Tag: pubmed

BMJ. 2024 May 16;385:e076509. doi: 10.1136/bmj-2023-076509.

ABSTRACT

OBJECTIVE: To examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.

DESIGN: Quasi-experimental difference-in-differences study SETTING: 20% sample of US Medicare beneficiaries, 2011-18.

PARTICIPANTS: People receiving long term opioid treatment whose prescriber stopped providing office based patient care or exited the workforce, as in the case of retirement or death (n=48 079), and people whose prescriber did not exit the workforce (n=48 079).

MAIN OUTCOMES: Discontinuation from long term opioid treatment, drug overdose, mental health crises, admissions to hospital or emergency department visits, and death. Long term opioid treatment was defined as at least 60 days of opioids per quarter for four consecutive quarters, attributed to the plurality opioid prescriber. A difference-in-differences analysis was used to compare individuals who received long term opioid treatment and who had a prescriber leave the workforce to propensity-matched patients on long term opioid treatment who did not lose a prescriber, before and after prescriber exit.

RESULTS: Discontinuation of long term opioid treatment increased from 132 to 229 per 10 000 patients who had prescriber exit from the quarter before to the quarter after exit, compared with 97 to 100 for patients who had a continuation of prescriber (adjusted difference 1.22 percentage points, 95% confidence interval 1.02 to 1.42). In the first quarter after provider exit, when discontinuation rates were highest, a transient but significant elevation was noted between the two groups of patients in suicide attempts (adjusted difference 0.05 percentage points (95% confidence interval 0.01 to 0.09)), opioid or alcohol withdrawal (0.14 (0.01 to 0.27)), and admissions to hospital or emergency department visits (0.04 visits (0.01 to 0.06)). These differences receded after one to two quarters. No significant change in rates of overdose was noted. Across all four quarters after prescriber exit, an increase was reported in the rate of mental health crises (0.39 percentage points (95% confidence interval 0.08 to 0.69)) and opioid or alcohol withdrawal (0.31 (0.014 to 0.58)), but no change was seen for drug overdose (-0.12 (-0.41 to 0.18)).

CONCLUSIONS: The loss of a prescriber was associated with increased occurrences of discontinuation of long term opioid treatment and transient increases in adverse outcomes, such as suicide attempts, but not other outcomes, such as overdoses. Long term opioid treatment discontinuation may be associated with a temporary period of adverse health impacts after accounting for unobserved confounding.

PMID:38754913 | DOI:10.1136/bmj-2023-076509

Lupus Sci Med. 2024 May 15;11(1):e001060. doi: 10.1136/lupus-2023-001060.

ABSTRACT

OBJECTIVE: Trauma history is associated with SLE onset and worse patient-reported outcomes; perceived stress is associated with greater SLE disease activity. Stress perceptions vary in response to life events and may be influenced by psychosocial factors. In an SLE cohort, we examined whether stressful events associated with perceived stress, whether psychosocial factors affected perceived stress, and whether these relationships varied by prior trauma exposure.

METHODS: This is a cross-sectional analysis of data from the California Lupus Epidemiology Study, an adult SLE cohort. Multivariable linear regression analyses controlling for age, gender, educational attainment, income, SLE damage, comorbid conditions, glucocorticoids ≥7.5 mg/day and depression examined associations of recent stressful events (Life Events Inventory) and positive (resilience, self-efficacy, emotional support) and negative (social isolation) psychosocial factors with perceived stress. Analyses were stratified by lifetime trauma history (Brief Trauma Questionnaire (BTQ)) and by adverse childhood experiences (ACEs) in a subset.

RESULTS: Among 242 individuals with SLE, a greater number of recent stressful events was associated with greater perceived stress (beta (95% CI)=0.20 (0.07 to 0.33), p=0.003). Positive psychosocial factor score representing resilience, self-efficacy and emotional support was associated with lower perceived stress when accounting for number of stressful events (-0.67 (-0.94 to -0.40), p<0.0001); social isolation was associated with higher stress (0.20 (0.14 to 0.25), p<0.0001). In analyses stratified by BTQ trauma and ACEs, associations of psychosocial factors and perceived stress were similar between groups. However, the number of recent stressful events was significantly associated with perceived stress only for people with BTQ trauma (0.17 (0.05 to 0.29), p=0.0077) and ACEs (0.37 (0.15 to 0.58), p=0.0011).

CONCLUSION: Enhancing positive and lessening negative psychosocial factors may mitigate deleterious perceived stress, which may improve outcomes in SLE, even among individuals with a history of prior trauma who may be more vulnerable to recent stressful events.

PMID:38754905 | DOI:10.1136/lupus-2023-001060

BMJ. 2024 May 16;385:q1108. doi: 10.1136/bmj.q1108.

NO ABSTRACT

PMID:38754903 | DOI:10.1136/bmj.q1108

BMJ Glob Health. 2024 May 15;9(5):e014640. doi: 10.1136/bmjgh-2023-014640.

ABSTRACT

BACKGROUND: Global health foregrounds trust as a key requirement for the achievement of international health initiatives, but it remains an elusive concept that is often mobilised without consideration of its dimensions, drivers and downstream behavioural consequences. This paper aims to contribute to the conceptual development and measurement of ‘patient trust in primary healthcare’ from the lower middle-income country perspective of rural Lao PDR.

METHODS: A two-phase mixed-method research design was implemented between January 2021 and April 2023. Phase 1 involved exploratory qualitative research to understand the local expressions and dimensions of patient trust in primary healthcare, with 25 semistructured interviews and 17 focus group discussions (120 participants) in eight villages in Bokeo Province. Phase 2 involved explanatory research to assess patterns of trust systematically at scale in 14 villages across four provinces, wherein 26 cognitive interviews, 17 expert interviews and non-participant community observations informed a community census survey with 1838 participants. We analysed qualitative data through content-oriented thematic analysis and developed an 8-item trust scale on that basis. Quantitative data analysis used descriptive statistical and regression analysis.

RESULTS: We found that trust in primary healthcare is readily understood and intrinsically valuable in rural Lao PDR. Key dimensions included communication, respectful care, relationship, fairness, integrity, reputation, assurance of treatment and competence. The survey highlighted that reputation, competence, integrity and respectful care had the lowest trust scores. Health centre operations predicted the local expressions of trust. The behavioural consequences of trust were limited to a positive statistical association with antenatal care uptake among pregnant women but outweighed by alternative measures that also captured the availability of healthcare facilities.

CONCLUSIONS: Overall, the development of our quantitative trust scale offers a process model for future researchers. We conclude that interpersonal, institutional and service-related trust require more explicit recognition in health system development and integration into health policy.

PMID:38754897 | DOI:10.1136/bmjgh-2023-014640

BMJ Paediatr Open. 2024 May 15;8(1):e002433. doi: 10.1136/bmjpo-2023-002433.

ABSTRACT

INTRODUCTION: Background: Childhood poisoning, characterised by exposure to toxic substances, poses a global health concern with variations across regions. Despite the importance of having current information about childhood acute poisoning in our region, there is a noticeable gap in such research in our local context. Regularly reviewing the agents responsible for poisoning in our locale is essential for devising prevention strategies and treatment approaches. This study aimed to examine the patterns and outcomes of childhood poisoning at the Children’s Emergency Department of the Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria.

METHODS: A retrospective cross-sectional study was conducted, analysing cases of childhood poisoning in the Children’s Emergency Ward, presenting from January 2013 to December 2022. Sociodemographic data, types of poisoning agents, home interventions, clinical features and outcomes were extracted from medical records.

RESULTS: Of 9389 admissions, 81 (0.8%) cases were admitted for childhood poisoning, but only 69 cases were analysed (total n=69). Children aged under 5 years (52.2%) and who were males (59.4%) were mostly involved. Organophosphates (21.7%) and kerosene (20.3%) were common poisoning agents, often accidental (72.5%) and occurring at home (94.2%). Delayed hospital presentation (>2 hours) was common (68.1%). Vomiting (72.5%) and drooling saliva (56.5%) were prevalent symptoms. Hydration (60.9%) was the main hospital intervention, while antidotes were infrequently used (15.9%). Mortality was 8.7%, predominantly due to kerosene ingestion in young children.

CONCLUSION: Organophosphate and kerosene poisoning are the most common in this facility. Enforcement challenges persist, emphasising the importance of safe storage practices and improved poison control measures. Addressing resource constraints for antidote availability and increasing awareness are vital for effective management and prevention.

PMID:38754895 | DOI:10.1136/bmjpo-2023-002433

BMJ Paediatr Open. 2024 May 15;8(1):e002329. doi: 10.1136/bmjpo-2023-002329.

ABSTRACT

BACKGROUND AND OBJECTIVES: This study aimed to identify predictors of sepsis-associated in-hospital mortality from readily available laboratory biomarkers at onset of illness that include haematological, coagulation, liver and kidney function, blood lipid, cardiac enzymes and arterial blood gas.

METHODS: Children with sepsis were enrolled consecutively in a prospective observational study involving paediatric intensive care units (PICUs) of two hospitals in Beijing, between November 2016 and January 2020. The data on demographics, laboratory examinations during the first 24 hours after PICU admission, complications and outcomes were collected. We screened baseline laboratory indicators using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, then we constructed a mortality risk model using Cox proportional hazards regression analysis. The ability of risk factors to predict in-hospital mortality was evaluated by receiver operating characteristic (ROC) curves.

RESULTS: A total of 266 subjects were enrolled including 44 (16.5%) deaths and 222 (83.5%) survivors. Those who died showed a shorter length of hospitalisation, and a higher proportion of mechanical ventilation, complications and organ failure (p<0.05). LASSO analysis identified 13 clinical parameters related to prognosis, which were included in the final Cox model. An elevated triglyceride (TG) remained the most significant risk factor of death (HR=1.469, 95% CI: 1.010 to 2.136, p=0.044), followed by base excess (BE) (HR=1.131, 95% CI: 1.046 to 1.223, p=0.002) and pH (HR=0.95, 95% CI: 0.93 to 0.97, p<0.001). The results of the ROC curve showed that combined diagnosis of the three indicators-TG+BE+pH-has the best area under the curve (AUC) (AUC=0.77, 95% CI: 0.69 to 0.85, p<0.001), with a 68% sensitivity and 80% specificity.

CONCLUSION: Laboratory factors of TG, BE and pH during the first 24 hours after intensive care unit admission are associated with in-hospital mortality in PICU patients with sepsis. The combination of the three indices has high diagnostic value.

PMID:38754894 | DOI:10.1136/bmjpo-2023-002329

BMJ Open. 2024 May 15;14(5):e082417. doi: 10.1136/bmjopen-2023-082417.

ABSTRACT

OBJECTIVES: This study aimed to investigate whether a significant trend regarding inpatient falls in Swiss acute care hospitals between 2011 and 2019 could be confirmed on a national level, and whether the trend persists after risk adjustment for patient-related fall risk factors.

DESIGN: A secondary data analysis was conducted based on annual multicentre cross-sectional studies carried out between 2011 and 2019.

SETTING: All Swiss acute care hospitals were obliged to participate in the surveys. Except for emergency departments, outpatient wards and recovery rooms, all wards were included.

PARTICIPANTS: All inpatients aged 18 or older who had given their informed consent and whose data were complete and available were included.

OUTCOME MEASURE: Whether a patient had fallen in the hospital was retrospectively determined on the survey day by asking patients the following question: Have you fallen in this institution in the last 30 days?

RESULTS: Based on data from 110 892 patients from 222 Swiss hospitals, a national inpatient fall rate of 3.7% was determined over the 9 survey years. A significant linear decreasing trend (p=0.004) was observed using the Cochran-Armitage trend test. After adjusting for patient-related fall risk factors in a two-level random intercept logistic regression model, a significant non-linear decreasing trend was found at the national level.

CONCLUSIONS: A significant decrease in fall rates in Swiss hospitals, indicating an improvement in the quality of care provided, could be confirmed both descriptively and after risk adjustment. However, the non-linear trend, that is, an initial decrease in inpatient falls that flattens out over time, also indicates a possible future increase in fall rates. Monitoring of falls in hospitals should be maintained at the national level. Risk adjustment accounts for the observed increase in patient-related fall risk factors in hospitals, thus promoting a fairer comparison of the quality of care provided over time.

PMID:38754884 | DOI:10.1136/bmjopen-2023-082417

BMJ Open. 2024 May 15;14(5):e077046. doi: 10.1136/bmjopen-2023-077046.

ABSTRACT

OBJECTIVE: This study aimed to examine the mediation role of perceived social support in the relationship between functional limitations, depressive symptoms and quality of life among older people in Malaysia.

SETTING: The Malaysian National Health Morbidity Survey 2018: Elderly Health was a cross-sectional health community survey among adults aged 50 and above.

PARTICIPANTS: 3977 community-dwelling older Malaysians aged 60 and above.

OUTCOME MEASURES: Functional limitations were defined as personal activities of daily living (PADL) and instrumental activities of daily living (IADL), tested in separate paths in all analyses. PADL was measured using the Barthel Index, while IADL was measured using the Lawton and Brody scale. Perceived social support, depressive symptoms and quality of life were measured using the Duke Social Support Index, Geriatric Depression Scale-14 and Control, Autonomy, Self-Realisation and Pleasure-19 tools. We used mediation analysis through structural equation modelling to explore the role of perceived social support.

RESULTS: Perceived social support mediated the relationship between PADL and IADL with depressive symptoms, with the indirect effects at -0.079 and -0.103, respectively (p<0.001). Similarly, perceived social support mediated the relationship between PADL and IADL with quality of life, with the indirect effects at 0.238 and 0.301, respectively (p<0.001). We performed serial multiple mediation analysis and found that perceived social support and depressive symptoms mediated the path between PADL and IADL with quality of life, with the indirect effects at 0.598 and 0.747, respectively (p<0.001). The relationship between functional limitations and all outcomes remained significant in all mediation analyses.

CONCLUSION: The present study provides evidence that perceived social support relieves the influence of functional limitations on depressive symptoms and declining quality of life among older people. Therefore, it is imperative to establish a social support system to improve the overall well-being of older people.

PMID:38754882 | DOI:10.1136/bmjopen-2023-077046

BMJ Open. 2024 May 15;14(5):e084882. doi: 10.1136/bmjopen-2024-084882.

ABSTRACT

INTRODUCTION: Upper limb (UL) dysfunctions are highly prevalent in people after breast cancer and have a great impact on performing activities in daily living. To improve care, a more comprehensive understanding of the development and persistence of UL dysfunctions is needed. Therefore, the UPLIFT-BC study will primarily examine the prognostic value of different factors at the body functions and structures, environmental and personal level of the International Classification of Functioning, Disability and Health (ICF) framework at 1-month post-surgery for persisting UL dysfunctions at 6 months after finishing cancer treatment.

METHODS AND ANALYSIS: A prospective longitudinal cohort study, running from 1-week pre-surgery to 6 months post-local cancer treatment, is performed in a cohort of 250 women diagnosed with primary breast cancer. Different potentially prognostic factors to UL dysfunctions, covering body functions and structures, environmental and personal factors of the ICF, are assessed pre-surgically and at different time points post-surgery. The primary aim is to investigate the prognostic value of these factors at 1-month post-surgery for subjective UL function (ie, QuickDASH) at 6 months post-cancer treatment, that is, 6 months post-radiotherapy or post-surgery (T3), depending on the individuals’ cancer treatment trajectory. In this, factors with relevant prognostic value pre-surgery are considered as well. Similar analyses are performed with an objective measure for UL function (ie, accelerometry) and a composite score of the combination of subjective and objective UL function. Second, in the subgroup of participants who receive radiotherapy, the prognostic value of the same factors is explored at 1-month post-radiotherapy and 6 months post-surgery. A forward stepwise selection strategy is used to obtain these multivariable prognostic models.

ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of UZ/KU Leuven (reference number s66248). The results of this study will be published in peer-reviewed journals and will be presented at several research conferences.

TRIAL REGISTRATION NUMBER: NCT05297591.

PMID:38754876 | DOI:10.1136/bmjopen-2024-084882

BMJ Open. 2024 May 15;14(5):e078942. doi: 10.1136/bmjopen-2023-078942.

ABSTRACT

BACKGROUND: The Rotterdam Eczema Study was an observational cohort study with an embedded pragmatic randomised controlled open-label trial. It was conducted in children with atopic dermatitis (AD) in the Dutch primary care system. The objective of the trial was to determine whether a potent topical corticosteroid (TCS) is more effective than a low-potency TCS.

OBJECTIVE: We are aiming to communicate transparently about the poor recruitment for the trial part and to explore the reasons why recruitment was weak.

DESIGN: We used a survey to find out what patients in the cohort did when they experienced a flare-up.

METHODS: Descriptive statistics were used to present the baseline characteristics of participants in the trial and the results of the survey.

RESULTS: In total, 367 patients were included in the cohort. Of these, 32 were randomly assigned to a trial treatment; they had a median age of 4.0 years (IQR 2.0-9.8). A total of 69 of the 86 children (80.2%) who could participate in the survey responded. 39 (56.5%) suffered a flare-up during the follow-up (making them potentially eligible for inclusion in the trial). 26 out of 39 (66.7%) increased their use of an emollient and/or TCS themselves. Only 12 of the 39 (30.7%) contacted their general practitioner (GP) as instructed in the study protocol, but 8 out of these 12 did not meet the inclusion criteria for the trial.

CONCLUSION: The main reason why cohort participants did not take part in the trial was that they did not contact their GPs when they experienced an AD flare-up. Furthermore, the majority of patients who contacted their GPs did not match the inclusion criteria of the trial. We expect that the lessons learnt from this study will be useful when developing future studies of children with AD in primary care.

PMID:38754875 | DOI:10.1136/bmjopen-2023-078942