Prognostic utility of sestamibi lung uptake does not require adjustment for stress-related variables: A retrospective cohort study

BACKGROUND: Increased (99m)Tc-sestamibi stress lung-to-heart ratio (sLHR) has been shown to predict cardiac outcomes similar to pulmonary uptake of thallium. Peak heart rate and use of pharmacologic stress affect the interpretation of lung thallium uptake. The current study was performed to determine whether (99m)Tc-sestamibi sLHR measurements are affected by stress-related variables, and whether this in turn affects prognostic utility. METHODS: sLHR was determined in 718 patients undergoing (99m)Tc-sestamibi SPECT stress imaging. sLHR was assessed in relation to demographics, hemodynamic variables and outcomes (mean follow up 5.6 ± 1.1 years). RESULTS: Mean sLHR was slightly greater in males than in females (P < 0.01) and also showed a weak negative correlation with age (P < 0.01) and systolic blood pressure (P < 0.01), but was unrelated to stress method or heart rate at the time of injection. In patients undergoing treadmill exercise, sLHR was also positively correlated with peak workload (P < 0.05) but inversely with double product (P < 0.05). The combined explanatory effect of sex, age and hemodynamic variables on sLHR was less than 10%. The risk of acute myocardial infarction (AMI) or death increased by a factor of 1.7–1.8 for each SD increase in unadjusted sLHR, and was unaffected by adjustment for sex, age and hemodynamic variables (hazard ratios 1.6–1.7). The area under the ROC curve for the unadjusted sLHR was 0.65 (95% CI 0.59–0.71, P < 0.0001) and was unchanged for the adjusted sLHR (0.65, 95% CI 0.61–0.72, P < 0.0001). CONCLUSION: Stress-related variables have only a weak effect on measured sLHR. Unadjusted and adjusted sLHR provide equivalent prognostic information for prediction of AMI or death

Medication Management: Perceptions and Opinions of Canadian Hospital Executives

ABSTRACT Background: Issues relating to access to new medications, medication safety, and the quality of medication use are important to many Canadian hospital executives and managers.Objective: To obtain the opinions of hospital executives and managers about medication management issues.Methods: A survey instrument was developed and pilot-tested with input from key informant interviews and the Canadian College of Health Service Executives (CCHSE). The survey was sent by e-mail and regular mail to a randomized stratified sample from the CCHSE membership of 250 middle managers and 250 executives at the CEO or vice-president level. The responses to the survey questions and underlying themes from respondents’ comments were analyzed using multivariate statistical techniques and content analysis. The results of these analyses are reported in relation to respondents’ demographic characteristics.Results: In total, 272 (56.1%) of the 485 surveys delivered were completed and returned. The respondents reported that changes in physician prescribing habits constituted the most important factor influencing demand for pharmaceuticals. The pharmacy department of the respondent’s organization was listed as the top source of information about medications, and clinical practice guidelines and disease management programs were chosen as the top 2 methods to optimize the use of pharmaceuticals. Respondents considered appropriateness of drug use, medication errors, and proper drug utilization as the drugrelated issues with the highest perceived importance. About 58% of respondents felt that their organizations were getting value for the money spent on drugs.Conclusions: This study provided insight into the perceptions of Canadian hospital executives and managers related to one of the most important issues that they face today—management of pharmaceuticals. There was remarkable consistency in responses across the demographic variables included in the survey. Further work is needed to determine the type of education related to medication management that executives and managers need, suitable methods for providing that education, and the career stages at which it is appropriate to do so.RÉSUMÉHistorique : Les problèmes liés à l’accès aux nouveaux médicaments, à l’innocuité des médicaments et à la qualité de l’emploi des médicaments sont importants aux yeux des dirigeants et des cadres d’hôpitaux canadiens.Objectif : Obtenir l’opinion de dirigeants et de cadres d’hôpitaux sur les problèmes de gestion des médicaments.Méthodes : Un outil de sondage a été mis au point et mis à l’essai par l’entrevue d’informateurs clés et auprès du Collège canadien des directeurs de services de santé (CCDSS). Le sondage a été envoyé par courriel et par la poste à un échantillon stratifié aléatoire des membres du CCDSS composé de 250 cadres intermédiaires et de 250 cadres supérieurs occupant un poste de directeur général ou de vice-président. Les réponses aux questions du sondage et les thèmes sous-jacents aux commentaires des répondants ont été analysés par des techniques statistiques multivariées et l’analyse de contenu. Les résultats de ces analyses sont présentés par rapport aux caractéristiques démographiques des répondants.Résultats : En tout, 272 (56,1 %) des 485 sondages envoyés ont été remplis et retournés. Les répondants ont déclaré que les changements des habitudes de prescription des médecins constituaient le facteur le plus important qui influence la demande de médicaments. Les répondants ont mis « Le service de pharmacie de votre établissement » en tête de liste des sources d’information sur les médicaments, alors que les guides de pratique clinique et les programmes de gestion thérapeutique ont été choisis comme les deux principales méthodes pour optimiser l’utilisation des médicaments. Les répondants ont identifié la pertinence de l’utilisation des médicaments, les erreurs de médication et l’emploi rationnel des médicaments comme les problèmes liés à la pharmacothérapie ayant la plus haute importance perçue. Environ 58 % des répondants ont estimé que leur établissement obtenait un bon rapport coût des médicaments-efficience.Conclusions : Cette étude a permis mettre en relief les perceptions des dirigeants et des cadres des établissements de santé canadiens relativement à l’un des enjeux les plus importants de leur milieu aujourd’hui, la gestion des médicaments. Les réponses étaient remarquablement homogènes pour toutes les variables démographiques utilisées.D’autres travaux du genre sont nécessaires afin de déterminer le type de formation en gestion des médicaments nécessaire aux dirigeants et aux cadres, ainsi que les méthodes et le moment de la carrière le plus propice à la prestation de cette formation

Movement disorders in elderly users of risperidone and first generation antipsychotic agents: a Canadian population-based study.

Despite concerns over the potential for severe adverse events, antipsychotic medications remain the mainstay of treatment of behaviour disorders and psychosis in elderly patients. Second-generation antipsychotic agents (SGAs; e.g., risperidone, olanzapine, quetiapine) have generally shown a better safety profile compared to the first-generation agents (FGAs; e.g., haloperidol and phenothiazines), particularly in terms of a lower potential for involuntary movement disorders. Risperidone, the only SGA with an official indication for the management of inappropriate behaviour in dementia, has emerged as the antipsychotic most commonly prescribed to older patients. Most clinical trials evaluating the risk of movement disorders in elderly patients receiving antipsychotic therapy have been of limited sample size and/or of relatively short duration. A few observational studies have produced inconsistent results.A population-based retrospective cohort study of all residents of the Canadian province of Manitoba aged 65 and over, who were dispensed antipsychotic medications for the first time during the time period from April 1, 2000 to March 31, 2007, was conducted using Manitoba's Department of Health's administrative databases. Cox proportional hazards models were used to determine the risk of extrapyramidal symptoms (EPS) in new users of risperidone compared to new users of FGAs.After controlling for potential confounders (demographics, comorbidity and medication use), risperidone use was associated with a lower risk of EPS compared to FGAs at 30, 60, 90 and 180 days (adjusted hazard ratios [HR] 0.38, 95% CI: 0.22-0.67; 0.45, 95% CI: 0.28-0.73; 0.50, 95% CI: 0.33-0.77; 0.65, 95% CI: 0.45-0.94, respectively). At 360 days, the strength of the association weakened with an adjusted HR of 0.75, 95% CI: 0.54-1.05.In a large population of elderly patients the use of risperidone was associated with a lower risk of EPS compared to FGAs