Direct oral anticoagulant concentrations and adherence in stroke patients.

No therapeutic ranges linking drug concentrations of apixaban and rivaroxaban to clinical outcomes have been defined. We investigated whether direct oral anticoagulant (DOAC) concentrations among patients admitted to hospital with symptoms of stroke differed between those later verified to suffer an ischaemic cerebrovascular event (stroke or transient ischaemic attack) and those having other diagnoses (control group). Serum concentrations in 102 patients on DOAC for atrial fibrillation (84%) and thromboembolic disease (16%) were measured within 24 h of the acute event, employing ultra-high performance liquid chromatography with tandem mass spectrometry. We converted all concentrations to standardized trough levels. DOAC concentrations were lower in the 64 patients with verified ischaemic cerebrovascular event than in the 30 controls, 255 ± 155 versus 329 ± 144 nmol/L (p = 0.029), despite no statistically significant difference in self-reported adherence and daily dosages. Calculated concentrations were 5.4-596 nmol/L (median = 229 nmol/L) in the ischaemic stroke group and 41-602 nmol/L (median = 316 nmol/L) in controls. CHA2 DS2 -VASc score was significantly higher in the ischaemic stroke group than in controls (4.9 ± 1.6 versus 4.1 ± 1.7; p = 0.007). These results may suggest that patients with high cerebrovascular risk might benefit from higher DOAC levels than those with a lower risk.

Academic detailing as a method to improve general practitioners' drug prescribing in type 2 diabetes: evaluation of changes in prescribing.

OBJECTIVE: To investigate the effect of an academic detailing intervention on the utilisation of type 2 diabetes medication among general practitioners. DESIGN: We developed an academic detailing campaign based on the revised national treatment guideline for diabetes and the best available evidence. General practitioners were offered a 20-minute one-to-one visit by a trained academic detailer. SETTING AND SUBJECTS: A total of 371 general practitioners received a visit and represented the intervention group. The control group consisted of 1282 general practitioners not receiving a visit. MAIN OUTCOME MEASURES: Changes in prescribing from 12 months before to 12 months after the intervention. The primary endpoint was a change in metformin. Secondary endpoints were changes in other groups of Type 2 diabetes medication and of these drugs in total. RESULTS: Prescribing of metformin increased by 7.4% in the intervention group and 5.2% in the control group (p = .043). Sodium-glucose cotransporter-2 inhibitors increased by 27.6% in the intervention group and 33.8% in the control group (p = .019). For sulfonylureas there was a decrease of 3.6% in the intervention group vs. 8.9% in the control group (p = .026). The total amount of prescribed medications for type 2 diabetes increased by 9.1% in the intervention group and 7.3% in the control group (p = .08). CONCLUSION: Academic detailing initiated a small but statistically significant increase in the prescription of metformin. For a complex subject like type 2 diabetes, we recommend reserving more time in the visit than the 20 min our campaign aimed for.

Academic detailing is a validated method for facilitating changes in prescribing, via interactive one-to-one meetings with a trained academic detailer.General practitioners who received a 20-minute visit on the treatment of type 2 diabetes prescribed more metformin, compared to the control group.For a complex interventions like the present, we recommend setting aside more than 20 minutes, to ensure sufficient time for discussion and reflection.Academic detailing can impact prescribing, even for a complex subject like the treatment of Type 2 Diabetes.

Academic detailing as a method of continuing medical education.

INTRODUCTION: Academic detailing is an interactive educational outreach to prescribers to present unbiased, non-commercial, evidence-based information, mostly about medications, with the goal of improving patient care. Academic detailing in Norway is an approach for providing continuing medical education to general practitioners (GPs). The basis of academic detailing is a one-to-one discussion between a trained health professional (the academic detailer) and the GP at the GP's workplace. METHOD: Our first campaign was named "Better use of non-steroidal anti-inflammatory drugs (NSAIDs)", which aim was to reduce the use of diclofenac due to the risk of serious cardiovascular adverse events. At the same time we advised the GPs to use naproxen as the drug of choice if an NSAID was needed. We did a one-to-one intervention in two cities, where a trained academic detailer met the GP during office hours. A total of 247 GPs were invited to participate and 213 visits (86%) were completed. This article reviews the theoretical framework underlying the method and describes the development and implementation of academic detailing to GPs in Norway. RESULTS: More than 90% the participating GPs considered academic detailing a suitable method for providing up-to-date evidence-based, manufacturer-independent information, and nearly all would most likely or probably welcome another visit. After the intervention there was a reduction of diclofenac prescribing of 16% and 18%, respectively, in the two cities. CONCLUSION: We consider that academic detailing is a suitable method to bring the best available evidence to the point at which care is delivered, to achieve the best for the patients. According to the Norwegian GPs' evaluation, it is a key supplement to other methods of continuing medical education. To have maximum impact, it is important that academic detailing is practiced according to the consensus that has evolved in the USA and Australia.

Effectiveness of an academic detailing intervention in primary care on the prescribing of non-steroidal anti-inflammatory drugs.

PURPOSE: The objective of this study was to examine the impact of an academic detailing programme in primary care in Norway on the prescribing rate of diclofenac, naproxen and non-steroidal anti-inflammatory drugs (NSAIDs) in total. METHODS: An academic detailing programme was delivered to general practitioners (GPs) in two Norwegian cities. The key message was to avoid diclofenac and COX-2 inhibitors and to use naproxen as the NSAID of choice. We analysed prescription data for 12 months before and after the programme to estimate its impact, using interrupted time series to control for underlying trends, and using the rest of Norway as a comparator. The primary outcome was change in the proportion of the population filling a prescription for diclofenac; secondary outcomes were change in naproxen prescribing and change in total NSAID prescribing. RESULTS: Controlling for baseline trends, and relative to changes in the rest of Norway, there was a statistically significant reduction in the prescribing rate of diclofenac in both cities (- 18% and - 16%, respectively) immediately after the intervention. The impact of the programme on prescribing of diclofenac was maintained by the end of the 12 month follow-up period. An increase in the prescribing of naproxen was observed in both cities. The programme had no impact on the overall rate of prescribing of NSAIDs. CONCLUSION: Academic detailing was effective in changing the choice of prescribed NSAID amongst Norwegian GPs. Academic detailing is potentially an important method for providing GPs with independent, evidence-based updates on pharmacotherapy to improve prescribing.

Quantification of Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in Human Serum by UHPLC-MS/MS-Method Development, Validation, and Application.

BACKGROUND: Direct oral anticoagulants (DOACs) are prescribed for anticoagulation in patients with atrial fibrillation and venous thromboembolic disease. Fixed doses are recommended, but measuring their serum drug concentrations as a basis for dose adjustments may be useful in some clinical settings. METHODS: An ultra-high-performance liquid chromatography-tandem mass spectrometry method for the analysis of the DOACs apixaban, dabigatran, edoxaban, and rivaroxaban in human serum was developed and validated. A 100-µL serum sample was handled using a pipetting robot. Protein precipitation was performed with 375 µL of 1% formic acid in acetonitrile (vol/vol), and phospholipid removal was performed using a Waters Ostro 96-well plate. The injection volume was 1 µL, and run time was 3.0 minutes. RESULTS: The calibration range was 5-800 nmol/L. The between-day precision relative SDs were in the range of 3.3%-10%. Recoveries ranged from 85% to 105%, and matrix effects from 88% to 102%, when corrected with internal standard. Edoxaban was, in contrast to the other DOACs, unstable when stored for more than 6 hours at 30°C. The suitability of the method was demonstrated by analyzing routine samples from 345 patients undergoing anticoagulation treatment. CONCLUSIONS: The developed method fulfilled the set validation criteria, and its suitability was demonstrated in a routine setting. The instability of edoxaban may complicate the transport of routine samples to the laboratory.

[New biomarkers for assesing alcohol consumption]. / Nye markører for påvisning av alkoholbruk.

Alcohol abuse has significant medical, social and socioeconomic consequences. Alcohol biomarkers may serve as a useful tool in identifying individuals with excessive alcohol consumption in medical as well as medico-legal contexts.

Peer academic detailing on use of antibiotics in acute respiratory tract infections. A controlled study in an urban Norwegian out-of-hours service.

OBJECTIVE: To analyse if peer academic detailing by experienced general practitioners (GPs) could be a useful way to change Medical Doctors, (MDs) prescription of antibiotics for acute respiratory tract infections (ARTIs) in out-of-hours service. METHOD: An educational Intervention study based on prescription data among MDs working in an out-of-hours service from June 2006 through October 2008. Specially trained GPs lectured a peer educational program (3 × 45 minutes) about use of antibiotics for ARTIs according to national recommendations. OUTCOME MEASURES: The type and frequency of antibiotics prescribed for different ARTIs before and after intervention comparing the intervention group with the control group. SUBJECTS: 22 MDs in the intervention group and 31 MDs in the control group. RESULTS: The intervention group showed an overall statistically significantly absolute increase in the use of penicillin V (Penicillin V) of 9.8% (95% CI: 2.3%-17.4% p < 0.05), and similarly an statistically significantly absolute decrease in the use of macrolides and lincosamides of 8.8% (95% CI: 2.6%-14.9.2% p < 0.05) for all diagnoses. For subgroups of ARTIs we found a significant increase in the use of Penicillin V for acute otitis media, sinusitis, pneumonia and upper ARTIs. There was no significant changes in total prescription rates in the two groups. 41% of all consultations with respiratory tract infections resulted in antibiotic prescription. CONCLUSIONS: Using trained GPs to give peer academic detailing to colleagues in combination with open discussion on prescription, showed a significant change in prescription of antibiotics towards national guidelines. Key points Phenoxymethylpenicillin is the first choice for the most of respiratory tract infections when indicated. Despite the guidelines for the choice of antibiotics in Norway, general practitioners' choice often differs from these. We showed that a session of three times 45 min of peer academic detailing changed significantly the choice of antibiotics towards the National Guidelines in an urban Norwegian out-of-hours service.

[Do urine tests for drugs of abuse cover the substances of interest?]. / Dekker rusmiddeltester i urin de aktuelle misbruksstoffene?

BACKGROUND: In Norway several hundred thousand urine samples are analysed annually to reveal substance abuse. Our laboratory analyses substances with a potential of abuse in about 60,000 urine specimens annually. We wished to find out if our standard panel of analyses can detect most of these substances. MATERIAL AND METHODS: In summer 2009, our department analysed ten substances that were not included in our standard test panel in all urine specimens received on an arbitrarily chosen weekday during five consecutive weeks. In addition, four other laboratories each sent 250 urine specimens to us to be analysed for the same ten substances. RESULTS: 1 854 urine specimens were analysed in total. Substances that were not covered by our standard test panel were detected in 123 samples (6.6 %): i.e. Pregabalin in 83 (4.5 %), methylphenidate in 33 (1.8 %), tramadol in four (0.2 %) and lorazepam in one (0.05 %) sample. The percentage of samples containing substances of abuse not covered by our standard test panel was: 20.8 % in Bergen, 9.8 % in Kristiansand, 8.0 % in Tromsø, 2.8 % in Oslo and 2.3 % in Trondheim. INTERPRETATION: This study indicates that most drugs of abuse are detected by common routine urine analyses. Laboratories that offer analyses of drugs of abuse in urine should have methods available to detect pregabalin and methylphenidate in addition to or included in the standard panel.