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[PMID]: 29499200
[Au] Autor:Petrides AK; Melanson SEF; Kantartjis M; Le RD; Demetriou CA; Flood JG
[Ad] Address:Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Electronic address: apetrides@bwh.harvard.edu.
[Ti] Title:Monitoring opioid and benzodiazepine use and abuse: Is oral fluid or urine the preferred specimen type?
[So] Source:Clin Chim Acta;481:75-82, 2018 Feb 27.
[Is] ISSN:1873-3492
[Cp] Country of publication:Netherlands
[La] Language:eng
[Ab] Abstract:BACKGROUND: Oral fluid (OF) has become an increasingly popular matrix to assess compliance in pain management and addiction settings as it reduces the likelihood of adulteration. However, drug concentrations and windows of detection are not as well studied in OF as in urine (UR). We compared the clinical utility and analytical performance of OF and UR as matrices for detecting common benzodiazepines and opioids. METHODS: OF and UR concentrations of 5 benzodiazepines and 7 opioids were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 263 paired OF and UR specimens. UR creatinine was measured and prescription medications were reviewed. RESULTS: The benzodiazepines 7-aminoclonazepam, lorazepam, and oxazepam exhibited statistically higher detection rates in UR. For opioids, 6-AM was statistically more likely to be detected in OF, while hydromorphone and oxymorphone were statistically more likely to be detected in UR. Chemical properties including glucuronidation explain preferential detection in each matrix, not UR creatinine nor prescription status. CONCLUSION: We found that OF is the preferred matrix for 6-AM, while UR is preferred for 7-aminoclonazepam, lorazepam, oxazepam, hydromorphone, and oxymorphone. However, OF should be considered if the risk of adulteration is high and use and/or misuse of benzodiazepines, hydromorphone, and oxymorphone is low.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher

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[PMID]: 29362796
[Au] Autor:Bouillon K; Bertrand M; Bader G; Lucot JP; Dray-Spira R; Zureik M
[Ad] Address:Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), Saint-Denis, France.
[Ti] Title:Association of Hysteroscopic vs Laparoscopic Sterilization With Procedural, Gynecological, and Medical Outcomes.
[So] Source:JAMA;319(4):375-387, 2018 01 23.
[Is] ISSN:1538-3598
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Importance: Safety of hysteroscopic sterilization has been recently questioned following reports of general symptoms such as allergy, tiredness, and depression in addition to associated gynecological results such as pelvic pain, perforation of fallopian tubes or uterus, and unwanted pregnancy. Objective: To compare the risk of reported adverse events between hysteroscopic and laparoscopic sterilization. Design, Setting, and Participants: French nationwide cohort study using the national hospital discharge database linked to the health insurance claims database. Women aged 30 to 54 years receiving a first hysteroscopic or laparoscopic sterilization between 2010 and 2014 were included and were followed up through December 2015. Exposures: Hysteroscopic sterilization vs laparoscopic sterilization. Main Outcomes and Measures: Risks of procedural complications (surgical and medical) and of gynecological (sterilization failure that includes salpingectomy, second sterilization procedure, or pregnancy; pregnancy; reoperation) and medical outcomes (all types of allergy; autoimmune diseases; thyroid disorder; use of analgesics, antimigraines, antidepressants, benzodiazepines; outpatient visits; sickness absence; suicide attempts; death) that occurred within 1 and 3 years after sterilization were compared using inverse probability of treatment-weighted Cox models. Results: Of the 105 357 women included (95.5% of eligible participants; mean age, 41.3 years [SD, 3.7 years]), 71 303 (67.7% ) underwent hysteroscopic sterilization, and 34 054 (32.3%) underwent laparoscopic sterilization. During the hospitalization for sterilization, risk of surgical complications for hysteroscopic sterilization was lower: 0.13% for hysteroscopic sterilization vs 0.78% for laparoscopic sterilization (adjusted risk difference [RD], -0.64; 95% CI, -0.67 to -0.60) and was lower for medical complications: 0.06% vs 0.11% (adjusted RD, -0.05; 95% CI, -0.08 to -0.01). During the first year after sterilization, 4.83% of women who underwent hysteroscopic sterilization had a higher risk of sterilization failure than the 0.69% who underwent laparoscopic sterilization (adjusted hazard ratio [HR], 7.11; 95% CI, 5.92 to 8.54; adjusted RD, 4.23 per 100 person-years; 95% CI, 3.40 to 5.22). Additionally, 5.65% of women who underwent hysteroscopic sterilization required gynecological reoperation vs 1.76% of women who underwent laparoscopic sterilization (adjusted HR, 3.26; 95% CI, 2.90 to 3.67; adjusted RD, 4.63 per 100 person-years; 95% CI, 3.38 to 4.75); these differences persisted after 3 years, although attenuated. Hysteroscopic sterilization was associated with a lower risk of pregnancy within the first year of the procedure but was not significantly associated with a difference in risk of pregnancy by the third year (adjusted HR, 1.04; 95% CI, 0.83-1.30; adjusted RD, 0.01 per 100 person-years; 95% CI, -0.04 to 0.07). Risks of medical outcomes were not significantly increased with hysteroscopic sterilization compared with laparoscopic sterilization. Conclusions and Relevance: Among women undergoing first sterilization, the use of hysteroscopic sterilization was significantly associated with higher risk of gynecological complications over 1 year and over 3 years than was laparoscopic sterilization. Risk of medical outcomes was not significantly increased over 1 year or over 3 years. These findings do not support increased medical risks associated with hysteroscopic sterilization.
[Mh] MeSH terms primary: Hysteroscopy/adverse effects
Laparoscopy/adverse effects
Postoperative Complications/etiology
Sterilization, Tubal/methods
[Mh] MeSH terms secundary: Adult
Cohort Studies
Female
France
Humans
Middle Aged
Postoperative Complications/epidemiology
Pregnancy
Pregnancy, Unplanned
Reoperation/statistics & numerical data
Sterilization, Tubal/adverse effects
Treatment Failure
[Pt] Publication type:COMPARATIVE STUDY; JOURNAL ARTICLE; OBSERVATIONAL STUDY
[Em] Entry month:1801
[Cu] Class update date: 180311
[Lr] Last revision date:180311
[Js] Journal subset:AIM; IM
[Da] Date of entry for processing:180125
[St] Status:MEDLINE
[do] DOI:10.1001/jama.2017.21269

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[PMID]: 29523484
[Au] Autor:Heinsbroek E; Glass R; Edmundson C; Hope V; Desai M
[Ad] Address:HIV & STI Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, NW9 5EQ, United Kingdom. Electronic address: ellen.heinsbroek@phe.gov.uk.
[Ti] Title:Patterns of injecting and non-injecting drug use by sexual behaviour in people who inject drugs attending services in England, Wales and Northern Ireland, 2013-2016.
[So] Source:Int J Drug Policy;, 2018 Mar 06.
[Is] ISSN:1873-4758
[Cp] Country of publication:Netherlands
[La] Language:eng
[Ab] Abstract:BACKGROUND: Higher levels of drug use have been reported in lesbian, gay, bisexual and transgender (LGBT) communities, some of which can be explained by sexualised drug use, including 'chemsex'; the use of drugs before or during planned sexual activity to sustain, enhance, disinhibit or facilitate sex. We explored injecting and non-injecting drug use by sexual behaviour among people who inject drugs (PWID) in England, Wales and Northern Ireland. METHODS: Data were used from an unlinked-anonymous survey of PWID (2013-2016), where participants recruited through services self-completed a questionnaire. We included sexually active participants who had injected in the previous year, and compared injecting and non-injecting drug use between men reporting sex with men (MSM) and heterosexual men, and between women reporting sex with women (WSW) and heterosexual women. The questionnaire did not include GHB/GBL and methamphetamine use. RESULTS: There were 299 MSM, 3215 heterosexual male, 122 WSW and 1336 heterosexual female participants. MSM were more likely than heterosexual men to use drugs associated with chemsex: injected or non-injected mephedrone (adjusted OR (AOR) 2.22, 95%CI 1.54-3.22; AOR 2.15, 95%CI 1.48-3.11) and injected or non-injected ketamine (AOR 1.98, 95%CI 1.29-3.05; AOR 2.57, 95%CI 1.59-4.15). MSM were also more likely to inject methadone, inhale solvents, take ecstasy, cocaine or speed. WSW were more likely than heterosexual women to use non-injected mephedrone (AOR 2.19, 95%CI 1.20-3.99) and use injected or non-injected ketamine (AOR 5.58, 95%CI 2.74-11.4; AOR 3.05, 95%CI 1.30-7.19). WSW were also more likely to inject methadone, inject cocaine, use non-injected cocaine, crack, benzodiazepines or ecstasy, inhale solvents, or smoke cannabis. CONCLUSION: Injecting and non-injecting drug use differed between MSM/WSW and heterosexual men and women. The use of drugs that have been associated with chemsex and sexualised drug use is more common among both MSM and WSW than heterosexual men and women.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher

  4 / 30663 MEDLINE  
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[PMID]: 29521774
[Au] Autor:Schuring CA; Dodge DL; Whitcomb TJ; Wall GC; Smith HL; Hicklin GA
[Ad] Address:Internal Medicine Residency Program, University of Iowa-Des Moines (Drs Schuring, Dodge, Whitcomb, Wall, and Smith); College of Pharmacy and Health Sciences, Drake University, Des Moines, Iowa (Dr Wall); and Pulmonary and Critical Care Medicine, The Iowa Clinic, Des Moines, Iowa (Dr Hicklin).
[Ti] Title:Overdoses and Substance Toxicity in Patients Admitted to Intensive Care Units in a Midwestern U.S. City.
[So] Source:J Trauma Nurs;25(2):87-91, 2018 Mar/Apr.
[Is] ISSN:1078-7496
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Toxic exposures with serious outcomes have increased over the last decade. Limited data exists on the pattern and outcomes of overdose-exposure patients requiring intensive care unit (ICU) admission. The primary objective of this study was to characterize the causes, treatments, and outcomes of toxic exposures in a mid-sized Midwestern health system. The secondary objective was to report cumulative economic costs associated with these patients. Data were obtained from medical records of patients 18 years or older with a diagnosis code of overdose admitted to the ICU at 2 teaching hospitals between August 1, 2012, and July 31, 2014. There were 470 (10%) of the 4,495 total ICU admissions that met inclusion criteria during the study period. Average patient age was 39 (SD = 14.2) years, with 64% females. Intentional overdose exposure was the cause of 87% of admissions. The majority (70%) of exposures involved multiple pharmacological agents, including ethanol. Most patients did not require therapeutic maneuvers, nor used decontamination methods. Primary substance classes included analgesics, benzodiazepines, ethanol, selective serotonin reuptake inhibitor antidepressants, and methamphetamine. Two hundred sixty-five (56%) patients were ICU to direct home discharges, whereas 198 (42%) were transferred to a lower level of care. The mortality rate in the sample was 1%. Average hospital charges per admission were $20,375 and average ICU charges were $5,284, which summed to more than $2 million in total charges. Causes, treatments, and outcomes of toxic exposures admitted to the ICU in a mid-sized Midwestern city reveal a potential ICU burden. Financial health care costs associated with these toxic exposures were substantial. Greater public health efforts are needed to attempt to minimize preventable admissions and better understand antecedents.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[St] Status:In-Process
[do] DOI:10.1097/JTN.0000000000000349

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[PMID]: 29498534
[Au] Autor:Skrobik Y; Duprey MS; Hill NS; Devlin JW
[Ad] Address:McGill University, Montreal, Quebec, Canada ; skrobik@sympatico.ca.
[Ti] Title:Low-dose Nocturnal Dexmedetomidine Prevents ICU Delirium: A Randomized, Placebo-controlled Trial.
[So] Source:Am J Respir Crit Care Med;, 2018 Mar 02.
[Is] ISSN:1535-4970
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:RATIONALE: Dexmedetomidine is associated with less delirium than benzodiazepines, and better sleep architecture than either benzodiazepines or propofol; its effect on delirium and sleep when administered at night to patients requiring sedation remains unclear. OBJECTIVES: To determine if nocturnal dexmedetomidine prevents delirium and improves sleep in critically ill adults. METHODS: This two-center, double-blind, placebo-controlled trial randomized 100 delirium-free critically ill adults receiving sedatives to receive nocturnal (21:30 to 6:15h) intravenous dexmedetomidine (0.2 mcg/kg/hr, titrated by 0.1 mcg/kg/hr every 15 minutes until a goal RASS = -1 or maximum rate of 0.7 mcg/kg/hr was reached) or placebo until ICU discharge. During study infusions, all sedatives were halved; opioids were unchanged. Delirium was assessed using the Intensive Care Delirium Screening Checklist every 12 hours throughout the ICU admission. Sleep was evaluated each morning by the Leeds Sleep Evaluation Questionnaire (LSEQ). MEASUREMENTS AND MAIN RESULTS: Nocturnal dexmedetomidine (versus placebo) was associated with a greater proportion of patients who remained delirium-free during the ICU stay [dexmedetomidine [40 (80%) of 50 patients] vs. placebo [27 (54%) of 50 patients] (RR = 0.44, 95% CI, 0.23 to 0.82, p=0.006). The average LSEQ score was similar [MD 0.02; 95% CI, 0.42 to 1.92] between the 34 dexmedetomidine (average 7 assessments/patient) and 30 placebo (6/patient) group patients able to provide ≥ 1 assessment. Incidence of hypotension, bradycardia or both did not differ significantly between groups. CONCLUSIONS: Nocturnal administration of low-dose dexmedetomidine in critically ill adults reduces the incidence of delirium during the ICU stay; patient-reported sleep quality appears unchanged. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01791296.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[Cl] Clinical Trial:ClinicalTrial
[St] Status:Publisher
[do] DOI:10.1164/rccm.201710-1995OC

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[PMID]: 29474272
[Au] Autor:Lawton B; Davis T; Goldstein H; Tagg A
[Ad] Address:Emergency Department, Lady Cilento Children's Hospital, South Brisbane.
[Ti] Title:An update in the initial management of paediatric status epilepticus.
[So] Source:Curr Opin Pediatr;, 2018 Mar 06.
[Is] ISSN:1531-698X
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:PURPOSE OF REVIEW: Over the last 2 years, algorithms for the optimal management of status epilepticus have changed, as the medical community has recognized the need to terminate seizures in status in a timely manner. Recent research has evaluated the different choices of benzodiazepine and has given consideration to second-line treatment options. RECENT FINDINGS: There has been a move to examine alternatives to phenytoin (such as levetiracetam and lacosamide) as second-line agents. Valproate should be used cautiously in view of the potential side effects. Three ongoing trials [Established Staus Epilepticus Treatment Trial (ESETT), Convulsive Status Epilepticus Paediatric Trial (ConSEPT), and emergency treatment with levetiracetam or phenytoin in status epilepticus in children (EcLiPSE)] are comparing the efficacy of levetiracetam and phenytoin. SUMMARY: Benzodiazepines remain the first-line agent of choice, although there is ongoing discussion about the mode of administration and the best drug to choose. The results of ESETT, ConSEPT, and EcLiPSE will affect our future management of status, as we give consideration to levetiracetam as an alternative to phenytoin. Other medications such as lacosamide may emerge in future algorithms too.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1802
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[St] Status:Publisher
[do] DOI:10.1097/MOP.0000000000000616

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[PMID]: 29441519
[Au] Autor:Verger P; Mmadi Mrenda B; Cortaredona S; Tournier M; Verdoux H
[Ad] Address:IRD, AP-HM, SSA, VITROME, IHU-Mditerrane Infection, Aix Marseille Universit, Marseille, France.
[Ti] Title:Trajectory analysis of anxiolytic dispensing over 10 years among new users aged 50 and older.
[So] Source:Acta Psychiatr Scand;137(4):328-341, 2018 Apr.
[Is] ISSN:1600-0447
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:OBJECTIVE: To identify temporal trajectories of anxiolytic benzodiazepine (A-BZD) use over 10 years among new A-BZD users aged 50 and older and describe treatment patterns and demographic and clinical characteristics associated with each trajectory. METHOD: A representative cohort of the French national health insurance fund users was tracked from 2006 through 2015. We used latent class mixed models to identify the trajectories. RESULTS: We observed four trajectories among new users (no A-BZD dispensing in 2005) plus one non-use trajectory. The proportion of occasional use among users was 60%; early increasing use, 10%; late increasing use, 17%; and increasing/decreasing use, 13%. Prevalence of occasional use decreased with age in women, but not men. Duration of treatment episodes and doses differed between trajectories. Multiple regression analyses with occasional use as the reference showed that the other three trajectories shared characteristics (age, coprescriptions of other psychotropic drugs, and more general practitioner consultations) but differed by the presence at inclusion or occurrence during follow-up of psychiatric, neurodegenerative, and somatic conditions. CONCLUSION: We found four different long-term temporal trajectories in new A-BZD users (occasional, early increasing, late increasing, and increasing/decreasing use). Difficulties quitting or reducing consumption may be very different for each trajectory, requiring tailored care approaches.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1802
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[St] Status:In-Data-Review
[do] DOI:10.1111/acps.12858

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[PMID]: 29177587
[Au] Autor:Benfield J; Musto A
[Ad] Address:Department of Pathology, Anatomy, and Neurology, Eastern Virginia Medical School, Norfolk, VA, USA.
[Ti] Title:Intranasal Therapy to Stop Status Epilepticus in Prehospital Settings.
[So] Source:Drugs R D;18(1):7-17, 2018 Mar.
[Is] ISSN:1179-6901
[Cp] Country of publication:New Zealand
[La] Language:eng
[Ab] Abstract:Status epilepticus (SE) is a medical emergency characterized by uncontrolled, prolonged seizures with rapid and widespread neuronal damage. Patients that suffer from longer episodes of SE are more likely to have poorer clinical outcomes and a higher cost of healthcare. Understanding novel molecular mechanisms that regulate inhibitory and excitatory neurotransmission that initiate SE and the necessary medical infrastructure to stop SE could help identify targets for early intervention. Intranasal administration of benzodiazepines may shorten the time between initiation and cessation of seizures when compared to other routes of administration. Current pharmaceutical administration guidelines are appropriate for sporadic incidences of SE, but exploring other approaches is necessary to prepare for situations involving multiple patients outside of a hospital, such as a massive chemical weapons attack. Intranasal drug delivery helps to circumvent the blood-brain barrier and offers a noninvasive way to quickly administer drugs in settings that require an immediate response, such as nerve agent exposure. In addition, examining the intranasal delivery of new drugs, such as nanotherapeutics, may lead to more effective, noninvasive, scalable, and portable methods of treating SE.
[Pt] Publication type:JOURNAL ARTICLE; REVIEW
[Em] Entry month:1711
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[St] Status:In-Process
[do] DOI:10.1007/s40268-017-0219-3

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[PMID]: 29516704
[Au] Autor:Garisto C; Ricci Z; Tofani L; Benegni S; Pezzella C; Cogo P
[Ad] Address:Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Ges Children's Hospital, IRCCS, Rome, Italy - cristiana.garisto@opbg.net.
[Ti] Title:Use of low dose dexmedetomidine in combination with opioids and midazolam in paediatric cardiac surgical patients: randomized controlled trial.
[So] Source:Minerva Anestesiol;, 2018 Mar 07.
[Is] ISSN:1827-1596
[Cp] Country of publication:Italy
[La] Language:eng
[Ab] Abstract:BACKGROUND: Dexmedetomidine is a selective agonist of α2 receptors that induces hypnotic, sedative and mild analgesic effect. The aim of our study was to test the effects of dexmedetomidine in combination with opioids and benzodiazepines compared to benzodiazepine-opioids alone. METHODS: A randomized controlled trial was conducted. Patients (children >30 days and <24 months undergoing correction of complex congenital heart diseases -CHD-) were randomized to receive 0.5 mcg/kg/h dexmedetomidine in addition to half dose of opioids and benzodiazepines (D- CASES) or standard dose opioids and benzodiazepines (CONTROLs). PRIMARY OUTCOME: to compare the duration of mechanical ventilation (MV) in D-CASEs and CONTROLs. SECONDARY OUTCOMES: 1) the degree of sedation, 2) the onset of withdrawal symptoms, 3) the occurrence bradycardia and hypotension. RESULTS: Overall, 48 patients, 26 in CONTROLs group and 22 in D-CASEs group were ultimately included in the analysis after enrollment. The median duration of MV was 33.5 (16.7-75) hours in CONTROLs and 41.5 (23.7-71.2) hours in D-CASEs (p=0.51). Dexmedetomidine did not affect COMFORT and FLACC scales but it reduced the SOS scale in 15 D-CASEs vs 11 CONTROLs (p=0.001). The incidence of bradycardia and hypotension and vasoactive support did not show significant differences in the two groups. CONCLUSIONS: Low dose of dexmedetomidine in combination with morphine and midazolam was safe in a high-risk cohort of CHD children after cardiac surgery and reduced the onset of withdrawal symptoms. However, it did not decrease MV time and the total amount of other sedative and analgesic drugs required in the post-operative period.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180308
[Lr] Last revision date:180308
[St] Status:Publisher
[do] DOI:10.23736/S0375-9393.18.12213-9

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[PMID]: 29514323
[Au] Autor:Zacay G; Hershkowitz Sikron F; Heymann AD
[Ad] Address:Department of Family Medicine, Meuhedet Health Maintenance Organization, Tel Aviv, Israel.
[Ti] Title:Israeli general practitioners' dissatisfaction with their own primary healthcare.
[So] Source:Occup Med (Lond);, 2018 Mar 05.
[Is] ISSN:1471-8405
[Cp] Country of publication:England
[La] Language:eng
[Ab] Abstract:Background: Many physicians treat themselves despite established guidelines against such practice. Aims: To examine whether general practitioners (GPs) are satisfied with their personal primary care and how this could be improved. Methods: We sent a questionnaire to GPs in Israel. We examined the gap between preference to use formal medical care and use in practice, satisfaction with physicians' primary healthcare, self-prescribing and ways to improve physician access to care. Results: There were 203 respondents (response rate 203/985; 21%). Sixty-one per cent reported not having a GP. Older respondents were less likely to have their own GP. Thirty-seven per cent of physicians reported receiving less formal medical care than they desired. This gap was higher in those reporting self-prescription of benzodiazepines and anti-depressants (P < 0.05) and was significantly associated with dissatisfaction with primary healthcare. Odds for being satisfied with personal care was reduced by more than 85% in GPs who reported receiving less formal medical care than they desired (odds ratio 0.146; 95% confidence interval 0.064-0.333). Conclusions: Our findings inform the profile of physician self-treatment and the dissatisfaction associated with it. Dissatisfaction was associated with a gap between desired and actual care rather than with having or not having a personal GP. There was no consensus regarding what would assist physicians to access GPs.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180307
[Lr] Last revision date:180307
[St] Status:Publisher
[do] DOI:10.1093/occmed/kqy037


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