Determining the optimal threshold for medication adherence in adult asthma patients: an analysis of British Columbia administrative health database in Canada.

OBJECTIVE: This study investigated the association between varying cutoffs for Medication Adherence (MA) among physician-diagnosed asthma patients and subsequent association with asthma exacerbation. METHODS: We linked four administrative health databases obtained from the Population Data in British Columbia. Index cases were physician-diagnosed asthma patients between January 1, 1998, to December 31, 1999, aged 18 years and older. Patients were prospectively assessed in the follow-up period from January 1, 2000, to December 31, 2018, to identify asthma exacerbation. Two proxy measures were used to assess MA: the proportion of days covered (PDC) and the medication possession ratio (MPR). Using the generalized estimating equation (GEE) logistic regression adjusted for patient covariates, the outcome of "asthma exacerbation" was modeled against varying MA cutoffs; excellent '≥0.90'; very good '0.80-0.89'; good '0.70-0.799'; moderate '0.6-0.699'; mild '0.50-0.599' compared to poor '<0.50' for both PDC and MPR. RESULTS: The sample included 68,211 physician-diagnosed asthma patients with a mean age of 48.2 years and 59.3% females. The adjusted odds ratios (OR) and 95% confidence interval (CI) at the various cutoff for PDC-levels predicting asthma exacerbation events were: Excellent MA [OR = 0.84, 95% (0.82-0.86), very good MA [OR: 0.86, (0.83, 0.89), good MA [0.91, (0.88-0.94)]; moderate MA [0.93, (0.90-0.96)]; mild MA [0.95, (0.92-0.98)]; compared to poor MA level. Threshold levels for both the PDC and MPR measure greater than 0.80 provided optimal threshold associated with over 15% reduced likelihood of experiencing asthma exacerbations. CONCLUSION: Intervention aimed at improving asthma exacerbation events in adult asthma patients should encourage increased medication adherence threshold level greater than 0.80.Supplemental data for this article is available online at at www.tandfonline.com/ijas .

Examining Risk Factors Accelerating Time-to-Chronic Obstructive Pulmonary Disease (COPD) Diagnosis among Asthma Patients.

Asthma patients may have an increased risk for diagnosis of chronic obstructive pulmonary disease (COPD). However, risk factors accelerating time-to-COPD diagnosis are unclear. This study aims to estimate risk factors associated with the incidence of COPD diagnosis in asthma patients. Canada's Population Data BC (PopData BC) was used to identify asthma patients without prior COPD diagnosis between January 1, 1998, to December 31, 1999. Patients were assessed for time-to-incidence of COPD diagnosis from January 1, 2000, to December 31, 2018. The study estimated the effects of several risk factors in predicting the incidence of COPD in asthma patients during the 18-year follow-up period. Patient factors such as Medication Adherence (MA) were assessed by the proportion of days covered (PDC) and the medication possession ratio (MPR). The log-logistic mixed-effects accelerated failure time model was used to estimate the adjusted failure time ratios (aFTR) and 95% Confidence Interval (95% CI) for factors predicting time-to-COPD diagnosis among asthma patients. We identified 68,211 asthma patients with a mean age of 48.2 years included in the analysis. Risk factors accelerating time-to-COPD diagnosis included: male sex (aFTR: 0.62, 95% CI:0.56-0.68), older adults (age > 40 years) [aFTR: 0.03, 95% CI: 0.02-0.04], history of tobacco smoking (aFTR: 0.29, 95% CI: 0.13-0.68), asthma exacerbations (aFTR: 0.81, 95%CI: 0.70, 0.94), frequent emergency admissions (aFTR:0.21, 95% CI: 0.17-0.25), longer hospital stay (aFTR:0.07, 95% CI: 0.06-0.09), patients with increased burden of comorbidities (aFTR:0.28, 95% CI: 0.22-0.34), obese male sex (aFTR:0.38, 95% CI: 0.15-0.99), SABA overuse (aFTR: 0.61, 95% CI: 0.44-0.84), moderate (aFTR:0.23, 95% CI: 0.21-0.26), and severe asthma (aFTR:0.10, 95% CI: 0.08-0.12). After adjustment, MA ≥0.80 was significantly associated with 83% delayed time-to-COPD diagnosis [i.e. aFTR =1.83, 95%CI: 1.54-2.17 for PDC]. However, asthma severity significantly modifies the effect of MA independent of tobacco smoking history. The targeted intervention aimed to mitigate early diagnosis of COPD may prioritize enhancing medication adherence among asthma patients to prevent frequent exacerbation during follow-up.

The Newfoundland and Labrador Bariatric Surgery Cohort Study: Rational and Study Protocol.

BACKGROUND: In Canada, there has been a disproportionate increase in adults with Class II (BMI 35.0-39.9 kg/m2) or Class III obesity (BMI ≥ 40 kg/m2) affecting 9 % of Canadians with increases projected. Individuals affected by severe obesity (BMI ≥ 35) are at increased risk of high blood pressure, cardiovascular disease, diabetes, cancer, impaired quality of life, and premature mortality. Bariatric surgery is the most effective treatment for severe obesity. Laparoscopic sleeve gastrectomy (LSG), a relatively new type of bariatric surgery, is growing in popularity as a treatment. The global prevalence of LSG increased from 0 to 37.0 % between 2003 and 2013. In Canada and the US, between 2011 and 2013, the number of LSG surgeries increased by 244 % and LSG now comprises 43 % of all bariatric surgeries. Since 2011, Eastern Health, the largest regional health authority in Newfoundland and Labrador (NL), Canada has performed approximately 100 LSG surgeries annually. METHODS: A population-based prospective cohort study with pre and post surgical assessments at 1, 3, 6, 12, 18, 24 months and annually thereafter of patients undergoing LSG. This study will report on short - to mid-term (2-4 years) outcomes. Patients (n = 200) followed by the Provincial Bariatric Surgery Program between 19 and 70 years of age, with a BMI between 35.0 and 39.9 kg/m2 and an obesity-related comorbidity or with a BMI ≥ 40 kg/m2 are enrolled. The study is assessing the following outcomes: 1) complications of surgery including impact on nutritional status 2) weight loss/regain 3) improvement/resolution of comorbid conditions and a reduction in prescribed medications 4) patient reported outcomes using validated quality of life tools, and 5) impact of surgery on health services use and costs. We hypothesize a low complication rate, a marked reduction in weight, improvement/resolution of comorbid conditions, a reduction in related medications, improvement in quality of life, and a decrease in direct healthcare use and costs and indirect costs compared to pre-surgery. DISCUSSION: Limited data on the impact of LSG as a stand-alone procedure on a number of outcomes exist. The findings from this study will help to inform evidence-based practice, clinical decision-making, and the development of health policy.

Maternal hypothyroidism may be associated with CHD in offspring.

OBJECTIVES: This study tested whether mothers with maternal hypothyroidism have increased odds of CHD in their offspring, and examined the relationship between CHD, maternal thyroid function, and nausea and vomiting in pregnancy. BACKGROUND: Maternal hypothyroidism increases the risk for foetal demise and prematurity and can have a negative impact on neurodevelopment. Prior studies have postulated a relationship between maternal thyroid function, CHD, and maternal nausea and vomiting in pregnancy. METHODS: A cross-sectional case-control study was conducted over a 17-month period to obtain a history of maternal thyroid status and nausea and vomiting in pregnancy. Paediatric echocardiograms were evaluated for CHD by a blinded paediatric cardiologist. Logistic regression analysis was performed to examine the association between CHD and maternal hypothyroidism. RESULTS: Of the 998 maternal-child pairs, 10% (98/998) of the mothers reported a history of prenatal hypothyroidism. The overall prevalence of CHD in the study sample was 63% (630/998). Mothers with a history of hypothyroidism were significantly more likely to have offspring with CHD compared with mothers without a history of hypothyroidism (72 versus 62%; p=0.04). The adjusted odds ratio (95% confidence interval) of CHD in offspring associated with reported maternal hypothyroidism was 1.68 (1.02-2.78). CONCLUSION: This study suggests that maternal hypothyroidism is a risk factor for the development of CHD. Further prospective investigations are necessary to confirm this association and delineate pathogenic mechanisms.

Patterns and correlates of cannabis use among individuals with HIV/AIDS in Maritime Canada.

BACKGROUND: The prevalence of cannabis use in HIV-infected individuals is high and its long-term effects are unclear. METHODS: The prevalence, perceived benefits and consequences, and predictors of cannabis use were studied using a cross-sectional survey in two immunodeficiency clinics in Maritime Canada. RESULTS: Current cannabis use was identified in 38.5% (87 of 226) of participants. Almost all cannabis users (85 of 87 [97.7%]) acknowledged its use for recreational purposes, with 21.8% (19 of 87) reporting medicinal cannabis use. The majority of patients enrolled in the present study reported mild or no symptoms related to HIV (n=179). Overall, 80.5% (70 of 87) of the cannabis-using participants reported a symptom-relieving benefit, mostly for relief of stress, anorexia or pain. Participants consumed a mean (± SD) of 18.3±21.1 g of cannabis per month and spent an average of $105.15±109.87 on cannabis per month. Cannabis use was associated with rural residence, lower income level, driving under the influence of a substance, and consumption of ecstasy and tobacco. Income level, ecstasy use and tobacco use were retained as significant predictors in regression modelling. Cannabis use was not associated with adverse psychological outcomes. DISCUSSION: Prolonged previous cannabis consumption and the substantial overlap between recreational and medicinal cannabis use highlight the challenges in obtaining a tenable definition of medicinal cannabis therapy.

HISTORIQUE: La prévalence de consommation de cannabis est élevée chez les personnes infectées par le VIH, mais on n'en connaît pas les effets à long terme. MÉTHODOLOGIE: Les chercheurs ont étudié la prévalence, les avantages perçus et les conséquences et prédicteurs de consommation de cannabis au moyen d'un sondage transversal mené dans deux cliniques d'immunodéficience des Maritimes, au Canada. RÉSULTATS: Les chercheurs ont constaté une consommation courante de cannabis chez 38,5 % des participants (87 sur 226). Presque tous les consommateurs de cannabis (85 sur 87 [97,7 %]) admettaient en prendre pour des fins récréatives, et 21,8 % (19 sur 87) indiquaient en prendre pour des fins médicinales. La majorité des patients qui participaient à la présente étude a déclaré des symptômes du VIH légers, sinon inexistants (n=179). Dans l'ensemble, 80,5 % des participants consommateurs de cannabis (70 sur 87) ont affirmé remarquer un soulagement des symptômes, particulièrement le stress, l'anorexie ou la douleur. Les participants consommaient en moyenne 18,3±21,1 g de cannabis par mois et dépensaient en moyenne 105,15±109,87 $ par mois pour se le procurer. La consommation de cannabis était liée à un logement en milieu rural, à un niveau de revenu plus bas, à la conduite sous l'influence d'une substance et à la consommation d'ecstasy et de tabac. Le niveau de revenu, la consommation d'ecstasy et la consommation de tabac étaient considérés comme des prédicteurs importants selon le modèle de régression. La consommation de cannabis ne s'associait pas à des résultats psychologiques indésirables. EXPOSÉ: Une consommation antérieure prolongée de cannabis et le chevauchement important entre la consommation de cannabis à des fins récréatives et médicinales font ressortir la difficulté d'obtenir une définition viable du traitement médicinal par le cannabis.

A cross-sectional study of breastfed infants referred for tongue tie assessment and frenotomy in one Canadian health region.

Importance: Tongue tie (TT) is a condition that can cause infant feeding difficulties due to restricted tongue movement. When TT presents as a significant barrier to breastfeeding, a frenotomy may be recommended. Universally accepted diagnostic criteria for TT are lacking and wide prevalence estimates are reported. New referral processes and a Frenotomy Assessment Tool were implemented in one Canadian health region to connect breastfeeding dyads with a provider for TT evaluation and frenotomy. Objective: To determine the proportion of babies with TT as well as the frequency of frenotomy. Methods: This cross-sectional study included infants who initiated breastfeeding at birth and were referred for TT evaluation over a 14-month period. Data were collected retrospectively by chart review and analyzed using SPSS. Factors associated with frenotomy were examined using logistic regression. Results: Two hundred and forty-one babies were referred. Ninety-two percent (n = 222) were diagnosed with TT and 66.0% (n = 159) underwent frenotomy. In the multivariate model, nipple pain/trauma, inability to latch, inability to elevate tongue, and dimpling of tongue on extension were associated with frenotomy (P < 0.05). Most referrals in our region resulted in a diagnosis of TT; however, the number of referrals was lower than expected, and of these two-thirds underwent frenotomy. Interpretation: TT is a relatively common finding among breastfed infants. Future research should examine whether a simplified assessment tool containing the four items associated with frenotomy in our multivariate model can identify breastfed infants with TT who require frenotomy.

Association Between Medication Adherence and Risk of COPD in Adult Asthma Patients: A Retrospective Cohort Study in Canada.

Background: Poor adherence to prescribed asthma medications and risk of severe asthma exacerbations have been well established. However, the effects of changes in asthma medication compliance levels and subsequent risk of COPD is unknown and yet to be investigated. This study investigated the independent effect of medication adherence (MA) and asthma severity levels on the risk of COPD. Methods: We used four linked administrative health databases from the Population data BC to identify asthma patients aged 18 years and older between January 1, 1998 and December 31, 1999 without diagnosis of COPD. The primary event was time-to-COPD diagnosis during the follow-up period (January 1, 2000 to December 31, 2018). The proportion of days covered (PDC) - was used as a surrogate measure for medication adherence (MA) assessed at optimal-level (≥ 0.80), Intermediate-level (0.50-0.79), and low-level (< 0.5) of adherence. A propensity adjusted analysis with Marginal Structural Cox (MSC) model was employed to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) for the effect of medication adherence and asthma severity over time. Results: At cohort entry, the sample included 68,211 asthma patients with an overall mean age of 48.2 years. The 18-year incidence of COPD in asthma patients was 9.8 per 1000-persons year. In an inverse weighted propensity adjusted analysis of the MSC model, higher MA levels were significantly associated with decreased risk of COPD as follows: optimal-level (aHR: 0.19, 95% CI: 0.17-0.24); Intermediate-level (aHR: 0.20, 95% CI: 0.18, 0.23) compared to the low-level adherence group. A significant increase in COPD risk was observed in severe asthma patients with low medication adherence (aHR: 1.72, 95% CI: 1.52-1.93), independent of other patient factors. Conclusion: Optimal (≥ 0.80) and intermediate adherence (0.5 to 0.79) levels were associated with reduced risk of COPD incidence over time. Interventions aimed at improving adherence to prescribed medications in adult asthma patients should be intensified to reduce their risk of COPD.

Assessment of variation in the Alberta Context Tool: the contribution of unit level contextual factors and specialty in Canadian pediatric acute care settings.

BACKGROUND: There are few validated measures of organizational context and none that we located are parsimonious and address modifiable characteristics of context. The Alberta Context Tool (ACT) was developed to meet this need. The instrument assesses 8 dimensions of context, which comprise 10 concepts. The purpose of this paper is to report evidence to further the validity argument for ACT. The specific objectives of this paper are to: (1) examine the extent to which the 10 ACT concepts discriminate between patient care units and (2) identify variables that significantly contribute to between-unit variation for each of the 10 concepts. METHODS: 859 professional nurses (844 valid responses) working in medical, surgical and critical care units of 8 Canadian pediatric hospitals completed the ACT. A random intercept, fixed effects hierarchical linear modeling (HLM) strategy was used to quantify and explain variance in the 10 ACT concepts to establish the ACT's ability to discriminate between units. We ran 40 models (a series of 4 models for each of the 10 concepts) in which we systematically assessed the unique contribution (i.e., error variance reduction) of different variables to between-unit variation. First, we constructed a null model in which we quantified the variance overall, in each of the concepts. Then we controlled for the contribution of individual level variables (Model 1). In Model 2, we assessed the contribution of practice specialty (medical, surgical, critical care) to variation since it was central to construction of the sampling frame for the study. Finally, we assessed the contribution of additional unit level variables (Model 3). RESULTS: The null model (unadjusted baseline HLM model) established that there was significant variation between units in each of the 10 ACT concepts (i.e., discrimination between units). When we controlled for individual characteristics, significant variation in the 10 concepts remained. Assessment of the contribution of specialty to between-unit variation enabled us to explain more variance (1.19% to 16.73%) in 6 of the 10 ACT concepts. Finally, when we assessed the unique contribution of the unit level variables available to us, we were able to explain additional variance (15.91% to 73.25%) in 7 of the 10 ACT concepts. CONCLUSION: The findings reported here represent the third published argument for validity of the ACT and adds to the evidence supporting its use to discriminate patient care units by all 10 contextual factors. We found evidence of relationships between a variety of individual and unit-level variables that explained much of this between-unit variation for each of the 10 ACT concepts. Future research will include examination of the relationships between the ACT's contextual factors and research utilization by nurses and ultimately the relationships between context, research utilization, and outcomes for patients.

The impact of hospital nursing characteristics on 30-day mortality.

BACKGROUND: Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. OBJECTIVE: To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. METHOD: A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. RESULTS: Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.6-00.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. DISCUSSION: Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Measuring Medication Adherence in a Population-Based Asthma Administrative Pharmacy Database: A Systematic Review and Meta-Analysis.

BACKGROUND: Limited studies have systematically reviewed the literature to identify and compare the various database methods and optimal thresholds for measuring medication adherence specific to adolescents and adults with asthma. In the present study, we aim to identify the methods and optimal thresholds for measuring medication adherence in population-based pharmacy databases. METHODS: We searched PubMed, Embase, International Pharmaceutical Abstracts (IPA), Web of Science, Google Scholar, and grey literature from January 1, 1998, to March 16, 2021. Two independent reviewers screened the studies, extracted the data, and assessed the quality of the studies. A quantitative knowledge synthesis was employed. RESULTS: Thirty-eight (38) retrospective cohort studies were eligible. This review identified 20 methods for measuring medication adherence in adolescent and adult asthma administrative health records. Two measures namely the medication possession ratio (MPR) and proportion of days covered (PDC) were commonly reported in 87% of the literature included in this study. From the meta-analysis, asthma patients who achieved adherence threshold of "0.75-1.00" [OR: 0.56, 95% CI: 0.41 to 0.77] and ">0.5" [OR: 0.71, 95% CI: 0.54 to 0.94] were less likely to experience asthma exacerbation. CONCLUSION: Despite their limitations, the PDC and the MPR still remain the most common measures for assessing adherence in asthma pharmacy claim databases. The evidence synthesis showed that an adherence threshold of at least 0.75 is optimal for classifying adherent and non-adherent asthma patients.

Early life factors associated with incidence of physician-diagnosed asthma in preschool children: results from the Canadian Early Childhood Development cohort study.

Background. Asthma is a common childhood illness. The objective of this study is to determine the incidence of physician-diagnosed asthma in preschool years and its relationship to host, prenatal and postnatal factors, early childhood factors, parental factors, household factors and demographic factors. Methods. The study sample was comprised of 8,499 infants and toddlers (<2 years at baseline) enrolled in the Canadian Early Childhood Development Study. Incidence of asthma was determined when the children were in preschool age (2 to 5 years). Results. The 4-year cumulative incidence at preschool age was 13.7% for physician-diagnosed asthma. History of early childhood wheezing before 2 years of age was a significant risk factor for incidence of asthma in preschool years (hazard ratio (HR): 2.32; 95% confidence interval (CI): 2.04-2.65). Factors that were protective for the development of asthma were breastfeeding more than 3 months (HR: 0.82; 95% CI: 0.69-0.97); history of nose or throat infection often in childhood (HR: 0.79; 95% CI: 0.67-0.93); early daycare attendance (HR: 0.85; 95% CI: 0.74-0.98); presence of two or more siblings at birth, (HR: 0.79; 95% CI: 0.64-0.97); and dwelling in rural non- central metropolitan areas (HR: 0.81; 95% CI: 0.69-0.95). Male sex, low birth weight, childhood allergy, single parent, maternal smoking during pregnancy, maternal medication use, parental atopy, and low SES at baseline were significant risk factors for the incidence of physician-diagnosed asthma in preschool years. Conclusion. This study emphasizes the role of wheezing in infant and toddler age on early onset of asthma during preschool years. The results also provide additional importance of early exposures to environmental factors such as early infections, daycare attendance, and rural environment in the development of proper immune dynamics to prevent asthma.

The contribution of hospital nursing leadership styles to 30-day patient mortality.

BACKGROUND: Nursing work environment characteristics, in particular nurse and physician staffing, have been linked to patient outcomes (adverse events and patient mortality). Researchers have stressed the need for nursing leadership to advance change in healthcare organizations to create safer practice environments for patients. The relationship between styles of nursing leadership in hospitals and patient outcomes has not been well examined. OBJECTIVE: The purpose of this study was to examine the contribution of hospital nursing leadership styles to 30-day mortality after controlling for patient demographics, comorbidities, and hospital factors. METHODS: Ninety acute care hospitals in Alberta, Canada, were categorized into five styles of nursing leadership: high resonant, moderately resonant, mixed, moderately dissonant, and high dissonant. In the secondary analysis, existing data from three sources (nurses, patients, and institutions) were used to test a hypothesis that the styles of nursing leadership at the hospital level contribute to patient mortality rates. RESULTS: Thirty-day mortality was 7.8% in the study sample of 21,570 medical patients; rates varied across hospital categories: high resonant (5.2%), moderately resonant (7.4%), mixed (8.1%), moderately dissonant (8.8%), and high dissonant (4.3%). After controlling for patient demographics, comorbidities, and institutional and hospital nursing characteristics, nursing leadership styles explained 5.1% of 72.2% of total variance in mortality across hospitals, and high-resonant leadership was related significantly to lower mortality. CONCLUSIONS: Hospital nursing leadership styles may contribute to 30-day mortality of patients. This relationship may be moderated by homogeneity of leadership styles, clarity of communication among leaders and healthcare providers, and work environment characteristics.

Effects of Delayed Newborn Bathing on Breastfeeding, Hypothermia, and Hypoglycemia.

OBJECTIVE: To determine whether delaying the newborn bath by 24 hours increases the prevalence of breastfeeding initiation and exclusive breastfeeding at discharge in healthy full-term and late preterm newborns (34 0/7-36 6/7 weeks gestation) and to examine the effect of delayed newborn bathing on the incidences of hypothermia and hypoglycemia. DESIGN: Pre-post implementation, retrospective, cohort study. SETTING: Provincial children's hospital with an average of 2,500 births per year. PARTICIPANTS: Healthy newborns (N = 1,225) born at 34 0/7 weeks or more gestation who were admitted to the mother-baby unit. METHODS: We compared newborns who were bathed before 24 hours (n = 680, preimplementation group) to newborns who were bathed after 24 hours (n = 545, postimplementation group). RESULTS: After adjustment for confounders, the odds of exclusive breastfeeding at discharge were 33% greater in the postimplementation group than in the preimplementation group (adjusted odds ratio = 1.334; 95% confidence interval [1.049,1.698]; p = .019). Delayed bathing was associated with decreased incidence of hypothermia and hypoglycemia (p = .007 and p = .003, respectively). We observed no difference in breastfeeding initiation between groups. CONCLUSION: Delaying the newborn bath for 24 hours was associated with an increased likelihood of exclusive breastfeeding at discharge and a decreased incidence of hypothermia and hypoglycemia in healthy newborns. The implementation of a delayed bathing policy has the potential to improve breastfeeding rates and reduce the incidence of hypothermia and hypoglycemia.

Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676].

BACKGROUND: Medical inpatients are at risk for suboptimal health outcomes from adverse drug events and under-use of evidence-based therapies. We sought to determine whether collaborative care including a team-based clinical pharmacist improves the quality of prescribed drug therapy and reduces hospital readmission. METHODS: Multicenter, quasi-randomized, controlled clinical trial. Consecutive patients admitted to 2 internal and 2 family medicine teams in 3 teaching hospitals between January 30, 2006 and February 2, 2007 were included. Team care patients received proactive clinical pharmacist services (medication history, patient-care round participation, resolution of drug-related issues, and discharge counseling). Usual care patients received traditional reactive clinical pharmacist services. The primary outcome was the overall quality score measured retrospectively by a blinded chart reviewer using 20 indicators targeting 5 conditions. Secondary outcomes included 3- and 6-month readmission. RESULTS: A total of 452 patients (220 team care, 231 usual care, mean age: 74 years, 46% male) met eligibility criteria. Team care patients were more likely than usual care patients to receive care specified by the indicators overall (56.4% vs. 45.3%; adjusted mean difference: 10.4%; 95% confidence interval [CI]: 4.9%, 15.7%) and for each targeted disease state except for heart failure. Team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%; adjusted OR: 0.63; 95% CI: 0.42, 0.94) but not at 6 months (50.7% vs. 56.3%; adjusted OR; 0.78; 95% CI: 0.53, 1.15). CONCLUSIONS: In patients admitted to internal and family medicine teams, team-based care including a clinical pharmacist, improved the overall quality of medication use and reduced rates of readmission.

Predictors for wheezing phenotypes in the first decade of life.

BACKGROUND AND OBJECTIVE: This study examined prenatal, perinatal and early childhood predictors of wheezing phenotypes in the first decade of life. METHODS: Information on current wheezing, was collected prospectively from five surveys conducted every 2 years over the first decade of life. Five wheezing phenotypes were defined: non-wheezers, preschool, primary-school, intermittent and persistent wheezers. Logistic regression with adjustment for survey design was used to determine the predictors of wheezing phenotypes. RESULTS: Data on 2711 children were used in the analysis. Early respiratory infection, the child's allergy and parental asthma were significant risk factors for preschool, intermittent and persistent wheeze. The child's allergy and parental asthma had stronger associations with persistent wheeze than with preschool wheeze. Breastfeeding was a significant predictor of both preschool and intermittent wheezing. Daycare attendance was a risk factor for preschool wheeze but a protective factor for primary-school wheezing. Crowding at home was a protective factor for both preschool and primary-school wheeze. Parental smoking was a significant factor for preschool wheeze. CONCLUSION: This study identified different predictors for each wheezing phenotype with some degree of overlap. The observed differential effects for these conditions raises the possibility that there are different aetiologies for asthma among children.

The risk of fragility fractures in new users of dipeptidyl peptidase-4 inhibitors compared to sulfonylureas and other anti-diabetic drugs: A cohort study.

AIMS: Mixed evidence exists for the effect of incretin-based therapies on osteoporosis in type-2 diabetes. Therefore, we conducted a cohort study to determine the association between dipeptidyl peptidase-4 (DPP-4) inhibitors and common osteoporotic "fragility fractures" (upper extremity, hip, spine). METHODS: The UK-based Clinical Practice Research Datalink was used to identify adults without prior fractures receiving a new anti-diabetic drug or a new type-2 diabetes diagnosis between 2007 and 2016. The primary aim was to compare new-users of DPP-4 inhibitors versus new-users of sulfonylureas (SU). The association between DPP-4 inhibitors and incident fractures was estimated using Cox proportional hazards models. Deciles of high-dimensional propensity scores and other anti-diabetic drugs were used as covariates. RESULTS: We identified 7993 and 26,636 new-users of DPP-4 inhibitors and SUs, respectively. At cohort entry, the mean age was 58.8, 40% were female, mean diabetes duration was 1.3 years, and 42% had A1c > 9%. Over 9 years (mean follow-up = 1.2 years), the incident rate of fragility fractures was lower among DPP-4 versus SU users (3.0/1000 vs. 5.2/1000 person-years; P-value = 0.007). After adjustment, there was no statistically significant difference in fracture risk (hazard ratio adjusted, aHR = 0.80, 95%CI 0.51-1.24; P-value = 0.3125). In a secondary analysis, DPP-4 inhibitors were not associated with a difference in fracture risk compared to insulin (aHR = 0.91, 95%CI 0.40-2.09); however were associated with a lower fracture risk versus thiazolidinediones (aHR = 0.47, 95%CI 0.26-0.83). Sensitivity analyses supported findings. CONCLUSIONS: DPP-4 inhibitors are not associated with an increased risk of fragility fractures compared with SUs or insulin; however, are associated with a lower risk versus thiazolidinediones.

Psychometric Assessment and Precision Remodeling of the Iowa Infant Feeding Attitude Scale to Improve Clinical Use and Efficacy Among Prenatal Women in Canada.

BACKGROUND: The 17-item Iowa Infant Feeding Attitude Scale (IIFAS) has been widely used to assess maternal attitudes toward infant feeding and to predict breastfeeding intention. The IIFAS has been validated among prenatal women located in Newfoundland and Labrador in Canada, although its length may prove challenging to complete in a clinical setting. Research aim: The authors aimed to reduce the number of items from the original 17-item IIFAS scale while maintaining reliability and validity. METHODS: A nonexperimental cross-sectional design was used among 1,283 women in their third trimester residing in Newfoundland and Labrador. Data were collected from August 2011 to June 2016. An exploratory factor analysis using principal component analysis was performed to explore the underlying structure of the IIFAS. The internal consistency of both the 17-item and reduced version was assessed using Cronbach's alpha and item-total correlation. The area under the curve and linear regression model were used to assess predictive validity of intention to breastfeed. RESULTS: Our findings revealed that a 13-item IIFAS (Cronbach's α = .870) had relatively similar internal consistency to the original IIFAS (Cronbach's α = .868). Three themes were extracted from the factor analysis, resulting in the removal of four items. The reduced scale demonstrated an excellent ability to predict breastfeeding intention (area under the curve = 0.914). CONCLUSION: The reduced 13-item version of the IIFAS is a psychometrically sound instrument that maintains its accuracy and validity when measuring maternal feeding attitudes during pregnancy and can be more time efficient in clinical settings compared with the 17-item IIFAS.

Association between early history of asthma and COPD diagnosis in later life: a systematic review and meta-analysis.

Background: Whereas most studies have reported prior history/diagnosis of asthma as an independent risk factor for chronic obstructive pulmonary disease (COPD) development in later life, no systematic review and meta-analysis has been conducted to synthesize these observational studies. The aim of this review is to investigate associations between prior history of asthma and later development of COPD. Methods: We conducted a comprehensive search in PubMed, CINAHL and EMBASE for studies related to prior history of asthma and COPD diagnosis. Articles were screened for relevance by two independent reviewers. Methodological quality was independently assessed and data extracted for qualitative and quantitative review. We explored heterogeneity and performed a publication bias check. Results: From the 1260 articles retrieved, 9 were included in the qualitative review and 7 in the meta-analysis. History of asthma was associated with developing COPD in later life (Inverse Variance Random-effects model, odds ratio: 7.87, 95% confidence interval: 5.40-11.45, p < 0.00001). Conclusions: Studies with high methodological quality provided sufficient evidence to suggest that individuals with previous history of asthma have an increasing likelihood of developing COPD in later life.

Comparative Safety of Dipeptidyl Peptidase-4 Inhibitors Versus Sulfonylureas and Other Glucose-lowering Therapies for Three Acute Outcomes.

Although the glucose lowering effect of dipeptidyl peptidase-4 (DPP4) inhibitors is well established, several potential serious acute safety concerns have been raised including acute kidney injury, respiratory tract infections, and acute pancreatitis. Using the UK-based Clinical Practice Research Datalink (CPRD), we identified initiators (365-day washout period) of DPP4 inhibitors and relevant comparators including initiators of sulfonylureas, metformin, thiazolidinediones, and insulin between January 2007 and January 2016 to quantify the association between DPP4 inhibitors and three acute health events - acute kidney injury, respiratory tract infections, and acute pancreatitis. The associations between drug and study outcomes were estimated using Cox proportional hazard models adjusted for deciles of high-dimensional propensity scores and number of additional glucose lowering agents. After controlling for potential confounders, the risk was not significantly increased or decreased for initiators of DPP4 inhibitors compared to sulfonylureas (hazard ratio (HR) [95% confidence interval (CI)] for acute kidney injury: 0.81 [0.56-1.18]; HR for respiratory tract infections: 0.93 [0.84-1.04]; HR for acute pancreatitis 1.03 [0.42-2.52], metformin (HR for respiratory tract infection 0.91 [0.65-1.27]), thiazolidinediones (HR for acute kidney injury: 1.12 [0.60-2.10]; HR for respiratory tract infections: 1.02 [0.86-1.21]; HR for acute pancreatitis: 1.21 [0.25-5.72]), or insulin (HR for acute kidney injury: 1.40 [0.77-2.55]; HR for respiratory tract infections: 0.74 [0.60-0.92]; HR for acute pancreatitis: 1.01 [0.24-4.19]). Initiators of DPP4 inhibitors were associated with an increased risk of acute kidney injury when compared to metformin initiators (HR [95% CI] for acute kidney injury: 1.85 [1.10-3.12], although this association was attenuated when DPP4 inhibitor monotherapy was compared to metformin monotherapy exposure as a time-dependent variable (HR 1.39 [0.91-2.11]). Initiation of a DPP4 inhibitor was not associated with an increased risk of acute kidney injury, respiratory tract infections, or acute pancreatitis compared to sulfonylureas or other glucose-lowering therapies.

Examining the risk of depression or self-harm associated with incretin-based therapies used to manage hyperglycaemia in patients with type 2 diabetes: a cohort study using the UK Clinical Practice Research Datalink.

OBJECTIVES: To compare population-based incidence rates of new-onset depression or self-harm in patients initiating incretin-based therapies with that of sulfonylureas (SU) and other glucose-lowering agents. DESIGN: Population-based cohort study. SETTING: Patients attending primary care practices registered with the UK-based Clinical Practice Research Datalink (CPRD). PARTICIPANTS: Using the UK-based CPRD, we identified two incretin-based therapies cohorts: (1) dipeptidyl peptidase-4 inhibitor (DPP-4i)-cohort, consisting of new users of DPP-4i and SU and (2) glucagon-like peptide-1 receptor agonists (GLP-1RA)-cohort, consisting of new users of GLP-1RA and SU, between January 2007 and January 2016. Patients with a prior history of depression, self-harm and other serious psychiatric conditions were excluded. MAIN OUTCOME MEASURES: The primary study outcome comprised a composite of new-onset depression or self-harm. Unadjusted and adjusted Cox proportional hazards regression was used to quantify the association between incretin-based therapies and depression or self-harm. Deciles of High-Dimensional Propensity Scores and concurrent number of glucose-lowering agents were used to adjust for potential confounding. RESULTS: We identified new users of 6206 DPP-4i and 22 128 SU in the DPP-4i-cohort, and 501 GLP-1RA and 16 409 SU new users in the GLP-1RA-cohort. The incidence of depression or self-harm was 8.2 vs 11.7 events/1000 person-years in the DPP-4i-cohort and 18.2 vs 13.6 events/1000 person-years in the GLP-1RA-cohort for incretin-based therapies versus SU, respectively. Incretin-based therapies were not associated with an increased or decreased incidence of depression or self-harm compared with SU (DPP-4i-cohort: unadjusted HR 0.70, 95% CI 0.51 to 0.96; adjusted HR 0.80, 95% CI 0.57 to 1.13; GLP-1RA-cohort: unadjusted HR 1.36, 95% CI 0.72 to 2.58; adjusted HR 1.25, 95% CI 0.63 to 2.50). Consistent results were observed for other glucose-lowering comparators including insulin and thiazolidinediones. CONCLUSIONS: Our findings suggest that the two incretin-based therapies are not associated with an increased or decreased risk of depression or self-harm.