Effectiveness of current treatment approaches for benzodiazepine discontinuation : a meta-analysis.

Aims: To assess the effectiveness of current treatment approaches to assist benzodiazepine discontinuation. Methods: A systematic review of approaches to benzodiazepine discontinuation in general practice and out-patient settings was undertaken. Routine care was compared with three treatment approaches: brief interventions, gradual dose reduction (GDR) and psychological interventions. GDR was compared with GDR plus psychological interventions or substitutive pharmacotherapies. Results: Inclusion criteria were met by 24 studies, and a further eight were identified by future search. GDR [odds ratio (OR) = 5.96, confidence interval (CI) = 2.08–17.11] and brief interventions (OR = 4.37, CI = 2.28–8.40) provided superior cessation rates at post-treatment to routine care. Psychological treatment plus GDR were superior to both routine care (OR = 3.38, CI = 1.86–6.12) and GDR alone (OR = 1.82, CI = 1.25–2.67). However, substitutive pharmacotherapies did not add to the impact of GDR (OR = 1.30, CI = 0.97– 1.73), and abrupt substitution of benzodiazepines by other pharmacotherapy was less effective than GDR alone (OR = 0.30, CI = 0.14–0.64). Few studies on any technique had significantly greater benzodiazepine discontinuation than controls at follow-up. Conclusions: Providing an intervention is more effective than routine care. Psychological interventions may improve discontinuation above GDR alone. While some substitutive pharmacotherapies may have promise, current evidence is insufficient to support their use.

Disseminated M. avium complex infection in the Swiss HIV Cohort Study: declining incidence, improved prognosis and discontinuation of maintenance therapy.

Introduction of potent antiretroviral combination therapy (ART) has reduced overall morbidity and mortality amongst HIV-infected adults. Some prophylactic regimes against opportunistic infections can be discontinued in patients under successful ART. (1) The influence of the availability of ART on incidence and mortality of disseminated M. avium Complex infection (MAC). (2) The safety of discontinuation of maintenance therapy against MAC in patients on ART. The Swiss HIV-Cohort Study, a prospective multicentre study of HIV-infected adults. Patients with a nadir CD4 count below 50 cells/mm3 were considered at risk for MAC and contributed to total follow-up time for calculating the incidence. Survival analysis was performed by using Kaplan Meier and Cox proportional hazards methods. Safety of discontinuation of maintenance therapy was evaluated by review of the medical notes. 398 patients were diagnosed with MAC from 1990 to 1999. 350 had a previous CD4 count below 50 cells/mm3. A total of 3208 patients had a nadir CD4 count of less than 50 cells/mm3 during the study period and contributed to a total follow-up of 6004 person-years. The incidence over the whole study period was 5.8 events per 100 person-years. In the time period of available ART the incidence of MAC was significantly reduced (1.4 versus 8.8 events per 100 person-years, p < 0.001). Being diagnosed after 1995 was the most powerful predictor of better survival (adjusted hazard ratio for death: 0.27; p < 0.001). None of 24 patients discontinuing maintenance therapy while on ART experienced recurrence of MAC during a total follow-up of 56.6 person-years (upper 95% confidence limit 5.3 per 100 person-years). Introducing ART has markedly reduced the risk of MAC for HIV-infected individuals with a history of very low CD4 counts. Survival after diagnosis of MAC has improved after ART became available. In patients responding to ART, discontinuation of maintenance therapy against M. avium may be safe.

Continuation and discontinuation of local institution in community based natural resource management

Currently the push toward frontier areas, which until twenty years ago were still largely untouched by commercial agriculture, is taking place on a massive scale. This push is being driven not the least by global economic developments, such as the price increase of agriculture commodities like coffee and cocoa. In most cases the indigenous communities become trapped between the state monopoly in natural resource management and the competition for resources by external actors. In this processes the indigenous communities start to lose their access to resources. Another victim in this process is the environment where the natural resources are imbedded. International and national organizations working to conserve environment have became conscious of the important role that indigenous people could fulfill as partners in this endeavour. This partnership in struggle has produced a new discourse on the relationship between indigenous people and their environment. As a further consequence, programs were set up to develop what became known as Community Based Natural Resource Management (CBNRM) with its numerous variations. Based on a case study in a village on the eastern border of the Lore Lindu National Park in Central Sulawesi, this study questioned the basic assumption behind the concept of Community Based Natural Resource Management (CBNRM). Namely the assumption that communities living at the margin of forest are socially and culturally homogenous, still more or less egalitarian, and basically living in harmony with their natural environment. This study was inspired by the persistent critique – although still a minority – on the basic assumption the CBNRM from academicians and practitioners working through the Entitlement perspective. Another inspiration was the mounting critique toward the participatory approach. In its effort the study explore further the usefulness of certain approaches. One of the approach much relied on in this study was the local history of the community studied, through exerting oral and local written documents on local history, legends and local stories. These sources proofed quite capable in bringing the local history into the light. Another was the actor oriented approach, which later came to be supported by the concept of Social Pool Resources. The latter concept proofed to be useful as analytical instrument to integrate social institutions and the common pool resources, as a field of action for the different actors as human agencies.

Serotonin discontinuation syndrome following utero exposure to antidepressant medication : prospective controlled study

Objectives: The aim of the present study was to examine neonatal symptoms previously reported to be associated with exposure to antidepressant medication in late pregnancy in a group of infants exposed to antidepressants, using a prospective and controlled design.

Method: A prospective case-control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy. Of the 27 women taking medication, 25 remained on medication in the third trimester and, of these, 23 women had complete data available. In pregnancy and after delivery women were assessed with the Beck Depression Inventory-II and a purpose-designed questionnaire. After delivery mothers were asked a set of nine questions pertaining to symptoms of discontinuation in their newborn and questions about pregnancy and delivery complications.

Results: There was an increased risk of discontinuation symptoms in neonates exposed to antidepressant medication in late pregnancy and an association with higher dose medication. The study group were found to be significantly more likely to display behaviour such as crying, jitteriness, tremor, feeding, reflux and sneezing and sleep for <3 h after a feed. They also had significantly higher rates of jaundice and admissions to the special care nursery.

Conclusions: Exposure to antidepressants in late pregnancy is associated with a range of symptoms in the neonate that are consistent with the effects of exposure to antidepressants in late pregnancy. The clusters of symptoms most highly correlated are the gastrointestinal and central nervous system symptoms. These finding helps to identify the common symptoms associated with a neonatal serotonin discontinuation syndrome.

Influence of peers on breastfeeding discontinuation among new parents : the Melbourne InFANT Program

OBJECTIVE We aimed to investigate whether the proportion of breastfeeding mothers in first-time parent groups influenced the likelihood of ceasing breastfeeding and whether this was independent of socioeconomic position.
METHODS Data were from 501 mothers (from 62 first-time parent groups initiated ~6 weeks after birth) who provided data at the baseline and mid-intervention assessments of the Melbourne Infant Feeding, Activity, and Nutrition Trial. Parent groups were divided into those in which ≤25% of mothers had ceased breastfeeding by 6 weeks (low-cessation groups) and those in which >25% had ceased by 6 weeks (high-cessation groups).
RESULTS With the exclusion of mothers who had already ceased breastfeeding by 6 weeks, the proportion of mothers who ceased breastfeeding between the time of parent group initiation (6 weeks) and 6 months was higher in high-cessation groups than in low-cessation groups (37.4% vs 21.7%; P = .001). After adjustment for maternal age, BMI, employment, and education and area-level socioeconomic position, membership in a group in which a large proportion of mothers had ceased breastfeeding by 6 weeks was strongly related to cessation of breastfeeding before 6 months (odds ratio: 2.1 [95% confidence interval: 1.3–3.3]).
CONCLUSIONS Attendance at parent groups where peers are breastfeeding infants of a similar age may have an important influence on the continuation of breastfeeding to 6 months. First-time parent groups or other similar groups may be an important setting in which to promote the continuation of breastfeeding.

The impact of contemporary contact lenses on contact lens discontinuation

Discontinuation or “dropout” from contact lens (CL) wear continues to afflict the CL industry. This study was conducted to determine whether the advent of new CL materials and designs has impacted the dropout rate and the reasons for discontinuation. Current and lapsed CL wearers residing in Canada were recruited using Facebook to take part in an on line survey investigating CL wearing experiences during 2008 to 2010 and to establish the percentage of participants who temporarily and permanently discontinued CL wear during the period surveyed. Four thousand two hundred seven eligible surveys were received (64% female; median age 27 years). Forty percent had lapsed from lens wear for at least 4 months; however, 62% of the lapsed wearers (LWs) resumed wear. There were no differences between LWs and nonlapsed wearers (NLWs) with respect to gender; however, LWs were older, started lens wear when older, and had not worn lenses for as long as NLWs (all P<0.001). More NLWs than LWs wore silicone hydrogel CLs (49% vs. 38%, P<0.001) and more LWs than NLWs wore daily disposable lenses and hydrogel CLs (24% vs. 19% and 22% vs. 18%, respectively, P≤0.001). Primary reasons for discontinuation were discomfort (24%), dryness (20%), red eyes (7%), and expense (7%). Compliance with lens replacement was no different between LWs and NLWs (48% vs. 45%). About 23% of those surveyed had discontinued CL wear permanently. The primary reasons for dropping out continue to be discomfort and dryness. Dropout rates were lower in silicone hydrogel wearers.

Association of pharmacogenetic markers with premature discontinuation of first-line anti-HIV therapy: an observational cohort study

Poor tolerance and adverse drug reactions are main reasons for discontinuation of antiretroviral therapy (ART). Identifying predictors of ART discontinuation is a priority in HIV care.

Learning from failure--rationale and design for a study about discontinuation of randomized trials (DISCO study)

Background Randomized controlled trials (RCTs) may be discontinued because of apparent harm, benefit, or futility. Other RCTs are discontinued early because of insufficient recruitment. Trial discontinuation has ethical implications, because participants consent on the premise of contributing to new medical knowledge, Research Ethics Committees (RECs) spend considerable effort reviewing study protocols, and limited resources for conducting research are wasted. Currently, little is known regarding the frequency and characteristics of discontinued RCTs. Methods/Design Our aims are, first, to determine the prevalence of RCT discontinuation for specific reasons; second, to determine whether the risk of RCT discontinuation for specific reasons differs between investigator- and industry-initiated RCTs; third, to identify risk factors for RCT discontinuation due to insufficient recruitment; fourth, to determine at what stage RCTs are discontinued; and fifth, to examine the publication history of discontinued RCTs. We are currently assembling a multicenter cohort of RCTs based on protocols approved between 2000 and 2002/3 by 6 RECs in Switzerland, Germany, and Canada. We are extracting data on RCT characteristics and planned recruitment for all included protocols. Completion and publication status is determined using information from correspondence between investigators and RECs, publications identified through literature searches, or by contacting the investigators. We will use multivariable regression models to identify risk factors for trial discontinuation due to insufficient recruitment. We aim to include over 1000 RCTs of which an anticipated 150 will have been discontinued due to insufficient recruitment. Discussion Our study will provide insights into the prevalence and characteristics of RCTs that were discontinued. Effective recruitment strategies and the anticipation of problems are key issues in the planning and evaluation of trials by investigators, Clinical Trial Units, RECs and funding agencies. Identification and modification of barriers to successful study completion at an early stage could help to reduce the risk of trial discontinuation, save limited resources, and enable RCTs to better meet their ethical requirements.