Utilization of marine and agro-waste materials as an economical and active food packaging: Antimicrobial, mechanical and biodegradation studies of O-Carboxymethyl chitosan/pectin/neem composite films.

The present work deals with the eco-friendly preparation of highly degradable food packaging films consisting of O-CMC (O-Carboxymethyl Chitosan) and pectin, incorporated with neem (Azadirachta indica) leaves powder and extract. This study aimed to investigate the tensile properties, antimicrobial activity, biodegradability, and thermal behavior of the composite films. The results of tensile strength and elongation at break, showed that the incorporation of neem leaves powder improved the tensile properties (7.11 MPa) of the composite films compared to the neat O-CMC and pectin films (3.02 MPa). The antimicrobial activity of the films was evaluated against a panel of microorganisms including both gram-positive and gram-negative bacteria as well as fungi. The composite films exhibited excellent antimicrobial activity with a zone of inhibition (12-17.6 mm) against the tested microorganisms. The opacity of the composite films ranges from 1.14 to 4.40 mm-1 and the addition of fiber causes a decrease in opacity value. Biodegradability studies were conducted by Soil burial method and the films demonstrated complete biodegradability within 75 days. The results of thermogravimetric analysis (TGA) and differential scanning calorimetry (DSC) of composite films show that they are thermally stable and might be used in food packaging.

The Role of Needle Arthroscopy in the Assessment and Treatment of Ankle Sprains.

Lateral ankle ligament complex injuries are most commonly managed nonoperatively. If no improvements have been made following conservative management, surgical intervention is warranted. Concerns have been raised regarding complication rates following open and traditional arthroscopic anatomical repair. In-office needle arthroscopic anterior talo-fibular ligament repair provides a minimally invasive arthroscopic approach to the diagnosis and treatment of chronic lateral ankle instability. The limited soft tissue trauma facilitates rapid return to daily and sporting activities making this an attractive alternative approach to lateral ankle ligament complex injuries.

Impact of first UK COVID-19 lockdown on hospital admissions: Interrupted time series study of 32 million people.

Background: Uncontrolled infection and lockdown measures introduced in response have resulted in an unprecedented challenge for health systems internationally. Whether such unprecedented impact was due to lockdown itself and recedes when such measures are lifted is unclear. We assessed the short- and medium-term impacts of the first lockdown measures on hospital care for tracer non-COVID-19 conditions in England, Scotland and Wales across diseases, sexes, and socioeconomic and ethnic groups. Methods: We used OpenSAFELY (for England), EAVEII (Scotland), and SAIL Databank (Wales) to extract weekly hospital admission rates for cancer, cardiovascular and respiratory conditions (excluding COVID-19) from the pre-pandemic period until 25/10/2020 and conducted a controlled interrupted time series analysis. We undertook stratified analyses and assessed admission rates over seven months during which lockdown restrictions were gradually lifted. Findings: Our combined dataset included 32 million people who contributed over 74 million person-years. Admission rates for all three conditions fell by 34.2% (Confidence Interval (CI): -43.0, -25.3) in England, 20.9% (CI: -27.8, -14.1) in Scotland, and 24.7% (CI: -36.7, -12.7) in Wales, with falls across every stratum considered. In all three nations, cancer-related admissions fell the most while respiratory-related admissions fell the least (e.g., rates fell by 40.5% (CI: -47.4, -33.6), 21.9% (CI: -35.4, -8.4), and 19.0% (CI: -30.6, -7.4) in England for cancer, cardiovascular-related, and respiratory-related admissions respectively). Unscheduled admissions rates fell more in the most than the least deprived quintile across all three nations. Some ethnic minority groups experienced greater falls in admissions (e.g., in England, unscheduled admissions fell by 9.5% (CI: -20.2, 1.2) for Whites, but 44.3% (CI: -71.0, -17.6), 34.6% (CI: -63.8, -5.3), and 25.6% (CI: -45.0, -6.3) for Mixed, Other and Black ethnic groups respectively). Despite easing of restrictions, the overall admission rates remained lower in England, Scotland, and Wales by 20.8%, 21.6%, and 22.0%, respectively when compared to the same period (August-September) during the pre-pandemic years. This corresponds to a reduction of 26.2, 23.8 and 30.2 admissions per 100,000 people in England, Scotland, and Wales respectively. Interpretation: Hospital care for non-COVID diseases fell substantially across England, Scotland, and Wales during the first lockdown, with reductions persisting for at least six months. The most deprived and minority ethnic groups were impacted more severely. Funding: This work was funded by the Medical Research Council as part of the Lifelong Health and Wellbeing study as part of National Core Studies (MC_PC_20030). SVK acknowledges funding from the Medical Research Council (MC_UU_00022/2), and the Scottish Government Chief Scientist Office (SPHSU17). EAVE II is funded by the Medical Research Council (MR/R008345/1) with the support of BREATHE - The Health Data Research Hub for Respiratory Health (MC_PC_19004), which is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. BG has received research funding from the NHS National Institute for Health Research (NIHR), the Wellcome Trust, Health Data Research UK, Asthma UK, the British Lung Foundation, and the Longitudinal Health and Wellbeing strand of the National Core Studies programme.

Economic Costs of Violence Against Women and Girls in Low- and Middle-Income Countries: A Pilot Study on Management's Outlook.

BACKGROUND: In low and middle-income countries (LMICs), violence against women and girls (VAWG) is rampant, primarily due to patriarchy. However, there is little understanding of its ripple effect in the workplace in LMICs. While recent studies in LMICs have attempted to understand the effects of VAWG on productivity using data collected from colleagues, survivors, or perpetrators, there is limited research on the employers' perspective of the impact of VAWG on productivity. METHODS: A survey, developed by the investigators, based on previous research in Peru and Vietnam, was administered to 74 senior management executives in Ghana, Pakistan, and South Sudan. Based on female employees' absenteeism, tardiness, and presenteeism, this study provides the management's perspective on the invisible costs of VAWG. FINDINGS: The results show that 25% and 36% of senior executives have witnessed intimate partner violence and non-partner sexual violence, respectively, against their female colleagues. One (32%) in three managers also acknowledged the impact of VAWG on productivity and day-to-day operations. CONCLUSIONS: This study provides evidence that there is a need for the development of employee assistance programs (EAPs) in LMICs. Due to significant increase in employees' productivity in the absence of VAWG, investing in occupational health services needs to be viewed as an investment, not cost. As many international companies in developed countries do business in LMICs, their occupational health departments need to be more aware of VAWG. Occupational health practitioners can assist in the needs assessment for EAPs as well as provide appropriate referrals and counseling to impacted employees.

Building Successful Models in Primary Care to Improve the Management of Adult Patients with Obesity.

Although several obesity clinical practice guidelines are available and relevant for primary care, a practical and effective medical model for treating obesity is necessary. The aim of this study was to develop and implement a holistic population health-based framework with components to support primary care-based obesity management in US health care organizations. The Obesity Care Model Collaborative (OCMC) was conducted with guidance and expertise of an advisory committee, which selected participating health care organizations based on prespecified criteria. A committee comprising obesity and quality improvement specialists and representatives from each organization developed and refined the obesity care framework for testing and implementing guideline-based practical interventions targeting obesity. These interventions were tracked over time, from an established baseline to 18 months post implementation. Ten geographically diverse organizations, treating patients with diverse demographics, insurance coverage, and health status, participated in the collaborative. The key interventions identified for managing obesity in primary care were applicable across the 4 OCMC framework domains: community, health care organization, care team, and patient/family. Care model components were developed within each domain to guide the primary care of obesity based on each organization's structure, resources, and culture. Key interventions included development of quality monitoring systems, training of leadership and staff, identifying clinical champions, patient education, electronic health record best practice alerts, and establishment of community partnerships, including the identification of external resources. This article describes the interventions developed based on the framework, with a focus on implementation of the model and lessons learned.

An Adult Immunization Best Practices Learning Collaborative: Impact, Scale Up, and Spread.

The research objective was to rapidly scale up and spread a proven learning collaborative approach (intervention) for adult vaccination rates for influenza and pneumococcal disease from 7 to 39 US health care organizations and to examine improvement in adult immunization rates after scale-up. Comparative analyses were conducted between intervention and nonintervention propensity score-matched providers on vaccination rates using a difference-in-differences approach. Qualitative data, collected during site visits and in-person and virtual meetings, were used to enhance understanding of quantitative results. In 2017-2018, an analysis of a subset of sites (n = 9) from 2 intervention cohorts (∼20 sites each) demonstrated greater improvement than their matched providers in pneumococcal vaccinations (PV) for patients ages ≥65 years (treatment effect range: 1.4%-3.7%, P < 0.01) and PV for high-risk patients (eg, with immunocompromising conditions) aged 19-64 years (0.8%-1.6%, P < 0.01). Significant effects were observed in one of the study cohorts for PV for at-risk patients (eg, with diabetes) aged 19-64 years (1.7%, P < 0.01), and influenza vaccination rates (2.4%, P < 0.001). Individual health systems demonstrated even greater improvements across all 4 vaccinations: 9.5% influenza; 8.7% PV ages ≥65 years; 11.8% PV high-risk; 16.3% PV at-risk (all P < 0.01). Results demonstrated that a 7-site pilot could be successfully scaled to 39 additional sites, with similar improvements in vaccination rates. Between 2014 and 2018, vaccination improvements among all 46 groups (7 pilot, 39 in subsequent cohorts) resulted in an estimated 5.5 million adult vaccinations administered or documented in 27 states.

Cytometric assessment of uterine receptivity via epithelial ß3 integrin expression.

RESEARCH QUESTION: Many techniques now exist to assess the receptivity status of the endometrium. Can a simple low-cost flow cytometric technique be used to rapidly assess uterine receptivity via a luteal phase endometrial biopsy? DESIGN: Epithelial ß3 integrin (EB3) evaluation was undertaken in 300 women presenting with repeated implantation failure or recurrent pregnancy loss who subsequently underwent 710 assisted reproductive technology (ART) cycles. Endometrial tissue was mechanically dissociated and evaluated using specific antibodies to capture integrin expression. Autologous and donor oocyte embryo transfers were evaluated. A 'High', 'Borderline' and 'Low' grading system was developed based on the pattern and percentage expression of EB3 relative to the total endometrial epithelium. Clinical outcomes of the resulting embryo transfers (n = 559) were analysed according to EB3 grading. RESULTS: Based on 180 completed transfers, the clinical pregnancy rate (CPR) per embryo transferred in the donor egg cycles was 41.7%. EB3 results from women with a 'High' grading showed a superior CPR (54.0%) compared with 'Low' (22.2% CPR) or 'Borderline' (37.4%) cases (P = 0.024). Similarly, following 379 autologous oocyte transfers, the CPR was 36.1% overall, with major variations between the 'High' (43.8%), 'Low' (17.5%) and 'Borderline' (34.8%) groups (P = 0.0008). Implantation rates showed similar significant trends in the 'High' versus 'Low' groups of 40.4% versus 16% (P = 0.048) in donor oocyte transfers, and 30.8% versus 16.1% (P = 0.025) in autologous oocyte transfers. CONCLUSIONS: The distribution patterns and percentage expression of EB3 assessed by a flow cytometry grading system shows a significant relationship to implantation rate and CPR success in ART cycles and may thus represent a useful additional tool for the assessment of uterine receptivity.

Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair.

PURPOSE: To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair. METHODS: 24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment. RESULTS: Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment. CONCLUSIONS: Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Endoinulinase production by a new endoinulinase producer Aspergillus tritici BGPUP6 using a low cost substrate.

Endoinulinase is an inulolytic enzyme which is used for the production of fructooligosaccharides from inulin. A new endoinulinase producing fungal strain BGPUP6 was identified as Aspergillus tritici on the basis of its molecular characterization. Response surface methodology was used to optimize the endoinulinase production at shake-flask level from Aspergillus tritici BGPUP6 using raw Asparagus inulin as carbon source. Four independent variables (raw inulin, 2-4%; peptone, 0.3-0.7%; (NH4)H2PO4, 0.3-0.7% and pH, 4.5-6.5) were selected for the study based on the CCRD model of RSM. The other media supplements (FeSO4·7H2O, 0.001%; MgSO4·7H2O, 0.05% and KCl, 0.02%) were kept constant in the production medium, throughout the study. Endoinulinase production and biomass yield were selected as dependent responses. The optimal combination of media ingredients obtained from the study was 3% raw inulin, 0.5% peptone, 0.5% (NH4)H2PO4 and pH 5.5. Using the optimized media constituents, maximum endoinulinase production (25.01 IU/mL) and biomass yield (0.514g dry weight/50 mL) obtained were in good agreement with the predicted values. Crude enzyme produced was also used for the hydrolysis of inulin. The hydrolysate showed the presence of a mixture of fructooligosaccharides with varied degree of polymerization. This is the first report on the production of an endoinulinase from Aspergillus tritici.

Laparoscopic Hysterectomy and Urinary Tract Injury: Experience in a Health Maintenance Organization.

STUDY OBJECTIVES: To evaluate the incidence, detection, characteristics, and management of urinary tract injury in a cohort undergoing laparoscopic hysterectomy, and to identify potential risk factors for urinary tract injury with laparoscopic hysterectomy. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Kaiser Permanente San Diego Medical Center, 2001 to 2012. PATIENTS: Women who underwent attempted laparoscopic hysterectomy for benign indications. INTERVENTIONS: Total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: Demographic and clinical characteristics, surgical techniques, and perioperative complications were abstracted from the medical record. Multivariable logistic regression analysis assessed independent risk factors for ureteral or bladder injury. RESULTS: A total of 3523 patients (mean age, 45.9 ± 8.0 years; median parity, 2; range, 0-10), with a median body mass index (BMI) of 29 kg/m(2) (range, 16-72 kg/m(2)), underwent laparoscopic hysterectomy; 20% had intraoperative cystoscopy. The incidence of urinary tract injury was 1.3% (46 of 3523); of the 46 patients with injuries, 19 (0.54%) had ureteral injuries, 25 (0.71%) had bladder injuries, and 2 (0.06%) had both types. Of the 21 ureteral injuries, 6 (29%) were diagnosed intraoperatively and 15 (71%) were diagnosed postoperatively, including 4 with normal intraoperative cystoscopy. Of the 27 bladder injuries, 23 (85%) were identified intraoperatively. In multivariable logistic analysis, a BMI of 26 to 30 kg/m(2) (compared with >30 kg/m(2)) was associated with an increased risk of ureteral injury, and a BMI ≤25 kg/m(2) (compared with >30 kg/m(2)) and the presence of endometriosis were associated with an increased risk of bladder injury. CONCLUSION: Urinary tract injury occurred in 1.3% of laparoscopic hysterectomies, with ureteral injuries almost as common as bladder injuries. Normal intraoperative cystoscopy findings did not exclude the presence of ureteral injury.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).

Laboratory assessment of iron status in pregnancy.

BACKGROUND: Efforts to improve maternal nutrition during pregnancy prompted an observational study of the occurrence of maternal iron deficiency and its laboratory diagnosis in almost 500 pregnancies. METHODS: In this longitudinal study, the biochemical and haematological iron indices of women (n=492) attending a prenatal clinic in a Dublin maternity hospital were assessed at first booking (mean 15.9 weeks), and after 24 weeks, and 36 weeks of gestation. Full blood counts were measured. Serum ferritin (SF), zinc protoporphyrin (ZPP), and transferrin receptor (sTfR) concentrations were assayed and transferrin receptor index (sTfR-Index) was calculated. The occurrence of low values and their diagnostic values were considered. RESULTS: A high occurrence iron deficiency (ID) at first booking (SF<12 µg/L) had increased over six-fold by 24 weeks, and all biochemical iron indices reflected progressive iron depletion right up to term. The WHO recommended anaemia "cut-off" (Hb<110 g/L) was insensitive to biochemical iron deficiency at booking, missing over 90% of the low SF values (SF<12 µg/L) which were mostly associated with much higher Hb levels. CONCLUSIONS: This study stresses the importance of including a biochemical index of iron status in prenatal screening and supports SF as the best indicator of biochemical ID overall. sTfR was insensitive to iron deficiency in early pregnancy, whereas the sTfR-Index, as a ratio, has the potential to distinguish between ID and physiological anaemia, and may offer stability in the assessment of iron stores from early pregnancy to full term. A policy of early screening of both Hb and SF concentrations is recommended as the minimum requirement for surveillance of maternal iron status in pregnancy.

Cost savings of an adult hospital nutrition support team.

OBJECTIVES: A hospital-based nutrition support team (NST) may need to demonstrate cost savings and quality benefits. The primary aim of this study was to determine whether an NST could show tangible cost savings (equipment, investigations, and medication costs) from managing patients considered for parenteral nutrition (PN). Secondary aims related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of parenteral nutrition, and mortality. METHODS: An NST was formed in 1999 and worked in all adult areas of a university hospital (Leicester Royal Infirmary). Comparative data about all patients given PN were collected for 2 consecutive years (a retrospective pre-NST year and a prospective NST year). RESULTS: In the pre-NST year there were 82 PN episodes (54 patients), 665 PN days, and a CRS rate of 71% (seven infections/100 PN days). In the NST year, there were 133 referrals for PN but only 78 PN episodes (75 patients, 59% of referrals), 752 PN days, and a decreased overall CRS rate of 29% (three infections/100 PN days, P < 0.05) but a rate of 7% (0.6 infection/100 PN days) in the final 3 mo of the NST year. Tangible cost savings for the NST year were derived from 55 avoided PN episodes (42741 pounds sterlings) and 35 avoided CRS episodes (7974 pounds sterlings). Thirty-nine percent of PN catheters were inserted by the NST with no insertion-related complications. Competency-based training of ward nursing staff decreased the CRS rate. Mean duration of PN increased from 8 to 10 d (P not significant). In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P < 0.05). CONCLUSIONS: Although the number of PN days increased with an NST, tangible cost savings of 50715 pounds sterlings were demonstrated within the NST year by avoided PN episodes and a decreased incidence of CRS. These savings justify the salaries of a nutrition nurse specialist and a senior dietitian.

Laparoscopic hysterectomy: the Kaiser Permanente San Diego experience.

STUDY OBJECTIVE: To evaluate patient and surgical characteristics of laparoscopic hysterectomy (LH), including both total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LSH), compared with total abdominal hysterectomy (TAH). DESIGN: Retrospective, comparative study (Canadian Task Force classification II-2). SETTING: Health maintenance organization/residency-training program. PATIENTS: One hundred eight patients who underwent TLH, 251 patients who underwent LSH, and 255 patients who underwent TAH. There was no randomized controlled system to assign patients to the three types of hysterectomy. Patients with ancillary procedures were excluded from all three groups. The study period included February 2000 through September 2002. INTERVENTION: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Analysis of covariance revealed that laparoscopic procedures require significantly more time to complete than TAH. Adjusted differences were 46.4 minutes longer for TLH (p <.0001) and 38.3 minutes longer for LSH (p <.0001). The adjusted estimated blood loss was 91.0 mL less with TLH (p <.0001) and 72.6 mL less with LSH (p < .0001) than with TAH. The hospital lengths of stay were significantly shorter for LH compared with TAH. The adjusted differences were 41.7 hours less with TLH (p <.0001) and 45.1 hours less with LSH (p <.0001). Rates of major complications were 5.6% with TLH, 0.8% with LSH, and 8.2% with TAH. Rates of minor complications were 17.6% with TLH, 16.7% with LSH, and 14.1% with TAH. Rates of any complication were 21.3% with TLH, 17.1% with LSH, and 20.8% with TAH. (Note: some patients in each group had both a minor and a major complication, so that minor and major complications do not exactly add up to "any complication.") The readmission rates for TLH, LSH, and TAH were 5.6%, 1.2%, and 2.0%, respectively. Same-day discharge for TLH and LSH occurred in 16.7% and 25.1% of patients, respectively. The variables indicating minor complications, any complications, wound infections, urinary tract infections, readmissions, and same-day discharges (in the laparoscopic groups) were not differentiated by surgery type. Major complications were differentiated by procedure class; namely, total hysterectomy (TLH and TAH) had significantly more major complications than LSH (adjusted p = .001). Wound abscesses (16 patients) occurred only in the TAH group (adjusted p <.0001). Pelvic cellulitis (17 patients) occurred in all surgical groups, but was more likely to occur in the LH groups (adjusted p = .01). CONCLUSIONS: Laparoscopic hysterectomy, both total and supracervical, can be successfully integrated into a large health maintenance organization/residency-training program. Laparoscopic hysterectomy took significantly longer to perform than TAH in this new program. Estimated blood loss was significantly less with LH than with TAH. Hospital length of stay was significantly less with LH than TAH. Major complications with TLH, minor complications with LH, overall complications, wound infections, urinary tract infections, and readmissions appear comparable with these parameters in TAH within the limits of our study size and design. Pelvic cellulitis was significantly more common with LH, and wound abscess was significantly more common with TAH. Major complications were significantly less common with LSH compared with combined TLH and TAH. Same-day discharge after LH seems to be an attractive option worth developing further. Our patients have enthusiastically accepted these new minimally invasive techniques for performing hysterectomy. We anticipate continued expansion of our LH program.

The rate, pattern, and cost of use of antiparkinsonian agents among patients treated for schizophrenia in a managed care setting.

OBJECTIVE: To examine the use and economic cost of antiparkinsonian agents during the medication management of patients diagnosed with schizophrenic disorders in a naturalistic healthcare setting. DESIGN: Cross-sectional retrospective analysis of 1-year (1999) administrative data from a large managed care organization. PATIENTS AND METHODS: Patients were 1938 adults who were treated for a schizophrenic disorder. Monthly per patient utilization rate and cost of antiparkinsonian agents, and the proportion of the total psychiatric medication costs attributed to the antiparkinsonian agents, were compared across antipsychotic medications (typical, atypical, olanzapine, risperidone), age, sex, and diagnostic subtype. RESULTS: About one third (39%) of the patients were treated with typical antipsychotics only, and half of them (51%) received antiparkinsonian agents. Those treated with atypical antipsychotics only (41%) were considerably less likely to receive antiparkinsonian agents (25%), and the rate of use differed by atypical type such that risperidone-treated patients were more likely to receive antiparkinsonian agents than those treated with olanzapine. Lower utilization rates of antiparkinsonian agents were also found among patients age 75 years or older, and among those diagnosed with a schizoaffective disorder. Average monthly per patient cost of antiparkinsonian agents was 3.0 dollars, constituting 2.6% of the monthly expenditure on all psychiatric medications. CONCLUSIONS: Adjunctive use of antiparkinsonian agents differs widely among patients who are treated with typical or atypical antipsychotic drugs, and differs between types of atypical antipsychotics. The choice of atypical antipsychotics that have a lower liability for extrapyramidal symptoms may assist in optimizing the long-term functional outcomes of schizophrenia patients.

Retrospective cohort study of diabetes mellitus and antipsychotic treatment in a geriatric population in the United States.

OBJECTIVES: The objective of this study was to investigate risk of diabetes among elderly patients during treatment with antipsychotic medications. DESIGN: We conducted a longitudinal, retrospective study assessing the incidence of new prescription claims for antihyperglycemic agents during antipsychotic therapy. SETTING: Prescription claims from the AdvancePCS claim database were followed for 6 to 9 months. PARTICIPANTS: Study participants consisted of patients in the United States aged 60+ and receiving antipsychotic monotherapy. The following cohorts were studied: an elderly reference population (no antipsychotics: n = 1,836,799), those receiving haloperidol (n = 6481) or thioridazine (n = 1658); all patients receiving any conventional antipsychotic monotherapy (n = 11,546), clozapine (n = 117), olanzapine (n = 5382), quetiapine (n = 1664), and risperidone (n = 12,244), and all patients receiving any atypical antipsychotic monotherapy (n = 19,407). MEASUREMENTS: We used Cox proportional hazards regression to determine the risk ratio of diabetes for antipsychotic cohorts relative to the reference population. Covariates included sex and exposure duration. RESULTS: New antihyperglycemic prescription rates were higher in each antipsychotic cohort than in the reference population. Overall rates were no different between atypical and conventional antipsychotic cohorts. Among individual antipsychotic cohorts, rates were highest among patients treated with thioridazine (95% confidence interval [CI], 3.1- 5.7), lowest with quetiapine (95% CI, 1.3-2.9), and intermediate with haloperidol, olanzapine, and risperidone. Among atypical cohorts, only risperidone users had a significantly higher risk (95% CI, 1.05-1.60; P = 0.016) than for haloperidol. Conclusions about clozapine were hampered by the low number of patients. CONCLUSION: These data suggest that diabetes risk is elevated among elderly patients receiving antipsychotic treatment. However, causality remains to be demonstrated. As a group, the risk for atypical antipsychotic users was not significantly different than for users of conventional antipsychotics.