Statins for primary prevention in multimorbid patients: to prescribe or not to prescribe? A qualitative analysis of general practitioners' decision-making processes.

INTRODUCTION: A better understanding of the determinants involved in general practitioners' (GPs) decision-making processes when it comes to prescribing statins as primary prevention in patients with multimorbidity could provide insights for improving implementation of primary prevention guidelines. METHODS: We conducted a qualitative study using a deductive framework-based and inductive analysis of GPs' semi-structured interviews verbatim, from which expertise profiles of prescribers were also drawn. The analytical framework was built from a pragmatic synthesis of the evidence-based medicine, Modelling using Typified Objects (MOT) model of clinical reasoning processes, Theoretical Domains Framework, and shared decision-making frameworks. RESULTS: Fifteen GPs were interviewed between June 2019 and January 2020. Diabetes seemed to represent a specific motivation for deciding about statin prescription for primary prevention purposes; and in situations of multimorbidity, GPs differentiated between cardiovascular and non-cardiovascular multimorbidity. Expert prescribers seemed to have integrated the utilisation of cardiovascular risk calculation scores throughout their practice, whereas non-expert prescribers considered them difficult to interpret and preferred using more of a "rule of thumb" process. One interviewee used the risk calculation score as a support for discussing statin prescription with the patient. CONCLUSION: Our results shed light on the reasons why statins remain under-prescribed for primary prevention and why non-diabetic multimorbid patients have even lower odds of being prescribed a statin. They call for a change in the use of risk assessment scores, by placing them as decision aids, to support and improve personalised shared decision-making discussions as an efficient approach to improve the implementation of recommendations about statins for primary prevention.

[Drugs: minors and harm reduction?] / Drogues : mineur-e-s et réduction des risques ?

The use of controlled substances (narcotics and psychotropic substances) poses increased risks for minors. However, minors are generally excluded from existing harm reduction services (e.g. drug consumption rooms, drug checking, exchange of consumption material). Based on public health considerations, the authors recommend the establishment of harm reduction services for minors.

La consommation de substances soumises à contrôle (stupéfiants et substances psychotropes) présente des risques accrus pour les mineur-e-s. Pourtant, ces derniers sont généralement exclus des offres existantes de réduction des risques et des méfaits (par exemple, locaux de consommation, drug checking, échange de matériel de consommation). Sur la base de considérations de santé publique, les auteurs recommandent la création de services de réduction des risques dédiés aux mineur-e-s.

Heterogeneity of definitions and measurements of binge drinking in research on adolescents and young adults.

INTRODUCTION: Binge drinking is a widespread health compromising behaviour among adolescents and young adults and is one of the leading causes of mortality and injuries among this population. The definitions and measurement methods of binge drinking are heterogeneous but constitute a crucial component in the literature on associated factors related to binge drinking. This study focused on how binge drinking is defined and measured in the literature exploring its associated risk factors among adolescents and young adults. METHODS: The databases PubMed, Embase, PsycINFO and Social Care were searched for articles published between 1 January 2006 and 30 April 2020 using 3 concepts: binge drinking; risk or protective factors; and adolescents/young adults with respective key words. Data were extracted on the main characteristics of studies and the parameters of binge drinking measurements. RESULTS: 173 studies were included, mostly cross-sectional (61 %) and longitudinal (38 %). Only 23 % of the studies explicitly referred to a standardised definition of binge drinking even though 76 % of the studies used a consensual threshold of 5 drinks or more for men. A lower threshold for women was applied in 26 % of the studies. Recall periods ranged between 2 weeks and 1 year in 85 % of the studies and only 16 % presented binge drinking in terms of frequency and/or quantity of drinks. CONCLUSION: Our results highlight the heterogeneity in the definitions and measurements of binge drinking, raising concerns for meaningful comparisons between studies focused on factors associated with the behaviour. The scientific community needs to be aware of these variations and address the gap of poor stratification and inconsistencies in binge drinking reporting.

Child-centred harm reduction.

Harm reduction has become increasingly influential in drug policy and practice, but has developed primarily around adult drug use. Theoretical, practical, ethical and legal issues pertaining to children and adolescents under the age of majority - both relating to their own use and the effects of drug use among parents or within the family - are less clear. This commentary proposes a sub-field of drug policy at the intersection of harm reduction and childhood which we refer to as 'child-centred harm reduction'. We provide a definition and conceptual model, as well as illustrative questions that emerge through a child-centred harm reduction lens. Many people in different countries are already working on these kinds of issues, whose work needs greater recognition, analysis and support. In beginning to name and define this sub-field we hope to improve this situation, and inspire further international debate, collaboration, and innovation.

Multimorbidity and statin prescription for primary prevention of cardiovascular diseases: A cross-sectional study in general practice in France.

Background: Statins are a first line, evidence-based yet underprescribed treatment for cardiovascular primary prevention. In primary care settings, multimorbidity is a complex situation which makes it difficult to apply prevention guidelines. Aim: To assess the associations between multimorbidity and prescription of statins in accordance with the 2016 ESC recommendations ("appropriate prescription"), and to identify the factors and conditions associated with these prescriptions. Design and setting: Cross-sectional prospective study in the French region of Rhône-Alpes among 40 general practitioners and their patients. Methods: We examined the association between appropriate statin prescription and several patient characteristics, including multimorbidity, using multivariate logistic regression models. Results: Between August 2017 and February 2019, 327 patients were included in the study. Seventy-four (22.6%) were on statin medication and 199 (60.9%) exhibited multimorbidity, defined as ≥2 diseases. Only 22.5% of eligible patients were prescribed statins for primary prevention. Diabetes was most strongly associated with appropriate statin prescription (aOR 8.10, CI 95: 3.81-17.80). Multimorbidity was not associated with appropriate statin prescription (aOR 1.31, CI 95: 0.54-3.26), except in the presence of diabetes which defined diabetic multimorbidity (aOR 10.46, CI 95: 4.87-23.35). Conversely, non-diabetic multimorbidity was associated with lower odds of being appropriately prescribed a statin (aOR 0.26, CI 95: 0.12-0.56). Conclusion: Multimorbidity, in itself, does not seem to be a determinant factor for appropriate statin prescription. The latter appears to be determined by a patient's type of multimorbidity, especially the presence or not of diabetes. Differentiating between diabetic and non-diabetic multimorbidity may be a pragmatic way for GPs to improve primary prevention in a patient-centered and shared decision-making approach.

Detaining people who use drugs in Cambodia: A dual-track system.

Reports focusing on drug detention centres in Cambodia have predominantly been concerned with documenting conditions and human rights abuses in the government centres, while highlighting the failure of the Royal Government of Cambodia (RGC) to adopt a human rights and public health-based approach to substance use issues. They have not focused as extensively on the underlying institutional, legal and regulatory reasons that help explain, though not justify, the RGC's law-enforcement-based approach to illicit substance use in Cambodia. Therefore, this policy analysis examines Cambodia's legal and regulatory set-up, in particular how the criminal provisions of the laws governing substance use combined with the administrative mechanisms in place shape the county's drug-related practices. This paper is based on a wide-ranging literature review of primary legislative and interpretive material; international human rights, public health and drug control instruments; research papers and international reports from multilateral agencies, international non-governmental organisations, civil society and academic experts. Qualitative interviews were also carried out with key international agency, national and international NGO officers. By examining the Law on the Control of Drugs (2012), the RGC's main law covering substance use, as well as relevant administrative provisions, it becomes apparent that there are two parallel systems in place for sending people to drug detention centres in Cambodia: one based on criminal law and the other through an 'alternative' administrative avenue. This division constitutes a structural fragmentation, or two 'parallel tracks', that provide law enforcement and other relevant RGC agencies with a wide sphere of discretion for how to address drug-related issues. The result is an enhanced risk of serious human rights violations for people who use drugs in Cambodia.

What Can Be Learned from the Early Stages of the COVID-19 Vaccination Rollout in Australia: A Case Study.

This paper addresses the SARS-CoV-2 vaccination progress in Australia. Globally, Australia was initially praised for its national COVID-19 response, reflecting well with regard to case numbers and mortality rates. However, Australia's progress with its vaccine rollout has come under scrutiny. When compared globally, it fares very low in terms of the number of vaccine doses administered. This paper discusses the first three months of the vaccination process, and the challenges Australia faced during that time. Through an extensive literature review, data was collected on relevant topics concerning all aspects of the Australian COVID-19 situation. The following key points are discussed: the specific COVID-19 organisation at the federal vs. the state government levels, the Australian economy, the vaccine supply strategy, and the vaccine priority roll out. In conclusion, we highlight the impact of Australia initially relying heavily on the AstraZeneca vaccine, which subsequently came under fire regarding safety issues likely linking the vaccine to thrombosis with thrombocytopenia syndrome (TTS).

A medical student in private practice for a 1-month clerkship: a qualitative exploration of the challenges for primary care clinical teachers.

PURPOSE: The predicted shortage of primary care physicians emphasizes the need to increase the family medicine workforce. Therefore, Swiss universities develop clerkships in primary care physicians' private practices. The objective of this research was to explore the challenges, the stakes, and the difficulties of clinical teachers who supervised final year medical students in their primary care private practice during a 1-month pilot clerkship in Geneva. METHODS: Data were collected via a focus group using a semistructured interview guide. Participants were asked about their role as a supervisor and their difficulties and positive experiences. The text of the focus group was transcribed and analyzed qualitatively, with a deductive and inductive approach. RESULTS: The results show the nature of pressures felt by clinical teachers. First, participants experienced the difficulty of having dual roles: the more familiar one of clinician, and the new challenging one of teacher. Second, they felt compelled to fill the gap between the academic context and the private practice context. Clinical teachers were surprised by the extent of the adaptive load, cognitive load, and even the emotional load involved when supervising a trainee in their clinical practice. The context of this rotation demonstrated its utility and its relevance, because it allowed the students to improve their knowledge about the outpatient setting and to develop their professional autonomy and their maturity by taking on more clinical responsibilities. CONCLUSION: These findings show that future training programs will have to address the needs of clinical teachers as well as bridge the gap between students' academic training and the skills needed for outpatient care. Professionalizing the role of clinical teachers should contribute to reaching these goals.

Protocol for a systematic review of the factors associated with binge drinking among adolescents and young adults.

BACKGROUND: Alcohol use is the behaviour that has the most significant impact on the mortality and morbidity of young people, and binge drinking is becoming the norm among this population. The burden of disease of binge drinking during adolescence and young adulthood is significant and warrants the development of effective prevention strategies. Although the literature on risk factors for excessive substance use has been increasing, to our knowledge, a systematic review of the factors associated with binge drinking among young people has not yet been conducted. This study aims to identify and organise the factors associated with binge drinking among young people aged 15 to 24 years; and to provide a framework to further understand these factors in order to better target prevention strategies. METHODS/DESIGN: This systematic review of the literature will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The databases PubMed, Embase, PsycINFO and Social Care will be searched for articles published between 1 January 2006 and 31 December 2015. Our search focuses on studies examining the risk factors for binge drinking among young people (between the ages of 15 and 24). Observational studies (cross-sectional, cohort and case-control studies) will be included, while randomised controlled trials will be excluded. Case series and case reports will also be excluded, while reviews, if relevant, will be included. The primary outcome is binge drinking. Secondary outcomes include indicators of frequency and consequences of binge drinking. Two reviewers will independently screen articles, extract relevant data and assess the quality of the studies. DISCUSSION: This systematic review will add to our knowledge and understanding of binge drinking among young people. It will allow us to identify the main risk and protective factors associated with binge drinking among this population and ultimately help to define the lines for further investigation and research, as an important part of prevention strategies in this area of work. SYSTEMATIC REVIEW REGISTRATION: This protocol is registered in the PROSPERO registry of the University of York (reference number: CRD42016032496 ).

Rape in Armed Conflicts in the Democratic Republic of Congo: A Systematic Review of the Scientific Literature.

We conducted a systematic review of the scientific literature between 1996 and 2013 on rape in war-ridden Eastern Democratic Republic of Congo (DRC) in order to better understand the interest of the scientific community in describing the magnitude and characteristics of the problem. The literature search was conducted in French and English using several databases (Pubmed, PsycInfo, Sapphire, BDSP, Embase, Rero, and Web of Science) with the key words "rape and DRC" combined with several Medical Subject Headings concepts. Our systematic review yielded 2,087 references, among which only 27 are original studies, that is 20 are based on population surveys and the remaining 7 are original data based on case studies and reviews. Ten studies provided prevalence rates of rape victims, 18 provided specific information on the profile of the victims, 10 reported that most of the perpetrators of rape were military personnel, 14 referred to the negligence of the government in protecting victims, and 10 reported a lack of competent health-care facilities. The awareness of rape in conflict-ridden DRC is still limited as reported in the scientific literature: Published scientific papers are scarce. Yet more research would probably help mobilize local authorities and the international community against this basic human rights violation.

Female genital mutilation: a systematic review of research on its economic and social impacts across four decades.

BACKGROUND: Global efforts to end female genital mutilation (FGM) have intensified in recent decades because of the rising awareness that such a practice is an act of extreme violence against women and girls. Articles on FGM have been published highlighting the combined efforts of international and non-governmental organizations, governments, as well as religious and civil society groups to end the practice. However, the consequences of this research are not well known, and it seems that the socioeconomic aspects of the practice are underreported. OBJECTIVE: This review aims to characterize over a 40-year period the scientific output on the consequences of FGM in African countries, the most affected region known for the high prevalence of FGM, and review data on the socioeconomic consequences of the practice. DESIGN: A systematic review of literature was done, looking at the following databases: PubMed, Embase, CINAHL, BDSP, Web of Science, PsycINFO, FRANCIS, Sociological Abstracts, WHOLIS, RERO, and SAPHIR. The analysis was limited to articles concerning the African continent, published in English and French, from January 1, 1972, to December 31, 2011. RESULTS: One hundred ninety-eight articles were reviewed. More than half of the articles were published during the last decade of the study period. The majority of papers were published in biomedical journals (64.1%). Most studies looked at Africa as a region (33.3%). Nigeria was the single country most investigated (19.2%), followed by Egypt (10.6%). Most first authors were affiliated to non-African countries (60.6%): among them 21.2% were US-based, 4% were from African institutions, and 16.2% from Nigeria.The medical and psychological consequences (51.5%) and the prevalence and ethics of the practice (34.4%) were the most frequently investigated topics. The socioeconomic consequences were addressed in a minority of the papers (14.1%): they were classified into direct economic consequences (2.5%), school attendance (1%), marriageability (2%), sexual and marital consequences (3.5%), fertility (2.5%), domestic violence (1%), and discrimination (1.5%). CONCLUSIONS: The publication of articles on the consequences of FGM is increasing, but there is little research on the socioeconomic consequences of the practice. More scientific data focusing on this dimension is necessary to strengthen prevention, advocacy, and intervention campaigns.

Estimating the Costs of Torture: Challenges and Opportunities.

Due to its nature, extent and consequences, torture is considered a major public health problem and a serious violation of human rights. Our study aims to set the foundation for a theoretical framework of the costs related to torture. It examines existing challenges and proposes some solutions. Our proposed framework targets policy makers, human rights activists, professionals working in programmes, centres and rehabilitation projects, judges and lawyers, survivors of torture and their families and anyone involved in the prevention and fight against this practice and its consequences. We adopted a methodology previously used in studies investigating the challenges in measuring and valuing productivity costs in health disorders. We identify and discuss conceptual, methodological, political and ethical challenges that studies on the economic and social costs of torture pose and propose alternatives in terms of possible solutions to these challenges. The economic dimension of torture is rarely debated and integrated in research, policies and programmes. Several challenges such as epistemological, methodological, ethical or political ones have often been presented as obstacles to cost studies of torture and as an excuse for not investigating this dimension. In identifying, analysing and proposing solutions to these challenges, we intend to stimulate the integration of the economic dimension in research and prevention of torture strategies.

Excessive substance use among young people consulting family doctors: a cross-sectional study.

BACKGROUND: Family doctors can only play a role in the prevention of excessive substance use in young people if those affected are seen in the practice. OBJECTIVE: To describe the prevalence of excessive substance use among young people consulting family doctors in a European context. METHODS: As part of a trial of an intervention addressing substance use we collected data from young people consulting 32 family doctors in the French-speaking part of Switzerland. Before the consultation, consecutive patients aged 15-24 years completed a self-administered questionnaire on their general health and substance use. Outcomes were excessive alcohol (defined as ≥1 episode of binge drinking), excessive cannabis (use ≥1/week), regular tobacco (≥1 cigarettes a day) and/or any other substance use in the past 30 days. Prevalence data were computed with 95% confidence intervals (CIs) adjusted for clustering within practices, stratified by age and gender. RESULTS: Between February 2009 and November 2010, 636 patients were eligible. Participation rate was 93.4% (n=594, 53% female). The prevalence of excessive use in the past 30 days was alcohol 44.9% (95% CI: 37.8-52.1), cannabis 11.1% (95% CI: 8.0-14.1), tobacco 23.4% (95% CI: 19.0-28.1) and any other drug 2.6 (95% CI: 1.4-4.2). Excessive use was higher in males than in females. Except for tobacco prevalence of excessive use was only slightly higher in young adults compared to adolescents. CONCLUSION: Excessive substance use is frequent among young people consulting family doctors in a European context. Future research should provide guidance about how to best seize this window of opportunity for prevention and early intervention.