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1.  A knowledge translation tool improved osteoporosis disease management in primary care: an interrupted time series analysis 
Background
Osteoporosis affects over 200 million people worldwide at a high cost to healthcare systems, yet gaps in management still exist. In response, we developed a multi-component osteoporosis knowledge translation (Op-KT) tool involving a patient-initiated risk assessment questionnaire (RAQ), which generates individualized best practice recommendations for physicians and customized education for patients at the point of care. The objective of this study was to evaluate the effectiveness of the Op-KT tool for appropriate disease management by physicians.
Methods
The Op-KT tool was evaluated using an interrupted time series design. This involved multiple assessments of the outcomes 12 months before (baseline) and 12 months after tool implementation (52 data points in total). Inclusion criteria were family physicians and their patients at risk for osteoporosis (women aged ≥50 years, men aged ≥65 years). Primary outcomes were the initiation of appropriate osteoporosis screening and treatment. Analyses included segmented linear regression modeling and analysis of variance.
Results
The Op-KT tool was implemented in three family practices in Ontario, Canada representing 5 family physicians with 2840 age eligible patients (mean age 67 years; 76% women). Time series regression models showed an overall increase from baseline in the initiation of screening (3.4%; P < 0.001), any osteoporosis medications (0.5%; P = 0.006), and calcium or vitamin D (1.2%; P = 0.001). Improvements were also observed at site level for all the three sites considered, but these results varied across the sites. Of 351 patients who completed the RAQ unprompted (mean age 64 years, 77% women), the mean time for completing the RAQ was 3.43 minutes, and 56% had any disease management addressed by their physician. Study limitations included the inherent susceptibility of our design compared with a randomized trial.
Conclusions
The multicomponent Op-KT tool significantly increased osteoporosis investigations in three family practices, and highlights its potential to facilitate patient self-management. Next steps include wider implementation and evaluation of the tool in primary care.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0109-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-014-0109-9
PMCID: PMC4182792  PMID: 25252858
Knowledge translation; Clinical decision support; Chronic disease management; Primary care; Risk assessment; Osteoporosis; Interrupted time series analysis
2.  Hip fracture prevention strategies in long-term care 
Canadian Family Physician  2010;56(11):e392-e397.
OBJECTIVE
To garner Canadian physicians’ opinions on strategies to reduce hip fractures in long-term care (LTC) facilities, focusing on secondary prevention.
DESIGN
A cross-sectional survey using a mailed, self-administered, written questionnaire.
SETTING
Canada.
PARTICIPANTS
Family physician members of the Ontario Long-Term Care Association (n = 165) and all actively practising geriatricians registered in the Canadian Medical Directory (n = 81).
MAIN OUTCOME MEASURES
The strength of recommendations for fracture-reduction strategies in LTC and barriers to implementing these strategies.
RESULTS
Of the 246 physicians sent the questionnaire, 25 declined study materials and were excluded. Of the 221 remaining, 120 responded for a response rate of 54%. About two-thirds of respondents were family physicians (78 of 120) and the rest were mostly geriatricians. Most respondents strongly recommended the following secondary prevention strategies for use in LTC after hip fracture: calcium, vitamin D, oral aminobisphosphonates, physical therapy, and environmental modification (such as handrails). Most respondents either did not recommend or recommended limited use of etidronate, intravenous bisphosphonates, calcitonin, raloxifene, testosterone (for hypogonadal men), and teriparatide. Postmenopausal hormone therapy was discouraged or not recommended by most respondents. Support was mixed for the use of hip protectors, B vitamins, and folate. Barriers to implementation identified by most respondents included a lack of strong evidence of hip fracture reduction (for B vitamins and folate, cyclic etidronate, and testosterone), side effects (for postmenopausal hormone therapy), poor compliance (for hip protectors), and expense (for intravenous bisphosphonates and teriparatide). Some respondents cited side effects or poor compliance as barriers to using calcium and potent oral bisphosphonates.
CONCLUSION
Canadian physicians favour the use of calcium, vitamin D, potent oral bisphosphonates, physical therapy, and evironmental modifications for LTC residents after hip fracture. Further study at the clinical and administrative levels is required to find ways to overcome the specific barriers to implementation and effectiveness of these interventions.
PMCID: PMC2980445  PMID: 21075980
3.  Dietary Iodine Restriction in Preparation for Radioactive Iodine Treatment or Scanning in Well-Differentiated Thyroid Cancer: A Systematic Review 
Thyroid  2010;20(10):1129-1138.
Background
Dietary iodine is often restricted before radioactive iodine (RAI) scanning or treatment of well-differentiated thyroid cancer. Our objective was to examine the impact of a low-iodine diet (LID) before RAI treatment or scanning on the following outcomes: (i) the efficacy of thyroid remnant ablation (or residual disease elimination), (ii) urinary iodine measurements, (iii) RAI kinetics, and (iv) long-term thyroid cancer outcomes.
Methods
We performed a systematic review of the English literature. We searched four electronic databases and conducted a hand search. Two reviewers independently screened citations and reviewed full-text articles and reached consensus on included articles. Two reviewers independently abstracted data.
Results
We reviewed 76 abstracts or citations and 26 full-text articles. Eight studies were included in the review. The most commonly studied diets allowed ≤50 μg/day of iodine for 1–2 weeks. In one study, 6-month successful remnant ablation rates were higher in patients following an LID than in controls. However, in another study, there was no significant benefit of an LID. LIDs reduce urinary iodine measurements and appear to increase I-131 uptake or lesional radiation compared to regular diets. No studies have examined long-term recurrence or mortality rates.
Conclusions
Given that LIDs reduce urinary iodine measurements, increase I-131 uptake, and possibly improve efficacy of I-131 treatment, we currently favor the use of a 1–2-week LID before I-131 therapy or scanning. However, more research is needed to clarify the role of this dietary intervention.
doi:10.1089/thy.2010.0055
PMCID: PMC2956383  PMID: 20860420
4.  Competing interests in development of clinical practice guidelines for diabetes management: Report from a multidisciplinary workshop 
Objective
To explore the complex issue of competing interests (CIs) in development of clinical practice guidelines (CPGs) in diabetes with stakeholders.
Methods
A multidisciplinary panel of 26 health, methodological, legal, and bioethical experts, trainees, and lay people from across Canada participated in a workshop on CIs in CPGs. Mixed methods were used such that qualitative themes were extracted from the discussions and quantitative survey data were collected.
Results
In the discussions, participants acknowledged that potential competing interests were not uncommon among sponsoring organizations and authors of CPGs. Avoidance of all potential CIs in development of CPGs was emulated as ideal, but considered probably unrealistic, given the paucity of peer-reviewed funding opportunities for development of evidence-informed CPGs and the scarcity of knowledgeable authors without CIs. An optimal approach for management of CIs in CPGs could not be agreed upon by participants. Full disclosure of any financial CIs for authors and sponsoring organizations as well as discouragement of external financial contributors from writing involvement, were endorsed by participants in the workshop and a subsequent survey.
Conclusions
Complete disclosure of financial CIs of sponsoring organizations and authors of CPGs is essential, yet the optimal approach to management of potential CIs is currently undefined.
PMCID: PMC3004553  PMID: 21197330
conflicts of interest; clinical practice guidelines; diabetes; knowledge translation; bioethics
5.  An interdisciplinary knowledge translation intervention in long-term care: Study protocol for the vitamin D and osteoporosis study (ViDOS) pilot cluster randomized controlled trial 
Background
Knowledge translation (KT) research in long-term care (LTC) is still in its early stages. This protocol describes the evaluation of a multifaceted, interdisciplinary KT intervention aimed at integrating evidence-based osteoporosis and fracture prevention strategies into LTC care processes.
Methods and design
The Vitamin D and Osteoporosis Study (ViDOS) is underway in 40 LTC homes (n = 19 intervention, n = 21 control) across Ontario, Canada. The primary objectives of this study are to assess the feasibility of delivering the KT intervention, and clinically, to increase the percent of LTC residents prescribed ≥800 IU of vitamin D daily. Eligibility criteria are LTC homes that are serviced by our partner pharmacy provider and have more than one prescribing physician. The target audience within each LTC home is the Professional Advisory Committee (PAC), an interdisciplinary team who meets quarterly. The key elements of the intervention are three interactive educational sessions led by an expert opinion leader, action planning using a quality improvement cycle, audit and feedback reports, nominated internal champions, and reminders/point-of-care tools. Control homes do not receive any intervention, however both intervention and control homes received educational materials as part of the Ontario Osteoporosis Strategy. Primary outcomes are feasibility measures (recruitment, retention, attendance at educational sessions, action plan items identified and initiated, internal champions identified, performance reports provided and reviewed), and vitamin D (≥800 IU/daily) prescribing at 6 and 12 months. Secondary outcomes include the proportion of residents prescribed calcium supplements and osteoporosis medications, and falls and fractures. Qualitative methods will examine the experience of the LTC team with the KT intervention. Homes are centrally randomized to intervention and control groups in blocks of variable size using a computer generated allocation sequence. Randomization is stratified by home size and profit/nonprofit status. Prescribing data retrieval and analysis are performed by blinded personnel.
Discussion
Our study will contribute to an improved understanding of the feasibility and acceptability of a multifaceted intervention aimed at translating knowledge to LTC practitioners. Lessons learned from this study will be valuable in guiding future research and understanding the complexities of translating knowledge in LTC.
Trial registration
ClinicalTrials.gov NCT01398527.
doi:10.1186/1748-5908-7-48
PMCID: PMC3533817  PMID: 22624776
Knowledge translation; Long-term care; Nursing home; Osteoporosis; Fractures; Vitamin D; Multifaceted; Interdisciplinary; Feasibility; Audit and feedback; Reminders; Interactive; Educational meeting; Opinion leader
6.  Decision aid on radioactive iodine treatment for early stage papillary thyroid cancer - a randomized controlled trial 
Trials  2010;11:81.
Background
Patients with early stage papillary thyroid carcinoma (PTC), are faced with the decision to either to accept or reject adjuvant radioactive iodine (RAI) treatment after thryroidectomy. This decision is often difficult because of conflicting reports of RAI treatment benefit and medical evidence uncertainty due to the lack of long-term randomized controlled trials.
Methods
We report the protocol for a parallel, 2-arm, randomized trial comparing an intervention group exposed to a computerized decision aid (DA) relative to a control group receiving usual care. The DA explains the options of adjuvant radioactive iodine or no adjuvant radioactive iodine, as well as associated potential benefits, risks, and follow-up implications. Potentially eligible adult PTC patient participants will include: English-speaking individuals who have had recent thyroidectomy, and whose primary tumor was 1 to 4 cm in diameter, with no known metastases to lymph nodes or distant sites, with no other worrisome features, and who have not received RAI treatment for thyroid cancer. We will measure the effect of the DA on the following patient outcomes: a) knowledge about PTC and RAI treatment, b) decisional conflict, c) decisional regret, d) client satisfaction with information received about RAI treatment, and e) the final decision to accept or reject adjuvant RAI treatment and rationale.
Discussion
This trial will provide evidence of feasibility and efficacy of the use of a computerized DA in explaining complex issues relating to decision making about adjuvant RAI treatment in early stage PTC.
Trial registration
Clinical Trials.gov Identifier: NCT01083550
doi:10.1186/1745-6215-11-81
PMCID: PMC2917435  PMID: 20659341
7.  A Scoping Review of Strategies for the Prevention of Hip Fracture in Elderly Nursing Home Residents 
PLoS ONE  2010;5(3):e9515.
Background
Elderly nursing home residents are at increased risk of hip fracture; however, the efficacy of fracture prevention strategies in this population is unclear.
Objective
We performed a scoping review of randomized controlled trials of interventions tested in the long-term care (LTC) setting, examining hip fracture outcomes.
Methods
We searched for citations in 6 respective electronic searches, supplemented by hand searches. Two reviewers independently reviewed all citations and full-text papers; consensus was achieved on final inclusion. Data was abstracted in duplicate.
Findings
We reviewed 22,349 abstracts or citations and 949 full-text papers. Data from 20 trials were included: 7 - vitamin D (n = 12,875 participants), 2 - sunlight exposure (n = 522), 1 - alendronate (n = 327), 1 - fluoride (n = 460), 4 – exercise or multimodal interventions (n = 8,165), and 5 - hip protectors (n = 2,594). Vitamin D, particularly vitamin D3 ≥800 IU orally daily, reduced hip fracture risk. Hip protectors reduced hip fractures in included studies, although a recent large study not meeting inclusion criteria was negative. Fluoride and sunlight exposure did not significantly reduce hip fractures. Falls were reduced in three studies of exercise or multimodal interventions, with one study suggesting reduced hip fractures in a secondary analysis. A staff education and risk assessment strategy did not significantly reduce falls or hip fractures. In a study underpowered for fracture outcomes, alendronate did not significantly reduce hip fractures in LTC.
Conclusions
The intervention with the strongest evidence for reduction of hip fractures in LTC is Vitamin D supplementation; more research on other interventions is needed.
doi:10.1371/journal.pone.0009515
PMCID: PMC2831075  PMID: 20209088
8.  The Impact of Thyroid Cancer and Post-Surgical Radioactive Iodine Treatment on the Lives of Thyroid Cancer Survivors: A Qualitative Study 
PLoS ONE  2009;4(1):e4191.
Background
Adjuvant treatment with radioactive iodine (RAI) is often considered in the treatment of well-differentiated thyroid carcinoma (WDTC). We explored the recollections of thyroid cancer survivors on the diagnosis of WDTC, adjuvant radioactive iodine (RAI) treatment, and decision-making related to RAI treatment. Participants provided recommendations for healthcare providers on counseling future patients on adjuvant RAI treatment.
Methods
We conducted three focus group sessions, including WDTC survivors recruited from two Canadian academic hospitals. Participants had a prior history of WDTC that was completely resected at primary surgery and had been offered adjuvant RAI treatment. Open-ended questions were used to generate discussion in the groups. Saturation of major themes was achieved among the groups.
Findings
There were 16 participants in the study, twelve of whom were women (75%). All but one participant had received RAI treatment (94%). Participants reported that a thyroid cancer diagnosis was life-changing, resulting in feelings of fear and uncertainty. Some participants felt dismissed as not having a serious disease. Some participants reported receiving conflicting messages from healthcare providers on the appropriateness of adjuvant RAI treatment or insufficient information. If RAI-related side effects occurred, their presence was not legitimized by some healthcare providers.
Conclusions
The diagnosis and treatment of thyroid cancer significantly impacts the lives of survivors. Fear and uncertainty related to a cancer diagnosis, feelings of the diagnosis being dismissed as not serious, conflicting messages about adjuvant RAI treatment, and treatment-related side effects, have been raised as important concerns by thyroid cancer survivors.
doi:10.1371/journal.pone.0004191
PMCID: PMC2615133  PMID: 19142227
9.  Improvement in health-related quality of life in osteoporosis patients treated with teriparatide 
Background
Individuals with osteoporosis and recent vertebral fractures suffer from pain and impaired health-related quality of life (HRQL). To determine whether patients with osteoporosis treated with teriparatide experienced improvement in HRQL and pain symptoms after several months of therapy.
Methods
We retrospectively studied a sample of osteoporosis patients treated with teriparatide in a Canadian rheumatology practice. We included patients that received teriparatide therapy with baseline and follow-up Mini-Osteoporosis Quality of Life Questionnaire (OQLQ) data. Follow-up data was measured at three or six months. We used a paired Student's t-test to compare baseline and follow-up measurements for each of the questionnaire's ten questions (five domains). Statistical analysis was also repeated to only include patients who suffered a prior vertebral fracture.
Results
57 patients were included in the study, including 47 women. The mean age was 63.8 years (standard deviation 12.1 years). About sixty five percent (37/57) had previously sustained one or more osteoporotic fractures and about 38.6% (22/57) had suffered a prior vertebral fracture. About 44% (25/57) of individuals were taking one or more types of pain medications regularly prior to starting therapy. At follow-up, significant improvements were observed in the OQLQ domains of pain symptoms. This was seen when all patients on teriparatide were included, and also when only patients with prior vertebral fractures were included. There was also an improvement in emotional functioning, relating to fear of falling at 3 months follow-up (p = 0.019). Respondents also reported improvement in the domain of activities of daily living, relating to vacuuming at 6 months follow-up (p = 0.036), and an improvement in the leisure domain, relating to ease of traveling in the prior vertebral fracture population at 3 months follow-up (p = 0.012). However, there was no significant improvement observed in the domains of physical functioning. Participants also reported a decrease in need for pain medications, with 26% (15/57) requiring analgesics at the time of follow-up.
Conclusion
Teriparatide use may be associated with improvements in HRQL in osteoporosis patients, in particular alleviation of pain symptoms. These results were especially evident in patients with a history of vertebral fractures. These findings should be confirmed in larger prospective studies with a suitable control group.
doi:10.1186/1471-2474-9-151
PMCID: PMC2588585  PMID: 18990249
10.  Patients’ adherence to osteoporosis therapy 
Canadian Family Physician  2008;54(3):394-402.
OBJECTIVE
To explore the experiences and perceptions of postmenopausal women regarding strategies to improve adherence to osteoporosis therapy.
DESIGN
Qualitative, mixed phenomenologic study using focus groups.
SETTING
Family physicians’ and specialists’ practices and community pharmacies in Hamilton, Ont.
PARTICIPANTS
A total of 37 postmenopausal women currently taking at least 1 prescription or over-the-counter medication for osteoporosis.
METHOD
Focus groups were conducted using a semistructured interview guide consisting of 10 open-ended questions about patients’ perceptions of their osteoporosis medications, their reasons for adherence and non-adherence to therapy, and the effectiveness of strategies they had tried to improve adherence. At least 2 research team members analyzed the data to find primary themes.
MAIN FINDINGS
Analysis of data from the 7 focus groups found 6 main factors that influenced adherence to medications: belief in the importance of taking medications for osteoporosis, medication-specific factors, beliefs regarding medications and health, relationships with health care providers, information exchange, and strategies to improve adherence. Strategies that facilitated adherence to medications included having a system for taking medications, using cues or reminders, being well informed about the reasons for taking medications, and having regular follow-up by health care providers for support and monitoring after having been prescribed medications.
CONCLUSION
Results of this study provide a better understanding of how patients’ perceptions and experiences affect their adherence to osteoporosis medications. Because each patient’s reasons for non-adherence might be different, depending on individual beliefs or circumstances, strategies to improve adherence to medications should be individualized accordingly.
PMCID: PMC2278357  PMID: 18337534
11.  Does Alendronate reduce the risk of fracture in men? A meta-analysis incorporating prior knowledge of anti-fracture efficacy in women 
Background
Alendronate has been found to reduce the risk of fractures in postmenopausal women as demonstrated in multiple randomized controlled trials enrolling thousands of women. Yet there is a paucity of such randomized controlled trials in osteoporotic men. Our objective was to systematically review the anti-fracture efficacy of alendronate in men with low bone mass or with a history of prevalent fracture(s) and incorporate prior knowledge of alendronate efficacy in women in the analysis.
Methods
We examined randomized controlled trials in men comparing the anti-fracture efficacy of alendronate to placebo or calcium or vitamin D, or any combination of these. Studies of men with secondary causes of osteoporosis other than hypogonadism were excluded. We searched the following electronic databases (without language restrictions) for potentially relevant citations: Medline, Medline in Process (1966-May 24/2004), and Embase (1996–2004). We also contacted the manufacturer of the drug in search of other relevant trials. Two reviewers independently identified two trials (including 375 men), which met all inclusion criteria. Data were abstracted by one reviewer and checked by another. Results of the male trials were pooled using Bayesian random effects models, incorporating prior information of anti-fracture efficacy from meta-analyses of women.
Results
The odds ratios of incident fractures in men (with 95% credibility intervals) with alendronate (10 mg daily) were: vertebral fractures, 0.44 (0.23, 0.83) and non-vertebral fractures, 0.60 (0.29, 1.44).
Conclusion
In conclusion, alendronate decreases the risk of vertebral fractures in men at risk. There is currently insufficient evidence of a statistically significant reduction of non-vertebral fractures, but the paucity of trials in men limit the statistical power to detect such an effect.
doi:10.1186/1471-2474-6-39
PMCID: PMC1182376  PMID: 16008835
12.  Measurement of fractionated plasma metanephrines for exclusion of pheochromocytoma: Can specificity be improved by adjustment for age? 
Background
Biochemical testing for pheochromocytoma by measurement of fractionated plasma metanephrines is limited by false positive rates of up to 18% in people without known genetic predisposition to the disease. The plasma normetanephrine fraction is responsible for most false positives and plasma normetanephrine increases with age. The objective of this study was to determine if we could improve the specificity of fractionated plasma measurements, by statistically adjusting for age.
Methods
An age-adjusted metanephrine score was derived using logistic regression from 343 subjects (including 33 people with pheochromocytoma) who underwent fractionated plasma metanephrine measurements as part of investigations for suspected pheochromocytoma at Mayo Clinic Rochester (derivation set). The performance of the age-adjusted score was validated in a dataset of 158 subjects (including patients 23 with pheochromocytoma) that underwent measurements of fractionated plasma metanephrines at Mayo Clinic the following year (validation dataset). None of the participants in the validation dataset had known genetic predisposition to pheochromocytoma.
Results
The sensitivity of the age-adjusted metanephrine score was the same as that of traditional interpretation of fractionated plasma metanephrine measurements, yielding a sensitivity of 100% (23/23, 95% confidence interval [CI] 85.7%, 100%). However, the false positive rate with traditional interpretation of fractionated plasma metanephrine measurements was 16.3% (22/135, 95% CI, 11.0%, 23.4%) and that of the age-adjusted score was significantly lower at 3.0% (4/135, 95% CI, 1.2%, 7.4%) (p < 0.001 using McNemar's test).
Conclusion
An adjustment for age in the interpretation of results of fractionated plasma metanephrines may significantly decrease false positives when using this test to exclude sporadic pheochromocytoma. Such improvements in false positive rate may result in savings of expenditures related to confirmatory imaging.
doi:10.1186/1472-6823-5-1
PMCID: PMC553971  PMID: 15737232
13.  A systematic review of the literature examining the diagnostic efficacy of measurement of fractionated plasma free metanephrines in the biochemical diagnosis of pheochromocytoma 
Background
Fractionated plasma metanephrine measurements are commonly used in biochemical testing in search of pheochromocytoma.
Methods
We aimed to critically appraise the diagnostic efficacy of fractionated plasma free metanephrine measurements in detecting pheochromocytoma. Nine electronic databases, meeting abstracts, and the Science Citation Index were searched and supplemented with previously unpublished data. Methodologic and reporting quality was independently assessed by two endocrinologists using a checklist developed by the Standards for Reporting of Diagnostic Studies Accuracy Group and data were independently abstracted.
Results
Limitations in methodologic quality were noted in all studies. In all subjects (including those with genetic predisposition): the sensitivities for detection of pheochromocytoma were 96%–100% (95% CI ranged from 82% to 100%), whereas the specificities were 85%–100% (95% CI ranged from 78% to 100%). Statistical heterogeneity was noted upon pooling positive likelihood ratios when those with predisposition to disease were included (p < 0.001). However, upon pooling the positive or negative likelihood ratios for patients with sporadic pheochromocytoma (n = 191) or those at risk for sporadic pheochromocytoma (n = 718), no statistical heterogeneity was noted (p = 0.4). For sporadic subjects, the pooled positive likelihood ratio was 5.77 (95% CI = 4.90, 6.81) and the pooled negative likelihood ratio was 0.02 (95% CI = 0.01, 0.07).
Conclusion
Negative plasma fractionated free metanephrine measurements are effective in ruling out pheochromocytoma. However, a positive test result only moderately increases suspicion of disease, particularly when screening for sporadic pheochromocytoma.
doi:10.1186/1472-6823-4-2
PMCID: PMC459231  PMID: 15225350

Results 1-13 (13)