Why are US military personnel prescribed transdermal fentanyl patches?

INTRODUCTION: Transdermal fentanyl is a continuous release opioid delivery system intended for use in opioid-tolerant patients requiring around-the-clock opioid therapy. The purpose of this study is to identify the most common indications for transdermal fentanyl prescriptions in active duty US military personnel, and determine whether these prescriptions meet US Food and Drug Administration (FDA) labelling. METHODS: Active duty US military personnel initiating transdermal fentanyl therapy with prescriptions filled at Military Health System pharmacies between 2015 and 2019 were identified in the Military Data Repository. Electronic health records were searched for patient demographic information, clinical information and prescription data. A total of 225 patients with complete data were identified. RESULTS: The most common reason for transdermal fentanyl initiation was chronic non-cancer musculoskeletal pain. Among patients with non-cancer pain, 36% received their initial prescription from an internal medicine/primary care provider, and 35% did not meet published US FDA criteria for opioid tolerance prior to treatment initiation. There was an 81% decrease in patients initiating therapy between 2015 and 2019. CONCLUSIONS: While a substantial minority of transdermal fentanyl prescriptions to US military personnel did not meet FDA guidelines on appropriate use, the overall number of prescriptions fell dramatically over the study period. This suggests that automated profile review or additional targeted policies to limit transdermal fentanyl prescribing are unnecessary at this time.

Estimating the direct cost of Type 2 diabetes in Greece: the effects of blood glucose regulation on patient cost.

AIMS: To estimate the annual cost of treatment for Type 2 diabetic patients in Greece and investigate the effect of blood glucose regulation on patient cost. METHODS: A multipoint data collection procedure based on the patient records of 51 geographically distributed physicians was used in order to obtain the necessary data for the analysis and the construction of the patient cost model. Patients were classified as controlled (i.e. maintaining blood glucose regulation for the 1 year retrospective time frame of the analysis) and non-controlled (the patients failing to do so in the specified time period). Cost categories included pharmaceutical expenditure, laboratory/diagnostic tests and consultation fees. Costs attributable to hospitalizations due to diabetic complications were not included. Calculations were based on 2007 fees and prices, and costs are expressed in Euros. RESULTS: The average annual cost of treatment for controlled patients was estimated at 981.72 euro (95% confidence interval, 940.66-1023.01 euro), whereas for non-controlled patients it was 1566.12 euro (95% confidence interval, 1485.42-1650.20 euro). Non-controlled patients had 29.7% higher annual pharmaceutical costs (340.50 vs. 441.96 euro), 70% higher costs for laboratory/diagnostic tests (422.54 vs. 718.49 euro) and 85.5% higher consultation costs (218.68 vs. 405.67 euro) compared with their controlled peers. The average cost for a Type 2 diabetic patient in Greece, regardless of blood glucose regulation, was 1297.30 euro (95% confidence interval, 1244.42-1349.61 euro). CONCLUSIONS: Failing to control blood glucose levels within 'glycaemic goals', apart from the clinical consequences, can also have a significant financial impact, resulting in a 59.5% increase in the mean annual patient cost.

Intramedullary spinal cord metastases in breast carcinoma: report of two cases and review of the literature.

Intramedullary spinal cord metastases (ISCM) are usually the result of rapidly progressing systemic malignancy. Breast cancer is one of the most common solid tumors with a high propensity of CNS dissemination. In the present report we describe two new cases with advanced breast cancer developing ISCM after a variable disease course. One of these patients had brain metastases at presentation, while at relapse developed leptomeningeal carcinomatosis which was treated successfully, but followed shortly, as a terminal event, by ISCM and parenchymal brain recurrence. The other patient was treated initially for locally advanced breast cancer and after multiple locoregional relapses, she developed liver metastases and subsequent ISCM and asymptomatic parenchymal brain deposits. Both patients experienced a rather rapidly evolving disease course leading to death 2 and 4 months, respectively, after widespread neuraxis dissemination of their cancer. Both these cases, added to the list of the anecdotally reported cases of ISCM after breast cancer, undermine the ominous prognosis and limited treatment options available for this disease manifestation, and an extensive literature review and discussion of similar cases is provided.

Timing of calcium hydroxide therapy in the treatment of root resorption in replanted teeth in dogs.

The effect of time of the onset of calcium hydroxide (CH) pulpectomy on root resorption of 31 permanent dog incisors was investigated. CH pulpectomy was delayed 4, 9, 14 and 18 days after the teeth were extracted and replanted. Control teeth were replanted 1) without pulpectomy, 2) with a pulpectomy only or 3) with a pulpectomy and CH filling. All teeth were prepared for histologic evaluation 8 weeks after the teeth were replanted. Cross section were examined using a computer microscope and linear (micron) and/or square areas (micron 2) of surface (SRR), inflammatory (IRR), and replacement (RRR) root resorption were calculated. From this data the percentage of linear and area resorption was averaged for each group. Duncan multiple range t-test (P < or = 0.05) revealed that teeth in which a pulpectomy with CH filling was done extraorally had significantly greater SRR than the rest of the groups; teeth in which a pulpectomy without CH filling was done extraorally had significantly greater RRR than teeth in which CH pulpectomy was delayed for 18 days; there was no significant difference in SRR, IRR or RRR when CH placement was delayed 4, 9, 14 or 18 days after replantation. Although it was not significant the overall resorption was least when CH pulpectomy was delayed 18 days.

Phenobarbital-induced gingival overgrowth? Report of two cases and complications in management.

Gingival overgrowth is a known side effect of several seizure, immunosuppressant and calcium channel-blocker medications. Gingival overgrowth is not a reported side-effect of phenobarbital. This case report describes two patients with marked gingival overgrowth who had been medicated with phenobarbital exclusively since the initiation of seizure disorders. The clinical findings, surgical management, bleeding complications, and recommendations in management are discussed.

Phase I-II study of docetaxel and ifosfamide combination in patients with anthracycline pretreated advanced breast cancer.

Given the established individual activity of docetaxel and ifosfamide in anthracycline pretreated advanced breast cancer, the present phase I-II study aimed to define the maximum tolerated dose (MTD), the dose-limiting toxicities (DLTs), and activity of the docetaxel-ifosfamide combination in this setting. Cohorts of three to six patients with histologically confirmed metastatic breast cancer after prior anthracycline-based chemotherapy were treated at successive dose levels (DLs) with escalated doses of docetaxel 70-100 mg x m(-2) over 1 h on day 1 followed by ifosfamide 5-6 g x m(-2) divided over days 1 and 2 (2.5-3.0 g x m(-2) day(-1) over 1 h), and recycled every 21 days. G-CSF was added once dose-limiting neutropenia was encountered at a certain DL and planned to be incorporated prophylactically in subsequent higher DLs. In total, 56 patients with a median age of 54.5 (range, 32-72) years and performance status (WHO) of 1 (range, 0-2) were treated at five DLs as follows: 21 in phase I DLs (DL1: 3, DL2: 6, DL3: 3, DL4: 6, and DL5: 3) and the remaining 35 were treated at DL4 (total of 41 patients at DL4), which was defined as the level for phase II testing. All patients were assessable for toxicity and 53 for response. Dose-limiting toxicity (with the addition of G-CSF after DL2) was reached at DL5 with two out of three initial patients developing febrile neutropenia (FN). Clinical response rates, on an intention-to-treat basis, in phase II were: 53.6% (95% CI, 38.3-68.9%); three complete remissions, 19 partial remissions, seven stable disease, and 12 progressive disease. The median response duration was 7 months (3-24 months), median time to progression 6.5 month (0.1-26 month), and median overall survival 13 months (0.1-33 months). Grade 3/4 toxicities included time to progression neutropenia in 78% of patients-with 63% developing grade 4 neutropenia (