Rafia S. Rasu

Rankings and symptom assessments of side effects from chemotherapy: Insights from experienced patients with ovarian cancer

Goals of workAlthough many patients with ovarian cancer achieve favorable responses to primary chemotherapy, the majority of women will experience recurrence of their cancer. Selection of second- or third-line chemotherapy ultimately depends on patient preferences for different side effects. To better understand this process, we evaluated preferences and symptom distress in patients with ovarian cancer.Patients and methodsA total of 70 women with ovarian cancer who had previously received at least three cycles of platinum-based chemotherapy and currently undergoing chemotherapy for newly diagnosed or recurrent disease were interviewed in an outpatient chemotherapy clinic. The patients were asked to rank order 27 health states using a modified visual analog scale and to complete the Memorial Symptom Assessment Scale (MSAS).Main resultsMost favorable health states included perfect health, clinical remission and complete control of chemotherapy-induced nausea and vomiting (CINV). Least favorable health states included more severe CINV health states and death. Patients on first-line chemotherapy had less symptom distress, and rated sexual dysfunction, fatigue and memory loss more favorably than patients on second- or third-line chemotherapy (P<0.05). Married patients generally had less symptom distress compared to patients who were not married, but married patients indicated more distress with sexual dysfunction (P=0.04). Married patients rated alopecia less favorably than unmarried patients (P=0.03), but married patients viewed certain CINV health states more favorably (P=0.02–0.04).ConclusionsCINV remains one of the most dreaded side effects of chemotherapy. Separate preference profiles exist for patients with newly diagnosed and recurrent disease, as well as for married versus unmarried patients. While MSAS scores and VAS rankings showed consistency across some health states, this was not true for CINV, suggesting that current symptom status may only influence patient preferences for selected side effects.

Assessing Chronic Pain Treatment Practices and Evaluating Adherence to Chronic Pain Clinical Guidelines in Outpatient Practices in the United States

UNLABELLED Chronic pain is a major health concern in the United States. Several guidelines have been developed for clinicians to promote effective management and provide an analytical framework for evaluation of treatments for chronic pain. This study explores sample population demographics and the utilization of various therapeutic modalities in an adult population with common nonmalignant chronic pain (NMCP) indications in U.S. outpatient settings. A cross-sectional study using the National Ambulatory Medical Care Survey (NAMCS) data from 2000 to 2007 was used to analyze various treatment practices for the management of NMCP and evaluate the results in comparison with guidelines. The study population of 690,205,290 comprised 63% females, with 45.17% of patient visits occurring in primary care settings. Treatment with at least 1 chronic pain medication was reported in 99.7% of patients. Nonsteroidal anti-inflammatory agents were the most common treatment prescribed, with use reported in approximately 95% of the patient visits. No other pain medication drug class or nonmedication therapy was prescribed more than 26.4%. These results point to a potential underutilization of many recommended NMCP treatments including combination therapies and the need for enhanced education of chronic pain guidelines. PERSPECTIVE This study, representing over 690 million patient visits, contributes to the relative paucity of data on the use of therapeutic modalities in the management of NMCP. These results may assist clinicians and healthcare policymakers in identifying areas where practices are at odds with guidelines with the goal to improve care.

Effect of educational level on knowledge and use of breast cancer screening practices in Bangladeshi women.

The Breast Health Global Initiative 2007 emphasized education and cultural values for promoting breast cancer screening in developing countries. This cross-sectional study investigated if educational level and cultural beliefs affect breast cancer screening practices in 152 women 40 years or older in Dhaka, Bangladesh. Women with a higher (>12 years) educational level were more likely to know about breast self-examination (BSE; ORadj, 95%CI = 22, 6.39–76.76), to know about mammograms (6, 2.49–15.70), and to practice BSE (3, 1.27–6.83) compared with those with a lower educational level. Breast cancer screening practices or knowledge was not affected by perceiving barriers to having mammograms.

Adherence to Antihyperlipidemic Medication and Lipid Control in Diabetic Veterans Affairs Patients with Psychotic Disorders

BACKGROUND Medication adherence for chronic medical illnesses has been studied extensively, but there is limited data evaluating medication adherence for comorbid medical illnesses in a psychiatric population. Furthermore, only one study has evaluated both medication adherence and clinical outcomes between the two populations. Examining medication adherence rates and clinical outcomes are important as chronic medical illnesses occur commonly in psychiatric patients, can be drug-induced, and have negative long-term consequences. OBJECTIVES To compare antihyperlipidemic medication adherence and lipid control between individuals with psychotic disorders and those without a psychiatric illness. METHODS This was a retrospective medical record review of 124 subjects with hyperlipidemia and diabetes (62 subjects with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched individuals without a psychiatric illness) receiving medical and psychiatric care through the Veterans Affairs Medical Center during 2008. Cumulative mean gap ratio (CMGR) was used to determine adherence. Lipid values were utilized to compare lipid control between groups. RESULTS A significant difference in CMGR was detected. Subjects with psychotic disorders were without antihyperlipidemic therapy for 44 days compared with 62 days for the nonpsychiatric comparison group (P = 0.034). Antipsychotic adherent subjects (≥80% adherent) were more likely to adhere to their antihyperlipidemic medication (P = 0.0007). There were no significant differences between the groups for lipid control. CONCLUSION Antihyperlipidemic medication adherence differed with the psychotic disorder group having fewer days without drug therapy. However, there was no significant difference in lipid control between subjects with a psychotic disorder and those without a psychiatric illness.

Medication adherence and glycemic control in patients with psychotic disorders in the Veterans Affairs healthcare system

Objective To compare antihyperglycemic medication adherence and glycemic control between individuals with schizophrenia and related psychotic disorders and a nonpsychiatric comparison group. Methods This was a retrospective medical record review. A total of 124 subjects with diabetes (62 patients with schizophrenia or a related psychotic disorder and 62 randomly selected, age-matched patients without a psychiatric illness) receiving their medical and psychiatric care exclusively through the Kansas City Veterans Affairs healthcare system during 2008 were included in the study. Adherence to antihyperglycemic and antipsychotic medication was determined by refill records obtained through the computerized patient record system to calculate the cumulative mean gap ratio. Hemoglobin A1C values were utilized to compare glycemic control between groups and compared to glycemic goals established by diabetes treatment guidelines. Results Antihyperglycemic medication adherence was poor for both groups as approximately 60% of the psychotic disorder group and 75% of the nonpsychiatric comparison group were without antihyperglycemic medication for greater than 30 days during the 12-month period but adherence did not differ between the groups (p=0.182). Antipsychotic adherent subjects (≥80% adherent) were more likely to be adherent to their antihyperglycemic medication (p=0.0003). There were no significant differences between groups in glycemic control. Conclusions Antihyperglycemic medication adherence and glycemic control was less than optimal for both groups. There were no significant differences in antihyperglycemic medication adherence and glycemic control between patients with a psychotic disorder and those without a psychiatric illness.

The influence of co-morbidities on prescribing pharmacotherapy for insomnia: evidence from US national outpatient data 1995–2004

Summary Objective: Patients with insomnia are likely to have other co-morbidities that could affect pharmacotherapeutic choices. This study examined the prevalence and impact of co-morbidities on the pharmacological treatment of insomnia. Study design: A retrospective data analysis of the National Ambulatory Medical Care Survey from 1995 to 2004, comprising patients with a diagnosis of insomnia, was conducted. Multivariate logistic regression models were used to predict the impact of co-morbidities on pharmacotherapy for insomnia. Results: A total of 5,487 unweighted patient visits with insomnia were identified, representing 161.4 million patients in the US. Approximately 38% of these patients had at least one co-morbid condition. Patients with mental co-morbidities, especially anxiety, had decreased likelihood of receiving pharmacotherapy for insomnia. Conclusions: Mental co-morbidities such as episodic mood disorder, anxiety and depression are prevalent in patients with insomnia. However, many co-morbid patients do not receive pharmacological therapy specific for insomnia.

An Exploratory Retrospective Evaluation of Ropinirole-Associated Psychotic Symptoms in an Outpatient Population Treated for Restless Legs Syndrome or Parkinson's Disease

Background: Traditional treatment approaches for the management of restless legs syndrome (RLS) and Parkinsons disease (PD) include the use of medications that either directly or indirectly increase dopamine levels. In turn, a potential adverse event that could be expected is the development or exacerbation of psychiatric-related symptoms. Objective: To evaluate and describe the incidence of psychosis and associated behavioral features in patients taking ropinirole for RLS or PD. Methods: Patients were identified from a computerized database search of outpatients being treated with ropinirole for 1 of 2 medical conditions: PD or RLS. Data were collected in a retrospective manner from 95 patients who were tracked over the course of their therapy to determine whether psychosis or associated behavioral symptoms developed as a result and whether an intervention was needed to adjust ropinirole dosing or if additional medications had to be added to control features associated with psychosis. Results: A total of 284 patients being treated for RLS or PD were identified; of this group, 95 patients were identified as being treated for PD or RLS with ropinirole. Of the 95 patients being treated with ropinirole, 13 developed psychotic features that required therapeutic intervention with either the use of an antipsychotic or dose adjustment of ropinirole. PD patients included in this study were numerically more likely to develop psychotic features compared with RLS patients; however, the difference was not statistically significant (p = 0.122). The results do suggest that this risk is increased when ropinirole is used as part of a dual therapy approach with dopamine agonists in the treatment of either PD or RLS (p = 0.003). Discussion: Dopamine agonists have long been used as preferred treatment in the management of PD and RLS. When treating either PD or RLS in the psychiatric population, the concern arises that increased activity at dopamine receptors may induce or exacerbate psychiatric features. A potential clinical concern with the use of ropinirole is the potential for patients to develop psychiatric features, although there are few data available to demonstrate whether stimulation of targeted individual dopamine receptors is linked to the development or exacerbation of psychotic features. It is also undetermined whether concurrent antipsychotic treatment provides any protective benefit against psychosis, especially in patients already being treated for psychotic symptoms. Conclusions: Our findings suggest that ropinirole may play a role in inducing or exacerbating psychosis and its associated features, although a number of confounding variables prevent the determination of a clear association and suggest that further investigation is warranted in controlled clinical trials.

Treatment and costs associated with anemic chronic kidney disease patients

ABSTRACT Objective: The purpose of this paper is to provide an overview of the current therapeutic options afforded to anemic chronic kidney disease (CKD) patients and the costs of these interventions. Methodology: Literature search of articles within Ovid MEDLINE between 1996 and 2007 that pertained to the treatment of anemia in chronic kidney disease patients. Results: Early detection and treatment of anemia associated with CKD has proven to provide positive cognitive and physical effects. Treatment options that increase iron storage and availability within the body and production of erythropoietin can assist in anemic CKD patients in achieving recommended levels of hemoglobin. Acknowledgement of the potential side effects associated with the medications selected to treat anemia can help in avoiding additional injury to the patient and thus reduce healthcare expenditure. A limitation of this review is that the search was performed within a single database. Conclusions: Health care providers can play an active role in detecting anemia early and optimizing available treatment options. Future research on the effects of erythropoiesis-stimulating agents (ESA) on patients before they need dialysis, and a cost analysis between epoetin and darbepoetin alpha, would be beneficial.

Treatment of hypertension and diabetes mellitus in patients with chronic kidney disease: a review

Hypertension and diabetes mellitus are the two leading causes of chronic kidney disease (CKD). The purpose of this paper is to provide an overview of the present pharmacologic and adverse events involved in the treatment of hypertension and diabetes mellitus in patients with CKD. Proper management of hypertension and diabetes mellitus, a common co-morbidity associated with CKD, would slow the progression of kidney disease and reduce healthcare expenditures. Awareness of potential side effects due to the medications or renal insufficiency could prevent unnecessary harm to the patient and provide cost-containment. Active involvement of all healthcare team members can reduce progression of CKD and improve quality of life outcomes in CKD patients.

Prescribing trends for management of congestive heart failure from 2002 to 2004

BACKGROUND The incidence and prevalence of the patients diagnosed with congestive heart failure (CHF) continues to grow in the United States. The use of prescription drugs is a vital part of the management of CHF, and pharmacological regimens may vary among patients. OBJECTIVES To examine the CHF prescription trends in the United States and to determine present prescribing patterns. METHODS National Ambulatory Medical Care Survey and both divisions (outpatient and emergency department) of the National Hospital Ambulatory Medical Care Survey from 2002 to 2004 were used to acquire the appropriate data. All analyses used weighted data to represent national estimates. The unit of analysis was individual patient visits. Analysis of the data was accomplished using SPSS 14.0.2 and Stata/SE 9.2 statistical programs. RESULTS During the 3 study years, 24,213,096 weighted visits were associated with a diagnosis of CHF. More than half (56.2%) of the study population were female; over 75% of the subjects were older than 65 years. Over one-quarter (27.3%; 6,618,208 visits) of CHF-related visits were not associated with being prescribed a CHF-related medication. Loop diuretics were the most commonly used medication (35%). Cardiovascular specialists (odds ratio [OR]=5.28; 95% confidence interval [CI]: 1.82-15.3; P=.002), general/family practice physicians (OR=4.5, 95% CI: 1.69-12.0; P=.003), and internal medicine physicians (OR=3.85, 95% CI: 1.39-10.7; P=.010) were more likely to prescribe CHF-related medication compared with other medical specialties. CHF patients who reside in the Northeast were more likely to receive CHF-related medications than other regions (Midwest OR=0.24; South OR=0.20; West OR=0.23; P<.05) of United States. CONCLUSIONS There were regional and medical specialty-related variations for prescribing CHF-related medications. The results from this study suggest a need for increased awareness of the benefit of CHF-related medications in the management of CHF. The increased implementation of the CHF management guidelines would improve overall patient care.