Prescription Plan Research Articles

Recommendations for dose calculations of lung cancer treatment plans treated with stereotactic ablative body radiotherapy (SABR)

The purpose of this study was to systematically evaluate dose distributions computed with 5 different dose algorithms for patients with lung cancers treated using stereotactic ablative body radiotherapy (SABR). Treatment plans for 133 lung cancer patients, initially computed with a 1D-pencil beam (equivalent-path-length, EPL-1D) algorithm, were recalculated with 4 other algorithms commissioned for treatment planning, including 3-D pencil-beam (EPL-3D), anisotropic analytical algorithm (AAA), collapsed cone convolution superposition (CCC), and Monte Carlo (MC). The plan prescription dose was 48 Gy in 4 fractions normalized to the 95% isodose line. Tumors were classified according to location: peripheral tumors surrounded by lung (lung-island, N=39), peripheral tumors attached to the rib-cage or chest wall (lung-wall, N=44), and centrally-located tumors (lung-central, N=50). Relative to the EPL-1D algorithm, PTV D95 and mean dose values computed with the other 4 algorithms were lowest for "lung-island" tumors with smallest field sizes (3-5 cm). On the other hand, the smallest differences were noted for lung-central tumors treated with largest field widths (7-10 cm). Amongst all locations, dose distribution differences were most strongly correlated with tumor size for lung-island tumors. For most cases, convolution/superposition and MC algorithms were in good agreement. Mean lung dose (MLD) values computed with the EPL-1D algorithm were highly correlated with that of the other algorithms (correlation coefficient =0.99). The MLD values were found to be ~10% lower for small lung-island tumors with the model-based (conv/superposition and MC) vs. the correction-based (pencil-beam) algorithms with the model-based algorithms predicting greater low dose spread within the lungs. This study suggests that pencil beam algorithms should be avoided for lung SABR planning. For the most challenging cases, small tumors surrounded entirely by lung tissue (lung-island type), a Monte-Carlo-based algorithm may be warranted.

A framework for post-earthquake rapid damage assessment of hospitals. Case study: Rasoul-e-Akram Hospital (Tehran, Iran)

Due to Iran's position in a seismic-prone region, the county is always at risk of earthquakes with potentially catastrophic results. Given earthquakes' potential for devastation, hospitals are among the main critical facilities that should be active continuously after an earthquake in order to provide necessary emergency services. In order to access the sufficiency of hospital services after an earthquake, and to reduce potential casualties due to subsequent effects, it is necessary to evaluate both structural and non-structural damage. In this article, methods of damage evaluation applicable to hospitals are reviewed and a summary of hospital damage that has been observed from previous earthquakes is provided. It concludes by proposing a new structure to support the continuity of hospital operations after an earthquake. This new approach is a framework for damage evaluation of hospitals including objectives, responsibilities, action time and operational criteria that covers structural and non-structural components (e.g. architectural, medical equipment and lifeline facilities). This new method, when used with human resources management, establishes primary roles in a prescriptive emergency recovery plan. The proposed framework was applied to Rasoul-e-Akram General Hospital in Tehran (Iran) as a case study. The results can be generalized to other hospitals in Iran and neighboring countries with similar construction and seismic conditions.

Radiation dose effect in locally advanced non-small cell lung cancer.

Radiation is the foundation of treatment for locally advanced non-small cell lung cancer (NSCLC), and as such, optimal radiation dose is essential for successful treatment. This article will briefly review biological considerations of radiation dose and their effect in the context of three-dimensional conformal radiation therapy (3D-CRT) including intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) for NSCLC. It will focus on literature review and discussions regarding radiation dose effect in locally advanced NSCLC including potential severe and lethal toxicities of high dose radiation given with concurrent chemotherapy. Potential new approaches for delivering safe and effective doses by individualizing treatment based on functional imaging are being applied in studies such as the PET boost trial and RTOG1106. The RTOG concept of delivering high dose radiation to the more resistant tumors with the use of isotoxic dose prescription and adaptive planning will also be discussed in detail.

Critical neurological structure sparing radiosurgery of vestibular schwannoma: dosimetric comparison of different techniques and dose prescription methods.

To investigate potential sparing of critical neurological structures (CNSs) during radiosurgery of vestibular schwannoma (VS) employing different techniques and dose prescription methods. Fused CT and MRI datasets of eight patients with unilateral VS representing a wide range of target volume (0.48 to 12.08 cc; mean = 3.56 cc), shape and proximity to CNSs such as cochlea, trigeminal nerve and brainstem were re-planned employing static conformal field (SCF), dynamic conformal arc (DCA) and intensity modulated radiosurgery (IMRS) techniques. For every patient, five plans were created for a fixed margin dose of 12 Gy prescribed at 80% in three plans (SCF_80%, DCA_80%, and IMRS_80%) and 50% in another two plans (SCF_50% and DCA_50%). All plans were compared using standard dosimetric indices. Primary goal of every plan to cover ≥99% of target volume with 12 Gy was fulfilled for all patients with minimum significant dose to target (D₉₉) ≥11.99 Gy. Best conformity index (CI Paddick = 0.62 ± 0.12) was observed in SCF_80% and DCA_80% plans whereas; sharpest dose gradient index of 3.40 ± 0.40 was resulted from DCA_50%. All five plans resulted similar maximum dose to brainstem (11.04 ± 2.23 to 11.53 ± 1.10 Gy), cochlea (9.02 ± 1.79 to 10.15 ± 1.26 Gy) and trigeminal nerve (11.55 ± 1.38 to 12.19 ± 2.12 Gy). Among 80% prescription plans, IMRS_80% reduces mean and D₅ (P < 0.05) to all CNSs. Prescription of dose at 50% isodose sharpened the dose gradient and significantly (P < 0.05) reduced mean dose and D₅ to all CNSs at the cost of target conformity (P = 0.01). Mean dose to cochlea and trigeminal nerve were least at 4.53 ± 0.86 and 6.95 ± 2.02 Gy from SCF_50% and highest at 6.65 ± 0.70 and 8.40 ± 2.11 Gy from DCA_80% plans respectively. This dosimetric data provides a guideline for choosing optimum treatment option and scope of inter institutional dosimetric comparison for further improvement in radiosurgery of Vestibular Schwannoma (VS).

A Proposal for Thinking Strategically About Ethics Education

Training in the responsible conduct of research (RCR) is mandated for select trainees supported by federal funds. RCR Instructors typically address standards and accepted practices for the planning, conduct and reporting of academic research. While this focus may be relevant to future academic scientists, the majority of science graduate students pursue careers in non-academic employment sectors (e.g., government, non-profit, industry). The ethical and regulatory conventions, norms and expectations of the academic setting may not always transfer to other work environments. As such, educators should focus less on answering specific questions about standards and practices in academia, and instead design ethics education to actively engage students in a learning process that prepares them with the skills to identify and navigate ethical dimensions in a wide range of possible science professions. This paper introduces the principles of andragogy and provides recommendations for educators to consider when designing research ethics education for graduate students seeking cross-sector science careers. By applying principles that resonate with adult learning and integrating strategies that promote self-directed and life-long learning (e.g., reflective practice and collaborative projects), professional and research ethics instructional effectiveness may be enhanced. Introduction Responsible Conduct of Research (RCR) training is provided to students and postdoctoral trainees at academic institutions throughout the United States, primarily in response to federal funding requirements (NIH 1992; NIH 2009; NSF 2009). Core areas of instruction associated with RCR training (e.g., data management, conflict of interest, authorship, research subject protections) were initially identified by the National Institutes of Health (NIH 1992) and, later by the Public Health Service (PHS 2000). While subject matter areas were identified, the NIH did not present a prescriptive plan or establish standards for training; leaving the scope of RCR training open to the discretion of each institution. As a result, RCR educational initiatives have emerged over the past quarter century with diverse goals, content and instructional approaches (Kalichman & Plemmons 2007; DuBois et al. 2010; Mastroianni & Kahn 1999).

Design and Practice Research of Sports Injury Network Consulting System

According to sports injuries knowledge and theory,combine module theory and Internet technology designed sports injuries network consultation system.This paper makes explanation on design ideas,technology crucial,module and function design,working example of the system.This system can appraisal sports injuries,give treating plan,exercise and rehabilitation prescription,and provide Internet platform for sports injuries treating and counseling of students and teachers.So the system has important practice and promotion values.

Antiparkinson Drug Use and Adherence in Medicare Part D Beneficiaries With Parkinson’s Disease

BackgroundAntiparkinson drugs (APDs) are the mainstay of managing Parkinson’s disease (PD). However, there is paucity of evidence documenting patterns of APD use and examining factors associated with adherence to APDs. ObjectivesOur goal was to provide updated, comprehensive population-based data on APD use and adherence and to examine characteristics associated with adherence behaviors. MethodsWe analyzed data from 7583 beneficiaries with PD who had ≥2 APD prescription fills and were continuously enrolled in Medicare Parts A, B, and D for up to 19 months (from June 1, 2006, through December 31, 2007) or until death in 2007. We assessed 5 patterns of APD use: (1) concurrent use of ≥2 APD classes for ≥30 days; (2) switching of APDs from 1 to another; (3) augmentation of the existing regimen with a new APD; (4) duration of therapy, defined as days of APD treatment; and (5) adherence measured by using the medication possession ratio (MPR). We corrected for sample selection bias inherent in patients’ self-selection into either a Part D plan or a Medicare Advantage Prescription Plan by using Heckman’s 2-stage procedures. ResultsAPD users were pre-dominantly aged ≥65 years (93.6%), female (59.9%), and white (89.3%). Almost one half (43.2%) of APD users concurrently used ≥2 APD classes. One in 4 APD users experienced changes in their APD regimen, with 16.4% switching medications and 21.1% augmenting their current regimen. Three quarters of APD users had therapy lasting ≥436 days (75.3%) and an MPR ≥0.8 (72.7%). Multivariate analyses revealed that patients aged ≥65 years, of non-white race, non–low-income subsidy recipients, late Part D enrollees, cognitively impaired, highly comorbid, and who experienced multiple changes in APD therapy were less likely to adhere to APD therapy. We were able to generalize our findings to all Part D enrollees by correcting for sample selection bias using the Heckman approach. These population-level, generalizable observations provide better understanding of APD use and adherence and assist in the design of interventions for poor adherence. Limitations include cross-sectional study design and constraints in administrative data that preclude measurement of other potential factors related to adherence. ConclusionsA substantial proportion of these Medicare beneficiaries with PD used multiple APDs concurrently, experienced switching and/or augmentation of APDs, and had poor adherence to APDs. Patient characteristics and clinical and drug-related factors were important predictors of APD adherence.

A Mechatronic System for Interactive Scan Plan Prescription during Real-Time Cardiac Magnetic Resonance Imaging

Real-time magnetic resonance imaging (MRI) has many advantages as compared to traditional MRI and can be used for the visualization of dynamic moving cardiac structures and functions without cardiac gating, as the fast data acquisition apparently freezes the motion resulting from heart beating and lung breathing. During the past decades, fast pulse sequences and image reconstruction algorithms had been developed to improve the temporal resolution with acceptable spatial resolution. However, the bottle neck of current real-time MRI systems is the availability of a user-friendly prescription tool to allow a MRI technician to prescribe the 6-Degree-of-freedom imaging plane of the MRI system. To meet the needs of real-time MRI, a 3D input tool is developed which facilitates user interactive specification of the center position and plane orientation of the MRI imaging plane. This paper reports such a custom designed 6 degree-of-freedom 3D input device, which allows the user to interactively and intuitively manipulate the scan plane to direct the real-time imaging capability to a target position based on the visual feedback provided on the MRI console in the form of real-time MRI images

‘Ground truths’ and scenarios: Examining and testing regional policy in North West Wales

This article describes how regional policy issues in North West Wales have been explored with local stakeholders, using scenario development to organise indigenous knowledge and elicit interpretations of the wider world. The context of scenario development, both in general and in its participatory form, is outlined, prior to an introduction to the study region and the policy framework which influences its development. In the latter part of the article, the process of construction and development of scenarios in combination with Delphi-like iterative questionnaires is described, showing how the gathering, organisation and interpretation of opinions, information and data from key stakeholders can illustrate a range of potential regional futures. The approach allows considerable broadening of stakeholder engagement at low cost. The four resulting scenario narratives and the policy insights they yield diverge considerably from top-down strategic planning perspectives and prescriptions. The article concludes by considering the general applicability of this guided method which draws on local knowledge of and involvement in policy decisions across different scales of impact, and provides more realistic and balanced perspectives, and demonstrates that enhanced quality and efficiency in decision making as well as opportunities for institutional learning can be achieved.

Escaping the National Forest Planning Quagmire: Using Public Participation GIS to Assess Acceptable National Forest Use

The appropriate role of the in the planning and management of national forests in the United States is both statutorily vague and socially dynamic. Should forest management be consistent with public values and preferences for these lands? And, how should be defined and evaluated? In 2012, a public participation geographic information systems (PPGIS) study was completed for the Chugach National Forest (CNF) in Alaska (United States) that measured public values and preferences to assist future forest plan revision. Place-based public preferences were assessed for consistency with existing CNF national forest plan (2002) prescriptions and to identify areas of potential conflict over forest management direction. Public use preferences were largely consistent with forest plan prescriptions but with some exceptions. Larger-scale analysis of PPGIS preference data provides more detailed information about potential forest conflict and indicates that large-area forest management prescriptions may be too general to guide place-specific forest planning needs. We discuss the use of PPGIS methods for future forest plans, given the release of a new regulatory planning rule for the USDA Forest Service in 2012.

Multimodality Image-based Target and Normal Structure Delineation for Dose Painting of Pancreatic Cancer

LC volume reduction. The mean LC maximum depths based on CT1 and CT2 were 6.4 1.3 cm and 5.2 1.3 cm, respectively (p Z 0.0002). Volume encompassed by the boost plan prescription isodose surface (V100%) was reduced in 18/20 (90%) patients after re-planning. V100% was 183.6 142.0 cc based on CT2 plans and 320.6 236.6 cc based on CT1 boost plans (p Z 0.008). While all 20 patients (100%) required a photon mini-tangential boost technique based on CT1, 8 patients (40%) became eligible for electron boost treatment after re-simulation. These 8 patients had a 2.7-fold greater absolute reduction in the mean V100% compared to patients treated with mini-tangents. This difference in mean V100% reduction was further pronounced, 4.5-fold, in 10 patients who experienced an increased LC volume on CT1 relative to pathologic surgical specimen volume. Large CT1 LC volume correlated with an increased reduction in CT2 LC maximum depth (Pearson correlation coefficient Z 0.42, p Z 0.066), and an increased reduction in V100% (Pearson correlation coefficient Z 0.63, p Z 0.003). Conclusions: In breast cancer patients with large lumpectomy cavities and maximum lumpectomy cavity depths >5 cm on initial CT simulation, tumor bed boost planning based on a newly acquired CT toward the end of the whole breast irradiation course is associated with significant treatment volume reduction and may result in a change of treatment technique. This has the potential to improve cosmesis, a clinically important outcome in breast-conserving therapy. Author Disclosure: N. Kovalchuk: None. K.K. Reddy: None. H. Bohrs: None. M.M. Qureshi: None. M.T. Truong: None. A.E. Hirsch: None. J. Willins: None. L.A. Kachnic: None.

Small Daily Doses of Insulin: Wasting Money?

Newer engineered insulin products are essential tools in diabetes therapy, but there is a potential for degrading glycemic control over time once a vial/pen is opened. Both patient and practitioner need to be aware of proper storage guidelines and the decrease in insulin potency after a seal is punctured. Basal insulins such as Lantus and Levemir are supplied in 10 ml multidose vials and 3 ml pen devices. Once the container is punctured, these products have declining potency that may result in reduced blood glucose control if used beyond the Food and Drug Administration-approved use range of 28 days for Lantus and 42 days for Levemir. When using low-dose therapy, considerable volume may remain available for use long after the insulin falls below 95% of its listed potency, setting the stage for unpredictable control and inaccurate clinical adjustment. There have been reports of decreased control when patients exceed open container stability limits; current market factors may increase this risk. Throwing away a container before it is empty is difficult to do for many patients, especially when their budgets are tight. To complicate matters, some prescription plans in the United States have dispensing limits based on prescribed dosage units per vial or pen instead of potency after opening. These plans may not take product stability into account, instead calculating the metric quantity of doses allowed for each prescription. As an example, for a basal insulin dose of 10 units per day, a 10 ml vial would be considered as more than a 90-day supply and a 3 ml pen device 30 days, which exceeds the recommended stability limit on an open container for both sizes of Lantus and the beyond-use date of Levemir's 10 ml vial. Potential for continued use until the vial is nearly empty creates an unknown variable in the evaluation of therapy outcome. When initiating low-dose basal insulin therapy, stability factors become a concern for all. Frequent or continuous self-monitoring of blood glucose could help determine when products will begin to lose significant potency and help defend a patient supply standard that is product appropriate. However, conducting clinical trials is costly and may not be in a manufacturer's best interest. Also, follow-up on patient compliance on proper home storage and disposal of these products is very difficult for a clinician to do. While seemingly a small concern on the surface, prescription drug plans with dose/quantity limits and individual financial constraints are affecting home supply, increasing the opportunity for expired use. The Kansas Diabetes Action Council will be posting an updated insulin stability chart on its Web site, http://www.kansasdiabetesactioncouncil.org, to help match insulin products to individual patient circumstances.

Briefing: An urban bill of rights

They say that the road to hell is paved with good intentions. There is no group of people more dedicated to making urban life humane and attractive than urban planners and designers. However, there is also no group that can do more damage to the cause of urban livability if they allow pet theories, resource management and utilitarian assumptions to set their course, rather than a full understanding of the fundamental needs of those they plan for – individual human beings. Popular planning prescriptions such as ‘smart growth,’ new urbanism, and transit-oriented development have largely lost touch with the human beings they are meant to serve. To articulate and safeguard the needs and rights of urban residents, therefore, the author proposes an urban bill of rights, summarised in this Briefing. The full explanation of the urban bill of rights can be found in the document entitled ‘Cities fit for people: the urban bill of rights,’ located at www.intbau.org and www.sharonhudson.com/urban_planning/Urban_Bill_of_Rights.html .

Dose prescription and treatment planning based on FMISO-PET hypoxia

Purpose. The study presents the implementation of a novel method for incorporating hypoxia information from PET-CT imaging into treatment planning and estimates the efficiency of various optimization approaches. Its focuses on the feasibility of optimizing treatment plans based on the non-linear conversion of PET hypoxia images into radiosensitivity maps from the uptake properties of the tracers used. Material and methods. PET hypoxia images of seven head-and-neck cancer patients were used to determine optimal dose distributions needed to counteract the radiation resistance associated with tumor hypoxia assuming various scenarios regarding the evolution of the hypoxic compartment during the treatment. A research planning system for advanced studies has been used to optimize IMRT plans based on hypoxia information from patient PET images. These resulting plans were compared in terms of target coverage for the same fulfilled constraints regarding the organs at risk. Results. The results of a planning study indicated the clinical feasibility of the proposed method for treatment planning based on PET hypoxia. Antihypoxic strategies would lead to small improvements in all the patients, but higher effects are expected for the fraction of patients with hypoxic tumors. For these, individualization of the treatment based on hypoxia PET imaging could lead to improved treatment outcome while creating the premises for limiting the irradiation of the surrounding normal tissues. Conclusions. The proposed approach offers the possibility of improved treatment results as it takes into consideration the heterogeneity and the dynamics of the hypoxic regions. It also provides early identification of the clinical cases that might benefit from dose escalation as well as the cases that could benefit from other counter-hypoxic measures.

Making Opioid Prescribing Safer: Time for a Checklist?

ISSN 1758-1869 10.2217/PMT.11.30 © 2011 Future Medicine Ltd Pain Manage. (2011) 1(4), 279–285 The safety of opioid analgesics is cur­ rently the subject of considerable medi­ cal, public and governmental scrutiny [101]. This attention to a class of medicines used for millennia, with well known ben­ eficial and harmful effects, stems largely from a recent (relatively speaking) change in the therapeutic use of opioids. Efforts to promote improved pain control over the past decades resulted in greater accep­ tance and use of opioids with (hopefully) better pain management and less ‘fear’ of these agents in both cancer and non­ cancer­related pain, producing a dramatic increase in the number of opioid prescrip­ tions in the USA [1]. A consequence of this wider use has been a dramatic increase in patient encounters for opioid adverse patient events, diversion to non­medical uses, misuse and abuse [101]. The limita­ tions and hazards of opioids in the treat­ ment of chronic noncancer pain have been recognized and consensus guide­ lines for use have been developed [2]. In response to the public health problem of widespread misuse of opioids, the White House has developed a ‘Prescription Drug Abuse Prescription Plan’ that includes a US FDA Risk Evaluation and Mitigation Strategy (REMS), and potentially, educa­ tional requirements for obtaining a Drug Enforcement Agency (DEA) license [101]. Despite the many problems with opio­ ids, they remain key tools in the man­ agement of pain, and are unlikely to be replaced in the near future by safer, less abuse prone or more effective agents. Thus, most clinicians will continue to use opioids in their practices, and the only available approach to the ‘opioid problem’ is to improve the way these drugs are used. Our experience [3], and others [4], suggest that the adverse outcomes observed with opioid use are the result of multiple fac­ tors, including suboptimal patient assess­ ment, therapeutic planning, opioid choice and use, monitoring and patient educa­ tion, and errors in executing a proper prescription. Prescribing errors and defi­ ciencies are not unique to opioids, but as a ‘high­alert’ drug class [5], opioids clearly present a more serious risk of harm than most other drug classes. A primary focus of the White House plan is the education of care providers in the proper use of opioids and other abuse prone drugs [1]. The effectiveness of these efforts will likely be determined by their

Education for Six-years Graduate School of Pharmaceutical Sciences: A Case of Tohoku University

We would like to introduce our new project to develop a course program for the 4-year system of graduate school of pharmacy Tohoku University after the 6-year program of the college of pharmacy. New course program designed will be two fields of 'cancer chemotherapy' and 'life-style related diseases' for clinical specialists and scientists of pharmacy. Our vision through this new program is to educate and produce the preeminent personnel being responsible for the safety and effective pharmaceutical care service in the clinical settings, with having the practical professional knowledge, skill and highly research ability, such as doing intervention and recommendation against a prescription planning process with an appropriate drug use. The personnel educated using our program will be called 'a next generation type pharmacist (or a Japanese-style pharmacist practitioner)'. Our program is a joint project with the graduate school of medicine and the university hospital, Tohoku University. The College of Pharmacy, Tohoku University placed two new laboratories and employed six faculties who are registered pharmacists in order to achieve above, and they also hold the post of pharmacist of the university hospital. And graduate students who are registered pharmacists also work in the university hospital now.

DM2 12-MONTH OUTCOMES OF A PHARMACIST-PROVIDED TELEPHONE MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM

12-MONTH OUTCOMES OF A PHARMACIST-PROVIDED TELEPHONE MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM Moczygemba L1, Barner JC2, Gabrillo E3 1Virginia Commonwealth University, Richmond, VA, USA, 2University of Texas at Austin, Austin, TX, USA, 3Scott & White Health Plan Prescription Services, Temple, TX, USA OBJECTIVES: Determine if Medicare Part D beneficiaries who received telephone MTM services had:1) Decreased medication/health-related problems (MHRPs); 2) Improved medication adherence; and 3) Decreased total Part D drug costs when compared to a control group. METHODS: Part D beneficiaries from a Texas health plan participated. The Andersen Model was the theoretical framework. Independent variables were: predisposing factors (age, gender, and race); and need factors (number of medications and chronic diseases and medication regimen complexity (MRC). The health behavior (intervention) was MTM utilization. Outcomes were change (from baseline to 12-month follow-up) in: 1) Number of MHRPs; 2) Medication adherence measured by the medication possession ratio (MPR); and 3) Total drug costs. Descriptive and inferential statistical analyses were conducted. RESULTS: The intervention (n 60) and control (n 60) groups were not statistically different regarding age (71.2 7.5 vs.73.9 8.0), medications (13.0 3.2 vs.13.2 3.4), chronic diseases (6.5 2.3 vs.7.0 2.1) or MRC [(21.5 (range 8–43) vs.22.8 (range 9–42.5)], respectively. The majority (51%) were male in the intervention group but only 28% were male in the control group (p 0.009). At baseline, 4.8 2.7 (intervention group) and 9.1 2.9 (control group) MHRPs were identified and 2.2 2.0 and 7.3 3.0 MHRPs remained at the 12-month follow-up, respectively. Multivariate regression revealed that MHRPs decreased significantly (p 0.0120) among the intervention group when compared to the control group. There were no significant predictors of change in MPR. Total drug costs (change from baseline to follow-up) decreased by $588 $2,086 in the intervention group and increased by $207 $1,752 in the control group. A t-test indicated the cost difference between the 2 groups was significant (p 0.03), but the multivariate regression did not indicate significant predictors. CONCLUSIONS: A telephone MTM program positively impacted MHRPs. Unadjusted cost comparisons also showed cost savings among the intervention group. Future research should focus on understanding predictors that impact adherence and cost-related MTM outcomes.

Medicare prescription drug plan coverage of pharmacotherapies for opioid and alcohol dependence in WA

Pharmacotherapeutic treatments for drug addiction offer new options, but only if they are affordable for patients. The objective of this study is to assess the current availability and cost of five common antiaddiction medications in the largest federal medication insurance program in the US, Medicare Part D. In early 2010, we collected coverage and cost data from 41 Medicare Part D prescription drug plans (PDPs) and 45 Medicare Advantage Plans (MAPs) in Washington State. The great majority of Medicare plans (82-100%) covered common pharmacotherapeutic treatments for drug addiction. These Medicare plans typically placed patent protected medications on their highest formulary tiers, leading to relatively high patient co-payments during the initial Part D coverage period. For example, median monthly co-payments for buprenorphine (Suboxone®) were about $46 for PDPs, and about $56 for MAPs. While Medicare prescription plans usually cover pharmacotherapeutic treatments for drug addiction, high co-payments can limit access. For example, beneficiaries without supplemental coverage who use Vivitrol® would exceed their initial coverage cap in 7-8 months, reaching the "doughnut hole" in their Part D coverage and becoming responsible for the full cost of the medication (over $900 per month). The 2010 Patient Protection and Affordable Care Act will gradually eliminate this coverage gap, and loss of patent protection for other antiaddiction medications (Suboxone® and Campral®) should also drive down patient costs, improving access and compliance.

Radiosurgery in the treatment of cerebral arteriovenous malformations

Stereotactic radiosurgery is one of the principle treatment options for small cerebral arteriovenous malformations, even in eloquent locations. Complete obliteration mainly depends on the applied single dose and treatment volume, although other potential factors may interfere. The risk of intracranial hemorrhage after radiosurgery is related to the obliteration status and depends on the size and volume of cerebral arteriovenous malformations. Radiosurgery has shown to be effective with minimum morbidity. According to appropriate criteria as far as characteristics of cerebral arteriovenous malformations are concerned, and, balancing dose prescription and optimum planning, radiosurgery results are undeniably encouraging.

Medications from the Web: Use of Online Pharmacies by Emergency Department Patients

BackgroundInternet access and online pharmacies are a resource for purchasing medications. It is unclear if this venue is being used by emergency department (ED) patients to obtain medications. ObjectiveWe sought to determine the frequency of and to characterize online pharmacy use by ED patients. We hypothesized that students and younger patients would be more likely than others to obtain medications via online pharmacies due to their familiarity with the Internet. MethodsThis prospective, cross-sectional survey occurred in an urban university ED. We enrolled a convenience sample of adult patients. The study was Institutional Review Board approved, and informed consent was obtained. To determine differences between online pharmacy users and non-users, chi-squared or Fisher’s exact tests were used for categorical data, and t-test or Wilcoxon rank sum tests were used for continuous variables. ResultsThere were 1657 patients who completed the survey. The mean age was 39 years, standard deviation 16 years; 947/1657 (57%) reported awareness of online pharmacies; 89/1657 (5.4%) patients used the Internet to order medications. More patients with prescription plans ordered medications from online pharmacies (94.3% vs. 70%; p<0.0001), and Internet users were more commonly on multiple medications (median 3 vs. 1; p<0.0001). There was no difference in age (39.4 vs. 41 years; p=0.2) or student status (13.8% vs. 14.9%; p=0.8) between the two groups. ConclusionsApproximately 5% of ED patients used the Internet to obtain medications. Contrary to our hypothesis, younger patients were not more likely to use the Internet for medications. Patients on multiple medications and those with prescription plans used online pharmacies more frequently.