Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Autism

Autism and its causes have been a heavily discussed issue.  This study specifically concerns the issue of the use of antidepressants during pregnancy and increased risk of autism spectrum disorders.  The study was conducted in Denmark and looked at live births from 1996 to 2005.  It looked at the use of SSRIs by the mother before and during pregnancy, autism spectrum disorders that were diagnosed and any other potential confounders.

The results of the study showed that there was no increased risk of autism spectrum disorders associated with use of SSRIs during pregnancy when compared to no SSRI use both before and during pregnancy.  While no significant association could be found, based on the upper boundary of the confidence interval relative risk of up to 1.61 could exist.  Therefore, the study concluded that more research had to be conducted to determine a conclusive answer.

I found this article interesting because of how much attention is being paid to autism and its potential causes.  I think it is extremely important to always do your research before making a claim or even sharing an article on Facebook.  So many people are willing to accept inaccurate information, especially if its explains something in their life that was previously unexplainable.

Hviid A, Melbye M, and Pasternak B. Use of Selective Serotonin Reuptake Inhibitors during Pregnancy and Risk of Autism. N Engl J Med. 2013;369(25): 2406-415.

http://www.nejm.org/doi/full/10.1056/NEJMoa1301449

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

Smoking cessation is still a heavily researched and talked about topic.  While quitting smoking may seem simple to a non-smoker, the reality is that trying to stop smoking can be a difficult and expensive choice.  This study looked at how financial incentives may increase sustained abstinence from smoking.

2,538 people enrolled in the study and were then assigned to either one of four incentive programs or the usual care for smoking cessation.  Of the the four incentive programs, two were targeted to individuals and two were targeted to groups of six.  These two groups then differentiated by being either a reward-based program or a deposit-based program (refundable deposit plus a reward).  The results of the study showed that while 90% of participants accepted the assignment when the program was reward-based, only 13.7% of participants accepted the assignment when the program was deposit-based.  After six months, rates of sustained abstinence were higher for every program (9.4% to 16.0%) than the basic care group (6.0%).  Additionally, the reward-based programs had higher abstinence rates than the deposit-based programs.

I found the results of this study surprising.  I understand that stopping smoking can be extremely difficult but I still expected the percentage of abstinence to be higher when the reward was $800 for six months of abstinence.  One of the programs had an extremely high denial rate.  It required people to deposit $150 dollars, which they would get back if they successfully completed the six months.  After seeing the results, I now understand why the amount was so low.  Incentive-programs like these do make a significant difference.  However, with the percentages being so low I find it hard to believe that anyone would fund the program without a financial incentive, which only comes from the deposit-based reward system that most smokers would not attempt.

Halpern SD, French B, Small DS, et al. Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation. N Engl J Med. 2015;372(22):2108-117.

http://www.nejm.org/doi/full/10.1056/NEJMoa1414293#t=articleMethods

Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a disease faced by civilian and military survivors who have experienced trauma.  The disease can greatly effect a person’s quality of life so a lot research is being done regarding pharmacotherapy after serious physical injury and other traumatic events to prevent PTSD from occurring.  Some drugs, including opioids, may decrease memory formation, and therefore the fear associated with the memory, if administered as part of trauma care.

This study involved 696 injured U.S. military personnel who did not have a traumatic brain injury.  The participants’ records were collected including their medication records from the combat trauma registry and their diagnosis of PTSD from the personnel system, which was then verified through medical records.  The results of the study showed that the use of morphine was significantly associated with a lower risk of PTSD.  61% of patients that were diagnosed with PTSD received morphine while 76% of the patients who were not diagnosed with PTSD received morphine.  This difference was statistically significant.

PTSD is a serious issue for returning military members.  I believe that more steps should be taken to prevent PTSD as the disease can reduce quality of life and lead to other problems including depression, anxiety, etc.  Since this is an acute usage of the medication, there should be little worry of abuse.  However, more research should be done since opioids are a common allergenic so other options, including those listed in the article, should be explored.

Holbrook TL, Galarneau MR, Dye JL, et al. Morphine Use after Combat Injury in Iraq and Post-Traumatic Stress Disorder. N Engl J Med. 2010;362(2):110-17.

http://www.nejm.org/doi/full/10.1056/NEJMoa0903326#t=article

NSAIDs Are Associated with Lower Depression Scores in Patients with Osteoarthritis

This study looked at whether or not NSAIDs, as an addition to antidepressant therapy, could decrease depressive symptoms in patients with osteoarthritis.  The study was a multicenter, double-blind, placebo-controlled study with patients who have active osteoarthritis.  Each participant was put into one of three groups: placebo group, ibuprofen 800 mg (three times a day) or naproxen 500 mg (two times a day) group, or Celebrex 200 mg (one time a day) group.  The patients were tested for major depression using the standard health questionnaire-9 (PHQ-9) scale.  Each person was tested at baseline, after two weeks of treatment and after six weeks of treatment.

The results showed that all three groups had similar average PHQ-9 scores at the baseline screening and at the last screening, after six weeks of treatment.  However, there was a detectable difference in change of PHQ-9 score between the groups with the ibuprofen/naproxen group and the Celebrex group having lower scores of .31 and .61 respectively.

The study concludes that NSAID usage in patients with osteoarthritis shows a trend of reduction in depressive symptoms.  I, however, do not believe there was enough evidence in the trial to conclude this.  Additionally, I believe they mistook correlation with causation.  Each group, in addition to a decrease in depression, also saw a decrease in pain.  As we have learned in class, pain can cause depression.  So while NSAID usage may correlate with decreased depression, it may have to do with the pain relief and not the specific mechanism of action of NSAIDs.  To disprove this, NSAIDs should also be compared to other pain relievers with different mechanisms of action.

Rupa IL, Gandhi s, Aneja A, et al. NSAIDs Are Associated with Lower Depression Scores in Patients with Osteoarthritis. Am J Med. 2013;126(11).

http://www.amjmed.com/article/S0002-9343(13)00358-6/abstract

A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management

Obesity is a serious problem in the United States.  Obesity increases a person’s risk for a multitude of health problems, including diabetes mellitus type 2.  However, it is sometimes extremely difficult for individuals to lose weight through lifestyle changes alone, especially as they get older.  In this study, the use of 3.0 mg of liraglutide daily for weight loss was studied to determine whether or not it is efficient and safe.

The study was a placebo-controlled, double-blind trial that lasted 56 weeks.  3731 patients were involved.  No participant had type 2 diabetes and every person had a BMI of 30 or more or a BMI of 27 or more and dyslipidemia or hypertension.  Each participant received either a daily dose of 3.0 mg liraglutide or a placebo.  At the end of the trial the primary end points were change in body weight and percentage of patients that lost at least 5% or 10% of their body weight. The results of the study showed that the group assigned liraglutide lost a mean of 8.4 ± 7.3 kg while the group assigned a placebo lost only 2.8 ± 6.5 kg.  Additionally, participants in the liraglutide group 63.2% lost at least 5% of their body weight and 33.1% lost at least 10%.  In the placebo group only 27.1% lost at least 5% and 10.6% lost at least 10%.  All of the differences between the groups were statistically significant.

I found this study interesting because I was unaware of any prescription medications currently being tested to help weight loss.  I believe if a medication can be determined to help weight loss without serious side effects then it should be used to help the country’s obesity problem.  However, a medication cannot be the sole technique used.  People on the medication should also restrict their diet and exercise regularly.  Even if the medication is approved for weight loss, it should only be temporary.  Patients need to learn how to maintain a healthy lifestyle so that they can eventually succeed without it and not take the medication permanently.

Pi-Sunyer X, Astrup A, Fujioka K, et al. A Randomized, Controlled Trial of 3.0 Mg of Liraglutide in Weight Management. N Engl J Med. 2015; 373(1): 11-22.

http://www.nejm.org/doi/full/10.1056/NEJMoa1411892#t=abstract

Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic

Studies have shown that up to 21% of prescriptions have one or more prescribing errors.  These errors not only create potentially harmful situations for patients, they also increase a pharmacist’s workload.  This problem is potentially due to the small amount of classes given in medical schools for therapeutics and how to write prescriptions.

This study was conducted at a family medicine clinic and observed twenty-four resident physicians and the prescriptions they wrote while conducting outpatient visits.  In the study, the rate of prescription errors for the resident physicians was observed before and after interventions to prevent these errors were put into place.  The interventions included a prescribing educational program, audits and feedback for prescriptions each resident filled and weekly newsletters that included the most common errors, examples of the errors, ways to correct the errors, etc.  These interventions were given for three months.  The assessments of the prescriptions occurred one year apart so that prescribing habits and seasonal illnesses would not differ.

The results of the study showed that overall prescription errors went down 4.1%, from 18.6% to 14.5%.  The study also showed that the pediatric prescription rates for the physicians who took part in the educational program were 36% lower than the error rates of physicians that did not participate.

I found this study interesting because I have firsthand knowledge of how many errors prescribers make.  Working in a retail pharmacy, I see these mistakes in all types of prescriptions.  While mistakes do happen, doctors are just humans, a lot of the mistakes could be prevented just by double checking the prescription and by knowing the proper way to write a prescription and proper dosing for certain medications.  These interventions only took three months and errors went down by over 4%.  Errors not only affect patients, but they also cause increase work for pharmacists and their staff and the doctors that eventually need to fix the mistakes.  By implementing interventions, a lot of time and frustration can ben avoided and patient safety can increase.

Winder, MB, Johnson JL, Planas LG, et al. Impact of Pharmacist-led Educational and Error Notification Interventions on Prescribing Errors in a Family Medicine Clinic. J Am Pharm Assoc. 2015;55(3): 238-45.

http://www.japha.org/article/S1544-3191(15)30054-6/fulltext

Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012

This study was conducted as part of the 50th anniversary of the first time the surgeon general released a report on smoking and its effects on health.  The purpose of the study was to determine the effects that tobacco control has had on smoking-related mortality.

The study was conducted by estimating the smoking histories of people under actual conditions and under conditions that would have occurred if tobacco control had not happened.  Mortality rates were determined using analytical studies that show the effect smoking has on death rates.  The actual mortalities caused by smoking from the year 1964 through 2012 were then compared to the estimated mortalities that would have occurred with no tobacco control.  The main outcomes of the study were to show the number of deaths avoided, the years of life saved and the change in life expectancy at age 40.

The study showed that 8.0 million fewer premature smoking-related deaths occurred because of tobacco control.  Additionally, 157 million years of life were saved, which divides into an average of 19.6 years per person.  During this 48-year period, the life expectancies of men and women increased by 7.8 and 5.4 years, respectively.  From the study it was found that 2.3 years for men and 1.6 years for women can be connected with tobacco control.

I found this study interesting because it shows the effects of tobacco control on a large scale.  A lot of time and money has been spent on this topic and it is still a heavily talked about issue.  While smoking rates are down, there are people who still smoke and who do not fully understand the consequences.  This study shows that the time and money spent had a purpose and shows that continuing to shine a light on the topic will have real effects.

Holford, Theodore R., Rafael Meza, Kenneth E. Warner, Clare Meernik, Jihyoun Jeon, Suresh H. Moolgavkar, and David T. Levy. “Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012.” Jama 311.2 (2014): 164. Web.

http://jama.jamanetwork.com/article.aspx?articleid=1812962

Cost analysis of a novel HIV testing strategy in community pharmacies and retail clinics

This study was conducted in six pharmacy sites in order to determine the cost of HIV testing in a retail or clinical setting.  The purpose of the study was to provide information to places who are planning on implementing HIV rapid testing so that they may plan and budget accordingly.  The results of the study found that the average cost of a test would be $47.21 per person.  Additionally, it found that the average counseling was two minutes pretest and two minutes posttest if negative or ten minutes posttest if positive. The average cost was comparable to data published in 2006 which stated that clinical testing would costing $28.05 per negative test and $86.84 per positive test. The study found that many factors could impact the actual cost of the tests including the quality of the tests, how many tests were ordered, and how many staff members would complete training for the tests. Additionally, the study was not allowed access to the sites’ overhead costs, including salaries and and utilities, and instead used median wage data so actual costs may be higher.

I was very surprised by the results of the study. I assumed such tests would be much more expensive and was why they were not already available to most pharmacies.  Pharmacies would be a great additional resource for individuals who want or need to be tested for HIV.  Pharmacies can provide the convenience of at-home testing while connecting people who are HIV-positive to the contacts and resources a clinical setting would also provide. With no increase in cost to other settings, pharmacies can become a medical source for patients with HIV to those who have limited access to other types of health care.

Lecher, Shirley Lee, Ram K. Shrestha, Linda W. Botts, Jorge Alvarez, James H. Moore, Vasavi Thomas, and Paul J. Weidle. “Cost Analysis of a Novel HIV Testing Strategy in Community Pharmacies and Retail Clinics.” Journal of the American Pharmacists Association 55.5 (2015): 488-92. Web.

http://www.japha.org/article/S1544-3191(15)30108-4/abstract