BMJ Evidenced-Based Medicine最新文献

{"title":"34 Overdiagnosis of low back pain","authors":"A. Traeger, Sweekriti Sharma, R. Buchbinder, I. Harris, Chris Maher","doi":"10.1136/BMJEBM-2018-111070.34","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.34","url":null,"abstract":"Objectives Low back pain cannot be overdiagnosed, at least not in the narrow sense of the word. However, it is a common symptom, and one that is often given a diagnostic label (slipped disc, pinched nerve, instability, arthritis, degeneration, and so on), despite there being no reliable way of determining the pain source in most cases. Once the symptom is labelled, however, the consequences begin to resemble those of overdiagnosis: many will experience no clinical benefit from receiving a diagnostic label, but will feel less well because of it, and are more likely to undergo costly, invasive treatments with questionable efficacy. We will present our current understanding of overdiagnosis of low back pain, discuss how low back pain might differ from other well-known examples of overdiagnosis, and detail efforts from within our research group and beyond to develop and evaluate solutions. Method If one were to consider the broader definitions of overdiagnosis proposed by Carter et al. (BMJ 2015;350:h869), healthcare for low back pain would have examples abound: disease mongering (‘Pain as the 5th vital sign’ campaign by US Veteran’s Affairs), overutilisation (spinal injections, opioids), overdetection (diagnostic imaging), overtreatment (spinal fusion surgery, early physiotherapy), and false positives (red flags for serious pathology). In 2013 Americans spent US$81.6 billion on care for low back pain. How did we end up here? Results Unlike other well-known examples, overdiagnosis of low back pain appears to have little to do with altering disease definitions or thresholds, or providing screening programs for the healthy. Some people with low back pain may receive no diagnosis but are overtreated. Conclusions We argue that many of the problems with overdiagnosis and overtreatment of low back pain arise because people enter a health system that is set up to encourage inappropriate care and discourage appropriate care.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"81 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124350477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"68 The stars back pain app – using real time emergency department data to address overdiagnosis","authors":"Macedo Gustavo, M. Oliveira, Noel Baidya, Hannah Storey, Bethan Richards, C. Maher","doi":"10.1136/bmjebm-2018-111070.68","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.68","url":null,"abstract":"Objectives When low back pain is managed in the emergency department overdiagnosis and overtreatment are common. Measuring this is usually cumbersome. An online data analytics and visualisation tool was designed and developed to capture, store, analyse and visually present ED care data of patients presenting with low back pain. Method This project was conducted in collaboration with the Performance Monitoring, System Improvement and Innovation Unit of the Sydney Local Health District (SLHD). An online data analytics and visualisation tool was designed and created using Qlik Sense® by a multidisciplinary team of researchers, clinicians, and information technology experts Results The online data analytics and visualisation tool (STARS Back Pain App) was developed within the SLHD Targeted Activity and Reporting System (STARS). It displays the total number of presentations for low back pain at the three SLHD’s EDs, as well as subsequent admissions to hospital. Data displayed in the app reflect ED practice for low back pain management, such as proportion of patients receiving: i) laboratory tests, ii) imaging, and iii) pain medications. The app also displays demographics and characteristics of patients, including age, gender, days and hours presenting, mode of arrival, and emergency triage category. The app allows interactive analysis using innovative visualisation techniques. Conclusions The STARS Back Pain App will provide emergency clinicians with a summary of their clinical performance. It will also allow us to efficiently measure unwarranted clinical variation and drive practice change using and audit and feedback approach to avoid inappropriate use of tests and treatments for low back pain.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"212 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125820864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"123 The psychosocial effects of a planned prostate biopsy on men with increased prostate specific antigen and suspected prostate cancer","authors":"Marika Jakusenoka, V. Silina, Oskars Jakusenoks, J. Brodersen","doi":"10.1136/bmjebm-2018-111070.123","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.123","url":null,"abstract":"Objectives Since the 1990’ties the incidence and prevalence of prostate cancer have increased across the higher-income countries of Northern, Western and Southern Europe, e.g., the incidence has increased from 3% to 10% per annum. At the same time the prostate cancer mortality has stayed stable or had a minor decrease, except for the Baltic States, where the mortality has increased steadily. There is still some contradiction in best available evidence if prostate antigen (PSA) screening and early identifying and treating prostate cancer can reduce prostate cancer mortality. On the other hand, PSA screening and early diagnosis could lead to overdiagnosis of prostate cancer and thereby overtreatment for those men treated for the cancer. This leaves undesirable effects on the men’s psychosocial and physical health. The aim of this study was to explore the potential psychosocial effects of prostate biopsy on men due to suspected cancer. Method A qualitative study was conducted at the outpatient clinic of Pauls Stradins Clinical University Hospital (Riga). We included men aged from 50 to 70 of various education levels, increased PSA levels and with no prior prostate biopsy. Specific PSA level and/or abnormal findings during digital rectal examination were not set as the pre-determinative inclusion criteria. Multi-morbid patients and those with prior biopsy were excluded. Semi-structured interviews were audio recorded, transcribed and subsequently analysed, using the Strauss and Corbin concepts: open, axial and selective coding, which identifies the main themes common to all interviews. Results Seven volunteers with an elevated PSA level and abnormal findings during a digital rectal examination were interviewed while awaiting prostate biopsy. The PSA test before referral to the biopsy was performed in interviewees with and without symptoms and was initiated by urologists, general practitioners or patients themselves. The majority of men felt anxiety and fear prior to the planned prostate biopsy. The men indicated that they had received an insufficient amount of information about the planned procedure. Some of interviewees had been seeking additional information about the procedure, while others had not. Psychosocial effects such as irritability, deterioration in relationships with relatives, denial, a feeling of hopelessness, despair, and pessimism about their future lives were identified. Knowledge of interviewees regarding PSA test was low and mostly related to prostate cancer. Conclusions Negative psychosocial experiences were identified in all patients before the expected prostate biopsy. The study implies that discomfort might be mitigated by providing detailed information about the planned procedure itself and its significance.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125836181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"53 Overinvestigation in the elderly? the role of guidelines on emergency intracranial imaging: experience from a DGH","authors":"R. Kulanthaivelu, G. McInnes","doi":"10.1136/BMJEBM-2018-111070.53","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.53","url":null,"abstract":"Objectives The aim of our project was to illustrate the effects that recent NICE head injury and stroke guidelines have had on the role of emergency intracranial imaging in patients older than 75 years and identify the reasons for this. Method We looked at the number of CT head scans performed in patients over the age of 75 years in the emergency department during the course of a month in 2013 (before the NICE head injury guidelines were updated) and compared this with those performed during a comparable time period in 2018. We analysed the number, the indications and compared these with those outlined in the NICE head injury, NICE and RCP stroke guidelines. Results During June 2013, 22 patients over 75 years were scanned compared with 139 in March 2018. Head injury (45% in 2013, 57% in 2018) followed by stroke (36% vs 29%) and other (headache, collapse, confusion) (14% vs 18%) were listed as indications, however the proportion of positive findings reduced in 2018 from 41% to 11% (9 to 11 patients). 54% of those performed for head injury in 2018 strictly complied with head injury guidelines. These guidelines are however open to interpretation, for example, although imaging for patients on NOACs is not explicitly advised, it is for bleeding disorders. On analysis of clinical information provided, multiple risk factors identified in each of these guidelines, were often listed as indications for intracranial imaging, rather than differential diagnoses. Incidental findings increased in 2018 (4%) and a number of patients underwent multiple CT scans in the preceeding 3–6 months for the same indication (2%). Conclusions Guidelines have reduced the threshold for imaging elderly patients and encouraged a shift towards investigation based on risk factors rather than individual circumstances. This unsurpisingly, has resulted in over investigation of elderly patients in particular, who often have multiple comorbidities and are subsequently at higher risk. Additionally, the increasing porportion of elderly patients in the population and seeking urgent care are factors to be considered. The only way investigations can be rationalised is through better assessment of elderly patients (a view that is shared by the Royal College of Emergency Medicine). This is difficult, especially against a background of defensive medical practice. However, even the smallest improvement can have significant cost saving implications, and so by increasing awareness we hope to shift the focus back to choosing the right investigations at the right time for the right patient, as surely this is ultimately in the patient’s best interests?","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"42 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126038178","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"28 A cochrane review of strategies to increase adoption of the ottawa ankle rules and reduce unnecessary imaging","authors":"J. Zadro, A. Dario, C. Maher","doi":"10.1136/bmjebm-2018-111070.28","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.28","url":null,"abstract":"Objectives The aim of this review is to establish the effectiveness of existing strategies to increase adoption of the Ottawa Ankle Rules (OARs) and reduce ankle/foot imaging. Method We will conduct a Cochrane systematic review according to the Methodological Expectations of Cochrane Intervention Reviews standards, within the Cochrane Musculoskeletal Group. A comprehensive keyword search (combining terms synonymous with ‘implementation’ and ‘Ottawa Ankle Rules’) will be performed in MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, Scopus and Web of Science from the earliest record to the time of search. Additional articles will be identified by hand-searching references lists and forward searching of included articles. We will include randomised controlled trials, uncontrolled trials, and interrupted time-series investigating strategies to increase adoption of the OARs. The primary outcome will be documented adherence to the OARs. The proportion of unnecessary ankle/foot imaging requests and the total number of ankle/foot imaging requests will be secondary outcomes. Two reviewers will independently perform the selection of studies, extract key data (e.g. trial characteristics, intervention parameters, outcomes), and assess the risk of bias of included studies. Results We anticipate to have extracted all study data by the conference and are confident we will be able to present preliminary results. Conclusions Nearly 10% of people suffer an ankle injury in their life; but although less than 20% have a fracture, 70%–95% receive imaging. In the absence of a fracture, imaging does not inform management and exposes patients to unnecessary/potentially harmful radiation. The OARs are a clinical decision tool with nearly 100% sensitivity for ruling out ankle/foot fractures, thereby indicating those who don’t require imaging. These rules have been validated in numerous countries, endorsed in practice guidelines for over two decades, and more recently included in Choosing Wisely lists. Successful implementation of the OARs could reduce unnecessary ankle/foot imaging and time spent in emergency departments. However, the OARs aren’t commonly used in practice. Identifying effective strategies to increase adoption of the OARs could reduce unnecessary ankle/foot imaging among various healthcare professionals and guide implementation activities to reduce low-value care across health disciplines.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127201257","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"82 Defining overdiagnosis of mental health disorders: secondary analysis of an overdiagnosis scoping review","authors":"K. Turner, I. Shrier, B. Thombs","doi":"10.1136/bmjebm-2018-111070.82","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.82","url":null,"abstract":"Objectives The term ‘overdiagnosis’ was first used as early as 1924, when J. D. Adamson used it to describe negative implications of attempts to achieve early diagnosis of pulmonary tuberculosis (CMAJ, 1924). Since then, the term has been used most frequently to describe negative outcomes from screening for early-stage asymptomatic cancers. Typical definitions describe overdiagnosis as detection of early-stage asymptomatic conditions that would never have led to morbidity or mortality. In other areas, including mental health, overdiagnosis can occur among people who experience symptoms but whose symptoms do not reflect disorders and may not be amenable to healthcare interventions. Thus, more recent alternative definitions have focused on diagnosis among people who would not be expected to experience net benefit. The degree to which such definitions have been adopted is not clear. Our objective was to describe how the term overdiagnosis has been defined explicitly or operationalized implicitly in mental health. Method A scoping review of overdiagnosis across medical disciplines searched PubMed in August 2017 for published articles that used keywords related to overdiagnosis. Articles from the scoping review were eligible for the present analysis if they were classified in the scoping review as related to mental health, excluding neurocognitive disorders, and if they used the term overdiagnosis in the text of the article and not just in the title. We extracted basic information about the article and whether it included an explicit or implicit definition of overdiagnosis. Explicit definitions were extracted. If the definition was implicit, the reviewer provided an explanation of how overdiagnosis was operationalized in the study or article. Data were extracted by one reviewer with validation by a second reviewer, and any disagreements resolved by consensus. Explicit and implicit definitions were grouped into categories by one investigator and verified by a second investigator. Results 148 articles were included. Of the 14 articles that explicitly defined overdiagnosis, 9 defined it as a false positive diagnosis, 2 as misdiagnosis (diagnosing people with one disorder rather than another), 1 as diagnosis of an individual who would not be expected to benefit from treatment, and 2 had vague descriptions. In the other 134 articles, implicit definitions fit into 4 categories; 68 articles implicitly defined overdiagnosis as diagnosis of people who do not meet diagnostic criteria, 59 as misdiagnosis, 13 as diagnosis resulting from overly broad or changed diagnostic criteria; and 2 as no net benefit from diagnosis. There were 13 with unclear or difficult to classify definitions. There was overlap of definitions with several articles fitting into more than one category. The most significant overlap involved 13 articles that were classified as both misdiagnosis and diagnosis of people who do not meet diagnostic criteria. Conclusions Definitions of overdiagnosi","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125406514","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"79 The impact of orthodontic treatment regulation in the german public health sector on the overuse of orthodontic services","authors":"A. Spassov, B. Braun, D. Pavlović, H. Bettin","doi":"10.1136/bmjebm-2018-111070.79","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.79","url":null,"abstract":"Objectives The provision of orthodontic (dental) care is part of the German Public Health sector comprising 90% of German population. The current regulations for the provision of orthodontic care in the public sector have been adopted in 2004 as a negotiation-process between providers and public health insurance companies without patient participation. To date patient-related data on the impact of the 2004 regulation on the quality and quantity of orthodontic services are lacking. In addition, patients (mostly adolescents) preferences and perceptions toward orthodontic treatment are almost unknown. Therefore, we first examined the content of the 2004 regulations in terms of formal criteria for treatment access, diagnostic and treatment guidelines as well as treatment duration. Secondly, we analyzed medical health record data to obtain information on real utilization of orthodontic services as diagnostic and treatment procedures. Finally we examined patient’s preferences and their role in the decision-making process. Method In the first stage we examined the formal criteria of the regulation of orthodontic services regarding treatment access, appropriateness criteria for diagnostic and treatment procedures as well as quality control. In the second stage we surveyed adolescents aged 10 to 14 years (n=2.991, 29% response rate) insured by a public health care insurance company before or at the beginning of treatment related to their perceptions of toward orthodontic treatment need using validated and standardized questionnaires. Finally, in the third stage we analyzed medical record data of patients undergoing orthodontic treatment from 2012–2017 (n=5.514) insured by a second, independent public health care insurance company to obtain quantitative data on the real utilization of detailed orthodontic services including diagnostic records, treatment procedures, costs as well as treatment duration time. Results Treatment guidelines adopted 2004 are mandatory for both providers and insurance companies. They regulate access through objective criteria and define criteria for the use of diagnostic and treatment procedures. Parallel guidelines adopted simultaneously regulate payment system and quality control. The described regulation has following impact on utilization of orthodontic services: Diagnostic procedures as panoramic X-ray and cephalograms were performed routinely (85%–90%) although their use is limited to defined diagnoses according to radiation guidelines and should not exceed 30%. About 64% of the patients received removable appliances despite their inappropriateness and inefficiency in comparison to fixed appliances. The mean treatment duration time was 36 months given that the published standard for a mean duration should be no longer than 18–20 months. Dentists were reported (81% of respondents) to be the primary driver for patients to start treatment. 93% of the patients reported to no complaints before starting treatment. Conclusions The ","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"17 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117123012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"98 Sarcopenia: a case study in how the phenomenon of overdiagnosis is generated","authors":"J. Bülow, L. Holm, J. Brodersen","doi":"10.1136/bmjebm-2018-111070.98","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.98","url":null,"abstract":"Objectives In 1989 the term Sarcopenia was introduced to describe the phenomenon of age-related loss of muscle mass. From 2010 to 2014 six consensus definitions were presented based on the previous two decades of research within the field of sarcopenia. Despite the fact that loosing muscle mass originally was seen as a normal process of ageing, it was classified as a disease in 2016 and dedicated its own ICD-10 code. The arguments for classifying age-related loss of muscle mass as a disease put forth by the consensus papers and leading scientist in the research field of sarcopenia are sparse and use tautological reasoning in its attempt to legitimate this transformation. The purpose of the study is firstly to clarify whether or not Sarcopenia is another case of overdiagnosis due to overdefinition, and if so, secondly to give new insight in how the phenomena of overdiagnosis arise. Method The analysis in this study is based on an historical approach to the scientific literature on Sarcopenia. An understanding of the transformation of the phenomenon from normal to pathological will be approached by analysing the conceptualization of sarcopenia in cornerstones articles in the research field of sarcopenia chronological from the introduction of the concept through the different decades up until its admission in ICD-10. The current consensus definitions of Sarcopenia and the argumentation for its admission in ICD-10 will be compared to the general understanding of the concept of overdiagnosis, to clarify whether or not this new disease is a case of overdiagnosis. Results During the decade of 1990 the transformation of sarcopenia from a normal to a pathological condition started. The phenomenon was made guilty by association to both mortality and decreased physical function, with the problem that over 50% of the population over 80 years would be considered as sarcopenic. From 2000 a decreased physical function became a criterion, to narrow down the amount of patients categorized with sarcopenia, in the effort of legitimizing it as an independent pathological phenomenon. It culminated in admission of an ICD-10 code in 2016, which put Sarcopenia in line with other age-related diseases such as osteoporosis, diabetes and hypertension. Comparing the consensus definitions with the concept of overdiagnosis, Sarcopenia seems to be a case of overdefinition. The change of the conception of Sarcopenia from a normal to a pathological process is a lowering of the threshold of what we in general categorize as disease. Conclusions With the rewarding of an independent ICD-10 code and its acceptance as a disease in the geriatric research field, Sarcopenia has become another example of the increase in overdiagnosis in especially the modern western societies. Despite differences in historical development the definition of Sarcopenia shows great similarities with other phenomena such as osteoporosis and hypertension where overdiagnosis is present. The historical analysis o","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"38 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126724499","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"95 Challenges and uncertainties regarding polycystic ovary syndrome (PCOS) and the potential for overdiagnosis: clinicians’ views and experiences","authors":"T. Copp, J. Hersch, J. Doust, K. McCaffery, A. Dokras, Anuja Dokrasl, J. Jansen","doi":"10.1136/bmjebm-2018-111070.95","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.95","url":null,"abstract":"Objectives The diagnostic criteria for polycystic ovary syndrome (PCOS) were broadened by experts in 2003, resulting in the inclusion of women with milder forms. This has contributed to a substantial increase in the number of women diagnosed. PCOS is associated with adverse reproductive, metabolic and cardiovascular outcomes, however not all women fitting the expanded criteria may be at risk. Although signs of PCOS often first appear during adolescence, symptoms of PCOS overlap with normal signs of pubertal development, making diagnosis challenging. Currently there are no clear criteria to differentiate normal variability from the abnormality of PCOS, especially in young women. Although the diagnosis is appropriate and beneficial for some women, such as those with severe forms, the benefit is uncertain for women with milder variants of the syndrome. We aimed to understand clinicians’ views about PCOS, and how they manage and communicate these uncertainties with their patients in practice. Method Doctors who diagnose and manage adult and/or adolescent women with PCOS (general practitioners, endocrinologists and gynaecologists) around Australia were recruited via professional organisations, specialist groups and through snowballing. We conducted 30 semi-structured telephone interviews. Topics included challenges and uncertainties with diagnosis and management of PCOS, patient communication, benefits and harms of a diagnosis, and the potential for overdiagnosis. Interviews were audio-recorded, transcribed and analysed thematically. Results Clinicians expressed a range of views regarding the uncertainties in the diagnosis and management of PCOS. Many clinicians reported difficulties with dispelling women’s preconceptions about PCOS (e.g. never able to conceive) as a result of misinformation online, and discussed the challenges with communicating the unpredictability of long-term consequences. Many clinicians expressed the importance of early diagnosis as it provided the opportunity to make lifestyle changes and initiate family planning. On the other hand, others were cautious about labelling women prematurely or inaccurately, and hesitant to discuss long-term consequences in the first consultation out of concern it might cause unnecessary anxiety, especially for adolescents and young women. Conclusions Clinicians who diagnose and manage PCOS provide valuable perspectives regarding the current issues surrounding diagnostic criteria and uncertainties regarding diagnosis and management. The key findings and their implications for future research and clinical practice will be discussed, such as the importance of effective communication and tailored care in minimising the potential harmful impact of the diagnosis and improving patient-centred outcomes.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129002859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"72 Is there really an epidemic of vitamin D deficiency? an investigation of the evidence base for vitamin D supplementation","authors":"M. Bolland, A. Grey, A. Avenell","doi":"10.1136/bmjebm-2018-111070.72","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.72","url":null,"abstract":"Objective Rickets and osteomalacia are rare diseases caused by vitamin D deficiency. The US Institute of Medicine considers that there is a risk of vitamin D deficiency with serum 25(OH)vitamin D<30 nmol/L, and potential risk between 30–50 nmol/L, relying on evidence from surrogate markers, e.g. parathyroid hormone suppression, unmineralised bone on biopsy. 25(OH)D shows considerable analytical variability, is not the bioactive metabolite, and is expensive to measure. Academic enthusiasm for, media coverage of, and public interest in, vitamin D supplementation to prevent a wide range of diseases, with some claims that serum 25(OH)D≥75 nmol/L is optimal, have led to marked increases in requests to measure 25(OH)D (119% increase in NE Scotland over 4 y). We investigated whether clinical endpoints from randomised controlled trials (RCTs) supported supplementation for diseases other than rickets and osteomalacia. Method In December 2015, we searched Pubmed, recent systematic reviews, and trial registries for RCTs of vitamin D with surrogate or clinical endpoints in adults. We examined whether vitamin D affected a range of clinical endpoints according to baseline 25(OH)D status, whether mean/median baseline 25(OH)D in RCTs changed over time, and whether ongoing trials will evaluate clinical endpoints from vitamin D supplementation in populations at risk of deficiency. Results We found 547 RCTs of vitamin D supplementation, with 137 reporting clinical endpoints, and 118 reporting baseline 25(OH)D. Mean/median baseline 25(OH)D was <25, 25–49,≥50 nmol/L in 12 (10%), 62 (53%), and 44 (38%) of RCTs, respectively. No effect was evident for nonskeletal outcomes in the full dataset. Of 12, mostly small, RCTs in populations with 25(OH)D<25 nmol 8 had neutral results and 4 showed benefit (3 primary endpoints, 1 secondary endpoint). Trials reporting subgroup analyses for 25(OH)D<20–32 nmol/L recapitulated the main analyses in all 7 trials, with only 1 trial showing benefit. Baseline 25(OH)D increased over time, and large (≥1000) ongoing trials are likely to have baseline 25(OH)D >40–50 nmol/L. Conclusions The evidence supporting supplementation with vitamin D in populations with 25(OH)D<25 nmol/L is weak for outcomes other than rickets and osteomalacia, and does not suggest benefit above this threshold. Assessing vitamin D status for healthy populations, with little risk of rickets or osteomalacia from very low sunlight exposure, is not clinically useful.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115799886","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}