with a mean (SD) age of 49.1 (15.6) years for men and 51.0 (18.0) years for women. Of the outcome events, 77 326 (2.6% pretest probability) occurred within 30 days of a dispensation in the validation set (XGBoost C statistic, 0.82 [95% CI, 0.81-0.82]). The top 0.1 percentile of estimated risk had a positive likelihood ratio (LR) of 28.7, which translated to a posttest probability of 43.1%. In our simulations, the weekly measured predictions had higher positive LRs in both the highest-risk dispensations and percentiles of estimated risk compared with predictions measured daily. Net benefit analysis showed that using machine learning prediction may not add additional benefit over the entire range of probability thresholds., Conclusions and Relevance: These findings suggest that prescription drug monitoring programs can use machine learning classifiers to identify patients at risk of opioid-related adverse outcomes and intervene on high-risk ranked predictions. Better access to available administrative and clinical data could improve the prediction performance of machine learning classifiers and thus expand opioid stewardship efforts.

Objectives: Depression is a known risk factor for poor medication adherence, but it is unclear whether depression treatment affects adherence rates. In this study, we examined the association between pharmacologic treatment of a new depressive episode and subsequent adherence to oral antihyperglycemic medications., Methods: In this retrospective cohort study, we used administrative health data to follow adult new metformin users in Alberta, Canada, between 2008 and 2018. Depressive episodes starting ≥1 year after metformin initiation were identified and individuals starting antidepressant treatment within the first 90 days were compared with those who did not. The proportion of days covered (PDC) with oral antihyperglycemic medications in the subsequent year (days 91 to 455) was used to estimate adherence. The association between antidepressant treatment and poor adherence (PDC<0.8) was examined using multivariate logistic regression models., Results: A new depressive episode occurred in 6,201 people, with a mean age of 56.0 (standard deviation [SD], 15.4) years. Of this cohort, 3,303 (53.2%) were women. Mean PDC was 0.55 (SD, 0.41); 924 (57.0%) of 1,621 people who started antidepressant treatment and 2,709 (59.2%) of 4,580 controls had poor adherence (p=0.13). After adjusting for baseline comorbidities and other characteristics, antidepressant treatment was associated with a lower likelihood of poor adherence (adjusted odds ratio, 0.85; 95% confidence interval, 0.75 to 0.96; p=0.007)., Conclusions: Although overall adherence to antihyperglycemic medications was low after onset of a depressive episode, antidepressant treatment was associated with a lower likelihood of poor adherence., (Copyright © 2022 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: We sought to develop machine learning (ML) models trained on administrative data which predict risk of readmission in patients with heart failure and to evaluate and compare the ML model with the currently used LaCE score using clinically informative metrics., Methods and Results: This prognostic study was conducted in Alberta, Canada, on 9845 patients with confirmed heart failure admitted to hospital between 2012 and 2019. The outcome was unplanned all-cause hospital readmission within 30 days of discharge. We used 80% of the data for the ML model development and 20% for independent validation. We reported, using the validation set, c-statistics (area under the receiver operating characteristic curves)and performance metrics (likelihood ratio, positive predictive values) for the XGBoost model and a modified LaCE score within their respective predictive thresholds. Boosted tree-based classifiers had higher area under the receiver operating characteristic curves (0.65 for XGBoost) compared with others (0.58 for neural networks) and 0.57 for the modified LaCE. Within the predicted threshold range of the XGBoost classifier, the positive likelihood ratio was 1.00 at the low end of predicted risk and 6.12 at the high end, resulting in a positive predictive value (post-test probability) range of 21%-62%; the pretest probability of readmission was 20.9% using prevalence. The corresponding positive likelihood ratios and positive predictive values across LaCE score thresholds were 1.00-1.20 and 21%-24%, respectively., Conclusions: Despite predicting readmissions better than the LaCE, even the best ML model trained on administrative health data (XGBoost) did not provide substantially informative prediction performance as it only generated a moderate shift from pre to post-test probability. Health systems wishing to deploy such a tool should consider training ML models with additional data. Adding other techniques like natural language processing, along with ML, to use other clinical information (like chart notes) might improve prediction performance., Competing Interests: Conflict of interest None., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: In this study, we aimed to characterize time to treatment intensification (TTI) in people on metformin with uncontrolled hyperglycemia, and estimated the frequency of physician visits until intensification., Methods: This work was a cohort study of Albertan adults with glycated hemoglobin (A1C) of >7.5% after at least 3 months of metformin monotherapy, using administrative databases from 2009 to 2018, with each subject followed for up to 4 years. Therapeutic intensification was defined as dispensation of an additional class of antihyperglycemic medication. Median TTI and the median number of physician visits were estimated from Kaplan-Meier functions within age/A1C strata. A Cox proportional hazards model was fitted to examine predictors of therapeutic intensification., Results: We included 38,846 people (average age, 57 years; 37% female; mean A1C, 8.8%). Overall, therapeutic intensification was observed in 23,077 (59%; 40% at 1 year). Median TTI was 1.4 years, varying from 0.7 years (A1C >8.5%, age <65 years) to 3.3 years (age ≥75 years, any A1C). The median number of physician visits until intensification was 9, varying between 5 (A1C >8.5%, age <65 years) and ≥30 (age ≥75 years); 93% of people awaiting intensification had at least 2 visits by 1 year. Higher A1C and younger age were the strongest predictors of intensification. Results were similar in people with ischemic heart disease., Conclusions: Despite ample contacts with community physicians, TTI exceeds the 6-month target recommended by guidelines, particularly in older adults. Further study is needed to better understand these foregone opportunities as guidelines call for wider promulgation of agents with cardiorenal benefits., (Copyright © 2021 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Aims: The association between depression and poor medication adherence is based on cross-sectional studies and cohort studies that measure adherence rates after depression status is determined. However, depressive symptoms occur well before diagnosis. This study examined adherence patterns in the year before a depressive episode., Methods: This retrospective cohort study followed new metformin users identified in Alberta Health's administrative data between 2008 and 2018. Depressive episodes starting ≥1 year after metformin initiation were identified using a validated case definition. Controls were randomly assigned a pseudo depression date. Adherence to oral antihyperglycemic medications was estimated using proportion of days covered (PDC) and group-based trajectory models to explore the association between depression and poor adherence (PDC<0.8)., Results: A depressive episode occurred in 17,418 (10.6%) of 165,056 new metformin users. Individuals with depression were more likely to have poor adherence compared to controls (adjusted odds ratio 1.21; 95% CI 1.17, 1.26). Five trajectories were identified: nearly perfect adherence (PDC >0.95 [34.8% of cohort]), discontinued (PDC=0 [18.3% of cohort], poor initial adherence (PDC 0.75) that declined either rapidly (9.2% of cohort) or gradually (30.1% of cohort), and poor initial adherence (PDC 0.26) that increased gradually (7.6% of cohort). Individuals with depression were more likely to be in one of the four trajectories of poor adherence compared to controls (adjusted odds ratio 1.24; 95% CI 1.19-1.29)., Conclusions: Poor medication adherence occurs in the year before a depressive episode; therefore, poor medication use patterns could be used as an early warning sign for depression., (© 2020 Diabetes UK.)

Aim: To examine whether early addition of sitagliptin to metformin is associated with a delay in type 2 diabetes progression., Methods: Administrative health records from Alberta, Canada, for the period April 2008 to March 2015, were used to conduct a retrospective cohort study in new metformin users. People who started sitagliptin on the same day they initiated metformin therapy were compared with those who added sitagliptin later. Insulin initiation served as a surrogate marker for diabetes progression, and multivariable logistic regression models were used to evaluate the association with sitagliptin addition (costart vs later use). A mixed-effects linear regression model was used to examine the effect of timing of sitagliptin addition on HbA 1c change over 1 year., Results: The mean (sd) age of the 8764 people who used sitagliptin was 52.1 (11.1) years, 5665 (64.6%) were men, and 1153 (13.2%) started sitagliptin on the same day as metformin. Insulin was added to the therapy of 173 (15.0%) costarters and 1453 (19.1%) later sitagliptin users. The adjusted odds ratio for adding insulin was 0.76 (95% CI 0.64 to 0.90) in favour of costarting sitagliptin. HbA 1c levels decreased in both groups 1 year after starting sitagliptin, with costarters having a significantly greater reduction [absolute between-group difference of 0.5% (95% CI 0.3 to 0.7)] compared with later sitagliptin users., Conclusion: Costarting drug therapy with sitagliptin and metformin was associated with a lower likelihood of disease progression in people with type 2 diabetes compared with adding sitagliptin later., (© 2019 Diabetes UK.)

Objectives: The primary objective was to determine medication-taking behaviours and factors influencing adherence in patients with mental illness and recent homelessness. Secondary objectives were to explore patients' perceptions on mobile technology use to support adherence., Methods: A constructivist approach and qualitative description method was used. The sample population consisted of patients with recent homelessness and mental illness affiliated with a community-based outreach programme in Canada. Participants were purposefully selected; semi-structured interviews were conducted to elicit information on medication-taking strategies and mobile technology to support adherence. A standardized questionnaire collected demographic and medical information; the Medication Adherence Rating Scale (MARS) was used to evaluate self-reported adherence. Questionnaire data were analysed using summary descriptive statistics. Interview data were subject to qualitative content analysis., Key Findings: Fifteen participants with a mean age of 44 years were included. The mean MARS score ± standard deviation was 7.3 ± 1.5. Themes arising from the data included patient factors (i.e. insight, attitudes towards medications, coping strategies) and external factors (i.e. therapeutic alliance, family support that impacted adherence) and technology use and health. Eight participants (53%) had access to a mobile phone. There was a moderate interest in the use of mobile technology to support adherence, with cost and technology literacy identified as barriers., Conclusion: External supports and individual medication management strategies were important in supporting medication adherence in this patient group. Perceived need for mobile technology, in addition to existing supports for adherence, was not high. Challenges accessing and maintaining consistent mobile technology and individual preferences should be considered when developing mobile technology-based interventions., (© 2020 Royal Pharmaceutical Society.)

We demonstrate an effect whereby stochastic, thermal fluctuations combine with nonconservative optical forces to break detailed balance and produce increasingly coherent, apparently deterministic motion for a vacuum-trapped particle. The particle is birefringent and held in a linearly polarized Gaussian optical trap. It undergoes oscillations that grow rapidly in amplitude as the air pressure is reduced, seemingly in contradiction to the equipartition of energy. This behavior is reproduced in direct simulations and captured in a simplified analytical model, showing that the underlying mechanism involves nonsymmetric coupling between rotational and translational degrees of freedom. When parametrically driven, these self-sustained oscillators exhibit an ultranarrow linewidth of 2.2 μHz and an ultrahigh mechanical quality factor in excess of 2 × 10 8 at room temperature. Last, nonequilibrium motion is seen to be a generic feature of optical vacuum traps, arising for any system with symmetry lower than that of a perfect isotropic microsphere in a Gaussian trap., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution License 4.0 (CC BY).)

Objectives: Our aim in this study was to determine whether differences exist in time to treatment intensification in newly treated type 2 diabetes patients in Canada and the United States (US)., Methods: Two separate retrospective cohorts of diabetes patients were used from Canada and the US. Time to treatment intensification (i.e. addition of a second antihyperglycemic agent after initial metformin use) was determined using multivariate Cox proportional hazard models., Results: Among new metformin users in 2004‒2007 (2,116 Canadians and 2,631 Americans) >65 years of age, the median time to treatment intensification was 362 days for Canadians and 170 days for Americans (adjusted hazard ratio, 1.99; 95% confidence interval, 1.69 to 2.36). In a second cohort of all adult ages with clinical data between 2008 and 2010 (23,022 Canadians and 19,318 Americans), the median time to treatment intensification was 197 days for Canadians and 119 days for Americans (adjusted hazard ratio, 5.62; 95% confidence interval, 5.246 to 6.029). At treatment intensification, the mean glycated hemoglobin was 9.0% (standard deviation, 2.0) in Canada and 8.6% (standard deviation, 2.2) in the US (p<0.01)., Conclusions: Although clinical practice guidelines are similar between Canada and the US, Canadian clinicians have historically demonstrated more clinical inertia compared with their US counterparts with respect to intensifying antihyperglycemic therapy. It is relatively unknown whether these differences currently exist or whether Canadian clinicians have closed the gap., (Copyright © 2019 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Aims: Pneumococcal vaccination is recommended in diabetes because of the high risk for invasive pneumococcal disease and mortality; however, vaccination rates are below recommended targets. This study was conducted to identify possible reasons behind the low rate of vaccine uptake., Methods: We examined baseline information from the Alberta Caring for Diabetes study, a prospective cohort study of 2040 adults with type 2 diabetes. Patients were recruited between December 2011 and December 2013. The baseline survey collected information on a wide range of socio-demographic characteristics, disease and management information, as well as health status measurements and health service utilization. Multivariable logistic regression analyses were conducted to identify factors associated with self-reported pneumococcal vaccination status., Results: Mean age was 64 (SD 11) years, 45% were women, mean duration of diabetes was 12 (SD 10) years, and 1090 (53%) were vaccinated. Age≥65 years (adjusted odds ratio [aOR] 2.52; 95% CI: 1.98-3.20), respiratory disease (aOR 1.50; 95% CI: 1.17-1.93), and cancer (aOR 1.45; 95% CI: 1.08-1.94) were independently associated with pneumococcal vaccination. In addition, women, retirees, people with diabetes≥10 years, people using antihypertensive medications or insulin, and those who had their HbA 1c , kidney function, or their weight or waist circumference measured by a healthcare professional in the past year were more likely to have been vaccinated., Conclusion: Based on this information, future programs aimed at people aged<65 years old, men, those who are currently working, those recently diagnosed with diabetes, and those with few comorbidities could have the most potential for improving pneumococcal vaccine uptake in people with diabetes., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Objective: The objective of this study is to characterise concurrent use of benzodiazepine receptor modulators and opioids among prescription opioid users in Alberta in 2017., Design: A population based retrospective study., Setting: Alberta, Canada, in the year 2017., Participants: All individuals in Alberta, Canada, with at least one dispensation record from a community pharmacy for an opioid in the year 2017., Exposure: Concurrent use of a benzodiazepine receptor modulator and opioid, defined as overlap of supply for both drugs for at least 1 day., Main Outcome Measures: Prevalence of concurrency was estimated among subgroups of patient characteristics that were considered clinically relevant or associated with inappropriate medication use., Results: Among the 547 709 Albertans who were dispensed opioid prescriptions in 2017, 132 156 (24%) also received prescriptions for benzodiazepine receptor modulators. There were 96 581 (17.6%) prescription opioid users who concurrently used benzodiazepine receptor modulators with an average of 98 days (SD=114, 95% CI 97 to 99) of total cumulative concurrency and a median of 37 days (IQR 10 to 171). The average longest duration of consecutive days of concurrency was 45 (SD=60, 95% CI 44.6 to 45.4) with a median of 24 days (IQR 8 to 59). Concurrency was more prevalent in females, patients using an average daily oral morphine equivalent >90 mg, opioid dependence therapy patients, chronic opioid users, patients utilising a high number of unique providers, lower median household incomes and those older than 65 (p value<0.001 for all comparisons)., Conclusions: Concurrent prescribing of opioids and benzodiazepine receptor modulators is common in Alberta despite the ongoing guidance of many clinical resources. Older patients, those taking higher doses of opioids, and for longer durations may be at particular risk of adverse outcomes and may be worthy of closer follow-up for assessment for dose tapering or discontinuations. As well, those with higher healthcare utilisation (seeking multiple providers) should also be closely monitored. Continued surveillance of concurrent use of these medications is warranted to ensure that safe drug use recommendations are being followed by health providers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Healthy user bias, whereby health-seeking patients are more likely to initiate preventive therapies and engage in healthy lifestyle behaviours, is well known in observational studies, particularly with statins. However, its influence in studies of oral antihyperglycemic therapies is unknown. We sought to explore the healthy user effects in metformin users vs. nonusers on various health outcomes that should not be associated with metformin use., Methods: We conducted a retrospective cohort study using data from Alberta, between 2008 and 2015, to examine the association between metformin use and various health outcomes., Results: We identified 135,301 new users of oral antihyperglycemic agents. The mean age was 55 years, 75,949 (56%) were men and 130,725 (97%) had had at least 1 metformin prescription during a mean follow-up period of 3.4 years. Metformin users were less likely to be involved in accident-related events (adjusted hazard ratio [aHR] 0.90; 95% CI 0.85 to 0.96), were more likely to have preventive screening services (aHR 1.16; 95% CI 1.11 to 1.21), were less likely to experience other clinical events, such as asthma and gout attacks (aHR 0.90; 95% CI 0.84 to 0.97), and had lower risks for all-cause mortality (aHR 0.57; 95% CI 0.51 to 0.63) compared to nonusers., Conclusions: Our results suggest that metformin users are more likely to initiate preventive therapies and engage in other healthy behaviours. Failure to account for these behaviours may introduce healthy user bias into studies evaluating the effects of oral antihyperglycemic therapies., (Copyright © 2018 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Heart failure (HF) exacerbations often relate to poor self-care. Education programs improve outcomes, but are resource-intensive. We developed a video-based educational intervention and evaluated it in patients with HF., Methods: Congestive Heart Failure O utreach P rogram of E ducation was a pragmatic multicenter randomized trial. We included subjects with HF if they were hospitalized, seen in the emergency department (ED), or high-risk outpatients, and randomized them to intervention or control. Intervention included a 20-minute video, supplementary booklet, and 3 bimonthly newsletters focusing on salt and fluid restriction, daily weights, and medications. Subjects watched the video and were encouraged to review it at home, along with the booklet/newsletters. Control subjects received the booklet only. The primary outcome was the difference in cardiovascular hospitalizations or ED visits between groups at 6 months. Secondary outcomes included clinical events and in-hospital days., Results: We recruited 539 subjects from 22 centers in Canada and the United States. Baseline characteristics were similar in both groups: 64% were male and had a mean age of 66 (± 13) years, mean ejection fraction 31% (± 13.5), and 65% New York Heart Association Functional Classification III/IV. The primary outcome occurred in 57 subjects (21%) in the intervention group compared with 61 subjects (23%) in the control group ( P  = 0.66). There were no significant differences in prespecified secondary outcomes; however, death occurred in 18 subjects (7%) in the intervention group and 33 subjects (12%) in the control group ( P  = 0.03)., Conclusion: Video education on self-care did not reduce hospitalizations or ED visits in patients with HF. Of note, mortality was lower in the intervention group., (© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc.)

Silicon nanowires are held and manipulated in controlled optical traps based on counter-propagating beams focused by low numerical aperture lenses. The double-beam configuration compensates light scattering forces enabling an in-depth investigation of the rich dynamics of trapped nanowires that are prone to both optical and hydrodynamic interactions. Several polarization configurations are used, allowing the observation of optical binding with different stable structure as well as the transfer of spin and orbital momentum of light to the trapped silicon nanowires. Accurate modeling based on Brownian dynamics simulations with appropriate optical and hydrodynamic coupling confirms that this rich scenario is crucially dependent on the non-spherical shape of the nanowires. Such an increased level of optical control of multiparticle structure and dynamics open perspectives for nanofluidics and multi-component light-driven nanomachines.

We provide a vivid demonstration of the mechanical effect of transverse spin momentum in an optical beam in free space. This component of the Poynting momentum was previously thought to be virtual, and unmeasurable. Here, its effect is revealed in the inertial motion of a probe particle in a circularly polarized Gaussian trap, in vacuum. Transverse spin forces combine with thermal fluctuations to induce a striking range of non-equilibrium phenomena. With increasing beam power we observe (i) growing departures from energy equipartition, (ii) the formation of coherent, thermally excited orbits and, ultimately, (iii) the ejection of the particle from the trap. As well as corroborating existing measurements of spin momentum, our results reveal its dynamic effect. We show how the under-damped motion of probe particles in structured light fields can expose the nature and morphology of optical momentum flows, and provide a testbed for elementary non-equilibrium statistical mechanics.

Objective: To determine whether use of a compensation plan to remunerate pharmacists for clinical pharmacy services was associated with the number of diabetes management activities provided., Methods: Alberta pharmacists were asked about compensation plan use and frequency they provide a list of 80 diabetes management activities., Key Findings: A total of 168 community pharmacists responded to the survey. When compensation plan use, diabetes-specific training, practice characteristics and additional authorizations were incorporated into a factorial ANOVA, pharmacists who used the compensation plan reported a mean of 42.9 (95% CI 39.4 to 46.4) diabetes management activities, while those who did not reported a mean of 29.9 (95% CI 21.4 to 38.4) activities (P = 0.016)., Conclusions: After considering other important influencing factors, use of the compensation plan is positively correlated with the number of diabetes management activities pharmacists provided., (© 2017 Royal Pharmaceutical Society.)

Background: In the past decade, pharmacist practice has evolved tremendously in Canada, but the scope of practice varies substantially from one province to another., Objective: To describe pharmacists' scopes of practice relevant to prescribing within various jurisdictions of Canada, using the prescribing model in Alberta (authors' province) as the reference point., Methods: This cross-sectional survey consisted of clinical scenarios for emergency prescribing, adapting or renewing a prescription, and initial-access prescribing for a chronic disease. Pharmacists were asked about their ability to administer injections and to order or access the results of laboratory tests, as well as certification and training requirements and reimbursement models., Results: Thirteen pharmacists representing Canadian provinces other than Alberta were surveyed in late 2015, for comparison with Alberta. With specific reference to the scenarios presented, pharmacists were able to prescribe in an emergency in 9 of the 10 provinces, renew prescriptions in all provinces, and adapt prescriptions in 6 provinces. Three provinces required that pharmacists have collaborative practice agreements identifying a specific practice area in order to initiate a prescription for a chronic disease (with 6-12 pharmacists per province having such agreements). Alberta required pharmacists to have authorization, based on a detailed application, in order to initiate any provincially regulated drug (with about 1150 pharmacists having this authorization). Pharmacists were allowed to administer vaccines in 9 provinces, and 5 provinces allowed pharmacists to administer drugs by injection. Three provinces had systems in place for pharmacists to access laboratory test results, and 2 allowed pharmacists to order laboratory tests. Five provinces had government-reimbursed programs in place for select prescribing services; however, all 9 provinces with public vaccination programs reimbursed pharmacists for this service., Conclusions: Pharmacist prescribing differs among Canadian provinces. Although most provinces allow emergency prescribing and renewal or adaptation of prescriptions by pharmacists, only 4 provinces allow prescription initiation, with variable criteria and scope. Despite some progress to enhance patient flow through the health care system (e.g., by allowing pharmacists to extend prescriptions), further work should be pursued to harmonize clinical practices across Canada and to enable pharmacists to initiate and manage drug therapy., Competing Interests: Competing interests: Tammy Bungard has received speaker’s honoraria from Bayer and Bristol-Myers Squibb, as well as unrestricted research grants from Bristol-Myers Squibb-Pfizer, and Bayer for work outside the topic of this article. Surya Bhatia and Scot Simpson have nothing to disclose.

Background: Inducement programs can promote customer loyalty; however, the clinical effects of these programs are unknown., Objective: To examine relationships among inducement program use, medication adherence, and health outcomes., Methods: Alberta residents with ≥ 1 physician visit for diabetes or hypertension between April 2008 and March 2014 were eligible for this study and included if they were new statin users and alive at least 455 days after the first statin dispensation. Group assignment was based on whether all statin dispensations in the first year were obtained from pharmacies with or without inducement programs. Discontinuation was defined as no statin dispensations between 275 and 455 days after the first statin dispensation. Acute coronary syndrome (ACS) hospitalizations or deaths were identified between 456 days and 3 years after the first statin dispensation. Multivariable regression analyses were conducted to examine relationships among inducement program use, discontinuation, and ACS events., Results: Among the 159 998 new statin users, mean age was 60.2 (±13.7) years and 67 534 (42%) were women. Statin discontinuation occurred in 22 455 (28.9%) of 77 803 inducement group participants and 25 816 (31.4%) of 82 195 noninducement group participants (adjusted odds ratio = 0.88; 95% CI = 0.86-0.90). Risk of an ACS event was similar between groups (adjusted hazard ratio = 1.00; 95% CI 0.92-1.08); however, discontinuing statin therapy was associated with a higher risk of an ACS event (adjusted hazard ratio = 1.27; 95% CI = 1.16-1.39)., Conclusions: Inducement programs are associated with better adherence and not directly associated with risk of health outcomes.

Multiple scattering of light induces structured interactions, or optical binding forces, between collections of small particles. This has been extensively studied in the case of microspheres. However, binding forces are strongly shape dependent: here, we turn our attention to dielectric nanowires. Using a novel numerical model we uncover rich behavior. The extreme geometry of the nanowires produces a sequence of stationary and dynamic states. In linearly polarized light, thermally stable ladder-like structures emerge. Lower symmetry, sagittate arrangements can also arise, whose configurational asymmetry unbalances the optical forces leading to nonconservative, translational motion. Finally, the addition of circular polarization drives a variety of coordinated rotational states whose dynamics expose fundamental properties of optical spin. These results suggest that optical binding can provide an increased level of control over the positions and motions of nanoparticles, opening new possibilities for driven self-organization and heralding a new field of self-assembling optically driven micromachines.