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National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain

January 26, 2015 Comments off

National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain
Source: Annals of Internal Medicine

The increase in the number of Americans with chronic pain and the concurrent increase in the use of opioids to treat this pain have created a situation in which large numbers of Americans are receiving suboptimal care. Patients who are in pain are often denied the most effective comprehensive treatments; conversely, many patients are inappropriately prescribed medications that may be ineffective or even harmful. At the root of the problem is the inadequate knowledge about the best approaches to treating various types of pain, which balance effectiveness with the potential for harm, as well as a dysfunctional health care delivery system that promotes prescription of the easiest rather than the best approach to addressing pain. The EPC report identified few studies that were able to answer key questions, which suggests a dire need for research on the effectiveness and safety of opioids as well as optimal management and risk mitigation strategies. Particularly striking to the panel was the realization that evidence is insufficient for every clinical decision that a provider needs to make about the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience.

Because of the inherent difficulties of studying pain and the large number of patients already receiving opioids, new research designs and analytic methods are needed to adequately answer the important clinical and research questions. Until the needed research is conducted, health care delivery systems and clinicians must rely on the existing evidence as well as guidelines issued by professional societies. Systems of care must facilitate the implementation of these guidelines rather than relying solely on individual clinicians, who are often overburdened and have insufficient resources.

Opioids are clearly the best treatment for some patients with chronic pain, but there are probably more effective approaches for many others. The challenge is to identify the conditions in patients for which opioid use is most appropriate, the optimal regimens, the alternatives for those who are unlikely to benefit from opioids, and the best approach to ensuring that every patient’s needs are met by a patient-centered health care system. For the more than 100 million Americans living with chronic pain, meeting this challenge cannot wait.

See also: The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians

July 1, 2014 Comments off

Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians
Source: Annals of Internal Medicine

Description:
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the utility of screening pelvic examination for the detection of pathology in asymptomatic, nonpregnant, adult women.

Methods:
This guideline is based on a systematic review of the published literature in the English language from 1946 through January 2014 identified using MEDLINE and hand-searching. Evaluated outcomes include morbidity; mortality; and harms, including overdiagnosis, overtreatment, diagnostic procedure–related harms, fear, anxiety, embarrassment, pain, and discomfort. The target audience for this guideline includes all clinicians, and the target patient population includes asymptomatic, nonpregnant, adult women. This guideline grades the evidence and recommendations using the ACP’s clinical practice guidelines grading system.

Recommendation:
ACP recommends against performing screening pelvic examination in asymptomatic, nonpregnant, adult women (strong recommendation, moderate-quality evidence).

Ready or Not: Responding to Measles in the Postelimination Era

May 16, 2014 Comments off

Ready or Not: Responding to Measles in the Postelimination Era
Source: Annals of Internal Medicine

Although endemic measles was eliminated in the United States in 2000, two concurrent measles outbreaks at opposite ends of the country offer a sobering reminder of the threat of this global disease. As more parents decline to vaccinate their children, measles incidence is increasing—a fact that alarms me both as a hospital epidemiologist and as a parent of a vulnerable infant too young to receive the measles vaccine. Because infected patients are likely to seek medical care, hospitals and clinics may inadvertently fuel transmission if those with measles are not rapidly triaged and isolated. Yet, because of the success of the measles vaccine, many clinicians have never seen measles and may not be able to recognize its features. It is crucial that providers become familiar with this deadly disease and apply the necessary control measures to contain it.

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

May 7, 2014 Comments off

Primary Care Behavioral Interventions to Reduce Illicit Drug and Nonmedical Pharmaceutical Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement
Source: Annals of Internal Medicine

Description:
Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for illicit drug use.

Methods:
The USPSTF reviewed the evidence on interventions to help adolescents who have never used drugs to remain abstinent and interventions to help adolescents who are using drugs but do not meet criteria for a substance use disorder to reduce or stop their use.

Population:
This recommendation applies to children and adolescents younger than age 18 years who have not been diagnosed with a substance use disorder.

Recommendation:
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care–based behavioral interventions to prevent or reduce illicit drug or nonmedical pharmaceutical use in children and adolescents. (I statement)

Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians

April 10, 2014 Comments off

Reducing Firearm-Related Injuries and Deaths in the United States: Executive Summary of a Policy Position Paper From the American College of Physicians
Source: Annals of Internal Medicine

Firearm violence is not only a criminal justice issue but also a public health threat. A comprehensive, multifaceted approach is necessary to reduce the burden of firearm-related injuries and deaths on individuals, families, communities, and society in general. Strategies to reduce firearm violence will need to address culture, substance use and mental health, firearm safety, and reasonable regulation, consistent with the Second Amendment, to keep firearms out of the hands of persons who intend to use them to harm themselves and others, as well as measures to reduce mass casualties associated with certain types of firearms.

As an organization representing physicians who have first-hand experience with the devastating impact firearm-related injuries and deaths have on the health of their patients, the ACP has a responsibility to participate in efforts to mitigate these needless tragedies. Because patients trust their physicians to advise them on issues that affect their health, physicians can help to educate the public on the risks of firearms and the need for firearm safety through their encounters with their patients. This Executive Summary provides a synopsis of the full position paper, which is available in Appendix 1.

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis

February 24, 2014 Comments off

The Accessibility of Firearms and Risk for Suicide and Homicide Victimization Among Household Members: A Systematic Review and Meta-analysis
Source: Annals of Internal Medicine

Background:
Research suggests that access to firearms in the home increases the risk for violent death.

Purpose:
To understand current estimates of the association between firearm availability and suicide or homicide.

Data Sources:
PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, and Web of Science were searched without limitations and a gray-literature search was performed on 23 August 2013.

Study Selection:
All study types that assessed firearm access and outcomes between participants with and without firearm access. There were no restrictions on age, sex, or country.

Data Extraction:
Two authors independently extracted data into a standardized, prepiloted data extraction form.

Data Synthesis:
Odds ratios (ORs) and 95% CIs were calculated, although published adjusted estimates were preferentially used. Summary effects were estimated using random- and fixed-effects models. Potential methodological reasons for differences in effects through subgroup analyses were explored. Data were pooled from 16 observational studies that assessed the odds of suicide or homicide, yielding pooled ORs of 3.24 (95% CI, 2.41 to 4.40) and 2.00 (CI, 1.56 to 3.02), respectively. When only studies that used interviews to determine firearm accessibility were considered, the pooled OR for suicide was 3.14 (CI, 2.29 to 4.43).

Limitations:
Firearm accessibility was determined by survey interviews in most studies; misclassification of accessibility may have occurred. Heterogeneous populations of varying risks were synthesized to estimate pooled odds of death.

Conclusion:
Access to firearms is associated with risk for completed suicide and being the victim of homicide.

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force

December 18, 2013 Comments off

Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force
Source: Annals of Internal Medicine

Background: Vitamin and mineral supplements are commonly used to prevent chronic diseases.

Purpose: To systematically review evidence for the benefit and harms of vitamin and mineral supplements in community-dwelling, nutrient-sufficient adults for the primary prevention of cardiovascular disease (CVD) and cancer.

Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects were searched from January 2005 to 29 January 2013, with manual searches of reference lists and gray literature.

Study Selection: Two investigators independently selected and reviewed fair- and good-quality trials for benefit and fair- and good-quality trials and observational studies for harms.

Data Extraction: Dual quality assessments and data abstraction.

Data Synthesis: Two large trials (n = 27 658) reported lower cancer incidence in men taking a multivitamin for more than 10 years (pooled unadjusted relative risk, 0.93 [95% CI, 0.87 to 0.99]). The study that included women showed no effect in that group. High-quality studies (k = 24; n = 324 653) of single and paired nutrients (such as vitamins A, C, or D; folic acid; selenium; or calcium) were scant and heterogeneous and showed no clear evidence of benefit or harm. Neither vitamin E nor β-carotene prevented CVD or cancer, and β-carotene increased lung cancer risk in smokers.

Limitations: The analysis included only primary prevention studies in adults without known nutritional deficiencies. Studies were conducted in older individuals and included various supplements and doses under the set upper tolerable limits. Duration of most studies was less than 10 years.

Conclusion: Limited evidence supports any benefit from vitamin and mineral supplementation for the prevention of cancer or CVD. Two trials found a small, borderline-significant benefit from multivitamin supplements on cancer in men only and no effect on CVD.

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