The Ineffectiveness of Retrospective Drug Utilization Review

As policymakers debate adding a prescription drug benefit to Medicare, they must also seek ways to promote cost-effective use of drugs and minimize inappropriate prescribing. For more than a decade, all state Medicaid agencies and most private insurers have used computerized drug utilization review (DUR) programs to prevent or rectify potential prescribing errors. DUR can be retrospective, in which claims data are reviewed to identify patterns of drug use, or prospective, in which prescriptions are reviewed before a drug is dispensed. This Issue Brief summarizes a landmark study that suggests that retrospective DUR has had no measurable effects on outpatient drug use or clinical outcomes in the Medicaid program

Risk of Major Complications From Coronary Angioplasty Performed Immediately After Diagnostic Coronary Angiography: Results From the Registry of the Society for Cardiac Angiography and Interventions

AbstractObjectives. This study was designed to determine the risk of performing percutaneous transluminal coronary angioplasty (PTCA) at the time of diagnostic catheterization (“combined procedures”).Background. Health care providers are under increasing pressure to combine diagnostic and interventional coronary procedures to reduce costs. However, the risk associated with combined procedures has not been rigorously assessed.Methods. A multicenter cohort study of 35,700 patients undergoing elective PTCA from 1992 through 1995 was performed to determine the risk of major complications (myocardial infarction, emergency coronary artery bypass graft surgery or death) from combined relative to staged procedures (i.e., performing PTCA at a session subsequent to diagnostic catheterization).Results. The risks of major complications from combined and staged procedures were 2.0% and 1.6%, respectively (unadjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.05 to 1.57). After adjusting for clinical and angiographic differences and clustering by laboratory, the risk from combined procedures was not significantly elevated (multivariable OR 1.18, 95% CI 0.89 to 1.55). However, several subgroups of patients did have an increased risk from combined procedures: patients with multivessel disease (multivariable OR 1.64, 95% CI 1.13 to 2.39); women (multivariable OR 1.64, 95% CI 1.05 to 2.55); patients >65 years old (multivariable OR 1.40, 95% CI 1.02 to 1.93); and patients undergoing multilesion PTCA (multivariable OR 1.53, 95% CI 1.06 to 2.21). The risk of combined relative to staged procedures decreased over the 4-year period (multivariable p = 0.029).Conclusions. Combining PTCA with diagnostic catheterization appears to be safe in many patients. However, several subgroups of patients may be at increased risk. Careful patient selection will most likely remain critical to ensuring the safety of combined procedures.(J Am Coll Cardiol 1997;30:193–200

Observational cohort study of the safety of digoxin use in women with heart failure

Objectives: This study aims to assess whether digoxin has a different effect on mortality risk for women than it does for men in patients with heart failure (HF). Design This study uses the UK-based The Health Information Network population database in a cohort study of the impact of digoxin exposure on mortality for men and women who carry the diagnosis of HF. Digoxin exposure was assessed based on prescribing data. Multivariable Cox proportional hazards models were used to assess whether there was an interaction between sex and digoxin affecting mortality hazard. Setting The setting was primary care outpatient practices. Participants The study cohort consisted of 17 707 men and 19 227 women with the diagnosis of HF who contributed only time without digoxin exposure and 9487 men and 10 808 women with the diagnosis of HF who contributed time with digoxin exposure. Main outcome measures The main outcome measure was all-cause mortality. Results: The primary outcome of this study was the absence of a large interaction between digoxin use and sex affecting mortality. For men, digoxin use was associated with a HR for mortality of 1.00, while for women, the HR was also 1.00 (p value for interaction 0.65). The results of sensitivity analyses were consistent with those of the primary analysis. Conclusion: Observational data do not support the concern that there is a substantial increased risk of mortality due to the use of digoxin in women. This finding is consistent with previous observational studies but discordant with results from a post hoc analysis of a randomised controlled trial of digoxin versus placebo

Characterization of the Morphometry of Impact Craters Hosting Polar Deposits in Mercury's North Polar Region

Earth-based radar images dating back two decades show that the floors of some polar craters on Mercury host radar-bright deposits that have been proposed to consist of frozen volatiles. Several hypotheses have been put forth to explain their source, including volcanic outgassing, chemical sputtering, and deposition of exogenous water ice. Calculations show that volatiles are thermally stable in permanently shadowed areas. An earlier study of the depths of north polar craters determined with photoclinometric techniques applied to Mariner 10 images yielded the conclusion that the mean ratio of crater depth d to rim-crest diameter D for craters hosting polar deposits is two-thirds that of the mean ratio for a comparable population of neighboring craters lacking such deposits. This result could be explained by (though doesn't require) the presence of a thick layer of volatiles within the polar deposit-hosting craters. Here we use altimetric profiles and topographic maps obtained by the Mercury Laser Altimeter (MLA) to revisit this analysis. MLA is an instrument on the MErcury Surface, Space ENvironment, GEochemistry, and Ranging (MESSENGER) spacecraft, which has been orbiting Mercury since March 2011. MLA transmits a 1064-nm laser pulse at 8 Hz during MESSENGER's trajectory over Mercury s surface. The MLA illuminates surface areas averaging between 15 m and 100 m in diameter, spaced approx 400 m apart along the spacecraft ground track. The radial precision of individual measurements is <1 m, and the current accuracy with respect to Mercury s center of mass is better than 20 m. As of mid-December 2011, MLA coverage had reached to 15 S and has yielded a comprehensive map of the topography of Mercury s northern hemisphere. The MLA data are used here to quantify the shapes of craters in the north polar region and to avoid the shadowing bias of photoclinometric techniques

Dark Spots on Mercury: A Distinctive Low-Reflectance Material and Its Relation to Hollows

Orbital images acquired by the Mercury, Surface, Space Environment, Geochemistry, and Ranging (MESSENGER) spacecraft reveal a distinctive low-reflectance material on the surface of Mercury. Such material occurs in small, isolated, and thin surficial units. We term these features “dark spots.” Dark spots have the lowest average reflectance yet documented on the planet. In every case observed at sufficiently high resolution, dark spots feature hollows at their centers. Not all hollows, however, are surrounded by a dark spot. Dark spots have been found on low-reflectance smooth plains, intercrater plains, heavily cratered terrain, and impact craters at almost all longitudes on Mercury, but they have not been documented on high-reflectance smooth plains material. Dark spots are one of the youngest endogenic features on Mercury, and some postdate craters with distinctive rays. Sulfides may be the phase responsible for the low albedo of dark spot material. We propose that dark spots form during the initial stages of hollow formation, perhaps in a manner similar to intense outgassing events that feature exit velocities in excess of 100 m/s. Such outgassing could contemporaneously produce a depression that constitutes an embryonic hollow. Under this scenario, dark spot material is subsequently removed or modified by regolith gardening or other surface processes on time scales shorter than the lifetime of the central hollow

Duration of activity on lobate‐scarp thrust faults on Mercury

Lobate scarps, landforms interpreted as the surface manifestation of thrust faults, are widely distributed across Mercury and preserve a record of its history of crustal deformation. Their formation is primarily attributed to the accommodation of horizontal shortening of Mercury's lithosphere in response to cooling and contraction of the planet's interior. Analyses of images acquired by the Mariner 10 and MErcury Surface, Space ENvironment, GEochemistry, and Ranging (MESSENGER) spacecraft during flybys of Mercury showed that thrust faults were active at least as far back in time as near the end of emplacement of the largest expanses of smooth plains. However, the full temporal extent of thrust fault activity on Mercury, particularly the duration of this activity following smooth plains emplacement, remained poorly constrained. Orbital images from the MESSENGER spacecraft reveal previously unrecognized stratigraphic relations between lobate scarps and impact craters of differing ages and degradation states. Analysis of these stratigraphic relations indicates that contraction has been a widespread and long‐lived process on the surface of Mercury. Thrust fault activity had initiated by a time near the end of the late heavy bombardment of the inner solar system and continued through much or all of Mercury's subsequent history. Such deformation likely resulted from the continuing secular cooling of Mercury's interior

The Potential of Antimicrobial Peptides as Biocides

Antimicrobial peptides constitute a diverse class of naturally occurring antimicrobial molecules which have activity against a wide range of pathogenic microorganisms. Antimicrobial peptides are exciting leads in the development of novel biocidal agents at a time when classical antibiotics are under intense pressure from emerging resistance, and the global industry in antibiotic research and development stagnates. This review will examine the potential of antimicrobial peptides, both natural and synthetic, as novel biocidal agents in the battle against multi-drug resistant pathogen infections

How Well Do Randomized Trials Inform Decision Making: Systematic Review Using Comparative Effectiveness Research Measures on Acupuncture for Back Pain

Background: For Comparative Effectiveness Research (CER) there is a need to develop scales for appraisal of available clinical research. Aims were to 1) test the feasibility of applying the pragmatic-explanatory continuum indicator summary tool and the six CER defining characteristics of the Institute of Medicine to RCTs of acupuncture for treatment of low back pain, and 2) evaluate the extent to which the evidence from these RCTs is relevant to clinical and health policy decision making. Methods: We searched Medline, the AcuTrials™ Database to February 2011 and reference lists and included full-report randomized trials in English that compared needle acupuncture with a conventional treatment in adults with non-specific acute and/or chronic low back pain and restricted to those with ≥30 patients in the acupuncture group. Papers were evaluated by 5 raters. Principal Findings: From 119 abstracts, 44 full-text publications were screened and 10 trials (4,901 patients) were evaluated. Due to missing information and initial difficulties in operationalizing the scoring items, the first scoring revealed inter-rater and inter-item variance (intraclass correlations 0.02-0.60), which improved after consensus discussions to 0.20-1.00. The 10 trials were found to cover the efficacy-effectiveness continuum; those with more flexible acupuncture and no placebo control scored closer to effectiveness. Conclusion: Both instruments proved useful, but need further development. In addition, CONSORT guidelines for reporting pragmatic trials should be expanded. Most studies in this review already reflect the movement towards CER and similar approaches can be taken to evaluate comparative effectiveness relevance of RCTs for other treatments. © 2012 Witt et al.published_or_final_versio