Association between risk factors for injurious falls and new benzodiazepine prescribing in elderly persons

<p>Abstract</p> <p>Background</p> <p>Benzodiazepines are frequently prescribed to elderly patients' despite concerns about adverse effects leading to injurious falls. Previous studies have not investigated the extent to which patients with pre-existing risk factors for falls are prescribed benzodiazepines. The objective of this study is to assess if some of the risk factors for falls are associated with new benzodiazepine prescriptions in elderly persons.</p> <p>Methods</p> <p>Using provincial administrative databases, elderly Quebec residents were screened in 1989 for benzodiazepine use and non-users were followed for up to 5 years. Logistic regression models were used to evaluate potential predictors of new benzodiazepine use among patient baseline characteristics.</p> <p>Results</p> <p>In the 252,811 elderly patients who had no benzodiazepine prescription during the baseline year (1989), 174,444 (69%) never filled a benzodiazepine prescription and 78,367 (31%) filled at least one benzodiazepine prescription. In the adjusted analysis, several risk factors for falls were associated with statistically significant increases in the risk of receiving a new benzodiazepine prescription including the number of prescribing physicians seen at baseline (OR: 1.12; 95% CI 1.11–1.13), being female (OR: 1.20; 95% CI 1.18–1.22) or a diagnosis of arthritis (OR: 1.11; 95% CI 1.09–1.14), depression (OR: 1.42; 95% CI 1.35–1.49) or alcohol abuse (OR: 1.24; 95% CI 1.05–1.46). The strongest predictor for starting a benzodiazepine was the use of other medications, particularly anti-depressants (OR: 1.85; 95% CI 1.75–1.95).</p> <p>Conclusion</p> <p>Patients with pre-existing conditions that increase the risk of injurious falls are significantly more likely to receive a new prescription for a benzodiazepine. The strength of the association between previous medication use and new benzodiazepine prescriptions highlights an important medication safety issue.</p

Palaeoproterozoic eclogites: exhumation and burial convolution of P-t histories

Dillon Brown, Renée Tamblyn, Martin Hand, and Laura Morrisse

Subduction and accumulation of lawsonite eclogite and garnet blueschist in eastern Australia

Lawsonite eclogite and garnet blueschist occur as metre‐scale blocks within serpentinite mélange in the southern New England Orogen (SNEO) in eastern Australia. These high‐P fragments are the products of early Palaeozoic subduction of the palaeo‐Pacific plate beneath East Gondwana. Lu–Hf, Sm–Nd, and U–Pb geochronological data from Port Macquarie show that eclogite mineral assemblages formed between c. 500 and 470 Ma ago and became mixed together within a serpentinite‐filled subduction channel. Age data and P–T modelling indicate lawsonite eclogite formed at ~2.7 GPa and 590°C at c. 490 Ma, whereas peak garnet in blueschist formed at ~2.0 GPa and 550°C at c. 470 Ma. The post‐peak evolution of lawsonite eclogite was associated with the preservation of pristine lawsonite‐bearing assemblages and the formation of glaucophane. By contrast, the garnet blueschist was derived from a precursor garnet–omphacite assemblage. The geochronological data from these different aged high‐P assemblages indicate the high‐P rocks were formed during subduction on the margin of cratonic Australia during the Cambro‐Ordovician. The rocks however now reside in the Devonian–Carboniferous southern SNEO, which forms the youngest and most outboard of the eastern Gondwanan Australian orogenic belts. Geodynamic modelling suggests that over the time‐scales that subduction products accumulated, the high‐P rocks migrated large distances (~>1,000 km) during slab retreat. Consequently, high‐P rocks that are trapped in subduction channels may also migrate large distances prior to exhumation, potentially becoming incorporated into younger orogenic belts whose evolution is not directly related to the formation of the exhumed high‐P rocks.Renée Tamblyn, Martin Hand, David Kelsey, Robert Anczkiewicz, David Oc

The Resolved Asteroid Program - Size, shape, and pole of (52) Europa

With the adaptive optics (AO) system on the 10 m Keck-II telescope, we acquired a high quality set of 84 images at 14 epochs of asteroid (52) Europa on 2005 January 20. The epochs covered its rotation period and, by following its changing shape and orientation on the plane of sky, we obtained its triaxial ellipsoid dimensions and spin pole location. An independent determination from images at three epochs obtained in 2007 is in good agreement with these results. By combining these two data sets, along with a single epoch data set obtained in 2003, we have derived a global fit for (52) Europa of diameters (379x330x249) +/- (16x8x10) km, yielding a volume-equivalent spherical-diameter of 315 +/- 7 km, and a rotational pole within 7 deg of [RA; Dec] = [257,+12] in an Equatorial J2000 reference frame (ECJ2000: 255,+35). Using the average of all mass determinations available forEuropa, we derive a density of 1.5 +/- 0.4, typical of C-type asteroids. Comparing our images with the shape model of Michalowski et al. (A&A 416, 2004), derived from optical lightcurves, illustrates excellent agreement, although several edge features visible in the images are not rendered by the model. We therefore derived a complete 3-D description of Europa's shape using the KOALA algorithm by combining our imaging epochs with 4 stellar occultations and 49 lightcurves. We use this 3-D shape model to assess these departures from ellipsoidal shape. Flat facets (possible giant craters) appear to be less distinct on (52) Europa than on other C-types that have been imaged in detail. We show that fewer giant craters, or smaller craters, is consistent with its expected impact history. Overall, asteroid (52) Europa is still well modeled as a smooth triaxial ellipsoid with dimensions constrained by observations obtained over several apparitions.Comment: Accepted for publication in Icaru

Blueschist from the Mariana forearc records long-lived residence of material in the subduction channel

From ca. 50 Ma to present, the western Pacific plate has been subducting under the Philippine Sea plate, forming the oceanic Izu-Bonin-Mariana (IBM) subduction system. It is the only known location where subduction zone products are presently being transported to the surface by serpentinite-mud volcanoes. A large serpentine mud “volcano” forms the South Chamorro Seamount and was successfully drilled by ODP during Leg 195. This returned mostly partially serpentinized harzburgites enclosed in serpentinite muds. In addition, limited numbers of small (1 mm–1 cm) fragments of rare blueschists were also discovered. U–Pb dating of zircon and rutile from one of these blueschist clasts give ages of 51.1 ± 1.2 Ma and 47.5 ± 2.0 Ma, respectively. These are interpreted to date prograde high-pressure metamorphism. Mineral equilibria modelling of the blueschist clast suggests the mineral assemblage formed at conditions of ∼1.6 GPa and ∼590 °C. We interpret that this high-pressure assemblage formed at a depth of ∼50 km within the subduction channel and was subsequently exhumed and entrained into the South Chamorro serpentinite volcano system at depths of ∼27 km. Consequently, we propose that the material erupted from the South Chamarro Seamount may be sampling far greater depths within the Mariana subduction system than previously thought. The apparent thermal gradient implied by the pressure–temperature modelling (∼370 °C/GPa) is slightly warmer than that predicted by typical subduction channel numerical models and other blueschists worldwide. The age of the blueschist suggests it formed during the arc initiation stages of the proto-Izu-Bonin-Mariana arc, with the P–T conditions recording thermally elevated conditions during initial stages of western Pacific plate subduction. This indicates the blueschist had prolonged residence time in the stable forearc as the system underwent east-directed rollback. The Mariana blueschist shows that subduction products can remain entrained in subduction channels for many millions of years prior to exhumation

Consumer Directed Healthcare: Except for the Healthy and Wealthy It’s Unwise

Many politicians and business leaders are advocating high deductible health insurance plans linked with health savings accounts—so-called consumer-directed healthcare. These policies penalize the sick, discourage needed care (especially primary and preventive care), and direct tax subsidies towards the wealthiest Americans. They offer little hope of slowing the growth of health care costs and add further bureaucratic costs and complexity to our health care financing system

Assessing the accuracy of an inter-institutional automated patient-specific health problem list

<p>Abstract</p> <p>Background</p> <p>Health problem lists are a key component of electronic health records and are instrumental in the development of decision-support systems that encourage best practices and optimal patient safety. Most health problem lists require initial clinical information to be entered manually and few integrate information across care providers and institutions. This study assesses the accuracy of a novel approach to create an inter-institutional automated health problem list in a computerized medical record (MOXXI) that integrates three sources of information for an individual patient: diagnostic codes from medical services claims from all treating physicians, therapeutic indications from electronic prescriptions, and single-indication drugs.</p> <p>Methods</p> <p>Data for this study were obtained from 121 general practitioners and all medical services provided for 22,248 of their patients. At the opening of a patient's file, all health problems detected through medical service utilization or single-indication drug use were flagged to the physician in the MOXXI system. Each new arising health problem were presented as 'potential' and physicians were prompted to specify if the health problem was valid (Y) or not (N) or if they preferred to reassess its validity at a later time.</p> <p>Results</p> <p>A total of 263,527 health problems, representing 891 unique problems, were identified for the group of 22,248 patients. Medical services claims contributed to the majority of problems identified (77%), followed by therapeutic indications from electronic prescriptions (14%), and single-indication drugs (9%). Physicians actively chose to assess 41.7% (n = 106,950) of health problems. Overall, 73% of the problems assessed were considered valid; 42% originated from medical service diagnostic codes, 11% from single indication drugs, and 47% from prescription indications. Twelve percent of problems identified through other treating physicians were considered valid compared to 28% identified through study physician claims.</p> <p>Conclusion</p> <p>Automation of an inter-institutional problem list added over half of all validated problems to the health problem list of which 12% were generated by conditions treated by other physicians. Automating the integration of existing information sources provides timely access to accurate and relevant health problem information. It may also accelerate the uptake and use of electronic medical record systems.</p

What differentiates primary care physicians who predominantly prescribe diuretics for treating mild to moderate hypertension from those who do not? A comparative qualitative study

<p>Abstract</p> <p>Background</p> <p>Thiazide diuretics are cost-effective for the treatment of mild to moderate hypertension, but physicians often opt for more expensive treatment options such as angiotensin II receptor blockers or angiotensin converting enzyme inhibitors. With escalating health care costs, there is a need to elucidate the factors influencing physicians' treatment choices for this highly prevalent chronic condition. The purpose of this study was to describe the characteristics of physicians' decision-making process regarding hypertension treatment choices.</p> <p>Methods</p> <p>A comparative qualitative study was conducted in 2009 in the Canadian province of Quebec. Overall, 29 primary care physicians--who are also participating in an electronic health record research program--participated in a semi-structured interview about their prescribing decisions. Physicians were categorized into two groups based on their patterns of prescribing antihypertensive drugs: physicians who predominantly prescribe diuretics, and physicians who predominantly prescribe drug classes other than diuretics. Cases of hypertension that were newly started on antihypertensive therapy were purposely selected from each physician's electronic health record database. Chart stimulated recall interview, a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinical encounters, was used to elucidate reasons for treatment choices. Interview transcripts were synthesized using content analysis techniques, and factors influencing physicians' decision making were inductively generated from the data.</p> <p>Results</p> <p>We identified three themes that differentiated physicians who predominantly prescribe diuretics from those who predominantly prescribe other drug classes for the initial treatment of mild to moderate hypertension: a) perceptions about the efficacy of diuretics, b) preferred approach to hypertension management and, c) perceptions about hypertension guidelines. Specifically, physicians had differences in beliefs about the efficacy, safety and tolerability of diuretics, the most effective approach for managing mild to moderate hypertension, and in aggressiveness to achieve treatment targets. Marketing strategies employed by the pharmaceutical industry and practice experience appear to contribute to these differences in management approach.</p> <p>Conclusions</p> <p>Physicians preferring more expensive treatment options appear to have several misperceptions about the efficacy, safety and tolerability of diuretics. Efforts to increase physicians' prescribing of diuretics may need to be directed at overcoming these misperceptions.</p

Resubduction of lawsonite eclogite within a serpentinite-filled subduction channel

Translating burial and exhumation histories from the petrological and geochronological record of high-pressure assemblages in subduction channels is key to understanding subduction channel processes. Convective return flow, either serpentinite or sediment hosted, has been suggested as a potential mechanism to retrieve rocks from significant depths and exhume them. Numerical modelling predicts that during convective flow, subducted material can be cycled within a serpentinite-filled subduction channel. Geochronological and petrological evidences for such cycling during subduction are preserved in lawsonite eclogite from serpentinite melange in the Southern New England Orogen, eastern Australia. Ar–Ar, Rb–Sr phengite and U–Pb titanite geochronology, supported by phase equilibrium forward modelling and mineral zoning, suggest Cambro–Ordovician eclogite underwent two stages of burial separated by a stage of partial exhumation. The initial subduction of the eclogite at ca. 490 Ma formed porphyroblastic prograde-zoned garnet and lawsonite at approximate P–T conditions of at least 2.9 GPa and 600 °C. Partial exhumation to at least 2.0 GPa and 500 °C is recorded by garnet dissolution. Reburial of the eclogite resulted in growth of new Mg-rich garnet rims, growth of new prograde-zoned phengite and recrystallization of titanite at P–T conditions of approximately 2.7 GPa and 590 °C. U–Pb titanite, and Ar–Ar and Rb–Sr phengite ages constrain the timing of reburial to ca. 450 Ma. This was followed by a second exhumation event at approximately 1.9 GPa and 520 °C. These conditions fall along a cold approximate geotherm of 230 °C/GPa. The inferred changes in pressure suggest the lawsonite eclogite underwent depth cycling within the subduction channel. Geochronological data indicate that partial exhumation and reburial occurred over ca. 50 M y., providing some estimation on the timescales of material convective cycling in the subduction channel.R. Tamblyn, M. Hand, L. Morrissey, T. Zack, G. Phillips, D. Oc