Sylvie Perreault

Efficacy and Costs of Patient-controlled Analgesia versus Regularly Administered Intramuscular Opioid Therapy

Background Many studies have shown in the efficacy of patient‐controlled analgesia (PCA). However, it is not clear whether PCA has clinical or economic benefits in addition to efficient analgesia. The current study was designed to evaluate these issues by comparing PCA with regularly administered intramuscular injections of opioids after hysterectomy. Methods This prospective study included 126 patients who underwent abdominal hysterectomy and were randomly assigned to receive PCA or regularly timed intramuscular injections of morphine during a period of 48 h. Doses were adjusted to provide satisfactory analgesia in both treatment groups. Pain at rest and with movement, functional recovery, drug side effects, and patient satisfactory were measured using rating scales and questionnaires. The costs of PCA and intramuscular therapy were calculated based on personnel time and drug and material requirements. Results Comparable analgesia was observed with the two treatment methods, with no significant differences in the incidence of side effects or patient satisfaction. The medication dosage had to be adjusted significantly more frequently in the intramuscular group than in the PCA patients. The PCA did not favor a faster recuperation time compared with intramuscular therapy in terms of times of ambulation, resumption of liquid and solid diet, passage of bowel gas, or hospital discharge. The results of the economic evaluation, which used a cost‐minimization model and sensitivity analyses, showed that PCA was more costly than regular intramuscular injections despite the fact that no costs for the pump were included in the analyses. Cost differences in nursing time favoring PCA were offset by drug and material costs associated with this type of treatment. Conclusions Compared with regularly scheduled intramuscular dosing, PCA is more costly and does not have clinical advantages for pain management after hysterectomy. Because of the comparable outcomes, the general use of PCA in similar patients should be questioned.

Use of inhaled corticosteroids during pregnancy and risk of pregnancy induced hypertension: nested case-control study

Abstract Objective To determine whether the use of inhaled corticosteroids during pregnancy increases the risk of pregnancy induced hypertension and pre-eclampsia among asthmatic women. Design Nested case-control study. Setting Three administrative health databases from Quebec: RAMQ, MED-ECHO, and Fichier des événements démographiques. Participants 3505 women with asthma, totalling 4593 pregnancies, between 1990 and 2000. Main outcome measuresPregnancy induced hypertension and pre-eclampsia. Results 302 cases of pregnancy induced hypertension and 165 cases of pre-eclampsia were identified. Use of inhaled corticosteroids from conception until date of outcome was not associated with an increased risk of pregnancy induced hypertension (adjusted odds ratio 1.02, 95% confidence interval 0.77 to 1.34) or pre-eclampsia (1.06, 0.74 to 1.53). No significant dose-response relation was observed between inhaled corticosteroids and pregnancy induced hypertension or pre-eclampsia. Oral corticosteroids were significantly associated with the risk of pregnancy induced hypertension (adjusted odds ratio 1.57, 1.02 to 2.41), and a trend was seen for pre-eclampsia (1.72, 0.98 to 3.02). Conclusion No significant increase of the risk of pregnancy induced hypertension or pre-eclampsia was detected among users of inhaled corticosteroids during pregnancy, while markers of uncontrolled and severe asthma were found to significantly increase the risks of pregnancy induced hypertension and pre—eclampsia.

Intraoperative floppy-iris syndrome associated with α1-adrenoreceptors : Comparison of tamsulosin and alfuzosin

PURPOSE: To compare the incidence of intraoperative floppy‐iris syndrome (IFIS) in men exposed to tamsulosin and men exposed to alfuzosin and evaluate the effect of IFIS on the complication rate of cataract surgery. SETTING: Tertiary care hospital, Chicoutimi, Quebec, Canada. METHODS: The medical charts of 64 men (92 eyes) who had phacoemulsification cataract surgery between June 2005 and July 2006 and reported having used tamsulosin or alfuzosin at their initial visit for cataract evaluation were reviewed. The presence or absence of IFIS, potential confounding clinical covariates, duration of surgery, and complications were noted. The history of taking an α1‐antagonist was verified. To address the main objective of the study, only patients who had exclusively used tamsulosin or alfuzosin were included. For the secondary objective, all eligible patients were included even if they had received more than one α1‐antagonist in the past. RESULTS: Of men exclusively exposed to tamsulosin (22) or alfuzosin (13), 86.4% and 15.4%, respectively, developed IFIS (P<.001). The adjusted odds ratio of IFIS in patients exposed to tamsulosin compared to those exposed to alfuzosin was 32.15 (95% confidence interval, 2.74‐377.11). Eyes with IFIS had a higher risk for complications (focal iris stromal atrophy, transient postoperative hypertension, major iris trauma, posterior capsule break with vitreous loss, zonular dehiscence, postoperative cystoid macular edema) than eyes without IFIS (P<.001). CONCLUSIONS: Men exposed to tamsulosin had a significantly higher risk for developing IFIS than men exposed to alfuzosin. Intraoperative floppy‐iris syndrome significantly increased the complication rate of cataract surgery.

Better adherence to antihypertensive agents and risk reduction of chronic heart failure.

Aims.  Antihypertensive (AH) agents have been shown to reduce the risk of major cardiovascular events including chronic heart failure (CHF). However, the impact of changes in patterns of AH agents use on CHF is unknown. Our objective was to estimate to which different patterns of AH agent use is associated with the occurrence of CHF in a population‐based study.

Impact of noncompliance with alendronate and risedronate on the incidence of nonvertebral osteoporotic fractures in elderly women.

AIMS To evaluate the association between noncompliance with alendronate and risedronate and the risk of nonvertebral osteoporotic fracture in community-dwelling elderly women. METHODS A nested case-control study was conducted using the Quebec administrative health databases. To be included in the cohort, women needed to be aged > or = 68 years and to have initiated treatment with alendronate or risedronate between 1 January 2002 and 31 March 2005. Cases consisted of all women with an incident nonvertebral osteoporotic fracture occurring > or = 1 year after initiation of therapy. Each case was matched with up to 20 controls using incidence density sampling, according to age (+/- 1 year) and follow-up duration. A woman was noncompliant if she had a medication possession ratio (MPR) <80% for total follow-up duration. Rate ratios (RR) for fracture were estimated through conditional logistic regression analysis, adjusting for potential confounders. RESULTS Among the 30 259 women included in the cohort, 1036 nonvertebral fracture cases were identified and were matched to 20 069 controls. Compared with women with a MPR > or = 80%, those with a MPR < 80% had a greater risk of nonvertebral fracture [adjusted RR 1.27, 95% confidence interval (CI) 1.12, 1.44]. Considering hip fracture only, the multivariate model yielded similar results, (adjusted RR 1.28, 95% CI 1.02, 1.61). CONCLUSIONS Among community-dwelling elderly women, noncompliance with alendronate or risedronate is associated with an increased risk of nonvertebral fracture.

Effect of maternal moderate to severe asthma on perinatal outcomes

BACKGROUND/OBJECTIVES It has been reported that adverse fetal outcomes are more prevalent in pregnant women with asthma than they are in women without asthma. In our study, we investigated the effect that the severity of asthma during pregnancy has on the risk of a small for gestational age (SGA) infant, low birth weight (LBW), and preterm birth. METHODS A population-based cohort of 13,007 pregnancies from asthmatic women was reconstructed through the linking of three of Quebecs (Canada) administrative databases covering the period between 1990 and 2002. A two-stage sampling cohort design was used to collect additional information on the selected womens life-style habits via a mailed questionnaire. Asthma severity during pregnancy was measured with a validated database index. A logistic regression model was used to obtain the adjusted odds ratios of SGA, LBW and preterm birth as a function of the level of asthma severity. RESULTS The proportions of women with mild, moderate and severe asthma were 82.5%, 12.5% and 5.0%, respectively. We sent 3,168 questionnaires to selected women, with a 40.2% (n=1274) response rate. Final estimates showed that the risk of SGA was significantly higher among severe (OR:1.48, 95%CI: 1.15-1.91) and moderate asthmatic women (OR: 1.30, 95%CI:1.10-1.55) than mild asthmatic women. No significant associations were found between asthma severity, preterm birth and LBW. CONCLUSIONS Mothers with severe and moderate asthma during pregnancy have a higher risk of SGA babies than those with mild asthma.

Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD

BACKGROUND AND OBJECTIVES Hyperkalemia affects up to 10% of patients with CKD. Sodium polystyrene sulfonate has long been prescribed for this condition, although evidence is lacking on its efficacy for the treatment of mild hyperkalemia over several days. This study aimed to evaluate the efficacy of sodium polystyrene sulfonate in the treatment of mild hyperkalemia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 33 outpatients with CKD and mild hyperkalemia (5.0-5.9 mEq/L) in a single teaching hospital were included in this double-blind randomized clinical trial. We randomly assigned these patients to receive either placebo or sodium polystyrene sulfonate of 30 g orally one time per day for 7 days. The primary outcome was the comparison between study groups of the mean difference of serum potassium levels between the day after the last dose of treatment and baseline. RESULTS The mean duration of treatment was 6.9 days. Sodium polystyrene sulfonate was superior to placebo in the reduction of serum potassium levels (mean difference between groups, -1.04 mEq/L; 95% confidence interval, -1.37 to -0.71). A higher proportion of patients in the sodium polystyrene sulfonate group attained normokalemia at the end of their treatment compared with those in the placebo group, but the difference did not reach statistical significance (73% versus 38%; P=0.07). There was a trend toward higher rates of electrolytic disturbances and an increase in gastrointestinal side effects in the group receiving sodium polystyrene sulfonate. CONCLUSIONS Sodium polystyrene sulfonate was superior to placebo in reducing serum potassium over 7 days in patients with mild hyperkalemia and CKD.

A cluster randomized controlled Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia: the TEAM study

Background: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia. Methods: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients’ adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors. Results: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was −0.2 mmol/L (95% confidence interval [CI] −0.3 to −0.1), and the adjusted reduction was −0.05 (95% CI −0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34). Interpretation: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Control and severity of asthma during pregnancy are associated with asthma incidence in offspring: two-stage case–control study

The extent to which childhood asthma incidence is influenced by asthma control and severity during pregnancy is unknown. We have studied this association during the childs first 10 yrs of life. A two-stage, case–control study, nested in a cohort of 8,226 children of asthmatic mothers, was conducted using three interlinked databases of Quebec, Canada, and mailed questionnaires. A total of 2,681 asthmatic children and 30,318 age-matched controls were selected (≤20 controls·case−1; stage 1), and 3,254 selected mothers were mailed questionnaires to obtain additional information (stage 2). Asthma control and severity was defined using validated indexes and childhood asthma incidence based on at least one asthma-related diagnosis and prescription received within 2 yrs. A total of 44 confounders were considered. Compared with children of mild controlled asthmatic mothers, children whose mothers had moderate-to-severe uncontrolled asthma during pregnancy had an increased risk of asthma (adjusted OR 1.27, 95% CI 1.06–1.52). No increased risk was observed for children of mild uncontrolled and moderate-to-severe controlled mothers. Based on one of the largest studies of children of asthmatic mothers, a significant increase in asthma risk was demonstrated among children whose mothers had poor control and increased severity of asthma during pregnancy, indicating that this element should be added to the expanding list of determinants of childhood asthma. As it constitutes a risk factor where pregnant asthmatic females can intervene, it is of great importance for physicians to optimally treat asthmatic females during pregnancy and to encourage females to be adherent to the prescribed asthma medications.

Population-based study of the effectiveness of bone-specific drugs in reducing the risk of osteoporotic fracture†

Evidence supports bone‐specific drugs (BSDs) efficacy in the fracture risk reduction. But treatment rates for osteoporosis among high‐risk patients are far below the recommended guidelines. A major concern about BSDs is the lack of adherence with treatment.