ket. A biosimilar of Sanofi's popular insulin Lantus was approved for use in the European Union in 2014 but was initially delayed for 2 more years by a lawsuit in the United States. 6 Now that the biosimilar product, Basaglar, has finally hit the market, its price is only minimally lower than the original brand. 7 The same insulin pen that retails for $140 in the United States costs less than $15 in Germany and Canada. 8 The US insurance system-private and public-does not cut people with chronic disease a break but instead tends to penalize them. People with type 1 diabetes are people who drew a short straw in the disease lottery. Most other developed countries have concluded that their citizens should therefore not be subject to copays or high deductibles. "If you have a chronic disease, you shouldn't be burdened by the cost," York F. Zöllner, a professor of health economics at Hamburg University of Applied Sciences, told me in an interview for the New York Times before explaining the German approach, in which out-of-pocket contributions for insulin are less than $100 per year. 9 Until very recently, the disease foundations (JDRF and the American Diabetes Association among them), as well as many diabetes patient groups, did not protest much as the prices rose, in part likely because so many receive funding from pharmaceutical companies. Extreme prices can lead to extreme solutions. A 29-year-old student in Missouri with diabetes whom I interviewed for my book 10 told me that she would only consider doctoral programs outside of the United States. "My one goal in life has been to move to Europe so I don't have to pay these staggering prices just to survive," she said. But others-that 25%-will quietly skimp on their insulin, taking less than they need but more, perhaps, than they can really afford. Some of them will die.
We examined the frequency of diabetic ketoacidosis (DKA) in cannabis users compared with nonusers in the T1D Exchange clinic registry (T1DX). RESEARCH DESIGN AND METHODSThe association between cannabis use by total substance score for cannabis (TSC) and DKA in the past 12 months was examined using a logistic regression model adjusted for potential confounders among adults in the T1DX. RESULTSOf 932 adults with type 1 diabetes, 61 had a TSC >4, which classified them as moderate cannabis users. Adjusting for sex, age at study visit, and HbA 1c , cannabis use was associated with a twofold increase in risk for DKA among adults with type 1 diabetes (odds ratio 2.5 [95% CI 1.0-5.9]). CONCLUSIONSCannabis use was associated with an increased risk for DKA among adults in the T1DX. Providers should inform their patients of the potential risk of DKA with cannabis use.Cannabis is the most commonly used illicit drug in the U.S. (1), and recent legislation has made cannabis legal for either medical or recreational use in more than half of states. Cannabis use among people with type 1 diabetes is not well described in the literature, but evidence from adolescents suggests that it does not differ from the general population (2). Delayed gastric emptying and reduced gut motility as a result of inhibition of the intrinsic cholinergic system have been shown in humans (3). Cannabis hyperemesis syndrome (CHS) has also been implicated in recurrent episodes of diabetic ketoacidosis (DKA) in patients with type 1 diabetes (4). The gastrointestinal effects of cannabis are not broadly recognized, and the primary reason for cannabis use in most users is recreational. Cannabis-induced alterations to gut motility, food absorption, and postprandial glycemic timing may be unexpected and inconsistent for the typical cannabis user with type 1 diabetes. A single-center study from Colorado showed an association between DKA and cannabis use in people with type 1 diabetes compared with non-cannabis users with type 1 diabetes (5). If this association between cannabis use and DKA holds true in the general population of people with
OBJECTIVE To assess production animal medicine veterinarians' prescription practices and identify factors influencing their use of antimicrobial drugs (AMDs) and their perceptions of and attitudes toward antimicrobial resistance (AMR). SAMPLE 157 production animal veterinarians in the United States. PROCEDURES An online cross-sectional survey and digital diary were used to gather information regarding perceptions on AMD use and AMR and on treatment recommendations for production setting-specific disease scenarios. Results were compared across respondents grouped by their selected production setting scenarios and reported years as veterinarians. RESULTS The most commonly selected production setting disease scenarios were dairy cattle (96/157 [61.1%]), backgrounding cattle (32/157 [20.4%]), and feedlot cattle (20/157 [12.7%]). Because few respondents selected swine (5/157 [3.2%]) or poultry (4/157 [2.5%]) scenarios, those responses were excluded from statistical analysis of AMD prescription practices. Most remaining respondents (147/148 [99.3%]) reported that they would recommend AMD treatment for an individual ill animal; however, responses differed for respondents grouped by their selected production setting scenarios and reported years as veterinarians when asked about AMD treatment of an exposed group or high-risk disease-free group. Most respondents reported that government regulations influenced their AMD prescribing, that owner and producer compliance was a veterinary-related factor that contributed to AMR, and that environmental modifications to prevent disease could be effective to mitigate AMR. CONCLUSIONS AND CLINICAL RELEVANCE Results of the present study helped fill important knowledge gaps pertaining to prescription practices and influencing factors for AMD use in production animal medicine and provided baseline information for future assessments. This information could be used to inform future interventions and training tools to mitigate the public health threat of AMR.
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