Retrospective Inception Cohort Study Research Articles

Impact of concomitant prescriptions and lifestyle factors on the initial course of newly diagnosed inflammatory bowel disease

Introduction: There is a close relationship between the relapse of inflammatory bowel disease (IBD) and lifestyle factors, including concomitant medications such as non-steroidal anti-inflammatory drugs (NSAIDs), antithrombotic drugs, smoking status, and alcohol consumption. However, solid evidence is limited regarding the risk factors at diagnosis and initial disease course. This study aimed to explore the impact of concomitant prescriptions and lifestyle factors in patients with newly diagnosed IBD using a large-scale real-world database. Methods: This is a retrospective inception cohort study using the insurance claims database. Newly diagnosed patients with UC and CD were enrolled between January 2005 and May 2020. Concomitant prescriptions and lifestyle factors were assessed for new biologics use, surgery, and hospitalization during the first year. Results: In total, 6,743 patients with UC and 1,000 patients with CD were enrolled. Proton pump inhibitors, antithrombotics, antibiotics, and NSAIDs were identified as associated factors for both biologics use and hospitalization in UC patients (all p<0.01), and antithrombotics were identified as associated factors for both biologics use and hospitalization in CD patients (all p<0.01) in multivariable analyses. Interestingly, smoking was protective against hospitalization in UC patients (p<0.01), but not in CD patients (p=0.997), analyzed by univariate analysis. Alcohol consumption was protective against hospitalization outcomes in UC patients (p=0.02) but not in CD patients (p=0.27), analyzed by univariate analysis. Conclusion: Immediate attention should be paid to concomitant medications at diagnosis, because they may have impact on the initial course of IBD.

Comparative Effectiveness of Anti-Hyperlipidemic Drugs Monotherapy in Primary Prevention of Cardiovascular Disease.

Anti-hyperlipidemic drug treatments are effective in reducing the risk of cardiovascular disease. In a long-term retrospective inception cohort study, we aimed to assess the real-world comparative effectiveness of anti-hyperlipidemic monotherapies for primary prevention of cardiovascular events. Patients aged 18 years and older, who initiated primary prevention with anti-hyperlipidemic monotherapy, were selected from the University of Groningen IADB.nl dispensing database. In intention-to-treat (ITT) analysis we included all patients, whereas in per-protocol (PP) analysis we included both all patients independent of adherence (PPIA) and adherent patients (PPA). Study outcome was the time to first prescription of acute cardiac drug therapy measured by valid drug proxies to identify a first major cardiovascular event. We applied inverse probability of treatment-weighted (IPTW) analysis using Cox regression and time-varying Cox regression with simvastatin as the reference category to estimate the average treatment effect hazard ratios (HR) and their corresponding 95% confidence intervals (CI). Atorvastatin users had significantly higher hazards compared to simvastatin users (HR range: 1.27 to 1.47, 95% CI: 1.15 to 1.69). Similarly, Pravastatin users also exhibited increased hazards compared to simvastatin users (HR range: 1.41 to 1.56, 95% CI: 1.14 to 2.04). Similar patterns were observed in patients with diabetes, rheumatoid arthritis, and asthma/COPD. No differences were found in the hazards of rosuvastatin, fluvastatin, fibrates, and simvastatin. Atorvastatin and pravastatin users had higher long-term rates of cardiovascular events compared to simvastatin monotherapy in primary prevention, the difference may be attributed to the confounding by severity, but also possibly due to differences in drug mechanisms or patient response. These findings could influence current guideline recommendations, suggesting a potential preference for simvastatin in primary prevention, underscoring the need for further research to explore long-term impacts and underlying mechanisms, especially in diverse populations.

The Association between Deductibles and Cardiovascular Medication Adherence: A Retrospective Inception Cohort Study.

Drug non-adherence in primary preventive cardiovascular therapy is one of the most important modifiable drivers of cardiovascular events. The effect of deductibles in healthcare cost-sharing plans (the amount that has to be paid for healthcare services before the insurance company starts to pay) on such non-adherence in a European setting is unknown. Therefore, we estimated the association between deductibles and the adherence to primary preventive antihypertensive and antihyperlipidemic medication. Using the claims database of Menzis Health Insurer in the Netherlands, we applied ordered beta regression mixed modelling to estimate the association between deductibles and adherence taking several demographic and social-economic factors, repeated measurements and within-patient variation into account. All in all, 106,316 patients starting primary preventive antihypertensive or antihyperlipidemic monotherapy were eligible for analysis. At index date, mean age of the study population was 58years and 52% were male. Reaching the deductible limit and no need to pay for medication anymore increased the adherence [relative adherence ratio (RAR) 1.03, 95% confidence interval (95% CI): 1.00-1.05] for antihyperlipidemic therapy and 1.02 (95% CI: 1.00-1.04) for antihypertensive therapy. A larger deductible amount decreases the adherence of antihyperlipidemic and antihypertensive therapy (RAR 0.83; 95% CI: 0.69-1.00 and RAR 0.85, 95% CI: 0.74-0.98, respectively). Independent of other risk factors for non-adherence, presence of deductibles in health insurance is associated with a small negative effect on the adherence to both primary preventive antihypertensive as well as antihyperlipidemic therapy. Further study is needed on the potential health-economic consequences.

Long-term comparative effectiveness of antihypertensive monotherapies in primary prevention of cardiovascular events: a population-based retrospective inception cohort study in the Netherlands

ObjectiveTo determine the long-term effectiveness of antihypertensive monotherapies in primary prevention of cardiovascular events.DesignRetrospective inception cohort study covering a 25-year study period.SettingUniversity Groningen IADB.nl pharmacy prescription database with data from...

Real-World Dispensing Patterns of Inhalation Medication in Young Adult Asthma: An Inception Cohort Study.

The Global Initiative for Asthma (GINA) suggests a step-wise approach for pharmacological treatment of asthma. Valid study of real-world treatment patterns using dispensing databases includes proper measurement of medication adherence. We aim to explore such patterns by applying a time-varying proportion of days covered (tPDC)-based algorithm. We designed a retrospective inception cohort study using the University of Groningen IADB.nl community pharmacy dispensing database. Included were 19,184 young adults who initiated asthma medication anywhere between 1994 and 2021, in the Netherlands. Main treatment steps were defined as: 1 - SABA/ICS-formoterol as needed, 2 - low dose ICS, 3 - low dose ICS + LABA or tiotropium, or intermediate dose ICS, 4 - intermediate to high dose ICS + LABA or tiotropium, triple therapy, or high dose ICS, 5 - treatment prescribed by a specialist. Changes in treatment steps were determined using a time-varying proportion of days covered (tPDC)-based algorithm. Individual drug treatment trajectories were visualized over time using a lasagna plot. At initiation, of the 19,184 included individuals, 52%, 7%, 15%, 16%, and 10% started treatment in steps 1 to 5, respectively. The median (IQR) follow-up time was 3 (1-7) years. Median (IQR) number of switches was 1 (0-3). Comparing starting step to last observed step, 37% never switched between treatment steps, 20% of individuals stepped down and 22% stepped up. The low proportion of treatment switches between steps indicates that tailoring of treatment to patients' needs might be suboptimal. The tPDC-based algorithm functions well in translating dispensing data into continuous drug-utilization data, enabling a more granular assessment of treatment patterns among asthma patients.

Risk factors for drug-treated major adverse cardio-cerebrovascular events in patients on primary preventive statin therapy: A retrospective cohort study

We aim to identify risk factors of major adverse cardio-cerebrovascular events (MACCE) using a proxy of drug treatment for a MACCE after the start of statin therapy in the primary cardiovascular prevention group, taking drug dose, persistency and adherence into account. We conducted a retrospective inception cohort study using data from the University of Groningen prescription database IADB.nl, covering patients in the Northern part of the Netherlands. We identified adult starters on primary preventive statin therapy as patients without any statin or cardiovascular drug prescription in the two years before the first statin dispensing and used a weighted Cox proportional hazard model to estimate hazard ratios (HR) with their 95 % confidence intervals (95 %CI). Among 39,487 primary preventive statin starters, 23% received drug treatment for a MACCE within a median follow-up period of four years. Increasing age, male gender and presence of diabetes drug treatment were significantly associated with the outcome (HR: 1.03; 95 %CI: 1.02–1.04; HR: 1.27; 95 %CI: 1.12–1.44 and HR: 1.39; 95 %CI: 1.24–1.56, respectively). If patients remained statin therapy persistent, adherence was no longer associated with drug treatment for a MACCE. In 23 % of the statin therapy initiators, incident drug treatment for a MACCE occurred with a median of four years. To reduce event rates in this group, older patients, males and diabetes patients should be closely monitored. Non-adherence in the early stage of treatment should be avoided to prevent non-persistence.

Determinants of excessive weight gain after the initiation of insulin therapy in type 2 diabetes mellitus: Retrospective inception cohort study (ZODIAC 60)

AimsTo explore determinants of excessive weight gain after initiation of insulin therapy in type 2 diabetes mellitus (T2DM), in particular variables identified in the pre-insulin phase. MethodsWe performed a retrospective observational intervention cohort study, by means of a new user design/ inception cohort concerning n = 5086 patients. We studied determinants of excessive weight gain (5 kg or more) in the first year after initiation of insulin therapy, using both visualization and logistic regression analysis with subsequent receiver operation characteristic (ROC) analyses. Potential determinants pre-, at- and post-insulin initiation were included. ResultsOne out of 10 patients (10.0%) gained 5 kg weight or more. The earliest determinants of excessive weight gain were weight change (inversely) and HbA1c change in the two years prior to insulin therapy (p < 0.001). Patients that lost weight parallel with HbA1c rise in the two-years pre-insulin, showed the most pronounced weight gain. Of these patients, roughly one out of five (20.3%) gained 5 kg weight or more. ConclusionsClinicians and patients should be alert for excessive weight gain after initiation of insulin, in the case of weight loss prior to insulin therapy initiation, particularly with increasing and prolonged high HbA1c at (and after) insulin initiation.

Predictors of ICU Mortality among Mechanically Ventilated Patients: An Inception Cohort Study from a Tertiary Care Center in Addis Ababa, Ethiopia.

Mechanical ventilation is a life-saving intervention for patients with critical illnesses, yet it is associated with higher mortality in resource-constrained settings. This study intended to determine factors associated with the mortality of mechanically ventilated adult intensive care unit (ICU) patients. A one-year retrospective inception cohort study was conducted using manual chart review in ICU patients (age >13) admitted to Tikur Anbessa Specialized Hospital (Addis Ababa, Ethiopia) from September 2019 to September 2020; mechanically ventilated patients were followed to hospital discharge. Demographic, clinical, and outcome data were collected; logistic regression was used to determine mortality predictors in the ICU. A total of 160 patients were included; 85/160 (53.1%) were females and the mean (SD) age was 38.9 (16.2) years. The commonest indication for ICU admission was a respiratory problem (n = 97/160, 60.7%). ICU and hospital mortality were 60.7% (n = 97/160) and 63.1% (n = 101/160), respectively. Coma (Glasgow Coma Score <8 or 7 with an endotracheal tube (7T)) (adjusted odds ratio [AOR] 6.3, 95% confidence interval 1.19-33.00), cardiovascular diagnosis (AOR 5.05 [1.80-14.15]), and a very low serum albumin level (<2 g/dl) (AOR 4.9 [1.73-13.93]) were independent predictors of mortality (P < 0.05). The most commonly observed complication was ICU acquired infection (n = 48, 30%). ICU mortality in ventilated patients is high. Coma, a very low serum albumin level (<2 g/dl), and cardiovascular diagnosis were independent predictors of mortality. A multifaceted approach focused on developing and implementing context appropriate guidelines and improving skilled healthcare worker availability may prove effective in reducing mortality.

Correlation between the 72-hour fatality ratios and out-of-hospital cardiac arrest ratios in patients with extremely high outlier values of 57 laboratory test items: A single-center retrospective inception cohort study.

The association between extremely high outlier values (EHOV) of laboratory test items (LTIs) and short-term prognosis or out-of-hospital cardiac arrest (OHCA) remains unclear. This retrospective study investigated the correlation between 72-hour fatality ratios and OHCA ratios in patients with the top 100 EHOV of 57 LTIs without focusing on the disease group and which test items were predictors of 72-hour fatality. This single-center retrospective inception cohort study enrolled patients aged ≥ 18 years who underwent any combination of laboratory tests at the Saitama Medical Center, Japan between January 1, 2008, and December 31, 2013. The primary outcome was the correlation between the 72-hour fatality ratios and OHCA ratios in patients with the top 100 EHOV for 57 LTIs without focusing on the disease group. The LTIs included hematology, blood chemistry, erythrocyte sedimentation, blood coagulation, and arterial blood gas test results. The secondary outcome was which of the 57 LTIs with the top 100 EHOV were more likely to associate with the 72-hour fatality. We evaluated the correlation between the 72-hour fatality ratios and the OHCA ratios for each laboratory test item using the Passing-Bablok regression method. The 72-hour fatality ratios for the top 100 EHOV of 57 LTIs were significantly positively correlated with the OHCA ratios. The regression coefficient of the regression line was 0.394, and the correlation coefficient (95% confidence interval) was 0.644 (0.458-0.775, P < .001). These 72-hour fatality ratios tended to be lower than the OHCA ratios. The top 100 EHOV of 13 LTIs including total bilirubin, direct bilirubin, C-reactive protein, base excess, bicarbonate ion, creatine kinase, uric acid, partial pressure of oxygen, sodium, chloride, blood urea nitrogen, aspartate aminotransferase, and lactate dehydrogenase had 72-hour fatality ratios that were above the upper limit of the linear confidence region of the regression line, with higher 72-hour fatality ratios than the OHCA ratios. The 72-hour fatality ratios for the top 100 EHOV of 57 LTIs tended to be lower than the OHCA ratios. The top 100 EHOV of these 13 LTIs were found to be more likely to associate with 72-hour fatality than OHCA.

Targeting the Beta-2-Adrenergic Receptor and the Risk of Developing Alzheimer's Disease: A Retrospective Inception Cohort Study.

Background:Animal studies suggested that β2-Adrenergic receptors (β2AR) may be a potential target for the treatment of Alzheimer’s disease (AD).Objective:This retrospective inception cohort study aimed to assess the association between antagonists and agonists of the β2AR and the risk of starting treatment for AD in older adults.Methods:A retrospective inception cohort study was conducted among older adults who initiated either non-selective βAR antagonists or selective β2AR agonists using the University Groningen IADB.nl prescription database (study period 1994–2019). For each exposed cohort, two reference cohorts (A and B) were matched on age at index date. The main outcome was defined as at least two prescriptions for cholinesterase inhibitors (rivastigmine, galantamine, and donepezil) and/or memantine. Cox proportional hazard regression models were used to estimate hazard ratios (HR).Results:The risk of developing AD was elevated among patients exposed to non-selective βAR antagonists (A: aHR 3.303, 95% CI 1.230–8.869, B: aHR 1.569, 95% CI 0.560–4.394) and reduced among patients exposed to selective β2AR agonists (A: aHR 0.049, 95% CI 0.003–0.795, B: aHR 0.834, 95% CI 0.075–9.273) compared to reference patients.Conclusion:These findings suggest that exposure to non-selective βAR antagonists is associated with an increased risk for developing AD whereas there may be a decreased risk for developing AD after exposure to selective β2AR agonists.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn's disease.

BACKGROUNDAcute severe lower gastrointestinal bleeding (LGIB) is an uncommon but challenging complication of Crohn’s disease (CD).AIMTo identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODSA retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center, a tertiary university hospital in Korea. Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB. A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD. RESULTSMultivariable Cox regression analysis revealed that early use of thiopurines [hazard ratio (HR): 0.23, 95% confidence interval (CI): 0.12-0.48; P < 0.001] and female sex (HR: 0.51, 95%CI: 0.27-0.94; P = 0.031) were significantly associated with a lower risk of acute severe LGIB. The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups (P = 0.139 and P = 0.769, respectively). The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group (22.1/100 vs 13.2/100 patient-years; P = 0.012). However, if hospitalizations due to bleeding episodes were excluded from the analysis, the hospitalization rate was not significantly different between the bleeding group and the matched non-bleeding group (14.5/100 vs 13.2/100 patient-years; P = 0.631).CONCLUSIONEarly use of thiopurines may reduce the risk of acute severe LGIB. History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Clinical Criteria Can Identify Children With Osteopenia in Newly Diagnosed Crohn Disease.

Chronic inflammation of Crohn disease (CD) is associated with reduced bone mineral density (BMD). As bone mass is almost exclusively accrued during childhood, early recognition of osteopenia is especially important in pediatric CD. We aimed to identify variables associated with osteopenia to guide dual-energy X-ray absorptiometry (DXA) scan screening to those who most need it. This was a retrospective inception cohort study of children newly diagnosed with CD, and routinely referred to DXA scans. Demographic and explicit clinical data were recorded along with whole-body less head BMD, adjusted for age, sex, and height by z-scores. Of the 116 included children (mean age 13 ± 3.1 years, 67 [58%] boys, mean body mass index [BMI] 16.7 ± 2.6), 63 (54%) had normal BMD (z-score > -1) or borderline osteopenia (-1 ≥ z-score > -2) and 53 (46%) had osteopenia (z-score ≤ -2). Osteopenia was associated with lower BMI z-score (-0.8 ± 1.2 vs -1.8 ± 1.1, P < 0.001) and higher PCDAI (33.7 ± 15.2 vs 25.7 ± 16.5; P = 0.009) than those with BMD z-score >-2. In total, 59% of children with BMI z-score <-0.5 had moderate-severe osteopenia and only 18% of those with higher z-scores. Multivariate logistic regression identified BMI z-score as the sole risk factor (OR 1.28 [95% CI 1.08-1.52], P = 0.005). BMI z-score ≥-0.5 excludes osteopenia with a sensitivity 87%, specificity 49%, NPV 82%, and PPV 59%. Osteopenia was found in nearly half of children with newly onset CD. BMI z-score <-0.5 should prompt referral to DXA screening.

Course of body weight before and after the initiation of insulin therapy in type 2 diabetes mellitus: Retrospective inception cohort study (ZODIAC 58).

AimsThe aim of this study was to explore the effect of insulin treatment initiation on weight by taking weight change prior to initiation into account.Materials and methodsWe performed an observational retrospective inception cohort study, concerning Dutch primary care. We identified all patients that initiated insulin treatment (n = 7967) and individually matched patients with a reference patient (n = 5213 pairs). We obtained estimated mean weight changes in the five years prior to five years post insulin therapy. We applied linear regression analysis on weight change in the first year after insulin therapy (T0 to T+1), with matched group as primary determinant adjusted for pre‐insulin weight change and additional covariates.ResultsEstimated mean weight increased in the five consecutive years prior to insulin therapy (−0.23 kg in year T‐5 to T‐4, 0.01 kg in year T‐4 to T‐3, 0.07 kg in year T‐3 to T‐2, 0.24 kg in year T‐2 to T‐1, and 0.46 kg in year T‐1 to T0) and continued to increase in the first year after, that is T0 to T+1, at a slightly lower rate (0.31 ± 3.9 kg). Pre‐insulin weight change had the highest explained variance and was inversely and independently associated with weight change (p < .001). Starting insulin was associated with weight increase, independent of pre‐insulin weight change (β‐adjusted 1.228, p < .001). Stratification revealed that despite having a more or less similar baseline BMI, patients with substantial weight increase showed higher estimated mean BMI’s followed by weight loss pre‐insulin. In matched references, estimated mean weight changes were negative in all years concerning the study period, indicating consistent weight loss.ConclusionsInitiation of insulin therapy was independently associated with weight increase; however, overall effect on weight was small and subject to substantial variation. Pre‐insulin weight change is identified as a relatively strong inverse determinant of weight change after insulin initiation.

TREATMENT COMPLETION AND IMPLEMENTATION BY PATIENTS INITIATING TICAGRELOR.

In secondary prevention of adverse events and death following acute coronary syndrome, patients may benefit from adhering to a ticagrelor treatment. The authors assessed the proportion of new ticagrelor users who completed 12 months of treatment, explored the factors associated with treatment completion and, among the completers, evaluated the 12-month treatment implementation. A retrospective administrative health database inception cohort study was conducted in a population that included Quebec residents ≥18 years of age who initiated ticagrelor between January 1, 2012 and March 31, 2014. A patient still on ticagrelor at the end of the 12-month period after treatment initiation was considered to have completed the treatment. Factors associated with treatment completion were identified using log-binomial regression. Implementation was assessed using the proportion of days covered (PDC). Of the 3,600 patients, 2,235 (62.1%) completed 12 months of treatment. The patients who were more likely to complete their treatment included those who had visited a general practitioner, had a percutaneous coronary intervention, used a statin or fibrate, and those who used an antihypertensive drug during the year preceding the ticagrelor treatment initiation. Older patients, those with atrial fibrillation, those who had ≥ 6 physician visits and those who used an anticoagulant were less likely to complete the 12-month treatment. The median PDC was 96.2%. Treatment completion might be improved. Among patients who completed the treatment, implementation was high. The factors associated with completion could help to identify patients who might benefit from interventions that aim to optimize treatment completion.

Health status, quality of life and socioeconomic situation of people with spinal cord injuries six years after discharge from a hospital in Bangladesh.

Cross-sectional analysis of a mixed retrospective and prospective inception cohort study. To determine health status, quality of life and socioeconomic situation of people with spinal cord injuries (SCI) 6 years after discharge from a hospital in Bangladesh. Bangladesh. All patients alive 6 years after discharge from a hospital in Bangladesh were interviewed using the SF12 health survey, the SCI Secondary Conditions Scale, the Centre for Epidemiologic Studies Depression Scale (CESD), and the participation in society items of World Health Organisation Disability Assessment Schedule (WHODAS 2.0). Additional questions determined participants' socioeconomic and employment status. The cohort comprised 260 participants: 145 used wheelchairs for mobility and 115 were able to walk at discharge. The median (IQR) Mental and Physical Component scores for the SF12 were 54 (49-57) and 44 (40-51) points, respectively. The median scores for the SCI Secondary Conditions Scale, CESD and WHODAS 2.0 were 8 (4-13), 7 (4-13) and 12 (6-17) points, respectively. Fourteen percent of all participants and 23% of those who used wheelchairs had a pressure ulcer at the time of interview. Forty-four percent of participants were unemployed and 65% were living below the poverty line (median (IQR) income, USD 0 (0-91)) per month. Many people with SCI in Bangladesh are unemployed and living in poverty with a reduced quality of life and participation. Pressure ulcers are a common complication.

Appropriateness of Ticagrelor Use at Initiation: A Population-Based Cohort Study.

Ticagrelor is recommended following an acute coronary syndrome if used appropriately. Its use has not yet been well described in the context of ambulatory clinical practice. The objective of this study was to assess the proportion of ticagrelor new users who initiated this medication appropriately and explore associated factors. A retrospective population-based inception cohort study was conducted using Quebec administrative databases. The study population included all Quebec residents aged ≥18 years who had a first ticagrelor prescription claim between 1 January, 2012, and 31 March, 2015, and had been continuously eligible in the Quebec public drug plan during the 365 days preceding the first ticagrelor claim. The initial ticagrelor prescription was considered appropriate if:1) it met the indication for use criterion, 2) the prescribed daily dose was 90 mg twice a day, and 3) there was a concomitant use of acetylsalicylic acid (ASA) 80-81 mg daily. Factors potentially associated with the ticagrelor appropriateness of use were included in a logistic log-binomial regression model. A total of 7,073 patients were included in the study, 6,013 (85.0%) had an appropriate indication, 6,895 (97.5%) were prescribed ticagrelor 90 mg twice a day, and 6,385 (90.3%) had a concomitant prescription of ASA. A total of 5,371 (75.9%) patients were prescribed ticagrelor in accordance with all criteria. Twelve factors were associated with prescription appropriateness. A large majority of patients initiated ticagrelor appropriately. Further improvement in appropriateness may come at targeting indication for use.

Continuation rates of alpha-blockers mono-therapy in adult men, prescribed by urologists or general practitioners: a pharmacy-based study

Purposeα-Blockers are commonly used for the treatment of male lower urinary tract symptoms (LUTS). The Dutch GP guideline on male LUTS contains an advice to discontinue treatment after 3–6 months of successful treatment. The guideline for urologists does not support this advice. It is unclear if these differences lead to other patterns of (dis)continuation of α-blockers. We aim to study continuation rates of α-blockers, prescribed by a urologist or a general practitioner (GP), and to predict discontinuation after 1 year.MethodsWe conducted a retrospective inception cohort study on prescription patterns of α-blockers among Dutch men between 2006 and 2014, using the IADB.nl pharmacy prescription database from the University of Groningen. We selected men aged 30 years or older with a first α-blocker prescription between 2006 and 2013, and analysed continuation of prescriptions.ResultsThe database included 12,191 individual patients with at least one α-blocker prescriptions from a urologist (44.5%) or a GP (55.5%). The median treatment period for patients who started in the GPs office was 210 days, compared to 150 days for patients with a prescription from a urologist. Of all patients, 60.3% (GP prescriptions) and 66.1% (urologists’ prescriptions) had discontinued treatment (Chi-square p < 0.001). Discontinuation rates were age dependent with higher rates in the youngest age groups.ConclusionIn this study, the discontinuation rate 1 year after the initiation of treatment was high. Although Dutch GP’s and urologist’s guidelines differ with respect to a discontinuation advice, we could not find clinically relevant difference in (temporary) discontinuation rates.

Effect of a gonadotropin-releasing hormone analog for ovarian function preservation after intravenous cyclophosphamide therapy in systemic lupus erythematosus patients: a retrospective inception cohort study.

To determine the effect of leuprolide acetate, a synthetic gonadotropin-releasing hormone analog (GnRH-a) on ovarian function preservation in systemic lupus erythematosus (SLE) patients treated with cyclophosphamide (CYC) in clinical practice. We enrolled 30 premenopausal female SLE patients who fulfilled the 1997 American College of Rheumatology revised criteria and were treated with intravenous CYC (IVCY) in 2008-2017. We used Kaplan-Meier survival estimates to compare the GnRH-a-treated patients and those not treated with GnRH-a as controls. We performed Cox regression analyses to identify factors associated with premature ovarian failure (POF), incidences of cardiovascular events, strokes and osteoporosis after IVCY therapy. After a mean follow-up of 41months, POF developed in one of the 16 GnRH-a-treated patients (6%) versus seven of the 14 controls (50%). Significantly improved cumulative ovarian protection over time was observed in the GnRH-a-treated group (P=0.030). The hazard model analysis showed that treatment with GnRH-a during IVCY therapy is an independent factor associated with POF after IVCY therapy (adjusted hazards ratio=0.12, 95% CI 0.01-0.67, P=0.013) but not incidences of cardiovascular events, strokes or osteoporosis. The combined use of GnRH-a with IVCY therapy was associated with a significant reduction of POF among premenopausal women with SLE, suggesting that the addition of GnRH-a can be a strategy to prevent POF among premenopausal women with SLE after IVCY therapy.

Glass half full: Survival analysis of new rural doctor retention in Western Australia.

To measure the time trends in retention of new rural doctors in Western Australia (WA) and identify factors associated with improved retention. Retrospective inception cohort study of the 1154 doctors first commencing rural practice in WA in 2004-2013, who provided 1222 tours of service consisting of up to eight attachments at different rural practice settings. Failure of doctor retention as evidenced by an absence from the rural medical workforce of greater than 1 year and analysed using actuarial survival methods and Cox proportional hazards regression. Comparing 2009-2013 with 2004-2008, there was an improvement of 10 percentage points in retention of new rural doctors at 2 years (58% versus 48% ) and 7 percentage points at 5 years (38% versus 31%). The retention failure rate ratio was 0.68 (95% CI, 0.58-0.83). The improvement at 5 years was largely attributable to gains in retention of those who began as GP registrars (37% versus 14%). Failure of doctor retention was lower in those who possessed procedural skills (RR 0.61, 95% CI, 0.47-0.78) and lower in international medical graduates than in those trained in Australia (RR 0.75, 95% CI, 0.59-0.95). New rural GP retention in WA has improved substantially, an observation at least consistent with government initiatives delivering a positive return. However, it remains the case that the majority of new doctors have left rural practice within 5 years of commencing their tour of service.

Enthesitis in an inception cohort of enthesitis‐related arthritis

To describe an enthesitis-related arthritis (ERA) inception cohort and determine which entheses and joints are most commonly affected. We reviewed a retrospective inception cohort study of children with ERA who were diagnosed and treated at The Children's Hospital of Philadelphia between November 2007 and December 2009. During the study period, there were 32 newly diagnosed ERA patients. Fifty-nine percent were male, and the median age at the date of initial evaluation was 12.5 years (interquartile range [IQR] 10.2-14.3 years). The median number of tender entheses at presentation was 2 (IQR 0-5), and 21 subjects (66%) had at least 1 tender enthesis. The most prevalent tender entheses were the patellar ligament insertion at the inferior pole of the patella, the plantar fascial insertion at the calcaneus, the Achilles tendon insertion at the calcaneus, and the plantar fascial insertion at the metatarsal heads. Enthesitis was most often symmetric. The median number of active joints was 2 (IQR 0-4). The most commonly affected joints were the sacroiliacs, knees, and ankles. Sacroiliitis, which was defined clinically, was most often symmetric, while peripheral arthritis was most frequently asymmetric. The odds of having active enthesitis at 6 months increased significantly with each additional tender enthesis at the initial evaluation. Among pediatric patients with ERA, lower extremity enthesitis is prevalent at the time of diagnosis and is likely to persist 6 months later. Future studies should address standardization of the enthesitis examination, the pattern of enthesitis over time, enthesitis response to therapy, and the impact of enthesitis on quality of life.