Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial.

Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.

Physical activity for chronic back pain: qualitative interview study with patients and GPs in German primary care.

BACKGROUND: Chronic back pain (CBP) is common among patients in primary care and is associated with significant personal and socioeconomic burden. Research has shown that physical activity (PA) is one of the most effective therapies to reduce pain; however, for GPs it remains challenging to advise and encourage individuals with CBP to exercise regularly. AIM: To provide insight into the views and experiences of PA in individuals with CBP, along with those of GPs, and to reveal the facilitators and barriers to engaging in, and maintaining, PA. DESIGN AND SETTING: Qualitative semi-structured interviews with individuals with CBP and GPs recruited via the local research practice network (Famprax) in Hessen, western-central Germany between June and December 2021. METHOD: Interviews were coded separately by consensus and analysed thematically. Findings of the two groups (GPs and patients with CBP) were compared and summarised. RESULTS: A total of 14 patients (n = 9 females and n = 5 males) and 12 GPs (n = 5 females and n = 7 males) were interviewed. Opinions and experiences of PA in individuals with CBP were similar both within and across the GP and patient groups. Interviewees expressed their views on internal and external barriers to PA, and provided strategies to address these barriers and concrete recommendations to increase PA. This study revealed a conflicting doctor-patient relationship ranging from paternalistic, to partnership based, to service provision, which could lead to negative perceptions on both sides, such as frustration and stigma. CONCLUSION: To the best of the authors' knowledge, this is the first qualitative study exploring opinion and experience of PA in individuals with CBP and GPs in parallel. This study reveals a complex doctor- patient relationship and provides an important insight to motivation for, and adherence to, PA in individuals with CBP.

Patients' perspectives on a patient-oriented electronic decision support tool to reduce overuse of proton pump inhibitors (arriba-PPI): a qualitative study in primary care.

BACKGROUND: To evaluate patients' perspectives and their experiences with a consultation involving a computer-assisted and patient-centered discontinuation strategy (arriba-PPI tool) as part of a German multicenter study on reducing the prescription of proton pump inhibitors (PPIs). METHODS: Qualitative in-depth telephone interviews on proton pump inhibitors with patients who had received an arriba-PPI tool-based counseling by their general practitioner (GP). A random sample of 30 patients was taken from study participants. Interviews were conducted in 2020 and analyzed using a thematic qualitative text analysis. RESULTS: Although this was meant to be the key to shared decision making with regard to PPI reduction, study participants mostly did not recall the visual features of the tool. However, a few patients remembered them very clearly. Above all, patients appreciated a trustful relationship with the GP as well as comprehensive, individualized counseling. CONCLUSION: Application of the arriba-PPI tool can support the decision process but can also hinder the consultation process if the tool is not properly embedded in the consultation. GPs using the arriba-PPI tool to support the shared decision-making process should consider the patients' and their own expectations on the benefit of the visual representation of the tool.

Mapping the methodological diversity of published drug discontinuation studies-a scoping review of study topics, objectives, and designs.

BACKGROUND: Trials evaluating drug discontinuation (drug discontinuation trials, DDTs) show a broad methodological spectrum. There are several specific methodological aspects in drug discontinuation trials (e.g., determination of research question; configuration of intervention; definition of outcomes). To verify this specifies, we did a scoping review about the study designs of drug discontinuation trials. METHODS: A systematic literature search in Medline (PubMed), The Cochrane Library, EMBASE, CINAHL, Web of Science, and PsycINFO was performed. In a two-step selection process, we identified DDTs, which evaluate the discontinuation of one or more long-term medication as the investigated intervention, by two independent reviewers. Besides bibliographic data, we extracted several parameters to describe the used study design of the included DDTs: motivation for DDT, initially treatment aim of the discontinued medication, study design, methods of discontinuation, follow-up times, number of study participants, and outcome parameter. RESULTS: Out of 12,132 records, we included 581 DDTs. The most common motivation for doing a DDT were expected side effects (48.8%), the motivation of proving the efficacy of medication (21.6%), or doubts on the expected benefit of the used medication (13.8%). The majority of the discontinued medication was initially prescribed to improve the prognosis of a chronic disease (60.4%) or to relieve symptoms (31%). The study designs of the trials showed a broad methodological spectrum. The minority of the drug discontinuation trials were randomized controlled trials (34%). CONCLUSION: The results of this scoping review illustrates the need for an evidence-based methodological standard for planning and conducting drug discontinuation trials.

MediQuit - an electronic deprescribing tool: a pilot study in German primary care; GPs' and patients' perspectives.

BACKGROUND: General practitioners (GPs) are the central coordinators for patients with multimorbidity and polypharmacy in most health care systems. They are entrusted with the challenging task of deprescribing when inappropriate polypharmacy is present. MediQuit (MQu) is a newly developed electronic tool that guides through a deprescribing consultation. It facilitates the identification of a medicine to be discontinued (stage 1), a shared decision-making process weighing the pros and cons (stage 2), and equips patients with take-home instructions on how to discontinue the drug and monitor its impact (stage 3). We here aim to evaluate utility and acceptance of MQu from GPs' and patients' perspectives. METHODS: Uncontrolled feasibility study, in which 16 GPs from two regions in Germany were invited to use MQu in consultations with their multimorbid patients. We collected quantitative data on demography, utility and acceptance of MQu and performed descriptive statistical analyses. RESULTS: Ten GPs performed 41 consultations using MQu. Identification (step 1) and implementation elements (Step 3) were perceived most helpful by GPs. Whereas, shared-decision making elements (step 2) revealed room for improvement. Patients appreciated the use of MQu. They were broadly satisfied with the deprescribing consultation (85%) and with their decision made regarding their medication (90%). CONCLUSIONS: Implementation of MQu in general practice generally seems possible. Patients welcome consultations targeting medication optimization. GPs were satisfied with the support of MQu and likewise gave important hints for future development.

Experiencing COVID-19, home isolation and primary health care: A mixed-methods study.

Objectives: Although the vast majority of COVID-19 cases are treated in primary care, patients' experiences during home isolation have been little studied. This study aimed to explore the experiences of patients with acute COVID-19 and to identify challenges after the initial adaptation of the German health system to the pandemic (after first infection wave from February to June 2020). Methods: A mixed-method convergent design was used to gain a holistic insight into patients experience. The study consisted of a cross-sectional survey, open survey answers and semi-structured telephone interviews. Descriptive analysis was performed on quantitative survey answers. Between group differences were calculated to explore changes after the first infection wave. Qualitative thematic analysis was conducted on open survey answers and interviews. The results were then compared within a triangulation protocol. Results: A total of 1100 participants from all German states were recruited by 145 general practitioners from August 2020 to April 2021, 42 additionally took part in qualitative interviews. Disease onset varied from February 2020 to April 2021. After the first infection wave, more participants were tested positive during the acute disease (88.8%; 95.2%; P < 0.001). Waiting times for tests (mean 4.5 days, SD 4.1; 2.7days, SD 2.6, P < 0.001) and test results (mean 2.4 days, SD 1.9; 1.8 days, SD 1.3, P < 0.001) decreased. Qualitative results indicated that the availability of repeated testing and antigen tests reduced insecurities, transmission and related guilt. Although personal consultations at general practices increased (6.8%; 15.5%, P < 0.001), telephone consultation remained the main mode of consultation (78.5%) and video remained insignificant (1.9%). The course of disease, the living situation and social surroundings during isolation, access to health care, personal resilience, spirituality and feelings of guilt and worries emerged as themes influencing the illness experience. Challenges were contact management and adequate provision of care during home isolation. A constant contact person within the health system helped against feelings of care deprivation, uncertainty and fear. Conclusions: Our study highlights that home isolation of individuals with COVID-19 requires a holistic approach that considers all aspects of patient care and effective coordination between different care providers.

Prevalence, aetiologies and prognosis of the symptom cough in primary care: a systematic review and meta-analysis.

BACKGROUND: Cough is a relevant reason for encounter in primary care. For evidence-based decision making, general practitioners need setting-specific knowledge about prevalences, pre-test probabilities, and prognosis. Accordingly, we performed a systematic review of symptom-evaluating studies evaluating cough as reason for encounter in primary care. METHODS: We conducted a search in MEDLINE and EMBASE. Eligibility criteria and methodological quality were assessed independently by two reviewers. We extracted data on prevalence, aetiologies and prognosis, and estimated the variation across studies. If justifiable in terms of heterogeneity, we performed a meta-analysis. RESULTS: We identified 21 eligible studies on prevalence, 12 on aetiology, and four on prognosis. Prevalence/incidence estimates were 3.8-4.2%/12.5% (Western primary care) and 10.3-13.8%/6.3-6.5% in Africa, Asia and South America. In Western countries the underlying diagnoses for acute cough or cough of all durations were respiratory tract infections (73-91.9%), influenza (6-15.2%), asthma (3.2-15%), laryngitis/tracheitis (3.6-9%), pneumonia (4.0-4.2%), COPD (0.5-3.3%), heart failure (0.3%), and suspected malignancy (0.2-1.8%). Median time for recovery was 9 to 11 days. Complete recovery was reported by 40.2- 67% of patients after two weeks, and by 79% after four weeks. About 21.1-35% of patients re-consulted; 0-1.3% of acute cough patients were hospitalized, none died. Evidence is missing concerning subacute and chronic cough. CONCLUSION: Prevalences and incidences of cough are high and show regional variation. Acute cough, mainly caused by respiratory tract infections, is usually self-limiting (supporting a "wait-and-see" strategy). We have no setting-specific evidence to support current guideline recommendations concerning subacute or chronic cough in Western primary care. Our study presents epidemiological data under non non-pandemic conditions. It will be interesting to compare these data to future research results of the post-pandemic era.

MediQuit, an Electronic Deprescribing Tool for Patients on Polypharmacy: Results of a Feasibility Study in German General Practice.

BACKGROUND: Deprescribing is an important task for general practitioners (GPs) in the face of risky polypharmacy. The electronic tool "MediQuit" was developed to guide GPs and patients through a deprescribing consultation that entails a drug-selection phase, shared decision making, and advice on safe implementation. OBJECTIVES: A pilot study was conducted to determine the target group of patients that is selected for consultation and to assess the impact, patient involvement, and feasibility of the tool. METHODS: This was an uncontrolled pilot study. GPs from two German regions were invited to use MediQuit in consultations with a view to deprescribing one drug, if appropriate. They selected patients on the basis of broad inclusion criteria. Collected data entailed participants' characteristics, patients' medication lists, deprescribed drugs, and feasibility assessments. Patients were contacted shortly after the consultation and again after 4 weeks. RESULTS: In total, 16 GPs agreed to participate, of whom ten actually performed deprescribing consultations. They selected 41 predominately older patients on excessive polypharmacy. Deprescribing was achieved in 70% of consultations in agreement with patients. Drugs deprescribed were symptom-lowering and preventive drugs (mainly anatomical therapeutic chemical classes A and C). GPs found MediQuit useful in initiating communication on this issue and enhancing deliberations for a deprescribing decision. The median consultation length was 15 min (interquartile range 10-20). At follow-up, GPs and patients infrequently disagreed on which drug(s) was discontinued, and GPs rated patient involvement higher than did patients themselves. DISCUSSION: MediQuit assists in identifying concrete deprescribing opportunities, patient involvement, and shared decision making. The three-step deprescribing procedure is well-accepted once initial organizational efforts are overcome. After revision, further studies are needed to enhance the quality of evidence on acceptance and effectiveness.

Coughing children in family practice and primary care: a systematic review of prevalence, aetiology and prognosis.

BACKGROUND: For evidence-based decision making, primary care physicians need to have specific and reliable information on the pre-test probabilities of underlying diseases and a symptom's course. We performed a systematic review of symptom-evaluating studies in primary care, following three research questions: (1) What is the prevalence of the symptom cough in children consulting primary care physicians? (2) What are the underlying aetiologies of cough and the respective frequencies? (3) What is the prognosis of children with cough? METHODS: Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. All quantitative original research articles in English, French or German were included if they focused on unselected study populations of children consulting a primary care physician for cough. We used the random effects model for meta-analysis in subgroups, if justifiable in terms of heterogeneity. RESULTS: We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7 and 23.3% of all reasons for an encounter, or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults, with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (up to 50.4% in cough persisting more than 3 weeks), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms. CONCLUSION: Cough is one of the most frequent reasons for an encounter in primary care. Our findings fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness in chronic cough of the possibility of asthma and pertussis. Further evidence of aetiological pre-test probabilities is needed to assess the diagnostic gain based on patient history and clinical signs for differential diagnoses of cough in children.

Promoting physical activity in primary care: a systematic review and meta-analysis.

BACKGROUND: Promoting physical activity is an important part of patient care in primary care and has been investigated in many studies with a wide range of intervention characteristics, often including external support. It is unclear, however, if promoting physical activity is effective. AIM: To investigate the effectiveness of behaviour change interventions to promote physical activity in primary care. DESIGN AND SETTING: This is a systematic review and meta-analysis to evaluate physical activity promotion in a primary care setting. METHOD: EMBASE, MEDLINE, PsycInfo, and the Joanna Briggs Institute Database were searched for 'physical activity', 'interview', 'motivation', 'primary care', and equivalent words to identify randomised controlled trials with physical activity as the outcome at patient level. RESULTS: The review identified 25 eligible studies. The quality appraisal showed that most studies reported insufficient details regarding randomisation, group allocation, blinding, and fidelity of intervention delivery. The included studies reported a wide range of interventions with varying numbers of follow-up visits or phone calls. The overall effect size for interventions with a 6-month follow-up interval was 0.04 (95% confidence interval [CI] = -0.06 to 0.14), and for interventions with a 12-month follow-up interval it was 0.20 (95% CI = 0.04 to 0.36). Only one intervention based on three motivational interviewing sessions achieved a moderate effect. CONCLUSION: Counselling to promote physical activity in primary care has a limited effect on patients' behaviour and it might not, on its own, be enough to change physical activity behaviour.

Typology of drug discontinuation trials - Methodological recommendations.

OBJECTIVE: Due to the increasing concerns about polypharmacy, there is a growing need for clinical recommendations for drug discontinuation. This requires studies investigating the process on several levels. This paper addresses the methodological problems of drug discontinuation trials (DDTs). To that end, we offer a new typology of research aims and corresponding methodological recommendations for trials evaluating drug discontinuation. STUDY DESIGN AND SETTING: Multi-stage development process, including literature search and expert panels. RESULTS: Clinical trials are only required in cases of scientific uncertainty. We identified three situations of uncertainty associated with drug discontinuation from which we derived three study types: 1) Uncertainty regarding the effectiveness and/or safety of a drug; 2) Uncertainty regarding the procedure of discontinuing a previously taken drug; 3) Uncertainty regarding the effectiveness of complex strategies used to discontinue one or more drugs. We developed specific methodological recommendations for each study type. CONCLUSION: We offer a comprehensive definition of research aims, study designs, and methodological recommendations regarding DDTs. The typology we propose can help investigators clarify their research aims and study design. The type-specific methodological recommendation should improve the quality of future drug discontinuation trials.

Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study.

BACKGROUND: Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs', community pharmacists' and specialist providers' role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches. METHOD: Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework. RESULTS: Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains 'Social/professional role and identity' (1), 'Social influences' (2), 'Reinforcement' (3) and ´Environmental context and resources' (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients' trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs' role and deprescribing attempts. Reinforcements (3) negatively affected GPs' and pharmacists' effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized. CONCLUSION: Understanding stakeholders' role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.

[Recommendations of the second update of the LONTS guidelines : Long-term opioid therapy for chronic noncancer pain]. / Empfehlungen der zweiten Aktualisierung der Leitlinie LONTS : Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen.

BACKGROUND: The second scheduled update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the LONTS (AWMF registration number 145/003), was started in December 2018. METHODS: The guidelines were developed by 28 scientific societies and 2 patient self-help organizations under the coordination of the German Pain Society. A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Scopus databases (up until December 2018) was performed. The systematic reviews with meta-analyses of randomized controlled trials with opioids for CNCP from the previous versions of the guideline were updated. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by formal multistep procedures in order to reach a consensus according to the Association of the Medical Scientific Societies in Germany (AWMF) regulations. The guidelines were reviewed by four external pain physicians. Public comments were possible for 4 weeks. RESULTS: Opioid-based analgesics are a drug-based treatment option for short-term (4-12 weeks), intermediate-term (13-25 weeks) and long-term (≥26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. Based on a clinical consensus the guidelines list other medical conditions for which a therapy with opioids can be considered on an individual basis. Long-term therapy of CNCP with opioids is associated with relevant risks. CONCLUSION: A responsible administration of opioids requires consideration of possible indications and contraindications as well as regular assessment of efficacy and adverse effects. Opioids remain a treatment option for CNCP if nonpharmacological therapies are not effective and/or other drugs are not effective, are not tolerated or are contraindicated.

Generic instruments for drug discontinuation in primary care: A systematic review.

AIMS: The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting. METHODS: We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified. RESULTS: We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web-applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision-making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines. CONCLUSION: Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user-friendly tools that support physicians in communicational aspects, visualise trade-offs and also enhance patient involvement.

Reduction of the long-term use of proton pump inhibitors by a patient-oriented electronic decision support tool (arriba-PPI): study protocol for a randomized controlled trial.

BACKGROUND: Proton pump inhibitors (PPIs) are increasingly being prescribed, although long-term use is associated with multiple side effects. Therefore, an electronic decision support tool with the aim of reducing the long-term use of PPIs in a shared decision-making process between general practitioners (GPs) and their patients has been developed. The developed tool is a module that can be added to the so-called arriba decision support tool, which is already used by GPs in Germany in routine care. In this large-scale cluster-randomized controlled trial we evaluate the effectiveness of this arriba-PPI tool. METHODS: The arriba-PPI tool is an electronic decision support system that supports shared decision-making and evidence-based decisions around the long-term use of PPIs at the point of care. The tool will be evaluated in a cluster-randomized controlled trial involving 210 GP practices and 3150 patients in Germany. GP practices will be asked to recruit 20 patients aged ≥ 18 years regularly taking PPIs for ≥ 6 months. After completion of patient recruitment, each GP practice with enrolled patients will be cluster-randomized. Intervention GP practices will get access to the software arriba-PPI, whereas control GPs will treat their patients as usual. After an observation period of six months, GP practices will be compared regarding the reduction of cumulated defined daily doses of PPI prescriptions per patient. DISCUSSION: Our principal hypothesis is that the application of the arriba-PPI tool can reduce PPI prescribing in primary care by at least 15% compared to conventional strategies used by GPs. A positive result implies the implementation of the arriba-PPI tool in routine care. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00016364. Registered on 31 January 2019.

Prescribing practice of pregabalin/gabapentin in pain therapy: an evaluation of German claim data.

OBJECTIVES: To analyse the prevalence and incidence of pregabalin and gabapentin (P/G) prescriptions, typical therapeutic uses of P/G with special attention to pain-related diagnoses and discontinuation rates. DESIGN: Secondary data analysis. SETTING: Primary and secondary care in Germany. PARTICIPANTS: Four million patients in the years 2009-2015 (anonymous health insurance data). INTERVENTION: None. PRIMARY AND SECONDARY OUTCOME MEASURES: P/G prescribing rates, P/G prescribing rates associated with pain therapy, analysis of pain-related diagnoses leading to new P/G prescriptions and the discontinuation rate of P/G. RESULTS: In 2015, 1.6% of insured persons received P/G prescriptions. Among the patients with pain first treated with P/G, as few as 25.7% were diagnosed with a typical neuropathic pain disorder. The remaining 74.3% had either not received a diagnosis of neuropathic pain or showed a neuropathic component that was pathophysiologically conceivable but did not support the prescription of P/G. High discontinuation rates were observed (85%). Among the patients who had discontinued the drug, 61.1% did not receive follow-up prescriptions within 2 years. CONCLUSION: The results show that P/G is widely prescribed in cases of chronic pain irrespective of neuropathic pain diagnoses. The high discontinuation rate indicates a lack of therapeutic benefits and/or the occurrence of adverse effects.

Prevalence, aetiologies and prognosis of the symptom dizziness in primary care - a systematic review.

BACKGROUND: Dizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care. METHODS: We systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms 'dizziness' or 'vertigo' as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates. RESULTS: We identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière's disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life. CONCLUSION: There is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.

Psychological risk and protective factors for disability in chronic low back pain - a longitudinal analysis in primary care.

BACKGROUND: Utilizing psychological resources when dealing with chronic low back pain might aid the prevention of disability. The observational study at hand examined the longitudinal impact of resilience and coping resources on disability in addition to established risk factors. METHODS: Four hundred eighty four patients with chronic low back pain (>3 months) were recruited in primary care practices and followed up for one year. Resilience, coping, depression, somatization, pain and demographic variables were measured at baseline. At follow-up (participation rate 89%), data on disability was collected. We first calculated bivariate correlations of all the predictors with each other and with follow-up disability. We then used a multiple regression to evaluate the impact of all the predictors on disability together. RESULTS: More than half of the followed up sample showed a high degree of disability at baseline (53.7%) and had suffered for more than 10 years from pain (50.4%). Besides gender all of the predictors were bivariately associated with follow-up disability. However in the main analysis (multiple regression), disability at follow up was only predicted by baseline disability, age and somatization. There was no relationship between resilience and disability, nor between coping resources and disability. CONCLUSIONS: Although it is known that there are cross-sectional relationships between resilience/coping resources and disability we were not able to replicate it in the multiple regression. This can have several reasons: a) the majority of patients in our sample were much more disabled and suffered for a longer time than in other studies. Therefore our results might be limited to this specific population and resilience and coping resources might still have a protective influence in acute or subacute populations. b) We used a rather broad operationalization of resilience. There is emerging evidence that focusing on more concrete sub facets like (pain) self-efficacy and acceptance might be more beneficial. TRIAL REGISTRATION: German Clinical Trial Register, DRKS00003123 (June 28th 2011).

The differential diagnosis of tiredness: a systematic review.

BACKGROUND: Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care. METHODS: MEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint. RESULTS: We found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6-4.8 %); malignancy: 0.6 % (CI 0.3-1.3 %); serious somatic disease: 4.3 % (CI 2.7-6.7 %); depression 18.5 % (CI 16.2-21.0 %). Pooling was not appropriate for CFS. In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness. CONCLUSIONS: Serious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems.

Influence of thyroid hormone therapy on the fracture rate - A claims data cohort study.

INTRODUCTION: It has been debated for years whether long-term thyroid hormone intake causes fractures. Not only have previous studies suffered from design limitations, they also reached contradictory conclusions. We investigated thyroid hormones (thyroxine) as a possible risk factor for fractures in a cohort of 6.7 million persons based on administrative data. METHODS: The database consists of anonymized settlement data of approximately 70 German statutory health insurances covering a time period of six years. All subjects aged 60 and above were included in the study; subjects with repeated thyroxine prescriptions were assigned to the exposure group; members without thyroxine prescriptions to the control group. Outcome was any incident fracture during a declared time period. In order to calculate fracture risk, we performed multivariate cox regression analyses to adjust for confounders. RESULTS: Of 798 770 subjects fulfilling the inclusion criteria, 11.7% took thyroxine regularly and belong to the exposure group. The final cox regression showed that subjects taking thyroxine have a 6.3% higher risk (HR 1.063; CI 1.046-1.080, p=<.0001) than members of the control group. DISCUSSION: The study supports the assumption that long term thyroxine intake leads to an increase in fracture risk among patients older than 60years. The findings have implications for long term thyroxine treatment.