The Prescription Opioid Epidemic: an Evidence-Based Approach

A group of experts, led by researchers at the Johns Hopkins Bloomberg School of Public Health, issued this report aimed at stemming the prescription opioid epidemic, a crisis that kills an average of 44 people a day in the U.S. The report calls for changes to the way medical students and physicians are trained, prescriptions are dispensed and monitored, first responders are equipped to treat overdoses, and those with addiction are identified and treated. The report grew out of discussions that began last year at a town hall co-hosted by the Bloomberg School and the Clinton Health Matters Initiative, an initiative of the Clinton Foundation. The recommendations were developed by professionals from medicine, pharmacy, injury prevention and law. Patient representatives, insurers and drug manufacturers also participated in developing the recommendations. The report breaks its recommendations into seven categories:Prescribing GuidelinesPrescription Drug Monitoring Programs (PDMPs)Pharmacy Benefit Managers (PBMs) and PharmaciesEngineering Strategies (i.e., packaging)Overdose Education and Naloxone Distribution ProgramsAddiction TreatmentCommunity-Based Prevention Strategie

The use of a plant capacity model for production scheduling and operations analysis

Thesis (S.M.)--Massachusetts Institute of Technology, Sloan School of Management; and, Thesis (S.M.)--Massachusetts Institute of Technology, Dept. of Mechanical Engineering, 1998.Includes bibliographical references (p. 65).by Caleb A. Dailey.S.M

Perovskites oxides for metal-air batteries and pseudocapacitor applications

Wind and solar energy’s rapid development has created a significant need for low-cost energy storage to enable renewables at grid level. To meet these challenges, metal-air batteries and fuel cells are being considered for base-load energy storage while high power applications like frequency regulation and uninterruptable power supplies (UPS) can be addressed using high energy pseudocapacitors. The major bottleneck to metal-air battery and fuel cell commercialization is the sluggish oxygen reactions at the positive electrode that are industrially catalyzed using expensive precious metal catalysts like Pt and IrO₂. Here, the aim is to replace precious metal-catalysts with low-cost LaNiO₃ perovskites and N-doped CNTs in alkaline conditions and study their synergistic interactions and composite stability. The work is continued by studying the anion-intercalation pseudocapacitance in a perovskite oxide library with composition La [subscript 1-x] Sr [subscript x] BO [subscript 3-δ] (B = Mn, Fe, Co; 0 ≤ x ≤ 1) and found that increasing oxygen vacancy content universally increases the pseudocapacitance while the B-site element controlled the redox potential. The most pseudocapacitive materials were then used to make the first all perovskite asymmetric pseudocapacitors with a maximum energy density of 31 Wh kg⁻¹. This work was followed by using the principles learned to further extent the redox voltage potential difference using LaNi [subscript 1-x] Fe [subscript x] O [subscript 3-δ] and brownmillerite-SrFeO [subscript 2.5] to make an asymmetric pseudocapacitor. Doing this, the redox discharge potential was pushed all the way to 1.1 V which is the highest asymmetric pseudocapacitor discharge peak potential reported to date.Chemical Engineerin

The impact of Medicare Part D on Medicare-Medicaid Dual-eligible Beneficiaries' Prescription Utilization and Expenditures

Features of Part D gave rise to broad concern that the drug benefit would negatively impact prescription utilization among the six million dual eligible beneficiaries, either during the transition from state Medicaid to Part D coverage, or in the long-run. At the same time, Part D contained other features, such as its auto-enrollment and premium subsidization policies, which were designed to safeguard utilization for this vulnerable group. Using national retail pharmacy claims, we examine the experience of dual eligibles during the first 18 months of Part D. We find no evidence that Part D adversely affected pharmaceutical utilization or out-of-pocket expenditures in the transition period, or in the 18 months subsequent to Part D implementation.

Does Access to Market Information Determine the Choice of Marketing Channel among Smallholder Yam Farmers in the Brong Ahafo Region of Ghana? A Multinomial Logit Regression Analysis

Asymmetric or missing information is likely to cause market failure and greater access of farmers to knowledge about markets and prices, is a key element in the efforts of breaking the cycle of poverty. This study describes the yam marketing distribution channel in Brong-Ahafo region. It also quantifies the magnitude and direction of the effect of market information access on the choice of yam marketing channel using the Multinomial Logit regression analysis. The study is cross sectional in designs. A total of 250 smallholder yam farmers participated in the survey. Data collected was analyzed using StataSE 11. Results indicate that there are six main channels of yam distribution comprising of producers, assemblers, wholesalers and retailers. The study observes, inter alia, that age of household head, access to cell phone, farm size and output price determine the choice of rural market relative to urban market whilst gender of household head, number of years of formal education and distance to tarred road significantly influences the choice of cooperative market relative to urban market. Access to cell phone and the interactive term (cell phone access*location of household head) are the most influential determinants of rural market and market cooperative choice both statistically and numerically respectively. These results have implications for agricultural policy in Ghana. Key words: Multinomial Logit, Brong-Ahafo, Market channel, Cell Phone, Market informatio

Association between sodium-glucose cotransporter 2 (SGLT2) inhibitors and lower extremity amputation: A systematic review and meta-analysis

BACKGROUND: The association between sodium-glucose cotransporter 2 inhibitors (SGLT2i\u27s) and lower extremity amputation is unclear. PURPOSE: To systematically review randomized control trials (RCTs) and observational studies quantifying risk of lower extremity amputations associated with SGLT2i use. DATA SOURCES AND STUDY SELECTION: We searched PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials from January 2011 to February 2020 for RCTs and observational studies including lower extremity amputation outcomes for individuals with type 2 diabetes mellitus treated with SGLT2i\u27s vs. alternative treatments or placebo. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data. MAIN OUTCOMES AND MEASURES: Our primary outcome was risk of lower limb amputation. Secondary outcomes included peripheral arterial disease, peripheral vascular disease, venous ulcerations, and diabetic foot infections. We also evaluated the risk of bias. We conducted random and fixed effects relative risk meta-analysis of RCTs. RESULTS: After screening 2,006 studies, 12 RCTs and 18 observational studies were included, of which 7 RCTs and 18 observational studies had at least one event. The random effects meta-analysis of 7 RCTs suggested the absence of a statistically significant association between SGLT2i exposure with evidence of substantial statistical heterogeneity (n = 424/23,716 vs n = 267/18,737 in controls; RR 1.28, CI\u27s 0.93-1.76; I2 = 62.0%; p = 0.12) whereas fixed effects analysis showed an increased risk with statistical heterogeneity (RR 1.27, 1.09-1.48; I2 = 62%; p = 0.003). Subgroup analysis of canagliflozin vs placebo showed a statistically significantly increased risk in a fixed effects meta-analysis (n = 2 RCTs, RR 1.59, 1.26-2.01; I2 = 88%; p = 0.0001) whereas the meta-analysis of dapagliflozin or empagliflozin (n = 2 RCTs each) and a single RCT for ertugliflozin did not show a significantly increased risk. The findings from observational studies were too heterogeneous to be pooled in a meta-analysis and draw meaningful conclusions. Both randomized and observational studies were of generally good methodological quality. CONCLUSIONS: Overall, there was no consistent evidence of SGLT2i exposure and increased risk of amputation. The increased risk of amputation seen in the large, long-term Canagliflozin Cardiovascular Assessment Study (CANVAS) trial for canagliflozin, and select observational studies, merits continued exploration

Association Between Direct-to-Consumer Advertising and Testosterone Testing and Initiation in the United States, 2009-2013

Testosterone initiation increased substantially in the United States from 2000 to 2013, especially among men without clear indications. Direct-to-consumer advertising (DTCA) also increased during this time

Risk of gastrointestinal bleeding associated with oral anticoagulants: population based retrospective cohort study

Objectives To determine the real world safety of dabigatran or rivaroxaban compared with warfarin in terms of gastrointestinal bleeding. Design Retrospective cohort study. Setting Large administrative database of commercially insured people in United States from 1 October 2010 through 31 March 2012. Participants Enrollees with a prescription of warfarin, dabigatran, or rivaroxaban between 1 October 2010 and 31 March 2012, who were aged 18 years or older, had continuous enrollment and no oral anticoagulant use during the six months before the entry date, with known age and sex, and with no gastrointestinal bleeding for at least six months before the cohort entry date. The final study sample of 46 163 patients included 4907 using dabigatran, 1649 using rivaroxaban, and 39 607 using warfarin. Main outcome measure Time to gastrointestinal bleeding. Hazard ratios were derived from Cox proportional hazard models with propensity score weighting and robust estimates of errors. Results Dabigatran users tended to be older (dabigatran v rivaroxaban v warfarin: 62.0 v 57.6 v 57.4 years) and more likely to be male (69% v 49% v 53%). The rate of gastrointestinal bleeding was highest among dabigatran users and lowest among rivaroxaban users (dabigatran v rivaroxaban v warfarin: 9.01 v 3.41 v 7.02 cases per 100 person years). After adjustment for potentially confounding covariates, there was no evidence of a statistically significant difference in the risk of gastrointestinal bleeding between dabigatran and warfarin users (adjusted hazard ratio 1.21, 95% confidence interval 0.96 to 1.53) or between rivaroxaban and warfarin users (0.98, 0.36 to 2.69). Conclusions Although rates of gastrointestinal bleeding seem to be similar in this commercially insured sample of adults in the United States, we cannot rule out as much as a 50% increase in the risk of gastrointestinal bleeding with dabigatran compared with warfarin or a more than twofold higher risk of bleeding with rivaroxaban compared with warfarin

Prescribing cascades in ambulatory care: A structured synthesis of evidence

The strength of evidence for specific ambulatory care prescribing cascades, in which a marker drug is used to treat an adverse event caused by an index drug, has not been well characterized. To perform a structured, systematic, and transparent review of the evidence supporting ambulatory care prescribing cascades. Ninety-four potential prescribing cascades identified through a previously published systematic review. Systematic search of the literature to further characterize prescribing cascades. (1) Grading of evidence based on observational studies investigating associations between index and marker drugs, including: Level I—strong evidence [i.e. multiple high-quality studies]; Level II—moderate evidence [i.e. single high-quality study]; Level III—fair evidence [no high-quality studies but one or more moderate-quality studies]; and Level IV—poor evidence [other]. (2) Listing of the adverse event associated with the index drug in the product's United States Food and Drug Administration (FDA) label. (3) Synthesis of the evidence supporting mechanisms linking index drugs and associated adverse events. Of 99 potential cascades, 94 were supported by one or more confirmatory observational studies and were therefore included in this review. The 94 cascades related to 30 types of adverse drug reactions affecting 10 different anatomic/physiologic systems and were investigated by a total of 88 confirmatory studies, including prescription sequential symmetry analysis (n = 51), cohort (n = 30), and case–control (n = 7) studies. Overall, the evidence from observational studies was strong for 18 (19.1%) prescribing cascades, moderate for 61 (64.9%), fair for 13 (13.8%), and poor for 2 (2.1%). Although the evidence supporting mechanisms that link index drugs and associated adverse events was variable, FDA labels included information about the adverse event associated with the index drug for most (n = 86) but not all of the 94 prescribing cascades. Although we identified 18 of 94 prescribing cascades supported by strong clinical evidence and most adverse events associated with index drugs are included in FDA label, the evidentiary basis for prescribing cascades varies, with many requiring further evidence of clinical relevance

Performance and Constraints of Small Scale Enterprises in the Accra Metropolitan Area of Ghana

Small Scale Enterprises play a crucial role in the development of entrepreneurial capabilities and indigenous technology which generate employment. Promotion of such enterprises in developing economies like Ghana is of paramount importance as it brings about a great distribution of benefits. The study seeks to quantify the determinants of the factors influencing performance of small scale enterprises in Accra Metropolitan Area of Ghana. Kendall’s coefficient of concordance was used to test the agreement between the ranked constraints of the small scale enterprises in relation to performance. The study uses structured questionnaire to interview 150 small scale entrepreneurs in Accra Metropolitan Area (AMA). Data collected was analyzed using Statistical Package for Social Science (SPSS) and Econometric views (E-views). Results of the analysis indicate that age of entrepreneur is the most influential determinant of performance of small scale enterprises. The Kendall’s coefficient of concordance indicates that there is 91 percent agreement between the respondents in the ranking of the constraints in relation to performance. High cost of borrowing is the most important constraint faced by the small scale entrepreneurs. Based on the results, we recommend a flexible policy geared towards helping young entrepreneurs, as well as reducing the high interest charges on loans. Key words: Performance, Constraint, Small Scale Enterprise, Accra Metropolitan Area, Ghan