BMJ Evidenced-Based Medicine最新文献

{"title":"49 Applying the checklist for modifying the definition of disease to attention deficit/hyperactivity disorder (ADHD) age of onset criterion (AOC)","authors":"Rae Thomas, S. Sanders, P. Glasziou, J. Doust","doi":"10.1136/bmjebm-2018-111070.49","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.49","url":null,"abstract":"Objectives Widening disease definitions is a major driver of overdiagnosis. In response, the Preventing Overdiagnosis working group of the Guidelines International Network developed a checklist to provide guidance on issues to consider when modifying disease definitions. This checklist recommends panels outline definition changes and the trigger for change, and examine research informing the potential changes to prevalence, the prognostic ability and precision of the disease definition, the potential benefits and harms of the disease definition and balance between them. Using this checklist as a framework, we examined the documented considerations of the panel responsible for modifying the ADHD diagnostic criteria, focusing on the age of onset (AOC) criterion, which widened the definition by changing the requirement that symptoms causing impairment need to be present before the age of 7 (DSM-IV), to the presence of symptoms before age 12 (DSM-5). Method For the checklist items requiring panels consult research studies (e.g. prevalence, prognosis, precision, benefit and harm), we examined the research considered by the panel modifying the DSM-IV ADHD AOC. We recorded the research studies identified by the panel and described how these informed their conclusions. We appraised these studies for risk of bias (ROB), and on their ability to address the checklist item (e.g. limitations in design and generalisability). We conducted searches to identify research that would have been available to the panel at the time of the modification and compared it to the research considered by the panel. We also identified studies related to checklist items published since the modification, assessed ROB, extracted data and compared the consistency of findings of these studies to the conclusions reached by the panel. Results DSM-5 panel documentation cited two studies: a ‘systematic literature review’ of studies related to the AOC conducted by panel members (the methods of this study were not documented), and a longitudinal cohort study assessing prevalence. Cited within the review, were studies we assessed as related to some checklist items (precision, prognosis and benefit) however no reference to these constructs were reported in the document and no systematic appraisal of this research or comment on the strength of the evidence was provided. The cohort study reported ‘negligible’ change in prevalence. We appraised the ROB in the cohort study to be low, however, study design precluded confidence in the prevalence estimate, and subsequent research reported larger prevalence increases with AOC changes. We found overlap in the studies identified by the panel and the studies we identified as being available at the time which we assessed for ROB and strength of evidence. Conclusions Minimal documentation of the considerations and decisions of the panel limits transparency and makes it impossible to judge the rigor of the process behind the modifications to ADHD diagnost","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"15 12 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":"127667233","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":"105 Mapping ghost management in medical research and public health","authors":"C. Riva, Serena Tinari","doi":"10.1136/bmjebm-2018-111070.105","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.105","url":null,"abstract":"Objectives At the Preventing Overdiagnosis Conference 2017, Marc-André Gagnon (Carlton University, Ottawa) built on the concept of ghost management in science (Sergio Sismondo) to develop a reflection on corporate capture and institutional corruption in the biopharmaceutical sector. He postulates that because of the current business model, the activity of pharmaceutical firms is more oriented towards producing influence on medical knowledge and social determinants of value, than towards producing innovative treatments. We wanted to verify the validity of this hypothesis by mapping the strategies and issues highlighted in three long-form Re-Check investigations on 3rd and 4th generation oral contraceptives, systematic breast cancer screening and HPV vaccines. Method Search for documents as well as for scientific and mainstream publications, FoIA requests, journalistic investigative methods, Re-Check evaluation grids and mapping tools. Results The mapping of our investigations confirms the hypothesis put forward by Gagnon. Our maps show ghost management at work in the case of these three health measures targeting healthy girls and women. Ghost management is practiced by the pharmaceutical industry, but also by other players in the health system (health authorities, regulatory authorities, research centers, NGOs) as soon as the stakes reach a critical size. Our maps illustrate how this ‘new model of science (…) drawing its authority from traditional academic science’ (Sismondo) is an effective strategy for capturing the different levels identified by Gagnon: science, regulation, market, health professions, media, technology and civil society. Conclusions Re-Check mapping highlighting ghost management currently at work in medical research and public health confirms Gagnon’s hypothesis (Sismondo’s concept). Such methods deserve to be developed, enriched, validated and applied by academic research. They should also become part of an evaluation grid used by journalists investigating pharmaceutical companies and health system’s players: organizations devoted ‘to influence ideas and social structures in a way that maximizes commercial value’ (Gagnon) and strengthens their position. The more investigations and academic research document the phenomenon, the better it may enable to develop solutions and transform institutional structures and medical practices to stem this endemic corruption.","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":"130342804","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":"31 Psychosocial consequences of participating in a national colorectal cancer screening programme","authors":"Jessica Malmqvist, V. Siersma, Mie Sara Hestbech, J. Brodersen","doi":"10.1136/bmjebm-2018-111070.31","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.31","url":null,"abstract":"Background Screening for life-threatening diseases has potential benefits and harms. In screening for colorectal cancer (CRC) some potential harms are the negative psychosocial consequences of being diagnosed with polyps or receiving a false-positive result. In 2014 a national CRC screening programme was implemented in Denmark, using an immunochemical faecal occult blood test (iFOBT) as the screening method and targeting all citizens aged 50–74. In the implementation period of the screening programme (2014–2017) citizens were invited to participate in a randomised design. According to the latest Danish CRC screening report from 2016, the positive rate has been approximately 7%. All citizens with positive results were urged to have a colonoscopy where subsequently 63.5% had a clean colon or benign polyps, 31% had adenomatous polyps and 5.5% were diagnosed with CRC. Hence, thousands of healthy people have undergone a colonoscopy to confirm that they do not have CRC. Moreover, thousands of people were diagnosed with polyps: benign and adenomatous. Previous studies investigating psychosocial consequences of CRC screening have shown diverging results. However, all these studies were performed using generic questionnaires, which have shown not to be adequate in measuring psychosocial consequences in a medical screening setting. Objectives The objective of this study was to investigate psychosocial consequences of participating in a national colorectal cancer screening programme, with a condition-specific questionnaire specifically developed for measuring psychosocial consequences in a CRC screening setting. Method The study was a longitudinal study with a randomised design. We performed data collection in the Region Zealand county of Denmark in the period of April 2017 – March 2018. We enrolled participants with a positive iFOBT consecutively and matched them on gender, municipality and year of birth in a 2:1 design with citizens with negative results, non-attenders and a control group randomised to screening in the last part of 2017. We sent a condition-specific questionnaire four days after the participants received their iFOBT result and again eight weeks after the final diagnosis. The primary outcome was psychosocial consequences measured by a condition-specific questionnaire. Results Preliminary results and conclusions will be presented at the conference.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"2014 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":"130967073","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":"102 Oral iron supplementation in pregnancy in austria: haphazard usage","authors":"Ulrike Spary-Kainz, T. Semlitsch, Sophie Rundel, A. Avian, S. Herzog, Heidelinde Jakse, A. Siebenhofer","doi":"10.1136/bmjebm-2018-111070.102","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.102","url":null,"abstract":"Objectives Iron-deficiency anemia is common in pregnancy, with a prevalence of about 16% in Austria. International guideline recommendations on regular anemia screening (none/once/twice) and treatment with iron preparations are inconsistent. Regardless of anemia screening guideline, recommendations for pregnant women might vary from routine intake with different daily dosages to no routine iron supplementation. The aim of our study was to identify how often pregnant women take iron or iron-containing multivitamin supplements, and to find out when they started and who recommended they do so. Method This cross-sectional study was conducted at the Mother-Child-Booklet (MCB) service center of the Styrian Health Insurance Fund in Graz, Austria. A questionnaire with 7 questions was developed and piloted by our study team, a psychologist, and an expert from the MCB service center. The 7 questions covered existing anemia diagnoses, current intake of iron-containing supplements, details on who recommended taking them, dosages, brand names, and socioeconomic data. The sample size calculation was based on a pre-examination of 70 pregnant women that indicated that, assuming a dropout rate of 10%, 322 pregnant women would have to be included to reach the targeted sample size of 289. Absolute and relative numbers and corresponding 95% confidence intervals were calculated using bootstrapping techniques. The study was approved by the Medical University of Graz ethics committee. Results 325 women completed the questionnaire. 62.1% were over 30 years of age, and for 51.7% it was their first pregnancy. 10.8% (n=35) were diagnosed with anemia before becoming pregnant. 72.9% (237/325, 95% CI: 67.7% to 77.8%) reported taking an iron or multivitamin supplement during pregnancy. 45 different products were taken, but 61% of women took one of three different supplements. Of the 185 women that were not diagnosed with anemia before becoming pregnant but reported taking an iron containing supplement, 78.4% (n=145) took it regularly and 28.1% (n=52) started before they knew they were pregnant. 88.6% (n=164) took supplements on the recommendation of their doctor. 11.9% (n=22) on the recommendation of family or friends and 4.9% (n=9) on the advice of a pharmacist. Conclusions Overall, 67% of pregnant women in our cohort were taking iron-containing compounds, irrespective of whether they were deficient in iron or not. Doctors were predominantly responsible for advising them to take it. No standardized procedure is available on which to base the decision to take iron during pregnancy, even in guidelines. Much more information on the harms and benefits of iron supplements should be provided to health care professionals, pharmacists and pregnant women, so they can make an informed decision on whether to take them.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"115 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":"132039527","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":"137 Audiologic monitoring of cisplatin ototoxicity in cancer treatment of adults: a balance between overdiagnosis and patient safety?","authors":"M. Rhainds, M. Bussières, S. L'esperance, A. Nourissat, M. Coulombe","doi":"10.1136/BMJEBM-2018-111070.137","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.137","url":null,"abstract":"Objectives Cisplatin, despite its effectiveness against various malignancies, can lead to serious side effects such as ototoxicity. However, ototoxicity monitoring has been shown inconsistent during drug treatment for adults. Over the last few years, a protocol on systematic audiologic monitoring for ototoxicity in adults receiving chemotherapeutic treatments has been developed by the audiology department of our hospital. Due to limited resources to manage a high volume of patients, the audiology department was unable to fully implement the protocol. The main objective of this project was to evaluate the most suitable approach to manage audiologic monitoring in adults receiving cisplatin. Method Literature searches were conducted in several databases and grey literature to retrieve data on audiologic monitoring and cisplatin ototoxicity in adults including systematic reviews, guidelines and primary studies. Two review authors (MB and SL) independently performed document selection, methodological quality assessment and data extraction. A web-based survey was carried out in 2017 to document the clinical practice of audiologists in Québec for cisplatin ototoxicity management. A local survey in our institution was also performed to describe roles and involvement of pharmacists, hematologist-oncologists and specialized oncology nurses relative to cisplatin ototoxicity monitoring. Data extraction from Electronic Patient Record (EPR) were performed to review local practice regarding cisplatin ototoxicity monitoring in 125 adults treated from 2015 to 2017. Evidence-based review and local perspective were shared with an interdisciplinary group including oncologists, audiologists, pharmacists, oncology nurses and hospital managers. Results Six publications specific to cisplatin ototoxicity monitoring in adults were retrieved. Clinical practice guidelines suggested that an audiologic monitoring program should be available for all patients including repeated audiologic tests. Results from literature and Quebec web-based survey showed that audiologic monitoring programs are often unknown and not always enforced in clinical practice. In our hospital, data from the EPR suggested that audiologic consultation before starting, during or after stopping chemotherapeutic treatments was performed in 35 patients (28%), mainly for head and neck cancer, and high cisplatine dose. Results from the local survey highlighted concerns about the chemotherapy treatment decision making process when ototoxicity is diagnosed and the importance of communication between audiologists, oncologists, pharmacists, nurses and patients. Threshold level to interpret audiologic tests was also among the concerns because of the risk of overestimating patients having nonsignificant hearing loss, and the consequences of less effective anticancer treatment options. Conclusions Results suggest that audiologic monitoring in adults under cisplatin cannot rely only on audiometric testing by audiologis","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":"130757129","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":"119 Polypharmacy and acuity among emergency department short stay unit patients","authors":"Jack Xu, T. Schmidt","doi":"10.1136/bmjebm-2018-111070.119","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.119","url":null,"abstract":"Background Emergency department (ED)-based short-stay units (SSUs) have been implemented globally with the primary scope of accommodating non-emergent, self-care sufficient adult patients who need either diagnostic tests, observation, or short-term treatment. Recently there has been a trend towards admitting patients with more complex disease to SSUs. Mainly because of increasingly overcrowded internal medicine departments. Objectives To investigate and evaluate the current patient clientele at a SSU, with an emphasis on polypharmacy. Methods We conducted a single center SSU point-prevalence study. Data collection included patients’ gender, age, Danish Emergency Process Triage (DEPT) acuity ranking upon admission (in order of decreasing severity: red, orange, yellow, green), primary diagnosis, number of active medications and types of medications. Results Out of 15 patients there were 10 men, mean age 70.3 (±SEM 4.16), and 5 women mean age 68.2 (±SEM 5.86), p=0.775. DEPT acuity ranking among men: 50% yellow, 50% green; among women: 20% orange, 60% yellow, 20% green. The most common diagnoses upon admission were pneumonia (33%), exacerbation of chronic obstructive pulmonary disease (27%), and the need of blood transfusion due to malignancy-induced anemia (20%). 87% of patients had ³ 5 active medications, of these 60% were on paracetamol, 40% were on anti-hypertensives, 27% received antidepressants, 20% were on anti-coagulants. Conclusion Currently other than non-emergent patients are SSU admitted, and polypharmacy is highly prevalent among them. The appropriateness of this development is questionable. A short stay focus may be inappropriate for sorting out polypharmacy in patients with increasingly complex disease.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"32 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":"123608649","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":"40 Changes in prescription routines for treating hypothyroidism between 2001 and 2015 – a population-based study of 929,684 primary care patients in copenhagen","authors":"Bjarke Borregaard Medici, B. Nygaard, J. L. Cour, M. Grand, V. Siersma, D. Nicolaisdóttir, B. Lind, N. Olivarius, C. Andersen","doi":"10.1136/bmjebm-2018-111070.40","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.40","url":null,"abstract":"Objectives Primary objective: To investigate changes in s-TSH threshold used by the general practitioners to initiate L-T4 therapy over the period 2001–2015 in Copenhagen. Method Primary objective Retrospective analysis of all s-TSH measurements between 2001 and 2015 performed at the general practitioners’ joint laboratory merged with The Danish Register of Medicinal Products Statistics and The Danish National Patient Registry. For each year in the period the estimated treatment threshold was calculated from the s-TSH measurements performed in that year as the level of s-TSH where the estimated probability of starting L-T4 therapy is 50%. Also the median level s-TSH at therapy initiation was recorded for each year. Results 929 684 individuals with 2 975 277 s-TSH measurements were included for the calculations. While the size and composition of the population serviced by the general practitioners remained virtually unchanged throughout the 15 year period, the number of performed s-TSH measurements increased from 110 886 in 2001 to 292 911 in 2015 and the number of patients initiating L-T4 therapy increased from 786 in 2001 to 1825 in 2015. The median s-TSH at L-T4 therapy initiation decreased from 10 mU/l (IQR 5.2–29.7) in 2001 to 6.8 mU/l (IQR 5.1–11) in 2015, while the estimated treatment threshold decreased considerably from 28.3 (95% CI 21.0 to 40.2) mU/l in 2001 to 14.2 (95% CI 12.0 to 18.0) in 2007 where it remained relatively unchanged for the rest of the study period. Conclusions This study performed on a sizeable primary care population demonstrates a considerable fall in the s-TSH threshold when initiating L-T4 therapy in hypothyroid patients, while the number of patients with s-TSH of 5–10 mU/l starting therapy increased considerably. Measuring TPO-antibodies appears to have influenced the s-TSH threshold considerably. The study also reveals that intensified TSH measuring from the 2010 level to the 2015 level did not lead to any further discoveries of hypothyroidism cases suggesting that very few hypothyroid persons remain undiagnosed.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"43 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":"122424720","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":"100 How accurate are argentine main on-line newspapers when they inform about breast cancer screening? cross-sectional study","authors":"S. Spina, Vanina Lombardi, S. Terrasa, Gabriel Villalón, K. Kopitowski","doi":"10.1136/bmjebm-2018-111070.100","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.100","url":null,"abstract":"Introduction Mass media have a key role in the communication of breast cancer screening strategy to the population. Misinformation and erroneous information, as well as the spreading of medical publications that are outdated or fail to be supported by any scientific evidence, serve as a barrier and prevent the implementation of adequate preventive practices from being carried out by the population. In furtherance of its early detection, the National Cancer Institute of Argentina (‘Instituto Nacional del Cáncer de Argentina’ -INC-, by its Spanish acronym), an agency of the Argentine Ministry of Health, following the recommendations issued by the U.S. Preventive Services Task Force (2016) and the Canadian Task Force on Preventive Health Care (2011), recommends healthy women to have a mammography once every two years after they turn 50, until they turn 70 years old. ObjectivesTo document the agreement between the breast cancer prevention information published on the Internet sites of the main Argentine newspapers and the INC recommendations.To describe and quantify the main messages that fail to agree with the recommendations of the INC. Design A cross-sectional documentary study was carried out. Context Two researchers looked for news articles related to breast cancer that were published between 01/Jan/2015 and 31/Dec/2015, on the websites of the five newspapers with the most digital traffic in the country -Clarín, Infobae, La Nación, Página/12 and Perfil. Inclusion criteria Digital content promoting secondary preventive strategies for breast cancer in women. Variables Two independent researchers determined whether such contents had information which followed the recommendations of the INC regarding secondary preventive strategies for breast cancer. Whenever there was disagreement between them, a third researcher studied the disagreeing contents, not knowing the findings of the other two researchers. All contents which recommended healthy women between 50 and 70 years old (with no personal or family breast cancer history) to have a mammography every two years were considered concordant with the recommendations of the INC. Results 135 news articles were identified, 95 of them were excluded because they failed to meet the inclusion criteria. 40 articles were included in the analysis. 95% of them (38/40) disagree with the INC recommendations on breast cancer screening in low risk general population (with no personal or family breast cancer history). Among the recommendations which failed to agree with those of the INC, the most frequently identified (33/40; 82.5%) was the one related to having a mammography once a year after turning 40; followed by the ones related to the promotion of periodical breast self-examinations (20/40; 50%) and the promotion of other periodical tests, such as breast scans or magnetic resonance imaging (6/40; 15%). Conclusions During the term under analysis, the mass media, which can create and consolidate conducts, beliefs an","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"25 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":"125807850","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":"84 The impact of a regulatory nudge on the overuse of low dose codeine in manitoba, canada","authors":"S. Bugden, K. Friesen, Jamie Falk","doi":"10.1136/bmjebm-2018-111070.84","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.84","url":null,"abstract":"Objectives Low-dose codeine products (⩽8 mg codeine/tablet) have been available over-the-counter from Canadian pharmacies for many years. In the era of the North American opioid crisis there has been concern about the volume of low-dose sales and their potential to contribute to the problem. This concern extended to the potential for acetaminophen/paracetamol toxicity. There has been widespread criticism about the lack of assessment by pharmacists in the provision of these products. In 2016, Manitoba became one of the few provinces to impose further regulation on the provision of low-dose codeine products. After February 2016 these products could only be dispensed with a prescription. Pharmacists were able to provide these prescriptions but only after a complete and documented assessment (sign and symptoms, medical history, length and severity of condition). In this study we explore the impact and potential unintended consequences of this regulatory nudge on low-dose codeine use. Method A drug utilization analysis was conducted for the year before and after the policy change. Sales information was reported by the College of Pharmacists of Manitoba from the Quintiles IMS Canadian Drug Store and Hospital Purchases Audit. Prescription codeine use was assessed using the Manitoba Population Research Data Repository using data released in January 2018. The effects of this policy change on the use of other prescribed opioids were assessed by piecewise Poisson regression analysis. Results In the year before the regulatory nudge sales data reported 52.5 million low-dose codeine tablets sold in Manitoba. This fell by 94% to 3.3 million tablets in the year after the change and this was confirmed in the research database which also showed dispensations for 3.3 million tablets. The prescribing of low-dose codeine was split evenly between pharmacists (49%) and physicians (48%). In its first year as a prescribed product, low-dose codeine use declined from 0.30 to 0.26 million tablets/month. Poisson regression analysis found no significant effect of this changeover on the trends in the utilization of higher strength codeine products, tramadol, and oxycodone with acetaminophen products. Conclusions Manitoba’s regulatory nudge reduced low-dose codeine usage by 94% without obvious negative implications. Other provincial or national policy changes should be considered to implement this simple change on a nationwide basis.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"19 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":"115496941","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":"120 Fatigue and pain leading to the diagnosis of depression. Diagnostic procedure experienced by patients with fibromyalgia. A qualitative study","authors":"Tiina Vuorio, Aleksi Varinen","doi":"10.1136/bmjebm-2018-111070.120","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.120","url":null,"abstract":"Objectives Fibromyalgia is a functional syndrome characterized by pain, fatigue and many other somatic symptoms. The lifetime prevalence of psychiatric comorbidities, such as depression, among patients with diagnosed fibromyalgia is high. It has been suggested that the reason for this phenomenon could result from similar pathophysiological mechanisms. Furthermore, the diagnostic criteria of these conditions are partly overlapping. The aim of this study was to explore experiences of fibromyalgia patients on diagnostic procedures using a qualitative analysis method. Method The study is based on the data from fibromyalgia patients of the city of Nokia, Finland. All the fibromyalgia patients who had been treated in the primary health care were identified from the electronic patient records of the heath care center of Nokia. 96 patients filling the diagnostic criteria (ACR2010) of fibromyalgia were identified. Further, 18 fibromyalgia patients (15 female and 3 male) were selected using the purposive sampling method into focus group interviews. Altogether, four sessions (4–5 participants per each) were carried out before the saturation of the data was reached. A semi-structured interview was used. The main focus of the interviews was to explore patients’ experiences and perspectives on diagnostic process of fibromyalgia. All the interviews were recorded, transcribed verbatim and analyzed through the inductive content analysis based on the phenomenological theory. The particular interest was focused on the diagnostic process of depression as a comorbidity. Results The data analysis revealed two main themes among the interviews. First, the patients had experienced that their fibromyalgia symptoms were frequently explained as depressive symptoms by the physicians. They described that the diagnosis of depression was based on the feeling of pain and fatigue rather than how they experienced their mood. Patients repeatedly pointed out that their own perception of their mental health differed from the physicians’ opinions. They did not feel themselves depressed even though they reported symptoms common with depression. Nevertheless, psychological interventions aiming to improve the management of pain and other symptoms of fibromyalgia were found useful by the patients. One participant described her perception on psychological intervention as follows: ‘I guess it would be worth prioritizing how to cope with the pain. Maybe it’s more psychological, but I think it’s the most important thing in this’. Conclusions Based on our findings from this qualitative analysis, setting the diagnosis of depression for fibromyalgia patients who do not regard their mood as low, does not seem to be useful. Psychological interventions aiming at to cope with the symptoms of fibromyalgia better could be included in the treatment instead.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"34 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":"116496867","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}