Ingunn Fride Tvete

A nationwide registry study to compare bleeding rates in patients with atrial fibrillation being prescribed oral anticoagulants.

Aims We aimed to evaluate bleeding risk in clinical practice in patients with atrial fibrillation (AF) being prescribed dabigatran, rivaroxaban, or apixaban compared with warfarin. Methods Using nationwide registries (Norwegian Patient Registry and Norwegian Prescription Database), we identified AF patients with a first prescription of oral anticoagulants between January 2013 and June 2015. Patients were followed until discontinuation or switching of oral anticoagulants, death, or end of follow-up. The primary endpoint was major or clinically relevant non-major (CRNM) bleeding. Results In total 32 675 AF patients were identified (58% men, median age 74 years): 11 427 patients used warfarin, 7925 dabigatran, 6817 rivaroxaban, and 6506 apixaban. After a median follow-up of 173 days (25th, 75th percentile 84, 340), 2081 (6.37%) patients experienced a first major or CRNM bleeding. Using a Cox proportional hazard model adjusting for baseline characteristics, use of apixaban [hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.61–0.80, P < 0.001] and dabigatran (HR 0.74, 95% CI 0.66–0.84, P < 0.001) were associated with a lower risk of major or CRNM bleeding compared with warfarin whereas use of rivaroxaban was not (HR: 1.05, 95% CI 0.94–1.17, P = 0.400). Use of dabigatran and rivaroxaban were associated with higher risk of gastrointestinal bleeding, whereas use of apixaban and dabigatran were associated with lower risk of intracranial bleeding, compared with warfarin. Conclusion In this nationwide cohort study in AF patients, apixaban and dabigatran were associated with a lower risk of major or CRNM bleeding compared with warfarin. The risk of gastrointestinal bleeding was higher with rivaroxaban and dabigatran compared with warfarin.

Behavior of lactating Holstein-Friesian cows during spontaneous cycles of estrus.

The objectives of the present study were to describe, in detail, behavior associated with standing estrus (STE) in lactating dairy cows and behavioral changes during complete estrous cycles. Estrus signs were monitored by continuous video recording of 20 Holstein-Friesian (HF) cows housed on an outdoor wood-chip pad during 1 estrous cycle (22 d). Other social behavior was recorded during STE and, for comparison, during 1 selected day when none of the cows were in estrus. Standing stationary when mounted was defined as the primary estrus sign. Anogenital sniff, chin rest, attempt to mount, and mount were defined as secondary estrus signs. Ovarian cyclicity was confirmed by progesterone measurements. This study reports short mean duration of STE (7.1±1.44h) and estrus (mount period; 12.9±1.84h) of the 13 cows expressing these signs. All mounting activities involved at least one cow in, or within 4h of, STE. The most frequent sign during STE was anogenital sniff initiated, followed by chin rest received, chin rest initiated, chase up initiated, anogenital sniff received, mount initiated, head butt, mount received, attempt to mount initiated, push away received, play rub, attempt to mount received, follow initiated, threat received, flehmen, avoid, bellow, and social lick received. Standing and mounting activity in HF cows was inconsistent during estrus, indicating that other signs could be of greater use. The frequency of secondary estrus signs initiated and received increased gradually during the last 12h before STE, revealing significant differences between periods from 4 to 6 and 1 to 3h before STE. A considerable increase in receptive behavior (secondary estrus signs received) was identified between 1 to 3h prior to STE and STE. Both frequent initiated and received behaviors were associated with STE. A significant decrease in the frequency of secondary estrus signs initiated and received occurred 3h after STE. Cows in STE simultaneously predominantly chose the other standing cow as mate and expressed secondary estrus signs more frequently. Based on the results of this study, we suggest that chase up could be regarded as a reliable indicator of estrus and that the changes in proceptive (initiated) and receptive (received) behavior could be used as predictors of different stages in estrus. Knowledge of these behavioral signs may improve heat detection rates and the ability to predict the optimum breeding time for dairy cows.

A review and Bayesian meta-analysis of clinical efficacy and adverse effects of 4 atypical neuroleptic drugs compared with haloperidol and placebo.

Aims: The objective of the study was to examine the efficacy and the degree of adverse effects connected with atypical neuroleptic drugs and haloperidol by using a previously described Bayesian statistical method that includes both direct and indirect comparisons simultaneously. Methods: The authors used the results of 30 double-blind, randomized studies including comparisons of 4 atypical neuroleptics and haloperidol, head-to-head or against placebo. We calculated the response ratios for drugs against placebo and thereafter the relative response ratios for one drug against another. With uniform priors, we calculated and ranked the posterior estimates of response ratios for antipsychotic effect, weight gain, and occurrence of extrapyramidal symptoms. Results: All second-generation neuroleptics analyzed are fairly effective with response ratios against placebo ranging between 1.55 (credibility interval, 1.36-1.76) and 1.99 (1.76-2.26), with clozapine being the most effective and aripiprazole the least effective among them. The risk of inducing weight gain is clearly very high for all 5 neuroleptic drugs compared with placebo with response ratios of 12.21 (10.22-15.05) for olanzapine and 11.28 (6.89-17.77) for clozapine. There is a clear increased risk of extrapyramidal adverse effects for haloperidol compared with placebo as the response ratio is 2.33 (2.03-2.49). The other drugs all have considerably less risk of extrapyramidal adverse effects. Conclusions: The 4 second-generation neuroleptics included in our meta-analysis show only small differences in overall efficacy, with clozapine being the most effective and aripiprazole the least effective among them. When the risk of adverse effects is analyzed, olanzapine and clozapine are afflicted with the highest risk of inducing weight gain and haloperidol with extrapyramidal symptoms. Even aripiprazole and risperidone, however, induce considerable weight gain compared with placebo but may be acceptable alternatives when tailoring drug treatment to the individual patient.

Does atenolol differ from other β-adrenergic blockers?

BackgroundA recent meta-analysis of drug effects in patients with hypertension claims that all β-adrenergic blockers are equally effective but less so than other antihypertensive drugs. Published comparisons of the β-adrenergic blocker atenolol and non-atenolol β-adrenergic blockers indicate different effects on death rates, arrhythmias, peripheral vascular resistance and prognosis post myocardial infarction, all in disfavour of atenolol. In keeping with these findings, the data presented in the meta-analysis indicate that atenolol is less effective than the non-atenolol β-adrenergic blockers both when compared with placebo and with other antihypertensive drugs. These findings were not, however, statistically significant.MethodsWe performed an additional analysis with a Bayesian statistical method in order to make further use of the published data.ResultsOur calculations on the clinical data in the meta-analysis showed 13% lower risk (risk ratio 0.87) of myocardial infarction among hypertensive patients taking non-atenolol β-adrenergic blockers than among hypertensive patients taking atenolol. The 90 % credibility interval ranged from 0.75 to 0.99, thereby indicating statistical significance. The probability of at least 10% lower risk (risk ratio ≤ 0.90), which could be considered to be of clinical interest, was 0.69.ConclusionTaken together with the other observations of differences in effects, we conclude that the claim that all β-adrenergic blockers are inferior drugs for hypertensive patients should be rejected. Atenolol is not representative of the β-adrenergic blocker class of drugs as a whole and is thus not a suitable drug for comparisons with other antihypertensive drugs in terms of effect. The non-atenolol β-adrenergic blockers should thus continue to be fundamental in antihypertensive drug treatments.

Sexually active groups in cattle-A novel estrus sign

The current study presents a novel objective measure for characterizing sexually active groups (SAG 3-5) and relates this measure to other behaviors of lactating Holstein-Friesian cows. Cows in SAG 3-5 were required to participate in a minimum of 1 estrus behavior per 5min while staying within 3m (2 cow lengths) of its partner(s) for a minimum of 5min. Twenty Holstein-Friesian cows were video-monitored continuously through 1 complete estrous cycle (22d). Standing behavior, SAG 3-5, secondary estrus signs (SEC), and other social and agonistic behaviors were recorded continuously. The period of mounting estrus (MTE) was divided into the 3 parts: prestand, standing estrus (STE), and poststand. The mean durations of MTE, prestand, STE, and poststand period were 12.9±1.84, 4.0±1.93, 7.1±1.44, and 1.8±0.57h (n=13). The fractions of time spent in SAG 3-5 during MTE, prestand, STE, and poststand period were 13, 8, 19, and 1% (n=11). During MTE, cows participated, on average, in 5.8±1.24 SAG 3-5 and initiated 9.5±2.99 mounts, with mean durations of 0.25±0.03h and 4.00±0.36s, respectively. The novel measure SAG 3-5 was a sign of long duration not confined only to groups of STE cows. On one day when no cows were in estrus and during the periods 4 to 24h before and after MTE, no SAG 3-5 behaviors were observed. Luteal-phase cows participated in SAG 3-5 only when the partner was a single cow in estrus. The time spent in SAG 3-5 increased between 1 and 3h before MTE and the prestand period (3 vs. 8%) and reached a peak level during STE. From STE to poststand, time spent in SAG 3-5 decreased considerably (19 vs. 1%). The observed decrease in nonmutual agonistic behaviors 4 to 24h before MTE is suggested as an early sign of pre-estrus. Changes in SAG 3-5, agonistic behaviors, and SEC are suggested as indicators of the specific stages of MTE. Increased SEC initiated and SAG 3-5 were indicators of late pre-estrus and early estrus (prestand). Peak levels of SAG 3-5, SEC, and social agonistic behaviors were indicators of STE. A sudden decrease in behaviors, preceded by frequent interactions, was indicative of late estrus (poststand). On the basis of the findings reported here, we propose that SAG 3-5, as well as proceptive and receptive patterns of SEC and agonistic behaviors, be included in estrus detection protocols. Updated knowledge of these behavioral interactions may assist when determining the stage of estrus and the optimal time to breed dairy cows.

Modelling and predicting customer churn from an insurance company

Within a companys customer relationship management strategy, finding the customers most likely to leave is a central aspect. We present a dynamic modelling approach for predicting individual customers’ risk of leaving an insurance company. A logistic longitudinal regression model that incorporates time-dynamic explanatory variables and interactions is fitted to the data. As an intermediate step in the modelling procedure, we apply generalised additive models to identify non-linear relationships between the logit and the explanatory variables. Both out-of-sample and out-of-time prediction indicate that the model performs well in terms of identifying customers likely to leave the company each month. Our approach is general and may be applied to other industries as well.

A 3-year survey quantifying the risk of dose escalation of benzodiazepines and congeners to identify risk factors to aid doctors to more rationale prescribing

Objectives This study investigated and quantified risk factors of dose escalation, as an indication of drug misuse and dependency of benzodiazepines and congeners, among presumably drug naïve patients in the Norwegian drug prescription database, observed over 3 years. Design Observational study. Setting Prescription database study. Participants We defined an excessive user as one redeeming more than two defined daily doses per day in 3 months. Primary and secondary outcome measures We examined the risk of excessive use over time and the effect of risk factors through multistate logistic regression and scenarios. Results Most of the 81 945 patients had zopiclone or zolpidem as the initial drug (63.8%), followed by diazepam (25.3%), oxazepam (6.1%), nitrazepam/flunitrazepam (2.9%), hydroxyzine/buspirone (1.6%) and alprazolam (0.3%). At any time 23% redeemed prescriptions, about 34% did not redeem any prescriptions beyond any 3-month period and 0.9% ended up as excessive users. Patients previously using drugs, such as opioids, antialcohol or smoke cessation treatment, had a higher risk to become excessive users compared to patients who had not. Patients whose first prescription was for oxazepam or nitrazepam/flunitrazepam had a higher risk of becoming an excessive user compared to those who started with diazepam. A specialist in general practice as the first-time prescriber was associated with a lower risk compared to doctors without specialty. Conclusions Most benzodiazepine use occurred according to guidelines. Still, some experienced dose escalation over time, and risk factors were previous use of other psychotropic drugs, long time use, choice of first-time drug and prescribers specialty. This could incite doctors to have a cessation plan when issuing first-time prescriptions.

Antibiotic resistance in hospitals: a ward-specific random effect model in a low antibiotic consumption environment

Association between previous antibiotic use and emergence of antibiotic resistance has been reported for several microorganisms. The relationship has been extensively studied, and although the causes of antibiotic resistance are multi-factorial, clear evidence of antibiotic use as a major risk factor exists. Most studies are carried out in countries with high consumption of antibiotics and corresponding high levels of antibiotic resistance, and currently, little is known whether and at what level the associations are detectable in a low antibiotic consumption environment. We conduct an ecological, retrospective study aimed at determining the impact of antibiotic consumption on antibiotic-resistant Pseudomonas aeruginosa in three hospitals in Norway, a country with low levels of antibiotic use. We construct a sophisticated statistical model to capture such low signals. To reduce noise, we conduct our study at hospital ward level. We propose a random effect Poisson or binomial regression model, with a reparametrisation that allows us to reduce the number of parameters. Inference is likelihood based. Through scenario simulation, we study the potential effects of reduced or increased antibiotic use. Results clearly indicate that the effects of consumption on resistance are present under conditions with relatively low use of antibiotic agents. This strengthens the recommendation on prudent use of antibiotics, even when consumption is relatively low.

Even more suicide attempts in clinical trials with paroxetine randomised against placebo

BackgroundFollowing our previous publication we have received critical comments to our conclusions as well as new data that are strengthening our findings.ResultsWith the new data, 11 suicide attempts among patients on paroxetine against 1 among patients on placebo, we found with a Bayesian technique that the posterior probability that medication with paroxetine is associated with an increased intensity per year of a suicide attempt is from 0.98 to 0.99, depending on the prior.We found that the comment to our article by GSK representatives contained errors, misunderstanding and unwillingness to accept Bayesian principles in the analysis of clinical trials.ConclusionWe were in our previous publication, with preliminary data and a Bayesian approach, able to raise a concern that suicide attempts might be connected with the use of paroxetine. This suspicion has now been confirmed.

Risk factors for excessive benzodiazepine use in a working age population: a nationwide 5-year survey in Norway

Abstract Objective: To identify risk factors for becoming an excessive user over time. Setting: Prescription database study over five years. Subjects and method: Norwegians between 30 and 60 years with a first dispensation of a benzodiazepine during 2006, encompassing 23 227 individuals. A Cox hazard regression model was defined, initially stratifying on gender, age, county, previous relevant drug dispensations, household income, education level, and vocational rehabilitation support. Main outcome measure: The time from the first redemption until excessive use was defined as using more than two DDDs per day on average within a three-month period. Results: Women’s risk was lower than men’s for excessive use (HR = 0.42, CI 0.35–0.51). Initial oxazepam, alprazolam, or nitrazepam/flunitrazepam use indicated higher risk compared with diazepam (HR = 1.51, CI 1.24–1.85, HR = 2.75, CI 1.54–4.91, HR = 1.67, CI 1.29–2.16). Previous antidepressants or lithium, antipsychotics or opioids, anti-alcohol and smoke cessation treatment indicated a higher risk compared with no such use (HR = 1.4, CI 1.16–1.69, HR = 1.92, CI 1.54–2.4, and HR = 2.88, CI 2–4.15). Higher education and average or high household income were associated with a low risk compared with low education and income (HR = 0.68, CI 0.57–0.81, HR = 0.58, CI 0.46–0.73, and HR = 0.37, CI 0.26–0.54). Working in the private or public sector was associated with a low risk compared with no registered work (HR = 0.53, CI 0.4–0.71 and HR = 0.57, CI 0.45–0.74). Conclusion: The prevalence of excessive use over a five-year observation period was 2.34%. Risk factors were indications of psychiatric illness, first benzodiazepine choice, low income, and education. Excessive users were also characterized by a more severe disease, indicated by having prescription fulfilments by a psychiatrist and by switching benzodiazepines. Key points Guidelines state that benzodiazepines should be used for a short time and excessive use indicates drug dependency. Of all new benzodiazepine users 2.34% became excessive users, defined as consuming above two defined daily doses (DDDs) per day on average over three months, within a five-year period. Previous use of other psychotropic drugs, opioids and anti-alcohol and smoke cessation drugs, first benzodiazepine prescribed, low household income, and low education were risk factors for excessive use. Excessive users were characterized by switching benzodiazepines and having prescription fulfilments by a psychiatrist suggesting a more severe disease.