Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 2: portrait of drug sample management in Quebec.

OBJECTIVE: To draw a portrait of drug sample management in academic primary health care settings and assess conformity to existing Canadian guidelines. DESIGN: Descriptive cross-sectional survey. SETTING: All 33 family medicine teaching units (FMTUs) in Quebec that kept drug samples. PARTICIPANTS: Health care professionals or FMTU staff who managed drug samples (ie, managers). MAIN OUTCOME MEASURES: Drug sample managers completed a self-administered questionnaire between February and December 2013. Questionnaires inquired about sample selection, procurement, reception, storage, inventory, and disposal. Results were compared with the Canada's Research-Based Pharmaceutical Companies Code of Ethical Practices (2012) and the Canadian Medical Association Guidelines for Physicians in Interactions with Industry (2007). RESULTS: All 33 FMTUs responded to the questionnaire. According to managers, no FMTUs had written selection criteria to guide sample choice. Almost one-third (30%) of FMTUs had uncontrolled access to drug sample cabinets. Even though pharmaceutical companies must distribute drug samples to authorized professionals only, these professionals were involved in the procurement and the reception of samples in 79% and 56% of FMTUs, respectively. Only 15% of FMTUs kept track of samples distributed, 82% checked expiration dates, and 85% ensured proper disposal as recommended. CONCLUSION: The management of drug samples in the FMTUs in Quebec is heterogeneous, with many FMTUs and pharmaceutical companies not following Canadian guidelines.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 3: availability and use of drug samples in Quebec.

OBJECTIVE: To draw a portrait of drug sample distribution and to assess the concordance between drug samples distributed and the medical problems encountered in the ambulatory primary health care setting. DESIGN: Descriptive cross-sectional survey. A self-administered questionnaire was distributed to all health care professionals (HCPs) in family medicine teaching units (FMTUs) that kept drug samples between February and December 2013. Dispensers were defined as HCPs reporting the use of drug samples. Concurrently, an inventory log sheet was completed by managers of drug samples to document the contents of sample cabinets. Data from the Canadian Disease and Therapeutic Index were used as the criterion standard to assess the consistency between the drug samples found in the cabinets and the profile of the most frequent health problems encountered in primary care. SETTING: All 33 FMTUs that kept drug samples in Quebec. PARTICIPANTS: Health care professionals authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses), and managers of drug sample cabinets. MAIN OUTCOME MEASURES: Dispensing practices of HCPs; number of doses of each drug contained in the sample cabinets; total market value of the samples; concordance between the drug sample categories made available and the most common medical problems encountered in primary care; and data on safe handling, ethical issues, effect of the pharmaceutical industry on prescribing behaviour, and inventory of samples. RESULTS: Among 859 HCPs, 579 (67%) reported dispensing drug samples. A large proportion of dispensers (88%) were unable to find the specific drug they sought and half of them (51%) provided the patients with a drug sample even if it was not their first choice for treatment. The drug sample cabinet inventory revealed products from 292 different companies and identified a total of 382 363 medication doses for a total value of $201 872. We found gaps among types of drugs provided to patients, those the HCPs would consider useful, and those available in the cabinets. CONCLUSION: Drug samples available in FMTUs do not meet the needs of many patients and HCPs, suggesting that the main driving force for drug sample distribution is not patient care. Policies on drug samples in FMTUs should be uniform across the province, and management should be as strict as in community pharmacies. Otherwise, prohibiting their use should be considered.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 1: drug sample management policies and the relationship between the pharmaceutical industry and residents in Quebec.

OBJECTIVE: To determine the existence and the level of health care professional (HCP) knowledge of local policies regarding drug sample use and the relationship between residents and the pharmaceutical industry in academic primary health care settings. DESIGN: Descriptive cross-sectional survey. Health care providers were invited to complete a self-administered questionnaire on drug sample use between February and December 2013. Managers of drug samples were also asked to complete a specific questionnaire on drug sample management and policies and an inventory log sheet. Data about the existence of written policies were validated with health and social services centre (HSCC) directors or pharmacy departments and family medicine teaching unit (FMTU) directors between February and June 2014. SETTING: All 42 FMTUs in Quebec. PARTICIPANTS: All HCPs in the FMTUs authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses). Dispensers were defined as those who reported using drug samples. Managers were defined as HCPs or staff members who managed drug samples. MAIN OUTCOME MEASURES: Existence of written policies on drug sample use in HSCCs and FMTUs; whether FMTUs applied the HSCC policies if they existed; whether dispensers were aware of the existence of the policies; and whether policies on the relationships between residents and pharmaceutical companies existed. RESULTS: Among the 42 FMTUs, 33 (79%) kept drug samples. Of these, 30% (10 of 33) did not have policies about drug samples in the FMTU or in the HSCC. A total of 67% (579 of 859) of HCPs from these FMTUs reported using drug samples. Most dispensers did not know if a policy existed in their FMTU (n = 297; 51%) or their HSCC (n = 420; 73%). Eleven (26%) of the 42 FMTU directors reported having a policy regarding relationships between residents and the pharmaceutical industry. Most drug sample dispensers were not aware whether such a policy existed (n = 310; 54%). CONCLUSION: Many FMTUs did not have policies regarding drug samples or relationships between residents and the pharmaceutical industry. Variation in use and management of drug samples and the lack of knowledge of HCPs about the existence of policies point to the need to implement uniform policies in all FMTUs in Quebec.

Leptin and adiponectin in obese and non-obese subjects with asthma.

OBJECTIVE: To understand the role of leptin and adiponectin in obese asthmatics. METHODS: We compared serum leptin, adiponectin and sputum leptin levels in 44 non-obese and 44 obese subjects. RESULTS: We found higher serum leptin (P < 0.0001) and lower adiponectin (P = 0.0002) levels in obese asthmatics. Sputum leptin was correlated with body mass index (BMI; r = 0.34, P = 0.03) and serum leptin (r = 0.43, P = 0.005); however, this last correlation was not significant after adjusting for BMI (r = 0.26, P = 0.11). CONCLUSION: Airway inflammation in obese asthmatics may present a different pattern involving leptin. Sputum leptin levels may partially originate from systemic circulation, with other contributing mechanisms.

Adiposity and pulmonary function: relationship with body fat distribution and systemic inflammation.

PURPOSE: Obesity is associated with changes in pulmonary function and increased systemic inflammation. We explored the relationships among adiposity, body fat distribution indices, serum inflammatory markers and pulmonary function. METHODS: This was a post-hoc cross-sectional analysis that included subjects who had previously participated in randomized studies on obesity at our centre. Non-smoking sedentary men (282 subjects, mean age 42) without respiratory diseases were studied. BMI, waist circumference (WC), visceral and subcutaneous adipose tissue (AT), lung residual volume (RV), vital capacity (VC) and expiratory reserve volume (ERV) were measured. Serum leptin, adiponectin, tumor necrosis factor alpha (TNF-α) and high-sensitive C-reactive protein (hs-CRP) levels were measured. RESULTS: In subjects with metabolic syndrome (n=124), percent predicted ERV and RV were significantly associated with BMI (ERV: r=-0.19, p=0.02, RV: r=-0.28, p=0.0007), WC (r=-0.20, p=0.02, r=-0.26, p=0.002), visceral (r=-0.22, p=0.007, r=-0.25, p=0.002) and subcutaneous AT (r=-0.19, p=0.02, r=-0.28, p=0.0007). Percent predicted VC correlated with visceral (r=-0.20, p=0.02) and subcutaneous AT (r=-0.18, p=0.03). Leptin was strongly correlated with BMI (MS/no-MS: r=0.52, p=0.0005/r=0.62, p < 0.0001), WC (r=0.41, p=0.008/r=0.49, p < 0.0001), visceral (r=0.27,p=0.09/0.43, p < 0.0001) and subcutaneous AT (r=0.46, p=0.003/r=0.66, p < 0.0001), while adiponectin levels were associated in subjects with no-MS with WC (r=-0.20, p=0.01), visceral (r=-0.22, p=0.008), and subcutaneous AT (r=-0.17, p=0.05). When adjusted for anthropometric measures, neither ERV, RV nor VC was significantly correlated with serum leptin, adiponectin, TNF-α, or hs-CRP levels. CONCLUSION: These results suggest that the influence of obesity on lung function in healthy subjects is mostly mediated by mechanical factors. Furthermore, not only BMI but also the pattern of fat distribution should be considered when studying associations between adiposity indices and mechanical or inflammatory variables potentially associated with pulmonary function.

Obesity and asthma: a specific phenotype?

BACKGROUND: Obesity is associated with an increased prevalence of asthma, especially in women, and appears to be more severe in the obese. This study aimed to determine if obese subjects have a specific asthma phenotype. METHODS: Forty-four consecutive obese subjects (body mass index [BMI] > or = 30 kg/m(2)) and 44 consecutive nonobese subjects (BMI < 25 kg/m(2)), all with asthma, completed an asthma control questionnaire, and underwent methacholine challenge with symptom perception scores, and sputum induction for differential cell count. BMI, waist circumference, and waist-to-hip ratio also were measured. RESULTS: Despite similar expiratory flows, bronchodilator response, airway responsiveness to methacholine, and symptom perception scores, asthma control was poorer in obese subjects than in nonobese subjects (p = 0.005). Total lung capacity (p = 0.01), expiratory reserve volume (p < 0.0001), functional residual capacity (p < 0.0001), and residual volume (p = 0.006) were lower in obese subjects than in nonobese subjects. Induced-sputum eosinophil and neutrophil counts were similar in both groups, although there was an inverse correlation between sputum eosinophils and waist circumference and a trend for a similar relationship for BMI. Blood serum C-reactive protein (p = 0.009) and fibrinogen (p = 0.0004) levels were higher in obese subjects than in nonobese subjects. CONCLUSION: Obese people with asthma had poorer asthma control than nonobese asthmatics despite similar symptoms perception. Bronchial and systemic inflammatory characteristics and the specific pattern of pulmonary function changes suggest a different phenotype of asthma in these subjects. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00532363 and NCT00532831.

Clinical management of chronic obstructive pulmonary disease and asthma in an obese patient.

The prevalence of obesity has noticeably increased worldwide. The clinician is now frequently facing the challenge of managing patients with concomitant chronic obstructive pulmonary disease (COPD) or asthma and obesity. Obesity is often associated with a poorer control of these chronic respiratory diseases and the optimal management of these conditions in the presence of obesity remains to be determined. Herein, the authors review the present understanding of the influence of obesity in the development, clinical manifestations and management of asthma and COPD. The influence of weight loss, response to present therapies as well as new targets for the treatment of COPD and asthma in obese subjects are also discussed, in addition to future directions for research.