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1.
Medicine (Baltimore) ; 98(38): e17265, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31568003

RESUMO

BACKGROUND: Observational studies indicate that religious values of physicians influence clinical practice. The aim of this study was to test prior hypotheses of prevalence of this influence using a meta-analysis design. METHODS: Based on a systematic literature search we performed individual participant data meta-analysis (IPDMA) on data based on 2 preselected questionnaires. Ten samples from 7 countries remained after exclusion (n = 3342). IPDMA was performed using a random-effects model with 2 summary measures: the mean value of the scale "Religiosity of Health Professionals"; and a dichotomized value of the question "My religious beliefs influence my practice of medicine." Also, a sensitivity analysis was performed using a mixed-models design controlling for confounders. RESULTS: Mean score of religiosity (95% confidence interval [CI]) was significantly lower in the European subgroup (8.46 [6.96-9.96]) compared with the Asian samples India (10.46 [9.82-10.21]) and Indonesia (12.52 [12.19-12.84]), whereas Brazil (9.76 [9.54-9.99]) and USA (10.02 [9.82-10.21]) were placed in between. The proportion of the European physicians who agreed to the statement "My religious beliefs influence my practice of medicine" (95% CI) was 42% (26%-59%) compared with Brazil (36% [29%-43%]), USA (57% [54%-60%]), India (58% [52%-63%]), and Indonesia (91% [84%-95%]). CONCLUSIONS: Although large cross-cultural variations existed in the samples, 50% of physicians reported to be influenced by their religious beliefs. Religiosity and influence of religious beliefs were most pronounced in India, Indonesia, and a European faith-based hospital. Education regimes of current and future physicians should encompass this influence, and help physicians learn how their personal values influence their clinical practice.


Assuntos
Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Religião e Medicina , Adulto , Austrália , Brasil , Dinamarca , Feminino , Alemanha , Humanos , Índia , Indonésia , Masculino , Médicos/psicologia , Religião , Inquéritos e Questionários , Estados Unidos
2.
Medicine (Baltimore) ; 98(40): e17411, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31577753

RESUMO

Evidence on the prescription patterns of antihypertensive drug use in children and adolescents in China is scarce. A descriptive analysis of the Beijing Medical Claim Data, which covered over 95% of the urban residents, was conducted to investigate antihypertensive prescribing patterns and trends in children and adolescents aged under 18 from 2009 to 2014 in Beijing, China. An additional meta-analysis of trends in hypertension prevalence was conducted to compare trends with antihypertensive medications.A total of 11,882 patients received at least 1 prescription for antihypertensive drugs from 2009 to 2014. The number of annual antihypertensive users increased from 2009 to 2012, then declined steadily until 2014, which was consistent with the trend of the hypertension prevalence estimated from the meta-analysis. ß-receptor blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors were the 3 most commonly prescribed antihypertensive drugs. More boys took the antihypertensive drugs than girls. For users aged under 3 years, thiazide diuretics, α-receptor blockers, and angiotensin-converting enzyme inhibitors were the most prescribed drugs, while ß-receptor blockers, thiazide diuretics were the most used drugs for users above 3 years.In conclusion, antihypertensive drug prescribing for children and adolescents increased from 2009 to 2014, with different characteristics in different subgroups.


Assuntos
Anti-Hipertensivos/classificação , Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adolescente , Fatores Etários , Pequim , Criança , Pré-Escolar , Feminino , Humanos , Hipertensão/epidemiologia , Lactente , Masculino , Padrões de Prática Médica/estatística & dados numéricos , Fatores Sexuais , População Urbana/estatística & dados numéricos
3.
BMJ ; 367: l5205, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578187

RESUMO

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Avaliação de Processos (Cuidados de Saúde)/métodos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Anti-Infecciosos/uso terapêutico , Conjuntos de Dados como Assunto , Substituição de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos/uso terapêutico , Inglaterra , Medicina Geral/organização & administração , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Humanos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Avaliação de Processos (Cuidados de Saúde)/estatística & dados numéricos , Medicina Estatal/normas , Fatores de Tempo , Infecções Urinárias/tratamento farmacológico
4.
J Opioid Manag ; 15(4): 333-341, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637685

RESUMO

BACKGROUND: The use of opioid analgesics in the United States has increased nearly fourfold since 1999 resulting in a similar increase in opioid-related overdose deaths. Although the Centers for Disease Control published guidelines for prescribing chronic opioids, there is a lack of guidance for prescribing postoperative opioids. OBJECTIVE: To offer an evidence-based approach to prescribing opioids for post-operative pain management in the orthopedic setting. METHODS: A narrative review was performed of studies evaluating and quantifying opioid use in orthopedic patients in the postoperative setting, as well as studies analyzing patient satisfaction and perception with regards to opioid use. RESULTS: Studies show that postoperative pain may not be the largest contributing factor to developing an opioid use disorder, but rather patient factors such as tobacco and substance use disorder, mental health disorders, anxiety, mood disorders, pre-existing chronic pain, and recent opioid use may play a role. The review also found that most patients do not utilize significant portions of prescribed opioids and most do not require a refill. This trend leaves patients with thousands of unused pills, which are either retained, shared, or diverted. Although there is no guideline for prescribing opioids postoperatively, data suggest that clinicians can prescribe smaller dosages and fewer quantities of opioids initially. There are also non-opioid strategies that can be employed to reduce opioid consumption. CONCLUSION: There is a need for more high quality research to be conducted to standardize postoperative opioid prescribing patterns and create best practice guidelines to guide clinicians. Orthopedic practices should consider creating institutional guidelines to reduce the amount of opioids prescribed.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Padrões de Prática Médica , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Procedimentos Ortopédicos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos
5.
Sante Publique ; Vol. 31(3): 395-404, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31640327

RESUMO

OBJECTIVE: The aim of this research is, on the one hand, to describe the customs and attitudes of Swiss general practitioners (GP) considering cardiovascular risk, and on the other, to put into perspective with the national recommendation Eviprev (summary representations of the primary and secondary preventions recommendations for patients aged between 18 and 70 years old). METHODS: The study was based on an online survey sent to general practitioners belonging to the same research network and who were randomly selected. The sample was made of 200 Swiss GP. This article focuses on the frequency with which GP give advice related to consumption of tobacco and alcohol, exercising and nutrition during a regular meeting with their patient or a first visit. The results were analyzed according to age, sex, linguistic area and the extent to which they lived in a city or in the countryside. RESULTS: Results suggest that the majority (97.6%) of GP show concern about informing patients on cardiovascular risk factors. Nonetheless most of the advice given are usually related to the patient's case and not given in a systematic way. Tobacco addiction is the most systematically discussed theme during a first visit (33.9%), exercise comes second (25.6%), then nutrition (16.1%), and finally alcohol consumption (18.5%). Differences in numbers based on the different languages are little, except dealing with exercise. CONCLUSIONS: Recommendations on prevention are followed by a majority of GP. Improvements could be made considering the training given and the remuneration of these counseling activities.


Assuntos
Atitude do Pessoal de Saúde , Doenças Cardiovasculares/prevenção & controle , Clínicos Gerais/psicologia , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Pesquisas sobre Serviços de Saúde , Humanos , Pessoa de Meia-Idade , Suíça , Adulto Jovem
6.
Sante Publique ; Vol. 31(3): 459-467, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31640334

RESUMO

INTRODUCTION: Patient education is an important component in the management and monitoring of chronic diseases. It plays an important role in the decline of the disease severity, mortality and socioeconomic burden and the complications of these chronic diseases. In Côte d'Ivoire, there are few studies to evaluate the reality of this activity. OBJECTIVE: To explore the practice of patient education in Ivory Coast. METHOD: This qualitative study has been carried out by means of semi-structured interviews with 24 healthcare professionals including 14 health managers for individual interviews and 10 care providers for focus group discussion. RESULTS: There are various representations of therapeutic patient education among health professionals. There was no real distinction between patient education and the broader concept of health education. Absence of national patient education policy, the lack of training in TPE and lack of experience of educational practice lead health professionals to realize an unstructured educational activity. CONCLUSION: These results show the need for Côte d'Ivoire to have a national policy of patient education to educate patients in accordance with international recommendations.


Assuntos
Doença Crônica/terapia , Pessoal de Saúde/psicologia , Educação de Pacientes como Assunto/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Costa do Marfim , Humanos , Pesquisa Qualitativa
7.
Br J Anaesth ; 123(5): 627-636, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31563269

RESUMO

BACKGROUND: Excessive opioid prescribing after surgery has been recognised as a contributor to the current crisis of opioid addiction and overdose. Clinicians may potentially tackle this crisis by using opioid-free postoperative analgesia; however, the scientific literature addressing this approach is sparse and heterogeneous, thereby limiting robust conclusions. A scoping review was conducted to systematically map the extent, range, and nature of the literature addressing postoperative opioid-free analgesia. METHODS: Eight bibliographic databases were searched for studies addressing opioid-free analgesia after a major surgery. We extracted the study characteristics, including design, country, year, surgical procedure(s), and interventions. Results were organised thematically according to surgical specialty and targeted phase of recovery: in hospital (early recovery, ≤24 h after operation; intermediate recovery, >24 h) and post-discharge (late recovery). Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for scoping reviews. RESULTS: We identified 424 studies addressing postoperative opioid-free analgesia. The number of studies conducted in countries where the opioid crisis is primarily focused was remarkably low (USA, n=11 [3%]; Canada, n=5 [1%]). Many RCTs compared opioid-free vs opioid analgesia during hospital stay (n=117), but few targeted analgesia post-discharge (n=8). Studies were predominantly focused on procedures in orthopaedic, general, and gynaecological/obstetric surgery. Limited attention has been directed towards non-pharmacological pain interventions. We did not identify knowledge synthesis studies (i.e. systematic reviews and meta-analyses) focused on the comparative effectiveness of opioid-free vs opioid analgesia. CONCLUSIONS: Opioids remain a mainstay analgesic for managing pain after surgery, but alternative analgesia strategies should not be overlooked. This scoping review indicates numerous opportunities for future research targeting opioid-free postoperative analgesia. REVIEW REGISTRATION: http://www.researchregistry.com; ID: reviewregistry576.


Assuntos
Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor Pós-Operatória/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Humanos , Manejo da Dor/métodos , Cuidados Pós-Operatórios/métodos
8.
Z Gastroenterol ; 57(9): 1059-1066, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31525798

RESUMO

BACKGROUND: In Germany, colorectal cancer (CRC) screening includes a fecal blood test or colonoscopy, but not a sigmoidoscopy, which has been shown to reduce CRC incidences and mortality. Our aim was to compile physicians' experiences with sigmoidoscopy and their assessments of this procedure being an additional, possible screening method for early CRC detection. METHODS: At the end of 2015, gastroenterologists and internists in Lower Saxony and North Rhine-Westphalia who regularly perform screening colonoscopies in outpatient care were contacted per mail. Standardized telephone interviews consisting of 17 questions and lasting 10-15 minutes were conducted. RESULTS: Nearly two-thirds (56/87) of the respondents reject sigmoidoscopy as an acceptable early detection method. Compared to colonoscopy, key features of the sigmoidoscopy include more favorable patient-related aspects, while procedural aspects, except sedation, clearly rate in favor of the colonoscopy. In the instance that colonoscopy is rejected, 75 % of the physicians consider a sigmoidoscopy to be a possible alternative. CONCLUSIONS: The survey provides important practical insights into outpatient sigmoidoscopy. A majority of the physicians does not support evidence-based sigmoidoscopy for CRC screening. However, individuals who reject a colonoscopy are, in line with the current guideline, identified as a target group for a screening sigmoidoscopy. The benefit from an additionally offered sigmoidoscopy in CRC screening should be further analyzed with special consideration given to the preferences of insurees within the German healthcare system.


Assuntos
Atitude do Pessoal de Saúde , Neoplasias Colorretais/diagnóstico , Programas de Rastreamento/métodos , Médicos/psicologia , Padrões de Prática Médica/estatística & dados numéricos , Sigmoidoscopia , Colonoscopia , Detecção Precoce de Câncer , Alemanha , Humanos , Sangue Oculto
9.
Schmerz ; 33(5): 415-423, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31432246

RESUMO

BACKGROUND: In Germany, physicians who prescribe cannabis-based medicines at the expense of the statutory health insurance are obliged to take part in an accompanying survey. Pain was the most commonly reported diagnosis, making an interim evaluation for the indication of pain feasible. METHODS: Patient-related data was transmitted to the German Federal Institute for Drugs and Medical Devices via an online portal. In addition to demographic data, information on the treated disease or symptoms, the course of therapy, adverse reactions and treatment success were evaluated. RESULTS: A total of 3138 data sets were evaluated for the main diagnosis of pain. Dronabinol was the most frequently (64%) prescribed cannabis-based drug. On average, patients were 57 years old and women and men were equally represented. Patients treated with cannabis flowers were significantly younger (48 years). The proportion of men in this group was 68% and 83% in the group of 18- to 40-year-olds. According to the assessment by treating physicians, pain was significantly improved in 35.5% of the patients. The most frequent side effects (fatigue, dizziness, nausea) corresponded to those already known from the product information of the cannabis-based medicinal products authorized under the pharmaceutical law. Treatment was discontinued in 1179 patients within 1 year. CONCLUSION: Physicians should comply with their legal obligation to participate in the accompanying survey. Pain is by far the most common diagnosis in cannabis drugs. For about one third of these patients, physicians reported a clear improvement in pain. Due to the amount of data hitherto and the limitations in the accompanying survey, the results should not be overinterpreted in terms of efficacy and should always be related to existing reviews. The lower age and higher proportion of men among patients treated with cannabis flowers were remarkable. At 37.6%, the overall drop-out rate was high. The most frequent side effects related to vigilance and are therefore highly relevant in terms of driving ability, work ability and risk of falling. For a differentiated evaluation of treatment success, more data needs to be available.


Assuntos
Cannabis , Maconha Medicinal , Manejo da Dor , Dor , Padrões de Prática Médica , Inquéritos e Questionários , Adolescente , Adulto , Demografia , Feminino , Alemanha , Humanos , Masculino , Maconha Medicinal/uso terapêutico , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Manejo da Dor/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto Jovem
10.
Schmerz ; 33(5): 408-414, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31444575

RESUMO

BACKGROUND AND METHODS: An online questionnaire about cannabis medication (CAM) was sent to German pain therapists 1 year after the introduction of the new act "Amendment to drug and other regulations" of 06.03.2017. RESULTS: A total of 120 pain therapists participated. Information on 1560 treated patients was analyzed. Only in the case of Dronabinol and Sativex® did at least 50% of physicians feel well informed. Requests for the coverage of costs were sent to the statuary health insurance companies for 1521 patients. These requests had already been decided for 1265 patients (83%) at the time of the questionnaire. A total of 457 requests (36.1%) were denied, including 28 requests from palliative care patients. Most of the pain therapists (67.5%) were well informed about Dronabinol, but less so about the other CAM. CONCLUSION: The study shows an information deficit in knowledge and handling of selected CAM among physicians. Given the high rejection rate, there may also be a knowledge gap on the side of the health insurances. From a certain number of patients upwards, the non-interventional accompanying survey required by law was deemed to be barely practicable from both a time and an economical point of view.


Assuntos
Cannabis , Manejo da Dor , Dor , Medicina Paliativa , Padrões de Prática Médica , Inquéritos e Questionários , Alemanha , Humanos , Internet , Dor/tratamento farmacológico , Manejo da Dor/estatística & dados numéricos , Medicina Paliativa/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Sociedades
11.
Pan Afr Med J ; 33: 48, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31448011

RESUMO

Introduction: diagnostic methods and management of iron deficiency and iron deficiency anemia in clinical practice in Algeria is poorly known. Methods: we conducted a cross-sectional survey among doctors in different specialties treating patients with iron deficiency anemia in 2016. Results: data analysis was based on 349 questionnaires which were validated (anesthesia/resuscitation: 39; obstetrics and gynaecology: 111; oncology/Hematology: 71; hepato-gastroenterology: 64; cardiology: 36; internal medicine: 28). All specialties combined, 73% (254/349) of physicians thought that at least 30% of their patients had iron deficiency anemia; 65% of physicians (226/349) thought that at least 30% of their patients had iron deficiency. Iron deficiency was investigated systematically by 57% (63/111) of physicians of the group obstetrics and gynaecology, but only by 11% (26/238) of the remaining doctors; indeed, 82% (195/238) of physicians investigated it only in patients with anemia. The assessment of iron deficiency showed that the hemoglobin (Hb) was almost always determined (89%; 310/349) while laboratory tests to explore iron metabolism were inadequate: 70% (244/349) of physicians performed serum ferritin test and only 37% (128/349) performed transferrin saturation. Patients with iron deficiency (with or without anemia) received oral iron therapy (prescribed by 92% (322/349) of physicians) and iron injections therapy depending on Hb level (prescribed by 36% (127/349) of physicians). Conclusion: this survey shows that iron deficiency is evaluated only in patients with anemia. In particular, laboratory tests to measure iron deficiency are insufficiently prescribed.


Assuntos
Anemia Ferropriva/diagnóstico , Ferro/deficiência , Médicos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Argélia , Anemia/diagnóstico , Anemia/terapia , Anemia Ferropriva/terapia , Estudos Transversais , Feminino , Ferritinas/sangue , Pesquisas sobre Serviços de Saúde , Hemoglobinas/análise , Humanos , Ferro/administração & dosagem , Masculino , Pessoa de Meia-Idade , Adulto Jovem
12.
Medicine (Baltimore) ; 98(32): e16646, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393363

RESUMO

To examine whether the Medicare Part D program had an impact on the generic drug prescription rate among residents in long-term care facilities.We analyzed prescription data for 3 drug classes (atypical antipsychotic, proton pump inhibitor, and statin) obtained from a regional online pharmacy serving long-term care centers in Pennsylvania from January 2004 to December 2007.Difference-in-difference is used as a primary analysis method, and different regression methods (probit and multinomial) are used to accommodate different types of outcome measures.Contrary to expectations, the Part D program did not have a statistically significant impact on the generic prescription rate in the long-term care setting during the study period. Only the statin class showed a dramatic increase in generic drug prescriptions, mainly due to the loss of patent protection for one of the most popular brand-name drugs in the class.The complex dynamics of the prescription drug market, particularly the availability of generic versions of popular prescription medications, had a bigger role in increasing the prescription rate of generic drugs than the Part D program. This warrants the need to relax prescription medicines' patent policies and for further study on the impact of such policies.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos , Seguro de Serviços Farmacêuticos/estatística & dados numéricos , Medicare Part D/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Antipsicóticos , Estudos de Casos e Controles , Prescrições de Medicamentos/classificação , Substituição de Medicamentos , Revisão de Uso de Medicamentos , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Inibidores da Bomba de Prótons , Estados Unidos
14.
Crit Rev Oncol Hematol ; 141: 112-124, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31276964

RESUMO

Protein kinase inhibitors (PKI) are a growing class of anticancer agents. They are prescribed with flat doses, and their oral administration is associated with interindividual variability in exposure. Patients can be over- or underexposed, due to numerous factors. We reviewed key pharmacokinetic concepts and mechanisms by which PKIs prescription could be altered. Challenging situations that could lead to increased toxicity or to therapeutic failure are described and recommendation for clinicians are proposed. Finally, the interest of therapeutic drug monitoring and indications for its use in daily practice is discussed.


Assuntos
Padrões de Prática Médica/normas , Inibidores de Proteínas Quinases/farmacocinética , Inibidores de Proteínas Quinases/uso terapêutico , Área Sob a Curva , Biomarcadores Farmacológicos/análise , Relação Dose-Resposta a Droga , Interações de Medicamentos , Monitoramento de Medicamentos/métodos , Humanos , Inativação Metabólica/fisiologia , Farmacologia Clínica , Padrões de Prática Médica/estatística & dados numéricos , Inibidores de Proteínas Quinases/farmacologia , Distribuição Tecidual
15.
Br J Radiol ; 92(1103): 20190386, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31356113

RESUMO

OBJECTIVE: Phantom studies and a prior patient study have shown up to 53% effective dose reduction when lumbar spine radiographs are acquired posteroanterior (PA) instead of anteroposterior (AP). Since November 2017, Taunton and Somerset NHS Foundation Trust has acquired all standing lumbar spine radiographs PA. The aim of this study was to locally evaluate dose and image quality in both projections and survey current UK practice. METHODS: 80 outpatients having a standing lumbar spine radiograph (40 AP; 40 PA) had their dose-area product recorded at a constant KV and focus film distance. Effective dose was calculated using PCXMC software. Each blinded radiograph was scored against an optimal reference image using European Guidelines criteria. The data were analyzed using Mann-Whitney U tests and linear regression. Eighty radiologists nationally were sent an anonymous survey to establish their current practice. RESULTS: A lumbar spine radiograph acquired PA instead of AP reduced effective dose by 41% (p < 0.001) with no difference in image quality (p = 0.9). 21 radiologists completed our survey and only 1 NHS Trust is currently using PA. CONCLUSION: PA lumbar spine radiography reduces patient radiation exposure with no affect on image quality, acquisition time or cost. The majority of NHS Trusts nationally are still using AP and it is time to standardize to PA. ADVANCES IN KNOWLEDGE: This patient study provides further good evidence of how reduction in exposure to ionizing radiation can be achieved in lumbar spine radiography and more widespread adoption of PA protocol could improve patient safety.


Assuntos
Vértebras Lombares/diagnóstico por imagem , Assistência Ambulatorial/estatística & dados numéricos , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cirurgiões Ortopédicos/estatística & dados numéricos , Posicionamento do Paciente , Imagens de Fantasmas , Padrões de Prática Médica/estatística & dados numéricos , Doses de Radiação , Reino Unido
16.
J Surg Oncol ; 120(4): 593-602, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31297826

RESUMO

BACKGROUND: With the opioid epidemic in the United States, evaluating opioid prescribing patterns is essential. We evaluated opioids prescribed at discharge following breast surgery and their association with patient factors and pain scores. METHODS: We retrospectively identified adult patients who underwent a mastectomy for cancer at Mayo Clinic sites from January 2010 to December 2016. Pain scores and prescription data were compared across operations and patient factors by univariate and multivariable analyses. RESULTS: Of 4021 patients, 3782 (94.1%) received an opioid prescription. Median oral milligram morphine equivalents (MME) were similar across all site-specific procedure groups (medians ranging from 225 to 375) while pain scores ranged from 1 to 4. Patients undergoing bilateral mastectomy (BM) and immediate breast reconstruction (IBR) reported the greatest pain scores. Pain scores did not vary with age or diagnosis for patients undergoing unilateral mastectomy or BM with lymph node surgery and IBR procedures. On multivariable analysis, variables associated with a MME discharge prescription >Q4 values included age, body mass index, site, year, inpatient status, and pain before discharge >3. CONCLUSION: Patient-reported pain following breast surgery varied by procedure, while MMEs prescribed remained similar. This suggests current opioid prescribing does not reflect intensity of pain and requires further research to optimize discharge opioid prescribing practices.


Assuntos
Analgésicos Opioides/administração & dosagem , Neoplasias da Mama/cirurgia , Excisão de Linfonodo/efeitos adversos , Mamoplastia/efeitos adversos , Mastectomia/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/patologia , Alta do Paciente , Prognóstico , Estudos Retrospectivos , Adulto Jovem
17.
N Engl J Med ; 381(2): 111-120, 2019 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-31291514

RESUMO

BACKGROUND: Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). RESULTS: A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. CONCLUSIONS: CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.).


Assuntos
Antibacterianos/uso terapêutico , Proteína C-Reativa/análise , Prescrição Inadequada/prevenção & controle , Testes Imediatos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Biomarcadores/sangue , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/sangue
18.
Presse Med ; 48(7-8 Pt 1): 767-779, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303371

RESUMO

OBJECTIVES: In France, too few general practitioners (GP) follow the training about suicide prevention and risk. This study aimed at reviewing international publications regarding GP's training on suicide risk, in order to inform us about the training practices in the world and potentially discover new methodologies. METHODS: We performed bibliographic databases searches on GPs training about suicide prevention and risk, for practicing GPs, excluding studies about particular population groups, following the PRISMA statement guidelines. Training duration, educational program, content, time of assessment, tools, and information about train the trainers or kirkpatrick's level were identified for each selected study. RESULTS: This review revealed that there is no consensus on the training program or on the assessment tools in GP's training about suicide prevention and risk. Nevertheless, it reveals a similar framework including a theoretical part, with a fundamental knowledge content, and an interactive part. CONCLUSION: If reaching standardized training practices seems difficult to achieve, standardizing assessment tools might be a relevant purpose. Indeed, using the same tools would allow proper training comparison. Practically speaking, this review inspired us in the implementation of in situ training and convincing us to undertake a French translation of an assessment scale.


Assuntos
Medicina Geral/educação , Clínicos Gerais/educação , Suicídio/prevenção & controle , Estudos de Casos e Controles , Educação Médica Continuada/métodos , Educação Médica Continuada/normas , Educação Médica Continuada/estatística & dados numéricos , Avaliação Educacional , França/epidemiologia , Medicina Geral/métodos , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Aprendizagem Baseada em Problemas/métodos , Aprendizagem Baseada em Problemas/normas , Suicídio/estatística & dados numéricos , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/estatística & dados numéricos
19.
J Opioid Manag ; 15(2): 111-118, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343712

RESUMO

OBJECTIVE: Prescription opioid misuse represents a social and economic dilemma in the United States. The authors evaluated primary care providers' (PCPs) prescribing of Schedule II opioids at our institution in Kentucky. DESIGN: Prospective evaluation of PCPs' prescribing practices over a 3-year period (October 1, 2014 to September 30, 2017) in an outpatient setting. METHODS: An analysis of Schedule II opioid prescribing following the implementation of federal and state guidelines and evidence-based standards. Special attention focused on Schedule II opioid prescriptions with a quantity > 90, Opana/Oxycontin, and morphine equivalent daily dosage. RESULTS: A statistically significant increase in the total number of PCPs and PCPs who prescribed Schedule II opioids was observed, while there was a concurrent significant decrease in the average number of Schedule II opioid pills prescribed per PCP, Schedule II opioid prescriptions per PCP, Schedule II opioid pills prescribed per patient by PCPs, Schedule II opioid prescriptions with a quantity > 90 per PCP, and Opana/Oxycontin prescriptions per PCP. A statistically significant decline in the average morphine equivalent daily dosage of Schedule II opioids per PCP was noted. CONCLUSIONS: This study reports the benefit of incorporating federal and state regulations and institutional evidence-based guidelines into primary care practice to decrease the number of Schedule II opioids prescribed. Further preventive measures include selecting alternative treatments to opioids and reducing the rates of opioid nonmedical use and overdose while maintaining access to prescription opioids when indicated.


Assuntos
Analgésicos Opioides , Substâncias Controladas , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Humanos , Atenção Primária à Saúde , Estudos Prospectivos , Estados Unidos
20.
J Opioid Manag ; 15(2): 119-127, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343713

RESUMO

OBJECTIVE: Legitimate opioid prescriptions have been identified as a risk factor for opioid misuse in pediatric patients. In 2014, Pennsylvania legislation expanded a prescription drug monitoring program (PDMP) to curb inappropriate controlled substance prescriptions. The authors' objective was to describe recent opioid prescribing trends at a large, pediatric health system situated in a region with one of the highest opioid-related death rates in the United States and examine the impact of the PDMP on prescribing trends. DESIGN: Quasi-experimental assessment of trends of opioid e-prescriptions, from 2012 to 2017. Multivariable Poisson segmented regression examined the effect of the PDMP. Period prevalence comparison of opioid e-prescriptions across the care continuum in 2016. RESULTS: There were 62,661 opioid e-prescriptions identified during the study period. Combination opioid/non-opioid prescriptions decreased, while oxycodone prescriptions increased. Seasonal variation was evident. Of 110,884 inpatient encounters, multivariable regression demonstrated lower odds of an opioid being prescribed at discharge per month of the study period (p < 0.001) and a significant interaction between passage of the PDMP legislation and time (p = 0.03). Black patients had lower odds of receiving an opioid at discharge compared to white patients. Inpatients had significantly greater odds of receiving an opioid compared to emergency department (Prevalence Odds Ratio 7.1 [95% confidence interval: 6.9-7.3]; p < 0.001) and outpatient (398.9 [355.5-447.5]; p < 0.001) encounters. CONCLUSION: In a large pediatric health system, oxycodone has emerged as the most commonly prescribed opioid in recent years. Early evidence indicates that a state-run drug monitoring program is associated with reduced opioid prescribing. Additional study is necessary to examine the relationship between opioid prescriptions and race.


Assuntos
Prescrição Eletrônica , Padrões de Prática Médica/estatística & dados numéricos , Programas de Monitoramento de Prescrição de Medicamentos , Analgésicos Opioides , Criança , Prescrição Eletrônica/estatística & dados numéricos , Grupos Étnicos/estatística & dados numéricos , Humanos , Alta do Paciente , Pediatria , Estados Unidos
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