Expert-based collaborative analysis of the situation and prospects of biomarker test implementation in oncology in Spain

PURPOSE

Biomarkers as screening for precision medicine is a fundamental step. The purpose of this article is twofold. First, to highlight the existing barriers in the implementation of Precision Medicine in Spain, with a special emphasis on barriers in access to the determination of biomarkers. Second, to provide a Roadmap that can help implement Precision Medicine equitably at the national level and optimize the use of biomarkers.

METHODS

A systematic review of literature (SRL) and a focus group (FG) with multidisciplinary experts has been carried out in 2023. Participants were contacted individually, and discourse analysis was processed anonymously.

RESULTS

We carried out a quantitative (SRL) and a qualitative approach (FG). The discourse analysis and roadmap were sent individually to each expert for approval.

CONCLUSIONS

The potential of Precision Medicine has not been fulfilled in Spain. While several regional initiatives are in place, a national plan or strategy around Precision Medicine and use of biomarkers is lacking. In a general context of rapid progress at a global and European level, including the 2021 Europe's Beating Cancer Plan, it is time to define and implement a National Plan to make the promise come true. While some comparable countries within Europe - such as the UK or France - are mature enough to adopt such strategies, in Spain there is still a long way to go. We consider that the different strands of work outlined in the Roadmap can be used as basis for such purpose.

Impact of a pharmaceutical algorithm on patients with upper-gastrointestinal symptoms: A pre-post intervention study

OBJECTIVE

To evaluate the algorithm impact on the upper gastrointestinal patients' symptoms (PROMs) and satisfaction with pharmaceutical care received (PREMs).

METHODS

The algorithm was previously developed by clinicians and pharmacists, through a pre-post intervention study in Spain (June-October 2022). We included 1221 patients who were seeking advice and/or medication for symptoms at 134 community pharmacies. Patients' sociodemographic and clinical variables were assessed at baseline and were classified in accordance with the Gastroesophageal Reflux Disease Impact Scale (GIS) into patients with either epigastric, retrosternal or overlapping symptoms. Interventions included medical referral; education on healthy habits; prescription of an OTC treatment or a non-pharmacologic prescription. Fourteen days later, patients were assessed through: a) the change on the GIS score, and b) patients' satisfaction with pharmaceutical care received.

RESULTS

Most patients reported overlapping symptoms (660, 54.0%), 171 (14.0%) reported epigastric symptoms and 390 (32.0%) retrosternal symptoms. Patients with epigastric symptoms did not show a difference in the GIS score after the intervention while those with retrosternal symptoms and those with overlapping symptoms did (mean 1.09 (4.28 SD), p < 0.001 and mean 3.18 (6.01 SD), p < 0.001, respectively). Patients who received education on healthy habits and those with a prescription of a pharmacological treatment (antiacids in monotherapy and alginates-antiacids) showed an increase in the GIS score. Patients' satisfaction with pharmaceutical care received was over 99.2% of sample.

CONCLUSION

Implementation of the upper-gastrointestinal symptoms algorithm in Community pharmacies had a positive impact on patients' symptoms, quality of life, and satisfaction with pharmaceutical care received.

Urologists' and general practitioners' knowledge, beliefs and practice relevant for opportunistic prostate cancer screening: a PRISMA-compliant systematic review

Background

Recent guidelines on opportunistic prostate cancer screening conclude that the decision to screen with prostate-specific antigen should be made by each patient individually together with the clinician. However, there is evidence of a lack of clinicians' awareness of prostate cancer screening. This study sought to assess the recent evidence of clinicians' knowledge, beliefs, and practice regarding opportunistic prostate cancer screening comparing urologists and generals practitioners.

Methods

A systematic search was conducted in 3 online databases: MEDLINE, Web of Science and EMBASE (from January 1, 2015, to January 9th, 2023). Studies that explored clinicians' knowledge, beliefs, and practices regarding opportunistic prostate cancer screening were included. Studies were assessed for quality reporting according to the Strengthening the Reporting of Observational studies in Epidemiology guidelines.

Results

A total of 14 studies met the inclusion criteria: ten studies included primary care health professionals, three studies included urologists, and one study included both. Studies involving general practitioners showed a generally low level of awareness of the recommended uses of the test, and urologists showed a greater knowledge of clinical practice guidelines. General practitioners' opinion of prostate-specific antigen was generally unfavourable in contrast to urologists' who were more likely to be proactive in ordering the test. Less than half of the included studies evaluated shared-decision making in practice and 50% of clinicians surveyed implemented it.

Conclusion

General practitioners had less knowledge of prostate cancer risk factors and clinical practice guidelines in the use of PSA than urologists, which makes them less likely to follow available recommendations. A need to carry out education interventions with trusted resources based on the available evidence and the current guidelines was identified.

Colonoscopy Satisfaction and Safety Questionnaire based on patient experience (CSSQP): A valuable quality tool for all colonoscopies

INTRODUCTION

The Colonoscopy Satisfaction and Safety Questionnaire based on Patient experience (CSSQP) was recently developed and validated within a Bowel Cancer Screening Program. We aimed to identify factor related to patient experience through the CSSQP, including all indications for colonoscopy. Indicators of satisfaction and perceived safety with colonoscopy were also assessed to compare the different centers.

METHODS

Multicenter study in nine Spanish hospitals. Consecutive patients who had undergone a colonoscopy completed the CSSQP adding a novel item on bowel preparation. Factors related to patient experiences and data from non-respondents were analyzed.

RESULTS

Of 2200 patients, 1753 filled out the questionnaire (response rate 79.7%, sample error 2%). Patients whose colonoscopy indication was a primary colorectal cancer screening (OR: 1.68, 95% CI: 1.15-2.44, p=0.007) or due to a +FIT (OR: 1.73, 95% CI: 1.18-2.53) reported higher satisfaction than patients with gastrointestinal symptoms. In addition, college-educated patients (OR: 2.11, 95% CI: 1.25-3.56) were more likely to report better overall satisfaction than patients with lower education level. Significant differences were observed in the majority of the CSSQP items between centers. Safety incidents were reported by 35 (2%) patients, and 176 (10%) patients reported that they received insufficient information.

CONCLUSION

The CSSQP identifies several significant factors on satisfaction and perceived safety in patients referred for colonoscopy for any reason. The CSSQP also allows comparison of patient-identified colonoscopy quality indicators between centers.

Barriers and facilitators of shared decision-making in prostate cancer screening in primary care: A systematic review

Objective

To identify barriers and facilitators of the implementation of shared decision-making (SDM) on PSA testing in primary care.

Design

Systematic review of articles.

Data sources

PubMed, Scopus, Embase and Web of Science.

Eligibility criteria

Original studies published in English or Spanish that assessed the barriers to and facilitators of SDM before PSA testing in primary care were included. No time restrictions were applied.

Data extraction and synthesis

Two review authors screened the titles, abstracts and full texts for inclusion, and assessed the quality of the included studies. A thematic synthesis of the results were performed and developed a framework. Quality assessment of the studies was based on three checklists: STROBE for quantitative cross-sectional studies, GUIDED for intervention studies and SRQR for qualitative studies.

Results

The search returned 431 articles, of which we included 13: five cross-sectional studies, two intervention studies, five qualitative studies and one mixed methods study. The identified barriers included lack of time (healthcare professionals), lack of knowledge (healthcare professionals and patients), and preestablished beliefs (patients). The identified facilitators included decision-making training for professionals, education for patients and healthcare professionals, and dissemination of information.

Conclusions

SDM implementation in primary care seems to be a recent field. Many of the barriers identified are modifiable, and the facilitators can be leveraged to strengthen the implementation of SDM.

Consensus on post COVID in the Spanish national health system: Results of the CIBERPOSTCOVID eDelphi study

BACKGROUND

In 2021, the Spanish Ministry of Health launched the CIBERPOSTCOVID project to establish what post COVID was. The present study reports the level of agreement among stakeholders on post COVID and its clinical and diagnostic characteristics in the Spanish health system.

METHODS

The agreement on post COVID among clinicians, public health managers, researchers and patients' representatives was explored in a real-time, asynchronous online Delphi. In a two-wave consensus, respondents rated from 1 (total disagreement) to 6 (total agreement) 67 statements related to terminology, duration, etiology, symptoms, impact on quality of life, severity, elements to facilitate diagnosis, applicability in the pediatric population, and risk factors. Consensus was reached when 70 % of ratings for a statement were 5 or 6, with an interquartile range equal or less than 1.

FINDINGS

A total of 333 professionals and patients participated in this eDelphi study. There was agreement that post COVID was "a set of multi-organic symptoms that persist or fluctuate after acute COVID-19 infection and are not attributable to other causes" with a minimum duration of 3 months. The highest levels of agreement were found in the most frequent symptoms and its impacts on everyday activities. Aspects related to the diagnostic process and the measurement of its severity reached a lower level of consensus. There was agreement on the need to rule out previous health problems and assess severity using validated functional scales. However, no agreement was reached on the risk factors or specific features in the pediatric population.

INTERPRETATION

This policy-based consensus study has allowed the characterization of post COVID generating collective intelligence and has contributed to an operational definition applicable in clinical practice, health services management and useful for research purposes in Spain and abroad. Agreements are consistent with existing evidence and reference institutions at European and international level.

Prevalence and risk factors of upper gastrointestinal symptoms in community pharmacies in Spain: a cross-sectional study

Background: Frequently, the community pharmacies are the only points of consultation for upper-gastrointestinal symptomology. However, the heterogeneity of symptoms often limits the correct management of the patient. The study aim is to describe the epidemiological and clinical characteristics of patients with upper-gastrointestinal symptoms who ask for advice in community pharmacies. Methods: A cross-sectional study was performed in 134 Spanish pharmacies (June-October 2022) and we included 1,360 patients. We collected sociodemographic, clinical variables and current medication data. The pharmacist evaluated the gastrointestinal symptoms through the application of the GERD Impact Scale (GIS questionnaire). Patients were classified into three groups according to their symptoms: epigastric, retrosternal and overlapping symptoms. Results: Median age was 49 years (interquartile range 36-62 years) and 59.3% were women. Most patients reported overlapping symptoms (738%, 54.3%), 433 (31.8%) retrosternal and 189 (13.9%) epigastric symptoms. Patients with overlapping symptoms were more likely to associated consumption of foods and/or drinks and symptoms and showed lower scores on the GIS scale (median 26, IQR 20-30) than those with epigastric (median 32, IQR 29-33) and retrosternal (median 32, IQR 28-34) symptoms (p < 0.001). Patients in treatment with a combination of alginates and antiacids were more likely to think that it better alleviated their symptoms in all the patients included (p = 0.012). Conclusion: More than half of the patients showed overlapping symptoms and were more likely to associate their symptoms with dietary habits and having poorer scores in the GIS scale. Clinical awareness of such overlapping condition would help optimize the management of patients with upper gastrointestinal symptoms in practice.

Reply to Jue, J.S.; Alameddine, M. Role of PSA Density and MRI in PSA Interpretation. Comment on "Lumbreras et al. Variables Associated with False-Positive PSA Results: A Cohort Study with Real-World Data. Cancers 2023, 15, 261"

We thank you and your co-authors for the comment [...].

Validation of a scale to assess adherence to oral chemotherapy based on the experiences of patients and healthcare professionals (EXPAD-ANEO)

Background: Lack of adherence to Oral antineoplastic agents (OAAs) treatment has important clinical, social and economic consequences.

Objective: To develop and validate a novel instrument for assessing adherence to OAAs, based on the reported experiences of people with cancer in relation to their treatment and the opinions of the healthcare professionals who care for them.

Methods: We performed a multicenter validation study of a scale designed to assess adherence to OAAs. First, a steering committee developed the items for an initial scale, based on the results of a qualitative study that evaluated patients’ and professionals’ experiences with this treatment. We then assessed the validity and reliability of the initial scale in a sample of 268 outpatients with cancer who received their OAAs from four Spanish hospitals.

Results: The mean age of the sample of 268 outpatients was 64.1 (standard deviation [SD] 12.4) years, and 47% of participants were women. With the results of this analysis, we developed the EXPAD-ANEO scale, which has 2 factors, one for beliefs and expectations and another for behavior. Both factors explain 52% of the explained common variance. Good reliability was obtained, with a McDonald’s omega of 0.7 for the first factor and 0.6 for the second factor. The fit indices were optimal (Root Mean Square Error of Approximation = 0.02, Comparative Fit Index = 0.99, Tucker Lexis Index = 0.99 and Standardized Root Mean Squared Residual = 0.03), which verifies the appropriateness of the items to the model. We measured EXPAD-ANEO criterion validity against pill count, obtaining a specificity of 80%. We measured convergent validity with the Morisky-Green test and found a significant association (p &lt; 0.001). We measured divergent validity with questions on health literacy from the 16-item European Health Literacy Survey and found no correlation (p = 0.153).

Conclusion: EXPAD-ANEO is the first validated instrument for evaluating patients’ experiences with and adherence to OAAs, providing valuable information that can help health professionals to establish individual strategies or collective programs for improving therapeutic results and reducing healthcare costs.

Contextual Factors That May Impact on the Development and Implementation of the Sugary Drinks Policy Comment on "Understanding Marketing Responses to a Tax on Sugary Drinks: A Qualitative Interview Study in the United Kingdom, 2019"

Forde et al proposed an interesting framework to understand marketing response to a tax in sugary drinks based on stakeholder interviews. Sugary drinks regulation can lead to various strategies in the industry's marketing activity. That is, it can either result in the industry introducing no changes or it can lead to changes, which can conflict or align with public health objectives. The importance of Forde and colleagues' analysis lies in the potential for governments to anticipate the industry's reaction to the legislation and the need of drivers to enable both big and small companies to follow the rules. Governments must not forget the importance of other contextual factors that will have an impact both on the development and implementation of this type of policies and on possible responses that could mitigate their impact such as public acceptance, the influence of mass media and corporate activities aimed at influencing policy.

Gender Differences in the Impact of Recommendations on Diagnostic Imaging Tests: A Retrospective Study 2007-2021

(1) Background: The frequency of imaging tests grew exponentially in recent years. This increase may differ according to a patient's sex, age, or socioeconomic status. We aim to analyze the impact of the Council Directive 2013/59/Euratom to control exposure to radiation for men and women and explore the impact of patients' age and socioeconomic status; (2) Methods: The retrospective observational study that includes a catchment population of 234,424. We included data of CT, mammography, radiography (conventional radiography and fluoroscopy) and nuclear medicine between 2007-2021. We estimated the associated radiation effective dose per test according using previously published evidence. We calculated a deprivation index according to the postcode of their residence. We divided the study in 2007-2013, 2014-2019 and 2020-2021 (the pandemic period). (3) Results: There was an increase in the number of imaging tests received by men and women after 2013 (p < 0.001), and this increase was higher in women than in men. The frequency of imaging tests decreased during the pandemic period (2020-2021), but the frequency of CT and nuclear medicine tests increased even during these years (p < 0.001) and thus, the overall effective mean dose. Women and men living in the least deprived areas had a higher frequency of imaging test than those living in the most deprived areas. (4) Conclusions: The largest increase in the number of imaging tests is due to CTs, which account for the higher amount of effective dose. The difference in the increase of imaging tests carried out in men and women and according to the socioeconomic status could reflect different management strategies and barriers to access in clinical practice. Given the low impact of the available recommendations on the population exposure to radiation and the performance of high-dose procedures such as CT, deserve special attention when it comes to justification and optimization, especially in women.

[Translated article] Design and validation of a scale to measure adherence to oral antineoplastic drugs

OBJECTIVE

Design and validate a scale to measure adherence to oral antineoplastic drugs. The availability of a simple, validated tool that can be applied to routine care will make it possible to detect and identify non-adherence in order to establish strategies to improve adherence and optimize the quality of healthcare services.

METHOD

Validation study of the scale designed to assess adherence to antineoplastic drugs in a sample of outpatients who collect their medication in two Spanish hospitals. Its validity and reliability will be analyzed, based on a previous qualitative methodology study, using classical test theory and Rasch analysis. We will examine its performance, item fit, response structure and person fit to the predictions of the model, as well as dimensionality, item-person reliability, the appropriateness of the level of difficulty of the items to the sample, and the differential performance of the items according to gender.

Sample size requirement in trials that use the composite endpoint major adverse cardiovascular events (MACE): new insights

BACKGROUND

The real impact of the degree of association (DoA) between endpoint components of a composite endpoint (CE) on sample size requirement (SSR) has not been explored. We estimate the impact of the DoA between death and acute myocardial infarction (AMI) on SSR of trials using use the CE of major adverse cardiac events (MACE).

METHODS

A systematic review and quantitative synthesis of trials that include MACE as the primary outcome through search strategies in MEDLINE and EMBASE electronic databases. We limited to articles published in journals indexed in the first quartile of the Cardiac & Cardiovascular Systems category (Journal Citation Reports, 2015-2020). The authors were contacted to estimate the DoA between death and AMI using joint probability and correlation. We analyzed the SSR variation using the DoA estimated from RCTs.

RESULTS

Sixty-three of 134 publications that reported event rates and the therapy effect in all component endpoints were included in the quantitative synthesis. The most frequent combination was death, AMI, and revascularization (n = 20; 31.8%). The correlation between death and AMI, estimated from 5 trials¸ oscillated between - 0.02 and 0.31. SSR varied from 14,602 in the scenario with the strongest correlation to 12,259 in the scenario with the weakest correlation; the relative impact was 16%.

CONCLUSIONS

The DoA between death and AMI is highly variable and may lead to a considerable SSR variation in a trial including MACE.

Mortality prediction models after radical cystectomy for bladder tumour: A systematic review and critical appraisal

INTRODUCTION

To identify risk-predictive models for bladder-specific cancer mortality in patients undergoing radical cystectomy and assess their clinical utility and risk of bias.

METHODS

Systematic review (CRD42021224626:PROSPERO) in Medline and EMBASE (from their creation until 31/10/2021) was screened to include articles focused on the development and internal validation of a predictive model of specific cancer mortality in patients undergoing radical cystectomy. CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and Prediction model Risk Of Bias ASsessment Tool (PROBAST) were applied.

RESULTS

Nineteen observational studies were included. The main predictors were sociodemographic variables, such as age (18 studies, 94.7%) and sex (17, 89.5% studies), tumour characteristics (TNM stage (18 studies, 94.7%), histological subtype/grade (15 studies, 78.9%), lymphovascular invasion (10 studies, 52.6%) and treatment with chemotherapy (13 studies, 68.4%). C-index values were presented in 14 studies. The overall risk of bias assessed using PROBAST led to 100% of studies being classified as high risk (the analysis domain was rated to be at high risk of bias in all the studies), and 52.6% showed low applicability. Only 5 studies (26.3%) included an external validation and 2 (10.5%) included a prospective study design.

CONCLUSIONS

Using clinical predictors to assess the risk of bladder-specific cancer mortality is a feasibility alternative. However, the studies showed a high risk of bias and their applicability is uncertain. Studies should improve the conducting and reporting, and subsequent external validation studies should be developed.

Evaluation of Diagnostic Strategies for Identifying SARS-CoV-2 Infection in Clinical Practice: a Systematic Review and Compliance with the Standards for Reporting Diagnostic Accuracy Studies Guideline (STARD)

We aimed to review strategies for identifying SARS-CoV-2 infection before the availability of molecular test results, and to assess the reporting quality of the studies identified through the application of the STARD guideline. We screened 3,821 articles published until 30 April 2021, of which 23 met the inclusion criteria: including at least two diagnostic variables, being designed for use in clinical practice or in a public health context and providing diagnostic accuracy rates. Data extraction and application of STARD criteria were performed independently by two researchers and discrepancies were discussed with a third author. Most of the studies (16, 69.6%) included symptomatic patients with suspected infection, six studies (26.1%) included patients already diagnosed and one study (4.3%) included individuals with close contact to a COVID-positive patient. The main variables considered in the studies, which included symptomatic patients, were imaging and demographic characteristics, symptoms, and lymphocyte count. The values for area under the receiver operating characteristic curve (AUC)ranged from 53-97.4. Seven studies (30.4%) validated the diagnostic model in an independent sample. The average number of STARD criteria fulfilled was 17.6 (maximum, 27 and minimum, 5). High diagnostic accuracy values are shown when more than one diagnostic variable is considered, mainly imaging and demographic characteristics, symptoms, and lymphocyte count. This could offer the potential to identify individuals with SARS-CoV-2 infection with high accuracy when molecular testing is not available. However, external validation for developed models and evaluations in populations as similar as possible to those in which they will be applied is urgently needed. IMPORTANCE According to this review, the inclusion of more than one diagnostic test in the diagnostic process for COVID-19 infection shows high diagnostic accuracy values. Imaging characteristics, patients' symptoms, demographic characteristics, and lymphocyte count were the variables most frequently included in the diagnostic models. However, developed models should be externally validated before reaching conclusions on their utility in practice. In addition, it is important to bear in mind that the test should be evaluated in populations as similar as possible to those in which it will be applied in practice.

EsReflux Protocol: Epidemiological Study of Heartburn and Reflux-like Symptoms in Spanish Community Pharmacies

(1) Background: Heartburn and reflux discomfort are frequent reasons for consultation at the community pharmacy. To facilitate the assistance work of the community pharmacist and its coordination between different levels of care, a group of experts in Community Pharmacy, Primary Care, and Gastroenterology have recently worked on an algorithm to manage these symptoms in the community pharmacy (Professional Pharmaceutical Service). The objective of this study is to analyze the clinical and sociodemographic characteristics of patients with heartburn and/or reflux-like symptoms who go to a community pharmacy, and to evaluate the clinical and humanistic results after the implementation of a Professional Pharmaceutical Service. (2) Methods: A pre-post study will be carried out to evaluate clinical and humanistic results after the implementation of a Professional Pharmaceutical Service. We will include 1200 patients who ask for advice or get a non-prescription medication due to acid and/or reflux symptoms in 240 Spanish pharmacies. Clinical data will be collected at baseline and 15 days after the pharmaceutical intervention. The GERD Impact Scale (GIS) questionnaire will be applied to assess changes in heartburn/reflux-like symptoms and quality of life after the intervention.

Appropriateness of radiological diagnostic tests in otolaryngology

Objective

To evaluate the appropriateness of imaging tests associated with radiation in the field of otolaryngology according to the available recommendations, and to estimate the effective radiation dose associated.

Method

Cross-sectional epidemiological study of the totality of the imaging test requests carried out by two Spanish hospitals (n = 1931). We collected the following information: patient demographic data, type of imaging test, imaging tests referred in the previous 12 months, referrer department and diagnostic suspicion. In accordance with the available guidelines, we considered the requests: (a) Appropriate; (b) Inappropriate; (c) Not adequately justified; (d) Not included in the guidelines. We calculated the prevalence of each category and their variation according to the different variables. Collective and per capita effective dose were calculated for each category.

Results

Of the 538 requests, 42% were considered appropriate, 34.4% inappropriate, 11.9% not adequately justified and 11.7% not included in the guidelines. Imaging tests requested by general partitioners (aOR: 0.18; 95% CI: 0.06–0.50) and clinical departments (aOR: 0.27; 95% CI: 0.11–0.60) were less likely to be considered appropriate than those requested by the Otolaryngology department. Patients with a diagnosis suspicion of tumour pathology were more likely to have a requested imaging test classified as appropriate (aOR: 7.12; 95% CI: 3.25–15.61). The cumulative effective dose was 877.8 mSv, of which 40% corresponded to tests classified as inappropriate.

Conclusions

A high percentage of imaging tests are considered as inappropriate in the field of otolaryngology, with a relevant frequency of associated effective radiation dose. Type of department, the diagnostic suspicion and the type of imaging tests were variables associated to the inappropriateness of the test.

Impact of Variation in Pill/Package Appearance of Drugs on Patients' Behavior: A Systematic Review

OBJECTIVE

This systematic review aims to identify and critically evaluate the available evidence on the impact of switches in pill appearance/packaging on patient's behavior.

METHODS

Studies from inception to March 2021 were searched across MEDLINE through PubMed, the Cochrane Library, Embase, and Scopus. Included studies carried out an original evaluation in English or Spanish language that evaluated the impact of switches in pill appearance/packaging on patient's behavior. Two authors independently extracted study data and evaluated studies for methodological quality according to the STROBE guidelines.

RESULTS

Ten studies were included, and the mean (SD) number of STROBE criteria satisfied was 17.2 (3.9). Three of 5 studies found a significant association between change in pill appearance and persistence to treatment; the 3 studies that evaluated the impact of a change on adherence to treatment found a significant association; 1 of the 2 studies that evaluated the relationship between a change a clinical outcome found a significant association with the prevalence of uncontrolled blood pressure; and 1 study showed lower rates of switchbacks to the branded product compared with patients who switched to generic drug products, with different appearance.

CONCLUSIONS

This systematic review showed an impact of the change in pill/package appearance on patients' behavior in 7 of the 10 studies included. Generic switching may lead to unintended consequences on patients' behavior, mainly regarding adherence to treatment.

Influence of the COVID-19 Pandemic on Adherence to Orally Administered Antineoplastics

Background: Several factors can influence adherence to orally administered antineoplastics, including fear or anxiety resulting from situations such as the COVID-19 pandemic. The aim of this study was to analyse the influence of these patients’ experiences on adherence to orally administered antineoplastics. Methods: Cross-sectional study in four hospitals including >18 year old cancer patients receiving orally administered antineoplastics during the first half of 2021. Data were collected from medical records and through telephone interviews. Adherence was assessed through the prescription refill records and pill counts. Patients’ fear resulting from the pandemic was assessed by means of a structured questionnaire using a 5-point Likert-type scale. Results: Our sample compr BARCELONAised 268 patients (54% men) with a mean age of 64 years (SD 12). More than 15% had experienced afraid and 5% had experienced a dangerous situation when attending hospital, 17% felt they had received less care, and 30% preferred telepharmacy. Adherence measured by pill count was 69.3% and 95.5% according to prescription refill records. Patients who had experienced fear or anxiety when attending hospital were less adherent (aOR 0.47, 95% CI 0.23−0.96, p = 0.039). Conclusion: The fear experienced by some patients has affected adherence to treatment.

Profiling the Bladder Microbiota in Patients With Bladder Cancer

Evidence suggests that microbiota may contribute to the pathogenesis of several diseases, including cancer. In the case of bladder cancer, preliminary studies have found alterations in the urinary microbiota of patients with urothelial carcinoma compared with healthy individuals. Conversely, the urinary microbiota differ between men and women, and it has been hypothesized that these differences are associated with the lower incidence of bladder cancers in women. The objective of this study was to characterize the bladder microbiota in paired samples of tumor and non-tumor mucosa of patients with malignant bladder neoplasia using next-generation sequencing. In addition, we aimed to study potential differences in microbial composition in tumor samples according to clinical and pathological variables, and to determine possible microbial profiles. We found significant differences in microbial richness at the genus level, with a higher richness observed in the non-tumor compared with the tumor mucosa. It was also shown that Actinobacteria were significantly more enriched in the non-tumor compared with the tumor mucosa (P = 0.014). In the multivariate analysis, we found significant differences in microbial composition according to tumor grade (P = 0.03 and 0.04 at the phylum and genus levels, respectively). Moreover, we detected a higher microbial richness in non-tumor vs. tumor tissues which agrees with the global assumption that microbial richness is an indicator of health. The greater abundance of members of the Actinobacteria phylum in the non-neoplastic bladder mucosa samples supports the hypothesis that a higher abundance of Actinomycetes is associated with a lower rate of bladder cancer in women and suggests a protective role for these microbiota. We detected a microbial profile that was enriched for Enterococcus in low-grade tumors. Finally, we identified the presence of two clusters in the microbial composition of the tumor mucosa samples, significantly enriched for the genera Barnesiella, Parabacteroides, Prevotella, Alistipes, and Lachnospiracea_incertae_sedis (Cluster 1), or Staphylococcus (Cluster 2). Further longitudinal studies are needed to assess the role of the bladder microbiota in carcinogenesis.

Adaptation and psychometric validation of Diabetes Health Profile (DHP-18) in patients with type 2 diabetes in Quito, Ecuador: a cross-sectional study

Introduction

The Diabetes Health Profile (DHP‐18), structured in three dimensions (psychological distress (PD), barriers to activity (BA) and disinhibited eating (DE)), assesses the psychological and behavioural burden of living with type 2 diabetes. The objectives were to adapt the DHP‐18 linguistically and culturally for use with patients with type 2 DM in Ecuador, and to evaluate its psychometric properties.

Methods

Participants were recruited using purposive sampling through patient clubs at primary health centres in Quito, Ecuador. The DHP-18 validation consisted in the linguistic validation made by two Ecuadorian doctors and eight patient interviews. And in the psychometric validation, where participants provided clinical and sociodemographic data and responded to the SF-12v2 health survey and the linguistically and culturally adapted version of the DHP-18. The original measurement model was evaluated with confirmatory factor analysis (CFA). Reliability was assessed through internal consistency using Cronbach’s alpha and test–retest reproducibility by administering DHP-18 in a random subgroup of the participants two weeks after (n = 75) using intraclass correlation coefficient (ICC). Convergent validity was assessed by establishing previous hypotheses of the expected correlations with the SF12v2 using Spearman’s coefficient.

Results

Firstly, the DHP-18 was linguistically and culturally adapted. Secondly, in the psychometric validation, we included 146 participants, 58.2% female, the mean age was 56.8 and 31% had diabetes complications. The CFA indicated a good fit to the original three factor model (χ2 (132) = 162.738, p < 0.001; CFI = 0.990; TLI = 0.989; SRMR = 0.086 and RMSEA = 0.040. The BA dimension showed the lowest standardized factorial loads (λ) (ranging from 0.21 to 0.77), while λ ranged from 0.57 to 0.89 and from 0.46 to 0.73, for the PD and DE dimensions respectively. Cronbach’s alphas were 0.81, 0.63 and 0.74 and ICCs 0.70, 0.57 and 0.62 for PD, BA and DE, respectively. Regarding convergent validity, we observed weaker correlations than expected between DHP-18 dimensions and SF-12v2 dimensions (r > −0.40 in two of three hypotheses).

Conclusions

The original three factor model showed good fit to the data. Although reliability parameters were adequate for PD and DE dimensions, the BA presented lower internal consistency and future analysis should verify the applicability and cultural equivalence of some of the items of this dimension to Ecuador.

Do the Prostate-Specific Antigen (PSA) Tests That Are Ordered in Clinical Practice Adhere to the Pertinent Guidelines?

Scientific societies have provided guidelines to reduce PSA-specific harms. We studied the potential non-compliance of PSA testing with current guidelines in general practice. A cross-sectional study of a random sample of 1291 patients with a PSA test was performed between January and April 2018 in primary health care. Patients with a previous prostate cancer diagnosis or those who were being followed-up for previous high PSA values were excluded. Two independent researchers classified whether each test was potentially non-compliant with recommendations. We estimated frequencies of potentially non-compliant PSA determinations and calculated prevalence ratios (PR) to assess their relationship with possible explanatory variables. A total of 66% (95% CI: 62-69%) of PSA requests in asymptomatic patients were potentially non-compliant with the current guideline. This was associated with having a previous diagnosis of neoplasm (PR adjusted by age and life expectancy: 1.18; 95% CI: 1.02-1.37) as well as being a current consumer of tobacco, alcohol, or other drugs (PR: 0.80; 95% CI: 0.67-0.97). Real world data shows that patients are still frequently exposed to overdiagnosis risk with a PSA potentially non-compliant with recommendations. Patients diagnosed with another neoplasm or non-consumers of toxic substances were more exposed, probably due to increased contact with doctors or health-seeking behaviour.

Impact of patients' perception of COPD and treatment on adherence and health-related quality of life in real-world: Study in 53 community pharmacies

BACKGROUND

Patient adherence to treatment in chronic obstructive pulmonary disease (COPD) is essential to optimize disease management. We aimed to assess the impact of patients' perception of their treatment and disease on adherence and Health-Related Quality of Life (HRQL) in patients attending a community pharmacy, where usually subjects have a better condition than those in clinical settings.

METHODS

We performed a cross-sectional study of 318 patients with COPD in treatment with inhalers in the last 3 months from 53 community pharmacies. We assessed HRQL with St George's Respiratory Questionnaire (SGRQ). Persistence was assessed from the three previous refills and adherence through the Test of Adherence to Inhalers test.

RESULTS

Persistence was achieved by 78.6% of the patients and 58.5% had good adherence. Patients having a multidose DPI and those with MDI showed a 2.8-fold and 4.1-fold increased association, respectively, with intermediate/poor adherence in comparison with those having a single dose DPI. Those patients who did not have knowledge about COPD (aOR 2.106, p = 0.006) and those who thought that the inhaler effectiveness was fair/poor (aOR 2.361, p = 0.006) were more likely to have intermediate/poor adherence. Overall SGRQ score was significantly worse in patients with intermediate/poor adherence (p = 0.036) and in those who thought the inhaler's effectiveness was fair/poor (p < 0.001).

CONCLUSIONS

The type of inhaler and patients' knowledge and perceptions of their disease and treatment were associated with good adherence and higher HRQL. Clinicians should promote shared-decision making in the choice of inhaler depending on patients' individual abilities and beliefs.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review

BACKGROUND

Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

METHODS

We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.

FINDINGS

We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies.

CONCLUSIONS

Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.

Untangling the association between prostate-specific antigen and diabetes: a systematic review and meta-analysis

Objectives

Several studies have shown an inverse association between diabetes mellitus and prostate cancer (PCa). Some researchers suggest that this relationship is due to reduced PCa detection in diabetics due to lower prostate-specific antigen (PSA) levels compared to non-diabetics. Our objective is to analyze the impact of diabetes on PSA in asymptomatic men without known prostate pathology and without prior prostate intervention.

Methods

We searched Medline (via PubMed), Embase and Scopus. We included studies that reported the relationship between serum PSA levels and diabetes or diabetes treatment in asymptomatic adult men without known prostate pathology, and without prior prostate intervention. Pooled mean differences were compared between diabetics and non-diabetics.

Results

Of 2,392 screened abstracts, thirteen studies met the inclusion criteria and 8 (62%) reported appropriate measures that could be included in a meta-analysis. Eleven (85%) examined the influence of diabetes on PSA levels and 8 (62%) evaluated the influence of diabetes treatments on PSA levels. Overall diabetics had a significantly lower PSA level compared to non-diabetics (mean difference: -0.07 ng/mL; 95% CI -0.10, -0.04).

Conclusions

Diabetes and related factors (such as disease duration, severity and treatment) were significantly associated with lower PSA levels among asymptomatic men, yet differences were small and are unlikely to influence PCa detection in a screening setting.

Impact of the EMA/FDA alerts on the use of effective contraceptive method in women of childbearing age undergoing valproic acid treatment in a long-stay psychiatric center

OBJECTIVE

We aimed to evaluate the impact of the European Medicines Agency (EMA) and Food Drug and Administration (FDA) alerts on the use of effective contraceptive method in women of childbearing age undergoing valproic acid treatment in a long-stay psychiatric center.

MATERIAL AND METHODS

An interrupted time-series analysis of women of childbearing age admitted in a long-stay psychiatric center (2013-2019), according to the EMA/FDA restrictions dates (October 2014 and February 2018).

RESULTS

Of the 82 cases included, 50 (61.0%) had an 'off-label' prescription. The percentage of cases with a contraceptive method before October 2014 (31.6%) increased to 61.5% after October 2014, p = 0.004. Women with an 'off-label' prescription after 2018 were more likely to use a contraceptive method than those before 2014, and there were not statistically significant differences in women with an 'under indication' prescription.

CONCLUSIONS

The recent regulatory restrictions on the use of a contraceptive method had a positive effect, mainly in women with an 'off-label' prescription. No effect was seen in women with epilepsy, probably because the intervention had started long before.

Contextualizing Evidence for Action on Diabetes in Low-Resource Settings-Project CEAD Part I: A Mixed-Methods Study Protocol

Challenges remain for policy adoption and implementation to tackle the unprecedented and relentless increase in obesity, diabetes and other non-communicable diseases (NCDs), especially in low- and middle-income countries. The aim of this mixed-methods study is to analyse the contextual relevance and applicability to low-resource settings of a sample of evidence-based healthy public policies, using local knowledge, perceptions and pertinent epidemiological data. Firstly, we will identify and prioritise policies that have the potential to reduce the burden of diabetes in low-resource settings with a scoping review and modified Delphi method. In parallel, we will undertake two cross-sectional population surveys on diabetes risk and morbidity in two low-resource settings in Ecuador. Patients, community members, health workers and policy makers will analyse the contextual relevance and applicability of the policy actions and discuss their potential for the reduction in inequities in diabetes risk and morbidity in their population. This study tackles one of the greatest challenges in global health today: how to drive the implementation of population-wide preventative measures to fight NCDs in low resource settings. The findings will demonstrate how local knowledge, perceptions and pertinent epidemiological data can be used to analyse the contextual relevance and applicability of potential policy actions.

Effectiveness of a Patient-Centered Weight Management Model in a Community Pharmacy: An Interventional Study

PURPOSE

The aim of this study was to evaluate the provision of a professional pharmaceutical patient-centered model in a weight management program and optimization of the medication in a Spanish community pharmacy.

PATIENTS AND METHODS

This was a single-group intervention study with a mean follow-up period of 8.2 months (sd 2.3). Patients ≥18 years old seeking to lose weight or improve eating habits were recruited. On the first visit, the pharmacist collected patients' sociodemographic and anthropometric variables, dietary history and lifestyle habits, biochemical measurements and other clinical and therapeutic data. The intervention was based on the Spanish Society of Community Pharmacy recommendations for diet and exercise and for pharmacotherapy management. The follow-up included a two-month visit and a final visit.

RESULTS

A total of 330 patients were included (80% women; mean age 51.3 years old (sd 15.3)). A statistically significant reduction in anthropometric measurements (weight, BMI, and waist circumference) and a statistically significant increase in the number of patients with normal cholesterol and LDL-cholesterol (p<0.001) were observed at two-month visit compared with first visit (p<0.001). The number of patients with normal triglyceride levels at final visit compared with first visit also increased significantly (p=0.04). A total of 186 (56.4%) patients had drug-related problems at first visit and 31 (9.4%) patients at two-month visit.

CONCLUSION

The implementation of a patient-centered weight management model had a positive impact on the improvement of anthropometric, clinical and therapeutic parameters.

Factors associated with false negative and false positive results of prostate-specific antigen (PSA) and the impact on patient health: Cohort study protocol

INTRODUCTION

Prostate-specific antigen (PSA) is the main tool for early detection, risk stratification and monitoring of prostate cancer (PCa). However, there are controversies about the use of PSA as a population screening test because of the high potential for overdiagnosis and overtreatment associated. The net benefit of screening is unclear and according to the available recommendations, it should be offered to well-informed men with an adequate health status and a life-expectancy of at least 10 years or to men at elevated risk of having PCa. In addition, the factors that influence test results are unclear, as is impact of false positive or negative results on patient health.Our objective is to assess the clinical and analytical factors associated with the presence of false positive and false negative results and the diagnostic/therapeutic process followed by these patients.

METHODS AND ANALYSIS

A prospective observational cohort study will be carried out. We will include a cohort of patients with a positive PSA result (1.081 patients) and a sample of patients with negative results (572 patients); both will be followed for 2 years by reviewing medical records to assess the variables associated with these results, as well as characteristics of patient management after a positive PSA value. We will include those patients with a PSA determination from 2 hospitals in the Valencian Community. Patients who have been previously diagnosed with prostate cancer or who are being followed for previous high PSA values will be excluded.

DISCUSSION

The study will estimate the frequency of false positive and false negative PSA results in routine clinical practice, and allow us to quantify the potential harm caused.

STUDY REGISTRATION

Clinicaltrials.gov (https://clinicaltrials.gov/): NCT03978299, June 7, 2019.

Cumulative exposure to ionising radiation from diagnostic imaging tests: a 12-year follow-up population-based analysis in Spain

OBJECTIVES

To calculate each patient's cumulative radiation exposure and the recurrent tests during a 12-year study period, according to sex and age, in routine practice.

DESIGN

Retrospective cohort study.

SETTING

A general hospital with a catchment population of 224 751 people, in the Southeast of Spain.

PARTICIPANTS

Population belonged to the catchment area of that hospital in 2007. We collected all consecutive diagnostic imaging tests undergone by this population until 31 December 2018. We excluded: imaging tests that did not involve radiation exposure.

MAIN OUTCOME MEASURES

The cumulative effective dose and the recurrent imaging tests by sex and age at entry of study.

RESULTS

Of the 224 751 people, 154 520 (68.8%) underwent an imaging test. The population had 1 335 752 imaging tests during the period of study: 1 110 077 (83.0%) plain radiography; 156 848 (11.8%) CT; 63 157 (4.8%) fluoroscopy and 5670 (0.4%) interventional radiography. 25.4% of the patients who had a CT, underwent five or more CTs (5.4% in the 0-20 years age group). The median total cumulative effective dose was 2.10 mSv (maximum 3980.30) and 16.30 mSv (maximum 1419.30 mSv) if we considered only doses associated with CT. Women received more effective dose than men (median 2.38 vs median 1.90, p<0.001). A total of 7142 (4.6%) patients received more than 50 mSv, with differences in men and women (p<0.001) and 2.5% of the patients in the 0-20 years age group, if we considered only doses associated with CT.

CONCLUSIONS

Nearly 5% of patients received doses higher than 50 mSv during the 12-year period of study and 2.5% of the patients in the 0-20 years age group, if we considered only doses associated with CT. The rate of recurrent examinations was high, especially in older patients, but also relevant in the 0-20 years age group.

Adaptation of a deprescription intervention to the medication management of older people living in long-term care facilities

Objectives: Inappropriate prescription is a problem related to aging and deprescription could be a possible strategy. The aim of this study was to adapt the available evidence on deprescribing to the medication management of older people living in long-term care facilities. Methods: The authors carried out a bibliographic search based on the most prevalent drugs in our context to develop a specific deprescribing intervention. A committee of experts reviewed this intervention which was later validated through an interobserver variability study. Finally, the authors evaluated it in a sample of patients through a controlled before-after study. Results: The authors included 119 subjects living in a public elderly long-term care center and 122 controls living in a center with similar clinical characteristics. The authors evaluated 852 medications, identifying a total of 175 (20.5%) potentially inappropriate medications and 162 (92.5%) drugs were deprescribed (1.4 per patient). The application of the intervention meant an annual saving of 9.525.25 €. Conclusion: The implementation of a deprescribing intervention aimed at the most prevalent drugs prescribed in a particular setting improves the appropriateness of pharmacotherapy in the patients.

The determinants of lung cancer after detecting a solitary pulmonary nodule are different in men and women, for both chest radiograph and CT

Objectives

To determine the factors associated with lung cancer diagnosis and mortality after detecting a solitary pulmonary nodule (SPN) in routine clinical practice, in men and in women for both chest radiograph and CT.

Materials and methods

A 5-year follow-up of a retrospective cohort of of 25,422 (12,594 men, 12,827 women) patients aged ≥35 years referred for chest radiograph or CT in two hospitals in Spain (2010–2011). SPN were detected in 893 (546 men, 347 women) patients. We estimated the cumulative incidence of lung cancer at 5-years, the association of patient and nodule characteristics with SPN malignancy using Poisson logistic regression, stratifying by sex and type of imaging test. We calculated lung cancer specific mortality rate by sex and SPN detection and hazard rates by cox regression.

Results

133 (14.9%) out of 893 patients with an SPN and 505 (2.06%) of the 24,529 patients without SPN were diagnosed with lung cancer. Median diameter of SPN in women who developed cancer was larger than in men. Men who had a chest radiograph were more likely to develop a lung cancer if the nodule was in the upper-lobes, which was not the case for women. In patients with an SPN, smoking increased the risk of lung cancer among men (chest radiograph: RR = 11.3, 95%CI 1.5–83.3; CT: RR = 7.5, 95%CI 2.2, 26.0) but smoking was not significantly associated with lung cancer diagnosis or mortality among women with an SPN. The relative risk of lung cancer diagnosis in women with SPN versus those without was much higher compared to men (13.7; 95%CI 9.2, 20.4 versus 6.2; 95%CI 4.9,7.9).

Conclusion

The factors associated with SPN malignancy and 5-year lung cancer mortality were different among men and women, especially regarding smoking history and SPN characteristics, where we observed a relatively high rate of lung cancer diagnosis among female non-smokers.

Diagnostic Biomarkers: Are We Moving from Discovery to Clinical Application?

BACKGROUND

Despite considerable research investment, moving from biomarker discovery to clinical application has presented unique challenges. We aimed to evaluate progress toward clinical application of a sample of molecular- and “omics”-based diagnostic tests over a 10-year period.

METHODS

We used Scopus to locate studies, published before the December 31, 2016, citing 107 original-research articles published in 2006 that assessed the diagnostic value of a molecular- or “omics”-based test. We identified diagnostic studies of the same test and disease and determined whether the article represented progress in the validation of the molecular test. We classified the types of progress: (a) clinical validation (measuring diagnostic accuracy in a series of patients similar to the population in which the test will be used in practice), (b) technical improvement, (c) extended diagnostic application (modification of the diagnostic question attended initially by the test), (d) economic evaluation, or (e) clinical use or implementation.

RESULTS

In the 10-year period analyzed, 4257 articles cited the 107 diagnostic studies; 118 (2.8%) were diagnostic studies of the same test, and of these papers, 25 (21.2%) did not constitute progress toward validation of the test for use in clinical practice (potential research waste). Of the 107 molecular- or “omics”-based tests described in 2006, only 28 (26.2%) appeared to have made progress toward clinical application. Only 4 (9.1%) of 44 proteomics-based tests had made progress toward clinical application.

CONCLUSIONS

Articles evaluating molecular- or “omics”-based diagnostic tests are numerous in biomedical journals. Few tests have made progress toward clinical application in the 10 years following their discovery.

The impact of the tax on sweetened beverages: a systematic review

Background

Obesity has a serious impact on public health. Sugar-sweetened beverages (SSBs) are implicated in the obesity epidemic. Regulation has been suggested as one approach to limit consumption.

Objective

The aim of this study was to synthesize existing evidence related to the impact of taxes on the consumption, purchase, or sales of SSBs.

Design

A systematic review was conducted by using MEDLINE through PubMed (https://www.ncbi.nlm.nih.gov/pubmed), the Cochrane Library (http://www.cochranelibrary.com/), the Web of Science (https://login.webofknowledge.com/error/Error?PathInfo=%2F&Error=IPError), and Scopus (https://www.scopus.com/search/form.uri?display=basic) in the period 2011-2017 for studies that analyzed the impact of fiscal regulatory measures on the consumption, purchase, or sales of SSBs. The quality of evidence was assessed according to the CONSORT (Consolidated Standards of Reporting Trials) and the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) statements.

Results

Of the 17 studies, 5 (29.4%) evaluated the impact of a tax on SSBs in naturalistic experiments by county or city in the United States and in Mexico. Findings indicated that purchases or sales of SSBs decreased significantly with taxation amounts of 8% (Berkeley, CA) and 10% (Mexico). One study found no effect on sales of SSBs in 2 states that enacted a 5.5% tax on sodas. Twelve (70.6%) studies were based on virtual or experimental conditions evaluating either purchasing behavior or sales (6 studies; 50.0%) or behavioral intent (6 studies; 50.0%), resulting in a decrease in either purchasing behavior or sales or intent behavior with heterogeneity according to the tax rate.

Conclusions

Taxation significantly influences planned purchases and increases the probability of the purchase of healthy beverages. SSB taxes have the potential to reduce calorie and sugar intake, but further research is needed to evaluate effects on diet quality.

Development and validation of a guide for the continuity of care in perioperative medication management

BACKGROUND

Increased longevity and the prevalence of associated pathologies is leading to more hospital admissions involving chronic patients with multiple pathological problems. In orthopedic surgical patients, it is very important to individually evaluate the risk/benefit of maintaining or suppressing chronic medications. For certain medications, there are consensus recommendations, but for others, the available information may be limited or controversial.

OBJECTIVE

To develop and validate a new guide for the continuity of care in perioperative medication management in older orthopedic surgical patients.

MATERIALS AND METHODS

An expert pharmacist developed the guide by systematically reviewing each medication category according to the Anatomical Therapeutic Chemical (ATC) classification system. The Pharmacy and Therapeutics Committee at the Hospital General Universitario de Elche reviewed the guide. After a training course on the guide for pharmacists, the guide was validated by studying the interobserver variability between pharmacists as well as between each pharmacist and the expert pharmacist. Cohen's kappa index (κ) was applied to determine interrater reliability.

RESULTS

The guide includes 51 therapeutic groups. Each ATC pharmacological subgroup is structured according to the benefits and risks of continuing therapy. When we compared each pharmacist's recommendations with those of the expert pharmacist, the kappa value was found to be 0.8 [95% CI (0.7, 0.9)], indicating almost perfect concordance (overall percentage agreement 89.3%).

CONCLUSIONS

We developed a guide for the continuity of care in perioperative medication management to improve the rationalization of medicines in the perioperative environment. After the pharmacists had been trained, the guide was validated by demonstrating a high level of concordance among the pharmacists' recommendations. Formal training seems to be essential to ensure consistency in medical decisions.

LEVEL OF EVIDENCE

IV (Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 ).

Appropriate use of medical imaging in two Spanish public hospitals: a cross-sectional analysis

OBJECTIVES

To determine the appropriateness of medical imaging examinations involving radiation and to estimate the effective radiation dose and costs associated.

DESIGN

Cross-sectional retrospective study.

SETTING

Two Spanish public tertiary hospitals.

PARTICIPANTS

2022 medical imaging tests were extracted from the radiology information system in February and March of 2014. MRI and ultrasound examinations were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Five outcomes were set independently by at least two researchers according to four guidelines: (1) appropriate; (2) inappropriate; (3) inappropriate due to repetition, if the timing to carry out next diagnostic tests was incorrect according to guidelines; (4) not adequately justified, if the referral form did not include enough clinical information to allow us to understand the patient's clinical condition; and (5) not included in the guidelines, if the referral could not be matched to a clinical scenario described in the guidelines. We estimated the prevalence of the five categories according to relevant clinical and sociodemographic variables and the effective radiation dose and costs for each category.

RESULTS

Approximately half of the imaging tests were deemed as appropriate (967, 47.8%) while one-third (634, 31.4%) were considered inappropriate. 19.6% of the effective dose and 25.2% of the cost were associated with inappropriate tests. Women were less likely than men to have an imaging test classified as appropriate (adjusted OR 0.70,95% CI 0.57 to 0.86). Imaging tests requested by general practitioners were less likely to be considered appropriate than those requested by central services (adjusted OR 0.60, 95% CI 0.38 to 0.93). Mammography and CT were more likely to be appropriate than conventional X-rays.

CONCLUSION

There was a significant frequency of inappropriateness, which resulted in a high percentage of associated effective radiation dose. Percentage of inappropriateness depends on sociodemographic and clinical characteristics such as sex, age, referral physician and medical imaging test.

Impact of changes in pill appearance in the adherence to angiotensin receptor blockers and in the blood pressure levels: a retrospective cohort study

OBJECTIVE

To assess the level of adherence to angiotensin receptor blockers (ARBs) in patients regularly attending a community pharmacy and the influence of a change in patients' adherence to pharmacological treatment.

DESIGN

Retrospective cohort study of a random sample of consecutive patients collecting their medication.

SETTING

40 community pharmacies in Alicante (Southeast Spain).

PARTICIPANTS

602 consecutive ≥18 years old patients following treatment with ARBs at least 3 previous refills were included.

MAIN OUTCOME MEASURES

Prevalence of uncontrolled blood pressure (BP) and adherence to prescribed pharmacological treatment (measured through both the Batalla and the Morisky-Green tests). A multivariate Poisson regression model was used to estimate the adjusted risk ratio (RRa) for non-adherence to pharmacological treatment by the presence of a change in patient's adherence and other significant variables.

RESULTS

161/602 (13.7%) patients presented uncontrolled BP. According to the Morisky test, 410/602 (68.2%) patients were considered adherent to pharmacological treatment and 231/602 (38.4%) patients according to the Batalla test. According to the Morisky-Green test, in the multivariable analysis, patients with a previous change in pill appearance were less likely to be adherent than those patients with no change in their pharmacological treatment (RRa 0.45; CI 95% 0.22 to 0.90; p=0.024). Systolic BP was higher in patients with a change in pill appearance in the previous 3 refills (median BP 142 mm Hg; IQR 136-148) than in those who did not have a change (median BP 127 mm Hg; IQR 118-135; p<0.001).

CONCLUSIONS

There was a low percentage of adherence and nearly 15% of uncontrolled BP in patients who regularly collected their medication. Switching between pills of different appearances was associated with lower patient adherence to pharmacological treatment and a higher uncontrolled BP than no change in pharmacological treatment or change only in package but not in pill appearance.

Referred Pain Patterns of the Infraspinatus Muscle Elicited by Deep Dry Needling and Manual Palpation

OBJECTIVES

To identify the most common referred pain (ReP) pattern of the infraspinatus myofascial trigger point (MTrP) and compare its coincidence with the original ReP pattern, to verify whether there are any significant differences by sex and types of technique and to determine the observed signs and symptoms evoked by deep dry needling (DDN) and manual palpation (MPal).

DESIGN

A cohort study of patients randomized to two different examination methods (July and August 2016).

SETTINGS

Students and staff recruited from Miguel Hernandez University (Southeast Spain).

PATIENTS

One hundred thirty-three participants (70.7% women) with shoulder complaints were randomly assigned to either an MPal (n = 67) or DDN group (n = 66).

INTERVENTIONS

The same physiotherapist carried out the techniques on all participants, and the same protocol was followed for both the DDN and MPal groups. The physiotherapist did not ask participants about their pain features or other relevant issues.

OUTCOME MEASURES

Local twitch response (LTR) and ReP assessed through a visual analogue scale and features of ReP of the infraspinatus muscle.

RESULTS

The areas with the highest percentage of ReP were the front (area 3; 27.1%) and back (area 11; 21.1%) of the arm, anterior (area 4; 36.1%) and posterior (area 12; 42.1%) shoulder, and infraspinatus muscle area. DDN proved to be significantly easier than MPal in evoking an LTR (p ≤ 0.001). There were significant differences between sexes in zone 2 (p = 0.041) and no statistically significant differences were found by technique.

CONCLUSIONS

The ReP pattern of the infraspinatus muscle coincides with the original pattern described by Travell and Simons, although the neck area should be questioned. The study found no significant differences in the ReP pattern by sex and when comparing MPal with DDN of MTrP of the infraspinatus muscle. DDN proved to be significantly easier than MPal in evoking an LTR.

Updated effective doses in radiology

The aim of this study was to review recent literature in order to provide updated values of the typical effective doses associated with the top 20 imaging tests for adults and children and for the most widely used set of weights (ICRP60) as well as for the most recent one (ICRP103). We performed a systematic research on radiation dosimetry in radiology published from 2007 onwards through the Medline, Embase and Cochrane Library Plus databases. We also included studies backed by scientific or governmental organizations. Other variables included: year and type of study (survey or descriptive), country, method and sample used for the measurement. Mean effective dose, minimum, maximum and standard deviation were calculated. We compared our results with previous evidence and with data from DDM2. We included 27 articles and 5 web references in the study. A total of 378 values from the 20 procedures included were obtained, 280 (74%) using ICRP60 and 98 (26%) using ICRP103. Effective doses for CT procedures in children were very similar to those for adults, with the exception of CT Trunk, but fluoroscopy procedures had consistently lower dose. There were differences between the current data with either ICRP60 or ICRP103, and the previous published data. In conclusion, we provided the best available evidence from literature to evaluate the effective dose received by each patient for the most typical examinations. According to the recommendations from the Report 154 and from the European Council Directive, these results could also be useful to estimate the range of average exposures to the population.

Evaluation of clinicians' knowledge and practices regarding medical radiological exposure: findings from a mixed-methods investigation (survey and qualitative study)

OBJECTIVES

To assess the impact of initiatives aiming to increase clinician awareness of radiation exposure; to explore the challenges they face when communicating with patients; to study what they think is the most appropriate way of communicating the long-term potential risks of medical radiological exposure to patients.

DESIGN

A quantitative and qualitative evaluation through a survey and focal groups.

SETTING

San Juan Hospital and Dr Peset Hospital (Southeast Spain) and clinicians from Spanish scientific societies.

PARTICIPANTS

The surveys were answered (a) in person (216: all the radiologists (30), urologists (14) and surgeons (44) working at both participant hospitals; a sample of general practitioners from the catchment area of one hospital (45), and a consecutive sample of radiologists attending a scientific meeting (60)) or (b) electronically through Spanish scientific societies (299: radiologists (45), pneumologists (123), haematologists (75) and surgeons (40)). Clinicians were not randomly selected and thus the results are limited by the diligence of the individuals filling out the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinicians' knowledge and practices regarding medical radiological exposure, and what they considered most appropriate for communicating information to patients.

RESULTS

Nearly 80% of the clinicians surveyed had never heard of the European recommendations. Fewer than 20% of the clinicians surveyed identified correctly the radiation equivalence dose of intravenous urography or barium enema. It was reported by 31.7% that they inform patients about the long-term potential risks of ionising radiation. All participants agreed that the most appropriate way to present information is a table with a list of imaging tests and their corresponding radiation equivalence dose in terms of chest X-rays and background radiation exposure.

CONCLUSIONS

Medical radiological exposure is frequently underestimated and rarely explained to patients. With a clear understanding of medical radiological exposure and proper communication tools, clinicians will be able to accurately inform patients.

The Fate of Patients with Solitary Pulmonary Nodules: Clinical Management and Radiation Exposure Associated

Background

The appropriate management of the large number of lung nodules detected during the course of routine medical care presents a challenge. We aimed to evaluate the usual clinical practice in solitary pulmonary nodule (SPN) management and associated radiation exposure.

Methods

We examined 893 radiology reports of consecutive patients undergoing chest computed tomography (CT) and radiography at two public hospitals in Spain. Information on diagnostic procedures from SPN detection and lung cancer diagnosis was collected prospectively for 18 months.

Results

More than 20% of patients with SPN detected on either chest radiograph (19.8%) or CT (26.1%) underwent no additional interventions and none developed lung cancer (100% negative predictive value). 346 (72.0%) patients with SPN detected on chest radiograph and 254 (61.5%) patients with SPN detected on CT had additional diagnostic tests and were not diagnosed with lung cancer. In patients undergoing follow-up imaging for SPNs detected on CT median number of additional imaging tests was 3.5 and the mean cumulative effective dose was 24.4 mSv; for those detected on chest radiograph the median number of additional imaging tests was 2.8 and the mean cumulative effective dose was 10.3 mSv.

Conclusions

Patients who did not have additional interventions were not diagnosed of lung cancer. There was an excessive amount of interventions in a high percentage of patients presenting SPN, which was associated with an excess of radiation exposure.

[A pilot study in a community pharmacy to determine the efficiency and the effectiveness of statin prescriptions]

BACKGROUND

The efficacy of statins to reduce LDL-cholesterol serum levels is high, but effectiveness is limited and costs are elevated.

OBJECTIVE

The efficiency and effectiveness of prescriptions were analyzed in a pilot study in a community pharmacy.

DESIGN

A cross-sectional study.

LOCATION

Community pharmacy. Prescriptions from two Murcian Health Service Centers in Lorca, Murcia (Spain).

PARTICIPANTS

A total of 141 patients and 32 general practitioners were included. The efficiency was analyzed in 141 and effectiveness in 110 patients.

MAIN MEASUREMENTS

Socio-demographic characteristics and clinical history of patients and information about statin type and dosage were collected. Each patient was analyzed to determine the effectiveness of treatment according to cardiovascular risk and previous LDL-cholesterol level, and efficiency comparing the statin prescribed against other statins with equal pharmacological power.

RESULTS

The most prescribed statin was atorvastatin (57.4%). Almost two-thirds (63.9%) of prescriptions were inefficient, and 17.3% were ineffective. In a bivariate analysis, patients with previous cardiovascular events (8/38; 21% vs 41/103; 39.8%. P=.040) and smokers (42/114; 36.8% vs 4/23; 17.4%, P=.047) were more likely to receive an inefficient prescription than patients with no cardiovascular events and non-smokers. In a multivariate analysis, smokers were more likely to receive an inefficient prescription than non-smokers (OR ajusted 3.76; 95% CI;1.03-0.77, P=.012).

CONCLUSIONS

Most of the participants reached therapeutic objectives for LDL-Cholesterol levels, but more than half of the prescriptions were considered inefficient.

[Public health competencies and contents in pharmacy degree programs in Spanish universities]

OBJECTIVE

To identify public health core competencies and contents in pharmacy degrees at a meeting of public health lecturers in pharmacy degrees from various public and private universities.

METHODS

The first Meeting of the Forum of University Teaching Staff in Pharmacy Degrees was held at the Faculty of Medicine in the Complutense University, Madrid, Spain on the 19(th) and 20(th) of November 2013. The meeting was attended by 17 lecturers. Participants brought their own teaching programs and were given two previous studies on public health competencies for analysis of public health contents and competencies in pharmacy degrees. Working groups were formed and the results were shared.

RESULTS

The highest number of core competencies was identified in the following functions: "Assessment of the population's health needs" and "Developing health policies". The final program included basic contents organized into 8 units: Concept of Public Health, Demography, Epidemiological Method, Environment and Health, Food Safety, Epidemiology of Major Health Problems, Health Promotion and Education, and Health Planning and Management.

CONCLUSIONS

Representation of almost all the Spanish Pharmacy Faculties and the consensus reached in the description of competences and program contents will greatly improve the quality of teaching in this area.