Understanding the reasons for provincial discordance in cancer drug funding-a survey of policymakers.

Background: Cancer drug-funding decisions between provinces shows discordance. The pan-Canadian Oncology Drug Review (pcodr) was implemented in 2011 partly to address uneven drug coverage and lack of transparency in the various provincial cancer drug review processes in Canada. We evaluated the underlying reasons for ongoing provincial discordance since the implementation of pcodr. Methods: Participation in an online survey was solicited from participating provincial ministries of health (mohs) and cancer agencies (cas). The 4-question survey (with both multiple-choice and free-text responses) was administered between 4 March 2015 and 1 April 2015, inclusive. Anonymity was ensured. Descriptive statistics were used to evaluate responses. Results: Data were available from 9 provinces (all Canadian provinces except Quebec), with a response rate of 100%. The 12 responses received each came from a senior policymaker with more than 5 years' experience in cancer drug funding decision-making (5 from mohs, 7 from cas). Responses for 3 provinces came from both a moh representative and a ca representative. The most common reason for funding a drug not recommended by pcodr was political pressure (64%). The most common reason not to fund a drug recommended by pcodr was budget constraints (91%). The most common reason for a province to fund a drug before completion of the pcodr review was also political pressure (57%). Conclusions: Political pressure and budgetary constraints continue to affect equity of access to cancer drugs for patients throughout Canada.

Impact of the pan-Canadian Oncology Drug Review on provincial concordance with respect to cancer drug funding decisions and time to funding.

BACKGROUND: The pan-Canadian Oncology Drug Review (pcodr) was implemented in 2011 to address uneven drug coverage and lack of transparency with respect to the various provincial cancer drug review processes in Canada. We evaluated the impact of the pcodr on provincial decision concordance and time from Notice of Compliance (noc) to drug funding. METHODS: In a retrospective review, Health Canada's Drug Product Database was used to identify new indications for cancer drugs between January 2003 and May 2014, and provincial formulary listings for drug-funding dates and decisions between 1 January 2003 and 31 December 2014 were retrieved. Multiple linear models and quantile regressions were used to evaluate changes in time to decision-making before and after the implementation of the pcodr. Agreement of decisions between provinces was evaluated using kappa statistics. RESULTS: Data were available from 9 provinces (all Canadian provinces except Quebec), identifying 88 indications that represented 51 unique cancer drugs. Two provinces lacked available data for all 88 indications at the time of data collection. Interprovincial concordance in drug funding decisions significantly increased after the pcodr's implementation (Brennan-Prediger coefficient: 0.54 pre-pcodr vs. 0.78 post-pcodr; p = 0.002). Nationwide, the median number of days from Health Canada's noc date to the date of funding significantly declined (to 393 days from 522 days, p < 0.001). Exploratory analyses excluding provinces with incomplete data did not change the results. CONCLUSIONS: After the implementation of the pcodr, greater concordance in cancer drug funding decisions between provinces and decreased time to funding decisions were observed.

The Austrian syndrome: a case report and review of the literature.

A 61-year-old man presented with fever and altered mental status. He was intubated for respiratory distress and was found to have multilobar pneumonia for which antibiotic therapy was instituted. However, his mental status continued to deteriorate despite appropriate antibiotic therapy for his pneumonia. The results from lumar puncture revealed meningitis and endocarditis was evident on a trans-esophageal echocardiogram. His blood and respiratory cultures grew Streptococcus pneumoniae. The patient was diagnosed with Austrian syndrome. After appropriate changes to his antibiotic regimen and an aortic valve replacement, he recovered and was discharged.

The association of the Friesinger score and estimated glomerular filtration rate in an urban South Asian patient population.

AIM: The correlation between kidney function and coronary artery disease (CAD) severity as assessed by an angiographic score has not yet been studied in the South Asian population. We sought to estimate the association by performing a single-center, cross-sectional study. PATIENTS AND METHODS: The estimated glomerular filtration rate (eGFR) calculated by the CKD-EPI equation and the Friesinger score to quantify the severity of CAD were the primary endpoints in patients undergoing coronary angiograms. RESULTS: The mean eGFR was significantly lower in participants with a Friesinger score of > 5 compared to participants with a score of < 5 (73 vs. 86 ml/min/1.73 m(2) by MDRD). In univariate analysis, an eGFR of < 55 ml/min/1.73 m(2) was associated with a 9.5-fold increased odds of a higher Friesinger score compared to an eGFR >= 55 ml/min/1.73 m2 (p = 0.043), which was unchanged in multivariate analysis. In multivariate analysis, a 10 ml/min/1.73 m(2) decrease in eGFR was associated with a 1.63-fold increased odds of a higher score (95% CI 1·10 - 2.37, p = 0.042). Traditional risk factors such as a history of previous CAD, hypertension, and dyslipidemia remained predictors of a higher Friesinger score. CONCLUSION: Our study demonstrates that kidney function as assessed by eGFR is a significant independent predictor of severity of CAD as determined by the Friesinger score.

Moderate to heavy caffeine consumption during pregnancy and relationship to spontaneous abortion and abnormal fetal growth: a meta-analysis.

The objective was to determine the association of moderate to heavy caffeine consumption during pregnancy on spontaneous abortion and birth weight in humans. Data sources used included a computerized literature search of MEDLINE (1966-July 1996); EMBASE (1988-November 1996); Psychlit I (1974-1986); Psychlit II (1987-1996); CINAHL (1982-May 1996) and manual search of bibliographies of pertinent articles. Inclusion criteria were: English language research articles; pregnant human females; case control or cohort design; documented quantity of caffeine consumption during pregnancy; control group with minimal or no caffeine consumption (0 to 150 mg caffeine/d); documented data regarding spontaneous abortion and/or fetal growth. The exclusion criteria were: case reports; editorials; review papers. The methods section of each study was examined independently by two blinded investigators with a third investigator adjudicating disagreements. Two independent investigators extracted data onto a standardized form. A third investigator adjudicated discrepancies. We compared a caffeine-exposed group (>150 mg/d) and controls (0 to 150 mg/d), using Mantel-Haenszel pooling. Of the 32 studies meeting inclusion criteria, 12 had extractable data (6 for spontaneous abortion, 7 for low birth weight, 1 common study). Mantel-Haenszel odds ratio (CI95%) was 1.36 (1.29-1.45) for spontaneous abortion in 42,988 pregnancies. The overall risk ratio was 1.51 (1.39-1.63) for low birthweight (<2500 g) in 64,268 pregnancies. Control for confounders such as maternal age, smoking, and ethanol use was not possible. We concluded that there is a small but statistically significant increase in the risks for spontaneous abortion and low birthweight babies in pregnant women consuming >150 mg caffeine per d. A possible contribution to these results of maternal age, smoking, ethanol use, or other confounders could not be excluded.

Nutritional status of the elderly.

Elderly become vulnerable to malnutrition owing to inappropriate dietary intake, poor economic status and social deprivation. Elderly are known to be easily subjected to inanition and avitaminosis resulting in multiple nutritional deficiencies. Urban slum dwellers, rural poor and those living alone appear to be at a higher risk of poor dietary intake. Though food consumption patterns of rural and urban elderly show a distinct difference, these are greatly influenced by regional dietary patterns. The diets of institutionalised and free living elderly reveal adequate nutrient intakes except iron and vitamin A. The nutrients least adequately supplied in the diets of Indian elderly are calcium, Iron, vitamin A, riboflavin and niacin along with energy deficits. Changes in body composition which mark the onset of the ageing process, include decline in lean body mass and increase in adipose tissue. A high prevalence of iron deficiency anaemia has also been reported among Indian elderly.