Psychiatric disorders and suicidal behavior in patients with acne prescribed oral antibiotics versus isotretinoin: Analysis of a large commercial insurance claims database

BACKGROUND

The association between isotretinoin and psychiatric disturbance, including depression and suicidal behavior, is controversial.

OBJECTIVE

To investigate whether acne patients prescribed isotretinoin or antibiotics were more likely to have psychiatric disorders and/or engage in suicidal behavior.

METHODS

Retrospective cohort study using the IBM MarketScan Research Databases, which contain commercial insurance claims in the United States, to identify acne patients who were prescribed isotretinoin or oral antibiotics between 2011 and 2017 and who were diagnosed with psychiatric disorders or suicidal behavior.

RESULTS

A total of 72,555 patients were included in the study. Patients in the general population were 1.47 times more likely to be diagnosed with suicidal ideation or attempt compared to acne patients prescribed isotretinoin (adjusted odds ratio [OR] 1.47; confidence interval [95% CI], 1.27, 1.70; P < .0001). The general population (adjusted OR 0.87; 95% CI, 0.84, 0.89; P < .0001) and acne patients prescribed antibiotics (adjusted OR 0.88; 95% CI, 0.85, 0.91; P < .0001) were less likely to have a psychiatric diagnosis compared to acne patients prescribed isotretinoin. The prevalence of suicidal behavior during isotretinoin treatment was lower (0.10%; P = .082) than in the year prior to isotretinoin treatment (0.22%) and in the year following treatment (0.34%; P = .004).

LIMITATIONS

The study excluded individuals with public insurance and those who were uninsured, and the data in the study relied on the accuracy of the medical coding.

CONCLUSIONS

Compared to the general population, acne patients prescribed isotretinoin were less likely to engage in suicidal behavior. Further exploration into the slight increase in suicidal behavior seen in isotretinoin patients 1 year after therapy is warranted.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Abstract P3-02-02: Impact of breast density notification laws on radiology practices: A survey of 110 radiology facilities

Purpose: Breast Density Notification laws, passed in 15 states as of April 2014, mandate that breast density information be given to patients often without guidance on modalities, patient selection or funding for supplemental screening. The purpose of this study is to assess the impact of breast density notification laws on radiology practices, specifically regarding breast cancer risk assessment and supplemental screening studies.

Methods:

We performed an anonymous 20-question web-based survey to Society of Breast Imaging radiologists using a Qualtrics Survey Tool between 8/2013-3/2014, with questions on radiology practices, breast cancer risk assessment, breast density measurement, supplemental screening tests, and support for referring physicians and patients. We compared survey results between groups using Fisher’s exact test.

Results:

121 radiologists from 110 facilities (48 academic, 43 large private hospital, 15 small private hospital and 4 other) representing 34 USA states and 1 Canadian site responded. 49% of facilities (54/110) were in states with an enacted breast density notification law. 37% of facilities (40/109) performed risk assessment, 26% (28/109) did not perform risk assessment, and 38% (41/109) did not but reported family history/other risk factors, with no significant difference in performing risk assessment between facilities with or without an enacted law (p-value 0.71). Of the 37 facilities performing risk assessment, 60% used the Gail model, 22% used the Tyrer-Cuzick model and 11% used the modified Gail model (multiple answers allowed [m.a.a.]). Of the 15 facilities performing risk assessment, 40% answered "yes" when asked whether performing risk assessment is a new task because of the density law. Breast density was estimated by only visual assessment in 98% of facilities (103/105), and by computer-based determination with or without visual assessment in 2% (2/105). Supplemental screening studies offered included magnetic resonance imaging (MRI) (88%, 92/105), handheld whole breast ultrasound (HHWBUS) (48%, 50/105), tomosynthesis (39%, 41/105), and automated WBUS (8%, 8/105) (m.a.a.). There was no significant difference in supplemental screening studies offered between facilities with or without an enacted law (p-value 0.26). In anticipation of the law, facilities implemented HHWBUS (33%, 16/48), tomosynthesis (6%, 3/48), automated WBUS (6%, 3/48) or none (60%, 29/48) (m.a.a.). Facilities with the enacted law prepared for the law with referring physician discussions (69%, 34/49), website (49%, 24/49), educational talks for referring physicians (43%, 21/49) or patients (31%, 15/49) (m.a.a.).

Conclusion:

Our survey showed variations in available supplemental screening modalities and policy implementation at each facility. There was no significant difference in performing risk assessment and supplemental screening studies between facilities with or without an enacted breast density notification law.

Citation Format: Lina Nayak, Kanae K Miyake, Yueyi Irene Liu, William R Thomas, Edward A Sickles, Bonnie N Joe, Karen Lindfors, R J Brenner, Stephen Feig, Lawrence W Bassett, Jessica W Leung, Haydee Ojeda-Fournier, Jonathan Hargreaves, Elissa Price, Jafi A Lipson, Allison W Kurian, Elyse Love, Donna D Walgenbach, Lauren Ryan, Meg Durbin, Bruce L Daniel, Linda Garcia, Debra M Ikeda. Impact of breast density notification laws on radiology practices: A survey of 110 radiology facilities [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-02-02.

Abstract P2-01-01: Impact of California breast density notification law SB 1538 on California women and their health care providers

Purpose: To describe the impact of California Breast Density Notification law (SB 1538) on policy development, policy implementation and supplemental screening strategies within California medical facilities. SB 1538 mandates that breast density information be given to patients but provides no funding for supplemental screening, no guidance on how to triage women for supplemental screening nor which imaging modalities to use.

Methods:

As a result of the law, the California Breast Density Information Group (CBDIG) formed from academic and private practice radiologists and risk assessment experts, reviewing scientific literature and nationally recognized guidelines to provide evidence-based recommendations regarding supplemental screening in women with dense breast tissue. A survey was sent to 6 academic and 3 large private practices in California to record their experience in implementing the law.

Results: CBDIG created a public, institution-neutral, evidence-based website, “breastdensity.info”, that includes information and recommendations regarding supplemental breast screening, with triage for supplemental MRI or US based on breast cancer risk assessment using genetic or family history risk models. CBDIG facilities worked with referring health care providers to inform them of the new law, educated their staff and technologists on implementing policy, and developed notification strategies to comply with legislation.

The survey showed that all 9 facilities recommended supplemental screening based on family history models or genetic testing. 3/9 calculated breast cancer risk in the breast imaging clinic, and 2/9 emailed a risk survey to the patient. 3/9 reported risk in the radiology report, and 1/9 reported risk only if the patient was high risk. Risk assessments were performed by technologists and risk assessment health practitioners. 8/9 facilities estimated breast density by visual methods, and 1/9 by computer. All facilities performed screening breast MRI, 4/9 performed handheld screening US, and 2/9 tomosynthesis. 1/9 obtained tomosynthesis in anticipation of the law, 2/9 are trying to obtain automated whole breast US, and 3/9 are trying to obtain tomosynthesis. Facilities expressed concerns about additional false-positive biopsies produced by supplemental screenings, out-of-pocket expenses for women, and disparities (low income) in notified populations.

Conclusion: SB 1538 resulted in the formation of the CBDIG and the website, “breastdensity.info”. Our survey showed variations in imaging modalities available and policy implementation at each facility. Given that several states currently have breast density laws or have laws that will become effective in the near future, it is important for breast imagers and clinicians to be informed of the current literature, realize the variation in equipment and policies at various facilities, and develop recommendation strategies to guide patients seeking supplemental screening. We plan to follow up this survey with a larger survey of the Society of Breast Imagers at a later date.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-01-01.

The California breast density information group: a collaborative response to the issues of breast density, breast cancer risk, and breast density notification legislation

In anticipation of breast density notification legislation in the state of California, which would require notification of women with heterogeneously and extremely dense breast tissue, a working group of breast imagers and breast cancer risk specialists was formed to provide a common response framework. The California Breast Density Information Group identified key elements and implications of the law, researching scientific evidence needed to develop a robust response. In particular, issues of risk associated with dense breast tissue, masking of cancers by dense tissue on mammograms, and the efficacy, benefits, and harms of supplementary screening tests were studied and consensus reached. National guidelines and peer-reviewed published literature were used to recommend that women with dense breast tissue at screening mammography follow supplemental screening guidelines based on breast cancer risk assessment. The goal of developing educational materials for referring clinicians and patients was reached with the construction of an easily accessible Web site that contains information about breast density, breast cancer risk assessment, and supplementary imaging. This multi-institutional, multidisciplinary approach may be useful for organizations to frame responses as similar legislation is passed across the United States. Online supplemental material is available for this article.

Phase II study of sorafenib with gemcitabine and erlotinib (GES) in first-line advanced pancreatic cancer

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Background: Addition of erlotinib (E) to gemcitabine (G) results in improved OS for patients (pts) with advanced pancreatic cancer. Many pancreatic tumors have constitutively activated ras/raf pathways and overexpress VEGF. Sorafenib (S), a multitargeted tyrosine kinase inhibitor, including VEGR 1-3, PDGFR-α and β and the RAF/MEK/ERK pathway, when combined with G and E may synergize, resulting in a more complete blockade of the signal transduction cascade in pancreatic cancer growth and progression, and improved outcome.

Methods: Pts with previously untreated, histologically confirmed, unresectable pancreatic adenocarcinoma, PS 0-1, and adequate organ function were eligible and received G 1,000 mg/m2 over 30 min qw x 3 every 4w. E 150 mg PO daily and S 400 mg PO bid were given continuously. CT scans were performed every 2 cycles (8w). Primary endpoint included PFS at 4 mos and secondary endpoints included safety and tolerability of the novel combination, RR, and OS.

Results: 45 pts enrolled, 44 evaluable for toxicity(1 not treated), and 30 evaluable for response. Median age was 64 (45-84), 32 males (71%), 43 (96%) had metastatic disease, PS was 0 in 26 (58%). Median number of cycles was 2 (0-10). Grade (gr) 3 toxicity included: thrombocytopenia 5; diarrhea 4; vomiting 4; HFS, hyperbilirubinemia, hyperglycemia and SOB each 3 pts; 1 bowel perforation and 1 epistaxis. Gr 4 toxicity included 1 each: bowel perforation, GI bleed, transaminitis, hyperglycemia and sepsis with hypotension. 2 patients only required dose reduction of S for HFS. There were 2 PR (7%), 13 SD (43%), overall RR of 7% and DCR of 50%. Median TTP 111 days (95% CI = 53-175) and median OS 195 days (144-290). PFS at 16 weeks was 49%, just reaching statistical significance.

Conclusions: The combination of G and E plus S in the treatment of advanced pancreatic cancer is a well tolerated regimen without significant increased toxicity as compared to G alone, except for very manageable cutaneous reactions. While the primary endpoint met our pre-determined criteria (compared with NCIC PA.3), this study does not suggest a major benefit for addition of S to G-E when compared to published data. Supported in part by grants from Bayer Healthcare Pharmaceuticals/Onyx and OSI.

No significant financial relationships to disclose.

Induction of anaesthesia with either midazolam or propofol in rabbits premedicated with fentanyl/fluanisone

Fifty-four rabbits that were to be neutered were premedicated with 0.1 ml/kg fentanyl/fluanisone and then randomly allocated to be anaesthetised with either midazolam or propofol. Anaesthesia was then maintained with isoflurane. The ease of orotracheal intubation, the rabbits' cardiorespiratory variables, and the speed and quality of recovery from anaesthesia were assessed by the same anaesthetist who was unaware of the induction agent used. Hypotension was common in both groups. The mean (sd) respiratory rates were 30 (12) breaths per minute in the midazolam group and 43 (15) breaths per minute in the propofol group. The mean (sd) time to first head lift was 36 (21) minutes in the midazolam group and 14 (11) minutes in the propofol group, and the mean (sd) times to the return of the righting reflex were 35 (19) minutes and 15 (eight) minutes, respectively. The quality of recovery was better in the propofol group than in the midazolam group.

The contribution of transfusion to HCV infection in England

The English HCV lookback programme has identified some individuals with transfusion-transmitted HCV infection. The path from the collection of donations from HCV-infected donors to the identification of infected recipients was constructed. The probability of different outcomes at each branch was derived from data collected during this programme. This path of probabilities was then used to produce a complete estimate of the number of recipients infected by blood transfusions (dead and alive at the end of 1995) by re-entry of blood components that fell out of the lookback at various steps prior to recipient testing, and entry of components from HCV-infected donations that were never identified for lookback. Less than 14,000 recipients were estimated to have been infected with HCV during the decade prior to the start of donation testing. Over 60% of these were expected to have died by the end of 1995. Transfusion has infected a large group of individuals. However, this group constitutes a very small, and declining, proportion of all HCV infections in the population.

The impact of direct and extra billing for medical services: evidence from a natural experiment in British Columbia

This paper examines the impact of direct and extra billing on patient demand for medical services as well as physicians' responses to changing patient demand. These issues are examined in the context of a "natural experiment" in British Columbia, Canada where, in 1992, 81 general practitioners and specialists "opted-out" of the provincial Medical Services Plan (MSP) and began direct and extra billing their patients. These opted-out physicians are compared to a matched sample of physicians who remained within the MSP. Switching costs for patients were relatively low because of the availability of non-direct/extra billing physicians. The data consists of the more than 140,000 patient visit claims over a 2-year time period, one year immediately prior to the opting-out date and one year immediately following. The results of this study show that, on average, female visits to opted-out general practitioners (GPs) dropped approx. 9% after direct/extra billing. There was no concurrent drop for male patient visits. On average, patient visits to opted-out specialists dropped approx. 6%. Within the observed timeframe, opted-out physicians' billing patterns changed; somewhat offsetting this demand decrease. On average, opted-out GPs' payments per remaining patient increased by 10% following direct/extra billing (the post period), while opted-out specialists' payments per patient increased by 7%. There were no corresponding changes in payments per patient for the control group of physicians who remained opted-in.

A comparison of physical and laboratory measures between two Hutterite leute and the rural Saskatchewan population

This study compares physical, laboratory and anthropometric measurements from each of two groups (leute) of Hutterites (N = 846) with a population of non-Hutterites from rural Saskatchewan (N = 750). Marked interleute differences were observed in the comparative analysis with the non-Hutterite population. Dariusleut males had significantly greater mean diastolic and systolic blood pressures, total cholesterols, LDL cholesterols and Body Mass Indexes (BMI) than non-Hutterites. Compared with non-Hutterite women, the Dariusleut females had significantly greater mean diastolic and systolic blood pressure, HDL cholesterols, BMIs and waist-hip ratios. In contrast, the only significant difference between non-Hutterites and Lehrerleut males was in BMI. Lehrerleut females had significantly greater mean systolic blood pressures, HDL cholesterol levels and BMIs. While the surprising inter-leute differences may be due to subtle variations in lifestyle, the genetic isolation of the groups suggests heredity may offer a more likely explanation for the differences.

Analysis of pre- and post-donation haematological values in plateletpheresis donors

Pre- and post-donation haematological values were measured in 112 donors undergoing plateletpheresis using Haemonetics PCS machines. We found significant differences between pre- and post-donation means for males (M) and females (F) for haemoglobin (M: pre 14.73 g/dl, post 15.25 g/dl; F: pre 13.57 g/dl, post 13.94 g/dl), haematocrit (M: pre 0.418, post 0.431; F: pre 0.389, post 0.4), total protein (M: pre 73.1 g/l, post 66 g/l; F: pre 72.2 g/l, post 63.7 g/l) and albumin (M: pre 42.2 g/l, post 38.5 g/l; F: 41.4 g/l, post 37 g/l). Significant differences were also seen for platelet count (pre 258.6 x 10(9)/l, post 229.2 x 10(9)/l), total white cells (pre 5.3 x 10(9)/l, post 5.55 x 10(9)/l) and neutrophils (pre 3.15 x 10(9)/l, post 3.33 x 10(9)/l), but there were no differences between males and females. This information was of value in establishing post-donation reference ranges which could be utilised when reviewing the suitability of donors for subsequent donations.

Comparison of false-positive reactions in direct-binding anti-HIV ELISA using cell lysate or recombinant antigens

In a 2-year study of false-positive anti-HIV-1 tests in blood donors at Manchester and Lancaster Blood Banks, the reactions associated with a HIV-infected cell lysate antigen were compared with those using recombinant-antigen-based tests. In year 1 (cell lysate test) at Manchester BTS 0.21% of 119.178 donations were repeatedly reactive, compared with 0.53% of 119,004 donations in year 2 (recombinant antigen). Reactive sera were tested at Manchester PHL by three different immunoassays. Referred specimens were classified as anti-HIV positive (95-100% reactive in all the assays), equivocal or negative (negative results in all three immunoassays). Two donors were confirmed to be anti-HIV positive over the 2-year period. Most sera were negative by confirmatory immunoassays in years 1 and 2. In year 1, a study of 60 referred sera with sex- and age-matched controls showed high correlation between a reactive anti-HIV-1 screening test and indeterminate anti-HIV-1 patterns on Western blot showing reactions with HIV gag-coded proteins. In year 2, less than 10% of referred sera were reactive by Western blot, and there was no correlation between a reactive screening anti-HIV test, the strength of signal in the test or a reactive Western blot. Follow-up showed that donors whose sera were reactive in years 1 and 2 by the anti-HIV-1 screening test formed almost two different populations. Four donors with equivocal anti-HIV-1 confirmatory tests had anti-HIV 'envelope' reactions.(ABSTRACT TRUNCATED AT 250 WORDS)

The science of medical librarianship: investing in the future

Information science is changing from an applied service-oriented activity to a basic research discipline. The library profession must earn a central place in this endeavor, and must address a number of important issues. These include ownership and intellectual property rights, a stronger research component for the profession, development of quality assurance systems for health information services, and a conceptual framework for training and career development of health sciences library technicians. The future of medical librarianship as a profession depends on a lasting commitment to research, a clear vision of the profession's fundamental mission and of the library's place in society.

Research: the third dimension of librarianship

The rapid accumulation of data through increasingly sophisticated computer technology has created an unprecedented information explosion which might better be called an ignorance explosion. Data gathering emphasizing quantity rather than quality, speed of transmission rather than reliability or relevance, poses a challenge to the future of librarianship. Two concerns are discussed: (1) Relationship of technology to the information age. Librarians must be concerned with the methodology used in data collection, including the value judgments reflected in this activity. (2) Preparation of medical librarianship for the future. The profession will grow only as a result of individual effort, the recognition of people, and an appreciation of human values. Thus far, attempts to evaluate needs focus on technology while neglecting research into the human aspect. The author proposes that dimensions of the total professional model for medical librarianship must include research, as well as education and practice. The need to aid in the development of library researchers at the Ph.D. level through a National Library of Medicine program similar to that offered to researchers by the National Institutes of Health is stressed. By way of federal assistance and scholarships made available through national library associations, library research can become the vital and effective third dimension that will redefine the traditional concept of information storage and service in human terms, thus introducing a new relevance into the area of medical librarianship during the coming decades.

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Mapping of the gene specifying DNA polymerase III of Bacillus subtilis

polC, the gene specifying the structure of the replication-specific DNA polymerase III of B. subtilis, was mapped by exploiting azp-12, a mutation conferring resistance to azopyrimidine which determines a mutant, azopyrimidine-resistant enzyme. azp-12 was located in the area of the pyrA locus and is between spcB1 and recA1. azp-12 was linked by transformation to four other mutations which influence the in vitro behaviour of DNA polymerase III--polC25, polC26, mut-1(ts), and DNAF133; the close linkage of these five mutations strongly suggests that they are alleles of the same gene.

Reclassification and documentation in talog cards and a computer stored record

A project to recatalog and reclassify the book collection of the Bowman Gray School of Medicine Library utilizing the Magnetic Tape/Selectric Typwriter system for simultaneous catalog card production and computer stored data acquisition marks the beginning of eventual computerization of all library operations. A keyboard optical display system will be added by late 1970. Major input operations requiring the creation of "hard copy" will continue via the MTST system. Updating, editing and retrieval operations as well as input without hard copy production will be done through the "on-line" keyboard optical display system. Once the library's first data bank, the book catalog, has been established the computer may be consulted directly for library holdings from any optical display terminal throughout the medical center. Three basic information retrieval operations may be carried out through "on-line" optical display terminals. Output options include the reproduction of part or all of a given document, or the generation of statistical data, which are derived from two Acquisition Code lines. The creation of a central bibliographic record of Bowman Gray Faculty publications patterned after the cataloging program is presently under way. The cataloging and computer storage of serial holdings records will begin after completion of the reclassification project. All acquisitions added to the collection since October 1967 are computer-stored and fully retrievable. Reclassification of older titles will be completed in early 1971.

Postage--boon or bane: an evaluation of one library's MLA exchange transactions

An analysis of MLA Exchange material shipped as well as received is presented. It was found that, of 10,382 items shipped during a twelve-month period to 588 libraries, 332 of these mailings, or 56 percent, were sent for ten cents or less, at a total of $24.80 for postage, an average of $6.20 per exchange list. Similarly, a six-month log of items received by the library shows that 55 percent of these mailings was sent to the library for ten cents or less. The results of this study suggest that the waiving of small fees could eliminate more than half of the donor library's record keeping on postal reimbursements and that it could cut the receiving library's actual reimbursement cost, which is shown to reach 250 percent.