Overtreatment Research Articles

Advisory Panel Guidance on Minimum Retesting Intervals for Lab Tests

What Is the Issue? Lab test overuse can contribute to further unnecessary follow-up and testing, negative patient experiences, potentially inappropriate treatments, and the inefficient use of health care resources. One review of lab testing in Canada found that around 22% of blood tests were likely unnecessary. One strategy to address lab test overuse is to establish minimal retesting intervals that can be implemented in medical laboratories to help identify and manage potentially inappropriate lab test requests. Minimum retesting intervals suggest the minimum time before a test should be repeated based on the biochemical properties of the test and the clinical situation in which it is used. They are intended to inform clinical decisions about repeat testing. The importance of lab resource stewardship is being addressed by Choosing Wisely Canada through Using Labs Wisely, a consortium of more than 150 hospitals committed to driving the appropriate use of lab testing in Canada. The hospitals participating in Using Labs Wisely identified a need for guidance on minimum retesting intervals for commonly used lab tests. What Did We Do? Choosing Wisely Canada and CADTH partnered to convene an independent time-limited advisory panel to develop consensus-based recommendations for minimum retesting intervals for 7 commonly used lab tests (antinuclear antibody [ANA], B-type natriuretic peptide [BNP] and N-terminal pro b-type natriuretic peptide [NT-proBNP], Hemoglobin A1C, lipase, lipid panel, serum protein electrophoresis [SPEP], and thyroid stimulating hormone [TSH]) in prespecified patient populations. The advisory panel included core and specialist members who were recruited from across Canada. The 7 core advisory panel members brought together expertise in laboratory medicine, family practice, and patient lived experience. Seven additional specialist members brought expertise in endocrinology, cardiology, pediatric cardiology, rheumatology, hematology oncology, gastroenterology, and general internal medicine. The Advisory Panel on Minimum Retesting Intervals considered patient group input, evidence from focused literature reviews, equity considerations, and clinical expertise. Through facilitated discussion, they reached consensus on the recommendations for minimum retesting intervals. Following external feedback, the recommendations for BNP and NT-proBNP and lipid panels were removed, and this document includes recommendations for minimum retesting intervals for 5 lab tests. These are not recommendations for repeat testing. They are recommendations that if testing is undertaken, it should not be repeated sooner than the indicated intervals. They are not intended to replace clinical judgment as there may be exceptions in which the recommendations do not apply. What Is the Potential Impact? The recommendations on minimum retesting intervals can support the hospitals participating in Choosing Wisely Canada’s Using Labs Wisely program in their effort to reduce unnecessary lab tests and their impact on patients, providers, health systems, and the environment. The recommendations may also be relevant to community and hospital lab stewardship efforts and may address the appropriate use of the 5 lab tests by enabling changes in lab test ordering in both inpatient and outpatient settings.

Longitudinal neurofunctional changes in medication overuse headache patients after mindfulness practice in a randomized controlled trial (the MIND-CM study)

BackgroundMindfulness practice has gained interest in the management of Chronic Migraine associated with Medication Overuse Headache (CM-MOH). Mindfulness is characterized by present-moment self-awareness and relies on attention control and emotion regulation, improving headache-related pain management. Mindfulness modulates the Default Mode Network (DMN), Salience Network (SN), and Fronto-Parietal Network (FPN) functional connectivity. However, the neural mechanisms underlying headache-related pain management with mindfulness are still unclear. In this study, we tested neurofunctional changes after mindfulness practice added to pharmacological treatment as usual in CM-MOH patients.MethodsThe present study is a longitudinal phase-III single-blind Randomized Controlled Trial (MIND-CM study; NCT03671681). Patients had a diagnosis of CM-MOH, no history of neurological and severe psychiatric comorbidities, and were attending our specialty headache centre. Patients were divided in Treatment as Usual (TaU) and mindfulness added to TaU (TaU + MIND) groups. Patients underwent a neuroimaging and clinical assessment before the treatment and after one year. Longitudinal comparisons of DMN, SN, and FPN connectivity were performed between groups and correlated with clinical changes. Vertex-wise analysis was performed to assess cortical thickness changes.Results177 CM-MOH patients were randomized to either TaU group or TaU + MIND group. Thirty-four patients, divided in 17 TaU and 17 TaU + MIND, completed the neuroimaging follow-up. At the follow-up, both groups showed an improvement in most clinical variables, whereas only TaU + MIND patients showed a significant headache frequency reduction (p = 0.028). After one year, TaU + MIND patients showed greater SN functional connectivity with the left posterior insula (p-FWE = 0.007) and sensorimotor cortex (p-FWE = 0.026). In TaU + MIND patients only, greater SN-insular connectivity was associated with improved depression scores (r = -0.51, p = 0.038). A longitudinal increase in cortical thickness was observed in the insular cluster in these patients (p = 0.015). Increased anterior cingulate cortex thickness was also reported in TaU + MIND group (p-FWE = 0.02).ConclusionsIncreased SN-insular connectivity might modulate chronic pain perception and the management of negative emotions. Enhanced SN-sensorimotor connectivity could reflect improved body-awareness of painful sensations. Expanded cingulate cortex thickness might sustain improved cognitive processing of nociceptive information. Our findings unveil the therapeutic potential of mindfulness and the underlying neural mechanisms in CM-MOH patients.Trial RegistrationName of Registry; MIND-CM study; Registration Number ClinicalTrials.gov identifier: NCT0367168; Registration Date: 14/09/2018

Hurdles on the way to the diagnosis of asthma and successful therapy

AbstractThere are many potential hurdles, obviously at the forefront of patient care which may impede the correct and early diagnosis of asthma, as well as successful, appropriate treatment. Although the illness is often accompanied by many typical signs which may enable a rapid diagnosis, these are often overlooked or misinterpreted. Symptoms may not be recognised or confused with others, such as respiratory infections, and inappropriate diagnostic tests used. Inappropriate therapy (absent or insufficient dosage of a topical anti-inflammatory and/or exclusive usage of a short-acting beta-agonist) and failure to adapt therapy may further impede the patient’s chance to live without symptoms.

Routine Chest X-Ray is Not Cost-Effective After Clavicle ORIF: A Cost Effectiveness Analysis with National Estimations

Introduction Clavicular fractures can be managed surgically or via a non-operative approach. In those electing for surgical fixation, post-operative CXR may be routine practice in the post-anesthesia care unit (PACU) for a rare complication of pneumothorax (PTX), thus driving up the cost for managing these fractures. The value and associated cost of this routine CXR in PACU following open reduction internal fixation (ORIF) of clavicles has not been thoroughly assessed. In this study we investigate the cost effectiveness of obtaining CXR after operative treatment of clavicle fracture. Materials and Methods Study was designed as a healthcare two-way dichotomous model with decision trees built in where a CXR was either obtained or not. Literature review was performed to determine the cost estimates of CXR, the cost of ORIF, and associated hospital stay expenses. Annual volume of clavicle ORIF’s performed were derived from the PearlDiver database, queried for CPT-23515 (Clavicle ORIF). Estimation of CXR rates were performed from 3% to 98% of patients undergoing clavicle ORIF. Net monetary analysis with associated sensitivity analysis of 10,000 repetitions was performed. Results The strategy without CXR proved to be the most cost-effective strategy with a net monetary benefit (NMB) of $32,022.50. At $50,000 willingness to pay (WTP), the no CXR strategy was the preferred option. This strategy was found to be optimal 76% of the time followed by routine CXR 23% of the time and less than 1% being indifferent. The national annual costs of routine CXR after clavicle ORIFs was estimated to range from $7,100 to $349,860, which over 10 years represents anywhere from $81,540 to $2,663,640 in additional expenses. Conclusion The provided study demonstrates that routine CXR after clavicle ORIF is not cost effective. Due to the exceedingly low incidence of PTX as a post-operative complication in clavicle ORIF, we recommend that hospitals and surgeons refrain from ordering radiographs in post-operative patients, with the exception of those displaying concerning clinical signs for PTX or those with known pre-operative pulmonary injury. Adopting this strategy will limit unnecessary healthcare costs accrued by patients and may be the more clinically appropriate management.

Inappropriate Laboratory Testing: Significant Waste Quantified by a Large-Scale Year-Long Study of Medicare and Commercial Payer Reimbursement.

Laboratory testing, beyond what is essential for managing health, is considered low-value care, posing patient risks and wasting resources. Measuring excess testing on a national level is crucial to identify waste and optimize healthcare resource allocation for maximum impact. To measure inappropriate laboratory testing and its cost across Medicare and many US commercial payers. A retrospective analysis on 2019 claims data measured the frequency of 4 commonly used laboratory tests among 64 million individuals with Medicare and 168 million with commercial insurance. Tests included 25-hydroxy vitamin D, prostate-specific antigen, lipid panel, and hemoglobin A1c. Clinical guidelines, medical literature, and payer recommendations were used to determine appropriate testing frequencies. Costs of excessive testing were calculated using the 2019 clinical lab fee schedule. A targeted analysis of 2022 data confirmed 2019 trends. Analysis of ∼84 million tests from ∼1 billion outpatient test claim records revealed that 7% to 51% of tests exceeded recommended frequencies, with some egregious overuse: for example hemoglobin-A1c or prostate-specific antigen every week. The conservative cost estimate for 4 excess tests surpassed $350 million. This extensive study, involving 232 million people, found that 14.4 million of 60.5 million individuals (23.8%) tested had undergone excessive laboratory testing, with likely little benefit and possible harm. Extrapolating findings to all laboratory testing suggests that Medicare alone may have incurred direct excess expenses from $1.95 to $3.28 billion in 2019, without factoring the hidden costs of excessive testing (eg, downstream care). Addressing unnecessary testing is crucial to lowering costs and redirecting resources for greater patient benefit.

Artificial Intelligence and Virtual Reality in Headache Disorder Diagnosis, Classification, and Management.

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

New Daily Persistent Headache in the Pediatric and Adolescent Population: An Updated Review.

New daily persistent headache (NDPH) is a primary headache disorder characterized by the sudden onset of continuous pain and its intractability to treatment. It is more prevalent in the pediatric population than the adult population, but remains understudied and underdiagnosed. The purpose of the current article is to provide a current overview of new daily persistent headache in the pediatric and adolescent population, including history, pathophysiology, clinical findings, current and emerging treatment options, and the results of recent studies and meta-analyses. Despite recent studies and meta-analyses showing significant phenotypic overlap between chronic migraine and NDPH in the pediatric population, multiple recent studies have come to conflicting conclusions about the overlap of medication overuse in headache and pediatric NDPH. Recent studies reveal alterations in neuroimaging, particularly in functional connectivity, in patients with NDPH. Patients frequently remain treatment-refractory even to medications that have historically proven helpful in this population; however, new treatment options, including calcitonin gene-related peptide (CGRP) monoclonal antibodies, may be more effective. NPDH remains a perplexing and difficult-to-manage condition for both children and adults. Despite a higher prevalence in the pediatric population, there are relatively few studies to guide the evaluation and treatment of NDPH in pediatric and adolescent patients. Early treatment, both pharmacological and non-pharmacological, should be employed to reduce disability. Overall, further studies are needed to better understand pathogenesis and to identify more effective therapeutic strategies, both pharmacological and non-pharmacological.

Trends in the providers’ uptake of advance care planning from 2016 to 2021.

1538 Background: Advance care planning (ACP) facilitates meaningful discussions and preparation for future medical decisions. This person-centered approach has been recognized for its potential to improve care quality and reduce unnecessary aggressive care at the end of life, especially among cancer patients. We examined the trends in ACP visits across specialty groups that may involve cancer care and between rural and urban areas. Methods: We used publicly available data from the Centers for Medicare & Medicaid Services, the Provider Utilization and Payment Data Physician and Other Practitioners Dataset – By Provider and Service files (2016-2021). We included providers in 3 specialty groups that may encounter cancer patients needing ACP: Cancer-Related Specialties, Hospice and Palliative Medicine (HPM), and Midlevel Providers. The primary outcome was billing for any ACP services each year, identified through Healthcare Common Procedure Coding System codes (99497 and 99498). Geographical areas were classified using Rural-Urban Commuting Area codes into metropolitan and non-metropolitan areas. Trends in the percent of providers billing any ACP and average ACP service volumes were described, with Wilcoxon tests used for statistical comparisons. Results: The primary analytic sample consists of 1,280,656 provider-years from 2016 to 2021 (Cancer-Related Specialties: 113,012, HPM: 7,320, and Midlevel: 1,160,324). The percentage of providers billing ACP visits tripled from 1.0% in 2016 to 3.3% in 2021. The highest uptake was among HPM physicians (12.8% to 36.9%) compared to cancer-related specialists and midlevel providers (Table). Average ACP service volume was higher in non-metropolitan areas among Cancer-Related Specialties (53.6 vs. 142.9). However, the average ACP service volume by metropolitan status was similar among HPM (75.0 vs. 66.7, P=0.65) and higher in metropolitan areas among Midlevel providers (70.2 vs. 54.8, P<.001). Conclusions: The proportion of physicians billing ACP codes increased including those in HPM and cancer-related specialties, but adoption remained low. Rural-urban disparities in average ACP service volume among cancer-related specialties might reflect a shortage of specialty-trained HPM physicians to provide ACP services. Particularly noteworthy is the absence of HPM specialty in non-metropolitan areas. A comprehensive strategy involving education, awareness, enhanced training capacity, innovative care models for advanced practice nurses, and increased resources, is needed to promote APC use and patient-centeredness in cancer care.[Table: see text]

Respiratory morbidity among offspring misclassified as growth restricted.

An ultrasound-based diagnosis implies that some fetuses suspected to be growth-restricted (FGR) are discovered at birth to be appropriately grown (appropriate for gestational age [AGA] birth weight, between the 10th and 90th percentile). These fetuses may thus be exposed to unnecessary medical interventions, including early labor induction. In this study, we have evaluated the long-term respiratory health of offspring misclassified as FGR. A population-based cohort analysis was conducted, including deliveries of AGA singletons between 1991 and 2021 at a tertiary referral hospital. Incidence of morbidity due to various respiratory conditions was compared between AGA offspring with prenatal diagnosis of FGR, and those without a false diagnosis of FGR. The Kaplan-Meier approach was used to estimate cumulative morbidity incidence. The stratified Cox proportional-hazards model was used to control for confounders. A total of 324,620 deliveries of AGA newborns were included in the analyses; 3249 of them (1.0%) were misclassified prenatally as FGR. The FGR subgroup delivered at an earlier gestational age (36.7 vs. 39.1 weeks, p < .001) and had more than 25% higher incidence of respiratory-related morbidity during childhood (33.2% vs. 26.5%), specifically related to asthma and obstructive sleep apnea (p < .001 for all). A higher cumulative morbidity rate due to respiratory conditions was observed in the Kaplan-Meier survival curve (log-rank p value < .001). This association between FGR and respiratory morbidity was independent of preterm delivery, maternal age, cesarean delivery, and child's birth year (adjusted hazard ratio = 1.14, 95% confidence interval: 1.07-1.21, p < .001), using a Cox proportional hazards model. AGA newborns misclassified as FGR, are at an increased risk for long-term respiratory morbidity during childhood and adolescence.

LAS TRIACAS, AYER Y HOY

The history of theriaca reveals several attributes of humankind in their relation to medicine that enriches their present understanding. A compound of numerous simples, it reigned through twenty centuries as a panacea against diverse ailments, was a symbol of therapeutic progress, and sustained the interest and hope of learned and lay people of many cultures and civilizations. Its fame and commercial success drove the apparition of copies and falsifications that have persisted under the names of their creators, the city of origin, or some special char­acteristics. Most famous are mithridatium, theriaca magna of Andromachus, diatessaron or of the poor, and Venice theriaca. Of Greeks origin, it grew in fame mainly due to Galen and an unknown contemporary in Rome. Byzantine, Arab and Persian medical authors, and later others in Montpellier, Salerno and Padua, preserved the ancient writings and elaborated on them. The apparition of bubonic plague meant an enormous impulse to its use, augmented by the commercial strategy of Venice, and amplified by the printing of numerous pamphlets and books. The Scientific Revolution and the diffusion of its ideas marked the beginning of its decline, but it was still present in most European pharmacopeias until the end of the 19th cen­tury. We propose that fear, greed and credulity were seminal factors in its success, conditions still present today in medical marketing, quackery and falsifications, unnecessary care, medical consumerism, and unregulated alternative medicines and cosmetic industries.

Effect of erenumab on the reversion from chronic migraine to episodic migraine in an Asian population: A post hoc analysis of the DRAGON study.

Erenumab is a fully human monoclonal antibody that selectively targets the calcitonin gene-related peptide receptor. It has been proven to be safe and efficacious in patients with episodic migraine (EM) and chronic migraine (CM) as demonstrated in phase 2 and 3 clinical trials including patients from Europe, Japan, and the United States. Reversion from CM to EM, as indicated by a reduction in the frequency of headache days, is an important indicator for efficacy outcome, though it has not been analyzed widely in patients with CM to date. Primary results of the DRAGON study demonstrated the efficacy and safety of erenumab in patients with CM from China and other Asian countries. This post hoc analysis evaluated the rate of reversion from CM to EM in the overall population and in subgroups of patients defined by baseline demographic and clinical characteristics (age, body mass index, gender, prior preventive treatment failure, medication overuse status, and disease duration). Reversion from CM to EM was defined as a reduction in headache frequency to < 45 headache days over the 12 weeks of the double-blind treatment period. In addition, migraine-related disability and disease impact on functional impairment were assessed within each treatment group in reverters and non-reverters using the Headache Impact Test-6 (HIT-6), Migraine Physical Function Impact Diary (MPFID), and modified Migraine Disability Assessment (mMIDAS). Overall, 557 patients with CM were randomized to monthly erenumab 70 mg (n = 279) or placebo (n = 278), of whom 52.3% (146 of 279) treated with erenumab reverted from CM to EM compared to 41.0% (114 of 278) in the placebo group (odds ratio [OR] 1.59, 95% confidence interval: 1.1-2.2; p = 0.007). Treatment with erenumab resulted in a greater mean change (standard error) from baseline in the HIT-6 total score for reverters versus non-reverters compared to placebo (erenumab: -9.5 [0.6] vs. -5.1 [0.5]; placebo: -8.9 [0.7] vs. -4.9 [0.5]). A similar pattern was observed for mMIDAS score in erenumab treatment groups versus placebo (erenumab: -22.1 [1.2] vs. -6.3 [1.8]; placebo: -19.9 [1.3] vs. -7.9 [1.6]). Substantial improvements were reported in MPFID-Physical Impairment (PI) and Everyday Activities (EA) scores in reverters versus non-reverters in erenumab treatment groups (MPFID-PI: -5.9 [0.3] vs. -1.9 [0.6]; MPFID-EA: -7.9 [0.4] vs. -3.4 [0.6]) and in placebo (MPFID-PI: -5.4 [0.4] vs. -1.0 [0.5]; MPFID-EA: -7.1 [0.5] vs. -3.2 [0.5]). This analysis demonstrated that a greater proportion of patients treated with erenumab reverted from CM to EM compared to patients treated with placebo. The reversion from CM to EM was reflected by the greater improvements in patient-reported outcomes in the erenumab group.

Functional impairment of chronic migraine with medication overuse: Secondary analysis from the Medication Overuse Treatment Strategy (MOTS) trial.

Chronic migraine exerts substantial negative impacts on daily functioning. Efforts to manage impaired functioning may result in medication overuse, which contributes to the worsening profile and chronification of migraine. The Migraine Functional Impact Questionnaire (MFIQ) is a recently developed measure assessing the impact of migraine on physical, social, and emotional function. The objective of this analysis was to assess changes in MFIQ scores following initiation or modification of migraine preventive medication and determine if changes in function are associated with changes in other aspects of migraine burden, such as headache frequency, headache intensity, and symptoms of anxiety and depression. This is a secondary analysis of data from the Medication Overuse Treatment Strategy (MOTS) trial, a prospective pragmatic clinical trial that investigated two treatment strategies for those with chronic migraine and medication overuse. Data from both treatment arms were pooled and analyzed using a pre-post design. Prior to and 12 weeks following initiation or modification of migraine preventive medication, participants completed a series of questionnaires that captured migraine characteristics, medication use, migraine-related physical impairment (MFIQ), anxiety (Generalized Anxiety Disorder-7), and depression (Patient Health Questionnaire 9 [PHQ-9]) symptoms. Changes from baseline in all measures were assessed using the paired t-test. Relationships between changes in MFIQ scores and other measures were assessed using linear regression. Multivariable modeling was performed to determine which additional variables contributed to the change in MFIQ beyond that already explained by an individual variable. Model terms were selected by using elastic net regularization. Only those participants who completed the baseline and 12-week MFIQ were included in this analysis. Of the 537 patients, 88.2% were female, and the average age was 45 years (standard deviation 13). The mean frequency of days with moderate-to-severe headache improved 39.2% from 13.5 per 30 days at baseline to 8.1 per 30 days at week 12. The mean MFIQ Usual Activities Global score improved by 15.0 points (on a 100-point scale). All five domains (Usual Activities Global, Usual Activities, Social Function, Emotional Function, Physical Function) of the MFIQ improved by a mean of at least 13.0 points. Changes in PHQ-9 score, followed by changes in headache frequency, had the strongest associations with change in all domains of the MFIQ. The negative impact of chronic migraine with medication overuse on physical, social, and emotional functioning substantially lessened following initiation or modification of migraine preventive medication. Improved functioning, as measured by the MFIQ, was most strongly associated with reductions in depression scores and headache frequency, highlighting the importance of recognizing and monitoring changes in depressive symptoms, in addition to headache frequency and functional impairment, when evaluating response to preventive medications.

Midwives' Belief in Normal Birth: The Canadian Survey of Maternity Care Providers’ Attitudes Toward Labour and Birth

Background: Midwifery has been integrated into the health care systems of over half of Canadian provinces and territories. While there are differences in legislation and payment mechanisms, the model of midwifery is fairly similar across the country. This study examined the similarities and differences among midwives' attitudestowardlabourandbirth. Inaddition,wecompareditemswhichrelatedtobeliefsaboutnormal birth between midwives and other care providers.Methods: A national cross-sectional survey was conducted comparing maternity care providers’ beliefs aboutchildbirthandintra-professionalvariationsinmidwives'attitudestowardsbirth. Therewere400 (54%) midwife respondents: 218 from Ontario, 75 from B.C, 53 from Quebec, 48 from the remaining regulated or pre-regulated provinces (six missed information for this field).Results: All midwives were critical of the routine use of interventions such as episiotomy, epidural analgesia andelectronicfetalmonitoring(EFM). Therewasstrongagreementaboutthesafetyofhomebirth,outof hospital birth centres and the importance of women's autonomy and decision-making in pregnancy and birth. However, some regional variations were identified. Quebec midwives were more opposed to epidural analgesia than BC and Ontario (p&lt;.001), and were more likely to believe that cesarean birth is more costly than vaginal birth (p=.005). Ontario midwives were most likely to believe that cesarean birth protects against urinary incontinence (p=.001), and sexual dysfunction (p=.002). Qualitative comments of midwives indicated a strong desire to reduce unnecessary medical intervention and to lower cesarean section rates.Conclusion: Canadian midwives share similar beliefs regarding place of birth, the routine use of episiotomy, EFM, and epidurals, but reported significant attitudinal differences for other issues. Regional differences may be related to midwives' primary practice settings, the historical development of midwifery in their region and the number of new midwives with less than 5 years of clinical experience. A set of core midwifery values was identified that demonstrate a strong belief in normal birth.

Multimodal digital health treatments for Chronic Migraine associated with Medication Overuse Headache: a literature appraisal and results of a single-arm open trial (the BE-HOME program).

Mindfulness-based treatments gained popularity for migraine treatment. In this manuscript we report the results of a single-arm open pilot study that evaluated the impact of a multimodal web-based intervention combining home-based medication withdrawal, patients' education, and online mindfulness-based interventions. We aimed to address whether our program had the ability to show a change in the observed parameters and the study should therefore be intended as an early phase trial. Consecutive patients with chronic migraine associated with medication overuse headache were enrolled, followed-up for 12months, in a program that included home-based medication withdrawal, education on the correct use of drugs and lifestyle issues, prescription of tailored pharmacological prophylaxis, and attendance to six online mindfulness-based sessions. We tested the effect of the program on improving headache frequency, medication intake, quality of life (QoL), headache impact, depression, self-efficacy, and pain catastrophizing. A total of 37 patients completed the study (10 dropped out). We observed a large improvement in headache frequency, medication intake, headache impact, and QoL, a moderate improvement in pain catastrophizing and a mild improvement in depression symptoms; 70% to 76% of patients achieved 50% or more reduction in headache frequency from baseline to each follow-up (p < .01). The results of our multimodal program showed significant improvements in headache frequency, medication intake, and patient-reported outcomes. Future studies are needed to better identify patients who might benefit most from Digital Health Interventions and to demonstrate at least an equivalence in outcome with in-person programs carried out in hospital settings.

Factors influencing referral to maternity models of care in Australian general practice.

In the Australian maternity system, general practitioners play a vital role in advising and directing prospective parents to maternity models of care. Optimising model of care discussions and the decision-making process avoids misaligning women with over or under specialised care, reduces the potential for disruptive care transitions and unnecessary healthcare costs, and is critical in ensuring consumer satisfaction. Current literature overwhelmingly focusses on women's decision-making around model of care discussions and neglects the gatekeeping role of the General Practitioner (GP). This study aimed to explore and describe the factors influencing Australian GPs decision-making when referring pregnant women to maternity models of care. This study used a qualitative descriptive approach. General practitioners (N = 12) with experience referring women to maternity models of care in Australia participated in a semi-structured interview. Interviews occurred between October and November 2021 by telephone or videoconference. Reflexive thematic analysis was facilitated by NVivo-12 data management software to codify and interpret themes from the data. Two broad themes were interpreted from the data. The first theme entitled 'GP Factors', incorporated three associated sub-themes including '1) GPs Previous Model of Care Experience', '2) Gaps in GP Knowledge' and '3) GP Perception of Models of Care'. The second theme, entitled 'Woman's Factors', encapsulated two associated sub-themes including the '4) Woman's Preferences' and '5) Access to Models'. This study provides novel evidence regarding general practitioner perspectives of the factors influencing model of care decision-making and referral. Predominant findings suggest that gaps in GP knowledge regarding the available models of care are present and are largely informed by prior personal and professional experience. Most GPs described referring to models of care they perceive positively and centring their model of care discussions on the woman's preferences and accessibility. The exploration and description of factors influencing model of care decisions provide unique insight into the ways that all stakeholders can experience access to a broader range of models of care including midwifery-led continuity of care models aligned with consumer-demand. In addition, the role of national primary health networks is outlined as a means to achieving this.

Community pharmacists’ awareness, identification, and management of prescribing cascades: A cross-sectional survey

BackgroundPrescribing cascades can lead to unnecessary medication use, healthcare costs, and patient harm. Pharmacists oversee prescriptions from multiple prescribers and are well positioned to identify such cascades, making pharmacists key stakeholders to address them. ObjectivesTo evaluate community pharmacists’ awareness, identification, and management of prescribing cascades and to assess behavioural determinants that may be targeted in future strategies to minimise inappropriate prescribing cascades. MethodsAn online survey was developed using the Theoretical Domains Framework (TDF) and emailed to all registered community pharmacists in Ireland (n = 3775) in November 2021. Quantitative data were analysed using descriptive and inferential statistics. Free-text sections were given to capture reasons for non-resolution of identified prescribing cascades and suggestions to aid prescribing cascade identification and management; this text underwent content analysis. ResultsOf the 220 respondents, 51% were aware of the term ‘prescribing cascade’ before the survey, whilst 69% had identified a potentially inappropriate prescribing cascade in practice. Over one third were either slightly confident (26.4%) or not confident at all (10%) in their ability to identify potentially inappropriate prescribing cascades in patients' prescriptions before the survey, whilst 55.2% were concerned that patients were receiving prescribing cascades they had not identified. Most respondents wanted further information/training to help prescribing cascade identification (88.3%) and management (86.1%). Four predominant TDF domains identified were common to both i) influencing non-resolution of identified prescribing cascades and ii) in the suggestions to help identify and manage prescribing cascades: ‘Environmental Context and Resources’, ‘Social/Professional Role and Identity’, ‘Social Influences’ and ‘Memory, Attention and Decision Processes’. ConclusionsThere is a clear need to provide additional resources to help community pharmacists identify and manage prescribing cascades. These findings will support the development of theory-informed behaviour change strategies to aid the minimisation of inappropriate prescribing cascades and decrease the risk of medication-related harm for patients.

FeverApp for Parents: A Multilingual and Socially Accountable Approach to Paediatric Fever Management in Germany

ABSTRACT Policymakers and practitioners are increasingly focused on achieving health equity and meeting the specific health needs of diverse populations, including vulnerable groups such as children. To address these challenges, the Fever App for Parents has emerged as a solution to guide parents through the complexities of managing fever in their children by improving fever management in children through real-time data collection and comprehensive educational support. This systematic approach aims to reduce unnecessary medical interventions and overuse of antibiotics, thereby improving the overall quality of pediatric care and reducing parental anxiety. In Germany, almost every second child aged 0-10 is a child with migration status and/or migration experience. This means that the parents of these children also need to be targeted in fever management and informed about the correct behavior in case of fever. This information will also be monitored anonymously to provide a feedback loop on the parent’s experience with the menu navigation and information design. The FeverApp provides parents with a structured, step-by-step guide to accurately track their child’s temperature and medication intake to encourage adherence to established fever management protocols. This study examines how the FeverApp embodies the principles of social responsibility through its multilingualism and digital development stages that incorporate user feedback. It shows why this app can be a resource to promote health equity through social responsibility in medical education and practice for parents, but also what barriers need to be considered at different stages of app development for parents from different cultural backgrounds to enable informal medical learning through apps.

Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania.

Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.

Panic Disorder Versus Thyroid Medication Overuse: A Case Report

Introduction: Panic disorder is defined as the occurrence of spontaneous panic attacks that are not triggered by any specific stimulus. The symptoms of panic disorder include panic episodes that occur frequently and unexpectedly, as well as anxiety about the possibility of experiencing further panic attacks, the repercussions of panic attacks, or a change in behavior as a result of panic attacks. This study presented the diagnosis and treatment of panic disorder comorbid with thyroid medication overuse. Case presentation: A 36-year-old female patient presented to the emergency room with a primary concern and symptoms consistent with panic disorder, including experiencing a sense of losing control or impending death, chest pain, difficulty breathing, rapid heartbeat, excessive perspiration, trembling, and dizziness. The patient experienced significant periods of anxiety between episodes, preoccupied with the anticipation of the next occurrence. Each episode had a duration of roughly 15 minutes. The patient refutes any history of alcohol or drug misuse, and her sole medical condition is hypothyroidism. Subsequently, we perform a comprehensive analysis of the thyroid profile and make a referral to an internal medicine specialist for collaborative treatment. We treated the patient with a combination of a selective serotonin reuptake inhibitor (SSRI) fluoxetine 20 mg/day and a course of cognitive-behavioral therapy. Conclusion: Repeated episodes of intense panic attacks, accompanied by feelings of anxiety and observable alterations in behavior, distinguish panic disorder as a medical illness. The treatment involves the use of selective serotonin reuptake inhibitors, antidepressants, and cognitive behavioral therapy.

Abstract PO1-28-06: Development of a plasma-based real-time qPCR gene expression assay for targeted screening and diagnosis of early-stage breast cancer

Abstract Background Over 12 million US women undergo follow-up breast imaging and exams annually due to breast cancer suspicions, incurring an $8 billion total cost, of which $2.18 billion is attributed to false-positive breast biopsies. Recent updates published to the Mammography Quality Standards Act (MQSA) now recommend supplemental imaging for women with heterogeneously dense and extremely dense breasts, regardless of suspicious findings. Given sensitivity limitations associated with mammography in dense-breasted women, as low as 30-47%, and non-specificity associated with ultrasound and MRI, these recent recommendations are likely to further strain the healthcare system and place substantial burden on patients and providers. With an estimated 25 million dense-breasted women who regularly screen for breast cancer now considered at-risk, there is a critical need for affordable and highly accurate testing, offering better specificity without sacrificing sensitivity. To address this gap, we developed an affordable and accurate plasma-based gene expression assay using real-time qPCR for targeted screening and diagnosis of early-stage breast cancer. Methods In previous studies, 26 cross-correlated mRNA gene targets were discovered and independently validated for non-invasive breast cancer detection across five independent patient cohorts using microarray gene expression profiling, comprised of peripheral blood mononuclear cells (n=337) and saliva (n=20), demonstrating strong efficacy, reproducibility, and concordance across bio-fluids and assay platforms in all studies. A sixth independent validation cohort comprised of 203 plasma samples was subsequently obtained for real-time qPCR clinical assay development and validation in our CLIA laboratory. The CLIA validation cohort was designed to be representative of different diagnosis status, stage, and ethnicity, and included Caucasian, Black/African American, Hispanic, and Asian women. After normalizing mRNA expression and clustering analysis, the signature was refined to 8 target genes and was assessed in a cohort of 87 plasma samples [Table 1] to verify the assay’s diagnostic performance for stage I breast cancer detection, under locked laboratory protocols. We leveraged machine learning methods derived from XGBoost classification, a supervised-learning algorithm that uses sequentially built shallow decision trees to provide accurate results and avoidance of overfitting. Results The XGBoost model, selecting from the 8 mRNA gene targets and patient age, achieved &amp;gt;99% sensitivity, 89% specificity for stage I breast cancer detection in the held-out test set, with an overall diagnostic accuracy of 94.5%. Normalized data showed significant differences in gene expression between healthy controls and stage I patients, and distinct clustering was observed for the 8 mRNA gene signature, including patient age. Conclusions Our plasma-based real-time qPCR gene expression clinical assay, with machine learning, is positioned as a highly accurate non-invasive tool for targeted screening and diagnosis of early-stage breast cancer. Furthermore, a clinically validated assay in this space addresses the need for more targeted diagnostics, while serving as a promising tool for clinicians as they make critical care decisions across the breast health continuum, accelerating time to earlier and more precise intervention and treatment, mitigating unnecessary healthcare expenditures, and reducing the mental, emotional, and financial burden on patients and their families. Citation Format: Martin Keiser, Elizabeth Cormier-May, Matthew Alderdice, Joy Kavanagh, William Guesdon, Heather Healy, Nathalie Jean-Charles, Jay Harness. Development of a plasma-based real-time qPCR gene expression assay for targeted screening and diagnosis of early-stage breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-28-06.