Doing referring in Murriny Patha conversation

Successful communication hinges on keeping track of who and what we are talking about. For this reason, person reference sits at the heart of the social sciences. Referring to persons is an interactional process where information is transferred from current speakers to the recipients of their talk. This dissertation concerns itself with the work that is achieved through this transfer of information. The interactional approach adopted is one that combines the “micro” of conversation analysis with the “macro” of genealogically grounded anthropological linguistics. Murriny Patha, a non-Pama-Nyungan language spoken in the north of Australia, is a highly complex polysynthetic language with kinship categories that are grammaticalized as verbal inflections. For referring to persons, as well as names, nicknames, kinterms, minimal descriptions and free pronouns, Murriny Patha speakers make extensive use of pronominal reference markers embedded within polysynthetic verbs. Murriny Patha does not have a formal “mother-in-law” register. There are however numerous taboos on naming kin in avoidance relationships, and on naming and their namesakes. Similarly, there are also taboos on naming the deceased and on naming their namesakes. As a result, for every speaker there is a multitude of people whose names should be avoided. At any one time, speakers of the language have a range of referential options. Speakers’ decisions about which category of reference forms to choose (names, kinterms etc.) are governed by conversational preferences that shape “referential design”. Six preferences – a preference for associating the referent to the co-present conversationalists, a preference for avoiding personal names, a preference for using recognitionals, a preference for being succinct, and a pair of opposed preferences relating to referential specificity – guide speakers towards choosing a name on one occasion, a kinterm on the next occasion and verbal cross-reference on yet another occasion. Different classes of expressions better satisfy particular conversational preferences. There is a systematicity to the referential choices that speakers make. The interactional objectives of interlocutors are enacted through the regular placement of particular forms in particular sequential environments. These objectives are then revealed through the turn-by-turn unfolding of conversational interaction

Impact of anticoagulant exposure misclassification on the bleeding risk of direct oral anticoagulants

Aims Drug exposure status based on routinely collected data might be misclassified when the database contains only prescriptions from 1 type of prescriber (e.g. general practitioner and not specialist). This study aims to quantify the impact of such exposure misclassification on the risk of major bleeding and stroke/transient ischaemic attack (TIA)associated with direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs).Methods Incident anticoagulant users (>12 mo free of anticoagulation use) in the Dutch PHARMO Database Network between 2008 and 2017 were included. Drug exposure was assessed using pharmacy dispensing information. The risks of hospital admission of major bleeding for DOAC vs. VKA users was assessed with Cox regression analysis, where exposure was based on all dispensings, on general practitioner (GP)-prescribed dispensings only or on specialist-prescribed dispensings only. Hazard ratios (HRs) were estimated also for hospitalization for gastrointestinal bleeding, intracranial bleeding and stroke/TIA.Results We included 99 182 VKA-initiators and 21 795 DOAC-initiators. Use of DOAC was associated with a lower risk of major bleeding compared to VKA use; HR 0.79 (95% confidence interval 0.70-0.90), 0.78 (0.68-0.91) and 0.62 (0.50-0.76), for exposure based on complete dispensing information, only GP- and only specialist-prescribed dispensings, respectively. Similar results were found for the other bleeding outcomes. For stroke/TIA the HRs were 0.96 (0.84-1.09), 1.00 (0.84-1.18) and 0.72 (0.58-0.90), respectively.Conclusion Including only GP-prescribed anticoagulant dispensings in this case did not materially impact the effect estimates compared to including all anticoagulant dispensings. Including only specialist-prescribed dispensings, however, strengthened the effect estimates.Clinical epidemiolog

Change in prescription pattern as a potential marker for adverse drug reactions of angiotensin converting enzyme inhibitors

Background Angiotensin converting enzyme inhibitors (ACEIs) are among the most frequently prescribed groups of medications. ACEI-induced adverse drug reactions (ADRs) are the main reason to discontinue or switch ACEI treatment. ADRs information is not available in prescription databases. Objective To identify a proxy for ACEI-induced ADRs in prescription databases. Setting The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the Netherlands and has included 14,926 subjects aged 45 years or older. Methods All ACEI starters from 2000 to 2011 were identified using prescription data within the Rotterdam Study. Participants were classified into 4 mutually exclusive groups: continuing, discontinuing, switching to angiotensin receptor blockers (ARBs), and switching to other antihypertensives. For categorization, the maximum time-interval between two prescription periods was set at 3 and 6 months. Subsequently, primary care physician files were searched and clinical events were classified as definite ADRs, probable ADRs, possible ADRs and definite non-ADRs. Finally the accuracy of different prescription patterns as indicators of ADRs was evaluated. Main outcome measure Positive predictive values (PPVs), negative predictive values (NPVs), sensitivity and specificity of the prescription patterns of the 4 groups were calculated. Results Totally, 1132 ACEI starters were included. The PPV for a definite ADR was 56.1 % for switchers to ARB, while the PPVs for switchers to other antihypertensives, and discontinuation were 39.5 and 19.5 %, respectively. After including probable ADRs and possible ADRs, PPVs for switchers to ARB increased to 68.3 and 90.5 %. A 6-month interval gave slightly higher PPVs compared to a 3-month interval (maximum 6.1 % higher). The differences in NPVs between 3 and 6-months interval groups were approximately 1.0 %. Conclusions Switching ACEIs to ARBs is the best marker for ACEI-induced ADRs in prescription databases

Incidence and determinants of sildenafil (dis)continuation: the Dutch cohort of sildenafil users.

Item does not contain fulltextSildenafil utilization was prospectively evaluated among 153 men with a history of erectile dysfunction (ED)-prescription drug use prior to starting sildenafil and 164 men who were new starters of ED-prescription drugs. Further, some determinants of sildenafil discontinuation were identified. During a median follow-up period of 18 months 45% of all patients discontinued sildenafil treatment, regardless of earlier treatment history. However, patients with a history of drug treatment for ED were nearly eight times as likely to switch or re-start another ED-prescription drug after discontinuing sildenafil compared to previously untreated users. Age >60 y, diabetes medication, nitrate use, and use of incontinence pads (a proxy for disease/surgery in the pelvic region) were associated with an increased likelihood of discontinuing sildenafil. Although the introduction of sildenafil reduced the barrier to seek medical help for erectile problems, sildenafil treatment failure in previously untreated patients results in a high dropout rate from further ED drug treatment of any kind

Evaluation of Risk Profiles for Gastrointestinal and Cardiovascular Adverse Effects in Nonselective NSAID and COX-2 Inhibitor Users: A Cohort Study Using Pharmacy Dispensing Data in The Netherlands

Background: Newly approved drugs, in comparison with older drugs, are more often prescribed to patients who have not responded satisfactorily to established related drugs or as first-line therapy to patients with a high baseline risk for adverse outcomes (i.e. channelling). However, these patients are less likely to benefit from the prescribed drug and/or are more prone to adverse drug reactions. Therefore, it is difficult to unravel whether observed risks or increases in risk of new drugs are real, i.e. related to the pharmacology, or whether these are related to selective prescribing to patients who are more susceptible to adverse events because of some underlying risk factor(s). The channelling paradox may exist for cyclo-oxygenase (COX)-2 selective inhibitors ('coxibs') instead of traditional nonselective NSAIDs in relation to both gastrointestinal (GI) and cardiovascular (CV) safety. Objective: To evaluate the risk profiles for GI and CV adverse effects in nonselective NSAID and coxib new-user populations over time, in terms of a quantitative measure since the introduction of coxibs. Methods: This was a population-based cohort study using the Dutch pharmaceutical claims database (Foundation for Pharmaceutical Statistics). Eligible patients (>= 18 years) were those where the date of their first prescription (index date) of an NSAID (first-line [e.g. ibuprofen] or second-line [e.g. piroxicam] nonselective NSAID, COX-2 preferential NSAID or coxib) was between January 1999 and December 2003. For each patient, GI and CV risk profiles at index date were defined by a cumulative score derived from dispensing data (patient age, sex and history of medication use within 6 months of index date). Risk scores were categorized as low (score = 0), medium (1) or high (2+). Patients were recorded as switchers based on other NSAID use prior to the index date. Other information collected included the Chronic Disease Score (CDS). Crude odds ratios (ORs) were calculated for risk factors for each NSAID group versus first-line nonselective NSAID users as the reference cohort. The effect of calendar time was examined by plotting mean CV or GI risk score by quarter-year. Correlation between GI and CV scores was examined using the Pearson correlation coefficient (R). Data were stratified by patients' history of switching. Results: The four cohorts comprised patients using: first-line nonselective NSAIDs (n = 42 750); second-line nonselective NSAIDs (n = 1771); COX-2 preferential NSAIDs (n = 3661) and coxibs (n = 4861) patients. New coxib users were most likely to have high GI and CV risk scores (OR 5.3 [95% CI 5.0, 5.6] and OR 2.2 [95% CI 2.1, 2.4], respectively). At the individual patient level, GI and CV risk profiles were moderately well correlated for all NSAID cohorts (R range 0.48 to 0.62). There was no remarkable change in mean GI or CV risk profile of patients over calendar time since the market introduction of coxibs. Discussion: Of the four NSAID cohorts, new coxib users tended to have the highest numbers of GI and CV risk factors, with no obvious change over calendar time. There was also evidence of correlation between GI and CV risk scores. Thus, selective prescribing of coxibs applies to people with co-existing CV as well as GI risk factors. This is important when comparing the safety and/or efficacy of new therapies to existing therapies, and emphasizes the difficulties encountered by prescribers in assessing levels of risk when initiating coxib treatment

Risk of infections in patients with gout: a population-based cohort study

Contains fulltext : 174658.pdf (publisher's version ) (Open Access)To investigate the risk of various types of infections (pneumonia and urinary tract infection (UTI)), and infection-related mortality in patients with gout compared with population-based controls. A retrospective cohort study was conducted using data from the UK Clinical Practice Research Datalink (CPRD). All patients with a first diagnosis of gout and aged >40 years between January 1987-July 2014, were included and matched with up to two controls. Time-varying Cox proportional hazards models were used to estimate the risk of infections and mortality. 131,565 patients and 252,763 controls (mean age: 64 years, 74% males, mean follow-up of 6.7 years) were included in the full cohort. After full statistical adjustment, the risk of pneumonia was increased (adj. HR 1.27, 95% CI 1.18 to 1.36), while the risk of UTI (adj. HR 0.99, 95% CI 0.97 to 1.01) was similar in patients compared to controls. No differences between patients and controls were observed for infection-related mortality due to pneumonia (adj. HR 1.03, 95% CI 0.93 to 1.14) or UTI (adj. HR 1.16, 95% CI 0.98 to 1.37). In conclusion, patients with gout did not have decreased risks of pneumonia, UTI or infection-related mortality compared to population-based controls

Benzodiazepinegebruik daalt als de gebruiker zelf betaalt.

Achtergrond: Veel mensen met angst- of slaapstoornissen krijgen van hun dokter een benzodiazepine voorgeschreven. Langdurig gebruik zorgt echter voor gewenningsproblemen en hoge maatschappelijke kosten. Om deze effecten te beperken heeft het ministerie van VWS de vergoeding van benzodiazepinen per 1 januari 2009 uit de basisverzekering gehaald. Sindsdien betalen de meeste gebruikers de kosten van benzodiazepinen zelf. Methode: In de gegevens van het Landelijk Informatie Netwerk Huisartsenzorg (LINH) keken wij hoeveel mensen tussen januari 2007 en december 2009 voor het eerst de diagnose slaap- en angststoornissen kregen bij de huisarts. Daarna onderzochten wij hoeveel recepten voor een benzodiazepine deze patiënten kregen en hoeveel van hen er ook weer mee stopten, en zo ja wanneer. Ook keken wij naar het aantal recepten voor een selectieve serotonineheropnameremmer (SSRI). Resultaten: Van de 13.596 patiënten die aan de voorwaarden voldeden had iets meer dan de helft een angststoornis, de anderen hadden een slaapprobleem. In 2009 kregen minder mensen de diagnose slaap- of angststoornis te horen dan in 2008. Ook het benzodiazepinegebruik daalde. Van de patiënten met slaapstoornissen kreeg 67,0% in 2008 een benzodiazepine voorgeschreven, versus 59,1% in 2009, en voor angststoornissen waren deze percentages 33,7% in 2008 versus 30,1% in 2009. Ook het aantal mensen dat meer dan één recept kreeg, daalde: voor slaapproblemen van 42,6% naar 35,0%, voor angststoornissen van 42,6% naar 36,4%. Slechts een klein (maar toenemend) aantal angstpatiënten stapte over op een SSRI: 0,3% in 2009 tegenover 0,1% in 2008. Conclusie: Het reduceren van de vergoeding heeft geleid tot een lichte daling in het aantal diagnoses, voorschriften en vervolgrecepten. Deze daling was groter bij slaapproblemen dan bij angststoornissen. De uitkomsten ondersteunen het beleid van de regering en laten zien dat er ruimte bestaat om het gebruik van deze geneesmiddelen te reduceren. (aut.ref.